2. TARRANT Annual Meeting 2010 J Dickinson April 2010

3. 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

4. Goals Review the year Inform what we are doing Obtain feedback from sentinels and staff

5. 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 Donald Add on Vaccine Effectiveness research program – Danuta Skowronski CIHR Survey of Family Physicians – Responses to threat of pandemic Analysis of our own data

6. Surveillance System Practitioners across Alberta – 40-50 each week

7. Location of Sentinels

8. 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

9. Influenza Surveillance: Canada FluWatch animated maps:

10. Sept 13-19 No Data No Activity Sporadic Activity Localized Activity Widespread Activity

11. Sept 20-26 No Data No Activity Sporadic Activity Localized Activity Widespread Activity

12. Sept 27 – Oct 3 No Data No Activity Sporadic Activity Localized Activity Widespread Activity

13. October 4-10, 2010 No Data No Activity Sporadic Activity Localized Activity Widespread Activity

14. 2010 2009

16. 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…

17. ProvLab tests for: – Influenza A Types (including pH1N1) – Influenza B – Respiratory syncytial virus – Adenovirus – Enterovirus/rhinovirus – Coronavirus – Parainfluenza virus – Human metapneumovirus

19. 105 159 133 134 169 123 123 74 90 60 101 364 256 90 55 36

20. Accuracy of FP diagnosis Positive predictive value – Related to severity of epidemic – Always less than 50% – Always majority of unidentifiable viruses

22. 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

23. 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

27. 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?

28. 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

29. 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

30. Survey

31. Percent of Physicians With A Pandemic Plan

32. 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%)

33. Use of Masks Before and After H1N1 Outbreak Physicians

34. Use of Masks Before and After H1N1 Outbreak Clinic Staff

35. CalgaryEdmontonOther UrbanRural Alcohol Sanitizer Use

36. 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

37. 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%)

38. 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

39. 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

40. Physicians’ Willingness to Work by Gender (%)

41. Limitations Low response rate of 21.9% (192 surveys completed) Timing of survey Limited amount of open ended feedback – Interpretation – Bias of opinions

42. 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

43. 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)

44. 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.

45. Recruitment of more Sentinels