PANDEMICS: DEALING WITH THE UNEXPECTED

“Scientific Theory and Practical Reality”

OPTIONS FOR THE CONTROL OF INFLUENZA VII CONFERENCE

HONG KONG –

6 September 2010

Professor Jim BishopChief Medical Officer

Department of Health and AgeingAustralian Government

World Health Organisation stages of PANDEMIC ALERT

WHO declared: phase 4 on 27 April 2009phase 5 on 29 April 2009phase 6 on 11 June 2009post-pandemic 10 August 2010

Health Management Plans for Pandemic Influenza

Evidence based plans –

often rehearsed

Frequently based on worse case scenarios

Valuable platform or inflexible

Starting Point

Lessler J et al. N Engl J Med 2009;361:2628-2636

Source: Lessler et al N Engl J Med Vol 361 (27): 2628-2636 –

Dec 31, 2009

Starting Point

Outbreak of 2009 Pandemic Influenza A (H1N1) at a New York City School

Starting Point

WHAT IS THE REAL CLINICAL PICTURE ?

Like 1918 ?

Like seasonal influenza?

Will it drift/re-assort early ?

Hospitalisations of pandemic (H1N1) 2009, 5 June –

23 October 2009, by week

8

0

100

200

300

400

500

600

700

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

Num

ber o

f hos

pita

lista

tions

ass

ocia

ted

with

pan

dem

ic (H

1N1)

200

9

Australia

2009 2010

CONFIRMEDPANDEMIC(H1N1 2009

CASES

HOSPITALISEDCASES

ICU CASES DEATHS CONFIRMED(H1N1) 2009

CASES

DEATHS

TOTAL NUMBER 37,636 13% 14% 191 362 2

CRUDE RATE PER100,000 POPULATION

172.1 22.8 3.1 0.9 1.7 n/a

M EDIAN AGE (YEARS)

21 31 44 53 28 38

FEMALES 51% 51% 53% 44% 48% 100%

SUMMARY of SEVERITY INDICATORS OF PANDEMIC (H1N1) IN AUSTRALIA,

2009 & 2010 (up to 30 July 2010)

SourceL: Australian Influenza Surveillance Report

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

Clinical Picture Pandemic (H1N1) 2009

SOURCE: The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators, JAMA 2009;302:1888-1895.

Histogram of Number of Concurrent Patients Receiving ECMO

Across Australia and New Zealand in 2009

Lung-Tissue Specimen Obtained at Autopsy from a 13-Year-Old Boy after a 7-Day Clinical

Course of 2009 H1N1 Virus Infection

SOURCE: Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza. N Engl J Med 2010;362:1708-1719

2009 2010CONFIRMEDPANDEMIC(H1N1 2009

CASES

HOSPITALISEDCASES

ICU CASES DEATHS CONFIRMED(H1N1) 2009

CASES

DEATHS

Vunerable

groups (Indigenous persons, pregnant women& individuals with at least 1 co-

morbidity)

n/a 58% 74% 67% n/a n/a

INDIGENOUSPEOPLE

11% 20% 19% 13% 9% n/a

PREGNANT WOMEN

n/a 27% 16% 4% n/a 0%

Cases with at least 1 co-

morbidity

n/a 46% 67% 62% n/a n/a

SUMMARY of SEVERITY INDICATORS OF PANDEMIC (H1N1) IN AUSTRALIA,

2009 & 2010 (up to 30 July 2010)

SourceL: Australian Influenza Surveillance Report

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 MJA 2010; 192 (10): 617-622

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

15

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

0-4

5-9

10-1

415

-19

20-2

425

-29

30-3

435

-39

40-4

445

-49

50-5

455

-59

60-6

465

-69

70-7

475

-79

80-8

4

85+

Age group (5 Years)

Age

spe

cific

rate

(per

100

,000

pop

ulat

ion) Males pandemic (H1N1) 2009

Females pandemic (H1N1) 2009

2004-07 seasonal influenza

What age group ?

Rate of deaths classified as influenza and pneumonia from the NSW Registered Death Certificates 2005 to 25 June 2010

What was the real death rate ?

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

Source of infection UK 238 cases -

31 May 2009

SOURCE: Eurosurveillance

June 4 2009

Epidemic Curve locally acquired disease by Onset of illness 361 cases -

Japan 9 May –

1 June 2009

4,466 schools closed for 1 week

Nishiura et al Transmission potential of the new influenza A (H1N1) eurosruveillance

June 4 2009

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’

H1N1 Influenza 09, mild in most and severe in

some (the vulnerable)

How should we modify our Plans?

Indigenous Annex

Cruise Ship Protocol

GP Roundtable

Expert Groups -

Respiratory Physicians

-

Intensive Care Physicians-

ED Physicians

Actions outside health

PLAN MODIFICATION

What Flexibility is needed

Vaccine available 5 months from start

Trial data available mid September 2009

Sufficient qualities end September 2009

One dose for adults

PANDEMIC VACCINE

Vaccine Reality

Serology suggest around 20% immune

Geographical differences

Age sensitive

Who is protected following wave 1 ?

Modelling of the Impact of Vaccination (ATAGI)

Expected Pandemic Influenza A(H1N11) 2009 without vaccination

(Second wave)

Influenza with vaccination ofHigh risk groups alone

Other scenarios of low toHigh vaccine uptake in the

population

What do we expect with wave 2

26

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

SOURCE: Steel Fisher et al. N Engl.J

Med 2010: 362

H1N1 vaccination campaign (3)

Brochure and poster

Weekly rate of ILI reported from GP ILI surveillance systems from 1 January 2007 to 22 August 2010

What happened with Wave 2 ?

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 53Week

Rat

e of

ILI p

er 1

,000

con

sulta

tions

ASPREN 2007ASPREN 2008ASPREN + NT + VIDRL 2009ASPREN + VIDRL 2010

First case of Pandemic

(H1N1) 2009 reported in Australia

Percentage of specimens tested by sentinel laboratories influenza positive

1 January 2010 to 30 July 2010, by subtype

Pandemic (H1N1) 200967%

Seasonal A/H1N10%

Seasonal A/H3N224%

Influenza A untyped4%

Influenza B5%

What happened with wave 2 ?

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

POST MORTEM