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CDC UPDATE: THE LATEST ON FLU, PNEUMONIA PROTECTION FOR ELDERSMay 6, 2004 CDC SAYS IMMUNIZATIONS COULD REDUCE DEATHS FROM INFLUENZA AND PNEUMOCOCCAL DISEASE AMONG OLDER ADULTS Older adults and most other Americans should seek vaccination annually against influenza. With an estimated average of 36,000 annual deaths and 114,000 hospitalizations from influenza-related causes, “every year is a serious year for influenza,” explained Dennis O’Mara, associate director for adult immunizations with the National Immunization Program at the U.S. Centers for Disease Control and Prevention (CDC). CDC recommends that people get vaccinated against influenza every October or November. “By definition, we have an epidemic of influenza in this country every year,” agreed Tamara J. Kicera, project coordinator for CDC’s Racial and Ethnic Adult Disparities Immunization Initiative. “Every year is bad, and some years are worse,” she said. Older adults are especially vulnerable. CDC reports that older adults comprise 90 percent of the 36,000 deaths that occur on average each year from influenza complications. Approximately 48,000 (42 percent) of the 114,000 hospitalizations from influenza-related causes involve people age 65 and older. CDC estimates that, for each additional million elderly persons vaccinated, approximately 900 deaths and 1,300 hospitalizations would be averted during the average influenza season. The number of deaths and the cost to society are likely to increase as the nation’s population ages. The U.S. Census Bureau projects the number of adults ages 65 or more will double from 35 million (or 13 percent of the population) in 2000 to 70 million (or 20 percent of the population) by 2030. In addition, 1998 data from CDC show that 3,400 older adults die from invasive pneumococcal disease each year. This type of illness results when pneumococci, a leading cause of bacterial infection, enter the bloodstream (bacteremia), or invade the tissues and fluids surrounding the brain and spinal cord, causing meningitis. Among people 65 and older with pneumococcal bacteremia, pneumococci often invade the lungs, causing pneumonia. CDC estimated total influenza deaths at about 20,000 per year in the 1970s and 1980s, but new estimates show that number nearly doubled during the last decade to 36,000 deaths a year. CDC epidemiologist Keiji Fukuda, M.D., M.P.H., said the new estimates on influenza deaths actually were based on a more conservative approach toward classification of deaths than was used for previous decades. Nonetheless, deaths from influenza were higher in the 1990s than the 1970s and 1980s. CDC researchers believe the increase in influenza-related deaths is due in part to the aging of the U.S. population and the fact that a more virulent subtype [A(H3N2)] of influenza predominated in most influenza seasons during the 1990s. Immunizations can reduce the risk for or severity of illness and save money for society, yet one-third of seniors do not get their influenza shots and nearly half have never been vaccinated against pneumococcal disease, CDC data indicate. This information — despite the fact that public health experts have long recommended these immunizations and that Medicare pays for them — highlights the need for continued public and physician education and incentives. “People don’t realize how serious influenza is,” commented Alison Johnson, deputy director of the Immunization Services Division of CDC’s National Immunization Program. The classic symptoms of the influenza virus are well known — sudden onset of fever and chills, dry cough, runny nose, body aches, headache and sore throat. Pneumonia begins with high fever, cough and chest pain. While anyone can get influenza, older adults have a higher risk for complications, pneumonia, hospitalization or death. Taken together, pneumonia and influenza are a leading cause of death among seniors, CDC reports. Serious illness and death are also a greater threat among those with medical conditions such as asthma and diabetes that place them at increased risk. The best way to prevent influenza is to get an annual vaccination but too many people don’t. One reason is the prevalence of a myth that people can get the flu from a vaccination, although the inactivated vaccine is made from a dead virus that cannot cause influenza. During fall months, however, when influenza vaccines are typically given, people often coincidentally experience a cold or other respiratory infection from another organism soon after receiving an influenza shot, and they may associate the vaccination with what they think may be a case of the flu. The most frequent side effect from the inactivated influenza vaccine is soreness at the vaccination site that lasts less than two days. The pneumococcal polysaccharide vaccine (PPV) for preventing invasive pneumococcal disease is also safe, CDC said. Up to half of patients have very mild side effects, such as redness or pain where the shot is given. Public health officials say immunization rates are too low, and the government’s goal set in its report Healthy People: 2010 is to vaccinate 90 percent of people ages 65 or more. Public awareness of the importance of influenza shots and increased offering of vaccinations by healthcare providers recently doubled the percentage of elders receiving vaccinations to about two-thirds (68%) in the 10-year period through the 1999-2000 flu season, National Center for Health Statistics (NCHS) reports. However, vaccination levels for the two following flu seasons, 2000-2001 and 2001-2002, were lower or about the same. Among nursing-home residents, the influenza- vaccination rate was 66 percent in 1999. Pneumococcal vaccination rates rose from 42 percent in 1997 to 56 percent in 2002. Both vaccination rates are lower, however, among African-Americans and Hispanics. CDC said physicians can improve immunization rates by using reminder/recall systems similar to the cards dentists send out. Also effective are standing orders, which allow nursing staff to administer vaccinations without the physician’s written or verbal consent; improving vaccination record keeping; using prompts, such as stickers on charts to remind physicians to deliver needed vaccines; measuring health professionals’ performance in delivering needed vaccines; and working with staff to think of other ways to improve. “Availability of influenza vaccine in places such as stores, pharmacies or senior centers can make it easier for some to get their annual flu shot, particularly for those who may not visit their doctor during October or November,” said Jim Singleton, M.S., an epidemiologist with CDC’s Viral Vaccine Preventable Diseases Branch. CDC EFFORTS TO PROMOTE ADULT IMMUNIZATION CDC’s national public health education campaign focuses on the benefits associated with influenza immunization as a way to increase the number of people getting influenza vaccinations, noted Glen Nowak, Ph.D., CDC associate director for communications of the National Immunization Program. The multifaceted campaign includes posters, fact sheets, media information in English and Spanish, an electronic newsletter called the Flu Bulletin, an online “Flu Gallery” of educational materials, satellite feeds through a partnership with CNN and frequent updates for journalists. CDC’s “Protect Yourself and Your Loved Ones” message uses visuals such as a grandparent with a child. The message “tested favorably” during focus groups with family members and caregivers in the fall of 2002 and was “a very visible element in the 2003 fall campaign,” Nowak said. In fiscal year 2001, CDC supported adult- immunization programs in 64 states, cities and territories with grant funds. It also provides guidelines and training for immunization programs; assists the government’s Centers for Medicare and Medicaid Services (CMS) with annual educational campaigns to improve immunization coverage among Medicare beneficiaries; tracks disease and vaccination coverage; and supports research on ways to reduce racial and ethnic disparities in vaccine coverage levels. WHO SHOULD GET SHOTS AND WHEN? CDC recommends that, optimally, persons age 50 and over should get an influenza shot in the fall of each year and a pneumococcal shot at least once after age 65, although a second pneumococcal shot is sometimes necessary for those with certain chronic or immunosuppressive diseases. Anyone with serious long-term health problems (such as heart or lung disease), metabolic disease (such as diabetes), anemia and other blood disorders, impaired immunity or kidney disease should be vaccinated. The agency’s Advisory Committee on Immunization Practices (ACIP) recommends that influenza vaccinations should be given to all residents and staff of nursing homes, chronic-care facilities, assisted-living facilities, retirement communities and recreation centers. Influenza vaccine should also be given to health care employees, visiting nurses, homecare workers and those in the household who can transmit influenza to persons at high risk. Health officials also recommend influenza shots for those ages 50-64 in general because this group has many people with high-risk conditions. However, as CDC’s Alison Johnson acknowledges, this is “an audience which is harder to target” because they tend to think they are invulnerable to flu. But, she added, “If you have the flu, you don’t have just a touch, you are flat on your back.” The optimal time to vaccinate against influenza is October through November, although influenza shots may also be offered in September during routine healthcare visits or during hospitalization if the vaccine is available. Shots should not be given too early, though, because antibody levels can begin to decline before the end of the flu months. Also, physicians should continue to offer immunizations in December and January, as well as throughout the influenza season to reach the greatest number of people. Influenza typically does not reach peak levels until late December through early March. That means “you can get a flu shot for a longer period of time than people thought,” CDC’s Glen Nowak added. ACIP recommends that people age 50 and older, and younger persons with high-risk conditions, who are hospitalized at any time during September through March, should be offered and strongly encouraged to receive influenza vaccine before they are discharged. In one study, 39 percent to 46 percent of adult patients hospitalized during the winter with influenza-related diagnoses had been hospitalized during the preceding autumn. In addition, ACIP recommends pneumococcal vaccination before hospital discharge for persons at risk if they have not received this vaccine previously. The pneumococcal vaccine should be given to those who are age 65 and older, as well as anyone with heart or lung disease, diabetes, cirrhosis, alcoholism, sickle cell disease, leaks of cerebrospinal fluid or impaired immunity. Persons ages 65 and older should receive a second dose of vaccine if they received the first dose more than 5 years previously and were younger than 65 at the time. A follow- up dose is also recommended for people with impaired immune systems. When needed, simultaneous administration of influenza and pneumococcal vaccine is strongly encouraged for persons who have not yet received their pneumococcal vaccination, CDC’s Jim Singleton explained. WHY DON’T OLDER ADULTS GET VACCINATED? The best indicator of whether someone will get an influenza shot is whether the person had done so in the past, according to CDC’s Tamara Kicera, who coordinates the Racial and Ethnic Adult Disparities Immunization Initiative (READII — pronounced “ready”). She said that many adults, when asked why they didn’t get vaccinated, state that they didn’t know they needed to or that their healthcare provider did not offer them the vaccines. In addition to those who do not get immunizations because they mistakenly believe the shot might give them influenza, many people tend to not see themselves as being in a high-risk category. Then there are those who know they should get a vaccination, but simply fail to do so. “People who get influenza shots tend to be proactive about their health and are interested in preventive care,” Singleton said. “Those are the ones we can most easily reach, either during regular healthcare visits, through use of patient reminders by healthcare providers, or by availability of vaccinations in stores or pharmacies.” One of the problems with the once-in-a-lifetime pneumococcal vaccination is that people often do not remember whether they have had it, and providers are reluctant to give unnecessary treatment and have concerns about possible risks from revaccinating too soon, Singleton said, but the ACIP recommends that persons for whom the vaccine is indicated should be immunized if no documentation is available. Those who receive this vaccine are strongly encouraged to obtain a record of its administration from the provider for future reference. Another reason older adults do not get recommended vaccinations is because their healthcare provider does not offer them, or has decided not to administer them. “Many providers have expressed concerns that the Medicare reimbursement rate, which covers the vaccine and the cost of administration, is too low,” CDC’s Alison Johnson explained. However, CMS nearly doubled the average Medicare payment for administration of influenza shots and other vaccines from $3.98 to $7.72 on March 1, 2003. Medicare reimbursement rates vary by locality. CDC also works with state health departments as well as pharmacies and other places that offer mass immunizations, Johnson said. However, due to resource constraints, many health departments focus their immunization programs on children. For those who do not like to get flu shots, researchers have developed a live attenuated nasal spray vaccination (FluMist), which contains weakened live influenza viruses instead of killed viruses. However, use of this form of influenza vaccine among healthy adults during the 2003-04 flu season has not been as extensive as its manufacturer had originally hoped, partly because it costs more than the traditional injection. The Vaccines and Related Biological Products Advisory Committee of the U.S. Food and Drug Administration concluded that there is not enough information to show the nasal vaccine is effective in patients ages 50 and over. Research is continuing in this area to see if the vaccine can be recommended for older adults. HEALTH DISPARITIES CDC data continue to show that vaccination levels for blacks and Hispanics lag behind those for whites. For the first quarter of 2002, 69 percent of older white people had received an influenza vaccination within the past 12 months, compared to only 50 percent of older African- Americans and 47 percent of Latino seniors, NCHS reported. Disparities for pneumococcal vaccination coverage were even more dramatic — 60 percent for whites, 32 percent for African-Americans and 26 percent for Hispanics. To help better understand how to increase immunizations among minority elderly, CDC launched its READII demonstration in 2002. The project is taking place in five areas: Chicago, Milwaukee, the Mississippi Delta Region, Rochester, N.Y., and San Antonio. READII is organizing partnerships of public health professionals, medical providers and community members to identify and implement strategies to increase immunization levels among older African-Americans and Hispanics. The project will provide information “on why members of minority communities don’t get immunized and we will be looking for creative ways to reach them,” according to READII coordinator Tamara Kicera. Possible reasons for lower immunization rates among minority patients include misperceptions about the vaccine, distrust of the government and lack of access to healthcare services, as well as physician beliefs and systemic biases that may inhibit providers from offering the vaccines, she said. Kicera added that the “problems of culture and language may complicate the provider-patient interaction.” “One way to overcome such biases or lack of interest in preventive care is with standing orders for vaccination of any patient who meets certain criteria, such as being age 65 and older or having diabetes or asthma,” Kicera said. Under these circumstances, a nurse is automatically empowered to evaluate a patient for contraindications and give necessary immunizations without a physician’s involvement. “This frees the physician to focus on other patient-care issues while establishing the process of routine vaccination without reference to race or ethnicity,” she explained. MEDICARE IMMUNIZATION POLICY Medicare began paying for annual influenza vaccinations in 1993 and pneumococcal vaccinations in 1981. It covers an initial pneumococcal shot and revaccination at least five years later for those at highest risk of serious pneumococcal infection. Routine pneumococcal revaccination of people age 65 or older who are not at highest risk is not appropriate, CMS states. For those of any age at medium to high risk of hepatitis B, including people with end- stage renal disease or hemophilia, Medicare also covers a vaccination series for hepatitis B. To improve vaccination of nursing-home residents, hospitalized patients and those receiving home health care, Medicare no longer requires that physicians write an individual order for each immunization. Instead, where state law permits, appropriate non-physician personnel can assess for contraindications and provide vaccinations under a facility-approved standing order, according to CMS. HOW THE VACCINE IS MADE Influenza vaccines must be updated annually to match the viruses expected to circulate in the coming year. Federal health officials and vaccine manufacturers start almost a year in advance determining which strains of influenza to vaccinate against, CDC explained. Sometimes the virus strains that begin circulating later in the year differ from those in the vaccine, but often they are sufficiently similar to provide some cross-protection, CDC’s Dennis O’Mara explained, even in years when it is not an exact match for the circulating virus. The influenza vaccine is made from viruses grown in eggs. For inactivated vaccines such as the “flu shot,” the virus is killed but may contain trace amounts of residual egg protein. The influenza viruses used in live attenuated influenza vaccine, such as FluMist, also are grown in eggs. People with an anaphylactic hypersensitivity to eggs or other components of the vaccine should consult a physician before getting an influenza vaccination. In a typical year, 70 million to 75 million Americans receive a flu shot. An early start to the 2003-04 influenza season and widely reported influenza-related deaths among children prompted more people than usual to seek vaccination at the end of 2003, resulting in supply shortages. Manufacturers, who determine each year how much vaccine to produce, had prepared about 87 million doses of vaccine. That amount was more than had been used the prior year. In fact, it was the first time the U.S. public sought more than 80 million doses of influenza vaccine in one season. For the 2002-03 influenza season, manufacturers had prepared 95 million doses, but an estimated 16 million of those remained unsold and were discarded. Because the vaccine has a short shelf life, and because the viruses change almost every year, unused supplies cannot be distributed in subsequent years and must be discarded. Delays in influenza vaccine availability can occur in years when it is difficult to determine which influenza strains are circulating worldwide, when a particular strain does not grow well or when manufacturers need additional time to implement prescribed quality control procedures. In 2000, for example, some manufacturers experienced difficulties growing and processing a vaccine strain, explains a research paper by CDC scientists that was published in the May 2002 issue of Pharmacy and Therapeutics. VACCINE SAFETY ISSUES A vaccine, like any medicine, is capable of causing serious problems, such as severe allergic reactions. However, the risk of a vaccine causing serious harm, or death, is extremely small, explained Beth Hibbs, RN, MPH with the Immunization Safety Branch in CDC’s National Immunization Program. Serious problems from flu or pneumococcal vaccine are very rare, she added, and patients are more likely to have serious problems from the disease than from immunization. However, some people should talk with their physician before deciding on whether to receive the flu or pneumococcal vaccine, Hibbs said. These include people who 1) have had a serious allergic reaction to a previous dose of influenza or pneumococcal vaccine; 2) have ever had a severe allergic reaction to any vaccine ingredient, including eggs, or 3) have a history of a severe paralytic illness called Guillain?Barré Syndrome (GBS). Mild problems from the inactivated influenza vaccine (“flu shot”) may include soreness, redness, or swelling where the shot was given and, occasionally, fever and aches. If these problems occur, they usually begin soon after the shot and last for one to two days, CDC said. Life- threatening allergic reactions are very rare. If they do occur, it is within a few minutes to a few hours after the shot. Signs of a serious allergic reaction can include difficulty breathing, hoarseness or wheezing, hives, paleness, weakness, a fast heart beat or dizziness, Hibbs explained. In 1976, swine flu vaccine was associated with GBS. Influenza vaccines since then have not been clearly linked to GBS. However, if there is a risk of GBS from current influenza vaccines, it is estimated at one or two cases per million persons vaccinated. “This is much less than the risk of severe influenza, which can be prevented by vaccination,” Hibbs explained. About half of those who get the pneumococcal vaccine have very mild side effects, such as redness or pain where the shot is given. Less than 1 percent develops fever, muscle aches, or more severe local reactions. Severe allergic reactions have been reported very rarely, Hibbs said. For more information about vaccines, call the CDC National Immunization Information Hotline, (800) 232-2522, or go online to: www.vaccines.ashastd.org. Spanish speakers can reach the hotline at (800) 232-0233, and those who are hearing-impaired may call TTY (800) 243-7889. For information on Medicare coverage, call (800) MEDICARE. This media background paper is available online at www.asaging.org/media. It was written by Nancy Aldrich and Cheryl M. Keyser. The lead editor was Bill Benson. STORY IDEAS FOR JOURNALISTS 1) What is being done in your local community to promote and increase the number of older adults who get an annual influenza vaccination? Given the lower immunization rates for minorities, what is being done to reach these populations? 2) Do providers in your area believe they receive sufficient reimbursement for vaccinations? 3) Do providers believe that influenza and pneumococcal immunizations are a high priority? What efforts do they make to get their older patients vaccinated? 4) Looking at the high death and hospitalization toll from these diseases, what are the costs to insurers (including Medicare and Medicaid) and society when people fail to get their immunizations? 5) Track ongoing research on FluMist to see if there is any change in the recommendations for its use, particularly for older adults. 6) An interesting sidebar might look at the process for developing each year’s vaccine supply. 7) What steps or efforts are hospitals and nursing homes in your area taking to promote adult vaccination, including using standing orders? What levels of coverage are they able to achieve among patients? What about vaccinations of staff? # # # RESOURCES FOR REPORTERS CENTERS FOR DISEASE CONTROL AND PREVENTION: National Immunization Program, www.cdc.gov/nip/ Background on Influenza, www.cdc.gov/flu/professionals/background.htm Flu Gallery: Patient-Education Materials, www.cdc.gov/nip/flu/gallery.htm Influenza: Protect Yourself and Your Loved Ones, www.cdc.gov/ncidod/diseases/flu/fluvirus.htm Influenza vaccine, www.cdc.gov/nip/vaccine/flu/default.htm Media page, www.cdc.gov/nip/home-media.htm Pneumococcal (PPV) vaccine, www.cdc.gov/nip/vaccine/pneumo/default.htm Spanish language information, www.cdc.gov/spanish/inmunizacion.htm Weekly influenza update, www.cdc.gov/ncidod/diseases/flu/weekly.htm GOVERNMENT PUBLICATIONS AND WEBSITES: Achievements in Public Health Hepatitis B Vaccination, www.cdc.gov/mmwr/preview/mmwrhtml/mm5125a3.htm Adult Immunization Programs in Nontraditional Settings: Quality Standards and Guidance for Program Evaluation, www.cdc.gov/mmwr/preview/mmwrhtml/rr4901a1.htm Flu Shot Trends in the Elderly Population, www.cms.hhs.gov/MCBS/MCBSprofiles/issue11.pdf Healthy Aging for Older Adults website, www.cdc.gov/aging/ (sign up here for the Public Health and Aging Listserv) Medicare – Fight Flu and Pneumonia, www.medicare.gov/health/FluDetails.asp Pneumococcal Polysaccharide Vaccine: What You Need to Know, www.cdc.gov/nip/publications/vis/vis-ppv.pdf Prevention and Control of Influenza Recommendations of the Advisory Committee on Immunization Practices, www.cdc.gov/mmwr/PDF/rr/rr5103.pdf Prevention of Pneumococcal Disease (Advisory Committee on Immunization Practices recommendations), www.cdc.gov/mmwr/preview/mmwrhtml/00047135.htm Public Health and Aging: Influenza Vaccination Coverage among Adults Aged >50 Years and Pneumococcal Vaccination Coverage among Adults Aged >65 Years -- United States, 2002, www.cdc.gov/mmwr/preview/mmwrhtml/mm5241a3.htm Recommendations of the Advisory Committee on Immunization Practices, www.cdc.gov/nip/publications/ACIP-list.htm Recommended Adult Immunization Schedule by Age Group and Medical Conditions, 2003-2004, www.cdc.gov/nip/recs/adult- schedule.pdf Safe and Appropriate Use of Influenza Drugs (Food and Drug Administration), www.fda.gov/cder/drug/advisory/influenza.htm Vaccine-Preventable Adult Diseases, www.cdc.gov/nip/diseases/adult-vpd.htm OTHER WEBSITES:
AARP, www.aarp.org/Articles/a2003-03-17-
vaccines/tools/printable
Links to state health departments,
www.cdc.gov/other.htm#states
Medicare Pneumonia Project,
www.medqic.org/content/nationalpriorities/topics/projectdes.
jsp?topicID=445&pageID=2
Vaccine Adverse Event Reporting System, (800) 822-7967,
www.vaers.org
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