DSHS Adult Vaccine Program

Adult Safety Net Vaccines Available at LHDs and DSHS regional clinics Uninsured and Underinsured adults Hepatitis A & B, HPV, MMR, MCV4, Pneumococcal polysaccharide, Tdap, Varicella, and Zoster vaccines Influenza vaccine for DSHS Regional Clinics (for high-risk adults/seniors) Expansion to FQHC, Family Planning, HIV/STD, Substance Abuse Centers in 9/09 (w/ ARRA funds) Over 400 clinic sites enrolled (as of 6/20/09) Brand new availability! Hep B-not available for refugee health programs Meningococcal-at risk DSHS has recently hired an Adolescent/Adult Coordinator and in process of hiring regional coordinators New activities aimed at adults and adolescents will be coming soon!

Texas Influenza Program

2008-2009 Flu Season- In Review

Flu Vaccines Licensed in the US Brandname/ Tradename Manufacturer Total Projected Doses Manufactured Influenza (Age 6 months and older) Fluzone® Sanofi Pasteur 38,000,000 Influenza (Age 6-35 months) Fluzone® Pediatric dose Preservative-free 6,000,000 Influenza (Age 36 months and older) Fluzone® No-Preservative 7,000,000 Influenza (Age 4 years and older) Fluvirin® Novartis 28,275,000 Fluvirin® Preservative-free 15,225,000 Influenza (Age 18 years and older) Fluarix™ GlaxoSmithKline 13,000,000 FluLaval™ 23,000,000 Afluria CSL Biotherapies Influenza Live, Intranasal (Age 2-49 years) FluMist® MedImmune 12,500,000   TOTAL 149,000,000 CDC US VFC Allocation (as of 9/1/2008): 22,000,000 CDC US VFC Allocation: 22,000,000

Flu Vaccine Age Indications 6 months 24 mo. 35 mo. 36 mo. 48 mo. …18 yrs…….49 yrs……+85 yrs Fluzone® Sanofi .25 mL Sanofi .5mL Sanofi .5 mL(no pres.) FluMist® Medimmune LAIV Fluvirin® Norvatis .5mL FluLaval™ GSK .5mL Fluarix™ Afluria CSL Biotherapies .5mL Note: Children < 9 years of age need 2 doses of influenza vaccine (administered 1 month apart) the first time they receive the vaccine. If they only received 1 dose the first year, they need to receive 2 doses the following year.

Texas Immunization Branch Influenza Programs Texas Vaccines For Children Program Federal funded program for eligible children 0-18 years of age Projected 809,270 doses (20% increase from 2007-2008 year) State purchased vaccine Used by HSRs for high-risk adults Projected 110,000 doses for 2008-2009 Local Health Departments Can purchase direct from manufacturer, from a 3rd party distributor, and off State of Texas Contract

Estimated Population of Texans to be Served Ages 0-18 Years by Public Funding Source in CY 2008* Total Public: 4,769,682 % Public: 69% 3% 6% 91% *Reported to National Immunization Program in Population Estimates Total 0-18: 6,899,565

Texas VFC Population Children 0-18 in Texas: 6,899,555 VFC Eligible Children : 4,769,681 Non VFC eligible VFC: 2,129,884 VFC Doses for Texas (2008-2009) 293,960 (.25 mL) 569,410 (.5 mL/mist) 863,370 total doses for +4,700,000 VFC eligible children Ordered additional 50,032 doses than originally projected

Texas DSHS Flu Doses Ordered for TVFC 2006-2008 Formulation 2008 2007 2006 .25 mL doses: 293,960 286,450 316,000 .5 mL doses and mist: 569,410 386,370 229,700 TOTAL 863,370 672,820 545,700

Doses of non .25 pf Texas VFC Flu Vaccine Shipped By Health Service Region 1 2/3 4/5N 7 9/10 Region 1: 23,160 Region 2/3: 174,010 Region 4/5N: 41,940 Region 6/5S: 133,430 Region 7: 66,960 Region 8* 14,220 Region 9/10: 44,060 Region 11: 71,630 6/5S 8 11 Total Doses: 569,410 * Does not include doses shipped for Bexar County

Doses of Texas VFC .5 and Flumist® Vaccine Shipped By Health Service Region Public Health Region Total Doses of Flumist® Total Doses of .5 Formulation w/o Flumist Total Doses of .5 Formulation & Flumist 1 3,510 19,650 23,160 2/3 28,720 145,290 174,010 4/5 N 8,310 33,630 41,940 6/5S 25,810 107,620 133,430 7 16,130 50,830 66,960 8 1,760 12,460 14,220 9/10 10,130 33,930 44,060 11 11,440 60,190 71,630 TOTAL 105,810 463,600 569,410

2009-2010 Flu Season

Provisional recommendations for prevention and control of influenza (2009-2010 influenza season): On February 25, 2009, the ACIP made policy recommendations for use of influenza vaccine for the 2009-2010 influenza season. The 2009–2010 trivalent influenza vaccines will contain A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Brisbane/60/2008-like antigens. Compared to the 2008-09 Northern Hemisphere influenza vaccines, only the B strain has changed. Age and risk groups previously recommended for annual vaccination against influenza have not changed. All children aged 6 months through 18 years are recommended to receive vaccination against influenza for the 2009-2010 influenza season.

Projected Doses Manufactured for 2009-2010 GSK: estimates 20 million total doses supplied to the US, 1 million delivered by the end of July, 80% of doses shipped by end of August. Novartis: estimates 30 million total doses supplied to the US, 10 million delivered by the end of August and the remaining doses delivered by the end of September. Sanofi Pasteur: estimates 50 million total doses (8 million will be pediatric formulation) supplied to US, 25 million delivered by the end of August and the remaining doses delivered in September and October. CSL Biotherapies: estimates 8 million total doses supplied to US, this could increase to 20 million if new filling plant in Illinois becomes operational. MedImmune: estimates 10-11 million doses of FluMist® supplied to US, shipping in August.

Summary Manufacturers' projections for availability of 2009-10 seasonal influenza vaccines* Total ~120 Million doses ~15 M doses available by mid August ~40M doses available by Sep 1 >90% shipped by November 1 Preservative-free and infant-toddler doses formulations included in early releases

Influenza Recommendations No change from 2008-2009 Season All children 6 months – 18 years of age Persons aged > 50 years Women who will be pregnant during influenza season Persons who have chronic pulmonary, cardiovascular, renal, hepatic, hematological or metabolic disorders Persons who have immunosuppression Residents of nursing homes and other chronic-care facilities Health-care personnel Household contacts and caregivers of children aged <5 and adults aged > 50, with particular emphasis on vaccinating contracts of children aged <6 months Household contacts and caregivers of persons with medical conditions that put them at high risk for severe complication from influenza

Texas DSHS Flu Doses Ordered for TVFC 2008-2009 Formulation 2009 2008 .25 mL doses: 355,930 293,960 Flumist® 297,270 105,810 .5 mL doses: 439,120 459,652 TOTAL 1,092,320 859,422

Doses of Texas .25 PF Pediatric Vaccine Ordered By Health Service Region 1 2/3 4/5N 7 9/10 Region 1: 12,640 Region 2/3: 110,848 Region 4/5N: 18,201 Region 6/5S: 93,553 Region 7: 46,008 Region 8* 9,024 Region 9/10: 23,365 Region 11: 42,290 6/5S 8 11 Total Doses: 355,930 * Does not include doses shipped for Bexar County

Doses of non .25 pf Texas VFC Flu Vaccine Shipped By Health Service Region 1 2/3 4/5N 7 9/10 Region 1: 23,472 Region 2/3: 208,749 Region 4/5N: 50,142 Region 6/5S: 189,054 Region 7: 116,771 Region 8* 16,506 Region 9/10: 48,703 Region 11: 82,994 6/5S 8 11 Total Doses: 736,390 * Does not include doses shipped for Bexar County

Doses of Texas VFC .5 and Flumist® Vaccine Ordered By Health Service Region (2009-2010) Public Health Region Total Doses of Flumist® Total Doses of .5 Formulation w/o Flumist® Total Doses of .5 Formulation & Flumist® 1 8,328 15,144 23,472 2/3 62,425 146,324 208,749 4/5 N 23,588 26,553 50,142 6/5S 70,442 118,612 189,054 7 71,376 45,395 116,771 8 5,629 10,877 16,506 9/10 23,877 24,826 48,703 11 31,605 51,389 82,994 TOTAL 297,270 439,120 736,390

% Flumist vs. total non .25 pf doses Doses of Texas VFC Flumist® and .5 ml Formulation By Percent (2009-2010) Public Health Region Total Doses of Flumist® % Flumist vs. total non .25 pf doses Total Doses of .5 Formulation w/o Flumist® % .5 vs. total non .25 pf doses Total Doses of .5 Formulation & Flumist® 1 8,328 35.48% 15,144 64.52% 23,472 2/3 62,425 29.90% 146,324 70.10% 208,749 4/5 N 23,588 47.04% 26,553 52.96% 50,142 6/5 S 70,442 37.26% 118,612 62.74% 189,054 7 71,376 61.12% 45,395 38.88% 116,771 8 5,629 34.10% 10,877 65.90% 16,506 9/10 23,877 49.03% 24,826 50.97% 48,703 11 31,605 38.08% 51,389 61.92% 82,994 TOTAL 297,270 40.37% 439,120 59.63% 736,390

Flu Season The Flu Season generally runs from early September to late May CDC encourages ‘flu campaigns’ to continue until the vaccines expires (June)

Healthcare worker target goal (2010)-60% (2020)-90%

Influenza Coverage Levels The 2007 NIS estimated 30.5% of children (6 to 23 months) within Texas has received one or more doses of Influenza Vaccine (US 32.2%) Texas 2007 Bi-Annual Childcare Assessment Survey estimated 18.1% of children surveyed,19-59 months of age, received one or more doses Influenza Vaccine The 2008 Texas Behavioral Risk Factor Surveillance System estimated 71.7% of adults 65 and older had received a flu shot

Influenza Coverage Levels 2007 NIS-Adult Survey currently estimated national percent vaccinated against the flu 37.3 % of High Risk Adults, 18-49 years of age, 42.2 % of all adults, 50-64 years of age 68.8 % of all adults 65+ Adolescent Immunization Rates* (one of the new influenza target population) for 13-17 year olds MMR (2 doses): 88.9% Hepatitis B (3 doses): 87.6% Td/Tdap: 72.3% (higher in older age group) Meningococcal Conjugate: 32.4% 2007 National Immunization Survey (13-17 year olds)

Texas Influenza Legislation House Bill (HB) 3184, which requires the DSHS to publish information about the benefits of annual vaccination against influenza; and, together with the Department of Family & Protective Services (DFPS), ensure the information is annually distributed to parents of children attending child-care in August or September.  A newly created Flu Fact Sheet for Child-Care Settings was mailed in September to child-care facility centers in Texas for distribution to all enrolled children. 

Texas Influenza Legislation Senate Bill (SB) 811, which requires the DSHS to allow each health care provider participating in the vaccines for children program to: select influenza vaccines from the list of all influenza vaccines that: (i)  within the limits of the vaccines annually allocated by the CDC to the department for the vaccines for children program; or (ii)  not offered in the annual allocation under Subparagraph (i), but are available from the Centers for Disease Control and Prevention of the United States Public Health Service and for which the Centers for Disease Control and Prevention awards to the department additional funds; and use both inactivated influenza vaccines and live, attenuated influenza vaccines.

DSHS Immunization Branch Resources DSHS Webpage Where to get a flu shot Call 211 (or visit 211 website for clinics) DSHS HSR or LHD Locations Flu Season Resources Recommendations Information for Health Care Professionals Vaccine Information Statements News Releases http://www.dshs.state.tx.us/immunize/flu.shtm

(Slide as written) http://www.dshs.state.tx.us/immunize/flu.shtm

DSHS Immunization Branch Resources Release Date: 2009 Influenza Roadmap: Implementing the Universal Childhood Influenza Vaccination Recommendation in Texas Adolescent/Adult Business Plan Pandemic Influenza Plan

Challenges Vaccine Supply (annual uncertainty) Universal Recommendation vs. prioritization of high-risk groups Vaccine Distribution (pre-booking) Vaccine delivery and reimbursement systems Vaccine uptake (especially in new recommended groups) Vaccine coverage levels (13 additional cohorts added to annual campaign with existing resources) Vaccine Funding and over-reliance on public health programs H1N1

Communication Strategies Transparency: identify and acknowledge uncertainty Provide context (compare to other public health threats and previous flu seasons) Build and maintain trust and credibility (provide timely and accurate information) Provide partners with information to support response efforts If seasonal flu vaccine is available first, promote using standard messages and encourage vaccination as soon as vaccine is available

Communication Strategies If H1N1 vaccine is available at same time as flu vaccine, use seasonal flu vaccination as communication core: promote seasonal flu vaccine broadly, early vaccination without waning immunity, vaccination throughout season until vaccine runs out. Be clear that seasonal influenza vaccine does not protect against H1N1. H1N1 messages will depend on a number of variables, don’t have clear information yet. But plan for key scenarios and identify and train spokespersons.

Considerations Need for clear program goals, roles and responsibilities Timelines for a vaccine program must consider all possibilities What vaccines are likely to be available, when, and in what quantities? What basic information is needed for the public and the providers and how will it be communicated effectively? How might a pandemic influenza vaccine program co-exist with a seasonal program? (Slide as written)

Reference Websites DSHS Flu Website: http://www.dshs.state.tx.us/immunize/flu.shtm http://www.dshs.state.tx.us/swineflu/default.shtm CDC Flu Website: http://www.cdc.gov/flu/ CDC H1N1 Flu Website: http://www.cdc.gov/h1n1flu/ Prevent Influenza Now (National Influenza Vaccine Summit): http://www.preventinfluenza.org/presentations_2009.asp