Symposium on Infectious Diseases: Pandemic H1N1

1. Symposium on Infectious Diseases: Pandemic H1N1 Dr. Liana Nolan Commissioner/Medical Officer of Health Region of Waterloo Waterloo Inn, November 4, 2009

2. Agenda pH1N1: Overview Current Trends Projections of upcoming activity Waterloo Region Pandemic Plan pH1N1 Vaccine Antiviral Recommendations Questions

3. Management is an AdventureManagement is an Adventure

4. H1N1 Overview The H1N1 flu virus is another strain of the influenza virus. It causes symptoms similar to those of the seasonal flu (fever and cough and one or more of the following: sore throat, muscle aches, joint pain, or weakness). It spreads in the same manner as seasonal influenza does. The methods to prevent and control it are the same as those for seasonal influenza.

5. H1N1 Overview What is different about H1N1, as compared to seasonal influenza: It predominantly affects younger populations: Children, adolescents, young adults. Hospitalization rate: 3.0 hospital admissions per 100,000 Ontarians Australia this past summer: 22.7 hospital admissions per 100,000 population Fatality rate: 1.9 deaths per 1 million Ontarians Ontario average for seasonal flu: 33 deaths per 1 million Ontarians

6. H1N1 � Age Distribution (Graph)

7. H1N1 Overview Groups at higher risk for complications: Age <5 Age =65 Pregnant women Those with chronic medical conditions (heart or lung disease, diabetes, cancer, immuno-suppression, morbid obesity, etc.) Individuals living in remote/isolated communities

8. Current Trends H1N1 activity has been increasing locally and across the province/ country in the last few weeks, especially in the last couple of weeks. Local status (Waterloo Region): Over 100 influenza cases since Sept. 1, 2009; at varying stages of confirmation of strain. Expecting vast majority, if not all, to be pH1N1. Number of confirmed cases who have died: 0 Reported cases will always be an under-estimate.

9. Current Trends Locally: ? Consultation rates for ILI in doctor�s offices 70-80 per 1,000 patient visits; mirrors provincial average. ? School absenteeism 25-30% of schools reporting absenteeism ?10%; Elementary schools ? Secondary schools ?? Emergency Room visits for ILI Most often mild-moderate

10. Southern Hemisphere Comparators Australia: Fully susceptible population, no vaccine Similar publicly funded health care system Racially diverse Aboriginal population Major urban centres along with large rural areas and very remote isolated communities

11. Australia Specific Data Overall hospitalization rate 22.7 per 100,000 Highest rates of hospitalization in children Pregnant women and aboriginal people disproportionately represented in hospital admissions pH1N1 was the predominant circulating strain of influenza

12. Queensland specific data Most detailed data comes from Queensland This data closely resembles Ontario data to date Rate of hospitalization 28.7 per 100,000 53% of cases admitted were within 48 hours of symptom onset 20.6% of hospital admissions required an ICU or special care bed Medium length of stay 9 days 38% of ICU admits had no underlying comorbidities

13. Potential Impact for RoW Estimates of Hospital Admissions: Includes all three sites Estimated rate 28.7 per 100,000 Translates into 142.5 hospital admissions over the course of the second wave to all three sites

14. Potential Impact for RoW Paediatric Bed Requirements: Total of 13.5 paediatric admissions for those less than 5 years of age Also increased demand for 5 to 16 year age group

15. Potential Impact for RoW Emergency Department Visits: 13.8% of RoW adults have difficulty accessing clinical services (2005 Public Health data) 51,084 people rely on urgent care or ED care 18 to 24 age group has greatest difficulty (21%) High rate of attack of pH1N1 Generally less likely to seek consultation Extrapolation from Australia data hospital admits require 712-1425 ED visits over 3 hospitals over entire second wave

16. Potential Impact for RoW ICU and Ventilator Requirements: 20.6% of hospital admissions require ICU bed Translates into 29.3 ICU admissions over 3 hospitals for entire second wave 73% require a ventilator (21.4 vents) 7% may require ECMO if available Median length of stay 9 days

17. Projections for ILI visits � Primary Care Based on Australian experience: This wave of influenza activity will last about 8 to 12 weeks. The peak of influenza activity for Ontario is anticipated to be mid November. Over 50% of patients who ended up admitted to hospital because of serious illness did so within the first 48 hours of symptom onset. Urgent bookings for ILI: focus on patients at higher risk for complications for whom antivirals are indicated within 48 hours of illness onset.

18. Waterloo Region Pandemic Plan

19. Waterloo Region Pandemic Plan Waterloo Region's Community Pandemic Influenza Preparedness Plan (CPIPP) Available at www.waterlooregionpandemic.ca (approximately 400 pages) Developed by over 200 individuals from over 50 organizations. This includes representatives from the hospitals, municipalities, emergency response agencies (police, fire, ambulance) and social service agencies.

20. Waterloo Region Pandemic Plan It is unlikely Waterloo Region's Community Pandemic Influenza Preparedness Plan (CPIPP), which includes provisions for a severe pandemic, will be implemented in full given the overall mild to moderate severity of the H1N1 virus to date. Some examples of differences between the full plan and the current response plan: Some public health measures may not be implemented. For example, schools and child care facilities are recommended to remain open and there is no recommendation to cancel mass gatherings. Antivirals are recommended only for people who are seriously ill (i.e. hospitalized) or at higher risk of complications (e.g. pregnant women, individuals with underlying chronic conditions). Antivirals are being distributed through the existing infrastructure (pharmacies).

21. Public Health's Role Collecting and reporting on local surveillance data Adapting its seasonal and H1N1 immunization campaigns based on evolving provincial direction Providing information to the public and health care partners Providing ongoing consultation and support to community partners Coordinating planning for the health care sector, re strategies for influenza assessment and treatment.

22. Vaccines (H1N1 & Seasonal)