Everybody forced here ripping 22 23 op chi hockey hobby eight box number two random teams You can find the results anytime a late sports cards calm. Let's go ahead and get started Yeah, seriously gilly everyone's ripping. Is anybody even ripping 18 19 prism now that the Brock's prices go up just because they announced bounties Like I'm guessing that's what happens Also, what if the thing is just been pulled and like the person pulled in just doesn't want to say We ever considered that What's it about that? I know we have some in the back. We've been using it for like mixtures and stuff I don't know how much we have it's not a lot. You'll see it in our mixers here and there Yeah ship to Canada. Yep Free shipping worldwide. You're just responsible for any import taxes tariffs fees duties, whatever it may be Larkin pink number to 17 to 75 red wings Shand and I want to see uh, I'll see some more variations this time No way Dude, what's up? What are you doing here, man? Johnson's it a Ready to check what variation is this? Which you a man go into that baseball game after this my brother's plan Is variation Outdoor retro no pregame no I don't know what variations it is variation Yeah, we're just talking about a baby break what if we're using your other car we have your first bowman would that be great? What if he's in that product? Not even gonna be able to forge your own boxes, dude Imagine if my car's in like a crazy expensive box No reason I took off it's our freakin Tom Brady of all people of all people Also, I'll sound like we really cool.   Yeah, I'm doing more you can get more on this one tomorrow. Yeah, I'll be like a whole band essentially Popple Zaka Marco Rossi Markey rookies wild Is it a headshot? That's what I thought it was because it's not as full body But yeah, I but it wasn't like straight up just his heads all the okay Lucas Reichel in the rookie there. We've got a rookie premier Jack Quinn there you go Sabres or you go Carl Ryan Lindgren Rangers 49 of 100 Retro black every single variation has that same back Rhino Riley Marco Rossi again Kenzie blackwood on the blue Pax pop open which is nice call grand. We've got a Dylan Sandberg did 350 jets Markey rookie foil rainbow foil You go jets This is pretty solid stuff for what the boxes go for Yeah, I did I don't know enough about the throwback jerseys. It's a variation regardless Red Killorn again reds are one every 18 packs of one at one a box in theory blue one every three Kim Talbot Lucas Reichel retro Yeah, that's fine, can you put them on like top though? Yeah, I got you was the original senators over. Thank you Carl Carl what doing the detective work right now? Jack Quinn on the rookie there March and Queen Queen of Clubs. No blank backs blank backs are one-of-one, right? Trayfix Walansky control premier rookie Shane right for the Kraken Blank backs are one-of-one, right? Let's pull a blank back Matt veneers Matty veneers Maybe we'll hit one. It's not impossible. It's tough though We did hit a pretty plate of Duncan Keith last break. So we did hit a one-of-one of some sort Two of spades on the keller Tarasenko Rangers looking scary now Rangers looking good Isimot, Aho, Krider Blank back red borders to there. There's so many different variations in this and it really is like the Gypsy Queen or like the Like the heritage of hockey An older product or an older to themed product God Stamco is black to 100 there you go lightning 44 of 100 Derek Grant There's more OPG on Sunday affordable hockey 20 bucks a spot Macelli, Marchand, Kivranta, oh March or so Did you really Carl? All 600 cards? Good Lord. I went through a lot and I was like, all right I pretty much just went to the rookies Premier Lindholm a Corsak. There we go. There he is Wildwing Joker card Blue Kam Talbot because Manko we've got Claude Giroux for the Senators at 350 Rainbow Claude Giroux to 350 Senators. Senators having a great break here numbered Claude and a Kachuk variation through two boxes. Or is that a Norris variation? That was Kachuk. I was like, I know his team. Red, Morgan, Geeky. The deck would be pretty cool to put together Lauko, Markey, Rookie Kolea Shonok for blue for the Yotes a Dylan Sandberg Kolea Shonok. Kolea Shonok. I think that's I think that's what Jeremiah said, right? Hunter Drew blue Kulzin, Rookie Premier, Slavkovsky Nice one Canadians He was number one. Spence with a printing plate for the Bruins, Pablo Zaka Wow, two breaks, two printing plates all in one case You know Zaka's been a pleasant surprise this year. Thank you, New Jersey Devils for that guy Oh, look at that. We got a blank back as well.  Montreal Holloway Rookie Premier for the Oilers Geez man Tell you man. There's this stuff is cool Chase Pearson, Couturier, Markey, Rookie, Matt Boldie There he is for the Wild Carlstrom, Sway, Pasta. There he is. There's our guy Pasta Signing in the new McDonald's when they released you think that would be a massive card. I Don't even know what that means Lewis. Hey, Bortalo. We've got Premier Rainbow William Neelander for the Leafs the 99 Premier Marner, Bukenevich, Hummin. We got Blue Mitch Marner Yeah, seriously Carl. You get some numbered rookies in this or that'd be pretty damn nice There's some good names in this one too Six of Spades, Barzal, Bifield Gully, which Disney cards are you talking about Mike? Trading card game isn't out yet, is it? Vice-Forts? Poglinder, Bailey Jekich? I don't know how to say that name. Lucas Raymond on the black Six of 100, Red Wings. Oh Brody James. I read that wrong. Yeah, that'll be a big card I don't know about I don't know how big but that's a big card For sure for sure So I read that wrong. That's my bad Lewis. That'll be a big card. Yes. That's Brawny, right? Yeah, that's Brawny. Yeah, it's a big card I would consider that massive especially out of that. It's his first autos. Yeah Dylan Dube at least said like circulation that you can pull out of a pack. So therefore they're his biggest autos so far I know nothing about him Mike. If anyone know anything about it, it's Caleb at late in gaming He'll be live tonight. It should be live now, right? Clayton Keller, Yotes Pink number 51 of 75 Yeah, we have a gaming channel Like a TCG channel Reggiano want to drop a link for I guess twitch or the youtube or just a website Yeah, we actually have someone that might know that would probably know way more than me Which would be any any amount of knowledge? Dylan Holloway on the Markey rookie retro Knowing more about that would be knowing any amounts about it than me A Holloway blue rookie now for the Oilers Dostal Jack McBain Lafreniere Jack Hughes hated diamonds Abrazysy Hayskinan Carlson Raquel Moncomon, we've got a mad so guard at 350 for the senators Markey rookie rainbow foil Go sins Yeah, man, they got a whole deck they got a whole deck ace of spades gotta be pasta, right? That's probably it's gotta be right. That's probably uh, tell me how He only got 11 million a year. Is that a lot? Yes, really? Yeah, he's like he's like top four AV right now. Maybe he's probably higher That's a lot That's like a role player in the NBA. Yeah, yeah, dude. Yeah, exactly. And that's like that's like, uh It's like window Carter jr. Yeah and like in MOB it's like It's like good like a pretty good reliever or like a bad starter. Yeah Or like a utility a utility a man I don't want to see rock bullets better than a starter It's like an Andrew Benintendi, but like not as good Yep, it is like that, which is crazy You're in the right sport Blake for the for the big dollars I think David. Yeah, I know make David was but a blue folk Lindholm Come on one of the one of the variation here You drop a link for Bowman and section Gunther we got sender's uh black alex de brinket. That's like a zack excellent contract 27 100 If zack definitely got a long-term deal that would have been like So weird Two of clubs farabie jacob chikrin a riley walsh orlaw. That's bobby orlaw right there Bobby or ever since he got to the Bruins. He's bobby orlov See you man. He's all right. Have fun tomorrow night. Thanks. See you man. Ten of diamonds lukas ramens I wish you would let us know Especially during the most base heavy break that i've done in weeks a matt murray like this is more than Like a tops jumbo because top jumbo is just like 10 packs Shock. Oh marky rookie black Nice no accades to 100 for the flyers Bailey omdeo Rock me. I'm a deal I'm a deal 14 to go bowman inception half case everybody coming up in a bit matty baneers Sorokin red ilia colgren a zack haze night's blue rookie burgeon No variation. Come on. I'm trying to will it in here uh sort of blum Riley putzolkin jacob Stamkos calorn hollander blue panarin yanni gourd pens black afgani mulkin 49 of 100 the retro the brusque pink shabbat for the senators to 75 30 of 75 silphburg you got a um trophy a steve iserman master masterton trophy your red wings manufactured relics steve y codry premier rookie no accades flyers good no accades box from the flyers all no accades for you what up smack all right y'all four more boxes here also if you want to like get cards and sort them this is a good box to rip this are like a tops jumbo or something or a hoops you'll end you got pink romanoff for the islanders the 75 islanders the mellow Yeah, they do they do crawl next year. They'll have it next year. They'll have it daleen red everlee the kraken aunty ranta ratcliff mirazic doomalyn tricidal a colt kepke it's at 350 marky rookie rainbow for the bolts she cos perot blue the ducks marky rookie vlasik vlasich kastelik dylan cousins in the blue austin matthews cousins blue is nice demko ferribi to clubs corner garland gunther premier rookie maddie baneers with a kraken a pink karmic michael caps 30 of 75 hey guys let's get bowman inception baseball filled up coming up in a bit we got a uh allen and get your chrome case after this we're gonna get some baseball breaks filled up holland or a rookie premier kane guli or gul or gula the montreal the elsky tenor hearts more its cider hey guys checklists are just gonna be randomly put in for certain teams just checklist cards i'll start kachuk goudreau five of diamonds jackets david perron maddie baneers on the rookie ryan poling blue philip chidl chidl it's a chidler chidl jordan harris premier rainbow it's a 99 andre vasilevsky lightning 85 out of 99 there premiere brady kachuk vtak vanechek calling white peterson briley walsh we've got marquis rookie black lukas dulstall for the ducks 44 of 100 best hockey player right now is uh connor mcdavid tenor diamonds lukas raymond what's up joshua paledge blue ryan strome jake sanderson clark criter drivesdale it's connor mcdavid uh skip skip skip a lot and then it says a few other guys skip a lot of space and there's a few other guys the tricidal pasta matthew's mckinnon mccar's a lot of guys there but a lot of guys in that range yes sir what's up josh how's it going matt sogaard ryan o'reilly nikolai illers you know the name connor mcdavid that's that's good he's gonna go down as the top five player ever when it's all said and done hues dimstutes of blue paul mary eric carlson best player this season zack haze pink tomasino nashville 33 to 75 got a um puzzle bounty here op number six that's a random at the end to everybody dry sidle dude completing one of those would be cool get like a nice auto or low numbered card uh colea colea chanok colea chonok colea chanok i don't even know phiala chase pierson no kates trevor zegras keppke aho queen of diamonds kempi i don't know he had that many points that's pretty wild he's having such a good year david pasta atkinson everyone thought he was cooked too dostal sod balsers jesson whole leafs 72 of 100 in the black de angelo everyone's favorite player tony de angelo hollaway a five of clubs jason robertson slavkowski rookie peterson troy terry come on now we won't we only had two one-on-ones this break so far we need some more i can't believe that was back to backpacks too yeah that was pretty wild premier spechnikov alias linholm i might have to pick up a box of this stuff uh roose tenis spades zegras ryan o'reilly come on variation taba greenway mantha roe rookie a nice colea chonok to 350 yachts rainbow marky rookie there christensen rad leckinen for the uh for the abs let's start hurt my hands like my ring and pinky finger just holding cards the whole time blue sow guard there's a lot of cars man need to do more strength training for breaking clearly i'm not i'm not i'm not in shape show up the spring training out of shape oh yeah 13 on bowman inception then 24 and 23 the division's case has won let's get bowman inception filled up guys 13 to go i'm the first one which is number 14 two more boxes here i know i haven't seen this mac pustin and jack uh jack of hearts is jack eichel of course he's a jack we got a rainbow foil platinum preview matt boldy nice rookie for the wild grads wild hay skinnin olivson jack quinn rookie pink uh year check for the jackets 56 to 75 sanski a caprisov outdoor variation outdoor game variation carol caprisov that's awesome man that's a really cool one uh hay skinnin luchich tim omeyer hunter drew related to nancy drew or steven drew uh regenda mcdavid mcdavid premiere is nice hay skinnin johnston tristan yari nine nine of clubs tyler tifoli and so premier rookie lucas rickle hawks boon jenner kocher kov brodeen hoaglander marky rookie mclaughlin kevin haze flyers 24 of 100 seven of diamonds copetar four goals in a game recently criter jack hughes and the all-star blue kale macar lasik tulvinan jordan spence marky rookie i hope so snipes i hope so i feel like it's going so fast for you to like take in rookie premiere jake sanderson for the sins at least like 45 on these i think so i can breathe in between yeah uh sanderson seven of clubs jordan everleaf for the kraken philip forestberg yeah good guy illegal over here lucas rickle patrick hornvist can't believe illegal hit that car is still such a mull we were talking about earlier today like value it's it's pretty wild oh we've got a matt boldy the 350 wild dude congrats wild also in the same box had that rainbow foil uh platinum from preview congrats wild nice boldies hey what's up sin sinister we have another sin victor that comes in so uh marco rossi uh you follow legal dude you don't let go peachy i'm enjoying this this is definitely a sometimes things like this are a better person or have them like uh watching for a group break out to be fair if you're in it it's cool but since there's no like there's there's some relics here and there but like the manufacturers there's not really like hits so i get it i get it but this is cool stuff though but hey i think we all i think we all wish i think we all uh blue mc david all star there he is there he is like shiny oh you want chrome cards well pg platinum comes out soon ish i'll say ish because does anyone really know an upper deck products come out now excuse me slup kofki uh slup kofsky ketchup six of clubs for the sins uh scott lofton one of 100 flyers yes nice well man grass on the plate sid blue nick richie dude i can't believe the richie brothers got traded for each other what in the hell what a weird day it must be for them uh roose we've got a tom wilson a 350 for the capitals the rainbow oh lotton okay i was wondering i was like he's a lofty or lotton good old english language cold kept key rookie for the lightning on the blue year check marquee another puzzle piece here so it's random to everybody at the ends number seven this time rookie premier matt boldie for the wilds yeah legal they do the lpg platinum has some of the cooler chrome parallels that event of any chrome product there is have you seen the sunset aqua aquamarine ones they're fire they're a fire yeah definitely as far as i chrome parallels go like it's sick uh hapus lindholm brodean i just uh brodean black 72 of 100 for the wilds what do you say his name henry okay harju what do you say that name yeah violet pixel sick year check ten of clubs boldie there we go darth of later darth dan darth dan vladar ruins legend tracy premier rookie braden schneider rangers spencer knight yoki haru boldie rookie again voleno blue kairu yoki haru marchesaw premiere petterson i wish i was home to watch hockey at night so i could hear these names said out loud rather than having to watch it on a mutant tv and see cards of them blue uh samuelson pk they'll also be easier to learn now that we're actually breaking hockey more consistently gmo adam larson kraken 27 to 75 oh and power red brandamont tour for the panthers big z puzzle bounties the random it's a real full case of this you'll theoretically get four of these i think we're right on odds with those okay two uh puzzle bounty cards we have was it six and seven so top spot's gonna get number six second spot on the random gets number seven everybody's in on this one good luck five and four nine times i get in top two teams here one two three four five six seven eight and nine so knights and capitals knights get the well six and the caps get the seven knights caps knight cap quick recap here variations i'm guessing this is a headshot variation of kachuk or it's a throwback jersey i think is what carl was saying i believe it's the the throwback though the other way it's a variation uh then we had the outdoor game for carl copresa for the wild do wild crush this break we had the um rainbow marquis rookie matt boldie wild on the um opc platinum preview uh the 350 now we had capke soguard jiru for the senators tom wilson uh coli it's an ox for the yachts boldie for the wild again there dylan samberg black to 100 lingren the brinket lucas raymond steven stamcoes rodin sagin um lotton dostal kevin haze justin hall gino noa kates to 100 as well uh vast less get a 99 and newlander to 99 pinkster to 75 clayton keller thomas shabbat adam larson romanoff tomasino yurichek mick michael larkin printing plate one of one for the bruins paul zaka steve y on the masterton trophy and one of one david savard blankback and that will do it thanks again everybody on to baseball


Hello everyone, I'm Doris McMillan, and welcome to the Center for Medicare and Medicaid Services Flu and Pneumonia Immunization in Nursing Homes Satellite and Webcast Program. The purpose of today's broadcast is to educate and inform regional office and state survey agencies, surveyors, and all interested healthcare providers and suppliers on flu and pneumonia immunization in nursing homes. Over the next two and a half hours, you will see and hear discussions on disease burden in nursing homes from influenza and pneumococcal disease, current nursing home immunization rates, myth and real life stories from a clinical perspective, administration and reimbursement from a carrier perspective, how to implement a flu and pneumonia immunization program, ACIP statement and implementation of standing orders programs, success stories, CMS CDC's approach to improving vaccination rates, and an introduction of proposed investigative protocol for influenza and pneumonia for surveyors. Our presenters will include staff from CMS's regional and central offices, CDC and field experts. At the conclusion of the presentations, we'll have a live Q&A session where youth of your will have an opportunity to ask our speakers questions on their presentations. I would also like to inform you that this broadcast is also being webcast simultaneously and can be seen up to one year following this program. I'll give you the website address at the end of this broadcast where you can view this program. Now that I have told you just a bit about what you can expect today and before we get into the presentations, I would like to have Dr. Stephen Jenks, Director, Quality Improvement Group, CMS, to welcome you to today's program. Hello, and welcome to this satellite broadcast on flu and pneumococcal immunization in nursing homes. I'm Dr. Stephen Jenks, Assistant Surgeon General in the United States Public Health Service and Director of the Quality Improvement Group at the Centers for Medicare and Medicaid Services, formerly the Health Care Financing Administration. We are collaborating with the Centers for Disease Control and Prevention and with others in producing this broadcast. I'm pleased to welcome surveyors and others who are committed to the care of nursing home residents to this broadcast. Our purpose is to tell you about the urgent need to immunize nursing home residents against both influenza and pneumococcus, to advocate a specific strategy to achieve high levels of immunization, and to give you an advanced view of interpretive guidelines that will define immunization as a standard of care. Each year, thousands of nursing home residents die of influenza and or pneumococcal disease or complications such as heart failure. Many of these lives could be saved by appropriate immunization, but about a third of residents do not have that appropriate immunization. Some of this failure results from inadequate understanding of the importance of immunization, but most of the failure results from systems of care that cannot produce consistently high levels of immunization and immunization for every resident. Our speakers will talk about the size of the problem and the need for action. In this telecast, we will also discuss an important strategy for saving lives in nursing homes, a strategy called standing orders for immunization. By standing orders, we mean an established policy under which staff immunize residents without a physician having to remember to order that immunization for every single resident. The policy can take different forms that reflect local laws and policies. In October of 1999, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommended standing orders as an organizational strategy for immunizing adults. The Task Force on Community Preventive Services and the RAND Corporation's Healthy Aging Report also strongly recommend standing orders. Standing orders are a low-cost, sustainable and effective strategy, but they are not yet in general use and many residents remain unimmunized. Our speakers will talk about standing orders and how they can be implemented in real life settings. Finally, our speakers will discuss proposed changes in the interpretive guidelines for nursing home surveys. Those changes will define influenza and pneumococcal immunization as a standard of care for nursing home residents. We very much appreciate your taking the time to participate in this broadcast, and we hope for your help in giving nursing home residents the immunization protection that can save their lives. Thank you Dr. Janks. And now we're going to hear from Dr. David Satcher, Surgeon General, US Public Health Service, with a short message. Greetings. I'm Surgeon General David Satcher. Did you know that there are over 17,000 nursing homes in the United States and 1.6 million nursing home residents? Every one of these residents should be immunized against flu and pneumonia. In 1999, however, only 68 percent received the flu shot and 38 percent received a pneumonia shot. These rates are alarming because, as you will learn, many residents will become ill resulting in hospitalization or death due to influenza and pneumonia. Today, we will focus on one of the populations most vulnerable to vaccine preventable diseases, nursing home residents. This live interactive broadcast will provide invaluable information on effective, feasible, and safe immunization programs for residents and staff of nursing homes. Thank you Dr. Satcher. And now let's get started with our presentations, which will include disease burden in nursing homes from influenza and pneumococcal disease, current nursing home immunization rates, myths and real life stories from a clinical perspective, administration and reimbursement from a carrier perspective. Our first presenter will be Dr. Raymond Strickus, physician trainer, training and education branch, CDC. He'll be followed by Dr. Dale Bratzler, principal clinical coordinator, Oklahoma Foundation for medical quality. And then last but not least, Alexis Christian, provider education specialist, Trailblazers Enterprises. So let's hear from Dr. Raymond Strickus. Hello, I'm Dr. Raymond Strickus from the National Immunization Program at the Centers for Disease Control and Prevention. I'm going to talk to you today about influenza and pneumococcal disease and influenza and pneumococcal vaccine use in nursing homes. Pneumonia and influenza, sometimes abbreviated as P&I, together are the fifth most common cause of death for persons age 65 years and older. Influenza accounts for an average of about 20,000 deaths per year. And at least 90% of those deaths occur in people 65 years and older. Pneumococcal disease caused by the bacterium streptococcus pneumoniae, or pneumococcus, accounts for over 10,000 deaths per year. And over half of those are in older persons. Up to 20% of older persons who develop pneumococcal disease will die despite antibiotic therapy. Pneumococcal bacteria or pneumococci are the most commonly identified cause of pneumonia leading to hospitalization. Treatment of pneumococcal infections has become more difficult in the last 10 years because of increasing antibiotic resistance. In some parts of the United States, over 30% of pneumococci are resistant to penicillin and other common antibiotics. Hospitalization rates from PNI among adults are also highest in older persons. Up to 500 are hospitalized per 100,000 population each year. The risks are even higher for persons in institutions such as nursing homes. Influenza outbreaks in populations with little or no vaccination can result in up to 60% of the population in a nursing home becoming ill, with 25% of those affected developing complications leading to hospitalization or death. Pneumococcal outbreaks occur less often in nursing homes, but sporadic cases of pneumococcal disease, particularly pneumonia, are common. Influenza viruses and pneumococcal bacteria are transmitted from person to person. Therefore, they're introduced into nursing home settings by visitors, residents who leave and return, or by staff members who acquire infections in the community. At least two studies have documented that increasing influenza vaccination in nursing home staff will prevent deaths from influenza in the residents, not withstanding varying vaccination levels among the residents. CDC's Advisory Committee on Immunization Practices, or ACIP, recommends that all healthcare workers receive influenza vaccine annually. We have effective vaccines to prevent influenza pneumococcal disease. So why do we have such a tremendous burden of disease? First, we have a very vulnerable population in nursing homes, which is highly susceptible to serious illness from influenza and pneumonia. Second, this older, less healthy population will not always respond as well as we would like with protective antibodies after vaccination. And third and most important to today's program, vaccination levels are lower than they should be. The Healthy People year 2000 objectives for influenza and pneumococcal vaccination called for 80% vaccination levels for influenza pneumococcal vaccines among nursing home residents. The Healthy People year 2010 objectives have been raised to 90% coverage for both vaccines. So how well are we doing in vaccinating nursing home residents? We measure national influenza and pneumococcal vaccination levels in nursing home residents with data primarily from the National Nursing Home Survey. This survey is administered by the National Center for Health Statistics at CDC. It was conducted in 1995, 1997, and 1999 and will next be conducted in 2003. It has had both facility administrator and resident sections. In 1999, the survey sample included 1,423 facilities and 8,215 residents. The relevant immunization question asked in the facility questionnaire was, does your facility have an organized program to annually offer influenza vaccination and pneumococcal vaccination to all residents? In the resident questionnaire, the staff member most familiar with each resident was asked, during the past 12 months or ever, has the resident had a flu shot or pneumococcal shot at this facility or any other location. The results indicate that the number of facilities offering organized influenza and pneumococcal vaccination programs increased between 1995 and 1999 from about 96% to 98% and from 60% to 86% for influenza and pneumococcal vaccines respectively. During that period, the proportion of residents with reported vaccinations increased from 63% to 66% for influenza vaccine and from 24% to 38% for pneumococcal vaccine. However, in 1999, the proportion of residents reported with unknown vaccination status was high at 19% and 39% for influenza pneumococcal vaccines respectively. While some of these residents were no doubt vaccinated, we do not know how many. But if we discard those people and only use data from residents with known vaccination status, the 1999 estimate for vaccination rises, but only to 81% for influenza vaccination and 63% for pneumococcal vaccination. Now, the true 1999 vaccination rates for influenza pneumococcal vaccination are somewhere in between these two estimates, but still short of the year 2010, 90% goals for both vaccines. So, in summary, data from the National Nursing Home Survey indicate that the vast majority of nursing homes offered organized vaccination programs in 1999, that vaccination levels improved between 1995 and 1999, particularly for pneumococcal vaccine, but vaccination status was often reported as unknown. Now, we also have some data from the National Health Interview Survey in 1998 that only 37% of all healthcare workers reported having received influenza vaccine in the previous year. While the survey did not distinguish between all healthcare workers and those who work in nursing homes, it's been suggested that vaccination rates of nursing home employees are likely similar to the national average. We do know that in 1999, the National Nursing Home Survey reported only 9% of nursing homes required staff to receive influenza vaccine. Although interpreting the definition of required influenza vaccination was left up to the nursing home in answering this question, the estimate probably reflects a reason for the very low healthcare worker vaccination rate. In conclusion, we have a long way to go before we reach the Healthy People 2010 vaccination objectives for nursing homes for residents and to improve compliance with the ACIP influenza vaccination recommendation for nursing home employees. In further segments of this program, we'll talk more about influenza pneumococcal disease outbreaks in nursing homes, the safety and effectiveness of these vaccines, the reasons for low vaccination levels in nursing homes, and strategies, particularly standing orders to improve them. We have the tools to improve and protect the health of these very vulnerable patients in nursing homes. We should make every effort to use them. And Dr. Strickers is in the studio joining us live now. Before we go to Dr. Bratzler, I've heard that there's going to be a shortage of the influenza vaccine again this year. How can we vaccinate nursing home residents if the vaccine isn't available? Doris, that's a significant problem and there are four major points I want to make on this issue. First, the influenza vaccine supply for 2001 and 2002 will be adequate, but it will be delayed, although not as much delayed as last year. Second, residents of chronic care facilities and the employees of these facilities continue to be designated by the advisory committee on immunization practices or ACIP as high priority groups for influenza vaccination and should receive the first allotments of vaccine available. Vaccine manufacturers and distributors have been asked to do everything possible to see that such allotment occurs. Low risk person should be deferred from vaccination until November or later. In addition, because influenza usually does not peak in the U.S. before January, vaccination in December, January, and even later as vaccine becomes available, should still protect people. Third, if staff in chronic care facilities cannot find influenza vaccine, they may contact their state health department's influenza vaccine contact person and a list of these individuals is on the CDC website at www.cdc.gov-nip-flu. And for more information and updates throughout the influenza season, viewers can check the same website. Now, let me elaborate on each of these four issues. First, this season, more influenza vaccine is expected to be available than in previous years. Now, some delays in distribution are projected, but they are not expected to be as great as those in the 2000-2001 season. In years without delays, most flu vaccine is distributed by the end of October. This year, however, manufacturers have told us to expect 60 percent of the vaccine to be delivered by the end of October, 30 percent by the end of November, and the final 10 percent in early December. Projected distribution of influenza vaccine for 2001, based on aggregate manufacturers estimates as of August 6th, is about 79 million doses, which is greater than in 2000, incomparable with 1999. The second point was that the ACIP has stated that delivery of vaccine to hospitals and chronic care facilities serving high-risk patients should not be delayed. All providers who've placed orders should receive some early season vaccine, and this strategy will ensure that virtually all providers will be able to vaccinate some of their high-risk patients early in the season. And as an exception, complete orders for chronic care facilities serving high-risk populations should be provided early so that vaccine can be administered in October or November, which is the optimal time for vaccination of this highest risk group. However, because influenza does not usually peak in the United States before January, I want to remind viewers that vaccination in December and even later should benefit those vaccinated then. Manufacturers, distributors, and vendors of vaccine should inform providers of the amount of vaccine they will be receiving and the date of shipment, and this will allow providers to notify high-risk patients when vaccine will be available. The third item was if you're a provider of influenza vaccination services who's been unable to place an order for influenza vaccine, or if you have more vaccine than you need, please call or email your state health department contact person. A list of these persons again is available at the CDC website cdc.gov slash nip slash flu. Your contact person will be able to tell you what if any efforts are being undertaken in your area to reallocate vaccine early in the season to attempt to assure every provider has at least some vaccine to begin vaccinating high-risk patients early. And finally, CDC will share additional information as it becomes available in the 2001-2002 flu bulletins at our website again cdc.gov slash nip slash flu. Thank you Dr. Strikas. Next we're going to hear a pre-recorded presentation from Dr. Dale Bratzler. We have just heard Dr. Strikas describe both the burden of influenza pneumococcal disease and the unacceptably low rates of vaccine coverage among nursing home residents in the United States. I would now like to review some of the clinical perspectives of influenza and pneumococcal vaccine in nursing home residents. During my presentation I will cover the following three points. First, I would like to re-emphasize the consequences of low vaccination rates. Second, I want to review some of what I call the myths of immunization, those unfounded concerns that prevent healthcare providers and patients from both providing and taking these vaccines. And finally I will review the current indications for influenza and pneumococcal vaccination in adults with a particular focus on the nursing home population. In mid-1998 an article was published in the New England Journal of Medicine that described an outbreak of pneumococcal disease in nursing home that occurred in 1996. This article caught my attention not only because of the consequences of the outbreak but also because it occurred in an Oklahoma community not far from where I lived and practiced. I recently had the opportunity to interview some of the healthcare professionals that were involved in the investigation of the outbreak. Over the next five minutes you will hear brief first-hand accounts of what transpired from the perspectives of a nursing home medical director, a hospital microbiologist, and the epidemiologist from the State Department of Health. This particular outbreak was in February of 1996 and I'm happened to be the medical director at this long-term care facility and I one of the patients that actually came down with this multi-drug resistant pneumococcal organism was one of my patients. Well in February of 1996 an elderly patient was admitted to the hospital and expired rapidly after admission. Her blood cultures revealed a pneumococcus that on testing was very resistant to multiple drugs. Well initially I just chalked off her susceptibility, I mean her septicemia as being a isolated incidence. Then three days later two additional patients were admitted to the facility. At that time I became concerned because it was abnormal for us to have three cases of septicemia in three days for our facility and they were all elderly and two of them had died. We knew that the first isolate was very resistant so at that time I began to wonder if they had something in common. I went to the admissions forms of the patients and discovered that they all reside at the same retirement center. I still didn't know if we had a problem or not because the susceptibilities and the identifications were not finished on the two other isolates but it was a Friday afternoon and the weekend was coming up so at this were to be the same strain of pneumococcus we might have a problem and therefore I contacted our infection controlled nurse and so she informed the county health department who there and informed the Oklahoma State Department of Health and then they informed the CDC. The first indication that something was abnormal was because the the microbiologist in the laboratory started noticing some strep pneumo that was coming through the laboratory that was resistant to penicillin and that was new that had not been seen in the in the laboratory before. Obviously over a two-week period of time when 11 people are hospitalized and three persons die it had quite a shock value on the nursing home and then especially obviously when a lot of people from outside from the state and from the county and from the CDC start showing up well pretty much consumed the nursing home for a period of time. Dr. Manch-Rick and the infection controlled nurse at the hospital and as well as all the people that worked at the nursing home we and the doctors from the CDC we perform nasopharyngeal swabs all the patients. We helped with isolating the pneumococcuses and then subculturing them and then sending them to the CDC for serogrouping. We just instituted procedures like doing antiseptic washing of the walls and all the floors. We went into the home. We vaccinated everyone all the residents in the home and we also cultured all the residents and also all the employees. We offered vaccinations to the employees that you know were in the home too. Everybody was wanting to get this stopped and trying to find out why this happened and it was a big camaraderie against the particular non-comcare facility the hospital the county health department and the state and national level. We found that of the 84 residents in the nursing home that only three of those residents had documentation of having received the pneumococcal vaccine in the previous five years. Well since the outbreak pneumococcal outbreak what we have required is that each patient that is admitted to the nursing home is screened for pneumococcal vaccine if they have not received it they are to receive the vaccine and additionally the flu vaccine is given every year. In the five years since the outbreak we have seen a very limited number a reduced number of bacteria is due to strep pneumonia. I do believe this has a direct correlation with the aggressive immunization process that went on during the outbreak. When you're looking at a population of high-risk people nursing homes are certainly a high-risk area there's there's probably very few people in nursing homes that don't meet the the requirements to to receive the pneumococcal vaccine and therefore virtually everyone in nursing home should be vaccinated and it's very unfortunate that we have such low levels of vaccination in nursing homes and it would seem to be a population that we could readily offer the vaccine and administer the vaccine to and increase our vaccination level significantly. I believe that this was a learning experience for our community. The physicians are now aware of importance of immunization. We have learned to not just take things for granted to think that something like this could not happen here because it can happen anywhere. This outbreak could have occurred at any nursing home in any town anywhere. I would like to reiterate several points from these interviews. Documentation of pneumococcal vaccination could be found for only three of 84 residents in this nursing home. Pneumonia occurred in 11 patients and three of them died from invasive pneumococcal disease. In addition to the hospitalizations and loss of life that occurred there was considerable use of resources associated with the time and materials necessary to investigate the outbreak and to implement infection control practices. Subsequent to vaccination of all the residents there were no additional cases of pneumonia reported from this outbreak. Sadly this was not an isolated event. At about the same time that the outbreak occurred in my state there were published reports of similar outbreaks of pneumococcal pneumonia among unvaccinated nursing home residents in Kansas, Maryland, Massachusetts and Washington state. In each of these outbreaks under utilization of pneumococcal vaccine was documented. Similarly there have been many reported outbreaks of influenza attributed to low rates of vaccination among residents and staff of nursing homes. Even in facilities with fairly high rates of resident immunization against influenza documented outbreaks have occurred outbreaks that have been attributed to disease transmission from outside the nursing home by unimmunized staff. I hope that it is clear from the information that Dr. Strickus and I have presented that low vaccine coverage levels have real consequences for nursing home residents. So why are rates of influenza and pneumococcal vaccination in nursing home residents far below the healthy people 2010 goals? In part this can be attributed to some of the myths that often surround these vaccines. The first myth that I want to mention is that the vaccines are not effective. While it is true that the flu vaccine is not as efficacious at preventing influenza in elderly nursing home residents as it is in young healthy adults, it is very effective in preventing severe illness, secondary complications, and deaths. While the effectiveness of the vaccine to prevent influenza illness may be only 30 to 40 percent in nursing home residents, those residents have fewer complications of the disease and are less likely to die if they get influenza. The vaccine is up to 50 to 60 percent effective in preventing hospitalization or pneumonia and up to 80 percent effective in preventing death. In addition the vaccine is cost effective by reducing health care cost associated with influenza. Similarly the pneumococcal vaccine may be less effective in elderly patients than in younger patients who receive the injection. While the exact role of pneumococcal immunization for the prevention of pneumonia remains controversial for some patient groups, the vaccine is up to 75 percent effective in the prevention of invasive disease that is bacterimias and meningitis. Vaccinated patients who become ill with pneumococcal disease are less likely to die and less likely to have severe complications of their disease. One point that cannot be argued, a vaccine not given is 100 percent ineffective. The second myth is that these vaccines are not safe. I want to first emphasize that the influenza vaccine cannot cause the flu and the pneumococcal vaccine cannot cause pneumonia. Neither vaccine contains any live organisms. It is important to realize the coincidental respiratory infections caused by other viruses or bacteria may occur at the same time as vaccine administration in this population of patients. A number of side effects, though rare, may occur in patients who receive these vaccines. Local reactions such as soreness at the side of the injection may occur but are generally short-lived and mild. Up to 10 to 15 percent of these patients who have been previously immunized with the pneumococcal vaccine may have a local reaction at the injection site characterized by mild pain, redness, and swelling. Once again this reaction is self-limited and usually resolves in a few days. Systemic reactions such as fever, malaise, and muscle aches are uncommon and do not occur in any greater frequency in elderly patients who receive these vaccines than in patients who have not received the vaccines. In particular side effects are rare in elderly patients who have had the influenza vaccine before. In studies of thousands of patients receiving both of these vaccines serious adverse events are exceedingly rare. For example in a review of nine clinical trials a pneumococcal vaccine efficacy that included more than 7,500 patients there were no reports of severe febrile, anaphylactic, or neurologic complications. Finally it is important to remember that when indicated both of these vaccines can be administered at the same time given at different injection sites without increasing the risk of side effects. These vaccines may also be administered at the same time that other routine procedures such as ppd skin testing are occurring. I think it is important to keep concerns of vaccine side effects in context when implementing immunization programs. Remember that we in healthcare on a daily basis give therapies such as antibiotics and cardiac medications to patients in nursing homes. Therapies for which the risk of systemic reactions and serious adverse events is many fold greater than risk of vaccine side effects. The third myth about these vaccines is that the cost of administration may not be reimbursed. The pneumococcal vaccine has been a covered benefit of the Medicare program since 1981 and the influenza vaccine has been a covered benefit since 1993. As mentioned before the economic benefits of both vaccines have been demonstrated in a variety of studies. Both have been shown to be cost saving. Additional information regarding reimbursement for these vaccines will be provided later in this program. The last myth that I want to mention is that most patients have been immunized. Dr. Strickus has provided evidence from the National Nursing Home Survey to refute this myth. Studies have consistently demonstrated the physicians and other healthcare providers overestimate the rates of immunization of their own patients. We perceive that our own immunization rates are higher than they actually are yet on review of our patients medical records vaccination status is often unknown or undocumented. As I talk to healthcare providers around the country about adult immunization I rarely hear anyone say that they are opposed to vaccination of nursing home residents. Physicians and other healthcare providers often identify oversight as the largest barrier to increasing immunization rates. Inadequate patient immunization history, poor reimbursement, anticipated patient refusal, inadequate time, difficulty obtaining the vaccines, limited staff support, and a lack of understanding of immunization guidelines have not been shown in studies to be important barriers to vaccination. A recent study of nursing homes in Minnesota demonstrated that many long-term care facilities have inadequate policies and practices for ensuring that their residents and employees are immunized against vaccine preventable diseases. It is the absence of a systematic approach to ensuring vaccination that leads to rates of immunization that fall short of national goals. To close I would like to review the current indications for influenza and pneumococcal vaccines. The advisory committee on immunization practices published updated recommendations for the prevention and control of influenza in April of this year. Because of the risk of outbreaks of influenza in populations of patients residing in chronic care facilities, vaccination is recommended for all residents of nursing homes. The vaccine is indicated for all patients aged 50 years old or greater. In addition adults and children with chronic cardiac or pulmonary disorders and patients with chronic metabolic diseases such as diabetes mellitus, renal disease, hemoglobinopathies, or any immunosuppression including HIV disease should be immunized. Children on long-term aspirin therapy should be vaccinated to prevent Rye syndrome and pregnant women who will be in the second and or third trimester during influenza season should also receive the vaccine. Also persons who can transmit influenza to those patients at risk should be immunized. At least two different studies have indicated that vaccination of healthcare workers has decreased deaths among nursing home patients. It is recommended that physicians, nurses, and other patient care personnel in both hospital and outpatient settings be immunized. All patient contact employees of nursing homes and chronic care facilities, employees of assisted living centers, and those who provide home care to high-risk groups should receive the influenza vaccine. Finally household members of high-risk patients should be immunized. Influenza vaccine should not be administered to persons known to have anaphylactic hypersensitivity to eggs or other components of the vaccine without first consulting a physician. Pneumococcal vaccine is recommended once for all patients aged 65 years or older. All residents of nursing homes and chronic care facilities regardless of age should be assessed for their need for pneumococcal vaccination and many, if not most, will meet the criteria for vaccination. Patients below the age of 65 who have chronic cardiac or pulmonary disease, diabetes mellitus, renal disease, or compromised immunity should also be immunized. Patients with chronic liver disease, alcoholism, sickle cell disease, or prior splenectomy, or cerebrospinal fluid leaks should also be immunized. Pneumococcal vaccine should not be given to patients with a history of serious reaction to the vaccine. Although the optimal time for administration of the influenza vaccine is October and November of each year, unimmunized patients should continue to receive the vaccine through the entire flu season, which usually runs through early March. Pneumococcal vaccine is indicated year-round. Finally, for pneumococcal and influenza vaccines, patients with indications for immunization who are uncertain about prior vaccination status or for whom the history is unreliable should be vaccinated. Let me reiterate this point. If the patient, their family, or their physician cannot recall or document prior immunization, you should give influenza and pneumococcal vaccines if indicated. In summary, pneumonia and influenza continue to be two of the major causes of hospitalization and death in this country. Despite widespread acceptance of the need for vaccination of nursing home patients by the health care community, we are far from achieving acceptable rates of immunization for this population. Failure to immunize these patients is associated with real consequences. It could occur at any nursing home in any town. The fact that patients with vaccine preventable diseases are still admitted to our hospitals is a sobering reminder that there is still a lot of important work to do. We must approach the failure to immunize these patients in the same ways that we are beginning to address other medical errors through systems based approaches that ensure we screen all nursing home patients, immunize those for whom it is appropriate, and document our care. Thank you for your attention. I would like to thank Dr. Bratzler for that interesting perspective on the myths and realities in influenza and pneumonia vaccinations. Administration and reimbursement of vaccinations is an important topic, and Alexis Christian will guide us through the process. But before we hear from Alexis, I would like to give you the phone number and the fax numbers that you'll need to talk to our panel. To ask questions of our panel, the number is 1-800-953-2233. To fax in your questions, the number is area code<PHONE_NUMBER>. All right, let's hear now from Alexis. Influenza and pneumococcal vaccinations are Medicare Part B covered preventive healthcare benefits. These vaccines greatly reduce hospital admissions for pneumonia and deaths due to complications from influenza. Research shows that a provider's recommendation is a strong motivator for a patient to get vaccinated. Standing orders are one example of an effective strategy that a hospital, public health clinic, or nursing home can use to increase immunization rates. For example, a physician could write a standing order in the hospital inpatient setting requiring the assessment and vaccination of all Medicare patients. A missed opportunity in the inpatient hospital setting occurs when a beneficiary is discharged without being offered and receiving an influenza and or pneumococcal vaccination. Missed opportunities can often result in a beneficiary being readmitted to a hospital for influenza and related illnesses like pneumonia. Unfortunately, missed vaccination opportunities occur in all settings. Strategies aimed at modifying systems for delivering care, such as standing orders, are one way of reducing missed opportunities. Standing orders are not required for Medicare coverage of influenza immunizations. Other strategies are also effective in reducing missed vaccination opportunities. Physicians and their office personnel can promote influenza and pneumococcal vaccinations by hanging posters on the clinic walls to function as reminders for both the provider and his patients and using wall charts to track immunizations. Most importantly, physicians can make influenza and pneumococcal vaccinations available in their office or refer patients to other healthcare providers for these vaccinations. Postcards and phone calls to patients to remind them to get vaccinated are also effective strategies. The most effective strategies for increasing influenza and pneumococcal immunizations involve the healthcare provider. Simply put, Medicare beneficiaries are most likely to get immunized when their physician specifically recommends vaccination. Influenza immunizations are seasonal and should be given every year in the fall. Pneumococcal vaccinations can be given at any time of the year. Generally, one pneumococcal vaccination after the age of 65 is all that a person needs to protect himself for a lifetime. However, persons who are considered at high risk, like persons with chronic illnesses like diabetes and cardiovascular or pulmonary disease, and people with compromised immune systems like chronic renal failure should ask their doctor if a booster pneumococcal vaccination is necessary. If any person 65 and over is unsure of his pneumococcal vaccination status, revaccination is recommended and will be covered by Medicare Part B. Medicare can provide brochures and posters free of charge to display in your offices to promote both influenza and pneumococcal vaccinations. Generally, only one influenza virus vaccination is medically necessary per year. Medicare beneficiaries may receive the vaccine once each flu season without a physician's order and without the supervision of a physician. The Medicare Part B deductible and coinsurance do not apply. The Social Security Act section 1848G4A requires that providers build Medicare for covered Part B services rendered to eligible beneficiaries. Public health clinics that have not provided Medicare covered services to their clients in the past must now build Medicare for the influenza virus vaccine and its administration when provided to Medicare beneficiaries. To alleviate concerns expressed by some publicly health clinics that have never provided Medicare covered services, the Health Care Finance Administration or HICVA initiated a simplified process for certain entities which administer the flu shot to file claims for multiple beneficiaries. Generally, providers will qualify to use the simplified process if they build Medicare for influenza virus vaccine for multiple beneficiaries and agree to accept assignments for influenza vaccination claims. However, the roster should not be used for single patient bills and the dates of service for each vaccination administered must be entered. Those providers who do not accept assignment must complete a standard HICVA 1500 claim form or bill electronically for each Medicare beneficiary receiving the influenza vaccine. For those providers who qualify for simplified billing procedure for influenza claims and those who do not have a Medicare provider number, Medicare will issue them a provider number for use in filing the influenza vaccine claims. Physicians may use their current provider number for roster billing. Health maintenance organizations or HMOs that furnish influenza immunization to non-member Medicare beneficiaries are treated as suppliers and should build the carrier. They must obtain a provider number for Medicare Part B billing purposes. The HMO may use simplified billing only if influenza immunizations are the only Medicare-covered services furnished by the HMO to non-member Medicare patients. Pre-printed HICVA 1500 claim form and influenza vaccine record form and an influenza vaccine roster form are available to the provider community. Use the pre-printed HICVA 1500 claim form to build Medicare for the influenza anemonia vaccination. You are only required to complete the blocks that are shaded on the HICVA 1500 claim form. Use the influenza record form or the influenza vaccine roster form as a record of the beneficiary information for those receiving the influenza vaccine. For each beneficiary include his or her name and health insurance claim number. Use these forms only to report the influenza vaccination. Medicare is also available to help you comply with this requirement by providing assistance in filing these claims electronically and information concerning your decision regarding acceptance of assignment of these claims. A software package called influenza pneumococcal roster billing or IPRB is available and is free to all providers who wish to file electronically. The IPRB software is easy to use and will allow you to take advantage of the 14-day payment floor. To process the simplified forms in a timely manner, send the paper of simplified billing claims to the addresses that you see on the screen. Put one HICVA 1500 claim form which each group of influenza vaccine record forms up to 100 beneficiaries can be built at one time. A stamped signature on file is acceptable on a simplified claim to qualify as an actual signature provided that the provider has assigned authorization on file to build Medicare for services rendered. As a reminder, when you accept assignment, you may not collect any money from the beneficiary for the flu vaccination. The procedure codes and allowables are shown on the screen. These are based on the median generic price. As with all injectable drugs, the allowable is subject to change if the price increases or decreases. The allowable fee for the administration of the flu vaccine G0008 is based on the locality of the provider. And we'd like to thank Alexis. And that concludes the first part of our broadcast. Before we go to the second half of our program, let's take a few calls from our viewers to ask questions of our panel. The number to call is 1-800-953-2233. To fax in your questions, the number is area code<PHONE_NUMBER>. And while we're waiting for our first call, Dr. Strikas, let me start off with you. Why does influenza vary in its impact from year to year? Influenza virus is a unique virus in that it changes its genetic material almost on a regular basis. Certainly annually we see what's called antigenic drift. The virus's genetic component changes. And so we see viruses that are a little bit different every year. And that's why the vaccine, even though it contains three viruses in it, representations of three viruses, we need to change one or more of those viruses every year to try to keep up with what the virus is doing. And usually on an average of 9 out of 10 years we get it right. Our surveillance system is good enough to anticipate what's going on in other parts of the world. And we can match that and match well the virus that we see or viruses we will see in the U.S. each fall and winter. Once in a while we don't match it very well. The last time this happened was in 1997. But even then we know the influenza vaccine offered some protection for those who received it. As compared to folks who didn't receive it and vaccinated people even then were less likely to develop pneumonia or die from influenza. All right, thank you. Dr. Bressel, let me come to you. Is sign consent required for administration of these vaccines? Thank you Doris. That's a tough question and I'm going to preface my remarks with the statement that most patients in a nursing home will have signed some general treatment consent for care in the nursing home. So that when the patient was admitted to the nursing home a general consent for treatment was signed by either the patient or if they're not competent their family members. First let me say there is no federal requirement for consent to receive these vaccines. And in fact some investigators have identified the need to get consent as a barrier to getting all of these patients vaccinated. And we do know of many facilities that have made the policy that if the patient has signed general treatment consent on admission to the nursing home that that would be an acceptable consent for vaccination of the patient on an annual basis for the flu vaccine and at least once for the pneumococcal vaccine. We certainly know that this varies from state to state and from facility to facility and certainly each facility may have policies that would recommend otherwise. I would certainly recommend that any patient who is competent to receive a copy of the vaccine information statements or sheets that come from the CDC and can be downloaded from the CDC's website. Okay thank you very much. We're going to take a telephone call now. We have Steve calling us from New York State. Steve thank you for calling. Please go ahead with your question. Well I'm wondering if this year there have been some rates increased because of the higher cost of influenza vaccine. At the reimbursement rate. At the reimbursement rate. I'll answer that question to the best of my ability. We know that the carriers set the reimbursement rate for the influenza vaccine on an annual basis. They set the rates after the manufacturers have posted what's called the average wholesale price. It turns out the average wholesale price has not been complete for the three manufacturers until very very recently. So that carriers currently are publishing rates for reimbursement that are based on last last year's manufacturers price. We do expect the reimbursement from the Medicare program to go up this year but the carriers have not published those new rates. Keep watching we would expect hopefully in the next quarter that the carriers will have the appropriate information to let you know what the current reimbursement rate will be for this year and it should cover the cost of acquisition of the vaccine. Well when you say the next quarter when would those rates actually be announced can you tell us that? I'm perhaps not the most qualified person but sometime I believe in the third quarter of the year so the September October update they should be setting the new rates. We know that there are many discussions going on about this right now. The manufacturers have just posted their average wholesale prices for the vaccine so the carriers have not had the information that they need to set this year's reimbursement rates. Okay thank you that's helpful. Steve thank you for your question. Let's come back to Maryland and we'll take a call from Fern. Thank you for calling Fern. Hi my question is how often is the pneumo vaccination to be given? Go ahead. The current recommendation for the pneumococcal vaccine is for patients who are over the age of 65 that they receive the vaccine one time only. For patients who are immunized for the first time before the age of 65 they should receive one booster dose at least five years after or at about five years after the first dose was given. The one caveat here is if you have a patient who is immunocompromised they do recommend a second booster dose five years after the first dose. Okay thank you. Thank you Fern. Let's go to Nancy who's calling from Missouri. Please go ahead Nancy. Yes this is Nancy. I understand that the billing for a flu in pneumonia vaccine is billed to Part B of Medicare. What I want to know is can a nursing home rather than a doctor bill for a vaccine given in their home? Once again I'm perhaps Alexis isn't here to give us the correct answer. Nursing homes can bill. They have to have a Medicare provider number. I believe it is Part B but don't hold me to that. But nursing homes can bill as long as they have a Medicare provider number. It does not have to come from the physician. All right. Thank you so much Nancy. I hope that answers your question. Let's take another call. We have Susan on the line from Pennsylvania. Please go ahead Susan. Yes my question is does the panel have any idea when the influenza nasal spray may become available because as we have found the biggest barrier for immunization for healthcare workers is that fear of needles. I don't blame them Dr. Strikas. Yeah I think it'd be nice if we could avoid the needles on a regular basis as well. The nasal spray live attenuated influenza vaccine has been researched for a long time probably well over 30 years around the world and well over about that period of time in this country. And there's been an aggressive effort by a couple of vaccine companies to bring this product to market. There was a detailed review of this product by the Food and Drug Administration's advisory committee on vaccines just this past July. And they felt that the vaccine was clearly effective in children and in many adult populations. And while the data they had suggested the vaccine was safe they felt there were not enough safety data to cover all the contingencies about the types of things one gets concerned about such as administration of this vaccine with other vaccines commonly given to children such as measles, mumps, rubella as well as issues around giving this vaccine to people with asthma or with other conditions where a live influenza virus the natural disease would exacerbate the illness. So the question is could you safely give an attenuated or weakened influenza vaccine to an asthmatic patient? Do we have some data there? So the request was made of the vaccine company to go back and collect these data and resubmit their application. So we will not see that vaccine this fall as some had hoped. The soonest we can anticipate seeing that vaccine approve for use in the United States would be fall of 2002 and at this point it's an open question whether the company could collect enough information to satisfy the safety requests made of it. All right. Well, still got to look forward to those needles. All right. Thank you very much, Susan. We're going to take another call from James who's calling from California. Please go ahead, James. Hello. My question deals with liability for the facilities. One of the barriers to giving vaccination has been the fear that somebody could have a reaction and the nursing home would be sued. And the other question I have is about what is the reporting of adverse reactions with vaccination? If I understand your question about liability concerns and Dale may wish to address this as well at this point unlike some other vaccines that are commonly given for children although they are covered under a national vaccine injury compensation program influenza vaccines not covered in that program. Vaccines as I say commonly given to children are covered and that's a process where if someone is concerned they were injured from by a vaccine they may petition the Department of Justice to have redress and compensation for that injury. Influenza vaccine and the macaquel vaccine are not covered under that statute because they are not recommended for routine use in children they're recommended only for children at high risk of those diseases. So at this point if there is concern about liability and if someone wants to sue unfortunately they are only recourses to petition or sue the person who gave them the vaccine to the vaccine company. Having said that liability has not been a major problem per the vaccine companies as Dr. Bratzter said adverse events following influenza and macaquel vaccination are serious ones are extraordinarily uncommon one is usually limited to a sore arm mild fever malaise allergic reactions are on the order of one in several hundred thousand vaccinations. So I think it's an extraordinarily uncommon event that most of us who offer vaccines are never going to see and these are very very safe vaccines. The other question could you repeat it please? I think it has there been any reaction I would just like to one thing that I wanted to add and I completely agree these vaccines are exceedingly safe and I just want to put vaccination of nursing home residents into perspective. I think that anybody who has practiced in a nursing home setting knows that you occasionally get a call from a nurse or something about a patient who's ill maybe they have a urinary tract infection and you order by phone and antibiotic that action is exceedingly more dangerous than giving the vaccines. We do things on a daily basis in healthcare to patients who are in nursing homes that have much more risk than giving these vaccines and liability I agree with Dr. Strikas that liability is not a big issue here. Yeah, I think I recall the second question was to do with monitoring of adverse events or side effects after vaccination and in this country what we have at our program at CDC is two systems one's called the Vaccine Adverse Events Reporting System abbreviated V-A-E-R-S or VAERS and that collects information from anyone who wants to submit it about an adverse event that occurs after any vaccination regardless of what it is and so we accept those data we analyze them on a regular basis and look for problems with any vaccine we use it as a signals as a monitoring system for signals problems in the vaccine supply and we have studied influenza vaccine with this to basically assess for example that Guillain-Barre syndrome following vaccination is a very uncommon event last documented in 1994 with any regularity there is also a group of managed care organizations together called the Vaccine Safety Data Link that let us look at administrative data their record systems to do focused studies on specific adverse event questions and we've been able to do those for pneumococcal vaccine and they're planning others for influenza vaccine so we do have mechanisms to monitor on a regular basis adverse events following vaccination including influenza pneumococcal vaccine James we thank you for your two questions let's take another question from Caroline who's calling from Washington DC please go ahead Yes Alexis Christian from Trailblazers gave an address for billing and we have a question could she repeat or could you repeat the address for the District of Columbia nursing homes you know we would really love to do that but I don't think I have that right here in front of me so if you'd be sure to give a call or perhaps we can have it before the end of the broadcast okay thank you very much thank you Caroline all right Dr. Strikas let me come back to you how are the vaccination answers for the residents in the National Nursing Home Survey validated we collect those data of the National Nursing Home Survey by looking at patient records as well as interviewing the staff member in the nursing home who is most familiar with the patient and having them check whatever records are necessary so unlike some other surveys CDC does for vaccination data or information where we take self-report from people living in the community for the nursing home residents we actually urge people to look at records and not do things from memory so it is we feel a very helpful survey and we believe that it's very accurate the problem is when the record is incomplete and we get these high rates of unknown vaccination status it leads us somewhat uncertain what the actual number is we know what the lowest possible number is a vaccinated residence but we don't know what the true high number might be Dr. Bratzler other than residents who else should be immunized in nursing homes during the flu season certainly any employee in the nursing home who has patient contact should receive the influenza vaccine on an annual basis once again there have been well documented outbreaks of disease in nursing homes from employees or other outside people bringing the infection into the nursing home the second group that I always remind people to think about is the family members of high risk patients if you are working in a nursing home and you have family members that routinely and consistently come to see family members in the nursing home they should probably be immunized also so that they don't bring influenza into the nursing home and let me ask you another question why are the rates of immunization against pneumococcal disease lower in nursing homes than they are in the general population of Medicare aged patients Doris thank you for the question this is one that's a little bit harder to answer part of it is due to lack of documentation as Dr. Strick has showed from the national nursing home survey if you look at those patients and discount those for whom there is not documentation the pneumococcal vaccination rate in nursing homes approaches that of the general Medicare population however I think it's important first to remember that we have a disadvantaged population in the nursing home they're completely dependent on the care given by health care providers about half the nursing home patients in the United States are non-ambulatory these patients cannot leave the nursing home to go out and see primary care physicians they can't go to their local pharmacy in those states where pharmacists can immunize so we have a population that's very dependent on the care that we give them in the nursing home and in many nursing homes we have policies that require the primary care physician to remember to order these vaccines rather than having a systematic program for immunization okay and one last question for you Dr. Strikas why is there an increasing antibiotic resistance in the pneumococci? this is a problem we've seen in the U.S. for about 10 years and the short answer is because we've been using more and more antibiotics to treat a lot of common ailments in people that are often either not infections at all are more like they're virus infections they're not documented in bacterial infections so overuse of antibiotics has led to increasing resistance of a lot of bacteria in pneumococci are the most perhaps the most common example to a point now where a third or more of pneumococci are resistant to penicillin on other common antibiotics making these infections harder to treat more expensive to treat and but making a case for vaccination of high risk individuals even more compelling than it was before okay thank you both and thank you all for your questions let's continue with the second half of our program in this half of our broadcast we'll focus on how to implement a flu and pneumonia immunization program ACIP statement and implementation of standing orders programs success stories CMS CDC's approach to improving vaccination rates and an introduction of proposed investigative protocol for influenza and pneumonia for surveyors and now that we've caught up let's hear from Dr. Linda McKibbin senior health policy scientist CDC Hi I'm Linda McKibbin a public health doctor at the Centers for Disease Control and Prevention in Atlanta Viewers of this program have become familiar with a problem of missed opportunities to vaccinate residents of nursing facilities against two vaccine preventable diseases which causes serious burden for this population influenza and streptococcus pneumonia or pneumococcus long-term care facilities are a high priority for evidence-based vaccination programs according to the National Advisory Committee of Immunization Practices or the ACIP As many of you know the ACIP sets standards of practice for immunizations in this country the ACIP encourages evidence-based policies and programs to improve delivery and receipt of immunizations recommended for adults Evidence-based policies or programs are those which have been systematically evaluated and shown to improve the delivery of vaccines to recommended populations One example of an evidence-based vaccination program for long-term care facilities recommended by the ACIP is institutional standing order policies The goal of the Health Care Financing Administration or HICFA which administers Medicare and Medicaid programs and the Centers for Disease Control and Prevention or CDC the lead federal agency charged with protecting the public against vaccine preventable diseases is to encourage all nursing facilities to implement standing orders programs for both influenza and pneumococcal also known as pneumonia vaccinations A new model a standing orders program is being promoted through community-based quality improvement activities by peer-review organizations or pros in nine states in partnership with HICFA and CDC The model standing orders program is based upon program implementation guidelines from ACIP's policy statement entitled use of standing orders programs to increase adult vaccination rates In this policy statement published by the CDC in March of 2000 the ACIP defines standing orders programs as programs that authorized nurses and pharmacists to administer vaccinations according to an institution or physician-approved protocol without a physician's exam The ACIP statement is available at CDC's website at www.cdc.gov To find the document there simply search on standing orders Standing orders programs or SOPs can be used in inpatient and outpatient facilities long-term care facilities managed care organizations assisted living facilities correctional facilities pharmacies adult workplaces and home health care agencies to vaccinate patient, client, resident and employee populations I'll briefly review some of the scientific evidence of the effectiveness of SOPs before outlining components of a successful SOP in your long-term care facility In 1999 two systematic reviews of the Health Services Research Literature recommended standing orders programs as an effective organizational intervention to improve vaccination coverage rates among adults Both the Task Force for Community Preventive Services and the Southern California Evidence-Based Practice Center, RAND endorsed these programs for adult populations In their review the Task Force for Community Preventive Services found that standing orders have increased vaccination rates about 51 percent when used alone The Task Force also found that standing orders are effective when combined with other interventions SOPs have resulted in higher vaccination rates than other vaccine delivery methods You can find a copy of the Task Force report on Evidence-Based Interventions to increase immunizations at the homepage for the guide to Community Preventive Services Go to www.thecommunityguide.org and click on Publications Are standing orders acceptable to primary care physicians? In one study in Massachusetts they found that standing order policies are acceptable to most primary care physicians The ACIP policy statement also suggests that SOPs may reduce constraints on physicians' time and improve efficiency of health care services Long-term sustainability and flexibility of SOPs may be another benefit A study by Dr. Kristen Nicoll documented an effective SOP for flu and pneumonia vaccines over a 10-year period in a Veterans Health Care Administration inpatient and outpatient setting A quality improvement study published in the Journal of Infection Control and Hospital Epidemiology in November of 2000 suggests that peer review organizations or PROs can successfully promote standing orders programs in long-term care facilities to improve vaccination rates statewide Stevenson and colleagues evaluated quality improvement strategies in four western states Alaska, Idaho, Montana and Wyoming In these four states 133 or 41 percent of the nursing facilities volunteered to participate to identify residents who should be offered pneumonia vaccination Two PROs, PRO West and Mountain Pacific Health Care Health Quality Foundation worked with these facilities to implement standing orders policies using chart stickers with pre-printed physician orders Facilities were generally responsible for measuring their own vaccination rates by obtaining self-reported information from patients or their families and from review of patient medical records The overall vaccination rates in the four states combined improved from 40 percent of nursing home residents at baseline to 75 percent of residents post-intervention in participating facilities The baseline immunization rates are seen in the dotted bars on the left of each pair of bars while the post-intervention rates are on the right As you see pneumonia vaccination rates improvements were significant ranging from approximately 20 to nearly 45 absolute percentage points The authors reported that 2,670 unvaccinated residents received vaccine during an intervention period of only two to three months In addition, they found that a number of participating facilities exceeded the Healthy People 2000 goal of 80 percent vaccination rate rose from 18 percent to 62 percent of the 133 facilities To organize or adapt your facilities vaccination program review the program implementation guidelines in the ACIP standing orders program policy statement The key to success is to begin with a plan for the program's infrastructure key service delivery components and quality assurance To accomplish this the ACIP recommends that a committee of the organization's medical director nursing director infection control and quality control personnel and medical or nursing staff representatives should develop written protocols for important procedures including identifying persons eligible for vaccination based on their age their vaccination status or the presence of a medical condition that puts them at high risk providing adequate information to patients or their guardians regarding the risk from and benefits of a vaccine and documenting the delivery of that information recording patient refusals or medical contraindications recording administration of a vaccine and any post-vaccination adverse events providing documentation of vaccine administration to patients and their primary care providers Standing orders protocols should also specify that vaccines be administered by healthcare professionals trained to screen patients for contraindications to vaccination administer vaccines and monitor patients for adverse events in accordance with state and local regulations Vaccine information statements developed by and available from CDC can be used for risk benefit counseling before administering a vaccine All healthcare personnel administering vaccines or providing care to vaccinated persons should be trained to report adverse outcomes to the vaccine adverse events reporting system or VAERS The appropriate VAERS forms and contact information should be readily available in all facilities delivering vaccines The standards for adult immunization practice established by the National Coalition for Adult Immunization recommend that standing orders programs include a standard personal and institutional immunization record to verify the immunization status of patients and staff members and to reduce the risk for inappropriate revaccinations A patient's primary care provider should be able to override institutional standing orders when medically appropriate Ongoing communication between the primary care provider, vaccinate and institutional staff members is recommended to reduce the possibility of inappropriate vaccinations None of the studies of standing orders programs for influenza and pneumococcal vaccination reported unnecessary or inappropriate vaccinations If repeated pneumococcal vaccinations did occur, studies have indicated that the risk for adverse events beyond self-limited local reactions was minimal for a second dose administered two to five years after the primary dose The risk for self-limited local injection site reactions does not represent a contraindication to revaccination with pneumococcal vaccine in recommended groups The policies and protocols for standing orders programs should include a quality insurance process to maintain appropriate standards of care It is very important that facilities document administration of vaccinations in a standard vaccine administration record that is never thinned or archived from the current portion of the residence chart In addition, a centralized tracking system for vaccines such as a log or card file is essential for a facility to know what proportion of its residents are unvaccinated especially where residents may have shorter stays Long-term care facilities may contact their state immunization programs and peer review organizations for further information such as templates for model policies and protocols and educational materials to get started or to improve the quality of existing vaccination programs The HICFA website www.nationalneumonia.org also has information about vaccination programs in nursing homes and other healthcare settings The CDC website for the National Immunization Program www.cdc.gov.nip has links to many resources including downloadable vaccination information statements for patients on influenza and pneumococcal polysaccharide vaccines The quality of care delivered to nursing home residents is greatly improved when they receive their pneumonia and annual flu vaccinations By keeping track of the improvements in the vaccination rates of residents in your facility your organization can share a quality indicator that is increasingly recognized and valued in your community I would like to thank Dr. McKibbin Now as you can see we have been joined by three new panel members Dr. Linda McKibbin who we just heard from Dr. Randy Ferris Regional Administrator Dallas Regional Office and Karen Shanaman Health Insurance Specialist in CMS's Nursing Homes Branch Now before we hear from these speakers I would like to introduce two providers from Massachusetts who would like to share their success stories in implementing a flu and pneumonia immunization program at their facility First we're going to hear a pre-recorded presentation from Anne-Marie Jett Director of Nursing at the Jewish Health Care Center and then we're going to hear a live presentation via the telephone from Donna McClung She's Director of Nursing at the Center for Optimum Care Now let's listen to Anne-Marie Jett Today I'm going to tell you about the Jewish Health Care Center's success story which is increasing immunization rates with standing orders Yes, it can be done with a lot of determination education and tracking First you need to be aware of some barriers you may encounter with administration corporate medical directors staff and staffing You need to be ready to sell the idea Give a brief overview why it's important to implement standing orders Our geriatric population today in long-term care facilities is older, frail with many comorbidities If this population gets the flu or pneumonia they don't have the ability to fight it The vaccines today are effective to prevent influenza and pneumococcal disease With a proactive approach using standing orders we can increase immunization rates in long-term care Some of the points and positive outcomes that can be mentioned are that standing orders will increase immunization rates They will decrease phone calls to physicians because there will be no need for telephone orders No additional staff is needed Decreases clerical time and sending out consents Inefficiency increases because immunizations become part of the routine Last but not least it increases license autonomy Other barriers you may encounter are staff buy-in We've always done it this way Change can be difficult but we need to be the change agent and sell the idea to our staff Staff want what is best for the residents So once they are informed about the immunization initiative for 2001 and that the pros HICFA and CDC and the Department of Public Health are all working together to make this happen It should be easy to get the cooperation from staff and increase immunizations in long-term care Inconsistent staffing can make it more difficult to roll out a new program standing orders But we need to attempt to make changes to our current programs to improve immunizations in long-term care With the staffing issues we are all experiencing today Implementing a new program can be even more challenging but it can be done Making it work means letting your staff know what is expected The Jewish Health Care Center expects all residents to be given information on immunizations Residents are encouraged to sign the consent to receive the flu vaccine between October and March and pneumonia vaccine through the year if they did not receive it and are over the age of 65 If a resident requests a vaccine but has an upper respiratory infection we will attempt to give the vaccine when the resident is well Our long-term care population signs for the flu vaccine once which states it will be given annually Both the flu and pneumonia vaccine consent forms are part of the admission packet Holding staff accountable Once staff know what is expected they need to be held to task This can be only done by designating someone to oversee the entire program with assistance or support from the director of nursing At the Jewish Health Care Center the infection control nurse which is also the director of staff education and the director of nurses oversee the program Additional oversight is done on each unit by the nurse managers The nurse managers do audits on all new admissions to ensure that immunizations have been addressed at the time of admission and at that time they're able to hold the staff accountable A vaccine tracking sheet is utilized during flu season so we can ensure that every resident either receives the flu vaccine or if not the reason why is documented They may have allergies or they may have already received it Pre-implementation You need to revise or implement your policy and procedure on standing orders for vaccines The following information needs to be included in the standing orders as outlined from the Board of Registration and Nursing Include specific immunizing agent The dose The method root of administration The assessment factors the nurse must ensure prior to administration procedure for informed consent documentation required provision for emergency treatment of adverse reactions and signature of the authorized prescriber which would be the medical director You should revise your consents so residents and families do not have to sign them annually Staff education is needed on the new or revised policy and procedure on standing orders Physicians need to be made aware of the changes in your policy and procedures for standing orders and specifically for vaccines With a letter to physicians a copy of the standing orders from the medical director in DON or administrator need to be sent out Set a start date to roll out the new program with goals Our goals for 2000 were 100% of our residents would be immunized for flu and pneumonia The implementation process a new resident comes into the facility The vaccination assessment is done on admission and the consents are signed The standing orders give us the ability to immunize immediately without contacting the physician The standing orders are listed on the physician's order sheet and when the physician comes into the facility he will sign them Between October and March the flu vaccine is given and year-round the pneumonia vaccine is given if the resident is over age 65 and has not received it Charting in the nurse's note is by exception only so the necessary documentation is on the medication administration record and on the immunization flow sheet Standing orders do work if the staff knows what is expected and if accountability is built in The Jewish Health Care Center's first set of standing orders was in 1994 but vaccines were not included In 1997 flu vaccine was added to the standing orders and flu immunization rates went up to 92% In 1999 and 2000 100% of our residents were immunized or a reason was listed why it was not given In 1999 we added pneumonia vaccine to the standing orders and went from 60% in 1998 to 100% in 1999 and 2000 At the Jewish Health Care Center our short-term unit had an unprecedented 862 admissions in 837 discharges in the year 2000 100% of our short-term admissions were appropriately immunized against influenza and pneumococcal disease or a reason was listed why it was not given Some key points List immunizations understanding orders under admission Set expectations 100% of all residents will be assessed for vaccines Have goals 100% of our long-term care population will be immunized with the flu vaccine by November 15, 2001 Positive outcomes that you will achieve using standing orders Increase autonomy of licensed staff Increase efficiency No more individual orders for vaccines Decrease phone calls to physicians Increased immunization rates As you can see with a lot of hard work and persistence education and follow-through it can be done Immunization rates can be increased with standing orders Thank you for your attention on this important subject And we thank you We've just heard from Anne-Marie Jett who told us about her success in implementing an immunization program at her facility Well, now let's talk to our next two panelists who will discuss CMS CDC's approach to improving vaccination rates and introduce the proposed investigative protocol for influenza and pneumonia for surveyors Dr. Ferris, let me start with you What is CMS's general approach to improving influenza pneumococcal immunization rates among Medicare beneficiaries? In July of 1981 Congress authorized coverage of pneumococcal immunizations for Medicare beneficiaries and coverage of influenza immunizations in May of 1993 Concurrent with these changes the then healthcare financing administration began to educate Medicare beneficiaries and providers about the benefits of pneumococcal and influenza immunizations Each CMS regional office has an influenza immunization coordinator who serves as the primary contact for inquiries regarding influenza or pneumococcal immunization in his or her respective region They also serve as leads for special immunization projects and as clearing houses for information and publications So committed is the agency now known as the Centers for Medicare and Medicaid Services to these efforts that one of its goals under the government performance and results act is to increase the percentage of Medicare beneficiaries aged 65 and older who receive an annual vaccination for influenza and a lifetime vaccination for pneumococcal disease Similarly, as its contribution to the United States Department of Health and Human Services initiative to eliminate racial and ethnic health disparities CMS has committed to the elimination of racial and ethnic disparities and immunization for influenza and pneumococcal disease All right, thank you Now how does CMS propose to reach these goals? To achieve these goals CMS works with a number of partners CMS contracts with peer review organizations which are independent physician review organizations required by Congress to review services provided or proposed to be provided to Medicare beneficiaries Every peer review organization in the United States is required to increase immunization rates for influenza and pneumococcal disease in its state Since 1996 CMS has been actively involved through regional office immunization coordinators with the process of building immunization coalitions All 50 states are involved in that effort In 1998, CMS began a partnership through the Kansas City Regional Office with the Congress of National Black Churches an ecumenical coalition of eight major historically African-American denominations representing 60