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Adult Vaccines: Increasing Influenza and Pneumococcal vaccination. ACHCA Annual Conference April 2006 James Marx, RN, MS, CIC Broad Street Solutions Agenda. Epidemiology of Influenza Epidemiology of Pneumococcal Disease Role of vaccination in disease prevention

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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 transfers

Vaccine preventable diseases
Vaccine preventable diseases

  • Residents, staff, visitors

    • Influenza (Oct-Mar)

    • Tetanus/diphtheria

  • Residents

    • Pneumococcal (All year)

  • Residents and Staff (Selected populations)

    • Hepatitis B

    • Varicella (chickenpox)




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 cases

Institutional outbreaks
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
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 basics
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 secretions

  • Incubation 1-4 days, 2 days average

Endemic epidemic pandemic
Endemic  Epidemic  Pandemic

The Two Mechanisms whereby Pandemic Influenza Originates

Belshe, R. B. N Engl J Med 2005;353:2209-2211

Influenza patterns
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
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
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
How Big is Pandemic Influenza ?

  • Pandemic influenza could infect 60% of the world’s 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

Influenza basics1
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
Influenza signs and symptoms

  • Abrupt onset with

    • Fever

    • Myalgia

    • Headache

    • Severe malaise

    • Nonproductive cough

    • Sore throat

    • Runny nose

Pathogenesis of influenza
Pathogenesis of Influenza

  • Mucosal epithelia are the most heavily infected cells

  • Disrupts host cell protein synthesis

  • May trigger apoptosis

  • Protein epitopes are similar to peptides toxic to neutrophils

Complications of influenza
Complications of Influenza

  • Progressive pneumonia (rare)

  • Bronchial mucosal sloughing

  • Loss of ciliated epithelia

  • Alteration to white cell function

  • Bronchoconstriction

  • Bacterial superinfection

Influenza vaccine
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
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
Vaccine effectiveness

  • Adults < 65 years

    • 70-90% protection against influenza

  • Adults > 65 years

    • 58% protection against influenza

    • 50-60% effective in preventing hospitalization

    • 80% effective in preventing death

Vaccine administration
Vaccine Administration

  • Intramuscular; 1 inch or longer needle

  • 0.5 ml

  • Soreness at the site occurs < 65% of the time and lasts < 2 days

Vaccine administration1
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
New influenza vaccine

  • Intranasal, live vaccine (FluMist)

  • Ages 5-49 only

  • Transmission of vaccine virus to others is possible

  • 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
Live Vaccine

  • Recombinants with less virulent strains

  • Cold adapted virus

  • DNA vaccines

Cost effective in staff
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
Vaccine recommendations: High Risk

  • Persons aged >65 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 risk1
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 aspiration

  • 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 infection

  • Women who will be pregnant during the influenza season

  • Children aged 6--23 months

Vaccine recommendations transmitters
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
Vaccine Recommendations: Other

  • Persons aged 50-64

  • Healthy young children

  • Travelers

  • General population

Define a influenza case
Define a influenza case

  • Use a written definition (A McGeer, AJIC, 1991)

    • Sudden onset of fever (>100.4° 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
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
Outbreak activities

  • Reinforce hand hygiene

  • Increase availability of tissue and disposal containers

  • 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

Mechanism of Action of Neuraminidase Inhibitors

Moscona, A. N Engl J Med 2005;353:1363-1373

Selected Treatment Trials of Neuraminidase Inhibitors

Moscona, A. N Engl J Med 2005;353:1363-1373

Avian influenza
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 2005;353:1363-1373

Pneumococcal disease
Pneumococcal Disease Inhibitors

  • Pneumonia

  • Bacteremia

    • has a 40% mortality

  • Meningitis

Pneumococcal disease and vaccination
Pneumococcal Disease and Vaccination Inhibitors

  • Basics

    • Vaccine protects from invasive Streptococcus pneumoniae

      • 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
Pneumococcal pneumonia Inhibitors

  • 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
Vaccine efficacy Inhibitors

  • 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 people

  • Reduces death by 50%

  • Uncertain vaccine status??- VACCINATE!

Vaccine administration2
Vaccine administration Inhibitors

  • 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
Vaccine recommendations Inhibitors

  • 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 recommendations1
Vaccine recommendations Inhibitors

  • 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
Other adult vaccines Inhibitors

  • Tetanus

  • Diphtheria

  • Pertussis

Adacel and boostrix
Adacel and Boostrix Inhibitors

  • 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


Implementation Inhibitors

State and Federal Laws

Outbreak Management

Cms requirement
CMS requirement Inhibitors

  • October 7, 2005

  • Sec. 483.25 Quality of care

    • Addresses both influenza and pneumococcal vaccination

    • Does not specifically address immunization of staff

Cms requirement1
CMS requirement Inhibitors

  • 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

Cms requirement2
CMS requirement Inhibitors

  • 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 immunization;

Cms requirement3
CMS requirement Inhibitors

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

    • 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 refusal.

Staff vaccination
Staff vaccination Inhibitors

  • Implied in the Federal Conditions of Participation

    • 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
Minimum Data Set (MDS) Inhibitors

  • 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

New york article 21
New York- Article 21 Inhibitors

  • Residents

    • Influenza

    • Pneumococcal vaccine

  • Staff

    • Influenza

    • Pneumococcal vaccine

Success stories
Success stories Inhibitors

  • Screening during intake assessment

  • Pre-printed admission orders

  • Medical records audits

  • Computer based tracking programs

Survey process
Survey process Inhibitors

  • 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
Consent and Billing Inhibitors

  • Separate written consent for vaccination may not be required; check your facility policy

  • Physician’s 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
Physician Orders Inhibitors

  • 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 physician’s or osteopath’s order.


Billing Inhibitors

  • HCFA-855, Provider/Supplier Enrollment application

  • 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

Billing Inhibitors

  • 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

    • Administration of influenza virus vaccine is billed using HCPCS code G0008

Billing Inhibitors

  • 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
Barriers to vaccination Inhibitors

  • Staff think:

    • Oh, the pain!

Barriers to vaccination1
Barriers to vaccination Inhibitors

  • Staff think:

    • Oh, the pain!

  • Nurses think:

    • Oh, the paperwork!

Barriers to vaccination2
Barriers to vaccination Inhibitors

  • Staff think:

    • Oh, the pain!

  • Nurses think:

    • Oh, the paperwork!

  • Administrators think:

    • Oh, the cost!

Implementation strategies
Implementation Strategies Inhibitors

  • 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 strategies1
Implementation Strategies Inhibitors

  • Monitor and report vaccination rates to the Infection Control or Quality Improvement Committee

  • Set goals for resident and staff vaccination rates

    • Healthy People 2010- 90% residents and staff

Implementation strategies2
Implementation Strategies Inhibitors

  • 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 facility

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

Implementation strategies3
Implementation strategies Inhibitors

  • 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 reimbursement

    • Use system to track vaccinees

      • Monthly recap

      • Separate vaccination sheet, combined with TB screen

      • Designate area on Face Sheet

Standing orders and consent
Standing Orders and Consent Inhibitors

  • 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
Hand Hygiene Inhibitors

  • Plan to monitor compliance

  • Feedback to staff and physicians

  • Information for resident and family members- “It’s OK to Ask”

Education for everyone
Education for everyone Inhibitors

  • Cough etiquette

Staff vaccination1

Staff Vaccination Inhibitors

Employees, Medical Staff and Volunteers

Group discussion
Group discussion Inhibitors

  • 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 facility’s resources related to vaccine preventable diseases?

Influenza planning exercise
Influenza planning exercise Inhibitors

  • 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
References and Resources Inhibitors



  • James Marx, RN, MS, CIC

    P.O. Box 16557, San Diego, CA 92176

    619-656-7887 Voice/Fax

References and resources1
References and Resources Inhibitors

  • National Immunization Program at the Centers for Disease Control and Prevention

  • 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, 2000


Thank you! Inhibitors