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California gives Telehealth a Push Forward

Posted on: October 20th, 2011 by accreditednursing

Model statute a guide for moving California telehealth forward
The Telemedicine Development Act of 1996 is as obsolete as the computers in use back then. Hence the effort by telemedicine professionals and advocates to bring the law up to speed with the technology. On Tuesday, the Sacramento-based Center for Connected Health Policy issued a “telehealth model statute,” a policy report that could influence state policy makers in updating the measure. Some of the report’s recommendations involve definitions, like replacing “telemedicine” with the more broadly encompassing term “telehealth,” and ending the ban on delivering such services by e-mail and phone. Another will require equipment and software vendors to prove their products comply with current telehealth industry interoperability standards. And one recommendation would require private healthcare payers and California’s Medicaid program (Medi-Cal) to cover “encounters between licensed health practitioners and enrollees irrespective of the setting of the enrollee and provider(s).”

“We wanted to create the ideal policy platform because we feel that California is a leader in so many ways in the telehealth field,” Patricia E. Powers, CCHP’s CEO, tells the News Alert.

That leadership, she adds, has eroded as other states have caught up. As noted in CCHP’s Model Statute Report, Medicaid programs in Arizona, Georgia, Wisconsin and Minnesota all cover the use of “store-and-forward” technologies for sending data such as images and video, regardless of the service provided, with Arizona and Georgia also reimbursing providers for store-and-forward in all specialties.

The 1996 act requires Medi-Cal to reimburse telemed procedures as it would traditional health services, however the state also set a 2013 sunset to end Medi-Cal reimbursements for store-and-forward for teledermatology, teleophthalmology, and teleoptometry information. CCHP wants Medi-Cal to continue to cover store-and-forward for all services.

As a non-profit health policy institute, CCHP will not lobby California lawmakers, but is counting on supporters to emerge in the legislature–possibly among lawmakers attending a Thursday CCHP briefing on the model statute.

CCHP has support from two key telehealth groups. One is the California Telemedicine & eHealth Center, one of six federally designated Telehealth Resource Centers nationwide. The other is the California Telehealth Network, which is connecting some 850 healthcare providers in poorer and thus underserved areas to a state and nationwide broadband network dedicated to healthcare.

Eric Brown, CTN’s president and CEO, tells the News Alert that this month, “the first 25 (providers) will be up and running, and it’s very likely that we’ll have another 20 to 25 by the end of the month.”

Another sign of telehealth’s growth these days: Last June, California’s largest private insurer Anthem Blue Cross announced its telemedicine program surpassed 25,000 clinical consultations with Medi-Cal members for members for cardiology, endocrinology, dermatology and neurology medical needs over a dozen years. As of Thursday, that number stands at more than 32,000. The number of participating specialists has risen over the past three years to include 34 specialist doctors, up from 31 last June.

In addition to becoming self-sustaining, supporters of expanded telehealth in California would be wise to continue building relations with two key groups.

One is the state’s medical community, which benefited from the limiting of telemed practices under the 1996 law. For example, patients cannot get coverage for services via telehealth under Medi-Cal without an informed consent waiver and documentation that a barrier existed to an in-person visit. The model statute recommends both rules be eliminated. Today’s doctors are expected to be supportive of any new telehealth measures, CCHP’s Martin and Powers says.

The state’s private health insurers, however, will likely be another story, judging from a statement to the News Alert by Patrick Johnston, CEO of the California Association of Health Plans. CAHP represents 39 member health plans insuring more than 21 million Californians.

“Many health plans use telemedicine as an important tool in expanding access to care, selecting quality providers and lowering costs. It can be particularly effective in rural communities or with specialists for rare conditions. Health plans should have the flexibility to apply this technology in the most appropriate fashion rather than dictating the specific use of this or any other innovation,” says Johnston.

CTeC Executive Director Christine Martin tells the News Alert CCHP is not alone in seeking that more healthcare providers be reimbursed for more telehealth procedures; the nonprofit is in synch with her group and the National Rural Health Association. As a result, she says, the model statute “should open a dialogue with our providers and payers as to how we can best optimize the use of telehealth.”

CCHP sought to encourage such dialogue by including an insurance industry professional (Carolyn Carter, business development manager withWellpoint Inc. Anthem Blue Cross) and several doctors on its Telehealth Model Statute Working Group, a 25-member panel of healthcare and policy professionals.

Whether that consensus gels will depend on how well telemed proponents can convince insurers that the savings promised by telehealth will outweigh the cost of services. A 2007 study by the Center for Information Technology Leadership projected telehealth would yield $511 million in annual savings for California and $4.3 billion nationwide. In today’s dollars, that would be $542.75 million and $4.57 billion, respectively.

The cost? Harder to calculate. The California HealthCare Foundation issued a pair of case studies last November for two specific clinics. One studied a year of operations at Open Door Community Health Centers’ telehealth program, which yielded a $220,734 profit. That reflected revenue from in-person visits with the centers’ own psychiatrist and diabetes educator, as well as grants and reimbursement from third-party payers including Medicaid, Medicare and private insurers.

The other studied the first six months of a teledermatology program at Oakland-based La Clinica de la Raza that lost money–$43,991 under the worst of three calculations. The loss was driven largely by La Clinica’s inability to find a doctor able to bill Medi-Cal or another third party; the clinic paid $40,000 to a dermatologist to whom digital images and clinical notes were forwarded by La Clinica providers.

Medi-Cal’s ability to take on additional costs for La Clinica and others is uncertain. As the state scrambles to plug a $26.6 billion shortfall, Gov. Jerry Brown has proposed reducing Medi-Cal spending, now at $41.6 billion, by $1.7 billion.

Flu Shot Recommendations for 2011

Posted on: October 20th, 2011 by accreditednursing

Prevention and Control of Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011

August 26, 2011 / 60(33);1128-1132

On August 18, 2011, this report was posted as an MMWR Early Release on the MMWR website (

This document provides updated guidance for the use of influenza vaccines in the United States for the 2011–12 influenza season. In 2010, the Advisory Committee on Immunization Practices (ACIP) first recommended annual influenza vaccination for all persons aged ≥6 months in the United States (1,2). Vaccination of all persons aged ≥6 months continues to be recommended. Information is presented in this report regarding vaccine strains for the 2011–12 influenza season, the vaccination schedule for children aged 6 months through 8 years, and considerations regarding vaccination of persons with egg allergy. Availability of a new Food and Drug Administration (FDA)–approved intradermally administered influenza vaccine formulation for adults aged 18 through 64 years is reported. For issues related to influenza vaccination that are not addressed in this update, refer to the 2010 ACIP statement on prevention and control of influenza with vaccines and associated updates (1,2).

Methodology for the formulation of the ACIP annual influenza statement has been described previously (1). The ACIP Influenza Work Group meets every 2–4 weeks throughout the year. Work Group membership includes several voting members of the ACIP, as well as representatives from ACIP Liaison Organizations. Meetings are held by teleconference and include discussion of influenza-related issues, such as vaccine effectiveness and safety, coverage in groups recommended for vaccination, feasibility, cost-effectiveness, and anticipated vaccine supply. Presentations are requested from invited experts, and published and unpublished data are discussed. CDC’s Influenza Division provides influenza surveillance and antiviral resistance data, and the Immunization Safety Office and Immunization Services Division provide information on vaccine safety and distribution and coverage, respectively.

Vaccine Strains for the 2011–12 Influenza Season

The 2011–12 U.S. seasonal influenza vaccine virus strains are identical to those contained in the 2010–11 vaccine. These include A/California/7/2009 (H1N1)-like, A/Perth/16/2009 (H3N2)-like, and B/Brisbane/60/2008-like antigens. The influenza A (H1N1) vaccine virus strain is derived from a 2009 pandemic influenza A (H1N1) virus (3).

Recommendations for Vaccination

Routine annual influenza vaccination is recommended for all persons aged ≥6 months (1). To permit time for production of protective antibody levels (4,5), vaccination should optimally occur before onset of influenza activity in the community, and providers should offer vaccination as soon as vaccine is available. Vaccination also should continue to be offered throughout the influenza season.

Although influenza vaccine strains for the 2011–12 season are unchanged from those of 2010–11, annual vaccination is recommended even for those who received the vaccine for the previous season. Although in one study of children vaccinated against A/Hong Kong/68 (H3N2) virus, vaccine efficacy remained high against this strain 3 years later, the estimated efficacy of vaccine decreased over the seasons studied (6). Moreover, several studies have demonstrated that postvaccination antibody titers decline over the course of a year (7–10). Thus, annual vaccination is recommended for optimal protection against influenza.

Vaccine Doses for Children Aged 6 Months Through 8 Years

Children aged 6 months through 8 years require 2 doses of influenza vaccine (administered a minimum of 4 weeks apart) during their first season of vaccination to optimize immune response. In a study of children aged 5 through 8 years who received trivalent inactivated vaccine (TIV) for the first time, the proportion of children with protective antibody responses was significantly higher after 2 doses than after 1 dose (11).

The importance of vaccine priming might depend more on the similarity of the antigenic composition between the priming and second dose than the temporal interval between doses. From the 2003–04 to 2004–05 influenza seasons, the A(H1N1) virus antigen remained unchanged; however, the A(H3N2) virus antigen changed to a drifted strain, and the B virus antigen changed more substantially to a different lineage. In a study conducted over those two seasons, influenza-vaccine naïve children aged 6 through 23 months who received 1 dose of TIV in the spring of their first year of vaccination followed by a second dose in the fall were less likely to have protective antibody responses to the A(H3N2) and B virus antigens when compared with children who received 2 doses of identical vaccine in the fall (12). Response to the unchanged A(H1N1) virus antigen was comparable between the groups. In another study conducted over the same two seasons, unprimed children aged 10 through 24 months who received 1 dose of TIV during the fall of each season had similar responses to the unchanged A(H1N1) virus antigen as well as to the drifted A(H3N2) virus antigen when compared with children aged 6 through 24 months who received 2 doses of the same TIV during the latter season; however, the first group had significantly lower response to the B virus antigen (13). During two seasons in which all influenza vaccine virus antigens were identical, unprimed children aged 6 through 23 months had similar responses when they received 1 dose in the spring followed by a second dose in the fall, as compared with 2 doses received 1 month apart in the fall (14). Studies of inactivated monovalent pandemic 2009 (H1N1) vaccine in children aged

Vaccination providers should note that, in previous seasons, children aged 6 months through 8 years who received only 1 dose of influenza vaccine in their first year of vaccination required 2 doses the following season. However, because the 2011–12 vaccine strains are unchanged from the 2010–11 season, children in this age group who received at least 1 dose of the 2010–11 seasonal vaccine will require only 1 dose of the 2011–12 vaccine. Children in this age group who did not receive at least 1 dose of the 2010–11 seasonal influenza vaccine, or for whom it is not certain whether the 2010–11 seasonal vaccine was received, should receive 2 doses of the 2011–12 seasonal influenza vaccine (Figure 1). Recommendations regarding the number of doses for this age group might change for the 2012–13 season if vaccine antigens change.

Available Vaccine Products and Indications

Multiple influenza vaccines are expected to be available during the 2011–12 season (Table). All contain the same antigenic composition. Package inserts should be consulted for information regarding additional components of various vaccine formulations.

TIV preparations, with the exception of Fluzone Intradermal (Sanofi Pasteur), should be administered intramuscularly. For adults and older children, the deltoid is the preferred site. Infants and younger children should be vaccinated in the anterolateral thigh. Specific guidance regarding site and needle length can be found in the ACIP’s General Recommendations on Immunization (18).

A new intradermally administered TIV preparation, Fluzone Intradermal, was licensed in May 2011. This vaccine is indicated for persons aged 18 through 64 years and contains less antigen than intramuscular TIV preparations (9 µg rather than 15 µg of each strain per dose) in a smaller volume (0.1mL rather than 0.5 mL). The vaccine is administered intradermally via a single-dose, prefilled microinjection syringe. The preferred site for administration is over the deltoid muscle (19). The most common adverse reactions include injection-site erythema, induration, swelling, pain, and pruritus. With the exception of pain, these reactions occurred more frequently than with intramuscular vaccine, but generally resolved within 3–7 days. This vaccine is an alternative to other TIV preparations for those in the indicated age range, with no preferential recommendation.

As during the 2010–11 season, a vaccine containing 60 µg of hemagglutinin per vaccine strain (rather than 15 µg per strain as in other intramuscular TIV preparations), Fluzone High-Dose (Sanofi Pasteur), is available as an alternative TIV for persons aged ≥65 years. No preference is indicated for this TIV versus other TIV preparations (1).

The intranasally administered live attenuated influenza vaccine (LAIV), FluMist (MedImmune) is indicated for healthy, nonpregnant persons aged 2 through 49 years. Within the indicated groups specified for each vaccine in the package inserts, no preference is indicated for LAIV versus TIV (1).

Vaccination of Persons Reporting Allergy to Eggs

Allergy to eggs must be distinguished from allergy to influenza vaccine. Severe allergic and anaphylactic reactions can occur in response to a number of influenza vaccine components, but such reactions are rare. A review of reports to the Vaccine Adverse Events Reporting System (VAERS) of adverse events in adults noted four reports of death caused by anaphylaxis following influenza vaccine during 1990–2005; the vaccine components potentially responsible for these reactions were not reported (20). A prior severe allergic reaction to influenza vaccine, regardless of the component suspected to be responsible for the reaction, is a contraindication to receipt of influenza vaccine.

All currently available influenza vaccines are prepared by inoculation of virus into chicken eggs. Hypersensitivity to eggs has been listed as a contraindication to receipt of influenza vaccine on most package inserts. However, several recent studies have documented safe receipt of TIV in persons with egg allergy (21–29), and recent revisions of some TIV package inserts note that only a severe allergic reaction (e.g., anaphylaxis) to egg protein is a contraindication. In general, these studies include relatively fewer persons reporting a history of anaphylactic reaction to egg, compared with less severe reactions. Several documents providing guidance on use of influenza vaccine in persons with egg allergy have been published recently (30–32).

The quantity of egg protein in vaccine is expressed as the concentration of ovalbumin per dose or unit volume. Among studies in which the ovalbumin content of the administered vaccine was reported, up to 1.4 µg/mL (0.7 µg/0.5 mL dose) was tolerated without serious reactions (22,23,25–29); however, a safe maximum threshold of ovalbumin, below which no anaphylactic reactions would be expected, is not known.

Although ovalbumin content is not required to be disclosed on package inserts for vaccines used in the United States, manufacturers either report maximum albumin content in the package inserts or will provide this information on request. Ovalbumin concentration can vary from season to season and from lot to lot for a given vaccine. Independent assessments of ovalbumin content of commercially available vaccines have noted lower concentrations than those listed on package inserts (33,34).

In several studies evaluating influenza vaccine in persons with egg allergy, additional safety measures have been taken, such as skin prick testing with vaccine (21–24,26,28,29) and administering the vaccine in 2 doses (e.g., 10% of the dose initially, followed by the remaining 90% if no reaction has occurred during a 30-minute observation period) (22,24–29). Skin prick testing with vaccine was poorly predictive of allergic reactions in these studies (22–24,26). In general, administration of both full doses and split doses have been well-tolerated without serious reactions, although systemic reactions (e.g., wheezing, eczema exacerbation, and hives on face/chest) were observed with the initial 10% dose among six (3.5%) of 171 participants in one study (24).

Recommendations Regarding Persons with Egg Allergy

Each of the following recommendations applies when considering influenza vaccination of persons who have or report a history of egg allergy.

1. Persons who have experienced only hives following exposure to egg should receive influenza vaccine with the following additional measures (Figure 2):

a) Because studies published to date involved use of TIV, TIV rather than LAIV should be used.

b) Vaccine should be administered by a health-care provider who is familiar with the potential manifestations of egg allergy.

c) Vaccine recipients should be observed for at least 30 minutes for signs of a reaction following administration of each vaccine dose.

Other measures, such as dividing and administering the vaccine by a two-step approach and skin testing with vaccine, are not necessary.

2. Persons who report having had reactions to egg involving angioedema, respiratory distress, lightheadedness, or recurrent emesis, or persons who required epinephrine or other emergency medical intervention, particularly those that occurred immediately or within minutes to hours after egg exposure are more likely to have a serious systemic or anaphylactic reaction upon reexposure to egg proteins. Before receipt of vaccine, such persons should be referred to a physician with expertise in the management of allergic conditions for further risk assessment (Figure 2).

3. All vaccines should be administered in settings in which personnel and equipment for rapid recognition and treatment of anaphylaxis are available. ACIP recommends that all vaccination providers be familiar with the office emergency plan (18).

4. Some persons who report allergy to egg might not be egg allergic. Those who are able to eat lightly cooked egg (e.g., scrambled eggs) without reaction are unlikely to be allergic. Conversely, egg-allergic persons might tolerate egg in baked products (e.g., bread or cake); tolerance to egg-containing foods does not exclude the possibility of egg allergy (35). Egg allergy can be confirmed by a consistent medical history of adverse reactions to eggs and egg-containing foods, plus skin and/or blood testing for immunoglobulin E antibodies to egg proteins.

5. A previous severe allergic reaction to influenza vaccine, regardless of the component suspected to be responsible for the reaction, is a contraindication to receipt of influenza vaccine.

Reported by

Lisa Grohskopf, MD, Timothy Uyeki, MD, Joseph Bresee, MD, Nancy Cox, PhD, Influenza Div; Carolyn Bridges, MD, Immunization Services Div, National Center for Immunization and Respiratory Diseases, CDC. Corresponding contributor: Lisa Grohskopf, lgrohskopfatcdcdotgov, 404-639-2552.


Members of the Advisory Committee on Immunization Practices (ACIP), July 2010–June 2011.* ACIP Influenza Work Group. John Kelso, MD, Div of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego California. Matthew Greenhawt, MD, Div of Allergy and Clinical Immunology, Univ of Michigan Health System. Neal Halsey, MD, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. Clinical Immunization Safety Assessment Network Hypersensitivity Working Group. Matthew Fenton, PhD, Marshall Plaut, MD, National Institute of Allergy and Infectious Diseases, National Institutes of Health.

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2. CDC. Update: recommendations of the Advisory Committee on Immunization Practices (ACIP) regarding use of CSL seasonal influenza vaccine (Afluria) in the United States during 2010-11. MMWR 2010;59:989–92.
3. Food and Drug Administration. February 25, 2011: Vaccines and Related Biological Products Advisory Committee meeting transcript. Rockville, Maryland: Food and Drug Administration; 2011.
4. Gross PA, Russo C, Dran S, Cataruozolo P, Munk G, Lancey SC. Time to earliest peak serum antibody response to influenza vaccine in the elderly. Clin Diagn Lab Immunol 1997;4:491–2.
5. Brokstad KA, Cox RJ, Olofsson J, Jonsson R, Haaheim LR. Parenteral influenza vaccination induces a rapid systemic and local immune response. J Infect Dis 1995;171:198–203.
6. Foy HM, Cooney MK, McMahan R. A/Hong Kong influenza immunity three years after immunization. JAMA 1973;226:758–61.
7. Ochiai H, Shibata M, Kamimura K, Niwayama S. Evaluation of the efficacy of split-product trivalent A(H1N1), A(H3N2), and B influenza vaccines: reactogenicity, immunogenicity, and persistence of antibodies following two doses of vaccines. Microbiol Immunol 1986;30:1141–9.
8. Künzel W, Glathe H, Engelmann H, Van Hoecke C. Kinetics of humoral antibody response to trivalent inactivated split influenza vaccine in subjects previously vaccinated or vaccinated for the first time. Vaccine 1996;14:1108–10.
9. Song JY, Cheong HJ, Hwang IS, et al. Long-term immunogenicity of influenza vaccine among the elderly: risk factors for poor immune response and persistence. Vaccine 2010;28:3929–35.
10. Ambrose CS, Yi T, Walker RE, Connor EM. Duration of protection provided by live attenuated influenza vaccine in children. Pediatr Infect Dis J 2008;27:744–8.
11. Neuzil KM, Jackson LA, Nelson J, et al. Immunogenicity and reactogenicity of 1 versus 2 doses of trivalent inactivated influenza vaccine in vaccine-naive 5–8-year-old children. J Infect Dis 2006;194:1032–9.
12. Walter EB, Neuzil KM, Zhu Y, et al. Influenza vaccine immunogenicity in 6- to 23-month-old children: are identical antigens necessary for priming? Pediatrics 2006;118:e570–8.
13. Englund JA, Walter EB, Gbadebo A, Monto AS, Zhu Y, Neuzil KM. Immunization with trivalent inactivated influenza vaccine in partially immunized toddlers. Pediatrics 2006;118:e579–85.
14. Englund JA, Walter EB, Fairchok MP Monto AS, Neuzil KM. A comparison of 2 influenza vaccine schedules in 6- to 23-month-old children. Pediatrics. 2005;115:1039–47
15. Plennevaux E, Sheldon E, Blatter M, Reeves-Hoché MK, Denis M. Immune response after a single vaccination against 2009 influenza A H1N1 in USA: a preliminary report of two randomised controlled phase 2 trials. Lancet 2009;375:41–8.
16. Nolan T, McVernon J, Skeljo M, et al. Immunogenicity of a monovalent 2009 influenza A(H1N1) vaccine in infants and children: a randomized trial. JAMA 2010;303:37–46.
17. Arguedas A, Soley C, Lindert K. Responses to 2009 H1N1 vaccine in children 3 to 17 years of age. N Engl J Med 2010;362:370–2.
18. CDC. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2011;60(No. RR-2).
19. Sanofi Pasteur, Inc. Fluzone [package insert]. Swiftwater, Pennsylvania: Sanofi Pasteur, Inc.; 2011. Available at…/ucm195479.pdf . Accessed August 15, 2011.
20. Vellozzi C, Burwen DR, Dobardzic A, Ball R, Walton K, Haber P. Safety of trivalent inactivated influenza vaccine in adults: background for pandemic influenza vaccine safety monitoring. Vaccine 2009;27:2114–20.
21. Bierman CW, Shapiro GG, Pierson WE, Taylor JW, Foy HM, Fox JP. Safety of influenza vaccination in allergic children. J Infect Dis 1977;136(Suppl):S652–5.
22. James JM, Zeiger RS, Lester MR, et al. Safe administration of influenza vaccine to patients with egg allergy. J Pediatr 1998;133:624–8.
23. Esposito S, Gasparini C, Martelli A, et al. Safe administration of an inactivated virosomal adjuvanted influenza vaccine in asthmatic children with egg allergy. Vaccine 2008;26:4664–8.
24. Chung EY, Huang L, Schneider L. Safety of influenza vaccine administration in egg-allergic patients. Pediatrics 2010;125:e1024–30.
25. Gagnon R, Primeau MN, Des Roches A, et al. Safe vaccination of patients with egg allergy with an adjuvanted pandemic H1N1 vaccine. J Allergy Clin Immunol 2010;126:317–23.
26. Greenhawt MJ, Chernin AS, Howe L, Li JT, Sanders G. The safety of the H1N1 influenza A vaccine in egg allergic individuals. Ann Allergy Asthma Immunol 2010;105:387–93.
27. Owens G, MacGinnitie A. Higher-ovalbumin-content influenza vaccines are well tolerated in children with egg allergy. J Allergy Clin Immunol 2011;127:264–5.
28. Webb L, Petersen M, Boden S, et al. Single-dose influenza vaccination of patients with egg allergy in a multicenter study. J Allergy Clin Immunol 2011;128:218–9.
29. Howe LE, Conlon ASC, Greenhawt MJ, Sanders GM. Safe administration of seasonal influenza vaccine to children with egg allergy of all severities. Ann Allergy Asthma Immunol 2011;106:446–7.
30. National Institutes of Health. Guidelines for the diagnosis and management of food allergies in the United States: summary of the NIAID-sponsored expert panel report. December 2010. Available at Accessed August 15, 2011.
31. Greenhawt MJ, Li JT. Administering influenza vaccine to egg allergic recipients: a focused practice parameter update. Ann Allergy Asthma Immunol 201;106:11–6.
32. Bernstein HH. Guidance offered on giving influenza vaccine to egg allergic patients. AAP News 2010;31:12.
33. Li JT, Rank MA, Squillace DL, Kita H. Ovalbumin content of influenza vaccines. J Allergy Clin Immunol 2010;125:1412–3.
34. Waibel KH, Gomez R. Ovalbumin content in 2009 to 2010 seasonal and H1N1 monovalent influenza vaccines. J Allergy Clin Immunol 2010;125:749–51.
35. Erlewyn-Lajeunesse M, Brathwaite N, Lucas JS, Warner JO. Recommendations for the administration of influenza vaccine in children allergic to egg. BMJ 2009;339:912–5.

* Roster available at

FIGURE 1. Influenza vaccine dosing algorithm for children aged 6 months through 8 years — Advisory Committee on Immunization Practices (ACIP), 2011–12 influenza season

Alternate Text: The figure above shows influenza vaccine dosing algorithm for children aged 6 months through 8 years for the 2011-12 influenza season, according to the Advisory Committee on Immunization Practices (ACIP). Children aged 6 months through 8 years who did not receive at least 1 dose of the 2010-11 seasonal influenza vaccine, or for whom it is not certain whether the 2010-11 seasonal vaccine was received, should receive 2 doses of the 2011-12 seasonal influenza vaccine.

TABLE. Influenza vaccine information, by age group — United States, 2011–12 influenza season*


Trade name



Mercury content (µg Hg/0.5 mL dose)

Ovalbumin content (µg /0.5mL dose)

Age group

No. of doses




Sanofi Pasteur

0.25 mL prefilled syringe



6–35 mos

1 or 2§


0.5 mL prefilled syringe



≥36 mos

1 or 2§


0.5 mL vial



≥36 mos

1 or 2§


5.0 mL multidose vial



≥6 mos

1 or 2§




Novartis Vaccines

0.5 mL prefilled syringe



≥4 yrs

1 or 2§


5.0 mL multidose vial






0.5 mL prefilled syringe



≥3 yrs

1 or 2§




ID Biomedical Corporation of Quebec (distributed by GlaxoSmithKline)

5.0 mL multidose vial



≥18 yrs





CSL Biotherapies (distributed by Merck)

0.5 mL prefilled syringe



≥9 yrs**



5.0 mL multidose vial



TIV High-Dose††

Fluzone High-Dose

Sanofi Pasteur

0.5 mL prefilled syringe



≥65 yrs



TIV Intradermal

Fluzone Intradermal

Sanofi Pasteur

0.1 mL prefilled microinjection system



18–64 yrs






0.2 mL prefilled intranasal sprayer



2–49 yrs***

1 or 2§


Abbreviations: TIV = trivalent inactivated vaccine; LAIV = live attenuated influenza vaccine; IM = intramuscular; ID = intradermal; IN = intranasal.

* Vaccination providers should check Food and Drug Administration–approved prescribing information for 2011–12 influenza vaccines for the most updated information.

† Information not included in package insert but is available upon request from the manufacturer, Sanofi Pasteur, by telephone, 1-800-822-2463, or e-mail, MISdotEmailsatsanofipasteurdotcom.

§ Children aged 6 months through 8 years who did not receive seasonal influenza vaccine during the 2010–11 influenza season should receive 2 doses at least 4 weeks apart for the 2011–12 season. Those children aged 6 months through 8 years who received ≥1 dose of the 2010–11 seasonal vaccine require 1 dose for the 2011–12 season.

¶ For adults and older children, the recommended site of vaccination is the deltoid muscle. The preferred site for infants and young children is the anterolateral aspect of the thigh.

** Age indication per package insert is ≥5 years; however, the Advisory Committee on Immunization Practices recommends Afluria not be used in children aged 6 months through 8 years because of increased reports of febrile reactions in this age group. If no other age-appropriate, licensed inactivated seasonal influenza vaccine is available for a child aged 5–8 years who has a medical condition that increases the child’s risk for influenza complications, Afluria can be used; however, providers should discuss with the parents or caregivers the benefits and risks of influenza vaccination with Afluria before administering this vaccine. Afluria may be used in persons aged ≥9 years.

†† TIV high-dose: A 0.5-mL dose contains 60 µg each of A/California/7/2009 (H1N1)-like, A/Perth/16/2009 (H3N2)-like, and B/Brisbane/60/2008-like antigens.

§§ FluMist is shipped refrigerated and stored in the refrigerator at 35°F–46°F (2°C–8°C) after arrival in the vaccination clinic. The dose is 0.2 mL divided equally between each nostril. Health-care providers should consult the medical record, when available, to identify children aged 2–4 years with asthma or recurrent wheezing that might indicate asthma. In addition, to identify children who might be at greater risk for asthma and possibly at increased risk for wheezing after receiving LAIV, parents or caregivers of children aged 2–4 years should be asked: “In the past 12 months, has a health-care provider ever told you that your child had wheezing or asthma?” Children whose parents or caregivers answer “yes” to this question and children who have asthma or who had a wheezing episode noted in the medical record within the past 12 months should not receive FluMist.

¶¶ Insufficient data available for use of LAIV in egg-allergic persons.

*** FluMist is indicated for healthy, nonpregnant persons aged 2–49 years.

FIGURE 2. Recommendations regarding influenza vaccination for persons who report allergy to eggs — Advisory Committee on Immunization Practices (ACIP), 2011–12 influenza season

* Persons with egg allergy might tolerate egg in baked products (e.g., bread or cake). Tolerance to egg-containing foods does not exclude the possibility of egg allergy.

Alternate Text: The figure above shows recommendations regarding influenza vaccination for persons who report allergy to eggs for the 2011-12 influenza season, according to the Advisory Committee on Immunization Practices (ACIP). Persons who have experienced only hives following exposure to egg should receive influenza vaccine with the following additional measures.

National Academy of Elder Law Attorneys to Recognize Parkinson’s Resource Organization Founder Jo Rosen at National Aging and Law Institute

Posted on: October 5th, 2011 by accreditednursing

Many years ago, I (Neil Rotter) was on the Board of Directors for the Parkinson’s Resource Organization. Jo Rosen is an amazing woman and advocate for Parkinsonians and their families. What a great honor for Jo!

Washington, D.C. – The National Academy of Elder Law Attorneys (NAELA) is proud to present its 2011 Elder Leadership Award to Jo Rosen, Palm Desert, Calif. Ms Rosen has devoted more than two decades to improving the quality of life for people with Parkinson’s disease, their caregivers, and their families. NAELA recognizes her significant contribution, and will present the 2011 Elder Leadership Award on November 11, 2011, at the Boston Seaport Hotel during the National Aging and Law Institute in Boston, Mass.

Ms Rosen is founder and current president of the non-profit Parkinson’s Resource Organization, which provides educational and emotional, group and individual, support to those making the journey through Parkinson’s.

“Through her selfless dedication to this community and her leadership getting volunteers to participate at the grassroots level, Ms Rosen has made a difference to the lives of seniors and others who deal with this debilitating disease,” said NAELA President Edwin Boyer, Esq. “We are pleased to have this opportunity to recognize her achievements with the NAELA Elder Leadership Award.”

Speaking of how she started the Organization, Ms Rosen says, “The concept of the Parkinson’s Resource Organization came about on a plane ride back from a Parkinson’s symposium.” Her mother and then fiancé had both been diagnosed with Parkinson’s. “I was the adult child of a person living with Parkinson’s and I was soon to become the spouse of a person with Parkinson’s. Where was I going to go to discuss my issues and concerns?

This became the mission and the niche of the Parkinson’s Resource Organization. Advocacy, education, emotional support and respite for those with Parkinson’s and their caregivers. The WELLNESS VILLAGE brand new resource on the Parkinson’s Resource Organization’s website is a user friendly online destination connecting the Parkinson’s community with professionals who understand Parkinson’s and who dedicate a portion of their business/practice to the care of the Parkinson’s community.

The NAELA Elder Leadership Award recognizes the recipient’s life and work for the benefit of seniors. The award can also be given to a senior (age 65 or over) who is making significant contributions to society. The Elder Leadership Award includes a monetary contribution in the recipient’s name to a charitable organization with which the award recipient has worked closely.

Accredited Home Health Services Achieves Home Care Elite for 2011

Posted on: October 5th, 2011 by accreditednursing

For the fourth time in the last five years, Accredited Home Health Services has achieved ‘Home Care Elite’ status as determined by OCS Home Care (  Accredited’s Superb Clinical Outcomes are calculated by Medicare and related to these specific indicators;

1) Improvement in Patient Mobility

2) Improvement in Patient’s Ability to Get in & out of bed

3) Patients got better in bathing

4) Patients’ breathing improved

5) Patients’ treatment of heart failure symptoms

6) Patients’ wounds improved after surgery

7) Patients’ got better at taking their oral medications correctly

8) Patients’ rehospitalization rates decreased

9) Patients’ need for urgent care was lessened

For more information about a Home Health Agency’s Outcomes, visit Home Health Compare on

Accredited Patient Outcomes - Among the Best in the Nation

Learn about our Home Care Elite status, our Medicare Outcome Scores and more.

The Accredited Family of Home Care Services Video

Click the thumbnail to view a video that covers the home health care services provided by The Accredited Family of Home Care Services.

Since 1980, The Accredited Family of Home Care Services has built a solid reputation for providing quality home care services in Southern California.

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