The Canadian Antiviral Strategy

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The Canadian Antiviral Strategy
Jill Sciberras RN, BNSC, MHSc Immunization and
Respiratory Infections Division Centre for
Infectious Disease Prevention and Control Public
Health Agency of Canada NVAC Pandemic Influenza
Meeting Washington, April 20, 2005
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Presentation Overview

• Background
• Antiviral Strategy
• Role
• Policy Considerations
• Planning
• Status
• Priority groups
• Ongoing Activities

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Background (1)

• Canada Federation of 10 provinces and 3
  territories
• Delivery of health services is a Provincial and
  Territorial responsibility
• Health Canada/Public Health Agency of Canada
  (Federal Health Department)
• National surveillance, coordination, outbreak
  investigations, guidelines, applied research
• Reference laboratory services
• Regulatory functions

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Background (2)

• Three antiviral drugs against influenza are
  currently approved for use in Canada
• - Amantadine for treatment and prophylaxis
• Oseltamivir for treatment and prophylaxis
• Zanamivir for treatment only
• Rimantadine is not approved for use in Canada

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Role of Antivirals

• Not a panacea
• Vaccines, if and when available, should be
  considered the first line for prevention of
  pandemic influenza.
• Avian/animal outbreaks
• have a role in protecting workers and treating
  cases
• Early containment/control
• role at the time of a pandemic alert
• Facilitate goal at time of pandemic
• Treatment and prophylaxis
• Protection of workers prior to vaccine
  availability

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Policy Considerations

• Equitable Access
• Role of National Stockpile access, consistency
  in use
• based on technical advice how much drug?
• Governmental control
• the supply and distribution of available
  anti-influenza drugs, to the end user, during a
  pandemic
• Implications of prioritization

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Planning (1)

• Priority groups for the use of anti-influenza
  drugs in times of short supply
• should be used for planning purposes during the
  inter-pandemic period
• should be based on overall goal and will need to
  be re-assessed once the pandemic strain emerges.

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Planning (2)

• Plan to monitor
• susceptibility / resistance
• Adverse events
• Compliance, use and wastage
• Triggers for use
• should only be used in a community when the
  pandemic influenza virus is detected in the
  community
• The trigger for starting the use of antivirals in
  the community will be decided at the local level
  in conjunction with the province/territory

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Antiviral Strategy Status

• Options for use and stockpiling
• Oseltamivir for treatment and prophylaxis (focus
  of stockpiling efforts)
• Amantadine for prophylaxis only (limited quantity
  stockpiled)
• Guidelines on use of antivirals in short supply
• Goal oriented
• Priority groups for planning purposes
• Clinical guidelines

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Antiviral Strategy Status

• Implementation issues
• strategies for delivery, administration,
  monitoring of distribution, uptake, wastage
• Professional and public education
• Evaluation issues
• monitoring for efficacy, impact, adverse events
  and resistance

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Antiviral Strategy Global Issues

• Security of Supply
• strategies for delivery, administration,
  monitoring of distribution, uptake, wastage
• Modeling of potential impact
• Alone and in combination with other potential
  interventions
• Research
• As identified in the WHO Guideline document

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Priority Groups

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Goal of Influenza Pandemic Planningand Response

• First, to minimize serious illness and overall
  deaths, and second to minimize societal
  disruption among Canadians as a result of an
  influenza pandemic.

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Terminology and Abbreviations

• Tx Treatment
• Px Prophylaxis
• HCW Health care worker
• ESW Essential/Emergency service workers
• High- risk individuals identified by the
  National Advisory Committee on Immunization as
  having a higher risk for complications of
  influenza due to age and/or pre-existing medical
  condition

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Current Thinking Priorities

• Tx of persons hospitalized for influenza
• Tx of ill HCW and ESW
• Px of front line HCW and key health decision
  makers
• Tx of high-risk in the community
• Px of remaining HCW
• Control outbreaks in high-risk residents of
  institutions
• Px of ESW
• Px of high-risk persons hospitalized for
  illnesses other than influenza
• Px of high-risk in the community

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Tx of persons hospitalized for influenza

• Consistent with goal of reducing morbidity and
  mortality
• Evidence to support this use
• Professional obligation to treat (ethical)

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2. Tx of ill HCW and ESW

• High risk of exposure and illness
• Essential to the response (indirect effect on
  morbidity and mortality)

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3. Px of front line HCW and key health
decision makers

• Continuing function of HCW essential to response
• Ideally provide until an effective vaccine is
  available or during the interval between
  administration of an effective vaccine (or
  vaccine series and induction of immunity)
• Front-line would include persons who provide or
  assist in the provision of direct health care
  (within 1 meter) to potential or known influenza
  cases with or without personal protective
  equipment.

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4. Tx of high-risk in the community

• Are at high risk for complications thus
  contributes to goal of reducing morbidity and
  mortality
• Potential to reduce demand for health services
  (hospital beds, intensive care etc.)

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5. Px of remaining HCW

• Continuing function of HCW essential to response
• Ideally provide until an effective vaccine is
  available or during the interval between
  administration of an effective vaccine (or
  vaccine series and induction of immunity)

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6. Control outbreaks in high-risk residents of
institutions

• Contribute to the objectives of reducing
  morbidity and mortality and reducing health care
  demands
• Reduce potential for delayed discharge of
  patients in hospitals

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7. Px of ESW

• Essential for maintaining the pandemic response,
  key community services and national defence.
• Prophylaxis of this group will minimise societal
  disruption
• Ideally provide until an effective vaccine is
  available or during the interval between
  administration of an effective vaccine (or
  vaccine series and induction of immunity)

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8. Px of high-risk persons hospitalized for
illnesses other than influenza

• At risk for acquiring influenza while in hospital
• may result in influenza-related complications in
  such patients, an increase in severity of their
  underlying illness, prolonged hospital stay and
  death
• Contributes to the objectives of reducing
  morbidity and mortality and reduce health care
  demands

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9. Px of high-risk in the community

• Are at high risk for complications
• relatively high demand on health services
  (hospital beds, intensive care etc.)
• Contributes to the objectives of reducing
  morbidity and mortality and reduce health care
  demands.

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Ongoing Activities

• Antiviral Working Group meeting monthly
• Further estimates for severe scenarios
• Resistance testing protocol
• Roles and usage considerations for other
  antiviral drugs (Amantadine Zanamivir)
• Logistics and administration sub-committee being
  formed (defining priority groups)
• Annual utilization (guidelines, KAB)
• Communication challenges (stay home vs present
  early)