IMMUNIZATIONS FOR HEALTH CARE WORKERS

1
IMMUNIZATIONS FOR HEALTH CARE WORKERS

• Fran Ircink RN, NP
• Clinic Manager
• Employee Health Service
• February 20, 2008

2
Objectives

• Understand the importance of vaccines in general
• Review currently recommended vaccines for health
  care workers (HCWs)
• Highlight recent vaccine updates for HCWs

3
Vaccine History

• The impact of vaccination on the health
• of the worlds peoples is hard to exaggerate.
• With the exception of safe water, no other
• modality, not even antibiotics, had had such
• a major effect on mortality reduction and
• population growth.
• (Plotkin)

4
Definition of HCWs

• Physicians, nurses, NAs, MAs, EMS
• personnel, dental care professionals,
• students in the medical setting, other
• hospital staff (custodians, food service
• workers, volunteers, etc.)

5
Immunizations for HCWs

• Recommendations based on
• Nosocomial transmission documented
• HCWs at significant risk for acquiring or
  transmitting infection

6
Recommendations

• Hepatitis B
• Influenza
• MMR (measles , mumps, rubella)
• Varicella (chickenpox)
• Tetanus, diphtheria, pertussis
• Meningococcal

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Hepatitis B Disease

• Virus affecting the liver
• Can cause acute and chronic liver disease
• Can cause liver cancer
• Incubation period 6 weeks 6 months
• gt 2 billion persons worldwide infected with the
  hepatitis B virus at some time in their lives
• 350 million life-long carriers of disease and can
  transmit virus to others
• One million carriers die each year from liver
  disease and liver cancer

8
Hepatitis B Disease

• Number of new infections per year declined from
  average of 450,000 in the 1980s to about 80,000
  in 1999
• Greatest decline occurred among children and
  adolescents due to routine hepatitis B
  vaccination

9
Hepatitis B Transmission

• Transmission via blood/body fluid via
• mucocutaneous and contaminated sharps
• exposures
• 30 of infected without identifiable risk factors
• 5-10 infected become chronic carriers
• Transmission risk 100X gt than HIV

10
Hepatitis B Transmission

• Risk of infection related to degree of contact
  with blood in the work place and to hepatitis B e
  antigen (HBeAg) status of source person
• HBV can survive in dried blood at room
  temperature on environmental surfaces for at
  least 1 week
• Potential for HBV transmission through contact
  with environmental surfaces has been demonstrated
  in investigations of HBV outbreaks among patients
  and staff of hemodialysis units

11
Hepatitis B - HCWs

• HBV infection a well recognized occupational risk
  for HCP
• Prior to 1987 - 1997 100-200 HCWs died annually
  due to hepatitis B infection
• The annual number of occupational infections
  decreased 95 since hepatitis B vaccine became
  available in 1982, from gt10,000 in 1983 to lt400
  in 2001.

12
Hepatitis B Vaccine

• Recombinant vaccine licensed in 1986
• Effectiveness 95 in adults who completed 3 dose
  series
• Immunity probably lifelong
• OSHA Blood Borne Pathogen Standard (1991)
• Mandates that hepatitis B vaccine be made
  available at the employers expense to all HCWs
  who are occupationally exposed to blood or other
  potentially infectious materials

13
Hepatitis B Vaccine

• Post vaccine series antibody testing for HCWs
• recommended
• Check titer 1-2 months after dose 3
• If positive/immune no need for future doses or
  periodic blood tests to check for immunity
• 100 effective when develop positive antibody
  response after vaccination
• If negative/not immune repeat 3 dose series
• If positive/immune done
• If negative/not immune non-responder-susceptible
  to hepatitis B

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Influenza - Disease

• Two types - A and B that cause epidemic human
  disease
• Causes 36,000 deaths and over 200,000
  hospitalizations on average in the United States
  annually
• Incubation period 1-4 days. Can be infectious
  from the day before symptoms begin through
  approximately 5 days after illness onset
• Characterized by the abrupt onset of fever,
  myalgia, headache, malaise, nonproductive cough,
  sore throat, and rhinitis

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Influenza - Disease

• Usually resolves after 3-7 days cough and
  malaise can persist for gt2 weeks
• Can exacerbate underlying medical conditions
  (e.g., pulmonary or cardiac disease), lead to
  secondary bacterial pneumonia or primary
  influenza viral pneumonia, or occur as part of a
  coinfection with other viral or bacterial
  pathogens

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Influenza - Transmission

• Influenza viruses spread from person to
• person, primarily through respiratory droplet
• transmission (cough, sneeze) in close
• proximity to an uninfected person

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Influenza Vaccine - TIV

• Licensed in 1945
• Inactivated vaccine
• Effectiveness 70-90 in adults lt 65 yrs of age
  
• Contains killed viruses does not cause
  influenza in recipient
• Administered intramuscularly
• Approved for use among persons aged gt6 months,
  including those who are healthy and those with
  chronic medical conditions

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Influenza Vaccine - LAIV

• Licensed in 2007
• Live attenuated vaccine
• Effectiveness 92
• Contains live, attenuated viruses and, therefore,
  has a potential to produce mild signs or symptoms
  related to influenza virus infection
• Administered intranasally
• Approved only for use among healthy persons aged
  5-49 yrs of age

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Influenza Vaccine

• Both Vaccines
• contain strains of influenza viruses that are
  antigenically equivalent to the annually
  recommended strains one influenza A (H3N2)
  virus, one A (H1N1) virus, and one B virus
• grown in eggs
• administered annually to provide optimal
  protection
• against influenza virus infection
• A cost-benefit economic study estimated an
  average annual savings of 13.66/person
  vaccinated

20
Influenza Vaccine - HCWs

• Health care-associated transmission of influenza
  has been documented among many patient
  populations in a variety of clinical settings,
  and infections have been linked epidemiologically
  to unvaccinated health care workers
• HCWs are included in the high risk group for
  vaccination
• CDC - All health-care workers should be
  vaccinated against influenza annually to protect
  themselves, their patients, and communities
• Vaccination levels for health-care workers are
  typically lt40

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Influenza Vaccine - UWHC

• Influenza Vaccine Usage in UWHC Employees in 2007
• Patient Care Titles 64
• Non Patient Care Titles 62
• EHS Survey 2006 Reasons for not taking flu shot
• Received a flu shot elsewhere
  28
• Fear of injections
  6
• I never get the flu-dont need the shot
  39
• Contraindication to receiving flu shot
  4
• Fear of getting flu from the vaccine
  12
• Fear of side effects 11
  
• 
  

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Influenza Vaccine - Update

• New JCAHO Standard Effective 1/1/07 requires
• organizations to
• Establish annual influenza vaccination program
  that includes at least staff and licensed
  independent practitioners
• Provide influenza vaccinations on-site

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Influenza Vaccine - Update

• Educate staff about flu vaccination non-vaccine
  control measures (i.e., use of appropriate
  precautions) and diagnosis, transmission and
  potential impact of influenza
• Annually evaluate vaccination rates and reasons
  for non-participation in the organizations
  immunization program
• Implement enhancements to program to increase
  participation

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Influenza Vaccine - Update

• Infectious Disease Society of America (1/24/07)
• The top professional society of infectious
  diseases experts is insisting that all
  physicians, nurses, and other health workers
  caring for patients be vaccinated against
  influenza each year or decline in writing
• In 2005
• 7 states had legislation requiring annual
  influenza vaccination of health-care workers or
  the signing of an informed declination
• 15 states had regulations regarding vaccination
  of health-care workers in long-term--care
  facilities
• Future Considerations
• Mandatory / Declination Waivers

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Influenza - Update

• Flu Outbreak in 11 states
• New strain emerging not targeted by this years
  vaccine
• H3N2/Brisbane-like emerged near end of
  Australias flu season, too late to be included
  in the US vaccine
• So far, majority of flu cases caused by strains
  that are a good match to the vaccine and should
  provide some cross-protection against the new
  strain
• Not too late to get influenza vaccine

26
Measles, Mumps, Rubella (MMR)

• Licensed in 1971
• Live virus vaccine
• 2 doses MMR for HCWs born in 1957 or later
  without serologic evidence of immunity or prior
  vaccination
• For HCWs born prior to 1957, immune if
• Physician diagnosed disease
• Laboratory evidence of immunity
• Documentation of two doses MMR given on/after 1st
  birthday separated by 28 days or more

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Measles (Rubeola) - Disease

• Serious, acute, highly communicable rash
• illness which may result in ear infection
• (7-9), diarrhea (8), serious lung
• infection such as pneumonia (1-6) or
• inflammation of the brain (1 in 1,500)

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Measles Disease

• Worldwide
• One of the most infectious diseases in the world
• gt 90 of people who are not immune get measles
  if exposed to the virus
• gt 20 million people get sick with measles each
  year, nearly 345,00 cases are fatal

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Measles Rubeola - Disease

• U.S.
• Before measles immunization available, nearly
  everyone in the U.S. got measles. Average of 450
  measles-associated deaths reported each year
  between 1953 and 1963
• Up to 20 percent of persons with measles are
  hospitalized
• 3 of every 1,000 persons with measles will die in
  the U.S.
• Since 1997, lt 150 cases reported annually
• 85 of cases in 2004 were imported

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Measles - Transmission

• Spread by droplet and airborne (less common)
  routes
• Incubation period from exposure to rash 7-18 days
• Contagious from 4 days before until 4 days after
  onset of rash

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Measles - Vaccine

• Licensed in U.S. in 1963
• Live-virus vaccine
• Effectiveness - 95 one dose 99 two doses
• Given as single antigen or part of MMR vaccine
• 2 doses if born after 1956 given on/after 1st
  birthday
• In U.S., widespread use of vaccine led to a gt 99
  reduction in measles compared with the
  pre-vaccine era.
• If immunization stopped, measles would increase
  to pre-vaccine levels.

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Mumps - Disease

• Acute viral disease characterized by fever,
  swelling and tenderness of one or more of the
  salivary glands. Usually mild viral disease
• Incubation period range 12-25 days
• Estimated 212,000 cases occurred in the U.S. in
  1964
• Annual reported cases in U.S. below 300 between
• 2001- 2005
• 2006 multistate outbreak (mainly in Midwest) gt
  4,000 cases reported

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Mumps - Disease

• Complications
• Can include deafness, inflammation of the
  testicles, ovaries, or breasts respectively,
  pancreatitis, meningitis, encephalitis, and
  spontaneous abortion
• With the exception of deafness, complications
  more common among adults than children

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Mumps - Transmission

• Airborne transmission
• Droplet spread
• Direct contact with saliva of infected person
• Contact with contaminated fomites

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Mumps Vaccine

• Licensed in 1967
• Live virus vaccine
• Effectiveness 78-91 one dose 90 two
  doses
• In 1986 and 1987 resurgence of mumps with 12,848
  cases reported in 1987
• Since 1989, incidence of mumps declined with 266
  reported cases in 2001

36
Mumps Vaccine

• Recent mumps decrease probably due to children
  having received a second dose of mumps vaccine
  (as part of 2nd MMR) and the eventual development
  of immunity in those who did not gain protection
  after the first mumps vaccination
• If vaccination against mumps stopped, expected
  number of cases to climb back to pre-vaccine
  levels since mumps easily spread among
  unvaccinated persons

37
Mumps - Update

• Its the largest mumps epidemic in this country
  in more than two decades, with confirmed cases in
  at least eight states, most in the Midwest. The
  bulk of the cases are in Iowa, where up to 975
  people have been affected, and the virus is
  spreading.
• Online News Hours, April 20th 2006

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Mumps Vaccine -Update

• All persons who work in health-care facilities
  should be immune to mumps
• Adequate mumps vaccination for health-care
  workers born in or after 1957 consists of 2 doses
  of a mumps vaccine
• HCWs with no history of mumps vaccination and no
  other evidence of immunity should receive 2 doses
  (at a minimum interval of 28 days between doses)

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Mumps Vaccine -Update

• HCWs who have received only 1 dose previously
  should receive a second dose
• Birth before 1957 is only presumptive evidence of
  immunity, health-care facilities should consider
  recommending 1 dose of mumps vaccine for
  unvaccinated workers born before 1957 who do not
  have a history of physician-diagnosed mumps or
  laboratory evidence of mumps immunity

40
Rubella (German Measles)

• Mild febrile viral disease with a diffuse
  maculopapular rash resembling measles or scarlet
  fever
• Since 1996, gt 50 of the reported rubella cases
  have been among adults
• Since 2004 no longer endemic in U.S but still
  common in many parts of the world

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Rubella (German Measles)

• Complications
• Congenital Rubella Syndrome (CRS)
• Occurs in up to 90 of infants born to mothers
  infected with rubella during the first trimester
  of pregnancy
• Results in heart defects, cataracts, mental
  retardation, and deafness
• From 1998 through 2004 93 of infants born with
  CRS were born to foreign-born mothers

42
Rubella - Transmission

• Contact with nasopharyngeal secretions of
  infected people
• Droplet spread or direct contact with patients

43
Rubella - Vaccine

• Licensed in 1969
• Live virus vaccine
• Effectiveness 95 1st dose
• In 1964-1965, before rubella immunization was
  used routinely in the U.S., an epidemic of
  rubella resulted in
• estimated 20,000 infants born with CRS
• 2,100 neonatal deaths
• 11,250 miscarriages
• Of the 20,000 infants born with CRS, 11,600 were
  deaf, 3,580 were blind, and 1,800 were mentally
  retarded

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Rubella Vaccine

• Since 2001, fewer than 25 cases of rubella
  reported annually (99.8 decline compared with
  pre-vaccine era)
• Since 2001 an average of 1 case of CRS reported
• annually in the U.S.
• If stopped rubella immunization, immunity would
  decline and rubella would once again return,
  resulting in pregnant women becoming infected
  with rubella and then giving birth to infants
  with CRS

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Rubella - HCW

• Department of Health and Family Services
• Chapter 124 Hospitals
• Protection against rubella the hospitals
  employee health program shall include vaccination
  or confirmed immunity against rubella for
  everyone who has direct contact with rubella
  patients, pediatric patients or female patients
  of childbearing age

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Varicella (Chickenpox)

• Highly contagious viral disease
• Prior to varicella vaccine almost all persons in
  the U.S. had suffered from chickenpox by
  adulthood
• Usually mild, but may be severe in some infants,
  adolescents, and adults

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Varicella (Chickenpox)

• Complications
• Secondary bacterial infections
• Pneumonia
• Central nervous system involvement

48
Varicella - Transmission

• Person to person by
• Direct contact
• Droplet
• Airborne spread of vesicle fluid of patients with
• shingles (zoster)
• Indirect contact
• articles freshly soiled by discharges from
  vesicles and mucous membranes of infected people

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Varicella - Vaccine

• Licensed in 1995
• Live virus vaccine
• Effectiveness 80 - 90 1st dose 98 2nd dose
• Past Recommendations
• One dose 12 months 12 years
• 2 doses age 13 or older

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Varicella - Vaccine

• New Recommendations
• All children lt13 years of age should be
  administered routinely two doses of
  varicella-containing vaccine
• Second dose catch-up varicella vaccination is
  recommended for children, adolescents, and adults
  who previously had received one dose to improve
  individual protection against varicella

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Varicella - HCWs

• All HCWs should be immune to varicella
• Immune if
• 2 doses varicella given at least 28 days apart
• History of varicella or herpes zoster based on
  physician diagnosis, laboratory evidence of
  immunity, or laboratory confirmation of disease

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Tetanus, diphtheria, pertussis

• Pertussis Disease
• Whooping cough - highly contagious respiratory
  tract infection
• Initially resembles ordinary cold, may eventually
  turn more serious, particularly in infants
• Characterized by irritating cough becoming
  paroxysmal within 1-2 weeks and lasting 1-2
  months or longer
• Best prevention is through vaccine

53
Tetanus, diphtheria, pertussis

• Pertussis Disease
• Immunity from prior illness or childhood vaccine
  is not lifelong
• In recent years in U.S., pertussis recognized
  with increasing frequency in adolescents and
  adults
• 1010 cases reported in 1976 25,287 cases
  reported in 2004

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Tetanus, diphtheria, pertussis

• Pertussis Transmission
• Direct contact with discharges from respiratory
  mucous membranes of infected persons by the
  airborne and droplet routes usually through
  coughing and sneezing
• Incubation period 7-20 days
• Most contagious before the coughing starts and
  contagious for weeks after
• Secondary attack rates 50 - 100 in close
  contacts

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Tetanus, diphtheria, pertussis

• Pertussis Complications
• Bacterial pneumonia and rib fracture
• Infants are at highest risk for apnea, pneumonia,
  seizures, encephalopathy, and death

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Tetanus, diphtheria, pertussis

• Pertussis HCWs
• Health care environments - setting for a number
  of pertussis outbreaks
• resulting in transmissions to HCWs, vulnerable
  infants and other patients
• In last decade numerous nosocomial outbreaks
  reported

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Tetanus-diphtheria-acellular pertussis-Vaccine
(Tdap)

• Licensed in 2005
• Effectiveness 92
• Contain reduced pertussis antigen compared with
  pediatric formula and similar amounts of tetanus
  and diphtheria toxoids in adult dT booster
• Single dose booster for age 19-64
• HCWs working in hospitals or ambulatory care
  settings and have direct patient contact should
  receive a single dose of Tdap as soon as feasible
  if they have not previously received Tdap
• Priority given to vaccination of HCWs with direct
  contact with infants aged lt12 months. Interval
  of 2 or more years from the last dose of Td
  recommended for the Tdap dose

58
Meningococcol Disease

• Acute bacterial disease caused by Neisseria
  Meningitidis characterized by
• sudden onset of fever, intense headache, nausea
  and often vomiting, stiff neck and frequently a
  petechial rash
• In the U.S., meningococcal disease is usually
  caused by groups A, B, C, Y, and W-135 of the
  meningococcus bacteria

59
Meningococcol Disease

• Approximately 2,600 cases of meningococcal
  meningitis in the U.S. each year mainly in
  children less than five years old
• Children younger than two years old have the
  highest incidence, with a second peak incidence
  between 15 to 24 years of age

60
Meningococcol Disease

• 11-19 of survivors deafness, other neurologic
  impairment, and impaired circulation leading to
  gangrene and amputation of limbs
• Death occurs in 10 to 14 of people with
  meningococcal disease
• highest in infants and adolescents

61
Meningococcol Transmission

• Close contact with direct contact including
  respiratory droplets from aerosols and secretions
  from nose and throat of infected
• people (patients or asymptomatic carriers)
• Incubation period 2-10 days, commonly 3-4 days

62
Meningococcol Vaccine - HCWs

• Although N. meningitidis regularly isolated in
  clinical laboratories, it has infrequently been
  reported as a cause of laboratory-acquired
  infection
• Two probable cases of fatal laboratory-acquired
  meningococcal disease and the results of an
  inquiry to identify previously unreported cases
  reported
• The findings indicate that N. meningitidis
  isolates pose a risk for microbiologists and
  should be handled in a manner that minimizes risk
  for exposure to aerosols or droplets

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Meningococcol Vaccine

• MPSV4 Licensed in 1981 Ages 2-10 and gt55
• 85-100 protection for 35 years in older
  children and adults
• High risk need revaccination every 35 years
• Not recommended and should not be administered
  routinely for adolescents ages 1112 or for
  adolescents entering high school. Adolescents in
  these age groups are recommended only to receive
  MCV4
• An acceptable alternative for persons at elevated
  risk ages 1154 years where MCV4 is not available

64
Meningococcol Vaccine

• MCV4 Licensed in 2005 Ages 11-55
• Need for revaccination not yet known
• Higher production of antibodies and longer
  duration of protection and similar efficacy
  compared to MPSV4 expected in adolescents and
  adults
• Both current vaccines effective against A,C,Y and
  W-135. Not effective against group B
• Recommended for microbiologists who are routinely
  exposed to isolates of N. meningitidis that might
  be aerosolized

65
Immunizations of HCWs - UWHC

• Immunization recommendations have become more
  comprehensive and standardized over the years
• All new applicants screened for appropriate
  immunizations
• Old timers may not be up to date
• Catch ups via periodic chart audits
• episodic visits

66
Future Considerations

• Greater emphasis on making sure HCWs adhere to
  current vaccine recommendations
• Better documentation of HCWs vaccination status