Canadian Pandemic Influenza Plan: Overview and Update

1
Canadian Pandemic Influenza Plan Overview and
Update
Dr. Theresa Tam, Associate Director Immunization
and Respiratory Infections Division
NVAC Pandemic Influenza Working Group, Washington
DC, 19-20 April, 2005
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Outline

• National planning process
• The Canadian Pandemic Influenza Plan
• Underlying assumptions
• components
• Current activities and next steps
• Provincial/Territorial and local planning

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Pandemic Planning in Canada

• 1988 First draft plan (planning began in 1983)
• 1996 Second draft plan
• 1997 Lessons from Hong Kong bird flu incident
• 1998-2000 Federal-provincial-territorial
  (F/P/T) planning process began
• Two national planning meetings and working groups
  established
• 2001 Political commitment - F/P/T Working
  Agreement accepted by all provinces and
  territories

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Pandemic Planning in Canada - II

• 2001 Multi-year pandemic and annual vaccine
  contracts signed
• 2002 Pandemic Influenza Committee (PIC)
  established
• 2002 Input on the Canadian Pandemic Influenza
  Plan elicited from multiple stakeholder groups
  and experts
• 07/2003-01/2004 Lessons from SARS incorporated
• 2003 Dec 12 Plan approved by Deputy Ministers
  of Health

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Public Release of the Plan February 2004

• http//www.phac-aspc.gc.ca/cpip-pclcpi/index.html

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Pandemic Influenza Committee (PIC)

• 2 Co-Chairs Federal and Provincial
• 18 voting members including all provinces and
  territories, technical experts and an ethicist
• Provides technical advice for pandemic influenza
  prevention and control
• Provides overall guidance on the Canadian
  Pandemic Influenza Plan
• Multiple working groups

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Overall Goal of Pandemic Preparedness and Response

• First, to minimize serious illness and
  overall deaths, and second to minimize societal
  disruption among Canadians as a result of an
  influenza pandemic.

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Canadian Pandemic Influenza Plan

• Based on nationally agreed upon goal
• Organized into components
• Uses WHO Pandemic Phases
• National plan, outlines roles and
  responsibilities of all levels of government
• Model for national health emergency response
  plans
• preparedness, response and recovery sections
• Contains checklists and technical annexes
• Dynamic or evergreen document

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Planning Components

• Surveillance and Laboratory Testing
• Public Health Measures (border measures)
• Vaccine Programs
• Antivirals
• Health Services Emergency Planning
• Infection control, Clinical Care (self care),
  Resource Management, Mass Fatalities,
  Non-Traditional Sites and Workers
• Emergency Services
• Communications

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Underlying Assumptions

• Another influenza pandemic is INEVITABLE yet
  timing and epidemiology UNPREDICTABLE
• SHORT LEAD TIME
• presence in Canada lt 3 months (much shorter?)
• 1st peak in illness within 5-7 months
• Outbreaks will occur SIMULTANEOUSLY in multiple
  locations, in multiple waves
• Limited resources will need to be PRIORITIZED

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Estimated Impact of Pandemic Influenza in Canada
Health Resource Scarcity

• If vaccine is unavailable, EXPECT
• 11,000 to 58,000 deaths
• 34,000 to 138,000 hospitalizations
• 2 to 5 million outpatients
• economic costs
• health care 330 million to 1.4 billion
• societal 5 to 38 billion

Societal Disruption
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Key Strategies for Reducing Spread and Impact

• Public health measures and infection control
• Respiratory etiquette and self care
• Vaccination is the primary means for preventing
  disease, reducing morbidity and mortality during
  a pandemic BUT unlikely to be available at start
• Antivirals are the only virus-specific
  intervention prior to vaccine becoming available
• Maintain public awareness and facilitate
  acceptance of response strategy
• Maintaining health, emergency and social services

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Key Considerations in Prioritizing Resources

• Effectiveness in reducing impact on health
  outcomes and societal function
• Efficiency optimizing use of a limited resource
• Feasibility of implementation
• Acceptability is the approach ethical (accepted
  by the public)

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What has been done to increase our preparedness?
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Pandemic Preparedness Strategy Building on
Annual Influenza Prevention and Control
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What has been done to increase our preparedness?
(1)

• Emergency Planning
• Canadian Pandemic Influenza Plan
• Developed Respiratory Illness Outbreak Response
  Protocol (RIORP)
• Surveillance
• FluWatch weekly surveillance real time
  paediatric hospitalization reporting through the
  IMPACT network
• Intelligence gathering Global Public Health
  Intelligence Network (GPHIN)
• Rapid dissemination of information e-mail and
  web-based alerts (CIOSC)
• Communications
• Established F/P/T Communication Network to
  coordinate messages across the country

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What has been done to increase our preparedness?
(2)

• Pandemic Influenza Vaccine Strategy
• Objective provide vaccine to all Canadians
• Established 10 yr contract (2001-2011) with ID
  Biomedical
• Production of at least 50 of annual requirement
• Pandemic readiness (production capacity raw
  materials)
• Manufacturing capacity (8 million monovalent 15
  µg HA doses / month) to be attained within 60
  months
• Manufacturers contingency plan to include the
  availability of raw materials and supplies
  (fertilized hen eggs)
• National coordinated approach to program
  priority groups

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Use of Vaccines in Short SupplyUnder review

• Health care providers
• Essential service providers / government leaders
• Persons at high risk of severe or fatal outcomes
• a) persons in nursing homes and long-term care
  facilities
• b) persons with high-risk medical conditions
• c) persons gt65 years
• d) children 6 to 23 months of age
• e) pregnant women
• Healthy adults
• Children 24 months to 18 years old

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What has been done to increase our preparedness?
(3)

• Antiviral Stockpiling 16 million doses
• Antivirals options and priority groups developed
  by PIC
• Federal contribution of 9.6 million oseltamivir
  doses (24M) toward a national stockpile - 2005
• P/Ts are considering, at minimum, purchasing the
  remaining 6.4 million doses (40 of 16 M) that
  would represent their respective per capita
  allocation from the National Stockpile

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Priority Groups for Antivirals

• Treatment of persons hospitalized for influenza
• Treatment of ill HCW and ESW
• Prophylaxis of front line HCW and key health
  decision makers
• Treatment of high-risk in the community
• Prophylaxis of remaining HCW
• Control outbreaks in high-risk residents of
  institutions
• Prophylaxis of ESW
• Prophylaxis of high-risk persons hospitalized for
  illnesses other than influenza
• Prophylaxis of high-risk in the community

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Cumulative Doses by Priority Groups
Doses (Millions)
NOTE THESE PRELIMINARY ESTIMATES HAVE NOT GONE
THROUGH SCIENTIFIC OR GOVERNMENT POLICY CHALLENGE.
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What has been done to increase our preparedness?
(4)

• Research
• influenza immunization program evaluation
  request for proposal through the CIHR (phase 1)
• Co-chair and provide secretariat support to the
  Emerging Infectious Diseases Clinical Trial
  Network (EID-CTN)
• Global Collaboration
• Providing support to WHO, Thailand, Vietnam,
  China
• Global Health Security Action Group partners (G7
  and Mexico)
• Share pandemic plans and joint exercises
• Antivirals (discussion on use in an early global
  intervention stockpile)
• mock pandemic vaccine development etc.

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Public Health Measures - Background

• Access to vaccines and antivirals will be limited
  - non-medical interventions will be important
• Recommendations based on limited scientific
  evidence and rely on expert opinion
• Tested during SARS but pandemic flu is different
• Effectiveness will depend on the behavior of the
  virus
• Strategy depends on cost, available resources,
  ease of implementation, public acceptance,
  political concerns

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Public Health Measures Guidelines

• Principles and Assumptions
• Uses new WHO phases
• Recommendations
• Public Health Management of Ill Individuals
• Public Health Management of Contacts of Cases
• Community-Based Strategies
• Travel and Border Measures
• Public Education

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Public Health Measures - Challenges

• Effectiveness and objectives will shift with the
  evolving epidemiology
• Prevent cases before human-to-human spread
• Slow pandemic spread
• Reduce impact of first wave
• How to respond to initial cases in Canada? Global
  pandemic alert vs pandemic phase

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Community-Based Strategies

• Strongly recommended
• Stay home from public events if ill
• Consider
• School and Day Care Closures
• Not recommended
• Restriction of indoor public gatherings (consider
  specific events depending on epidemiology)
• Use of masks by well individuals
• Hand sanitizing stations in public settings
• Increase frequency of cleaning surfaces in public
  places

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Travel and Border Measures

• WHO recommendations
• Providing information to travelers is better use
  of health resources than formal screening
• Potential value of exit screening from areas with
  human-to-human transmission
• No entry screening (e.g. thermal scanners) of
  travelers from affected areas

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Next Steps

• Publish guideline on Management of Human Health
  Issues related to Domestic Avian Influenza
  Outbreaks
• Finalize and post new Annexes (2004)
• First Nations
• Public Health Measures
• Surveillance
• Pandemic influenza communications working group
  communication matrix
• Increase public and professional awareness

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Next Steps

• Update the national Plan to be in line with new
  WHO guidance documents (including new phase
  terminology)
• Exercising the Plan (e.g. U.K. June 2005)
• Produce mock H5N1 pandemic vaccine and conduct
  clinical trials - Federal budget 2005 (34
  million)
• Testing domestic vaccine production
  infrastructure, regulatory processes and clinical
  trial protocols using the H5N1 vaccine strain
  Influenza research agenda (2004)
• Determine the optimal H5N1 dosage and schedule
• Investigate antigen sparing strategies e.g.
  adjuvants, intra-dermal administration, whole
  cell vaccine

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Next Steps

• Vaccines
• Allocation plan
• Monitoring usage, effectiveness, adverse effects
  during a pandemic
• Indemnification
• Role of new technologies
• Antiviral Stockpile
• inventory management and distribution (including
  First Nations communities)
• guidelines for delivery, monitoring of use

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Next Steps

• Research
• Develop an Influenza Research Agenda (Sept. 2005)
• International Vaccine Centre (InterVac), U. of
  Saskatchewan (2005) 24 million
• Mathematical Modelling of the impact of pandemics
  and potential interventions
• Strengthen collaboration and coordination between
  animal and human health for surveillance and
  response to zoonotic/emerging infectious disease

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Preparedness Activities

• Provincial/Territorial and Local Levels

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Within Canada

• Most Provinces and Territories have developed
  plans for pandemic influenza
• Alberta, BC, Manitoba and Ontario on the web
• Some provinces and territories are at the stage
  where they are testing their plans
• Local level planning is occurring
• Post-SARS high level of recognition for need for
  plans to mitigate the impact of pandemic influenza