what's new with the flu in 2019? · influenza infection. 1 • a study in va patients showed...

immunization action coalition

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What's New with Flu in 2019-2020

Litjen (L.J) Tan, MS, PhD Chief Strategy Officer,

Immunization Action Coalition Co-Chair, National Adult and

Influenza Immunization Summit

September 24th, 2019


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Disclosures

•I have no conflicts of interest.

•I do NOT intend to discuss an unapproved or investigative use of a commercial product/device in my presentation.


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Disclaimer

The opinions expressed in this presentation are solely those of the presenter and do not necessarily represent the official positions of the Immunization Action Coalition, or the National Adult and Influenza Immunization Summit


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Outline

•Review 2018-2019 influenza season activity and vaccination coverage rates •Discuss influenza vaccine effectiveness •Describe influenza recommendations for 2019-2020 influenza season •Discuss communication messages


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The 2018-2019 Influenza Season

........ ..... ...... ........... ....·······-· A Weeldj l■flueaza S■rveillance Re.port Prep~red by ·the ln1fluenz.-i Divisi:on Percentage of Visits for In fluenza- like Il lness (IU) Reported by

the U.S. Outpatient Infl uenza-like Illness Surveillance Network {ILiNet), Weekly Nationa l Summary, 2018-2019 and Selected Previous Seasons

8 .0

2017-18 season

- 2016-17 seasori 70 - 2015-16 Season

-- 201 4-15 seasori

2011-12 season 6.0 --2009-10 season

- - Natiorial Baseline

.,..._2018-19 season 5.0

-' ._ .g

~4.0 (I)

-5 0

cf!. 3.0

2.0

1.0

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40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32

Week

30

25,

5

0 0 ""3" • U") .,...., 0 •N

I nfluenza-Associa,ted Pediatric D1eaths by Week of Death 2015-21016 season to 2018,- '119 season

<O ""31' ' U')

·.,---0 N

Number of Deaths Reported = 95

N tO N • 0 ILO o , ,,_ -- N ("')

I I ' ' ' Lt), (0, c,o co f.O co ,....., ...--- - ...--- ...--- ...... O · o , 0 o , 0 0 N N N N N N

co N M 'Id'" " ' co c,o

...--- ...--- ,,...... 0 0 0 N N N

2016-2017

Number of Deaths Reported! == 1. o

..... I

v- ..--- ,..... ...--- ·..--0 0 0 0 0 NI N N N N

,..... ..---,o 0 •N I N

..---0 N

2011~2018

Number of Deaths Reported = 187

,,.... ,,_ I

co a) y- ..--- '"[""""" ..,--- '~ ..--o , 0 0 0 ,o 0 N N N N N •N

w ·eek. of Death

,.- ..--- ..,-0 0 0 N N N

■ Deaths Heported Pr,evious Weeks Deaths !Reported Current Week

2:018-2019

Number of Deaths Report.edi == 35

-I m O> ...---0 -0 Q N N N

80% were unimmunized!

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

Influenza-Associated Pediatric Deaths by Age Group (percent of total deaths)

17.1 9.5 4.7 6.7 6.6 6.7

27

18.2 16.5 13.3 16.4 16.3

7.2

15.5 22.4 13.3

18 23

28.8 31.1 32.9

36.2 35.5

36.3

19.8 25.7 23.5 30.5 23.5 17.8

54.1%

12-17 years5-11 years2-4 years6-23 months0-5 months

47.9% had NO underlying high-risk condition

2013-14 2014-15 2015-16 2016-17 2017-18 2018-19

*Data through September 24th, 2019

- 65+ yr

~.M'Ml: Wttl:

lJ

:.1

:o - 5-17 yr - 18-49 yr

LI

L4

11

" OJ

,.,

,.,

Ol

" 11.M't.RWHI;

- 0-4 yr - 50--64 yr

i!l.tl'IRl'lffll


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2018 – 2019 Hospitalization Rates…

65 + years Cumulative Rate: 216.6/100,000

5-17 yearsCumulative Rate: 21.0/100,000





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Prevalence of Chronic Conditions and Their Association With Influenza Hospitalizations in Adults

50 Years of Age and Older

Prevalence of Chronic Conditions US Adults 50-64 Years of Age1

30% No chronic condition

50% Diagnosed

with 2 or more chronic

conditions

20% 1 chronic condition

Americans 50 years of age and older are a priority group for influenza immunization.2

• In a study covering the 2005-2006, 2006-2007,and 2007-2008 influenza seasons, >80% ofadults hospitalized with lab-confirmed influenzahad 1 or more underlying medical condition;half had 2 or more conditions3

• In the 2016-2017 influenza season, 94.2% ofhospitalized adult patients with influenza had atleast 1 underlying medical condition4

References: 1. CDC, AARP, American Medical Association. https://www.cdc.gov/aging/pdf/promoting-preventive-services.pdf. Accessed March 1, 2018. 2. CDC. https://www.cdc.gov/flu/protect/ whoshouldvax.htm. Accessed March 1, 2018. 3. Dao CN, et al; Emerging Infections Program Network. J Infect Dis. 2010;202(6):881-888. 4. CDC. https://www.cdc.gov/flu/weekly/weeklyarchives2016-2017/Week20.htm. Accessed March 1, 2018.

https://www.cdc.gov/aging/pdf/promoting-preventive-services.pdf.%20Accessed%20January%201,2018

https://www.cdc.gov/flu/protect/whoshouldvax.htm

https://www.cdc.gov/flu/weekly/weeklyarchives2016-2017/Week20.htm


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Influenza and Cardiovascular Disease • Incidence of admissions for acute myocardial infarction was six

times as high during the 7 days after laboratory confirmation of influenza infection1

• A study in VA patients showed that 24% of 600 VA patients who tested positive for influenza had acute cardiac injury and 80% occurred within 3 days of the influenza diagnosis2

• A systematic review showed consistent associations between influenza and acute myocardial infarction, with weaker evidence of an association with cardiovascular death3

• Acute infections, such as influenza, have been associated with cardiovascular events, and it is hypothesized to be due to triggering of inflammation that elicit cardiovascular events4

1. Kwong JC, et al. N Engl J Med 2018; 378:345-353. 2. Ludwig A, et al. BMC Cardiovasc Disord. 2015 Sep 30;15:109. doi: 10.1186/s12872-015-0095-0. 3. Warren-Gash C, et al. Lancet Infect Dis. 2009 Oct;9(10):601-10. 4. Santos-Gallego CG, et al. JAHA 2018; 7(22):e011175.


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Influenza and Diabetes

• People with diabetes experienced more hyperglycemic events, and substantial increases in pneumonia, sepsis, and coronary heart disease up to 4 weeks after an influenza claim, as compared to a non-influenza period in the same year1

• People with diabetes are 3-6 times more likely to be hospitalized during influenza epidemics2

• People with diabetes have a much higher rate of death associated with an influenza infection3

• Influenza vaccination recommended by the World Health Organization for high risk patients with diabetes

1. Samson SI, Lee W-N, Quisel T, et al. Diabetes. 2018;67(Supplement 1):1616. 2. Bouter KP, Diabetes Res Clin Pract 1991;12:61-8. Allard R, Diabetes Care 2010;33:1491-3. 3. https://www.gov.uk/government/publications/influenza-the-green-book-chapter-19 (p4).

https://www.gov.uk/government/publications/influenza-the-green-book-chapter-19

........ ··~ •......•••--. ••• ••• r••••--••••

Influenza Positive Tests Reported to CDC by U.S. Public Health Laboratories, 3,soo

3,000

fJ'J C Q,)

E (.) 2,500Q,) C.

CJ)

~ :e 2,000 fJ'J 0

CL-0 .... (I.) 1,500

..0 E :::s z

1,000

500

0

National Summary, 2018-2019 Season

oA (subtyping not performed)

DA (H 1N1)pdm09

• A (H3N2)

• HJN2v

·

~~~~~~~~~~~~~~~~~~~~~~~~~· Week

• B (lineage not perfomied)

oB (Victoria !Lineage)

D B (Y:amagata lineage}

200 180

160

140 120

100

80 60 40 20

__A__

~~~~~~~~~~~~~~~~~~~~~~~&~ • ~ ~ ~ .~ ~ ~ .~ ~ ~ · ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~

□ A (subtyping not performed) ■ B (lineage not performed)

..... VI

o A (H 1 N1 )pdm09 □ B (Victoria Lineage)

■A (H3N2) □ B (Yamagata Lineage)


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H1N1 H3N2

Early December 2018 Mid/Late March 2019

Graphic courtesy of Alicia Budd, CDC

3C.2al 52

48%

VIA,1

5 45%

Influenza A(H3N2)

3C.2a 41

38%

Influenza A(H1Nl)pdm09

Influenza B Yamagata

3C.2al 173

VlA-lDEL 44 ,,,.

Influenza AIH3N2) 3C.2a

66

VIA.I ~l

5696

Influenza A(H1Nl]pdm09

68.1 1080

--. ....... ""='=:.._ _ _ 100%

lnOuenza B Yamasata


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Changing Proportion of H3 Genetic Clades/Sub-clades

End of 2018 Late April 2019


97-98 98-99 99-00 00-01 01-02 02-03

03-04 04-05 05-06 06-07 07-08 08-09

09-10 10-11 11-1 2 12-13 13-1 4 14-15

C) e) 15-16 16-1 7 17-1R

- A(H3) D B - A(H1) D B(Vic) CJ A(H1)pdm09 - B(Yam)

Influenza Virus Co-circulation, 1997-1998 through 2018-2019

2018-2019

H1 – 56% H3 – 41%


9


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Summary of Influenza Activity 2018-2019

• Two separate waves of influenza A activity – H1 first then H3

• Almost equal proportions of H1 and H3 by season end, but H1 wins out, barely – H3 drifted away from strain in the vaccine – WHO delays vaccine strain selection by a month

• Very little B virus circulation and no later B wave • Record breaking long season as measured by ILI

activity


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The 2018-2019 Influenza Season – Vaccination Coverage

(preliminary, final numbers released September 26th, 2019)


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2018-2019 Pediatric Influenza Vaccination Coverage (Preliminary*)

• 59.9% of all children 6 months through 17 years of age vaccinated

• 70.9% of children 6 months to 4 years vaccinated

• 60.7% of children 5 to 12 years vaccinated

• 49.7% of children 13 to 17 years vaccinated

*Preliminary results from NIS-Flu interviews conducted October through March of each season, presented at May 2019 NAIIS meeting 20

2018-2019 Adult Influenza Vaccination Coverage (Preliminary*)

• Only 34.4 of all adults over 18 years of age vaccinated

• Only 55.9% of those over 65 years of age vaccinated

• Only 36.9% of adult between 50 -64 years of age vaccinated

• Only 24.3% of adults 18-64 years of age vaccinated – From 2017-18, only 38.8% of adults 18-64 years of age with at

least one high-risk medical condition vaccinated (cf. 46.4% previous year)

*Preliminary results from BRFSS interviews conducted October through December 2018, presented at May 2019 NAIIS meeting 21

2018-2019 Influenza Vaccination Coverage – Healthcare Personnel (preliminary#)

95.7

80.7

68.1

74.9

0

10

20

30

40

50

60

70

80

90

100

Perc

ent v

acci

nate

d

96.8 91.5 92.1 91.7 86.1

76.0 72.3

0 10 20 30 40 50 60 70 80 90

100

Perc

ent v

acci

nate

d

Hospital Ambulatory care Long-term care Other settings‡ setting†

# Internet Panel Survey, United States, as of early April 2019 † Nursing home, assisted living facility, other long-term care facility, home health agency or home health care. ‡ Settings other than hospitals, ambulatory care setting, or long-term care facilities; includes dentist office or dental clinic, pharmacy, EMS, and other settings where clinical care or related services was provided to patients. $ Allied health professional, dentist, technician, or technologist. @ Administrative support staff or manager and nonclinical support staff (including food service workers, housekeeping staff, maintenance staff, janitor, and laundry workers). ~--------------------------------------------------_J


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22

■

■


Impact of Employer Policy on Healthcare Personnel Vaccination (by setting)*

97 91 89 90

40

49

42

55

0

10

20

30

40

50

60

70

80

90

100

Hospital Physician's office LTC setting Other settings§

Perc

ent V

acci

nate

d

Requirement

None

Work setting

§ Settings other than hospitals, ambulatory care setting, or long-term care facilities; includes dentist office or dental clinic,pharmacy, EMS, and other settings where clinical care or related services was provided to patients.

* Internet Panel Survey, United States, March 27–April 17, 2018 23

24

Healthcare Personnel Vaccination Policy by Setting

44.1

68.3

39.229.6

37.9

14.3

14.8

13.1

13.9

15.4

14.6

11.5

16.0

17.49.4

9.6

3.3

8.415.6 11.2

17.4

2.1

23.2 23.5 26.1

0

10

20

30

40

50

60

70

80

90

100

Total Hospital Physician's office LTC setting Other settings†

Perc

ent w

ith p

olic

y

Work setting

None

Other promotion

Onsite 1 day

Onsite >1 day

Requirement

More than 500 organizations!

† Settings other than hospitals, ambulatory care setting, or long-term care facilities; includes dentist office or dental clinic, pharmacy, EMS, and other settings where clinical care or related services was provided to patients

2018-2019 Influenza Vaccination Coverage in Healthcare Personnel (Preliminary, early April

2019) •HP 2020 goal of 90%. •81.0% vaccinated by internet panel surveys, some

improvement over previous season data at this time point.

•Long-term care facilities had lower coverage (68.1%) than other facility types (hospitals at 95.7%).

•Higher vaccination coverage among HCP was associated with employer vaccination requirements or access to vaccination at the workplace at no cost.

25

2018-2019 Influenza Vaccination Coverage – Pregnant Women (preliminary*)

•Pregnant Women (HP 2020 goal of 80%) –53.7% vaccinated (cf. 49.1 previous season)

–Of the pregnant women who reported visiting a doctor or other medical professional at least once before or during pregnancy,

• 67.2% reported receiving a recommendation for and offer of flu vaccination from a doctor or other medical professional

• 13.9% received only a recommendation for and no offer of flu vaccination

• 18.9% did not receive a recommendation for or an offer of flu vaccination

* Internet Panel Survey, United States, through January 2019 26

immunization action coa\ition

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Influenza Vaccination Among Pregnant Women by Provider Recommendation or Offer of

Vaccination, 2018-19 Season (preliminary*) Influenza vaccination coverage before and during pregnancy among women pregnant any time after August 1, 2018 and who visited a health care provider at least once since July

2018, by provider recommendation or offer 100%

80% 66.5%

nate

d

57.0%

Vacc

i 60%

Perc

ent

40% 36.3%

20% 18.4%

0%

Recommended and offered Recommended,

not offered, Recommended, referred not offered, not No

referred recommendation

Provider recommendation or offer

* Internet Panel Survey, United States, through early April, 2019


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Impact of influenza on pregnant women1

• Up to 4X increased risk of hospitalization, especially in third trimester, and for those with co-morbid conditions*

• Up to 8X increased risk for influenza-associated complications, including death, particularly for those with co-morbid conditions**

• Increased risk for influenza-associated complications among postpartum women – Risk highest during the first postpartum week

* Chronic cardiac disease, chronic pulmonary disease, diabetes mellitus, chronic renal disease, malignancies, and immunosuppressive disorders ** Preexisting diabetes mellitus, pulmonary disease that included asthma, heart disease, renal disease, and anemia 1. Rasmussen, S.A., et al. 2012. American Journal of Obstetrics & Gynecology; 207(3): S3 - S8.

Some coverage thoughts •Influenza vaccination coverage appears to still be well below HP2020 targets

– May see little improvement in adults – Improvement may have occurred in the pediatric population – Coverage in the 65 years and older population remains very poor...– Coverage in the 18-64 years of age high risk adults unacceptably low…– Coverage in pregnant women has leveled off; a strong provider recommendation makes a difference – HCW coverage remains strong, except in LTCF!


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Vaccine Effectiveness


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Preliminary Adjusted VE against medically attended influenza, US Flu VE Network,

2018-19

• Interim results for 2018–19 season through February 2, 2019) indicate protection against influenza • 47% (CI: 35, 57) vaccine effectiveness against any

influenza virus • 46% (CI: 30, 58) against H1N1pdm09, 44% (CI: 13,

64) against H3N2 • H3N2 predominates in later season with drifted strain

MMWR. February 15, 2019 / 68(6);135–139


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However…


2018-19*

47

34

46 44 44

10

-20

0

20

40

60

80

100

Any influenza A (H1N1)pdm09

A (H3N2)

ADJU

STED

VAC

CIN

E EF

FECT

IVEN

ESS

(%)

INFLUENZA (SUB)TYPE

VE at March 8, 2019

* Multivariate logistic regression models adjusted for site, age categories (6m-8y, 9-17y 18-49y, 50-64y, ≥65y), sex,race/Hispanic ethnicity, self-rated general health status, interval from onset to enrollment, and calendar time(biweekly intervals), presented at May 2019 NAIIS Meeting


2018-19

Any Influenza A and B Adjusted VE* (95% CI)*

All patients aged ≥ 6 months 29% (21 to 35)

6 mos–8 y 49% (38 to 58)

9–17 6% (-22 to 27)

18–49 25% (10 to 37)

50-64 12% (-12 to 31) ≥65 12% (-29 to 41)

* Multivariate logistic regression models adjusted for site, age categories (6m-8y, 9-17y 18-49y, 50-64y, ≥65y), sex, race/Hispanic ethnicity, self-rated general health status, interval from onset to enrollment, and calendar time (biweekly intervals)

Preliminary Adjusted VE against medically attended influenza by virus subtype, US

Flu VE Network, 2018-19

Influenza Subtype Adjusted VE* (95% CI)*

Any influenza 29% (21 to 35)

A(H1N1)pdm09 44% (36 to 51)

A(H3N2) 9% (-4 to 20)

A(H3N2) clade 3C.3a 11% (-6 to 26) A(H3N2) clade 3C.2a1 45% (5 to 68)

* Multivariate logistic regression models adjusted for site, age categories (6m-8y, 9-17y 18-49y, 50-64y, ≥65y), sex, race/Hispanic ethnicity, self-rated general health status, interval from onset to enrollment, and calendar time (biweekly intervals)

Preliminary VE against influenza hospitalizations in adults, HAIVEN, 2018-

19


All patients aged ≥ 18 years 25% (1 to 41) 18–49 1% (-58 to 38) 50-64 47% (22 to 63) ≥65 15% (-24 to 41)

* Multivariate logistic regression models adjusted site, age group, sex, race/ethnicity, days from illness onset to specimen collection, calendar time of illness onset, home oxygen use, frailty score, and number of self-reported hospitalizations in the past year

Preliminary VE against pediatric influenza hospitalizations, NVSN, 2018-19


All patients aged 6 mos. to 17 years 31% (5 to 51)

6 mos. to 8 years 26% (-6 to 49)

9 to 17 years 53% (5 to 77) By virus subtype

H3N2 13% (-31 to 43)

H1N1pdm09 48% (14 to 68)

* Multivariate logistic regression models adjusted for age group, study site, and calendar time (month of enrollment)


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Summary of preliminary VE for the 2018-2019 influenza season

• Increased percentage of A(H3N2) cases enrolled in US Flu VE network through 8 March • Updated interim results suggests reduced VE against A(H3N2)

compared to earlier estimate published in February 15 MMWR (vs. no change in H1N1pdm09 estimate)

• Circulation of antigenically drifted A(H3N2) clade 3C.3a • Supports WHO delay and decision to update A(H3N2) vaccine

component • Remember that vaccine offers significant protection

against influenza hospitalizations • Vaccine reduced influenza hospitalizations by 22% among all adults

and by 24% among adults ≥65 years of age (influenza A and B viruses) in 2017-18 season

the benefits of flu vaccination 2017-2018

The estimated number of flu illnesses prevented by vaccination during the 2017-2018 season:

1million About the population of

New York City

The estimated number of flu hospitalizations prevented by vaccination during the 2017-2018 season:

109,000 About the number of vehicles

crossing the Golden Gate Bridge each day

The estimated number of flu deaths prevented by vaccination during the 2017-2018 season:

8,000 Twice the number of hospitals in

the United States

OATk.Jou1n.1I Cl1nk..,1il tofe-th ow.Obt!J~. Effed 1ol lnnu.1il:Ji V.t<.dn•lk>I\ tn tlw United SuilfoS t.J oung tM 1017-1018 lnlUl!n.t4 Se'"'on_. f,U,»J/OOlo 1g/10.109J /dJ /t.lz07S


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Another way to look at influenza vaccine effectiveness – negative outcomes averted


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Another way to look at influenza vaccine effectiveness – negative

outcomes averted • Influenza vaccination was associated with reduced

risk of laboratory-confirmed influenza-associated pediatric death1

– Estimated influenza vaccine effectiveness was 65% (95% credible interval, 54% to 74%) against laboratory-confirmed influenza-associated deaths among children

• Influenza vaccination reduces the risk of hospitalization for children 6 – 59 months of age during most influenza seasons2

1. Flannery et al. 2017. Pediatrics. May. doi: 10.1542/peds.2016-4244 2. Buchan SA, et al. 2017. PLoS ONE. doi: 10.1371/journal.pone.0187834

Modeling the Effec t of Di ffe rent Va cine Effe tivencss Estimates on the Number of Va ci n ·-Prevented lnlluenza -Asso iat ed Hospi ta lizations in Older Adults

ljl''I! 1111ll1lU1 1. t!I Iii: 1 t· r 111 lC 111 I: • It(" .. - , 11!1

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tlnn1 in old« ~uhs wu.) 10 6 told higher 1h;an during the- 2 prcvlmu leMODI 141- lntlu~n7.4 vacdntuilln l1 the- m:al.n pre\~f\ tlon ~tN:I~ forln!lm) ll hl. D11tlng 2012-2013, lnti·rlm t'-' l lm1lllf"•

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lion. 1'hl1 lllOtic'I Lloes fh)I 11.i.;CrnHH for 111.11, " ' ('m: I

v-,1~i 1,(\tJfJ II,

Optimizing the impact of low-efficacy influenza vaccines Prith• S•h·. Ji n M~!odi;11, MH91n c . fl\l.patrlc:k ..... e.urton H, Sin~,,-.•. il'ld Allson P, Gilvan1·

=~n:r~t~.i~J: :-;rir:1~= foi=u!:l~=~~:k~~.:~-=~~i==~~~::~~~~,~~~ !t.tlhogl!M IM!ltuu, UnMnlly ot Florldl, ~lnewllll, Fl 32110

ConuilluH1d ~ IWIOrl 11. ilno,t, Mir!h 31). ~II (iffll tot rhlew ,itbruMy t. 201l, fltYlffi'N by M1hait\y S Flud ill'ld 0.tvld Fkn'Yil'I)

The effk:Acy of lnflue:n:u vKdnes varies from one ~Hr to the next,, with effk.acy durln9 thl! 2017 01B seHDn ■ntklp11ted ta be lowei' th■n u11.1al. However, the lmpKt of low,cffiuqr VK[lnn 111t the population leYel and their opdmal ~ dk trlbutlon h11w111 r,t to be uurt.a,ln,ed. ~plyt,,9 an optlml.udo,, ■i9orlthm to • mathematk.111 mod.I of lntluanu u11ruml11k>n ■nd vaa::ln■don In th■ Unlt■d Stat.es. wt1 d■t■rmlrwd th■ optimal •~ uptake of lowoe-tflcacy vKdM that would minimize lndd■me, holp/tallz■• don, mort.111ty, and dlsabllity4d)ustad 1/fa.yHr> (DAI.YI). ....-,Jyaty. W■ found that ...,.n rel.attv.l~ k>W..tfic.Ky lnfkMfWI vac.clnn mn ba ~hay lmpactful, ~tkularty whffl vKClna uptake Is optl~iy llstrib, uted across age groups. Al vacdn■ ■fflc.acy dadinH. the optimal dinrllb~loi\ o f VM(I~ l,iP.\i'li;t JhllU ~ iifd \M t4dt,ty ~o Mli"ilfflllt i'i'IOr,.,81lil~ • nd OAl,,Vt,., Hti.hh Pf~ I\Jofll, tnC;Oi,lr~, oiind (On

' l"l:td rtcrultMtnl t UOrU Mt teqr,,ll'i'd IO Ad',~ opll~I (0\i'tt'11gt Ji'li0ft9 Yiftil J94' 9'Wli't v-.tby MlnlMttit.9 1r1n~u ~•t1 \II~ mo,\~iity fo,t V'4 pop,i,l lJ \~ it Ovtfioll ,

Acemuf}' si~ 1hc Pll 8 lnnucnza ,,anlNmk- kHleJ 11 1rrn1ucd 5t}-J(N..1 ml.!Uon f'C.Of'k, lnllucnza r mains a 2fnbel

1hrclit, lnOucoza c1tui;c1 1J.2-3S,t1 mlllwn lnfookins, 141 1,ll{I0-710,0IX) h0!ipil alw1thmx. 11 11d I2,000-56,1.Xl} lk11th.'levt:IJ' rear In lh!:! U nilcd SIJtll.~~ ulunc, ( 1). "!"be rapit.1 cmluUun u f innucnZ11 11n1is.cn~ n:'4Ult'Cll ttnnual rc:furmulu tk>n or the vut.-cinci. &lk."tr• b.i tina;. 1ha m11urul 11ntip:nit.'. cvululiun. viral atlupluliun tna)' U1.tur within the ch~kcll ~ ti~ in rhe mnnufocn1re of the inl'ICTiwt.;d vac..\.'u,-; (2). In thtr L"Urn.,11 ~I7-~l,8 ulflocr~ .i,c:IUIJl1. MK:h tttl-

•s me.in. Tn identify !lilJCially optimal vacdnc uptake fo r MJW. efl"'8C)' llfluenza ~()C. 'IA'C tlfli)llcd n optlmlzatJon al&ofhhm

~(o~u!!~~&~~=,~~lt~C~&o~~ u::k~~~cu~; zdjlL'llcd lffc-yi::an. (DALY~). DALYs mcot•1uru d i'll:OL'ie lJ1.1 1tk: 11 hy c.1phnin5 both morbi<lily and 111U111.dil)', in ~ilich it i'lin.glc- DALY n:-fNt"SCnL~ I bt )t:M or hc:al thy life (9). Our n.."'iUll.'1 int.lica.10 th ti 1l\ el~cy lk.'ClincJ. Olltim.11 uptllkc 1,, minimi,e n•,nnti1y nnd DALY,;. ~m~ ~le ,~ fn, m li(:hool-"&e ct,ildreD '"I youn1 iHiult ""'ho have , li:,;im--.i11··mio1m1;:ly hl&h i1 1¥,mi'-~W.)11 r.ii~ 10 1hc ;:ld;:rty, Vioho ,1te ill gil:'"o1h.:r 1i,k It.II ~-..1:rcdi11K.'al uull"u11 1oi:, We l'urlhc, ~1,ht,.... l11o1I L-..t:ti rur \'llt.U110 wllh 111•,n::t clfK:11\.)'. ufJlin\al upC11.l..c:: L~ ftf'ujtth::iJ tu lllll~tamiaUy 1ciJUL: • li-.cldi:i'll.."t', IMJ!i°'t laliz.111'Jw OCalh!!. aiiiJ DALY~ awnp.1rei.l wilh pn.,jec.1kMlli under l)'fMCill U. vacx:lne uptake.

Results We h~t -!illlmhih:ll tfMllciiilUlulj.le.tl lra]l:Cton~:J pru,c~lcd utkkr 111 ;;pecific v.tccin.atinn awcrn.iie.;; th.11 a rc lypiotl in lhe Unilcd SlnteM. We then considc.retl lhc op4 inml u1llnkc or 140 million do~:_;; (the nvcn1e numl,cr nf ckN!..~ lhal hm hccn tie.live red 11nnu1t ll)' uvu the fl\'!:! 'i4:'i1M1n , p;mning 2012- 2017), c11u iYillen1 10 11 t:lmra.gc u( ~J'l. Epidcmiol,,gicnl 1.mta1mc~ uf inkt:1it1m., hn-.flh4illi~tioo;;, de,111):;i, 1mJ fl/\LY:rr. O"'~ried 'I.\' re COfllfl;l l'efl 11,i1!1 •~ Vil~in.:11 jon Sr«lf1~11 II)', 111 1hc lihi;el~ of v~inmkm, Rhou1 77 mlllkln Jnfcairn1'- 47tl,1Nl) h0!ripi111l1:,.111t0n (11 11d 110)¥10 de111h,; would I ;, e1t1 1 d du rin1- 11n inOoen;ro M:ti<.011,

Even when VE is < 50%, current vaccinescan have a major impact

CID; Modeling Effect of VE on Preventing Hospitalizations in 65+

40% VE would prevent 60,000 hospitalizations

PNAS; Optimizing the Impact of Low-efficacy Influenza Vaccines

20% VE projected to avert 130,000 hospitalizations and 62,000 deaths

41


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Vaccine Effectiveness – Influenza and CVD

• Acute respiratory illness or influenza-like illness increases acuteMI risk 2x; 5x is those with history of MI

• Influenza vaccination effectiveness: Meta-analyses1–2

• 29% (95%CI 9,44) against acute MI in persons with existing CVD • 36% (95%CI 14,53) against major cardiac events with existing CVD

• Vaccine effectiveness 29% in acute MI prevention • “On par or better than accepted preventive measures [as] statins

(36%), anti-hypertensives (15–18%), and smoking cessation (26%)” • Influenza vaccination recommended as secondary prevention by

American College of Cardiology and American Heart Association

1. Barnes M, et al. Acute myocardial infarction and influenza: a meta-analysis of case–control studies. Heart 2015;101:1738–1747 2. Udell JA, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis. JAMA 2013;310:1711–20


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Vaccine Effectiveness – Influenza and Diabetes

• Six cohort and five case-control studies were included in a recently-published systematic review and meta-analysis1.

• In working age persons with diabetes mellitus, • There was pooled VE of 58% against all cause hospitalization • No significant effects on all-cause mortality and influenza-like

illness

• In elderly patients with diabetes mellitus, adjusted VEs of 38% against all-cause mortality and 23% against all-cause hospitalization were seen.

1. Remschmidt C, Wichmann O, Harder T. Vaccines for the prevention of seasonal influenza in patients with diabetes: systematic review and meta-analysis. BMC Med 2015;13:53.


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Vaccine Effectiveness – Influenza and Diabetes

• A retrospective study demonstrated that influenza vaccination was associated with a significant decrease in risk for hospital admission due to stroke, heart failure, and influenza or pneumonia.1

• However, another recent systematic review that factored in confounders such as indirect health outcomes, selection and health seeking bias, and the frequent absence of adjustment for pneumococcal vaccination status, indicated that the overall evidence for influenza vaccine effectiveness may be low.2

• Yet another report states that the present evidence suggests that influenza vaccination among adults and elderly with diabetes mellitus is efficacious and safe.3

1. Eszter P. Vamos, Utz J. Pape, Vasa Curcin, Matthew J. Harris, Jonathan Valabhji, Azeem Majeed and Christopher Millett. CMAJ October 04, 2016 188 (14) E342-E351.

2. Casanova L, Gobin N, Villania P, Verger P. 2016. Primary Care Diabetes 10(6):398–406. 3. M. Goeijenbier, T.T. van Sloten, L. Slobbe, C. Mathieu, P. van Genderen, Walter E.P. Beyer, Albert D.M.E. Osterhaus.

2017. Vaccine 35(38):5095-5101

Resilience to Influenza with Aging

Frailty Index

0.25 0.3

0.4 0.5 0.6

0.1 0

0.15

0.7

0.2

0.05 Inflammaging & Multimorbidity

Graphic courtesy of Janet McIlhaney, MD

. munization ~~ion coalition

. munization ~~ion coalition

Keeping your glass half 0 full! 0.1

Exercise, diet, smoking 0.2 cessation

and vaccination 0.3

Are you willing to risk 0.4 0.5

your independence this 0.6 0.7

winter?

Graphic courtesy of Janet McIlhaney, MD


immunize.org

2019-2020 Influenza Vaccine Strains

•Two strain changes from last year! •New seasonal influenza vaccine formulations

– Trivalent preparations: an A/Brisbane/02/2018 (H1N1)pdm09–like virus, A/Kansas/14/2017 (H3N2)-like virus, and a B/Colorado/06/2017-like (B/Victoria lineage) virus (Victoria lineage). – Quadrivalent preparation adds a B/Phuket/3073/2013–like virus (Yamagata lineage).

Vaccine Products for the 2019-2020 Influenza Season

Mercury Manufacturer Trade Name How Supplied Content Age Range CVXCode

(vaccine abbreviation) 1 {mcg Hg{O.Sml)

AstraZeneca FluMist (LAIV4) 0.2 ml (single-use nasal spray) 0 2 through 49 years 149

Fluarix (IIV4) O.S ml (single-dose syringe) 0 6 months & older3 1SO

GlaxoSmithKline O.S ml (single-dose syringe) 0 6 months & older3 1S0 Flulaval (1 IV4)

5.0 ml (multi-dose vial) <25 6 months & older3 158

Flublok (RIV4) O.S ml (single-dose syringe) 0 18 years & older 18S

0.2S ml (single-dose syringe) 0 6 through 35 months1 161

0.S ml (single-dose syringe) 0 6 months & older3 1SO Sanofi Pasteur

Fluzone (IIV4) 0.S ml (single-dose vial) 0 6 months & older1 1SO

5.0 ml (multi-dose vial) 25 6 through 35 months1 158

5.0 ml (multi-dose vial) 25 3 years & older 158

Fluzone High-Dose (IIV3-HD) O.S ml (single-dose syringe) 0 65 years & older 135

0.2S ml (single-dose syringe) 0 6 through 3S months1 161

O.S ml (single-dose syringe) 0 3 years & older1 1S0 AAuria (IIV4)

5.0 ml (multi-dose vial) 24.S 6 through 35 months1 158

Seqirus 5.0 ml (multi-dose vial) 24.S 3 years & older' 158

Fluad (allV3) 0.S ml (single-dose syringe) 0 65 years & older 168

0.S ml (single-dose syringe) 0 4 years & older 171 Flucelvax (ccllV4)

5.0 ml (multi-dose vial) 25 4 years & older 186

NOTES 1. IIV3/IIV4 • egg-based trivalent/quadrivalent inactmted influenza vaccine (injectable); where nectmry to rtfer to

c,II culture-hued vaccin,, the pr•rut •cc· is used (,.g., ccllV4); RIV4 • quadrivaltnt recombinant htmagglutinin influe,m vaccine (in1ectable); allV) • adjuvanted trivalent inactivated influenza vacane.

3. Dosrng for infants and diildren age 6 throug!, 35 months:

2. All administration code shoukl always be rtported in addition to the v.iccint product codt. Nott: Third part)' payers may have specific policies and guidelrnes that might require providing additional information on their claim forms.

Afluria 0.25 ml Fluarix 0.S ml Flulaval 0.S ml Fluzont 0.25 ml or 0.5 ml

Vaccine Product Billing Code'

CPT

90672

90686

90686

90688

90682

90685

90686

90686

90687

90688

90662

90685

90686

90687

90688

90653

90674

90756 immunization action coalition

4. Afluria is approved by the Food and Drug Administration for intramuscular administration with th• PharmaJet Stratis Needle-Free Injection System for persons age 18 through 64 years. j mm Un j ze. 0 rg

Influenza Vaccines 2019-2020 (www.immunize.org/catg.d/p4072.pdf)

http://www.immunize.org/catg.d/p4072.pdf

~ National Adult and

~ Influenza Immunization Summit

• • . . . . ..... . ' search: Gooc custom searcn

Influenza Vaccine Availability Tracking System -IVATS

Information for the 2017-2018 influenza season The Summit regularly posts updated informalion to IVATS. A resource for healthcare settings lookng to purchase influenza vaccine. !VATS contains information from approvec. enroled. and participati"lg wtolesale vacc ine distributo rs o · manufacturers of U .S. lic ensed influenza vaccine.

O11goi11g upcates are being naae ana w111 co1t1nue to be maae :nrougnounne 2017- 2018

ini uenza vaccinaton season. Keep checkng back.

CLINICIANS: LOOKING FOR VACCINE?

Ci nicians IVATS can help you 1no inOuenza vacci ,e

ACCESS II/ATS SPREADSHEET

DISTRIBUTORS AND MANUFACTURERS For distributors/manufacturers with wholesale v~ccinc stock

IVAlS REPORTING FORM

Disclaime': Please note that an informalion in IVATS is provic1f!c1 hy wholfasal~ rtistributors or manutacture·s on a ,·oJuntary basi:i. IVATS is not intended to ent1o rse or promote cne w holesale

Otstrt>u:or's or manufacturer's .roouct over anomer, ano atl ncensea. wno1esate atstnDutors or manufacture'S are welc~me and encouraged to enroU.

•••

Resources

:, Adutt Vaccination Resourees

> Editoral Calendar

G:J

:. Influenza Vaccinat10n Resources

lnfiuenza vaccine Re:ommendations

' Targeting People ai i-,gn R1SK

Influenza Vaccore Products

IVATS - Influenza Vaccine Availability

Tracking System

Patient tnformat,on

, va:cria:,ng Heann:are Personnel

Toots for Off-Site Clinics

National Adult lmmunzaticn

Coorainators' Pannersnlp

' Tne summit Buzz

ln~uenza Vaccine Products immunization action coalition

immunize.org

The Summit’s Influenza Vaccine Availability Tracking System (IVATS)

https://www.izsummi tpartners.org/ivats/

https://tpartners.org/ivats

https://www.izsummi


immunize.org

ACIP Influenza Recommendations (2019-20)

• All persons 6 months of age or older should receive influenza immunization • Influenza vaccination should not be delayed to procure a

specific vaccine preparation if an appropriate one is already available

• LAIV is back! But capacity is low for 2019 – 20 season • You should receive a flu vaccine by the end of

October, if possible. – For those requiring only 1 dose for the season, early

vaccination (i.e., in July and August) is likely to be associated with suboptimal immunity before the end of the influenza season, particularly among older adults.

59


immunize.org

ACIP Influenza Recommendations (2019-20)

• Vaccination should be offered as long as influenza viruses are circulating and unexpired vaccine is available • Vaccine administered in December or later, even if

influenza activity has already begun, is likely to be beneficial in the majority of influenza seasons

• Final 2019 – 20 recommendations: https://www.cdc.gov/mmwr/volumes/68/rr/rr680 3a1.htm?s_cid=rr6803a1_w

60

https://www.cdc.gov/mmwr/volumes/68/rr/rr6803a1.htm?s_cid=rr6803a1_w

61

Did the child r,eceive ~2 doses. of trivalent or q adrivalent i _fluenza1 vaccine

before J u'ly 1, 2019' (Doses need not have lbee received

during the s me or consecutive se.aso s.)

Yes

'

1 dose of 2019- 20

influenza, vaccine·

!No, or Don't Know

i 2 doses ,of 2019-20

influenza vaccine (administered 4 we,eks apart)


immunize.org

ACIP Pediatric Algorithm (2019-20)

For children aged 8 years who require 2 doses of vaccine, both doses should be administered even if the child turns age 9 years between receipt of dose 1 and dose 2.


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How do we discuss Vaccine Effectiveness?

• Address vaccine effectiveness directly, early, and as needed, during season

• Communicate the variability and unpredictability of flu

• Acknowledge that flu vaccination is not a perfect tool, but it is the best way to protect against flu infection

• Communicate the benefits of flu vaccination beyond prevention of disease – Flu vaccination can reduce doctors’ visits, missed work

and school due to flu, as well as prevent flu-related hospitalizations and deaths.

62


immunize.org

More messaging on Vaccine Effectiveness…

• So do not measure vaccine effectiveness by incidence alone

– Hospitalizations prevented – Medical visits prevented – Quality of Life Benefits - vaccine preventable disability


immunize.org

Some communications thoughts

• Important benefits can be gained by increasing vaccination rates across all age groups with currently available vaccines. – One CDC study* concluded that flu vaccination prevented

an estimated 13.6 million flu cases, 5.8 million medical visit & nearly 113,000 flu-related hospitalizations in the United States over a 6-year period (2005-2011).

*Kostova, D. et al. 2013. PLoS ONE 8(6): e66312.doi:10.1371/journal.pone.0066312 64


immunize.org

More messaging on Vaccine Effectiveness…

• Questions about efficacy and duration remain – Do not base efficacy or duration of immunity discussions on one season but look collectively at multiple seasons

• Use impact data, and data over multiple years to provide perspective on vaccine benefits

– Vaccine in the patient is 40%-60% effective; vaccine on the shelf is 0% effective.


immunize.org

Messaging on Vaccination Timing*

• July through August – It might be too soon to get vaccinated unless the person is

a child needing two doses of vaccine. CDC recommends flu vaccination by the end of October

• Beginning September – CDC recommends flu vaccination by the end of October. While it’s fine to get vaccinated in September, keep four things in mind: 1. Current flu levels are (low/rising/high); 2. It takes about two weeks after vaccination for protective antibodies

to develop; 3. Immunity from vaccination wanes over time; and, 4. Flu activity most often peaks in February and can last as late as May.

* From the CDC, presented at the NAIIS Weekly call September 19th, 2019


immunize.org

Messaging on Vaccination Timing*

• October – Get vaccinated before the end of OctoberBeginning

September

• Beginning in November – CDC recommends vaccination continue as long as influenza

viruses are circulating. Though the timing of flu season varies, significant flu activity can last as late as May.

• Early December through February – It's not too late to get vaccinated. CDC recommends

vaccination continue as long as influenza viruses are circulating. Though the timing of flu season varies, flu season most often peaks in December and February, but significant flu activity can last as late as May



immunize.org

Messaging on Vaccination Timing* • March-May

– Flu viruses are circulating at X levels nationally though activity varies by location. CDC recommends vaccination continue as long as influenza viruses are circulating. Check FluView Interactive for more information about flu activity in your state: https://www.cdc.gov/flu/weekly/fluviewinteractive.htm

• June – Most flu vaccine expires by the end of June. If you haven't

gotten vaccinated and plan a trip to the Southern Hemisphere, where their flu season is just beginning, or plan to travel in a relatively crowded setting where people from many parts of the country might be in close proximity, e.g., a cruise, get a flu vaccine at least two weeks before traveling. Vaccine for the upcoming season will be available next fall.


https://www.cdc.gov/flu/weekly/fluviewinteractive.htm

zation ,alition

immunize.org

Dispelling Myths and Handling Objections About Flu Shots

OBJECTION: The flu shot will give me the flu.

RESPONSE: It’s impossible to get the flu from the flu vaccine. It is made with viruses that are not infectious or with no viruses at all. You can get the flu from someone else.

OBJECTION: I’m healthy. I don’t need a shot.

RESPONSE: Every year, healthy people get sick from the flu, and some even die. Many people have underlying conditions that they are not aware of. Even with a mild case, you can still pass the virus along to the people you love and care about.

OBJECTION: I’ve never had the flu.

RESPONSE: Every year, up to 20% of Americans get the flu—that’s up to 60 million people—many of whom have not had the flu before.

OBJECTION: The flu shot doesn’t work.

Effectiveness varies from season to season and between flu strains. Vaccine RESPONSE: effectiveness is not just measured by the percentage of disease prevented but more

importantly, by the myriad of negative outcomes that vaccination prevents even ifyou catch the flu, such as hospitalization and quality of life (disability).

~

FLU DEFENSE™ Help Shield Older Adult Patients from Influenza

YOUR OLDER ADULT PATIENTS ARE AT RISK

YOUR RECOMMENDATION MATTERS

VACCINATION: THE BEST PROTECTION

ABOUT INFLUENZA

TOOLS AND RESOURCES

IAC Resource for clinicians (www.influenza-defense.org

http://www.influenza-defense.org/

S. Notifications of laboratory confirmed influenta, Australia, 1 January 2013 to 8 September 2019, by manth and week of diagnosis.•

,oow

25000

E 20000

~ "' g 15000 "5 .x ; Z 10000

SITT]

, I I

Month a,cl week of diaenosis:

\ I

- - 2014

- - 2015

- - 2016

- - 2017

- - 2018

- 2019

S year :::IVPr agP

S.:>urce: I\NDS.i •NNnc;i; nt~lifit'::lltinr t1::11;i prn-.ri1Pt1 fnr · hP l"Utr~nt ::in rl "l'lmt rPtPnt w?P~"- m::ty hP inrom:'IIP0 P. l U tl;,t;:'I ;uP prPlim in::irv anti ~ •hjPrt u~ r h::ne~ ;:'I<. nprt::itP<

are rece1·1eCI.

Figure 2. Unweighted rate of ILi reported from •entinel GP •urveilla nce •Y•t em•, Australia, 1 January 2014 t o 8 September 2019, by month a nd week.

25

"'

- - 201-'

- - 101!)

- - 2016

- - 2017

- - 2018

twe~ge --2019

5ourc.e. ASPf..EN


immunize.org

2019 Southern Hemisphere Influenza Season


immunize.org

Why do we immunize

against influenza? Amanda, died at age 4½ yrs from

influenza Breanne, died at age 15 mos from influenza complications

Alana, died at age 5½ yrs from Barry, a veteran fire-fighter, died at Lucio, died at age 8 yrs from influenza age 44 yrs from influenza influenza complications

Slide Courtesy of Families Fighting Flu


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Visit IAC Resources! •IAC’s Influenza Educational Materials

– https://immunize.org/influenza/

•Read our publications! – http://www.immunize.org/publications/

•Visit our websites! – www.immunize.org – www.vaccineinformation.org – www.immunizationcoalitions.org – www.izsummitpartners.org

•Stay ahead of the game! Subscribe to our updates! – http://www.immunize.org/subscribe/

https://immunize.org/influenza/

http://www.immunize.org/subscribe

www.izsummitpartners.org

www.immunizationcoalitions.org

www.vaccineinformation.org

www.immunize.org

http://www.immunize.org/publications


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Thank You

for your attention!

what's new with the flu in 2019? · influenza infection. 1 • a study in va patients showed...

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