A summary of presentations from the weekly Summit partner webinars
November 18, 2021 – The latest Summit summary
- ACIP Updates to the 2022 Adult Immunization Schedule – Neil Murthy (CDC)
- Flu Surveillance Update – Alicia Budd (CDC)
- Flu Uptake Update – Julian Ritchey (Sanofi)
ACIP Updates to the 2022 Adult Immunization Schedule – Neil Murthy (CDC)
Neil Murthy, MD, MPH, MSJ, LCDR, United States Public Health Service, Immunization Services Division, NCIRD, CDC, gave a presentation on the vaccine recommendation and adult immunization schedule changes that were voted upon at the October and November ACIP meetings that will be reflected in the 2022 adult immunization schedule.
- The use of vaccine trade names is for identification purposes only and does not imply endorsement by the CDC.
- The 2022 schedules presented in the following presentation are drafts and could be subject to change before expected publication in February 2022.
2022 Adult Immunization Schedule Changes to the Cover Page
There are five changes to the cover page from the 2021 adult immunization schedule to the 2022 schedule:
- The “How to Use the Adult Immunization Schedule” box now has a fourth step that asks the provider to check the Appendix for contraindications and precautions of each vaccine.
- The box in the upper righthand corner of the cover page has a change to the AAPA (aapa.org) from “American Academy of Physician Assistants” to “American Academy of Physician Associates.”
- The same box in the upper righthand corner of the cover page now includes of the Society of Healthcare Epidemiology of America (shea-online.org) as a partner.
- In the list of adult vaccines, PCV13 was removed and the two new pneumococcal conjugate vaccines, PCV15 and PCV20, are now included in the list.
- Finally, there was an addition of a QR code at the bottom of the righthand corner of the cover page. When this code is scanned from a mobile device, it will pull up the adult immunization schedule on the CDC website.
2022 Adult Immunization Schedule Changes to Table 1: Age-Based Recommendations for Adult Vaccines
There were three changes to the 2022 schedule from the 2021 schedule:
- The zoster recombinant vaccine is now recommended in two doses for immunocompromised adults age 19–49. A two-dose series continues to be recommended for all adults 50 years and older.
- The new pneumococcal conjugate vaccines, PCV15 and PCV20, and the polysaccharide vaccine, PPSV23, have been added into one row with corresponding age groups.
- The hepatitis B row now includes the recommendation for universal vaccination of all adults age 19–59 years. The recommendation for persons age 60+ years have not changed and include recommendations to vaccinate anyone who wants to be protected against hepatitis B and persons at increased risk of hepatitis B exposure.
2022 Adult Immunization Schedule Changes to Table 2: Medical and Other Indications Table
Six changes have been made to the medical and other indications table to reflect the new ACIP recommendations:
- The header now has CD4 percentages displayed along the CD4 counts to harmonize the language with child/adolescent schedule.
- The legend at the bottom of the table has been reworded. The red description now says “contraindicated” instead of “not recommended” for adults in high-risk groups.
- The text overlays in the red boxes for LAIV4, MMR, and VAR now say “contraindicated” instead of “not recommended,” with the exception of HPV vaccine text, which still says “not recommended for pregnancy.”
- The zoster vaccine row now states that two doses of the vaccine are now recommended for immunocompromised adults age 19–49.
- The new pneumococcal conjugate vaccines, PCV15 and PCV20, and the polysaccharide vaccine, PPSV23, have been added into one row with corresponding age groups.
- Hepatitis B row is now entirely yellow, indicating that the vaccine is recommended for all of the risk-based groups presented.
2022 Adult Immunization Schedule Changes to the Notes Section
There have been many changes made to the notes section of the adult immunization schedule:
- The COVID-19 vaccination box now contains a hyperlink to the CDC interim clinical considerations for the use of COVID-19 vaccines.
- The hepatitis B row now includes the universal recommendation of adults age 19–59 years, as the vaccine is university recommended. Those age 60+ are included as risk-based on the list. This section now includes a detailed description of the two, three, and four dose series in the routine vaccination section.
- The hepatis B special situations section now describes risk-based recommendations for adults age 60 years and over with a note that anyone 60+ who wants to be vaccinated with the hepatitis B vaccine should be vaccinated.
- In the HPV vaccine box, the final bullet of the routine vaccination section has been changed to read that no additional dose is recommended when any HPV vaccine in the series has been completed using the recommended dosing intervals. The bullet for immunocompromising conditions under the special situations sections has also changed and HPV is now a 3-dose series, even for those who initiate vaccination at age 9–14.
- The wording of the pregnancy bullet in the special situations section now states, “pregnancy testing is not needed before vaccination; HPV vaccination is not recommended until after pregnancy; no intervention needed if advertently vaccinated while pregnant.”
- The first bullet in the influenza section now states, “for age 19 years or older” and the hyperlink to the 2021–2022 influenza recommendation bullet has been added as a placeholder for the 2022–23 influenza recommendations. The special situations section has been substantially condensed as now healthcare providers are referred to the appendix for contraindications and precautions for influenza vaccines.
- In the MMR special situation section under the HIV bullet, CD4 percentages have been added in addition to the CD4 counts for HIV infection (to harmonize language with child/adolescent schedule).
- In the meningococcal vaccination section, there is now a note at the end of the section stating, “meningitis B vaccines may be administered simultaneously with MenACWY vaccines if indicated, but at a different anatomic sites, if feasible.”
- The pneumococcal section has been substantially modified to reflect the new ACIP recommendations. There is now a bullet that states that those age 65+ who have not previously received a pneumococcal vaccine or whose vaccination history is unknown should get one dose of PCV15 or PCV20. PCV15 should be followed with a dose of PPSV23. Once the details about the dosing intervals between PCV15 and PPSV23 are finalized, there will be a link to the guidance on the schedule. There will also be a link for providers to reference the guidance for those who have received PCV13 or PPSV23 in the past. The special situations of the pneumococcal vaccination section has also changed. A bullet has been changed to say that those age 19–64 with underlying medical conditions or other risk factors who haven’t received a pneumococcal vaccine or has an unknown history of vaccination should receive one dose of PCV15 or PCV20. If PCV15 is used, it should be followed by PPSV23. Once the dosing information is determined, there will be a URL to the information included. There will also be a link for providers who have patients who have received PCV13 or PPSV23 in the past. The pneumococcal section ends with a note that states that all underlying medical conditions or risk factors would make those 19–64 year eligible for vaccination with PCV15 or PCV20. Conditions and risk factors have all be combined into one group of high risk conditions, including:
- Chronic heart/liver/lung disease
- Cigarette smoking
- Diabetes mellitus
- Chronic renal failure
- Nephrotic syndrome
- Iatrogenic immunosuppression
- Generalized malignancy
- Hodgkin disease
- Multiple myeloma
- Solid organ transplants
- Congenital or acquired asplenia
- Sickle cell disease or other hemoglobinopathies
- CSF leak
- Cochlear implant
- The varicella vaccination special situation section under the HIV bullet, CD4 percentages have been added in addition to the CD4 counts for HIV infection (to harmonize language with child/adolescent schedule)
- The zoster section now includes a special situation bullet that states, “there is currently no ACIP recommendation for RZV use in pregnancy. Consider delaying RZV until after pregnancy.” Language was also added to reflect the new recommendations for immunocompromising conditions stating, “RZV is recommended for persons age 19 years or older who are or will be immunodeficient or immunosuppressed due to disease or therapy.”
Newest Addition to the 2022 Schedule this Year: Appendix, Which Lists Contraindications and Precautions to All Vaccines
The beginning of the Appendix states that the Appendix is adapted from the ACIP General Best Practice Guidelines for Immunization: Contraindication and Precautions and the ACIP’s Recommendations for the Prevention and Control for 2021–22 Seasonal Influenza with Vaccines.
Interim Clinical Considerations for Use of COVID-19 Vaccines including contraindications and precautions to the COVID-19 vaccines can be found at: https://www.cdc.gov/vaccines/covid-19/clinical-considerations/covid-19-vaccines-us.html
The first page of the appendix lists the contraindications and precautions for all of the influenza vaccines approved for adults and the second page lists the contraindications and precautions for all other non-influenza vaccines.
For those who are over sixty and would like to get the hepatitis B vaccination, will the affordable care act cover that now that hepatitis B vaccination is on a risk-recommendation basis for those over sixty?
There is that note in the hepatitis B section that says those 60 and over who want to get vaccinated can do that, so it should be covered.
Will the CDC vaccine schedule app be updated, and will the clinical decisions support integration tool for electronic health records also be updated?
Yes, we are working very closely with our colleagues on the communications side to update all of our ancillary resources. The app and adult assessment tool will be updated to reflect the new ACIP recommendations.
Flu Surveillance Update – Alicia Budd (CDC)
Influenza Virologic Surveillance––U.S., May 23, 2021, through November 6, 2021
Overall, in week 44 the U.S. flu activity is still relatively low. The clinical laboratories are reporting 0.3% influenza positive tests to the CDC this week. Public health laboratories are seeing influenza A (H3N2) as the he most frequent flu virus. This is being reported in most parts of the country––7 out of 10 regions so far this year. Virus characterization data (genetic/antigenic and antiviral resistance) will be reported later this season.
Influenza Virologic Surveillance––U.S., May 23, 2021, through November 6, 2021. Compared to Similar Time Period in 2019
The CDC is seeing slight increases in flu activity, however it is still low compared to what was seen at this same time during the fall of 2019. At the same time in 2019, there were 600 cases and 3% of specimens positive for the flu in week 44. This year there are 100 positives and 0.3% positivity. During late October and early November 2019 public health laboratories were reporting about 200 cases of flu each week. So far this season there have been nearly 100 cases of positives for the whole season. Virus characterization data (genetic/antigenic and antiviral resistance) will be reported later this season.
Influenza Virologic Surveillance––U.S., Public Health Laboratory Data––by Age Group––May 23, 2021, through November 6, 2021
The public health labs are reporting that most of the positive flu cases have been within the 5–24 age group, which matches the age group expected to be most highly infected. The CDC has also been receiving some anecdotal reports from a number of states about flu outbreaks in young adults attending universities.
Percentage of Outpatient Visits for Influenza-Like Illness (ILI) Influenza, ILINet, U.S.
This system monitors visits for ILI (fever and cough or sore throat), not laboratory confirmed influenza and may capture patient visits due to other respiratory pathogens that cause similar symptoms. This year we are seeing a respiratory virus that wasn’t there in other years before March 2020, and that’s COVID-19, which makes it hard to compare this and last season to previous seasons.
ILI increased slightly to 2.1% in week 44, but is still below baseline of 2.5%. This is tracking similar to the 2019–2020 season. There were some slight increases for ages 0–4 and 5–24, however those over age 25 have remained relatively stable.
ILI Activity Level, Determined by Data Reported to ILINet, Week ending November 6, 2021 (Week 44)
This system monitors visits for ILI (fever and cough or sore throat), but not laboratory confirmed influenza, and may capture patient visits due to other respiratory pathogens that cause similar symptoms.
Data from providers in particular geographic areas report each week and that data is compared to baseline from the providers. This gives a look at the state and local levels. One state in particular has high activity––New Mexico––and several other states are showing moderate activity.
When higher activity arises, CDC also looks at surveillance coordinators in those areas, as well as lab data to make sure that these increases in respiratory activity to the flu or other viruses is consistent.
Percent of Long-Term Care Facilities (LTCF) with at least One Confirmed Influenza Case among Residents, Reported to CDC National Healthcare Safety Network (NHSN), National Summary, May 24, 2021–November 7, 2021
The LTC survey component contains reports from about 15,000 facilities across the country and looks at the percent of facilities that have at least one positive case among residents. Currently, the number of positive cases is very low and has been stable since mid-May. Most of the flu cases right now are among children and young adults.
Influenza Hospitalizations, U.S.
Hospital admissions across the country with at least one lab-confirmed case of flu report their data to HHS. There were 295 flu admissions in week 44, which is similar to the LTC facility data, which is very low.
FluSurv-NET hospitalization rates will be updated starting later in the season when there is enough information to make sure that there are stable and informative rates.
Influenza-Related Mortality, U.S.
The National Center for Health Statistics Mortality Surveillance System looks at data from the death certificates that listed pneumonia, flu, or COVID-19 as the cause of death. In week 44, 14% of death certificates list one of these as the cause of death. This percentage has been decreasing for several weeks, however, does remain above the epidemic level. There were about 2,200 deaths reported during this week; 1,500 or so had COVID-19 listed as the cause of death and none listed flu as cause of death. The flu is not currently impacting this number currently, therefore right now the majority of what this system is tracking is COVID-19-related deaths.
There have been no pediatric-related flu deaths so far this year, and only one from the previous season, which is much lower than is typically seen.
International Influenza Activity Influenza Positives Reported to WHO’s FluNet
WHO’s FluNet gives a clue as to what we should expect this season. When looking at the number of influenza positives reported to WHO’s FluNet over the past year, there is much lower activity than would typically be seen this time of year. In both the northern and southern hemispheres, there are reports of influenza B Victoria lineage. In the northern hemisphere there are reports of influenza A (H3), and in the southern hemisphere there are reports of influenza A (H1).
Flu vaccine projections this year
There are a projected 200 million doses of flu vaccine available this season. Since we are seeing increases in flu activity, especially with college-age people, and the holidays are coming up, it is a great time to get vaccinated if you haven’t done so yet.
There is also some confusion about the flu vaccine and the COVID-19 vaccine. In a poll of 2,000 Americans, about 26% thought that a COVID-19 vaccine would protect against flu. Around 28% thought a COVID-19 booster would protect against flu. About 23% thought the flu shot would protect against COVID-19. This shows that we need more education about the importance of receiving both of the vaccines and that both COVID-19 and flu vaccine can be administered at the same visit.
Flu activity is still low across the nation, but there are some increases in activity that could mark the beginning of influenza season. The most predominant flu virus right now is H3N2, which is being reported across the country. Most of the positive cases are being reported in children and young adults. There are reports of outbreaks in young adults in the college and university setting in several states. The timing and occurrence of these outbreaks isn’t unusual; however, they are notable because they represent the first significant influenza activity of the season. It’s important to get a flu vaccine and COVID-19 vaccine/booster right now, as flu season is now underway.
Other Respiratory Virus Activity
- COVID Data Tracker Weekly Review
- COVID Data Tracker
- National Respiratory Virus Surveillance System (NREVSS)
Can you shed some clarity on the flu outbreak at the University of Michigan?
It is definitely an outbreak, as there have been a number of influenza positives. However, this is not particularly concerning compared to other outbreaks we have seen. It gives us an opportunity to begin to understand how flu and COVID-19 might be interplaying with each other since we haven’t really seen that yet.
Flu Uptake Update – Julian Ritchey (Sanofi)
Julian Ritchey, BS, MBA, Head of Public Affairs and Patient Advocacy, U.S. Vaccines, Sanofi Pasteur gave a presentation on flu uptake.
The U.S. is experiencing its lowest influenza immunization rate (YTD) since 2016 and anticipated extension of the season has not materialized.
The new claims data demonstrates overall lower vaccination rates and a downturn in flu vaccination. From week one in August 2021, the uptake of flu was delayed several weeks, which is in line with the ACIP recommendations and co-administration of the COVID-19 vaccine. Following that, there was an upward trend as seen in previous years, but now there is a downward trend that could mirror what is typically seen at the end of the flu season. Fortunately, last year there was a very high uptake, which was exciting, but this year we are trending behind the last five or six seasons based on the total usage of flu vaccines across the entire market, as reflected by the claims data. It’s estimated that currently the U.S. is 17% behind the uptake of influenza vaccine from the 2019–2020 season across the market.
Claims remain down across all age groups, variance versus 2019 driven by 18–64 age group.
When the claims data is broken down by age, flu uptake is consistently lower across all age groups when compared to both the 2019–2020 and the 2020–2021 flu seasons. This trend is consistent across age groups with significantly less uptake among the 0–17 age groups.
There is still time to immunize patients this season before flu activity begins to rise and as we approach the historical peak of influenza activity which is usually in February.
The good news is that there’s still time to do something about this downward trend. The onset of flu isn’t generally until later in the year or the beginning of the following year. When looking at CDC data over a 28-year period (1982–2020), flu activity most often peaked in February, followed by December, January, and March. We need to extend the flu season and get more people vaccinated. Providers need to let their patients know that the vaccine is still on the market and that they are still actively immunizing.
Reminders are needed to continue provider engagement.
Flu vaccination typically falls off around Thanksgiving, and steadily declines as the season progresses. Providers need to reach out to patients who have received the flu vaccination in the past but have not so far this year and remind them why the vaccination is important for their health and that it’s not too late to get vaccinated. Providers can use the opportunity when their patients come in for COVID-19 vaccination/boosters and talk to them about the recommendation of co-administration with flu vaccine. If the patient declines, let them know that they need to make a separate appointment for the flu shot. There are many tools available from CDC and immunize.org that can be helpful for speaking with patients about the flu vaccine.
Providers need to keep reminding and encouraging their patients and the community about the importance of flu vaccination and the ability to co-administer the flu vaccine with the COVID-19 vaccine. This is really important right now to avoid future problems that only compound the present issues.
Does Sanofi have any public data they’ve been collecting to get a sense of why the public is not getting vaccinated like they used to? Might this have to do with healthcare staff shortages and overwhelming emphasis on COVID-19 vaccination that has drowned out flu vaccination?
We don’t have any substantially significant data on this, but all of these issues do persist and are what’s making flu vaccine uptake so difficult. Along with those, logistics, misunderstanding, and access seem to be the biggest challenges. The most successful avenue to increasing uptake is for providers to continue to engage and continue to dispel misinformation.
Are there still benefits of getting vaccinated in December and beyond, as recommended by CDC?
We need to have the back end of the season have better flu uptake. With the analysis of the CDC on the last 38 years, we can see when flu typically occurs in terms of disease, and we are bringing that into the conversation now. People need to see that they can still get vaccinated as the end of the season nears and there are benefits to doing that.
How is claims data being submitted? Can you give more details on that?
The data comes from retail and medical offices. This is national data across all products that are filed under CPT codes as “flu immunization.” So, the information is not brand specific. We have found these data trends very consistent over the years.
L.J Tan (IAC)
1. The Immunization Action Coalition (IAC), with funding support from Seqirus, is offering a limited quantity of FREE Flu Vaccine buttons and stickers in English and Spanish to support your flu vaccine promotion efforts this season. IAC also offers free COVID-19 buttons and stickers. To receive these supplies at no cost, please order now.
2. IAC hosted two influenza webinars in September that can now be viewed online.
- The Continued Threat of Influenza and How to Sustain Influenza Vaccination Efforts
- Translating COVID-19 Strategies to Improve Influenza Seasonal Flu Vaccination Efforts
3. We would welcome having even more NAIIS member organizations to add their support to the Call to Action on adult immunization. Access the call to action and click on the top righthand button to add your organization.