# Presentation: 371211

## THE NATIONAL INFLUENZA VACCINE SUMMIT: UPDATE

**Raymond A. Strikas, M.D.**
**Associate Director for Adult Immunization**
**Immunization Services Division****National Immunization Program**
**Coordinating Center for Infectious Diseases**
- Centers for Disease Control and Prevention
- Department of Health and Human Services
- NVAC; February 7, 2006

## Summit conceived in response to delays in influenza vaccine production and distribution in 2000 
Co-sponsored by AMA and CDC
1st  two Summits:March and August 2001
Annual meetings 2002-2006
7th Summit January 24-25, 2006

- Co-sponsored by AMA and CDC
- 1st  two Summits:March and August 2001
- Annual meetings 2002-2006
- 7th Summit January 24-25, 2006

**(Brief) History of the National Influenza Vaccine Summit**

## The Summit is . . .

- An annual meeting
- A concept
- An informal, action-oriented organization
- A resource

## Composition of the Summit (1)

- Vaccine Manufacturers
- Vaccine Distributors
- Federal Agencies
- Professional Medical Organizations
- Nursing Organizations
- Public Health
- Hospitals
- Pharmacists

## Composition of the Summit (2)

- Community Immunization Providers
- Occupational Health Providers
- Business
- Private Health Insurance and Managed Care
- Long-term Care
- Quality Improvement Organizations
- Consumers
- Advocacy Groups

## 2006 Summit  Participation

- Organizations
- 112 Participated
- Individuals
- 423 Invited
- 226 Attended (vs. 160 in 2005)

## 2006 National Influenza  Vaccine Summit Objectives

- Identify issues (related to vaccine, supply, ordering and distribution) identified in 2005
- Review trends from survey data
- Prioritize identified issues
- Develop Summit recommendations
- Develop Summit activities

## Surveys’ Objectives

- To better understand which providers have been affected by influenza vaccine supply problems in 2005, and to what extent
- To assess the public’s experience in seeking influenza vaccine in 2005** **
- Surveys executed mid-Nov to early Dec, 2005

## Groups Surveyed

- Internists, pediatricians, family physicians (via organizations)
- Local public health (NACCHO)
- State and local immunization grantees (POB)
- Community, occupational, and pharmacy vaccinators (National Influenza Vaccine Summit, American Pharmacists Association)
- Hospitals (AHA)
- Federally qualified health centers (NACHC, HRSA)
- The public (Gallup)

## Provider Survey Instrument

- Surveys conducted mid to late November
- Questions asked (Core questions):
- What was your experience with ordering influenza vaccine?
- What occurred when your vaccine order(s) were/were not accepted?
- What sources accepted your order?
- What percent of your total order(s) have you received to date?
- Due to inadequate vaccine supplies, have you referred any priority group to another location(s)?

## Response Rates

**77% Grantees**
**71% Community Vaccinators**
**64% Pediatricians**
**62% Federally Qualified Health Centers**
**52% Visiting Nurses Association**
**51% Internists**
**38% Hospitals**
**36% County & City Health Departments**
- 10% Occupational Health Groups
-   6% Family Physicians
-   3% Pharmacists

## Results - Ordering

- Very few groups did **not** order vaccine [median 4%; range 0%-15%)
- Majority placed single or multiple orders that were accepted [median 63%; range 52%-92%]
- Very few groups reported they attempted to order but no orders were accepted [median 2%; range 0%-10%]

## Results – Order Sources

- More Pediatricians (60%) and Hospitals (50%) reported ordering FluZone® (sanofi) directly from manufacturer
- More Community Vaccinators (60%) and members of the Visiting Nurses Association (86%) than other providers (median: 22%; range: 0%-42%) reported ordering FluZone® (sanofi) from a vaccine distributor
- More Community Vaccinators (60%) and members of the Visiting Nurses Association (74%) than other providers  (median: 23%; range: 8%-47%) reported ordering FluvirinTM (Chiron) from a vaccine distributor

## Vaccine ordering practices by group

## Results – Order Sources 2

- More Community Vaccinators (30%) and Internists (25%) ordered from unknown distributors than other providers (median: 4%; range: 0%-9%).
- Most community vaccinators, Pediatricians, Federally Qualified Health Centers, and members of the Visiting Nurses Association ordered from _>_ 2 sources, whereas most respondents in all other groups ordered from 1 source.** **

## Results - % Orders Received

- At least 50% in all groups reported they received >40% of their orders except Family Physicians (43%)
- More government providers, including state and local federal immunization grantees (86%) and county & city health departments (70%) received >80% of their orders than providers in other groups [median 50%; range 24%-64%]

## Results – >60% Orders Received by Source

- FQHCs
- Chiron only: 			25%
- Source other than Chiron: 	61%
- Sanofi manu only: 		25%
- Sanofi dist only:			67%
- Hospitals
- Chiron only: 			16%
- Source other than Chiron: 	86%
- Sanofi manu only: 		91%
- Sanofi dist only: 			89%

## Results – >60% Orders Received by Source

- Internists
- Chiron only: 			16%
- Source other than Chiron: 	67%
- Sanofi manu only: 			69%
- Sanofi dist only: 			91%
- Pediatricians
- Chiron only: 			0% (2 responses)
- Source other than Chiron: 	76%
- Sanofi manu only: 			90%
- Sanofi dist only: 			40%

## Results – Patient Referral

- At least 50% in all groups reported they referred priority group patients to another location for flu shots due to inadequate vaccine supplies, except Pediatricians (39%) and Occupational Health Groups (25%)
- Common complaint among many groups
- Grocery stores and pharmacies are getting the vaccine but we [physicians] can’t get it

## Gallup Survey Methods

- Survey panel of 1000 participants
- Originally included only respondents who received the flu shot shot last year (~300)
- Conducted survey again to capture everyone ~900 responded so response rate varied by questions
- Weighted by region, age and education level to represent U.S.

## Gallup Results

- Gender
- 46% male
- 54% female
- Age
- 58% 18-49 yrs
- 24% 50-64 yrs
- 17% _>_ 65 yrs

## Gallup Results

- Did you get a flu shot this year?
- 38% Yes
- 10% Not yet, but intend to
- 4%   Tried to, but not available
- 48% No, don’t plan to
- Have you ever been told to get the flu shot because you are _>_ 65 yrs or because you have high-risk condition?
- 22% Yes

## Gallup Results

- Among those who received the flu shot, Where did you get your flu shot?
- 39% Dr office/HMO
- 17% Workplace
- 10% Other clinic/health center
- 10% Store (grocery/pharmacy)
- 8% Health Department
- 6% Hospital
- 4% Senior/Recreation center
- 4% Other
- 2% School

## Gallup Results

- Among those who received the flu shot, Where would you prefer to get your flu shot?
- 50% Dr office/HMO
- 17% Workplace
- 11% Other
- 8% Other clinic/health center
- 5% Hospital
- 4% Health Department
- 3% Store (grocery/pharmacy)
- 2% Senior/Recreation center

## Limitations

- Surveys conducted with different methods
- Convenience sampling
- Low response rates
- Response bias

## Summary

- Most groups are referring patients to other providers if supplies were inadequate
- Most received >40% supply
- About half of all groups received >80%
- (Subset analysis):  those ordering from non-Chiron source more likely to report >60% order received
- Uncertain if public demand increased since 2003 or 2004; not decreased

## Acknowledgements

**University of Colorado **
**Allison Kempe, Miriam Dickinson,  Matthew Daley, Art Davidson, Lori Crane, Jennifer Barrow, Steve Berman, Christine Babbel, John Steiner, Brenda Beaty, Al Marcus, and Tammy Smith**
**AHA**
**Roslyne D. W. Schulman, **** Alyssa Keefe, ****Scott Bates**
**NACHC**
**Thomas F. Curtin, Peter Van Brunt**
**Community Vaccinators**
**Steve Wright**
**Occupational Health Groups**
**Roslyn Stone, Judith Strauss**
**APhA**
**Kelly Goode, Deborah Dratch, and Mitch Rothholz**
**State and Local Immunization Grantees**
**Immunization Program Managers**
**Local Public Health Departments (NACCHO)**
**JR Ransom, Donna Brown, Katherine Schaff, Nana Bennett, Paul Etkind, Kim Thorburn, Denice Tracy, Geof Swain, David Bibus, Tony Iton**
**VNAA**
**Jean K. Ellis, ****Tim Duffy**
**AAFP**
**Herbert F. Young, Bellinda K. Schoof,   Greg Tolleson**
**Gallup**
**Richard Blizzard**
**CDC**
**ISD/POB, Nancy Fasano, Shannon Stokley, Dennis O’Mara, Jiames Harrison, Tamara Kicera, Alan Janssen, Kate Shaw, Claudia Vellozzi, Bayo Willis**

## Issues Identified

- Vaccine Supply and Distribution – multiple recommendations
- CDC’s tiering recommendations – prefer none
- Communications – early and often
- Process of vaccine testing and release – improve efficiency
- Communicating ordering and shipping policies – transparency needed
- Hospital and long-term care facility residents (including home-health care recipients) – acknowledge shortages effects on accountability
- Knowing the location of influenza vaccine – pre-book, distribution, provider levels
- Governments’ role in a vaccine supply issue – tracking, purchase, guarantees, redistribution
- Anti-thimerosal legislation – advocacy by members recommended
- Improving vaccine demand – especially if >100 million doses arrive in 2006
- universal immunization
- adult immunization program
- Prebooking of vaccine – transparency and communications – already lacking?

## Selected Issues:  Vaccine Supply and Distribution

- Recommendations
- Communicate in a timely way, timing of supply and distribution
- Make distribution system(s) transparent
- Guarantee to manufacturers of minimum demand (purchase)
- Complete production and distribution by September
- Increase demand to justify increased supply
- e.g., work with employers, employees, insurers
- Address late season vaccine – returns, govt. purchase, tax credits
- Limit partial shipments if supply is adequate
- Consistent policies, well communicated about partial shipments
- CDC to purchase pre-season stockpile, not late season

## Selected Short Term Issues - I

- Establish vaccine supply Task Force to address activities derived at the Summit meetings
- Prepare letter to ACIP highlighting:
- Previous season exposed weaknesses in the tiering recommendation
- Summit strongly supports universal recommendation
- Summit urges timely and clear communication of ACIP recs re: vaccine use
- Data suggest that a springtime  "priming " dose for young children is of little value.  Should providers offer 2 doses this fall to these patients?
- Communications WG and Executive Committee to examine
- Immediate communication necessities (eg, explanatory message to nation on the past influenza season)
- Mid-term communications (eg, create contingency messages for upcoming season and design communication plan through summer for educating and preparing public)
- Long-term plans (e.g., create strategy to increase demand for vaccine).

## Selected Short Term Issues - II

- Follow up with reimbursement WG to see direction with respect to encouraging coverage of influenza vaccine and other payment issues
- Summit to issue statement on national adult immunization program
- Arrange meeting between CDC, manufacturers, distributors, and Summit partners to discuss data availability and accessibility.
- National Strategy for Influenza
- Urge FDA and manufacturers to maximize efficiencies.

## Summit Contacts

- Litjen J. Tan, Ph.D.*Director, Infectious Diseases, Immunology, and Molecular Medicine*American Medical Association
- _[515 N. State Street_x000b_Chicago, IL 60610](http://maps.yahoo.com/py/maps.py?Pyt=Tmap&addr=515+N.+State+Street&csz=Chicago%2C+IL+60610&country=us)_Tel: 312-464-4147Fax: 312-464-5841
- Email: _[litjen.tan@ama-assn.org](mailto:litjen.tan@ama-assn.org)_
- Raymond A. Strikas, M.D.
- ISD / NIP / CDC
- 1600 Clifton Road NE · MS E-52
- Atlanta, GA 30333
- 	Telephone:	404-639-8813
- 	Fax:	404-639-8627
- 	E-mail:	rstrikas@cdc.gov
- Summit Web Site:
- http://www.ama-assn.org/ama/pub/category/13732.html