National Influenza Vaccine SummitDecember 6, 2007

National Center for Immunization and Respiratory Diseases (NCIRD)

Breaking From Your Comfort Zone

Extending the Influenza Vaccination Season

OverviewOverviewAndrew Kroger M.D., M.P.H.Andrew Kroger M.D., M.P.H.

What is the comfort zone, and why What is the comfort zone, and why extend the season?extend the season? Current state of influenza disease in Current state of influenza disease in

U.S.U.S. Current state of influenza vaccine Current state of influenza vaccine

supplysupply Highlights of the 2007 ACIP Highlights of the 2007 ACIP

recommendationsrecommendations Materials available from CDCMaterials available from CDC

What is the Comfort Zone?What is the Comfort Zone?

Fallacy: Vaccination season ends Fallacy: Vaccination season ends after National Influenza Vaccination after National Influenza Vaccination WeekWeek

The job is NOT done!The job is NOT done!

Why Extend the Season?Why Extend the Season?

Burden of Influenza DiseaseBurden of Influenza Disease Infections – 15-60 million Total deaths – 36,000 Total hospitalizations – 200,000 Pediatric deaths – 56 – 154 Pediatric hospitalizations 20,000

Why Extend the Season?Why Extend the Season?

Burden of influenza disease Burden of influenza disease It is early in influenza season It is early in influenza season

CDC Laboratory Surveillance CDC Laboratory Surveillance

http://www.cdc.gov/flu/weekly/index.htmhttp://www.cdc.gov/flu/weekly/index.htm

Why Extend the Season?Why Extend the Season?

Burden of influenza disease Burden of influenza disease It is early in influenza seasonIt is early in influenza season There are still persons at risk for There are still persons at risk for

influenza complications as yet influenza complications as yet unvaccinated unvaccinated

There are still people who are at There are still people who are at risk for transmitting influenza to risk for transmitting influenza to others, as yet unvaccinatedothers, as yet unvaccinated

At-Risk of Influenza ComplicationsAt-Risk of Influenza ComplicationsGroups Recommended to Receive Vaccine: Children aged 6–59 months All persons aged >50 years Household contacts (including children) and

caregivers of infants younger than 6 months Children and adolescents on long-term aspirin

therapy Pregnant women Adults and children who have chronic diseases Immunosuppressed adults and children Adults and children with conditions that can

compromise respiratory function, handling of respiratory secretions, or increase risk of aspiration

Residents of nursing homes and other chronic-care facilities.

At-Risk of Influenza At-Risk of Influenza ComplicationsComplications

At risk but cannot receive vaccine:At risk but cannot receive vaccine: Infants younger than 6 monthsInfants younger than 6 months

At-risk of TransmittingAt-risk of TransmittingHealthcare providersHealthy household contacts (including children) and caregivers of:

Children birth-59 months of age, adults >50 years

Children and adults with medical conditions that put them at increased risk for severe complications from influenza

0

50

100

150

200

250

300

1964 1974 1984 1994 2004 2006

Year

Millio

ns

24-59 mos. of age

6-23 mos. of age

50-64 years

Household contacts

Health care workers

Nursing home residents

Pregnant women

<65 years with a highrisk condition

>65 years

Estimated Size of Estimated Size of ACIP Recommended GroupsACIP Recommended Groups

Emphasizing the Permissive Emphasizing the Permissive Component of the Seasonal Component of the Seasonal

RecommendationsRecommendations

Vaccination is recommended for persons, including school-age children, who want to reduce the likelihood of becoming ill with influenza or transmitting influenza to others should they become infected.

Cumulative Monthly Influenza Cumulative Monthly Influenza Vaccine DistributionVaccine Distribution

*Through 11/23/2007*Through 11/23/2007

70.4

57.1

0

20

40

60

80

100

120

July Aug Sept Oct Nov Dec Jan Feb

2000 2002 2004-05 2005-06 2006 2007

Do

ses

(Mill

ion

s)

83 81.2

102.5

*

109.3

0

10

20

30

40

50

60

70

80

90

100

Year

Covera

ge L

evel (%

)

All 65+ yrs

High-risk 50-64 yrsHealthy 50-64yrsHigh-risk 18-49 yrsPregnantwomenHealth-careworkers

Self-Reported Influenza VaccinationSelf-Reported Influenza Vaccination Coverage Levels AmongCoverage Levels Among

Selected US Adult Populations Selected US Adult Populations 1989-2005, National Health Interview Survey1989-2005, National Health Interview Survey

Vaccine shortage: 2004-05 seasonVaccine shortage: 2004-05 season

National Health Interview Survey data available at: www.cdc.gov/nip/coverage/default.htm#NHIS

Why is it so Important to Vaccinate Why is it so Important to Vaccinate Healthcare Providers (HCP)?Healthcare Providers (HCP)?

HCP contact infected materials from HCP contact infected materials from patientspatients

HCP have direct contact with HR HCP have direct contact with HR patients every daypatients every day

Transmission of disease seen in many Transmission of disease seen in many different healthcare settingsdifferent healthcare settings

HCP immunity is key to infection HCP immunity is key to infection prevention and control programsprevention and control programs

Which HCP Need Vaccination? Which HCP Need Vaccination? Includes physicians, nurses, nursing Includes physicians, nurses, nursing

assistants, therapists, technicians, EMTs, assistants, therapists, technicians, EMTs, dental, pharmacists, laboratory personnel, dental, pharmacists, laboratory personnel, autopsy, students, trainees, contract staff, autopsy, students, trainees, contract staff, persons potentially exposed to infectious persons potentially exposed to infectious agents that can be transmitted to and from agents that can be transmitted to and from HCP.HCP.

Settings include hospitals, nursing homes, Settings include hospitals, nursing homes, skilled nursing facilities, physicians’ skilled nursing facilities, physicians’ offices, urgent care centers, outpatient offices, urgent care centers, outpatient clinics, home healthcare, and emergency clinics, home healthcare, and emergency medical servicesmedical services

...unvaccinated healthcare workers can ...unvaccinated healthcare workers can be the index case for influenza in a be the index case for influenza in a facility, potentially posing a threat to facility, potentially posing a threat to high-risk patients and other workers.high-risk patients and other workers. May 2004,32(3)May 2004,32(3)

Why Don’t Healthcare Why Don’t Healthcare Providers get Vaccinated?Providers get Vaccinated?

There are many reason, including: Insufficient time, inconvenient Belief that vaccine doesn’t work Belief that you can get the flu from the flu

vaccine Concerns about adverse events Perception of low risk of influenza disease Misperceptions about risk of transmission to

high risk patients Avoidance of all medications Fear of needles

Strategies for Improving HCP Strategies for Improving HCP Vaccination RatesVaccination Rates

Education and campaignsEducation and campaigns Improved access to vaccineImproved access to vaccine Vaccination clinicsVaccination clinics

Mobile cartsMobile carts Access during all work shiftsAccess during all work shifts

Institutional role modelsInstitutional role models Measurement and feedbackMeasurement and feedback

Influenza MaterialsInfluenza Materials www.cdc.gov/fluwww.cdc.gov/flu

Office-based Office-based Recommendations for Recommendations for Extending the SeasonExtending the Season

Office-based Office-based Recommendations for Recommendations for Extending the SeasonExtending the Season

Andrew Eisenberg, M.D.Andrew Eisenberg, M.D.

Practice Based Influenza Practice Based Influenza VaccinationVaccination

Standing Orders: Make the process as Standing Orders: Make the process as easy as possible, let the front office easy as possible, let the front office initiate the question about status, and initiate the question about status, and the vaccine can be delivered as soon the vaccine can be delivered as soon as possible. This has great utility for all as possible. This has great utility for all vaccines and avoids missed vaccines and avoids missed opportunities.opportunities.

Educate Staff: They must believe in the Educate Staff: They must believe in the utility of vaccination even if just from a utility of vaccination even if just from a financial viability standpoint.financial viability standpoint.

Practice Based Practice Based Influenza VaccinationInfluenza Vaccination

Utilize influenza immunization as a Utilize influenza immunization as a Preventive visit. Payers often Preventive visit. Payers often compensate for preventive health compensate for preventive health visits and thus an E & M code can be visits and thus an E & M code can be attached with proper documentation.attached with proper documentation.

Update other Vaccines at the same Update other Vaccines at the same time, Meningococcal vaccine, Tdap, time, Meningococcal vaccine, Tdap, Pneumovax, Zoster etc. can all be Pneumovax, Zoster etc. can all be given concomitantlygiven concomitantly

Practice Based Influenza Practice Based Influenza VaccinationVaccination

Other preventive screening can be Other preventive screening can be addressed at the same time, i.e. addressed at the same time, i.e. cancer screening, colon breast, cancer screening, colon breast, cervical and prostate…cervical and prostate…

In general, influenza vaccine lasts In general, influenza vaccine lasts through June 30. Vaccination through June 30. Vaccination anytime (from start of vaccination anytime (from start of vaccination season through June 30) may season through June 30) may provide at least some coverageprovide at least some coverage

Practice Based Practice Based Influenza VaccinationInfluenza Vaccination

Above all be sure that all staff have Above all be sure that all staff have received vaccine, as they will be able received vaccine, as they will be able to counter the many myths about ‘flu’to counter the many myths about ‘flu’

Be familiar with the very few real Be familiar with the very few real contraindications and use vaccine contraindications and use vaccine liberally during acute visits.liberally during acute visits.

Virtually every patient can be linked Virtually every patient can be linked to a target population (especially to a target population (especially Household, close contacts)Household, close contacts)

The Changing Paradigm…The Changing Paradigm… We must:We must:

Push to better immunize direct contacts of the vulnerablePush to better immunize direct contacts of the vulnerable Support advances in vaccine production technology and Support advances in vaccine production technology and

expansion of current capacityexpansion of current capacity Adapt messages about the timing of vaccination to take vaccine Adapt messages about the timing of vaccination to take vaccine

production/distribution into accountproduction/distribution into account For BOTH providers AND the publicFor BOTH providers AND the public Messages about timing of vaccination must take supply and Messages about timing of vaccination must take supply and

distribution into account as well as disease epidemiologydistribution into account as well as disease epidemiology Begin vaccinating as soon as doses become availableBegin vaccinating as soon as doses become available October distribution is variable—so providers planning October distribution is variable—so providers planning

clinics and persons seeking vaccination must take this clinics and persons seeking vaccination must take this into accountinto account

Vaccination activities must continue throughout all of Vaccination activities must continue throughout all of November and then cross Thanksgiving into December November and then cross Thanksgiving into December and beyondand beyond

Broaden the vaccination season [again!]Broaden the vaccination season [again!]

It is Medically Relevant to It is Medically Relevant to Immunize Throughout the Immunize Throughout the

Entire SeasonEntire Season

1)Centers for Disease Control and Prevention (CDC). Prevention and control of influenza: recommendations of Advisory Committee on Immunization Practices (ACIP) MMWR Early Release. 2006;55:1-42.

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

Flu Vaccination Visits

Source: Surveillance Data Inc. Electronic Physician Claims Database

Based upon medical claims data accounting for:

200k physicians>25% of the influenza

immunizations in the US

Traditional Immunization

Season

Immunizations

3yr Avg

I Sept I Oct I Nov I Dec I Jan I Feb I Mar I

Influenza Immunizations Peak in Mid-Influenza Immunizations Peak in Mid-NovemberNovember

Source: Surveillance Data Inc. Electronic Physician Claims Database

Disease Activity

Immunizations

Disease Peaks after Peak of Influenza Disease Peaks after Peak of Influenza ImmunizationsImmunizations

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

0

50000

100000

150000

200000

250000

Flu Vaccination Visits Flu Diagnosis Visits

16 week gap between peak of

immunization activity and peak of

disease activity

3-year Avg

3-year Avg

I Sept I Oct I Nov I Dec I Jan I Feb I Mar I

Influenza Vaccination Opportunities Influenza Vaccination Opportunities Abound!Abound!

0

500000

1000000

1500000

2000000

2500000

3000000

3500000

4000000

0

50000

100000

150000

200000

250000

Total Visits High Risk Patients Flu Vaccination Visits Flu Diagnosis Visits

Source: Surveillance Data Inc. Electronic Physician Claims Database

Influenza Vaccination Opportunity

Immunizations /patient visits

Disease Activity

3-year Avg

3-year Avg

2yr Avg

I Sept I Oct I Nov I Dec I Jan I Feb I Mar I

At All Times, We Should…At All Times, We Should…

Work to immunize until vaccine runs outWork to immunize until vaccine runs out In accordance with ACIP recommendationsIn accordance with ACIP recommendations Move toward universal influenza recommendationMove toward universal influenza recommendation HCW Immunization must be improvedHCW Immunization must be improved

Not only patient safety issue but also role Not only patient safety issue but also role modelingmodeling

Improve communications to providers and public Improve communications to providers and public on the complexities of influenza vaccine on the complexities of influenza vaccine production and if supply issues ariseproduction and if supply issues arise

National Influenza Vaccine SummitNational Influenza Vaccine Summit

What is it and what has it done?What is it and what has it done?

Diane PetersonDiane PetersonImmunization Action CoalitionImmunization Action Coalition

Co-chair of the Influenza Summit Co-chair of the Influenza Summit Workgroup on Extending the Workgroup on Extending the Influenza Vaccination SeasonInfluenza Vaccination Season

National Influenza Vaccine SummitNational Influenza Vaccine Summit

What is it and what has it done?What is it and what has it done?

Diane PetersonDiane PetersonImmunization Action CoalitionImmunization Action Coalition

Co-chair of the Influenza Summit Co-chair of the Influenza Summit Workgroup on Extending the Workgroup on Extending the Influenza Vaccination SeasonInfluenza Vaccination Season

Origin of the SummitOrigin of the Summit

Co-sponsored by AMA and CDCCo-sponsored by AMA and CDC First two Summits held in March First two Summits held in March

and August 2001, in response to and August 2001, in response to vaccine supply issues of 2000-vaccine supply issues of 2000-2001 season2001 season

Annual meetings 2002-2007Annual meetings 2002-2007

The Summit is…The Summit is…

A partnership of both private and A partnership of both private and public stakeholders in influenza public stakeholders in influenza vaccine research, production, vaccine research, production, distribution, advocacy, and distribution, advocacy, and administrationadministration

All members are committed to All members are committed to achieving the achieving the Healthy People 2010Healthy People 2010 goals for influenza vaccine. goals for influenza vaccine.

The Summit is also. . .The Summit is also. . .

An annual meetingAn annual meeting A conceptA concept An informal, action-oriented An informal, action-oriented

organizationorganization A tool for improving A tool for improving

communications between communications between stakeholdersstakeholders

A resourceA resource

Members of the Summit include…Members of the Summit include… Vaccine Vaccine

ManufacturersManufacturers Vaccine DistributorsVaccine Distributors Federal AgenciesFederal Agencies Professional Medical Professional Medical

OrganizationsOrganizations SpecialtySpecialty StateState

Nursing Nursing OrganizationsOrganizations

Pharmacist Pharmacist OrganizationsOrganizations

Public Health Public Health HospitalsHospitals

Community Community Immunization Immunization ProvidersProviders

Occupational Health Occupational Health Providers Providers

Business/EmployersBusiness/Employers Private Health Private Health

Insurance and Insurance and Managed CareManaged Care

Long-term Care Long-term Care Quality Improvement Quality Improvement

OrganizationsOrganizations ConsumersConsumers Advocacy GroupsAdvocacy Groups

Influenza Vaccine Summit Influenza Vaccine Summit InitiativesInitiatives

Influenza Vaccination Pocket Information GuideInfluenza Vaccination Pocket Information Guide Multiple letters to CMS on the acceptable Multiple letters to CMS on the acceptable

cost/benefit ratio for immunizers administering cost/benefit ratio for immunizers administering influenza vaccine - CMS increases payment for influenza vaccine - CMS increases payment for vaccine administration to the current $18vaccine administration to the current $18

Letter to CMS on impact of the Medicare Letter to CMS on impact of the Medicare Modernization Act on influenza vaccinationModernization Act on influenza vaccination

Summit response to JCAHO Infection Control Summit response to JCAHO Infection Control Standards white paperStandards white paper

Summit endorsement of JCAHO healthcare Summit endorsement of JCAHO healthcare worker influenza immunization standardworker influenza immunization standard

Influenza Vaccine Summit Influenza Vaccine Summit InitiativesInitiatives

Summit Press Release in January 2005 urging Summit Press Release in January 2005 urging late season vaccinationlate season vaccination

Summit Endorsement of NFID’s “Kids need Summit Endorsement of NFID’s “Kids need influenza vaccine too!” initiativeinfluenza vaccine too!” initiative

Letter to ACIP on vaccine prioritization – ACIP Letter to ACIP on vaccine prioritization – ACIP removes recommendations for 2006 seasonremoves recommendations for 2006 season

Letter to ACIP urging routine immunization of Letter to ACIP urging routine immunization of school-aged childrenschool-aged children

Annual letter for stakeholders to provide to Annual letter for stakeholders to provide to constituents on new CMS reimbursement ratesconstituents on new CMS reimbursement rates

Seeking new ways to link ideas with resources Seeking new ways to link ideas with resources and to bring action items to fruitionand to bring action items to fruition

www.preventinfluenza.orgwww.preventinfluenza.org

Towards the FutureTowards the Future

Immunization Excellence AwardsImmunization Excellence Awards