TARRANT Annual Meeting 2010

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



• Implications for oseltamivir prescribing?– Especially with oseltamivir resistance



• 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


Always Mostly Sometimes Never

Use of Masks Before and After H1N1 OutbreakClinic Staff


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

Documents

TARRANT Annual Meeting 2010