Texas Department of State Health Services
Texas Perspective Influenza Vaccine Texas DSHS Immunization Unit Assessment, Compliance, and Evaluation Epidemiologists
Texas Department of State Health Services
DSHS Immunization Unit
Mission: Eliminate the spread of vaccine
preventable diseases by increasing vaccine
coverage for Texans, raise awareness of the
diseases that vaccines prevent, and educate the
public about vaccine safety.
Texas Department of State Health Services
Coverage Measures
Hepatitis B Birth Dose MMR Vaccine Coverage for 19-35
Coverage, 2008-2016 Month Old Texas Children, 2016 100% 100%
90% 90%80%78% 75% 80%80% 68%
70%70% 60% 73% 72%71% 60%60% 62% 50%50%
51% 40%40%
30%30%
20%20% 10%10% 0%0%
2008 2010 2012 2014 2016 US Texas City of Houston
Bexar County El Paso County Dallas County Texas U.S.
Texas Department of State Health Services
Adult Coverage
Tetanus Vaccine Coverage for Texas Adults,
2016
70%
Yes No
0%
10%
20%
30%
40%
50%
60%
Tdap Other Tetanus Not Sure Type No Tetanus
Flu Vaccine Coverage by Age Group, Texas 2016-2017 Flu Season
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
72%
60% 62%
50%
33%
6 mos−4 yrs 5−12 yrs 13−17 yrs 18−64 yrs ≥65 yrs
····O c::J ccccc ccccc ccccc
Texas Department of State Health Services
Challenges with Flu
Annual Efficacy and Belief about
Recommendation Effectiveness Disease Risk
Texas Department of State Health Services
Introduction
Texas Flu Family Grandma Flu
Mama Flu
Baby Flu
Papa Flu
Sissy Flu
Texas Department of State Health Services
Baby Flu
Profile
• 12 month-old baby
• Vaccinated
Flu Fact: Children 6 months – 4 years are the highest vaccinated age group:
• Texas: 71.9% • US: 70.0% • HP2020 Goal: 70%
the child received >2 doses of
trivalent or quadrivalent influenza vaccine
before July 1, 2017 (Doses need not have been given during san1e or
consecutive seasons)
, , Yes
+ 1 dose of
2017-18 influenza vaccine
, , No I Don't know
+ 2 doses of
2017-18 influenza vaccine
( ad1ninistered >4 weeks apart)
Child Vaccine Recommendations
Texas Department of State Health Services
Who should absolutely be vaccinated?
Groups
• Children and infants
• Pregnant women
• Seniors
• Residents of nursing homes and long-term care facilities
• American Indians and Alaska Natives
• Healthcare workers
• Care givers and close contacts of infants and elderly
Chronic Health Conditions
• Asthma
• Neurological and neurodevelopmental conditions
• Chronic lung disease
• Heart disease
• Blood, Endocrine, Kidney, Liver, and Metabolic disorders
• Immunosuppression
• Children receiving long-term aspirin therapy
• BMI of 40 or more
Texas Department of State Health Services
Who should discuss with their health care provider?
• Guillain-Barré Syndrome (GBS)
• Moderate to severe illness with or without a fever
• IIV Precaution: Egg allergy (not hives)
• With supervision of a health care provider able to manage severe allergic reactions
• LAIV Precautions
• Asthma in persons ≥ 5 years
• Those at higher risk of complications attributable to influenza
Texas Department of State Health Services
Who should not receive flu vaccine?
1. Children <6 months
2. Those with severe, life threatening allergic reaction(s) to vaccine/ingredients
3. LAIV Contraindication • Adolescents and Children: Use of aspirin • Influenza antivirals within the previous 48
hours • Pregnant women
Texas Department of State Health Services
Grandma Flu
• 70 year old, female
• Received high dose vaccine at a pharmacy
Flu Fact: In 2016, 62.1% of Texans 65+ were vaccinated against influenza.
Profile
• Vaccinated
TEXAS Health and Human Services
Texas Department of State Health Services
Flu Vaccine Types
• Trivalent Inactivated Vaccine (IIV3)
o Adjuvanted
• High-dose (IIV3)
• Quadrivalent Inactivated Vaccine (IIV4)
• Cell culture-based (ccIIV4)
• Recombinant Influenza Vaccine (RIV3 & RIV4)
• Live attenuated influenza vaccine (LAIV4)
https://www.cdc.gov/flu/protect/vaccine/vaccines.htm
Texas Department of State Health Services
Sissy Flu
Profile
• 7 years old
• Not vaccinated
• Enrolled in Medicaid - eligible to receive Texas Vaccines for Children (TVFC) vaccine
Flu Fact: Coverage for annual flu vaccine varies by race.
Race/Ethnicity 2016 Flu Vaccine Coverage
White only, non-Hispanic 44.6%
Black, non-Hispanic 37.2%
Hispanic 44.0%
Other and multiple races 42.5%
TEXAS Health and Human Services
Texas Department of State Health Services
TVFC
Passed nationally in 1994 as the Vaccines for Children Program,
our Texas Vaccines for Children Program guarantees ACIP-
recommended vaccines will be available at no cost to providers in
order to immunize children who meet the eligibility requirements.
• Texas has approx. 3,200 VFC provider sites
• 2017-2018 1.7 million influenza doses distributed
Prebook Allocation Distribution
2019 Texas Target Population (TVFC)
•Total (0-18) Population: 8,258,118
•Total TVFC Eligible Children (0-18): 4,577,748
Projected TVFC Percent of Age Age Eligible Group Eligible
0-1 285,277 62.4%
1-2 517,033 56.9%
3-6 1,000,199 55.5%
7-18 2,775,239 54.5%
18
2019 Texas Target Population (TVFC)
Eligibility No. VFC
Medicaid 3,019,202
Uninsured 795,723
CHIP 405,372
FQHC 149,538
American Indian/Alaska Native 147,719
Underinsured 60,194
Total 4,577,748
Total Flu Doses Pre-booked in 2018-19:
1,851,230 Pediatric IIV4 + 117, 420 FluMist
19
2018-19 Flu Doses Pre-Booked
Region Total TVFC Providers
TVFC Providers Not TVFC Providers
Ordering Flu/Did Not Ordering Flu
Complete Survey
% Providers Ordering Flu
Vaccine
00 (San Antonio) 152 141 11 92.8%
01 145 121 24 83.4%
02 95 78 17 82.1%
03 566 512 54 90.5%
04 163 145 18 89.0%
05 96 75 21 78.1%
06 369 322 47 87.3%
07 322 302 20 93.8%
08 161 138 23 85.7%
09 100 80 20 80.0%
10 124 104 20 83.9%
11 430 363 67 84.4%
25 (City of Houston) 305 250 55 82.0%
Grand Total 3,028 2,631 397 86.9%
13% of TVFC Providers will not be offering flu vaccine to their eligible clients in 2018-2019
2017-18 Flu Doses Wasted/Expired
33.6% Vaccinated
2,991,649 Missed opportunities
1,513,326
Doses Administered
1,831,890
Doses Ordered
4,504,975
TVFC Eligible Children
Texas Department of State Health Services
Mama Flu
Profile
• Vaccinated
• 31 year old, female
• Works in health care facility
Flu Fact: Adult women (34.5% 95% CI:31.8-37.4%) are more likely to be vaccinated than adult men (31.8%; 95% CI: 29.1-34.5%).
Texas Department of State Health Services
Type of Employee Influenza Policy, Texas
Policy Type 100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
54%
38%
5% 3%
Mandatory Recommended Combined Unspecified
Mandatory Requires dates of immunization or laboratory evidence of immunity.
Recommended Recommends but does not require immunizations for employment.
Combined Designates employees in specified areas as required but only recommends immunizations for others.
Location of Flu Shot Receipt, .All .Adults, 2016 Texas BRFSS
Health and Human SNvices
Te,as Department ofState Health Sen,lces
Clinic or Health
At Work Center 12°/o 12°/o
Doctors office 34°/o Store 30°/o Hospital 9°/o 1 0/o
Texas Department oJ State Health Services
Papa Flu
Profile
• Not vaccinated
• 38 year old male
• Covered by Adult Safety Net (ASN) but…ASN does not offer flu vaccination
Flu Fact: Coverage for annual flu vaccine varies by insurance status.
2016 Flu Vaccine Coverage
Insured 37.8%
Uninsured 19.2%
Reasons for not getting flu shot, 2015 Texas BRFSS
Health and Human SNvices
Te,as Department ofState Health Sen,lces
Believe that
Unlikely to flu vaccines do not work
get very Other 8°/o very well 7°/o Did not have time sick from 19°/o the flu
Cannot Do not
12°/o likeafford it Sideshots
Concerned 7°/o effects
about 5°/o 4%
getting the Do not Do not
flu from the trust
Never get the flu vaccination need the Allergic/C govern
ontraindic ment...
18°/o 9°/o shot 6°/o ation 40/o 10/o
Texas Department of State Health Services
Safety
Texas Department of State Health Services
Safety Monitoring
• Vaccine Adverse Events Reporting System
• Vaccine Safety Data Link
• Clinical Immunization Safety Assessment
Texas Department of State Health Services
Option 1 • Report Online to VAERS (Preferred) Submit a VAERS report on line. The report must be completed onllne and submitted in one sitting and cannot be saved and returned to at a later time. Your information will be erased If you are inactive for 20 mlnutes: you will receive a warning after 15 minutes.
DSHS Vaccine Safety Role
• Encourage providers to submit directly to VAERS online
HHS VAERS website: https://vaers.hhs.gov/
• Facilitate reporting to VAERS if receiving paper forms
• Facilitate follow-up on specific cases
• Gathering death certification, autopsy reports, etc.
• about how and what to report Respond to questions from the public and providers
Texas Department of State Health Services
Education, Awareness, and ImmTrac2
Texas Department of State Health Services
Public Education, Information, and Training Activities
• Printed educational materials https://www.dshs.texas.gov/immunize/flu.shtm
• Media Campaigns • Radio
• Television
• National Influenza Vaccination Week
Texas Department of State Health Services
The Emily Lastinger Story Emily was a liltle kid who got Ille flu.
U n Wednt"sday. January 28. 2004 threc-ytar-uhl Em:ly Lastinger took a long :13p 3.nd began to ,ho·N signt th.al she wa.; gtttir.g skk. Strep throat vr,u goi.ngaround in her pteschool. her pare-nt5 kept hc1: home a:ld took her to see :te:-doctor to 1r.:1kc .sure she was ok. Aftc-.r running some tests the doctor detcrrnin~d ~he had the flu.
The doctor g:3.vc Er.'lity a.nti·Yiral medication to Jes.sen tbe severity ()( 1ht ill nN~ . HM p:u~nr.~ w?rt' mlcl It) gtw htr p1tn1y off!uic1~ a n,1 keep 11n eye on her fc..,,er.
On that J-riday. :i.nd over the •Neckcnd, ~mily got skkc-r. Her ic!vcr ~pikt<l. sht· bc:-gan tu vomit. kt:pt on \'omiting. and she hat.1 uoubli: holdi ng down fluids.
On Monday momrng, February 2, ~ 1ly's p3rcnts made a JO\'.tor's appoinlltX:111 fut· later that day. When they ca] ed 1hey ~,'ere mid rn5tw• F.mi'y Onid~ f'vf'~y l 'l ltli nm,~i unril ~hf' go1 ro1 h.~OOt1or·s ofu.
Emily had o bath, ~ot dre=d -~he wa~ read;t to gu to Lhe Joctor. \\rhile sh<' waited, :;he lo.id dm.,.n on htJ pa1cots' bc:d to resl ;,nJ watch tcle\'ision. Hftcen m:nutes l:Hn·, sht' Wli lifeles~ .. As soon as her parents found her they b•gan CPR.
f-orty.fi,rc m:nutes later in the cmerg<'nc-y room the doctor.; were able rn g,-,r h.~r NY,lrr M:i m"Ct lht"y s.~.,, hM t-> the loc1l children's trru.uno. center for � ure trcallncnL Pur LWdve hou:s, t:ic doctors :ll the renttr tried to fulty
Flu Mail-Out
• Required by House Bill (HB) 3184 of the 80th Texas Legislature
• Mail-outs to 15,000 childcare facilities
• Scheduled for Sept. 15th
Included
• Flu brochures in English and Spanish
• Influenza fact sheet
• Child-care provider and employee letters
• Required vaccines for childcare (does not include flu)
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TVFC Score Card
Goals
• Increase vaccine coverage
• Decrease vaccine wastage
Plan
• Send to all TVFC providers each month of the flu season
• Include provider-, county-, and state-level data on ordering and coverage
Texas Department of S_tate Health Services
ImmTrac2
• Texas Immunization Registry
• Bi-directional capabilities January 2018
• Evolving data quality improvements
• Re-vitalized push for adult consent via
emergency responders
Texas Department of State Health Services
HURRICANE EVACUATION
ROUTE
Hurricane Harvey Response
• Stood up immunization response
team
• Coordinated with SMOC to fulfill
vaccine requests
• Courier service to affected sites
• Total Flu Doses Sent: 7,690
Texas Department of State Health Services
Take Home Message
The flu vaccine is safe and protects
you and your family!
Immunization Unit flu vaccine
resources are readily available to help
you educate and protect Texans!
Texas Department of State Health Services
Questions?
Lauren Hoffman, MPH Jessica Cheng, MPH
Texas Department of State Health Services
Extra Slides
Texas Department of S_tate Health Services
Option 1- Report Online to VA ERS
IPreferredi
5ubrnll a VArn5 rEp�l" t on rne. T 1e re1X1rt must be co mple:cd onlinc, and submitted h one aitt i,1g
and ca1r,o : te saved and retur1Ed to a: a later time. YD111· infDrr.1ation ;,,· ill be e rascci if yoc are
in.,ctiv,, ' ,v ?llrr i111JtP<· w, , .,,, ill r<>c<>iV",
VAERS
Strengths
All U.S. states and territories
Data on the vaccine, the recipient, and the AE
Data is publicly available
Early warning system to identify rare AEs
Follow-up with patients to obtain health records, when necessary.
Limitations
Cannot determine causality
Cannot assess prevalence in the general population
Reports often lack details/contain errors
Serious AEs are more likely to be reported than mild side effects
Reporting may increase due to new recommendations and media attention.
Texas Department of State Health Services
Vaccine Safety Datalink
• Electronic Health Data
• Vaccine type, date, and co-administered vaccines
• In-patient, urgent care, and ED visits, hospital stays
• Purpose:
• Conduct studies on rare and serious adverse events (AEs)
• Monitor safety of new vaccines and recommendations
• Investigate issues submitted in VAERS or the medical literature
• Provide information to committees
Texas Department of State Health Services
CISA (Clinical Immunization Safety
Assessment)
• Clinical Case Reviews
• Expert Evaluation of Vaccine Safety Issues
• Research
• Well suited to study more common, non-medically attended events (e.g., fever) and to collect biological specimens after vaccination.
• CISA investigators also have access to special populations (e.g., persons with autoimmune diseases) and specialists who care for these patients.
• Public Health Response
Texas Department of State Health Services
Safety Q&A
Pregnancy
• Any trimester.
• Protect Mom + Protect Baby.
Febrile seizures
• Vaccines can cause fevers.
• Febrile seizures are rare after vaccination.
• Getting sick with the flu also can cause febrile seizures.
Thimerosal (Mercury-based preservative)
• Contained in some multi-dose preparations of flu vaccine.
• Today, breastfed infants ingest 15 times more mercury in breast milk than is contained in the influenza vaccine.