Shoo the Flu Why & How to School NCASM Spring Conference March 2, Flu Impact. Overview. Flu in Alameda County. How/Where to Report

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1 Shoo the Flu Why & How to School NCASM Spring Conference March 2, 2018 Erica Pan, MD, MPH, FAAP Director, Division of Communicable Disease Control & Prevention Deputy Health Officer Alameda County Public Health Department Clinical Professor, Pediatric Infectious Diseases Overview Flu Impact Epidemiology, Surveillance & Reporting Flu Vaccine Basics Formulations Recommendations Rates School Located Flu Vaccine Clinics Why immunize at schools? Shoo the Flu Program Evaluation of Shoo the Flu impact Flu Impact Flu in Alameda County Annual estimates: 111, ,000 illnesses* ~ hospitalizations^ o seasons ~$ million* * Mao, Yang, et al International Journal of Health Geographics 2012, 11:16 ^California Emerging Infections Program What s Reportable (clinicians)? Immediately by phone Concern for novel flu Outbreaks Residential settings >2 within 72h Within 7 days: Deaths* <65 years ICU Admissions* <65 years Voluntary *lab confirmed Other Actions: Infection Control Standard & Droplet Precautions IF novel flu suspected LAB reportable Submit to PHL for testing How/Where to Report Report to local health jurisdiction where case resides disease/disease reporting and control 1

2 Alameda County flu deaths trends How bad is flu this year? As of 2/23/18 As of week 7 2/17/18 Hospitalizations Alameda, CoCo, SF Lab data: % positive flu trends CA As of week 7 2/17/18 (Alameda, Contra Costa, SF) As of week 7 2/17/

3 Flu Vaccine Flu Vaccine 101 The influenza virus is unique - "antigenic drift" requiring annual vaccination Every year scientists predict the predominant strain Between vaccine production and administration - strains can mutate or a non-predicted strain can emerge After flu season, researchers and the ACIP review vaccine effectiveness data and make recommendations for the following season Advisory Committee on Immunization Practices (ACIP) Recommendations Routine annual influenza vaccination for all persons 6 months of age who do not have contraindications Increased importance for: People aged 6 months who are at high risk of complications and severe illness Contacts and caregivers of these people, and of infants under age 6 months (because there is no vaccine approved for children this age) At high risk for complications/severe illness: Ages <5 years and 50 years; Persons with chronic pulmonary (including asthma) disease Cardiovascular (except isolated hypertension), renal, hepatic, neurologic, hematologic, or metabolic disorders (including diabetes mellitus); Immunosuppressed persons; Pregnant women; Children and adolescents receiving aspirin therapy Children at risk for experiencing Reye syndrome after influenza virus infection; Residents of nursing homes and other long term care facilities; American Indians/Alaska Natives; and Persons who are extremely obese (BMI 40) Flu Vaccine formulations 13 products! Trivalent or quadrivalent 2 A antigens, 1 2 B antigen changes yearly Inactivated vs Live attenuated IM vs intranasal vs intradermal Flu antigen dose standard vs high Egg grown vs recombinant vs cell culture Flu Vaccine alphabet soup Changes in nomenclature: Inactivated Influenza Vaccine (IIV#) Live attenuated Influenza Vaccine (LAIV#) Recombinant hemagglutinin Influenza Vaccine (RIV) Cell culture based vaccine (cc) 3

4 How is the vaccine match this year? Vaccine Efficacy U.S. Overall efficacy estimate ~36% (27% 44%) All ages by flu strain type: A (H3N2) 25% (CI = 13% to 36%) A(H1N1)pdm09 67% (CI = 54% 76%) B 42% (CI = 25% 56%) Specific age groups: 6mos 8yo: 59% (44 69%) yo: 33%(16% 47%) As of week 7 2/17/ % 40% 35% 30% CAIR Flu Vaccination rates By Year and Youth Age (3 14yo) CHIS Rates 5 11yo Alameda County Vaccinated for flu in last 12 mos 53.4% 64.6%* 73.2%* 25% 20% 15% 10% 5% 0% CA Immunization Registry incomplete flu vaccine data CA Health Interview Survey (CHIS) * Statistically unstable School-located Influenza Vaccination (SLIV) 4

5 Why vaccinate at school? Increase vaccination in school-age kids Young children are super spreaders Community Immunity Reduce absenteeism Cost savings: Direct: health care costs Indirect: work days lost Safe and convenient for parents Influenza vaccination coverage in intervention and control schools by school-located vaccination (SLV) and community physicians, as documented in the Los Angeles-Orange County California immunization registry, Pia S. Pannaraj et al. Clin Infect Dis. 2014;59: The Author Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please Why Focus on School Children? Children are super-spreaders and the most common sources of influenza transmission in the community: highest rates of flu infection, higher viral load once infected, shed more virus and are contagious for longer have poor cough-etiquette and hand washing habits. have a high level of social connectivity. generally have an effective response to vaccination. Computer modeling suggests that immunizing 20% of children in a community is more effective at protecting >65 year olds than immunizing 90% of the elderly. (Weycker D,e t al. Vaccine 2005; 23(10)1284) Community Immunity Vaccinating children can benefit the entire community: Reduce rates of flu infection, especially in the elderly Reduce student and teacher absences due to illness Parents/caregivers do not need to take time off work to care for sick children Research suggests that vaccinating 70% of school children can protect entire community from flu (Longini, et al, Vaccine 2000; 18(18):1902) Japan saw decrease in flu and pneumonia deaths after implementing nation-wide vaccination School based Flu Vaccine Impact Bars in green represent schools that participated in flu vaccine program benefits extended to adults and older children in the intervention school households King JC, Stoddard JJ, Gaglani MJ, et al. Effectiveness of school based influenza vaccination. N Engl J Med 2006;355:

6 LA County: Flu Season MEDI CAL lab tested Pia S. Pannaraj et al. Clin Infect Dis. 2014;59: What is Shoo the Flu? Shoo the Flu Four-year program vaccinating a large number of Oakland school children at school against influenza Goal is to increase vaccination coverage and evaluate if this delivery model is effective in limiting community-level transmission. Vaccinate all who consent, regardless of insurance status Includes a clinical impact study to evaluate child, family and community level outcomes. Shoo the Flu Program Overview CDPH OUSD CEIP Parents/guardians fill out consent 2 3 weeks ahead of clinics Clinics held at school sites during school hours Up to 7 clinics per day over 5 6 weeks Vaccine provided to students, staff and volunteers Clinics staffed by: ACPHD and OUSD staff, contracted nursing staff, volunteers (nursing schools, high school students, MRC) Other charter/ private schools Collaboration 6

7 Evaluation UCB team independently evaluating impact of the program on flu illness, flu vaccination rates, and absenteeism. Current analysis plan includes using: Vaccine coverage rates School absenteeism data CEIP flu surveillance data Lab flu testing Collaboration with Kaiser Vaccine Study Center for clinical impact Year 3 analysis (16-17 season) available later this year A Unique Opportunity Broadly use one of our best tools of prevention: vaccination Provide access and decrease health disparities by removing barriers to vaccination Practice public health response to provide mass vaccination to the community Build coalition/collaborative across Oakland to make SLIV routine Build a sustainable financial model to expand the service Contributions from health insurers Acknowledgements ACPHD: Shoo the Flu & IZ team: Kate Holbrook, Katherine Aguirre, Amy Pine, Crystal Scott, Catharine Ratto Rita Shiau epidemiologist UC Berkeley School of Public Health Oakland Unified School District California Department of Public Health Page Family Foundation - Casey Wright CA Emerging Infections Program Pam Daily Special thanks to participating schools & parents/guardians and their students who signed up for StF! 7