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H1N1 Outbreak

D. Blicq dblicq@rrc.mb.ca  June 2006  (update 01/04/2010) DIRECTORY I BIO I NOTICE BOARD

"World now at the start of 2009 influenza pandemic"   Dr Margaret Chan, Director-General of the World Health Organization (June 12, 2009)

On March 18, 2009 Mexican Health authorities detected cases of swine flu. By April 28th, seven countries reported H1N1 cases: Canada, the US, Mexico, New Zealand, UK Spain and Israel. What began as a virus largely confined to swine populations has evolved and transferred to human populations. A snapshot of confirmed cases and mortalities is below:

"Flu pandemic alert raised to phase 6" -  11 June 2009 -- On the basis of available evidence and expert assessments of the evidence, the scientific criteria for an influenza pandemic have been met. The Director-General of WHO has therefore decided to raise the level of influenza pandemic alert from phase 5 to phase 6."  (WHO news release June 11, 2009)

Pandemic influenza phases

http://www.who.int/csr/disease/influenza/GIPA3AideMemoire.pdf

The World Health Organization defines pandemic phases as follows:

"In nature, influenza viruses circulate continuously among animals, especially birds. Even though such viruses might theoretically develop into pandemic viruses, in Phase 1 no viruses circulating among animals have been reported to cause infections in humans.

In Phase 2 an animal influenza virus circulating among domesticated or wild animals is known to have caused infection in humans, and is therefore considered a potential pandemic threat.

In Phase 3, an animal or human-animal influenza reassortant virus has caused sporadic cases or small clusters of disease in people, but has not resulted in human-to-human transmission sufficient to sustain community-level outbreaks. Limited human-to-human transmission may occur under some circumstances, for example, when there is close contact between an infected person and an unprotected caregiver. However, limited transmission under such restricted circumstances does not indicate that the virus has gained the level of transmissibility among humans necessary to cause a pandemic.

Phase 4 is characterized by verified human-to-human transmission of an animal or human-animal influenza reassortant virus able to cause “community-level outbreaks.” The ability to cause sustained disease outbreaks in a community marks a significant upwards shift in the risk for a pandemic. Any country that suspects or has verified such an event should urgently consult with WHO so that the situation can be jointly assessed and a decision made by the affected country if implementation of a rapid pandemic containment operation is warranted. Phase 4 indicates a significant increase in risk of a pandemic but does not necessarily mean that a pandemic is a forgone conclusion.

Phase 5 is characterized by human-to-human spread of the virus into at least two countries in one WHO region. While most countries will not be affected at this stage, the declaration of Phase 5 is a strong signal that a pandemic is imminent and that the time to finalize the organization, communication, and implementation of the planned mitigation measures is short.

Phase 6, the pandemic phase, is characterized by community level outbreaks in at least one other country in a different WHO region in addition to the criteria defined in Phase 5. Designation of this phase will indicate that a global pandemic is under way."

(World Health organization 2009)

The H1N1 virus has spread globally with remarkable speed, with clinically confirmed cases and deaths confirmed worldwide. The following chart exhibits this rapid growth:

http://a2.vox.com/6a010980b45731000b01101687abc2860d-500pi

Susceptibility and Canada

Most susceptible are those with other health complications - diabetes, lung conditions, immunosupressed individuals, infants / children, the elderly, etc., although some variants are lethal to even previously healthy individuals.  A number of pockets of the disease have appeared within isolated Canadian Indigenous communities (Garden Hill, St. Theresa Point in Manitoba), at a higher proportion than other demographic communities. 

A second wave of Canadian cases appears to have broken out in Canadian schools in Calgary and Ottawa (June 12, 2009).

 

Vaccine Developed?

Swiss pharmaceuticals company Novartis AG announced June 12, 2009 that it has created an initial batch of H1N1 vaccine.  In light of the current situation, clinical trials will be obviously expedited.  Over 30 countries have already requested supplies of the vaccine.

Stay posted for updates and developments.

World Health Organization (WHO) H1N1

http://upload.wikimedia.org/wikipedia/commons/6/65/Influenza-2009-new-A(H1N1)-WHO.PNG

 

SUMMARY WHO RECOMMENDATIONS - PHASES 5-6 PANDEMIC

C. PHASES 5-6

During Phases 5-6 (pandemic), actions shift from preparedness to response at a global level. The goal of recommended actions during these phases is to reduce the impact of the pandemic on society.

  • • Encourage international assistance to resource-poor countries

  • and/or seriously affected countries.

  • • Interact with international organizations and agencies inside

  • and outside of the health sector to coordinate interventions.

AFFECTED COUNTRIES

  • • Maintain trust across all agencies and organizations and with the public through a commitment to transparency and credible actions.

  • • Designate special status as needed, such as declaring a state of emergency.

  • • Provide leadership and coordination to multisectoral resources to mitigate the societal and economic impact of a pandemic.

  • • Work for rational, ethical, and transparent access to resources.

  • • Assess if external assistance is required to meet humanitarian needs.

COUNTRIES NOT YET AFFECTED

  • • Finalize preparations for an imminent pandemic, including activation of crisis committee(s) and national command and control systems.

  • • Update, if necessary, national guidance and recommendations taking into account information from affected countries.

NATIONAL ACTIONS

PLANNING AND COORDINATION

26. Resolution WHA 56.19 Prevention and PHASES 5-6 control of influenza pandemics and annual epidemics. In: Fifty-sixth World Health Assembly, Geneva 19-28 May, 2003

27. Resolution WHA 56.19 Prevention and control of influenza pandemics and annual epidemics. In: Fifty-sixth World Health Assembly, Geneva 19-28 May, 2003.

28. Resolution WHA 56.19 Prevention and control of influenza pandemics and annual epidemics. In: Fifty-sixth World Health Assembly, Geneva 19-28 May, 2003.

29. Ethical considerations in developing a public health response to pandemic influenza (WHO/CDS/EPR/GIP/2007.2), World Health Organization, 2007.

PHASES 5-6   42

  • • Coordinate the assessment and monitoring of the disease characteristics and severity, and provide guidance accordingly.

  • • Monitor the global spread of disease and possible changes in epidemiological, clinical, and virological aspects of infection, including antiviral drug resistance.

  • • Support affected Member States as much as possible in confirming the spread of human infections and assessing the epidemiological situation.

AFFECTED COUNTRIES

Pandemic disease surveillance 58

  • • Undertake a comprehensive assessment of the earliest cases of pandemic influenza.

  • • Document the evolving pandemic including geographical spread, trends, and impact.

  • • Document any changes in epidemiological and clinical features of the pandemic virus.

  • • Maintain adequate virological surveillance to detect antigenic and genetic changes, as well as changes in antiviral susceptibility and pathogenicity.

  • • Modify national case definitions and update clinical and laboratory algorithms for diagnosis, as necessary.

Monitoring and assessment of the impact of the pandemic

  • • Monitor essential health-related resources such as: medical supplies; antivirals, vaccines and other pharmaceuticals; health care worker availability, hospital occupancy/availability; use of alternative health facilities, laboratory material stocks; and mortuary capacity.

  • • Monitor and assess national impact using criteria such as workplace and school absenteeism, regions affected, groups most affected, and essential worker availability.

  • • Assess the uptake and impact of implemented mitigation measures.

  • • Forecast economic impact of the pandemic, if possible.

SITUATION MONITORING AND ASSESSMENT

PHASES 5-6 58. Global surveillance during an influenza pandemic, World Health Organization 2009 (to be published 2009 to http://www.who.int/csr/disease/influenza/ ).

5-6 PANDEMIC WIDESPREAD HUMAN INFECTION 43

PHASES 5-6

  • • Consider and issue any new or revised Temporary Recommendations under IHR (2005), including advice from Emergency Committee as appropriate.59

  • • Facilitate assessment of interventions and update recommendations if needed.

  • • Facilitate assessment of antiviral susceptibility, effectiveness, and safety.

  • • Make recommendations for pandemic vaccine composition60 and switch to pandemic vaccine production if not previously done.

  • • Facilitate development of national guidelines for national authorities to conduct targeted vaccination campaigns if pandemic vaccine is available.

WHO ACTIONS ALL COUNTRIES International travel measures

• Take into account WHO guidance and information when issuing international travel advisories and health alerts.

AFFECTED COUNTRIES Individual/household level measures

  • • Advise people with acute respiratory illness to stay at home and to minimize their contact with household members and others.

  • • Advise household contacts to minimize their level of interaction outside the home and to isolate themselves at the first sign of any symptoms of influenza.

  • • Provide infection control guidance for household caregivers61 taking into account the WHO Guidance.62 Societal level measures

  • • Implement social distancing measures as indicated in national plans, such as class suspensions and adjusting working patterns.

  • • Encourage reduction in travel and crowding of the mass transport system.63

  • • Assess and determine if cancellation, restriction, or modification of mass gatherings is indicated.64 International travel measures

  • • Consider implementing exit screening as part of the early global response (i.e. first few affected countries).65

  • • Provide advice to travellers.

Pharmaceutical measures

  • • Distribute antivirals, and other medical supplies in accordance with national plans.

  • • Implement vaccine procurement plans.

  • • Plan for vaccine distribution and accelerate preparations for mass vaccination campaigns.

  • • Modify/adapt antiviral and vaccine strategies based on monitoring and surveillance information.

  • • Implement medical prophylaxis campaigns for antivirals and/or vaccines according to priority status and availability in accordance with national plans.

  • • Monitor safety and efficacy of pharmaceutical interventions to the extent possible and monitor supply.

COUNTRIES NOT YET AFFECTED

  • • Be prepared to implement planned interventions to reduce the spread of pandemic disease.

  • • Update recommendations on the use of planned interventions based on experience and information from affected countries.

  • • Implement distribution and deployment plans for pharmaceuticals, and other resources as required.

  • • Consider implementing entry screening at international borders.66

NATIONAL ACTIONS

REDUCING THE SPREAD OF DISEASE

59. Assuming a PHEIC has been PHASES 5-6 determined to be occurring as defined by IHR (2005)

60. Especially if non-pandemic strains are still circulating.

61. If medical masks are available and the training on their correct use is feasible, they may be considered for symptomatic persons and susceptible caregivers in household settings when close contact can not be avoided.

62. Infection prevention and control of epidemic- and pandemic-prone acute respiratory diseases in health care, WHO Interim Guidelines. Geneva, World Health Organization 2007. (WHO/CDS/EPR/2007.6)

63. Symptomatic people should self-isolate and avoid using public transport. There is, however, insufficient evidence to date to either support or oppose the closure or restriction of mass transport systems as a measure to reduce disease transmission in the community.

64. If a country decides to cancel, restrict or modify all or certain mass gatherings, this decision should be based on the nature of the gathering and on local disease levels, and should only be

implemented once the disease is present in the community.

65. It exit screening is implemented, it should be considered as a time-limited intervention and the isolation and treatment of cases and quarantine of contacts resulting from screening must be carried out in accordance with IHR (2005).

66. It entry screening is implemented, it should be considered as a time-limited intervention and the isolation and treatment of cases and quarantine of contacts resulting from screening must be carried out in accordance with IHR (2005).

WHO recognizes individual country considerations will affect national decisions, but, in general, does not encourage:

  • • Pandemic-related international border closures for people and/or cargo.

  • • General disinfection of the environment during a pandemic.

  • • The use of masks in the community by well persons.

  • • The restriction of travel within national borders during a pandemic, with the exception of a globally led rapid response and containment operation, or in rare instances where clear geographical and other barriers exist.

44

  • • Coordinate response with other international organizations.

  • • Provide guidance to national authorities in assisting clinicians in recognition, diagnosis, and reporting of cases and other critical issues as needed.

  • • Implement pandemic contingency plans for full mobilization of health systems, facilities, and workers at national and subnational levels.

  • • Implement and adjust the triage system as necessary.

  • • Enhance infection control practices in healthcare and laboratory settings and distribute personal protective equipment in accordance with national plans.

  • • Provide medical and non-medical support for patients and their contacts in households and alternative facilities if needed.

  • • Provide social and psychological support for health care  workers, patients, and communities.

  • • Implement corpse management procedures as necessary.

FOR COUNTRIES NOT YET AFFECTED

• Prepare to switch to pandemic working arrangements.

WHO ACTIONS NATIONAL ACTIONS CONTINUITY OF HEALTH CARE AND PROVISION PHASES 5-6

  • • Update national authorities, other partners and stakeholders, and the public on global situation, trends, epidemiological characteristics, and recommended measures.

  • • Continue to work with partners to promote consistent messages. • Regularly update the public on what is known and unknown about the pandemic disease, including transmission patterns, clinical severity, treatment, and prophylaxis options.

  • • Provide regular communications to address societal concerns, such as the disruption to travel, border closures, schools, or the economy or society in general.

  • • Regularly update the public on sources of emergency medical care, resources for dealing with urgent non-pandemic health care needs, and resources for self-care of medical conditions.

Local Activity - Manitoba, Canada

January 2010

Specialty clinics now closed. A variety of smaller clinics and resources available for vaccination.

November 24, 2009

H1N1 inoculation clinics open to everyone.  Turnouts slow but steady at most Winnipeg clinics. A single fatality reported to date along with several hundred clinically-confirmed H1N1 cases.

October 24, 2009

WRHA has begum distributing H1N1 vaccine to priority "at risk" groups - aboriginals, metis, pregnant women, toddlers and those with suppressed immunological function or asthma. All others are asked to wait.

Locations for receiving the vaccine in Winnipeg:

Clinic Hours

Monday to Thursday: 9:30 a.m. to 8 p.m.

Friday: 9:30 a.m. to 4 p.m.

Clinic Locations

Assiniboine South St. Demetrios Greek Orthodox Church 2255 Grant Avenue View Details
Downtown Portage Place Shopping Centre
393 Portage Avenue		 View Details
Fort Garry University of Manitoba, Fort Garry Campus Room 210, Multi Purpose Room, 2nd Floor University Centre View Details
Inkster Fred Douglas Lodge
1275 Burrows Avenue		 View Details
Point Douglas St. Joseph's Parish Hall
515 College Avenue		 View Details
River East Holy Eucharist Parish Centre
460 Munroe Avenue *
* Except Tuesdays 3:30 - 8:00 p.m.

Polson School
491 Munroe Avenue *
 * Tuesdays 4:00 - 8:00 p.m. only		 View Details
River Heights Grant Park Shopping Centre
1120 Grant Avenue		 View Details
St. Boniface Centre culturel franco-manitobain
340 Provencher Boulevard		 View Details
St. James St. Paul the Apostle Parish Centre
2400 Portage Avenue		 View Details
St. Vital Indo-Canadian Arts and Cultural Centre
479 St. Mary's Road		 View Details
Seven Oaks Garden City Shopping Centre
2305 McPhillips Street		 View Details
Transcona DeFehr Furniture Plant
770 Pandora Avenue East		 View Details

H1N1 flu shots are free for everyone. Patients will be seen on a first-come, first-served basis, and no appointment is necessary.

Please remember to bring your Manitoba Health card.

 

Government of Manitoba

Confirmed Cases of H1N1 Flu in Manitoba 

(as of October 26, 2009)

Confirmed H1N1 Cases for Manitoba
New cases this week
19
Total cases reported to date
924
H1N1 associated deaths
7

 (as of June 12, 2009**)

Health Region
Assiniboine 0
Brandon 7
Burntwood/Churchill 47
Central 0
Interlake 2
Nor-Man 10
North Eastman 2
Parkland 1
South Eastman 1
Winnipeg 49
Total 119

**NOTE: The information provided in this table is based on preliminary data and may change as more information becomes available.

 

September 2009 - Province of Manitoba Data:

"In Manitoba, during the first wave of H1N1 flu, the risk factors for severe illness have been:

• people with underlying medical conditions such as diabetes, lung disease or heart disease;

• people with immune disorders or receiving cancer treatment;

• pregnancy;

• obesity or malnutrition;

• social conditions, such as smoking, substance abuse or alcoholism; and

• Aboriginal ancestry.

To date, the data indicates that people under the age of 55 are more likely to develop severe illness."

 

June 15th 2009 - Winnipeg Sun:

"After a recent jump in the number of H1N1 flu cases in Manitoba, Winnipeg emergency crews reported plenty of related calls for help. The United Fire Fighters Association of Winnipeg told local media that Winnipeg fire and paramedic crews received a whopping 220 calls from people about suspected cases of the virus formerly known as swine flu over the weekend. The panic, however, has not exceeded capacity to deal with all emergency calls so far, according to the union. Manitoba Health officials have repeatedly warned Manitobans not to panic, even as the World Health Organization officially declared the flu outbreak a pandemic."

 

Shades of 1918?

WHAT CAN YOU DO TO LIMIT TRANSMISSION?

- Sick means no contact.  Stay home, get professional advice.

- Wash hands - door knobs transfer more interpersonal germs than many other tactile sources. Wash and rewash.

- Cover that cough.  Air-borne aerosols are excellent vectors. Cover with a mask, cough into hands or just stay home!

LINKS & INFORMATION

World Health Organization (WHO) H1N1

Government of Canada:  H1N1 Swine Flu

Province of Manitoba H1N1

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