Planning for Influenza Season

IHS Influenza Working GroupJuly 12th, 2017

Increasing Influenza Vaccine Coverage

• Planning for Influenza Season is a year – round activity• Vaccine Supply

– Sufficient vaccine supply to EXCEED previous year coverage– Using the data to predict vaccine needs

• Vaccine Availability– EARLY and SUSTAINED Influenza vaccination activity– Broad availability

• Vaccine Promotion– Engaging with Communities

Speakers

– Influenza Vaccine Ordering - National Supply Service Center (NSSC)

• James Cummings, PharmD, NSSC, Oklahoma City, OK

– Planning for Flu Season – Pharmacy Perspectives • Ann Gorman, PharmD, MPH, BCPS, NCPS, Red Lake Service Unit, Bemidji

IHS Area

– Planning for Flu Season – Facility Perspectives• Lindsey Border, PHN, Tuba City Regional Health Corporation, AZ, Navajo IHS

Area• Adelia Cuka, PHN, Yankton Service Unit, SD, Great Plains IHS Area

IHS National Supply Service CenterPharmacy Support Branch

CDR James J. Cummings, PharmDJames.Cummings@ihs.gov

• During the past two flu seasons, NSSC has requested your totals for future seasons which is very difficult to determine especially if you have not completed the current flu season.

• The reason is…well, actually a couple. In order to receive the best possible price and selection, this process has to start before the end of the calendar year. (ex. Oct. 2016 for 2017-2018 flu season)

• Other large buying groups and insurance companies are doing this earlier and earlier competing for selection and pricing. They know vaccinating people annually is one of the single, most important things health professionals can do to prevent hospitalizations and save lives.

Product Name Dosage Form NDC Price/dose

Afluria®Quadrivalent

Multi-Dose Vial (MDV) -10 doses/vialPeds/Adult (**18 years & older) 33332-0417-10 $12.51

Fluzone® Quadrivalent

PFS - 0.25mL - 10 doses/packagePediatric (6-35 months) 49281-0517-25 $14.20

Fluarix®Quadrivalent

PFS – 0.5mL – 10 doses/packagePeds/Adult (3 years & older) 58160-0907-52 $12.78 =

Fluzone® HD PFS – High Dose - 10 doses/package 49281-0401-65 $26.75

Fluzone® ‡Intradermal PFS 0.1ml – 10 doses/package $??

Flumist® ‡Intranasal PFS 0.2ml – 10 doses/package May or May not be available

for 2017-2018 $??

Flublok®‡ Single Dose Vial – 0.5mL—10 doses/box $??

‡ Vaccine is supplemental to the four contract vaccines and IHS receiving FSS pricing**Seqirus has submitted to FDA approval for ages 5 years and older

Product Name Dosage Form Delivery timeline

Afluria®MDVs

Multi-Dose Vial (MDV) -10 doses/vialPeds/Adult by Seqirus 50% by Sept. 15th, rest by Oct. 15th

Fluzone® 6-35 months

PFS - 0.25mL - 10 doses/packagePediatric (6-35 months) by Sanofi 40% by Aug. 15th, rest by Nov. 11th

Fluarix®3 years & older

PFS – 0.5mL – 10 doses/packagePeds/Adult (3 years & older) by GSK 50% by Sept. 15th, rest by Oct. 15th

Fluzone® High Dose

PFS – High Dose - 10 doses/package by Sanofi 50% by Sept. 15th, rest by Oct. 15th

**Other Vaccines not under a delivery contract

• Contact “Gabe” Wyatt aaron.wyatt@ihs.gov– He will forward a Flu 413 Form for ordering

• Submit Seasonal Flu Form 413 to NSSC– NSSC may have stock of additional contract vaccine

If not NSSC will contact manufacturers to obtain and if authorized, will purchase additional vaccine If contract vaccine not available NSSC will contact additional vendors to find best price

• Occasionally, FSS priced vaccine available through McKesson but no guarantees

• Tamiflu® 75mg Capsules may purchase from NSSC at substantially reduced prices by contacting “Gabe” Wyatt (Aaron.Wyatt@ihs.gov) and he will forward a 413 form

• Sign & Complete 413 and fax to “Gabe” (405) 951-6054 or e-mail . E-mail works much better

• Other dosage forms & strengths available thru McKesson

• NOT Reimbursable thru Insurance (POS)

• Relenza® available thru McKesson Connect

June 2019

Influenza VaccineDoses Purchased and Adult Vaccine Coverage*

0%10%20%30%40%50%60%70%80%90%100%

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

2011/2012 2012/2013 2013/2014 2014/2015 2015/2016 2016/2017 2017/2018

Doses sold % Adults Vaccinated

HP 2020 Goal – 70%

* Coverage data based on the IHS Influenza Awareness Report Data, Active Clinical Users

Uptake - Influenza Vaccine Coverage as of 04/15/2017

Per

cent

0

10

20

30

40

50

60

70

80

90

100

Weeks

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

01

02

03

04

05

06

07

08

09

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

Adults (18 + years) All (6 months +) Children (6 months-17 years)

*Based on data from the IHS Influenza Awareness System (IIAS)

Planning for the Influenza Season:Pharmacy Perspective

July 12, 2017 (12 pm – 1 pm MDT)

Presented By:Ann Gorman, PharmD, MPH, BCPS, NCPS

CDR, US Public Health ServicePharmacists Expanding Vaccine Access (PEVA) Workgroup Lead

Flu Season Already?

Research

• Population Totals– RPMS Immunization Reports

– VGEN Reports

• Historical Influenza Rates– RPMS Immunization Reports

• Historical Ordering Quantities & Amounts Wasted– National Supply Service Center (NSSC)

– Vaccines for Children (VFC)

– McKesson

• Previous Vaccine Uptake Strategies

Getting Started!

RPMS Flu Report

IMM Immunization Menu ...REP Reports Menu ...

FLU Influenza ReportINFLUENZA IMMUNIZATION REPORT

1 - Report Year (Flu Season).......: 2016/2017 (07/01/16 - 12/31/16)

2 - Community......................: ALL

3 - Health Care Facility...........: ALL

4 - Case Manager...................: ALL

5 - Beneficiary Type...............: INDIAN/ALASKA NATIVE

6 - Patient Population Group.......: Active Users (2+ visits, 3 yrs)

7 - Report Type (Standard or H1N1).: Standard Flu

Immunization v8.5*4 Apr 02, 2013 15:44:54 Page: 1 of 3

CIHA HOSPITAL* Standard Flu Immunization Report *

Report Date: 04/02/2013Date Range: 09/15/2012 - 12/31/2012

Registered Patients (All)-------------------------------------------------------------------------------Beneficiary Type: INDIAN/ALASKA NATIVE

-------------------------------------------------------------------------------| Age in months/years on 12/31/2012 |

Dose# |------------------------------------------------------- | Totals| 10-23m 2-4y 5-17y 18-49y *18-49hr 50-64y 65+yrs|

Denominator | 1 3 1732 3111 17 603 506 | 5973-------------------------------------------------------------------------------

1-FLU | 0 0 1 1 1 0 0 | 32012 Season | 0% 0% 0% 0% 6% 0% 0%| 0%

-------------------------------------------------------------------------------Fully | 0 0 1 1 1 0 0 | 3

Immunized | 0% 0% 0% 0% 6% 0% 0%| 0%-------------------------------------------------------------------------------

Total Patients included who had Influenza Refusals on record 21*NOTE: The 18-49hr column tallies patients who are High Risk in that

Age Group. They are not included in the normal 18-49y column.-------------------------------------------------------------------------------

Uptake Strategies • Assess Vaccine Needs at Every Encounter

• Use State Immunization Information Systems (IIS)

• Decrease Barriers

• Increase Demand

• Provide Walk-in/On-demand Services

• Utilize Standing Orders

• Implement Client Reminder and Recall Systems

• Offer Extended Clinic Hours

• Plan Community Outreach Activities

• Utilize Provider Reminders

• Include Provider Assessment and FeedbackWhat Works?

Spreadsheet for Historical Tracking

Vaccine Where Ordered

Date Ordered

Doses Ordered

Date Received Cost Lot # Doses

Wasted# Given by

Nurses# Given by

PHN# Given by

Pharmacists

MDV NSSC

0.5ml Syringes NSSC

0.25mlSyringes

VFC

0.5ml Syringes

VFC

McKesson

Order

• Monitor Emails– NSSC Site Contact

– VFC Site Coordinator

• (Over)Estimate TOTAL for Season

• Submit Forms by Deadlines

• Monitor Stock

• Supplies

Order Enough Vaccine!

Products – review available options

• Multi-dose Vials

• Syringes

• High-dose

• Intra-dermal

• Intra-nasal

What to Stock?

Facility Collaboration• Multidisciplinary

– Internal Medicine

– Family Medicine

– Pediatricians

– Nurses

– Public Health Nurses

– Pharmacy

– Inpatient

– Registration

– Property and Supply

– Support Staff

Get a Team!

Department Referral Flow Sheet

Think Outside the Box!

Engage the Community

• Schools– Head Start

– Elementary

– Middle or High School

– Colleges

– Vocational

• Daycares

• Senior Centers

• Health Fairs/Community Events

• Tribal Healthcare ServicesThink Outside the Box!

Consider Your Populations

• Employees

• Children

• Adults

• Nursing Homes

• Inpatient Services

• Other Special Populations

Don’t Forget to Advertise!

Consider Locations

• Primary Care Encounters

• Improving Patient Care (IPC) Clinics

• Same Day/Walk-in/Urgent Care Clinics

• Nurse Visits

• Pharmacy Clinics

• Medication Refills

• Home Visits

• Offsite Clinics

• Mass Vaccination Drills

Increase ACCESS!

It’s All in the Timing

• Evening Clinics

• Weekend Clinics

• During Community Events

Increase ACCESS!

Uptake Strategies

https://www.thecommunityguide.org/sites/default/files/assets/AF-healthsysteminterventions.pdf

Set Attainable Goals• Healthy People 2020

– Adults over 18-years-old: 70%

– 6-months to 17-years-old: 70%

– Healthcare Workers: 90%

– Pregnant: 80%

• Indian Health Service Rates– National

• Overall: 32%– Area

• Range: 17% - 40%)– Service Unit

https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases/objectiveshttps://www.ihs.gov/NonMedicalPrograms/IHPES/immunizations/index.cfm?module=immunizations&option=reports

Tips

• Be Flexible

• Communicate Often

• Be Transparent

• Be a Team

• Monitor the CDC flu website– https://www.cdc.gov/flu/index.htm

• Monitor Local Flu-like Illness Reports

• Set Goals

Start As Soon as Vaccine Available and Keep Vaccinating Until Your Out or it Expires!

Questions?

Navajo Area Influenza Clinic

Lindsey Border, MSN, RN Public Health Nurse

School & Community Flu Clinic CoordinatorTuba City Regional Health Care Corporation

July 2017

Community Approach

• 4 approaches to immunizing community– School- based clinics– Community clinics– Outpatient Clinics at TCRHCC– Employee Health Clinic at TCRHCC

Focus is from October to December

Committees• Flu Steering Committee

– Key individuals (~4-5 people)– Discuss allocation of first doses of vaccine– Resources needed– Concerns we may face as a whole

• School and Community

• Organizational – Outpatient Clinics– Employee Health

Committee Team Members • Public Health Nursing• Med Staff

– Chief of Family Medicine– NAIHS Immunization

Coordinator

• Pharmacy– Pharmacy Director– VFC Coordinator

• Health Information• Patient Registration

• Information Technology

• Coding & Billing• Mobile Medical Team• Community Relations

School-Based Clinics

• 11 schools• Each school completed in 5 hours or less • Team of:

– Patient registrars– Medical staff (NP or MD)– Immunizers (mostly PHN staff)– Assistants (to help hold kiddos) (often CHRs)– Pharmacist and tech– Additional team members: flow director, RPMS entry

Timeline

• March & April– Make consents and begin

distributing to schools

• May– First team meeting

• June– Create advertisements – Inventory Checks and Supply

ordering

• July– Prep for TCBS Registration Days– TCBS Registration Day- July 28th

and 29th – Confirm inventory and supplies

• August– Begin advertising– Collect student rosters– Set dates for clinics– Create school boxes

• Consents• Rosters

• September– Scheduling of team members– Team meeting every 2 weeks

• October– Final preparations

• November– Wrap up meeting & celebration

Registration & Consents

– Consent packet is created containing • Patient registration update form • Flu consent form• Newest VIS• Any other medical consent or hospital forms

– Distributed with school registration packets

• Tuba City Boarding School – Attend school registration days at end of July to

complete consents with parents during enrollment period.

Consents• Collect and organize (class and alphabetically)

• Patient Registration– Updates demographic information– Creates pre-reg. visit number– Creates PCC and attaches to consent– Verifies vaccine status within 24 hours of clinic

Day of Clinic Tips• Be early!

• Ensure Internet connectivity in advance

• Have volunteers well prepped on role & expectations

• Know the set-up and flow desired at each location

• Group huddle prior to starting clinic

• Provide lunch or snacks

• Incentives for kids (stickers, pencils, small toy)

Community • Locations:

– Senior Centers– Chapter Houses

• Partner with Medical Mobile Unit

• Create a mini health fair

• Have vaccine available for all age groups

• Usually about 5-6 community locations

Outpatient Clinics• Flu Clinic set-up in outpatient building

– Separate adult and pediatric clinics outside of normal service– Held in lobby of each floor

• Pharmacy based immunization clinic year round– Gives all adult vaccines, separate billable visit!!

• Address in OB– Prenatal & intrapartum – Cocooning strategy

• Ask all fathers and household contacts if they have been immunized• Provide vaccine prior to baby being discharged

Clinics are staffed by an independent provider- NP or Pharmacist credentialed by state of AZ to give vaccines

Creates a separate billable visit!!!!

Employee Clinic

– Mass immunization of employees

– Usually vaccinate ~400 in one morning

– Target satellite clinics and night shift workers over the next couple of weeks

– Offer incentive when vaccine received

– Provide sticker to wear on name tag

Advertising• Movie Theater Advertisements

– Harkins Theater in Flagstaff– Goen Theater in Tuba City

• Newspaper • Posters for Community locations• Flyers• Banners on campus and community locations• Small flyers to hand out to patients

In General

• Vaccine numbers are based off of previous numbers and projected change (i.e. number of kids enrolled in school).

• We typically do not set organizational goals with the exception of striving for 100% of employees immunized.– 2016: 98% of staff immunized

Planning for the Influenza Season

Wagner IHS; Wagner, South DakotaAdelia Cuka, RN, MSN, CNS, PHN

Planning for the Influenza Season

• Set Flu vaccine coverage goals for our facility

• Estimate our vaccine needs

• Plan for flu clinics

• Educate the community

• Provide engagement facility wide

• Monitor vaccination activities

Flu vaccine coverage goals for our facility

• Offer influenza vaccinations to all patients 6 month and over

– Vaccinate at each encounter, unless contraindicated

– Vaccinate at the patients convenience

• Work closely with local clinics and CHN’s

– Share information through SDIIS and keep EHR up to date

– Work together in planning school/community clinics

• Vaccinate all staff (unless contraindicated)

• Provide monthly reports to staff, and plan extra activities like health fairs to help increase rates

Estimate vaccine needs

• How much we ordered the previous year• How much influenza vaccine was wasted the previous year• What our current birth rates are• What our user rates are

Planning for flu clinics

• DPHN orders infant/teen influenza vaccine from the State Health Department • Director or Pharmacy orders influenza vaccine for adults• DPHN works closely with the State Health Department, school nurses, local

clinics, and the County CHNs in planning school influenza clinics– By looking at what did and did not work last year we can plan changes – Plan POD at Wagner School this year

• DPHN works with tribal entities to set up clinics at the Yankton Sioux tribal hall, BIA, Casino, Yankton Sioux housing, college, treatment center, correction facility, daycares, and elderly complexes

• PHNs provide multiple clinics at the Casino (major employer) to cover all the shifts and pay day

• Three public health nurses are available to provide influenza vaccinations in the home, schools, and tribal facilities

• Standing orders allow pharmacy and nursing staff to provide vaccinations at all patient encounters

Engagement facility wide

• Three PHNs provide vaccinations in the schools, tribal facilities, and in the homes

• Two PHNs provide education and vaccinations in clinic on Wednesdays to prenatal patients

• Clinic nursing staff offer vaccinations at each patient encounter (unless contraindicated)

• Four pharmacists assist in providing influenza vaccinations

• Infection control nurse vaccinates all staff

Community education

• Individual education• Flyers• Good Health TV• Facebook• Tribal Education Leaders

Monitoring vaccination activities

• Immunization coordinator

– updates historical information in EHR,

– updates information in SDIIS,

– monitors and reports immunization rates,

– updates staff on new vaccine information and trends,

– works with staff to problem solve and further increase rates

• Staff report activities monthly

• CEO provides GPRA rates and solicits feedback to increase rates