Texas Immunization Branch Influenza Update

July 24th, 2008

Influenza Update

• ACIP Recommendation• Influenza Vaccine

– Strains– Types/Indications– Manufacturing/Supply

• Texas Influenza Program– Vaccines For Children– Adult Program– Legislation

• Links to Influenza Websites

http://www.cdc.gov/mmwr/PDF/rr/rr57e717.pdf

Influenza Recommendations For Children 6 Months – 18 Years of AgeAdvisory Committee on Immunization Practices (ACIP) recently revised the influenza recommendations to include all children 6 months – 18 years beginning before or during the 2008-2009 influenza season if feasible, but not later than the 2009-2010 influenza season. Previously, children 5-18 years of age were only recommended to receive the influenza vaccine if they were at higher risk for influenza complications.

In addition, annual vaccination of all children aged 6 months through 4 years (59 months) continue to be a primary focus of vaccination efforts because these children are at higher risk for influenza complications compared with older children

Children and Adolescents at High-risk For Influenza

•Aged 6 months to 4 years;

•chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological or metabolic disorders (including diabetes mellitus);

•who are immunosuppressed (including immunosuppression caused by medications or by human immunodeficiency virus);

Children and Adolescents at High-risk For Influenza

•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;

•who are receiving long-term aspirin therapy who therefore might be at risk for experiencing Reye syndrome after influenza virus infection;

•who are residents of chronic-care facilities; and,

•who will be pregnant during the influenza season.

Adult Recommendations For Influenza

Annual vaccination against influenza is recommended for any adult who wants to reduce the risk for becoming ill with influenza or of transmitting it to others.

Vaccination also is recommended for all adults in the following groups, because these persons are either at high risk for influenza complications, or are close contacts of persons at higher risk:

•persons aged >50 years;

•women who will be pregnant during the influenza season;

Adults at High-risk For Influenza

•persons who have chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, hematological or metabolic disorders (including diabetes mellitus);

•persons who have immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus);

•persons 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;

Adults at High-risk For Influenza

•residents of nursing homes and other chronic-care facilities;

•health-care personnel;

•household contacts and caregivers of children aged <5 years and adults aged >50 years, with particular emphasis on vaccinating contacts of children aged <6 months; and,

•household contacts and caregivers of persons with medical conditions that put them at high risk for severe complications from influenza.

Vaccine Strains

Vaccines containing the 2008–09 trivalent vaccine virus strains include:

• A/Brisbane/59/2007 (H1N1)-like,

• A/Brisbane/10/2007 (H3N2)-like, and

• B/Florida/4/2006-like

All 3 vaccine virus strains were changed for the 2008-2009 season

2007-2008 Vaccine Strains: A/Solomon Islands/3/2006 (H1N1)-like, A/Wisconsin/67/2005 (H3N2)-like, and B/Malaysia/2506/2004-like viruses

Vaccine Composition2 types of vaccines (same strains in both)• Trivalent Inactivated Influenza Vaccine (TIV)

– Multiple Products Available– Intramuscular Injection– Licensed between 6 months to +85 yrs.

• Live, Attenuated Influenza Vaccine (LAIV) – Single Product (FluMist®) from MedImmune– Intranasal Spray– Licensed between 2* and 49 yrs.

* the previous recommendation was to administer LAIV to person aged 5–49 years

Vaccine Supply

• During the 2007–08 influenza season, 113 million doses of influenza vaccine were distributed in the United States (est. 141 million were produced).

• Total production of influenza vaccine for the United States is anticipated to be >140 million doses for the 2008–09 season, depending on demand and production yields

Flu Vaccines Licensed in the USVaccine Brandname/ Tradename Manufacturer

Total Projected Doses

Manufactured

Influenza (Age 6 months and older) Fluzone®

Sanofi Pasteur

38,000,000

Influenza (Age 6-35 months)Fluzone® Pediatric dose Preservative-free

6,000,000

Influenza (Age 36 months and older) Fluzone® No-Preservative 7,000,000

Influenza (Age 4 years and older)Fluvirin®

Novartis28,275,000

Fluvirin® Preservative-free 15,225,000

Influenza (Age 18 years and older)Fluarix™

GlaxoSmithKline13,000,000

FluLaval™ 23,000,000

Influenza (Age 18 years and older) Afluria CSL Biotherapies 6,000,000

Influenza Live, Intranasal (Age 2-49 years)

FluMist® MedImmune 12,500,000

    TOTAL 149,000,000

CDC US VFC Allocation: 22,000,000

Flu Vaccine Age Indications

Fluzone®Sanofi .25 mL

Fluzone®Sanofi .5mL

Fluzone®Sanofi .5 mL(no pres.)

FluMist®Medimmune LAIV

Fluvirin®Norvatis .5mL

FluLaval™GSK .5mL

Fluarix™GSK .5mL

AfluriaCSL Biotherapies .5mL

6 months 24 mo. 35 mo. 36 mo. 48 mo. …18 yrs…….49 yrs……+85 yrs

Note: Children < 9 years of age need 2 doses of influenza vaccine (administered 1 month apart) the first time they receive the vaccine. If they only received 1 dose the first year, they need to receive 2 doses the following year.

Flu Season• The Flu Season generally runs from early

September to late May

• CDC encourages ‘flu campaigns’ to continue until the vaccines expires (June)

Influenza Disease• Influenza viruses causes disease among

all age groups– Rates of infection are highest among children– Risk of complications, hospitalizations, and

death are highest among person aged > 65 years, young children, and persons with medical conditions that increase risk

• Children deaths due to flu-associated complications

2003-04: 153 2005-06: 46 2007-08: 83 2004-05: 47 2006-07: 76

Texas Immunization Branch Influenza Programs

• Texas Vaccines For Children Program – Federal funded program for eligible children 0-18

years of age– Projected 809,270 doses (20% increase from

2007-2008 year)

• State purchased vaccine– Used by HSRs for high-risk adults – Projected 110,000 doses for 2007-2008

• Local Health Departments – Can purchase direct from manufacturer, from a 3rd

party distributor, and off State of Texas Contract

Texas VFC Population

• Children 0-18 in Texas: 6,899,555– VFC Eligible Children : 4,091,148– Non-eligible VFC: 2,367,118

• VFC Doses for Texas (2008-2009)– 289,500 (.25 mL)– 519,770 (.5 mL)

809,270 total doses for +4,000,000 children

Influenza Coverage Levels

• The 2006 NIS estimated 30.5% of children (6 to 23 months) within Texas has received one or more doses of Influenza Vaccine (US 32.2%)

• Texas 2007 Bi-Annual Childcare Assessment Survey estimated 18.1% of children surveyed,19-59 months of age, received one or more doses Influenza Vaccine

• The 2007 Texas Behavioral Risk Factor Surveillance System estimated 66.7%, adults 65 and older had received a flu shot

Influenza Coverage Levels• 2007 NIS-Adult Survey currently estimated national percent

vaccinated against the flu

– 37.3 % of High Risk Adults, 18-49 years of age,

– 42.2 % of all adults, 50-64 years of age

– 68.8 % of all adults 65+

• Adolescent Immunization Rates* (one of the new influenza target population) for 13-17 year olds

– MMR (2 doses): 86.9%

– Hepatitis B (3 doses): 81.3%

– Td/Tdap: 49.4% (higher in older age group)

– Meningococcal Conjugate: 11.7%•2006 National Immunization •Survey (13-17 year olds)

Texas Influenza Legislation

• House Bill (HB) 3184, which requires the DSHS to publish information about the benefits of annual vaccination against influenza; and, together with the Department of Family & Protective Services (DFPS), ensure the information is annually distributed to parents of children attending child-care in August or September.  A newly created Flu Fact Sheet for Child-Care Settings will be mailed in September to child-care facility centers in Texas for distribution to all enrolled children. 

Texas Influenza Legislation• Senate Bill (SB) 811, which requires the DSHS to

allow each health care provider participating in the vaccines for children program to:1. select influenza vaccines from the list of all influenza

vaccines that:• (i)  within the limits of the vaccines annually allocated by

the CDC to the department for the vaccines for children program; or

• (ii)  not offered in the annual allocation under Subparagraph (i), but are available from the Centers for Disease Control and Prevention of the United States Public Health Service and for which the Centers for Disease Control and Prevention awards to the department additional funds; and

2. use both inactivated influenza vaccines and live, attenuated influenza vaccines.

Challenges• Vaccine Supply (annual uncertainty)

• Universal Recommendation vs. prioritization of high-risk groups

• Vaccine Distribution (pre-booking)

• Vaccine delivery and reimbursement systems

• Vaccine uptake (especially in new recommended groups

• Vaccine coverage levels (13 additional cohorts added to annual campaign with existing resources)

• Vaccine Funding and over-reliance on public health

Links To Influenza Websites• CDC Influenza webpage www.cdc.gov/flu

• DSHS Immunization Branch Website www.dshs.state.tx.us/immunize/flu.shtm

• MMWR Recommendations for Health Care PersonnelInfluenza Vaccination of Health-Care Personnel: Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the ACIP. February 24, 2006. www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm

• Vaccine Information Statements (VIS) The 2008-2009 Vaccine Information Statements are not available at this time. Refer to the following website for updates www.cdc.gov/vaccines/pubs/vis/default.htm

• CDC’s Flu Gallery contains educational materials for promoting influenza vaccination.  The Gallery contains printed materials such as flyers and posters, in color and black and white, English and Spanish. It is available at: www.cdc.gov/flu/professionals/flugallery/index.htm.