The Role of Clinicians in Addressing the Opioid Overdose Epidemic

Coordinator:
Welcome and thank you for standing by. Today’s call is being recorded. If you have any objections, you may disconnect at this time. All participants will be in a listen-only mode for the duration of the call. During the question and answer session if you would like to ask a question, please press star 1. I would now like to turn the call over to Dr. Khan. You may begin.

Dr. Ibad Khan:
Thank you Monet. Good afternoon. I am Ibad Khan, and I am representing the Clinician Outreach and Communication Activity -- COCA -- with the Emergency Risk Communications Branch at the Centers for Disease Control and Prevention.

We are delighted to welcome you to today’s COCA webinar, How to Prevent and Control Pediatric Influenza. You may participate in today’s presentation by audio only, via webinar, or you may download the slides if you are unable to access the webinar.

The PowerPoint slide set and the webinar links can be found on our COCA Web page at emergency.cdc.gov/coca. Again, that’s emergency.cdc.gov/coca. Click on October 1 COCA call. The slide set is located under “call materials.”

Free continuing education is provided for this COCA call. Instructions on how to earn continuing education will be provided at the end of the call.

CDC, our planners, presenters, and their spouses, partners wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. Planners have reviewed content to ensure there is no bias. The presentation will not include any discussion of the unlabeled use of a product, products under investigational use.

At the end of the presentation, you will have the opportunity to ask the presenters questions. On the phone, dialing star 1 will put you the queue for questions. You may submit questions through the webinar system at any time during the presentation by selecting the Q and A tab at the top of the webinar screen and typing in your question.

Please note that questions are limited to clinicians only. For those who may have media questions, please contact CDC Media Relations at 404-639-3286, or send an email to Media@cdc.gov. If you are a patient, please refer your questions to your healthcare provider.

At the conclusion of today’s session, the participants will be able to describe strategies to assist in preparing for the 2015-2016 influenza season, identify gaps and opportunities to improve influenza prevention and control for children with chronic medical conditions, discuss the importance of properly identifying children clinically presumed to have influenza disease for rapid antiviral treatment when indicated to reduce morbidity and mortality, identify ways to improve preparedness for infectious disease outbreaks within the office practice.

Our first presenter is Dr. Lisa Groskoff. Dr. Groskoff is a medical officer with the Influenza Division at the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention. She is the CDC lead for the influenza workgroup of the Advisory Committee on Immunization Practices since October 2010. Dr. Groskoff will briefly update our audience on the latest ACIP recommendations.

Our second presenter is Dr. Hank Bernstein. Dr. Bernstein is a professor of pediatrics at Hofstra Northshore School of Medicine. HE is associated editor of the Redbook online and recent member of the Committee on Infectious Diseases on the American Academy of Pediatrics, whose responsibility it is to develop and revise guidelines of the AAP for control of infectious diseases in children. Dr. Bernstein also represents the AAP on the influenza workgroup of the CDC’s Advisory Committee on Immunization Practices.

Dr. Groskoff, you may begin.

Dr. Lisa Groskoff:
Thank you very much. So I’m going to give you a brief update on the most recent ACIP recommendations. The ACIP Influenza Vaccination Statement comes out every year sometime in August and came out this year on August 7.

And we had a couple of pertinent updates for the 2015-2016 season, some of which don’t apply to the pediatric population but I’m going to mention them very briefly anyway.

This year’s recommendations were published in a short format policy note rather than a full recommendations and report document. We will be probably going forward doing the recommendation and reports documents about every two to three years, and having the interceding years be short policy note updates with whatever is new for that upcoming season.

The first topic that’s discussed in the current reqs is the influenza vaccine composition for 2015-16, which has changed somewhat compared to last season. We have strain changes in two of the viruses.

Trivalent vaccines, as you probably know, usually contain an H1N1 virus, and H3N2 virus, and a B virus. For this upcoming season for 2015-16, the H1N1 virus is the A California 7-2009 virus, which is the pandemic virus from 2009. And this is the same H1N1 virus that’s been present in the vaccine since the 2010-11 season.

However, we have a change in the H3N2 virus. This season it will be A Switzerland 9715293-2013 live virus. This replaces last season’s -- the ’14-’15 season -- A Texas 50-2012; the reason for this being that there was drift in H3N2 viruses over the course of the season and we had relatively poor match with the vaccine viruses compared with the H3N2 virus, which ended up being really the predominant circulating virus last season.

For B viruses, there’s also a change. It is a B Phuket 3073-2013 live virus. This is a Yamagata lineage virus just like the ’14-’15 virus was, but it’s just a different Yamagata lineage virus. It replaces B Massachusetts 2-2012.

For quadrivalent vaccines, those same three viruses are present that I just mentioned. However, in addition -- because quadrivalent vaccines contain two B’s, one from each lineage -- quadrivalent vaccines will also contain a B Brisbane 60-2008 live virus. And this is the same second B virus that we’ve had in the quadrivalent vaccine since they first came out on the scene in ’13-’14.

We also have a discussion of some new FDA approvals that came out since the ’14-’15 statement was published. And a couple of these don’t really apply to the pediatric population, but just to mention briefly one of them is the approval of the administration of Afluria, which is an inactivated influenza vaccine trivalent that’s made by CSL. They received FDA approval for this vaccine to be administered via a jet injector, and it’s a specific jet injector. It’s something called the Stratus from a company called Pharmajet.

Important to note that there’s only approval for that vaccine to be administered by a jet injector for adults. It is not to be used for those under eighteen. The approval is for eighteen through sixty-four years. So that won’t be something that would be used within the pediatric population.

Another change is that Flublock, which is a recombinant vaccine and which is currently the only one in the US that can be marketed as an egg-free vaccine, did have an expansion in its age indication. It used to be eighteen through forty-nine years; now it’s eighteen and up. Still unfortunately cannot be used for children, which somewhat limits it’s utility for purposes of administering to patients with egg allergy. It would be good if we had that for the pediatric population at some point.

So I just mention those briefly.

The two main changes in the upcoming guidance that are particularly relevant to pediatrics are, first of all, there has been an update in the dosing algorithm for children aged six months through eight years, and you can see this in the guidance that’s available at MMWR and also available on the ACIP Web site.

We were able to make the algorithm somewhat simpler for this year in that the algorithm no longer counts separately doses of the pandemic antigen - the 2009 H1N1 antigen in the vaccine. Since pandemic - the doses of vaccine that contained that virus -- the H1N1 2009 -- were counted separately because we wanted to make sure that children were getting adequate exposure for that relatively novel virus.

Because that virus has been in the vaccine since monovalent vaccine in 2009 and then in the seasonal vaccine since 2010-11, and has also been the predominant circulating H1N1 since pandemic, the decision was made that it’s probably no longer all that novel, so that going forward for 2015-16 the algorithm considers doses of trivalent and quadrivalent seasonal influenza vaccine without separately counting those that had the monovalent or the 2009 H1N1.

Children who have received at least two doses in the six months to eight year age range of either trivalent or quadrivalent influenza vaccine prior to July 1, 2015 will only need one dose going forward. If children in this age group have not received at least two doses of trivalent or quadrivalent influenza vaccine, they’ll need two for this season.

Finally, I wanted to mention updated recommendations regarding use of LAIV and IIV for healthy two to eight year olds. For the ’14-’15 season, ACIP had recommended a preference for the use of LAIV for healthy two through eight year olds in situations where either vaccine was available. And subsequent to that recommendation being made, after the full seasons’ worth of data for the 2013-14 season came out, it was revealed that LAIV did not perform well in terms of VE, particularly for children and particularly for younger children.

Following on that, for the ’14-’15 season, there was also low vaccine efficacy for LAIV. The difference during that season was that during ’13-’14, inactivated vaccine actually did have appreciable efficacy whereas LAIV didn’t. For ’14-’15, neither vaccine performed well.

The reasons for poor performance between the two seasons are probably different. We know for example, of course, that during ’14-’15 we had substantial drift of the H3N2 viruses and that the vaccine virus was not adequately covering the drifted virus. So that would explain poor performance for both vaccines in that setting.

The reason for the ’13-’14 poor efficacy for LAIV are currently still being investigated and are not clear. There have been discussions as was presented at the ACIP meetings last year that it might be related to some issues with poor temperature stability of the H1N1 2009 that was in the vaccine. But as of yet we don’t have a confirmation on what exactly caused that problem.

So in light of that information, this past June - actually it was during the February meeting -- ACIP voted to remove the preference for LAIV for healthy two through eight year olds. For the ’14-’15 season, that preference was in effect. For the 2015-16 season, there is no preference between LAIV and IIV for the ACIP recommendations for healthy two through eight year olds.

Those are my main updates and I think I’m ready to turn it over to Hank.

Dr. Hank Bernstein:
Fantastic. Thank you Lisa. We’re on slide seven, please.

As we all know, influenza is a common and serious public health problem and it contributes significantly to patient morbidity and mortality. And of course, this creates a financial burden on all healthcare systems.

Because it’s so highly contagious and a respiratory disease, influenza is responsible for an average of fifty to sixty million infections and illnesses annually which results in about twenty-five millions physician visits, hundreds of thousands of hospitalizations, and thousands of deaths.

Slide eight, please.

Over the past thirty-one years, the peak month of influenza activity has most often been in February; but as you can also see on this histogram, influenza peak activity may be as early as October and November. And any flu activity actually can go into April or May. So you can see that the season is predominantly December through March, but can happen early and it’s also possible that it can happen late.

Next slide, please.

This table highlights the deaths and hospitalizations each flu season for the past ten years. Notice in the second column that the predominant strain varies from year to year. The 2013-2014 season was almost all pandemic H1N1, while this most recent season -- 2014-2015 -- was mostly H3N2 as we heard from Dr. Groskoff.

H3N2 seasons tend to take a bigger toll on children. There are more deaths and more hospitalizations. And you’ll note in the last two columns that the rate of hospitalizations for children under five years of age always exceeds the rate for children five to seventeen years each and every season.

Next slide, please.

Among children hospitalized with laboratory-confirmed influenza, almost half -- 46% -- did not have any known underlying medical condition. They were considered healthy.

Of those with underlying medical conditions, 26% had asthma, 14% had a neurologic disorder, and 10% were obese.

Next slide, please.

The American Academy of Pediatrics released its annual recommendations for the prevention and control of influenza in children online in early September.

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As Lisa mentioned and everyone knows, there are both trivalent and quadrivalent influenza vaccines available for the 2015-2016 influenza season. And as you can see, the two of the three strains in the trivalent vaccine have changed from last year - the H3N2 and the B Yamagata. And then, obviously, with the quadrivalent we add the Victoria lineage, as Lisa also mentioned.

Next slide, please.

The bottom line about influenza is that it’s truly unpredictable. Only five seasons in the past thirty years have vaccine strains not changed from the previous season.

Next slide, please.

This is the algorithm that Lisa mentioned, and it highlights that many children will need only one dose of vaccine for the 2015-2016 season, unless this is the very first time they are getting any flu vaccine in their life. And just to reiterate, children six months through eight years of age need only one dose if they’ve received two or more total doses of trivalent or quadrivalent vaccine before July 1, 2015. And it’s irrespective of whether they received IIV or LAIV in the past.

And it’s important to remember that these two doses need not have been received during the same season or even consecutive seasons.

Next slide, please.

The flu virus changes from year to year, which makes it so unpredictable. So annual vaccination is necessary. And even when the vaccine strains stay the same, vaccination is recommended because immunity tends to wane over time by about 50% after six months.

Special effort should be made to vaccinate children and pregnant women. The vaccine protects not just the pregnant woman but she then passes her antibodies transplacentally to her newborn and that infant is protected in the first six months of life when he or she cannot receive the influenza vaccine himself or herself.

And since infants younger than six months of age are too young to be immunized with the vaccine, we also recommend cocooning, which is vaccinating everyone around the infant. It makes sense to try to minimize the exposure to influenza virus of those young infants.

To accomplish cocooning, household contacts of high risk children and young children, as well as all healthcare personnel, should be vaccinated with the influenza vaccine each year.

Next slide, please.

This calendar reminds us to offer flu vaccine throughout most of the year until the vaccine expiration date, which is no later than June 30, marking the end of the influenza season. Since influenza is unpredictable, we also know that there can be more than one disease peak in any given community. And international travel may result in potential exposure to influenza throughout the year.

Next slide, please.

According to data from the 2014-2015 season, the most common place of vaccination among both adults and children was the doctor’s office. Two-thirds of children received it in their doctor’s office while a third of adults received it in their doctor’s office. These results are similar to the previous influenza season.

But there are other common places that flu vaccine is received. For children, it was clinics, health centers, and other medical places other than the doctor’s offices, including pharmacies or stores and, of course, college students and schools.

The next most common places of influenza vaccination for adults were pharmacies or stores and the workplace. What’s most important is that we immunize as many people against the flu each and every year.

Next slide, please.

The caption of this cartoon reads, “I hate it when we’re not sure we’re inoculating against the right strain of flu virus.” As mentioned earlier by Lisa, most of the H3N2 strains circulating last year were actually drifted strains. And of course, this negatively impacted vaccine effectiveness.

Next slide, please.

This is a large study by Belshi and colleagues where almost 8000 children six through fifty-nine months of age were randomly assigned in a one-to-one ratio to receive either trivalent LAIV or trivalent IIV. The percentage of children with culture-confirmed influenza was monitored throughout the 2004-2005 season. In this study, there were 55% fewer cases of culture-confirmed influenza in the LAIV group compared with the IIV group.

And in fact, LAIV had higher efficacy for both well-matched and drifted strains. But unfortunately, the same impact was not achieved with quadrivalent LAIV during this past influenza season when drifted H3N2 was the most predominant strain.

Next slide, please.

The AAP and the CDC recommend that healthy children two through eight years of age be immunized with either IIV or LAIV. There is no preference expressed for either vaccine. Vaccination should never be delayed to obtain a specific product.

Observational studies of LAIV and IIV vaccine effectiveness indicate that the current quadrivalent LAIV did not perform as well as expected and did not show greater effectiveness than IIV. So in the absence of data demonstrating consistent greater relative effectiveness of LAIV 4, preference for LAIV over IIV is no longer warranted. Influenza vaccine effectiveness will continue to be reviewed throughout the season.

Next slide, please.

Estimated IIV effectiveness ranged between forty to sixty-seven percent between the 2011-2012 season and the 2013-2014 season for two- through eighteen-year-olds. Last season, the 2014-2015 season, vaccine effectiveness was moderately lower, particularly in children under nine years of age.

You’ll recall that the H3N2 was the predominant strain, and this was characterized by mostly drifted H3N2 viruses.

Next slide, please.

Overall effectiveness of LAIV has been highly variable during the last four influenza seasons among children two through eighteen years of age. And you’ll notice that it has notably declined over the past two seasons.

For the 2013-2014 season, LAIV showed very low vaccine effectiveness in this age population. Three observational studies of LAIV for this particular season, which was the first season in which LAIV 4 was available, revealed no effectiveness of LAIV 4 against pandemic H1N1 among children aged two through eighteen years. And that was the predominant strain circulating that particular season.

And you’ll notice in the 2014-2015 season LAIV was not effective against the predominant circulating drifted H3N2 viruses either, resulting in low vaccine effectiveness overall.

Next slide, please.

So the take-home messages form this portion of the talk is that we should immunize everyone six months of age and older, especially close contacts of children at high risk for influenza-related complications. The vaccine composition has changed. The dosing algorithm for children six months through eight years reflects that H1N1 pandemic virus no longer is believed to be antigenically novel.

Vaccine effectiveness can vary from season to season, as we’ve experienced. And neuraminidase inhibitors continue to be important in influenza control. Now I’ve not touched on treatment yet, but I plan to do so in just a few minutes.

But before we get to antiviral treatment, I just wanted to mention that the AAP has reaffirmed its support for a mandatory influenza immunization policy for all healthcare personnel nationwide. This policy statement was also published online in early September.

Next slide, please.

The influenza vaccination rate in all healthcare settings is represented in the solid blue line. And as you can see, has been steadily increasing each and every year. The overall rate is still below the Healthy People 2020 target goal of a 90% vaccination rate for all healthcare personnel.

You’ll notice the top arrow shows that the vaccination rate is highest for hospitals with mandatory policies in place, followed by ambulatory care and physicians’ offices; but there is still room for improvement in vaccination rates of healthcare personnel.

Next slide, please.

In a 2014 study based on four cluster randomized trials and four observational studies conducted mostly in long term care and some hospital settings, influenza vaccination of healthcare personnel resulted in or was associated with a 29% reduction in all caused death and a 42% reduction in influenza-like illness for patients.

The grade analysis showed that the quality of evidence for reduced mortality was moderate and for reduced morbidity was low. Since mortality is considered a critical outcome for decision-making, the overall quality of evidence across these outcomes was moderate.

Next slide please.

Influenza vaccination of healthcare personnel also leads to lower rates of influenza infection in healthcare personnel, higher productivity through less sick days due to respiratory infection, less days lost from work overall, and -- again -- lower patient mortality.

Next slide, please.

The take-home messages from this portion of the talk are that voluntary efforts to improve and sustain healthcare personnel immunization rates have failed. A mandate is considered ethical, just, and necessary. And mandatory vaccine programs have been successful and would be expected to cut costs. This concept has growing, widespread support across the country.

Next slide, please.

As promised earlier, let’s talk briefly about the treatment of influenza.

Next slide, please.

Influenza diagnostic tests vary by method, availability, process time, sensitivity, and cost. And these different factors should be considered in making the best clinical judgment for diagnostic test use. Some of the more rapid tests have lower sensitivity and this must be kept in mind because a negative test does not mean the patient does not have influenza.

Unfortunately, most of the higher sensitivity tests take longer to process. The rapid influenza molecular assays, as listed at the bottom of this slide, detect RNA and have a much higher sensitivity. But you’ll also notice in the lower right-hand corner that they are also most expensive.

Next slide, please.

The neuraminidase inhibitors are the only antiviral medications recommended for the treatment of influenza in children during the 2015-2016 season. Most influenza viruses likely to cause 2015-2016 seasonal influenza in North America are sensitive to oral oseltamivir, known as Tamiflu; inhaled zanamivir, known as Relenza; or IV peramivir, known as Rapivab.

Next slide, please.

Oseltamivir has been shown to be clinically efficacious in children. In a double-blind randomized placebo-controlled multicenter 2001 study of children aged one through twelve years of age, oseltamivir treatment resulted in a significant decrease in symptom duration by 1.5 days as compared with placebo, and a forty-four hour faster return to normal activity.

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Oseltamivir also resulted in eleven percent reduction in complications requiring antibiotics, a nine percent reduction in otitis media, and a ten percent reduction in physician-prescribed antibiotics in the same study.

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In a double-blind, randomized, placebo-controlled parallel group multicenter study in 2000 of children aged five to twelve years of age, treatment with inhaled zanamivir was also efficacious with a reduction in time to resolution of symptoms by 1.25 days -- from five and a quarter days down to four days for the resolution of symptoms.

Next slide, please.

A 2013 review of the California surveillance data found that early treatment resulted in decreased mortality. In their multivariate model that included receipt of mechanical ventilation and other factors associated with disease severity, the estimated risk of death was reduced in the neuraminidase inhibitor treated cases by 64%. As you can see on this slide, treatment within forty-eight hours of illness onset was significantly associated with survival.

Prompt treatment with neuraminidase inhibitors may improve survival of children who are critically ill with influenza. And if we don’t use neuraminidase inhibitors for treatment of influenza, we’ll be placing critically ill children at an increased risk of death as demonstrated on this slide.

Next slide, please.

Of the adverse events occurring in greater than 1% in pediatric patients aged one to twelve years of age who have received oseltamivir, only vomiting occurred more frequently than in patients treated with placebo.

Next slide please.

Given these studies and the information that we know, providers should offer treatment as soon as possible to all children hospitalized for presumed influenza or with severe, complicated, or progressive illness attributed to influenza. Providers should also offer treatment to children with influenza of any severity who are at high risk for complications if they were to get influenza.

And remember that no physician can predict which children who are hospitalized with influenza will progress further in illness, including death, or which - to the opposite effect, which ones will improve if they were not to receive neuraminidase inhibitors.

Next slide, please.

Providers should consider treatment for presumed influenza in any otherwise healthy child for whom they feel that a decrease in symptoms is warranted. They should also consider treatment for children with presumed influenza who have siblings at home that are less than six months of age or have siblings at home who have underlying medical conditions that predispose them to influenza complications.

Next slide, please.

There currently are no placebo-controlled randomized trials available for neuraminidase inhibitor treatment of hospitalized influenza patients. And it’s challenging to undertake RCT’s with mortality and severe morbidity as the outcomes.

However, observational studies consistently report clinically meaningful benefits of neuraminidase inhibitor treatment, creating a large body of evidence for the benefit of their use.

Next slide, please.

Treatment is twice a day for five days and chemoprophylaxis is once a day for ten days. For children twelve months of age and older, oseltamivir dosage depends upon their body weight.

Children greater than or equal to seven years of age may be treated with zanamivir, and children greater than or equal to five years of age may be given zanamivir for chemoprophylaxis.

Next slide, please.

Given preliminary pharmacokinetic data and limited safety data, oseltamivir can be used to treat influenza in both term and preterm infants from birth, as the benefits of therapy are likely to outweigh the possible risks of treatment. Recommended dosing for infants may lead to high drug concentrations in this young age group. And remember that preterm infants may have lower clearance of oseltamivir because of their immature renal function.

If you have extreme premature infants -- those under twenty-eight weeks of age -- please consult a pediatric infectious disease physician for management.

Next slide, please.

In a 2013 double-blind randomized controlled trial of hospitalized patients with severe influenza, doubling the dose of oseltamivir given to children or adults did not significantly reduce patient mortality. It did not reduce the median days on supplemental oxygen. It did not reduce the median days in the ICU. It did not reduce the median days on mechanical ventilation or the number of patients testing negative for influenza by reverse transcriptase PCR on day five of treatment.

Therefore, it is not recommended to use higher than approved doses of oseltamivir in patients with severe influenza.

Next slide, please.

The take-home messages for this particular section is that annual influenza outbreaks cause significant morbidity and mortality in children, as we all well know. Antiviral treatment of influenza is indicated in young children, hospitalized patients, and patients at higher risk of complications.

Oseltamivir dosing down to two weeks of age has now been determined and is FDA approved; but also the use of oseltamivir is fine for newborns down to the day of birth. There is no benefit of doubling oseltamivir dosing.

Next slide, please.

It is important for us to improve our office preparedness for seasonal and pandemic influenza. Certainly, things happen when the 2009 pandemic happened, but we should be thinking about seasonal influenza and how we’re going to prepare our offices.

And the AAP has prepared a number of resources to help pediatric office practices prepare for these outbreaks. They help with vaccine handling and a storage plan should power outages occur. And it’s also important to help educate and talk with office staff about infection control practices.

Next slide, please.

It is also recommended that a written office management plan that includes an office respiratory protection plan; how gloves and masks and hand sanitizers, et cetera, are recommended; strategies to address office flow issues as patients who are sick come into the office, and how to try to maintain separation with those that are well; how important it is to rapidly triage patients; and of course, to enhance cleaning and disinfection strategies.

Next slide, please.

This slide has all the resources that the American Academy of Pediatrics has put together, and there are multiple links available on the website to help all pediatric practices prepare for seasonal influenza.

And I wanted to turn the presentation over to Drs. Needle and Fisher for further comment about office preparedness. Thank you.

Dr. Scott Needle:
Thank you. This is Dr. Scott Needle from the AAP Disaster Preparedness Advisory Council. And I just wanted to follow up very briefly to really hit home that even though the flu is an annual event that occurs every season, it’s fairly easy to take it for granted.

As we’ve seen from the presentation earlier, the effects can be very unpredictable year to year. If it's a very mild season, then it’s fairly easy for your typical office operations to absorb the impact without much forethought. Unfortunately, when you get into a season that’s going to be much more significant and much more disruptive, then the usual operations are going to be hit that much harder; which is why this is a disease that you really have to have some respect for.

And to accomplish that, I think every office needs to be prepared for the worst that could happen. The H1N1 pandemic was really a call to action in putting a lot of offices to the test.

So again, as mentioned, the AAP has a number of resources which can help in terms of anticipatory guidance in terms of what you can do to prepare your staff and prepare yourself and prepare the patient flow. I would encourage everyone to at least take a look at it and to think about it and develop a plan because even though a plan may not be perfect, it may not cover every single contingency -- just the exercise of going through thinking of the scenario and thinking of what you have to consider is going to be extremely helpful.

Just as an example, I would suggest to everyone who is in an office-based practice - consider what would happen on a typical day in the winter when you’re already booked up, seeing physicals, seeing numerous sick patients -- ADD checks, orthopedic problems -- all the usual ones seen. And you have a rush of patients who also want to be seen because they might have influenza, and you also have a number of patients who want to get in to receive the flu shot.

How would your office handle that kind of scenario in terms of accommodating sick patients, accommodating the routine vaccinations, and while trying to keep a normal flow as well?

And with that I’m also going to turn it over to Dr. Fisher for a few other comments.

Okay. We seem to be having problems with getting Dr. Fisher on the line there, but what Dr. Fisher was going to talk about was also the fact of immunizations. Again, with the typical season, the number of vaccines a typical office is going to have is going to rise considerably. So that’s a big investment in terms of not only the capital, but also you have to preserve that supply in order to protect kids for the season from the influenza there.

So it’s very important to have a plan as well to handle not only the vaccine stock and keeping track of it but, more importantly, how to preserve it, how to preserve the cold chain if there’s a power outage.

Dr. Fisher was personally affected by Superstorm Sandy and she saw in her area of New Jersey that many practices lost hundreds of thousands of dollars’ worth of vaccines from the power outage. There’s nothing that precludes a disaster from coming within flu season, so you have to make sure that you have a robust backup system to make sure that the vaccines are going to be temperature-stable. And if that can’t be in your office, then perhaps there’s another facility nearby that you can use as a backup there.

Again, the best way to prepare for flu season as far as patient care is to encourage the vaccinations and keep people from getting it in the first place. So in order to do that, you have to make sure that you have the vaccine, that you have it kept safely, and that you have contingency plans in case your office does lose power, which is not an inconceivable event during the winter across any part of this country here.

Dr. Ibad Khan:
Thank you Dr. Bernstein, Groskoff, Fisher, and Needle for providing our COCA audience with such a wealth of information on such a timely and relevant topic. We would now like to open the lines for the question and answer session. And also remember you can submit questions to the webinar system.

Coordinator:
Absolutely. At this time if you would like to ask a question, please press star 1 from your phone and record your first and last name clearly when prompted. If you want to withdraw your question, you may press star 2. Again, if you would like to ask a question, please press star 1 from your phone. And one moment as we wait for our first question.

Dr. Ibad Khan:
And Monet, while we wait for our first question, I have a question here for the presenters. Can the vaccine provide protection even if the vaccine is not a good match?

Dr. Hank Bernstein:
This is Hank Bernstein. And the answer to that is yes, but it’s not nearly as effective as was demonstrated last year with drifted strains. But it can provide some protection. Optimally, as we know, there’s worldwide surveillance of influenza viruses and the decision is made in February as to which strains are anticipated to be circulating that particular coming season.

And we try to predict and produce a vaccine that matches the circulating strains. And that provides much better vaccine effectiveness, on average, in the fifty to sixty percent range. Although, we saw in some of the earlier slides there it’s even a little bit higher. When there’s drifted strains, we also saw that the vaccine effectiveness was notably lower. So the short answer is yes, there’s some protection; but not nearly as much as when the circulating strains and the strains in the vaccine are a perfect match.

Coordinator:
We do have one question in queue if you would like to take that question.

Dr. Ibad Khan:
Please proceed.

Coordinator:
This question comes from Meg Fisher. Your line is open.

Dr. Meg Fisher:
Hi. This is Meg Fisher. Sorry I couldn’t get on for my comments earlier. Scott Needle said everything I would have said and said it probably better than I would have said it.

I do, though - I’m sitting right now in New Jersey awaiting to see what’s going to happen with this hurricane. So I think that this is a very timely webinar because everyone sitting on the East Coast of the US needs to think of what they’re going to do with their vaccines should the hurricane decide not to turn out to the Atlantic.

But it’s not just hurricanes. It’s any kind of office disasters or any kind of disasters that can hit. And I think that we’ve had a good discussion of getting your office prepared and thinking about the little things as to how you’re going to get everybody immunized in a short period of time, how you’re going to reach your at-risk patients, particularly those with chronic illnesses. And I think that poses a challenge for all of us, and the sooner we can do that and get started the better. And let’s hope the hurricane does not hit New Jersey again.

Thank you.

Coordinator:
Thank you. We have no...

Dr. Hank Bernstein:
This is Hank Bernstein, and I’d add to what Dr. (Fisher) said that all of these resources are available on the AAP Web site. And if you go to AAPredbook.org as one of the sites, there’s an influenza resource page that has all the materials from the American Academy of Pediatrics as well as resources from the Centers for Disease Control and Prevention and other organizations around the country.

All of the information is there and we encourage you. It’s available for free and we encourage everyone to take advantage of it.

Dr. Ibad Khan:
Monet, do we have any other questions on the line, please?

Coordinator:
There are no other questions in queue at this time.

Dr. Ibad Khan:
I have a question I’ve received that I would like to pose to the presenters. In light of the strategies to help increase vaccination rates for healthcare staff as well as in line with the importance of office preparedness, what recommendations would the presenters make for clinicians to help increase those vaccination rates for their healthcare staff?

Dr. Hank Bernstein:
This is Hank again. I’ll start and I’m sure Meg or Lisa or Scott can chime in.

As I mentioned earlier, mandatory - unfortunately or fortunately, mandatory policies have shown better rates than voluntary programs. But some of the factors that can be included is obviously the healthcare leadership - the physician leadership in a practice, the leadership in a chronic care facility, the hospital system leadership - having their full support can also maximize success.

I think it’s also important, as Dr. Fisher was pointing out as well, in preparing for disasters or preparing for immunizing all healthcare personnel; you really need to customize the plan for your institution, your particular practice, your particular chronic care facility. If at all possible, making the vaccine free to all healthcare personnel or at least helping to bill for it through commercial or federal billing would be helpful.

Publicizing the program as much as possible to all healthcare personnel, offering convenient times and locations not just for giving the vaccine - but it’s also important to offer convenient times to educate healthcare personnel about the vaccine and preferably giving the vaccine and educating your personnel. If it could happen right in the workplace, that will also optimize success.

We also know that it’s important to limit the number of exemptions as much as possible. We know that it’s a controversial topic that’s happening around the country at this point, and I would - I think it would be important for offices and hospitals and other facilities to define what’s considered an acceptable medical exemption. And it should probably be a concrete and uniform document that is reviewed with the individuals. And it really - if there is a medical exemption, it would be good to require a physician’s note that documents that.

And lastly, each place of work should create a clear policy for the management of employees who are exempted from immunization. Some places have removed personnel from clinical settings where - patient care clinical settings. Others are required to wear masks form the beginning of flu season until the end of flu season.

What’s most important is that whatever policy is established that it is made clear to all employees who are not - choosing not to receive the influenza vaccine.

I don’t know if my friends on the call have additional comments to make.

Dr. Scott Needle:
Dr. Bernstein, I think you said it absolutely perfectly. I think we really have an obligation to our patients to really support the universal influenza vaccination. And I’m the Chief Medical Office of a community health center here in Southwest Florida, and we’ve personally taken on almost all of those things that you’ve talked about, whether it’s a little of the carrot and a little of the stick. We want to make it easy and convenient for our employees and for our providers and physicians; and we have taken it on as - we offer it for free to all of our staff and we feel that it’s a very reasonable investment in the health of them and the health of our patients there.

And we let them know that everyone is behind this. This is what’s expected and if you don’t choose this, there might be ramifications during the season as far as your abilities to show up to work to provide care to the patients.

Dr. Ibad Khan:
Monet, do we have any other questions on the line, please?

Coordinator:
Yes, we do have two questions that came into queue. This first question comes from Barbara Otis. Your line is open.

Barbara Otis:
Thank you for taking my question. I work at a large clinic system in the Minneapolis area and we’re really struggling with getting an adequate supply of the 0.25 dose. And we’re starting to get a little more of the intranasal, but that was slow in being released, I realized. I’m really interested in whether or not there are issues with getting the 0.25 across the country or whether this is something that’s just in our area.

Dr. Hank Bernstein:
Lisa, do you want to comment on that?

Dr. Lisa Groskoff: 
I will try to. I don’t have a lot in terms of specifics. We have heard that there are issues in terms of delays of getting the 0.25 out. I’m not sure exactly about the geographic distribution. I believe it’s not just in certain areas, but that’s about as much as I know about that at this point.

Barbara Otis:
Our VFC doses - we’ve received a quarter of what we need for VFC doses. So I’m really concerned about those youngest kids who need two doses.

Dr. Hank Bernstein:
In our hospital, we actually have vaccines for our VFC program but not for commercial insurance.

Dr. Ibad Khan:
Monet, we’ll take one last question, please.

Coordinator:
Yes, and we actually just have one question in queue. Our next question - or the last question comes from Betsy Miller. Your line is open.

Betsy Miller:
Hello. Thank you so much for taking this call, and I really appreciated your webinar. I thought it was very well-done. I am a childcare health consultant in Pennsylvania, and one thing I try to stress to childcare providers is to also get their flu vaccines so that also helps with the cocooning of young children under six months old.

So I just wanted to let other pediatricians know that possibly talking to the parents, of making sure that there’s - wherever they take their child for early care and education that they’re also getting their vaccines at a timely rate.

Thank you.

Dr. Ibad Khan:
Thank you.

Coordinator:
Thank you. There are no more questions in queue.

Dr. Ibad Khan:
Thank you very much. On behalf of COCA, I would like to thank everyone for joining us today, with a special thank you to our presenters -- Drs. Bernstein, Groskoff, Fisher, and Needle. We invite you to communicate with our presenters after the webinar.

If you have additional questions, please email us at coca@cdc.gov. That’s C O C A at CDC dot G O V. Put “October 1 COCA call” in the subject line of your email and we will ensure that your question is forwarded to the presenters for a response. Again, that email address is coca@cdc.gov.

The recording of this call and the transcript will be posted to the COCA Emergency Web site at emergency.cdc.gov/coca within the next few days. That’s emergency.cdc.gov/coca.

Free continuing education is available for this call. Those who participated in today’s COCA conference call and would like to receive continuing education should complete the online evaluation by October 23, 2015 using course code WC2286.

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Thank you again for being a part of today’s COCA webinar and have a great day.

Coordinator:
Thank you for your participation in today’s conference. All participants may disconnect at this time. Leaders, please stand by.

END