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A summary of presentations from the weekly Summit partner webinars

November 14, 2024 – The latest Summit Summary

Implementing Hepatitis B Vaccinations – Camilla Graham, MD, MPH, Assistant Professor in Medicine, Part Time, and Staff Physician, Division of Infections Disease at Beth Israel Deaconess Medical Center and Harvard Medical School; Flu Coverage Rates – Courtney Peters, MBA, Public Affairs, U.S. Vaccines at Sanofi

Camila Graham, MD, MPH gave a presentation about implementing hepatitis B vaccinations; Courtney Peters, MBA gave a presentation about coverage rates for the influenza vaccine.

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Implementing Hepatitis B Vaccinations

Hepatitis B (HBV) vaccination is one of the more complicated vaccination programs, and it is important to help support providers who are trying to implement this program. ACIP’s HBV Vaccination Recommendation In 2022, ACIP recommended hepatitis B vaccination for all eligible adults 19 to 59 years of age and for adults ≥60 years of age with risk factors for hepatitis B. ACIP also said adults ≥60 years of age without risk factors may receive hepatitis B vaccines, which could necessitate conversations for which providers may need support. HBV Screening In 2023, CDC also recommended that all adults aged ≥18 years should receive hepatitis B screening using three laboratory tests at least once during a lifetime (https://www.cdc.gov/mmwr/volumes/72/rr/rr7201a1.htm?s_cid=rr7201a1_w). A paper titled Implementing Adult Hepatitis B Immunization and Screening Using Electronic Health Records: A Practical Guide was published in response to concerns and frustration about integrating the immunization and screening recommendations and serves as decision support.

  • For example, the guide provides decision-making guidance on how to provide HBV vaccination by using the electronic health record, and that this can be done in the absence of HBV screening.
  • The publication also provides information to make vaccination decisions in adults 60 years of age and older, based on their risks. The guide also provides a list of the potential risk factors that would influence the vaccination decision (e.g., risks by sexual exposure, percutaneous or mucosal exposure to blood).
  • For those over 60 years of age, the guidance suggests two options for identifying those for hepatitis B immunization.
    • Option 1: Identify risk factors or proxies to tie a patient’s record to a hepatitis B vaccine prompt; send a letter to all patients 60+ years of age who lack documentation of a full vaccine series or evidence of immunity/exposure to inform of vaccine option.
    • Option 2: Add a hepatitis B vaccination prompt into the electronic health records for all patients >60 years of age who lack documentation of a full vaccine series or evidence of immunity/exposure.
  • The ACA/IRA requires commercial payors to cover HBV vaccination, and Medicare part B also covers HBV vaccination.
  • Other factors that provide hepatitis B vaccine decision support:
    • Dosing for the hepatitis vaccine is variable and dependent on the population
    • Being specific about the brand of vaccine – different brands have different dosing
    • Identifying indicated populations
    • Ensuring appropriate dose and number of vaccines in full series
    • Adding a pre-populated vaccine schedule to provider dashboards
    • Scheduling future appointments for additional vaccines in a series
    • Sending reminders to patients for follow up
    • Providing decision support tables and FAQs
  • Dr. Graham provided a snapshot of her institution’s EMR HBV vaccination prompt to providers as an example of EMR support.

Challenges of interpreting HBV serologies and how to support providers

  • Screening and immunization became complicated with the Centers for Disease Control and Prevention (CDC) recommendations for screening and testing that were not integrated with existing United States Preventive Services Task Force (USPSTF) screening recommendations. As a result of the confusion and frustration created by multiple recommendations, only risk-based testing for adults is consistently covered by insurance.
  • What if there is HBV serology data on the patient?
    • Some institutions may not be testing but may still have data on hepatitis B serology of the patient. The guidance for vaccination, in that case includes the following: using a series of tests that presents evidence of past recurrent hepatitis B infection; asking about whole courses of prior vaccination combined with considering evidence of past or current epidemic infection that may indicate exposure; and using that information to decide about vaccination.
    • For screening, a hepatitis B screening panel set that includes the three tests recommended by USPSTF and CDC – comprising surface antigen, surface antibody, and core antibody – is recommended.
      • Someone with no evidence of infection from these three screens, and without documented receipt of a full vaccine series, should receive vaccination.
      • Someone who screens positive with an isolated surface antigen test is almost always a false positive and needs retesting but can also begin the vaccine series.
      • Someone who screens positive with an isolated hepatitis B core antibody test is a source of a lot of confusion, and institutions may want to refer them to a hepatitis B specialist. But more questions can be asked in this case and, almost always, the answer is not to vaccinate someone who is isolated core antibody positive, which has a very low rate of false positives.
  • Communication with patients is a critical part of the decision-making process. Letters can provide information and can suggest a consultation at the patient’s next appointment.

Hepatitis B is a vaccine-preventable disease and can be eradicated. Electronic health record companies and healthcare organizations may need positive pressure to begin to implement these best practices and increase screening and immunization rates.

QUESTIONS & ANSWERS

Q: The USPSTF has not given the screening recommendation component a category A or B recommendation level, yet, meaning payment coverage by payors for screening becomes a bit more challenging. Can you give advice as to how your institution is handling that?
Camilla Graham (Beth Israel Deaconess Medical Center/Harvard Medical School): We are not doing universal screening because one of our sister organizations tried to do that and had a lot of charges unreimbursed. So that was a hard lesson. Right now, for example, if someone is being screened for sexually transmitted infections, they’re being considered for PrEP… if they have other obvious risk factors, that’s a grade B; those are all reimbursed. If a patient has elevated liver enzymes, this is part of your medical workup. So there are lots of reasons for someone to get screened: if you look at all the risk factors, about 70% of adults fit into one or more categories. So you can probably figure out something that justifies the need to test for hepatitis B. But a lot of doctors are really pressed right now and just that little extra mental effort is often more than we should be asking of people right now. I’m hopeful that we will have those recommendations revisited because, as we’ve seen from the relationship between hepatitis B serologies and vaccines, if you do a screening program, you dramatically increase your vaccination rates because people see, “Oh my gosh, this person has never been exposed to hepatitis B and I don’t have any documentation, I need to vaccinate them.” So, whether they should be or not, they’re intimately connected. And success in vaccines is going to require broader screening programs for hepatitis B serologies, besides the fact that we’ve got two million people and 60% of them haven’t been diagnosed, besides the fact that we’ve got people with chronic disease that needs to be diagnosed, we’ve got lots of reasons to implement universal screening.

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Flu Coverage Rates

A review on uptake of influenza vaccines based on private claims data for all manufacturers and all age groups in the medical and retail claims setting for influenza vaccine was provided. Unfortunately, rates are trending downward as compared with trends for last year.

Influenza Vaccination Trends

  • Flu vaccinations in the U.S. adult population
    • Overall, flu vaccines delivered in medical settings are down 1.1% compared with last year, and flu vaccinations delivered in retail settings are down 0.5% compared with last year.
    • The largest impact of the overall decline is occurring in those ≥18 years of age.
    • For those 50 to 64 years of age (62 million Americans), flu vaccinations are declining compared with last year and versus historical rates in 2022.
    • For those ≥65 years of age, a population with some of the highest risk factors and in which influenza can be devastating, flu vaccinations are declining compared with last year.
  • Flu vaccinations in the pediatric population
    • Overall, the news is good in this area: for children under the age of 5, there has been significant growth this year, compared with prior seasons, where we had seen declines.
    • For those 6 to 11 years of age, flu vaccinations are increasing.
    • For those 12 to 17 years of age, flu vaccinations are increasing.
  • Looking at the data for total flu claims across the U.S. by age for the current season (2024-2025) versus the prior season (2023-2024), reveals national trends by age group.
    • Overall, the national claims average is up 22%.
    • The national claims average for those 18 to 49 years of age is down 2.6%.
    • The national claims average for those 50 to 64 years of age is down 7.2%.
    • The national claims average for those ≥65 years of age is down 5.6%.
  • There are noticeable differences in flu vaccination statistics dependent on U.S. state. Some states are ramping up work on vaccination efforts, which has an impact. Some areas are experiencing pharmacy deserts, with more and more pharmacies closing in certain areas.

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Rural Vaccination Disparities and Successes of Partners in the Field – Julie Zajac, MPH, Senior Evaluator Immunization Services Division, CDC, and Michelle Rodgers, PhD, EXCITE Program Director, and Lindsey McConnell-Soong, MS, Program Manager, Idaho’s Well Connected Communities Initiative, EXCITE Program

Julie Zajac, MPH, Michelle Rodgers, PhD, and Lindsey McConnell-Soong, MS gave an accounting of rural vaccination disparities and successes.

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Rural Vaccination Disparities and Successes of Partners in the Field

Work is being done in rural communities with the Extension Collaborative on Immunization Teaching & Engagement and land grants.

CDC Rural Health Initiatives & Partnerships

  • The Office of Rural Health has released a seminal report on the leading causes of death in rural areas: three are health conditions for which recommended adult immunizations can lessen the chance for severe illness and mortality.
    • Barriers to healthcare in rural areas include transportation issues, health insurance coverage, health literacy, stigma associated with getting healthcare, privacy issues, and workforce shortages.
    • Socioeconomic factors also influence the health of rural adults.
  • The Office of Rural Health has recently released their strategic plan. Key priorities include the following:
    • Advancing partnerships
    • Strengthening infrastructure and workforce in rural areas
    • Advancing the science
    • Improving preparedness and response capacity
  • National partners addressing rural health include the Health Resources and Services Administration (HRSA), CDC, the United States Department of Agriculture (USDA), the National Organization of State Offices of Rural Health (NOSORH), the National Association of Rural Health Clinics (NARHC), the National Rural Health Association (NRHA), and the Extension Collaborative on Immunization Teaching & Engagement (EXCITE).

Rural Adult Vaccination Coverage Disparities

  • For the 2023-2024 season, data show generally lower vaccination coverage status in rural versus urban communities, according to several factors.
    • For flu vaccination coverage, there was a 7.4 percentage point difference between urban and rural vaccination status, approximately a 30 percentage point difference between insured versus non-insured status, and a range of 7.4 to 15.4 percentage point difference between those with incomes above poverty level and those below poverty level.
    • For COVID-19, there was a 6.1 percentage point difference between urban and rural vaccination status, a 13.2 percentage point difference between insured versus non-insured status, and a range of 5.8 to 12.7 percentage point difference between those with incomes above poverty level and those below poverty level.
    • For RSV, there was a 4.1 percentage point difference between urban and rural vaccination status for RSV, a 17.6 percentage point difference between insured versus non-insured status, and a range of 8.3 to 12.9 percentage point difference between those with incomes above poverty level and those below poverty level.
  • For flu, for the period of August 2024 to October 2024, cumulative totals are as follows: rural, 24.2%; urban, 26.5%; suburban, 29.6%; national, 28.1%.
  • For COVID-19, for July 2024, cumulative totals are as follows: a 7.4 percentage point difference between rural and urban vaccination and a 3.4% difference between rural and urban populations who said they intended to get vaccinated.
    • To support and encourage people who intend to get vaccinated, partnering organizations can answer questions, provide further education, and use motivational interviewing techniques, for example.
  • For RSV, cumulative totals are as follows: rural, 28.8%; urban, 28.1%; suburban, 31.7%; national, 30.7%.

Factors Affecting the Rural Immunization Landscape

  • Strategies to address vaccine confidence, derived from February 2023 Rural Adult Immunization Listening Sessions, include interventions such as community outreach and the use of trusted messengers, frequent touch points, provider education on vaccines and confidence messaging, partnerships with pharmacists.
  • In February 2023, CDC’s State of Vaccine Confidence Insights Report included concerns among patients about safety, long-term side effects, effectiveness, and the necessity of vaccines; lower levels of vaccine access and confidence; and lack of trust in government and science.

What Can Be Done?

  • Recognize that rural health care providers are trusted messengers and that delivery of strong and persistent recommendations on vaccination for patients and families is key.
  • Employ vaccine technology innovations, such as using non-needle approaches to lessen anxiety and fear.
  • Employ long-term strategies to rebuild trust in institutions and systems, with partnerships like the EXCITE project, for example.

National Rural Health Day – November 21, 2024

  • The tagline for this event is “Celebrating the Power of Rural!”
  • There is a promotional toolkit available to share with constituents.

EXCITE Project Overview

  • EXCITE is an interagency agreement between CDC and USDA.
  • At the start, the focus was on COVID-19 but the program addresses all adult immunization and has the goal to reduce vaccine hesitancy in medically underserved and rural communities.
  • The Cooperative Extension is federally (USDA), state (land grant university), and locally (in every county or parish in the US) organized. It is a national network that shares lessons learned, curriculum, and experiences.
    • There are more than 3,000 offices in communities, with academic faculty and staff embedded in the community.
    • There are 112 land grant universities, including historically black colleges and universities and tribal colleges and universities.
    • The focus is on using the trusted messenger approach with research- and science-based information and combatting misinformation and disinformation.
  • Areas of work in EXCITE include the following:
    • EXCITE 3: adult immunization education
    • Engaging new partners: immunization education
    • Bridge funding: expansion of existing immunization education scope
    • Adult immunization education, integration, and awareness
    • Recruiting new immunization educators and establishment of a sustainable model for integration of vaccine education
    • H5N1: education program focused on Cooperative Extension dairy agents and producers.
  • EXCITE by the numbers:
    • Reach = more than 23 million
    • Engagement & Activities = 179,954
    • Vaccination Clinics = 1,109
    • Immunizations = 48,909
  • The Cooperative Extension is also taking training on science, media literacy, and motivational interviewing, in addition to neuromarketing of their own materials.

EXCITE – University of Idaho Extension – Poverty-Informed Approach

  • The University of Idaho applied poverty-informed care when working to decrease vaccination hesitancy and increase adult uptake of immunizations. The EXCITE team coaches public health partners in direct application of strategies for immunization work with populations experiencing poverty. Strategies include the following:
    • Encouraging public health teams to establish or expand partnerships with, for example, local food pantries or schools that participate in the Community Schools model.
    • Offering immunization education and vaccines at community events; for example, at a car seat safety check event.
    • Focusing on simple but powerful messaging, for example a Tdap campaign for families with new babies: “Don’t give them everything,” which highlights the fact that adults can pass pertussis to infants and reminding that boosters are needed every 10 years.

QUESTIONS & ANSWERS

Q: Idaho is one of the states that has had outbreaks of H5N1 among dairy herds. Can you talk about how well placed you are to address this?
Lindsey McConnell-Soong (EXCITE): I haven’t been directly involved in those efforts, but I know from our last EXCITE project, one of our approaches was taking educational mobile vaccine clinics directly to our dairies. So having that combination of our dairy and farm specialists delivering information about immunizations… it was just phenomenal to see the impact that having a non-medical but also trusted authority provide that information, especially if that trusted authority could be somebody who was culturally like the audience, which ours was, and speaking a similar language. Having that background really made a huge impact in those who were planning to get immunizations before the clinic and those who actually did.

Q: What do you think some of the reasons might be for seeing the bump in pediatric influenza vaccination, Courtney? And, Lindsey, do you have any insights into how that’s going in rural areas, places like Idaho?
Courtney Peters (Sanofi): I think it’s probably multifaceted: strong campaigns from CDC and their continuation with Wild to Mild, as well as some of the efforts in communications plans from the American Academy of Pediatrics. But also, and it’s unfortunate, the motivation from the record number of pediatric deaths last year probably had an impact on what we’re seeing in uptake, as well. I wish there was one thing we could point to, so we could replicate it everywhere, but I think those would be the three things that we’ve seen and are hearing thus far.
Lindsey McConnell-Soong (EXCITE): We’ve focused mostly on adult immunizations, but I think if there’s been an increase in our rural communities in having mobile vaccine clinics or having our community health partners come to schools and these sites that families can more easily access, I would imagine that’s an important piece of it.

Q: Could you comment on the challenges rural health clinics are having with billing for influenza vaccination this season, in Colorado in particular, but also generally?
Courtney Peters (Sanofi): Some challenges have existed with the transition of quadrivalent to trivalent vaccines, but I’d love to connect to see what we can do in terms of supportive services to try to help get the underlying issue resolved.
Carolyn Bridges (Immunize): Whoever is having billing and payment problems for flu is in good company: lots of people are having challenges with CPT codes being delayed and insurance codes not being updated. It has been a real challenge for providers to get paid this year.

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Announcements
  • Upcoming Summit webinars include the following:
    • November 21: Nicole Richardson Smith, from CDC, will be presenting about National Influenza Vaccination Week (NIVW).
    • December 12: Carla Black and Alicia Budd, both from CDC, will be presenting about both the vaccine coverage surveillance, as well as disease and virologic surveillance.

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