Report: PH-13-041

REGION OF WATERLOO PUBLIC HEALTH Infectious Disease, Dental and Sexuality Resources
Chair Sean Strickland and Members of the Community Services Committee October 1, 2013 INFLUENZA UPDATE FILE CODE: P14-80

TO: DATE: SUBJECT:

RECOMMENDATION: For information. SUMMARY: Influenza (commonly known as the flu) is a contagious virus that circulates on a seasonal basis, usually from October to April causing outbreaks of respiratory illness. In Waterloo Region, during the October 1, 2012 to May 11, 2013 influenza season, there were 392 laboratory-confirmed cases of influenza, 140 influenza related hospitalizations and 12 deaths where influenza was at least a contributing factor. In addition, there were 34 influenza outbreaks declared in long term care facilities, retirement homes and hospitals. This represented a level of activity higher than that seen in the previous few years. Immunization is one of the most effective ways to protect against influenza. During the 2012-2013 season, 14 Public Health community clinics were held where 8,665 people were immunized. Although Public Health clinic attendance was 25.5% lower than in the previous season, overall distribution of vaccine in the Region remained stable as 21 pharmacies introduced influenza vaccine offering additional access points for the general public. This year, 81 pharmacies across the region will be participating in the influenza program. As a result of the increase in access points for residents through the expansion of participating pharmacies, Public Health will decrease the number of community clinics offered from 14 to 8 in the 2013-2014 season. As well, an appointment-based system with bookings that can be made either via phone or online is planned for implementation this fall in order to enhance the efficiency of the Public Health clinics. Analysis of the distribution of vaccine for the 2012-2013 flu season indicates that 77 per cent of flu vaccine received by Public Health was distributed to physicians, acute care and long term care, retirement homes and workplaces. Approximately 8 per cent of flu vaccine was distributed to 21 pharmacies and 15 per cent was used by Public Health in Region of Waterloo community influenza clinics. Background Influenza (commonly known as the flu) is a contagious virus that circulates on a seasonal basis, usually from October to April, causing outbreaks of respiratory illness. People who get the flu may experience symptoms including fever, headache, chills, muscle aches, physical exhaustion, cough, sore throat and runny or stuffy nose. Most healthy individuals are able to recover from the flu, but certain segments of the population, such as the elderly and those with underlying medical conditions, may experience further complications. In some cases, the flu can be fatal.
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Yearly circulation of influenza virus can account for significant illness within the community. Public Health programs aim to reduce the incidence, spread and complications from influenza illness through: Promotion of annual influenza immunization for all persons six months of age or older (without medical contraindication); and Implementation of outbreak control measures and recommendations when influenza illness is detected in a long term care facility, retirement home or hospital. REPORT: Waterloo Region had an early start to the 2012-2013 influenza season with the first local cases reported the week of October 1, 2012. Local influenza activity peaked in mid-December and began to steadily decline in mid-January. Sporadic activity continued between February and May. Although Provincial influenza activity did not begin to increase until the end of October and did not reach peak activity until early January, the overall trend was consistent with what was observed locally. Locally, during the period of Oct 1, 2012 to May 11, 2013, there were 392 laboratory confirmed cases of influenza, 140 influenza-related hospitalizations and 12 deaths for which flu was at least a contributing factor. Influenza activity can vary significantly in intensity from season to season. While this past seasons activity remained within the expected levels for an influenza season, it represented a level of activity higher than that seen in the previous few years. Table 1 presents the total number of lab confirmed influenza cases and deaths in Waterloo Region by influenza season in the past six seasons. Table 1: Total number of lab confirmed influenza cases and deaths, by influenza season, Waterloo Region 2007-2008 to 2012-2013 Influenza Season Total Number of lab confirmed Number of deaths in lab cases confirmed cases 2007-2008 224 6 2008-2009 240 2 2009-2010 238* 3* 2010-2011 274 8 2011-2012 159 4 2012-2013 392 12 **H1N1 influenza pandemic. The number of immunizations given this season is not comparable to other seasons. Most (93%) 2012-2013 cases of influenza in the Region were subtyped as Influenza A. A small proportion of cases (7%) were caused by Influenza B, most occurring at the end of the season. A small percentage of cases (20%) are further strain-typed to determine compatibility with this seasons vaccine. Strain typing indicated a good match with the 2012-13 influenza vaccine. During the 2012-2013 season, a total of 34 influenza outbreaks and 27 additional respiratory outbreaks caused by other circulating viruses (e.g. RSV, coronavirus) were declared in long-term care facilities, retirement homes and hospitals. The intensity and volume of cases and outbreaks and the early arrival of the 2012-2013 influenza season presented challenges for Public Health and health care partners (hospitals, pharmacies, long term care homes, and retirement homes) in coping with the volume of patients requiring health care. Despite these challenges, Public Health staff successfully assisted hospitals, long term care and retirement facilities with outbreak, bed and staffing issues.
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Immunization is one of the most effective ways to protect against influenza. The flu viruses are capable of changing every year, so the composition of the vaccine is updated annually. This is why it is necessary to be immunized every year. Significant illness and societal costs also occur with seasonal influenza in people who may not be considered at high risk of complications (i.e. healthy people aged 5 to 64 years). Therefore, it is recommended that all Canadians six months of age or older be immunized. Since 2000, the Government of Ontario offers an annual Universal influenza immunization program (UIIP), which offers the vaccine free of charge to all persons in Ontario six months of age or older. Vaccine, through the Universal Influenza Immunization Program, was offered at 14 Public Health community influenza clinics that were open to the public. In addition, Public Health distributed vaccine to local physicians, pharmacies, walk-in clinics, long-term care and retirement homes, hospitals and workplaces through local nursing agencies. During the 2012-2013 season, Public Health immunized 8,665 people at its community influenza clinics. This is approximately 25.5 per cent lower than in the previous season. However, it should be noted that most members of the community are immunized in other settings (as listed above), attendance at Public Health clinics decreased as the number of vaccine providers increased (i.e. pharmacies offering influenza vaccine) and the total amount of vaccine distributed to the community remained stable. Analysis of the distribution of vaccine for the 2012-2013 flu season indicates that 77 per cent of the flu vaccine received by Public Health was distributed to physicians, acute care and long term care, retirement homes and workplaces. Approximately 8 per cent of flu vaccine was distributed to 21 pharmacies and 15 per cent was used by Public Health in Region of Waterloo community influenza clinics. 2013-14 Planning/Next Steps Due to the 4 fold increase in pharmacies offering influenza vaccine in the region in the 2013-2014 season, Public Health will reduce the number of community influenza immunization clinics offered from 14 to 8 clinics. Clinic locations were geomapped with participating pharmacies and community health centers to maximize access to a clinic or pharmacy as much as possible. It should be noted that the map does not include doctors offices and workplaces, where influenza vaccine is also available (see Appendix A). As well, Public Health will implement a new appointment-based system, with bookings that can be made either via phone or online, to help reduce wait times for clients and improve efficiency in its community clinics. Region of Waterloo Public Health will continue to provide enhanced health promotion and community awareness regarding the benefits of the influenza vaccine and will continue to distribute influenza vaccine to health care partners that require additional supply. It should be noted that Public Health continues to receive $5.00 per dose in cost recovery from the Province for the delivery of influenza vaccine. This fee has remained unchanged since the beginning of the Universal Influenza Immunization Program in 2000. Reduction of clinics and implementation of an appointment based delivery system are attempts to keep the program within budget. The large increase of the number of pharmacies delivering flu vaccine will more than off-set the reduction of Public Health clinics and increase hours of access for the general public. Recognizing that the immunization of health care workers is a key strategy for protecting the most vulnerable in our community, Region of Waterloo Public Health and their health care partners will enhance focus on the promotion of health care worker influenza immunization this year through: the Big Shot Challenge, a local program designed to increase uptake of flu vaccine among staff that work in long term care and retirement homes; and
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working with partners in both the acute and long term care sectors to develop resources that will be used to promote vaccination of health care professionals during Infection Control Week (October 21-25, 2013).

Public Health will continue to receive reports of confirmed cases of influenza and work with facilities (e.g. long-term care homes, retirement homes) to monitor and manage respiratory and influenza outbreaks. As well, Public Health will continue to work with their health care partners to achieve optimal staffing levels during outbreaks through education and policy development. CORPORATE STRATEGIC PLAN: Healthy and Inclusive Communities: Foster healthy, safe, inclusive and caring communities Service Excellence: Deliver excellent and responsive services that inspire public trust FINANCIAL IMPLICATIONS: Public Health continues to receive $5.00 per dose in cost recovery from the province for the delivery of influenza vaccine. This fee has remained unchanged since the beginning of the Universal Influenza Immunization Program in 2000. The program strives to provide the required services within the limits of the cost recovery fee of $5.00 per dose. When expenditures related to the delivery of influenza clinics exceed the revenues generated, they are covered within the remaining cost shared Vaccine Preventable Disease Program or overall cost shared Public Health Budget. OTHER DEPARTMENT CONSULTATIONS/CONCURRENCE: NIL ATTACHMENTS Attachment A: Mapping of Pharmacies, Community Health Centres and Public Health Clinics for Influenza vaccine

PREPARED BY:

Kristy Wright, Manager Infectious Disease and Tuberculosis Control and Emergency Management Linda Black, Manager, Vaccine Preventable Disease Dr. Liana Nolan, Commissioner/Medical Officer of Health

APPROVED BY:

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Attachment A: Mapping of Pharmacies, Community Health Centres and Public Health Clinics for Influenza Vaccine

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