ARCHIVED: Mandate #2: The Management of the National Antiviral Stockpile: Options Report - Integration of the Technical Recommendations

 

Mandate #2: Integration of the Technical Recommendations

Technical recommendations arising from the Antiviral Working Group (on stockpile composition) and those from the Antiviral Stockpile Management Task Group (on stockpile management) were first presented to PHNC on January 29, 2009.  This section describes the integration of both sets of recommendations, and incorporates the new population estimates using both 2005 (for paediatric) and 2008 (for adults) census data.  These recommendations represent the targets required to maintain the NAS at 17.5% of the total population of Canada.  Some P/Ts may have purchased more than the minimum quantity for their jurisdiction. 

Doses Needed of Zanamivir, Paediatric Oseltamivir and Amantadine

  1. Recommendation to purchase 5.7 million more doses of zanamivir to reach NAS target of 20% (includes adults and paediatrics)
  2. Recommendation to acquire 7.2 million more capsules of paediatric oseltamivir capsules to meet the paediatric targets (based on 2005 population estimates)
  3. Recommendation to purchase 5.8 million amantadine capsules to mirror 10% of the current size of the NAS.

(See Appendix 6 – Summary of National Antiviral Stockpile Composition Changes)

Considering the above recommendations on new stockpile composition, and the 28.4 million doses of expiring oseltamivir in 2009/2010, there was an opportunity to adjust the amount of new stock to be purchased or exchanged to best meet the new stockpile targets.  The AVSMTG provided recommendations on how best to replace the expiring stock in light of these considerations.    

Implications for the 28.4M Doses of Expiring Oseltamivir

Given the new composition of the NAS increases the proportion of zanamivir to 20% from 10%, less oseltamivir is needed.  Taking this into account, along with the new population estimates, there will still be 7.7 million doses of expiring adult oseltamivir in the NAS no longer needed (considered ‘redundant’).    

7.7 million doses are redundant
The AVSMTG recommended the 7.7M redundant doses of antivirals be managed as follows: 

  1. exchange 3.1M adult oseltamivir doses to paediatric oseltamivir doses (will convert 75 mg capsules into enough 30mg and 45mg capsules to equal 7.2M for paediatric populations); and
  2. hold and stability test 4.6M doses with no plans to exchange.  If considered potent through regular stability testing, these antivirals could be used for an additional 2 years, if necessary, using an Interim Order.

20.7 million doses need to be replaced Of the 28.4 million expiring adult oseltamivir doses (of which 7.7M were redundant), there remains an additional 20.7M doses to be replaced.  These doses could either be replaced at a reduced price through the Exchange Program; held and stability tested; or a combination of the two in various proportions. 

The AVSMTG recommended that P/Ts exchange all or a portion of expiring oseltamivir stock now and replace the rest later.  The following proportions were presented: 

  • 100% exchanged now, 0% replaced later: $24.2 million*
  • 50% exchanged now, 50% replaced later:  $36.3 million* ($12.1M now, $24.2M in 2011/2012)
  • 33% exchanged now, 67% replaced later: $40.4 million* ($8M now, $32M 2011/2012)
  • 0% exchanged now, 100% replaced later: $48.4 million* in 2011/2012

* - note that this does not take into account future expenditures for upcoming stockpile expiries

As discussed above, all purchases for zanamivir and amantadine require straight purchases (i.e. no exchanges are possible). 

All quantities and costs were estimated for each province and territory and were allocated on a per capita basis.  The tables and cost estimates were provided to Public Health Network Council for discussion. (See Appendix 7a – Purchase Requirements, by Jurisdiction, to meet paediatric oseltamivir, zanamivir, and amantadine targets)

Outcomes of the Recommendations

On February 13, 2009, the AVSMTG recommendations were approved by PHNC.  On February 26, 2009, PHNC presented the recommendations to the Conference of P/T Deputy Ministers of Health.  The agreement was as follows: 

  • There was agreement in principle to maintain stockpile at 17.5% of the total population for the purpose of early treatment.
  • There was agreement on each of the three recommendations on stockpile composition/size (increase quantity of zanamivir, add quantity of amantadine, increase quantity of paediatric capsules)
  • It was agreed that each jurisdiction will decide on how best to manage their antiviral stockpile and will notify PHAC of purchasing decisions for a national perspective.

It was agreed that the PHNC would report P/T progress on the above recommendations to the Conference of Deputy Ministers of Health in December 2009.  It is requested that a review of broad planning and pandemic preparedness priorities be discussed with a view to recommending future directions including if there is an appropriate balance of investment in antivirals, other pandemic supplies, public education, vaccine or other strategies. 
           
A roundtable discussion was held with the AVSMTG on April 2, 2009 and a discussion was held on Best Practice Recommendations for inclusion in the Report.  Subsequent to this meeting, a survey summarizing each P/T purchasing decision was circulated and will be presented to PHNC in the future. 

A summary of the new National Antiviral Stockpile targets reflecting the new stockpile recommendations is provided in the table below. 

Table 3, Summary of the National Antiviral Stockpile Targets

*The 7.7 million dose excess will be replaced by 3.1 million paediatric doses to meet all paediatric targets. 

The remaining 4.6 million ‘redundant’ doses will be held and stability tested  (see below).
National Antiviral Stockpile

 

Current composition Recommended Future Composition Difference

Adult oseltamivir (75 mg)

48.7 M capsules

41 M capsules

7.7 M excess*

Paed. oseltamivir (45 mg)

0.6 M capsules

1.9 M capsules

1.3 M short

Paed. oseltamivir (30 mg)

1.4 M capsules

7.3 M capsules

5.9 M short

Adult & paed. zanamivir (10 mg)

5.0 M doses

10.7 M doses

5.7 M short

SUBTOTAL:

60.9M ‘dose equivalents’, (or 5.8 million treatment courses or 58 million doses)

Amantadine
(for combination therapy)

0 doses

5.8 M capsules (2.6 M doses)

5.8 M short

 

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