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A summary of presentations from the weekly Summit partner webinars

January 12, 2023 – The latest Summit Summary

COVID-19 Bivalent and Flu Vaccines Coverage Update – Carla Black (CDC)

Carla Black, PhD, Epidemiologist, Immunization Services Division, CDC, gave a presentation on COVID-19 bivalent and flu vaccines coverage. (View Slides.)

Influenza Vaccination Coverage (Data from: Weekly Flu Vaccination Dashboard)   

Cumulative Doses of Influenza Distributed by Week and Season

  • Currently, the U.S. has distributed between 170–180 million doses of flu vaccine, which is where we were last season and in previous seasons

Weekly Cumulative Flu Vaccination Coverage by Flu Season, Children 6 Months–17 Years, U.S., through December 24, 2022

  • The U.S. is almost exactly where we were for coverage at the same time last season, at 47.5%
  • Flu coverage has been declining among children during this year and the last year compared to pre-pandemic years
    • Six percentage points lower last season than the pre-pandemic season
    • Last season has been similar to this season

Flu Vaccination Coverage, by Flu Season and Race/Ethnicity, Children 6 Months–17 Years, U.S., through December 24, 2022

  • Last season non-Hispanic Black children had lower coverage compared to most other race/ethnicity groups, which is seen in most seasons and was found for this season, as well, looking at data through the end of December 2022.

Flu Vaccination Coverage in Children 6 Months to 17 Years

  • Coverage has been lower historically in rural children compared to urban children
  • Compared to last season, coverage has decreased in rural children, but not in urban and suburban children
  • At this point in the season, coverage is at about a 15 percentage point disparity in rural children compared to urban and suburban children

Weekly Cumulative Estimated Number of Flu Vaccinations Administered in Pharmacies and Physician Medical Offices by Flu Season, Adults 18 Years and Older, U.S., through Week Ending December 17, 2022

  • For the 2020–2021 season, adult coverage based on claims data was highest compared to the other years shown.
  • Currently, for the 2022-23 season, he U.S. is at about 1.5 million doses lower this season than at the same time last season in terms of influenza vaccination claims filed. (Does not capture doses with claims not filed, missed, or workplace doses where an insurance claim may be filed.)

Flu Vaccination Coverage, by Fly Season and Race/Ethnicity, Adults ≥18 Years, U.S., through Mid-November 2022

  • As of mid-November 2022, data from the National Immunization Survey Adult Covid Module shows overall coverage at 4 percentage points higher this season compared to last season
  • Looking at race/ethnicity through mid-November, all race/ethnicities have lower coverage than non-Hispanic White and Asian adults

This pattern in flu vaccine coverage by race and ethnicity is similar to the prior year.

Flu Vaccination Coverage in Adults 18 Years and Older

  • As of mid-November 2022, there have been increases in flu vaccine coverage for suburban, urban, and rural adult groups
  • However, this year and in prior years, coverage is lower among adults living in rural areas, and highest in suburban areas

Monthly Cumulative Flu Vaccination Coverage by Flu Season, Pregnant Persons 18–49 Years, U.S., through End of November 2022 (Vaccine Safety Data Link)

  • Decrease in coverage for pregnant individuals this season through end of November compared to the last three seasons
    • 43% in 2022-23 compared to 55% in 2021-22, 62% in 2019-2020, and 62% in 2020-21

Monthly Cumulative Flu Vaccination Coverage by the End of September, by Flu Season and Race/Ethnicity, Pregnant Persons 18–49 Years, U.S. through December 31, 2022

  • Non-Hispanic Black pregnant individuals have lower coverage each season shown (2019-2020 through current season) and do so far this year again
  • Non-Hispanic Asian pregnant individuals have higher coverage than non-Hispanic White individuals
  • Other races have lower coverage than White and Asian race/ethnicity for the past four seasons, and do this season, as well

COVID-19 Vaccination Coverage

COVID-19 Vaccination Primary Series and Bivalent Booster Dose Coverage as of January 4, 2023, U.S. (Data from: CDC’s COVID Data Tracker)

  • 81% of the US population has had at least one dose of primary series vaccine; 95% for age 65+
  • Completion of primary series is highest in age 65+ at 94.1%
  • Bivalent booster coverage is 15.4% coverage for people age 5 years and older; 38.1% for age 65+

Vaccination Status and Intent by Demographics, Adults ≥18 Years, National Immunization Survey – Adult COVID Module, December 25–31, 2022

  • About 87.5% of adults have had at least one COVID-19 vaccine dose based on the National Immunization Survey.
  • Asians and Asian adults have the highest coverage; however, other groups are similar
  • Persons without insurance, persons in rural areas, and younger adults were more likely to say they will not get vaccinated.
  • Among racial and ethnic groups, non-Hispanic Whites were the most likely to say they will definitely not get vaccinated

Bivalent Booster Status and Intent among Adults Who have Completed the COVID-19 Primary Series by Demographics, National Immunization Survey – Adult COVID Module, December 25–31, 2022

  • About 31% of adults who completed the primary series have gotten a bivalent booster
    • Decreases with age
    • Hispanic, non-Hispanic Black, and non-Hispanic multi-racial adults have a lower bivalent booster coverage compared to non-Hispanic white adults
      • However, expressed intent for vaccination doesn’t differ [i.e., the proportion vaccinated already plus those who definitely intend to get the bivalent booster]

Vaccination Status and Intent by Demographics, Children 5–17 Years, National Immunization Survey-Child COVID Module, November 27–December 31, 2022

  • About 47% of children age 5–17 have had at least one dose of COVID-19 vaccine
  • White, Black, and Hispanic children have similar coverage
  • Coverage and intent to vaccinate is lower among parents of rural children and of younger age groups

Bivalent Booster Status and Intent among Children 5–17 Years Who have Completed the COVID-19 Primary Series by Demographics, National Immunization Survey – Child COVID Module, November 27–December 31, 2022

  • Among children who have had a primary series, only 19% have had a booster
  • Disparities in race/ethnicity
    • 6% of Black children have received a bivalent booster
    • 24% of white children have received a bivalent booster
    • 15% of Hispanic children have received a bivalent booster

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COVID-19 Vaccination Coverage in Healthcare Facilities – Hannah Reses (CDC)

Hannah Reses, MPH, Epidemiologist, Vaccination Unit Lead, National Healthcare Safety Network, Division of Healthcare Quality Promotion, CDC, gave a presentation on COVID-19 vaccination coverage in healthcare facilities. Information comes from the National Healthcare Safety Network (NHSN).

Nursing home residents and healthcare personnel COVID-19 vaccination coverage. The data source can be found at www.cdc.gov/nhsn/covid19/ltc-vaccination-dashboard.html

Nursing Home Resident and Staff COVID-19 Vaccine Coverage (Facilities reporting within the last two weeks) – provisional data

  • Among residents, 86% have completed the primary series
    • Among this group, 87% have received any additional booster dose
  • Among all residents, about 50% are up to date with COVID-19 vaccines (completed primary series in last two months or completed primary series and boosted)
  • About 21.8% of staff are up to date with COVID-19 vaccines
  • An estimated 49% of Nursing home residents have received a bivalent booster dose
  • Most nursing homes report that either a very low (≤10%) or a moderate (60-80%) percentage of residents have received a booster dose
    • Remains steady week to week
  • Less than a quarter (21%) of nursing home staff have received a bivalent booster
  • Most nursing homes report that ≤20% of staff have received a bivalent booster dose
  • Bivalent booster uptake among nursing home residents is lowest in the southern regions and highest in the northern regions of the U.S.
  • Bivalent booster uptake among nursing home staff is lowest in the southern regions and Midwest and highest in the northeast and western regions of the U.S.

Outpatient Dialysis Facilities

Dialysis patient and healthcare personnel COVID-19 vaccination coverage – provisional data  

  • Data can be found at: www.cdc.gov/nhsn/covid19/dial-vaccination-dashboard.html
  • 72% of dialysis patients have completed their primary series
    • Only 10% are up to date
  • Among dialysis staff or healthcare personnel, 81% have completed their primary series
    • Only 2% are up to date

Inpatient Facilities

Acute care hospital staff COVID-19 vaccine coverage – provisional data

  • In the past four weeks, only 26 of the facilities reported
    • 88% have completed primary series
    • 18% are up to date

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Flu Surveillance Update – Alicia Budd (CDC)

Alicia Budd, MPH, Influenza Division, CDC, gave an update on influenza surveillance through the end of 2022. (View Slides.)

Virologic Surveillance

Virologic Surveillance – Percent Positive for Influenza

  • Starting to see a decline after about three weeks of plateau
  • All regions are declining
  • Very little influenza B activity detected by clinical labs
  • Almost all viruses tested at the public health labs are influenza A (99%)
    • 80% H3
    • 20% H1

Virologic Surveillance – Virus Characteristics

  • Almost all viruses characterized are in the same clade or subclade as the vaccine reference viruses and antigenically very similar to the cell-grown reference viruses; vaccine working well
  • Antiviral susceptibility – almost 900 viruses were tested; not seeing any indications of resistance or reduced susceptibility to any of the influenza antiviral medications

Outpatient Respiratory Illness

  • Percent of outpatient visits for respiratory illness has significantly declined in recent weeks
    • Largest decline has been in children
    • Adult groups have been stable, with a slight increase
    • Overall trend is decreasing activity
  • Seeing lower levels of activity on the state level

Long-term Care Facilities (LTCF) and Hospitals

There have been several weeks of declining activity

HHS Protect

  • Nationally there had been a sharp decline for a couple of weeks, followed by two weeks of plateau

FluSurv-NET

  • Flu activity increased early in the year this year. In a few weeks, we may be approaching a cumulative hospitalization rate that is similar to some recent years.
  • Overall, hospitalizations have dropped in recent weeks

Mortality

  • Percent of deaths from pneumonia, influenza, and COVID-19 (PIC)
  • Flu had been increasingly contributing to overall PIC deaths
  • COVID-19 still contributing to the vast majority of PIC deaths
  • Influenza-associated pediatric deaths
    • 74 lab-confirmed influenza deaths among children so far this season

Preliminary In-Season Flu Burden Estimates, 2022–2023

  • 22–43 million illnesses
  • 10–21 million medical visits
  • 230–490 thousand hospitalizations
  • 14–43 thousand deaths

Summary

  • Flu activity remains high but is declining
  • H3N2 remains predominate
  • H1 also circulating
  • Little Influenza B
  • This wave may have peaked, however, more than one wave of flu can be seen in any given year.
  • Surveillance will be continuing

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Efforts to Improve Vaccinations of LTCF Workers – Elizabeth Sobczyk (AMDA), Heather Roney (AMDA), and David Casey (AMDA)

Elizabeth Sobczyk, MSW, MPH, Project Director, Heather Roney, MA, Program Manager, and David Casey, PhD, Data Manager, AMDA gave a presentation on efforts to improve vaccinations in long term care facility (LTCF) workers.

Moving Needles – Six months of results from the pilot study

Moving Needles is a five-year cooperative agreement between AMDA and CDC to make routine adult immunization a standard of care in post-acute and long term care residences, as well as an expectation for staff.

Timeline

  • Currently wrapping up year one – nine sites including nursing homes and assisted living facilities that have adopted intervention strategies to improve immunization rates for residents and staff
  • Preparing for year 2 – recruiting new facilities and home and community-based services to join the project
  • Proposal for remaining years of the project – expanding the reach of the program, continuing education and quality improvement, and conducting cost-benefit analyses

Round 1–  Pilot sites

  • Nine locations
    • Three in the greater Pittsburgh area (both urban and suburban)
    • Three in Charlotte, NC
    • Three rural facilities outside Philadelphia
  • Each chose two intervention strategies to increase immunization rates, one for residents and one for staff

Results

Residents

Picked five vaccinations for the residents and facilities to focus on based on the Moving Needles advisory panel

  • Residents: COVID-19 Vaccination Rates
    • Facilities added the bivalent booster in September
  • They increased coverage with the bivalent booster being a measure back to pre-booster levels in the last few months
  • Residents: Influenza Vaccination Rates
  • Influenza rates have reached a similar level as during last season
  • Residents: Pneumococcal Vaccination Rates
    • Only some sites have made this vaccine a priority
    • Those, that have reported jumps between 15–20% in their rates
  • Residents: Takeaways
    • COVID-19 bivalent vaccination rates are the same or higher than when the program started, similar to flu rates
    • Working on implementing structured processes and procedures, as well as standing orders
    • Working on reminders, recall, and prompts and integrating those into their workflows
    • Working on routinizing offerings, expanding what vaccines they are providing
    • Billing for Tdap and shingles remains a big challenge for skilled nursing facilities
    • Some facilities are hesitant or cannot bill for Medicare Part D

Staff

Facilities can tailor the approach that works best for them. For example, have been using staff incentives to get movement.

  • Staff: COVID-19 Vaccination Rates
    • Concerns about staff shortages have contributed to low rates
    • All facilities are struggling with COVID-19 booster rates
  • Staff: Influenza Vaccination Rates
    • Seeing success in increasing influenza rates with the increasing accessibility of vaccines, such as rounding units instead of only offering vaccines during specific clinics
    • Vaccine fatigue spilling over into influenza vaccine
  • Staff: Hepatitis B Rates
    • Lack of data on prior staff vaccinations
    • One facility had great success with groups of peers in housekeeping, kitchen staff, etc., meeting and providing education
  • Staff: Takeaways
    • Vaccines are being made more accessible
    • Accessibility, information, and awareness aren’t the challenges
    • Going to be focusing on providing direct support to help leaders build peer champions and trust with their staff
    • More convenient scheduling to get the vaccines is an option, which will lead to better reminding to get the vaccine
    • Staff often become more resistant the more a vaccine is offered, so backing off and focusing on trust-building may be helpful in some cases
    • Removing staff cost from getting vaccinated is important
    • Using pieces from the American Healthcare Association

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Questions
  • Q: There is a lot of vaccine fatigue on the part of not just staff, but also administrators. Have you come across any strategies to help mitigate or alleviate this kind of fatigue?

    Elizabeth Sobczyk: The best that we have been able to come up with in instances where it’s really pushing people away from vaccination is to back off a little bit and to give some space to and time to breathe. Focus on other things for a little bit. I think the big issue is around staffing and recognizing that healthcare workers are being worked to their limit. A lot of workers have left the LTC space in the last couple of years, and not many new ones have come in. Celebrating successes is always a great way to employ those motivational techniques. It’s a small place to start having a sense of community and camaraderie. A sense of common purpose and common goal is another thing that one of our group speakers talked about.

    You can find summaries on our website as well as for our group speakers. Joanne Reeves Synder spoke about the behavioral economics side of this and how to encourage that sense of common purpose and goal, encourage small wins, and overcome exhaustion to bring people together. Really, we need to give permission for people to back off.

     

    Q: We have seen a significant decrease in flu vaccination of pregnant women this year. Do you see that spilling over into LTC facility workers and COVID-19 vaccines?

    Hannah Reses: In the NHS data we have seen decreases in influenza vaccination among healthcare workers across most facility types during and throughout the COVID-19 pandemic. We weren’t sure which way it would go. We thought we might see more emphasis on vaccination and increases in influenza as they were receiving COVID-19 vaccines. But it seems we are mostly seeing decreases compared to prior years before COVID-19, and we don’t yet have this current flu season data. This is the first year that flu vaccination and healthcare workers in nursing homes were required to be collected, so we can’t compare to past seasons, but we will soon be able to look at the data for the season.

     

    Q: In our state, our adult flu vaccination rates are not great, except for the age 65+, which is far and above the other adult age groups. Wondering if you can comment on this at a national level.

    Carla Black: This is true nationally, as well, and has always been true. Since we have been monitoring coverage, the coverage is highest in age 65+. The season immediately following the pandemic, we saw an increase in overall coverage, which was almost solely among the age 65+ group. We did not see increases in those under age 50. That group, on average, has a lot more healthcare visits than younger adults, especially since the pandemic. Since this flu season is getting back to prior year’s influenza activity and virus circulation, I think that resonates more with older adults or with providers who treat older adults.

    Carolyn Bridges (Immunize.org): We have been discussing vaccine payment for a long time for those age 65+ and how vaccine costs are a barrier. So, payment for COVID-19, influenza and pneumococcal vaccine have not been an issue for Medicare Part B and now we have changes in Medicare D removing copayments/cost sharing for all other vaccines.   o I’m sad to hear that if someone is in a long-term care facility or an acute care facility, they can’t get payment for a Part D-covered vaccine. That is just another complication in getting vaccines paid for and removing the cost of the vaccine.

    Elizabeth Sobczyk: Some people that switch over to Medicaid payment have challenges. It’s that 100-day stay or if it gets extended there are challenges, and it shouldn’t be that way. We haven’t found anyone who’s willing to step up at this point to give specific guidance that says you can get coverage for vaccines during a 100-day stay.

    Carolyn Bridges (Immunize.org): If someone is contracting with the pharmacy to do some of the immunizations, are the pharmacists able to bill Part D for the immunization while they’re in a Part A stay?

    Elizabeth Sobczyk: The reason that we found out about this was that long-term care pharmacies identified that they were getting some claw backs from COVID-19 and flu vaccines where they have been given to people who were in their Part A stay, so that doesn’t solve the problem. That’s who identified the problem for us, and not only have there been claw backs but they were denying the claim. CMS was taking back money that they already provided for the administration for those vaccines.

     

    Q: Do you know where people are getting their flu and COVID-19 vaccines? Has that changed from previous years?

    Carla Black: We assess that information for flu vaccines on the BRFSS every three years. If you go back to the FluView website, you can see that information. Looking at it now, in the most recent season, 2020–2021, for those age 65+, about 45% have gotten the flu vaccine at a pharmacy and a little over 50% in physician offices. Compared to the 2017–2018 season, only about 35% got the vaccine in the pharmacy and about 60% in a medical office. So, since the pandemic, it does seem like it’s changed to pharmacies. We do not have the data for the COVID-19 vaccine, I don’t believe.

     

    Q: Do you know if there is an increase in the proportion of adults age 65+ that are getting one of the preferred vaccines, the high dose or adjuvanted or the flu block?

    Carla Black: I do not have that information.

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