Influenza Vaccination: Providing Standard of Care

Presentation to: Georgia Hospital Association Presented by: Matthew B. Crist, MD, MPHDate: September 27, 2012

Outline• Who should be vaccinated and vaccines

offered• Contraindications and side effects• Strain selection and manufacturing of

vaccine• Healthcare Worker Vaccination

– Working Sick– Mortality Benefit– Improving vaccination rates– Mandates

Who gets the flu?• From 5 -- 20 % of the U.S.

population develops influenza each year.

• This leads to more than 200,000 hospitalizations from related complications.

• Persons at higher risk for complicated flu are:– People with asthma– People with diabetes– People with heart disease or history of stroke– People >65 years of age– Pregnant women– People with HIV infection– People with cancer– Children <5, especially those <2 years of age

Who should get the shot?

• Annual vaccination is recommended for all persons aged 6 months and older.

2012-2013 Algorithm for Children 6 mos. - 8 yrs.

Types of VaccinesVaccine Trade

NameAge Group

Route Immuno-compromised

Trivalent Inactivated Vaccine (TIV)

Many ≥6 months IM Y

TIV High Dose Fluzone High-Dose

≥65 years IM Y

TIV Intradermal Fluzone Intradermal

18-64 years

ID Y

Live Attenuated Influenza Vaccine (LAIV)

FluMist 2-49 years IN N

Contraindications• Under 6 months of age• History of anaphylactic reaction to vaccine

or eggs• Moderate-to-severe illness with a fever (wait

until they recover)• Guillain-Barre syndrome within six weeks of

a previous influenza shot in a person not at high risk for complications from influenza– If the risk from influenza is high, they should be

vaccinated because the established benefits of the vaccine justify vaccination 

Contraindications to LAIV• History of asthma or other reactive airway

diseases• Chronic medical conditions that predispose

to severe influenza infections• Pregnancy• History of Guillain-Barre syndrome• Acute serious illness with fever• LAIV should not be given concurrently with

other live-virus vaccines

Adverse Reactions• TIV

– Soreness, redness, or swelling at the injection site– Fainting– Low grade fever– Muscle aches– Nausea

• LAIV– Runny nose– Headache– Sore throat– Cough

Can occur shortly after vaccine is given and usually last 1-2 days

Adverse Reactions: Severe• Anaphylactic Reaction- Occur in less than 1 in

10,000• Guillain-Barre Syndrome- Occur in approximately

1 in a million • Febrile Seizures- Increase associated with vaccine

in Australian vaccine which is not used in the US

• Safety is Monitored through– Vaccine Safety Datalink Project (VSD)– Vaccine Adverse Event Report System

(VAERS)

What’s on the horizon?• Quadrivalent live attenuated influenza vaccine, FluMist

Quadrivalent® (MedImmune) was approved February 2012– Live, attenuated influenza vaccine– Administered as a nasal spray– Approved for use in people ages 2 through 49 years– The first to contain four strains of the influenza virus -- two

influenza A and two influenza B lineage strains.– Anticipated to be available for 2013-2014 US season

• Vaccines from cell-based media• Universal Vaccine?-target the stem of the hemagglutinin

surface protein

Vaccine Strain Selection Process• 130 national influenza centers in 101

countries conduct year-round surveillance for influenza and send influenza viruses to the 5 WHO Influenza collaborating centers :– Atlanta, GA (CDC) – London, UK(National Institute for Medical Research)– Melbourne, Australia (Victoria Infectious Diseases Reference

Laboratory) – Tokyo, Japan (National Institute for Infectious Diseases)– Beijing, China (National Institute for Viral Disease Control and

Prevention)– Experts from the FDA, the WHO, the CDC, and other

public health experts identify virus strains likely to cause the most illness during the upcoming flu season.

Vaccine Strains for 2012-2013• The strains selected for inclusion in the 2012-

2013 flu vaccines are:– A/California/7/2009 (H1N1)-like virus – A/Victoria/361/2011 (H3N2)-like virus – B/Wisconsin/1/2010-like virus.

INFLUENZA VACCINATION IN HEALTHCARE WORKERS

Prevention of Healthcare-Associated Influenza

• Early identification/isolation of suspect cases

• Source control/mask patient• Restrict ill visitors/healthcare personnel• Hand hygiene• Vaccination of patients• PPE• Antiviral prophylaxis• Vaccination of HCP

Talbot TR et al ICHE 2005;26:882+

• Frequent contact with high-risk patients

• Serve as a vehicle for spread of flu

• HCP absenteeism can stress health system

• Influenza vaccination of HCP may reduce patient mortality

• Model for their patients

Why is Healthcare Personnel Influenza Vaccination

Important?

Talbot TR ICHE 2005;26:882 Stott DJ Occ Med 2002;52:249 Foy HM Am J Epi 1987;126:506 Weingarten S AJIC

1989;17:202 Lester RT ICHE 2003;24:839

Healthcare-Associated Influenza• Outbreaks reported in most care areas• Influenza infection causes minimal or no

symptoms in up to 25%• Such workers still shed (and spread) virus• 76.6% HCP work while ill with ILI• Worked mean 2.5 days while ill with ILI

Risk of HA-ILI in Acute Care Setting• Prospective

surveillance of pts and HCWs

• App 20-25% ILI = influenza

Vanhems P et al Arch Intern Med 2011;171:151+

UnitInfluenza Vaccinatio

n Coverage

# HCWs Infected

with Influenz

a

Transmission Bet HCWs

Unit A 75% 1 0

Unit B 5.3% 5 3

Healthcare personnel influenza vaccination coverage, US mid-

November 2011 Population Unweighted

sample size*Weighted n Coverage

% (95% CI)Overall 2,442 13,337,764 63.4 (60.7, 66.1)

Occupation:      Physician/Dentist

469 626,136 77.6 (73.7, 81.5)

Nurse practitioner/ physician assistant

126 153,151 76.8 (69.5, 84.1)

  Nurse 398 2,814,843 75.7 (71.1, 80.4)

  Other† 1,449 9,743,634 58.7 (55.3, 62.0)† "Other" includes allied health professionals, technicians/assistants and aides, and administrative and non-clinical support staff.

Healthcare worker influenza vaccination coverage by age, US mid-November 2011

Healthcare personnel influenza vaccination by work setting, US mid-November 2011

Reason for healthcare worker reporting they will not be vaccinated during the flu season, US mid-November 2011

Heimberger T ICHE 1995;16:412 Lester RT ICHE 2003;24:839

Martinello RA ICHE 2003;24:845 Nichol KL ICHE 1997;18:189 Steiner M ICHE 2002;23:625 Weingarten S AJIC 1989;17:202

Reason % (Range)

Inconvenient/Too busy/Forgot 15-83Concerned for vaccine adverse events

27-66

Perception of low risk for influenza 15-23Cost 1-5Fear of needles/Vaccine-averse 8-18Vaccine not effective 8-24Egg allergy 1-7

Reported Reasons for Low HCP Vaccination Rates

HCP Vaccination & the Impact Upon Patient Mortality

Pati

ent

Mor

talit

y (%

)

6 LTCF/ arm

N = 1059 pts

10 LTCF/ arm

N = 1437 pts

22 LTCF/ arm

N = 2604 pts

20 LTCF/ arm

N = 3483 pts

ns

Lemaitre M et al JAGS 2009

Lower patient mortality significantly correlated with HCP vaccination coverage

Salgado CD et al ICHE 2004;25:923+

Lower nosocomial influenza frequency significantly correlated with higher HCP

vaccination coverage

Talbot TR ICHE 2005;26:882

Methods to Improve HCP Vaccination Rates

Make it a priority:– Strong and visible administrative leadership – Visible vaccination of key leaders– Vaccination champions– Provision of adequate staff and resources – Train-the-trainer programs that empower unit

staff

Make it available:– Off-hours clinics– Use of mobile vaccination carts– Vaccination at staff/departmental meetings– Provision of vaccine free of charge

Talbot TR ICHE 2005;26:882

Methods to Improve HCP Vaccination Rates

Tackle the myths:– Targeted education– Assess comprehension of the message

Monitor and feedback progress:– Tracking of individual & unit-based HCP

vaccination compliance– Surveillance for healthcare-associated influenza

Make it mandatory/hard to refuse– Signed declination statements– Condition of employment

Talbot TR Clin Infect Dis 2009;49:773+

DECLINATION OF VACCINE - You MUST complete if refusing vaccineI am eligible to receive the influenza vaccine BUT do not want to take it. I understand that by refusing the vaccine I may be

putting my FAMILY, FRIENDS and PATIENTS at risk of getting influenza. I am aware that hospitalized patients are at increased risk of getting serious complications following influenza infection. Please CHECK YOUR REASON(S) for not receiving the influenza vaccine.

Afraid of needles Afraid of side effects Fear of getting influenza from the vaccine Don’t believe in vaccines Don’t think vaccines work I never get the flu Other: _____________________________________________________________________________

Mandates and Healthcare Workers

Conditions for Employment in Healthcare

• Conditions for employment in place at many facilities– MMR or evidence of immunity– Hepatitis B vaccine series, evidence of

immunity, or signed declination– Annual tuberculin skin testing– Varicella vaccine if no evidence of

immunity

Sources: www.immunize.org, University HealthSystem Consortium,

Emerging Infections Network

Virginia Mason Medical Center

2005

Virginia Mason Medical CenterMandatory Influenza Vaccination

Program

Rakita RM et al Infect Control Hosp Epidemiol 2010;31:881+

Sources: www.immunize.org, University HealthSystem Consortium, Emerging

Infections Network

Virginia Mason Medical Center

2007

Sources: www.immunize.org, University HealthSystem Consortium, Emerging

Infections Network

BJC Healthcare

(11 hospitals)

Virginia Mason Medical Center

2008

Babcock HM et al CID 2010;50:459+

Talbot TR Clin Infect Dis 2009

Sources: www.immunize.org, University HealthSystem Consortium, Emerging

Infections Network

BJC Healthcare

(11 hospitals)

CHOP/ Hospital of

UPenn

MedStar Health (9 hospitals)

U of Iowa

Virginia Mason Medical Center

NC Baptist Hospital (Wake Forest)

Emory Health Systems

2009

Sources: www.immunize.org, University HealthSystem Consortium, Emerging

Infections Network

BJC Healthcare

(11 hospitals)

CHOP/ Hospital of

UPenn

MedStar Health (9 hospitals)

U of Iowa

Virginia Mason Medical Center

163 Hospitals, 20 states

NC Baptist Hospital (Wake Forest)

Emory Health Systems

2009/10

Sources: www.immunize.org, University HealthSystem Consortium, Emerging

Infections Network

BJC Healthcare

(11 hospitals)

CHOP/ Hospital of

UPenn

MedStar Health (9 hospitals)

U of Iowa

Virginia Mason Medical Center

163 Hospitals, 20 states

NC Baptist Hospital (Wake Forest)

Emory Health Systems

2011-12

Johns Hopkins System

U. Wash. Medicine B-I

Deaconess/ Children’s Hospital Boston

Commonalities Among Those Institutions/Healthcare Systems That Have Mandated Influenza Vaccination of HCP

• Dissatisfaction w/ rates already above national average

• Strong leadership advocacy– Willing to take brunt of opposition

• Patient and HCP safety emphasized• Initial implementation = intense

– Resources– Challenges (HCP, unions)

• Engrains into culture “No big deal” (eventually)• Rates ≥ 95%

Professional Societies and Organizations Endorsing Mandatory Influenza Vaccination of Healthcare

Personnel

Updated 2/13/2012

Communication of Policy

Daugherty et al. ICHE 2011

CommunicationIn summary, our findings suggest a need for more investigation of factors influencing HCW beliefs about vaccine effectiveness in order to tailor policies and programs to address not just adherence but the drivers behind it. Although we agree that mandatory vaccination will likely significantly improve adherence, the perception of unfairness and excessive pressure on the part of the institution is not a trivial concern. Policies that foster trust, rather than mistrust and resentment, are likely to be far more effective in the long run.

Daugherty et al. ICHE 2011

Acknowledgements• Tom Talbot, MD, MPH: Vanderbilt School of

Medicine• Christine Hahn, MD: Idaho Dept. of Health and

Welfare• Delmar Little, MPH: Georgia Dept. of Public Health• Jeanne Negley, MBA: Georgia Dept. of Public

Health

Resources• www.cdc.gov/flu/professionals• http://

www.immunizationinfo.org/vaccines/influenza• http://www.health.state.ga.us/epi/flu/primer.asp• http://www.cdc.gov/flu/weekly/

Surveillance(Extra Slides)

Influenza A (H3N2) Variant Virus Outbreak

• Appears to spread more easily from pigs to people than other variant viruses.

• Main risk factor is exposure to pigs, mostly in fair settings. • Most cases have occurred in children. • Only limited person-to-person spread with this virus has

occurred.• Symptoms are similar to seasonal flu. • People at high risk of serious complications include:

– children < 5 – people with chronic conditions like asthma, diabetes, heart disease,

weakened immune systems, pregnant women and people >65 years – These people are urged to avoid pigs and pig arenas at fairs this

season.

Influenza A(H3N2) Variant Virus (aka“H3N2v”)

• Influenza A (H3N2) viruses with genes from avian, swine and human viruses that normally circulate in swine can sometimes infect humans.

• When these viruses are found in swine, they are called swine influenza A (H3N2) viruses.

• When human infections with these viruses occur, these viruses are called “variant” viruses (which can also be denoted with the letter “v”).

• In 2011, a new influenza A (H3N2v) virus was detected that had acquired the M gene from the influenza A(H1N1)pdm09 (2009 H1N1) virus.

• Continued human infections with this H3N2v virus have been detected in the US.

Diagram of swine-origin trH3N2

Summary of Ongoing H3N2v infections

• Influenza A (H3N2) viruses with genes from avian, swine and human viruses that normally circulate in swine can sometimes infect humans.

• Current outbreak of cases started in July 2012• 12 total variant cases in 2011• As of Sept. 14th, there were now 306 H3N2v total

cases, 16 hospitalizations, and 1 death in 11 states.• Cases have presented with mild illness• 90% of cases are aged 10 and younger• Main risk factor for infection is exposure to pigs, mostly in fair

settings,• However, CDC has previously reported the identification of likely

cases of human-to-human spread of this virus during the current outbreaks.

Summary of Ongoing H3N2v infections

• No cases have been observed in Georgia• Enhanced surveillance by ILINet provider and District

Epidemiologist• Public Health messaging has been jointly developed

and disseminated by Public Health and the Department of Agriculture

• Public health has also coordinated with the 4-H club, Jr. swine exhibitors, and Fair coordinators, to distribute education and prevention messages.

GET YOUR Seasonal FLU SHOT!!

H3N2v precautions