Transcript Influenza Update 2014-2015

Robert S Jones DO FACP FIDSA
Reading Health System
 Clinical trials
 Sanofi Pasteur
 Cempra
 Actelion
 Serono
 I also have conflicts in that I get up every morning
determined to both change the world and have one
hell of a good time. Sometimes this makes planning
my day difficult.
-EB White
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2. False
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2. False
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Influenza is nothing more
than a bad cold
Influenza hospitalizes over
200,000 people a year and
can kill up to 40,000 people a
year
More people are killed by
AIDS than by influenza each
year
The flu is only dangerous to
the elderly
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40-50%
50-60%
60-70%
70-80%
80-90%
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1.
Flu seasons are predictable
2.
Flu vaccine is the best way to
protect yourself, family and
patients from flu
Pregnant women are at
higher risk complications
related to flu
Severely obese persons are at
higher risk for complications
from the flu
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 Which of the following statements is false?
 A. Flu seasons are predictable
 B. Flu vaccine is the best way to protect yourself,
family and patients from flu
 C. Pregnant women are at higher risk complications
related to flu
 D. Severely obese persons are at higher risk for
complications from the flu
 Those who do not remember the past are condemned
to repeat it.
-George Sanayana
 http://www.youtube.com/watch?v=J83DZQcDFy8
 Contagious respiratory illness caused by influenza
virus
 Characterized fever (often high), cough, body aches,
headache, malaise, rhinnitis
 Yearly winter epidemics
 Peak activity usually in January and February
 Sporadic, unpredictable pandemics
 Seasonal in U.S.
 Average 6-7% adults and up to 30% children ill
 36,000 deaths, >200,000 hospitalizations
 20,000 hospitalizations in <5 year olds
 Pandemic
 30% illness rates across age groups
Moderate (1957-like)
Severe (1918-like)
Illness
90 million (30%)
90 million (30%)
Outpatient medical care
45 million (50%)
45 million (50%)
Hospitalization
865,000
9, 900,000
Deaths
209,000
1,903,000
 Type A
 moderate to severe
illness
 all age groups
 humans and other
animals
 Type B
 changes less rapidly than
type A
 milder epidemics
 humans only
 primarily affects
children
Type A
Type B


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
 Humans
Humans
Swine
Birds
Horses
Seals
Type C
 Humans
 Swine
16
http://www-ermm.cbcu.cam.ac.uk/01002460a.pdf
RNA = Ribonucleic acid
Reference: 1. Adapted from Plotkin: Vaccines figure 15-2, ©2008. Used with permission of Elsevier Inc.
All rights reserved.
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A/Brisbane/59/2007/(H1N1)
 A = The type of isolate: A or B
 Brisbane = Geographic location where it was
isolated
 59 = A laboratory identification number
 2007 = The year of isolation
 H1N1 = For influenza A viruses, the subtype of HA
and NA
References: 1. World Health Organization. http://www.who.int/csr/disease/influenza/recommended_
compositionFeb08FullReport.pdf. Accessed September 25, 2008. 2. Bridges CB, et al. In: Plotkin SA,
Orenstein WA, eds. Vaccines. Fifth edition. Philadelphia, Pa.: Saunders, 2008:261.
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 Antigenic drift1,2
 Minor genetic variations that occur continually
 Associated with seasonal epidemics
 Permits virus to escape population’s immunity1
 Antigenic shift1,2
 Major genetic changes that occur infrequently
 Produces novel viruses that spread quickly
 Little or no human immunity2
 Causes global (pandemic) disease
 (pandemics since 1900; 1918,1957, 1968 & 2009)
References: 1. CDC. MMWR. 2008;57(RR-7):4. 2. CDC. How the flu virus can change: “drift” and “shift.”
http://www.cdc.gov/flu/about/viruses/change.htm. Accessed September 6, 2008.
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VRBPAC: vaccines and related
Biological products advisory
Committee, part of FDA
21
 The 2013-2014 trivalent influenza vaccine was made
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from the following three viruses:
A/California/7/2009 (H1N1)pdm09-like virus;
A(H3N2) virus antigenically like the cell-propagated
prototype virus A/Victoria/361/2011;
a B/Massachusetts/2/2012-like virus.
the quadrivalent vaccine contained two influenza B
viruses include the above three viruses and a
B/Brisbane/60/2008-like virus.
Peak Month of Flu Activity
1982-83 through 2013-14*
* Month with the highest percentage of specimens testing positive
http://www.cdc.gov/flu/about/season/flu-season.htm
Number* and percentage of respiratory specimens testing positive for influenza, by type,
subtype, surveillance week, and year — World Health Organization and National Respiratory and Enteric Virus
Surveillance System collaborating laboratories, United States, 2013–14 influenza season†
 2,005 (99.8%) of the 2,008 2009 H1N1 viruses tested were characterized
as A/California/7/2009-like. This was the influenza A (H1N1)
component of the Northern Hemisphere quadrivalent and trivalent
vaccines for the 2013-2014 season.
 406 (95.3%) of the 426 influenza A (H3N2) viruses tested were
characterized as Texas/50/2012-like. This was the influenza A (H3N2)
component of the Northern Hemisphere quadrivalent and trivalent
vaccines for the 2013-2014 season.
 269 (70.6%) of the 381 influenza B viruses tested belonged to the
B/Yamagata lineage of viruses. 268 (99.6%) of these 269 viruses were
characterized as B/Massachusetts/02/2012-like. This is an influenza B
component for the 2013-2014 Northern Hemisphere quadrivalent and
trivalent influenza vaccines.
 The 112 (29.4%) other influenza B viruses belonged to the B/Victoria
lineage of viruses, and were characterized as B/Brisbane/60/2008-like.
This is the recommended influenza B component of the 2013-2014
Northern Hemisphere quadrivalent influenza vaccine.
 61% for all age groups (95% CI: 52-68%)
 Effectiveness for flu A (H1N1) 62%
 Recent studies show vaccine can reduce the risk of flu
illness by about 60% among the overall population
during seasons when most circulating flu viruses are
like the viruses the flu vaccine is designed to protect
against.
 70% - 90% effective among healthy persons <65 years
of age
 30 - 40% effective among frail elderly persons
 50% - 60% effective in preventing hospitalization
 80% effective in preventing death
 Virus is shed 1 day before getting sick
 And is typically shed for 5-7 days after
 This can vary in people with weakened immune
systems
Days After Inoculation -1
Temp °F
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Illness
Headache, Malaise, Myalgia
Nasal Obstruction and Discharge,
Throat Pain, Cough
Adapted from Mandell GL, Bennett JE, Dolin R, eds. Mandell, Douglas and Bennett’s Principles
and Practice of Infectious Disease. 5th ed. 2000:1831.
 Trivalent
 A/California/7/2009 (H1N1)pdm09-like virus
 A/Texas/50/2012 (H3N2)-like virus
 B/Massachusetts/2/2012-like virus
 Quadrivalent
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A/California/7/2009 (H1N1)pdm09-like virus
A/Texas/50/2012 (H3N2)-like virus
B/Massachusetts/2/2012-like virus
B/Brisbane/60/2008-like virus
 CDC antigenically characterized 391 viruses collected
during May 18–September 20 from the United States and
worldwide, including 70 pH1N1 viruses, 141 influenza A
(H3N2) viruses, and 180 influenza B viruses.
 All 70 (100%) pH1N1 viruses (64 international and six U.S.)
were antigenically similar to the A/California/7/2009, the
influenza A (H1N1) vaccine component.
 Of the 141 influenza A (H3N2) viruses characterized (78
international and 63 U.S.), 69 (49%) were antigenically
similar to A/Texas/50/2012, the influenza A (H3N2)
component of the 2014–15 influenza vaccine for the
Northern Hemisphere.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6339a3.htm?s_cid=mm6339a3_e
 Everyone over the age of 6 months without a
contraindication
 <6 months of age
 Those with severe life-threatening allergies to flu
vaccine or any ingredient in the vaccine
 Certain flu vaccinations have age restrictions
 Nasal vaccine 2-49 years
 High dose >65 years
 Intradermal 18-64
 Recombinant flu vaccine 18-49
 Egg allergies
 Different flu shots for different ages
 History of Guillain-Barre Syndrome
 Should not get nasal vaccine
 Allergy to eggs
 Children with long-term ASA use
 Pregnant women
 Ages 2-4 with asthma
 People who have taken influenza antivirals within 48 hrs
 People who care for severely immunocompromised
 The abbreviation TIV (Trivalent Influenza Vaccine,
previously used for inactivated influenza vaccines) has
been replaced with the abbreviation IIV (Inactivated
Influenza Vaccine)
 For 2014-2015, IIVs as a class will include:
 egg-based and cell culture-based trivalent inactivated
influenza vaccine (IIV3); and
 egg-based quadrivalent inactivated influenza vaccine
(IIV4).
 RIV refers to recombinant hemagglutinin influenza
vaccine, which will be available as a trivalent
formulation (RIV3) for 2014-2015
 LAIV refers to live, attenuated influenza vaccine,
which will be available as a quadrivalent formulation
(LAIV4) for 2014-2015
 LAIV, IIV, and RIV denote vaccine categories; numeric
suffix specifies the number of influenza virus antigens
contained in the vaccine
 Where necessary to refer specifically to cell culture-
based vaccine, the prefix “cc” is used (e.g., “ccIIV3”)
Morbidity and Mortality Weekly Report
Prevention and Control of Seasonal Influenza with Vaccines:
Recommendations of the Advisory Committee on Immunization
Practices (ACIP) — United States, 2014–15 Influenza Season
Lisa A. Grohskopf, MD1, Sonja J. Olsen, PhD1, Leslie Z. Sokolow, MSc, MPH1,
Joseph S. Bresee, MD1, Nancy J. Cox, PhD1, Karen R. Broder, MD2, Ruth A.
Karron, MD3, Emmanuel B. Walter, MD4 (Author affiliations at end of text)
MMWR / August 15, 2014 / Vol. 63 / No. 32
47
Prevention and Control of Seasonal Influenza with
Vaccines: Recommendations of the Advisory
Committee on Immunization Practices (ACIP) —
United States, 2014–15 Influenza Season
Lisa A. Grohskopf, MD1, Sonja J. Olsen, PhD1, Leslie Z. Sokolow, MSc, MPH1, Joseph S. Bresee, MD1, Nancy J.
Cox, PhD1, Karen R. Broder, MD2, Ruth A. Karron, MD3, Emmanuel B. Walter, MD4 (Author affiliations at end of
text)
This report updates the 2013 recommendations by the Advisory Committee on Immunization Practices (ACIP)
regarding use of seasonal influenza vaccines (1). Updated information for the 2014–15 influenza season includes
1) antigenic composition of U.S. seasonal influenza vaccines; 2) vaccine dose considerations for children aged 6
months through 8 years; and 3) a preference for the use, when immediately available, of live attenuated influenza
vaccine (LAIV) for healthy children aged 2 through 8 years, to be implemented as feasible for the 2014–15 season
but not later than the 2015–16 season. Information regarding issues related to influenza vaccination not
addressed in this report is available in the 2013 ACIP seasonal influenza recommendations (1).
For recommendations pertaining to use of influenza vaccines in children, ACIP reviewed data on the relative
efficacy and safety of LAIV and inactivated influenza vaccines (IIVs). An adapted version of the Grading of
Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of
the evidence (2). Evidence summary tables and assessment of risk and benefits are available at http://www.
cdc.gov/vaccines/acip/recs/grade/table-refs.html. Information in this report reflects discussion during public
meetings of ACIP on February 26, 2014, and June 25, 2014. Meeting minutes, information on ACIP membership,
and information on conflicts of interest are available at http://www.cdc.gov/vaccines/acip/ meetings/meetingsinfo.html. Modifications were made during review at CDC to update and clarify wording. Any updates will be
posted at http://www.cdc.gov/flu.
Morbidity and Mortality Weekly Report MMWR / August 15, 2014 / Vol. 63 / No. 32 691
Influenza vaccine dosing algorithm for children aged 6 months through 8 years
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6332a3.htm
Despite longstanding recommendations and the
implementation of intensive voluntary vaccination
campaigns, influenza immunization rates are still
unacceptably low. The average 2012-13 seasonal
influenza vaccination rate was 63.5 percent among HCP
in the United States, far below the Healthy People 2020
goal of 90 percent. In contrast, the vaccination rate was
98.1 percent among HCP who had an employer
requirement for vaccination. No other policy or
campaign to promote HCP influenza vaccination has
consistently achieved equivalent success
 1. Influenza (the flu) is a serious disease that can lead to
hospitalization and sometimes even death. Anyone can get
sick from the flu.
 2. While flu can make anyone sick, certain people are at
greater risk for serious complications from the flu, causing
hospitalization or even death, such as:
 a. older people,
 b. young children
 c. people with chronic lung disease (such as asthma and COPD),
diabetes (type 1 and 2), heart disease, neurologic conditions, and
certain other long-term health conditions
 d. pregnant women and
 e. severely obese persons
 3. Flu viruses are constantly changing. Each flu season, different
flu viruses can spread, and they can affect people differently based
on their body’s ability to fight infection. Even healthy children and
adults can get very sick from the flu and spread it to family and
friends.
 a. Flu seasons are unpredictable and can be severe. Studies going back
30 years to 1976 show that seasonal flu-related deaths have ranged
from about 3,000 people to 49,000 people. Flu seasons are
unpredictable and can be severe. Over a period of 30 years, between
1976 and 2006, estimates of flu-associated deaths range from a low of
about 3,000 to a high of about 49,000 people.
 b. In the United States, thousands of healthy adults and children have
to visit the doctor or are hospitalized from flu complications each year.
Flu vaccination can protect you and your family from the flu and its
complications.
 c. Last flu season (2009-2010) is an example of how unpredictable flu
can be. The 2009 H1N1 virus that caused a lot of illness was more
serious for younger people than seasonal flu usually is.
 4. The first and most important step in protecting against
the flu is to get a flu vaccine each season.
 a. CDC recommends a three step approach to fighting flu:
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vaccination, everyday preventive actions and the correct use of
antiviral drugs if your doctor recommends them.
b. Everyone 6 months of age and older is recommended to be
vaccinated against influenza.
c. Getting a flu vaccine is easy, and it is the single best way to
protect yourself and your loved ones from flu.
d. Get vaccinated as soon as vaccine becomes available in your
community.
e. The flu vaccine provides protection that lasts through the flu
season.
 Influenza vaccination of HCP is a core
patient and HCP safety practice
 Noncompliance places patients, HCPs
and their families at a largely preventable
risk
 It is professional and ethical
responsibility of HCP and the
institutions in which they work to prevent
spread of infectious pathogens to their
patients
 Influenza vaccination is an evidence based
infection prevention practice
 Mounting evidence over past 5 years shows the
most consistent method to attain
immunization rates of > 95% is to make
annual influenza vaccination a condition
of both initial and continued HCP
employment and /or professional
privileges, and volunteers
 100% HCP vaccination affords 43% risk
reduction in acute and 60% in chronic care
 HCP vaccination is cost effective strategy
to prevent patient morbidity
 HCP vaccination reduces patient
mortality
 Proven means of reduction of infection and
transmission of influenza virus in healthy
adults
 Even in years of mis-match, vaccine is partially
effective
 Voluntary absenteeism not completely
reliable since HCP can be contagious the day
before onset of symptoms of influenza
 Beneficence – acting in best interest of
patient
 Nonmaleficence – not placing patient at risk
of harm
 Placing patient interest first
 Safe work environment
 Educating HCP and patients of best, safe
practices
 Existing requirement for vaccines or proof of
immunity (MMR, Varicella, Hepatitis B)
 Currently >30% of RHS HCPs remain
unvaccinated for reasons not supported in
scientific evidence.
 Declination option has done virtually nothing
to increase vaccination rates.
 Despite many years of trying clever ideas,
posters, incentives, handouts, education, etc
our rates have only marginally improved.
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National Patient Safety Foundation
Society for Healthcare Epidemiology of America
Association for Professionals in Infection Control and Epidemiology
American Pharmacists Association
National Foundation for Infectious Disease
American College of Physicians
Infectious Diseases Society of America
National Quality Forum
Association of Perioperative Registered Nurses
American Medical Association
DOD (2008) Department of Defense
National Patient Safety Foundation
American Academy of Family Physicians
American Academy of Pediatrics
American Hospital Association
 University of Pennsylvania
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 Geisinger Wyoming Valley, Wilkes-
Philadelphia
CHOP, Philadelphia
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Aria Health, Langhorne

Bradford Regional Medical Center,

Bradford

Abington Memorial, Abington
Charles Cole Memorial Hospital,

Coudersport
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Communities at Indian Haven, Indiana 
Crozer Chester, Upland

Delaware County Memorial, Drexel
Hill
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DuBois Regional Medical Center,

DuBois
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Einstein Healthcare Network,
Philadelphia

Geisinger Health System, Danville
Barre
Grand View Hospital, Sellersville
Hanover Hospital, Hanover
Jersey Shore Hospital, Jersey Shore
Lankenau Medical Center,
Wynnewood
Lehigh Valley, Allentown
Main Line Health System, Bryn Mawr
Springfield Hospital, Springfield
St. Christopher’s Hospital for Children,
Philadelphia
St Joseph Hospital, Reading
Taylor Hospital, Ridley Park
Thomas Jefferson University Hospital,
Philadelphia
Wellspan Health, York
 Approval by MEC winter of 2013
 Developed team: ID, IP, IM resident, chaplain, employee
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health, pharmacy, nursing, HR, ethics, pediatrics, and
communication services
Multiple, multiple meetings
Medical and religious exemption forms developed along
with policy
Three person team to evaluate exemptions
Two phases of roll out
 First year all employees, volunteers, students, etc
 Second year all medical personnel on staff and anyone who
comes into the hospital for professional reasons
 Medical: egg allergy (no longer, now an
egg-free vaccine); documented severe
adverse effect from prior immunization
(eg. GBS within 6 weeks of vaccine);
 Religious - few religions prevent
vaccination; risk to patient requires mask
use to be consistent; SHEA does not endorse
 Personal/philosophical - contrary to
fundamental principle of patient safety
 Early identification of Influenza infection
 Isolation of known or suspected flu cases
 Mask use by patients and HCPs
 Private rooming or cohorting
 Hand hygiene and cough etiquette
 Voluntary absenteeism of ill HCPs
 Vaccination of HCPs
 Antiviral medication
 Visitor limitations under special
circumstances
 Influenza season and severity is not predictable
 Influenza is serious disease that can lead to
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
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hospitalization and sometimes death
Everyone over the age of 6 months should be
vaccinated
Mandatory flu vaccination among HCP has been the
only successful way to achieve >90% vaccination rates
Nasal vaccine should be used in children ages 2-8
Influenza vaccination is safe during pregnancy and
should be administered
50%
50%
1. True
2. False
1
2
50%
50%
1. True
2. False
1
2
1.
2.
3.
4.
Influenza is nothing more
than a bad cold
Influenza hospitalizes over
200,000 people a year and
can kill up to 40,000 people a
year
More people are killed by
AIDS than by influenza each
year
The flu is only dangerous to
the elderly
25%
1
25%
25%
2
3
25%
4
20%
1.
2.
3.
4.
5.
20%
20%
2
3
20%
20%
40-50%
50-60%
60-70%
70-80%
80-90%
1
4
5
1.
Flu seasons are predictable
2.
Flu vaccine is the best way to
protect yourself, family and
patients from flu
Pregnant women are at
higher risk complications
related to flu
Severely obese persons are at
higher risk for complications
from the flu
3.
4.
25%
1
25%
25%
2
3
25%
4