1. Pandemic H1N1 (pH1N1) ‘State of the Union’
Alfred Gin, BScPharm, PharmD

2. Objectives pH1N1 Update Guidance documents Antivirals Key Points
Risk Groups
Antivirals
availability
Pharmacare
Special groups
Key Points

3. Pandemic Influenza 2009 pH1N1 - official designation Timeline 2009
influenza A
Timeline 2009
February – respiratory illness, La Gloria, Mexico
Mid-April – CDC, PAHO notified severe resp. illness
June 11 – WHO Alert 6 – global pandemic
Canada
1st wave – April–Aug
2nd wave - now

4. FluWatch October 17, 2009

5. pH1N1 Origins Garten et al. Science. May 2009
Fig. 1. Host and lineage origins for the gene segments of the
2009 A(H1N1) virus: PB2 polymerase basic 2, PB1
polymerase basic 1, PA polymerase acidic, HA
hemagglutinin, NP nucleoprotein, NA neuraminidase, M
matrix gene, NS nonstructural gene. Color of gene segment in
circle indicates host. Determination of lineage explained in
main text.
Garten et al. Science. May 2009

6. pH1N1 Symptoms Almost always Common Sometimes
Sudden onset of cough and fever
Common
Fatigue
Muscle aches
Sore throat
Headache
Decreased appetite
Runny nose
Sometimes
Nausea
Vomiting
Diarrhea

7. pH1N1 Different from Seasonal Flu
children and young adults
pregnant women
severe cases
rapid respiratory deterioration
Aboriginal ancestry

8. H1N1 in Canada 1,604 hospitalized cases
312 (19.5%) cases admitted to ICU
164 (10.2%) cases required ventilation
83 deaths
90% hospitalized cases and 85% of deaths in 4 provinces
QC, ON, MB, AB
FluWatch October 17, 2009

9. pH1N1 Hospitalization By Age Group in Canada
No. Hospitalized
Rate per 100,000
adapted from Dr. John Spika, PHAC – Sept. 2, 2009
Severe H1N1 – Preventing Disease, Reducing Mortality Conference

10. pH1N1 Demographics Hospitalization National rate - 4.6 per 100,000
Age (years)
rate per 100,000
5-14
7.3
1-4
12.5
<1
33.8
Mortality
National rate – 0.25 per 100,000
> 45 years – 0.35 per 100,000
FluWatch October 17, 2009

11. H1N1 in Canada FluWatch Week 41 – Oct. 17, 2009
61%
56%
51%
Females
Deaths
(n=83)
Intensive Care
(n=312)
Hospitalized
(n=1,604) 50 37 2
Median Age
12%
15%
18%
Aboriginal Status
77%
72%
62%
Underlying
Conditions1
24%
19%
28%
Pregnancy2
1based on available info; 2Among women aged between 15 and 44.

12. H1N1 in Manitoba
New 13
Cases to date
905
Deaths 7
as of Oct. 19, 2009

13. Guidance for Clinicians
Public Health Agency of Canada (PHAC)
Manitoba Health
Regional Health Authorities
Winnipeg Regional Health Authority

14. MB Health Clinical Management* October 21, 2009
Interim Guidance
adults and adolescents
Pregnancy and post-partum women
Clinical Decision Algorithm
adult and adolescents
pediatric
*new or updated

15. Manitoba Health Mild ILI Severe ILI
risk conditions for severe ILI should get prompt assessment and care within 24 hours (including antivirals) even if they only have symptoms of mild ILI
Severe ILI
symptoms of severe ILI should get immediate medical and/or hospital care

16. Severity Indicators Shortness of breath Chest pain cyanosis
Bloody or coloured mucus/spit
Sudden dizziness or confusion
severe vomiting
High fever >3days
hypotension
Additional symptoms to watch for in children:
Not drinking enough fluids or eating
Not waking up or interacting
Irritability; not wanting to play or be held
PHAC H1N1 Preparedness Guide

17. Groups at Risk of pH1N1 Complications
Children < 5 years of age
Elderly ≥ 65 or those frail, mobility problems or live alone.
Chronic diseases
Immune disorders or immunosuppression
Child < 19 years old on chronic aspirin therapy
Severe obesity and/or malnutrition
Other conditions that may increase complications
smoking, substance abuse, alcoholism, homelessness
delay in care
Aboriginal ancestry.
Pregnant women
chronic conditions such as:Heart disease, Liver disease, Kidney disease, Blood disorders, Diabetes, Severe obesity, Asthma and chronic lung disease,
Immunosuppressed (people taking cancer drugs or people with HIV AIDS), Neurological disorders
Manitoba Health

18. Adults and Adolescents MB Interim Guidance Highlights*
Infection control
ILI definition and presentation
Testing
Clinical Management
Treatment
oseltamivir or zanamivir
renal/other dose adjustments – ‘contact pharmacist’ added

19. Recommended Clinical Management* Abbreviated version
Clinical Presentation
Recommendations
non-ILI - mild URI or other
no treatment, no test
assess other causes
ILI – No risk factors, normal vital signs
antiviral treatment not generally recommended but at discretion of clinician;
NP test if antiviral started
ILI – risk factors, normal vital signs
early antiviral treatment; NP test
ILI – abnormal vital signs OR severe ILI*
urgent attention: diagnosis, treatment, support, consultation
*refer to complete Interim Guide for Clinicians in Ambulatory Care Settings

20. Clinical Care Algorithm
MB Health
Clinical Care Algorithm

21. Pregnant Women MB Interim Guidance Highlights*
Infection control
ILI definition
Testing
Clinical Management
Treatment
oseltamivir preferred; zanamivir OK if N&V present
breastfeeding OK
pregnant women may receive antiviral prescription in advance – fill if ILI

22. Influenza Management supportive infection control antivirals*
neuramindase inhibitors
oseltamivir, zanamivir
amantadine
influenza vaccination
*treatment within 48 hours, earlier the better

23. Antiviral Availability
Oseltamivir
commercial
pandemic stockpile (NAS)
emergency preparation suspension
Zanamivir
commercial (now available)
Others - Special Access Programme

24. Goals of pH1N1 Antiviral Therapy
early treatment within 48 hours of onset of symptoms
treat severe cases even if beyond 48 hours of initial onset
decrease
symptoms
severity
mortality

25. Pharmacare Coverage
Oseltamivir
Part 2
Zanamivir
Part 3

26. Pharmacare Criteria
Patient shows ILI and one or more of the following risk factors:
Chronic Diseases*
Immunosuppression*
Pregnancy
“Lifestyle” conditions (i.e. smoking, substance abuse, alcoholism, homelessness);
Obesity and/or malnutrition;
Persons of aboriginal ancestry
Severe Respiratory Illness (SRI)
Patient shows Influenza Like Illness and one or more of the following
risk factors
• Chronic Diseases (lung including asthma, heart, kidney, central
nervous system including neuromuscular diseases, endocrine system
including diabetes mellitus);
• Immune disorders or immunosuppression (such as cancer patients on
treatment, autoimmune diseases or rheumatologic diseases on TNF
inhibitors or corticosteroids, transplant patients, HIV infection);
• Pregnancy
• “Lifestyle” conditions (i.e. smoking, substance abuse, alcoholism,
homelessness);
• Obesity and/or malnutrition;
• Persons of aboriginal ancestry
Severe Respiratory Illness (SRI)
*abbreviated

27. Adult Antiviral Dosing
Group
Early Treatment
Prophylaxis
Oseltamivir
Adult and children >13 yo
75 mg bid oral
x 5 days
75 mg oral daily
x 10 days
Zanamivir
Adult and children >7 yo
10 mg bid inhaled
10 mg inhaled
Manitoba Health

28. Oseltamivir Dosing Considerations
renal impairment
hemodialysis
continuous renal replacement therapy
obesity

29. Antiviral Dosage – Special Populations
Oseltamivir Dosing Recommendations
Dosing Situation
Manufacturers Recommendations
WRHA Suggested Dosing
Renal Function
CrCl > 30 ml/min
75 mg bid
Same
CrCl 10 – 30 m/min
75 mg daily
CrCl < 10 ml/min
No recommendation
75 mg q48h
Dialysis
High Flux hemodialysis
75 mg post each dialysis session
CRRT
Weight ≥ 150 kg
150 mg bid
WRHA Pharmacy Program Flu Q&A Update – July 28, 2009

30. “Over 9,000 prescriptions of antivirals were filled last week alone, which is a 78 per cent increase from the previous week” said Dr. Fawziah Marra, pharmacy director at the BC CDC….We want to remind British Columbians that if you have received a prescription for Tamiflu from your physician as part of your ‘flu plan’, then please do not fill the prescription unless you are experiencing moderate to severe influenza-like symptoms, or experiencing mild symptoms but have a high risk condition. Tamiflu is intended for treatment and not prevention…..help reduce the risk of this virus becoming drug-resistant.”
Oct. 23, 2009
“Over 9,000 prescriptions of antivirals were filled last week alone, which is a 78 per cent increase from the previous week” said Dr. Fawziah Marra, pharmacy director at the BC Centre for Disease Control, an agency of the Provincial Health Services Authority. “We want to remind British Columbians that if you have received a prescription for Tamiflu from your physician as part of your ‘flu plan’, then please do not fill the prescription unless you are experiencing moderate to severe influenza-like symptoms, or experiencing mild symptoms but have a high risk condition. Tamiflu is intended for treatment and not prevention. It is important to follow your physician’s instructions carefully to help reduce the risk of this virus becoming drug-resistant.”
FluWatch October 17, 2009

31. Key Points antiviral treatment as soon as possible
understand your patient population
identify those at risk of complications
pregnant women, chronic disease, etc….
be familiar with clinical guidelines
stay informed and participate