Labrador-Grenfell Health's experience

Summary

In Spring 2009, Pandemic Influenza A (H1N1), a novel influenza virus subtype originally associated with infection in swine, crossed the species barrier becoming infectious to humans. The first cases of widespread illness in the Americas occurred in Mexico and the United States before spreading to Canada. The ability of the virus to sustain human to human transmission, coupled with high infectivity rates, resulted in worldwide outbreaks and the declaration of Phase Six of the Pandemic Alert by the World Health Organization in June 2009.

The Labrador-Grenfell Health region experienced the tail end of the first wave of this pandemic in July 2009, with a few scattered cases of confirmed H1N1 in the region. None required hospitalization and symptoms were similar to those of mild to moderate influenza and resolved with minimal supportive care. Across the province, preparations were underway for a second wave of illness, anticipated at the time of the seasonal influenza season. Pandemic Influenza planning by public health officials kicked into high gear with the completion of the regional pandemic influenza plans, including mass immunization plans, the cornerstone of public health protection activities.

Public Health measures utilized by Labrador-Grenfell Health included monitoring the level of Influenza-like Illness (ILI) circulating in the region throughout the summer and into the fall, testing for H1N1 in those with ILI who were at high risk for complications, pre positioning antivirals in remote and isolated communities, promoting the provincial Clean, Cover and Contain hygiene campaign and disseminating knowledge to health professionals. Communications and linkages with other partners such as Innu First Nations, the Nunatsiavut Government, First Nations and Inuit Health and other agencies were strengthened.

Labrador-Grenfell Health's Pandemic Plan became operational at about the same time the second pandemic wave of H1N1 arrived in Newfoundland and Labrador in the second week of October 2009. Mass immunization roll-out began on October 28 2009 with the arrival of the first of several subsequent shipments of H1N1 vaccine to the Labrador-Grenfell Health region.

Epidemiology

As stated above, in Labrador-Grenfell Health region, the second wave began sometime in mid October with an increase in the numbers of ILI, the first case of H1N1 being confirmed on October 25, 2009. The second wave appears to have ended by December 1, 2009, lasting approximately six weeks in this region.

The total number of admissions for ILI between October 25 and December 1, 2009 were 68. Of these, 25 were confirmed H1N1, 11 of which required ICU admission. The ages of admissions ranged from less than one year to 65 years. The greatest number of ICU admissions occurred in the 25-44 and 45-64 year ranges.

For the confirmed H1N1 hospitalizations, the mean age was 25.8, with a median age of 21.0. The mean age of those admitted to ICU was 35.3, with a median age of 29. There were two deaths in total, related directly and indirectly to H1N1.

The greatest number of admissions by sex and age occurred in men 25-45 years of age. Women aged 45-64 and individuals over 65 comprised the remaining majority of admissions.

In this region, characteristics of patients infected with H1N1 were consistent with those across Canada, the United States and Australia. Hospitalized patients were generally younger than those typically seen with seasonal influenza. The majority had at least one underlying medical condition, the two most common being asthma (or some other chronic respiratory disease) and obesity. Whereas pregnant women are over-represented in the H1N1 patient cohorts in other regions, this was not observed for this region during the second wave.

By December 8, 2009, approximately sixty-nine percent of the population in the Labrador-Grenfell Health region was successfully vaccinated, achievable by a joint collaborative effort between Labrador-Grenfell Health, the Nunatsiavut Government, Innu First Nations and First Nations and Inuit Health.

Future Considerations

A feature of pandemic influenza is recurrent waves of illness which occur over a prolonged period (i.e., up to eighteen months). We have just reached the end of the second wave of the H1N1 pandemic.

Now is the opportune time to review the provincial and regional pandemic plans and responses, looking at what worked well, what can be improved and what gaps in services were identified. This will allow us to prepare for the third wave.

At the public health level, measures that were developed and implemented must be reinforced. While mass immunization is now complete, H1N1 vaccination will continue by appointment - this is essential in order to maximize protection of our population by ensuring "heard immunity". Surveillance of circulating viruses and ILI needs to be continued, particularly for the emergence of more virulent strains of the virus. Clean, Cover and Contain practices must be sustained and we need to continue to strive for speed, efficiency and consistency in communications to both the public and health professionals alike. Strengths and weaknesses in the linkages and coordination of the regional health authority's response in relation to our health partners and other agencies must also be reviewed.

Operationally, hospitals, health centres and community clinics will review their infection control protocols and practices and critical care triage mechanisms, institute bed utilization reviews, review materials management, business continuity practices and the roles and responsibilities of all employees. The challenge in an organization such as Labrador-Grenfell Health is that it has to administer health care to a region with a diversely varied geography where culturally different population groups live in remote and isolated communities, but which also faces challenges of timely access to tertiary care from larger towns with hospital facilities. To this end, self sufficiency in the delivery of critical and intensive care services needs to be further explored.

From pandemic planning and preparedness, to emergency and inpatient care, to mass immunization and all other related services, the dedication, professionalism, commitment and patience of Labrador-Grenfell Health employees was commendable and for this, we thank each and every one of them.