Symposium on Infectious Symposium on Infectious Diseases: Diseases: Pandemic H1N1Pandemic H1N1

Dr. Liana NolanDr. Liana Nolan

Commissioner/Medical Officer of Health Commissioner/Medical Officer of Health

Region of WaterlooRegion of Waterloo

Waterloo Inn, Waterloo Inn,

November 4, 2009November 4, 2009

AgendaAgenda

pH1N1:pH1N1: OverviewOverview Current TrendsCurrent Trends Projections of upcoming activityProjections of upcoming activity

Waterloo Region Pandemic PlanWaterloo Region Pandemic Plan pH1N1 VaccinepH1N1 Vaccine Antiviral RecommendationsAntiviral Recommendations QuestionsQuestions

H1N1 OverviewH1N1 Overview

The H1N1 flu virus is another strain of the influenza The H1N1 flu virus is another strain of the influenza virus.virus.

It causes symptoms similar to those of the seasonal It causes symptoms similar to those of the seasonal flu (fever and cough and one or more of the flu (fever and cough and one or more of the following: sore throat, muscle aches, joint pain, or following: sore throat, muscle aches, joint pain, or weakness).weakness).

It spreads in the same manner as seasonal influenza It spreads in the same manner as seasonal influenza does.does.

The methods to prevent and control it are the same as The methods to prevent and control it are the same as those for seasonal influenza. those for seasonal influenza.

H1N1 OverviewH1N1 Overview

What is different about H1N1, as compared to seasonal What is different about H1N1, as compared to seasonal influenza:influenza: It predominantly affects younger populations: Children, It predominantly affects younger populations: Children,

adolescents, young adults. adolescents, young adults. Hospitalization rate:Hospitalization rate:

3.0 hospital admissions per 100,000 Ontarians3.0 hospital admissions per 100,000 Ontarians Australia this past summer: 22.7 hospital admissions per Australia this past summer: 22.7 hospital admissions per

100,000 population 100,000 population Fatality rate:Fatality rate:

1.9 deaths per 1 million Ontarians1.9 deaths per 1 million Ontarians Ontario average for seasonal flu: 33 deaths per 1 million Ontario average for seasonal flu: 33 deaths per 1 million

OntariansOntarians

H1N1 – Age Distribution (Graph)

H1N1 OverviewH1N1 Overview

Groups at higher risk for complications:Groups at higher risk for complications: Age Age <5<5 Age ≥65Age ≥65 Pregnant womenPregnant women Those with chronic medical conditions (Those with chronic medical conditions (heart or heart or

lung disease, diabetes, cancer, immuno-lung disease, diabetes, cancer, immuno-suppression, morbid obesity, etc.)suppression, morbid obesity, etc.)

Individuals living in remote/isolated communitiesIndividuals living in remote/isolated communities

Current TrendsCurrent Trends

H1N1 activity has been increasing locally and across H1N1 activity has been increasing locally and across the province/ country in the last few weeks, the province/ country in the last few weeks, especially in the last couple of weeks.especially in the last couple of weeks.

Local status (Waterloo Region): Local status (Waterloo Region): Over 100 influenza cases since Sept. 1, 2009; at varying Over 100 influenza cases since Sept. 1, 2009; at varying

stages of confirmation of strain. Expecting vast majority, stages of confirmation of strain. Expecting vast majority, if not all, to be pH1N1.if not all, to be pH1N1.

Number of confirmed cases who have died: 0Number of confirmed cases who have died: 0

Reported cases will always be an under-estimate.Reported cases will always be an under-estimate.

Current TrendsCurrent Trends

Locally:Locally: Consultation rates for ILI in doctor’s officesConsultation rates for ILI in doctor’s offices

70-80 per 1,000 patient visits; mirrors provincial 70-80 per 1,000 patient visits; mirrors provincial average.average.

School absenteeismSchool absenteeism 25-30% of schools reporting absenteeism 10%; Elementary schools Secondary schools

Emergency Room visits for ILIEmergency Room visits for ILI Most often mild-moderateMost often mild-moderate

Southern Hemisphere ComparatorsSouthern Hemisphere Comparators

Australia:Australia: Fully susceptible population, no vaccineFully susceptible population, no vaccine Similar publicly funded health care systemSimilar publicly funded health care system Racially diverseRacially diverse Aboriginal populationAboriginal population Major urban centres along with large rural Major urban centres along with large rural

areas and very remote isolated communitiesareas and very remote isolated communities

Australia Specific DataAustralia Specific Data

Overall hospitalization rate 22.7 per 100,000Overall hospitalization rate 22.7 per 100,000 Highest rates of hospitalization in childrenHighest rates of hospitalization in children Pregnant women and aboriginal people Pregnant women and aboriginal people

disproportionately represented in hospital disproportionately represented in hospital admissionsadmissions

pH1N1 was the predominant circulating strain pH1N1 was the predominant circulating strain of influenzaof influenza

Queensland specific dataQueensland specific data Most detailed data comes from QueenslandMost detailed data comes from Queensland This data closely resembles Ontario data to dateThis data closely resembles Ontario data to date Rate of hospitalization 28.7 per 100,000Rate of hospitalization 28.7 per 100,000 53% of cases admitted were within 48 hours of 53% of cases admitted were within 48 hours of

symptom onsetsymptom onset 20.6% of hospital admissions required an ICU 20.6% of hospital admissions required an ICU

or special care bedor special care bed Medium length of stay 9 daysMedium length of stay 9 days 38% of ICU admits had no underlying 38% of ICU admits had no underlying

comorbiditiescomorbidities

Potential Impact for RoWPotential Impact for RoW

Estimates of Hospital Admissions:Estimates of Hospital Admissions: Includes all three sitesIncludes all three sites Estimated rate 28.7 per 100,000Estimated rate 28.7 per 100,000 Translates into 142.5 hospital admissions over Translates into 142.5 hospital admissions over

the course of the second wave to all three sitesthe course of the second wave to all three sites

Potential Impact for RoWPotential Impact for RoW

Paediatric Bed Requirements:Paediatric Bed Requirements: Total of 13.5 paediatric admissions for those less Total of 13.5 paediatric admissions for those less

than 5 years of agethan 5 years of age Also increased demand for 5 to 16 year age Also increased demand for 5 to 16 year age

groupgroup

Potential Impact for RoWPotential Impact for RoWEmergency Department Visits:Emergency Department Visits: 13.8% of RoW adults have difficulty accessing 13.8% of RoW adults have difficulty accessing

clinical services (2005 Public Health data)clinical services (2005 Public Health data) 51,084 people rely on urgent care or ED care51,084 people rely on urgent care or ED care 18 to 24 age group has greatest difficulty (21%)18 to 24 age group has greatest difficulty (21%)

High rate of attack of pH1N1High rate of attack of pH1N1 Generally less likely to seek consultationGenerally less likely to seek consultation

Extrapolation from Australia data hospital Extrapolation from Australia data hospital admits require 712-1425 ED visits over 3 admits require 712-1425 ED visits over 3 hospitals over entire second wavehospitals over entire second wave

Potential Impact for RoWPotential Impact for RoWICU and Ventilator Requirements:ICU and Ventilator Requirements: 20.6% of hospital admissions require ICU bed20.6% of hospital admissions require ICU bed Translates into 29.3 ICU admissions over 3 Translates into 29.3 ICU admissions over 3

hospitals for entire second wavehospitals for entire second wave 73% require a ventilator (21.4 vents)73% require a ventilator (21.4 vents) 7% may require ECMO if available7% may require ECMO if available Median length of stay 9 days Median length of stay 9 days

Projections for ILI visits – Projections for ILI visits – Primary CarePrimary Care

Based on Australian experience:Based on Australian experience: This wave of influenza activity will last about 8 to 12 This wave of influenza activity will last about 8 to 12

weeks. weeks. The peak of influenza activity for Ontario is anticipated to The peak of influenza activity for Ontario is anticipated to

be mid November.be mid November. Over 50% of patients who ended up admitted to hospital Over 50% of patients who ended up admitted to hospital

because of serious illness did so within the first 48 hours of because of serious illness did so within the first 48 hours of symptom onset.symptom onset.

Urgent bookings for ILI: focus on patients at higher risk for Urgent bookings for ILI: focus on patients at higher risk for complications for whom antivirals are indicated within 48 complications for whom antivirals are indicated within 48 hours of illness onset. hours of illness onset.

Waterloo Region Pandemic PlanWaterloo Region Pandemic Plan

Waterloo Region Pandemic PlanWaterloo Region Pandemic Plan

Waterloo Region's Community Pandemic Waterloo Region's Community Pandemic Influenza Preparedness Plan (CPIPP) Influenza Preparedness Plan (CPIPP) Available at Available at www.waterlooregionpandemic.ca

(approximately 400 pages)(approximately 400 pages) Developed by over 200 individuals from over 50 Developed by over 200 individuals from over 50

organizations. This includes representatives from the organizations. This includes representatives from the hospitals, municipalities, emergency response agencies hospitals, municipalities, emergency response agencies (police, fire, ambulance) and social service agencies.(police, fire, ambulance) and social service agencies.

Waterloo Region Pandemic PlanWaterloo Region Pandemic Plan It is unlikely Waterloo Region's Community Pandemic It is unlikely Waterloo Region's Community Pandemic

Influenza Preparedness Plan (CPIPP), which includes Influenza Preparedness Plan (CPIPP), which includes provisions for a severe pandemic, will be implemented in full provisions for a severe pandemic, will be implemented in full given the overall mild to moderate severity of the H1N1 virus given the overall mild to moderate severity of the H1N1 virus to date.to date.

Some examples of differences between the full plan and the Some examples of differences between the full plan and the current response plan: current response plan: Some public health measures may not be implemented. For example, Some public health measures may not be implemented. For example,

schools and child care facilities are recommended to remain open and schools and child care facilities are recommended to remain open and there is no recommendation to cancel mass gatherings.there is no recommendation to cancel mass gatherings.

Antivirals are recommended only for people who are seriously ill (i.e. Antivirals are recommended only for people who are seriously ill (i.e. hospitalized) or at higher risk of complications (e.g. pregnant women, hospitalized) or at higher risk of complications (e.g. pregnant women, individuals with underlying chronic conditions). Antivirals are being individuals with underlying chronic conditions). Antivirals are being distributed through the existing infrastructure (pharmacies).distributed through the existing infrastructure (pharmacies).

Public Health's RolePublic Health's Role Collecting and reporting on local surveillance dataCollecting and reporting on local surveillance data Adapting its seasonal and H1N1 immunization Adapting its seasonal and H1N1 immunization

campaigns based on evolving provincial directioncampaigns based on evolving provincial direction Providing information to the public and health care Providing information to the public and health care

partnerspartners Providing ongoing consultation and support to Providing ongoing consultation and support to

community partnerscommunity partners Coordinating planning for the health care sector, re Coordinating planning for the health care sector, re

strategies for influenza assessment and treatment.strategies for influenza assessment and treatment.

Vaccines (H1N1 & Seasonal)Vaccines (H1N1 & Seasonal)3 Phase Roll-Out:

*H1N1: Due to temporary, limited supply, H1N1 vaccine reserved for higher-risk groups at beginning of November

H1N1 Vaccine SequencingH1N1 Vaccine Sequencing

Groups in First Sequence:Groups in First Sequence: Persons with chronic conditions under the age of 65Persons with chronic conditions under the age of 65 Pregnant womenPregnant women Children 6 months to less than 5 years of ageChildren 6 months to less than 5 years of age Health care workers (i.e. all health care system workers involved with Health care workers (i.e. all health care system workers involved with

the pandemic response or delivery of essential health services)the pandemic response or delivery of essential health services) Household contacts and care providers of: infants under 6 months of Household contacts and care providers of: infants under 6 months of

age or persons who are immunocompromisedage or persons who are immunocompromised Persons residing in remote and isolated settings or communitiesPersons residing in remote and isolated settings or communities

Groups in Second Sequence:Groups in Second Sequence: Everyone elseEveryone else

H1N1 Vaccine DistributionH1N1 Vaccine Distribution

As per Ministry direction, distribution of the H1N1 As per Ministry direction, distribution of the H1N1 vaccine will occur through a more restricted number vaccine will occur through a more restricted number of providers than for the seasonal influenza vaccine of providers than for the seasonal influenza vaccine (primary care providers, Public Health-organized (primary care providers, Public Health-organized community clinics, health care facilities, etc.)community clinics, health care facilities, etc.)

Workplaces not among those authorized to provide Workplaces not among those authorized to provide immunization clinics for H1N1.immunization clinics for H1N1.

Components of H1N1 VaccineComponents of H1N1 Vaccine

The H1N1 vaccine is made exactly like the seasonal The H1N1 vaccine is made exactly like the seasonal influenza vaccine that is produced each year, except influenza vaccine that is produced each year, except for the addition of an adjuvant.for the addition of an adjuvant.

The use of an adjuvant allows a comparable immune The use of an adjuvant allows a comparable immune response at a significantly lower antigen dose, thus response at a significantly lower antigen dose, thus allowing faster production of more doses of vaccine. allowing faster production of more doses of vaccine.

Adjuvant use is also expected to provide some cross Adjuvant use is also expected to provide some cross protection against virus drift.protection against virus drift.

H1N1 AdjuvantH1N1 Adjuvant

ASO3 is the name of the adjuvantASO3 is the name of the adjuvant It is an oil-in-water suspension with the oil component It is an oil-in-water suspension with the oil component

consisting of DL-consisting of DL-αα-tocopherol (Vitamin E) and -tocopherol (Vitamin E) and squalene. squalene.

SqualeneSqualene is a naturally occurring substance found in is a naturally occurring substance found in plants, animals, and humans. It is manufactured in the plants, animals, and humans. It is manufactured in the liver of every human body and circulates in our liver of every human body and circulates in our bloodstream. Squalene is commercially extracted from bloodstream. Squalene is commercially extracted from fish oil. The squalene in the vaccine is derived from fish oil. The squalene in the vaccine is derived from shark liver oil and highly purified (i.e. no allergens). shark liver oil and highly purified (i.e. no allergens).

H1N1 AdjuvantH1N1 Adjuvant

The substance used to maintain the oil in suspension The substance used to maintain the oil in suspension is polysorbate 80 (also known as Tween 80)is polysorbate 80 (also known as Tween 80) An emulsifier found in other vaccines and also used in ice An emulsifier found in other vaccines and also used in ice

creamcream Therefore, Therefore, the adjuvant is made up of natural the adjuvant is made up of natural

ingredients such as fish oil, water, and vitamin Eingredients such as fish oil, water, and vitamin E..

H1N1 AdjuvantH1N1 Adjuvant

The ASO3 adjuvant has been studied in The ASO3 adjuvant has been studied in 45,000 people. 45,000 people.

Its use has resulted in increased local reactions Its use has resulted in increased local reactions at the injection site but no serious safety at the injection site but no serious safety concerns have been noted.concerns have been noted.11

1 WHO Virtual Consultation on the Safety of Adjuvanted Influenza Vaccines (3 June 2009): http://www.who.int/vaccine_research/InfluenzaMeeting/en/index.html

H1N1 Vaccine: H1N1 Vaccine: Recommendations for UseRecommendations for Use

All Canadians 10 years of age and older All Canadians 10 years of age and older should receive one dose of adjuvanted vaccine.should receive one dose of adjuvanted vaccine.

Children from six months to nine years of age Children from six months to nine years of age should receive the adjuvanted vaccine in two should receive the adjuvanted vaccine in two half-doses, administered 21 days apart.half-doses, administered 21 days apart.

Pregnant women: See next slidePregnant women: See next slide

Pregnancy: Adjuvanted or Pregnancy: Adjuvanted or Unadjuvanted?Unadjuvanted?

There are two types of H1N1 vaccine approved by There are two types of H1N1 vaccine approved by Health Canada for pregnant women: the adjuvanted Health Canada for pregnant women: the adjuvanted H1N1 vaccine and the un-adjuvanted (or non-H1N1 vaccine and the un-adjuvanted (or non-adjuvanted) H1N1 vaccine.  adjuvanted) H1N1 vaccine.  

All evidence suggests that adjuvanted vaccines are All evidence suggests that adjuvanted vaccines are just as safe as unadjuvanted vaccines; however the just as safe as unadjuvanted vaccines; however the adjuvanted vaccine has not been specifically studied adjuvanted vaccine has not been specifically studied in pregnant women. in pregnant women.

Unadjuvanted vaccine won’t be available in Canada Unadjuvanted vaccine won’t be available in Canada until at least the second week of November.  until at least the second week of November. 

Pregnancy: Adjuvanted or Pregnancy: Adjuvanted or unadjuvanted?unadjuvanted?

Given that influenza rates are rising in our Given that influenza rates are rising in our community, it is recommended that community, it is recommended that pregnant women pregnant women with pre-existing health conditions or who are with pre-existing health conditions or who are more than 20 weeks pregnantmore than 20 weeks pregnant be offered the be offered the adjuvanted vaccine that is available now.  These adjuvanted vaccine that is available now.  These pregnant women are at greater risk of complications pregnant women are at greater risk of complications from H1N1.from H1N1.

Healthy pregnant women Healthy pregnant women 20 weeks gestation may 20 weeks gestation may wait for the unadjuvanted vaccine if they wish.wait for the unadjuvanted vaccine if they wish.

Pregnancy: Adjuvanted or Pregnancy: Adjuvanted or unadjuvanted?unadjuvanted?

SOGC recommendations:SOGC recommendations: www.sogc.org ““The SOGC recommends that all pregnant women over 20 The SOGC recommends that all pregnant women over 20

weeks gestation and those less than 20 weeks with weeks gestation and those less than 20 weeks with underlying risk conditions be vaccinated against H1N1 as underlying risk conditions be vaccinated against H1N1 as soon as a vaccine is available, whether or not it includes an soon as a vaccine is available, whether or not it includes an adjuvant. In areas where H1N1 flu rates are high or adjuvant. In areas where H1N1 flu rates are high or increasing, health-care providers should offer immediate increasing, health-care providers should offer immediate vaccination with adjuvanted vaccines and not wait for non-vaccination with adjuvanted vaccines and not wait for non-adjuvanted vaccines which may only be available in adjuvanted vaccines which may only be available in November.”November.”

Who should NOT receive the Who should NOT receive the vaccine?vaccine?

Infants under 6 months of age (tInfants under 6 months of age (the H1N1 flu vaccine he H1N1 flu vaccine is not approved for children under six months of age).is not approved for children under six months of age).

Anyone who had a serious allergic reaction (i.e. Anyone who had a serious allergic reaction (i.e. developed hives, swelling of the mouth of throat, or developed hives, swelling of the mouth of throat, or trouble breathing) to:trouble breathing) to: A previous dose of the influenza vaccineA previous dose of the influenza vaccine Egg or egg productsEgg or egg products ThimerosalThimerosal Any other component of the vaccineAny other component of the vaccine

Who should NOT receive the Who should NOT receive the vaccine?vaccine?

Persons who developed Guillain-Barré Syndrome Persons who developed Guillain-Barré Syndrome within 8 weeks within 8 weeks of receiving a seasonal flu vaccine.of receiving a seasonal flu vaccine.

People who are currently seriously ill with an People who are currently seriously ill with an infection should wait until they recover before infection should wait until they recover before receiving the vaccine.receiving the vaccine.

Persons with a mild egg allergy Persons with a mild egg allergy consult a consult a healthcare provider before immunization healthcare provider before immunization may be may be able to be immunized with some additional able to be immunized with some additional precautions.precautions.

Adverse ReactionsAdverse Reactions

Clinical trials found the most common reactions after Clinical trials found the most common reactions after getting the adjuvanted vaccine included pain, swelling getting the adjuvanted vaccine included pain, swelling and redness at the injection site. and redness at the injection site. Pain at the injection site was more frequent Pain at the injection site was more frequent the adjuvant the adjuvant

improves immunogenicity by causing an increased improves immunogenicity by causing an increased inflammatory reaction.inflammatory reaction.

Other commonly reported reactions were fatigue, Other commonly reported reactions were fatigue, muscle and joint pain, and headache. muscle and joint pain, and headache.

In younger children, a fever, drowsiness, irritability and In younger children, a fever, drowsiness, irritability and loss of appetite were also reported in low percentages.loss of appetite were also reported in low percentages.

Adverse ReactionsAdverse Reactions

As with the seasonal influenza vaccine, it is As with the seasonal influenza vaccine, it is expected that most side effects will be mild, expected that most side effects will be mild, and that serious side effects will be very rare.and that serious side effects will be very rare.

What about the 1976 Guillain-What about the 1976 Guillain-Barré Syndrome?Barré Syndrome?

The story:The story: In January and February 1976, a new strain of influenza A In January and February 1976, a new strain of influenza A

of swine origin appeared among military personnel on a of swine origin appeared among military personnel on a military base at Fort Dix, New Jersey. military base at Fort Dix, New Jersey.

Although the strain of influenza did not spread beyond the Although the strain of influenza did not spread beyond the base and cases ceased within a few weeks, in October 1976 base and cases ceased within a few weeks, in October 1976 officials began a mass immunization campaign to prevent officials began a mass immunization campaign to prevent the circulation of this New Jersey strain. the circulation of this New Jersey strain.

1976 Guillain-Barré Syndrome1976 Guillain-Barré Syndrome

In total, 45 million doses of vaccine were administered in In total, 45 million doses of vaccine were administered in the United States between October and December 1976. the United States between October and December 1976.

The program was stopped when it was realized that 500 The program was stopped when it was realized that 500 cases of Guillain-Barré Syndrome (GBS) had arisen after cases of Guillain-Barré Syndrome (GBS) had arisen after vaccination, resulting in 25 deaths. vaccination, resulting in 25 deaths.

It is estimated that slightly less than 1 in It is estimated that slightly less than 1 in 100,000 vaccinated people developed GBS in 100,000 vaccinated people developed GBS in 1976. 1976.

Risk of GBS with Influenza Risk of GBS with Influenza ImmunizationImmunization

In subsequent vaccination seasons, studies In subsequent vaccination seasons, studies have shown either a non-existent risk of GBS have shown either a non-existent risk of GBS after influenza vaccine or an increased risk of after influenza vaccine or an increased risk of approximately 1 per 1 million doses of approximately 1 per 1 million doses of influenza vaccine administered.influenza vaccine administered.

Reference: Haber P et al. Vaccines and Guillain-Barré Syndrome. Drug Safety 2009;(32)4:309-323. Credit to Dr. Bryna Warshawsky for slide bullet points.

Background incidence of GBSBackground incidence of GBS

In a Canadian study, the background incidence of In a Canadian study, the background incidence of GBS due to any cause was estimated at 2.02 per GBS due to any cause was estimated at 2.02 per 100,000 person-years in Ontario and 2.30 per 100,000 person-years in Ontario and 2.30 per 100,000 person-years in Quebec100,000 person-years in Quebec11..

A variety of infectious agents, including A variety of infectious agents, including Campylobacter jejuniCampylobacter jejuni, cytomegalovirus, Epstein-Barr , cytomegalovirus, Epstein-Barr virus and virus and Mycoplasma pneumoniaeMycoplasma pneumoniae, have been , have been associated with GBSassociated with GBS22..

1 McLean M, Duclos P, Jacob P et al. Incidence of Guillain-Barre syndrome in Ontario and Quebec, 1983- 1989, using hospital service databases. Epidemiology 1994;5(4):443-48.2 Hughes RA, Cornblath DR. Guillain-Barre syndrome. Lancet 2005;366(9497):1653-66.

““What about the mercury in the What about the mercury in the vaccine?” vaccine?”

Both the adjuvanted and unadjuvanted vaccines contain a Both the adjuvanted and unadjuvanted vaccines contain a small amount of thimerosal. small amount of thimerosal.

Thimerosal is a form of mercury used in the H1N1 vaccine to Thimerosal is a form of mercury used in the H1N1 vaccine to stabilize it and maintain its quality during storage. stabilize it and maintain its quality during storage.

Thimerosal is a different form of mercury than the mercury Thimerosal is a different form of mercury than the mercury known to cause health problems. known to cause health problems.

The amount in the H1N1 adjuvanted flu vaccine is much less The amount in the H1N1 adjuvanted flu vaccine is much less than the daily limit recommended for environmental exposure than the daily limit recommended for environmental exposure to mercury.  For example, to mercury.  For example, there is significantly less mercury there is significantly less mercury in the vaccine than you would find in a can of tuna fishin the vaccine than you would find in a can of tuna fish..

What if someone already had What if someone already had influenza-like illness?influenza-like illness?

Unless they’ve had laboratory confirmed Unless they’ve had laboratory confirmed pH1N1, recommendation is that they be pH1N1, recommendation is that they be immunized.immunized.

No harm if they've already had pH1N1.No harm if they've already had pH1N1.

Co-administration with other Co-administration with other vaccinesvaccines

H1N1 flu vaccine may be administered H1N1 flu vaccine may be administered concurrently with seasonal flu vaccine and concurrently with seasonal flu vaccine and other vaccines.other vaccines. If co-administered, injections should be given in If co-administered, injections should be given in

separate limbs.separate limbs. If not given concurrently, there is no minimum If not given concurrently, there is no minimum

interval required between the H1N1 flu interval required between the H1N1 flu vaccine and other vaccines.vaccine and other vaccines.

How long after immunization for How long after immunization for immunity?immunity?

Most people will start to develop immunity Most people will start to develop immunity within 10 days after receiving the vaccine.within 10 days after receiving the vaccine.

Recommendations to Prevent/ Recommendations to Prevent/ Reduce Spread of H1N1Reduce Spread of H1N1

Get the H1N1 & Seasonal Flu Shots

Antiviral Recommendations:Antiviral Recommendations:

Those who are asked to Those who are asked to contact their doctor as soon as contact their doctor as soon as they become ill with symptoms of influenza, to discuss they become ill with symptoms of influenza, to discuss antiviral treatment within 48 hoursantiviral treatment within 48 hours of illness onset:of illness onset: Pregnant women Pregnant women

The risk of developing complications from pH1N1 is higher later in The risk of developing complications from pH1N1 is higher later in pregnancy – 2nd and 3rd trimester – and up to 4 weeks post-partumpregnancy – 2nd and 3rd trimester – and up to 4 weeks post-partum

Those age Those age <5 <5 In particular, < 2In particular, < 2

Those aged Those aged 65 65 Those with chronic medical conditions (see next slides)Those with chronic medical conditions (see next slides)

What medical conditions are What medical conditions are considered higher risk?considered higher risk?

Chronic respiratory disease, including asthmaChronic respiratory disease, including asthma Cardiac diseaseCardiac disease Diabetes mellitus and other metabolic diseases Diabetes mellitus and other metabolic diseases CancerCancer Immunodeficiency or immunosuppression (due to Immunodeficiency or immunosuppression (due to

underlying therapy and/or disease including underlying therapy and/or disease including HIV/AIDS)HIV/AIDS)

(cont’d next slide)(cont’d next slide)

What medical conditions are What medical conditions are considered high risk?considered high risk?

Renal disease Renal disease Anemia or hemoglobinopathyAnemia or hemoglobinopathy Morbid obesityMorbid obesity Children less than 18 years of age on long term Children less than 18 years of age on long term

aspirin therapyaspirin therapy Conditions that compromise the management of Conditions that compromise the management of

respiratory secretions and are associated with an respiratory secretions and are associated with an increased risk of aspiration, such as neurologic increased risk of aspiration, such as neurologic conditions or cognitive disordersconditions or cognitive disorders

ResourcesResources

Region of Waterloo Public Health:Region of Waterloo Public Health: www.waterlooregionpandemic.ca 519-883-2289519-883-2289

Ontario Ministry of Health and Long-Term Care:Ontario Ministry of Health and Long-Term Care: www.ontario.ca/flu

Public Health Agency of Canada:Public Health Agency of Canada: www.fightflu.ca

All key information for physicians will continue to be All key information for physicians will continue to be included in Physician faxes/ packages sent by included in Physician faxes/ packages sent by courrier.courrier.

CONCLUSIONCONCLUSIONQ&AQ&A