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Pandemic Influenza: lessons learnt Pandemic Influenza: lessons learnt Margaret Dolan Pharmacy Advisor,Pharmacologistics National Procurement National Services.

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Presentation on theme: "Pandemic Influenza: lessons learnt Pandemic Influenza: lessons learnt Margaret Dolan Pharmacy Advisor,Pharmacologistics National Procurement National Services."— Presentation transcript:

1 Pandemic Influenza: lessons learnt Pandemic Influenza: lessons learnt Margaret Dolan Pharmacy Advisor,Pharmacologistics National Procurement National Services Scotland November 2009

2 AIM Background to Pandemic Where we are --thought we might be what we are doing Opportunities

3 Influenza virus An RNA virus, types A, B, and C Influenza A & B are major human pathogens (winter flu outbreaks) Only influenza A recognised as having pandemic potential H N (16) (9)

4 1920194019601980 2000 Circulating influenza strains in humans and pandemics in 20 th Century H1N1 H2N2 H3N2 1918: “Spanish Flu” 40-50 million deaths 1957: “Asian Flu” 2 million deaths 1968: “Hong Kong Flu” 1 million deaths

5 Lessons learned from previous pandemics 1.maximum recorded interval between pandemics is 39 years – 1998-2009 2.the likely origin will be SE Asia – Mexico spread will be rapid – we either prepare now, or risk being caught by surprise ?? 4.may be several epidemic waves; first may be ‘milder’ sustainability and resilience will be key issues 5.excess mortality /morbidity difficult to predict may be high (repeat of 1918) 6.overall population clinical attack rate is likely to be 25-33% 7.there may be a shift towards younger age groups in terms of severity and mortality – with implications for business workforce

6 Pre-requisites for pandemic influenza New influenza A sub-type: Haemagglutinin (H) unrelated to immediate (pre-pandemic) predecessor. Little or no pre-existing population immunity Causes significant clinical illness Efficient person-to-person spread

7 What is being done WHO surveillance Government Influenza Pandemic Contingency Plan-- - HB plans /Trust plans Supplier business contingency arrangements Amendments to medicines and associated legislation during an influenza pandemic Pandemic Influenza Preparedness Programme Vaccines / stockpiles / strengthening the supply chain Surge capacity and prioritisation in health services ITU surge capacity

8 Avian influenza 2003-08: epidemiology H5N1 In general, not considered transmissible person-to-person One or two instances where very close person-to-person contact (mainly health care) may have resulted in transmission Person-person-STOP Extremely rare compared to human contact with poultry No evidence of widespread asymptomatic infection

9 Bird flu and pandemic influenza: what are the risks? WHO UPDATE: last modified -14 th February 2008 360 people have caught the infection, 226 subsequently died Still no firm evidence that H5N1 has acquired the ability to pass easily from person to person. It is the ability of avian influenza, to change and to mix, that has given rise to the fear of a new human flu pandemic.

10 Avian Influenza in the UK 7 incidents of highly pathenogenic avian influenza in the UK since 1959: H5N1 among chickens, in Scotland in 1959; H7N3 in turkeys in England in 1963 H7N7 among turkeys, in England in 1979 H5N1 in turkeys, in England in 1991 H5N1 in a wild swan in Scotland, in 2006 H5N1 in turkeys in England, in 2007 and the current outbreak of H5N1 in turkeys near Diss Incidents of low pathogenic avian influenza, of which the most recent were H7N2 affecting chickens in North Wales in 2007 and H7N3 In Suffolk in 2006 affecting chickens.

11 Avian influenza 2003-08: a severe multi-system illness Associated with close contact with, or proximity to, sick, dying or dead poultry Incubation period: 1-5 days Rapid onset fever, cough, short of breath Rapid deterioration with multi-organ failure High case-fatality rate (~60%)

12 Influenza A reservoirs Wild aquatic shore birds: largest and most important reservoir for influenza A Humans and other animals (wild birds, domestic and farmed poultry, pigs, horses, cats, seals, mink, whales) also infected Pigs: support the growth of both human and avian viruses (“mixing vessel”) But H5N1 provides clear evidence of direct bird-human transmission…

13 The reality – swine flu Emergent H1N1 cases in Mexico showing transmission WHO pandemic alert level--- 5 April 29 th 2 cases in Scotland-- 27 th April (148) WHO pandemic alert level 6 – 16 th June Slow growth in the UK and worldwide

14 Pandemic Influenza: the illness WHO14-16 th Oct 2009 Small subset –severe progressive pneumonia Underlying medical conditions (including pregnancy) increased risk BUT majority of severe case in previously healthy young people Rapid deterioration 3-5 days after onset of syptoms–ITU –respiratory and refactory shock most common cause of death(within 24 hours of admission) Secondary bacterial infections in 30% of fatalities

15 Predicted model of pandemic wave (25% attack rate ) april may junejuly


17 Daily GP consultation rate 2008-2009 61 per 100,000 comaparable to Dec 2008


19 Clinical countermeasures strategy stage 1.Pre pandemic vaccine 2. antivirals 3. antibiotics 4. Hand washing And hygiene

20 Virus survival Hard surfaces: viruses detectable for up to 72h, but in viable quantities to be transferable and detectable on hands for only 24h Soft surfaces (eg furnishings): detectable for up to 24h but in viable quantities on hands for only 15 minutes Survival on hands after transfer: 5 minutes Easily inactivated on surfaces by household cleaners, bleach solutions, and standard detergents Easily inactivated on hands by soap, water and drying, OR by alcohol based gels/solutions (30 sec)

21 Infection control principles Incubation period (time from exposure to onset of symptoms) likely to be 1-4 days (2-3 typical) Period of infectivity (when someone is capable of infecting others): immediately from the onset of symptoms… - for 3-5 days in most adults - for 7-8 days in most children (can be longer) Infectiousness proportional to symptoms Period of infectivity likely to be reduced by early treatment with Tamiflu® (within 12h) ‘Safe’ option is to assume infectious until symptoms have resolved

22 Societal interventions Societal interventions Aims To minimise the mortality and morbidity associated with an influenza pandemic by: delaying its arrival slowing its spread reducing the proportion of the population infected So as to: minimise the impact at any one time allow more time for specific countermeasures such as immunisation

23 Methods of spread droplets contact

24 Public campaign

25 Use of masks by the public and/or healthcare workers Persons with symptoms who have to go out should wear a face mask (to protect others) but this must not encourage or imply a permissive stance to going out whilst symptomatic Employers will have to consider if their employees are more likely to be exposed to persons with flu than members of the general public and the extent to which other distancing measures can be applied Practical constraints –Supply and logistics –Can the public use them safely? –Fit testing; unmasking; lifespan –Adequacy of some designs –Mixed messages; presentation –Magic bullets HPA presumptive stance: insufficient evidence and too many potential downsides to recommend general use

26 PIPP STRATEGIES PPV ----purchase of H5N1 vaccine/1 st line defence PPE -- reduce spread ----healthcare workers vs public ---- which mask Antivirals to reduce incidence/ severity/ complications Antibiotics H1N1 vaccine Strengthening the supply chain for essential medicines

27 H1N1 Pandemic vaccination –lessons learnt Modelling – based on 2 vaccines per patient/ mass vaccination campaign Licensing issues Low yield – availability for priority groups Vaccination centres ? Presentation 50 x 10 – repackaging Public perception

28 Antiviral drugs 01 March 2005: Health Secretary John Reid announced the Department of Health was to procure 14.6 million courses of oseltamivir (Tamiflu ® ), an antiviral drug, as part of the UK's preparedness for an influenza pandemic. This has now been secured. Prevent the virus from reproducing and thus Reduce periods infectivity and symptom Prevent secondary complications and can reduce hospital admissions by 50% But: Must be taken within 48 hours of onset of symptoms Effectiveness in a pandemic is unknown (not 100%) May not be enough – prioritising needed

29 The anti viral machinery Now stocks to treat 75-80% tamiflu and relenza Logistics challenges storage distribution administration Key issues paediatric products- / suspension vs solution licensing changes Secure supply to patients –flu line - flu friends - ACPs --- Uptake


31 Antibiotic Project Range of medicines - British Thoracic Society Guidelines Trigger for release Storage and Distribution - Primary /secondary care Debate – stock rotation

32 ‘Lessons not learnt’ as five die in C diff outbreak TIMES ON LINE 11 th November 2009

33 Essential Medicines List of medicines– hybrid EU advert (with volumes) 5 year contract – exit strategy Contract award – in progress WORK IN PROGRESS

34 www.Swine Flu Financial Report “the swine flu pandemic is one of the most profitable opportunities ever encountered by the healthcare sector” Race is on to develop swine flu efficient anti-viral and swine flu vaccine Sign up to find out who will win Stocks to watch---------

35 Opportunities for Investors Get our timely new report, "Investor Essentials: Picking Winners for Pandemic Profits," today and find out how you can profit from the Swine Flu panic. The special report features the following stocks: Gilead Sciences (GILD) Novavax (NVAX) Hemispherix Biopharma (HEB) GlaxoSmithKline (GSK) BioCryst Pharmaceuticals (BCRX) Sinovac Biotech (SVA) Alpha Pro Tech (APT) Dynavax (DVAX) Generex Biotechnology (GNBT) Inovio Biobedical (INO) Sanofi-Aventis (SNY) Novartis (NVS) AstraZenaca (AZN) Baxter International (BAX) AND More... Remember, this report is 100% FREE.

36 Retail opportunities Chemist And Druggist “concern about swine flu likely to increase demand “ OTC £406million winter remedies market –46% share community pharmacies Every cloud has a silver lining

37 Thanks for listening Any questions ?? (That wont put me in breach of commercial and in confidence)

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