Adult Immunizations New York State Updates Christine Compton, MD, MPH Medical Director New York State Department of Health Bureau of Immunization October 11, 2017 2 Disclosures I have no financial interest in, or conflict with, the manufacturer of any product discussed in this CME activity. I will not discuss any investigational use of any product in this presentation. 1
3 Adults Need Vaccinations Too!! Influenza, Td/Tdap, Pneumococcal (PCV, PPSV), Herpes Zoster, MMR, Varicella, Meningococcal (MenACWY, MenB), HPV, Hepatitis A, Hepatitis B, Hib October 11, 2017 4 Standards for Adult Immunization Practice Assess immunization status at every clinical encounter Strongly recommend needed vaccinations Administer needed vaccinations or Refer Document vaccines received by your patients 4 2
5 Influenza, New York: 2016-2017 Season Available at: https://www.health.ny.gov/diseases/communicable/influenza/surveillance/ October 11, 2017 6 3
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October 11, 2017 9 https://gis.cdc.gov/grasp/fluview/mortality.html 10 Influenza Vaccine 5
October 11, 2017 11 Benefits of Flu Vaccination Reduces the risk of getting the flu (Efficacy varies by age & year) Reduces the severity or illness Reduces the risk of hospitalization in those 50 years by half* Recent study looked at effect of flu vaccination on disease severity in adults hospitalized with flu** Risk of death reduced 21 39% ( 18) ICU admission reduced 63% (18 49, 65) Shortened ICU length of stay 1.34-1.36 days ( 50) Reduces the risk of spreading the flu Reduces time lost from work or school *Havers et al., CID, Volume 63, Issue 10, 15 November 2016 **Arriola et al., CID, Volume 65, Issue 8, 15 October 2017 Influenza Vaccination Coverage, 18 years 2016-2017 12 US: 43.3 % NYS: 45.6 % Source: www.cdc.gov/flu/fluvaxview 6
October 11, 2017 13 Influenza Vaccination Coverage by Age, US and NY 2016-2017 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% U.S. N.Y. HP 2020 Target Source: www.cdc.gov/flu/fluvaxview October 11, 2017 14 100% 80% 60% 40% 20% 0% Influenza Vaccine Coverage by Age, US and NY 2011-2017 37.2% 45.6% HP 2020 Target US children NY children US adults NY adults Source: www.cdc.gov/flu/fluvaxview 7
October 11, 2017 15 Influenza Vaccine Coverage by Age, US and NY 2011-2017 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 Source: www.cdc.gov/flu/fluvaxview 18-49 US 18-49 NY 50-64 US 50-64 NY 65+ US 65+ NY HP 2020 Target October 11, 2017 16 NYS Influenza Vaccination Coverage, by Race/Ethnicity, 6 months and older, 2011-2017 60% 50% 40% White Black Hispanic 30% 20% 10% 0% 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 Source: www.cdc.gov/flu/fluvaxview 8
October 11, 2017 17 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Influenza Vaccination Coverage, Adults 18 years Living in a Nursing Home, 2005-06 to 2014-15 No Vaccine Offer, Decline Not Offered 2006 2014 36.2% 71.9% 43.8% 10.6% US NYS HP 2020 Goal Source: Center for Medicare and Medicaid Services (CMS) Minimum Data Set Black et al., J Am Med Dir Assoc. 2017 Aug 1;18(8):735.e1-735.e14 18 Healthcare Provider Influenza Vaccine Coverage 9
October 11, 2017 19 Regulation for Prevention of Influenza Transmission by Healthcare and Residential Facility and Agency Personnel Effective 2013 2014 flu season Applies to Article 28, Article 36, and Article 40 (hospice) agencies Once flu is declared prevalent by the Commissioner of Health, all personnel who have not received the flu vaccine must wear a surgical mask when in patient care areas Report to the NYSDOH % of personnel vaccinated FluMaskReg@health.ny.gov Median HCP Influenza Vaccination Rates by Year, 2008-2017 Hospitals and Nursing Homes 100% 20 90% 88% 89% 89% 89% 80% 70% 60% 50% 47% 47% 54% Hospitals Nursing Homes Overall 40% 30% HP 2020 Target 20% 10% 0% 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17 10
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Median HCP Influenza Vaccination Rates, by Year and Facility/Agency Type, 2013/14 2016/17 Hospitals Nursing Homes ADHCPs D&TCs Hospices Home Health Agencies LHCSAs 2013-14 2014-15 2015-16 2016-17 HP 2020 Target Median 2016-17 21 October 11, 2017 22 Influenza Vaccination Coverage Among Health Care Personnel, US, 2016-2017 Influenza Season* Vaccination was highest among HCP working in settings where vaccination was required (90 98.3%) If no requirement: o 80.3% coverage if vaccination was available at the worksite at no cost for > 1 day o 73.8% if vaccination available onsite 1 day only o 70.4% if actively promoted but not available onsite o 45.8% not offered onsite, not promoted o Most vaccinated HCP reported being vaccinated at their worksite o Long term care settings had the lowest vaccination rates (68%) o Assistant/Aides and nonclinical personnel had lowest coverage * MMWR September 29, 2017 22 11
23 Flu Vaccine & Tdap in Pregnancy October 11, 2017 24 Flu Vaccination and Pregnancy Pregnant women and their infants are at increased risk for severe influenza-related illness ACIP recommends all women who are or may become pregnant during the flu season receive influenza vaccine Flu vaccination during pregnancy: Reduced the risk of flu-associated acute respiratory infection in pregnant women by up to one-half. 41-63% effective in preventing influenza infection and 39-91.5% effective in preventing hospitalization during the first 6 months of life (transplacental transfer of antibodies) Decreased all-cause acute lower respiratory infection (ALRI) hospitalization during the first 3 months of life* *Nunes et al. CID 2017:65 (1 October) 12
October 11, 2017 25 Receipt of Flu Shot Before or During Pregnancy, by Year, PRAMS, NYS (excluding NYC) 60% 50% Percentage 40% 30% 20% 10% 0% 2012 2013 2014 2015 Before 13.2% 11.9% 10.8% 9.0% During 33.6% 42.5% 47.9% 48.4% October 11, 2017 26 Influenza Vaccination Coverage of Pregnant Women by Provider Recommendation and Offer 80% 70% 60% 50% 40% 30% 20% 10% 0% 53.6% Overall 70.5% Recommend and Offer 43.7% Recommend; No Offer 14.8% No Recommendation CDC Internet Panel Survey 3/28 4/7/2017 67.3% reported Recommendation and offer 11.9% reported Recommendation; no offer 20.7 % reported no recommendation 13
October 11, 2017 27 Tdap Vaccination and Pregnancy Infants are at greatest risk of pertussis-related complications and mortality, especially in the first months of life ACIP recommends one dose of Tdap during each pregnancy in the early part of gestational weeks 27 36 to maximize transplacental antibody transfer Multiple studies show Tdap vaccination during the second or third trimester of pregnancy prevents pertussis in 9 out of 10 infants younger than 2 months of age Also reduces hospitalizations by over 90% October 11, 2017 28 Receipt of Tdap Vaccine Around the Time of Pregnancy PRAMS, NYS (excluding NYC) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 39.9% 13.4% 27.0% 43.7% 52.9% 14.1% 32.3% 32.4% 15.1% 22.3% 17.1% 10.7% 9.5% 25.5% 23.3% 20.5% 2012 2013 2014 2015 None Before During After 14
October 11, 2017 29 Cocooning ACIP recommends that close contacts of the infant be up to date with pertussis and influenza vaccination NYS PHL 2805-h: o Hospitals with NICUS must offer influenza vaccine annually, September 1 to April 1, to all persons who are parents, or who are reasonably anticipated to be caregivers in the households of newborns being treated in NICUs. o Hospitals with newborn nurseries or obstetric services must offer Tdap vaccine to parents and anticipated caregivers of all newborns treated in the hospital following birth October 11, 2017 30 Training Resources: Vaccination in Pregnancy Collaboration with the SUNY Albany School of Public Health, Center for Public Health Continuing Education Series of 5 programs, given by subject matter experts, that address the importance of maternal immunization and how to implement o The Importance of Maternal Immunization o Management of Vaccination Programs for OB-GYN Practices o Using Electronic Medical Records to Improve Tdap Vaccination Rates in Pregnant Women o Communicating with Pregnant Women about Vaccines: Using the CASE Approach to Address Vaccine Hesitancy o Vaccine-Preventable Diseases and the Newborn Infant: The Roles of Serologic Testing and Maternal Vaccination Available at: http://www.albany.edu/sph/cphce/vaccinateny.shtml CMEs are available 30 15
31 Tdap and Td Vaccination October 11, 2017 32 Reported Pertussis Cases in New York State, excluding NYC* Year #Cases 1997 200 1998 357 1999 818 2000 571 2001 175 2002 409 2003 895 2004 2132 2005 662 2006 1044 2007 631 2008 437 2009 275 2010 701 2011 864 2012 2739 2013 778 2014 880 2015 626 2016 677 2017** 439 Confirmed and Probable Cases Reported between 01/01/2016 and 09/30/2017 ** 2017 Case counts are preliminary and subject to change. 16
October 11, 2017 33 Tetanus/Pertussis Vaccination Coverage in Adults, NYS, BRFSS 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Tdap Td, not Tdap Type unknown None 2011 2013 34 Pneumococcal Vaccine Coverage 17
October 11, 2017 35 Pneumococcal Disease 2015 National Estimates of Invasive Pneumococcal Disease* Cases: 29,500 (9.2/100,000) Deaths: 3,350 (1.04/100,000) 90% of cases and most deaths are in adults 2016: 916 cases of invasive pneumococcal disease in NYS (exc. NYC) *https://www.cdc.gov/abcs/reports-findings/survreports/spneu15.pdf October 11, 2017 36 PCV13 Vaccine Effectiveness Adults 65 years o45.6% efficacy against pneumococcal pneumonia o75% efficacy against invasive pneumococcal disease 18
October 11, 2017 37 Pneumococcal Vaccination, 65 years, BRFSS, 2016 NY: 69.3% US: 73.4% Source: https://www.cdc.gov/brfss/data_tools.htm 37 Adults 65 years who have ever had a pneumococcal vaccination, BRFSS 2011-2016 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 65.2% 2011 2012 2013 2014 2015 2016 U.S. New York HP 2020 Target 69.3% 38 19
Pneumococcal Vaccination Trends, NY 2011 2015 BRFSS 80% 70% 60% 50% 40% 30% 20% 10% 0% 2011 2012 2013 2014 2015 18-64 yrs, increased risk 65+ 39 October 11, 2017 40 Pneumococcal Vaccination Coverage, Adults 18 Years Living in a Nursing Home 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 2006 2007 2008 2009 2010 2011 2012 2013 2014 US NYS HP 2020 Goal Source: Center for Medicare and Medicaid Services (CMS) Minimum Data Set Black et al., J Am Med Dir Assoc. 2017 Aug 1;18(8):735.e1-735.e14 No Vaccine Offer, Decline Not Offered 2006 2014 38.5% 73.2% 49.7% 16.0% 20
41 Zoster Vaccination October 11, 2017 42 10 30% of those will get post-herpetic neuralgia (PHN) Risk of both shingles and PHN increases with age 21
October 11, 2017 43 Zoster Vaccination, 60 years BRFSS, 2014 NY: 26.4% US: 31.8% Source: https://www.cdc.gov/vaccines/imz-managers/coverage/adultvaxview/ 43 Zoster Vaccine Zostavax Attenuated, live virus vaccine ACIP recommends a single dose 60 years Vaccine is 51% effective against shingles and 66% effective against PHN Shingrix (Not yet available) New vaccine awaiting final FDA approval Inactivated vaccine 2 doses (0, 2 months) Longer duration 44 22
45 Pharmacists as Immunizers Pharmacists as Immunizers New York State Education laws 6527, 6801, and 6909 permit pharmacists who obtain additional certification to administer to adults aged 18 years and older: o Influenza vaccines o Pneumococcal vaccines o Meningococcal vaccines o Tetanus, Diphtheria, and Pertussis containing vaccines o Herpes Zoster vaccine May administer vaccines under patient specific or nonpatient specific orders 46 23
October 11, 2017 47 Pandemic Influenza Memorandum of Understanding (MOU) Grant with ASTHO; develop and promote the MOU Engaging pharmacists to provide vaccination during a pandemic response o Established providers of vaccinations MOU is a non-binding agreement between the pharmacy and the NYSDOH Outlines the roles and responsibilities of each partner Facilitates coordination of vaccine distribution and administration Enable timely vaccination of the public once vaccine is available 48 New York State Immunization Information System - NYSIIS 24
October 11, 2017 49 Documentation: Adult Reporting in NYSIIS Provides a complete vaccination record in one place: Lifetime Registry Access to multiple users: Record and/or Read Primary Care Providers Emergency Room Providers Schools Public Health Case management and outbreak control Improved patient care Recommend needed doses Avoid overvaccination October 11, 2017 50 NYSIIS: Key Milestones Established in Public Health Law January 1, 2008 Healthcare providers must report all vaccines administered to persons 18 years, including vaccine history if not recorded HCPs may report vaccines administered to persons 19 years, with consent o July 2013: Consent may be verbal or written (include in existing consent) o Consent must be documented Switch indicator to Yes in NYSIIS, or Document in EMR/EHR and send electronically to NYSIIS October 2014: RNs and pharmacists who administer vaccines to persons 19 years must report to NYSIIS, with consent 25
October 11, 2017 51 NYSIIS: Doses Administered at 19 years, 2008 2017* *2017 data through 9/9/2017 NYS Adults Aged 19 Years (excluding NYC) in NYSIIS As of December 31, 2016: 8,672,519 adults aged 19 years in NYS (Census) 2,880,055 adults aged 19 years in NYSIIS (33%) 1,673,210 adults aged 19 years with 1 or more adult immunizations in NYSIIS (19%) 52 26
October 11, 2017 53 Who is reporting to NYSIIS? 4,444 locations have reported adult vaccines 1,906 Traditional Providers 1,576 Pharmacies Overall, pharmacies have reported 27% of adult vaccinations found in NYSIIS Trend shows increased contribution year to year 53 October 11, 2017 54 Doses in NYSIIS, by Provider and Age July 1, 2016 to June 30, 2017 600,000 500,000 400,000 Total Doses: 1,146,204 300,000 200,000 100,000 - Pharmacy Primary care FQHC LHD Other 19 to 44 45 to 64 65+ 27
Pharmacy, Doses in NYSIIS, July 1,2016 June 30,2017 55 Vaccine Doses Influenza 471,791 Tdap/Td 11,900 Pneumococcal 42,198 Zoster 24,600 Meningococcal 643 TOTAL 551,132 56 Vaccine Preventable Disease (VPD) Updates 28
Mumps Viral disease that is no longer very common in the US Year-to-year variation in the numbers of cases As of September 9, 2017, 47 states have reported infections in 4,439** people to the CDC Arkansas experienced an outbreak from August 2016- August 2017 and reported a total of 2,954 cases Arkansas normal baseline is between 1-6 cases annually 57 **case count is preliminary and subject to change October 11, 2017 58 Parotitis seen in 31 65% of cases http://www.immunize.org/photos/mumps-photos.asp 29
Reported Mumps Cases in New York State (excluding NYC), by Year Year 59 #Cases 1997 16 1998 14 1999 12 2000 14 2001 4 2002 5 2003 3 2004 5 2005 33 2006 51 2007 24 2008 21 2009 346 2010 964 2011 10 2012 5 2013 11 2014 11 2015 24 2016 204 2017** 146 **Cases (Confirmed or Probable) as of 9/30/2017. 2017 Case counts are preliminary and subject to change. Number of Reported Mumps Cases in New York State (excluding NYC) by Outbreak Confirmed and Probable Cases Reported between 01/01/2016 and 09/30/2017** Outbreak #Cases % of Total Sporadic Cases/Clusters 127 36.1% SUNY New Paltz 88 25.2% Nassau County (Long Beach) 51 14.6% SUNY Geneseo 27 7.7% SUNY Albany 25 7.2% Syracuse University*** 8 2.3% Albany Hockey 7 2.1% Clifton Park Gym 6 1.7% SUNY Buffalo 6 1.7% Camp Timberlake 5 1.4% Total. 350 60 **Cases (Confirmed or Probable) as of 09/30/2017. Case counts are preliminary and subject to change. ***Includes one previously resolved outbreak and one ongoing outbreak. 30
61 Age Distribution of Reported Mumps Cases, New York State, Excluding NYC* Age Group #Cases Percent <=1 Year 3 0.9% 2-10 Years 11 3.1% 11-17 Years 16 4.6% 18-24 Years 194 55.4% 25-30 Years 48 13.7% 31-40 Years 30 8.6% 41-50 Years 20 5.7% 51-60 Years 21 6.0% 60+ Years 7 2.0% Total Cases = 350 Average Age 26 years Median Age 21 years Range 1 to 73 *Confirmed and Probable Cases Reported between 01/01/2016 and 09/30/2017 Factors Contributing to Mumps Outbreaks Crowded environments favor prolonged close contact Living in dormitory or other student housing, playing on sports teams together Certain behaviors increase spread of virus Parties, kissing, sharing cups, water bottles, utensils, cigarettes, etc.) Vaccine effectiveness: protects against most but not all cases Waning immunity? Lower levels of neutralizing antibody (NA) observed among persons who received MMR #2 15 years ago demonstrates antibody decay over time.¹ 1. Date AA, KyawMH, Rue AM, et al. Long-term persistence of mumps antibody after receipt of 2 measles-mumps-rubella (MMR) vaccinations and antibody response after a third MMR vaccination among a university population. J Infect Dis 2008;197:1662 8. 62 31
October 11, 2017 63 Use of a 3 rd dose of MMR ACIP has not recommended for or against Effectiveness of a 3 rd dose has not been established CDC has provided guidance for consideration of use of a 3 rd MMR for mumps outbreak control Sustained transmission > 2 weeks despite outbreak control measures Intense exposure setting (prolonged close contact) Population with high 2-dose MMR vaccination coverage (>90%) High attack rates (> 5 cases per 1,000 population) The state and local health departments should be consulted anytime the use of a 3 rd dose of MMR is being considered October 11, 2017 64 Measles Measles is a viral illness Airborne and droplet spread Remains in the air for 2 hours after an infected person leaves a room 90% of susceptibles will become infected after exposure Although rare, we do see cases that have a significant impact on LHDs, healthcare providers, facilities and the public Early identification and isolation of cases important to limit public health impact 64 32
October 11, 2017 65 Measles Cases, 2017 Unvaccinated infant recently arrived from abroad o Seen at a local hospital and at an FQHC; Measles confirmed o 340+ exposures; No secondary cases Secondary Vaccine failure (SVF) o Known exposure to measles on a domestic flight o Adult with 2 valid, documented doses of MMR o Mild prodrome; worked while infectious o No cough, no coryza, no conjunctivitis, no Koplik spots o Highest documented temperature: 97.7 F o 5 days of a mild maculopapular rash o Laboratory results o PCR positive o IgM positive (confirmed at CDC) and IgG positive (robust) o High avidity result indicating a secondary immune response o No secondary cases 65 October 11, 2017 66 Measles Live in a very connected, small world o Travel: international as well as domestic travel can lead to exposure Measles is endemic in many other countries Risk of exposure is real Ensure that your adult patients are up-to-date with vaccination o Acceptable evidence of immunity for adults: Born before January 1,1957 One live measles-containing vaccine, if not at high risk Two measles-containing vaccines for college students, healthcare personnel or international travelers Laboratory confirmation of disease or immunity MMWR Prevention of Measles, Rubella, CRS and Mumps, 2013: Summary of Recommendations of the Advisory Committee on Immunization Practices (ACIP) https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm#tab3 33
October 11, 2017 67 Resources NYSDOH Vaccines and Immunization: https://www.health.ny.gov/prevention/immunization/ Adult Immunization Schedule: https://www.cdc.gov/vaccines/hcp/adults/forpractice/adult-recommendations.html Standards for Adult Immunization Practice: https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/index.html CDC Adult Vaccination Resources: https://www.cdc.gov/vaccines/hcp/adults/index.html Immunization Action Coalition: http://www.immunize.org/ Take a Stand: https://www.standingorders.org/ National Adult and Influenza Immunization Summit: https://www.izsummitpartners.org/ The Pink Book: https://www.cdc.gov/vaccines/pubs/pinkbook/index.html 67 68 Questions?? Contact NYSDOH at: immunize@health.ny.gov 34