January 28, 2014


Summit Call Recap – January 23, 2014
Summit Call Recap – January 16, 2014
News Highlights


Announcements – L.J Tan, IAC

L.J reminded call participants that it is important to keep promoting influenza vaccine. Persons needing to order vaccine may check the Influenza Vaccine Availability Tracking System (IVATS). This system is current through January 16. L.J thanked distributors for voluntarily submitting information to IVATS.

The 2014 National Adult and Influenza Immunization Summit meeting will take place on May 13–15 in Atlanta, Georgia. Information on registration and booking a hotel room will be posted in the near future. Based on feedback received during last year’s meeting, the 2014 event will last 3 full days. Persons considering attending the meeting should plan to arrive on May 12 and depart in the late afternoon or evening of May 15.

Influenza Surveillance Update – Scott Epperson, CDC

Scott reported that seasonal influenza remains at fairly high levels, and 2009 H1N1 is still the predominant strain. Through Week 2 (ending January 11, 2014), there has been a slight decline in submissions to CDC for testing. However, all 10 public health regions report being above their baselines for outpatient visits attributed to ILI. In particular, activity remains strong in the northeast, mid-Atlantic, and west coast regions. Scott cautioned callers that it is important to examine regional data and not rely solely on the national report, which may “hide” more localized activity levels.

The overwhelming majority of the specimens submitted to CDC for testing have been characterized as 2009 H1N1, and 99.8% of these have been similar to the strain found in this year’s vaccine. The one case (1/648; 0.2%) of 2009 H1N1 that has drifted is antigenically different, so we shouldn’t expect any substantial impact from this.
No real changes have been observed in the trends on hospitalizations or pediatric deaths. Ten new pediatric deaths were reported during Week 2, bringing this season’s total to 20. Three of the 20 (15%) were ineligible for vaccination. Only 1 of the 15 pediatric cases with a known vaccine history was fully vaccinated.

The number of influenza H7N9 cases detected in China has been increasing in recent weeks. Eighty-four (84) cases have been reported since October 2013, and this number may increase when the WHO updates its statistics later today. Thirteen of the 84 (16%) cases have resulted in a fatality. A total of 219 cases have been reported since H7N9 was first detected last year. Scientists are concerned about the potential for additional transmission during the upcoming Lunar New Year, when many people in China will travel from urban areas (where most cases have been identified) to more rural areas of the country. To date, transmission remains associated with poultry; there is no suggestion of human-to-human transmission. At this point, China has not recommended decreased contact between humans and poultry.

Recommendations have been made for routine disinfection, etc., but it is up to each health jurisdiction to determine how they will implement these recommendations. Currently, markets are expected to remain open during the holiday season.

A caller questioned whether information is available on how well wild type H3N2 viruses react with antisera to egg grown strains, but Scott was unfamiliar with any data on this. In addition, a question was asked about the high activity level of H1 strains in age groups that previously had a lower incidence. Scott reported that the rates of hospitalization are not necessarily higher than what we have seen in adult age groups in previous years. However, the proportion of hospitalizations in the 18-64 year age group is higher, at just over 60%. We saw higher rates of infection in young adults in 2009. Scott speculated that the lower rates now could be a combination of pre-existing immunity and higher vaccination rates.

Scott reported that the interim vaccine efficacy data for this season should be released in mid-to-late February. There was a brief discussion about the cost-benefit of using quadrivalent vaccine in healthcare workers. However, the benefit is difficult to determine because it depends upon how well the B strains in the vaccine match each year’s circulating virus. Two papers regarding IIV4 and IIV3 cost effectiveness are listed below:

Lee BY, Bartsch SM, Willig AM. The economic value of a quadrivalent versus trivalent influenza vaccine. Vaccine. 2012;30:7443-6.

Reed C, Meltzer MI, Finelli L, Fiore A. Public health impact of including two lineages of influenza B in a quadrivalent seasonal influenza vaccine. Vaccine. 2012 Mar 2;30(11):1993-8.

Partner Updates

NACCHO has been funded by CDC to collect information on vaccination of children with special needs or disabilities. Anyone with resources to contribute on this subject may contact Rebecca Gehring.


Influenza Surveillance Update – Scott Epperson, CDC

Scott reported that influenza activity remains high in the U.S., with widespread activity being reported by 40 states. Approximately 25% of specimens tested and reported during week 2 (January 5–11) were positive for influenza. The proportion of deaths attributed to pneumonia and influenza (P&I) was above the epidemic threshold. During the week, 3.6% of outpatient visits were due to ILI, which is above the national baseline of 2.0%.

Unfortunately, ten influenza-associated pediatric deaths were reported during week 2. Of these, 7 were associated with 2009 H1N1, 2 were influenza A but no subtyping was performed, and 1 was not associated with a particular virus.
The vast majority (99.8%) of specimens tested for antigenic characterization were 2009 H1N1, a component of this year’s vaccine. All H3N2 and influenza B specimens also are contained in this year’s vaccines.
Updated surveillance information is available at CDC’s FluView website.

Review of Antiviral Treatment Recommendations – Angela Campbell, CDC

Angela began her presentation by acknowledging that vaccination remains the best method for preventing influenza, and it is not too late to encourage everyone age 6 months and older to be vaccinated. However, many younger adults, particularly if they are healthy, are less likely to be vaccinated. Early estimates indicate that only 31% of persons age 18–49 years had been vaccinated by mid-November, which is 10% lower than the national average. Angela also emphasized the importance of vaccination for pregnant women.

In spite of vaccine recommendations, not everyone is vaccinated, and some vaccinated persons will still get influenza. For these persons, initiation of treatment with antiviral medications soon after illness onset can help reduce severe outcomes. Clinical trials and observational data show that early antiviral treatment may shorten the duration of fever and illness symptoms, reduce the risk for complications and death, and shorten the duration of hospitalization.

Antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who is hospitalized; has severe, complicated, or progressive illness; or is at higher risk for influenza complications. Persons at higher risk for influenza complications in whom antiviral treatment is recommended include children younger than 2 years of age, adults 65 and older, pregnant or postpartum women, American Indians and Alaskan Natives, residents of long-term care facilities, persons who are morbidly obese, persons with immunosuppression, and persons with certain underlying medical conditions.

Angela noted that clinical benefit is greatest when antiviral treatment is initiated early. When indicated, antiviral treatment should be started as soon as possible after illness onset, ideally within 48 hours of symptom onset. However, observational studies show that antiviral treatment might still be beneficial in patients with severe, complicated, or progressive illness and in hospitalized patients when started even later than 48 hours after illness onset. However, delay in treatment initiation may result in reduced effectiveness.

Angela also emphasized that decisions about starting antiviral treatment should not wait for test results or laboratory confirmation of influenza. In particular, rapid influenza diagnostic tests (RIDTs) have very poor sensitivity; CDC has had numerous reports of patients who initially test negative by a RIDT, and are later found to have H1N1. Sensitivities of RIDTs are low, generally 40-70%, but a range of 10-80% has been reported compared to viral culture or reverse transcription polymerase chain reaction (RT-PCR). Specificities of RIDTs are approximately 90-95% (range 85-100%). Thus, false negatives occur more commonly than false positives, and they are particularly more common during influenza season. It is important for clinicians to recognize that a negative RIDT result does NOT exclude a diagnosis of influenza in a patient with suspected influenza. When there is clinical suspicion of influenza and antiviral treatment is indicated, antiviral treatment should be started as soon as possible without waiting for results of additional influenza testing. And, of course, a history of influenza vaccination does not rule out the possibility of influenza virus infection in an ill patient with clinical signs and symptoms that are compatible with influenza. For previously healthy outpatients with confirmed or suspected influenza who are not in one of the high-risk groups, clinicians can use their clinical judgment and consider antiviral treatment, especially if treatment can be initiated within 48 hours of illness onset.

Oseltamivir (Tamiflu®) and zanamivir (Relenza®) are recommended this season. Both are neuraminidase inhibitors that are active against both influenza A and B. Oral oseltamivir is FDA-approved for treatment of acute uncomplicated influenza in persons >14 days old. Although its use is not FDA-approved in infants

For outpatients, treatment with either neuraminidase inhibitor is recommended, provided the patient is old enough to receive it and there is no underlying airway disease. For hospitalized patients and patients with severe or complicated illness, treatment with oral or enterically administered oseltamivir is recommended. Inhaled zanamivir is not recommended because of the lack of data for use in patients with severe influenza disease.

A subset of influenza viruses collected for national surveillance and additional specimens from public health and academic laboratories are tested for resistance to neuraminidase inhibitors. Of the influenza viruses tested for resistance, no virus has been found to be resistant to zanamivir, and no influenza B or influenza A(H3N2) viruses have had resistance detected. In H1N1 viruses, 13 (1.2%) have been found to be resistant. Angela commented that such reports are neither unexpected nor unusual. High levels of resistance to the adamantanes (amantadine and rimantadine) continue to persist among H1N1 and H3N2 viruses. Adamantanes are not effective against influenza B viruses. Adamantanes are not recommended for use against influenza this season.

Intravenous (IV) formulations have been developed for three neuraminidase inhibitor medications – oseltamivir, peramivir, zanamivir. However, IV peramivir and IV oseltamivir are currently not available via clinical trial, compassionate use, or Emergency Use Authorization. IV zanamivir is available via clinical trials or for compassionate use by contacting GlaxoSmithKline (GSK). For hospitalized patients and patients with severe or complicated illness, treatment with oral or enterically administered oseltamivir is recommended. Inhaled zanamivir is not recommended because of the lack of data for use in patients with severe influenza disease.

Limited data suggest that oseltamivir delivered by oral or nasogastric administration is generally well absorbed in critically ill influenza patients. However, for patients who cannot tolerate or absorb oral oseltamivir because of suspected or known gastric stasis, malabsorption, or gastrointestinal bleeding, the use of investigational IV zanamivir may be considered. CDC recommends IV zanamivir for severely ill patients with oseltamivir-resistant 2009 H1N1 virus infection. An IV zanamivir compassionate use request may be made by contacting the GSK Clinical Support Help Desk or by calling 1-877-626-8019 or 1-866-341-9160.

During any shortages of oseltamivir oral suspension (for pediatric use), adult capsules are available and can be compounded to an oral suspension. The FDA has posted instructions for pharmacists on how to compound an oral suspension from Tamiflu 75-mg capsules.

CDC currently is updating the novel influenza A virus treatment recommendations – basically same as H7N9 guidance currently posted. The new guidance continues to recommend treatment for all hospitalized H5N1 or H7N9 cases, and for confirmed and probable outpatient cases. Empiric treatment with oseltamivir should be started as soon as possible, without waiting for laboratory confirmation. Outpatient cases under investigation who have had recent close contact with a probable or confirmed H5N1/H7N9 case should receive antiviral treatment, whereas outpatients meeting only the travel exposure criteria for a case under investigation are not recommended to receive antiviral treatment.
Angela provided links to several useful references on antivirals:

Seasonal influenza
Clinical and Laboratory Diagnosis
FDA Current Drug Shortages
Avian Influenza Updated Guidance

CDC/Influenza Division Weekly Influenza Surveillance Report and CDC Key Points

The CDC weekly influenza surveillance report for week 3 (ending January 18, 2014) and region specific data are now available. Of deaths reported through the 111 Cities Mortality Reporting System, 8.1% were due to P&I. This percentage was above the epidemic threshold of 7.2% for week 3.

Eight influenza-associated pediatric deaths were reported to CDC during week 3. Five deaths were associated with a 2009 H1N1 virus and occurred during weeks 1, 2, and 3 (weeks ending January 4, January 11, and January 18, 2014). Three deaths were associated with an influenza A virus for which no subtyping was performed and occurred during week 2 (week ending January 11, 2014).

A total of 28 influenza-associated pediatric deaths have been reported during the 2013–2014 season from 17 states (AR [2], CA [2], FL [1], GA [1], IA [1], KY [1], LA [1], MA [1], MI [1], MS [1], NC [1], OK [1], OR [1], TN [4], TX [7], VA [1], and WV [1]).

Nationwide during week 3, 3.4% of patient visits reported through the U.S. Outpatient Influenza-like Illness Surveillance Network (ILINet) were due to influenza-like illness (ILI). This percentage is above the national baseline of 2.0%. ILI is defined as fever (temperature of 100°F [37.8°C] or greater), and cough and/or sore throat. An Influenza Summary Update of the influenza activity reported by state and territorial epidemiologists, which indicates geographic spread of influenza viruses but does not measure the intensity of influenza activity, is available.

During week 3, thirteen states (Arkansas, Kansas, Louisiana, Minnesota, Mississippi, Missouri, New Mexico, North Carolina, Oklahoma, Oregon, Tennessee, Texas, and Virginia) experienced high ILI activity. Seven states (Alabama, Colorado, Delaware, Idaho, Nevada, Utah, and West Virginia and New York City) experienced moderate ILI activity. Fifteen states (Alaska, Arizona, California, Illinois, Indiana, Kentucky, Maryland, New Jersey, Pennsylvania, Rhode Island, South Dakota, Vermont, Washington, Wisconsin, and Wyoming) experienced low ILI activity. Fifteen states (Connecticut, Florida, Georgia, Hawaii, Iowa, Maine, Massachusetts, Michigan, Montana, Nebraska, New Hampshire, New York, North Dakota, Ohio, and South Carolina) experienced minimal ILI activity. Data were insufficient to calculate an ILI activity level from the District of Columbia.

Archives of previous FluViews and CDC’s seasonal influenza key points for January 24, 2014 are available for review.

More information from CDC

CDC has updated its key points regarding the first confirmed case of human infection with avian influenza A (H5N1) virus in North America. Additional information on this subject is available for review.

CDC also has released key points and additional information related to recent human infections with avian influenza A (H7N9) virus in China.


2014 NAIIS Immunization Excellence Awards Call for Nominations (Deadline: COB March 25, 2014)

The National Adult and Influenza Immunization Summit (NAIIS) is soliciting candidates for the 2014 NAIIS Immunization Excellence Awards. The 2014 awards recognize individuals and organizations that have made extraordinary contributions towards improving vaccination rates within their communities during 2013. The awards focus on individuals and organizations that exemplify the meaning of the “immunization neighborhood” (collaboration, coordination, and communication among immunization stakeholders dedicated to meeting the immunization needs of the patient and protecting the community from vaccine-preventable diseases). Unless specifically indicated in the award description, the immunization activities should be broader than influenza activity. A National Winner and possibly an Honorable Mention recipient will be selected for each award category, including:
• Overall Flu Season Activities
• Healthcare Personnel Campaign
• “Immunization Neighborhood” Champion
• Adult Immunization Champion
• Corporate Campaign
The winners will be presented with their awards at the National Adult and Influenza Immunization Summit meeting (to be held on May 12-15/Atlanta, GA). The national winner in each category will be invited to present their programs at the National Adult and Influenza Immunization Summit meeting.

CMS Announces Resource on Part D Vaccines

This CMS fact sheet is designed to provide education on Vaccine Payments under Medicare Part D. It includes information on the difference between Part B and Part D vaccine coverage, what Part D covers, and additional information on vaccine coverage under Part D plans. Please feel free to link to this resource from your web pages.

NACCHO Request for Info on Seasonal Influenza for Children/Youth with Special Healthcare Needs

The National Association of County and City Health Officials (NACCHO) has been funded by the CDC to collect educational, promotional, or general resources that focus on seasonal influenza for children/youth with special healthcare needs and people with disabilities. These resources will be shared with local health departments to help support their efforts in reaching these groups. If you have any resources that you would like to share, please email Rebecca Gehring.

National Quality Forum (NQF) Holds Webinar for Feedback on Adult IZ Measures Development

As part of its Multistakeholder Input on Priority Setting for Health Care Performance Measurement – Adult Immunization Project, the NQF will seek to identify critical areas for performance measurement to optimize vaccination rates and outcomes across adult populations. The Adult Immunization Planning Committee will meet via the web on January 29 from 2 – 4 pm ET. The meeting is open to members and the public, and registration is available online.

SAVE THE DATE! 2014 Summit Face-to-Face Meeting Information

The 2014 face-to-face annual meeting of the National Adult and Influenza Immunization Summit will be held in Atlanta, Georgia, at the Hyatt Regency hotel on May 13-15, 2014. As details are finalized, we will continue to inform the Summit partners on the agenda, rooming block, etc. Thank you all for your continued support and participation!

Early Registration for the National Conference on Immunization and Health Coalitions Ends February 14, 2014!

Partnering for Prevention from Sea to Summit is the theme of the 11th National Conference on Immunization and Health Coalitions (NCIHC), which will take place in Seattle, WA from May 21-23, 2014. NCIHC is the only conference solely dedicated to collaboration and partnership as a way to improve the health status of communities. Keynote speakers will include Drs. David Williams, William Foege, Wendy Sue Swanson (Seattle Mama Doc), and Sara Rosenbaum, JD.

Fourteen More Healthcare Organizations Join IAC’s Influenza Vaccination Honor Roll for Mandatory Healthcare Worker Vaccination

IAC urges qualifying healthcare organizations to apply for its Influenza Vaccination Honor Roll. The honor roll recognizes hospitals, medical practices, professional organizations, health departments, and government entities that have taken a stand for patient safety by implementing mandatory influenza vaccination policies for healthcare personnel. More than 350 organizations are now enrolled.
Since January 7th, 2014, the 14 organizations below have been enrolled.
• Alamosa County Public Health Department and Nursing Service, Alamosa, CO
• Cullman Regional Medical Center, Cullman, AL
• Delo Medical Associates, Port St. Lucie, FL
• Florida Hospital Memorial Medical Center, Daytona Beach, FL
• Harrington Hospital, Southbridge, MA
• Holy Cross Hospital, Taos, NM
• Marion County Public Health Department, Indianapolis, IN
• Memorial Health University Medical Center, Savannah, GA
• Three Rivers Health, Three Rivers, MI
• University Medical Center of Southern Nevada, Las Vegas, NV
• University of New Mexico Hospitals, Albuquerque, NM
• Upson Regional Medical Center, Thomaston, GA
• Weber Morgan Health Department, Ogden, UT
• West Central District Health Department, North Platte, NE

Summit Website Offers Wonderful Resources on Influenza Vaccination!

Remember to visit the Summit website for the latest on influenza immunization resources. You also can find archival copies of these newsletters there.


Fever-reducing Medications May Contribute to Spread of Influenza

Researchers from McMaster University recently discovered a correlation between fever-reducing over-the-counter medications and the spread of influenza, and claimed the medications may be responsible for more than 1,000 flu-associated deaths in North America annually.

New Evidence: Diabetes Does Up Risk for Flu-Related Illness

Adults with diabetes show a significantly greater risk for serious illness related to influenza compared with those without diabetes, justifying existing guidelines that call for influenza vaccination in the adult diabetic population, according to new research [4 – Lau – flu and diabetes] published online January 24 in Diabetologia. An additional article on this subject also is available.

China Reports Second H10N8 Case

Health authorities in east China’s Jiangxi Province on Saturday confirmed a second human case of H10N8, a new strain of bird flu known to affect humans. The patient, a 55-year-old woman in Nanchang, capital of Jiangxi, is in a critical condition, the provincial health and family planning department said in a statement.
She had been to an agricultural market, said the statement. Those who had come into contact with her have not shown any abnormal symptoms.

Hong Kong to cull 20,000 chickens after H7N9 found

Hong Kong will cull approximately 20,000 chickens after discovering the H7N9 avian influenza virus in a batch of poultry imported from mainland China, authorities said Monday. The positive reading came just days after the southern Chinese city introduced widespread testing of imported live poultry following growing public concern over the safety of imports, particularly from the mainland. Two people have died from the human form of the virus in Hong Kong since the first infection was publicly reported in December.

First Rapid Molecular Diagnostic Test to Detect Influenza A and B Virus in Under 15 Minutes Now Available in Europe

Alere Inc., a global provider of point-of-care rapid diagnostic and health information solutions, has announced the availability in Europe of the Alere i Influenza A & B test, the first and only molecular test to detect and differentiate influenza A and B virus in less than 15 minutes. The test is now commercially available in Austria, France, Spain, Switzerland, Germany, Italy and the UK. Alere i Influenza A & B is currently under regulatory review in the United States by the US Food and Drug Administration (FDA) and is not available in the US pending completion of such review.

Reminder: Summit calls are scheduled every Thursday at 3:00 p.m. ET, unless cancelled. The next call is scheduled for January 30, 2014. Thank you for your continued participation. Please email L.J Tan or LaDora Woods if you have any updates on activities to provide to the Summit.

Reminder: Please email L.J or LaDora if you have any updates on activities to provide to the Summit.

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