H1N1 Pandemic

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H1N1 Pandemic

• Andre Lalonde, MD
• EVP, SOGC

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Objectives

• Review epidemiology of H1N1 infection
• Prepare Obstetricians and Gynaecologists in the
  counseling of pregnant woman on
• Measures of preventions
• Treatment of H1N1 suspect in infant
• Immunization against H1N1
• Up to date information on H1N1 available on SOGC
  website

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Disease Characteristics and Burden

• How severe is the pandemic?
• Who is the most affected in terms of illness,
  complications and death?
• Who are the persons most likely to spread
  infection?

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Ethical Considerations

• What ethical principles and values should be
  applied?
• How do they inform the decision?
• Are the recommendations fair and equitable?

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Data source Health Canada
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Epidemic Curve No Vaccination
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Cumulative Attack Rates No Vaccination
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Hospitalization Rate per 100 000 person years in
healthy individuals
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Hospitalization Rate per 100 000 person years in
individuals with underlying conditions
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Epidemiological curve for hospitalized cases and
deaths
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Canadian Situation

• Total of 7,276 laboratory confirmed cases
• 1,315 cases were hospitalized (line-list info on
  1282 (97))
• 239 (18.1) of those hospitalized admitted to ICU
• 66 (5.0) of those hospitalized died

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Data Highlights - I

• Population incidence rates are highest for those
  5-19 years and infants
• Hospitalization rates are highest in the under 15
  years, pregnant women, those with underlying
  conditions and Aboriginal populations
• Presence of underlying condition is the greatest
  risk factor of admission to ICU or death
• Female gender is associated with higher risk of
  ICU admission and death

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Data Highlights - II

• Rates in healthy individuals,
• Incidence highest in 0-24 years
• Hospitalization highest in 0-24 years
• ICU Similar between 1 and 64 y
• Death Similar between 1 and 64 y
• ICUdeath Similar between 1 and 64 y
• Vaccinating 2-24 year olds would have a greater
  epidemiological impact compared to older age
  groups

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Data Highlights - III

• H1N1 Vaccine characteristics
• Many unknowns remain first clinical trial
  results in mid-late September (CSL product)
  initial GSK results late Oct./early Nov.
• Unknowns
• Need for second dose
• Vaccine safety increased reactogenicity if
  adjuvanted, otherwise unknown
• Effect of adjuvant for dose-sparing,
  immunogenicity, cross-reactive immunity

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Data Highlights - IV

• Vaccine logistical assumptions
• 3.5 million doses per week capacity minimum
  level
• Production limited by fill line capacity
• First lots filled mid to late October probably
  including an unadjuvanted lot.
• HC authorization mid November (up to 17.5 m
  doses available)
• Projected 49 million doses produced by first week
  of February

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Whos at Risk for a Severe Outcome?Analysis
based on cases who were hospitalized or died
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Hospitalized cases by PTs
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Overall Hospitalization Rates by Age Group
Assumes rate of hospitalization will remain
constant
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Hospitalized cases by gender and pregnancy
status
Assumes rate of hospitalization will remain
constant Depending on estimations of total
number of pregnant women per year between 330,000
and 475, 000
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Pregnant Women

• 48 women hospitalized were pregnant
• 11 Admitted to ICU of which 2 died
• 4 of all hospitalized cases were pregnant
• Information about trimester was available for 26
  pregnant women
• 1st Trimester 3 women
• 2nd Trimester 4 women
• 3rd Trimester 19 women
• Of the 7 women in their 1st or 2nd trimester all
  had non-severe hospitalizations
• 4 (21) out of 19 women in their 3rd trimester
  were admitted to ICU or Died

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Hospitalized Women and Pregnancy
Risk of ICU Admission or Death for Pregnant Women
relative to Non-pregnant women OR 0.72
(0.34-1.52)
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Signs Symptoms of H1N1 Infection

• fever
• cough
• runny nose
• sore throat
• body aches
• fatigue
• lack of appetite

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Prevention

• Stay away from people infected or suspected of
  Flu like disease
• Ask people around you at home or work to wear
  protection mask if they have the flu
• Use antiseptic soaps in your home or office in
  case of flu epidemic
• In case large number of people at work are
  infected, stay home
• Do not shake hands
• Avoid crowded public areas

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Treatment of H1N1

• All Health Care Professionals should provide
  their pregnant patien with a Tamiflu prescription
  in readiness, in case symptoms develop.
• Pregnant women with onset of flu like symptoms
• Send someone immediately to get the prescription
  filled
• Take medication immediately
• Do not go to the emergency room or your doctors -
  start taking medication ASAP
• Go to the hospital if you have breathing
  difficulties with or without medication

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Vaccination 2 types

• Unadjavent vaccine
• Adjavent vaccine (ASO3) available in mid november

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Vaccine Characteristics

• Any expected population differences in protection
  from the pandemic vaccine?
• Any people who do not need the vaccine?
• Need for a second dose?
• Are dose-sparing strategies possible, e.g.
  intradermal administration?
• Are there any vaccine safety concerns?
• What is the proposed indication for use and what
  indication/market authorization has been granted
  by the Health Canada regulator?
• What pre-market assessment has been performed,
  and what post-market surveillance requirements
  are imposed?

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H1N1 and the Aboriginal Population
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Access to Care

• Nursing stations, health stations, health centres
  , health offices-heavy orientation to nursing
  provided care and a lot of community health
  representatives
• More limited scope of services than urban health
  services

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Population Rates by Aboriginal Status
Assumes rates will remain constant
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Risk of ICU Admission or Death by Aboriginal or
First-Nations Status amongst those hospitalized

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H1N1 Aboriginal Population on Reserves

• Risk factors for severe H1N1 younger population,
  higher rates of underlying disease that are
  associated with higher risk, more pregnancies
  among younger mothers.
• Difficulties access to appropriate medical care
  for early treatment given geographic isolation
  and lack of health human resources
• Operational factors make rapid spread and
  infection control difficult higher housing
  density and lack of running water in several
  communities
• All of these issues relate to equity, which is
  also an ethical consideration.

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PRIORITY SEQUENCE FOR IMMUNIZATION FOR CANADA
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Primary Targets Canada

• Persons with chronic conditions (NACI list) under
  the age of 65 - at higher risk of complications
  65 less affected to date
• Pregnant women - at higher risk of complications
  and to potentially protect their infants
• Healthy Children 6 to 23 months of age - at
  higher risk of severe disease children
  identified as a priority by the public

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Primary Targets (cont.)

• Remote and isolated communities (First Nations,
  Inuit and other communities)
• - limited access to medical care, potential for
  development of herd immunity and prevention of
  infection, logistically easier to target whole
  community equity, high concentration of persons
  with chronic conditions, observed
  morbidity/mortality

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Summary of findings

• Population incidence rates are highest for those
  5-19 years and infants
• Hospitalization rates are highest in the under 15
  years, pregnant women, those with some underlying
  conditions and Aboriginal populations
• Increasing age, presence of underlying condition,
  female gender are associated with higher risk of
  admission to ICU or death
• Presence of an underlying condition and
  increasing age have the greatest impact on risk
  of ICU admission or death

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What is SOGC Doing

• Guidelines
• Update website regularly (www.sogc.org)
• Patient information tear out pad
• Posters

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What you should do

• Advise all patients about H1N1 and their risk
• Give each pregnant woman a prescription
• Keep checking SOGC website and provincial health
  announcements
• Protect yourself and your staff
• - medication to treat H1N1 information
• - immunization of you, your family and staff
• Consider providing immunization to your patients.
  If you want to do so make yourself aware of how
  to immunize and register with Public health to
  receive vaccine.

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The Executive Committee of the SOGC adopted the
following motions regarding H1N1 and pregnancy
during the September 4th, 2009 meeting held in
Ottawa.SOGC Members should

• Promote the yearly influenza vaccine to all
  pregnant women.
• Inform, counsel, and promote to all pregnant
  women the availability and benefits of H1N1
  vaccination.
• Inform pregnant women of the risks, signs,
  symptoms, severity and management of a possible
  H1N1 infection.

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SOGC Members should

• Provide pregnant women with a prescription for
  Tamiflu (75mg bid for 5 days) during their
  antenatal visit, to be used when a suspected H1N1
  infection occurs.
• Inform all pregnant women of the benefits and
  risks associated with the use of Tamiflu, and
  its follow-up, such as the side effects, when to
  use the medication, and in case of serious
  respiratory difficulties to report to the nearest
  hospital.
• Be aware that Tamiflu should NOT be used as a
  prophylaxis drug.