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Canadian Pandemic Influenza Preparedness

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Title: Canadian Pandemic Influenza Preparedness


1
Canadian Pandemic Influenza Preparedness
  • Arlene King, MD, MHSc, FRCPC
  • Director General for Pandemic Preparedness
  • College of Physicians and Surgeons of
    Saskatchewan, September 2006

2
Presentation Outline
  • What are the differences between annual, pandemic
    and avian influenza?
  • Why prepare for a pandemic?
  • What are we planning for?
  • How is the planning occurring in Canada?
  • What has been done to increase our level of
    preparedness in Canada?
  • Remaining challenges and the way forward

3
Influenza Virus
  • 8 gene segments mutate or mix resulting in new
    strains
  • 2 spike proteins on its surface
  • Haemagglutinin H
  • Neuraminidase N
  • 3 types A, B and C

4
Influenza A Virus
  • 16 H and 9 N subtypes
  • Aquatic birds are natural reservoir for all
    influenza A viruses
  • Only H1, H2, H3 have resulted in human pandemics
    in the past century
  • Only H1 and H3 have caused annual epidemics

5
How are Annual, Pandemic and Avian Flu Different?
  • Annual (Seasonal) Flu The flu is a contagious
    respiratory illness in humans caused by influenza
    viruses that occurs every year.
  • Pandemic Flu An influenza pandemic is a global
    outbreak that occurs when a new influenza A virus
    to which virtually no-one is immune spreads
    easily from person to person and causing serious
    human illness.
  • Avian (bird) flu Bird flu is an infection caused
    by avian influenza viruses, which occur naturally
    among wild birds but can cause illness in
    domestic poultry.

6
Annual Influenza
  • Influenza A (H3N2, H1N1) and influenza B viruses
    circulate in humans causing annual outbreaks
  • 10-25 of a population ill with flu
  • Average of 4,000 deaths and 20,000
    hospitalizations due to flu or its complications
    per year in Canada
  • Fever and cough, sore throat, unwell, muscle
    aches, headaches (up to 1 week)
  • Pneumonia, exacerbation of underlying chronic
    illnesses, encephalitis
  • Most severe in the very old and very young

7
How Does Influenza Spread?
  • Influenza is spread primarily via infected
    respiratory droplets and also via contact with
    contaminated hands and surfaces
  • The onset of clinical illness after the initial
    exposure (the incubation period) is usually
    short 1 to 3 days (range 1-7 days)
  • An infected person may shed the virus one day
    before the onset of symptoms and continue for 5
    days after symptom onset, however, transmission
    is most efficient during the first 3 days of
    illness when symptoms, such as cough and fever,
    are present and viral shedding is highest

8
Influenza Vaccines
  • Vaccines prevent influenza by inducing immunity
  • Vaccines used in Canada consist of killed split
    viruses
  • As the influenza viruses change, the vaccine
    needs to be updated every year
  • Influenza vaccine is 70 effective in young
    adults

The best protection against annual flu is
vaccination
9
Influenza Antivirals
  • 2 main types
  • Neuraminidase inhibitors e.g. oseltamivir,
    zanamivir
  • Adamantanes (M2 inhibitors) e.g. amantadine
  • Used to treat patients infected with influenza
  • Most effective if taken early on in the course of
    illness (within 48 hours)
  • Reduce symptom duration and severity (1 day),
    complications and antibiotic use
  • Used to prevent influenza illness (prophylaxis)
  • Does not produce immunity
  • 60-90 effective in preventing symptoms
  • Has to be taken continuously for the duration of
    the outbreak in a given community (6-8 weeks)
  • Drug resistance may develop

Antivirals are an adjunct to vaccination and
other general public health measures
10
Shift Happens
Dr. David Shay, CDC, Atlanta
11
Antigenic Drift and Shift
  • Antigenic drift a gradual change in the
    hemagglutinin and/or the neuraminidase proteins
    when the virus goes through a series of minor
    mutations and evolves over time (Influenza A B)
  • Antigenic shift major change in the
    hemagglutinin and/or the neuraminidase proteins
    resulting in the sudden appearance of a new
    influenza virus subtype (Influenza A)

12
Generation of Pandemic Viruses
  • Adaptive mutation
  • Re-assortment

13
Origin of Pandemic Influenza Viruses
14
Each Pandemic is Different
Credit US National Museum of Health and Medicine
1918 Spanish Flu
1957 Asian Flu
1968 Hong Kong Flu
40-50 million deaths
1 million deaths
1 million deaths
H1N1
H2N2
H3N2
Source WHO
15
Impact of the Next Pandemic is Unpredictable
  • Depends upon many factors
  • Direct impact of influenza
  • Attack rate
  • Affected age groups
  • Virulence of the strain and rates of adverse
    outcomes/complications
  • Speed of spread from country to country and
    within a country
  • Effectiveness of the response
  • Vaccines, antivirals and non-pharmaceutical
    interventions
  • Psychologically induced impacts / public behaviour

16
What are We Preparing For?
  • A public health emergency that is inevitable but
    unpredictable in timing and epidemiology
  • Arrival of the pandemic virus in Canada within 3
    months of its appearance elsewhere may be much
    more rapid
  • 1st peak in illness 2 to 4 months after the
    arrival of the virus in Canada
  • Outbreaks will occur simultaneously in multiple
    locations, although different areas of the
    country may experience peak activity at different
    times.
  • In a local community a pandemic wave will
    generally last 6-8 weeks but this can vary
  • A pandemic may last 12 to 18 months and more than
    one wave may occur within a 12 month period

17
Influenza Pandemic 1957 children and adults had
highest rates of illness deaths highest in the
elderly
- 300 - 250 - 200 - 150 - 100 - 50 0
Mortality Rate per 100,000
Clinical Influenza Attack Rates (Kansas City,
1957) and Annual Mortality Rate Pneumonia and
Influenza (U.S. 1957) - Modified from Monto AS.
Am J Med. 1987 8220-5.
18
The 1918 pandemic was unusual in that those aged
20 to 40 experienced high mortality rates
Mortality rates in different pandemics and
epidemics Modified from Monto AS. Am J Med.
1987 8220-5.
19
Health Impacts of Pandemics
  • Assumptions for planning
  • The majority of the population (over 70) will be
    infected over the course of the pandemic
  • 15-35 clinically ill over the course of the
    pandemic and of these
  • assume that the majority of cases occur in the
    first wave (e.g. for a clinical attack rate of
    35, plan for 25 illness rate over 6 weeks in
    the first wave)
  • 50 will not require clinical care
  • up to 50 will seek outpatient care
  • 1 will be hospitalized
  • 0.4 will die

U.S. Meltzer Model adapted
20
Health Impacts of a Pandemic in Canada
  • Moderate severity and no vaccines or antivirals
    scenario
  • 11,000 to 58,000 deaths
  • 34,000 to 138,000 hospitalizations
  • 2 to 5 million outpatients
  • 4.5 to 10.6 million clinically ill but no formal
    care
  • economic costs
  • health care 330 million to 1.4 billion
  • societal (lost productivity) 5 to 38 billion

U.S. Meltzer Model adapted
21
symptomatic cases
  • Impact on workforce may vary depending on setting
  • Asking sick staff to stay at home for 5 days or
    until symptoms have resolved will help reduce the
    spread and impact
  • Plan for staff absenteeism of up to 25 (due to
    death, illness, caring for ill family, fear of
    infection, public health interventions) during
    the peak week of the outbreak in a community,
    with lower rates during the weeks before and
    after the peak

In a setting of high population density /
enclosed environment
In a setting of low population density
Dept of Finance model
Time
22
Industry planning estimates include estimates of
possible workplace-avoidance impacts (based on
social density and leave availability) and
additional prudence
Peak Absenteeism Rates by Industry Planning
  • Prudence is substantial greater than illness
    impact
  • Equivalent to planning for an 80 attack rate

23
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24
H5N1 An Ongoing Human Health Risk
  • H5N1 confirmed in wild birds or poultry in
    growing number of countries in Asia, Middle East,
    Europe and Africa
  • Occasional human H5N1 cases high case fatality
    rate (gt50)
  • Limited implementation of protective measures
  • Circulating human influenza viruses

25
Animal to Human Transmission of H5N1
  • History of direct contact with poultry in
    majority of cases
  • Plucking and preparing poultry
  • Handling fighting cocks
  • Playing with poultry, including asymptomatic
    infected ducks
  • Consumption of duck blood or possibly undercooked
    poultry

No recent change in the assessment of pandemic
risk
26
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27
What is the Risk of H5N1 Entering Canada?
28
Public Health Network Structure
Expert Groups (permanent expertise)
Communicable Disease Control
Issue Groups
Emergency Preparedness Response
Canadian Public Health Laboratory
Reporting through respective Expert Groups on key
issues
Conference of F/P/T Deputy Ministers of Health
Council F/P/T members
Public Health Surveillance Information
Chronic Disease Injury Prevention Control
Is accountable to
Population Health Promotion
CCMOH
Task Groups (time limited)
Public Health Human Resources Task Group
Task Groups
29
Pandemic Influenza Committee (PIC)
  • 2 Co-Chairs Federal and Provincial
  • 18 voting members including all provinces and
    territories, technical experts and an ethicist
  • Provides technical advice on pandemic influenza
    preparedness and response
  • Provides overall guidance on the Canadian
    Pandemic Influenza Plan

30
Canadian Pandemic Influenza Plan
  • Based on nationally agreed upon goal
  • Organized by components, by pandemic phase
  • Outlines roles and responsibilities of all levels
    of government
  • Balanced, multifaceted approach to preparedness
    and response
  • Evergreen document, incorporating rapidly
    involving science and perspectives

31
Updating the Canadian Pandemic Influenza Plan
  • Health sector plan
  • New WHO pandemic phases
  • New annexes, including
  • Public Health Measures
  • Communications
  • Surveillance
  • Updates to annexes

October 2006
32
Key Components
  • Surveillance and laboratory preparedness
  • Pandemic vaccine
  • Antivirals
  • Health services
  • Infection Control, Clinical Management, Resource
    Management, Non-Traditional Sites and Workers
  • Emergency preparedness
  • Public health measures
  • Communications
  • Research is the foundation of an optimal response
    during the preparedness and response phases

33
Surveillance and Laboratory What has been done
  • Global information gathering and dissemination
  • eg, Global Public Health Intelligence Network
    (GPHIN)
  • FluWatch weekly surveillance of influenza
    addition of real-time pediatric hospitalizations
    and deaths
  • Rapid dissemination of information e-mail and
    web-based alerts (CIOSC)
  • Evaluation of options for real-time death
    surveillance in Canada
  • Capacity to perform influenza testing is
    improving through Canadian Public Health Network

34
Pandemic Vaccine What has been done
  • Most effective public health intervention to
    mitigate the impact of a pandemic is through
    immunization with an effective vaccine against
    the new virus
  • Established 10 year contract (2001-2011) with ID
    Biomedical/GSK annual and pandemic vaccine
  • Production and testing of a prototype pandemic
    influenza vaccine against the H5N1 strain 2006/7
  • Nationally coordinated approach to program
    priority group development

35
Antivirals What has been done
  • (Target of) 55M dose national antiviral stockpile
    for treatment of everyone in Canada who needs it
  • To be distributed on a per capita basis to all
    P/Ts
  • Federal surge in national emergency stockpile (3
    million doses at present 10 million dose target)
  • Implementation plans at various stages of
    development

36
Health Services What has been done
  • Annexes in the Canadian Pandemic Influenza Plan
    on
  • Infection prevention and control and occupational
    health
  • Clinical management of influenza
  • Resource management
  • Non-traditional sites and workers
  • Mass fatalities

37
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38
Communications What has been done
  • FPT communications network in place
  • Public and professional information on seasonal
    influenza, pandemic influenza and avian influenza
  • Media briefings
  • Working with UK, USA, G7 plus Mexico, WHO to
    further coordinate pandemic communications
    response

39
Research What has been done
  • Influenza immunization program evaluation studies
  • Phase 1 results expected later in 2006
  • Phase 2 proposals currently being evaluated
  • Influenza research agenda
  • Funding through Budget 2006 to CIHR and the
    Public Health Agency

40
Summary State of Preparedness
  • Our level of preparedness is among the best in
    the world
  • Further preparedness should serve the dual
    purpose of enhancing pandemic preparedness, and
    improving our capacity to address
  • any health/EID/emergency
  • day to day public health issues

41
Challenges General
  • Cross-sectoral planning
  • Health sector v. emergency management paradigm
    differences
  • Inconsistent national assumptions and approaches
  • Information knows no borders
  • Opportunity costs
  • Domestic
  • Global
  • Avian influenza preparedness

42
Challenges Health Sector
  • Engagement of clinicians, other independent
    health professionals in some regions
  • Scope of indications for national antiviral
    stockpile
  • Influenza infection control practices
  • Mode of transmission of influenza
  • Masks type and indications

43
Way forward General
  • Release next version of Canadian Pandemic
    Influenza Plan for the Health Sector October
    2006
  • Finalize avian influenza response plans
  • Finalize all sector Government of Canada
    strategy on avian and pandemic preparedness

44
Way forward Antivirals
  • Antivirals are only one component of a
    multifaceted pandemic strategy
  • Task Group under Canadian Public Health Network
    Council considering whether antivirals should be
    stockpiled for prophylaxis
  • Process proposal under consideration by
    Conference of Deputy Ministers of Health (CDMH)
  • External scientific review, reviews of other
    considerations (legal, ethical, economic,
    international, FPT policy, logistical, etc)
  • Includes public and stakeholder dialogue
  • Recommendation to CDMH, January 2007

45
Way forward Pandemic Vaccine
  • A Pandemic Influenza Vaccine Working Group has
    been re-established to address current and future
    pandemic vaccine issues
  • eg, stockpiling and pre-pandemic use of
    prototype vaccines (eg, H5N1)
  • Produce mock or prototype pandemic vaccine and
    conduct clinical trials ? 2006-2007
  • Establishment of a rapid vaccine development and
    testing capacity and service at PHAC-National
    Microbiology Laboratory
  • Harness enough Canadian vaccine production
    capacity to produce enough vaccine for all
    Canadians as quickly as possible

46
Way forward Health Services
  • Continued refinement and revision of health
    services annexes
  • Clinical care and infection control
  • Consensus meeting on infection control measures
    for avian, seasonal and pandemic influenza in
    health settings
  • October 26-27, 2006 (Toronto)

47
Way forward Research
  • Establish an influenza research infrastructure
    e.g. vaccine research and rapid response network
  • Fund and support the implementation of the
    national influenza research agenda
  • Coordinate with USA/NIH, WHO and other research
    initiatives/organizations (eg, IDRC)

48
Way forward International
  • Further collaboration with the United States and
    Mexico under the Security and Prosperity
    Partnership (SPP)
  • Global Health Security Initiative (G7 plus
    Mexico), G8, APEC, International Partnership on
    Avian and Pandemic Influenza
  • Continued support to countries, WHO, FAO and OIE
    for capacity development

49
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50
Supplementary Slides
51
International Health Regulations
  • Proposed revisions reflect WHO recognition of
    importance of migration health on global health
    security
  • Revised IHRs would maintain the same overall goal
    as the current regulations
  • To provide security against the international
    spread of disease while avoiding unnecessary
    interference with international traffic

52
International Health Regulations
  • Key changes
  • Require notification of all events constituting a
    Public Health Emergency of International Concern
  • Establish new legal framework to underpin the
    WHOs global health security epidemic alert and
    response strategy

53
International Health Regulations
  • Key changes
  • Require member states to meet core requirements
    for surveillance and response at the community
    and national level
  • Require each member state to establish a National
    IHR Focal Point for the WHO on all IHR matters
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