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Clinical Corner: Immunization in Long Term Care





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  • High-Dose Flu Vaccine

    A study in the most recent issue of the New England Journal of Medicine (NEJM) (http://www.nejm.org/doi/full/10.1056/NEJMoa1315727?query=featured_home%20) regarding high-dose influenza vaccine for those age 65 and older may generate questions for AMDA members.

    The CDC provides guidance on flu vaccine at these links, from which the following language is excerpted: http://www.cdc.gov/flu/about/disease/65over.htm and http://www.cdc.gov/flu/protect/vaccine/qa_fluzone.htm

    “People 65 years and older have two flu shots available to choose from - a regular dose flu vaccine and a newer flu vaccine designed for people 65 and older with a higher dose. The high dose vaccine is associated with a stronger immune response to vaccination. However, whether the stronger immune response results in greater protection against influenza illness in older adults is not yet known. The CDC and its Advisory Committee on Immunization Practices (ACIP) have not expressed a preference for either vaccine.”

    Based on the NEJM study, it appears that the higher dose vaccine does lead to greater protection against the flu. The primary end point of the study was the occurrence, at least 14 days after vaccination, of laboratory-confirmed influenza caused by any influenza viral types or subtypes, in association with a protocol-defined influenza-like illness. This randomized, double-blind, active-controlled efficacy trial showed that IIV3-HD provided improved protection against laboratory-confirmed influenza illness among adults 65 years of age or older. The overall efficacy of 24.2% against the primary end point indicates that about one quarter of all breakthrough influenza illnesses could be prevented if IIV3-HD were used instead of IIV3-SD.

    However, it should be noted that the study did not include LTC residents or patients with any cognitive condition, and with study participants having an approximate upper age limit of 79, most LTC residents would not be included in the sample. The study was funded by Sanofi Pasteur.

    Accordingly, until CDC and ACIP have expressed a preference for it, AMDA makes no recommendation for or against the use of the high-dose flu vaccine. However, a more important recommendation than the type of flu vaccine to be administered is AMDA’s position that all PA/LTC patients and staff get an annual flu vaccination. In the meantime, AMDA members are advised to use information provided by CDC/ACIP.

  • Update on Influenza Vaccine Supply
    For the 2012-2013 season, 145 million doses of influenza vaccine have been produced for the U.S. market. And, as of January 4, 2013, 128 million doses have been distributed.

    Providers interested in ordering additional influenza vaccine can visit the Influenza Vaccine Availability Tracking System IVATS at http://www.preventinfluenza.org/ivats/ to find information regarding distributors and vaccine manufacturers that have vaccine for sale.

    Providers who have exhausted their influenza vaccine supply should refer patients to the flu vaccine locator tool at http://flushot.healthmap.org/ and should work with other providers in their area, including public health, to identify supplies of vaccines and where patients can be referred.

  • Influenza Antiviral Medications
    CDC has issued recommendations for clinicians on the use of antiviral medications for treatment and prevention of influenza. A summary is available here.

  • CDC Releases MMWR Report Evaluating Influenza Rapid Tests
    Click here to read

  • CDC publishes recommendations for use of PCV13 and PPSV23 in adults with immunocompromising conditions
    Click here to read

  • CDC 2012-2013 Key Points Immunization Document
    Click here to read

  • Recommended Adult Immunization Schedule – United States, 2012
    Click here to read

  • Summary of CDC antiviral guidance for the 2011-2012 influenza season
    Click here to read

  • CDC releases provisional ACIP recommendations for Tdap use in people age 65 and older.
    Click here to read

  • CDC ADVISORY - Early Cases of Seasonal H3N2 Being Reported
  • Summary 
    Clinicians are reminded to consider influenza as a possible diagnosis when evaluating patients with acute respiratory illnesses, including pneumonia, even during the summer months. Treatment decisions should not be made on the basis of a negative rapid influenza diagnostic test result since the test has only moderate sensitivity. False positive results also can occur, particularly at times when overall influenza prevalence is low. For patients for whom laboratory confirmation is desired, or to confirm initial influenza cases in a community in which cases have been tested by rapid influenza diagnostic tests, it is recommended that reverse transcriptase-polymerase chain reaction (RT-PCR), and/or viral culture is utilized. Clinicians should use empirical treatment with influenza antiviral medications for persons hospitalized with suspected influenza, and for suspected influenza infection of any severity in high-risk individuals, regardless of influenza immunization status. Early initiation of treatment provides more optimal clinical responses, although treatment of moderate, severe, or progressive disease begun after 48 hours of symptoms can still provide benefit.

    The neuraminidase inhibitors oseltamivir (Tamiflu®) and zanamivir (Relenza®) are recommended for use against circulating influenza viruses. The adamantanes (amantadine and rimantadine) are not recommended because of high levels of resistance to these drugs among recently circulating influenza A (H3) and 2009 H1N1 pandemic viruses.   

    Clinical judgment is an important factor in treatment decisions for patients presenting with influenza-like illness. Prompt empiric antiviral treatment with influenza antiviral medications is recommended while results of definitive diagnostic tests are pending, or if diagnostic testing is not possible, for patients with clinically suspected influenza illness who have:

    1. Illness requiring hospitalization;
    2. Progressive, severe, or complicated illness, regardless of previous health status; and/or 
    3. Patients at increased risk for severe disease.

    Persons at high risk of influenza complications include people aged 65 years and older, young children, pregnant women, people with long-term health conditions like asthma, diabetes, neurologic and neuro-developmental disorders, heart disease, and people with immunosuppressive conditions or medications.

    Antiviral treatment, when clinically indicated, should not be delayed pending definitive laboratory confirmation of influenza. Influenza antiviral medications are most effective when initiated within the first 2 days of illness, but these medications may also provide benefits for severely ill patients when initiated even after 2 days. Point of care rapid tests capable of detecting influenza A and B virus infections are available, but health care providers and public health personnel should be aware that rapid influenza diagnostic tests have limited sensitivity and false negative results are common. Thus, negative results from rapid influenza diagnostic test should not be used to guide decisions regarding treating patients with influenza antiviral medications. In addition, false positive tests can occur and are more likely when influenza is rare in the community. When laboratory confirmation is desired, testing by RT-PCR and/or viral culture is recommended.   

    Providers are asked to report unusual increases in febrile respiratory disease outbreaks to their local and state health departments and to confirm positive rapid test results with PCR or culture when community circulation of influenza viruses is low. 

    For More Information
    More information on influenza prevention, diagnosis and treatment can be found at www.cdc.gov/flu. Beginning this influenza season, the Advisory Committee on Immunization Practices (ACIP) recommends influenza vaccination of all persons 6 months of age and older. These updated recommendations can be found at http://www.cdc.gov/mmwr/pdf/rr/rr59e0729.pdf.

  • Medicare coverage and reimbursement rules for the H1N1 vaccine and seasonal flu coverage and reimbursement information.
  • Note that Medicare will pay for seasonal flu vaccinations even if the vaccinations are rendered earlier in the year than normal.  Such preparations are critical for the upcoming flu season, especially in planning for the influenza A (H1N1) vaccine.

    Though Medicare typically pays for one vaccination per year, if more than one vaccination per year is medically necessary (i.e., the number of doses of a vaccine and/or type of influenza vaccine), then Medicare will pay for those additional vaccinations. Medicare claims processing contractors have been notified to expect and prepare for earlier-than-usual seasonal flu claims and there should not be a problem in getting those claims paid.  Furthermore, in the event that it is necessary for Medicare beneficiaries to receive both a seasonal flu vaccination and an influenza A (H1N1) vaccination, then Medicare will pay for both. 

    Please be advised that if either vaccine is provided free of charge to the health care provider, then Medicare will only pay for the vaccine’s administration (not for the vaccine itself). 

    All providers administering flu vaccine should review this article and be sure that their billing staffs are aware of this information. For more information, please read the article located at:

  • The Centers for Medicare & Medicaid Services has issued new Minimum Data Set (MDS) coding guidance for skilled nursing facilities for the upcoming flu season.  Nursing facilities should only code the MDS for the "Seasonal Influenza Vaccine," not for the "H1N1 Influenza Vaccine," according to CMS. For H1N1 influenza, nursing facilities should follow the specific guidance from the Centers for Disease Control and Prevention. H1N1 information and guidance can be found at www.cdc.gov/flu.
  • http://www.amda.com/tools/clinical/pandemic.cfm

  • H1N1 vaccine effective after one dose, not two doses as original predicted.

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Tamiflu Resistance Confirmed in H7N9 Flu Cases
Chinese researchers report clinical evidence of oseltamivir resistance in patients infected with the novel avian H7N9 flu. See PDF for report.

Randomized, Double‐Blind Controlled Phase 3 Trial Comparing the Immunogenicity of High-Dose and Standard-Dose Influenza Vaccine in Adults 65 Years of Age and Older (Falsey A., Treanor J., Tornieporth N., Capellan J., Gorse, G., Journal of Infectious Diseases, February 2009)

The Imperative of Influenza Vaccines for Elderly Individuals—An Evolving Story (Poland G., Mulligan M., Journal of Infectious Diseases, March 2009)

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  • Influenza Immunization and the Health Care Worker (DVD)
    Vaccination of health care workers against influenza has been shown to protect patients by potentially reducing illness and by decreasing mortality by as much as 40%, independent of patient vaccination status. Unfortunately, health care worker influenza immunization rates remain inexcusably low at 37% to 42%, and those rates have changed little over the past decade. Experts show that the main reason surrounding this low rate is the myths and misconceptions around influenza vaccination, not making employee vaccination a priority and not having a good educational program in place to dispel myths about influenza vaccination. Well AMDA has come up with your solution in one powerful 18 minute DVD. Let Dr. Gregory Poland, the nation’s immunization expert break down those myths and barriers in lay terms for you staff. Then let them hear from a wide variety of health care workers speak to them unscripted, peer-to-peer, about why they get immunized and why they want their peers to get immunized. A very moving and heartfelt DVD that will raise your employee immunization rates. View the DVD by clicking here.

  • Caring in the Community: Immunization and the Older Adult
    Take the lead in initiating and implementing activities to address and prevent influenza and pneumococcal disease in LTC facilities. Learn about three diseases especially dangerous to the elderly population, their safe and effective vaccinations, and how to best manage them in your facility. View the video by clicking here.

  • Patient Self-Screening Form for Inactivated Influenza Vaccine (from CDC)

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Immunization Action Coalition

Institute for Vaccine Safety

National Network for Immunization Information

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Products & Publications

Immunization in the Long Term Care Setting (LTC Information Series, published 2009)

Influenza Immunization and the Health Care Worker (DVD)

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