A summary of presentations from the weekly Summit partner webinars
July 28, 2022 – The latest Summit Summary
- Cooperative Agreement to Improve Immunization Rates Among Staff and Residents in Long-term Care Update – Elizabeth Sobczyk (AMDA)
- Southern Hemisphere Flu Season Update – Jonathan Anderson (Seqirus)
Cooperative Agreement to Improve Immunization Rates Among Staff and Residents in Long-term Care Update – Elizabeth Sobczyk (AMDA)
Elizabeth Sobczyk, MSW, MPH, Project Director, CDC Cooperative Agreement on Immunization, AMDA – The Society for Post-Acute and Long-Term Care Medicine, presented on improving adult immunization rates in post-acute and long-term care (PALTC), a five-year, CDC-funded cooperate agreement with AMDA. (VIEW SLIDES)
AMDA is one recipient of a larger pot of CDC funding targeted at improving adult immunization rates. AMDA is working with PALTC organizations, electronic health records and IIS organizations, and other partners across the PALTC spectrum, which includes nursing home chains, assisted living chains, and PACE/HCBCS programs. The other portion of the funding goes to the Council of Medical Specialist Societies (CMSS).
The AMDA “Moving Needles” project focuses on making routine adult immunizations a standard of care for PALTC residents and employees. AMDA is working with both residents and staff who have had historically low rates of immunizations to align immunization policies and procedures to develop a pilot to (1) establish baseline data and measure improvement; (2) integrate routine immunization reporting to state IISs; (3) establish a permanent source for PALTC immunization; and (4) demonstrate clinical benefits and operational/cost benefits to implementation.
This project started in September of 2021, and it goes through September of 2026. There are two rounds in the pilot and based upon the results, AMDA will work to develop a change package and curriculum that can be distributed widely to members and partners to give them the resources they need to make change and improve their immunization rates. AMDA is also working on the workflow and cost-benefit analyses; which should be completed in September of 2025.
For the pilot, AMDA contracted with three chains: ALG Senior (assisted living), Saber (skilled nursing facility), and UPMC (skilled nursing facility).
The structure of the pilot includes teams in each of the nine sites and includes a medical director (where applicable), and a front-line staff member in each team (2–4 people in each team). Once a month, someone from each team participates in a virtual meeting with the other teams to check in and find out where changes need to be made. Each team also submits immunization data to AMDA.
There are three options for interventions for both staff and residents. The sites have each picked one of those interventions:
- Adopt Standard Operating Procedures (SOP)
- Address Concerns of Residents and Family Members
- Develop Immunization Champions
See this video for more information.
AMDA is measuring COVID-19, influenza, pneumococcal, Tdap, and shingles vaccine levels for residents of the facilities and COVID-19, influenza, and hepatitis B vaccines for staff. AMDA is focusing on vaccinating staff against diseases that are considered most communicable to residents and that made the most sense for employer-employee relationship. Contract staff vaccine uptake levels were not measured. Findings show that historically, the hepatitis B vaccine had the lowest levels of vaccine uptake.
Visit www.movingneedles.org and go to the resources tab at the top of the page for resources regarding interventions that may be of use to partners. Please email email@example.com (with the subject “newsletter”) to subscribe to the new quarterly newsletter.
Q: Given ACIP’s updated recommendation around age 65+ for the flu vaccine, will the measure language be revised to be stronger than “consider” a preferred vaccine?
A: We currently have language that was approved. But, we are consistent with the CDC recommendations on this so once the MMWR comes out, all will point to new recommendations. Our first newsletter had the news about the new recommendation for the enhanced influenza recommendation.
Q: Do you track reimbursement/billing?
A: We are not tracking reimbursement or billing but if it comes up as a technical barrier then we have resources for that on the website under the category of coding and billing. We have not heard from the sites so far that this is an issue. That doesn’t mean that it won’t be. We have resources should this become an issue on the sites.
Q: Are you encouraging or tracking coadministration of these recommended vaccines?
A: We have encouraged all the sites in our initial discussions to consider coadministration of flu and COVID-19 vaccines. The sites are dealing primarily with boosters in staff and residents. So, we have talked about offering boosters and flu vaccines together. We also do have a cumulative measure to show who has all five of the resident vaccines, as well as all three of the staff recommended vaccines. We are tracking them individually, but also all together. We are starting off small, which is better for sustainability and understanding if the integrations can be integrated into the system. While they can do coadministration upon admission, right now for intervention purposes they are looking at one vaccine to start with, and then we will build on it from there.
Southern Hemisphere Flu Season Update – Jonathan Anderson (Seqirus)
Jonathan Anderson, MD, MPH, PhD, Seqirus’ Executive Director, Medical Affairs – International Regions, gave an update on influenza in Australia. (VIEW SLIDES)
Looking at the WHO FluNet data sources, influenza notifications in the Southern Hemisphere have been showing flu activity since June, which has been sustained over time, following two years of hardly any activity.
In 2022, there has been an earlier start to the flu season and the peak of the season came earlier than usual; however recently this has settled down. The peak this year was higher than the peak in 2017 (a severe season in Australia) as well as the pandemic years. With over 200k lab-confirmed cases so far this year in a population of 25MIL, the Australian governments (federal and state) were concerned. The concern prompted an unprecedented provision of free flu vaccines to all adults and children in an effort to reduce infections and ease pressure on the healthcare system.
In addition to this rise in flu cases and high peaks in Australia, there also has been a rise in flu cases in other countries in the Southern Hemisphere.
The increase in cases is not due to an artifact of increased testing. While there have been more flu tests performed this year, there were a greater number of positives for flu. It’s interesting to see that there has been an increase in positive tests through May and into June. There have been many patients with influenza-like illness (ILI), those of which are testing 40% flu, 10% COVID-19, and 50% other respiratory viruses. This supportive data suggests that the rise in flu positives is not due to increase in testing. The increase in positives is seen across Australia.
Australia’s circulating subtypes are mainly H3N2 with some H1N1 in two of the states and one territory. There has hardly been any B Victoria or B Yamagata. Although Australian cities and towns are spread out, there is flu in all states and territories.
The majority of the population testing positive for flu is weighted towards younger people. There hasn’t been a huge rise of cases in the populations that are normally most vulnerable––older adults, particularly those over age 65+. Findings show that those who have been vaccinated early are less likely to test positive.
There was a rise in hospitalizations in May, which fell in July, which is encouraging. However, sometimes people who get admitted to the hospital don’t get reported as having flu, and instead are treated for the complications of the flu. The rise in flu hospitalizations caused challenges in emergency departments as well as ICUs. The good news is that the overall uptake in vaccines has been reported to be 10MIL out of 18MIL doses. That means that 40-50% of the population has been vaccinated. There will be more detailed statistics forthcoming around vaccine uptake and hospitalization.
The increasing flu numbers are what led the state health departments to decide to take the step to fund vaccines for all. Normally funding comes from the national government for young children, at risk, and adults age 65 and older. However, there was concern that the hospitals and their staff and across other sectors would be negatively affected by COVID-19 and flu at the same.
There have been consistent levels of COVID-19 activity over the last six months. Australia has a high uptake for COVID-19 vaccination with over 95% of adults have had two doses of a vaccine (diminishing with boosters). This has helped healthcare systems with the burden of COVID-19 disease.
Vaccine match: In terms of H1N1 isolates being tested by the WHO Collaborating Center (WHOCC), there’s a high match with the corresponding vaccine components. With the H3N2, 92% of the isolates have been antigenically similar. At the recent NIBSC meeting, there was a verbal report that there had been some drift between vaccine strains. There are no absolute vaccine effectiveness estimates yet.
A paper was published in 2019 by a group that looked at how modeling could predict influenza activity for the following Northern Hemisphere season based on Southern hemisphere (Australian) data.
They took the data for the United States, China, and the UK from 2020–2018 and they compared this against the Australian influenza notifications for the comparable seasons. They used the Australian influenza surveillance data combined with local internet search data, to try to predict the Northern Hemisphere flu epidemics. They concluded that using this model you could have a fair degree of prediction of whether the flu season that occurred in the Southern Hemisphere could predict the immediately following flu seasons in the Northern hemisphere. The researchers hope to be able to use the model to forecast what might be happening in the Northern hemisphere based on what happened in the Southern Hemisphere.
Another model (Susceptible-Exposed-Infectious-Removed [SEIR]) looks at the impact of influenza immunization rates in Australia and the U.S., while COVID-19 is circulating at the same, on the healthcare system resources. This study has been accepted for presentation at the OPTIONS-XI conference in September 2022.
Briefly, the study assumes a flat 45% influenza immunization rate and suggests that if 300,000 acute hospital beds and 30,000 ICU hospital beds are available for influenza and COVID-19 patients, then in a low incidence flu season, ICU bed capacity will be exceeded. In a high incidence flu season, ICU bed capacity becomes saturated, and acute hospital bed capacity is nearly reached; but if rates drop below 45%, then both acute and ICU hospital beds will be overwhelmed.
It’s important to improve the immunization of people against influenza before the disease arrives because the assumption can’t be made that the flu will arrive at the usual time. The flu may come earlier and then come back again like it did in the Northern Hemisphere last season. Flu vaccination is not only for individual benefit but reduces the burden on the healthcare system.
Q: Why can the Southern Hemisphere be used to predict the Northern Hemisphere and not the other way around?
A: We will look at the Northern Hemisphere data and spend a lot of time wondering how this will reflect Australia’s upcoming season this year. In terms of the available data, we can look at the Northern Hemisphere, but there are a lot of places to work from so there is more data but it’s inconsistent.
Q: In the past have we seen U.S. healthcare professionals or policy decision makers act on Southern Hemisphere data presentations/models, or do they tend to say “good to know” but take a more wait/see approach?
Jonathan Anderson – We had immunization campaigns around the same time as we first had lockdowns/stay-at-home orders for the pandemic. We communicated to the U.S. through a number of presentations and papers in journals to come up with solutions.
L.J Tan (Immunize.org) – Back when the COVID-19 season hit, we leveraged messaging about the fact that we needed to be prepared for a potentially bad flu season. That is the season we hit 172.5MIL doses of flu vaccines administered. We don’t know what will happen this upcoming fall and many are worried that we don’t want to “cry wolf.” We have heard CDC say they pay attention to the data in the Southern Hemisphere to understand what kind of season we will have in the U.S.
Jonathan Anderson – we watch the U.S. very closely and collect ILI data. The data shows that the predominant cause of ILI activity is due to flu and it helps to know it’s most likely not due to higher numbers of testing. It’s interesting to see an earlier introduction of flu into the population. We had years where we couldn’t get in or out of the country [due to the lockdown], so we had very little flu over that period. This may have been something that doesn’t have anything to do with the Northern Hemisphere. We need to plan for the worst and hope for the best. I’m interested in the impact that vaccines had on the incidence rate this past season, and will watch carefully to see what impact we have had in terms of absolute vaccine effectiveness. We were still vaccinating around the second week of June (when our program normally stops), and this continued halfway into July when we were giving a million vaccines a week.
Q: For Australia, flu season started early and ended later due to a late peak, so in total, is an extended flu season with an earlier start and a later end possible for the U.S.? Should we get flu shots earlier than September?
L.J Tan – the ACIP recommendation is that flu vaccination optimal time is September and October. The publication of the recommendations will be in August. Based on the ACIP’s June discussion, there will be language that for certain populations, June and July will not be optimum.
Kelly L. Moore – we have had a couple of years where the recommendation is that with certain exceptions for people who may not come back later, are children who need their first dose of vaccine, are older adults, or are women during pregnancy that the July/August timeframe is for them. For these people, September/October is the sweet spot. Changes are significant with the 65+ population and those recommendations won’t be in print until later in August. We always expect to see sporadic cases of flu that are diagnosed in early September. That doesn’t necessarily mean the beginning of a wave. You see those cases every year. Right now we hold fast to the general recommendations.
Jonathan Anderson – I always agree with the ACIP. They have the opportunity to think about the relevant data for the U.S. and all the different factors. As a general practitioner, I would comment that you must think about how the programs were set up within primary care and pharmacy, and I think what we need is to be sure people are vaccinated before the season starts. I would always follow what the ACIP recommends, and I would avoid people getting vaccinations after December. That’s one of the things that COVID-19 taught us: for any infectious disease, get vaccinated before the disease arrives if you can, and after you’ve caught it.
Kelly L. Moore – this is a good opportunity to remind people about the importance of timely vaccination. Australia saw flu early int the season. September and October is early in the U.S., but we have had this universal recommendation for so long. People don’t need to wait to get flu and COVID-19 vaccines at the same time so it’s important to not put a vaccine off.
L.J Tan – The ACIP has said to not stop vaccinating just because Thanksgiving has hit. There are benefits to late-season vaccination. Get your vaccine before you get the disease but don’t just stop thinking about it. There are still benefits to getting the vaccine in December.
Jonathan Anderson – We can speculate that may be why we had this late-season surge in vaccination. Vaccines may have helped control what looked like was going to be a prolonged season.
Q: Did you find that because your surveillance system in Australia is so close to real-time and being able to make on the fly changes in policy like the free vaccines translated into higher vaccine uptake?
A: Yes we did. The fact that we have taken what looked like a not completely lethargic year of vaccination. I think it will come back to a reasonable vaccine rate. We got some data this year due to an adult vaccine registry mandated by COVID-19. Everyone’s vaccines were recorded and accessible by providers and anonymously by researchers to find out what’s happening with vaccination rates against influenza.
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