Immunization Update Call 8/14/2012 CDPH Immunization Branch These slides are posted on the Immunization Coordinators’ website

Topics Covered on Today’s Call Flu Season State-Purchased VFC AB 354 Legislation Update IZ Coordinator Survey Results (I&E) 317 Policy 317/VFC Vaccine Dose Tracking

2012-2013 Flu Season Vaccine influenza virus strains A (H1N1) California/7/2009-like (same) A (H3N2) Victoria/361/2011-like (new) B Wisconsin/1/2010-like (new) Manufacturers expected to bring 146-149 million doses to the market for 2012-2013 season FDA maintains a webpage where information on lot releases are posted once a week

State-purchased flu vaccine Final allocations released and LHDs have confirmed allocations Product Number of doses Fluzone MDV 186,000 Fluvirin MDV Fluvirin syringes 164,000 Flumist sprayers 78,000 Fluzone Intradermal 9,000 Total 623,000

Flu Vaccine Shipping

Update on CA Flu Program Packet will be released shortly All materials will be posted on the IZ Coordinators page Working with CAIR to generate Accountability Report

Pediatric 0.25 Fluzone Because we don’t purchase pediatric Fluzone with state dollars, it is purchased with a combination of VFC/317 funds. Like other pediatric vaccines, this allows LHDs to immunize anyone that comes to their clinics. Like other pediatric vaccines, VFC screening must be done. October 1 317 policy change will not affect pediatric Fluzone for this year.

VFC 2012-2013 Flu Order Confirmations On-line order confirmations All confirmed orders have been approved A notification was sent to the provider of record on July 31, 2012 3,072 providers have confirmed 536 provider have not confirmed Providers who did not confirm orders by the July deadline or providers who may need additional flu doses may submit a supplemental vaccine request once supplemental ordering becomes available this fall. All confirmed orders will sent to McKesson as soon as sufficient doses are available to fulfill provider orders. Orders will be filled in the order received, and will likely arrive in multiple shipments.

Flu Vaccine Supply Vaccine Supply It is anticipated that 50% of our expected flu doses will become available by late September, with the remaining balance available by late October. FluMist doses: 50% of doses are expected mid August and the balance at the end of August. Limited doses are already at McKesson for: 0.25mL fluzone Fluzone MDV FluMist

Vaccine Distribution Plan Depending upon vaccine supply, it is likely that orders for each flu product will be shipped in 2-3 shipments. Orders less than 100 doses will be shipped in full Orders will be processed per product, and based on available doses. Ex: if only doses for 0.25mL Fluzone become available to fulfill orders in queue, we will process orders only for this product Need doses available at McKesson to fulfill at least 25% of the majority of provider orders

Distribution Timeline Estimated distribution timeline Mid-Late August: Initial shipments for available products LHD orders, followed by small orders ~25 % of orders >100 doses Timeframe for flu order shipment by McKesson is 1-2 business days Due to accelerated distribution timeline, influenza orders cannot be marked as urgent. Initial provider shipments will include a set of influenza materials, including the Flu ID Chart.

VFC-Provider Communications VFC Letter in the approval stages and likely to go out this week. ACIP recommendations are not out yet. If not out by this week, VFC provider letter will only reference location where recommendations will be posted (ACIP’s page) Product will not ship until a letter is sent to providers FluMist Replacement Program Information will be included in the letter Provider FAX Blast Heads up on flu vaccine shipments, program letter and reminder on flu vaccine returns to go out this week

FluMist® 2012-2013 Replacement Program The Replacement Program allows for the replacement of unused, expiring FluMist doses MedImmune has a separate contract with McKesson Specialty Health Distribution the Replacement Program. Program structure remains the same as in previous years: FluMist doses must be purchased through the CDC contract and must expire between August 2012 and January 31, 2013 to be eligible for the Replacement Program. Providers have from 15 days prior to the exp date until January 31, 2013 to request replacement doses. Any doses sent prior to 15 days of expiry will not be replaced. All requests should be placed with McKesson Specialty Health by calling 1-877-633-7375. All expired/expiring doses must be received by 2/15/2013. Replacement product will not be shipped until expired/expiring doses are received.

Flu Communications 2012-13 Flu ID Guide (mix-up/vial chart) Updated Flu Resources on EZIZ.org CDC “FluView” App – http://www.cdc.gov/flu/apps/fluview-mobile-app.html Early Messages for Providers: Make room for flu vaccine. Start scheduling appts and clinics. Promote flu vaccination. “Give it, once you get it.”

AB 354 - 2012-13 and future school years Pupils needing proof of a Tdap booster shot before starting school: All entering or advancing into 7th grade All transferring from out-of-state or country into 8th through 12th grades Exclusion if haven’t met requirement Applies to all public and private schools About 500,000 students affected As of July 2012 - no extension periods

What’s your back-to-school plan? LHD Schools Vaccinators

Reports yet from year-round schools?

AB 354 Communications Weekly Emails to CA Private and Public Schools serving 6th and/or 7th Grade Students Suggested checklist for schools (Spring – Autumn 2012) (see also checklist for providers) Bi-weekly Emails to Providers Back-to-School Press Release - NIAM School & Childcare IZ Assessment Results Posted on ShotsForSchool.org

Current Legislation AB 2109 – Pan Parents seeking PBEs would submit to schools a form signed by the parent and a health care practitioner who has provided information about vaccines and the diseases they prevent. Similar law in Washington State decrease in kindergarten PBEs in 2011 Senate Appropriations Committee 8/6

Current Legislation SB 1318 - Wolk Would require Who: All employees, medical staff, contractors, students, volunteers Where: All clinics and health facilities What: Worksites with HCW influenza immunization rates <90% subject to masking policy TBD by CDPH and stakeholders. Assembly Appropriations Committee

Current Legislation AB 2009 – Gagliani CDPH’s influenza vaccine for LHDs – CDPH may provide guidance on prioritizing doses, based upon ACIP recommendations or other criteria Passed Senate – back to Assembly for reconciliation SB 659 - Negrete McLeod Permit inclusion of TB testing data in CAIR Assembly Appropriations Committee

IZ Coord Communications Capacity & Preferences Conducted online May-June 2012 57 responses

Capacity for IZ Activities Only me 25% FTE or less 100% FTE 3 + staff

How Many Annual Campaigns are Realistic? 1 2 3 4

Can You Make Enough Copies? YES 52% YES—but only B&W 35% NO 26%

Resources/Capacity Conclusions & Interventions LHDs vary greatly in resources and capacity Hard copy, color materials appreciated! I&E Possible Interventions Expectations for IZ education to be adjusted by capacity of each LHD Campaigns can be geared to 3 tiers to allow different levels of effort

Where LHDs DO NOT Have Contacts 4. pharmacies 1. non-ER urgent care 3. IHS clinics 2. Local med assns

Who Helps You Distribute IZ Information? More contacts helpful

Outreach Capacity Conclusions & Interventions Some gaps in provider contacts and community partners I&E Possible Interventions IZB can facilitate certain partnerships from the state level IZB can develop a list of recommended groups for LHDs to support IZ outreach and distribution

Websites Not Known to All vacunasYMiSalud MyBestShot WhyIChoose GetImmunizedCA (CDPH) ShotByShot

What I&E Support is Helpful? Health Ed/ graphics Messaging help Translation New Media Campaign teleconfs

IZB Communication Support Interventions I&E Possible Interventions Improve orientation/promotion of lesser known resources Ensure graphics, plain writing, translations, teleconference support shared with all Explore barriers/need for social media

Interest in More Training Topics Parent Vacc. Safety Forums Prenatal classes HCW IZs None

Blended Learning for ISI 20% use BL approach now. Many more would if guidance was available Yes unsure No

IZB Help to Support Local Training Blue: I could use help Orange: I’m confident PPTs Promotion Handouts Speaking skills Webinars Evaluation Curriculum Talking Points

IZ Coord. Training Support Interventions I&E Possible Interventions Package guidance for ISIS blended learning approach Be a resource for LHD training assistance requests. Webinars on training skills

Section 317 Immunization Program Vaccine Funding: National 317: Discretionary funding through Section 317 grant funds. This funding has historically allowed the State to expand eligibility for vaccines. 317 vaccine funds are made available to states to use according to local needs. The use of 317 varies from state to state, but was historically used for non-VFC eligible children in public clinics and limited vaccines for adults. 37

New CDC Guidance: 317 Vaccine CDC has announced that effective October 1, 2012, 317 vaccine can no longer be used on privately insured individuals. Implications: LHDs would have to either bill private insurances or refuse service to insured clients and refer them to their medical home.

New CDC Guidance: 317 Vaccine 317 vaccine funds may be used to vaccinate the following: Underinsured children Uninsured or underinsured adults Fully insured individuals seeking vaccines during public health response activities including: Outbreak response Post-exposure prophylaxis Disaster relief efforts Mass vaccination campaigns or exercises for public health preparedness

New CDC Guidance: 317 Vaccine Fully Insured: Anyone with insurance that covers the cost of vaccine, even if the insurance includes a high deductible or co-pay, or if a claim for the cost of the vaccine and its administration would be denied for payment by the insurance carrier because the plan’s deductible had not been met. Underinsured: A person who has health insurance, but the coverage does not include vaccines or a person whose insurance covers only selected vaccines. Children who are underinsured for selected vaccines are VFC-eligible for non-covered vaccines only through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC).

Implementation of Policy Initial letter sent to Health Officers on July 13th. Presentation to CCLHO on 8/2 Eligibility Tables, and Insured Policy under revision. Templates for provider communications under revision New signs for LHDs in development. Outreach to physicians (from state and local) Revisions of policies at LHD level Training of staff on new 317 guidelines

317/VFC Tracking Requirement went into effect July 1, 2012. LHDs will be required to track doses in the registry, through their EHR, or with a manual system. LHDs will be required to submit vaccine administration with the VFC/317 breakdown for their first ordering period after July. e.g. monthly providers would submit breakdown with August order (30 days after launch), bimonthly providers would submit with September order, quarterly providers would submit with October order.

CAIR Changes & Tracking Verification of VFC/317 eligibility must occur for every session in CAIR. New reporting will provide vaccine administration data needed for vaccine ordering. State-Supplied Vaccine Report-Technical issue with the report not displaying 317 doses administered is now resolved. LHD orders must be submitted through MYVFCVaccines Resources available include webinar, FAQ.

LHD PIN Verification & Order Form All PINs identified as LHDs clinics or specially authorized clinics in June have been linked to the detailed on-line ordering page

Order Processing All orders (317 vs non-317 reporting) are processed utilizing the same procedure. Inventory and total doses administered are looked at when reviewing order accountability Order Corrections: An issue with the system not saving corrections on returned orders has been corrected.

 Reimbursement for administration MediCal beneficiaries, 2013-2014 May 11, 2012 Federal Register: Proposed rule implementing a provision in the Affordable Care Act that increases Medicaid payment rates to at least 100% of Medicare rates in 2013 and 2014 for certain primary care services and immunizations. June 2012: Supreme Court upholds ACA. January 2013: In effect Any amendments for final rule based on comments?

 Reimbursement for administration MediCal beneficiaries, 2013-2014 Current reimbursement - $9 For 2013 and 2014, increase to the lesser of Medicare reimbursement for immunization >$25 in California, depending on region New proposed maximum for VFC immunization $26.03 in California States will receive 100 percent federal funding to cover the increase in payments ($25-26 minus $9). Applies to immunization at any age, not just VFC Applies to managed care as well as fee-for-service

 Reimbursement for administration MediCal beneficiaries, 2013-2014 VFC: Same for combination as individual vaccines Services must be delivered by practitioners supervised by qualifying physicians: Family medicine General internal medicine Pediatric medicine, including subspecialists >60% of MediCal payment claims for primary care Reimbursement policy separate for other VFC categories: Uninsured, Underinsured, Amer. Indian Also separate for FQCHCs/RHCs

 Reimbursement for administration MediCal beneficiaries, 2013-2014 Potential source of funding in 2013 and 1014 for immunization in your LHD Additional >$16 per each immunization 1-2 million doses of VFC vaccine given by LHDs in 2011 MediCal population will increase – Healthy Families, ACA Are you ready to bill MediCal? Where in your system will MediCal reimbursement go? Brainstorming – How might this funding assist local immunization capacity? Possibilities include augmented Staffing, School-located immunization, Other Possibility of CAIR assisting in billing