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2010 TSANZ Annual Scientific Meeting

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A presentation by Australia's Chief Medical Officer, Professor Jim Bishop AO, to the TSANZ Annual Scientific Meeting - 24 June 2010

A presentation by Australia's Chief Medical Officer, Professor Jim Bishop AO, to the TSANZ Annual Scientific Meeting - 24 June 2010

Published in: Health & Medicine

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  • 1. 2010 TSANZ ANNUAL SCIENTIFIC MEETING pH1N1 Influenza in Transplantation Professor Jim Bishop AO Chief Medical Officer Australian Government Department of Health and Ageing Thursday 24 June 2010 PANDEMIC (H1N1) 2009
  • 2. Overview  Epidemiology of Pandemic H1N1 09 Influenza  Severity indices  Influenza in Transplantation  Current Global Situation
  • 3. The Australian Health Management Plan for Pandemic Influenza (AHMPPI) • The AHMPPI (2008): third edition of the national health management plan • Exercise Cumpston 06 recommended – AHMPPI revision: policy gaps – Streamlined decision making – More flexible policy PANDEMIC POLICIES and PLANNING
  • 4. Pandemic H1N1 2009 Timeline WHO announces novel human influenza24 Apr WHO moves to Pandemic phase 427 Apr Australia moves to Pandemic DELAY28 Apr WHO moves to Pandemic phase 529 Apr Australia moves to Pandemic CONTAIN22 May Victoria moves to MODIFIED SUSTAIN3 Jun WHO moves to Pandemic phase 611 Jun Australia moves to Pandemic PROTECT17 Jun
  • 5. H1N1 Influenza 09 Pandemic Phases ALERT (pre 24 April 09) DELAY (24 April 09) CONTAIN (22 May 09) SUSTAIN Victoria moved to a MODIFIED SUSTAIN on 3 June 2009 CONTROL RECOVER PROTECT 17 June 2009 Evidence supports focusing efforts on protecting the ‘vulnerable’ Australia's response is continual informed by the emerging evidence around the virus and effectiveness of control measures H1N1 Influenza 09, mild in most and severe in some (the vulnerable)
  • 6. KEY ELEMENTS OF THE PROTECT PHASE  Identifying the vulnerable  Early treatment of those identified as vulnerable  Voluntary home isolation for those who are sick  Controlling outbreaks in special settings  Limited school action, limiting ILI  A re-focus of testing to the vulnerable, severe  Public Communications Plan
  • 7. Laboratory confirmed cases of pandemic (H1N1) 2009 and total influenza in Australia
  • 8. OVERALL STATISTICS Australia 2009  37,000 laboratory confirmed cases, underestimate  4,500 hospitalisations  13% of laboratory confirmed cases, higher in ATSI  700 ICU admissions  336 cases of viral pneumonia (around 57 per year usually)  13% of hospitalisations were admitted to ICU  1/3 had no known risk factor  61 patients treated using ECMO, 2/3 survived  191 deaths  Median age 53 years (83 years usually)  1/3 of deaths occurred in people with no known risk  Deaths reduced by: - Older Australians spared - Use of ECMO
  • 9. Summary of severity indicators AUSTRALIAN INFLUENZA SURVEILLANCE REPORT. No. 22, 2010, 29 May 2010 – 4 June 2010
  • 10. Rate of deaths classified as influenza and pneumonia (NSW)
  • 11. SEVERITY INDICES p H1N1 2009  Hospitalisations - Chronic underlying medical condition - Higher proportion of Indigenous Australians (20%) - Over 50% admitted within 48 hours of onset  Higher rate of ICU admissions than expected  The clinical syndrome in intensive care was diffuse viral pneumonitis associated with severe hypoxemia
  • 12. Clinical Presentation Chest Radiograph and Computed Tomogram of 2 Patients Successfully Treated With ECMO for Confirmed 2009 Influenza A(H1N1) Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. JAMA. 2009;302(17):1888-1895
  • 13. Pathological Features  Consistent histopathological findings - diffuse alveolar damage - hyaline membranes - septal oedema - necrotizing bronchiolitis.  The 2009 H1N1 virus targets alveolar lining cells (type I and II pneumocytes) as well as upper airway lining cells Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza, Clinical Aspects of Pandemic 2009 Influenza A (H1N1) Virus Infection N Engl J Med 2010 362: 1708-1719
  • 14. KEY FINDINGS FROM ANZICS  Infants and younger adults 25-64 predominated  Risk of death increased with age  Underlying risk factors were pregnancy, chronic lung disease, Indigenous or obese  1/3 had no pre-existing risk factors Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand. The ANZIC Influenza Investigators N Engl J Med 2009;361:1925-34.
  • 15. ANZICS Data Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand. The ANZIC Influenza Investigators N Engl J Med 2009;361:1925-34.
  • 16. ECMO Study
  • 17. Influenza in Transplant Recipients  Infection in transplant recipients - Harder to recognize as signs and symptoms may be diminished - Fever may result from allograft rejection [1].  Influenza - is a common infection in solid organ transplant recipients - is associated with higher morbidity (viral pneumonia, secondary bacterial pneumonia) and mortality than in immunocompetent hosts [2]. 1. Jay Fishman New England Med 357, 25 Dec 2007 2. Ison, MG, Hayden, FG. Viral infections in immunocompromised patients: what's new with respiratory viruses?. Curr Opin Infect Dis 2002; 15:355.
  • 18. Influenza in Lung Transplant Patients  Influenza causes significant morbidity and mortality, including obliterative bronchiolitis  Neuraminidase inhibitors shorten the duration of symptoms, virus shedding and fewer antibiotic complications  In lung transplant recipients - Oseltamivir is well tolerated - Infection resolved in all patients and there were no deaths - None of the patients had persistent abnormalities noted on chest imaging and most did not show significant changes on pulmonary function testing Ison, M. G., A. Sharma, et al. (2008). "Outcome of Influenza Infection Managed With Oseltamivir in Lung Transplant Recipients." The Journal of Heart and Lung Transplantation 27(3): 282-288.
  • 19. REVIEW of pH1N1 in TRANSPLANTATION  115 Adult and paediatric solid organ transplants  76 adults (median age, 49 years) 39 children (median age, 8 years)  38 kidney, 23 liver, 22 heart, 18 lung, and 14 other  median time since transplant was 3.8 years ( 2 - 21.9 years) American Transplant Congress (ATC) 2010: Abstract 5. Presented May 2, 2010 From http://www.medscape.com/viewarticle/721412
  • 20. REVIEW of pH1N1 in TRANSPLANTATION OUTCOMES:  91% received anti-viral therapy  65.2% of patients were hospitalized  61.1% of patients were lymphopenic  25.2% experienced pneumonia  13.0% were admitted into the intensive care unit (ICU)  One death American Transplant Congress (ATC) 2010: Abstract 5. Presented May 2, 2010 From http://www.medscape.com/viewarticle/721412
  • 21. A mulitvariate analysis with hospitalization more likely with: - fever (P < .001), - recent antilymphocyte globulin therapy (P = .04) - or delayed antiviral therapy (P = .03) Antiviral treatment within 48 hours of symptom onset - Less likely to be admitted to the ICU — 0 of 36 compared with 15 of 67 patients (22.4%) who received late antiviral treatment (P = .005) American Transplant Congress (ATC) 2010: Abstract 5. Presented May 2, 2010 From http://www.medscape.com/viewarticle/721412 REVIEW OF pH1N1 in TRANSPLANTATION
  • 22. World Transplant Games  Held in Queensland -20 – 30 August 2009  2000 transplant recipients from 50 countries  At a single campus  No reported cases  No hospitalisations  No fatalities
  • 23. GUIDANCE FOR TRANSPLANT RECIPIENTS Endorsed by the American Society of Transplantation (ABT), The Transplantation Society (TSS) and the Canadian Society of Transplantation (CST):  Diagnosis  Treatment  Chronoprophylaxis  Recommendations for patients and family  Recommendations for health care workers Kumar D et al American Journal of Transplantation 2010; 10: 18-25
  • 24. 0 10 20 30 40 50 60 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 Week RateofILIper1,000consultations ASPREN 2007 ASPREN 2008 ASPREN + NT + VIDRL 2009 ASPREN + VIDRL 2010 First case of Pandemic (H1N1) 2009 reported in Australia Weekly rate of ILI GP surveillance systems - 1 January 2007 to 6 June 2010
  • 25. Currently  Australia has low pH1N1 activity with no increase in Influenza A levels  Following first wave natural immunity 15-25% of the population  Vaccination induced immunity is high: - 9 Million pandemic vaccine does (41%) - 5 Million + seasonal vaccine doses (23%)
  • 26. WHO Update May 30 2010 Northern Hemisphere – Overall pandemic influenza activity remains low – Active but declining p H1N1 in the Caribbean and Southeast Asia – Seasonal influenza type B viruses in China Southern Hemisphere – Pandemic and seasonal influenza activity is low – ILI remains low in Australia and New Zealand – Limited pandemic influenza virus in Chile. – Low levels of H3N2 viruses in Kenya and Tanzania. WHO Summary as at 30 May 2010