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INSIDE THIS ISSUE Pandemic Influenza Update Allison Mcgeer 4 February 2006 1 TIBDN T O R O N T O I N V A S I V E B A C T E R I A L D I S E A S E S N ETWORK Volume 4, Issue 1 T ORONTO Use of antiviral medication and stockpiling Issues Karen Green RN, MSc I NVASIVE B ACTERIAL ISEASES Vaccines are always the best protection strategy’s effectiveness depends on (ii) Individual stockpiling may result in D N ETWORK from influenza, but it is unlikely that a the ability to quickly identify cases inappropriate use of the medications. TIBDN vaccine against the new pandemic strain and their contacts, since the generation of influenza will be available during the time of influenza (average time from So we are faced with the dilemma. It Pandemic influenza update Allison McGeer, MD early stages of a pandemic. During this onset of symptoms in one case to onset is clear that individuals are better off period, the use of antiviral medication in the second case) is only 2 days. with a stockpile, but it is also clear In January, 2006, the first A/H5N1 influenza cases outside of Southeast Asia were must be carefully evaluated. For the foreseeable future, there are that society is better off if the supply is reported from Turkey. The bad news is that this virus has rapidly become widespread in insufficient supplies of neuraminidase centralized. In addition, there is a lack wild waterfowl and chickens throughout Turkey. There may be as many as 30 human Antiviral medications effective against inhibitors to attempt this strategy. of consensus about what an optimal cases, still with a high mortality rate. The hemagglutinin protein of the viruses isolated current influenza strains are effective stockpile size is, with some physicians from Turkey has changes that make it closer to a human virus than ever before. The against pandemic strains in vitro, Treatment believing that currently planned good news is that there has been no human to human transmission identified in Turkey, and will likely provide substantial There is good evidence that early Canadian government stockpile sizes and that control measures being implemented there seem to have been effective in protection. Resistance is a potential treatment with oseltamivir is (enough to treat 10% of the population) slowing the number of new human cases. issue, but is unlikely to be a significant effective in reducing the duration are too small. problem for the next few years. There and severity of influenza, and the risk Our knowledge about influenza viruses and influenza infection is growing rapidly. are drawbacks to the use of antiviral of serious complications, including Thus, physicians have found Nonetheless, it remains impossible to predict whether H5N1 will be the cause of the medication. Antivirals only provide hospitalization. It seems likely that themselves bombarded with requests next pandemic. We do know that the time to the next pandemic gets shorter every day, protection while a person is taking treatment of pandemic influenza will for oseltamivir prescriptions. In and our chronic shortages in health care combined with our “just-in-time” delivery them. Thus, if antivirals run out before also be effective. Early treatment is the absence of clear directives or system will mean that even a mild pandemic will severely stress the system. � a vaccine is available, everyone is at more effective than later treatment, so recommendations on how to respond risk, and the pandemic impact may attempts will be made to start everyone to these requests, physicians find Both Health Canada and the Ontario Ministry of Health will be releasing new versions only be delayed. Long term use might with compatible illness on therapy themselves in a struggle between their of their pandemic plans later this spring. Many local health units have first versions of also have side effects that we have within the first 48 hours after symptom responsibility to their patients and their their plans, and most hospitals are also working on plans. It is also time for physician not yet identified. There are several onset. There is no doubt that this will be responsibility to the public good. In offices, pharmacies, and clinics to start preparing. While the Ontario Ministry of ways that antivirals may be used in a difficult, since so many people will be the fall of 2005, Roche decided to stop Health is building stockpiles of personal protective equipment, they are expecting that pandemic. ill simultaneously. Additional problems sales to private pharmacies in North INSIDE THIS ISSUE individual offices and hospitals will also contribute to their own protection. A list of with this strategy are that treatment for America. In late January, this ban was supplies that offices and clinics should consider stockpiling is shown in the box: each Continuous prophylaxis influenza is much less effective than lifted in the United States, but not in office should have enough to manage for 4-6 weeks. Clinics should also consider how Use of antiviral medication by prophylaxis, and many treated people Canada. PAGE they will separate influenza patients from non-influenza patients (it may be a good idea uninfected individuals for the duration will likely get complications. At the to consider “shared” clinics or triage sites in cooperation with local hospitals and public health, where physicians and other staff contribute hours), and how to start providing of influenza activity (probably 50-100 moment, government stockpiles are The best each of us can do is to offer 1 Pandemic influenza update � days) is an effective option, but one that targeted to treatment of 10% of the ‘credible’ explanations to patients patient teaching about preventive practices and home management of influenza. requires large stockpiles. This option is population at currently recommended seeking drugs for personal stockpiles. 2 What’s new in seasonal influenza? not feasible for the general population, doses. It is estimated that about 35% Patients are rational in wanting their Pandemic Influenza Planning because such supplies cannot be of people will develop influenza, and own stockpile and society is rational in 2 Laboratory confirmed Suggested supply list obtained; it is also not cost-effective likely that higher doses and longer not wanting them to have it. As long influenza illness requiring for offices and clinics Canadian Pandemic Influenza Plan: hospital admission: Clinical http://www.phac-aspc.gc.ca/cpip-pclcpi in most pandemic scenarios. Long- duration of therapy will be needed for as oseltamivir remains in short supply, features, treatment, and Alcohol handwash term prophylaxis may be beneficial pandemic influenza. Our stockpiles there is only one really legitimate outcomes Fluid resistant masks Ontario Health Plan for an Influenza Pandemic: Eye protection http://www.health.gov.on.ca/english/providers/ in groups in whom minimizing for therapy are still inadequate if the argument against personal antiviral 4 Use of antiviral medication (eg. 2 pairs safety glasses program/emu/pan_flu/pan_flu_plan.html absenteeism during a pandemic is pandemic is moderate or severe. stockpiles. That is, that society as a and stockpiling issues per person) critical, eg. healthcare professionals. whole will be better off if the entire Gloves Toronto Pandemic Influenza Plan: Surface cleaning supplies http://www.toronto.ca/health/pandemicflu Individual Stockpiling versus supply is centrally controlled for Re-useable thermometer Postexposure prophylaxis Government Stockpiling optimal use. In order to support this Public Safety Canada: Close contacts of an individual with Public health stockpiling of anti-viral argument, however, each of us needs http://www.safecanada.ca/pandemic influenza could be treated with antiviral drugs for an influenza pandemic is to be educated about the potential medication after exposure but before viewed as an appropriate and cost- uses of oseltamivir, to make a decision This newsletter has been generously the onset of symptoms. This strategy, effective strategy. The disadvantages about what the size of our stockpiles sponsored by an unrestricted Editor: Mount Sinai Hospital, Room 1460 educational grant from: Karen Green, RN, MSc Toronto, ON, M5G 1X5 if used in conjunction with immediate of individual stockpiling are: should be for Canada, and to lobby our Toronto Invasive Bacterial Diseases Network 416-586-3124 isolation of the ill person, might reduce (i) When shortages exist, centralized professional organizations, local public transmission once a case has been decision making gives us the best health units, and governments to ensure This newsletter is a publication of the Toronto Invasive Bacterial Diseases Network (TIBDN), a collaboration of the microbiology laboratories, infection control practitioners, and public health officials who serve the population identified, and permit close contacts chance of allocating drug in a way that that these stockpiles exist. of Metropolitan Toronto, Peel, York, Durham, Simcoe, Hamilton, and Halton Regions. For an electronic copy of to care for that person at home. This minimizes mortality and morbidity; this newsletter please visit our website at: microbiology.mtsinai.on.ca/tibdn 2 3 TIBDN T O R O N T O I N V A S I V E B A C T E R I A L D I S E A S E S N ETWORK http://microbiology.mtsinai.on.ca/tibdn What’ s new in seasonal influenza? Allison McGeer, MD A case of influenza requiring hospital in hospitals and nursing homes, but community-acquired illness had a test is positive. admission is defined as a patient because diagnostic testing is done more physician visit before their admission. Although much of our attention is years vaccine will not be very effective whose illness requires hospitalization, commonly in these circumstances. Twenty-four percent of patients were Physicians should also think about focused on when the next influenza against. Those people who have had a and who has a positive antigen test started on an antibiotic, while less than replacing empiric antibiotics with pandemic will emerge, annual vaccine in previous years will likely or a culture yielding influenza A.
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