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A summary of presentations from the weekly Summit partner webinars

October 31, 2024 – The latest Summit Summary

Seasonal Influenza Updates – Katie Reinhart, PhD, MPH, Influenza Division, Centers for Disease Control and Prevention (CDC)
Development of Resources to Increase Adult Immunizations in Community Health Centers through Learning Communities – Sarah Price, MSN-ED, Director, Public Health Integration, National Association of Community Health Centers (NACHC)
Announcements

Seasonal Influenza Updates – Katie Reinhart, PhD, MPH, Influenza Division, Centers for Disease Control and Prevention (CDC)

Katie Reinhart, PhD, MPH, Influenza Division, CDC gave an update on seasonal influenza.

Influenza Update 2024-2025 Season
This was the first update of the 2024-2025 influenza season and included what has been seen for influenza A H5N1 cases, as well.

Influenza-Like Illness Surveillance Network (ILINet) and the National Syndromic Surveillance Program (NSSP) Data
Data from the Influenza-Like Illness Surveillance Network (ILINet) and the National Syndromic Surveillance Program (NSSP), two different systems for monitoring activity for outpatient respiratory illness, reveal influenza activity that has been stable and below baseline for the past week: specifically, 2.1% of visits were for respiratory illness.

Influenza-like illness has been stable nationally among all age groups, as well as by individual age, for weeks 20 – 42 of the year, i.e., summer up to late October.
- The highest percentage of visits due to ILI was for 0- to 4-year-olds, at 6.6%.
- The only jurisdiction showing a higher percentage of visits than low or minimal activity for ILI was Washington, DC. There were 5 other jurisdictions at low.
NSSP numbers, which include emergency department visits with a diagnosis code for influenza, have also been stable over the summer and remain so now, which was expected.

Virologic surveillance was reviewed utilizing clinical lab data and public health lab data. Clinical lab data revealed low and stable influenza activity, most of which was influenza A, with some B viruses found each week. Public health lab data revealed positive specimens by type and subtype; in recent weeks, influenza AH1N1, H3N2 and a few B Victoria have been circulating, as well as some AH5 specimens.

As yet, for seasonal influenza for 2024-2025, there are no increases in hospitalizations or mortality and no pediatric deaths reported. However, for the 2023-2024 season, there were the highest number of reported pediatric deaths (n=202) since reporting began in 2004.

Influenza H5
Influenza H5 is still widespread in wild birds worldwide. It is causing outbreaks in poultry and dairy cows in the United States, and there have been several cases in humans. CDC posts case counts several times a week and associated information weekly.

The public health risk is still low.
The situation is being monitored and CDC is working with states to monitor people who have been exposed to animals and those who develop symptoms.
In 2024, 39 cases, across 6 states, have been confirmed in humans. Twenty of those people had exposure to cattle, 18 to poultry, and 1 reported no exposure to either.
Most H5 cases were picked up through animal exposure monitoring, but typical flu surveillance systems are also designed to detect H5 and did pick up one human case (out of over 55,000 specimens tested).
Targeted H5 surveillance since March 24, 2024, has identified over 6,100 people for monitoring following exposure to an infected animal, over 300 have been tested, and 38 infections were detected this way.

QUESTIONS & ANSWERS
Q: Does CDC have preliminary insights into the update of seasonal vaccines through the targeted farm work initiative?
Katie Reinhart (CDC): I think that probably varies by location. There have been some sites where workers have been very open to getting vaccinated on site. There have been others where they’ve been a little bit less so. But what CDC is trying to do is to make sure that vaccine is available and accessible for these people who are on farms. And then the public health staff that are on the ground are doing their best to provide it and encourage the uptake. [I don’t have actual numbers, yet, but I can try to find out from people who are working more closely with that program.]

Q: I’m hearing that there’s an H5 infection case in a pig right now in the Pacific Northwest and that is concerning for people regarding the traditional mixing vehicle. Any talking points on that?
Katie Reinhart (CDC): I don’t have too much to add to that, but yes, it was detected in a pig in the Pacific Northwest. I think it is a mixing vessel, which is concerning. But I think it’s also important to note that it’s in one isolated area. It isn’t anything that we’ve seen spread from pig to pig at this point; it hasn’t spread any farther than that, so that’s a reassuring point on this.

Q: It’s our first year going back to trivalent; are you seeing much in the way of influenza B, any concerns out there?
Katie Reinhart (CDC): We have not been seeing too much influenza B circulating so far in the past months. Obviously, no B Yamagata has been resurfacing. So that’s great news. At this point, no real concerns about the trivalent vaccine.

Development of Resources to Increase Adult Immunizations in Community Health Centers through Learning Communities – Sarah Price, MSN-ED, Director, Public Health Integration, National Association of Community Health Centers (NACHC)

Sarah Price, MSN-ED, Director, Public Health Integration, NACHC gave an update on NACHC communications and new immunization resources.

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NACHC Communications and New Immunization Resources
NACHC is the membership and advocacy body for all CHCs – there are almost 1,500, which makes CHCs the largest primary care network in the nation, serving 1 in 10 people. NACHC centers their work around equity, empowered infrastructure, workforce funding, improved care models, and supportive partnerships.

Development of Resources to Increase Adult Immunization in Community Health Centers Through Learning Communities
Since 2018, NACHC has developed a variety of best practices and resources for adult immunization with 5 years of funding from the CDC and in partnership with over 90 health centers, networks, and primary care associations. A review of the accomplishments per year was provided.

Year 1 focused on vaccination capacity inventory and exploration of the landscape of adult immunizations in CHCs.
- Work included a report, Vaccination Capacity Inventory of Community Migrant and Homeless Health Centers, A Survey Report, and exploration of the results.
Year 2 coincided with the beginning of the COVID-19 pandemic. In addition to a focus on that, there was a focus on vaccine hesitancy.
- There was the addition of some Health Center Control Networks and four Health Center Pharmacy teams.
- The first policy papers were published, including a white paper, in collaboration with the Summit, exploring key policy factors affecting immunization programs, including barriers and solutions. (That white paper was refreshed in 2024.)
Year 3 included the introduction of an informatics team and quality improvement focused on data collection.
Year 4 saw the beginning of some innovation work, including the following:
- Human-Centered Design projects, where 15 CHCs worked to increase vaccine access using the design process;
- Messaging Matters, co-designed listening sessions for vaccine hesitant staff and patients around COVID vaccines; and
- Vaccine Ambassadors, a program with the Healthcare for the Homeless Coalition for training and implementing ambassadors to educate about, and administer, vaccines (this program resulted in a truly co-designed resource called “10 Tips to Start a Vaccine Ambassador Program.”)
Year 5 was about going back to the basics – the standards for adult immunization practice adopted in 2014, which were the following: Assess, Recommend, Administer, and Refer.
- A cohort of 19 CHCs spent several months on each standard and developed tools to improve vaccine coverage, including chart audits, assessment tools, and a survey to identify best practices.
- Some of the lessons learned included the following: care team members need ongoing education for complex guidelines, particularly pneumococcal vaccination; vaccine fatigue and hesitancy regarding COVID are real; there is a need to address the barriers for health centers with low or no standing orders for flu.
- Results: more than 80% of CHCs that participated in the learning communities increased their flu vaccination rates by at least 5%, and some did better. There was movement for pneumococcal and COVID vaccination, as well.
- The “Lining Up the Shots Learning Series,” a series of 3- to 5-minute cartoonish stories that are micro-learnings about the immunization experience, was developed.
Year 6 was made possible with additional funding and allowed a deep dive into standing orders and documenting declination.
- There was a wide range of implementation of standing orders within CHCs, from zero to many. NACHC worked with a small cohort and explored standing orders for several months and came up with best practices.
- Standardization in electronic health records for documenting declination does not exist, so it can be hard to know the reasons for declination.
- NACHC developed a free, healthcare worker-vetted curriculum called “The Standards for Adult Immunization Practice: Optimizing Programs in Health Centers.” The program includes information about the standards, access to tools, and one continuing education credit upon completion. The intention is to add modules and continuing education credits in the future.

Publications
Publications in the near term will share current insights on the following:

“Foundational” Adult Immunization Intervention
Addressing Vaccine Hesitancy

Publications in the long term will be planned in conjunction with future partnerships and data collection design and include the following:

Leveraging Health Center Staff to Expand Access
Automating Compliance with Clinical Guidelines

QUESTIONS & ANSWERS
Q: Can you provide a link to the vaccine ambassador program?
Sarah Price (NACHC): Yes: https://nhchc.org/research/vaccine-ambassador-project/. We could not have done that program without Healthcare for the Homeless Council. They have a very robust website about that program, as well, and a lot more resources. They wrote up a piece that is almost published that we contributed to, as well.

Q: As you did this program, what were the challenges in some of your healthcare systems, e.g., vaccine access and securing vaccines? Maybe that’s in your publication, but can you share some of the top challenges that were faced by your CHCs: how did they get access to vaccines, and so on?
Sarah Price (NACHC): First is just the lack of standardization; there might be one or two champions at a health center, but they didn’t always see it as a program. I had one chief medical officer that joined us the very last year – and I was recruiting for some more health centers – and he said, “Well, one of the questions you ask is whether we have an adult immunization program. I don’t know, do we?” And I said, “Well, do you give adult vaccines?” He said, “Yeah,” so I said, “Well, then, you have a program. We may just need to refine the program a little bit.” So, first and foremost is standardizing.
Pediatric vaccines, it is a machine, right? We have the Vaccines for Children (VFC) program, etc. The adult immunizations were a little more willy-nilly. Some of that is based on funding. Some of it’s based on whether we can afford to keep these vaccines in our health centers. [People say] we want to do the right thing, but we can only have 5 doses in our health center at any given time, because we can’t afford them…. So I think, looking at those processes and thinking how can we do this smarter? How can we maintain access? And also, what are some referral sites; how can I partner with the Walgreens down the street? But also saying, “If I send you a patient, I really need that record back.” So those were the some of the challenges.
And learning communities discovered that they’re not alone: we all have this challenge; so, here’s how I did this, here’s how I did that. And maybe I can’t do exactly this, because I work in a different state, but we are trying to figure out what the commonalities and the common solutions are. During COVID, we saw the rise of the power of the pharmacy tech. Before COVID, pharmacists could give some vaccines but pharmacy techs couldn’t. And so there was a huge area of growth around pharmacists being able to immunize more. But then most states’ pharmacy techs cannot immunize. And so it was both a blessing and another challenge: now you have to train all these pharmacy techs. You must get them all certified, and you have to know the vaccination schedule. But what a workforce! And the pharmacy techs that I’ve talked to have said that their job is more interesting now, and pharmacists’ jobs, too. They love immunizing. It’s more fun, you get to talk to more people. So those are the challenges that came up the most, but always solutions, too.

Q: Are you connecting your healthcare systems with each other in any way, formally or informally, through some kind of learning network, so that they can ask each other questions, or do they all come through you?
Sarah Price (NACHC): No, I just say that I’m just the convener; the magic happens outside of me, I just have a platform. Many of the health centers that participated were already part of networks called Health Center Controlled Networks (HCCNs). So, throughout the 6 years, we were able to work with six different HCCNs, and there are 49. So there are so many more I would have loved to work with. But we did say, “Hey, we want to do work on adult immunizations. Can you find some health centers to do this?” And some networks would bring two or three health centers. Some networks would bring nine or 10, and we would get everybody on a call, both the individual health centers and representatives from that network. So, then you get the frontline people from the health centers talking to each other, but the networks are learning how they can support their frontline people, as well.
Oh, we also partnered with primary care associations (PCAs). But the networks and PCAs were also present at the calls to learn and say, “Okay, how can I support? How can I do this?” So then they can spread and scale it. NACHC can’t do that alone. A good example is the Alaska PCA. For several years they had three health centers that participated but, as a PCA, they can spread these learnings throughout all of their health centers. That’s kind of their job. So those calls were always magical. We always had a time where we would do breakout groups, or we’d have a piece highlighting a site’s work. We convened them on a virtual platform called Confluence, so when they would upload something, everyone could see what they uploaded, to convene those resources. Then, when we could, we were able to do some small in-person meetings; people could see each other’s faces, which is always nice, a little less because it was COVID, which was sad for me. We were supposed to go to Alaska for a site visit one time, then COVID hit.

Q: An operational question: Given my very limited understanding about how the whole payment system works…there’s a pie, and then you have to break up that pie. But, given the increasing cost of some individual vaccines, are you able to send, for example, your patients who are on Medicaid, who need maybe a more expensive vaccine, to the healthcare system in your area? Is that how that works, or are they more likely to be able to offer lower cost vaccines in the clinics? But then they have to refer out and find partners for the more expensive…or how do you feel about that issue of ‘you get this much money per visit’?
Sarah Price (NACHC): And that’s exactly how it works: a pie or a pizza. There’s one payment for any visit at health centers generally. And some of that is changing and some of that, especially in the Medicaid space, is shifting, depending on the state. But generally, there’s an amount of money that you get regardless of the visit. Health centers always prefer to vaccinate in-house, because you will lose that patient if you ask the patient to cross the street or take another bus; they may not get it. That said, vaccines are really expensive: RSV, super expensive; COVID is not free anymore, and it’s not cheap; flu is pretty cheap. So we find solutions.
We found if a health center felt that they needed to refer patients, they could set up a system where it makes it so easy for that patient to do that. So, whether it’s a partnership now with Uber Health and you can get free rides from here to there or, if transportation isn’t an issue but you’re afraid that you’re not going to get that record back, then partnering with Walgreens, CVS, or the Department of Health, and not making the patient schlep the paperwork from one place to another. That’s not a system, that’s a workaround. A lot of vaccine manufacturers have patient assistance programs. So if we can work that out, we use those partnerships with Departments of Health…I worked at a Federally Qualified Health Center (FQHC) here in DC for many years and when I knew that I was running out of hep A, or whatever it was, I’d call up the health department and say, “Do you have any update?” And if there was some left over, he knew we were good to use it. We also had a ton of patients.
But all those different partnerships of how to get those shots in arms at the point of care…but also working on those other systems, as well. And I do hope that we see a change. I know we have a lot of people that are working on that. Can we get different reimbursements? Or can there be a Vaccines for Adults (VFA) program, and things like that. So, fingers crossed for all the systems. But, in the interim, we create systems/work-arounds where we can.

Announcements

Save the Date: The May Summit meeting will be in-person on May 13 – 15, 2025, with early arrivals for a pre-meeting on May 12. The meeting will be held in Atlanta, GA at the Crowne Plaza Ravinia Hotel.
The National Coalition’s Network, in conjunction with the Summit, hosted an RSV Implementation Webinar on November 7, 2024 about how to move forward with implementation of RSV vaccines for the following groups: maternal, over 75 year of age, and 60 to 75 years of age with high risk; and also how to use the server map, especially with the increased focus on birthing hospitals.