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A summary of presentations from the weekly Summit partner webinars

June 6, 2024 – The latest Summit Summary

American Academy of Pediatrics, Flu Vaccine Plans Update – Jesse Hackell, MD, FAAP, American Academy of Pediatrics

Jesse Hackell, MD, FAAP, Chairperson, Committee on Practice & Ambulatory Medicine, American Academy of Pediatrics, gave the update for flu vaccine plans.

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Pediatric Influenza Vaccination: Challenges & Opportunities
Pediatricians have ordered vaccines for the coming influenza season. Most order in February for arrival at the start of season in late summer. This year there was concern among pediatricians regarding how many doses to order, the variable return policies of manufacturers, communicating the change from quadrivalent to trivalent vaccine to their patients, and uncertain demand for vaccination.

Influenza will be part of the CDC’s respiratory disease plan this year, so pediatricians are expecting more input from that agency, from the ACIP meeting in June 2024, and from a statement from the AAP that will be released before the vaccine arrives.

Influenza Vaccine Coverage for the 2023–2024 Season
Influenza vaccine uptake has been on a steady decline since the 2019-2020 season, when it was 60%. This year the coverage is about 53% nationwide, which is 2.2% lower than it was in the 2022-2023 season and 9% lower than pre-pandemic.

  • For the 2023–2024 season, offices have struggled to reach a 60% acceptance rate, perhaps in part owing to offices not dismissing patients who refuse the vaccine, and/or the variable track record [for vaccine effectiveness] of the influenza vaccine.
  • Also, for 2023–2024, there was a drop in every ethnic and racial group except the Hispanic population. Even though that may be a fluke, there is a need both to consider the role outreach plays in vaccine uptake among various populations and to gather more data about messaging in order to tailor communications in the future.
  • Also, for 2023–2024, data show that children who live in rural areas have an almost 19% lower vaccine uptake than children living in non-rural areas. This is a dramatic difference and raises questions about the reasons: differences in access, attitudes (perhaps driven by politics), or something yet unidentified.
  • Also, for 2023–2024, intent to vaccinate surveys showed the steady conversion of intent to vaccinate to becoming vaccinated, but also an increase in the number of people who definitely will not or probably will not receive an influenza vaccine.
    • The data also show a segment of the population that have an intent to vaccinate but do not follow through, which highlights the potential of offering the vaccine during an existing appointment (“Let’s do it now”) to help people follow through on their intention.
  • There were 164 influenza-related pediatric deaths as of the end of May, for the 2023–2024 season. It’s a slight but probably not statistically significant decrease from last season.
    • About 80% of influenza-related pediatric deaths occur in children who are not vaccinated, a statistic that can help in conversations with parents who are deciding whether to opt for vaccination. However, it is of concern that, because 20% of influenza-related deaths occur in children who have been vaccinated, there can be an argument that the vaccine is not foolproof and, therefore, not worth getting.
    • It is important to message the improved odds and potential to reduce the most severe outcomes.

The challenges faced in achieving pediatric influenza vaccination are multi-factorial.

  • There are logistical barriers, such as transportation, work schedules/time off needed to take a child to get vaccinated, and missed school.
    • It is important to ensure that providers are available to vaccinate whenever possible; every visit to the office should be an opportunity to vaccinate.
    • Mass vaccination events, where even families and adults can receive vaccines, are helpful, although they require extra staff.
  • There are vaccine complacency challenges. For many people, influenza does not seem to be a big threat, in terms of severity. It is important to continue to remind people that severe and even fatal outcomes are possible.
  • There are practice-level administrative burdens, such as cost, storage and handling, and staffing shortages.
  • There are vaccine confidence issues and safety concerns.
    • There is an overall resistance to vaccines. For example, there has been a small but significant drop in receipt of the measles vaccine over the past couple of years, which could be related, in part, to the politicizing of the COVID vaccine and political attitudes about resistance and individual rights to choose whether to receive vaccination.
    • As a result, the country is currently at risk of falling below protective levels of 95% vaccine uptake for measles.

There are several opportunities available to achieve higher influenza vaccination for children.

  • In February 2024, the AAP pushed out a clinical report on strategies to improve vaccine communication and uptake.
    • The report includes information on the scope and impact of vaccine hesitancy or refusal for children, families, and society.
    • It includes a discussion of parents’ concerns and the latest evidence about effective conversation techniques to build vaccine confidence and mobilize trust.
    • Pediatricians are still the most trusted resource for families about their children’s health.
    • The report has reference material for learning/training on these learnable techniques to address concerns to increase uptake.
  • The AAP is performing outreach with trusted messengers to reach under-resourced communities, including rural, urban, healthcare deserts, etc.
    • Resources are available in many languages.
    • The AAP maintains this information on an open website that does not require login or membership: https://www.aap.org/influenza. The website includes tools and resources to support pediatricians in providing and promoting influenza vaccination.

QUESTIONS

Q:We are hearing that clinicians are sending patients to the retail space, but the data shows that retail vaccination is also down. This tells me that those patients that are sent to go get the vaccine at retail settings are not getting the vaccine. The fact is those groups don’t have the staffing to handle the shift from the traditional provider setting to retail. What message is being sent to providers to prevent this from happening this upcoming season?
Jesse Hackell (AAP): Well, we’re not seeing a whole lot of it in pediatrics. And one of the reasons is that every state has different regulations in terms of who can vaccinate children, specifically, when you’re talking about retail sites and retail pharmacies. Many states don’t allow vaccination of the youngest children – if you’re talking about teenagers and 16-year-olds, absolutely, they can get the vaccine in the retail setting. But once you’re stocking it in your practice for 6-month-olds and 2-year-olds, you have it available for everybody. We would not dissuade somebody who says, “It’s easier for me to go to the pharmacy and get it instead of coming to your office.” But most practices who stock the vaccine will vaccinate all comers, and some of them will even vaccinate adults if they happen to be there at the time. The only issue we do run into is sometimes the pharmacies receive their vaccine stocks well before the pediatric offices do and, in the interest of getting kids vaccinated and not missing an opportunity, if it’s available someplace, we encourage parents to get it where it’s available.

Q:Do you have a sense about why the flu [vaccination] rates are going down? Is it vaccination fatigue? Or are you getting a lot more refusals from parents? What do you think is responsible for the 3 to 5 percentage points decline, depending on which state you look at?
Jesse Hackell (AAP): I think that the decline that we’re seeing is in a group of parents who were not strongly committed to vaccination in the first place, and I think this is a group of parents who are uncertain, who may have concerns about safety or efficacy or necessity, and who may be swayed away from vaccination based on the amount of discussion that you see in the press and on social media. We know that there are populations who are ready to get their children vaccinated as soon as it’s available, and we know that there’s a population who will not, under any circumstance. And it’s the ones who are in the middle who may need that extra push from their pediatrician who we are having trouble reaching. That’s the population of people who in surveys are ‘probably going to get vaccinated.’ And yet, week after week, they just have not done it. And again, I think that’s the population that we should be reaching out to and is probably the easiest group of parents to impact. But I think that when your commitment is less strong, it’s easier to be swayed by an opposing opinion or an opposing story, or by misinformation or disinformation.

Q:Regarding the challenges that you talked about in terms of the administrative burden, is there anything that you are recommending in terms of actions or solutions to practices that are having those kind of administrative logistical burdens, whether it be staff, whether it be having to speak too long to parents trying to convince them to get vaccinated, or some of the other things that you might have mentioned?
Jesse Hackell (AAP): Well, you know, that’s nothing new. We’ve had these discussions. I can say that easily 75% of the of parents that we see accept our recommendations about vaccines and go ahead and vaccinate, and maybe 2% or 3% absolutely, adamantly refuse. So you’re dealing with, you know, just under 25% of parents who do require more discussion, more interaction in order to get them to accept the vaccine. So it’s small, it’s not your entire practice. It’s a quarter of your practice who you must spend the extra time with. We encourage practices to understand what parents’ concerns are, to discuss with them why they are hesitant and why they’re concerned. Because, again, each parent is concerned for different reasons. It’s important that we validate their concerns and that we work with them to understand how to address the concerns, and assure them on how the entire process of vaccine development and testing and licensing works to make sure that vaccines are safe and effective. And you know, explaining this to parents goes a long way to helping to relieve their concerns. We have to work to combat the misinformation and disinformation as well. And these are time consuming conversations. There’s no getting around that. One thing that we’ve seen recently is recognition, at least by state Medicaid plans, that this does require time, and it has become a payable service now for pediatricians in many states. You know we did it for years without getting paid. Getting paid a little at least recognizes the time that’s involved in it. But you know, this is what we do. We immunize kids because it’s important to protect their health. It’s a big part of pediatrics, and I think anybody who’s in that field understands that this is a time expenditure that they simply need to have.

The vaccine fatigue is another issue, and while it affects parents, it also affects pediatricians. When we talk about the COVID vaccine, we’ve had so many refusals that I know many colleagues have stopped mentioning it at all. I don’t think we’re there with the flu vaccine and I don’t want to see us get there, and that’s why it’s important to have the conversations and to bring parents along.

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National Association of Community Health Centers White Paper Update – Sarah Price, MSN-Ed, RN, National Association of Community Health Centers

Sarah Price, MSN-Ed, RN, Director, Public Health Integration, NACHC, gave the update on challenges and emerging policy solutions for adult immunizations.

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Challenges and Emerging Policy Solutions for Adult Immunization: A Post-Pandemic Updated White Paper
In 2019, the National Association of Community Health Centers (NACHC) developed a white paper focused on strategies to address policy barriers that was widely disseminated.

  • With funding from the CDC and others, the NACHC has been running learning communities, Sprint Working Sessions, and more, with more than 90 health centers since 2019 to address barriers to adult immunization, including seeking information on people, processes, technology, and policy.
  • In 2024, the NACHC released an update to the white paper, focused on strategies to address policy barriers to adult immunization in federally qualified health centers (FQHCs).

The Updated White Paper
The update has six sections, and each section begins with information/context and then provides strategies for that area. The updated white paper can be found at https://www.nachc.org/topic/adult-immunizations/.

  • What makes FQHCs unique – FQHCs target the neediest individuals, offer a broad range of care, turn no one away, and are community-based and governed.
  • Statutory and HRSA Requirements on FQHCs – Barriers to immunization include adherence to government requirements, incentivization of immunization of children who are considered patients of an FQHC, annual reporting requirements, and under-reporting. Solutions include adding a composite measure for adult immunization to data reporting, incentivizing adult immunization as well, considering performance as a part of grant funding or recognition, and increased outreach and support.
  • Federal Torts Claims Act – Barriers include lack of information about FTCA coverage. Solutions include various malpractice coverage possibilities.
  • Medicaid – Barriers include issues around payment, and billing and administrative efforts that have a financial impact. Solutions include making nurse/pharmacist immunization “billable visits” and permitting FQHCs to bill for immunization-only visits outside of the FQHC PPS.
  • Medicare – Barriers include the challenge that the cost of most immunizations are already capped in FQHC’s PPS rates and Medicare reimbursement for influenza and pneumococcal vaccination can take too long. Solutions include the removal of cost sharing through the Inflation Reduction Act, maximizing nurse/pharmacist visits for vaccines for Medicare patients, and using certain permissions to reduce delays in reimbursement for certain vaccines.
  • Pharmacy – The barrier is the lack of information on the role of the pharmacy in immunization. The solutions include the exploration of the role of in-house and clinical pharmacists.

Some Practical Applications of the Identified Policy Strategies in the Field

  • Enhancing the scope of practice of pharmacy technicians
  • COVID-19 commercialization
  • Inflation Reduction Act – coverage of Shingles vaccine and other offerings

Some Suggested Applications of White Paper in the Field

  • Grounding and education
  • Partnerships
  • Advocacy

QUESTIONS

Q: You may cover this, but what is an "FQHC look-alike"?
Sarah Price (NACHC): An FQHC look-alike is not funded in the same way as a regular FQHC and they don’t necessarily sit under all the requirements of Section 330 under HRSA, but they often offer the same services or similar services. They don’t have to report the same way the FQHCs do but, generally, they’re driven by the same mission. They are in the community and can be supported by a lot of different sources of funding; Section 330 from HRSA is not their main source of funding, but their mission is generally the same.

Q: Is there a role for someone, maybe from NACHC as a national leader, to figure out short, medium, and long-term approaches to tackling those solutions, because there were many of them and not all are easily done? Have you thought about how to implement this and how some of the Summit partners might be able to join you to do some of that work?
Sarah Price (NACHC): Absolutely. Some of the work is already starting. We work with AVAC a lot. We have been doing some Congressional meetings with them, mostly just to inform. The white paper is being passed around Congress as we speak, which is also great. NACHC has worked on immunizations in the past. I’ve only been there for 6 years, but it’s been my baby for 6 years and I feel like we’re finally at a really good spot where we’ve turned over every rock and said, “What’s going on here? What are the people, processes, technology, and – now – policy?” I think we’re at a great time to dive deeper into that. I think the Summit is a great source for that because all of you probably have some ideas and solutions. And we would be totally open to looking at some short-term…what we can do. We can’t take it all on, and some of it really is a CMS change or a HRSA change – those are bigger. But, even making a small impact here and there, we would love to partner on that.

Q: Regarding the adult composite measure, how might that work for CHCs and how does that fit into the uniform data system that’s at HRSA?
Sarah Price (NACHC): We think it would allow for a better kind of pre-preventive health measure, rather than just someone getting a Tdap or just someone getting the flu [vaccine] is not the whole picture. So, we also understand that it would be a burden to health centers for those that have to refer a lot of those out. So, are we sure we really want to ask for that? It’s wonderful care, great care, but do health centers have the access/capacity to do that. If we ask for that composite measure, it would be a reporting burden. One of the things that we have been doing, especially the last 2 years, is building the data capacity of health centers to know how to pull immunization data. It’s not just, “Let me look in my EMR for every flu vaccine;” there are standard codes. I’m not an informatist, I’m not even pretending to be one, but our informatics team, per se, has built an entire data dictionary to help health centers be able to do that. So, we’re kind of on the cusp of that and, in some ways, even if it’s not an official composite measure that you have to report out, some health centers are doing it anyway, for themselves. They’re saying, if someone has diabetes, let me make sure they’re fully immunized, and the centers may be getting and doing their own composite measures, anyway. So, we know it’s possible.

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Announcements
  • The Respiratory Viral Season Webinars on May 16 and May 23, 2024 are now up on the Summit website (IZSummitPartners.org), including recordings and the slide decks for which NAIIS received permission to share. The notes from the Q&A portions of those webinars – questions and answers from the panelists – are also posted there.
  • The National Adult and Influenza Immunization Summit in-person meeting on August 15-16 at the Marriott Marquis in Atlanta, GA is now full.

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