TARRANT Annual Meeting 2010
J DickinsonApril 2010
Welcome
Interesting mix • Sentinels and their staff.• ProvLab staff• Alberta Health: AHW, AHS • Public Health• Community Medicine residents
• Our staff: Karen Rivera– Sandy Berzins, Craig Pierce, Leah Ricketson
Goals
• Review the year• Inform what we are doing• Obtain feedback from sentinels and staff
Development
• Start from Sentinel program: Mike Tarrant 1983– Baseline for what we do: with Kevin Fonseca ProvLab– Informs Public Health what is happening in the
community. Judy Mac DonaldAdd on Vaccine Effectiveness research program
– Danuta Skowronski CIHR• Survey of Family Physicians
– Responses to threat of pandemic• Analysis of our own data
Surveillance System
• Practitioners across Alberta– 40-50 each week
Location of Sentinels
Surveillance System
• Practitioners across Alberta• Systematically Take Swabs from ILI pts
– Influenza Like Illness: fever and cough• Send to Provlab• Weekly reports to Alberta Health
• Combine with hospital, school, nursing homes data– Thence to PHAC– Onwards to WHO
Influenza Surveillance: Canada
• FluWatch animated maps:
Sept 13-19
No Data
No Activity
Sporadic Activity
Localized Activity
WidespreadActivity
Sept 20-26
No Data
No Activity
Sporadic Activity
Localized Activity
WidespreadActivity
Sept 27 – Oct 3
No Data
No Activity
Sporadic Activity
Localized Activity
WidespreadActivity
October 4-10, 2010
No Data
No Activity
Sporadic Activity
Localized Activity
WidespreadActivity
Influenza-like Illness (ILI) Visits to TARRANT Sentinel Physicians by Week Over The Past Year Compared to Historical Data from the Previous
15 Influenza Seasons
0.0
1.0
2.0
3.0
4.0
5.0
6.0
Month
ILI r
ate
(%)
2009/10 Rate
AVERAGE 94/95 to 08/09
20102009
Surveillance System
• Practitioners across Alberta• Systematically Take Swabs from ILI
– Influenza Like Illness• Send to Provlab
– Uses PRC methods: very sensitive• Consistent measure of community viruses
– We look at 6 other respiratory viruses too…
ProvLab tests for: – Influenza A
• Types (including pH1N1)– Influenza B – Respiratory syncytial virus– Adenovirus– Enterovirus/rhinovirus– Coronavirus– Parainfluenza virus– Human metapneumovirus
Monthly TARRANT Viral Submissions
0
50
100
150
200
250
300
350
400N
ov 2
008
Dec
200
8
Jan
2009
Feb
2009
Mar
200
9
Apr
200
9
May
200
9
June
200
9
July
200
9
Aug
200
9
Sep
t 200
9
Oct
200
9
Nov
200
9
Dec
200
9
Jan
2010
Feb
2010
Month and Year of Submission
Tota
l Num
ber of
Sub
mis
sion
s
Negative
Other Resp
Entero/Rhino
Flu B
Flu A H3
Flu A H1(seasonal)Flu A H1(swine)
Monthly TARRANT Viral Submissions
0%
20%
40%
60%
80%
100%Nov
200
8
Dec
200
8
Jan
2009
Feb
2009
Mar
200
9
Apr
200
9
May
200
9
June
200
9
July 2
009
Aug
200
9
Sep
t 200
9
Oct 2
009
Nov
200
9
Dec
200
9
Jan
2010
Feb
2010
Month and Year of Submission
Perc
ent o
f Sub
mis
sion
s
Negative
Other Resp
Entero/Rhino
Flu B
Flu A H3
Flu A H1(seasonal)Flu A H1(swine)
105 159 133 134 169 123 123 74 90 60 101 364 256 90 55 36
Accuracy of FP diagnosis
• Positive predictive value– Related to severity of epidemic– Always less than 50%– Always majority of unidentifiable viruses
Accuracy of FP diagnosis
• Positive predictive value– Related to severity of epidemic– Always less than 50%– Always majority of unidentifiable viruses
• Implications for oseltamivir prescribing?– Especially with oseltamivir resistance
Accuracy of FP diagnosis
• Positive predictive value– Related to severity of epidemic– Always less than 50%– Always majority of unidentifiable viruses
• Implications for oseltamivir prescribing?• Age relationship
– Highest viral retrieval in children– Very low in old: who get more severe illness
0%
10%
20%
30%
40%
50%
60%
70%
80%
0 - 1 2 - 3 5 - 9 10 - 14 15 - 19 20 - 29 30 - 39 40 - 49 50 - 59 60 +
Age Categories
Prop
ortio
n Po
sitiv
e
All Viruses Combined Flu A Pandemic Entero/Rhinovirus Flu A Seasonal
Research Questions
• How did family physicians in Alberta respond to the epidemic?– Clinic pandemic plan– Measures taken in their clinic to reduce influenza
transmission
• What were physicians’ reactions regarding pandemic H1N1 preparedness in Alberta?
Survey Methods• 3558 general practitioners from College of Physicians and
Surgeons of Alberta• 1,000 physicians from list
– 250 from Calgary– 250 Edmonton– 250 Other Urban Areas– 250 Rural Areas
Survey Methods• Paper survey
– Limited to 4 pages– Mixture of closed questions and spaces for comment– Piloted during July/ August.
• Survey conducted – early September through October 2009– Reminders sent up to 3 times– Response rate 21.9%– Last survey was received November 5, 2009
Provincial Influenza SurveillanceNov 2009 - Jan 2010
0200400600800
1000120014001600
Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Oct Nov Dec Jan
Num
ber o
f Cas
es
Alberta Seasonal Flu Alberta pH1N1
Survey
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Calgary Edmonton Other Urban RuralRegion
Perc
ent %
Plan No Plan
Percent of Physicians With A Pandemic Plan
Precautions to Prevent Transmission
• 92% of physicians put in place some form of precaution
– Providing hand sanitizer for patients (85%)– Posting signs on doors (69%)– Providing masks for patients (69%)– Isolating ILI patients in separate room (54%)– 2 meter space between patients and receptionists (27%)– 2 meter space between patients (19%)– Direct patients with cough/cold elsewhere (17%)
0%
20%
40%
60%
80%
100%
Before After Before After Before After Before After
Calgary Edmonton Other Urban Rural
Always Mostly Sometimes Never
Use of Masks Before and After H1N1 OutbreakPhysicians
0%
10%
20%30%
40%
50%
60%
70%80%
90%
100%
Before After Before After Before After Before After
Calgary Edmonton Other Urban Rural
Always Mostly Sometimes Never
Use of Masks Before and After H1N1 OutbreakClinic Staff
Calgary Edmonton Other Urban Rural
Alcohol Sanitizer Use
Use of Personal Protective Equipment
• Use of PPE – recommended during nasopharyngeal swab– 76% ‘always’ or ‘mostly’ wear gloves– 63% ‘always’ or ‘mostly’ wear a procedural mask– 42% ‘never’ wear an N95 mask– 42% ‘never’ wear eye or face shield
Obtaining PPE
• 53% of physicians did not encounter trouble in obtaining PPE
• 35% had trouble obtaining N95 masks– Calgary (57%)– Edmonton (26%)– Other Urban (26%)– Rural (25%)
Replacement Staff
• 73% of physicians did not think there would be enough replacement staff for their clinic if some fell ill.
• How would clinic staff react?– 21% continue working regular hours– 58% fearful to deal with ILI patients– 32% stay at home to care for family– 22% don’t know
Willingness to work in epidemic
64% of respondents expressed concern about being infected
78% of males and 60% of females would work longer in severe pandemic
Physicians’ Willingness to Work by Gender (%)
Limitations
• Low response rate of 21.9% (192 surveys completed)
• Timing of survey• Limited amount of open ended feedback
– Interpretation– Bias of opinions
Conclusions
Most doctors accept their responsibility to work in an epidemic.
They are concerned, and are less willing to work in identified high risk situations.
Unhappy about:• potential for negative triage decisions
for certain cases• being required to work in situations not
trained for
Physicians legal rights and duties
Key Points:• Primary duty of care to patients where
relationship exists• In Emergency or rural settings, duty of care to
community who use the facility• Particular susceptibility justifies refusal. e.g.
pregnancy, reduced immunity
CMAJ 2009.DOL:10.1503/cmaj.091628 (Jan 2009)
Conclusions/Recommendations
• Develop a pandemic plan– Involve all staff members
• Build own stocks of PPE– Sanitizer, masks, swab kits, gowns, gloves, eye/face shield
• Be cautious and use protection– when seeing coughing patients– while taking NP swabs
• Public Health planning: – Focus on supporting front line when epidemic threatens.
Recruitment of more Sentinels