Immunization of Health Care Workers: more than just influenza

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Immunization of Health Care Workersmore than
just influenza

• Mary Vearncombe, MD, FRCPC
• Medical Director, Infection Prevention Control
• Sunnybrook Health Sciences Centre, Toronto

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Disclosure

• No conflict of interest to disclose.

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Objectives

• To identify vaccine preventable diseases relevant
  to hospital occupational health
• To determine HCW susceptibility/immunity
• To determine appropriate immunization and serology

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HCW 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

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HCW 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

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HCW 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

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HCW 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

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Occupational 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

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HCW 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

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Hepatitis 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

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Hepatitis 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

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Hepatitis 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

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Hepatitis 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

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Influenza 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

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Influenza 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

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Influenza 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

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Influenza 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

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Influenza 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?

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Influenza 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

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Annual 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.

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Measles 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

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Measles 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

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Measles Vaccine

• Post-Exposure
• immunization of susceptible person within 72
  hours of exposure usually prevents measles
• still require furlough

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Rubella 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

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Mumps 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

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Mumps 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

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Mumps Vaccine

• Post-Exposure
• mumps immunization after exposure may not prevent
  disease, but will confer protection against
  future exposures

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Varicella 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

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Varicella 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

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Varicella 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

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Varicella 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

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Pertussis 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

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Meningococcal 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

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Meningococcal 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)

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Meningococcal 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

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Hepatitis 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

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Hepatitis 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

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BCG 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

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Tetanus/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

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Routine 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)

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HCWs 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

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Essential 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

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