Immunization of Health Care Workers: more than just the flu

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Immunization of Health Care Workersmore than
just the flu

• Mary Vearncombe, MD, FRCPC
• Medical Microbiologist, Hospital Epidemiologist
• Sunnybrook and Womens College Health Sciences
  Centre
• phone [phone]
• FAX [phone]
• e-mail mary.vearncombe_at_swchsc.on.ca

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HCW Immunization Background

• HCWs are at risk of exposure to and possible
  transmission of communicable diseases
• - some vaccine preventable
• establishing and maintaining immunity is an
  essential component of Occupational Health and
  Infection Prevention and Control programs
• applies to all health care facilities
• offices, clinics, acute care, LTC, labs, first
  responders
• applies to all health care personnel
• employees, physicians, students, contract
  workers, volunteers

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HCW Immunization Background

• immunization protects HCWs, their families,
  colleagues and patients
• cost containment through prevention of infection
• furloughing susceptibles after exposure
• costs of prophylaxis
• costs of treatment
• absenteeism during acute illness
• disability following illness
• outbreak investigation and control

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Disease Categories for HCW Immunization

• active immunization strongly recommended -
  specific risk for HCWs
• i.e., hepatitis B, influenza, measles, mumps,
  rubella, varicella
• active passive immunization may be indicated in
  certain circumstances
• e.g., hepatitis A, meningococcal disease, TB,
  pertussis
• immunization recommended for all adults
• i.e., tetanus, diphtheria

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Occupational Health Assessment

• before placement (after employment)
• health inventory
• immunization status
• history predisposing conditions for
  acquisition/transmission of infection
• to guide further immunizations,
• post-exposure management
• opportunity for adult immunization in immigrant
  HCWs
• education
• importance of maintaining personal health
• need for annual influenza vaccine

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Personnel Immunization

• prevent transmission
• prevent work restrictions after exposure
• cost-effective compared to
• 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
• complete 2nd 3 dose series for primary series
  non-responders, then re-test for anti-HBs
• if anti-HBs positive, consider immune
• if non-immune, counsel regarding exposure

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Hepatitis B Vaccine Pre-Exposure

• 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

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Hepatitis B Vaccine Post-Exposure

• HBV contact
• 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
• health care workers acute care, long term care,
  home care and outpatient settings

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Influenza VaccineWhy 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 VaccineWhy 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

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Influenza Vaccine

• Pre-placement
• counsel with regard to implications of
  transmission of respiratory viruses (esp
  influenza) to high risk patients
• counsel with regard to expectation of annual
  influenza immunization
• Ongoing Surveillance
• recommend influenza vaccine annually to all HCWs
  before the beginning of the influenza season
• utilize strategies to maximize vaccine coverage
• e.g., mobile carts, shift coverage, education,
  incentives

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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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Measles Vaccine

• Pre-placement immunization
• acceptable evidence of immunity
• positive serology
• documented receipt of vaccine
• (single vs double dose (NACI))
• physician documented clinical measles
• born before 1970
• offer vaccine to all non-immune HCWs (MMR)
• immunity should be condition of employment
• HCW responsibility to avoid causing harm

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Measles Vaccine

• Post-Exposure
• airborne transmission, highly contagious (masks
  may not provide protection)
• only immune HCWs should be assigned to patients
  with measles
• immune HCW no restriction
• non-immune HCW exclude from work day 5 to day
  21
• immunization of susceptible persons within 72
  hours of exposure usually prevents measles

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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
• immunity should be condition of employment
• HCW responsibility to avoid causing harm
• vaccine contraindicated during pregnancy

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Rubella Vaccine

• Post-Exposure
• direct face-to-face contact (even if mask worn)
• only immune HCWs should be assigned to patients
  with rubella
• immune HCW no work restriction
• non-immune HCW exclude from work day 7 - 21

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Mumps Vaccine

• Pre-placement immunization
• acceptable evidence of immunity
• positive serology
• documented receipt of vaccine
• physician documented clinical mumps
• born before 1970
• offer vaccine to all non-immune HCWs (MMR)

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Mumps Vaccine

• Post-Exposure
• droplet transmission, saliva
• only immune HCWs should be assigned to patients
  with mumps
• immune HCW no restriction
• non-immune HCW exclude from work day 12 - 26
• 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 to HCWs who are non-immune
• post-vaccine serology not recommended
• high efficacy of vaccine
• commercially available tests not sufficiently
  sensitive
• assign only immune HCWs to patients with
  varicella / zoster

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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
• varicelliform rashes within 2 weeks of vaccine
  are usually due to wild-type virus

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Varicella Vaccine

• Post-Exposure
• airborne transmission for varicella or
  disseminated zoster, or direct contact with
  lesions
• masks may not be effective in preventing
  transmission
• report exposure to OHS
• immune status unknown test for antibody
• immune may continue to work
• non-immune exclude from work from 10th day
  after the first exposure to the 21st day after
  the last exposure
• pregnant and non-immune offer VZIG, exclude
  until 28th day after last exposure

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Varicella Vaccine

• Post-Exposure
• management of vaccine recipients ???
• vaccine offers 70 - 90 protection against
  varicella 95 protection against severe
  varicella
• consider
• test for immunity if negative, repeat in 5-6
  days (serology insensitive - natural exposure
  may boost to detectable level), and/or
• observe daily at start of shift for signs/
  symptoms of varicella

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Varicella Vaccine

• Post-exposure vaccine use
• vaccine may prevent or reduce severity of
  varicella if given within 3 days (possibly up to
  5 days) after exposure
• furlough still required
• immunity for subsequent exposures
• outbreak control

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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

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Meningococcal DiseaseOccupational Risk in
Clinical HCWs

• retrospective survey 1982-1996 doctor, nurse,
  ambulance worker - prolonged contact, airway
  management Lancet 3561654-1655, Nov 11, 2000
• pediatrician performed endotracheal intubation
  ICHE 20564, Aug 1999
• 4 medical staff after mouth-to-mouth
  resuscitation
• JAMA 2201107-1112, 1972
• ER nurse assisted in intubation, suctioning
• CDC, MMWR 27358-363, 1978
• all no barriers (i.e., mask), no prophylaxis

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Meningococcal DiseaseOccupational Risk in
Laboratory Technologists

• 2 technologists MMWR 4046-47, 1991
• 1 technologist CCDR 2012-14, 1994 (Quebec)
• Biosafety Advisory, Health Canada, Jan, 1992
• 3 technologists HIC 2845-60, April 2001
• 33 cases retrospectively since 1965
• 2 technologists MMWR 51141-144, 2002
• electronic request 14 cases worldwide in 15 years

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Meningococcal DiseaseOccupational Risk in
Laboratory Technologists

• no identified breaches in laboratory technique
• many cases fatal
• at least one case from a non-invasive isolate
• rate of disease in lab workers dealing with N.
  meningitidis cultures elevated (US, UK)

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Meningococcal Vaccine NACILaboratory and
Healthcare Workers

• routine vaccination of healthcare workers not
  currently recommended
• antibiotic chemoprophylaxis sufficient in high
  risk situation
• research, industrial and clinical laboratory
  personnel who are routinely exposed to
  N. meningitidis cultures
• MenACYW-Ps recommended
• consider MenC-conjugate in addition
• vaccine does not replace lab safety standards

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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
• 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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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
• role of acellular pertussis vaccine in previously
  immunized HCWs needs evaluation

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BCG Vaccine

• BCG vaccine does not provide permanent or
  absolute protection against TB
• loss of tuberculin skin test 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
• maintain immunity with booster Td
  (tetanus/diphtheria toxoid) every 10 years

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Polio Vaccine

• Pre-placement
• immunization history
• HCWs who may have close contact with patients who
  may be excreting wild or vaccine poliovirus and
  laboratory workers handling specimens that may
  contain polioviruses should be immunized if
  previously unvaccinated use inactivated polio
  vaccine

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ROUTINE IMMUNIZING AGENTS STRONGLY
RECOMMENDED FOR HEALTH CARE PROVIDERS

• Hepatitis B vaccine
• Influenza vaccine
• Measles/Mumps/Rubella vaccine (MMR)
• Varicella vaccine
• Tetanus/Diphtheria vaccine (Td)
• Polio vaccine
• DISEASES FOR WHICH POSTEXPOSURE
• PROPHYLAXIS MAY BE INDICATED
• Diphtheria Rabies
• Hepatitis A Scabies
• Hepatitis B Varicella/Zoster
• Meningococcal disease HIV
• Pertussis Influenza (outbreaks)

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Essential References

• 1. Chin, Control of Communicable Diseases Manual,
  17th edition, 2000, American Public Health
  Association
• 2. Canadian Immunization Guide, 6th edition,
  2002, NACI Recommendations, Health Canada
• 3. Guide for Infection Control in Healthcare
  Personnel, 1998, Centers for Disease Control and
  Prevention, Public Health Service, US Department
  of Health and Human Services
• 4. Prevention and Control of Occupational
  Infections in Health Care, Health Canada, 2002
• 5. Immunization of Health-Care Workers, 1997
  Recommendations of ACIP and HICPAC, Centers for
  Disease Control and Prevention, Public Health
  Service, US Department of Health and Human
  Services