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Symposium on Infectious Diseases: Pandemic H1N1 Dr. Liana Nolan Commissioner/Medical Officer of Health Region of Waterloo Waterloo Inn, November 4, 2009.

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Presentation on theme: "Symposium on Infectious Diseases: Pandemic H1N1 Dr. Liana Nolan Commissioner/Medical Officer of Health Region of Waterloo Waterloo Inn, November 4, 2009."— Presentation transcript:

1 Symposium on Infectious Diseases: Pandemic H1N1 Dr. Liana Nolan Commissioner/Medical Officer of Health Region of Waterloo Waterloo Inn, November 4, 2009

2 Agenda pH1N1: pH1N1: Overview Overview Current Trends Current Trends Projections of upcoming activity Projections of upcoming activity Waterloo Region Pandemic Plan Waterloo Region Pandemic Plan pH1N1 Vaccine pH1N1 Vaccine Antiviral Recommendations Antiviral Recommendations Questions Questions

3

4 H1N1 Overview The H1N1 flu virus is another strain of the influenza virus. The H1N1 flu virus is another strain of the influenza virus. It causes symptoms similar to those of the seasonal flu (fever and cough and one or more of the following: sore throat, muscle aches, joint pain, or weakness). It causes symptoms similar to those of the seasonal flu (fever and cough and one or more of the following: sore throat, muscle aches, joint pain, or weakness). It spreads in the same manner as seasonal influenza does. It spreads in the same manner as seasonal influenza does. The methods to prevent and control it are the same as those for seasonal influenza. The methods to prevent and control it are the same as those for seasonal influenza.

5 H1N1 Overview What is different about H1N1, as compared to seasonal influenza: What is different about H1N1, as compared to seasonal influenza: It predominantly affects younger populations: Children, adolescents, young adults. It predominantly affects younger populations: Children, adolescents, young adults. Hospitalization rate: Hospitalization rate: 3.0 hospital admissions per 100,000 Ontarians 3.0 hospital admissions per 100,000 Ontarians Australia this past summer: 22.7 hospital admissions per 100,000 population Australia this past summer: 22.7 hospital admissions per 100,000 population Fatality rate: Fatality rate: 1.9 deaths per 1 million Ontarians 1.9 deaths per 1 million Ontarians Ontario average for seasonal flu: 33 deaths per 1 million Ontarians Ontario average for seasonal flu: 33 deaths per 1 million Ontarians

6 H1N1 – Age Distribution (Graph)

7 H1N1 Overview Groups at higher risk for complications: Groups at higher risk for complications: Age <5 Age <5 Age ≥65 Age ≥65 Pregnant women Pregnant women Those with chronic medical conditions (heart or lung disease, diabetes, cancer, immuno- suppression, morbid obesity, etc.) Those with chronic medical conditions (heart or lung disease, diabetes, cancer, immuno- suppression, morbid obesity, etc.) Individuals living in remote/isolated communities Individuals living in remote/isolated communities

8 Current Trends H1N1 activity has been increasing locally and across the province/ country in the last few weeks, especially in the last couple of weeks. H1N1 activity has been increasing locally and across the province/ country in the last few weeks, especially in the last couple of weeks. Local status (Waterloo Region): Local status (Waterloo Region): Over 100 influenza cases since Sept. 1, 2009; at varying stages of confirmation of strain. Expecting vast majority, if not all, to be pH1N1. Over 100 influenza cases since Sept. 1, 2009; at varying stages of confirmation of strain. Expecting vast majority, if not all, to be pH1N1. Number of confirmed cases who have died: 0 Number of confirmed cases who have died: 0 Reported cases will always be an under-estimate. Reported cases will always be an under-estimate.

9 Current Trends Locally: Locally:  Consultation rates for ILI in doctor’s offices  Consultation rates for ILI in doctor’s offices per 1,000 patient visits; mirrors provincial average per 1,000 patient visits; mirrors provincial average.  School absenteeism  School absenteeism 25-30% of schools reporting absenteeism  10%; Elementary schools  Secondary schools  Emergency Room visits for ILI  Emergency Room visits for ILI Most often mild-moderate Most often mild-moderate

10 Southern Hemisphere Comparators Australia: Fully susceptible population, no vaccine Fully susceptible population, no vaccine Similar publicly funded health care system Similar publicly funded health care system Racially diverse Racially diverse Aboriginal population Aboriginal population Major urban centres along with large rural areas and very remote isolated communities Major urban centres along with large rural areas and very remote isolated communities

11 Australia Specific Data Overall hospitalization rate 22.7 per 100,000 Overall hospitalization rate 22.7 per 100,000 Highest rates of hospitalization in children Highest rates of hospitalization in children Pregnant women and aboriginal people disproportionately represented in hospital admissions Pregnant women and aboriginal people disproportionately represented in hospital admissions pH1N1 was the predominant circulating strain of influenza pH1N1 was the predominant circulating strain of influenza

12 Queensland specific data Most detailed data comes from Queensland Most detailed data comes from Queensland This data closely resembles Ontario data to date This data closely resembles Ontario data to date Rate of hospitalization 28.7 per 100,000 Rate of hospitalization 28.7 per 100,000 53% of cases admitted were within 48 hours of symptom onset 53% of cases admitted were within 48 hours of symptom onset 20.6% of hospital admissions required an ICU or special care bed 20.6% of hospital admissions required an ICU or special care bed Medium length of stay 9 days Medium length of stay 9 days 38% of ICU admits had no underlying comorbidities 38% of ICU admits had no underlying comorbidities

13 Potential Impact for RoW Estimates of Hospital Admissions: Includes all three sites Includes all three sites Estimated rate 28.7 per 100,000 Estimated rate 28.7 per 100,000 Translates into hospital admissions over the course of the second wave to all three sites Translates into hospital admissions over the course of the second wave to all three sites

14 Potential Impact for RoW Paediatric Bed Requirements: Total of 13.5 paediatric admissions for those less than 5 years of age Total of 13.5 paediatric admissions for those less than 5 years of age Also increased demand for 5 to 16 year age group Also increased demand for 5 to 16 year age group

15 Potential Impact for RoW Emergency Department Visits: 13.8% of RoW adults have difficulty accessing clinical services (2005 Public Health data) 13.8% of RoW adults have difficulty accessing clinical services (2005 Public Health data) 51,084 people rely on urgent care or ED care 51,084 people rely on urgent care or ED care 18 to 24 age group has greatest difficulty (21%) 18 to 24 age group has greatest difficulty (21%) High rate of attack of pH1N1 High rate of attack of pH1N1 Generally less likely to seek consultation Generally less likely to seek consultation Extrapolation from Australia data hospital admits require ED visits over 3 hospitals over entire second wave Extrapolation from Australia data hospital admits require ED visits over 3 hospitals over entire second wave

16 Potential Impact for RoW ICU and Ventilator Requirements: 20.6% of hospital admissions require ICU bed 20.6% of hospital admissions require ICU bed Translates into 29.3 ICU admissions over 3 hospitals for entire second wave Translates into 29.3 ICU admissions over 3 hospitals for entire second wave 73% require a ventilator (21.4 vents) 73% require a ventilator (21.4 vents) 7% may require ECMO if available 7% may require ECMO if available Median length of stay 9 days Median length of stay 9 days

17 Projections for ILI visits – Primary Care Based on Australian experience: Based on Australian experience: This wave of influenza activity will last about 8 to 12 weeks. This wave of influenza activity will last about 8 to 12 weeks. The peak of influenza activity for Ontario is anticipated to be mid November. The peak of influenza activity for Ontario is anticipated to be mid November. Over 50% of patients who ended up admitted to hospital because of serious illness did so within the first 48 hours of symptom onset. Over 50% of patients who ended up admitted to hospital because of serious illness did so within the first 48 hours of symptom onset. Urgent bookings for ILI: focus on patients at higher risk for complications for whom antivirals are indicated within 48 hours of illness onset. Urgent bookings for ILI: focus on patients at higher risk for complications for whom antivirals are indicated within 48 hours of illness onset.

18 Waterloo Region Pandemic Plan

19 Waterloo Region's Community Pandemic Influenza Preparedness Plan (CPIPP) Waterloo Region's Community Pandemic Influenza Preparedness Plan (CPIPP) Available at (approximately 400 pages) Available at (approximately 400 pages)www.waterlooregionpandemic.ca Developed by over 200 individuals from over 50 organizations. This includes representatives from the hospitals, municipalities, emergency response agencies (police, fire, ambulance) and social service agencies. Developed by over 200 individuals from over 50 organizations. This includes representatives from the hospitals, municipalities, emergency response agencies (police, fire, ambulance) and social service agencies.

20 Waterloo Region Pandemic Plan It is unlikely Waterloo Region's Community Pandemic Influenza Preparedness Plan (CPIPP), which includes provisions for a severe pandemic, will be implemented in full given the overall mild to moderate severity of the H1N1 virus to date. It is unlikely Waterloo Region's Community Pandemic Influenza Preparedness Plan (CPIPP), which includes provisions for a severe pandemic, will be implemented in full given the overall mild to moderate severity of the H1N1 virus to date. Some examples of differences between the full plan and the current response plan: Some examples of differences between the full plan and the current response plan: Some public health measures may not be implemented. For example, schools and child care facilities are recommended to remain open and there is no recommendation to cancel mass gatherings. Some public health measures may not be implemented. For example, schools and child care facilities are recommended to remain open and there is no recommendation to cancel mass gatherings. Antivirals are recommended only for people who are seriously ill (i.e. hospitalized) or at higher risk of complications (e.g. pregnant women, individuals with underlying chronic conditions). Antivirals are being distributed through the existing infrastructure (pharmacies). Antivirals are recommended only for people who are seriously ill (i.e. hospitalized) or at higher risk of complications (e.g. pregnant women, individuals with underlying chronic conditions). Antivirals are being distributed through the existing infrastructure (pharmacies).

21 Public Health's Role Collecting and reporting on local surveillance data Collecting and reporting on local surveillance data Adapting its seasonal and H1N1 immunization campaigns based on evolving provincial direction Adapting its seasonal and H1N1 immunization campaigns based on evolving provincial direction Providing information to the public and health care partners Providing information to the public and health care partners Providing ongoing consultation and support to community partners Providing ongoing consultation and support to community partners Coordinating planning for the health care sector, re strategies for influenza assessment and treatment. Coordinating planning for the health care sector, re strategies for influenza assessment and treatment.

22 Vaccines (H1N1 & Seasonal) 3 Phase Roll-Out: *H1N1: Due to temporary, limited supply, H1N1 vaccine reserved for higher-risk groups at beginning of November

23 H1N1 Vaccine Sequencing Groups in First Sequence: Groups in First Sequence: Persons with chronic conditions under the age of 65 Persons with chronic conditions under the age of 65 Pregnant women Pregnant women Children 6 months to less than 5 years of age Children 6 months to less than 5 years of age Health care workers (i.e. all health care system workers involved with the pandemic response or delivery of essential health services) Health care workers (i.e. all health care system workers involved with the pandemic response or delivery of essential health services) Household contacts and care providers of: infants under 6 months of age or persons who are immunocompromised Household contacts and care providers of: infants under 6 months of age or persons who are immunocompromised Persons residing in remote and isolated settings or communities Persons residing in remote and isolated settings or communities Groups in Second Sequence: Groups in Second Sequence: Everyone else Everyone else

24 H1N1 Vaccine Distribution As per Ministry direction, distribution of the H1N1 vaccine will occur through a more restricted number of providers than for the seasonal influenza vaccine (primary care providers, Public Health-organized community clinics, health care facilities, etc.) As per Ministry direction, distribution of the H1N1 vaccine will occur through a more restricted number of providers than for the seasonal influenza vaccine (primary care providers, Public Health-organized community clinics, health care facilities, etc.) Workplaces not among those authorized to provide immunization clinics for H1N1. Workplaces not among those authorized to provide immunization clinics for H1N1.

25 Components of H1N1 Vaccine The H1N1 vaccine is made exactly like the seasonal influenza vaccine that is produced each year, except for the addition of an adjuvant. The H1N1 vaccine is made exactly like the seasonal influenza vaccine that is produced each year, except for the addition of an adjuvant. The use of an adjuvant allows a comparable immune response at a significantly lower antigen dose, thus allowing faster production of more doses of vaccine. The use of an adjuvant allows a comparable immune response at a significantly lower antigen dose, thus allowing faster production of more doses of vaccine. Adjuvant use is also expected to provide some cross protection against virus drift. Adjuvant use is also expected to provide some cross protection against virus drift.

26 H1N1 Adjuvant ASO3 is the name of the adjuvant ASO3 is the name of the adjuvant It is an oil-in-water suspension with the oil component consisting of DL-α-tocopherol (Vitamin E) and squalene. It is an oil-in-water suspension with the oil component consisting of DL-α-tocopherol (Vitamin E) and squalene. Squalene is a naturally occurring substance found in plants, animals, and humans. It is manufactured in the liver of every human body and circulates in our bloodstream. Squalene is commercially extracted from fish oil. The squalene in the vaccine is derived from shark liver oil and highly purified (i.e. no allergens). Squalene is a naturally occurring substance found in plants, animals, and humans. It is manufactured in the liver of every human body and circulates in our bloodstream. Squalene is commercially extracted from fish oil. The squalene in the vaccine is derived from shark liver oil and highly purified (i.e. no allergens).

27 H1N1 Adjuvant The substance used to maintain the oil in suspension is polysorbate 80 (also known as Tween 80) The substance used to maintain the oil in suspension is polysorbate 80 (also known as Tween 80) An emulsifier found in other vaccines and also used in ice cream An emulsifier found in other vaccines and also used in ice cream Therefore, the adjuvant is made up of natural ingredients such as fish oil, water, and vitamin E. Therefore, the adjuvant is made up of natural ingredients such as fish oil, water, and vitamin E.

28 H1N1 Adjuvant The ASO3 adjuvant has been studied in 45,000 people. The ASO3 adjuvant has been studied in 45,000 people. Its use has resulted in increased local reactions at the injection site but no serious safety concerns have been noted. 1 Its use has resulted in increased local reactions at the injection site but no serious safety concerns have been noted. 1 1 WHO Virtual Consultation on the Safety of Adjuvanted Influenza Vaccines (3 June 2009):

29 H1N1 Vaccine: Recommendations for Use All Canadians 10 years of age and older should receive one dose of adjuvanted vaccine. All Canadians 10 years of age and older should receive one dose of adjuvanted vaccine. Children from six months to nine years of age should receive the adjuvanted vaccine in two half-doses, administered 21 days apart. Children from six months to nine years of age should receive the adjuvanted vaccine in two half-doses, administered 21 days apart. Pregnant women: See next slide Pregnant women: See next slide

30 Pregnancy: Adjuvanted or Unadjuvanted? There are two types of H1N1 vaccine approved by Health Canada for pregnant women: the adjuvanted H1N1 vaccine and the un-adjuvanted (or non- adjuvanted) H1N1 vaccine. There are two types of H1N1 vaccine approved by Health Canada for pregnant women: the adjuvanted H1N1 vaccine and the un-adjuvanted (or non- adjuvanted) H1N1 vaccine. All evidence suggests that adjuvanted vaccines are just as safe as unadjuvanted vaccines; however the adjuvanted vaccine has not been specifically studied in pregnant women. All evidence suggests that adjuvanted vaccines are just as safe as unadjuvanted vaccines; however the adjuvanted vaccine has not been specifically studied in pregnant women. Unadjuvanted vaccine won’t be available in Canada until at least the second week of November. Unadjuvanted vaccine won’t be available in Canada until at least the second week of November.

31 Pregnancy: Adjuvanted or unadjuvanted? Given that influenza rates are rising in our community, it is recommended that pregnant women with pre-existing health conditions or who are more than 20 weeks pregnant be offered the adjuvanted vaccine that is available now. These pregnant women are at greater risk of complications from H1N1. Given that influenza rates are rising in our community, it is recommended that pregnant women with pre-existing health conditions or who are more than 20 weeks pregnant be offered the adjuvanted vaccine that is available now. These pregnant women are at greater risk of complications from H1N1. Healthy pregnant women  20 weeks gestation may wait for the unadjuvanted vaccine if they wish. Healthy pregnant women  20 weeks gestation may wait for the unadjuvanted vaccine if they wish.

32 Pregnancy: Adjuvanted or unadjuvanted? SOGC recommendations: SOGC recommendations: “The SOGC recommends that all pregnant women over 20 weeks gestation and those less than 20 weeks with underlying risk conditions be vaccinated against H1N1 as soon as a vaccine is available, whether or not it includes an adjuvant. In areas where H1N1 flu rates are high or increasing, health-care providers should offer immediate vaccination with adjuvanted vaccines and not wait for non- adjuvanted vaccines which may only be available in November.” “The SOGC recommends that all pregnant women over 20 weeks gestation and those less than 20 weeks with underlying risk conditions be vaccinated against H1N1 as soon as a vaccine is available, whether or not it includes an adjuvant. In areas where H1N1 flu rates are high or increasing, health-care providers should offer immediate vaccination with adjuvanted vaccines and not wait for non- adjuvanted vaccines which may only be available in November.”

33 Who should NOT receive the vaccine? Infants under 6 months of age (the H1N1 flu vaccine is not approved for children under six months of age). Infants under 6 months of age (the H1N1 flu vaccine is not approved for children under six months of age). Anyone who had a serious allergic reaction (i.e. developed hives, swelling of the mouth of throat, or trouble breathing) to: Anyone who had a serious allergic reaction (i.e. developed hives, swelling of the mouth of throat, or trouble breathing) to: A previous dose of the influenza vaccine A previous dose of the influenza vaccine Egg or egg products Egg or egg products Thimerosal Thimerosal Any other component of the vaccine Any other component of the vaccine

34 Who should NOT receive the vaccine? Persons who developed Guillain-Barré Syndrome within 8 weeks of receiving a seasonal flu vaccine. Persons who developed Guillain-Barré Syndrome within 8 weeks of receiving a seasonal flu vaccine. People who are currently seriously ill with an infection should wait until they recover before receiving the vaccine. People who are currently seriously ill with an infection should wait until they recover before receiving the vaccine. Persons with a mild egg allergy  consult a healthcare provider before immunization  may be able to be immunized with some additional precautions. Persons with a mild egg allergy  consult a healthcare provider before immunization  may be able to be immunized with some additional precautions.

35 Adverse Reactions Clinical trials found the most common reactions after getting the adjuvanted vaccine included pain, swelling and redness at the injection site. Clinical trials found the most common reactions after getting the adjuvanted vaccine included pain, swelling and redness at the injection site. Pain at the injection site was more frequent  the adjuvant improves immunogenicity by causing an increased inflammatory reaction. Pain at the injection site was more frequent  the adjuvant improves immunogenicity by causing an increased inflammatory reaction. Other commonly reported reactions were fatigue, muscle and joint pain, and headache. Other commonly reported reactions were fatigue, muscle and joint pain, and headache. In younger children, a fever, drowsiness, irritability and loss of appetite were also reported in low percentages. In younger children, a fever, drowsiness, irritability and loss of appetite were also reported in low percentages.

36 Adverse Reactions As with the seasonal influenza vaccine, it is expected that most side effects will be mild, and that serious side effects will be very rare. As with the seasonal influenza vaccine, it is expected that most side effects will be mild, and that serious side effects will be very rare.

37 What about the 1976 Guillain- Barré Syndrome? The story: The story: In January and February 1976, a new strain of influenza A of swine origin appeared among military personnel on a military base at Fort Dix, New Jersey. In January and February 1976, a new strain of influenza A of swine origin appeared among military personnel on a military base at Fort Dix, New Jersey. Although the strain of influenza did not spread beyond the base and cases ceased within a few weeks, in October 1976 officials began a mass immunization campaign to prevent the circulation of this New Jersey strain. Although the strain of influenza did not spread beyond the base and cases ceased within a few weeks, in October 1976 officials began a mass immunization campaign to prevent the circulation of this New Jersey strain.

38 1976 Guillain-Barré Syndrome In total, 45 million doses of vaccine were administered in the United States between October and December In total, 45 million doses of vaccine were administered in the United States between October and December The program was stopped when it was realized that 500 cases of Guillain-Barré Syndrome (GBS) had arisen after vaccination, resulting in 25 deaths. The program was stopped when it was realized that 500 cases of Guillain-Barré Syndrome (GBS) had arisen after vaccination, resulting in 25 deaths. It is estimated that slightly less than 1 in 100,000 vaccinated people developed GBS in It is estimated that slightly less than 1 in 100,000 vaccinated people developed GBS in 1976.

39 Risk of GBS with Influenza Immunization In subsequent vaccination seasons, studies have shown either a non-existent risk of GBS after influenza vaccine or an increased risk of approximately 1 per 1 million doses of influenza vaccine administered. In subsequent vaccination seasons, studies have shown either a non-existent risk of GBS after influenza vaccine or an increased risk of approximately 1 per 1 million doses of influenza vaccine administered. Reference: Haber P et al. Vaccines and Guillain-Barré Syndrome. Drug Safety 2009;(32)4: Credit to Dr. Bryna Warshawsky for slide bullet points.

40 Background incidence of GBS In a Canadian study, the background incidence of GBS due to any cause was estimated at 2.02 per 100,000 person-years in Ontario and 2.30 per 100,000 person-years in Quebec 1. In a Canadian study, the background incidence of GBS due to any cause was estimated at 2.02 per 100,000 person-years in Ontario and 2.30 per 100,000 person-years in Quebec 1. A variety of infectious agents, including Campylobacter jejuni, cytomegalovirus, Epstein-Barr virus and Mycoplasma pneumoniae, have been associated with GBS 2. A variety of infectious agents, including Campylobacter jejuni, cytomegalovirus, Epstein-Barr virus and Mycoplasma pneumoniae, have been associated with GBS 2. 1 McLean M, Duclos P, Jacob P et al. Incidence of Guillain-Barre syndrome in Ontario and Quebec, , using hospital service databases. Epidemiology 1994;5(4): Hughes RA, Cornblath DR. Guillain-Barre syndrome. Lancet 2005;366(9497):

41 “What about the mercury in the vaccine?” Both the adjuvanted and unadjuvanted vaccines contain a small amount of thimerosal. Both the adjuvanted and unadjuvanted vaccines contain a small amount of thimerosal. Thimerosal is a form of mercury used in the H1N1 vaccine to stabilize it and maintain its quality during storage. Thimerosal is a form of mercury used in the H1N1 vaccine to stabilize it and maintain its quality during storage. Thimerosal is a different form of mercury than the mercury known to cause health problems. Thimerosal is a different form of mercury than the mercury known to cause health problems. The amount in the H1N1 adjuvanted flu vaccine is much less than the daily limit recommended for environmental exposure to mercury. For example, there is significantly less mercury in the vaccine than you would find in a can of tuna fish. The amount in the H1N1 adjuvanted flu vaccine is much less than the daily limit recommended for environmental exposure to mercury. For example, there is significantly less mercury in the vaccine than you would find in a can of tuna fish.

42 What if someone already had influenza-like illness? Unless they’ve had laboratory confirmed pH1N1, recommendation is that they be immunized. Unless they’ve had laboratory confirmed pH1N1, recommendation is that they be immunized. No harm if they've already had pH1N1. No harm if they've already had pH1N1.

43 Co-administration with other vaccines H1N1 flu vaccine may be administered concurrently with seasonal flu vaccine and other vaccines. H1N1 flu vaccine may be administered concurrently with seasonal flu vaccine and other vaccines. If co-administered, injections should be given in separate limbs. If co-administered, injections should be given in separate limbs. If not given concurrently, there is no minimum interval required between the H1N1 flu vaccine and other vaccines. If not given concurrently, there is no minimum interval required between the H1N1 flu vaccine and other vaccines.

44 How long after immunization for immunity? Most people will start to develop immunity within 10 days after receiving the vaccine. Most people will start to develop immunity within 10 days after receiving the vaccine.

45 Recommendations to Prevent/ Reduce Spread of H1N1 Get the H1N1 & Seasonal Flu Shots

46 Antiviral Recommendations: Those who are asked to contact their doctor as soon as they become ill with symptoms of influenza, to discuss antiviral treatment within 48 hours of illness onset: Those who are asked to contact their doctor as soon as they become ill with symptoms of influenza, to discuss antiviral treatment within 48 hours of illness onset: Pregnant women Pregnant women The risk of developing complications from pH1N1 is higher later in pregnancy – 2nd and 3rd trimester – and up to 4 weeks post-partum The risk of developing complications from pH1N1 is higher later in pregnancy – 2nd and 3rd trimester – and up to 4 weeks post-partum Those age <5 Those age <5 In particular, < 2 In particular, < 2 Those aged  65 Those aged  65 Those with chronic medical conditions (see next slides) Those with chronic medical conditions (see next slides)

47 What medical conditions are considered higher risk? Chronic respiratory disease, including asthma Chronic respiratory disease, including asthma Cardiac disease Cardiac disease Diabetes mellitus and other metabolic diseases Diabetes mellitus and other metabolic diseases Cancer Cancer Immunodeficiency or immunosuppression (due to underlying therapy and/or disease including HIV/AIDS) Immunodeficiency or immunosuppression (due to underlying therapy and/or disease including HIV/AIDS) (cont’d next slide)

48 What medical conditions are considered high risk? Renal disease Renal disease Anemia or hemoglobinopathy Anemia or hemoglobinopathy Morbid obesity Morbid obesity Children less than 18 years of age on long term aspirin therapy Children less than 18 years of age on long term aspirin therapy Conditions that compromise the management of respiratory secretions and are associated with an increased risk of aspiration, such as neurologic conditions or cognitive disorders Conditions that compromise the management of respiratory secretions and are associated with an increased risk of aspiration, such as neurologic conditions or cognitive disorders

49 Resources Region of Waterloo Public Health: Region of Waterloo Public Health: Ontario Ministry of Health and Long-Term Care: Ontario Ministry of Health and Long-Term Care: Public Health Agency of Canada: Public Health Agency of Canada: All key information for physicians will continue to be included in Physician faxes/ packages sent by courrier. All key information for physicians will continue to be included in Physician faxes/ packages sent by courrier.

50 CONCLUSION Q&A


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