Cover Story - November 2009
Tex Med. 2009;105(11):16-22.
By Crystal Conde
Putting patients first comes naturally to physicians. They strive to eliminate suffering among patients and to give the highest quality care at all times. This flu season, however, public health experts are urging physicians to think of themselves and their staff members first by getting vaccinated against seasonal flu and H1N1 flu.
James K. Morgan, MD, MPH, Texas Department of State Health Services (DSHS) assistant commissioner for regional and local health services, says physicians and their employees should be first in line to receive both shots.
"Health care workers need to take care of themselves first. Our health care workforce needs to be protected. If we lose up to 30 percent of our health care workforce at any one time to H1N1 influenza, we'll have a major disaster in terms of a failing health care system," he said. "We want the system to remain healthy this season. We want to make sure it's not the victim."
Herminia Palacio, MD, executive director of Harris County Public Health & Environmental Services (HCPHES) and chair of the Texas Public Health Coalition, concurs. She stresses that physicians should be vigilant in vaccinating themselves and their patients against H1N1 influenza and seasonal flu.
"As health care providers, we have an obligation to protect our patients as best we can. Seasonal flu and H1N1 flu vaccination is a simple step we can take. Getting vaccinated ourselves allows us to serve as role models for our patients and to practice what we preach," she said.
Having a healthy and robust medical workforce during flu season will help local health officials efficiently and effectively respond to the unpredictable H1N1 flu that continues to circulate. Local health departments have developed plans to monitor H1N1 flu outbreak, support the vaccination of priority populations against the novel disease, and communicate with the public and physicians regarding updates and information on H1N1 flu to mitigate its spread among the community.
Vaccination Key to Response
Local health departments rely on physicians to provide first-line defense against H1N1 flu in the form of immunizations. Public health departments in Dallas County, Harris County, San Antonio, El Paso, Amarillo, and Hidalgo County and elsewhere around the state are safety-net vaccination providers to close any gap in supply at the local level and to ensure protection against H1N1 flu for residents who face access-to-care barriers.
To combat H1N1 flu, DSHS will receive vaccine supply from the federal government and distribute it to health care practitioners throughout the state, free of charge. Physicians won't be reimbursed for acquisition of the free vaccine, but they will be paid for administering the vaccine.
At press time, some health care payment plans had determined their H1N1 flu vaccine administration reimbursement policies for health care professionals. The Centers for Medicare & Medicaid Services (CMS) also published details on its payment policies for Medicare-participating physicians. (See " Medicare, Two insurers Set H1N1 Flu Vaccine Payments .")
To analyze and assess the gap in vaccination coverage and to determine the amount of vaccine to purchase, Matt Richardson, MPH, Amarillo Public Health Department director, says his department and others across the state need to know how many health care professionals in their areas have committed to provide H1N1 flu vaccine and the amount of vaccine they've requested.
To obtain H1N1 flu vaccine, physicians must first register online with DSHS and complete a questionnaire. Physicians must estimate the number of office personnel and patients in each age and risk category they plan to vaccinate. DSHS expected to receive an estimated 3.3 million doses of H1N1 flu vaccine by the end of October.
The Centers for Disease Control and Prevention's (CDC's) Advisory Committee on Immunization Practices recommends that when vaccine is first available, physicians administer shots to those in the following five target groups:
- Pregnant women;
- People who live with or care for infants aged 6 months and younger;
- Health care and emergency medical services personnel;
- People aged 6 months to 24 years; and
- Those aged 25 years to 64 years with medical conditions that put them at higher risk for flu-related complications.
At press time, DSHS was advising physicians to focus initially on three subgroups of the priority groups. They are the caregivers of infants 6 months and younger, health care workers, and pregnant women and those living in their homes.
"DSHS will work closely with physicians across the state to make sure they get the amount of vaccine they need when they need it. Because the initial supply of vaccine will be limited, physicians should focus on vaccinating a subset of the priority groups," Dr. Morgan said.
Physicians and medical staff members with vaccine questions may call the DSHS helpline toll-free at (800) 252-9152. For more information on vaccine availability and influenza in Texas, visit www.texasflu.org .
Another weapon in the H1N1 flu treatment arsenal at physicians' disposal is antiviral medications such as Tamiflu and Relenza. (See " Antiviral Drug Guidelines .")
Fernando A. Guerra, MD, MPH, director of health for the San Antonio Metropolitan Health District, encourages doctors who don't usually think of themselves as having a public health responsibility because of the nature of their specialties to register with the state health department and order H1N1 flu vaccine. He says the public would benefit if surgeons, obstetrician-gynecologists, and internists, for example, give their patients the vaccine.
"Their involvement will help us minimize missed immunization opportunities," he said. "Physicians have to expand their thinking as H1N1 vaccine becomes available. We have to start out with priority groups that must be protected. All of us need to think of ourselves as immunizers."
Mr. Richardson adds that society benefits when more physicians and health care practitioners consider the public health implications of preventable diseases.
"Physicians should consider how H1N1 vaccination can benefit the community and not just the patient," he said.
In Hidalgo County, vaccination against H1N1 flu requires coordination among many groups. Eduardo Olivarez, chief administrative officer of the Hidalgo County Health & Human Services Department, says his department encourages federally qualified health centers in the county to provide vaccination.
At press time, the department also was talking with larger school districts about offering vaccine clinics on campuses. Hidalgo County health officials were communicating with more than 340 area school nurses and the superintendents of more than 30 school districts to ensure a coordinated, efficient response to H1N1 flu in local schools. Mr. Olivarez says his department also met with the Pan American Health Organization to discuss documentation of H1N1 flu vaccination of children in the United States and Mexico.
Other organizations are working with the health department, as well.
"Our local independent pharmacy association has stepped up to the plate and has offered to assist us with H1N1 vaccination clinics. In addition, South Texas College and The University of Texas-Pan American officials have agreed to let us use their nursing students and physician assistants," Mr. Olivarez said.
Trends in H1N1 Flu
Flu-like illness is hitting Texas hard, and medical experts expect the seasonal flu virus and H1N1 to be around for a while. In the spring, when H1N1 flu first spread, DSHS asked physicians to submit samples to its lab from all patients who had influenza-like illnesses. The response was overwhelming. The DSHS lab received 10,000 specimens and increased surge capacity tenfold.
CDC and DSHS modified H1N1 surveillance guidelines for the fall. Now that Texas and the rest of the world are in the midst of a pandemic, rather than focus on case counts, local health departments and the state want to observe trends in illness.
To avoid overrunning local health department labs and the DSHS lab with specimens, commercial labs and some hospital labs will handle testing. A list of labs where H1N1 specimens may be sent is available online .
Dr. Morgan advises physicians to go ahead and treat patients with flu-like symptoms rather than wait on test results. Circumstances that warrant sending samples to the DSHS lab include a patient who has been in the hospital more than 48 hours with an influenza-like illness, and deaths associated with flu. In addition, Dr. Morgan says DSHS would like physicians to report H1N1 positive test results for patients hospitalized more than 48 hours.
Despite the change in surveillance protocol, Dr. Morgan says DSHS can monitor H1N1 flu throughout Texas. DSHS implements the CDC's U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet). Participants provide data on influenza-like illnesses each week to help CDC monitor the impact of influenza.
During the 2008-09 influenza season, 145 Texas health care professionals participated by reporting influenza-like illness data each week. Participation in the program involves reporting the number of patient visits for influenza-like illness by age group (0-4, 5-24, 25-64, 65 and older), along with the number of patient visits for any reason.
Physicians interested in enrolling in the program may request a form from Irene Brown, sentinel influenza coordinator in the DSHS Infectious Disease Control Unit, by calling (512) 458-7111, ext. 6878, or by e-mailing firstname.lastname@example.org .
"Based on the information we gather through ILINet, we can tell from that how widespread H1N1 and seasonal flu are around the state. We can also determine the characteristics of the viruses and can test submitted samples to see if there's a change in resistance patterns to antiviral medications," Dr. Morgan said.
John Carlo, MD, MSE, Dallas County Health and Human Services (DCHHS) medical director and health authority for Dallas County and the City of Dallas, says officials rely heavily on sentinel providers strategically placed throughout the county to submit flu samples. The results give the department a good indication of trends in illness, he says.
"We also get reports of school influenza-like illness absentee rates, and we receive information on inpatient cases of influenza-like illness from area hospitals to gauge whether the severity of the disease has changed," Dr. Carlo said.
Communicate to Mitigate
Minimizing risk of infection with H1N1 flu is a priority for local health departments in all parts of Texas. Public health officials are working with community stakeholders to make sure residents understand what they can do to prevent spread of the disease.
To ensure coordinated preparation for and response to H1N1 flu across the state, DSHS and the Texas Division of Emergency Management cohosted 13 Pandemic Influenza Regional Conferences in August and September. Dr. Morgan says the meetings proved successful in spurring communities to work together. He added that the gatherings connected stakeholders who can share resources in preparing for and responding to H1N1 flu. Attendees included independent school district officials, local health department employees, first responders, hospital personnel, elected officials, emergency management personnel, community-based organizations, and various other stakeholders.
Throughout Texas, local response to H1N1 flu has centered on public health, according to Dr. Guerra.
"Since last spring, we've had to maintain a high level of visibility and communication with the community and with elected public and school officials, business executives, and chambers of commerce," he said.
The San Antonio Metropolitan Health District has taken steps to share its H1N1 response plan with a number of pivotal health care entities and community leaders. The health district hosted a conference call with hospital chiefs of staff to present its fall H1N1 plan and inform them of hospital-specific rules regarding vaccination, antiviral medications, and employee safety.
District officials also met with school officials to outline communitywide vaccination plans and the role of schools in H1N1 surveillance and mitigation activities. Guidance for San Antonio health care professionals is available on the health district Web site .
In Harris County, Dr. Palacio urged physicians and their staff members early on to talk with patients at high risk for H1N1 flu about measures they could take to decrease their exposure to the disease. She also encouraged physicians to move to prompt clinical diagnosis and treatment for patients with influenza-like illness.
HCPHES developed resources and adapted H1N1 flu guidelines from CDC to share with the public and health care professionals on its Web site, www.hcphes.org. For example, the department has H1N1 guidelines for businesses to use to decrease the spread of flu in the workplace during the 2009-10 influenza season. They include:
- Reminding sick employees to stay home;
- Advising employees to cover coughs and sneezes;
- Improving hand hygiene in the workplace; and
- Cleaning surfaces and items that are more likely to have frequent hand contact.
Resources for schools are also available. Recommended response actions for education officials include:
- Separating ill students and staff;
- Encouraging students and staff to wash their hands frequently with soap and water when possible or to use hand sanitizers;
- Cleaning areas that students and staff touch often; and
- Advising students and staff with flu-like illness to stay home for at least 24 hours after they no longer have a fever or signs of a fever, without the use of fever-reducing medicines.
The Texas Medical Association's H1N1 Flu Resource Center has the latest news, relevant articles, information for physicians, lab testing protocol, reports from the governor, and resources. Physicians can also sign up there for the TMA Flu Hotline.
And a group of physicians known as the "Flu Fighters" is serving as a resource to answer practitioners' questions about H1N1 flu. (See " 'Flu Fighters' Keep Physicians Informed on H1N1 .")
Physicians in Harris County can sign up to receive Health Alert Network System notifications with the latest information on H1N1 flu by sending an e-mail message to email@example.com .
Dallas County physicians and community leaders can sign up to receive H1N1 flu updates in their area by e-mailing firstname.lastname@example.org . The DCHHS Web site features pandemic H1N1 influenza educational posters free of charge. Posters are available in English and Spanish and promote flu prevention for children, the general public, and parents. The Web site also features H1N1 flu guidance for schools, day-care facilities, laboratories, employers, municipalities, clinicians, and health care professionals.
R. Michael Hill, MPH, director of the El Paso Department of Public Health, says his department is educating the public about practicing cough etiquette, washing their hands, and staying home when they're sick to avoid a large outbreak of illness this flu season.
The El Paso public health department's Web site has PDFs on topics including how to stop the spread of flu and facts about H1N1 flu.
To educate physicians and health care groups on H1N1 flu as a pandemic pathogen, mitigation of the disease, use of antiviral medications, and vaccine guidelines, the Amarillo Public Health Department has met with long-term health care professionals, hospital infection control experts, and members of the Potter-Randall County Medical Society.
The Amarillo Public Health Department Web site has an H1N1 flu page with links to information for health care professionals.
Mitigation of H1N1 flu in Hidalgo County, home to nearly 900,000 people, involves a diverse group of stakeholders. The Hidalgo County Health & Human Services Department has created a series of public service announcements in English and Spanish to educate residents about signs and symptoms of H1N1 flu, the use of antiviral drugs, and the importance of hygiene and social distancing.
The health department has also conducted training with border patrol and customs agents, as well as law enforcement officials, on identifying indications of influenza-like illness and appropriate use of masks for detainees and immigrants entering the United States.
At the state level, DSHS has an abundance of Texas-specific influenza information on its Web site at www.texasflu.org. And the department has launched a media campaign aimed at educating the public about H1N1 flu that involves social networking sites, as well as television, newspaper, and radio advertisements.
Physicians can participate in weekly state operation center calls with David Lakey, MD, DSHS commissioner, and Adolfo Valadez, MD, MPH, commissioner for prevention and preparedness services at DSHS. Calls cover updated information health care professionals need to know about vaccines, disease surveillance, and other flu-related topics. For information on how to participate in the calls, contact the emergency management coordinator in your county.
Up-to-date information on H1N1 influenza is available on the CDC Web site , which has a site dedicated to resources for clinicians .
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by e-mail at Crystal Conde .
Medicare, Two Insurers Set H1N1 Flu Vaccine Payments
The federal government is providing the H1N1 flu vaccine to health care professionals at no cost. Physicians and practitioners who vaccinate their patients won't be reimbursed for vaccine acquisition cost because it's free, but they can receive payment for administering the vaccine.
Two health plans and Medicare had determined their reimbursement policies for vaccine administration at press time. Medicaid hadn't yet posted its plan for paying participating physicians for H1N1 flu vaccine administration. Visit the Texas Medicaid & Healthcare Partnership Web site for more information.
Medicare Part B beneficiaries will receive the H1N1 vaccine as an additional preventive immunization service. Medicare will pay for administering the vaccine.
These new HCPCS codes for H1N1 are effective for dates of service on or after Sept. 1:
G9141 - Influenza A (H1N1) immunization administration (includes the physician counseling the patient/family).
G9142 - Influenza A (H1N1) vaccine, any route of administration.
Payment for G9141 immunization administration will be paid at the same rate established for G0008 (administration of influenza virus vaccine). H1N1 administration claims will be processed using the diagnosis V04.81 (influenza) and, depending on the provider type, using revenue code 771.
More information is available from the Centers for Medicare & Medicaid Services (CMS) publication MLN Matters [ PDF ].
WellPoint had determined its H1N1 flu vaccine administration payment policy at press time. The health plan indicated it would cover the cost of vaccine administration for members whose benefit plans provide vaccine coverage. WellPoint directs policyholders who wish to confirm their benefits to call the toll-free number listed on their insurance card.
UnitedHealth Group agreed to provide coverage for the administration of the H1N1 flu vaccine to all members covered by its insured plans. If a self-funded employer group's plan doesn't currently cover the administration of the vaccine, and the employer notifies United of its intent not to cover the vaccine in the future, United will reimburse the cost of the administration of the vaccine.
United indicated it would coordinate its efforts with federal and state authorities to ensure the widest possible administration of the H1N1 flu vaccine in an effort to mitigate the potential consequences of an H1N1 pandemic. The health plan set up an H1N1 Frequently Asked Questions Web page for members on its site .
At press time, Blue Cross and Blue Shield of Texas, Humana, Aetna, and CIGNA had not yet established H1N1 flu vaccine administration payment policies.
Antiviral Drug Guidelines
The Centers for Disease Control and Prevention (CDC) updated its antiviral drug guidelines to help clinicians appropriately prescribe the medications, while ensuring those in greatest need receive the drugs quickly.
CDC advises clinicians to prioritize the following populations at increased risk of influenza complications for treatment with antiviral drugs:
- People hospitalized with suspected or confirmed influenza;
- People with suspected or confirmed influenza who are at higher risk for complications;
- Children younger than 5 (children younger than 2 are at higher risk for complications than older children);
- Adults 65 years and older;
- Pregnant women;
- People with certain chronic medical or immunosuppressive conditions; and
- People younger than 19 who are receiving long-term aspirin therapy.
Additional information is available online .
Patients who can't afford an antiviral medication may obtain it through a state supply of antiviral drugs, available in select pharmacies across the state.
At press time, the Texas Department of State Health Services (DSHS) hoped to sign contracts with five major chain retail pharmacies to distribute antiviral drugs to uninsured and underinsured residents. Antiviral medications are also available from federally qualified health centers, which should receive stocks of the drugs in September.
In addition, local health departments and DSHS health services regions can serve as backups and help supply independent pharmacies with medications in areas that don't have retail pharmacies.
At press time, some 194 HEB pharmacies in 42 Texas counties had received antiviral shipments from DSHS. The state department has established a process for dispensing state-provided antiviral drugs through contracted private retail pharmacies, as well as a list of contracted pharmacies in your area, available online or by calling 211 to be transferred to DSHS.
"Flu Fighters" Keep Physicians Informed on H1N1
Physicians battling H1N1 flu this season have someone in their corner. A subcommittee known as the "Flu Fighters," made up of four physician-members of the Texas Medical Association's Committee on Infectious Diseases and one Texas Department of State Health Services (DSHS) infectious disease consultant, will keep practitioners up to date on H1N1 information and answer questions.
The group's overall objective, according to Wendy Chung, MD, MSPH, is to develop physician-directed 2009 H1N1 influenza messages. Dr. Chung is the chief epidemiologist at Dallas County Health and Human Services (DCHHS).
In addition to Dr. Chung, the Flu Fighters are:
- Donald Murphey, MD, Fort Worth;
- Carl Vartian, MD, Houston;
- Susan Penfield, MD, Austin; and
- Bob Kaspar, MD, DSHS infectious disease consultant, Austin.
At press time, the Flu Fighters had met once by conference call and discussed physicians' frequently asked questions. As a result of the call, DSHS and TMA shared the H1N1 clinician guidance algorithm, developed by DCHHS, as an online physician resource. The algorithm can be accessed on the DSHS Web site and on the TMA Web site .
"As we are now on the threshold of an H1N1 wave in our communities, this type of information is timely for physicians who are on the front lines of seeing patients with influenza-like illnesses," Dr. Chung said.
According to Dr. Chung, the Flu Fighters have discussed possibly sharing with physicians' offices templates of prerecorded telephone messages, which would educate patients about influenza and when to seek care. The group also is considering setting up a flu hotline and Webinar and developing patient case scenarios to help physicians diagnose and treat flu-like illnesses.
Guidance on treating H1N1 flu and updates from the Flu Fighters are available on TMA's Web site. Log on to www.texmed.org/swineflu .
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