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