1. INFLUENZA AND INFECTIOUS DISEASE FORUM JULY 29, 2010 ERIN BACHUS, ADULT IMMUNIZATION COORDINATOR COMMUNICABLE DISEASE CONTROL AND PREVENTION SAN FRANCISCO DEPARTMENT OF PUBLIC HEALTH Flu Season 2010-2011 Vaccine Update

3. A blast from the past: Lessons learned about H1N1 Vaccine Distribution Vaccine distribution was divided into phases  Phase 1 (mid-October): Limited doses available, focused only on providers serving primarily priority groups – based on how provider registered (Ob/Gyn, Pediatrics, Family Practice, Hospital, etc.)  Strategy: decrease each order by the same percentage based on total number of doses available for each type of vaccine Best option since SFDPH had no way of knowing how large or small a provider/practice was Orders decreased by 0-82%, depending on vaccine type Learned that this was not the most equitable strategy because some providers over-ordered

4. Vaccine distribution was divided into phases  Phase 2 (Nov-Dec): Divided into 3 tiers: A, B, C  Strategy: same basic concept for each tier – distribute a certain number of doses based on what a provider ordered rather than cutting by percentages; restrictions lessened as more vaccine became available  Phase 3 (late Dec-Jan): Divided into 4 tiers: A, supplemental, B-C  Strategy: same as Phase 2 By the end of this phase, we were able to provide some vaccine for every provider registered, regardless of provider type All need for p-free doses and LAIV was met Demand for Multidose vials and Pediatric formulations always outweighed supply A blast from the past: Lessons learned about H1N1 Vaccine Distribution

5. Some things we had control over…  # doses of vaccine going to a specific office  Vaccination, testing, and treatment recommendations being communicated to providers Some things we had no control over at all…  # doses ordered by each provider – did they under-order, over- order?  When the vaccine would arrive  The amount of vaccine coming into San Francisco  The potency recalls/short-dating of vaccine  Whether or not providers actually followed priority group restriction guidelines  Supplies providers were receiving

6. Other Lessons Learned from H1N1 Logistics planning for school-based mass clinics proved to be too difficult You don’t have to bring vaccine to the people  If they want it, they will come! Our Mass Prophylaxis Plan works great!  Used for December 22 clinic at Bill Graham Civic Auditorium  Vaccinated over 9,000 people in 9 hours  Most people waited less than 30 minutes!  Most reported that the clinic met or exceeded their expectations  Conducted a shift change during the clinic without closing

7. 2010-2011 Flu Season Update

8. 2010-2011 official influenza recommendations from CDC are still pending  ACIP Provisional Recommendations  New recommendation for the 2010-2011 influenza season for influenza vaccine annually for all persons 6 months and older ACIP Provisional Recommendations for Use of Influenza Vaccines: http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-vac-mar-2010-508.pdf

9. What’s in this year’s flu vaccine? Content: 2010-2011 A/California/07/2009 (H1N1) A/Perth/16/2009 (H3N2)-like B/Brisbane/60/2008-like 2009-2010 Seasonal A/Brisbane/59/2007 (H1N1)-like A/Brisbane/10/2007 (H3N2)-like B/Brisbane/60/2008-like 2009-2010 (monovalent pandemic H1N1) A/California/07/2009 (H1N1) ACIP Provisional Recommendations for Use of Influenza Vaccines: http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-vac-mar-2010-508.pdf

10. Who needs 2 doses for 2010-2011? Only applies to children less than age 9  A child who got any H1N1 vaccine during the 2009-2010 season AND who got seasonal influenza vaccine prior to the 2009-2010 flu season should get 1 dose.  A child immunized for influenza before 2009-10 but who did not get H1N1 vaccine during the 2009-10 influenza season should get 2 doses.  A child immunized for influenza before 2009-10 but who got 1 or 2 doses of H1N1 vaccine during the 2009-10 influenza season should get 1 dose  A child with an unknown or uncertain history of seasonal or H1N1 influenza vaccine should get 2 doses Source: California Department of Public Health, Immunization Branch

11. Who needs 2 doses for 2010-2011? For children less than age 9 never immunized against influenza before 2009-10: If your practice has kids <9 years who did not get H1N1 vaccine, but who got 2 doses of seasonal in 2009-2010 or at least 1 dose in an earlier season, but none in 09-10, you can give them 1 dose of H1N1 now, then they will only 1 dose during the 2010-2011 season. Summer travelers to the Southern Hemisphere should be immunized with 1 or 2 doses depending on age. Source: California Department of Public Health, Immunization Branch

12. Who needs 2 doses for 2010-2011? DRAFT Algorithm for providers being developed by CDPH Meant to be used for all patients <9 years Source: California Department of Public Health, Immunization Branch

13. New Influenza Vaccines Fluzone High-Dose ® (Sanofi-Pasteur) licensed by FDA on December 23, 2009 for use in persons ages 65 years and older  Inactivated influenza virus vaccine  0.5 mL prefilled syringe  Gray syringe plunger rod  Contains four times the amount of influenza antigen  Higher antibody levels in one study  However, it is not known whether this vaccine will be more effective in protecting people over age 65 from getting sick  Studies are being conducted, but data will not be available before the 2010-2011 flu season  Slightly higher frequency of local reactions ACIP Provisional Recommendations for Use of Influenza Vaccines: http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-vac-mar-2010-508.pdf

14. New Age Indications Afluria ® (CSL) now licensed for use in persons 6 months of age and older (36 months in CA). Fluarix ® (GSK) licensed for use in persons 36 months and older Reminder: Flumist ® licensed for healthy persons ages 2 through 49 years ACIP Provisional Recommendations for Use of Influenza Vaccines: http://www.cdc.gov/vaccines/recs/provisional/downloads/flu-vac-mar-2010-508.pdf

15. Reminders Pre-filling of syringes for Flu Clinics  Not recommended  If you must do it, all doses that are drawn up must be used within 24 hours The Mercury Free Act of 2004 - AB 2943 is still in effect for children <36 months and women “knowingly pregnant”  An exemption waiver is in place until September 30, 2010  Only applies for influenza A (H1N1) 2009 monovalent influenza vaccine

16. Legislation Update SB 739 (Health and Safety Code Section 1288.7) went into effect July 1, 2007 requiring general acute care hospitals  Annually offer onsite flu vaccinations to all employees at no cost  Institute respiratory hygiene and cough etiquette protocols  Revise/develop disaster plans to include pandemic influenza components Vaccines required to be offered to health care workers is expanding with Cal/OSHA Aerosol Transmissible Disease (ATD) standard  Goes into effect September 1, 2010  Applies in most health care settings and other high risk environments Source: California Department of Public Health, Immunization Branch

17. Vaccines that are required to be offered* per the Cal/OSHA Aerosol Transmissible Disease (ATD) standard as of September 1, 2010 Vaccine Influenza † Measles Mumps Rubella Tetanus, diphtheria, and acellular pertussis (Tdap) Varicella-zoster (VZV) Schedule One dose annually Two doses One dose One dose, booster as recommended Two doses * To all susceptible employees who might be exposed. If vaccine is declined, a declination form must be signed. † Seasonal vaccine was required to be offered in 2009. Source: California Department of Public Health, Immunization Branch

18. Where is the best place to find updated Flu Vaccine information?  San Francisco Department of Public Health, Communicable Disease Control & Prevention Flu Webpage www.sfcdcp.org/flu  Flu vaccine recommendations  Where to get a flu shot  Information about the Influenza Vaccine Distribution Program  Vax Faxes and Health Alerts  Much, much more!  Influenza Vaccine Availability Tracking System (IVATS) http://www.preventinfluenza.org/ivats/  Vaccine Information Statements (VIS) http://www.immunize.org/vis/  California Department of Public Health Flu Webpage http://www.cdph.ca.gov/healthinfo/discond/Pages/Influenza%28Flu%29.aspx  ACIP Recommendations http://www.cdc.gov/vaccines/pubs/ACIP-list.htm  CDC Flu Webpage http://www.cdc.gov/flu  Cal/OSHA Aerosol Transmissible Disease (ATD) standard http://www.dir.ca.gov/Title8/5199.html

19. Questions? Erin Bachus, MPH (expected spring 2011) Adult Immunization Coordinator Communicable Disease Prevention Unit San Francisco Department of Public Health 101 Grove Street, Room 408 San Francisco, CA 94102 Tel: (415) 554-2798 Fax: (415) 554-2579 erin.bachus@sfdph.org, http://www.sfcdcp.org/