The 2009-10 “Pandemic” Experience

1. The 2009-10 “Pandemic” Experience “This year, it’s a different flu season”

4. What are We Preparing For? • A public health emergency that is inevitable but unpredictable in timing and epidemiology • Short lead time: - presence in Canada < 3 months - 1st peak in illness within 5-7 months • Outbreaks will occur simultaneously in multiple locations, in multiple waves • Limited resources will need to be prioritized • Extremely high demand for information

5. History of Influenza Pandemics Year Influenza A Strain 1847 ? 1889 - 1890 H2N2 1899 - 1900 H3N2 1918 - 1919 H1N1 Spanish flu 1957 H2N2 Asian flu 1968 H3N2 Hong Kong flu 2009 H1N1 ??

6. Pandemic Mortality No. of deaths Death rate Worldwide Canada per 100,000 pop. 1918-19 40-50 m 50-60,000 218 1957 1-2 m 7,000 22 1968 1 m 3,000 14

7. Historical Analysis - 1918-19 Pandemic (“Spanish Flu”) • Public health units overwhelmed • Traditional measures were largely unsuccessful • Quarantine, “community lockdown” did not limit spread • Major failure: Lack of honest communication

8. World Health Organization (WHO) Alert Periods and Phases

9. Pandemic Influenza Phases Source: WHO Global Influenza Programme 2009

10. Whole of Society Approach to Pandemic Preparedness Source: WHO Global Influenza Programme 2009

11. Ontario’s Pandemic Planning • Activities correspond to the WHO pandemic phases (Inter-pandemic, Pandemic Alert and Pandemic) • Aligned with direction in Canadian Pandemic Influenza Plan • Provides detail on federal, provincial and localroles/responsibilities and commitments • Includes an ethical framework for decision-making • Focuses on the health care system’s preparedness and readiness, including stocking supplies and equipment • Supports and guides community response and includes a number tools designed to undertake effective local planning and preparedness. • Continues to be updated and improved with emerging clinical, epidemiological, and operational information.

12. Local Planning Peterborough Interagency Pandemic Planning Team Annual Exercises and Conferences Peterborough Community Influenza Assessment Committee Municipal Emergency Planning Internal Pandemic Planning Committees

13. PIPPT Objectives To facilitate and strengthen collaboration with all key stakeholders. To facilitate in the development, integration and ongoing maintenance of local pandemic influenza plans. To ensure that pandemic plans for Peterborough are consistent with national and provincial plans and reflect local needs. To ensure clarity of roles in an influenza pandemic. To facilitate training, education, and/or support for the design, testing and implementation of local pandemic influenza plans.

14. WHO Non-PharmaceuticalInterventions (2006) • National / community and international guidance • Isolation of cases, quarantine of contacts (during Alert) • SARS strategies not likely to work in a pandemic • Exit screening, health advisories recommended • Consider school closures • Do not encourage* nor discourage masks

15. Key Strategies for Reducing Spread and Impact • Public health measures and infection control - respiratory etiquette, hand hygiene and self care • Vaccination - the primary preventive measure but not likely available until after first wave • Antivirals - the only virus-specific intervention until vaccine is available • Maintaining health, emergency and social services • Maintaining public awareness and facilitating acceptance of response strategy

16. So why is Influenza such a problem?

17. Influenza Virus Structure and Surface Proteins Segmented RNA genome Neuraminidase e.g. N1, N2 Haemagglutinin e.g. H1, H2, H3 M2 Protein Laver WG, Bischofberger N, Webster RG. Disarming flu viruses, Sci Am 1999;January.

18. ABC of Human Influenza • acute respiratory viral infection • caused by members of the Orthomyxoviridae family Type A Type B Type C Annual Flu Epidemics PANDEMIC Novel Virus No Resistance Human to Human Transmission Severe Disease

19. Influenza Virus: Promiscuity!!

20. Influenza viruses in their natural reservoirs are in evolutionary stasis Rapid evolution occurs after transfer to new hosts The Ecology of Influenza A Viruses

21. Source: Lou Donofrio, OMAFRA

22. Principles of Influenza Transmission • Contact with respiratory secretions and large droplets appears to account for most transmissions of influenza • Both influenza A and B can survive on hard, non-porous surfaces for 24-48 hours, on cloth or paper for 8-12 hours and on hands for 5 minutes • Transmission by airborne route is controversial and unproven for humans

23. Novel H1N1 Influenza A (2009) Characteristics: a disease of younger people • significant numbers of people are likely to be afflicted • the illness is at worst like a seasonal influenza • severe disease occurs but is not common • overall mortality is low • risk groups: co-morbidities, remote communities, pregnant women DR I. M. GEMMILL, MD, CCFP, FRCP(C)

24. Pandemic (H1N1) influenza is the most common flu virus circulating worldwide: The overwhelming majority worldwide of persons infected with pH1N1 continue to experience uncomplicated influenza-like illness, with full recovery within a week – even without medical treatment.

25. All confirmed cases of Influenza A in Ontario by week, 2004-2010†

26. pH1N1 Deaths In Children

27. Hospitalized cases in Ontario by age group and gender, April 13 to October 28, 2009

28. Incidence of hospitalization and death due to pH1N1 in Ontario, April 13 to October 28, 2009

29. Provincial Update Some health units reported very high rates of H1N1 activity (several indicators) Positivity of respiratory specimens ranged from 20% to 60% Increased school absenteeism noted and now returned to baseline (n=14 in Peterborough, Nov 2/09) Emergency Departments busier with ILI and respiratory symptoms

30. Local Update

32. PCCHU Emergency Response • IMS implemented in April. Resumed in October • Communications, Liaison and Safety Officers • Operations includes surveillance, case and outbreak management, health sector liaison, public enquiry, vaccine delivery • Logistics includes staffing, training and clinics support • Planning includes pregnant and vulnerable populations, and assessment centres • F&A includes procurement, IT support • Essential services being delivered

33. pH1N1 Vaccine • Based on influenza A/California/07/2009 (H1 N1)-like strain (X-179A). • Different vaccines are being used in different countries • In Canada, GSK will supply up to 50,000,000 doses • Most will be an adjuvanted European style vaccine • A limited amount will be a traditional unadjuvanted formulation • ‘Vaccine will be available to every person who wants or needs it.’

34. pH1N1 Vaccine Formulations • unadjuvanted: for pregnant women and healthy 10 – 64 year olds • similar to seasonal vaccine formulations • 15 μg nH1N1 antigen • good seroconversion in adults • adjuvanted with AS03 ((Arepandrix™) • allows over 75% reduction in antigen (3.75 μg) • similar seroconversion rates in adults (better in children, seniors)

35. pH1N1 Vaccine Roll-out in community, and at PRHC, began October 26 High risk groups targeted first, while supplies of vaccine still limited City and County site clinics offered daily (Mon-Sat) School-based clinics College and University clinics

39. Risk/Crisis Communications When perceived risk is high but known risk is low, strategy must allay fears Uncertainty and scientific complexity could be a losing formula Judged on extent of preventative measures and degree of preparation (either too little or too much) Response speed and effectiveness critical to success