Title: Immunization of Health Care Workers: more than just influenza
1Immunization of Health Care Workersmore than
just influenza
- Mary Vearncombe, MD, FRCPC
- Medical Director, Infection Prevention Control
- Sunnybrook Health Sciences Centre, Toronto
2Disclosure
- No conflict of interest to disclose.
3Objectives
- To identify vaccine preventable diseases relevant
to hospital occupational health - To determine HCW susceptibility/immunity
- To determine appropriate immunization and serology
4HCW Immunization Background
- HCWs are at risk of exposure to and possible
transmission of communicable diseases - - some are vaccine preventable
- establishing and maintaining immunity is an
essential component of both Occupational Health
and Infection Prevention and Control programs
5HCW Immunization Background
- applies to all health care settings
- offices, clinics, acute care, LTC, laboratories,
first responders, etc. - applies to all health care personnel
- employees, physicians, students, contract
workers, volunteers - student immunization should occur before clinical
placement
6HCW Immunization Background
- immunization protects HCWs, their families,
colleagues and patients - cost containment through prevention of infection
- furloughing susceptible HCWs after exposure
- costs of prophylaxis
- costs of treatment
- absenteeism during acute illness
- disability following illness
- outbreak investigation and control
7HCW Immunization
- active immunization strongly recommended -
specific risk for HCWs - i.e., hepatitis B, annual influenza, measles,
mumps, rubella, varicella, acellular pertussis - immunization recommended for all adults
- i.e., tetanus, diphtheria
8Occupational Health Assessment
- Before placement
- health inventory
- immunization status
- to guide further immunizations, post-exposure
management - opportunity for adult immunization in immigrant
HCWs - education
- importance of maintaining personal health
healthy workplace - need for annual influenza vaccine
9HCW Immunization
- prevent transmission
- prevent work restrictions after exposure
- cost-effective compared to
- furlough
- treatment of cases
- outbreak control
- mandatory vs voluntary programs
- screening programs HBV, MMR, varicella
- documentation of vaccine receipt or immune
serology - document refusal
10Hepatitis B Vaccine Pre-Exposure
- Pre-placement
- HB vaccine for all HCWs at risk of exposure to
hepatitis B, i.e., who may have contact with
blood, body fluids or sharps - risk often highest during training period
- vaccination should be completed during training,
before clinical exposure - test for anti-HBs 1 month after vaccine series
complete
11Hepatitis B Vaccine Pre-Exposure
- primary series non-responders
- complete 2nd 3 dose series
- re-test for anti-HBs
- if anti-HBs positive, consider immune
- if non-immune, counsel regarding exposure
response - may be a carrier
12Hepatitis B Vaccine Ongoing Surveillance
- periodic antibody testing not recommended
- booster doses not recommended
- HBV unimmunized or non-responders to vaccine at
risk for exposure should be offered annual
screening for HBsAg - assessment and treatment
- protection of partner and household contacts
13Hepatitis B Vaccine Post-HBV Exposure
- response dependent on the vaccination and
antibody status of the HCW - known anti-HBs positive no further action
required - non-responder HBIG repeat in 1 month
- unvaccinated HBIG initiate vaccine
- give HBIG ASAP and within 48 hours of exposure
- risk for non-immune contact up to 30
14Influenza Vaccine
- NACI Recommended Recipients
- People capable of transmitting influenza to
those at high risk for influenza- related
complications - All health care workers acute care, long term
care, home care and outpatient settings
15Influenza Vaccine
- Why should I be immunized?
- You will protect yourself from acquiring the
flu, or if you do get the flu it will be less
severe. Influenza vaccine is effective in
otherwise healthy adults. - NEJM 33314 889-893, 1995
- JAMA 28110 908-913, 1999
- JAMA 28413 1655-1663, 2000
16Influenza Vaccine
- Why should I be immunized?
- You will protect your patients from influenza.
Vaccination of HCWs reduces illness and mortality
of frail elderly patients more effectively than
vaccination of patients. - JID 1751-6, 1997
- Lancet 3558/1/ 2000, 93-97
- BMJ 333(7581)1241, 2006
- J Am Ger Soc 57(9)1580-6, 2009
17Influenza Vaccine
- Pre-placement
- counsel with regard to implications of
transmission of respiratory viruses to patients - healthy workplace
- counsel with regard to expectation of annual
influenza immunization - pregnancy is an indication, not a
contraindication, for influenza vaccine
18Influenza Vaccine
- Ongoing Surveillance
- recommend influenza vaccine annually to all HCWs
before the beginning of the influenza season - The advice of a health care professional is an
important factor in acceptance of vaccine - utilize strategies to maximize vaccine coverage
- e.g., mobile carts, shift coverage, education,
incentives, peer immunization, declination forms - mandatory immunization?
19Influenza Vaccine
- Influenza outbreaks
- immunized personnel may continue to work
- unimmunized personnel working in the affected
unit must take antiviral chemoprophylaxis for 2
weeks if they also receive vaccine or until end
of outbreak - unimmunized personnel who refuse chemoprophylaxis
should not provide patient care
20Annual Influenza ImmunizationNational Advisory
Committee on ImmunizationPublic Health Agency of
Canada
- The provision of influenza vaccination for HCWs
involved in direct patient care is an essential
component of the standard of care for influenza
prevention. - HCWs involved in direct patient care should
consider it their responsibility to provide the
highest standard of care, which includes annual
influenza vaccination. - In the absence of contraindications, refusal of
HCWs who are involved in direct patient care to
be immunized against influenza implies failure in
their duty of care to their patients.
21Measles Vaccine
- Pre-placement immunization
- acceptable evidence of immunity
- positive serology
- documented receipt of 2 doses of vaccine
- documentation of laboratory confirmed measles
- (born before 1970 no longer considered
sufficient for HCWs) - offer vaccine to all non-immune HCWs (MMR)
- contraindicated during pregnancy
- immunity should be condition of employment
- HCW responsibility to avoid causing harm
22Measles Vaccine
- Continuing surveillance
- Consider giving second dose to those born after
1969 who have received single dose - Consider immunizing those born before 1970 who do
not have laboratory evidence of immunity - Focus on areas at increased risk for measles
exposure, e.g. ED, UCC, FP
23Measles Vaccine
- Post-Exposure
- immunization of susceptible person within 72
hours of exposure usually prevents measles - still require furlough
24Rubella Vaccine
- Pre-placement immunization
- acceptable evidence of immunity
- positive serology
- documented receipt of vaccine
- offer vaccine to all non-immune HCWs (MMR)
- goal prevention of CRS
- females and males
- contraindicated during pregnancy
- immunity should be condition of employment
- HCW responsibility to avoid causing harm
25Mumps Vaccine
- Pre-placement immunization
- acceptable evidence of immunity
- positive serology
- documented receipt of 2 doses of vaccine
- documentation of laboratory confirmed mumps
- offer vaccine to all non-immune HCWs (MMR)
- contraindicated during pregnancy
26Mumps Vaccine
- Continuing surveillance
- Consider giving second dose to those born after
1969 who have received single dose - Consider immunizing those born before 1970 who do
not have laboratory evidence of immunity - Focus on areas at increased risk for mumps
exposure, e.g. ED, UCC, FP
27Mumps Vaccine
- Post-Exposure
- mumps immunization after exposure may not prevent
disease, but will confer protection against
future exposures
28Varicella Vaccine
- Pre-placement
- ascertain history of varicella/zoster
- definite history assume immune
- negative or uncertain antibody screen
- offer vaccine (2 doses) to HCWs who are
non-immune - contraindicated during pregnancy
- post-vaccine serology not recommended
- high efficacy of vaccine
- commercially available tests not sufficiently
sensitive for post-vaccine immunity
29Varicella Vaccine
- Adverse Events
- Post-vaccine rash
- at injection site cover and may continue to work
- non-injection site small number of papules/
vesicles and low grade fever - should not work
with high-risk patients, e.g. newborns,
obstetrics, transplants, oncology - Note varicelliform rashes within 2 weeks of
vaccine are usually due to wild-type virus
30Varicella Vaccine
- Post-Exposure management of vaccine recipients
- vaccine offers 70 - 90 protection against
varicella 95 protection against severe
varicella - observe daily at start of shift for signs/
symptoms of varicella day 10 to 21
31Varicella Vaccine
- Post-exposure vaccine use
- vaccine may prevent or reduce severity of
varicella if given within 72 hours of exposure - furlough still required day 10 to 21
- immunity for subsequent exposures
- outbreak control
32Pertussis Vaccine
- pertussis is a frequent cause of cough illness in
adolescents and adults major reservoir of
disease and source of transmission - nosocomial transmission to both patients and HCWs
occurs - prevention of secondary cases difficult as
symptoms are non-specific and diagnosis difficult
during catarrhal stage - a single dose of Tdap should be offered to all
HCWs who have not received an adolescent/adult
dose
33Meningococcal Disease
- Occupational Risk in Clinical HCWs
- There is no risk to HCWs from casual contact with
patients with meningococcal disease - Transmission to HCWs from patients with invasive
meningococcal disease may occur after intensive,
direct contact where the patients respiratory
secretions contaminate the HCWs oral/nasal
mucous membranes, e.g. intubation, airway
management, suctioning, close examination of
oropharynx, when facial protection not worn
34Meningococcal Disease
- Occupational Risk in Microbiology Laboratory
Technologists - several reports of invasive infection in
technologists - no identified breaches in laboratory technique
- many cases fatal
- rate of disease in microbiology laboratory
technologists dealing with N. meningitidis
cultures elevated (US, UK)
35Meningococcal Vaccine NACI
- routine vaccination of healthcare workers not
currently recommended - antibiotic chemoprophylaxis sufficient if
exposure occurs - research, industrial and clinical laboratory
personnel who are routinely exposed to N.
meningitidis cultures - quadrivalent A,C,Y,W-135 conjugate vaccine
- vaccine does not replace laboratory safety
standards serogropup B not in vaccine
36Hepatitis A Vaccine
- Pre-placement
- routine use of vaccine not recommended
- HCWs not at increased risk
- routine infection control practices prevent
transmission - counsel re prevention of transmission, i.e., hand
hygiene no eating, drinking, in patient care
areas
37Hepatitis A Vaccine
- Post-Exposure/Outbreak Control
- give vaccine for post-exposure prophylaxis as
soon as possible and within 7 days of exposure - not required for routine care of patients with
hepatitis A
38BCG Vaccine
- BCG vaccine does not provide permanent or
absolute protection against TB - loss of TST as marker of infection
- BCG vaccination of HCWs, including MLTs, may be
considered when all of the following exist - there is a considerable risk of exposure/
transmission of tubercle bacilli - a high percentage of strains are drug-resistant
- infection control measures have been ineffective
or are not feasible
39Tetanus/Diphtheria Vaccine
- Pre-placement
- immunization history
- immigrant HCWs may not have received primary
immunization series - maintain immunity with booster Td
(tetanus/diphtheria toxoid) every 10 years - One dose with acellular pertussis (Tdap) do not
need to wait until next booster due
40Routine Vaccines Strongly Recommended for HCWs
- Hepatitis B vaccine
- Annual Influenza vaccine
- Measles/Mumps/Rubella vaccine (MMR)
- Varicella vaccine
- Acellular Pertussis (Tdap)
- Meningococcal vaccine for microbiology MLTs
- Tetanus/Diphtheria vaccine (Td)
41HCWs and Vaccine Preventable Diseases
- HCWs are at risk for acquiring infections from
patients and, if infected, transmitting
infections to patients and initiating or
propagating outbreaks - The most effective way to prevent vaccine
preventable diseases is by ensuring immunity - Start with pre-clinical health care students
- Susceptible HCWs should be immunized with the
appropriate vaccine(s) unless there is a medical
contraindication - Personal belief systems against vaccines are not
acceptable when patient safety is at risk - The advice of a health care professional your
advice - is an important factor in vaccine
acceptance
42Essential References
- Canadian Immunization Guide, 7th edition, 2006,
National Advisory Committee on Immunization
Recommendations, Public Health Agency of Canada - OHA/OMA/MOHLTC Communicable Disease Surveillance
Protocols - www.oha.com ? Disease Protocols
43(No Transcript)