1. National Influenza Vaccine Summit December 6, 2007 National Center for Immunization and Respiratory Diseases (NCIRD) Breaking From Your Comfort Zone Extending the Influenza Vaccination Season

2. Overview Andrew Kroger M.D., M.P.H.  What is the comfort zone, and why extend the season?  Current state of influenza disease in U.S.  Current state of influenza vaccine supply  Highlights of the 2007 ACIP recommendations  Materials available from CDC

3. What is the Comfort Zone?  Fallacy: Vaccination season ends after National Influenza Vaccination Week  The job is NOT done!

4. Why Extend the Season?  Burden of Influenza Disease   Infections – 15-60 million   Total deaths – 36,000   Total hospitalizations – 200,000   Pediatric deaths – 56 – 154   Pediatric hospitalizations 20,000

5. Why Extend the Season?  Burden of influenza disease  It is early in influenza season

6. CDC Laboratory Surveillance http://www.cdc.gov/flu/weekly/index.htm

7. Why Extend the Season?  Burden of influenza disease  It is early in influenza season  There are still persons at risk for influenza complications as yet unvaccinated  There are still people who are at risk for transmitting influenza to others, as yet unvaccinated

8. At-Risk of Influenza Complications Groups 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.

9. At-Risk of Influenza Complications At risk but cannot receive vaccine:  Infants younger than 6 months

10. At-risk of Transmitting   Healthcare providers   Healthy 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

11. Estimated Size of ACIP Recommended Groups

12. Emphasizing the Permissive Component of the Seasonal Recommendations 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.

13. Cumulative Monthly Influenza Vaccine Distribution *Through 11/23/2007 Doses (Millions) 83 81.2 102.5 * 109.3

14. Self-Reported Influenza Vaccination Coverage Levels Among Selected US Adult Populations 1989-2005, National Health Interview Survey Vaccine shortage: 2004-05 season National Health Interview Survey data available at: www.cdc.gov/nip/coverage/default.htm#NHIS

15. Why is it so Important to Vaccinate Healthcare Providers (HCP)?  HCP contact infected materials from patients  HCP have direct contact with HR patients every day  Transmission of disease seen in many different healthcare settings  HCP immunity is key to infection prevention and control programs

16. Which HCP Need Vaccination?  Includes physicians, nurses, nursing assistants, therapists, technicians, EMTs, dental, pharmacists, laboratory personnel, autopsy, students, trainees, contract staff, persons potentially exposed to infectious agents that can be transmitted to and from HCP.  Settings include hospitals, nursing homes, skilled nursing facilities, physicians’ offices, urgent care centers, outpatient clinics, home healthcare, and emergency medical services

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

18. Why Don’t Healthcare 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

19. Strategies for Improving HCP Vaccination Rates  Education and campaigns  Improved access to vaccine  Vaccination clinics  Mobile carts  Access during all work shifts  Institutional role models  Measurement and feedback

20. Influenza Materials www.cdc.gov/flu

21. Office-based Recommendations for Extending the Season Andrew Eisenberg, M.D.

22. Practice Based Influenza Vaccination  Standing Orders: Make the process as easy as possible, let the front office initiate the question about status, and the vaccine can be delivered as soon as possible. This has great utility for all vaccines and avoids missed opportunities.  Educate Staff: They must believe in the utility of vaccination even if just from a financial viability standpoint.

23. Practice Based Influenza Vaccination  Utilize influenza immunization as a Preventive visit. Payers often compensate for preventive health visits and thus an E & M code can be attached with proper documentation.  Update other Vaccines at the same time, Meningococcal vaccine, Tdap, Pneumovax, Zoster etc. can all be given concomitantly

24. Practice Based Influenza Vaccination  Other preventive screening can be addressed at the same time, i.e. cancer screening, colon breast, cervical and prostate…  In general, influenza vaccine lasts through June 30. Vaccination anytime (from start of vaccination season through June 30) may provide at least some coverage

25. Practice Based Influenza Vaccination  Above all be sure that all staff have received vaccine, as they will be able to counter the many myths about ‘flu’  Be familiar with the very few real contraindications and use vaccine liberally during acute visits.  Virtually every patient can be linked to a target population (especially Household, close contacts)

26. The Changing Paradigm…  We must:  Push to better immunize direct contacts of the vulnerable  Support advances in vaccine production technology and expansion of current capacity  Adapt messages about the timing of vaccination to take vaccine production/distribution into account  For BOTH providers AND the public  Messages about timing of vaccination must take supply and distribution into account as well as disease epidemiology  Begin vaccinating as soon as doses become available  October distribution is variable—so providers planning clinics and persons seeking vaccination must take this into account  Vaccination activities must continue throughout all of November and then cross Thanksgiving into December and beyond  Broaden the vaccination season [again!]

27. It is Medically Relevant to Immunize Throughout the Entire 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.

28. 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- November

29. Source: Surveillance Data Inc. Electronic Physician Claims Database Disease Activity Immunizations Disease Peaks after Peak of Influenza Immunizations 16 week gap between peak of immunization activity and peak of disease activity 3-year Avg I Sept I Oct I Nov I Dec I Jan I Feb I Mar I

30. Influenza Vaccination Opportunities Abound! Source: Surveillance Data Inc. Electronic Physician Claims Database Influenza Vaccination Opportunity Immunizations / patient visits Disease Activity 3-year Avg 2yr Avg I Sept I Oct I Nov I Dec I Jan I Feb I Mar I

31. At All Times, We Should…  Work to immunize until vaccine runs out  In accordance with ACIP recommendations  Move toward universal influenza recommendation  HCW Immunization must be improved  Not only patient safety issue but also role modeling  Improve communications to providers and public on the complexities of influenza vaccine production and if supply issues arise

32. National Influenza Vaccine Summit What is it and what has it done? Diane Peterson Immunization Action Coalition Co-chair of the Influenza Summit Workgroup on Extending the Influenza Vaccination Season

33. Origin of the Summit  Co-sponsored by AMA and CDC  First two Summits held in March and August 2001, in response to vaccine supply issues of 2000- 2001 season  Annual meetings 2002-2007

34. The Summit is…  A partnership of both private and public stakeholders in influenza vaccine research, production, distribution, advocacy, and administration  All members are committed to achieving the Healthy People 2010 goals for influenza vaccine.

35. The Summit is also...  An annual meeting  A concept  An informal, action-oriented organization  A tool for improving communications between stakeholders  A resource

36. Members of the Summit include…  Vaccine Manufacturers  Vaccine Distributors  Federal Agencies  Professional Medical Organizations  Specialty  State  Nursing Organizations  Pharmacist Organizations  Public Health  Hospitals  Community Immunization Providers  Occupational Health Providers  Business/Employers  Private Health Insurance and Managed Care  Long-term Care  Quality Improvement Organizations  Consumers  Advocacy Groups

37. Influenza Vaccine Summit Initiatives  Influenza Vaccination Pocket Information Guide  Multiple letters to CMS on the acceptable cost/benefit ratio for immunizers administering influenza vaccine - CMS increases payment for vaccine administration to the current $18  Letter to CMS on impact of the Medicare Modernization Act on influenza vaccination  Summit response to JCAHO Infection Control Standards white paper  Summit endorsement of JCAHO healthcare worker influenza immunization standard

38. Influenza Vaccine Summit Initiatives  Summit Press Release in January 2005 urging late season vaccination  Summit Endorsement of NFID’s “Kids need influenza vaccine too!” initiative  Letter to ACIP on vaccine prioritization – ACIP removes recommendations for 2006 season  Letter to ACIP urging routine immunization of school-aged children  Annual letter for stakeholders to provide to constituents on new CMS reimbursement rates  Seeking new ways to link ideas with resources and to bring action items to fruition

39. www.preventinfluenza.org

40. Towards the Future

41. Immunization Excellence Awards