# Presentation: 050720

## The Canadian Antiviral Strategy

- 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**, 200**5*

## Presentation Overview

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

## 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

## 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

## 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

## 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**

## 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.

## 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

## 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

## 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

## 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

## Priority Groups

## Goal of Influenza Pandemic Planningand Response

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

## 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

## 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

## Tx of persons hospitalized for influenza

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

**Notes:**
Rationale

##  2.  Tx of ill HCW and ESW

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

## 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.

## 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.)

## 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)

## 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

## 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)

## 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

## 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.

## 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)