2015 Influenza Update
Get Immunized!
Presented by Dr. Sheam Bakri, MPH, PharmD
and Dr. Paul Mulhausen, MD
Moderator: Karen Boland, RN, CIC
Objectives
• Describe Advisory Committee on Immunization Practices
(ACIP), 2015-2016 Recommendations
• Discuss types of vaccines available for 2015-2016
• Discuss influenza vaccination rates
• Discuss myths about influenza
• Present action steps to improve influenza immunization
2
Medication Safety
Dr. Sheam Bakri, MPH, PharmD
Clinical Pharmacy Specialist
Telligen QIN-QIO
Email: sheam.bakri@area-d.hcqis.org
Phone: 630-928-5849
3
ACIP Recommendations for 2015-2016 Influenza
Season
• Advisory Committee on Immunization Practices (ACIP)
Recommendations*:
– All persons aged ≥6 months should receive influenza
vaccine annually
 Either Live Attenuated Influenza Vaccine (LAIV) or
Inactivated Influenza Vaccine(IIV)
– Children 2 to 8 yrs. may receive either LAIV or IIV
– If child (ages 2 to 6) has not received vaccine in past, then
give 2 doses (each dose ≥ 4 weeks apart)
 8 years is the upper age limit for receipt of 2 doses of
influenza vaccine in a previously unvaccinated child
*For
4
complete recommendations visit:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm
ACIP Recommendations for 2015-2016 Influenza
Season
• LAIV should not be used in the following populations:
– Persons aged <2 years or >49 years
– Persons with contraindications listed in the package insert:
 Children aged 2 through 17 years who are receiving aspirin or
aspirin-containing products;
 Persons who have experienced severe allergic reactions to the
vaccine or any of its components, or to a previous dose of any
influenza vaccine
– Pregnant women
– Immunocompromised persons
– Persons with a history of egg allergy
5
http://www.cdc.gov/media/releases/2015/s0226-acip.html
ACIP Recommendations for 2015-2016 Influenza
Season
• LAIV continued:
– Children aged 2 through 4 years who have asthma history of
wheezing in the past 12 months
– Persons who have taken influenza antiviral medications within
the previous 48 hours
– Other underlying medical conditions that might predispose them
to complications after wild-type influenza infection
– Persons who care for severely immunosuppressed persons who
require a protective environment
 Should avoid contact with such persons for 7 days after receipt
http://www.cdc.gov/media/releases/2015/s0226-acip.html
6
Vaccines for 2015- 2016 Influenza Season
•
•
•
•
•
Trivalent vs. Quadrivalent
Live vs. Inactivated
Egg-based influenza vaccines
Cell-based influenza vaccines
Recombinant influenza vaccines
http://www.cdc.gov/flu/protect/whoshouldvax.htm
7
Vaccines for 2015-2016 Influenza Season
• Trivalent vaccines cover:
– an A/California/7/2009 (H1N1)pdm09-like virus
– an A/Switzerland/9715293/2013 (H3N2)-like virus
– a B/Phuket/3073/2013-like virus
• Quadrivalent vaccines cover:
–
–
–
–
an A/California/7/2009 (H1N1)pdm09-like virus
an A/Switzerland/9715293/2013 (H3N2)-like virus
a B/Phuket/3073/2013-like virus
B/Brisbane/60/2008-like virus
http://www.cdc.gov/flu/protect/whoshouldvax.htm
8
Inactivated Influenza Vaccine, Trivalent (IIV3)
Standard Dose
Trade Name
9
Presentation
Age
Indications
Route
Afluria®
0.5mL single-dose
prefilled syringe,
5.0mL multidose vial
≥9 yrs.
IM
Fluvirin®
0.5mL single-dose
prefilled syringe,
5.0mL multidose vial
≥4 yrs.
IM
Fluzone®
5.0mL multidose vial
≥6 mos.
IM
Fluzone HighDose®
0.5mL single-dose
prefilled syringe
≥ 65 yrs.
IM
Inactivated Influenza Vaccine, Quadrivalent
(IIV4) Standard Dose
Trade Name
Presentation
Age indications
Route
Fluarix®
Quadrivalent
0.5 mL single dose
prefilled syringe
≥ 3 yrs.
IM
FluLaval®
Quadrivalent
5.0mL multidose vial
≥ 3 yrs.
IM
Fluzone®
Quadrivalent
0.25mL single-dose
prefilled syringe
6-35 mos.
IM
0.5mL single-dose
prefilled syringe
≥ 36 mos.
IM
0.5 mL single-dose
vial
≥ 36 mos.
IM
5.0mL multidose vial
≥ 6 mos.
IM
0.1 mL single-dose
prefilled microinjection
system
18 through 64 yrs.
ID
Fluzone ®
Intradermal
10
Quadrivalent
Vaccines for 2015-2016 Influenza Season
Age specific vaccine information:
– Younger than 65 years of age should not receive the high-dose
Fluzone®
– Younger than 18 years old or older than 64 yrs. not receive the
intradermal Fluzone® Quadrivalent
•AFLURIA®
– Indicated for ≥5 years on package insert
 ACIP recommends not to be used in children aged 6 months through
8 years due to increased risk of febrile reaction
– Available for 18 – 64 yrs. via jet injector
– Contains thimerosal
11
Inactivated Influenza Vaccine, Trivalent (IIV3)
and Quadrivalent (IIV4)
Contraindications:
•
•
•
Not recommended for children younger than 6 months
People with severe, life-threatening allergies to flu vaccine or any ingredient
in the vaccine
– Egg protein/ allergy, gelatin, antibiotics, or other ingredients found in
vaccine
After previous dose of any influenza vaccine
Precautions:
•
•
With moderate to severe illness with/without fever
History Guillain-Barre syndrome within 6 weeks of influenza vaccine
http://www.cdc.gov/flu/about/season/index.htm
12
Inactivated Influenza Vaccine, Trivalent, Cell
Culture-Based (ccIIV3)
Trade Name
Flucelvax®
Presentation
0.5mL singledose prefilled
syringe
Age Indication
≥ 18yrs.
http://www.cdc.gov/flu/about/season/index.htm
13
Route
IM
Inactivated Influenza Vaccine, Trivalent, Cell
Culture-Based (ccIIV3)
“Cell-based” refers to how the flu vaccine is made
• Cell-based flu vaccines are developed through a different
manufacturing process
– viruses cultured cells of mammalian origin instead of in
hens’ eggs
• Cell-based flu vaccines are being developed as an
alternative to the egg-based manufacturing process
• Potentially more flexible than the traditional technology,
which relies upon adequate supply of eggs
• http://www.cdc.gov/flu/about/season/index.htm
14
Inactivated Influenza Vaccine, Trivalent, Cell
Culture-Based (ccIIV3)
• A major advantage of cell culture technology includes the potential
for a faster start-up of the vaccine manufacturing process in the event
of a pandemic.
– cells kept frozen and “banked”
– assures an adequate supply of cells is readily available for vaccine
production
– growing the influenza viruses in cell culture for the manufacture
of Flucelvax is not dependent on an egg supply
• Clinical studies demonstrate that Flucelvax is safe and effective for
use in individuals 18 years of age and older
• Typical side effects
– Pain, redness and soreness at the injection site and headache and
fatigue were the most common reactions
15
http://www.cdc.gov/flu/about/season/index.htm
Live Attenuated Influenza Vaccine,
Quadrivalent (LAIV4)
Trade Name
FluMist®
Quadrivalent
Presentation
0.2mL singledose prefilled
intranasal
Age Indications
2-49 yrs.
http://www.cdc.gov/flu/about/season/index.htm
16
Route
IN
FluMist® Quadrivalent Vaccine
• Not recommended for:
– Children younger than 2 years
– Adults 50 years and older
– People with a history of severe allergic reaction to any
component of the vaccine or to a previous dose of any
influenza vaccine
– Those with egg allergies
http://www.cdc.gov/flu/about/season/index.htm
17
FluMist® Quadrivalent Vaccine
• Not recommended for:
– Children or adolescents (2 years through 17 years of age) on long-term
aspirin treatment.
– Pregnant women
– People with weakened immune systems (immunosuppression)
– Children 2 years through 4 years who have asthma or who have had a
history of wheezing in the past 12 months.
– People who have taken antiviral medications within the previous 48
hours.
– People who care for severely immunocompromised persons who
require a protective environment (or otherwise avoid contact with
those persons for 7 days after getting the nasal spray vaccine).
http://www.cdc.gov/flu/about/season/index.htm
18
Recombinant Influenza Vaccine, Trivalent (RIV3)
Trade Name
Presentation
FluBlok®
0.5mL singledose vial
Age
Indications
≥18 yrs.
Route
IM
• Recombinant-based = “egg-free”
• approved for use in the U.S. market in 2013 and that involves using
recombinant technology
• production method does not require an egg-grown vaccine virus and
does not use chicken eggs at all in the production process
• manufacturers isolate a certain protein from a naturally occurring
“wild type" recommended vaccine virus
http://www.cdc.gov/flu/about/season/index.htm
19
Recombinant Influenza Vaccine, Trivalent (RIV3)
• Proteins are then combined with portions of another virus
that grows well in insect cells
• This “recombinant” vaccine virus is then mixed with insect
cells and allowed to replicate
• Flu protein is harvested from cells and purified
• Recombinant flu vaccine is the only 100% egg-free
vaccine on the U.S. market
http://www.cdc.gov/flu/about/season/index.htm
20
Recombinant Influenza Vaccine, Trivalent (RIV3)
• Process can produce vaccine in the shortest amount of
time
– not dependent on an egg supply or limited by the
selection of vaccine viruses that are adapted for
growth in eggs
• Precaution with moderate to severe illness with/without
fever
– History Guillain-Barre syndrome within 6 weeks of
influenza vaccine
http://www.cdc.gov/flu/about/season/index.htm
21
Thank You!
22
Telligen QIN-QIO Chief Medical Officer
Paul Mulhausen
Chief Medical Officer, Telligen QIN-QIO
Email: pmulhausen@telligen.com or
Paul.mulhausen@hcqis.org
Phone: 515-440-8504
23
Influenza (“The Flu”)
• Influenza is the most frequent cause of death
from a vaccine-preventable illness in the United
States.
• Influenza is highly contagious and attacks the
body’s airways.
• Incubation is from 1-4 days after exposure.
• Signs and Symptoms include
 Fever
 Nasal congestion
 Headache
 Runny Nose
 Dry cough
 Muscle aches
 Sore throat
24
http://www.cdc.gov
Influenza (“The Flu”)
• Each year, 5% - 20% of the U.S.
population develops influenza
– 200,000 hospitalizations
– 36,000 influenza-associated
pulmonary and cardiac deaths
each year
• In outbreaks, as many as 10% to
40% of people are attacked by
the virus
25
http://www.cdc.gov
Influenza is spread by air droplets and hands.
• The influenza virus is spread
from person to person!
• The viruses are spread mainly
by large-particle respiratory
droplets: cough, sneeze, or
talk.
• People infected with influenza
start being contagious one day
prior to showing signs or
symptoms.
26
http://blogs.cdc.gov/niosh-science-blog/2013/01/15/catchingtheflu/
Preventing the Flu!
• Vaccination remains the single
best way to prevent the flu!
– Reduce flu illnesses,
– Reduce doctors' visits,
– prevent flu-related
hospitalizations and deaths.
• Vaccination reduces the need
to use antibiotics and over-thecounter medications
http://www.cdc.gov
27
The Circulating Viruses that Cause Influenza often
change from year-to-year
2012-2013
2013-2014
2014-2015
2009 H1N1
A(H3)
A(Subtyping not done)
B
H3N2v
28
FluView - http://gis.cdc.gov/grasp/fluview/fluportaldashboard.html
The Flu vaccine is excellent, but not perfect
The 2014-2015 Influenza Season
Mismatch on the Influenza A (H3N2)
2014-2015 Influenza Vaccine
•
•
•
•
12/31/2014
29
A/Texas/50/2012 (H3N2)
A/California/7/2009 (H1N1)
B/Massachusetts/2/2012
B/Brisbane/60/2008-like
2014-2015 Vaccine worked against well-matched
circulating viruses
•
•
•
•
•
2014-2015 Vaccine Effectiveness (Overall):
2014-2015 Vaccine Effectiveness (Influenza B Y):
2014-2015 Vaccine Effectiveness (Influenza B V):
2014-2015 Vaccine Effectiveness (matched H3N2):
2014-2105 Vaccine Effectiveness (mismatched H3N2):
23%
55%
63%
43%
9%
June 2015 ACIP Meeting-Novel Influenza and Flu https://www.youtube.com/watch?v=iYwm6qId4-k
30
More of Us Can Get the Influenza Vaccination!
Vaccination Rates
Flu Seasons:
2013-2014; 2014-15
FluVax View http://www.cdc.gov/flu/fluvaxview/nifs-estimates-nov2014.htm
31
Why don’t our patients get the influenza
vaccination?
• Underestimate the Impact of Influenza: “It’s just the flu,
what’s the big deal?”
• Underestimate the prevention power of the vaccination:
“last year, the flu shot didn’t even work!”
• Expense: “I can’t afford it!”
• Underestimate need for annual vaccination: “I got the
shot last year.”
• Concern about the risks of the vaccination: “My friend
took the flu shot and it gave her the flu. Plus it has
mercury in it.” “Vaccines are dangerous!”
• Concern about discomfort: “I hate shots.”
• “I didn’t know I needed it. My doctor didn’t say anything.”
32
Influenza Vaccination Myth Busters!
• Flu vaccine gives you the flu – Busted!
• CDC mandates that everyone has to get a flu shot. It’s the
law – Busted!
• You don’t need to get the flu vaccine every year – Busted!
• Pregnant women should not get the annual flu vaccine –
Busted!
• Children should not get the flu vaccine each year – Busted!
• It’s better to get the flu than to get the flu vaccine – Busted!
• http://www.cdc.gov/flu/about/qa/misconceptions.htm#misconception
33
What can you do in your care setting to break
down barriers to influenza vaccination
• Provide a strong, intentional message recommending
the vaccination.
• Build systematic reminders into clinic workflow
• Standing orders for vaccination of all eligible patients.
• Message the safety of the vaccine while empathically
recognizing the concerns raised by patients
• Message the potential to protect loved ones by
blocking transmission
• Ask about barriers and take time to address
knowledge gaps.
34
Examples from the field of Telligen partners
• "I can respect that decision [to not get the Flu Shot]
for you yourself, but please consider how it is a very
responsible thing to do for those around you; for
instance, you can actually carry the flu, and without
even knowing it, spread it to someone else--and
some others can get hit very hard with it [yes, I do
even share that "tens of thousands die of the flu
every year," but I know that number has been put
into question!].”
35
More examples from the Field of Telligen partners
• “In my experience the more convenient it is for a
patient to receive vaccine the more likely they will get
it. We have used drive thru vaccination clinics, walkin vaccination clinics. Sending reminders and calling
to bring people in helps. “
• Allow the nurse to advocate and provide vaccine
• Standing orders so nurses can administer the vaccine
without a doctor order.
36
Another example from the field of Telligen partners
• “Once patients start to get the vaccine they will get it
in subsequent years because they note how healthy
they remain during the winter. The problem is how to
make a person a ‘believer’ initially. Testimonials from
peers helps.”
37
Clean Hands Save Lives!
• Hand-washing prevents illness and the
spread of germs to others.
• Live Influenza virus can transfer from
nonporous surfaces to hands for 24 h
and from tissues to hands for 15 min.
• Hand-washing reduces the total rate of
respiratory illnesses
• Hand sanitation using 95% ethanol, kills
influenza viruses on the hands.
Clinical Infectious Diseases 2003; 37:1094–1101
38
http://www.cdc.gov
Knowledge Sharing
• Everyone 6 months of age and older should be vaccinated if
they have no contraindications (if contraindicated speak with
healthcare provider about alternatives)
• Get vaccinated as soon as vaccine available
• It is possible to get a respiratory virus other than flu during
flu season- similar symptoms
• Influenza virus spread through droplets
• Influenza virus can survive on surfaces between 2 and 8
hours
• Persons can be contagious 1 day before symptoms appear
and up to 7 days after
39
What can we all do?
• Get influenza vaccine as soon as possible
• Avoid contact with sick people, limit your contact with others
when you are sick
• Wash your hands frequently
• Cover your nose and mouth with a tissue when you cough or
sneeze, then immediately wash your hands
• Be aware of touching your eyes, nose or mouth, avoid
spreading germs
• Clean commonly touched or exposed surfaces
often(workspaces, door knobs, faucets, handles, etc.)
• Use alcohol based hand rubs
40
Q&A
Questions/Comments for
presenters?
41
Summary
• Getting the influenza vaccine decreases likelihood of
getting the flu and, although not perfect, offers the
best opportunity for protection against influenza.
• There are a number of reasons that people choose
not to receive the seasonal influenza vaccination.
A variety of strategies can be used to successfully
overcome the barriers and optimize use of the
influenza vaccine to fight influenza.
42
THANK YOU!
For additional information please visit:
http://www.cdc.gov/flu/about/season/flu-season-20152016.htm
43
This material was prepared by Telligen, the Medicare Quality Improvement
Organization for Colorado, under contract with the Centers for Medicare & Medicaid
Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy. 11SOW-ILQIN-8/2015-11174