Pandemics: Dealing with the Unexpected "Scientific Theory and Practical Reality"

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A presentation by Australia's Chief Medical Officer, Professor Jim Bishop AO. Options for the control of Influenza VII Conference - Hong Kong 6 Sept 2010

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Pandemics: Dealing with the Unexpected "Scientific Theory and Practical Reality"

  1. 1. PANDEMICS: DEALINGWITH THE UNEXPECTED“Scientific Theory and Practical Reality” OPTIONS FOR THE CONTROL OF INFLUENZA VII CONFERENCE HONG KONG – 6 September 2010 Professor Jim Bishop Chief Medical Officer Department of Health and Ageing Australian Government
  2. 2. World Health Organisation stages of PANDEMIC ALERTWHO declared: phase 4 on 27 April 2009 phase 5 on 29 April 2009 phase 6 on 11 June 2009 post-pandemic 10 August 2010
  3. 3. Starting Point Health Management Plans for Pandemic Influenza Evidence based plans – often rehearsed Frequently based on worse case scenarios Valuable platform or inflexible
  4. 4. Starting Point Outbreak of 2009 Pandemic Influenza A (H1N1) at a New York City School Lessler J et al. N Engl J Med 2009;361:2628-2636Source: Lessler et al N Engl J Med Vol 361 (27): 2628-2636 – Dec 31, 2009
  5. 5. Starting Point
  6. 6. WHAT IS THE REAL CLINICAL PICTURE ?  Like 1918 ?  Like seasonal influenza?  Will it drift/re-assort early ?
  7. 7. Hospitalisations of pandemic (H1N1) 2009, 5 June – 23 October 2009, by week 700Number of hospitalistations associated 600 w ith pandemic (H1N1) 2009 500 Australia 400 300 200 100 0 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 Week of report 8
  8. 8. SUMMARY of SEVERITY INDICATORS OF PANDEMIC (H1N1) IN AUSTRALIA, 2009 & 2010 (up to 30 July 2010) 2009 2010 CONFIRMED HOSPITALISED ICU CASES DEATHS CONFIRMED DEATHS PANDEMIC CASES (H1N1) 2009 (H1N1 2009 CASES CASESTOTAL NUMBER 37,636 13% 14% 191 362 2CRUDE RATE 172.1 22.8 3.1 0.9 1.7 n/aPER100,000POPULATIONM EDIAN AGE 21 31 44 53 28 38(YEARS)FEMALES 51% 51% 53% 44% 48% 100% SourceL: Australian Influenza Surveillance Report
  9. 9. Clinical Picture Pandemic (H1N1) 2009 Hospitalisations - Respiratory, diabetes, immuno-compromised, obesity, chronic cardiac, renal, pregnancy, rapidly deteriorating flu patient  Higher proportion of Indigenous Australians  Over 50% admitted within 48 hours of onset  Higher ICU Admissions than expected
  10. 10. Histogram of Number of Concurrent Patients Receiving ECMO Across Australia and New Zealand in 2009SOURCE: The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators, JAMA 2009;302:1888-1895.
  11. 11. Lung-Tissue Specimen Obtained at Autopsy from a 13-Year-Old Boy after a 7-Day Clinical Course of 2009 H1N1 Virus InfectionSOURCE: Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza. N Engl J Med 2010;362:1708-1719
  12. 12. SUMMARY of SEVERITY INDICATORS OF PANDEMIC (H1N1) IN AUSTRALIA, 2009 & 2010 (up to 30 July 2010) 2009 2010 CONFIRMED HOSPITALISED ICU CASES DEATHS CONFIRMED DEATHS PANDEMIC CASES (H1N1) 2009 (H1N1 2009 CASES CASESVunerable groups n/a 58% 74% 67% n/a n/a(Indigenouspersons, pregnantwomen&individuals withat least 1 co-morbidity)INDIGENOUS 11% 20% 19% 13% 9% n/aPEOPLEPREGNANT n/a 27% 16% 4% n/a 0%WOMENCases with at n/a 46% 67% 62% n/a n/aleast 1 co-morbidity SourceL: Australian Influenza Surveillance Report
  13. 13. Disproportionate impact of pandemic (H1N1) 2009 influenza on Indigenous people in the Top End of Australia’s Northern Territory Shaun M Flint, Joshua S Davis, et al MJA2010; 192 (10): 617-622
  14. 14. What age group ? Age specific rates of hospitalised confirmed cases of pandemic (H1N1) 2009 to 3 October 2009, compared with average annual age specific rates of hospitalisations from seasonal influenza 2004-05 to 2006-07*, Australia 80.0 Males pandemic (H1N1) 2009 e 0 ,0 0 o u tio )A es e ificr te(p r 1 0 0 p p la n 70.0 Females pandemic (H1N1) 2009 60.0 2004-07 seasonal influenza 50.0 40.0 30.0 a 20.0 g pc 10.0 0.0 4 9 4 9 4 9 4 9 4 9 4 4 9 4 9 4 9 + -1 -1 -2 -2 -3 -3 -4 -4 -5 -6 -7 -8 -5 -6 -7 85 0- 5- 10 15 20 25 30 35 40 45 65 50 55 60 70 75 80 Age group (5 Years) 15
  15. 15. What was the real death rate ?Rate of deaths classified as influenza and pneumonia from the NSW Registered Death Certificates 2005 to 25 June 2010
  16. 16. What is the best Public Health Response ? Pandemic Health Management Plan Flu etiquette/home quarantine/social distancing/geographical differences Anti-viral use: treat vs prophylaxis Personal protection equipment for frontline Best communication methods
  17. 17. Source of infection UK 238 cases - 31 May 2009SOURCE: Eurosurveillance June 4 2009
  18. 18. Epidemic Curve locally acquired disease by Onset of illness 361 cases - Japan 9 May – 1 June 2009 4,466 schools closed for 1 weekNishiura et al Transmission potential of the new influenza A (H1N1) eurosruveillance June 4 2009
  19. 19. How should we modify our Plans? H1N1 Influenza 09 Pandemic Phases ALERT (pre 24 April 09) DELAY (24 April 09) H1N1 CONTAIN (22 May 09) Influenza 09, mild in most and severe in some (the PROTECT vulnerable) SUSTAIN 17 June 2009Victoria moved to a MODIFIED Evidence supports focusing SUSTAIN on 3 June 2009 efforts on protecting the ‘vulnerable’ CONTROL RECOVER
  20. 20. What Flexibility is needed PLAN MODIFICATION Indigenous Annex Cruise Ship Protocol GP Roundtable Expert Groups - Respiratory Physicians - Intensive Care Physicians - ED Physicians Actions outside health
  21. 21. Vaccine Reality PANDEMIC VACCINE Vaccine available 5 months from start Trial data available mid September 2009 Sufficient qualities end September 2009 One dose for adults
  22. 22. Who is protected following wave 1 ? Serology suggest around 20% immune Geographical differences Age sensitive
  23. 23. What do we expect with wave 2Modelling of the Impact of Vaccination (ATAGI) Expected Pandemic Influenza A (H1N11) 2009 without vaccination (Second wave) Influenza with vaccination of High risk groups alone Other scenarios of low to High vaccine uptake in the population
  24. 24. Barriers to Vaccination Impression pandemic peak has passed Poor self-recognition of vulnerable status Pandemic not severe Vaccine safety concerns - Thiomersal - GBS - Use of multi-dose vials 26 SOURCE: Steel Fisher et al. N Engl.J Med 2010: 362
  25. 25. H1N1 vaccination campaign (3)Brochure and poster
  26. 26. What happened with Wave 2 ? Weekly rate of ILI reported from GP ILI surveillance systems from 60 1 January 2007 to 22 August 2010 ASPREN 2007 ASPREN 2008Rate of ILI per 1,000 consultations 50 ASPREN + NT + VIDRL 2009 ASPREN + VIDRL 2010 40 First case of Pandemic (H1N1) 2009 30 reported in Australia 20 10 0 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
  27. 27. What happened with wave 2 ?Percentage of specimens tested by sentinel laboratories influenza positive 1 January 2010 to 30 July 2010, by subtype Seasonal A/H1N1 0% Seasonal A/H3N2 24% Pandemic (H1N1) 2009 67% Influenza A untyped 4% Influenza B 5%
  28. 28. POST MORTEM Pre-pandemic consensus of experts on the evidence and the plan Early complete characterization of clinical picture On-going modification of plans as needed Clear direction on PPE/Antivirals/HCW/Vaccine Improved methods for vaccine timelines

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