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Adult Vaccines: Increasing Influenza and Pneumococcal vaccination


If as lethal as swine flu (1917) 450,000 to 750,000 deaths. If as lethal as avian H5N1 ... of fever ( 100.4 F) plus three or more of the following symptoms ... – PowerPoint PPT presentation

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Title: Adult Vaccines: Increasing Influenza and Pneumococcal vaccination

Adult Vaccines Increasing Influenza and
Pneumococcal vaccination
  • ACHCA Annual Conference
  • April 2006
  • James Marx, RN, MS, CIC
  • Broad Street Solutions

  • 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

  • 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

  • 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

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

  • Influenza
  • Pneumococcal Disease

  • 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

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.

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

Influenza peak in past 26 seasons
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
  • Incubation 1-4 days, 2 days average

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

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

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

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

Current status of pandemic
(No Transcript)
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

Influenza signs and symptoms
  • Abrupt onset with
  • Fever
  • Myalgia
  • Headache
  • Severe malaise
  • Nonproductive cough
  • Sore throat
  • Runny nose

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

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

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

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

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

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

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

New influenza vaccine
  • Intranasal, live vaccine (FluMist)
  • Ages 5-49 only
  • Transmission of vaccine virus to others is
  • 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

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

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

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)

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
  • 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
  • Women who will be pregnant during the influenza
  • Children aged 6--23 months

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)

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

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

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

Outbreak activities
  • Reinforce hand hygiene
  • Increase availability of tissue and disposal
  • 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

(No Transcript)
Mechanism of Action of Neuraminidase Inhibitors
Moscona, A. N Engl J Med 20053531363-1373
Selected Treatment Trials of Neuraminidase
Moscona, A. N Engl J Med 20053531363-1373
Avian Influenza
  • Causes influenza in birds
  • Has been transmitted to humans
  • Rare human-to-human transmission (1 case)
  • Future mutations could effect humans

Selected Trials of Prophylaxis with the Use of
Neuraminidase Inhibitors
Moscona, A. N Engl J Med 20053531363-1373
Pneumococcal Disease
  • Pneumonia
  • Bacteremia
  • has a 40 mortality
  • Meningitis

Pneumococcal Disease and Vaccination
  • Basics
  • Vaccine protects from invasive Streptococcus
  • 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

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

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
  • Reduces death by 50
  • Uncertain vaccine status??- VACCINATE!

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.

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

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

Other adult vaccines
  • Tetanus
  • Diphtheria
  • Pertussis

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

  • State and Federal Laws
  • Outbreak Management

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

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

(No Transcript)
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

CMS requirement
  • The resident's medical record includes
    documentation that indicates, at a minimum, the
  • 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

Staff vaccination
  • Implied in the Federal Conditions of
  • 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.

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

(No Transcript)
New York- Article 21
  • Residents
  • Influenza
  • Pneumococcal vaccine
  • Staff
  • Influenza
  • Pneumococcal vaccine

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

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

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

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//

  • HCFA-855, Provider/Supplier Enrollment
  • 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

  • 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 of influenza virus vaccine is
    billed using HCPCS code G0008

  • 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

Barriers to vaccination
  • Staff think
  • Oh, the pain!

Barriers to vaccination
  • Staff think
  • Oh, the pain!
  • Nurses think
  • Oh, the paperwork!

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

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

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

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
  • Continue to vaccinate all new admissions after
    annual influenza program is completed in the Fall

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
  • Use system to track vaccinees
  • Monthly recap
  • Separate vaccination sheet, combined with TB
  • Designate area on Face Sheet

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

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

Education for everyone
  • Cough etiquette

Staff Vaccination
  • Employees, Medical Staff and Volunteers

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?

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

References and Resources
  • James Marx, RN, MS, CIC
  • P.O. Box 16557, San Diego, CA 92176
  • 619-656-7887 Voice/Fax

References and Resources
  • National Immunization Program at the Centers for
    Disease Control and Prevention http//
  • 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,
  • http//

  • Thank you!