what's new with flu in 2018-2019 - texas department of ... · 7/31/2018 · what's new with flu in...

immunization action coalition

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What's New with Flu in 2018-2019

Litjen (L.J) Tan, MS, PhD Chief Strategy Officer,

Immunization Action Coalition

Co-Chair, National Adult andInfluenza Immunization

Summit

Texas DSHS Annual Influenza Surveillance

Workshop July 31, 2018


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Disclosures

•I have no conflicts of interest. •I do NOT intend to discuss an unapproved or investigative use of a commercial product/device in my presentation.


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Disclaimer

The opinions expressed in this presentation are solely those of the presenter and do not necessarily represent the official positions of the Immunization Action Coalition, or the National Adult and Influenza Immunization Summit


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Outline •Review 2017-2018 influenza season activity and vaccination coverage rates •Discuss influenza vaccine effectiveness •Describe influenza recommendations and vaccines available for 2018-2019 influenza season •Time permitting, discusscommunication messages


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The 2017-2018 Influenza Season

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80% were unimmunized!

Influenza-Associated Pediatric Deaths by Age Group (percent of total deaths)

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49.1% had NO high risk condition

2013-14 2014-15 2015-16 2016-17 2017-18

*Data through June 30, 2018

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Laboratory-Confirmed Influenza Hospitalizations

Preliminary cumulative rates as of Jun 30, 2018

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' Season Selection

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KZl 2016-17

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KZl 2012-13

The Influenza Hospitalization Surve illance Network (FluSurv-NETI conducts population-based surveillance for laboratory•confirmed influenza.associated hospitalizations in ch ildren (persons younger than 18

years) and adults . The current netwol1< covers over 70 counties in the 10 Emerging Infections Program (EIP) stales (CA, CO, CT, GA, MD, MN , NM, NY, OR, and TN) and three additional slales (Ml, OH, and

UT). The network represents approximately 9% of US population (-27 million people). Cases are identified by reviewing hospital, laboratory, and admission databases and infection control logs for patients

hospitalized during the influenza season with a documented positive influenza test (Le., viral cu lture, direct/indirect fluorescent antibody assay {DFNIFA), rapid influenza diagnostic test {RIOT), or molecular

assays includlng reverse transcripUon-polymerase chain reaction {RT-PCR)). Data gathered are used to esUmate age-specific hospitalization rates on a weekly basis, and describe characteristics of persons

hospitalized with associated influenza illn ess . Laboratory-confirmation is dependent on clin ician-ordered influenza testing. Therefore, the unadjusted rates provided are likely to be underestimated as

influenza-associated hospitalizations can be missed if influenza is not suspected and tested for. FluSurv-N ET hospitalization data are preliminary and subject to change as more data become available. All

incidence rates are unadjusted. Please use the following citation when referencing these data : EfluVlew: Influenza Hospitalization Surveillance Network, Centers for Disease Control and Prevention. WEBSITE.

Accessed on DATE".


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Hospitalization rates were at historic rates!

2014 – 15 season was the previous high

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Summary of Influenza Activity 2017-2018

•Very high influenza activity for the 2017-2018 season, and overall disease was considered to be severe

•Activity peaked in early January and stayed high through March

–Most states reported widespread activity simultaneously –Very low activity being reported this summer…

•H3N2 viruses predominated through the peak of the season with some H1N1 activity •Significant influenza B activity peaking in late February

– Predominantly B/Yamagata (contained in IIV4) •Egg adaptation of H3N2 an issue this season?


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The 2017-2018 Influenza Season - Coverage


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2017-2018 Influenza Vaccination Coverage (early season, Nov. 2017)

•38.6% of all persons 6 months and older (cf. 39.8% previous year)

•38.8% of those 6 months through 17 years of age vaccinated (cf. 37.3% previous year)

•38.5% of adults 18 years of age and above vaccinated (cf. 40.6% previous year)

•Final numbers will be released on September 2018.

15


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2017-2018 Pediatric Influenza Vaccination Coverage (early season,

Nov. 2017) •49.2% of children 6 months to 4 years vaccinated (cf. 45.0% previous year)

•39.0% of children 5 to 12 years vaccinated (cf. 39.0% previous year)

•29.8% of children 13 to 17 years vaccinated (cf. 28.7% previous year)

16


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2017-2018 Adult Influenza Vaccination Coverage (early season, Nov. 2017)

•Only 56.6% of those over 65 years of age vaccinated (cf. 56.6% previous year)

•40.6% of adult between 50 -64 years of age vaccinated (cf. 41.7% previous year)

•40.4% of adults 18-64 years of age with at least one high-risk medical condition vaccinated (cf. 43.5% previous year)

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2017-2018 (early season) Influenza Vaccination Coverage – Healthcare

Personnel*

18

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Early Season 2017-2018 Influenza Vaccination Coverage – Healthcare Personnel#

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d Hospital Ambulatory care Long-term care Other settings‡ (n = 890) (n = 610) setting† (n = 681)

(n = 577)

# Internet Panel Survey, United States, November 2017 † Nursing home, assisted living facility, other long-term care facility, home health agency or home health care. ‡ Settings other than hospitals, ambulatory care setting, or long-term care facilities; includes dentist office or dental clinic, pharmacy, EMS, and other settings where clinical care or related services was provided to patients. $ Allied health professional, dentist, technician, or technologist. @ Administrative support staff or manager and nonclinical support staff (including food service workers, housekeeping staff, maintenance staff, janitor, and laundry workers). 19


Impact of Employer Policy on Healthcare Personnel Vaccination (by setting)*

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0 Influenza Vaccination Honor Rol l Honorees with Influenza Vaccmation Mandates

ID IL IN IA KS KY LAME MOMA Ml MN

WY WI WY U.S. Temtofies

Alabama

Baptist South Medical Center, Montgomery, AL l~tallon date: October 1. 2014

Cullman Regional Medical Center, Cullman. AL lrtl)lementalion date: October t , 2011

Cullman Family Practice, Cullman, AL

Huntsville Pediatric Associates, Huntsville, AL

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2017-2018 Influenza Vaccination Coverage in Healthcare Personnel (early

season, Nov. 2017) •HP 2020 goal of 90%. •67.6% vaccinated by internet panel surveys, similar to previous season at this time point.

•Long-term care facilities had lower coverage (58.5%) than other facility types (hospitals at 82.6%).

•Higher vaccination coverage among HCP was associated with employer vaccination requirements or access to vaccination at the workplace at no cost.

22

2017-2018 (early season) Influenza Vaccination Coverage – Pregnant Women*

•Pregnant Women (HP 2020 goal of 80%) – 35.9% vaccinated (comparison with previous season not

possible due to change in survey methodology) – No racial/ethnic disparity in vaccination coverage between

non-Hispanic black and non-Hispanic white women seen at this time point

– Most pregnant women (97.9%) reported visiting a doctor or other medical professional at least once before or during pregnancy since July 1, 2017.

• 58.7% reported receiving a recommendation for and offer of flu vaccination from a doctor or other medical professional

• 15.6% received only a recommendation for and no offer of flu vaccination

• 25.7% did not receive a recommendation for or an offer of flu vaccination

* Internet Panel Survey, United States, November 2017 23


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Influenza Vaccination Among Pregnant Women by Provider Recommendation or Offer of Vaccination, 2017-18 Season*

(early season, Nov. 2017) Influenza vaccination coverage before and during pregnancy among women pregnant any time August 1 through November 8, 2017 and who visited a

health care provider at least once since July 2017, by provider 100% recommendation or offer

80% 52.4%

60%

40% 26.1%

20%

0% 5.7%

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* Internet Panel Survey, United States, November 2017


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Impact of influenza on pregnant women1

• Up to 4X increased risk of hospitalization, especially in third trimester, and for thosewith co-morbid conditions*

• Up to 8X increased risk for influenza-associated complications, including death,particularly for those with co-morbidconditions**

• Increased risk for influenza-associated complications among postpartum women

• Risk highest during the first postpartum week

* Chronic cardiac disease, chronic pulmonary disease, diabetes mellitus, chronic renal disease, malignancies, and immunosuppressive disorders ** Preexisting diabetes mellitus, pulmonary disease that included asthma, heart disease, renal disease, and anemia 1. Rasmussen, S.A., et al. 2012. American Journal of Obstetrics & Gynecology; 207(3): S3 - S8.

Some coverage thoughts •Influenza vaccination coverage appears to still be well below HP2020 targets

– No increase from the 2016-2017 coverage (waiting on final data) – Coverage in the 65 years and older population stagnant...– Coverage in the 19-64 years of age high risk adults still very low…– Significant disparities exist in the non-Hispanic, black and Hispanic adult populations…– Coverage in pregnant women has leveled off; a strong provider recommendation makes a difference – HCW coverage remains strong, except in LTCF!


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Vaccine Effectiveness

Preliminary Adjusted VE against medically attended influenza, US Flu

VE Network, 2017-18

Any Influenza A and B Adjusted VE* (95% CI)*

All patients aged ≥ 6 months 40% (34 to 46)

6 mos–8 y 53% (42 to 62)

9–17 29% (8 to 46)

18–49 35% (23 to 46)

50-64 33% (17 to 47) ≥65 20% (-9 to 41)

* Multivariate logistic regression models adjusted for site, age categories (6m-8y, 9-17y 18-49y, 50-64y, ≥65y), sex, race/Hispanic ethnicity, self-rated general health status, interval from onset to enrollment, and calendar time (biweekly intervals)


VE Network, 2017-18

Influenza A/H3N2 Adjusted VE* (95% CI)*


6 mos–8 y 37% (17 to 52)

9–17 10% (-23 to 35)

18–49 14% (-6 to 30)

50-64 25% (0 to 44) ≥65 17% (-22 to 44)



VE Network, 2017-18

Influenza A/H1N1pdm09 Adjusted VE* (95% CI)*


6 mos–17 y 82% (71 to 88)

18–49 48% (17 to 67)

50-64 45% (-6 to 72) ≥65 10% (-116 to 63)



VE Network, 2017-18 Influenza B/Yamagata Adjusted VE* (95% CI)*

All patients aged ≥ 6 months 49% (40 to 56) 6 mos–8 y 46% (19 to 64) 9–17 39% (9 to 59) 18–49 57% (42 to 68) 50-64 45% (24 to 60) ≥65 29% (-12 to 55)

Influenza B/Victoria

All patients aged ≥ 6 months 78% unadjusted * Multivariate logistic regression models adjusted for site, age categories (6m-8y, 9-17y 18-49y, 50-64y, ≥65y), sex, race/Hispanic ethnicity, self-rated general health status, interval from onset to enrollment, and calendar time (biweekly intervals)

Preliminary VE against influenza hospitalizations in adults, HAIVEN,

2017-18

Any Influenza A and B Adjusted VE* (95% CI)*

All patients aged ≥ 18 years 22% (8 to 35) 18–49 18% (-20 to 44) 50-64 32% (9 to 49) ≥65 24% (0 to 41)

* Multivariate logistic regression models adjusted site, age group, sex, race/ethnicity, days from illness onset to specimen collection, calendar time of illness onset, home oxygen use, frailty score, and number of self-reported hospitalizations in the past year


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Summary of preliminary VE for the 2016-2017 influenza season

• Vaccine reduced outpatient influenza visits by 40% for influenza A and B viruses among persons 6 mths of age and older

• Inpatient and outpatient VE estimates were similar among adults

• Vaccine offered significant protection against influenza hospitalizations • Vaccine reduced influenza hospitalizations by 22% among

all adults and by 24% among adults ≥65 years of age (influenza A and B viruses)

• VE estimates were higher for H1N1pdm09 and B/Yamagata influenza viruses than for H3N2 viruses

benefits of flu vaccination

The estimated number of flu illnesses prevented by f lu vaccination during the 2016-2017 season:

5.3 million, about the populat ion of the Atlanta metropolitan area.

The estimated number of flu medical visits prevented by vaccination during the 2016-201 7 season:

2.6 mill iion, or more than the number of students in all K-1 2 schools

in Florida .

• C : - .... DATA: lnnuenz:a, Olv lslon progr;1m rmpact re-port 2016-2017. hUp$.://www..cdc.gov/ fluJaboul/di~ase/2016· 17.htm..

The estimated number of flu hospltallzatlons prevented by vaccination during the 2016-2017 season:

85,000, or more than the number of

hospital beds in California and Oregon.

t I t d ge vacc1na e ~ ~f:!~;~~:F.?e~~~fServ1ces www.cdc.gov/flu ~ ControlandPrevent,on


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Another way to look at influenza vaccine effectiveness – negative

outcomes averted


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Vaccine Effectiveness – Influenza • Acute respiratory illness or influenza-like illness

increases acute MI risk 2x; 5x is those with history ofMI

• Influenza vaccination effectiveness: Meta-analyses1–2 • 29% (95%CI 9,44) against acute MI in persons with existing

CVD • 36% (95%CI 14,53) against major cardiac events with

existing CVD • Vaccine effectiveness 29% in acute MI prevention • “On par or better than accepted preventive measures [as]

statins (36%), anti-hypertensives (15–18%), and smoking cessation (26%)”

• Influenza vaccination recommended as secondary prevention by American College of Cardiology and American Heart Association

1. Barnes M, et al. Acute myocardial infarction and influenza: a meta-analysis of case–control studies. Heart 2015;101:1738–1747 2. Udell JA, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis. JAMA 2013;310:1711–20

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Resilience to Influenza with Aging

Frailty Index

0.25 0.3

0.4 0.5 0.6

0.1 0

0.15

0.7

0.2

0.05 Inflammaging & Multimorbidity

Graphic courtesy of Janet McIlhaney, MD

~, im~unization action coalition

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Vaccine Preventable Disability1 Catastrophic disability Defined as a loss of independence in ≥ 3 basic Activities of

Daily Living2

14.6% of older adults hospitalized with influenza experience catastrophic disability3

Disability due to influenza hospitalization4,5 is also linked to leading causes of catastrophic disability2

1. Strokes 2. CHF 3. Pneumonia and influenza 4. Ischemic heart disease 5. Cancer

1 McElhaney JE et al. Front Immunol. 2016;7:41. 2 Ferrucci et al. JAMA 1997;277:728. 3 Andrews MK et al. Canadian Immunization Conference. December 7, 2016. 4 Barker et al. Arch Int Med 1998;158:645. 5 Falsey et al. N Engl J Med. 2005;352:1749.

6. Hip fracture


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Keeping your glass 0 half full! 0.1

Exercise, diet, 0.2 smoking cessation

and vaccination 0.3

Are you willing to 0.4 0.7 0.6 risk your

0.5

independence this winter?



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Influenza Vaccine Refresher


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2018-2019 Influenza Vaccine Strains

•Two strain changes from last year! •New seasonal influenza vaccine formulations

– Trivalent preparations: an A/Michigan/45/2015 (H1N1)pdm09–like virus, A/Singapore/INFIMH-16-0019/2016 (H3N2)-like virus, and a B/Colorado/06/2017-like (B/Victoria lineage) virus (Victoria lineage). – Quadrivalent preparation adds a B/Phuket/3073/2013–like virus (Yamagata lineage).


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Adjuvanted Influenza Vaccine •Fluad® from Sequirus

– trivalent – Adjuvanted with a well-studied compound called MF59, an oil-in-water emulsion of squalene oil – Immunogenically non-inferior to licensed comparator IIV3 in preclinical studies – Side effects similar to IIV4

•FDA approved for persons 65 years and older.

* Infect Chemother. 2013 Jun; 45(2): 159–174.


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Cell Culture Influenza Vaccine •Flucelvax® from Sequirus

– Quadrivalent – Immunologically non-inferior to IIV4 – Uses cultured animal mammalian cells instead of chicken eggs to grow vaccine virus – Preliminary data presented at June ACIP suggests 10% improved relative efficacy over egg-based IIV4 in persons 65 years and older – Side effects similar to IIV4 – FDA approved for persons 4 years and older


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Recombinant DNA Influenza Vaccine

•Flublok® from Sanofi – quadrivalent – HA DNA sequence produced by recombinant technology and expressed in baculovirus that infects an insect cell line. – Totally egg-free process, ACIP recommends use in those with severe egg allergies – Side effects similar to IIV4 – FDA approved for adults 18 years and older – Recent data suggest improved cross-reactivity in persons >50 years of age during mismatched seasons1

1. Dunkle, L. et al. 2017. N Engl J Med 2017; 376:2427-2436


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Other Influenza Vaccines •FluLaval® - from GSK

– Quadrivalent – Indicated for persons ≥6 months (since last season)

• Children aged 6 through 35 months may receive FluLaval Quadrivalent at the same 0.5 mL per dose (containing 15 µg of hemagglutinin [HA] per vaccine virus) as is used for older children and adults


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Other Influenza Vaccines •Afluria® - from Seqirus

– Quadrivalent – FDA-indicated for persons aged ≥5 years

•Flumist® – For the 2018–19 U.S. influenza season, providers may choose to administer any licensed, age-appropriate influenza vaccine (IIV, recombinant influenza vaccine [RIV], or LAIV4). LAIV4 is an option for those for whom it is otherwise appropriate. No preference is expressed for any influenza vaccine product.1

1. Grohskopf L. et al. 2018. MMWR Morb Mortal Wkly Rep 2018;67:643–645. DOI: http://dx.doi.org/10.15585/mmwr.mm6722a5

http://dx.doi.org/10.15585/mmwr.mm6722a5


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Other Influenza Vaccines •Fluzone ID®

– Quadrivalent – Novel microinjection system for intradermal delivery

• Ultra-fine needle that is 90% shorter than the typical needle

– Licensed for use in adults 18-64 years of age – Contains 9 mcg of influenza virus hemagglutinin for each strain – Similar safety profile as IIV, erythema most common complaint


Other Influenza Vaccines •Fluzone HD®

– Trivalent – Contains 4 times the amount of antigen - 60 mcg of influenza virus hemagglutinin for each strain – Indicated for 65 and older; most common complaint is injection site pain and erythema – Medicare covers this higher dose formulation – Trial of 30,000 participants, Fluzone HD was 24.2% more effective in preventing influenza in adults ≥65 years of age than Fluzone vaccine*

*DiazGranados, et al. 2014. NEJM. 371:635-645.

Influenza Vaccine Products for the 2017-2018 Influenza Season

Trade Name MercuJ Vaccine Product Billing Code' Manufacturer How Supplied Conten Age Group (vaccine ab breviat ion) ' (mcg Hg/0.Sm L) CPT M ed icare Ast raZeneca FluM ist' (l AIV4) 0.2 ml (single-use nasa l spray) 0 2 th rough 49 years 90672 90672

GlaxoSmithKl ine Fluarix (IIV4) 0.5 m l (single-dose syringe) 0 3 years & olde r 906&6 906&6

ID Biomedical Corp. of Quebec, Flu laval (IIV4)

0.5 ml (single-dose syr inge) 0 6 months & olde r 906&6 906&6 a subsidiary of GlaxoSmithKli ne 5.0 m l (mu lt i-dose vial)

ACIP Influenza Recommendations •All persons 6 months of age or older should receive influenza immunization

– Influenza vaccination should not be delayed to procure a specific vaccine preparation if an appropriate one is already available

•You should receive a flu vaccine by the end of October, if possible. •Vaccination should be offered as long as influenza viruses are circulating and unexpired vaccine is available •Don’t delay to procure a specific vaccine preparation •Final recommendations to be published in the

49 August 2018. Stay tuned!


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How do we discuss Vaccine Effectiveness?

• Address vaccine effectiveness directly, early, and as needed, during season

• Communicate the variability and unpredictability of flu

• Acknowledge that flu vaccination is not a perfect tool, but it is the best way to protect against flu infection

• Communicate the benefits of flu vaccination • Flu vaccination can reduce flu illnesses, doctors’

visits, missed work and school due to flu, as well as prevent flu-related hospitalizations and deaths.

50

How do we discuss Vaccine Effectiveness?

• Be transparent regarding flu VE • Use caution when discussing “match”

– With a good match, flu vaccine can reduce the risk of having to go to the doctor for flu by about 60% among the overall population.

– This number may be higher for some groups of people and lower for others (e.g., older people with weaker immune systems)

• Use impact data and data over multiple years to provide perspective on vaccine benefits

• At all opportunities, continue to educate providers, partners and the public on the reasons people may get sick with ILI following flu vaccination.

–http://www.cdc.gov/flu/about/qa/misconceptions.htm 51

http://www.cdc.gov/flu/about/qa/misconceptions.htm


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More messaging on Vaccine Effectiveness…

•Questions about efficacy and duration remain – Do not base efficacy or duration of immunity discussions on one season but look collectively at multiple seasons – Vaccine in the patient is 50%-60% effective; vaccine on the shelf is 0% effective. – Season of 2014-2015 had about 62% vaccine effectiveness…

•And vaccine effectiveness should mot be measured by incidence alone

– Hospitalizations prevented – Medical visits prevented


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Some communications thoughts •Vaccination also can reduce the risk of hospitalizations and deaths.

–vaccine preventable disability •Important benefits can be gained by increasing vaccination rates across all age groups with currently available vaccines.

•One CDC study* concluded that flu vaccination prevented an estimated 13.6 million flu cases, 5.8 million medical visit & nearly 113,000 flu-related hospitalizations in the United States over a 6-year period (2005-2011).

*Kostova, D. et al. 2013. PLoS ONE 8(6): e66312.doi:10.1371/journal.pone.0066312 53


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Why do we immunize

against influenza? Amanda, died at age 4½ yrs from influenza Breanne, died at age 15 mos from influenza complications

Alana, died at age 5½ yrs Barry, a veteran fire-fighter, Lucio, died at age 8 yrs from influenza died at age 44 yrs from from influenza complications influenza

Slide Courtesy of Families Fighting Flu


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Visit IAC Resources! •Read our publications!

– http://www.immunize.org/publications/ •Visit our websites!

– www.immunize.org – www.vaccineinformation.org – www.izcoalitions.org – www.izsummitpartners.org

•Stay ahead of the game! Subscribe to our updates!

– http://www.immunize.org/subscribe/

http://www.immunize.org/subscribehttp:www.izsummitpartners.orghttp:www.izcoalitions.orghttp:www.vaccineinformation.orghttp:www.immunize.orghttp://www.immunize.org/publications


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What's New with Flu in 2018-2019DisclosuresDisclaimerOutlineThe 2017-2018 Influenza SeasonSlide Number 6Slide Number 7Slide Number 8Influenza-Associated Pediatric Deaths by Age Group (percent of total deaths)Hospitalization rates were at historic rates!Hospitalization rates indicate very severe season!Slide Number 12Summary of Influenza Activity 2017-2018The 2017-2018 Influenza Season - Coverage2017-2018 Influenza Vaccination Coverage (early season, Nov. 2017)2017-2018 Pediatric Influenza Vaccination Coverage (early season, Nov. 2017)2017-2018 Adult Influenza Vaccination Coverage (early season, Nov. 2017)2017-2018 (early season) Influenza Vaccination Coverage – Healthcare Personnel*Early Season 2017-2018 Influenza Vaccination Coverage – Healthcare Personnel#Impact of Employer Policy on Healthcare Personnel Vaccination (by setting)*Healthcare Personnel Vaccination Policy by Setting*2017-2018 Influenza Vaccination Coverage in Healthcare Personnel (early season, Nov. 2017)2017-2018 (early season) Influenza Vaccination Coverage – Pregnant Women*Influenza Vaccination Among Pregnant Women by Provider Recommendation or Offer of Vaccination, 2017-18 Season* (early season, Nov. 2017)Impact of influenza on pregnant women1Some coverage thoughtsVaccine EffectivenessPreliminary Adjusted VE against medically attended influenza, US Flu VE Network, 2017-18Preliminary Adjusted VE against medically attended influenza, US Flu VE Network, 2017-18Preliminary Adjusted VE against medically attended influenza, US Flu VE Network, 2017-18Preliminary Adjusted VE against medically attended influenza, US Flu VE Network, 2017-18Preliminary VE against influenza hospitalizations in adults, HAIVEN, 2017-18Summary of preliminary VE for the 2016-2017 influenza seasonAnother way to look at influenza vaccine effectiveness – negative outcomes avertedVaccine Effectiveness – InfluenzaSlide Number 36Slide Number 37Slide Number 38Slide Number 392018-2019 Influenza Vaccine StrainsAdjuvanted Influenza VaccineCell Culture Influenza VaccineRecombinant DNA Influenza VaccineOther Influenza VaccinesOther Influenza VaccinesOther Influenza VaccinesOther Influenza VaccinesInfluenza Vaccines 2017-2018�(www.immunize.org/catg.d/p4072.pdf)ACIP Influenza RecommendationsHow do we discuss Vaccine Effectiveness?How do we discuss Vaccine Effectiveness?More messaging on Vaccine Effectiveness…Some communications thoughtsSlide Number 54Visit IAC Resources!Slide Number 56

what's new with flu in 2018-2019 - texas department of ... · 7/31/2018 · what's new with flu in...

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