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Title: VACCINES FOR HEALTHCARE WORKERS


1
VACCINES FORHEALTHCARE WORKERS
  • David Jay Weber, M.D., M.P.H.
  • Professor of Medicine, Pediatrics, Epidemiology
  • Associate Chief of Staff
  • University of North Carolina at Chapel Hill

2
VACCINE SUCCESS STORIES
3
10 GREAT PUBLIC HEALTH ACHIEVEMENTS, US, 1900-1999
  • Immunization
  • Motor vehicle safety
  • Safer workplaces
  • Control of infectious diseases
  • Decline in deaths from coronary artery disease
    and stroke
  • Safer and healthier foods
  • Healthier mothers and babies
  • Family planning
  • Fluoridation of drinking water
  • Recognition of tobacco use as a health hazard

CDC. MMWR 199948241-243
4
VACCINE PREVENTABLE DISEASES
14 indigenous, 26 imported
MMWR 200857903-913
5
INACTIVATED POLIO VACCINE(SALK) PROGRAM, 1955
6
IMPACT OF DISCONTINUING A VACCINE PROGRAM
DIPHTHERIA IN THE RUSSIAN FEDERATION
Markina SS, et al. J Infect Dis 2000181(suppl
1)S27-34
7
MAJOR INFECTIOUS RISKS FOR HEALTHCARE WORKERS
  • Airborne or droplet transmitted diseases
  • Varicella, pertussis, meningococcal infection,
    influenza, mumps, measles, others (e.g., RSV)
  • Bloodborne pathogens
  • Via percutaneous or mucosal exposure (gt30
    documented)
  • Major risks HBV, HCV, HIV
  • Contact transmitted diseases (direct, indirect)
  • C. difficile, MRSA, herpes simplex, syphilis,
    adenovirus (keratoconjunctivitis)

8
WHY IMMUNIZATION OF HEALTHCARE WORKERS IS SO
IMPORTANT!!!
  • Infection introduced or propagated by infected
    HCWs leading to large outbreaks
  • Mumps, measles, rubella, varicella, pertussis,
    influenza
  • Asymptomatic or minimally symptomatic patients
    may transmit infection
  • Influenza, chronic hepatitis B (gt25 outbreaks of
    HCW-to-patient transmission documented)
  • Patients in prodromal phase of illness may
    transmit infection
  • Measles, varicella

9
WHY IMMUNIZATION OF HEALTHCARE WORKERS IS SO
IMPORTANT!!!
  • HCWs may acquire infection entering room after
    the infectious patient has left
  • Measles (up to 75 minutes)
  • Aerosolization of infective fluids may lead to
    infection
  • Meningococcus (spinning CSF in laboratory)
  • Airborne infections may result from autopsies
    (source cadaver)
  • Varicella (Paul N, Jacob ME. Clin Infect Dis
    200643599-601)

10
UNC OHS EVALUATIONS, 2006-07
11
PROTECTING HCWs
  • Immunizations Pre- and post-exposure
  • Hand hygiene Before and after direct patient
    contact
  • Personal protective equipment Gloves, masks/N95
    respirators, gowns
  • Patient isolation precautions
  • Contact via direct or indirect contact gloves,
    gowns
  • Droplet via large droplets (lt3 feet) mask,
    private room
  • Airborne via small droplets (gt3 feet) N95
    respirator (TB) or surgical mask, private room,
    negative air pressure, gt12 air exchanges per
    hour, direct out exhausted air

12
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13
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14
RECOMMENDED VACCINES FOR HCWs CDC, ACIP, HICPAC
  • Measles (MMR preferred)
  • Mumps (MMR preferred)
  • Rubella (MMR preferred)
  • Varicella (V)
  • Hepatitis B (OHSA required)
  • Influenza
  • Tetanus (Tdap)
  • Diphtheria (Tdap)
  • Pertussis (Tdap)
  • Required at UNC

15
ASSURING HCW COVERAGE
  • Healthcare facility employees - requirement for
    employment
  • Medical staff - include in credentialing process
  • Students - require for attending class
  • Volunteers - require
  • Contract workers - require in contract
  • Emergency responders - require

16
SPECIAL USE VACCINES IN HCWs
  • Anthrax Post-exposure
  • BCG Pre-exposure (high risk)
  • Hepatitis A Post-exposure, outbreak, research,
    travel
  • Japanese encephalitis Research, travel
  • Meningococcal Outbreak, laboratory (spinning
    CSF), travel
  • Polio Research, travel
  • Rabies Post-exposure, research, travel
  • Typhoid Research, travel
  • Vaccinia Pre-exposure?, post-exposure, research
  • Yellow fever Research, travel

17
PROVIDING VACCINES
  • Employee name and identification number
  • Vaccine
  • Dose, Site, Route of Administration
  • Date given
  • Manufacturer, Lot number
  • Name, title, address of person providing vaccine
  • Date next dose due
  • Signed informed consent

18
PROVIDING VACCINES SEROLOGIC TESTING
  • Pre-immunization testing for immunity
  • Do not obtain serological screening for immunity
    unless cost-effective or vaccine contraindicated
    (e.g., MMR, V)
  • Post-immunization testing for immunity
  • Indicated for hepatitis B (all HCWs), rabies
    (high risk exposure situation)
  • Consider persons with an indeterminate antibody
    level susceptible

19
PREGNANCY
  • Pregnancy test prior to immunization not required
    (except for vaccinia)
  • Indicated vaccines Influenza (inactivated), Td
    (Tdap?)
  • Use if warranted (benefit exceeds risk)
  • Inactivated vaccines (e.g., pneumococcal,
    hepatitis A, hepatitis B, meningococcal, rabies)
  • Contra-indicated (No reports of fetal toxicity)
  • Live attenuated vaccines Mumps, measles,
    rubella, varicella, influenza, typhoid
  • Contra-indicated (Fetal toxicity reported)
  • Vaccinia

20
SPECIAL CONSIDERATIONS FOR HCWs WORK
RESTRICTIONS POST-IMMUNIZATON
  • Live attenuated nasal influenza Restrict from
    working in a stem cell transplant unit (i.e.,
    protected environment) for 7 days
  • Vaccinia Lesion must be maintained under a
    porous dressing and under clothes
  • Varicella Furlough if generalized rash develops
  • No other work restrictions recommended (i.e.,
    immunized employees may work with neonates,
    pregnant women, and immunocompromised patients)

21
MUMPS
  • Microbiology
  • Paramyxovirus, genus rubulavirus (single-stranded
    RNA)
  • Single antigenic type
  • Epidemiology
  • Incubation period 16-18 days (range, 14-25
    days)
  • Prevalence Generally 200-300 cases in US per
    year
  • Reservoir Humans only
  • Distribution Worldwide
  • Transmission Droplet contact (spread through
    contact with respiratory secretions and saliva or
    via fomites)

22
MMWR 200655(No. 53)
23
CDC. MMWR 200655366-68
24
MUMPS VACCINE
  • Universal vaccine (attenuated virus vaccine)
  • Ages 12-15 months follow-up MMR at 4-6 years
  • Immunity (HCWs)
  • MD diagnosed disease, positive serology, 2 doses
    (1 dose if born before 1957, except in outbreak
    setting provide 2nd dose)
  • Efficacy
  • 1 dose 80 (range, 60-90) 2 doses 90
  • Administration (MMR preferred)
  • 0.5 mL SC
  • Contraindications
  • Pregnancy immunocompromised allergy to eggs,
    gelatin or neomycin

25
MEASLES
  • Microbiology
  • Paramyxoviridae, genus morbillivirus (single
    stranded RNA)
  • Single antigenic type
  • Epidemiology
  • Incubation period 10-14 days (range, 7-18 days)
  • Prevalence lt100 cases per year (usually
    imported)
  • Reservoir Humans only
  • Distribution Worldwide
  • Transmission Airborne

26
MMWR 200655(No. 53)
27
MEASLES OUTBREAKS
  • More than 30 reports in the literature
  • Between 1985 and 1989, 3.5 of all case acquired
    in a medical facility (Atkinson Wl, et al. Am J
    Med 199191(S 3B)320-24S
  • Investigation of individual outbreaks has
    revealed that 17 to 53 were acquired in a
    medical facility)
  • Nosocomial outbreaks have led to hospitalization
    of medical staff and severe complications in
    infected patients including death
  • Cost of outbreaks has ranged from 28,000 to more
    than 100,000

28
MEASLES VACCINE
  • Universal vaccine (attenuated virus vaccine)
  • Ages 12-15 months follow-up MMR at 4-6 years
  • Immunity (HCWs)
  • MD diagnosed disease, positive serology, 2 doses
  • Administration (MMR preferred)
  • 0.5 mL SC
  • Contraindications
  • Pregnancy immunocompromised allergy to eggs,
    gelatin, or neomycin

29
RUBELLA
  • Microbiology
  • Togaviridae, genus rubivirus (small enveloped
    RNA)
  • Single antigenic type
  • Epidemiology
  • Incubation period 14-17 days (range 14-21 days)
  • Prevalence lt10 cases per year
  • Reservoir Humans only
  • Distribution Worldwide
  • Transmission Droplet

30
MMWR 200655(No. 53)
31
RUBELLA VACCINE
  • Universal vaccine (attenuated virus vaccine)
  • Ages 12-15 months follow-up MMR at 4-6 years
  • Immunity (HCWs)
  • Positive serology, 1 dose
  • Administration (MMR preferred)
  • 0.5 mL SC
  • Contraindications
  • Pregnancy immunocompromised persons allergy to
    gelatin

32
VARICELLA
  • Microbiology
  • Lipid enveloped DNA virus (pox virus)
  • Single antigenic type
  • Epidemiology
  • Incubation period 14-16 days (range, 8-21 days)
  • Prevalence Formerly near universal disease
    prior to vaccine 4 million cases per year with
    11,000 hospitalizations and 100 deaths (highest
    risk of death neonates and immunocompromised)
  • Reservoir Humans only
  • Distribution Worldwide
  • Transmission Airborne

33
DECLINING VZV IN THE US
34
DECLINING VZV IN THE US
35
ISSUES FOR HOSPITALS
  • Multiple outbreaks reported in hospitals
  • Airborne transmission
  • Highly communicable
  • Serious disease in immunocompromised persons
  • Infection in pregnant woman may lead to
    congenital malformations
  • Seropositivity lower in persons born in tropical
    countries
  • For near future, how to manage HCWs with remote
    immunization

36
CHICKENPOX FROM AN IMMUNO-SUPPRESSED INDEX CASE
WITH ZOSTER
Faizallah R, et al. BMJ 19822851022-1023
37
Gustafson TL, et al. Pediatr 198270550-6
38
VARICELLA VACCINE
  • Universal vaccine (attenuated virus vaccine)
  • Ages 12-15 months follow-up at 4-6 years
  • Immunity (HCWs)
  • MD diagnosed disease, immunization, positive
    serology, report of varicella or zoster?
  • Administration
  • 0.5 mL SC deltoid

39
VARICELLA VACCINE IN HCWs
  • To prevent disease and nosocomial spread of VZV,
    healthcare institutions should ensure that all
    HCWs have evidence of immunity to varicella
  • Birth before 1980 is NOT considered evidence of
    immunity
  • Serologic screening before vaccination of
    personnel who have a negative or uncertain
    history of varicella and are unvaccinated is
    likely to be cost effective
  • Institutions may elect to test all HCWs
    regardless of disease history because a small
    proportion of persons with a positive history
    might be susceptible
  • Institutions should consider precautions for
    personnel in whom rash occurs after vaccination.
    HCWs in who a vaccine related rash occurs should
    avoid contact with persons without evidence of
    immunity who are at risk for severe disease

40
PROOF OF IMMUNITY
41
HEPATITIS B
  • Microbiology
  • DNA virus
  • Single antigenic type
  • Impact Causes acute and chronic hepatitis
  • Epidemiology
  • Prevalence 1.2 million Americans have chronic
    HBV infection
  • Reservoir Humans only
  • Distribution Worldwide
  • Transmission Blood (percutaneous, transfusion,
    organs), sexual, vertical (mother-to-child),
    horizontal

42
HEPATITIS BISSUES FOR HEALTHCARE
  • Hepatitis B stable in the environment for at
    least 1 week
  • Highly infectious
  • Risk via needlestick
  • HBeAg positive source 22.0 to 30.0
  • HBeAg negative source 1.0 to 6.0
  • Examples of transmission
  • Nurse with eczema while obtaining blood gases
  • File cards used in a microbiology laboratory
    (paper cuts)
  • Fomites Glucose measuring devices (multiple),
    multi-dose medication vials, vaccine
    administration devices

43
Hepatitis B by Year, United States, 1966 - 2000
HBsAg screening of pregnant women recommended
Infant immunization recommended
Vaccine licensed
OSHA Rule enacted
Adolescent Immunization recommended
Decline among injecting drug users
Decline among MSM HCWs
Source NNDSS
44
Estimated Incidence of HBV infections among HCP
and General Population, United States, 1985-1999
Healthcare Personnel
General U.S. Population
45
HEPATITIS B VACCINE
  • Dose Recombivax 1.0 ml (10 ug), Engerix 1.0 ml
    (20 ug)
  • IM dose into deltoid 1-1.5 needle, 20-25 gauge
  • May mix and match vaccine from different
    companies
  • Schedule 0, 1, 6 mo OR 0, 1, 2, 12 mo (more
    rapid antibody rise)(Engerix)
  • Prior to administration do not routinely perform
    serologic screening for hepatitis B unless cost
    effective
  • After 3rd dose, test for immunity (i.e., gt10
    mIU/mL)OSHA required if inadequate provide 3
    more doses and test again for immunity if
    inadequate consider as nonresponder
  • If non-immune after 6 (or 3) doses, test for HBsAg

46
INFLUENZA
  • Microbiology
  • Single stranded RNA virus
  • Types A (epidemic, pandemics), B (epidemics), C
    (mild)
  • Epidemiology
  • Incubation period 2 days (range, 1-4 days)
  • Prevalence 10-20 attack rate each year
  • Reservoir Birds, humans
  • Distribution Worldwide
  • Transmission Droplet contact

47
Influenza Disease Burden to U.S. Societyin an
Average Year
Deaths 25,000 - 72,000
Hospitalizations 114,000 - 257,500
Physician visits 25 million
Infections and illnesses 50 - 60 million
Thompson WW et al. JAMA. 2003289179-86. Couch
RB. Ann Intern Med. 2000133992-8. Patriarca PA.
JAMA. 199928275-7. ACIP. MMWR.
200453(RR06)1-40.
48
INFLUENZA VACCINE INDICATIONS
  • Children aged 6 mo to 18 years
  • Women who will be pregnant during influenza
    season
  • Persons aged gt50 years
  • Children (6 mo18 yr) receiving aspirin (risk for
    Reye syndrome)
  • Adults and children with chronic
    cardio-respiratory illnesses
  • Adults and children with chronic metabolic
    disorders, immune deficiencies, or
    immunosuppression
  • Adults and children with any chronic condition
    that compromised respiratory tract function or at
    increased risk for aspiration
  • Persons who live with people at high risk for
    influenza complications
  • Residents of extended care facilities of any age
  • Healthcare workers

CDC/ACIP. MMWR 200857(RR-7)
49
INFLUENZA VACCINE STRAINS
50
AVAILABLE INFLUENZA VACCINES
CDC. MMWR 200453
51
AVAILABLE INFLUENZA VACCINES
52
INFLUENZA VACCINE (Inactivated)CONTRAINDICATIONS
PRECAUTIONS
  • Contraindication
  • Hypersensitivity to eggs or vaccine components
  • Precaution
  • Moderate-to-severe acute febrile illness
    (postpone vaccine)
  • Untrue (vaccine may be administered)
  • Pregnancy or breastfeeding
  • Nonsevere allergy (e.g., contact) to latex or
    thimerosal
  • Concurrent administration of coumadin or
    aminophylline

53
INFLUENZA VACCINE (Live)CONTRAINIDATIONS
  • lt2 years or gt50 years of age
  • Reactive airway disease, asthma, or chronic
    cardio-pulmonary disorders
  • Children receiving aspirin
  • Persons with a history of Guillain-Barre syndrome
  • Pregnant women
  • Hypersensitivity to eggs or vaccine components
  • Persons with contact with severely
    immunocompromised persons in the next 7 days

54
INFLUENZA IN HEALTHCARE FACILITIES
  • More than 25 outbreaks described in literature in
    acute care hospitals
  • Infected staff may initiate outbreak or aid in
    propagation
  • HCW infection may lead to absenteeism and
    disruption of health care
  • Attack rates in HCWs have ranged from 25 to 80
  • More than 15 outbreaks described in literature in
    extended care facilities
  • Important morbidity and mortality among residents
    may result
  • High rates of immunization (gt60) among staff may
    lead to decreased attack rate in residents

55
Indirect Benefits of Influenza Vaccination of
Health Care Workers
Mortality of residents was significantly reduced
(10 vs 17) in nursing homes where the staff
was vaccinated (SV) compared to facilities where
they were not (S0)
20
Vaccine groups
SV (n490) SO (n561)
(P0.0009)
Total patient mortality ()
10
0
0
20
40
60
80
100
120
140
Time in days
Potter J et al. J Inf Dis. 19971751-6.
56
Indirect Benefits of Influenza Vaccination of
Health Care Workers
  • 20 long-term care facilities, stratified cluster
    randomization staff influenza vaccination or not
  • Resident mortality odds ratio 0.58 (95 CI 0.40,
    0.84) p0.014

Resident mortality ()
n 688
n 749
No significant difference in residents positive
for influenza Vaccine hospitals 5.4 no
vaccine hospitals 6.7
Carman WF et al. Lancet. 200035593-7.
57
REDUCTION IN OUTCOMES IN HCWS RECEIVING INFLUENZA
VACCINE
Talbot TT, Weber DJ, et al. ICHE 200526882-890
58
BARRIERS AND SOLUTIONS TO HCW INFLUENZA VACCINE
CONCERNS
  • Access to vaccine, inconvenience
  • Off-hours clinics
  • Use of mobile vaccination carts
  • Vaccination at staff and department meetings
  • Cost
  • Provision of vaccine free of charge
  • Concerns for adverse events
  • Targeted education, including specific
    information to dispel vaccine myths

59
BARRIERS AND SOLUTIONS TO HCW INFLUENZA VACCINE
CONCERNS
  • Fear of needles
  • Use of LAIV for eligible HCWs
  • Other
  • Strong and visible leadership
  • Visible vaccination of key leaders
  • Surveillance of HCW-associated influenza
  • Accurate tracking of individual and unit-based
    compliance
  • Active declination for HCWs who do not wish to be
    or cannot be vaccinated

60
ARGUMENTS IN FAVOR AND AGAINST CONDITIONAL
(MANDATORY) USE OF INFLUENZA VACCINE IN HCWs
  • In favor of conditional vaccine use
  • Key principle First do no harm (nosocomial
    transmission linked to infected staff)
  • Protects the staff and their families
  • Institutional benefit Decreased absenteeism,
    cost effective
  • Against conditional vaccine use
  • Feasibility Difficult to capture all employees
    each year
  • May result in staff dissatisfaction
  • Union concerns

61
INFLUENZAHICPAC RECOMMENDATIONS, 2004
  • Vaccinate per ACIP high risk groups in acute-care
    settings (IA)
  • Vaccinate per ACIP residents of ECFs (IA)
  • Place patients with influenza in private room
    (IB)
  • Wear a mask with 3 feet of a patient with
    influenza (IB)
  • Practice hand hygiene (IA)
  • Use rapid tests on patients with suspected
    influenza (IB)
  • Use antiviral as prophylaxis to all patients
    without illness during an outbreak for a minimum
    of 2 weeks (IA)
  • Do not allow contact between persons at risk for
    influenza and patients or personnel taking
    antiviral prophylaxis during and for 2 days after
    therapy discontinued (IB)

62
INFLUENZAHICPAC RECOMMENDATIONS - OHS, 2004
  • Provide influenza vaccine to HCWs (IA)
  • Offer antiviral prophylaxis to unvaccinated HCWs
    during an outbreak (IA)
  • Consider antiviral prophylaxis to all HCWs,
    regardless of vaccination status, if outbreak
    caused by varient of influenza not well matched
    to vaccine (1B)
  • Furlough employees with influenza (IB)

63
Hampson AW, Mackenzie JS. MJA 2006185S39-43
64
PANDEMIC INFLUENZA PLANNING CHALLENGES
  • Pandemic strain unknown (likely H5N1 but many
    others possible)
  • The ability of the virus to rapidly spread
    worldwide
  • Simultaneous outbreaks throughout the US,
    limiting the ability of an jurisdiction to
    provide assistance to other areas
  • People may be asymptomatic while infectious
  • Long duration (gt2 years) and multiple waves
  • Enormous demands on the healthcare system
  • Need for surge capacity Medications,
    ventilators, beds, personnel
  • Personnel Exhaustion, concerns about infection
  • Maintaining social distancing
  • Providing adequate antivirals including
    distribution/allocation
  • Vaccine development and distribution/allocation

65
DIFFERENCES BETWEEN SEASONALAND PANDEMIC
INFLUENZA
66
DIFFERENCES BETWEEN SEASONALAND PANDEMIC
INFLUENZA
Modified from www.pandemicflu.gov
67
POTENTIAL USES OF VACCINESAND ANTIVIRALS
  • Vaccines
  • Develop vaccine when pandemic hits
  • Pre-pandemic stockpile of likely strain
  • Pre-pandemic primer
  • Pre-pandemic primer and boost
  • Early initiation of vaccine from stockpile
  • Antivirals
  • Treatment
  • Post-exposure prophylaxis
  • Seasonal prophylaxis

68
HHS VACCINE PRIORITIES
69
PERTUSSIS
  • Microbiology
  • Gram negative bacteria
  • Epidemiology
  • Incubation period 9-10 days (range, 6-20 days)
  • Prevalence Most common vaccine preventable
    disease (estimated at gt1,000,000 cases per year)
  • Reservoir Humans only
  • Distribution Worldwide
  • Transmission Droplet

70
MMWR 200655(No. 53)
71
(No Transcript)
72
Pertussis Stages, Communicability
period of communicability
Catarrhal runny nose, sneezing, low- grade
fever, mild cough Paroxysmal severe spasms of
cough, thick mucus, whoops, vomiting,
exhaustion Convalescent gradual recovery with
less frequent and less severe cough
paroxysmal cough onset
exposure
2
4
-1
1
3
5
6
8
9
10
11
12
-2
0
7
weeks of cough
catarrhal stage
paroxysmal stage
convalescent stage
CDC. Epidemiology and Prevention of
Vaccine-Preventable Diseases. PHF 2004
73
Pertussis Spectrum of Disease
CLASSIC
EXHAUSTION PROLONGED COUGH PAROXYSMAL COUGH
INSPIRATORY WHOOP POSTTUSSIVE VOMITING
Disease Severity
DIFFICULTY SLEEPING DIFFICULTY BREATHING POSTTUSSI
VE GAGGING
PERSISTENT COUGH WHOOP MAY BE
ABSENT INDISTINGUISHABLE FROM URI
MILD/ATYPICAL
Hewlett EL, Edwards KM. NEJM. 20053521215-1222.
Lee GM et al. CID. 2004391572-1580. Wirsing
von Konig CH et al. Lancet Infect Dis.
20022744-750. Centers for Disease Control and
Prevention. Epidemiology and Prevention of
Vaccine-Preventable Diseases. Atkinson W et al,
eds. 8th ed. 2004 75-76.
74
CDC. MMWR 2006(RR-17)
75
CDC. MMWR 2006(RR-17)
76
OUTBREAK MAYO CLINIC, ROCHESTER, MN
Leekha S, et al. SHEA (abstract), 2206
77
PERTUSSIS VACCINE
  • Provided as Tdap for adolescents and adults
  • Provide to HCWs unless Td within past 2 years or
    vaccine contra-indication
  • Immunity (HCWs)
  • Tdap vaccine within past 10 years
  • Administration
  • 0.5 mL IM

78
VACCINIA
  • Microbiology
  • Exact source unclear
  • Single antigenic type
  • Epidemiology
  • Prevalence Eradicated (potential bioterrorist
    agent)
  • Reservoir Humans
  • Distribution US, Russia, others?
  • Transmission Airborne contact

79
Airborne Spread of Smallpox in the Meschede
Hospital
Fenner. 1988.Fig. 4.9
80
VACCINIA VACCINE
  • Special use vaccine
  • Bioterrorist attack Pre- and post-exposure
  • Care for patients with active vaccinia lesion
  • Post-exposure prophylaxis for monkey pox exposure
  • Immunity (HCWs)
  • Proof of vaccination with 10 years
  • Administration
  • Vaccination

81
Portrait of Edward Jenner (1749-1823)
Ann Intern Med 1997127635-42
82
PROTECTIVE EFFECT OF INFANT IMMUNIZATION AGAINST
MORTALITY BY AGE OF INFECTION
Deaths per 100 Cases
Hanna, W. 1913, Studies in smallpox and
Vaccination. Bristol, Wright.
83
Vaccination With the Bifurcated Needle
Henderson JAMA 28119992127-2137
84
EVOLVING PRIMARY VACCINATION
85
VACCINIA VACCINEPRECAUTONS AND CONTRAINDICATIONS
  • Severe allergic reaction to prior dose of vaccine
  • History or presence of eczema, other skin
    conditions
  • Pregnancy (children in the household is not a
    contraindication)
  • Altered immocompetence
  • HIV, Leukemia, lymphoma, generalized malignancy
  • Solid organ transplant, BMT
  • Corticosteroids, alkylating agents,
    antimetabolites, radiation
  • Cardiac disease
  • Allergies
  • Neomycin, polymyxin b, tetracyclines, streptomycin

86
VACCINIA VACCINEPREVENTION OF CONTACT
TRANSMISSION
  • Vaccinia virus can be cultured from primary
    vaccination site beginning at the time of
    development papule (2-5d after vaccination)
  • Transmission via direct skin contact may occur
  • Vaccination site should be covered with a porous
    bandage until scab has separated and underlying
    skin has healed (do not use an occlusive
    dressing)
  • Use impermeable bandage when bathing
  • Vaccinated HCWs may continue to work (vaccination
    site covered with sterile gauze and semipermeable
    dressing, and practice of good handwashing)

87
Adverse Reaction Rates
Adapted from CDC.Vaccinia (smallpox vaccine)
recommendations of the ACIP, 2001. MMWR
200150(RR-10)
88
(No Transcript)
89
VACCINIA USE IN A HCWPREVENTION OF CONTACT
TRANSMISSION
  • Vaccinia virus can be cultured from primary
    vaccination site beginning at the time of
    development papule (2-5d after vaccination)
  • Transmission via direct skin contact may occur
  • Vaccination site should be covered with a porous
    bandage until scab has separated and underlying
    skin has healed (do not use an occlusive
    dressing)
  • Use impermeable bandage when bathing
  • Vaccinated HCWs may continue to work (vaccination
    site covered with sterile gauze and semipermeable
    dressing, and practice of good handwashing)

90
ADVERSE EVENTS REPORT (AERs) FOLLOWING CIVILIAN
SMALLPOX VACCINATIONS
N37,802 immunizations
MMWR 200352639
91
MANAGEMENT OF EXPOSED, INCUBATING OR ILL EMPLOYEES
92
OCCUPATIONAL HEALTH MANAGEMENT
  • Mumps
  • Exposure Close patient contact (lt3 feet)
  • Post-exposure Exclude from the 12th days from
    first exposure through 25th day after last
    exposure
  • Active disease Exclude for 5 days from onset of
    parotitis
  • Measles
  • Exposure Within same room as infectious patient
  • Post-exposure Exclude from the 5th day from
    first exposure through the 21st day after last
    exposure
  • Active disease Exclude for 7 days after the rash
    appears

Serosusceptible and not wearing appropriate PPE
93
OCCUPATIONAL HEALTH MANAGEMENT
  • Rubella
  • Exposure Close patient contact (lt3 feet)
  • Post-exposure Exclude from 7th day after first
    exposure through 21st day after last exposure
  • Active disease Exclude until 5 days after rash
    appears
  • Varicella
  • Exposure Within same room as infectious patient
  • Post-exposure Exclude from the 8th day after
    first exposure through 21st day after last
    exposure (28th day if VZIG provided)
  • Active disease Exclude until lesions dried and
    crusted

Serosusceptible and not wearing appropriate PPE
94
OCCUPATIONAL HEALTH MANAGEMENT
  • Zoster
  • Exposure Within same room as patient (lesions
    not covered by an occlusive bandage) or direct
    contact with lesions
  • Post-exposure Exclude from the 8th day after
    first exposure through 21st day after last
    exposure (28th day if VZIG provided)
  • Active Allow to work if lesions can be covered
    with a sterile dressing and located under
    clothing (avoid working with severely
    immunocompromised patients)

Serosusceptible and not wearing appropriate PPE
95
OCCUPATIONAL HEALTH MANAGEMENT
  • Hepatitis B
  • Exposure Percutaneous, mucus membrane or
    non-intact skin exposure to a contaminated body
    fluid (blood, blood contaminated fluid, CSF,
    pleural, pericardial, semen, vaginal, amniotic,
    peritoneal not sweat, saliva, urine, stool,
    vomitus)
  • Post-exposure No exclusion necessary
  • Active disease While acutely ill
  • Chronic carrier Set up expert panel (may be
    required by law) if performing invasive
    procedures (surgery, dentistry, obstetrics)

96
OCCUPATIONAL HEALTH MANAGEMENT
  • Pertussis
  • Exposure Close contact contact with
    respiratory secretions (e.g., intubation)immuniza
    tion not shown to be protective
  • Post-exposure No exclusion necessary (if not
    symptomatic)
  • Active disease For 5 days after beginning
    effective therapy
  • Invasive meningococcal infection
  • Exposure Close contact contact with
    respiratory secretions (e.g., intubation)immuniza
    tion not shown to be protective
  • Post-exposure No exclusion necessary (if not
    symptomatic)
  • Active disease For 24 hours after beginning
    effective therapy

Not wearing appropriate PPE
97
OCCUPATIONAL HEALTH MANAGEMENT
  • Influenza
  • Exposure Close patient contact (lt3 feet)
  • Post-exposure No exclusion necessary (if not
    symptomatic)
  • Active illness Exclude for 5-7 days

Not wearing appropriate PPE
98
VACCINES INDICATED FORPOST-EXPOSURE PROPHYLAXIS
  • Mumps No post-exposure prophylaxis available
  • Measles lt3 days post-exposure (alternative Ig)
  • Rubella No post-exposure prophylaxis available
  • Varicella lt4 days post-exposure (alternative
    VZIG or acyclovir)
  • Hepatitis B lt7 days post-exposure /- HBIG
    (alternative HBIG)
  • Influenza Vaccine not indicated may use
    oseltamivir or zanamivir x 5 days
  • Pertussis Vaccine not indicated (use
    antibiotics azithromycin, TMP-SMX)
  • Tetanus Post-wound /- TIG (no time limit
    Tdap preferred)
  • Rabies Prior to symptoms /- RIG (avoid RIG if
    previously vaccinated)
  • Vaccinia lt4 days post-exposure (may also be
    indicated for monkey pox)
  • Outbreak control Hepatitis A, pertussis,
    meningococcal

May need to be provided with an immunoglobulin
preparation
99
USE OF IMMUNE GLOBULIN
  • Hepatitis A (post-exposure)
  • Immune serum globulin (IG) 0.02 mL/kg IM
  • Measles (post-exposure, normal host)
  • Immune serum globulin (IG) 0.25 mL/kg
  • Rubella (post-exposure, pregnant female, abortion
    not acceptable)
  • Immune serum globulin (IG) 20 mL
  • Hepatitis B (post-exposure prophylaxis)
  • Hepatitis B immune globulin (HBIG) 0.06 mL/kg
  • Tetanus (post-exposure prophylaxis)
  • Tetanus immune globulin (TIG) 250 units IM
  • Varicella (post-exposure)
  • Varicella immune globulin (VZIG)

100
VACCINIA IMMUNE GLOBULIN (VIG)
  • Indicated
  • Accidental implantation (extensive lesions)
  • Eczema vaccinatum
  • Generalized vaccinia (severe or recurrent)
  • Progressive vaccinia
  • Not recommended
  • Accidental implantation (mild instances)
  • Generalized vaccinia (mild or limited most
    cases)
  • Post-vaccinial encephalitis
  • Consider
  • Vaccinia keratitis

101
VACCINIA IMMUNE GLOBULIN
  • Indicated
  • Accidental implantation (extensive lesions)
  • Eczema vaccinatum
  • Generalized vaccinia (severe or recurrent)
  • Progressive vaccinia
  • Not recommended
  • Accidental implantation (mild instances)
  • Generalized vaccinia (mild or limited most
    cases)
  • Post-vaccinial encephalitis
  • Consider
  • Vaccinia keratitis

102
SELECTED REFERENCES
  • Bolyard EA, et al. Guideline for infection
    control in health care personnel, 1998.
    www.cdc.gov/ncidod/dhqp/pdf/guidelines/InfectionCo
    ntrol98.pdf
  • CDC. Immunization of health-care workers.
    199746(RR-18)
  • Weber DJ, Rutala WA. Vaccines for health care
    workers. In Vaccines (Plotkin S, Orenstein W,
    Offit P, eds). 5th ed. Saunders, 2008.
  • Decker MD, Weber DJ, Schaffner W. Vaccination of
    healthcare workers. In Hospital Epidemiology amd
    Infection Control (Mayhall CG,ed). 3rd ed.
    Lippencott Williams Wilkins, 2004.

103
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