Plan of Preparedness of the Health System for the Case of an Influenza Pandemic
2005
Ministry of Health
Abridged version
September 2005
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Contents
Chapter Subchapter Subject Professional committees A B C 1 Introduction Introduction and stages of prevention Preparation for avian influenza Avian influenza – attention to a suspected or diagnosed patient 2 Instructions for protecting workers in the poultry branch against avian influenza D Preparation for pandemic influenza Summary of actions at stage 0 and in transition to stage 1 1 Monitoring and early identification
Page 3 4 5-10
1116 1720
2124 2531
2
Vaccinations and antiviral drugs
3241
3
Community preparation
4257
2
4
Activity for checking the spread of the disease in the community
5881 6270
5
Preparation of hospitals
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Laboratory preparation and activity
7177
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Preparation of public education unit and spokesman department
7879 8085
8
Information dissemination
9
List of committee members
8689
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A. Introduction
The combination of circumstances that leads to the occurrence of influenza pandemic is not rare, and about 41 pandemics have been documented in the last 400 years. In the previous century, there were three such pandemics, the best known and most lethal one being in 1918 at the time of World War One, killing about 50-100 million people. A smaller outbreak of a new strain of influenza (H5N1), which occurred in 1997, constituted a warning signal that was heard around the world, and many countries who until then put preparations for a pandemic at low priority started feverish preparations for facing the disease. Even then, it was obvious to all parties engaged in the field that the appearance of another pandemic was undisputed, the only question being when it would break out, and with what intensity. The return of the H5N1 strain in recent months to the international scene with a particularly lethal form of “avian flue”, which arose in Southeast Asia, intensifies the fears of an impending pandemic. The World Health Organization called, in an emergency conference on March 16, 2004, for expediting the plans for defending against the imminent danger, which it defined as “inevitable”.
The State of Israel has been dealing with preparations for an influenza pandemic since 1977, which have been boosted in the last two years upon
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the convening of dedicated professional committees. The committees have covered a range of fields of plans for national preparedness for the next pandemic – monitoring, vaccinations, antiviral drugs, preparations of hospitals, the community and laboratories and plans for disseminating knowledge to medical teams and an information program for the general public. This booklet summarizes the results of the work of these committees, divided into two major chapters: actions required today, before a strain of pandemic potential starts to spread, and a series of actions required for execution upon the onset and spread of the pandemic in Israel and around the world. This plan, like other ready made plans in the world, cannot cover the details of the planning required in every field. The aim of this plan is to specify the principles for coping with the expected pandemic, flood the problematic issues and establish the issues to be solved at present and those that may be coped with during an actual event. Again, we thank all the committee members for devoting their time and energy to writing the chapters of the plan, and hope that it will remain a contingency plan for many years.
Dr. Alex Leventhal
Mr. Shmual Reznikovich
Dr. Ran Blitzer
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B. Introduction and Preparation Stages
Background: Every winter, the influenza virus causes significant morbidity and mortality with local outbreaks around the world. The main damage cause by these outbreaks is sustained by the extreme age groups – the elderly and infants, and in patients of certain chronic diseases. Influenza A viruses can also cause a sudden outbreak of severe disease, covering the entire population, over extensive areas of the world. This ability of influenza viruses arise from a combination of a number of factors, which include high contagiousness, ability to change the genome that encodes the main viral antigens, hemagglutinin and neuraminidase, and the presence of other strains of the virus in other animals (particularly birds and swine), and the potential for the transition of genes from animal viruses to human viruses.
In the twentieth century, there have been three pandemics (worldwide plagues), the most famous being in 1918, being known as “Spanish flu”. In this outbreak, 50-100 million people died around the world, particularly young adults. Despite the later pandemics that occurred in 1957 and 1968 having a lower death toll (which can be partly attributed to the development of antibiotics and treatment of infections secondary to
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the disease and the development of more aggressive supportive care), they still involved significant morbidity and mortality and damage to society and its economy.
Pandemic influenza may be caused by the appearance of a new A type virus that is adapted for person to person transfer, but with an antigenic structure that is unknown to the human population. The appearance of such a virus may occur with two main mechanisms of genetic shift: Gene reassortment between animal viruses (usually avian viruses) and human viruses, creating a new hybrid virus that is contagious from person to person. This is how the viruses that cause the pandemics of 1957 and 1968 probably appeared. A genetic mutation or series of mutations in an avian virus that has infected a person, allow it to be contagious from person to person. This is how the influenza virus that caused the 1918 pandemic probably appeared.
An examination of the genetic structure of the H5N1 virus indicates that despite it being an avian virus, changes in its genetic structure with characteristics similar to those of the 1918 virus (recently reconstructed) have appeared, which increases the fear of additional changes that will make the virus contagious from person to person.
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Importance: The World Health Organization has warned of the outbreak of a pandemic (worldwide epidemic) of influenza for several years. The greatest fear is of the appearance of an influenza A strain that is not one of the three strains included in the vaccine, which are established by the World Health Organization before the winter. Up to twenty-five years ago, such a pandemic would break out every decade. We have now had more than twenty-five years without a pandemic. Most experts believe that the next pandemic is inevitable, but its timing of onset cannot be predicted.
The American Center of Disease Control estimates that the next pandemic will involve a loss of 71 – 166 billion dollars for the US economy. In such a state, each country must individually and together cope with a state of excess morbidity of influenza and its complications, including a workload in community clinics, emergency rooms and hospitals, alongside absences from work, including in the healthcare system. This situation calls for prior preparation for the next pandemic.
In recent years, we have witnessed a number of precipitating signs that attest to an increasing likelihood of the appearance of pandemic strains.
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The appearance of the H5N1 strain in Hong Kong in 1997 was the first warning, and in the years that have elapsed since, there have been a number of humans infected by avian viruses of varying lethality. The events since the end of 2003 – with the spread and consolidation of the high lethality rate H5N1 virus in Southeast Asia that affected humans, and the ongoing risk of this strain becoming capable of effective personto-person infection – constitute another indicator of the urgent need for Israel’s preparation for the onset of pandemic influenza. The continued spread of the avian virus to Eastern Europe and the fear of transfer of the disease by migratory birds this winter make the risk immediate in Israel too.
Aims: This document is intended to offer a master plan for the preparation of the health system for the outbreak of a pandemic of influenza and to define the principles of action upon such an outbreak. The aims of the plan are: 1. Reducing the mortality and morbidity rate of pandemic influenza. 2. Facilitating as normal a continued lifestyle as possible for the population during a pandemic (with emphasis on the activity of the police, army, fire brigade and other essential parties).
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3. Minimizing the expected burden on the health system and preventing collapse due to a large number of referrals and hospitalizations. 4. Minimizing economic damage due to the pandemic.
Pandemic characteristics – basic assumptions:
1. Time of onset: an influenza pandemic may appear throughout the year, not necessarily during the regular time of activity of influenza in Israel (November – March). 2. Duration: past experience leads to the assumption that the expected duration of the peak of the outbreak will be 6-8 weeks, although the spread may be gradual over months. The number of waves of morbidity occurring cannot be anticipated, although it is usual to assume that at least two waves of morbidity will occur. 3. Incubation time: according to the characteristics of the virus and past experience, the incubation time will last 24-72 hours at the individual level. 4. Infection time – according to nasopharynx swab tests, contagiousness in adults lasts 4-5 days. In children the contagious term is longer. 5. Occurrence of the illness – the World Health Organization suggests preparing for a scenario of morbidity of 25% of the population. A higher prevalence may be expected for children compared to adults.
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6. Ascribed scenario – according to a model developed by members of the steering committee (Dr. Blitzer and Dr. Grutu), based on assumptions used by the CDC, a scenario of about 25% of the population being affected is to be prepared for (i.e. 1,600,000 patients), with 780,000 physician visits, 10,000 hospitalizations and 2,900 deaths. A slightly more severe scenario, according to CDC data, will lead to higher hospitalization and illness rates for the same scopes of morbidity. 7. Contagiousness – the degree of contagiousness of the pandemic strain cannot be anticipated, but this figure will substantially affect the efficacy of various preventive steps for stopping the outbreak, such as prophylactic medication, isolation of patients, quarantine, etc. The establishing of coping principles will therefore be determined, to a great degree, after the outbreak of the pandemic in the world and receiving initial data on virus properties. According to mathematical models, it can be expected that an affected person will infect an average of two more persons. 8. Age of onset of illness – in regular years, most morbidity is in children, whereas the severest morbidity and mortality are in elderly people with background diseases. This pattern of appearance may change with the onset of a pandemic. In the pandemic of 1918, morbidity concentrated mainly on young adults, whereas the pandemic of 1968 concentrated mainly on children under the age of 5 and the elderly population.
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9. Mortality – seasonal influenza results in death mainly at extremes of age – children and the elderly. In the pandemic of 1918, there was significant mortality in young adults. In the pandemic of 1957, pneumonia and bronchitis, frequent complications of the disease, were the main reasons for hospitalization and contributed 50% of the causes of death following the disease. In the pandemic of 1957, which was relatively mild, the lethality rate of the illness in England was estimated at 1.3 to 3.5 deaths per 1,000 cases of the illness. 10. Medical services – the influenza pandemic is a community disease. The large number of patients will cause a tremendous burden for the community medical service, but also in emergency rooms and in-patient departments. CDC estimates, adapted to Israeli estimates, may lead to a hospitalization of 3,500 people per week at the peak of the outbreak. 11. Absence from work – during a pandemic, a significant proportion of the population will be absent from work. In the pandemic of 1957, 8-10% of the population was absent from work for three days or more. The absence included medical staff, and in Liverpool, UK, an absence rate of 12.6-19.44% was reported among nurses during the first four weeks of the outbreak. 12. Hospitals – influenza may spread rapidly at schools. In the pandemic of 1957, up to 50% of school age children in England developed the
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disease. During the onset of a pandemic, the possibility of closing down schools should be prepared for as a step for checking the outbreak. 13. Vaccination – for preparing a new vaccine specifically for the pandemic strain, a few months (about 4-6 months at least) of the new virus’ insulation time will be needed. Even after this term, the production rate of vaccines will be slow. Therefore, at the time of onset of a pandemic, there will be no specific influenza vaccines for the pandemic virus. However, if time constants permit it, vaccine manufacturers will probably concentrate efforts on its production. The working assumption should be that the obtaining of a specific vaccine for a pandemic strain for Israel would be impossible for many months. Vaccine production factories exist in a few countries, and it is assumed that they will nationalize their produce for their own countries, and the vaccine may not be purchased in the initial stages, if at all. The possibility for creating a human vaccine against avian flue in advance has been discussed in detail in the drugs and vaccines chapter. 14. Antiviral drugs – there is a drug that is used for treating patients and as prophylaxis for preventing morbidity and complications. 15. Drug resistance – most seasonal influenza strains are resistant to Amantadine, whereas avian flue strains that have been isolated heretofore are probably resistant to this drug. If the new strain is formed from the
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reassortment of genetic material between these two strain types, it cannot be anticipated whether it will be sensitive to this drug.
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Stages of Preparation and Handling for a Pandemic
Period between pandemics: Stage 1: New influenza virus in animals. Low risk of cases appearing in humans. Stage 2: New influenza virus in animals. High-risk of cases appearing in humans.
Period of warning before pandemic
Stage 3: Cases of avian flu in humans (rare, sporadic transfer from person to person)
A. Outside of Israel B. In Israel (in birds, infection of humans from birds)
Stage 4: Limited contagiousness from human to human, localized disease. A. Low morbidity groups outside Israel B. Morbidity as above in Israel too
Stage 5: Significant contagiousness from person to person, disease still localized
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A. Significant morbidity groups outside Israel B. Morbidity as above in Israel too
Pandemic period
Stage 6: Pandemic (extensive, diffuse transfer around the world) A. Disease has yet to spread to Israel B. Disease has spread to Israel
Establishing the stage at which we are at any given moment will be performed by the WHO. Establishing the local sub-stage will be determined by the Ministry of Health. The time elapsing from stage 3 to stage 6 cannot be determined. This may last many months, a situation that will give time for comprehensive preparation and planning, but which may occur very quickly.
In this plan, we relate to the state of return to routine after the pandemic. The planning for this stage will be performed during the outbreak.
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Stages of preparation and handling for a pandemic
D. 2 – Vaccines and antiviral drugs
Basic assumptions 1. The only medicinal solution for reducing the scope of morbidity, as long as specific vaccines for the specific strains are not globally available, is antiviral drugs, which are administered for prevention and/or treating influenza. 2. The efficacy of drugs for preventing and treating pandemic influenza is similar to their efficacy for non-pandemic influenza. 3. If no sufficient stock of antiviral drugs is prepared in advance, they may not be obtained in “real time”. 4. The main part of the pandemic will last about 50 days, with heterogeneous distribution. 5. In a model that has no intervention, an additional 1,600,000 patients, 780,000 physician visits, 10,000 hospitalizations and 2,900 mortalities may be expected. The morbidity and mortality data for southeast Asia may indicate the potential for higher rates than those indicated above.
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Influenza vaccines 1. As noted, a number of countries in the world are currently preparing for the development of vaccines. The basic assumption is that a vaccine will not be available in real time – in the first months of the outbreak of the pandemic.
2. However, some preparations for a pandemic have room for recommending increasing awareness and compliance for administering a seasonal influenza vaccine to medical personnel and risk groups as defined in each year (at the preparation stage) and during the pandemic for the following reasons: A. During a pandemic, there may also be “regular” influenza activity. The administration of the vaccine will reduce cases of morbidity that may be suspected as pandemic influenza. For this reason, an attempt must be made at increasing compliance for vaccines against pneumococcus according to routinely accepted indications. B. A seasonal vaccine against influenza may reduce the re-assortment effect tin human beings (co-infection of avian and human influenza and creating a pandemic strain in affected humans).
3. During the pandemic itself, there is no room for changing the regular priorities for administering the seasonal vaccine.
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4. During education at the preparation stage, it is important to emphasize that the seasonal vaccine is ineffective against pandemic influenza, but it is important to be vaccinated for the reasons stated in section 2 above.
5. As soon as the specific vaccine for the pandemic train becomes available, the purchase and distribution of the vaccine will be performed together by Sarel Ltd. and by the logistics departments of the healthcare organizations, after consulting the epidemiology and infectious disease department. It must be assumed that in such a case, not enough vaccines may be purchased to vaccinate all residents of Israel. Population groups should be vaccinated in the following order of priority: A. Medical personnel that come into contact with patients, including ambulance drivers and community medical personnel. B. Essential workers (as defined by the Ministry of Trade, Industry and Employment) whose absence from work will impair the functioning of the country, such as the workers of Israel Electric Corporation, communication, firefighting, burial, Mekorot water company, transport authority and other service providers. C. Workers of the Ministry of Agriculture who are in charge of the field of poultry and poultry breeders, due to their being a high-risk population.
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D. Patients with chronic heart or lung diseases, patients with severe renal disorders, diabetics and immunosuppressed patients. This group necessitates separation of patients under and over the age of 50. E. Women in the last trimester of pregnancy. F. Residents of homes for the elderly and other nursing homes in which people stay for extended periods. G. Population over the age of 75 (including most of the celibate population living alone). H. Population over the age of 65. I. Population over the age of 50. J. The residents of homes with persons of increased risk. K. Other age groups that have been found to be sensitive based on screening tests (morbidity surveys, mortality surveys, antibody surveys, etc.). If the outbreak has yet to commence, surveys performed in countries in which the outbreak has already occurred may be used. L. Workers of other sectors. M. Persons aged 0-19 years. N. Persons aged 20-50 years. O. Upon demand.
The individual vaccination policy will be determined by the epidemiology department. The vaccine itself will be given at the
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responsibility of the public health services (through the health bureaus) and healthcare organizations, the vaccination being documented and the patient being issued a confirmation of vaccination. In view of the anticipation of the first vaccines reaching Israel a few months after the outbreak of the pandemic, a detailed plan for performing the vaccines will be formed according to the circumstances. If appropriate vaccines may be purchased, a detailed mass vaccination plan will be prepared accordingly. If the vaccine is not supplied in a ready for use syringe, preparations must be made for obtaining accessories for vaccination, i.e. needles, syringes, gauze pads, chlorhexidine for disinfecting, etc. The army, police and other security forces are to prepare for performing vaccination based on their own medical personnel. It must be noted, that today, proceedings are underway in the world for various developments of vaccinations that may be effective against a pandemic, including the option of producing vaccines of sufficient scope before the outbreak of a pandemic. These processes include, inter alia, producing a specific vaccine against the HSN1 strain avian flu virus, which was isolated from humans in Asia. This vaccine is currently undergoing advanced trial phases in humans, but it cannot be anticipated whether the virus, which continues to transform frequently, will remain sensitive to this vaccine at the stage of the clinical trials being completed.
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Neither can the degree of immunity this vaccine will give against a pandemic strain that arises from reassortment of this strain with a human influenza strain be anticipated. Active and passive vaccinations (the latter = antibodies) that may be effective against influenza irrespective of specific strain are at stages of development in Israel and abroad. These processes are at different stages, some more advanced, and most are at initial stages, the conclusion of development and licensing being expected only in a few years time.
As of September 2005, these vaccines may not be included in the preparation plan, as it is not clear whether, when and to what extent may these vaccines be practically used. However, the pharmaceutical committee is continuing to track developments in Israel and the world, and the doctrine may be updated according to changes.
Antiviral drugs 1. There are 2 groups of influenza prevention and treating drugs: A. M2 channel blockers. Amantadine and Rimantadine belong to this group. B. Neuraminidase inhibitors. The drugs Oseltamivir and Zanamivir belong to this group (at this stage, only Osaltamivir is covered, as
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this drug is registered in Israel for the indication of influenza treatment and prevention, but Zanamivir may probably be used in a similar fashion). 2. The differences between the various drugs are listed in table number 1.
Table number 1: Comparative figures currently available in literature concerning the efficacy, safety and adverse effects, expected resistance rate and compliance rates in accordance with the side effects in different schemes:
Drug Criterion Efficacy against influenza Effect for treating influenza
Amantadine
Rimantadin
Oseltamivir
A
A
A+B
Reducing disease by a day
Reducing disease by a day
Reducing disease by a day + reducing hospitalizations, drugs
Reduction of morbidity –
63%
63%
71%
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prevention before exposure * Reduction of morbidity – prevention after exposure * Development of resistance Discontinuing treatment (side effects) Use in children In Israel from 9 years age only Viral shedding No effect: From one year’s age No effect: From one year’s age Reduces by 2 orders of magnitude Reduction of mortality Shelf life 5 years 5 years 5 years (final product) No data No data No data Rapid (present in HSN1 strain) 11% (partly severe) Rapid (present in HSN1 strain) 6% 2% Slow, if any 63% 63% 80%
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6 years (raw amaterial) Duration of treatment PEP duration 10 days 10 days 7-10 days 10 days 10 days 5 days
* According to a systematic review and meta-analysis that we have performed for this purpose.
Purchase and stocking of antiviral drugs: The government has allotted a dedicated budget for purchasing antiviral drugs. The drugs will be divided based on the therapeutic strategy authorized by the ministry’s management. There are findings whereby the pathogenic strain S55N1, which currently causes avian flu in Asia has shown signs of resistance to M2 channel blockers. However, according to the experts of the World Health Organization whom we have consulted, because the pandemic strain will probably be formed by reassortment between the avian strain (Amantadine resistant) and a human strain (mostly Amantadine resistant), which may be resistant or sensitive to this drug, we believe that we must focus on purchasing drugs from the NAI group despite their higher price. These drugs have other advantages, as shown in the table above.
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However, given a limited budget, it is reasonable to allot a small proportion of the budget to purchasing a larger quantity of Amantadine, knowing that there is a chance the drug may not be used.
A cost-benefit model that we have developed indicates that the purchase and stockpiling of antiviral drugs will not only help reduce morbidity (possibly mortality too) but will also lead to a major financial saving. The ratio between the potential saving during a pandemic and the costs of the drug shows, according to our calculations, that the purchase of the drugs is economically viable if the annual risk for the outbreak is as low as 1.25%. For the sake of comparison, if we assume that there will be only three major pandemics this century (as in the previous one), the annual risk for an outbreak of a pandemic will be about 3%.
Therapeutic strategies: In general, therapeutic strategies will be chosen in accordance with the existing drug stock at the time and the characteristics of the disease known at that time. One or more therapeutic strategies may be chosen, the priorities being determined in real time.
Possible strategies: 1. Preventive care:
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A. Continuous preventive care over a period defined upon the outbreak of the pandemic for one or more of the following groups: 1) High-risk medical personnel (physicians, nurses, auxiliary forces caring for general and geriatric patients and in healthcare organizations). 2) Staff essential to the economy as defined by the Ministry of Trade, Industry and Employment.
B. Treatment after exposure to a patient at home, which will be given: 1) Only to persons exposed (living in the same house) who are at risk for influenza complications. 2) To all persons living with patients.
C. Outbreak control: to be given to a defined population group (institute, school, kindergarten, military base) when an outbreak occurs (as defined in real time).
The dosage for preventive care for exposed subjects: Amantadine – 100mg twice a day for 10 days.
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Rimantadine – 100mg twice a day for 10 days. Oseltamivir – 75mg once a day for 7-10 days.
2. Patient care: Administration of drugs for treating the patient himself is considered to be effective as soon as possible after the onset of illness, and in any case is not effective more than 48 hours after onset. The treatment may be given in a general or specific manner: A. B. Treatment of all patients (about 1,300,000 persons). Treatment of patients at high-risk for complications only (about
180,000 persons)
The dosage for curative care: Amantadine – 100mg twice a day for 10 days. Rimantadine – 100mg twice a day for 10 days. Oseltamivir – 75mg twice a day for 5 days.
Selected care strategy:
The results of a cost-benefit model (mentioned above) demonstrate that out of the options shown above, the strategy that yields a saving for the
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economy relative to the investment cost is caring for patients and their families, on the condition that they may receive treatment by no later than 48 hours after the appearance of clinical signs in the patient. The treatment of patients at high-risk for developing influenza, such as patients with cardiac and respiratory disease is particularly economically viable because of the high cost of hospitalizing these patients. A dynamic mathematical model developed by us demonstrates that if the drugs are also utilized for prophylaxis in family members after exposure, the quantity of drugs required will be identical to or less than that required for treating patients only, significantly reducing levels of morbidity and mortality.
Constant prophylaxis in large population groups, including extended prophylaxis in populations at high-risk for complications, does not constitute efficient use of drugs. Despite the foregoing, in view of the anticipated shortage of medical personnel at the time of a pandemic and in view of the risk of insufficient capacity in hospitals, the committee believes that there is no avoiding providing continuous preventive care of all medical personnel at hospitals and in the community who are exposed to acute stage respiratory disease patients. In addition, it is recommended to give extended prophylaxis to staff essential to the economy, in order to preserve their vital functioning.
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The rationale for setting priorities The rationale that the committee faced when recommending treatment priorities is as follows: Care / prevention for medical personnel: o Minimal disruption in providing essential healthcare services o Reducing the spread of the disease by the population with a greater chance of transmitting the virus Prevention in essential workers o Preventing absences will provide for minimal disturbance in the provision of essential services o Reducing the disruption of the economy by ensuring vital stocks
Treatment of high-risk population o Reduction of morbidity and mortality o Reduction of consumption of medical services Treatment for the entire population o Reduction of morbidity and mortality and reduction of the effect of the pandemic in the country.
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Therefore, the top priority for using drugs during a pandemic is as follows: 1. Care for of affected medical personnel 2. Curative care for patients at high-risk for complications. 3. Extended prophylaxis during the peak of the pandemic for staff essential to the economy (including medical personnel). 4. Treatment of all other patients and their families. It must be noted that these priorities require the final approval of the ethics committee appointed by the Director General of the Ministry of Health. The specific therapy strategy will be determined, inter alia, by the quantity of drugs available in storerooms, and epidemiological data on the pandemic strain (drug sensitivity, contagiousness, high-risks groups for infection and complications).
1. Treatment of affected medical personnel in hospitals (general and geriatric) and in the community: treatment with Oseltamivir 75 mg, twice a day, for 5 days (total of 10 tablets). 2. Treatment of patient at high-risk for influenza complications (as specified in section 6) – treatment with Oseltamivir 75 mg, twice a day
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for 5 days (total of 10 tablets). This treatment will be given until the drug stock is exhausted. 3. Extended prophylaxis with Amantadine for medical personnel in hospitals and in the community + for staff essential to the economy – 100 mg, twice a day, duration of treatment to be defined later, thus determining the quantity to be distributed to each staff member.
Principles for logistic preparation for distribution of drugs The principles for distributing the drugs are as follows:
1. Definition of parties to receive the drugs: At the current stage of drug stocks being partial, drugs are to be distributed as follows: 1) Oseltamivir: A. Oseltamivir care for patients at a high-risk of exposure to patients in general hospitals (caring for patients in emergency rooms, internal and pediatric in-patient departments admitting patients and intensive care departments) – physicians, nurses, administrative and para-medical staff (cleaners, orderlies, Roentgen technicians) – if affected, they are to receive 1 cycle
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of drugs per treatment. Total of 10 tablets per worker. About a quarter of this target population is expected to be affected and to need treatment. B. Oseltamivir care for teams at a high-risk of exposure to patients in healthcare organization clinics (physicians, nurses, admission clerks and pharmacists) – if affected, they are to receive 1 cycle of drugs per treatment. Total of 10 tablets per worker. About a quarter of this target population is expected to be affected and to need treatment. C. Oseltamivir therapy for high-risk patients: Currently calculated for this population group defined in the context of seasonal influenza. At the time of the pandemic outbreak, the high-risk population will be determined finally according to epidemiological data received from the first countries to be affected by the pandemic. The estimated number of patients in this population is several times higher than the currently existing drug inventory. Real time prioritization will therefore be performed. Total of 10 tablets per person.
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Summary – operative answer for winter of 2005/6:
2) Amantadine: A. During the peak of the pandemic, prophylaxis for vital personnel in general hospitals, as defined out of the list of all hospital staffs by the hospital committee and the pharmaceutical committee. Are to receive Amantadine (two tablets per day) for prophylaxis for up to 6 weeks (depending on the size of the population determined and the existing drug stock). Total of up to 80 tablets per worker. B. During the peak of the pandemic, prophylaxis for vital personnel in healthcare organization clinics as defined out of the list of all hospital staffs by the hospital committee and the pharmaceutical committee. Are to receive Amantadine (two tablets per day) for prophylaxis for up to 6 weeks (depending on the size of the population determined and the existing drug stock). Total of up to 80 tablets per worker. C. Prophylaxis after exposure for vital parties according to a list prepared by the Ministry of Labor and Social Affairs. The list includes about 25 organizations, including: Israel Electric
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Corporation, Mekorot water company, essential foodstuff producers, Bezeq, etc. They are to receive up to 2 cycles of drugs for prevention (each of ten days), total of 40 tablets per worker.
At the next stage, during 2006, upon arrival of additional drugs, the drugs are to be distributed as follows:
1) Oseltamivir A. Treatment of patients out of essential staff in general hospitals (unchanged from section 1A). B. Treatment of patients out of essential staff in healthcare service clinics (unchanged from section 1A). C. High-risk patients insured in healthcare organizations (unchanged from section 1C); apart from the scope, which is to suffice for caring for all expected patients (according to existing estimates). Total of 10 tablets per person. D. Prophylaxis for essential personnel in general hospitals: identical target population to that stated in section 2A, but using Oseltamivir, with a dosage of one tablet for prophylaxis for up to 6 weeks (total of up to 40 tablets per worker).
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E. Prophylaxis for essential personnel in healthcare organization clinics: identical target population to that stated in section 2A, but using Oseltamivir, with a dosage of one tablet for prophylaxis for up to 6 weeks (total of up to 40 tablets per worker). F. Essential parties as specified in section 1) 2) C, but receiving Oseltamivir, one pill per day for two 10 days cycles of treatment (total of 20 tablets per worker). Use of Amantadine for prophylaxis and Oseltamivir for treatment in this group will be considered, based on actual data.
2) Amantadine: To be kept for reserve use only. No predetermined population.
2. Routes of distribution from the stores of the emergency division to customers: According to a distribution plan to be prepared by the emergency division.
3. Routes of distribution at workplaces: A. Prophylaxis: physicians, nurses, and essential office staff in the community and hospitals will receive drugs from hospital pharmacists and their organizations. The exact scope will be reported to the
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emergency division by the hospitals and healthcare organizations using a questionnaire to be disseminated. B. Treatment of affected medical personnel: it is recommended for hospital personnel to receive the drugs from the hospital through a “personnel clinic” and the hospital pharmacy. C. Healthcare organization staff – prophylaxis: the vital populations must be defined and drugs allocated to the organizations’ districts. Healthcare service workers – treatment: mechanism for determining illness and distribution through organization / district management. D. Essential parties: necessitates further discussion with the participation of the representative of the Ministry of Labor and representatives of essential parties.
4. Establishing policy for drug distribution: establishing of policy for distribution timing will be at the responsibility of the supreme hospitalization authority.
5. A meeting is to be held with the representatives of the essential parties for update purposes: this will be performed with the help of the Ministry of Trade, Industry and Employment.
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6. Definition of high-risk patients: to ensure that the drugs for treatment are distributed only to high-risk patients rather than all patients in the population, it is recommended to mark out this population at present. As of today, we cannot exactly assess the patients at elevated risk for severe morbidity, as it depends on the virus’ real-time behavior. However, the standard policy in the world is to define this group in accordance with the population at high-risk for seasonal influenza due to background illness rather than based on age. This group has a similar composition to the group indicated for seasonal vaccination for influenza.
We recommend that preparatory activity be performed at healthcare organizations for predefining this population and marking special treatment in their medical records for facilitating control during the distribution of the drugs for a pandemic.
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