Manitoba RSV Prophylaxis Program: Past, Present and Future Aaron Chiu Section of Neonatology Department of Paediatrics University of Manitoba
Questions for consideration n Who should be given palivizumab? Why are we giving palivizumab? What is the cost?
Objectives n n Review RSV – burden of disease, later disease Review palivizumab Eligibility Criteria Program: how it works q q q n n Regional challenges Outreach program 2005 -06 Program statistics Manitoba approach to 33 -35 wks infants 2006 -07 Program and Eligibility Criteria
Disclosure n Abbott Canada provides q q n n n Yearly funding to run the program Funds for nursing staff to run clinics No part of funding from Abbott goes to physician remuneration No physician remuneration from MB Health I do not directly hold shares in Abbott
Quiz n Which of the following is true? q q Infection with RSV confers immunity for the rest of the season Immunization with palivizumab decreases likelihood of becoming infected with RSV Palivizumab, like RSV-IVIG is contraindicated in infants with congenital heart disease A single dose of palivizumab is sufficient to provide immunity for the next month
Answer n Which of the following is true? q q Infection with RSV confers immunity for the rest of the season Immunization with palivizumab decreases likelihood of becoming infected with RSV Palivizumab, like RSV-IVIG is contraindicated in infants with congenital heart disease A single dose of palivizumab is sufficient to provide immunity for the next month
RSV n n Most common cause of LRTI in young children Infection does not result in immunity Re-infection common Common presentation = bronchiolitis
Burden of RSV Illnesses n n Wheezing later Morbidity and Mortality Apnea Hospitalization – 1 -2% require hospitalization
Infants at risk significant RSV n n n Preterm infants with BPD/CLD Children with other lung diseases Aboriginal Premature Infants Hemodynamically significant cardiac disease Pulmonary hypertension
Children’s Hospital – RSV Burden 05 -06 04 -05 03 -04 02 -03 01 -02 Total HSC 63 219 159 216 115 HSC not admit 6 12 10 24 14 HSC admitted 57 207 149 192 101 Non-HSC 22 114 105 106 54 Total 85 333 264 322 169 Courtesy of Infection Prevention Control – Karen Olekson
Children’s Hospital – RSV Burden Year ICU Days 05 -06 25 04 -05 223 03 -04 140 02 -03 85 01 -02 170 Courtesy of Infection Prevention Control – Karen Olekson
Immunoprophylaxis Palivizumab
Immunoprophylaxis n Passive Immunization: q q n n Respi. Gam™ (RSV-IVIG) Synagis® Respi. Gam manufactured by Genesis Biopharm Synagis® manufactured by Med. Immune q In Canada – Abbott Laboratories Ltd. has license for distribution
Palivizumab n Humanized, mouse monoclonal antibody against F protein of RSV q q n Immunoglobulin G-1 Against F glycoprotein of RSV+ 50 -100 times more potent than RSV-IVIG
Human Ig. G Mouse monoclonal - Palivizumab Adapted from B. Law – presentation 2004
IMpact-RSV Trial n n 1502 infants (1002 palivizumab, 500 placebo) Participants: q q ≤ 35 wks GA and < 6 months age 24 months or younger and clinical diagnosis of BPD requiring ongoing medical treatment (oxygen steroids, bronchodilators, diuretics) within past 6/12 Pediatrics 1998; 102: 531 -537
IMpact-RSV Trial n Primary Outcome: q q Hospitalization with tested positive RSV Positive RSV test while hospitalized for non-RSV Pediatrics 1998; 102: 531 -537
IMpact-RSV Trial - Outcome Placebo Palivizumab (Synagis®) P-value NNT RSV Hospitalization 10. 6% 4. 8% <0. 001 18 Prem without BPD 8. 1% 1. 8% <0. 001 16 Prem with BPD 12. 8% 7. 9% 0. 038 21 < 32 weeks (84%) 11% 5. 8% 0. 003 20 32 -35 wks (16%) 9. 8% 2% 0. 002 13 ICU Admissions 3% 1. 3% 0. 026 44 Pediatrics 1998; 102: 531 -537
IMpact-RSV Trial - Outcome Placebo Palivizumab (Synagis®) P-value NNT RSV Hospitalization 10. 6% 4. 8% <0. 001 18 Prem without BPD 8. 1% 1. 8% <0. 001 16 Prem with BPD 12. 8% 7. 9% 0. 038 21 < 32 weeks (84%) 11% 5. 8% 0. 003 20 32 -35 wks (16%) 9. 8% 2% 0. 002 13 ICU Admissions 3% 1. 3% 0. 026 44 Pediatrics 1998; 102: 531 -537
IMpact-RSV Trial - Outcome Placebo Palivizumab (Synagis®) P-value NNT RSV Hospitalization 10. 6% 4. 8% <0. 001 18 Prem without BPD 8. 1% 1. 8% <0. 001 16 Prem with BPD 12. 8% 7. 9% 0. 038 21 < 32 weeks (84%) 11% 5. 8% 0. 003 20 32 -35 wks (16%) 9. 8% 2% 0. 002 13 ICU Admissions 3% 1. 3% 0. 026 44 Pediatrics 1998; 102: 531 -537
Eligibility Criteria
Quiz n Which of the following is true? q q There is standardized eligibility criteria for palivizumab across Canada. Each province has its own eligibility criteria. Parents/guardians of non-eligible patients can purchase palivizumab on their own. An infant born at 29 weeks gestation in Canada would receive palivizumab regardless of which tertiary centre he/she is born in.
Answer n Which of the following is true? None q q There is standardized eligibility criteria for palivizumab across Canada. Each province has its own eligibility criteria. Parents/guardians of non-eligible patients can purchase palivizumab on their own. An infant born at 29 weeks gestation in Canada would receive palivizumab regardless of which tertiary centre he/she is born in.
CPS Recommendations (1999) n Priority for palivizumab given to patients at highest risk of developing severe RSV infection: q q q <24 months with BPD requiring oxygen in past 6 months preceding RSV season Infants 32 weeks gestation or less who are 6/12 months of age or less at start of RSV season Consideration for children 33 -35 in isolated communities where hospital care is not readily accessible Recommendations reaffirmed in 2005
AAP Recommendations (2003) n “immunoprophylaxis should be reserved for use in infants and children at greatest risk of RSV infection because of the high cost of this intervention” Pediatrics 2003; 112: 1442 -1446.
AAP Recommendations (2003) n Parental education important: q q Eliminate exposure to cigarette smoke Limit participation in child care Limit exposure to crowds and infected individuals Importance of hand hygiene in all settings including the home Pediatrics 2003; 112: 1442 -1446.
AAP Recommendations (2003) n <320 weeks gestation q q n n ≤ 280 weeks 28 -320 weeks up to 6 months age < 2 years age if CLD requiring medical therapy (oxygen, bronchodilator, diuretic, steroid) < 2 years age with hemodynamically significant congenital heart disease Pediatrics 2003; 112: 1442 -1446.
AAP Recommendations (2003) n 321 -350 weeks gestation, < 6 months at start of season, if 2 or more risk factors: q q q Child care attendance School-aged siblings Environmental air pollutants, Congenital abnormalities of the airways Severe neuromuscular disease Pediatrics 2003; 112: 1442 -1446.
AAP Recommendations (2003) n Uncertain: q q q Immunocompromised children Cystic fibrosis Prevention of nosocomial RSV disease Pediatrics 2003; 112: 1442 -1446.
NACI Recommendations (2003) n n Infants born ≤ 32 week gestation and < 6 months age at start of during season (IA) Children < 24 months at with BPD/CLD requiring oxygen or medical therapy within past 6 months (IA) Children < 24 months with hemodynamically significant heart disease (IA) Consideration for children both at < 35 weeks’ gestation who are < 6 months at start of season who live in remote northern communities (IIIF) CCDR September 15, 2003 Volume 29; ACS-7, 8
Different Criteria Across Canada n British Columbia: q q n < 2 yo with BPD/CLD requiring oxygen and/or medical therapy 28 wks gestation, and < 6 months age at start of season 29 -35 weeks gestation and < 6 monhts at start of season with additional risk factors < 2 yo with hemodynamically significant CHD Quebec: BMT
Economics of Palivizumab
Quiz n Assuming an ex-premature infant remains at 4 kg during the entire RSV season, what is the cost ($Cnd) to provide the standard 5 doses of Synagis? n n n $500 $1200 $2500 $4500 $8500
Answer n n n $4500 Cost is $1500/100 mg vial or $750/50 mg Approximately $15/mg Usual dose is 15 mg/kg or $225/kg/dose Usual 5 doses or $1125/kg/season (assuming no increase in weight)
Quiz n During the 2004 -05 season, what is the total cost of palivizumab ordered through CBS? q q q $4 million $10 million $13 million $19 million $23 million
Quiz n During the 2004 -05 season, what is the total cost of palivizumab ordered through CBS? q q q n $4 million $10 million $13 million $19 million $23 million Does not include Hema-Quebec
Economics of Synagis n n Worldwide annual sales ~ $1 billion US Med. Immune partnered with Abbott since 1998 q q q n Abbott received commission based on amount of drug sold Concern about conflict with 2 drugs in market: Synagis and Numax Med. Immune will sale and promote Synagis as of July 1, 2006 Abbott Laboratories has rights to market and distribute Synagis (and Numax) outside of USA Med. Immune Press Release - August 31, 2005
Palivizumab Packaging n 100 mg and 50 mg vials q q n 100 mg – upto 6. 7 kg infant 50 mg – upto 3. 3 kg infant No preservative q q Opened vials must be used within 6 hours Potential for drug wastage Rationale for cohorting patients into clinic days (Thursday) Pharmacy reconstitute and pharmacy and clinic staff draws up dose to limit wastage
Manitoba RSV Prophylaxis Program (RSVP)
Program Structure n n RSV (immuno)prophylaxis Program since 1998 2 main hospital sites in Winnipeg involved with neonates and paediatrics q q n In-patient Out-patient clients Evolving to be a true provincial program
MB RSV Prophylaxis Program n n n n Capture, register and follow all prems with fulfill Program criteria Follow upon discharge to community Winnipeg (hospital) vaccination clinics Arrange for vaccinations outside of Winnipeg Arrange shipment of Synagis to outreach sites Record compliance with doses provided to each patient – reminders if necessary Education to outreach communities about RSV and RSV Prophylaxis Meeting with entire team each fall to prepare for season – review of program, changes
Tertiary NICU Catchment Area n Winnipeg is referral centre for: q q q Manitoba Western Nunavut Northwestern Ontario
MB RSV Prophylaxis Program n n Database of almost all preterm infants born in Manitoba and catchment area Regionalization of Synagis clinics within the city of Winnipeg to 2 major sites running clinics
Out-Reach Liaisons n Established Regional Medical Units q q Northern Medical Unit First Nations-Inuit Health Branch** n n n First Nations Reserves Nurse Practitioners Local medical clinics q Physicians
RSVPP – Enrolment Process
RSVPP – Enrolment Process n n n Identification Consent Referral to Canadian Blood Services CBS Approval and ID# Rx: Palivizumab q q q In hospital In clinic (HSC, St. B) Other: other clinics, nursing stations, MD offices
Patient Identification n Direct q q n Staff identify eligible newborns All admissions to the three nurseries are reviewed Indirect q Referral from physicians
Consent n Verbal consent obtained q Role of primary physician
Canadian Blood Services n CBS runs program q n n n Hema-Quebec for Quebec CBS established criteria for funding approval CBS grants approval and provides patient ID for tracking CBS bills the referral province for cost
Sites of Vaccination n Winnipeg Hospital Clinics: q q n Children’s Hospital St. Boniface Hospital Regional: q q Physician’s office Health Unit/Nursing Stations
RSVPP Statistics
Program Enrollment Year Total ≤ 32 wks BPD CHD 33 -35 wks Other Outreach 99 -00 45 41 4 0 0 ? 14 00 -01 158 144 14 0 0 ? 44 01 -02 154 145 9 0 0 ? 56 02 -03 181 177 4 0 0 ? 72 03 -04 177 143 5 29 0 ? 63 04 -05 186 142 6 30 0 8 67 05 -06 231 180 2 25 10 14 72
2005 -2006 n n n Total eligible for program = 273 Total number enrolled = 231 (85%) Infants < 33 wks and < 6 months at season start q q N = 203 Enrolled = 170 (84%)
Reasons for Non-Enrollment Non Eligible (>6 months old when season began) 2 Cardiac corrected prior to season start 16 Refused by family 8 Family cannot be located 8 No consent or No reply from MD/Family 3 Baby discharged & resides in USA 1 Deceased 4
Who Initiated Enrollment n n Program – 223 (97%) Outreach Communities – 8 (3%)
Outreach Infants and Location of Vaccinations Community MB ONT SK AB BC Nunavut All Hospital 3 2 0 0 0 1 13 2 1 0 0 7 Hospital and Community 38 6 0 8 2 12 72 infants in the program received at least one dose outside of hospital clinics
Shipping of Synagis® to Outreach Sites n 2004 -05 Season q q n Attempt made to ship from HSC Pharmacy in Winnipeg to all outreach sites Failure 2005 -06 Season q q Shipping directly from Montreal (Abbott) UPS Supply Chain Solutions (Winnipeg) Winnipeg HSC Pharmacy (rare cases) Success!
Outreach Sites n Manitoba - 18 sites: q n Ontario - 4 sites q n Altona, Berens River, Brandon, Boundry Trails, Cross Lake, Dauphin, Easterville, Koostatak, Minnedosa, Norway House, Pine Falls, Shamattawa, Steinbach, Swan River, The Pas, Thompson, Vita, Waywayseecappo Kenora, Pikangikum, Sioux Lookout, Thunder Bay Nunavut - 4 sites q Arviat, Baker Lake, Coral Harbour, Rankin Inlet
Synagis® Utilization 2005 -06 (794 doses) Location Hospital In-Patient – HSC Site Hospital In-Patient – St. Boniface Hospital Out-Patient – HSC Site Hospital In-Patient – St. Boniface Outreach - Manitoba Outreach - Ontario Outreach - Nunavut Edmonton (Post-op Cardiac) Doses 150 81% 59 421 14 104 14 26 6 18%
Quiz n What was the cost of palivizumab used for the Manitoba RSV Prophylaxis Program for 2005 -2006?
Answer n Total dose used = 55, 722 mg n Total cost of drug (assuming no wastage) $835, 830 n Assuming 50% wastage, total cost of palivizumab used: $1, 671, 660
Program Outcome 2005 -06 n Number of Infants enrolled in Program hospitalized for RSV admission q q One Infant admitted at beginning of season and had yet to receive a dose
Program Outcome 2005 -06 n Number of infants hospitalized for RSV who were eligible for Program but was not enrolled q None
33 -35 weeks gestation cohort 2005 -06 (Last Season)
Impact-RSV Trial - Outcome Placebo Palivizumab (Synagis®) P-value NNT RSV Hospitalization 10. 6% 4. 8% <0. 001 18 Prem without BPD 8. 1% 1. 8% <0. 001 16 Prem with BPD 12. 8% 7. 9% 0. 038 21 < 32 weeks (84%) 11% 5. 8% 0. 003 20 32 -35 wks (16%) 9. 8% 2% 0. 002 13 ICU Admissions 3% 1. 3% 0. 026 44 Pediatrics 1998; 102: 531 -537
Issues – Against Immunoprophylaxis n n Large cohort, significant costs Lack of direction from expert groups (CPS, NASI)
Cost in Canadian Dollars Ottawa General Level III 1995 -96 Average Cost = $15, 980
Issues – For Immunoprophylaxis n n Benefit in preventing hospitalization Evidence to suggest increased morbidity after RSV-associated infection/hospitalization q n n Increased hospitalization, need for RT visits, medical visits, hospital stay Lack of Canadian expert guidelines Acknowledgment of potential benefit to some q q First Nations Residents of Northern communities
Decision n n Look at available evidence Find a way to apply evidence in practical and pragmatic manner Made in Manitoba solution Major protection from palivizumab = decrease rate of RSV hospitalization Sampalis. J Pediatr 2003; 143: S 150 -156.
PICNIC: 33 -35 week Cohort n Risk Factors for Hospitalization: q q q q Birth Nov, Dec, Jan Male Gender SGA (birth weight < 10 ile) Attending day care Any preschool siblings ≥ 2 smokers in household > 5 individuals in home (include subject) Eczema in first degree relative Law et al. Pediatr Infect Dis J 2004; 23: 806 -14.
PICNIC: 33 -35 weeks gestation cohort Risk Factor for RSV Hospitalization OR* Risk Score+ Born Nov, Dec, Jan 4. 88 25 Male 1. 91 11 SGA (bwt < 10 ile) 2. 19 12 Subject attend day care 12. 32 Any preschool siblings 2. 76 ≥ 2 smokers in household 1. 71 10 >5 individuals in home 1. 69 13 Eczema in 1 st degree relative 0. 42 12 (no FHx) *Law et al. Pediatr Infect Dis J 2004; 23: 806 -14. 17 +Langley et al. CPS Abstract 2006
Risk Score: 33 -35 weeks gestation cohort Risk of RSV Hospitalization Level of Risk Score Range % in Risk Group Low Risk 0 -48 70. 4% Moderate Risk 49 -64 25. 6% High risk 65 -100 4. 0% Langley et al. CPS Abstract 2006
Risk Score: 33 -35 weeks gestation cohort Risk Factor Born Nov, Dec, Jan Male SGA (bwt < 10 ile) Subject attend day care Any preschool siblings ≥ 2 smokers in household >5 individuals in home Eczema in 1 st degree relative OR 4. 88 1. 91 2. 19 12. 32 2. 76 1. 71 1. 69 0. 42 Risk Score 25 11 12 17 10 13 12 (no FHx) SUM = 65
Manitoba Approach to 33 -35 n Criteria: q q n Born during RSV season Infants residing in ‘remote’ North Definition remote North: q requiring air medical transport for urgent medical care
Manitoba Approach to 33 -35 n No formal cost analysis: q n Cost of typical air medical transport q n Assumption cost of medical transport justifies use of palivizumab in this cohort Estimate of $5000 -$10, 000 Nunavut – cost of medical transport and hospitalization q $40, 000
Pragmatic Definition: ‘Remote’ North n Communities north of Winnipeg were reviewed q n Communities south of Winnipeg not included due to greater availability of regional hospitals Based on likelihood of air medical transport q q Communities 500 N Latitude or greater North of Eriksdale – Poplar Field - Arborg
Postal codes of communities were compiled for inclusion list
Postal Code n n n RO (rural code) – select R 7 N - Dauphin R 8 – Thompson, Flin Flon R 9 – The PAS P – Northern Ontario X - Nunavut
Comparison to Children’s RSV Data R 0 (rural) R 1 (Portage, Selkirk) R 2/3 (Winnipeg) R 4 (Headingly) R 5 (Steinbach) R 6 (Winkler, Morden) R 7 (Brandon, Dauphin) R 8 (Thompson) R 9 (The Pas) P (Northern Ontario) X (Nunavut) 05 -06 16 0 39 0 0 2 0 2 4 04 -05 03 -04 02 -03 01 -02 79 38 48 25 3 2 5 3 114 89 143 70 0 0 1 2 0 1 1 1 0 3 0 1 2 2 0 1 1 2 0 14 4 9 4 3 18 2 11 Courtesy of Infection Prevention Control – Karen Olekson
33 -35 weeks gestation cohort 2006 -07 Current Season
Children’s RSV Data R 0 (rural) R 1 (Portage, Selkirk) R 2/3 (Winnipeg) R 4 (Headingly) R 5 (Steinbach) R 6 (Winkler, Morden) R 7 (Brandon, Dauphin) R 8 (Thompson) R 9 (The Pas) P (Northern Ontario) X (Nunavut) 05 -06 16 0 39 0 0 2 0 2 4 04 -05 03 -04 02 -03 01 -02 79 38 48 25 3 2 5 3 114 89 143 70 0 0 1 2 0 1 1 1 0 3 0 1 2 2 0 1 1 2 0 14 4 9 4 3 18 2 11 Courtesy of Infection Prevention Control – Karen Olekson
Countries with Guidelines for Palivizumab use in 33 -35 week GA Infants n n n n Italy Japan Poland Germany Hungary Spain Latin American USA
Canadian Criteria for Palivizumab use in 33 -35 weeks GA infants (2005 -2006) Province Criteria - # Risk Factors Quebec < 6 months + day care OR 3 risk factors Saskatoon 2 or more risk factors BC < 6 months + 3 risk factors S. Ontario Risk Score > 49 ( Moderate- High Risk) Ottawa 2 or more risk factors New Brunswick Risk Score > 49 ( Moderate- High Risk) Alberta < 6 months + 3 risk factors
Palivizumab Utilization 33 -35 wks (05 -06) Province 33 -35 wks enrolled (Total = 582) BC 13 Alberta 71 Saskatchewan 12 Manitoba 10 Ontario 241 Quebec 221 New Brunswick 14
Risk Score: 33 -35 weeks gestation cohort Risk Factor for RSV Hospitalization Risk Score Born Nov, Dec, Jan 25 Male 11 SGA (bwt < 10 ile) 12 Subject attend day care Any preschool siblings 17 ≥ 2 smokers in household 10 >5 individuals in home 13 Eczema in 1 st degree relative 12 (no FHx) Langley et al. CPS Abstract 2006 Overall Sensitivity = 68. 2%
Risk Score: 33 -35 weeks gestation cohort Risk of RSV Hospitalization Level of Risk Score Range % in Risk Group Low Risk 0 -48 70. 4% Moderate Risk 49 -64 25. 6% High risk 65 -100 4. 0% Langley et al. CPS Abstract 2006
Total Score vs Predicted Probability of RSV Hospitalization Mean Predicted probability= 0. 18741 High Risk Mean Predicted probability= 0. 07137 Mean Predicted probability= 0. 01677 Moderate Risk Low Risk Langley et al. CPS Abstract 2006
Risk Score: 33 -35 weeks gestation cohort Risk of RSV Hospitalization Level of Risk Low Risk Score Range 0 -48 % in Risk Group 70. 4% Predicted Probability 1. 7% Moderate Risk High risk 49 -64 25. 6% 7. 1% 65 -100 4. 0% 18. 7% Langley et al. CPS Abstract 2006
Eligibility Criteria for n Reside in ‘remote North’ q Eligibility will be assessed based on place of primary residence (address and postal code) n 0 -356 33 wk GA Not residing in ‘remote North’ q q q Eligibility based on scoring of risk factors Infants in High Risk Category will be considered Risk factor: n n n n Born Nov 2006 -March 2007 Male Small for gestational age Patient or sibling attending daycare > 5 individuals living in household (including patient) ≥ 2 smokers in household No family history of eczema
Plans for 2006 -07 Season n n Collection of data all infants <36 week Active enrolment of 33 -35 q q Residing in Remote North Risk factors scoring in high risk range for RSV hospitalization
Eventual Plan n Linkage of: q q preterm birth database participation in RSV Prophylaxis Program (including compliance and dose scheduling) air medical transport for illness admission for RSV +ve bronchiolitis
2006 -2007 RSVP Program Eligibility Criteria and Start Date
Start Date n November 15, 2006 q q Unless sudden start of RSV Season If season start early: n n Start in-patient program immediately Outpatient clinics once space available and families notified
Why Fixed Start Date? n Previous moving start date q Pros n n q tailor to season Limit to 5 doses Cons – wait for 2 admissions for 2 consecutive weeks n n n Infants already infected – season started before first vaccination Initial admissions can be quite sick New recommendation allow up 7 doses per season
Standard Eligibility Criteria n n n <330 weeks gestational at birth and ≤ 6 months age at start of season ≤ 24 months of age with BPD/CLD and who have required oxygen within the past 6 months preceding season ≤ 24 months of age with hemodynamically significant heart disease
Eligibility Criteria for n Reside in ‘remote North’ q Eligibility will be assessed based on place of primary residence (address and postal code) n 0 -356 33 wk GA Not residing in ‘remote North’ q q q Eligibility based on scoring of risk factors Infants in High Risk Category will be considered Risk factor: n n n n Born Nov 2006 -March 2007 Male Small for gestational age Patient or sibling attending daycare > 5 individuals living in household (including patient) ≥ 2 smokers in household No family history of eczema
Other Category n n Other infants ≤ 2 years of age considered on individual basis Will require letters of support from paediatrician AND respirologist, infectious disease specialist, cardiologist (or other specialists)
Parental Education n n Eliminate exposure to cigarette smoke Limit participation in child care Limit exposure to crowds and infected individuals Importance of hand hygiene in all settings including the home
MB RSV Prophylaxis Program Team n Program Team: q q q n Rose Paulley Sherree Anderson Dr. Joanne Embree q q Ruth Reimer Cory Kress Lise Bourrier Debbie Cote Debby Shaski St. Boniface: q q Darlene Mihalchuk Naomi Granke Pharmacy Representative: q q q Children’s Clinic Nurse: q n n q q n Community/Outreach Rep: q q q n Ron Eros Helen Ferens Lydia Smart Luke Mackenzie Roxanne Burton Dr. Bruce Martin Dr. Dave Williams Celina Denechezhe Liason: q q Lea Legge (cardiology) Paul Brenneman (Abbott)
Forms n Referral Form n Pocket Card
Objectives n n Review RSV – burden of disease, later disease Review palivizumab Eligibility Criteria Program: how it works q q q n n Regional challenges Outreach program 2005 -06 Program statistics Manitoba approach to 33 -35 wks infants 2006 -07 Program and Eligibility Criteria
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