Transcript Pandemic Influenza ‘State of the Union

Pandemic H1N1 (pH1N1)
‘State of the Union’
Alfred Gin, BScPharm, PharmD
Objectives
• pH1N1 Update
• Guidance documents
 Risk Groups
• Antivirals
 availability
 Pharmacare
 Special groups
• Key Points
Pandemic Influenza 2009
• pH1N1 - official designation
 influenza A
• Timeline 2009
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February – respiratory illness, La Gloria, Mexico
Mid-April – CDC, PAHO notified severe resp. illness
June 11 – WHO Alert 6 – global pandemic
Canada
• 1st wave – April–Aug
• 2nd wave - now
FluWatch October 17, 2009
pH1N1 Origins
Garten et al. Science. May 2009
pH1N1 Symptoms
Almost always
• Sudden onset of
cough and fever
Common
• Fatigue
• Muscle aches
• Sore throat
• Headache
• Decreased
appetite
• Runny nose
Sometimes
• Nausea
• Vomiting
• Diarrhea
pH1N1 Different from Seasonal Flu
• children and young adults
• pregnant women
• severe cases
 rapid respiratory deterioration
• Aboriginal ancestry
H1N1 in Canada
• 1,604 hospitalized cases
 312 (19.5%) cases admitted to ICU
 164 (10.2%) cases required ventilation
 83 deaths
• 90% hospitalized cases and 85% of
deaths in 4 provinces
 QC, ON, MB, AB
FluWatch October 17, 2009
pH1N1 Hospitalization By Age Group
in Canada
400
Rate per 100,000
No. Hospitalized
25
20
300
15
200
10
100
5
0
0
<1
1-4
5-14
15-24
25-44
45-64
>65
Age Groups
adapted from Dr. John Spika, PHAC – Sept. 2, 2009
Severe H1N1 – Preventing Disease, Reducing Mortality Conference
pH1N1 Demographics
Hospitalization
• National rate - 4.6 per 100,000
Age (years)
rate per 100,000
5-14
1-4
<1
7.3
12.5
33.8
Mortality
• National rate – 0.25 per 100,000
 > 45 years – 0.35 per 100,000
FluWatch October 17, 2009
H1N1 in Canada
FluWatch Week 41 – Oct. 17, 2009
Hospitalized
Intensive Care
Deaths
(n=1,604)
(n=312)
(n=83)
51%
56%
61%
2
37
50
Aboriginal
Status
18%
15%
12%
Underlying
Conditions1
62%
72%
77%
Pregnancy2
28%
19%
24%
Females
Median Age
1based
on available info; 2Among women aged between 15 and 44.
H1N1 in Manitoba
New
13
Cases to date
905
Deaths
7
as of Oct. 19, 2009
Guidance for Clinicians
• Public Health Agency of Canada (PHAC)
• Manitoba Health
• Regional Health Authorities
 Winnipeg Regional Health Authority
MB Health Clinical Management*
October 21, 2009
• Interim Guidance
 adults and adolescents
 Pregnancy and post-partum women
• Clinical Decision Algorithm
 adult and adolescents
 pediatric
*new or updated
Manitoba Health
• Mild ILI
 risk conditions for severe ILI should get
prompt assessment and care within 24 hours
(including antivirals) even if they only have
symptoms of mild ILI
• Severe ILI
 symptoms of severe ILI should get immediate
medical and/or hospital care
Severity Indicators
•
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•
•
•
•
Shortness of breath
Chest pain
cyanosis
Bloody or coloured
mucus/spit
Sudden dizziness or
confusion
severe vomiting
High fever >3days
hypotension
• Additional symptoms to
watch for in children:
 Not drinking enough
fluids or eating
 Not waking up or
interacting
 Irritability; not wanting
to play or be held
PHAC H1N1 Preparedness Guide
Groups at Risk of pH1N1 Complications
• Children < 5 years of age
• Elderly ≥ 65 or those frail, mobility problems or live
•
•
•
•
•
alone.
Chronic diseases
Immune disorders or immunosuppression
Child < 19 years old on chronic aspirin therapy
Severe obesity and/or malnutrition
Other conditions that may increase complications
 smoking, substance abuse, alcoholism, homelessness
 delay in care
• Aboriginal ancestry.
• Pregnant women
Manitoba Health
Adults and Adolescents
MB Interim Guidance Highlights*
•
•
•
•
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Infection control
ILI definition and presentation
Testing
Clinical Management
Treatment
 oseltamivir or zanamivir
 renal/other dose adjustments – ‘contact
pharmacist’ added
Recommended Clinical Management*
Abbreviated version
Clinical Presentation
non-ILI - mild URI or other
ILI – No risk factors, normal vital
signs
Recommendations
• no treatment, no test
• assess other causes
• antiviral treatment not generally
recommended but at discretion of
clinician;
• NP test if antiviral started
ILI – risk factors, normal vital signs • early antiviral treatment; NP test
ILI – abnormal vital signs OR
severe ILI*
• urgent attention: diagnosis,
treatment, support, consultation
*refer to complete Interim Guide for Clinicians in Ambulatory Care Settings
MB Health
Clinical Care Algorithm
Pregnant Women
MB Interim Guidance Highlights*
•
•
•
•
•
Infection control
ILI definition
Testing
Clinical Management
Treatment
 oseltamivir preferred; zanamivir OK if N&V
present
 breastfeeding OK
 pregnant women may receive antiviral
prescription in advance – fill if ILI
Influenza Management
• supportive
• infection control
• antivirals*
 neuramindase inhibitors
• oseltamivir, zanamivir
 amantadine
• influenza vaccination
*treatment within 48 hours, earlier the better
Antiviral Availability
• Oseltamivir
 commercial
 pandemic stockpile (NAS)
 emergency preparation suspension
• Zanamivir
 commercial (now available)
 pandemic stockpile (NAS)
• Others - Special Access Programme
Goals of pH1N1 Antiviral Therapy
• early treatment within 48 hours of
onset of symptoms
• treat severe cases even if beyond 48
hours of initial onset
• decrease
 symptoms
 severity
 mortality
Pharmacare Coverage
• Oseltamivir
 Part 2
• Zanamivir
 Part 3
Pharmacare Criteria
• Patient shows ILI and one or more of the
following risk factors:
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Chronic Diseases*
Immunosuppression*
Pregnancy
“Lifestyle” conditions (i.e. smoking, substance abuse,
alcoholism, homelessness);
 Obesity and/or malnutrition;
 Persons of aboriginal ancestry
• Severe Respiratory Illness (SRI)
*abbreviated
Adult Antiviral Dosing
Antiviral
Group
Early Treatment
Prophylaxis
Oseltamivir
Adult and
children >13 yo
75 mg bid oral
x 5 days
75 mg oral daily
x 10 days
Adult and
children >7 yo
10 mg bid
inhaled
x 5 days
10 mg inhaled
x 10 days
Zanamivir
Manitoba Health
Oseltamivir Dosing Considerations
•
•
•
•
renal impairment
hemodialysis
continuous renal replacement therapy
obesity
Antiviral Dosage – Special
Populations
Oseltamivir Dosing Recommendations
Dosing Situation
Renal
Function
Dialysis
Manufacturers
Recommendations
WRHA Suggested
Dosing
75 mg bid
Same
75 mg daily
Same
CrCl < 10 ml/min
No recommendation
75 mg q48h
High Flux
hemodialysis
No recommendation
75 mg post each
dialysis session
CRRT
No recommendation
75 mg q48h
No recommendation
150 mg bid
CrCl > 30 ml/min
CrCl 10 – 30
m/min
Weight ≥ 150 kg
WRHA Pharmacy Program Flu Q&A Update – July 28, 2009
“Over 9,000 prescriptions of antivirals were filled last
week alone, which is a 78 per cent increase from the
previous week” said Dr. Fawziah Marra, pharmacy director
at the BC CDC….We want to remind British Columbians that
if you have received a prescription for Tamiflu from your
physician as part of your ‘flu plan’, then please do not fill the
prescription unless you are experiencing moderate to
severe influenza-like symptoms, or experiencing mild
symptoms but have a high risk condition. Tamiflu is
intended for treatment and not prevention…..help reduce
the risk of this virus becoming drug-resistant.”
Oct. 23, 2009
FluWatch October 17, 2009
Key Points
• antiviral treatment as soon as possible
• understand your patient population
• identify those at risk of complications
 pregnant women, chronic disease, etc….
• be familiar with clinical guidelines
• stay informed and participate