Preparing for the Next Pandemic – VA Enhances Flu Vaccination and Surveillance Programs

by U.S. Medicine

May 15, 2012

By Annette M. Boyle

WASHINGTON–Influenza attacks 5% to 20% of Americans and kills between 3,000 and 49,000 individuals in the average year. Annually, more than 225,000 people require hospitalization for the symptoms of seasonal influenza.

The Department of Health and Human Services projects that a moderate pandemic, such as that experienced in 1957 and 1968, would cause 865,000 hospitalizations and 209,000 deaths, while a severe, 1918-like pandemic could send nearly 10 million people to hospitals and kill more than 1.9 million.

VA’s patient population includes many of those most vulnerable to the disease. With seasonal influenza, individuals over the age of 65 account for 90% of deaths, and risk rises sharply with increasing age.  Patients who are immunocompromised or have chronic medical conditions such as pulmonary or cardiac disease or diabetes also face significantly elevated risk. Among patients with cardiovascular disease who contract influenza, 50% will develop pneumonia, and10% will die.


The Wilmington, DE, VA Medical Center has held drive-through influenza vaccine clinics to increase compliance. Photo from Wilmington VA website.

Annual vaccinations provide the most effective protection against influenza and limit its spread within institutions and communities. As a result, communicating the importance of immunizing veterans and healthcare workers is a central feature of the VA’s “Infection: Don’t Pass It On” (I:DPIO) program. Annual efforts to develop new and engaging messaging have been so successful that “one poster ended up on the TV show ‘Glee’ and others have been requested by people in New Zealand and Wales,” said Connie Raab, director, public health communications at the VA.

“A very impressive 82% of VA patients over age 65 were vaccinated in 2009-2010, compared to 67% of those over age 65 in the country as a whole. For VA patients ages 50-64, 71% were vaccinated, compared to the flu vaccine rate in the United States overall, which was 41%. In 2009-2012, we vaccinated 77% of our VA healthcare personnel, and we continue to strongly promote vaccination among our health care providers,” wrote Robert Petzel, MD, under secretary of health, Veterans Health Administration in the VA influenza Manual 2011-2012. For 2011-2012, the VA “set goals of 80% for employee vaccination rates, 95% for inpatient veterans, 83% for outpatients 65 years or older and 66% for those aged 60-64,” according to the manual.

Vaccination rates in 2010-2011 were notably lower, dropping 21% among healthcare workers, which Kristin Nichol, MD, MPH, MBA, associate chief of staff for research, Minneapolis VA Medical Center, attributed to “flu fatigue” following the intensive push for immunization during the 2009 pandemic.

“Obtaining the seasonal flu vaccine each year is one of the most important interventions VA healthcare workers can take to protect the health of their patients, their colleagues, themselves and their families,” Richard Martinello, MD, chief consultant, Clinical Public Health, told U.S. Medicine. Healthcare workers (HCWs) are at especially high risk for influenza infection, he noted.

According to research co-authored by Martinello and three other members of the VHA Office of Public Health that appeared in the September 2011 issue of Disaster Medicine and Public Health Preparedness, 50% of the H1N1 influenza infection among HCWs in the first wave of the 2009 pandemic was acquired in the workplace. Because of their position in the front line of an epidemic, the authors wrote, tracking illness among HCWs may “represent a means of conducting near-real-time syndromic surveillance that may prove useful in identifying and managing future influenza pandemics.”  In addition, they noted that this surveillance mode “may prove to be a sensitive indicator of the severity of influenza and potential outbreaks of other transmissible infections.”

Preparing for the Next Pandemic – VA Enhances Flu Vaccination and Surveillance Programs Cont

DoD’s Surveillance System Helped Detect, Respond to Influenza Pandemic
The initial detection of the novel A/H1N1 influenza in the United States and several other countries resulted from surveillance networks established by the Armed Forces Health Surveillance Center’s Division of Global Emerging Infections Surveillance and Response System (AFHSC-GEIS). Viruses isolated from those cases were used as seed strains for the 2009 pandemic influenza vaccine.1
AFHSC-GEIS keeps track of emerging infectious diseases, including respiratory diseases, of concern to DoD, using a global network of partners for disease surveillance.
During the H1N1 pandemic, those partner agencies provided diagnostic laboratory training and capacity building in their home countries, adapted U.S.-approved methods for diagnosing the influenza virus in a variety of settings and helped estimate seasonal vaccine effectiveness against the illness.
DoD established the Global Emerging Infections Surveillance and Response System (DoD-GEIS) in 1997, in response to a presidential directive. Its mission was to monitor newly emerging and re-emerging infectious diseases among U.S. servicemembers and dependent populations. Over time, a great deal of the focus has been on respiratory ailments.
Respiratory infections are responsible for 25% to 30% of both outpatient illness and hospitalizations among U.S. military personnel, with influenza and adenovirus infections among the biggest contributors to morbidity and mortality in military members.
This is nothing new. During the 1918 influenza pandemic, the U.S. military experienced attack rates as high as 25%and case-fatality rates averaging 5 %.
AFHSC-GEIS provides direction, funding and oversight to a network of global partners, including approximately 500 sites in 70 countries.
AFHSC also maintains a database containing up-to-date and historical data on medical encounters, vaccinations and personnel and demographic data about servicemembers from all military services.
That database, the Defense Medical Surveillance System (DMSS), uses ICD-9 codes from hospitalization and outpatient
encounters and influenza vaccination data.
Weekly summaries track influenza-like illness (ILI) and pneumonia and influenza (P&I) for health system beneficiaries by geographic regions. That includes both servicemembers and their families.
The summary report includes electronic, medical and lab-based surveillance data from the MHS as well as surveillance data from the DoD’s overseas research laboratories and their partners.
AFHSC also receives standardized case reports of RME from all services and goes beyond the Centers for Disease Control and Prevention’s Nationally Notifiable Diseases Surveillance System. Unlike the CDC system, AFHSC requires that the reporting of respiratory illnesses that meet a clinical case definition, including sudden onset of fever >102.2°F, respiratory symptoms, myalgia and headache, and are laboratory-confirmed as influenza.

1: Burke RL, Vest KG, Eick AA, Sanchez JL, et al. Department of Defense influenza and other respiratory disease surveillance during the 2009 pandemic. BMC Public Health. 2011 Mar 4;11 Suppl 2:S6. Review. PubMed PMID: 21388566; PubMed Central PMCID: PMC3092416.

As a result, one goal for improving surveillance has been to simplify and automate communication, although there are drawbacks, says Martinello. “Electronic systems are incredibly helpful, but there is no replacement for people who have their hands in the matter.”

That personal communication goes two ways, he said. “In the Public Health Office, we may notice aberrations in the data coming from HAIISS. That would prompt us to reach out to national clinical leadership and the local facility to see what is actually going on.

“If someone at a facility has reason to believe an outbreak may be occurring, they may call us directly. If they have strong relationships with local and state departments of public health, they may call them first. We do not yet have a formal structure for that. Either way, the goal is to communicate what is happening so that our network offices, local and state public health, VA leadership and front-line clinicians know what’s being seen. That knowledge can help physicians identify whether a patient likely has influenza, indicate what tests should be done and what treatment is effective.”

Beyond identifying that a patient probably has influenza, clinicians need to know what strain they are battling. Larger facilities can send samples to their virology laboratories, but smaller facilities, long-term care and outpatient centers typically need to send specimens to labs at larger facilities or to state or local public health departments.

“If we’re seeing unusual cases, we gather resources within the VA — infectious disease specialists in the region and nationally, our public health resources and experts in infection prevention and influenza — and contact the CDC to develop plans and advise individual healthcare providers how to deal with the situation,” Martinello said.

If VA laboratories in larger centers are unable to determine the strain or subtype, “they may have an atypical strain, which is how the 2009 pandemic virus was first recognized,” said Martinello. “The test being used was unable to identify the strain, so it was sent to the CDC.”

That scenario could unfold at any time. In December, the CDC issued interim guidance for influenza surveillance to detect additional cases of influenza A(H3N2)v, a variant virus that affected 12 people in five states (Indiana, Iowa, Maine, Pennsylvania and West Virginia) in the last half of 2011. This variant appears to be transmitted primarily from swine but also has shown limited human-to-human transmission. The influenza virus is highly mutagenic, and influenza A(H3N2)v or other strains could quickly become much more transmissible.

The CDC notes that molecular assays “may give an influenza A ‘unsubtypable’ result,” even when using assays that can detect all currently circulating influenza subtypes. Alternatively, assays may give a false positive result for human influenza A(H3) virus. The sensitivity and specificity of rapid influenza diagnostic tests and immunofluorescence tests for influenza A (H3N2)v virus are unknown and may give false positives or false negatives. The CDC advises labs with unusual results or specimens from especially severe cases to forward them to a public-health department for further evaluation.

Back to 2012 Compendium

Preparing for the Next Pandemic – VA Enhances Flu Vaccination and Surveillance Programs Cont

Surveillance System

A more formal system, Electronic Surveillance System for Early Notification of Community-Based Epidemics (ESSENCE), was developed by Johns Hopkins University’s Applied Physics Laboratory and the Department of Defense (DoD) for use by both the DoD and the VA for syndromic-disease surveillance. By 2008, the VA was working with Johns Hopkins and the CDC to modify ESSENCE to better monitor emerging infectious diseases or syndromes by leveraging the VHA’s advanced electronic medical-record system, according to Gina Oda, MS, CIC, associate director of the VA’s Office of Public Health Surveillance and Research.


Ultimately, that effort led to updates to ESSENCE specifically for the VA and the development of the Healthcare Acquired Infection and Influenza Surveillance System (HAIISS) suite that could incorporate more data sets, said Martinello. Beta testing of the new system finished in the first quarter of 2012. Martinello said he expects HAIISS to be rolled out nationwide by the end of the year, “but it’s still a real work in progress.”

HAIISS now includes the HAIISS Data Warehouse as well as the QC PathFinder electronic healthcare acquired infection detection application developed by Vecna Technologies and the revised ESSENCE biosurveillance application, according to Oda. The system will be used by infection preventionists, hospital epidemiologists, infectious diseases clinicians, primary-care physicians, pharmacists and national program offices.

Biosurveillance/Syndromic Surveillance is one of the four pillars of the HAIISS. The surveillance components aim to allow early event detection of outbreaks, such as seasonal flu outbreaks or emergent pandemic influenza within the VA, and to monitor the magnitude, location and rate of spread-of-disease outbreaks at the local and national level. The surveillance system also monitors seven syndrome groups that could be associated with bioterrorism. With its refinements, HAIISS “will likely serve as a model for other national and international health care systems,” Oda noted.

New sources of data have been added to improve the system’s detection abilities. “Using the existing systems, we could find hotspots of influenza during the pandemic and make calls to medical centers to see what was going on,” said Martinello. “Starting this year, we receive call-center data daily, which gives us data on the kinds of calls the centers nationwide are getting, specifically those concerning influenza-like illnesses (ILI), where the calls are coming from, and the severity of disease reported. We can see how many are told to stay home, go see a doctor or go to the hospital.”

“With the development of ESSENCE and HAIISS over the last few years, we are in a much better position to respond to a pandemic or other events that impact public health when they occur. What we learned from the 2009 influenza pandemic was the importance of communications,” added Martinello. Effective communications help all levels within the VHA understand the situation and coordinate actions. “It also is important to have systems that don’t place an undue burden on people to communicate. It is critical to have timely, accurate data,” he noted.


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