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A summary of presentations from the weekly Summit partner webinars

September 19, 2024 – The latest Summit Summary

Seasonal Influenza Updates – Alicia Budd, MPH, Influenza Division, NCIRD, CDC

Alicia Budd, MPH, gave an update on recent influenza activity.

Seasonal Influenza Updates
The updates for influenza included flu activity over the past season, with a focus on summer 2024, along with updates on activity in the Southern Hemisphere and updates on the highly pathogenic avian influenza (A H5). Information about flu vaccine recommendation changes and the monitoring of influenza activity going forward was also provided.

Influenza Activity

United States: 2023-2024 Season
- By May of 2024, the height of the season had passed and the percent positivity for influenza had decreased to inter-seasonal levels, where they remained through the summer across the country.
- For the summer, activity was predominantly H1 and H3, with very few influenza B viruses identified.
  - The regular flu season was predominantly H1, with a little more H3 and influenza B activity showing up towards the end of the season.
- Both genetically and antigenically, the circulating viruses were similar to the vaccine reference viruses. Also, for anti-viral susceptibility, very few viruses showed any reduced inhibition or susceptibility.
- Typically, the majority of novel influenza A viruses in the United States are variant viruses. However, this year, influenza A H5 viruses are the majority of novel influenza A viruses. (Variant viruses such as H1N1, H1N2, and H3N2 have also been scattered across the country this year.)
- The Outpatient Influenza-like Illness Surveillance Network (ILINet) system has historically been used for flu surveillance, although it is not flu specific. ILINet monitors visits for a syndrome of fever plus cough or sore throat.
  - The virologic data from the National Respiratory and Enteric Virus Surveillance System (NREVSS) shows relatively low percentage of visits for influenza-like illnesses, although an increase – primarily in pediatric age groups – has begun. These increases were associated with rhino enterovirus and COVID-19, although those infections seem to be decreasing. So, it is likely that increases in respiratory illness may be driven by something other than influenza.
- Discharge diagnoses for influenza from emergency departments also shows a typical season; and across all age groups, flu discharge diagnoses were very low throughout the summer.
- Hospitalization data also shows low influenza rates throughout the summer, with the highest rates of hospitalizations for influenza in those 65 years of age and over.
- For mortality surveillance, based on data from the National Center for Health Statistics’ death certificates, and the influenza-associated pediatric mortality system, there has been low mortality despite a robust flu season.
- Flu activity, and the timing of it for 2023-2024, was within the range of the flu seasons pre-COVID-19, and it is the first time that has happened since COVID-19 emerged. This suggests that for the 2023-24 season, the levels and the timing of influenza were back to normal pre-pandemic ranges.
- Burden estimates, based on mathematical modeling using data from the surveillance systems, show that illnesses, hospitalizations, and deaths for the 2023-2024 season fall within the range that had been established from 2010 to 2023. Therefore, the severity of the 2023-2024 season was classified as moderate.
Southern Hemisphere: Summer of 2024
- Based on data reported by countries in the Southern Hemisphere to WHO, the timing and intensity of influenza activity is back within the pre-COVID-19 range, as well.
- There has been a mix of H1 and H3 viruses in the Southern Hemisphere, along with a little bit of influenza B.
- Although most Southern Hemisphere countries reported H3 viruses as most common, the one significant exception was South Africa, where H1N1 viruses were predominant.
- Southern Hemisphere countries, with an April to September season, can give a sense of the upcoming season in the United States. However, this is not a definitive predictor because there are different predominant viruses, different levels of herd immunity, and different populations. Also, the lack of predominant trends makes predictions based on these data virtually impossible.
Highly Pathogenic Avian Influenza (A H5)
- In late March 2024, USDA confirmed the first H5 infection in a dairy cow; now, more than 200 farms across 14 states have confirmed infection in dairy herds.
- Although this has been primarily an outbreak among animals – dairy cows, poultry, wild birds, and other mammals – there has been spillover into humans.
  - 14 cases in humans have been identified in 2024; one case was identified in 2022.
  - Of those 14 cases, 4 are associated with dairy cattle exposure, 10 with poultry exposure, and 1 with no known animal exposure.
    - With all but the case with no known animal exposure, the illnesses were mild, without hospitalization, and followed by recovery. In the one case with no known animal exposure, there were underlying medical conditions and hospitalization, but ultimately ended with patient discharge and recovery.
  - All H5 cases in humans have been investigated and, to date, no human-to-human transmission has been confirmed. For the public, the risk is low. However, people with prolonged, unprotected exposures to infected animals and their environments are at increased risk.
  - CDC does not want to minimize the risk and is continuing to examine the virus. Every H5 identification is being analyzed, including for genetic changes that might increase transmission between humans. The impact of potential changes on diagnostic tests, antivirals, and vaccines are also being considered.
- The outbreak is involving multiple agencies in a OneHealth approach at the federal, state, and local level (e.g., CDC, USDA, agricultural partners, FDA).
- Frontline public health workers and clinicians need to monitor people that are exposed to relevant animals, including asking patients about animal exposures, monitoring for symptoms, testing when necessary, and maintaining or enhancing virologic surveillance.

Preparations for the 2024-2025 Season

Influenza Vaccination
- The ACIP is recommending annual influenza vaccination to everyone six months of age or older who does not have contraindications.
  - Solid organ transplant recipients between the ages of 18 and 64 and on immunosuppressive medication may receive standard influenza vaccine or either the high dose or adjuvanted vaccine.
- All vaccines in the United States this year will be trivalent (consisting of H1, B Victoria, and an updated H3N2 strain; B Yamagata has been dropped due to lack of circulation globally since 2020.)
- For flu vaccine campaign communications, the key objectives are to increase awareness about the severity of flu, educate on benefits of vaccination, and address barriers to vaccination.
  - Efforts include the GEAR UP campaign, with a specific emphasis on Black, LatinX, and Hispanic adults and the Wild to Mild 2.0 campaign continues its general goal of increasing vaccination rates, with a focus this year on pregnant people and parents of children 6 months to 17 years. Questions about these efforts can be directed to the CDC Influenza Division Communications Group.
Monitoring Activity
- The CDC website has many resources for monitoring activity.
  - There are the FluView and FluView Interactive websites for monitoring seasonal activity.
  - There are H5-specific pages for human activity and general H5 information.
  - CDC’s Respiratory Data Channel provides information about influenza, COVID-19, and RSV; there is high level information that provides comparisons and links, and also more specific details about each viral disease.

QUESTIONS & ANSWERS

Q: There is a recent Lancet Network meta-analysis on anti-viral effectiveness which showed limited effectiveness for antivirals. Do those conclusions affect CDC recommendations for clinical use of antivirals for treatment and prophylaxis?
Alicia Budd (CDC): At this point, the recommendations for treatment and prophylaxis have not changed. We can get back to you with more details on that.
L.J Tan (Immunize): Thank you. Maybe we will have you come back, or we will have someone from the clinical side come back and talk about this, because I know one of the important components is treatment.

Q: Have serological studies shown or excluded evidence of H5 in close contacts of the 14 known cases? Have the close contacts of your 14 cases that are H5 positive been surveyed for serological evidence of \ lack of infection?
Alicia Budd (CDC): There are some serologic studies that have been performed on populations in Colorado and Michigan. Those results are being analyzed and will be coming out shortly. I don’t have them available yet but stay tuned. It’s a point of high interest for all of us.

Coronavirus and Other Respiratory Viruses Updates –Benjamin Silk, PhD, Coronavirus and Other Respiratory Viruses Division, NCIRD

Benjamin Silk, PhD, gave an update on surveillance and prevention of COVID-19 and RSV.

Surveillance and Prevention of COVID-19 and RSV
Dr. Silk shared resources prior to the presentation and briefly reviewed each one.

NCIRD Bulletin – latest news, hot topics
NCIRD Data Channel – high level summaries of respiratory virus activity updated weekly; many data sources are consolidated and integrated for COVID, flu, and RSV
COVID Data Tracker
Genomic Surveillance Portion of the COVID Data Tracker – location for updates on the proportion of SARS COV2 variants that change with estimates every 2 weeks
NERVES – original integrated respiratory virus surveillance system, includes data for the big three: COVID, flu, and RSV, as well as many other respiratory viruses of public health importance
RESP-NET – active population-based surveillance for hospitalizations.

The National Respiratory and Enteric Virus Surveillance System (NREVSS)

NREVSS is a passive laboratory-based surveillance system established in the 1980s. Its goal is to monitor real-time circulation and the seasonality of respiratory and enteric viruses.
NREVSS data comes from about 600 reporting labs from across the country, including data from state and local public health labs, commercial labs, and clinical labs.
- The data is mostly PCR data (e.g., 94% or more tests for RSV are PCR). Percent positivity is the surveillance metric, that is, the number of positive tests over the total number of tests performed.
The NREVSS Dashboard allows users to toggle through data, including percent positivity, test volume, and maps.

COVID-19 Surveillance, Seasonality and Trends

The threat of COVID-19 has changed since the pandemic began, from hundreds of thousands of deaths in the early years to a dramatic drop in deaths as population immunity has increased through infections and vaccination.
The seasonal trends have continued, with percent positivity increasing about twice a year at the national level. With almost 4 years of data, a trend has been established of COVID-19 peaks in winter and in late summer. The seasonal trends correlate with trends in hospitalizations.
- These trends have implications for vaccination, including for older adults and people with immunocompromising and chronic conditions: a second dose annually might be indicated.
RESP-NET is a sentinel network in select states. It conducts active, population-based surveillance in acute care hospitals for 12 states for RSV, 13 for COVID-19, and 14 for influenza – about 8% to 10% of the U.S. population.
- Based on COVID-NET data, hospitalization rates for COVID-19 are highest, by far, for adults aged 65 and older. There are also elevated hospitalization rates in young children under 5 years of age. The risk of hospitalization increases among older adults by age, with those 85 years of age and older having the highest rates of hospitalization.

RSV Surveillance, Seasonality and Trends

Over time, the seasonality of RSV has changed, with pre-pandemic peaks typically in winter (i.e., January and February); in the 2020-2021 season, there was virtually no RSV; in the 2022-2023 season, there was an earlier season. For the 2023-2024 season, an earlier season with a shift towards pre-pandemic patterns was seen, and for the 2024-2025 season, expectations are for timing even more similar to pre-pandemic.
RSV seasonality also varies geographically in the United States. The characteristic pattern has the season starting in the southeast and then moving north and west.
Active population-based surveillance for hospitalizations shows that the highest rates are in young children, 0 to 4 years of age. The next highest rates are in adults 65 years of age and older.

Prevention

COVID-19
- Essentially everyone should get a 2024-2025 updated vaccine: infants and children, 6 months to 17 years (some may need multiple doses); pregnant people; and adults.
- Recommended annual COVID-19 vaccination timing is to get it as soon as it is available.
- Evidence for the benefits of vaccination for COVID-19 from surveillance data is strong, based on rates of hospitalizations by age group.
  - In terms of age and vaccination status, the percentages of hospitalizations among those with no record of a bivalent or 2023-2024 vaccine dose are much higher in all age groups compared with those who either got a bivalent dose but no 2023-2024 dose versus those who were current with the 2023-2024 dose.
  - Risk of hospitalization for persons with certain chronic conditions is well documented by the data.
RSV
- Infants under 8 months and children 8 to 19 months with additional risk factors can get nirsevimab; maternal vaccination at 32- to 36-weeks’ gestation with an RSV vaccine is also recommended to prevent RSV in infants.
- Adults 75 years of age and older, as well as adults 60 to 74 years of age with certain risk factors, have a recommendation to get one lifetime dose of RSV vaccine.
- The RSV recommendations changed this season from shared clinical decision making-based to a simple recommendation for these groups (60-74 years of age), which is stronger.
- Recommended timing for giving RSV vaccination for older adults is late summer or early fall; for maternal RSV it is September through January in most of the United States; for infants who are receiving nirsevimab, ideally it is during October through March.
- Evidence of the benefits of vaccination for RSV is strong, based on rates of hospitalizations by age group.
  - Before the pandemic, hospitalization rates were much higher for older adults. Older adults with chronic disease are at higher risk of hospitalization with RSV.
Long-term care residents
- Long-term care residents are at higher risk of hospitalization for all three: COVID-19, influenza, and RSV.
  - Hospitalization rates for COVID-19-associated disease are 8 times higher for nursing home residents.
  - Seventeen percent of hospitalized patients with RSV were long-term care residents.
  - Adults over 65 years of age have the highest rates of hospitalization during most flu seasons.

QUESTIONS & ANSWERS

Q: Regarding reports of a new COVID variant, called XCC, popping up in Europe and approximately 100 cases have shown up in the United States, do the new vaccines, either the protein JN1-based or the KP 2 mRNA-based vaccines cross neutralize XCC?
Ben Silk (NCIRD): I don’t know the answer to that question. I would have to check with the lab and others to see if any of those data are available yet, but I’d be happy to get back to you on that. I’m just not sure that those studies have been done.

Q: Is the maternal RSV vaccine just once per lifetime, currently, meaning you do it for one/the first pregnancy, but there’s no recommendation from the ACIP about subsequent pregnancies?
Carolyn Bridges (Immunize): I believe that is the current recommendation, and there will be more ACIP discussion.
Kelly Moore (Immunize): At this stage, it is one-time only for all people. So people who are pregnant this season, who were pregnant last season and got RSV vaccine should not get RSV vaccine and should be counseled that their child should receive nirsevimab, the monoclonal antibody, at birth.
Ben Silk (NCIRD): [Provided a link to the clinical guidance for pregnant people: https://www.cdc.gov/rsv/hcp/vaccine-clinical-guidance/pregnant-people.html]

Announcements

You may now register for a webinar about operationalizing adult immunizations in the practice. The webinar, on October 1, 2024, will feature Doctor James Goleman, a leader in the area of vaccinations in the medical practice. It will be about vaccine storage and handling, managing inventory, and ways to operationalize the flow of vaccines.
The Billing and Coding Work Group will be meeting on Monday, September 23 at 1:00 p.m. to talk about payment issues and issues that came out of the action items from the Summit at the in-person meeting in August.
- If you are not a member of any of the work groups, including the Billing and Coding Work Group, please feel free to submit your name and information via email to the work group leads to be added to those groups.
Announcements about billing and coding
- Regarding maternal RSV vaccination coding, there have been claims rejections if you are giving maternal immunization with RSV vaccine and you do not put the gestational age in the claim form.
- With the trivalent influenza vaccination, there have been denials from payers and the denial rate is, according to our partners, about 10%. The manufacturers are aware of these issues and are working with our partners to resolve them. The three reasons for the denials are
  - Between the 6-month and 36-month age group and the 5mL dose for pediatric immunizations, when it was dropped to 6 months from 3 years of age, the quadrivalent code was updated with the new age group to reflect the new 6- to 36-months old category; however, now that we’ve gone back to the trivalent codes, those codes were not updated to reflect the drop to 6 months. So, if you file a trivalent code for a patient who is between 6 months and 3 years of age, that code is getting rejected because it’s not there.
  - The trivalent codes have not been reactivated in some of the payer systems yet. So, if you file the trivalent code for the trivalent vaccine, that’s also being rejected.
  - The trivalent codes, when they got reactivated, there is no associated previous payment with those because the trivalent codes have not been used for more than 10 years. (We’ve been quadrivalent for almost 10 years.)
- Also, Medicare Part B claims are being rejected; CMS is aware of this and they have issued an internal technical guidance to their payers to make sure that the system gets corrected so the denials can be addressed and paid retroactively to the providers. Providers need to ensure that the retroactive payments are being processed and, if not, may need to submit some forms for that.