September 28th, 2009
Formatting is a little wonky but the information is solid:
This automated email message is being sent to all physicians in BC by the College of Physicians and Surgeons of British Columbia on behalf of the BC Ministry of Health Services, the BC Centre for Disease Control, the College of Physicians and Surgeons, and the British Columbia Medical Association. Please do NOT reply to this email address.
September 28, 2009
RE: Pandemic (H1N1) Influenza Issues Update
At the request of B.C.’s physicians, a web resource has been established to provide a centralised and ongoing source of current information about the emerging issues surrounding the novel 2009 pandemic H1N1 (pH1N1) influenza virus (see http://www.hls.gov.bc.ca/pho/physh1n1.html - please bookmark this site). You are encouraged to visit the website and sign up to receive notifications when significant updates or additions are available.
In B.C. we work closely with many partners to provide accurate and timely information for providers and the public. The Office of the Provincial Health Officer has developed an ongoing process, including the establishment of formalized working groups, for expert review of the materials that will be posted to this site.
Throughout the evolving influenza season we will update and revise this information as necessary and also provide access to provincial- and health-authority specific information.
In particular, we draw your attention to the following points below. Please see the website for more details and regular updates.
SEASONAL INFLUENZA VACCINATION
As a result of national level discussions about the complexities of concurrently running 2 or even 3 influenza vaccine programs, the possibility of novel 2009 pandemic H1N1 (pH1N1) influenza infections replacing the usual predominance of H3N2 infections, and the potential interaction between seasonal vaccine receipt and pH1N1, we have made the following decisions:
Vaccination against seasonal influenza using the trivalent product (contains the three strains of influenza virus – A/Brisbane/59/2007(H1N1), A/Brisbane/10/2007(H3N2), and B/Brisbane/60/2008) will:
- Be targeted in October for those aged 65 years and older and residents of long term care facilities beginning mid-October;
- For others at higher risk of influenza complications the seasonal vaccine will be offered following the November-December delivery and administration of the pH1N1 vaccine (i.e. seasonal trivalent influenza vaccine will be offered to eligible persons in early 2010). More details on this latter offering will be forthcoming.
In addition, we recommend that workplace-based seasonal influenza immunization programs be delayed until after the pH1N1 vaccination programs have been implemented (i.e. pH1N1 vaccination programs are expected to be completed by end of 2009).
Note these are subject to change if the regular seasonal H3N2 virus makes an unexpected recurrence.
Given patterns of activity over recent years in the northern hemisphere, and more recently in the southern hemisphere this past season, it is considered unlikely that seasonal influenza H3N2 strains will play a major role in influenza illness early in the 2009/2010 season. Thus, delay represents the best balance of benefits, risks and logistics while the focus is on preventing pH1N1 illness.
B.C. has thus made a decision to delay the usual broader offering of seasonal influenza vaccination. We are also aware of preliminary research findings suggesting that prior receipt of seasonal vaccine was associated with moderately increased likelihood of pH1N1 illness (odds ratio approximately 2) during the spring/summer 2009 in Canada. Although this association has not been linked to more severe disease or found in other countries and study methods are still undergoing scientific peer review, expert opinion has been to take the results into consideration pending more definitive knowledge and this has also informed decisions. Should patients under the age of 65 request seasonal influenza vaccine prior to receipt of pH1N1 vaccine, they should also be informed of this so they can make an informed decision.
TESTING FOR pH1N1 FLU VIRUS
Most adults and children with pH1N1 will have typical influenza-like illness. Nearly all children are infected with a number of different viruses during winter and pH1N1 is another with similar signs and symptoms. It is at the clinical discretion of the physician whether the patient needs testing for pH1N1 and/or treatment with antivirals.
Test ONLY to support appropriate treatment as follows:
- Patients NOT at high risk for complications, with typical influenza-like illness who request testing, should be advised that it is NOT NECESSARY.
- Testing by nasopharyngeal swab is recommended only for cases of influenza requiring hospitalization or if the test result will affect management (such as discontinuing antivirals based on a negative test in a pregnant woman).
- As antiviral medications are most effective when started early, treatment decisions in the community should not wait for the results of laboratory testing if performed, but should be made based on the severity of symptoms, the presence of risk factors and the influenza viruses circulating in your community.
ANTIVIRAL TREATMENT FOR pH1N1 FLU VIRUS
If influenza is strongly suspected based on clinical presentation and the presence of pH1N1 is in the community, antiviral use should be considered for the following patients:
· All patients (including children) with moderate to severe clinical influenza-like illness regardless of whether they are admitted to hospital;
· Patients with milder illness who may be at higher risk for subsequent complications, including:
o Pregnant women
o Adults and children with chronic health conditions including cardiac or pulmonary disorders (including bronchopulmonary dysplasia, COPD, cystic fibrosis and asthma), diabetes mellitus, other metabolic diseases, cancer, immunodeficiency or immunosuppression, renal disease, anemia or hemoglobinopathies as well as conditions that compromise the management of respiratory secretions and are associated with an increased risk of aspiration
You may wish to consider giving higher risk patients a prescription in advance, seeing patients quickly if they develop influenza-like symptoms and planning for calling in a prescription if the person becomes ill. To help guard against the development of resistance, please familiarize yourself with the proper antiviral dosing regimen and duration and reinforce clinically-indicated use with patients. Currently, dosing regimens are unchanged from that of regular seasonal influenza, and are dependent upon weight and require adjustments for people with renal failure. Check package inserts. The WHO also advises that risk of antiviral resistance is higher in severely immuno-compromised people with prolonged illness and persistent viral replication given extended treatment and in patients given post-exposure prophylaxis.
REPORTING CASES OF pH1N1 FLU VIRUS INFECTION
Physician reporting of serious outcomes dues to pH1N1 influenza is important to monitor the impact of the pandemic. Physicians are required to report to their Medical Health Officers any cases of lab-confirmed pH1N1 respiratory infection:
- Whose illnesses are severe enough to require admission to hospital; or
- Who die, regardless of whether admitted to hospital.
pH1N1 INFLUENZA VACCINATION
pH1N1 vaccine is anticipated to be available in both adjuvanted and non-adjuvanted formulations by mid-November with the possibility of earlier emergency release. Non-adjuvanted vaccine will be available for pregnant women and children under three years of age and has been selected because there will not have been adequate testing of adjuvanted product on these groups.
Enough vaccine is anticipated to be available to immunize all British Columbians and those visiting B.C. who need and want to be vaccinated.
The immediate priority will be to target those who are anticipated to need and benefit most from immunization, as well as those who care for them, including:
· persons with chronic medical conditions under the age of 65
· pregnant women
· children 6 months to less than 5 years of age
· persons residing in remote and isolated settings or communities
· health care workers involved in pandemic response or who deliver essential health services
· household contacts and care providers of infants < 6 months of age and persons who are immunocompromised
· populations otherwise identified as high risk
Early indications are that a single dose might be adequate for older children and adults. Younger children (age to be determined) may need two doses given three weeks apart.
Vaccine will be available through health authorities, special clinics organized by public health nurses, physicians’ offices, community health nurses who work in First Nations communities, and through health care facilities for health care workers and residents of long-term care. Details of clinic dates and locations will be available through the regional health authorities or local health unit.
We commit to keeping the medical community updated on any further changes.
P.R.W. Kendall Eric R. Young, MD
OBC, MBBS, MHSc, FRCPC BSc, MHSc, CCFP, FRCPC
Provincial Health Officer Deputy Provincial Health Officer
Message from the College of Physicians and Surgeons of British Columbia
The College of Physicians and Surgeons of British Columbia appreciates the work of provincial experts and the collaboration of many stakeholders in compiling a single provincial source of reliable information regarding the diagnosis and management of novel pH1N1 influenza. Successful management of pandemic influenza is dependent upon timely dissemination of relevant information to those who need to know. We strongly encourage your participation in subscribing to the updated features of this website to ensure that the physicians who manage influenza-like illness (ILI) are conversant with the management and treatments listed.
Dr. Heidi Oetter, Registrar
Dr. W. Robbert Vroom, Deputy Registrar , CPSBC liaison to pH1N1 Clinical Advisory Committee
Message from the BCMA
The BCMA is pleased that there will be one source of reliable information for physicians about H1N1. We believe this approach will greatly reduce possible confusion about emerging information and minimize the time physicians and their MOAs will need to spend on keeping up-to-date about the issue. The BCMA has agreed to assist in sending notices of important updates to members.
Brian Brodie, MD
President, BC Medical Association