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A summary of presentations from the weekly Summit partner webinars

September 26, 2024 – The latest Summit Summary

American College Health Association presentation led by the tri-chairs for the Vaccine Preventable Diseases committee – Thevy Chai, Clinical and Administrative Lead Physician, University of North Carolina, Chapel Hill; Ashlee Halbritter, Executive Director, Public Health and Wellbeing, University of Pennsylvania; Sara Lee, Assistant Vice President, University Health and Counseling Services, Chief Health Officer, Case Western Reserve University

The tri-chairs for the Vaccine Preventable Diseases committee (Thevy Chai, Ashlee Halbritter, and Sara Lee) gave updates about college health and immunization efforts.

College Student Health Association & Immunization
The American College Health Association (ACHA) helps students become and stay healthy so that they can thrive in college. There are many models of college health and a large range of services from nurses providing first aid and triaged referrals, to community resources, to large, accredited, multi-specialty, ambulatory healthcare clinics with hundreds of employees.

The professionals involved in college health care include physicians, physician assistants, administrators, nurses, mental health professionals, dieticians, pharmacists, and more.
There are a range of payment structures for college health services: health insurance, tuition-funded/no-cost at point of care, general university allocations from centralized funds, and out-of-pocket payments at a flat fee, for example.

Immunizations for college students are essential to individual well-being and contribute to the well-being of faculty, staff, and all students on campus.

Because college students generally live in close quarters and congregate settings, they can become super spreaders of disease on campus. They also travel into the community and back, domestically and internationally on breaks, potentially exposing people off campus during travel and then to others on campus upon their return.
Recent outbreak statistics include 10 meningococcal disease outbreaks across seven states between January 2013 and May 2018, 75 mumps outbreaks between January 2016 and June 2017, and an essentially constant outbreak of COVID-19 since the beginning of the pandemic.

Immunization Requirements Compared to Recommendations

Immunization requirements for college students vary from state to state.
- 22 states require meningococcal vaccination for college students.
- At least 23 states require up-to-date vaccines for measles, with many of those also requiring MMR.
- At least 13 states require up-to-date vaccinations for Tdap.
- At least 10 states require vaccination for hepatitis B.
There are institutional requirements for immunization: public institutions must follow state guidelines; private institutions have leeway and may have more robust requirements than the home state, or fewer, or none at all.
Beyond those requirements, many universities have multiple programs or schools that may have their own requirements, beyond those of the institution.
Colleges and universities receive guidance from multiple organizations.
- The Children’s Hospital of Philadelphia released a policy brief on vaccine requirements related to institutions of higher education.
- Influencers for college student immunization recommendations include CDC, ACHA (influenced by the Vaccine Preventable Diseases Committee with NCHA), states, and institutions.
  - ACHA is a large, member-based group. Data gathering takes a lot of time and effort because it is gathered by individual user survey input from schools, and surveys include topics and items beyond just vaccines.
    - Within the most recent survey, a flu vaccine item showed a flu vaccination rate of 48.8% and an HPV vaccination rate of 50.6%, in a sample size of about 100,000.
  - Current ACHA recommendations, which are updated annually, include
    - Influenza vaccine
    - Measles, mumps, rubella (MMR) vaccine
    - Meningococcal quadrivalent (ACWY) vaccine
    - Serogroup B meningococcal vaccine
    - Meningococcal pentavalent (MenABCWY) vaccine
    - Mpox vaccine
    - COVID-19 vaccine
    - Human papillomavirus (HPV) vaccine
    - And more

Barriers to College Student Immunization
Some of the many reasons for unvaccinated or undervaccinated college students include parental hesitancy; vaccine availability; insurance restrictions, including plan restrictions specific to international students.

One of the biggest challenges and barriers to college student immunization is the lack of a national vaccine registry. Although many universities and colleges have moved to electronic health records, some have not. Those that can feed into local and state vaccine registries, are still often limited to registries from the states next to them, geographically, despite their national and international student bodies.
Other barriers to immunization include the high cost of storing and delivering vaccines, including the cost of the vaccine stock; limited time, space, and staffing; varying levels of institutional support; various sizes of college health centers and types of funding models; and college students’ limited experience making personal decisions.

Opportunities for Increasing College Student Immunizations

The most important thing to do to help college students get vaccinations is to get them vaccinated before they go to college.
- A standard visit/platform for 18-year-olds would be helpful and would also be a good opportunity to have a health planning conversation with prospective students regarding how they will handle their health at school, where they will get vaccinations, what they will do when they do not feel well, etc.
Establish herd immunity standards to include knowledge of the real target for the specific population, i.e., 18- to 22-year-olds or 18- to 26-year-olds, rather than the more standard 18 to 45 or 65 years of age range.
Establish vaccine requirements.
Address barriers related to access.
Address barriers related to costs.
Establish a national vaccine registry.

QUESTIONS & ANSWERS

Q: Do you have any plans or publications on after-action for colleges regarding the COVID-19 pandemic, including the vaccine rollout?
Ashlee Halbritter (ACHA/UPenn): They created a plan of action as soon as the pandemic hit, and then they did an off-boarding from a pandemic report that includes ongoing recommendations for COVID-19 boosters, and those are included in in the ACHA recommendations.
Q [follow up]: Are you seeing repercussions on your campuses? Any increasing hesitancy or more challenges with vaccination that may be related to the COVID-19 pandemic?
Sara Lee (ACHA/CWRU): I think it’s going to be delayed. When I talk about COVID-19, that time wasn’t just for college students. It was for everybody. I think we’re seeing, globally, among everyone, some sort of developmental delay. I don’t think everybody accomplished their tasks of development, whether you were a 25-year-old student, a 30-year-old medical resident, a 2-year-old trying to learn to talk. There’s a lot of delay, and we’re just starting to discover that, based on what I’ve been reading. We’re going to see some vaccine hesitancy. I don’t know if what we’re going to see is students who are arriving 10 years from now who didn’t get their MMR or exactly how we’re going to see it. I don’t know that we’re seeing it yet. We saw some interesting behavior around COVID vaccines and COVID vaccine requirements. I don’t know what effect that’s going to have, as we move forward.
Thevy Chai (ACHA/UNC): It may be a bit too early for us to say. At UNC Chapel Hill, we’re trying to connect the COVID vaccine to the flu vaccine. We’ve tried to reduce barriers. So, we have clinics in the campus facilities at various times and days, and we also ask if people want the flu and COVID vaccines when they’re here for something else. So far, I’m noticing that students are receptive to the flu vaccine, which we’ve been promoting every year in the past. And COVID, now we’re just sort of trying to slide that in, as well.

Q: Regarding the meningococcal vaccine recommendations, do you typically go beyond the pure shared clinical decision-making recommendation and recommend both the ACWY plus the men B for college students?
Thevy Chai (ACHA/UNC): At UNC, we are very lucky, because it is a state requirement for the ACWY. And the men B just became a state requirement. When it becomes a requirement that is very helpful to us, because then it’s no longer in the recommended or shared decision-making category. It is helpful, for colleges in a state where maybe no vaccines are required or there may be one or 2 required, to make recommendations.
Carolyn Bridges (Immunize): I have to say both my boys had to submit, or were requested to submit their full immunization record. but then it’s hard to tell which ones are required. So, are students making that distinction, or how are colleges able to at least encourage or recommend vaccines? You know, when they don’t have requirements.
Ashlee Halbritter (ACHA/UPenn): Most colleges and universities have either requirements or recommendations listed out on a piece of paper. Most colleges and universities suggest or recommend that students have a physical before arriving at college and have their medical provider help fill out that form ahead of time. So, there are some best practices in our work that help highlight that and facilitate the opportunities to get students up-to-date pre-arrival. But most colleges and universities, at this point, have vaccine recommendations, if not on their main website, certainly on their Health Center’s website. Every year we update our handout and guidelines on the ACHA website. That also mimics what CDC and ACIP recommends. That goes out to all the various schools of various sizes, as well.

Q: We talk a lot about healthcare worker vaccination and the role of workplace requirements as a huge predictor of vaccination. Do you have data on the impact of a recommendation versus a requirement? Are you seeing significant uptake of vaccine?
Sara Lee (ACHA/CWRU): I don’t think we have specific data we can infer from. When you have a requirement, everybody gets it, and X number of people will have an exemption. We know that exemptions also have challenges, like California having to take away the philosophical exemption. We all have the recommended vaccines listed on our websites. But I do think about students who are transferring into the university and the overwhelming amount of information required. They and their parents have a number of different worries, including paying for college; the list of worries is astronomical. So, I’m not sure that the recommendations really hold much weight, and then you have to think about what we do to ensure compliance. First, we need staff to review them and record them, and then what will the consequence be if you’re not compliant? Are you not going to let somebody attend school, or are you going to have a registration hold or a fee? Those kinds of things can get sticky and are not usually the place where the Health Service wants to be. We’re there to help them do their work, not get in the way.
Thevy Chai (ACHA/UNC): And here at UNC, we have robust programs, Health Science School programs, we have students who are healthcare workers, and it definitely makes a difference when something is required versus recommended. And if there is an exception, usually there education is provided for them to sign off on. There’s a formal process for them to go through when they’re asking for religious or medical exemptions. But I think it is very helpful for medical exemptions to be very clear, not just something like, “Oh, I had a cough,” or something that makes the student worried about a potential side effect when it’s something severe and clear, like a severe allergic reaction. That’s a contraindication that is very helpful for all involved from the student to the Health Science Schools.

2024 Clade Mpox Response Updates, Centers for Disease Control and Prevention (CDC) – Christy Hutson, PhD, MS, Senior Science Advisor, 2024 Clade Mpox Response

Christy Hutson, PhD, MS gave an update on the 2024 Clade Mpox response at CDC.

2024 Clade Mpox Response
The monkeypox virus (MPXV) causes the disease referred to as mpox and belongs to the same genus as variola virus, which causes smallpox. It is presumed that the reservoir for monkeypox virus is a small African mammal, most likely a rodent living in the forested areas of Africa. The first human case of mpox was confirmed in 1970 in the Democratic Republic of Congo.

There are two different clades of monkey pox: clade I, historically associated with a higher number of severe outcomes, and clade II, which started the global outbreak that began in 2022 and with ongoing cases globally. The clades are very closely related (95% the same genetically) but geographically distinct, with clade I found in Central African countries and clade II found in West African countries.

Both clades are transmitted via the same routes.

Direct contact with an infected animal in endemic countries, including during food preparation and bites/scratches.
Close contact with a person who has mpox, generally skin-to-skin contact but also contact with saliva, upper respiratory secretions, and bodily fluids or lesions.
Objects that are contaminated, such as fabrics (e.g., towels, bedding) or surfaces.

Clade II MPXV Overview
In 2022, the peak of clade II mpox cases was reached in the United States (472 cases/day on average); the number dropped in 2023 and into 2024 but there were still consistently low levels across the country.

For 2024, the average case number is 3.71 cases/day across the country, which is still considered low.

After the 2022 outbreak, ACIP recommended vaccination with the 2-dose JYNNEOS vaccine series for persons aged 16 years and older at risk for mpox.

Persons considered at risk include those that are gay, bisexual, men who have sex with men, transgender people, and non-binary people who have had certain additional risk factors in the past 6 months; and sexual partners of people with those risks described, and persons who anticipate experiencing any of the risks described.

Although the mpox vaccine is widely available, there has been a drastic drop in vaccination since the peak of 2022, with overall uptake of only about 25% of 2 doses for those at risk and about 40% of 1 dose for those at risk.

Several studies have shown that greater than 50% immunity is necessary to significantly decrease the risk of large outbreaks.
Vaccine effectiveness is not waning. The serology titers decrease a few months after vaccination, but in the real world, vaccine effectiveness continues to be strong.
- In those who have received 2 doses, as of May 2024, breakthrough infections occurred in less than 1% of those fully vaccinated.
- Breakthrough infections are generally associated with less severe infections and occur at disparate time intervals. There is currently no booster recommendation.

Clade I MPXV Circulating in the United States
There has not been a case of clade I mpox in the United States to date, but CDC is monitoring for that.

CDC is soliciting all mpox specimens from labs and performing PCR testing and sequencing to look for mutations.
CDC is supporting labs that are able and willing to bring up clade-specific testing.
CDC is collaborating with labs to flag high likelihoods of clade I.
CDC is testing wastewater across the country and has increased capacity to detect cases of mpox through this surveillance: some testing is specific to clade II, but some sites have the ability to test for both clade I and clade II.

Patient care and IPC does not change based on clade.

Clade I MPXV Outbreak Response
There has been an ongoing outbreak in the Democratic Republic of Congo (DRC), starting in 2023 and continuing to date, with a dramatic spike in suspect clade I mpox.

Importantly, there were mpox cases in provinces which had previously never seen mpox cases.
As of September 2024, this outbreak had resulted in over 21,000 suspect cases and 700 suspect deaths.
There are at least two concurrent outbreaks in provinces in the DRC.
- In the Equateur Province, where most cases were reported in 2023 going into 2024 (although recent weeks have seen a decrease):
  - The outbreak is clade Ia, the older clade.
  - Cases are seen mostly in children.
  - The historical mortality rate is 1.4% to 11%; more recent studies have shown a case fatality rate of 1.4% to 1.7% with routine supportive care.
- In Sud Kivu Province, there is currently a steady increase in cases:
  - The outbreak is clade Ib.
  - Cases are mostly driven through sexual transmission in adults.
  - The mortality rate that is less than 1%, and clade Ib seems to cause less severe disease.
- Clade Ia is only detected in endemic countries: Central African Republic and Republic of Congo; clade Ib is potentially associated with sustained spread to Uganda, Rwanda, Burundi, but is not associated with sustained spread to Kenya, Thailand, or Sweden – despite some travel-associated cases.
- In DRC, the clade I mpox virus is spreading: from animals to people, with a high proportion of cases in children; through close physical contact in households; and through sexual transmission (especially in men who have sex with men and in sex workers).
  - In countries outside DRC, Burundi has the most clade Ib cases, affecting less than 0.002% of the population. Transmission is primarily through sex, with limited secondary spread.
- Because clade Ib seems to be mostly transmitted through sexual exposure, CDC recently released another Health Alert Network that outlines prevention strategies for mpox, including vaccinating people at risk by sexual exposure for U.S. travelers visiting those countries with clade I mpox outbreaks.
- CDC believes that the potential impact to travelers from the United States is low, because there are few countries with sustained transmission and few cases in most of those countries currently.
- The CDC has assessed the risk as low to the general U.S. population. Even with artificially inflated attack rates, the modeling suggested that even with an extremely high secondary attack rate, household transmission would most likely involve 10 or fewer clade I cases, with minimal spread between households.
- The United States has vaccine therapeutics and diagnostics available if clade I begins circulating in the country.

QUESTIONS & ANSWERS

Q: Is it correct that there appears to be good cross-reactivity between clade 1 and clade 2, such that people infected with one or the other would not be likely to be infected with the other?
Christy Hutson (CDC): That’s right. Orthopoxviruses are genetically very similar, more than 90% genetically the same. So I like to compare it to smallpox eradication: that was done by using vaccinia virus vaccines, which is an orthopoxvirus. And that’s actually what JYNNEOS is, as well, a non-replicating vaccinia virus vaccine. Immunization with vaccinia virus protected against smallpox; immunization with vaccinia virus, right now, is protecting against mpox. Clade I and clade II are even more genetically the same than mpox and vaccinia virus. So, certainly, infection with one would protect against the other.

Q: In terms of the age distribution, are you seeing any cases in people 60 and older who may have received the original smallpox vaccine…evidence that there may be long-lasting immunity?
Christy Hutson (CDC): We do see some cases in older individuals, but if I recall the breakdown, it’s not as many. We don’t know, though, if that’s due to some lasting protection from a childhood vaccine, which stopped back in the seventies or early eighties and would likely be very little. As far as protection goes, it might just be the different risk that’s occurring with older individuals, but certainly it could be a combination of the two, some lasting protection and different risk factors.
Faisal Minhaj (CDC): It is unknown, due to a variety of factors, if there is any immunity, after all this time, in those individuals.

Q: According to a local health department participant, doses in their state are expiring at the end of October and no local providers are offering the vaccine. To whom should they be referring people to once their stock expires? And, what are the resources for getting people vaccinated?
Christy Hutson (CDC): So I will start, and then I’ll ask Faisal to add. The vaccine is now commercially available. It is available in, I believe, all the large pharmacies, however, that can vary state to state. ACHA has a vaccine provider finder online.
Faisal Minhaj (CDC): I was going to reiterate those same points. We do have a little vaccine tool that’s helpful to find vaccine in your area. And because it’s commercially available, now it is available at most pharmacies, although they may not carry it in stock, usually. It is like other vaccines that are available in pharmacies or agencies: if there’s interest in one, they can usually get it within a few days.

Q: What are you seeing in terms of vaccine uptake, in general?
Faisal Minhaj (CDC): Most of our update data on vaccine uptake is reported quarterly, so we haven’t seen any recent data. However, most of the vaccine doses that have been administered in the United States were predominantly during the early phase of the outbreak, during 2022 and early 2023. Since then, we have seen a decrease in the eligible population who’s been getting vaccinated, and this is a concern, as Dr. Hutson pointed out. It’s really that coverage greater than 50% that prevents large outbreaks from occurring. Nationally, we are at about 25% of 2-dose coverage for those that would be eligible for vaccination. And those numbers really haven’t budged too far within the past year. So, one of the biggest important points is getting those who are eligible their primary vaccination, especially as adolescents age into this population of those who are eligible.

Q: Can you talk a little bit about the incubation period and at what point vaccination is still recommended after a potential exposure?
Christy Hutson (CDC): The incubation period can vary for this virus, but we see it anywhere from as early as 3 days up to 14 days. And, as far as post-exposure, it is recommended to try to get the vaccine within 4 days of exposure, but it is possible to go out to as many as 14 days.

Q: Is there any discussion with FDA about extending the expiration date of vaccine currently in clinics?
Christy Hutson (CDC): I’m not familiar with that.
Faisal Minhaj (CDC): I’m unsure if that is under consideration right now for the existing lots. Usually the FDA keeps an updated website detailing lots for which they have extended expirations. I don’t know if that’s something that’s being considered right now for current vaccine doses.

Announcements

The webinar about operationalizing adult immunizations in the practice will take place on October 1, 2024. It will feature Doctor James Goldman, 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.