Seasonal and Pandemic Influenza Preparedness

US Department of Veterans Affairs

Lawrence Deyton, MSPH, MD Chief Public Health and

Environmental Hazards Officer

VA Medical Care

The largest integrated healthcare system in US

• 158 hospitals (18,828 beds, 5.4M BDOC)

• 132 nursing homes (33,408 ADC)

• 73 home care programs

• 43 domiciliary programs

• 206 veterans counseling centers

• 854 clinics (50 M outpatient visits)

• 186,600 employees (VHA)

Fiscal Year 2004 – VHA Statistics

• 7.5 million total enrollees of 25 million US veterans

• 5.5 million patients treated

• $30 billion total budget

• 200 million 30-day equivalent Rx’s dispensed

• 190 million lab tests performed

Who Are VA Patients?

• Older - 49% over age 65

• Sicker - Compared to Age-Matched Americans

– 3 Additional Non-Mental Health Diagnoses

– 1 Additional Mental Health Diagnosis

• Poorer

– 70% with annual incomes < $26,000

– 40% with annual incomes < $16,000

– 31% have no health insurance

VA Seasonal Influenza Vaccination Program

• Influenza prevention is a public health priority for VA

• Annual Under Secretary for Health Flu Directive– Communicates priorities, implementation issues, clinical

issues

– Flu vaccine coordinator appointed at each facility

• National vaccination campaign launched each Fall

• Flu vaccine resource toolkit distributed

• Flu vaccine supplies purchased/distributed

• Flu vaccine Performance Measures established and monitored

VHA Flu Directive

• Written and published annually

• Uses annual ACIP/CDC influenza vaccine recommendations

• Provides VHA policy and vaccine implementation guidance

• Covers patients and VA staff

• Provides documentation expectations

• Provides contacts for implementation of influenza vaccination program, legal issues, and questions on influenza/influenza vaccine

VA’s Flu Vaccine Purchases

Year Doses Purchased

1998 986,530

1999 1,163,250

2000 1,461,280

2001 1,841,760

2002 1,587,250

2003 2,049,750

2004 2,070,790

2005 estimate 2,225,470

VA’s 2004-2005 Flu Vaccine Utilization

• As of April 6, 2005

1,874,176doses used for 2004-2005 season

(91% of total doses ordered)

Annual Flu Vaccination Rates

2003-2004 2004-2005VA Rates – age 50+

Clinic chart sample 70% 75%Self-report/survey 71% 78%

Source: VHA Office of Quality and Performance

Non-VA RatesAdults in US – age 65+ 68% 63%

Phone surveySource: National Committee for Quality Assurance

Medicare population – age 65+Survey 74% 75%

Source: National Committee for Quality Assurance

Commercial insurance plans – ages 50-64Mail/phone survey 52% 28%

Source: Centers for Disease Control and Prevention

VA Annual Flu Vaccination Program

Influenza - http://www.publichealth.va.gov/flu

Wide dissemination of general and clinical information• VHA Directive: Influenza Vaccine• VA Influenza Vaccine Advisories• Messages, articles on flu vaccination

Focused dissemination to 8 categories of flu vaccination programs staff• VA Influenza Toolkit, 2005-2006, and regular bulletins

Manual– Strategies for Improving vaccination rates of health care workers and patients– Frequently asked questions (flu, novel/pandemic flu, eligibility, vaccine

storage and usage) – Resources, references and Web sites

Materials – Vaccine information statements (VISs)– 27 posters - Influenza vaccination, infection control, hand and respiratory hygiene– Buttons for health care staff, stickers for all who get flu shots

VA Annual Flu Vaccination Program

Goals for VA’s 2005-2006 Influenza vaccination program:

• Increasing the vaccination rates of healthcare workers and all personnel at VA health care sites

• Maintaining or increasing vaccination rates of veteran patients

• Providing vaccination against pneumococcal illness where indicated.

• Promoting non-vaccine methods of preventing infection through hand and respiratory hygiene (the VA “Infection: Don’t Pass It On” campaign)

• Involving all staff and providers in promoting influenza vaccination

VA Pandemic Flu Preparedness

• Annual Influenza Vaccination Program– Under Secretary for Health’s Flu Directive

– Resources to enhance vaccine uptake

– Performance measure

• Oseltamivir Stockpile

• Oseltamivir Stockpile Use Plan

• Oseltamivir-Probenecid Study

• Respiratory Infex Disease Emergency Plan

• VA National Pandemic Influenza Plan

Oseltamivir Stockpile

• Fall 2004 – VA purchased 5.5 million capsules (550,000 courses) of oseltamivir

• Quantity based on supply needed for– Treatment for 550 patients and staff and

– Prophylaxis for 5000 patients and staff

• At 40 of VA’s 157 medical centers = 25% coverage

VA Oseltamivir StockpileUse Plan

• Stockpile divided in 7 geographically diverse locations

• Plan to coordinate distribution with CDC/DoD – Depending on epidemiology

• Geographic targeting for isolated or limited outbreak/control

• Widespread distribution for treatment and prophylaxis

• VA will act to protect veterans’ health when needed– Prefer to work with CDC under the cooperative model

of last year’s flu vaccine shortage

VA Oseltamivir-Probenecid Research Project

• Oseltamivir is made by one non-US drug company – there is a worldwide shortage

• VA Public Health and clinical researchers have initiated a study of co-administration of oseltamivir with probenecid

• Hypothesis: probenecid will slow the elimination of oseltamivir resulting sustained therapeutic levels

• If successful, co-administration of oseltamivir with probenecid could extend the effective supply of oseltamivir potentially doubling or tripling supply

• IND approved; VA funding approved

• Study is underway

Respiratory Infectious Disease Emergency Plan

Instructions to VA facilities:• Preparations/planning needed• Pandemic responses• Follow-up actions post event• Areas of Preparations/Responses:

– Communication– Education– Staffing and Human Resources– Environmental, Facility, and Equipment– Patient Care Management

VA National Pandemic Influenza Plan

• Describe how VA will protect employees and veteran patients, maintain operations, and work with other agencies

• Help VA employees establish and implement pandemic flu-specific emergency procedures

• Help VHA, VBA, NCA leadership at national, regional, and local levels support employees and functions at all levels and sites

• Intersect with COOP plans, National Response Plan, NDMS, VA’s missions

Developing the VA Pandemic Influenza Plan

• Lead: VA Public Health

• Working Groups– Patient and Healthcare Delivery

– Infrastructure Support

– Communications/Public Health Community Partners

– Workforce/Occupational Health/Unions

– Education

– Tabletop Exercises

Ongoing Activities

• Non-vaccine preventive measures encouraged in a national campaign:

Infection: Don’t Pass It On

http://www.publichealth.va.gov/infectiondontpassiton

Pandemic Flu US Government Strategy

• President Bush – Nov 1, 2005

• Three Pillars of US Govt Strategy:

• Preparedness and Communications

• Surveillance and Detection

• Response and Containment National Implementation Plan for Pandemic

Influenza (currently in draft) will flow from the National Strategy

VA Role in National Plan

• White House Homeland Security Council leading development of National Pandemic Flu Implementation Plan from National Strategy

• VA is one of 5 Federal Agencies asked to draft Natl Plan (with DHHS, DHS, DoD, DOT)

• Public Health SHG backup and leading development of VA-specific response plan

Agency-Specific Plans

The President has charged that Agency plans:• Be operational

• Protect employees

• Maintain continuity of operations

• Communicate with stakeholders

• Support US Govt efforts

2004-2005 Flu Season VA’s Response to Shortage

• September 30, 2004: Annual Flu Directive released

• October 5, 2004: CDC announced shortage due to possible contamination at Chiron plant. – Assessed VA purchase: 100% purchased from

Aventis Pasteur – Expected shortage: 2003-4 season, of those who got

vaccinated, 38% from extra-VA source– Most of these expected to come to VA for vaccine– Entered discussions with CDC and Aventis Pasteur

to assure a vaccine supply for VA

2004-2005 Flu Season VA’s Response to Shortage

Seven Under Secretary for Health “FluVaccine Advisories” issued October – February

• Established priority groups to receive vaccine• Defined “hands-on” health care providers• Provided contacts for questions• Provided status updates of vaccine supplies• Clarified VA’s relationship to state/local health

departments • Recommended appropriate use of antivirals• Redefined priority groups (CDC definitions)• Pushed for late vaccination due to flu epidemiology

2004-2005 Flu Season VA’s Response to Shortage

• Constant two-way communication between front-line and VACO– Ascertained remaining supply at 3 points in time

– Recommendations re: redistribution to best meet VA demands

– Handled a myriad of questions – FAQs posted

– Regular updates on Friday calls, VISN Director and CMO calls, NLB meetings

– Assisted with Congressional/advocacy/press inquires

• Regular contact with HHS/CDC on VA issues