1. Seasonal and Pandemic Influenza Preparedness US Department of Veterans Affairs Lawrence Deyton, MSPH, MD Chief Public Health and Environmental Hazards Officer

2. VA Medical Care The largest integrated healthcare system in US 158 hospitals (18,828 beds, 5.4M BDOC) 132 nursing homes (33,408 ADC) 73 home care programs 43 domiciliary programs 206 veterans counseling centers 854 clinics (50 M outpatient visits) 186,600 employees (VHA)

3. Fiscal Year 2004 – VHA Statistics 7.5 million total enrollees of 25 million US veterans 5.5 million patients treated $30 billion total budget 200 million 30-day equivalent Rx’s dispensed 190 million lab tests performed

4. Who Are VA Patients? Older - 49% over age 65 Sicker - Compared to Age-Matched Americans –3 Additional Non-Mental Health Diagnoses –1 Additional Mental Health Diagnosis Poorer –70% with annual incomes < $26,000 –40% with annual incomes < $16,000 –31% have no health insurance

5. VA Seasonal Influenza Vaccination Program Influenza prevention is a public health priority for VA Annual Under Secretary for Health Flu Directive –Communicates priorities, implementation issues, clinical issues –Flu vaccine coordinator appointed at each facility National vaccination campaign launched each Fall Flu vaccine resource toolkit distributed Flu vaccine supplies purchased/distributed Flu vaccine Performance Measures established and monitored

6. VHA Flu Directive Written and published annually Uses annual ACIP/CDC influenza vaccine recommendations Provides VHA policy and vaccine implementation guidance Covers patients and VA staff Provides documentation expectations Provides contacts for implementation of influenza vaccination program, legal issues, and questions on influenza/influenza vaccine

7. VA’s Flu Vaccine Purchases YearDoses Purchased 1998986,530 19991,163,250 20001,461,280 20011,841,760 20021,587,250 20032,049,750 20042,070,790 2005 estimate2,225,470

8. VA’s 2004-2005 Flu Vaccine Utilization As of April 6, 2005 1,874,176 doses used for 2004-2005 season (91% of total doses ordered)

9. Annual Flu Vaccination Rates 2003-20042004-2005 VA Rates – age 50+ Clinic chart sample70%75% Self-report/survey71%78% Source: VHA Office of Quality and Performance Non-VA Rates Adults in US – age 65+68%63% Phone survey Source: National Committee for Quality Assurance Medicare population – age 65+ Survey74%75% Source: National Committee for Quality Assurance Commercial insurance plans – ages 50-64 Mail/phone survey52%28% Source: Centers for Disease Control and Prevention

10. VA Annual Flu Vaccination Program Influenza - http://www.publichealth.va.gov/fluhttp://www.publichealth.va.gov/flu Wide dissemination of general and clinical information VHA Directive: Influenza Vaccine VA Influenza Vaccine Advisories Messages, articles on flu vaccination Focused dissemination to 8 categories of flu vaccination programs staff VA Influenza Toolkit, 2005-2006, and regular bulletins Manual –Strategies for Improving vaccination rates of health care workers and patients –Frequently asked questions (flu, novel/pandemic flu, eligibility, vaccine storage and usage) –Resources, references and Web sites Materials –Vaccine information statements (VISs) –27 posters - Influenza vaccination, infection control, hand and respiratory hygiene –Buttons for health care staff, stickers for all who get flu shots

11. VA Annual Flu Vaccination Program Goals for VA’s 2005-2006 Influenza vaccination program: Increasing the vaccination rates of health care workers and all personnel at VA health care sites Maintaining or increasing vaccination rates of veteran patients Providing vaccination against pneumococcal illness where indicated. Promoting non-vaccine methods of preventing infection through hand and respiratory hygiene (the VA “Infection: Don’t Pass It On” campaign) Involving all staff and providers in promoting influenza vaccination

12. VA Pandemic Flu Preparedness Annual Influenza Vaccination Program –Under Secretary for Health’s Flu Directive –Resources to enhance vaccine uptake –Performance measure Oseltamivir Stockpile Oseltamivir Stockpile Use Plan Oseltamivir-Probenecid Study Respiratory Infex Disease Emergency Plan VA National Pandemic Influenza Plan

13. Oseltamivir Stockpile Fall 2004 – VA purchased 5.5 million capsules (550,000 courses) of oseltamivir Quantity based on supply needed for –Treatment for 550 patients and staff and –Prophylaxis for 5000 patients and staff At 40 of VA’s 157 medical centers = 25% coverage

14. VA Oseltamivir Stockpile Use Plan Stockpile divided in 7 geographically diverse locations Plan to coordinate distribution with CDC/DoD –Depending on epidemiology Geographic targeting for isolated or limited outbreak/control Widespread distribution for treatment and prophylaxis VA will act to protect veterans’ health when needed –Prefer to work with CDC under the cooperative model of last year’s flu vaccine shortage

15. VA Oseltamivir-Probenecid Research Project Oseltamivir is made by one non-US drug company – there is a worldwide shortage VA Public Health and clinical researchers have initiated a study of co-administration of oseltamivir with probenecid Hypothesis: probenecid will slow the elimination of oseltamivir resulting sustained therapeutic levels If successful, co-administration of oseltamivir with probenecid could extend the effective supply of oseltamivir potentially doubling or tripling supply IND approved; VA funding approved Study is underway

16. Respiratory Infectious Disease Emergency Plan Instructions to VA facilities: Preparations/planning needed Pandemic responses Follow-up actions post event Areas of Preparations/Responses: –Communication –Education –Staffing and Human Resources –Environmental, Facility, and Equipment –Patient Care Management

17. VA National Pandemic Influenza Plan Describe how VA will protect employees and veteran patients, maintain operations, and work with other agencies Help VA employees establish and implement pandemic flu-specific emergency procedures Help VHA, VBA, NCA leadership at national, regional, and local levels support employees and functions at all levels and sites Intersect with COOP plans, National Response Plan, NDMS, VA’s missions

18. Developing the VA Pandemic Influenza Plan Lead: VA Public Health Working Groups –Patient and Healthcare Delivery –Infrastructure Support –Communications/Public Health Community Partners –Workforce/Occupational Health/Unions –Education –Tabletop Exercises

19. Ongoing Activities Non-vaccine preventive measures encouraged in a national campaign: Infection: Don’t Pass It On http://www.publichealth.va.gov/infectiondontpassiton

21. Pandemic Flu US Government Strategy President Bush – Nov 1, 2005 Three Pillars of US Govt Strategy: Preparedness and Communications Surveillance and Detection Response and Containment  National Implementation Plan for Pandemic Influenza (currently in draft) will flow from the National Strategy

22. VA Role in National Plan White House Homeland Security Council leading development of National Pandemic Flu Implementation Plan from National Strategy VA is one of 5 Federal Agencies asked to draft Natl Plan (with DHHS, DHS, DoD, DOT) Public Health SHG backup and leading development of VA-specific response plan

23. Agency-Specific Plans The President has charged that Agency plans: Be operational Protect employees Maintain continuity of operations Communicate with stakeholders Support US Govt efforts

24. 2004-2005 Flu Season VA’s Response to Shortage September 30, 2004: Annual Flu Directive released October 5, 2004: CDC announced shortage due to possible contamination at Chiron plant. –Assessed VA purchase: 100% purchased from Aventis Pasteur –Expected shortage: 2003-4 season, of those who got vaccinated, 38% from extra-VA source –Most of these expected to come to VA for vaccine –Entered discussions with CDC and Aventis Pasteur to assure a vaccine supply for VA

25. 2004-2005 Flu Season VA’s Response to Shortage Seven Under Secretary for Health “Flu Vaccine Advisories” issued October – February Established priority groups to receive vaccine Defined “hands-on” health care providers Provided contacts for questions Provided status updates of vaccine supplies Clarified VA’s relationship to state/local health departments Recommended appropriate use of antivirals Redefined priority groups (CDC definitions) Pushed for late vaccination due to flu epidemiology

26. 2004-2005 Flu Season VA’s Response to Shortage Constant two-way communication between front- line and VACO –Ascertained remaining supply at 3 points in time –Recommendations re: redistribution to best meet VA demands –Handled a myriad of questions – FAQs posted –Regular updates on Friday calls, VISN Director and CMO calls, NLB meetings –Assisted with Congressional/advocacy/press inquires Regular contact with HHS/CDC on VA issues