Transcript Manitoba RSV Prophylaxis Program

Manitoba
RSV Prophylaxis Program: Past,
Present and Future
Aaron Chiu
Section of Neonatology
Department of Paediatrics
University of Manitoba
Questions for consideration



Who should be given palivizumab?
Why are we giving palivizumab?
What is the cost?
Objectives




Review RSV – burden of disease, later disease
Review palivizumab
Eligibility Criteria
Program: how it works





Regional challenges
Outreach program
2005-06 Program statistics
Manitoba approach to 33-35 wks infants
2006-07 Program and Eligibility Criteria
Disclosure

Abbott Canada provides





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

Which of the following is true?




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

Which of the following is true?




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




Most common cause of LRTI in young
children
Infection does not result in immunity
Re-infection common
Common presentation = bronchiolitis
Burden of RSV Illnesses




Wheezing later
Morbidity and Mortality
Apnea
Hospitalization – 1-2% require hospitalization
Infants at risk significant RSV






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

Passive Immunization:




RespiGam™ (RSV-IVIG)
Synagis®
RespiGam manufactured by Genesis Biopharm
Synagis® manufactured by MedImmune

In Canada – Abbott Laboratories Ltd. has license
for distribution
Palivizumab

Humanized, mouse monoclonal antibody
against F protein of RSV



Immunoglobulin G-1
Against F glycoprotein of RSV+
50-100 times more potent than RSV-IVIG
Human IgG
Mouse monoclonal
-
Palivizumab
Adapted from B. Law – presentation 2004
IMpact-RSV Trial


1502 infants (1002 palivizumab, 500 placebo)
Participants:


≤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

Primary Outcome:


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

Which of the following is true?




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

Which of the following is true? None




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)

Priority for palivizumab given to patients at
highest risk of developing severe RSV
infection:



<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)

“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)

Parental education important:




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)

<320 weeks gestation




≤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)

321-350 weeks gestation, < 6 months at start
of season, if 2 or more risk factors:





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)

Uncertain:



Immunocompromised children
Cystic fibrosis
Prevention of nosocomial RSV disease
Pediatrics 2003;112:1442-1446.
NACI Recommendations (2003)




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

British Columbia:





< 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

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?





$500
$1200
$2500
$4500
$8500
Answer





$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

During the 2004-05 season, what is the total
cost of palivizumab ordered through CBS?





$4 million
$10 million
$13 million
$19 million
$23 million
Quiz

During the 2004-05 season, what is the total
cost of palivizumab ordered through CBS?






$4 million
$10 million
$13 million
$19 million
$23 million
Does not include Hema-Quebec
Economics of Synagis


Worldwide annual sales ~ $1 billion US
MedImmune partnered with Abbott since 1998




Abbott received commission based on amount of drug sold
Concern about conflict with 2 drugs in market: Synagis and
Numax
MedImmune will sale and promote Synagis as of July 1,
2006
Abbott Laboratories has rights to market and
distribute Synagis (and Numax) outside of USA
MedImmune Press Release - August 31, 2005
Palivizumab Packaging

100 mg and 50 mg vials



100 mg – upto 6.7 kg infant
50 mg – upto 3.3 kg infant
No preservative




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


RSV (immuno)prophylaxis Program since
1998
2 main hospital sites in Winnipeg involved
with neonates and paediatrics



In-patient
Out-patient clients
Evolving to be a true provincial program
MB RSV Prophylaxis Program








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

Winnipeg is referral
centre for:



Manitoba
Western Nunavut
Northwestern Ontario
MB RSV Prophylaxis Program


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

Established Regional Medical Units


Northern Medical Unit
First Nations-Inuit Health Branch**



First Nations Reserves
Nurse Practitioners
Local medical clinics

Physicians
RSVPP – Enrolment Process
RSVPP – Enrolment Process





Identification
Consent
Referral to Canadian Blood Services
CBS Approval and ID#
Rx: Palivizumab



In hospital
In clinic (HSC, St. B)
Other: other clinics, nursing stations, MD offices
Patient Identification

Direct



Staff identify eligible newborns
All admissions to the three nurseries are reviewed
Indirect

Referral from physicians
Consent

Verbal consent obtained

Role of primary physician
Canadian Blood Services

CBS runs program




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

Winnipeg Hospital Clinics:



Children’s Hospital
St. Boniface Hospital
Regional:


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



Total eligible for program = 273
Total number enrolled = 231 (85%)
Infants < 33 wks and < 6 months at season
start


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


Program – 223 (97%)
Outreach Communities – 8 (3%)
Outreach Infants and Location of
Vaccinations
MB
ONT
SK
AB
BC
Nunavut
Community
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

2004-05 Season



Attempt made to ship from HSC Pharmacy in
Winnipeg to all outreach sites
Failure
2005-06 Season




Shipping directly from Montreal (Abbott)
UPS Supply Chain Solutions (Winnipeg)
Winnipeg HSC Pharmacy (rare cases)
Success!
Outreach Sites

Manitoba - 18 sites:


Ontario - 4 sites


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

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

What was the cost of palivizumab used for
the Manitoba RSV Prophylaxis Program for
2005-2006?
Answer

Total dose used = 55,722 mg

Total cost of drug (assuming no wastage)
$835,830

Assuming 50% wastage, total cost of
palivizumab used: $1,671,660
Program Outcome 2005-06

Number of Infants enrolled in Program
hospitalized for RSV admission


One
Infant admitted at beginning of season and had
yet to receive a dose
Program Outcome 2005-06

Number of infants hospitalized for RSV who
were eligible for Program but was not
enrolled

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


Large cohort, significant costs
Lack of direction from expert groups (CPS,
NASI)
Ottawa General Level III 1995-96
Cost in Canadian Dollars
80000
70000
60000
50000
40000
30000
20000
10000
0
<25
25-27
27-29
29-31
31-33
Average Cost = $15,980
33-37
Issues – For Immunoprophylaxis


Benefit in preventing hospitalization
Evidence to suggest increased morbidity after
RSV-associated infection/hospitalization



Increased hospitalization, need for RT visits,
medical visits, hospital stay
Lack of Canadian expert guidelines
Acknowledgment of potential benefit to some


First Nations
Residents of Northern communities
Decision




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:S150-156.
PICNIC: 33-35 week Cohort

Risk Factors for Hospitalization:








Birth Nov, Dec, Jan
Male Gender
SGA (birth weight < 10ile)
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 < 10ile)
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 1st degree relative
0.42
12 (no FHx)
*Law et al. Pediatr Infect Dis J 2004;23:806-14.
+Langley
17
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 < 10ile)
Subject attend day care
Any preschool siblings
≥ 2 smokers in household
>5 individuals in home
Eczema in 1st 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

Criteria:



Born during RSV season
Infants residing in ‘remote’ North
Definition remote North:

requiring air medical transport for urgent medical
care
Manitoba Approach to 33-35

No formal cost analysis:


Cost of typical air medical transport


Assumption cost of medical transport justifies use
of palivizumab in this cohort
Estimate of $5000-$10,000
Nunavut – cost of medical transport and
hospitalization

$40,000
Pragmatic Definition: ‘Remote’ North

Communities north of Winnipeg were
reviewed


Communities south of Winnipeg not included due
to greater availability of regional hospitals
Based on likelihood of air medical transport


Communities 500 N Latitude or greater
North of Eriksdale – Poplar Field - Arborg
Postal codes of
communities
were compiled
for inclusion list
Postal Code






RO (rural code) – select
R7N - Dauphin
R8 – Thompson, Flin Flon
R9 – The PAS
P – Northern Ontario
X - Nunavut
Comparison to Children’s RSV Data
R0 (rural)
R1 (Portage, Selkirk)
R2/3 (Winnipeg)
R4 (Headingly)
R5 (Steinbach)
R6 (Winkler, Morden)
R7 (Brandon, Dauphin)
R8 (Thompson)
R9 (The Pas)
P (Northern Ontario)
X (Nunavut)
05-06
16
0
39
0
0
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
0
1
2
0
1
1
1
0
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
R0 (rural)
R1 (Portage, Selkirk)
R2/3 (Winnipeg)
R4 (Headingly)
R5 (Steinbach)
R6 (Winkler, Morden)
R7 (Brandon, Dauphin)
R8 (Thompson)
R9 (The Pas)
P (Northern Ontario)
X (Nunavut)
05-06
16
0
39
0
0
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
0
1
2
0
1
1
1
0
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








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 < 10ile)
12
Subject attend day care
17
Any preschool siblings
≥ 2 smokers in household
10
>5 individuals in home
13
Eczema in 1st 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

Reside in ‘remote North’

Eligibility will be assessed
based on place of primary
residence (address and postal
code)

0
6
33 -35
wk GA
Not residing in ‘remote
North’



Eligibility based on scoring of
risk factors
Infants in High Risk Category
will be considered
Risk factor:







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


Collection of data all infants <36 week
Active enrolment of 33-35


Residing in Remote North
Risk factors scoring in high risk range for RSV
hospitalization
Eventual Plan

Linkage of:




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

November 15, 2006


Unless sudden start of RSV Season
If season start early:


Start in-patient program immediately
Outpatient clinics once space available and families
notified
Why Fixed Start Date?

Previous moving start date

Pros



tailor to season
Limit to 5 doses
Cons – wait for 2 admissions for 2 consecutive
weeks



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



<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

Reside in ‘remote North’

Eligibility will be assessed
based on place of primary
residence (address and postal
code)

0
6
33 -35
wk GA
Not residing in ‘remote
North’



Eligibility based on scoring of
risk factors
Infants in High Risk Category
will be considered
Risk factor:







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


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




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

Program Team:




Rose Paulley
Sherree Anderson
Dr. Joanne Embree




Ruth Reimer
Cory Kress
Lise Bourrier
Debbie Cote
Debby Shaski
St. Boniface:


Darlene Mihalchuk
Naomi Granke
Pharmacy Representative:



Children’s Clinic Nurse:






Community/Outreach Rep:




Ron Eros
Helen Ferens
Lydia Smart
Luke Mackenzie
Roxanne Burton
Dr. Bruce Martin
Dr. Dave Williams
Celina Denechezhe
Liason:


Lea Legge (cardiology)
Paul Brenneman (Abbott)
Forms

Referral Form

Pocket Card
Objectives




Review RSV – burden of disease, later disease
Review palivizumab
Eligibility Criteria
Program: how it works





Regional challenges
Outreach program
2005-06 Program statistics
Manitoba approach to 33-35 wks infants
2006-07 Program and Eligibility Criteria