Adult Vaccines: Increasing Influenza and Pneumococcal vaccination

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Adult Vaccines Increasing Influenza and
Pneumococcal vaccination

• ACHCA Annual Conference
• April 2006
• James Marx, RN, MS, CIC
• Broad Street Solutions
• www.InfectionControl.net

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Agenda

• Epidemiology of Influenza
• Epidemiology of Pneumococcal Disease
• Role of vaccination in disease prevention
• Role of antiviral medication
• Infection Control measures
• Droplet Precautions
• Hand Hygiene
• Restriction of Activities and Group Dining

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Agenda

• Requirement for vaccination of SNF residents (CMS
  and AB 691)
• Standing Orders in SNF- AB 1711
• Minimum Data Set- Section W
• Barriers to vaccination
• Lack of education
• Consent issues
• Vital Signs
• Billing

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Agenda

• Monitoring for Performance Improvement
• Hospital Core Measures to prevent Community
  Acquired Pneumonia
• Percent of vaccinated staff
• Percent of vaccinated SNF residents
• Percent of vaccinated eligible inpatients
• Group Discussion on improving interfacility
  transfers

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Vaccine preventable diseases

• Residents, staff, visitors
• Influenza (Oct-Mar)
• Tetanus/diphtheria
• Residents
• Pneumococcal (All year)
• Residents and Staff (Selected populations)
• Hepatitis B
• Varicella (chickenpox)

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Epidemiology

• Influenza
• Pneumococcal Disease

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Influenza

• Sixth leading cause of death
• Death in the elderly is about 1/1000 cases or
  36,000 deaths per year
• Hospitalization in the elderly is about 1/250
  cases

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Institutional outbreaks

• To date this season, respiratory outbreaks have
  been reported in seven long-term care and
  developmental facilities in Santa Clara, Marin,
  Orange and Santa Cruz counties.
• Five outbreaks were associated with influenza A
  in two an etiology was not identified.

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Influenza Nomenclature

• A/New York/55/2004/(H3N2)
• Influenza A
• First isolated in New York
• Strain number 55
• First isolated in 2004
• Hemagglutinin type 3
• Neuraminidase type 2

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Influenza peak in past 26 seasons
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Influenza Basics

• Influenza A and B
• Influenza A subgroups, H and N
• Antigenic drift and shift
• Results of viral mutation over time
• Transmitted person-to-person via respiratory
  secretions
• Incubation 1-4 days, 2 days average

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Endemic ? Epidemic ? Pandemic
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The Two Mechanisms whereby Pandemic Influenza
Originates
Belshe, R. B. N Engl J Med 20053532209-2211
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Influenza Patterns

• Sporadic ? year round, A, B, and C
• Seasonal ? December to February, mostly Influenza
  A (annual)
• Epidemic ? Exaggeration of the seasonal pattern,
  involves a geographic region with an attack rate
  of 10 to 40 (299 in recorded history- last one
  was 1997)
• Pandemics ? Global impact (31 in recorded
  history- last in 1968)

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How big is a seasonal outbreak?

• Clinical illness in 16,000,000 per year in the US
• 4,500,000 cases in the elderly
• 3,600,000 doctors visits
• May result in 40,000 excess deaths

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How Big is Epidemic Influenza ?

• An epidemic but not pandemic year may infect 15
  to 35 of the population
• 90,000 to 210,000 deaths
• 310,000 to 730,000 hospitalizations

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How Big is Pandemic Influenza ?

• Pandemic influenza could infect 60 of the
  worlds population
• If no more lethal than current H3N2
• 150,000 to 450,000 deaths
• If as lethal as swine flu (1917)
• 450,000 to 750,000 deaths
• If as lethal as avian H5N1
• 75,000,000 deaths

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Current status of pandemic
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Influenza Basics

• Infectious period is 1 day before and 5 days
  after symptoms appear, in adults
• In children and the elderly, infectious period
  may be 6 days before and 10 days after
  symptoms appear

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Influenza signs and symptoms

• Abrupt onset with
• Fever
• Myalgia
• Headache
• Severe malaise
• Nonproductive cough
• Sore throat
• Runny nose

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Pathogenesis of Influenza

• Mucosal epithelia are the most heavily infected
  cells
• Disrupts host cell protein synthesis
• May trigger apoptosis
• Protein epitopes are similar to peptides toxic to
  neutrophils

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Complications of Influenza

• Progressive pneumonia (rare)
• Bronchial mucosal sloughing
• Loss of ciliated epithelia
• Alteration to white cell function
• Bronchoconstriction
• Bacterial superinfection

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Influenza Vaccine

• Technology developed in the 1940s
• Virus is inoculated into embryonated chicken eggs
• Each egg produces enough virus for 1 to 3 doses
  of vaccine
• At least 9 months are needed to produce adequate
  amounts of any given strain

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Intramuscular Vaccine

• Inactivated virus, grown in chicken eggs
• Protection in 2 weeks after vaccination
• 2005-6 vaccine contains
• A/California/7/2004 (H3N2)
• A/New Caledonia/20/99 (H1N1)
• B/Shanghai/361/2002
• Selection each year is a guess made in April
  vaccine made in summer

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Vaccine effectiveness

• Adults lt 65 years
• 70-90 protection against influenza
• Adults gt 65 years
• 58 protection against influenza
• 50-60 effective in preventing hospitalization
• 80 effective in preventing death

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Vaccine Administration

• Intramuscular 1 inch or longer needle
• 0.5 ml
• Soreness at the site occurs lt 65 of the time and
  lasts lt 2 days

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Vaccine Administration

• Fever, malaise and myalgia occurs within 6-12
  hours of administration and occurs most often in
  first time vaccinees
• Anaphylaxis and Guillain-Barré Syndrome are
  extremely rare
• Can be given at the same time as other vaccines,
  at different sites

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New influenza vaccine

• Intranasal, live vaccine (FluMist)
• Ages 5-49 only
• Transmission of vaccine virus to others is
  possible
• Close contact with people at high risk of
  influenza should be avoided for 21 days after
  vaccine is given
• Nasal swab may be positive for up to 3 weeks
  after vaccine
• Not recommended for pregnant women
• In 2005-2006 CDC changed recommendations to
  include healthcare workers

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Live Vaccine

• Recombinants with less virulent strains
• Cold adapted virus
• DNA vaccines

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Cost effective in staff

• Influenza vaccine
• Reduces physician office visits 34-44
• Reduces lost work days 32-45
• Reduces antibiotic use 25
• 60 - 4,000/illness averted among healthy persons
  aged 18--64 years

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Vaccine recommendations High Risk

• Persons aged gt65 years
• Residents of nursing homes and other chronic-care
  facilities that house persons of any age who have
  chronic medical conditions
• Adults and children who have chronic disorders of
  the pulmonary or cardiovascular systems,
  including asthma (hypertension is not considered
  a high-risk condition)
• Adults and children who have required regular
  medical follow-up or hospitalization during the
  preceding year because of chronic metabolic
  diseases (including diabetes mellitus), renal
  dysfunction, hemoglobinopathies, or
  immuno-suppression (including immunosuppression
  caused by medications or by human
  immunodeficiency virus HIV)

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Vaccine recommendations High Risk

• Adults and children who have any condition (e.g.,
  cognitive dysfunction, spinal cord injuries,
  seizure disorders, or other neuromuscular
  disorders) that can compromise respiratory
  function or the handling of respiratory
  secretions or that can increase the risk for
  aspiration
• Children and adolescents (aged 6 months--18
  years) who are receiving long-term aspirin
  therapy and, therefore, might be at risk for
  experiencing Reye syndrome after influenza
  infection
• Women who will be pregnant during the influenza
  season
• Children aged 6--23 months

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Vaccine Recommendations Transmitters

• Employees of assisted living and other residences
  for persons in groups at high risk
• Persons who provide home care to persons in
  groups at high risk
• Household contacts (including children) of
  persons in groups at high risk
• Healthcare Workers (HCWs)

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Vaccine Recommendations Other

• Persons aged 50-64
• Healthy young children
• Travelers
• General population

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Define a influenza case

• Use a written definition (A McGeer, AJIC, 1991)
• Sudden onset of fever (gt100.4 F) plus three or
  more of the following symptoms (Dec-Mar only)
• Headache or eye pain
• Myalgia(Muscle aches)
• New or increased dry cough
• Chills
• Sore throat
• Malaise or loss of appetite
• Laboratory confirmed influenza

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Define an influenza outbreak

• One laboratory confirmed and two suspect cases of
  influenza in a 48-72 hour period among staff,
  residents, or visitors (SHEA position paper)
• Ten percent (10) of residents meet written
  definition of influenza in a 7 day period (SHEA
  position paper)
• Write the outbreak definition in your policy

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Outbreak activities

• Reinforce hand hygiene
• Increase availability of tissue and disposal
  containers
• Institute droplet precautions for residents with
  symptoms standard surgical masks
• Remind staff to stay home if they have symptoms
  consistent with influenza
• Consider use of antiviral prophylaxis
• Consider restriction of admissions, groups
  activities, dining and visitation
• Notify reporting agencies

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Mechanism of Action of Neuraminidase Inhibitors
Moscona, A. N Engl J Med 20053531363-1373
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Selected Treatment Trials of Neuraminidase
Inhibitors
Moscona, A. N Engl J Med 20053531363-1373
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Avian Influenza

• Causes influenza in birds
• Has been transmitted to humans
• Rare human-to-human transmission (1 case)
• Future mutations could effect humans

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Selected Trials of Prophylaxis with the Use of
Neuraminidase Inhibitors
Moscona, A. N Engl J Med 20053531363-1373
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Pneumococcal Disease

• Pneumonia
• Bacteremia
• has a 40 mortality
• Meningitis

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Pneumococcal Disease and Vaccination

• Basics
• Vaccine protects from invasive Streptococcus
  pneumoniae
• Pneumonia
• Bacteremia
• Meningitis
• More than 80 different subtypes of this bacteria
• 5- 70 of people are carriers of this bacteria
  in their nose, mouth, and lungs
• Pneumococcal pneumonia is the most common cause
  of pneumonia in adults

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Pneumococcal pneumonia

• Symptoms
• fever, chills, shaking, chest pain, productive
  cough, shortness of breath, rapid heart beat, and
  general weakness
• More than 50,000 cases occur each year
• The overall death rate is 20 but in the elderly
  it may be as high as 60

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Vaccine efficacy

• This vaccine provides protection against 23
  serotypes of St. pneumoniae
• Protection usually lasts from 5-10 years or
  longer in healthy individuals
• No recommendation for revaccination in most
  people
• Reduces death by 50
• Uncertain vaccine status??- VACCINATE!

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Vaccine administration

• May be given at same time a influenza vaccine
• For IM injection administer vaccine at a 90
  angle with a 1 to 2 inch 22-25-gauge needle in
  the deltoid
• For SC injections, administer vaccine at a 45
  angle with a 5/8-inch, 23-25-gauge needle into
  the subcutaneous tissue of the upper-outer arm.

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Vaccine recommendations

• Older than 65 years of age
• Anatomic or functional asplenia, CSF leak,
  diabetes mellitus, alcoholism, cirrhosis, chronic
  renal insufficiency, chronic pulmonary disease,
  or advanced cardiovascular disease
• multiple myeloma, lymphoma, Hodgkin's disease,
  HIV infection, organ transplantation, or chronic
  use of glucocorticosteroids

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Vaccine recommendations

• Persons who are genetically at increased risk,
  such as Alaskan and Native Americans
• Persons who live in special environments where
  outbreaks may occur, such as nursing homes

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Other adult vaccines

• Tetanus
• Diphtheria
• Pertussis

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Adacel and Boostrix

• Tdap vaccines for adolescents and adults
• Tdap should be given 5 years after the last Td to
  adolescents and 10 years after to adults
• Adults or adolescents who will be exposed to
  infants can be immunized with one of the new
  vaccines as soon as 2 years after their last Td

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Implementation

• State and Federal Laws
• Outbreak Management

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CMS requirement

• October 7, 2005
• Sec. 483.25 Quality of care
• Addresses both influenza and pneumococcal
  vaccination
• Does not specifically address immunization of
  staff

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CMS requirement

• Before offering the influenza immunization, each
  resident or the resident's legal representative
  must receive education regarding the benefits and
  potential side effects of the immunization

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CMS requirement

• Each resident is offered an influenza
  immunization October 1 through March 31 annually,
  unless the immunization is medically
  contraindicated or the resident has already been
  immunized during this time period
• The resident or the resident's legal
  representative has the opportunity to refuse
  immunization

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CMS requirement

• The resident's medical record includes
  documentation that indicates, at a minimum, the
  following
• That the resident or resident's legal
  representative was provided education regarding
  the benefits and potential side effects of
  influenza immunization
• That the resident either received the influenza
  immunization or did not receive the influenza
  immunization due to medical contraindications or
  refusal.

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Staff vaccination

• Implied in the Federal Conditions of
  Participation
• 42 CFR 483.65 requires nursing facilities (NF) to
  establish and maintain an infection control
  program designed to prevent the development and
  transmission of disease and infection. The CDC
  recommends that all health care workers be
  immunized annually.

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Minimum Data Set (MDS)

• Developed as a reimbursement tool based on acuity
  of illness
• Now also used as a measure of quality
• Section W
• Influenza vaccine between Oct 1- March 31
• Pnuemococcal vaccine year round

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New York- Article 21

• Residents
• Influenza
• Pneumococcal vaccine
• Staff
• Influenza
• Pneumococcal vaccine

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Success stories

• Screening during intake assessment
• Pre-printed admission orders
• Medical records audits
• Computer based tracking programs

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Survey process

• HCFA 672
• number of residents with Influenza vaccine
• number of residents with Pneumococal vaccine
• Include both residents who were vaccinated in the
  facility AND residents who have been vaccinated
  prior to admission
• Do not include residents who refuse vaccine

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Consent and Billing

• Separate written consent for vaccination may not
  be required check your facility policy
• Physicians order for vaccination is covered
  under the general consent to treat
• Alternate would be to get consent from the
  resident and not obtain a physician's order
• Physician order is not required for reimbursement
  under Medicare
• Use Roster billing to decrease billing paperwork

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Physician Orders

• Medicare Requirement for Consent
• B.7 Is a physician order (written or verbal),
  plan of care, or any other type of physician
  involvement required for Medicare coverage of the
  flu and PPV vaccinations?
• No. For Medicare coverage purposes, it is no
  longer required that either of the vaccines be
  ordered by a doctor of medicine or osteopathy
  though individual state law may require a
  physician order or other physician involvement.
  Therefore, when allowable under state law, the
  beneficiary may receive the vaccines upon request
  without a physicians or osteopaths order.
• http//new.cms.hhs.gov/AdultImmunizations/Download
  s/2005-2006QAGuide.pdf

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Billing

• HCFA-855, Provider/Supplier Enrollment
  application
• This enrollment process currently applies only to
  entities that will
• bill the carrier
• use roster bills
• bill only for flu and PPV shots
• Provided by the Part B carrier

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Billing

• Diagnosis Coding
• Influenza virus vaccine is billed using diagnosis
  code V04.8
• HCPCS Coding
• Influenza virus vaccine is billed using HCPCS
  codes 90657, 90658 or 90659. This code is for
  the vaccine only and does not include
  administration
• Administration of influenza virus vaccine is
  billed using HCPCS code G0008

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Billing

• Diagnosis Coding
• Pneumococcal vaccine is billed using diagnosis
  code V03.82.
• HCPCS Coding
• Pneumococcal vaccine is billed using HCPCS code
  90732. This code is for the vaccine only and does
  not include administration
• Administration of pneumococcal vaccine is billed
  using HCPCS code G0009

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Barriers to vaccination

• Staff think
• Oh, the pain!

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Barriers to vaccination

• Staff think
• Oh, the pain!
• Nurses think
• Oh, the paperwork!

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Barriers to vaccination

• Staff think
• Oh, the pain!
• Nurses think
• Oh, the paperwork!
• Administrators think
• Oh, the cost!

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Implementation Strategies

• Remove financial barriers
• Use roster billing
• Bill separately for vaccine and administration
• Physician order is not required for reimbursement
  of Medicare or Medicaid residents
• Offer vaccine in October and continue with all
  admissions until the end of March

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Implementation Strategies

• Monitor and report vaccination rates to the
  Infection Control or Quality Improvement
  Committee
• Set goals for resident and staff vaccination
  rates
• Healthy People 2010- 90 residents and staff

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Implementation Strategies

• Offer incentives to staff who get vaccinated at
  the facility or elsewhere
• Require staff to be vaccinated or sign a
  declination statement
• Request vaccination status, both influenza and
  pneumococcal vaccine, for all admissions to the
  facility
• Continue to vaccinate all new admissions after
  annual influenza program is completed in the Fall

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Implementation strategies

• Education of staff, family and residents
• Remove administrative barriers
• Informed consent is required does not require a
  the resident or family signature
• Vital signs after administration are not required
• Use Standing Orders or pre-printed orders
• Physician signature is no longer required for
  reimbursement
• Use system to track vaccinees
• Monthly recap
• Separate vaccination sheet, combined with TB
  screen
• Designate area on Face Sheet

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Standing Orders and Consent

• Many States now allow standing orders
• Some States require informed consent
• Oral
• Written
• Facility policy will determine consent practice
• Only Maryland requires Written Consent

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Hand Hygiene

• Plan to monitor compliance
• Feedback to staff and physicians
• Information for resident and family members-
  Its OK to Ask

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Education for everyone

• Cough etiquette

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Staff Vaccination

• Employees, Medical Staff and Volunteers

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Group discussion

• Where is immunization documented?
• How is vaccine history communicated between
  healthcare providers?
• How can we help the patient track their
  vaccination history?
• Where are your facilitys resources related to
  vaccine preventable diseases?

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Influenza planning exercise

• Seasonal influenza
• Vaccination planning and promotion
• Early detection
• Reducing transmission
• Pandemic influenza
• Bed capacity
• Staffing capabilities
• Supplies- masks, medications, vaccine, tissues
• Temporary morgue

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References and Resources

• www.cdc.gov/nip
• www.apic.org
• James Marx, RN, MS, CIC
• P.O. Box 16557, San Diego, CA 92176
• 619-656-7887 Voice/Fax
• www.InfectionControl.net

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References and Resources

• National Immunization Program at the Centers for
  Disease Control and Prevention http//www.cdc.gov/
  nip
• S Bradley, Prevention of Influenza in Long-Term
  Care Facilities, ICHE, September 1999
• Adult Immunization Programs in Nontraditional
  Settings and Use of Standing Orders Programs to
  Increase Adult Vaccination Rates, MMRW, March 24,
  2000
• http//new.cms.hhs.gov/AdultImmunizations/
  Downloads/2005-2006QAGuide.pdf

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• Thank you!