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A summary of presentations from the weekly Summit partner webinars

January 25, 2024 – The latest Summit Summary

PANEL PRESENTATION – Three speakers: Lisa Foster (AVAC), Rachel Banks (NAFSA), and Jennifer Serling (Appalachian State Univ. Veterinary Technology Program)

Influenza Surveillance Update – Alicia Budd (CDC)

Alicia Budd, MPH, Influenza Division, CDC, gave an update on influenza surveillance through January 13, 2024.

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Outpatient Respiratory Illness (See: FluView)

  • Influenza-like Illness (ILI), fever plus cough or sore throat
  • Two weeks of decline in all age groups through the last week
    • Peak was less sharp in those aged 5–24 years

Outpatient Respiratory Illness Activity by Jurisdiction 

  • Eight jurisdictions have very high activity and 17 have high activity
  • Slightly better than last week

Virologic surveillance

  • Influenza positive tests as detected in Clinical labs
  • While the number of positive specimens have been declining, we are seeing a leveling off
  • Influenza positive tests as detected in Public health labs
  • Majority of samples were influenza H1
  • Some influenza B was also detected
  • Influenza AH3N2 viruses are circulating
  • All viruses are antigenically similar to the vaccine reference viruses

Hospitalization

  • Looking at NHSN hospital admissions across country
  • There has been two weeks of declining activity
  • Lower currently than at this time last year
  • Lower currently than at this time for a couple of seasons
  • Highest rates in those age 65 and older, followed by age 50–64 years, and age 0-4 years

Mortality

  • National Center for Health Statistics looking at the percent of death certificates that have flu coded as a cause of death
  • One week of decline
  • Influenza-associated pediatric deaths
  • 47 deaths so far this season

Summary

  • There have been two weeks of decline in key indicators, however we are still watching for possible post-holiday increases
  • Influenza activity remains elevated
  • Outpatient respiratory illness has been above baseline nationally since November and is above baseline in all 10 HHS Regions
  • Influenza A(H1N1) is still the predominant influenza virus circulating although influenza A(H3N2) and influenza B viruses are also being reported
  • CDC estimates that there have been at least 16 million illnesses, 180,000 hospitalizations, and 11,000 deaths from flu so far this season
Questions

Q: Is there any thought about CDC trying to equate some of the hospitalization as well as illnesses into the cost to the healthcare system?

Alicia Budd (CDC): We have to talk with our team who does a lot of our modeling work. Certainly, we look at vaccine and averted burden and things like that. Some of the economic pieces could be related to all of that, so I don’t have enough data for you right now. It certainly is an interesting idea, and I could find out if others have that in process at the moment.

L.J Tan (Immunize.org): With this potential post-Christmas peak, I want to make sure I’m correct when I say this, is that because of disease that people caught during the holiday period? It doesn’t account for the fact that we typically have B type that comes in spring?

Alicia Budd (CDC): Right. This sort of post-holiday increase is not what I usually think of when I think about a second wave of activity. That second wave of activity, for many years, we have seen things change around there, but typically that’s where you think about a different flu virus, one of the ones that was circulating at lower levels early on. It takes off later in the year. You’re right; that’s different than this post-holiday, which really comes down to kids being out of school for two weeks and not sharing viruses with each other. It slows things down and then it takes off again so it’s two different phenomena.

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PANEL PRESENTATION – Three speakers: Lisa Foster (AVAC), Rachel Banks (NAFSA), and Jennifer Serling (Appalachian State Univ. Veterinary Technology Program)

Vaccine Coverage & Access Landscape: Opportunities & Challenges – Lisa Foster (AVAC)

Lisa Foster, Manger, Adult Vaccine Access Coalition (AVAC) gave a presentation on the vaccine coverage and access landscape and opportunities and challenges.

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Adult vaccine Access Coalition (AVAC)

  • Established in 2015
  • Goal is to leverage the opportunities within federal policy space to increase access and improve utilization of vaccines among adults
  • Diverse group of healthcare providers and innovators, over 70 public health organizations, and patient and consumer groups
  • AVAC: Our Membership

Barriers to adult immunizations

 Vaccine Coverage Landscape

  • Private insurance – Routine vaccines covered
  • Other forms of coverage look to the ACIP to provide direction around who should and shouldn’t get a vaccine, and when they should get it
    • ACIP has a great deal of influence on coverage decisions

Private Sector

  • Affordable Care Act (ACA)
    • Expanded access to healthcare as a whole
    • In 2010, made insurance available to millions of Americans
    • 21 million Americans have purchased insurance
    • Expanded Medicaid program to cover all adults with income below 138% of the poverty level
    • Part of the ACA (Sect. 2713) says health plans need to provide vaccines with no cost sharing (copayments, deductibles, or co-insurance)
      • Vaccines recommended by the ACIP for routine use are covered under this section (child/adolescent or adult immunization table)
      • No travel and occupational vaccines (which remain subject to cost-sharing)

Medicare and Medicaid

  • Inflation Reduction Act (IRA)
    • Medicare – sec. 11401: eliminates copays and out of pocket costs for ACIP-recommended vaccines
    • Medicaid – sect 11405: requires coverage for ACIP-recommended adult vaccines in traditional Medicaid and CHIP programs
  • Medicare
    • Previously
      • Part B
        • Covered flu, pneumococcal, hepatitis B vaccines at no cost Added coverage of COVID-19 during the pandemic
      • Part D
        • Covers all other vaccines with cost-sharing
      • Now
        • In January 2023, all adult vaccines recommended by CDC/ACIP are now available under part D at no cost
        • Vaccines include: shingles, Tdap, RSV, future vaccines
      • CMS specifies:
        • “adult vaccine” and “vaccine for use by adult populations” means all ACIP recommended vaccines including those based on shared clinical decision making (such as RSV vaccine) are covered
        • Limited population circumstances: traveling vaccines, vaccines needed for employment are covered
      • Medicaid

Vaccine coverage landscape: a few bumps along the way

  • Lack of consistency in interpreting the regulations and so some plans adopt a narrow interpretation of ACA limiting vaccine coverage with no cost sharing to only ACIP- recommended vaccines on CDC child/adolescent or adult immunization table.
  • Consistent coverage in how approaching vaccines is needed
  • ACA granted plans a year to implement new vaccine recommendations
    • Resulting in coverage delays for new RSV vaccine
    • Some plans are imposing cost-sharing with vaccines needing shared clinical decision making

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Study Abroad and Vaccine Coverage – Rachel Banks (NAFSA)

Rachel Banks, MPIA, Senior Director, Public Policy & Legislative Strategy from NAFSA, the Association of International Educators, gave a presentation on study abroad and vaccine coverage following the pandemic.

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 U.S. Overseas Travel Rebounding

  • In 2023 U.S. Dept. of Commerce reported 41 million overseas travelers (31.5% increase over prior year)
    • Doesn’t include travelers to Mexico or Canada (that would increase the number to around 100 million travelers)
    • Returning to pre-pandemic levels
  • In the academic year 2021–22, almost 189,000 U.S. college students studying abroad (54% of pre-pandemic total of 347, 000 students in 2018–19 academic year), and continuing to climb

U.S. students studying abroad, 1989–90 through 2021–22

  • Study abroad plummeted during pandemic (by 91% at the height of the pandemic)
  • Participation is quickly rebounding; increased by 188,753 students (113-fold increase of 1,197%)

Leading destinations of U.S. study abroad students during academic year 2021–22

  • Europe traditionally top destination with 73% of U.S. abroad students
  • Outside of Europe, Costa Rica and South Korea most popular destinations
  • Other top destinations during academic year 2021–22
    • Mexico
    • Israel
    • Ecuador
    • South Africa
    • Peru
    • United Arab Emirates
    • Argentina
    • Belize
  • Anticipate other destinations to rebound as they become more accessible to students post-pandemic

Study abroad health and safety

  • S. colleges and universities play a role in ensuring the health and safety of students traveling abroad
  • Want more U.S. students to pursue study abroad (particularly outside of Europe) prior to graduation
  • Cost burden of travel vaccines can be deterrent

Example: Ghana

  • Pre-pandemic 2018–19 year had 2,000 U.S. students
  • Number two African destination behind South Africa
  • Requires a Yellow Fever vaccine (among others), which costs around $200
  • Covering vaccine costs will increase access and equity in study abroad

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Rabies Vaccine Requirements in Veterinary Medicine – Jennifer Serling (Appalachian State University Veterinary Technology Program)

Jennifer Serling, , President, Association of Veterinary Technician Educators, Interim Director, Appalachian State University Veterinary Technology Program, gave a presentation on rabies vaccine requirements in veterinary medicine.

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Risk to Veterinary Medical Professionals

  • CDC listed vet processionals as a risk three category for the rabies virus compared to the general population
  • Pre-exposure rabies vaccine: 2-dose PrEP schedule has replaced the 3-dose PrEP schedule in 2022 to protect for up to three years
    • Following the pre-exposure doses, titers are done to determine the effectiveness and whether a booster is necessary
  • Rabies is 100% fatal and symptoms do not always show up immediately

American Veterinary Medical Association (AVMA) requirements for veterinary technician programs

AVMA Committee on Veterinary Technician Education and Activities (CVTEA) requires:

  • Students to be vaccinated for the rabies virus before they are allowed to handle live animals
  • Delay in vaccination can cause issues to graduate on time
  • Aren’t able to incorporate the costs into tuition so cost is falling on students
  • Most insurance companies deny the vaccine
  • Mitigation program elect for mandatory vaccination requirements
  • Need to add ACIP recommended vaccines for occupational health
  • CVTEA accreditation policies and procedure: https://www.avma.org/education/center-for-veterinary-accreditation/committee-veterinary-technician-education-activities/cvtea-accreditation-policies-and-procedures-appendix-a

Prophylactic vs post-exposure costs

  • Prophylactic cost without insurance
    • Two-dose series at average of $400/vaccine
  • Post-exposure cost without insurance
    • Cost on average $3800 plus hospital fees and wound care

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Questions

Q: If your state didn’t expand Medicaid, when will the no-copay benefit kick in?

Lisa Foster (AVAC): That’s one of the areas that is still a gap in coverage and is one of the things that AVAC is working on. The CDC has the Bridge program. I think we learned a lot with COVID-19 regarding a number of people who don’t have access to insurance at all, which is a totally different issue than what we’re talking about today, but it’s something that our coalition is working on. We are trying to make sure that those who do not have insurance at all have access to vaccines in an equivalent way to those who do have coverage. One of the things I was just thinking about is that if someone is on Medicare and is a veterinary technician, they should presumably have access to the rabies vaccine, but somebody with a Blue Cross Blue Shield plan will not and it does not make sense. I think it is great that CMS was clear in their interpretation on the Medicare and Medicaid side, but we really do need to go back and fix the ambiguity that happened on the commercial side back in 2010. You know as we come out of this pandemic world, we want to be able to encourage people to pursue careers that they want to pursue or travel where they want to travel. We are in a unique time where we have so much to be grateful for in terms of coverage and while we do still have these nuances around certain states that did not expand Medicaid, we have populations there we need to help. We have new vaccines coming that certain plans might be covering right away, and then other plans are saying they will take their time until recommendations are published. These are good problems to have and they are very solvable problems.

 

Q: For those that have Medicare Advantage plans and do not have Medicare Part D, how do they get RSV vaccination covered?   

Lisa Foster (AVAC): It should be covered without cost sharing and Medicare Advantage is covered by the same rules as Medicare Part D. Some plans have been slower than others to get the word out to providers, but it should be covered under Medicare Advantage in the same way it is covered under a free-standing plan.

L.J Tan (Immunize.org): The reason you would be having some transitional challenges is ibecause plans are dragging their feet a little bit. That is something AVAC has already pointed out that they are working on.

Lisa Foster (AVAC): Different plans are taking different strategies. Some plans are very proactive in terms of making sure that their subscribers know that new vaccines are available and making sure that the providers can provide the vaccinesg. Other plans are saying CDC has not published their MMWR yet so they are going to wait until those recommendations come out until they change their plan rules. It varies tremendously by plan sometimes. That is a challenging thing to deal with at a federal policy level. I think highlighting these issues and making sure that people are aware that these immunizations should be covered is important.

 

Q: If you only have Medicare A and B, are non-preventative vaccines available to people with that coverage?

Lisa Foster (AVAC): If we are talking about basic vaccines and you have Medicare Part B, the vaccines covered are influenza, pneumococcal, and in some cases hepatitis B if you are at a high-risk population. Those are the ones that are written into the law, and other vaccines are covered under the pharmacy benefits under Part D. To my knowledge, Medicare Part A does not cover vaccines specifically, which has its own challenges. That is certainly another area where there can be gaps for Medicare populations.

 

Q: Doesn’t private insurance have one year to provide coverage for new ACIP vaccines?

Lisa Foster (AVAC): The law says that plans have a year to adjust their coverage to accommodate for a new vaccine recommendation. I think the challenge that we run into today is that with the pandemic, at least in the adult space, people became much more attuned to ACIP. I do not think most people even knew what that acronym stood for before COVID-19. Those people are eager to get vaccinated against RSV and different conditions. When they hear we have a new vaccine for RSV or shingles they want to go out the next day and get vaccinated but there are a lot of things that need to happen on the provider side, and plans also need time to be able to adjust their coverage to accommodate the new vaccine recommendation to be able to work with the providers and their networks. The Affordable Care Act did give plans a year to cover vaccines. On the positive side, I would say several plans have embraced the benefits of vaccination and understand the savings that vaccines do represent from their standpoint as well. If they can make sure that their subscribers are vaccinated, they are going to avoid having to pay healthcare cost in terms of hospital visits or doctor visits or medications to help treat the symptoms. I think a lot of plans have been more proactive in incorporating vaccines into their plans more quickly, but yes, by statute they do have a year to be able to make those adjustments.

 L.J Tan (Immunize.org): A comment: Texas’s Adult Safety Net program only covers hepatitis A, hepatitis B, Meningococcal, MMR, Tdap, and TD, and excludes those with Medicare or Medicaid. So huge gaps for us.

Lisa Foster (AVAC):  I think we are hoping that if we can get a robust uninsured adults program off the ground at the federal level, that can help fill in those gaps at the state level in different states, depending on what their populations look like or what their current programs are able to cover. It is something that we are actively working on.

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Announcements
  • Please put on your calendars that the Summit in person meeting has been moved to August to accommodate the National Immunization Conference (NIC), which is being held in Atlanta, GA, on August 12–14. The Summit in person meeting, focusing on operationalizing adult immunizations, will be held August 15 (full day) and August 16 (half day). Stay tuned for further information.
  • The Summit workshop developed tools to address challenges in providing multiple adult vaccines along with COVID-19, flu, and RSV vaccines. See the Summit’s Operationalizing Adult Immunizations in the 2023 Fall Season and Beyond Workshop web page for the deliverables.
  • There is a new zoom link for the Summit meetings for 2024. If you do not have the new link, please contact info@izsummitpartners.org.
  • If you have agenda items you are interested in sharing with the Summit, please tell us and we can add you to an upcoming call as a speaker or panelist. Contact information: info@izsummitpartners.org

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