# Presentation: 699093

## Wisconsin Antiviral Plan

- Thomas Haupt M.S.
- Wisconsin Division of Public Health
- 608-266-5326
- hauptte@dhfs.state.wi.us

## Fold Increase in Antiviral Drug Use: Prophylaxis vs. Treatment

| 
Illness
attack rate | Ratio Prophylaxis:Treatment  |  |
| --- | --- | --- |
|  | 40 days
(~6-weeks) | 8-weeks |
| 15% | 26.7:1 | 37.3:1 |
| 25% | 16.0:1 | 22.4:1 |
| 35% | 11.4:1 | 16.0:1 |

## Number of Antiviral Drug Courses for Prophylaxis vs. Treatment

| Group | Population | Number of courses |  |
| --- | --- | --- | --- |
|  |  | Prophylaxis* | Therapy** |
| HCWs | 12.6 m | 70.6 m | 4.4 m |
| Hospital - Patient care |   3.0 m | 16.8 m | 1.1 m |
| Public safety | 2.3 m | 12.9 m | 0.8 m |

-   *Assumes 8-week prophylaxis
- **Assumes 35% attack rate

## Critical Factors in Defining Drug Use Strategy: Prophylaxis vs. Treatment

- Effectiveness
- Impact on health outcomes
- Ability to maintain essential functions
- Efficiency – optimal use of a limited antiviral supply
- Feasibility – can the recommended approach be implemented?
- Acceptability – is the approach ethical and acceptable to the public?

## Summary of Antiviral Drug Strategies

- With limited antiviral supply, treatment is the best strategy to prevent adverse health outcomes – especially if delivered early
- Ability to maintain essential services with a treatment strategy is unclear
- Effectiveness related to pandemic severity, ability to implement early, and ability to tolerate some work loss
- Prophylaxis reasonable in defined settings
- Small high risk or critical service groups
- Institutional settings – post-exposure prophylaxis

## Possible Antiviral Strategy Groups

| Group | Strategy |
| --- | --- |
| HCW - direct contact | Tx/P |
| Admitted patients with probable influenza | Tx |
| Highest risk outpatient | P |
| Increased risk outpatient. | Tx |
| LTCF resident | PEP |
| Pandemic health responder | Tx |
| Public safety worker | Tx |

**Possible Antiviral Strategy Groups**

## Admitted patients with probable influenza

**TREATMENT ASAP, (<48 hours after onset)**

**  ****Most applicable during high ILI activity  **
**During increased ILI activity in the regional  the PPV of**
**    ****rapid tests should be high  i.e.. Positive test result **
**    ****reliable**
**  ****Hospitalization protocol is needed**
**  ****Clinicians need Influenza “101”**
**  ****However, during low ILI activity (pre pandemic), when **
**    ****PPV of rapid tests are low...**
** ****Epi link to endemic areas endemic with avian**
**  ****influenza followed by PCR tests (24 hours)**

## Highest- risk outpatients

**Prophylaxis**
**  ****CA with ongoing or recent therapy**
**  ****Transplant**
**  ****Dialysis  (****???****)**
**  ****Pregnancy (especially 2****nd**** or 3****rd**** trimester)**
**  ****Other immune suppression (medications,**
**    ****disease) including chronic lung or heart disorders  **
** **

## DPH Definition of Health Care Workers with Direct Patient Contact:

**Treatment**
**Health care workers with direct patient care are those who perform **_**hands on patient care or medical procedures that bring them in direct physical contact with a patient**_**. Such procedures include blood pressure checks, bedpan duty, phlebotomy, ADL’s physical examinations and any other care in which the person "lays hands on a patient."**

## DPH Definition of Health Care Workers with Direct Patient Contact (Treatment):

**Individuals likely to be in this category are:**
** ****Physicians, PA’s, NP’s**
** ****Nurses, nurse aids, medical assistants, **
** ****respiratory therapists, (certain) lab personnel, **
** ****dentists, x-ray technicians**
** ****emergency medical service personnel, and**
** ****others who perform activities that bring them **
**   ****in close physical contact with patients.**

## DPH Definition of Health Care Workers with Direct Patient Contact (Prophylaxis):

**Individuals likely to be in this category are:**
** ****Those with direct patient care (defined previously)**
** ****Those in specialty areas where little to no  **
**   ****absenteeism can occur, including:**
** ****EMS**
** ****Emergency Room**
** ****ICU**
** ****OR (???)**
** ****Dialysis**

## Pandemic Health Responders

**(Decision –Makers)**
**Prophylaxis/Treatment**
**Persons necessary to provide legal authority to initiate activities not governed by current state laws  including: **
** ****The Governor of Wisconsin**
** ****The Lieutenant Governor and **
** ****Secretary of State **
**Treatment**
**Persons essential to maintain basic community infrastructure contingent on the epidemiology of the pandemic and the quantity of antiviral medication available: **
**  ****Chief Medical Officer **
**  ****State Health Officer, **
**  ****members of the Clinical Management Team**

## DPH Definition of Health Care Workers with Direct Patient Contact:

**Those who are **_**excluded**_** include:**
** ****social workers**
** ****administration and support staff**
** ****maintenance workers**
** ****pharmacy staff**
** ****housekeeping staff**
** ****dietary staff**
** ****chaplains**
** ****patient representatives**
** ****others who do not perform hands on care or medical procedures that bring them in close physical contact with patients. **

## Health Care Worker- Direct Patient Contact

**Wisconsin Division of Public Health definition of health care workers with direct patient care is based on the consideration:**
**Risk of transmission in health care settings is**
**greater with prolonged close contact than**
**with short term, more indirect contact.**

##                        Public Safety Workers

**Treatment**
**  ****Police  **
**  ****Fire**
**  ****Utility field workers (gas, electric, water,), **
**  ****Air travel personnel (pilots, air traffic controllers, etc.) **
**  ****Corrections workers**
**  ****Morticians/Coroners/Medical Examiner** ** **

## Increased Risk Outpatients

**  ****Those >65 years old**
**  ****Children 12-23 months**

## Long Term Care Facilities

**Post exposure prophylaxis**

**  ****Nursing homes, assisted living and group**
**    ****homes for the elderly or chronically ill**
** ****Does not include group homes for adolescents**
**  ****After a confirmed case of the pandemic **
**   ****influenza strain is identified in a resident**
**  ****To all residents and unvaccinated staff (when**
**    ****vaccine is available) for **
**           ****4 weeks, 8 weeks, longer?**

## Implementation Issues

- Drug likely to be distributed to States *pro rata*
- Treatment delivery site will become the point of care
- Hospitals may be critical delivery node
- Through occupational health for employees
- At admission
- In Emergency Department for high-risk outpatients
- Many clinics are associated or have agreements with a hospital and can become delivery sites

## Potential Priority Groups for Antiviral Drug Interventions: Assumptions

- Ability to stratify among HCWs or other occupations
- A second stratification of HCW may be necessary from the local level (Local emergency plan, HRSA)
- Definition of “essential service personnel” needs to be defined locally

## Potential Priority Groups for Antiviral Drug Interventions: Assumptions

- Local Public Health will not be able to disperse medication to high risk patients
- Ability for local plans to “fit” state and national plans is essential