Clinical Corner: Immunization in Long Term Care
News
CDC ADVISORY - Early Cases of Seasonal H3N2 Being Reported
Summary
Influenza A (H3N2) virus infections have been recently detected in people in a number of states across the U.S., including two small localized outbreaks. 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.
Recommendations
Health care providers are reminded to consider influenza as a possible diagnosis when evaluating patients with acute respiratory illnesses, including pneumonia, even during the summer months. The neuraminidase inhibitors oseltamivir (Tamiflu®) and zanamivir (Relenza®) are currently 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:
- Illness requiring hospitalization,
- Progressive, severe, or complicated illness, regardless of previous health status, and/or
- 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. We understand that 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. Our 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:
http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0920.pdf
The Centers for Medicare & Medicaid Services has issued new 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.
Articles
Falsey A, Treanor J, Tornieporth N et al. 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
Poland G, Mulligan M. The Imperative of Influenza Vaccines for Elderly Individuals—An Evolving Story
Cate TR, Rayford Y, Niño D, Winokur P, A high dosage influenza vaccine induced significantly more neuraminidase antibody than standard vaccine among elderly subjects.
Dean AS, Moffatt CR, Rosewell A, Et al. Incompletely matched influenza vaccine still provides protection in frail elderly.
Tools
Links
100% Immunization Campaign
CDC National Immunization Information Hotline
CDC National Immunization Program
Immunization Action Coalition
Institute for Vaccine Safety
National Coalition for Adult Immunization
National Network for Immunization Information
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