A presentation by Australia's Chief Medical Officer, Professor Jim Bishop AO. Options for the control of Influenza VII Conference - Hong Kong 6 Sept 2010

1. 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 Bishop
Chief Medical Officer
Department of Health and Ageing
Australian Government

2. World Health Organisation
stages of PANDEMIC ALERT
WHO declared: phase 4 on 27 April 2009
phase 5 on 29 April 2009
phase 6 on 11 June 2009
post-pandemic 10 August 2010

3. Starting Point
Health Management Plans for
Pandemic Influenza
 Evidence based plans – often
rehearsed
 Frequently based on worse
case scenarios
 Valuable platform or
inflexible

4. Starting Point
Outbreak of 2009 Pandemic Influenza A (H1N1) at a
New York City School
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

6. Starting Point

7. WHAT IS THE REAL CLINICAL PICTURE ?
 Like 1918 ?
 Like seasonal influenza?
 Will it drift/re-assort early ?

8. Hospitalisations of pandemic (H1N1) 2009,
5 June – 23 October 2009, by week
700
Number of hospitalistations associated
600
w ith pandemic (H1N1) 2009
500
Australia
400
300
200
100
0
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 8

9. SUMMARY of SEVERITY INDICATORS
OF PANDEMIC (H1N1) IN AUSTRALIA,
2009 & 2010 (up to 30 July 2010)
2009 2010
CONFIRMED HOSPITALISED ICU CASES DEATHS CONFIRMED DEATHS
PANDEMIC CASES (H1N1) 2009
(H1N1 2009 CASES
CASES
TOTAL NUMBER 37,636 13% 14% 191 362 2
CRUDE RATE 172.1 22.8 3.1 0.9 1.7 n/a
PER
100,000
POPULATION
M EDIAN AGE 21 31 44 53 28 38
(YEARS)
FEMALES 51% 51% 53% 44% 48% 100%
SourceL: Australian Influenza Surveillance Report

10. Clinical Picture
Pandemic (H1N1) 2009
 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

11. Histogram of Number of Concurrent Patients
Receiving ECMO
Across Australia and New Zealand in 2009
SOURCE: The Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators, JAMA 2009;302:1888-1895.

12. 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

13. SUMMARY of SEVERITY INDICATORS
OF PANDEMIC (H1N1) IN AUSTRALIA,
2009 & 2010 (up to 30 July 2010)
2009 2010
CONFIRMED HOSPITALISED ICU CASES DEATHS CONFIRMED DEATHS
PANDEMIC CASES (H1N1) 2009
(H1N1 2009 CASES
CASES
Vunerable groups n/a 58% 74% 67% n/a n/a
(Indigenous
persons, pregnant
women&
individuals with
at least 1 co-
morbidity)
INDIGENOUS 11% 20% 19% 13% 9% n/a
PEOPLE
PREGNANT n/a 27% 16% 4% n/a 0%
WOMEN
Cases with at n/a 46% 67% 62% n/a n/a
least 1 co-
morbidity
SourceL: Australian Influenza Surveillance Report

14. 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

15. What age group ?
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
80.0
Males pandemic (H1N1) 2009
e 0 ,0 0 o u tio )
A es e ificr te(p r 1 0 0 p p la n
70.0
Females pandemic (H1N1) 2009
60.0
2004-07 seasonal influenza
50.0
40.0
30.0
a
20.0
g pc
10.0
0.0
4
9
4
9
4
9
4
9
4
9
4
4
9
4
9
4
9
+
-1
-1
-2
-2
-3
-3
-4
-4
-5
-6
-7
-8
-5
-6
-7
85
0-
5-
10
15
20
25
30
35
40
45
65
50
55
60
70
75
80
Age group (5 Years) 15

16. What was the real death rate ?
Rate of deaths classified as influenza and pneumonia from the
NSW Registered Death Certificates 2005 to 25 June 2010

18. 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

19. Source of infection UK
238 cases - 31 May 2009
SOURCE: Eurosurveillance June 4 2009

20. 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

21. How should we modify our Plans?
H1N1 Influenza 09 Pandemic Phases
ALERT (pre 24 April 09)
DELAY (24 April 09)
H1N1
CONTAIN (22 May 09) Influenza 09,
mild in most
and severe in
some (the
PROTECT
vulnerable)
SUSTAIN 17 June 2009
Victoria moved to a MODIFIED Evidence supports focusing
SUSTAIN on 3 June 2009 efforts on protecting the
‘vulnerable’
CONTROL
RECOVER

22. What Flexibility is needed
PLAN MODIFICATION
 Indigenous Annex
 Cruise Ship Protocol
 GP Roundtable
 Expert Groups - Respiratory Physicians
- Intensive Care Physicians
- ED Physicians
 Actions outside health

23. Vaccine Reality
PANDEMIC VACCINE
 Vaccine available 5 months from start
 Trial data available mid September 2009
 Sufficient qualities end September 2009
 One dose for adults

24. Who is protected
following wave 1 ?
 Serology suggest around 20% immune
 Geographical differences
 Age sensitive

25. What do we expect with wave 2
Modelling of the Impact of Vaccination (ATAGI)
Expected Pandemic Influenza A
(H1N11) 2009 without vaccination
(Second wave)
Influenza with vaccination of
High risk groups alone
Other scenarios of low to
High vaccine uptake in the
population

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
26
SOURCE: Steel Fisher et al. N Engl.J Med 2010: 362

27. H1N1 vaccination campaign (3)
Brochure and poster

28. What happened with Wave 2 ?
Weekly rate of ILI reported from GP ILI surveillance systems from
60
1 January 2007 to 22 August 2010
ASPREN 2007
ASPREN 2008
Rate of ILI per 1,000 consultations
50 ASPREN + NT + VIDRL 2009
ASPREN + VIDRL 2010
40
First case of
Pandemic
(H1N1) 2009
30 reported in
Australia
20
10
0
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 53
Week

29. What happened with wave 2 ?
Percentage of specimens tested by sentinel laboratories influenza positive
1 January 2010 to 30 July 2010, by subtype
Seasonal A/H1N1
0%
Seasonal A/H3N2
24%
Pandemic (H1N1) 2009
67%
Influenza A untyped
4%
Influenza B
5%

30. POST MORTEM
 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