Influenza Update. Kelly L. Moore, MD, MPH Medical Director, Immunization Program TN Department of Health TPHA Epi Section September 3, 2009

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1 Influenza Update Kelly L. Moore, MD, MPH Medical Director, Immunization Program TN Department of Health TPHA Epi Section September 3, 2009

2 Outline Epidemiology to date What to do until vaccine protects Vaccine update Distribution process and challenges

3 Epidemiology/Surveillance Pandemic H1N1 Cases Rate per 100,000 Population by Age Group As of 09 JULY 2009 (n=35,860*) Rate / 100,000 Pop by Age Group n= n= n= n= n= Yrs 5-24 Yrs Yrs Yrs 65 Yrs Age Groups *Excludes 1,386 cases with missing ages. Rate / 100,000 by Single Year Age Groups: Denominator source: 2008 Census Estimates, U.S. Census Bureau at:

4 Epidemiology/Surveillance Pandemic H1N1 Hospitalization Rate per 100,000 Population by Age Group (n=3,779) as of 09 JULY 2009 Hospitalizations per 100,000 Population in Age Group n= n= n= 178 n= 906 n= Yrs 5-24 Yrs Yrs Yrs 65 Yrs Age Group *Hospitalizations with unknown ages are not included (n=353) *Rate / 100,000 by Single Year Age Groups: Denominator source: 2008 Census Estimates, U.S. Census Bureau at:

5 Epidemiology/Surveillance Pandemic H1N1 Hospitalizations Reported to CDC Underlying Conditions as of 19 JUN 2009 (n=268) 32% 32% 27% 18% 13% 14% 15% 7% 7% 8% 9% 10% 6% 6% 8% 4% 3% 0% 7% 6% 8% 1% 1% 0% 0% 4% Cancer Seizure Dis Pregnant Neuromuscular Dis Neurocognitive Dis Obesity Current Smoker Chronic Renal Dis. (st. III&IV) Immunocompromised Chronic CVD* Diabetes COPD Asthma 35% 30% 25% 20% 15% 10% 5% 0% Prevalence, Hospitalized H1H1 Patients Prevalence, General US Pop *Excludes hypertension

6 Week 33: National Specimen Types

7 Week 33: Cumulative Pediatric Deaths

8 Week 33: National ILINet

9 Week 33: Region IV (Southeast)

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13 Almost all children recover in a few days, but not always

14 Recommended Strategies: Stay Home when Sick Individuals with ILI should remain home for at least 24 hours after they are free of fever or feverishness without the use of fever-reducing medications 3 to 5 days in most cases Avoid contact with others Can shed virus before fever, > 24 hours after fever ends, without any fever, and while using antivirals Hand hygiene Respiratory etiquette Longer exclusion period may be appropriate for settings with high numbers of high-risk persons

15 Recommended School Responses (Similar Severity as in Spring 2009) Stay home when sick Separate ill students and staff Hand hygiene and respiratory etiquette Early treatment of high-risk students and staff Routine cleaning Consideration of selective school dismissal

16 Summary of Antiviral Resistance, U.S Antiviral Seasonal A (H1N1) Influenza viruses Seasonal A (H3N2) Seasonal B Adamantanes Susceptible Resistant No activity Pandemic H1N1 Resistant Oseltamivir Resistant Susceptible Susceptible Susceptible Zanamivir Susceptible Susceptible Susceptible Susceptible

17 Pandemic H1N1 Vaccine FDA-Licensed Ages: Same as Seasonal (% of total supply) 26.4% 45.7% 18.7% 3.4% MedImmune (FluMist ) 5.8% 0.2 ml nasal spray 2-49 years, healthy

18 Vaccine ancillary supplies: provided with the vaccine 100-dose kit in a separate box to accompany the 100 dose box of vaccine Needle/syringe units for multidose vials Sharps containers Alcohol pads A wallet sized record of immunization (proposed have not seen it yet)

19 ACIP Priority Recommendations (lists in no particular order) July 29, 2009 When supply limited or adequate: Pregnant women People who live with or care for children <6 months old Health care and emergency medical services personnel Persons 6 months through 24 years of age People 25 through 64 years who are at higher risk because of chronic health disorders or compromised immune systems If supply very limited: Pregnant women People who live with or care for children <6 months old Health care and emergency medical services personnel with direct patient contact Children 6 months through 4 years of age Children 5 through 18 years who have chronic medical conditions

20 Summary vaccination of population groups over time Increasing vaccine availability and demand met by immunization programs Consult local public health authorities 1 Proportion of population 0.5 Primary target groups* Pregnant women Infant contacts HCP/EMS Persons 6m 24y Adults high risk <65y (159 million) Healthy adults (103 million) Adults 65+ (38 million) 0 Population groups ACIP Influenza Workgroup Considerations. ACIP Meeting, July 29, *Note prioritization of ~42 million persons within primary target groups if vaccine demand exceeds availability: 1)pregnant women; 2) contacts and care providers for infants <6 months old; 3) HCP/EMS with direct contact with patients or infectious material; 4) children aged 6m through 4 y; and, 5) children aged 5y through 18 y with chronic medical conditions

21 Current dose estimates for TN through October: Ship beginning mid-october (Not distributed until 10/15)

22 TWIS Pre-Registration for Private Providers Collects shipping and contact details of providers willing to vaccinate Not necessary for providers in VFC Program Not necessary for providers to whom shipments may not be sent or those seeking information only Not for facilities and persons who are not legitimate immunization providers

23 Pre-Registration Contd. Not being used for major pharmacy chains (agreements at corporate level, shipments to their distributor so they handle distribution among outlets) Pre-registered providers get weekly or more frequent updates on information Storage guidance Federal provider agreement updates Instructions for ordering when available

24 Federal Provider Agreement Federal requirements are fixed States will put agreement on state letterhead and collect agreements Corporate office may sign on behalf of outlets where the agreement will be used (e.g., retail pharmacy chains) All who receive vaccine (even small quantities) must sign one (e-signature ok)

25 Terms of Federal Provider Agreement (1) Agree to administer vaccine in accordance with ACIP recommendations Store and handle vaccine properly Provide VIS and counsel recipients before vaccination Record each vaccine administered in medical record or office log Date, site, vaccine type, lot #, name of provider Keep record for at least 3 years Report moderate or severe adverse events to VAERS

26 Terms of Federal Provider Agreement (2) Cannot charge for vaccine or supplies, nor sell them May charge/bill administration fee Fee may not exceed regional Medicare fee If billing TennCare MCO, cannot exceed the negotiated vaccine administration fee May refer persons who cannot pay fee to public health Must report number of doses given as requested by state health department Must report to state doses unused because expired or wasted. Must dispose of them appropriately. Encouraged to provide immunization record card to recipient (included with vaccine supplies)

27 Required Weekly Dose Administered Data

28 Vaccine Dose Administered Reporting Health Departments will document shots administered in Registry Off-site clinics will use TWIS Quick, accessed through internet, will update existing PTBMIS records automatically Shots given in HD put in PTBMIS as usual Clinically valuable because 2 doses needed Possibility that federal funds for implementation linked to doses given by public health All private providers strongly encouraged to enter data (already registered for TWIS)

29 Next Steps In Development Mechanism for provider agreements Assignment of PIN numbers Establish mechanism for collection of initial orders Lots will be continuously released, partial shipments distributed Will a few days notice of shipments be possible? If so, how would TDH do it? Mechanism for re-orders ( , fax, phone?) Structure for responding to vaccine shipment problems ( , phone?)

30 Conclusions Signs of wave 2 already picking up in Southeast Colleges, school Non-pharmaceutical strategies primary Surveillance for circulating virus strains through SPN is critical treatment choices depend on it Vaccination is best Not early enough to significantly affect wave 2 (protection is ~2 weeks after 2 nd dose) Still important for uninfected a spring wave 3 is possible based on historical pandemics!

31 Vaccine only works if you get it. v