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Healthcare Personnel Immunization Recommendations


Healthcare Personnel Immunization Recommendations: 2014 Update Kathleen Harriman, PhD, MPH, RN Vaccine Preventable Disease Epidemiology Section California ... – PowerPoint PPT presentation

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Title: Healthcare Personnel Immunization Recommendations

Healthcare Personnel Immunization
Recommendations 2014 Update
Kathleen Harriman, PhD, MPH, RN Vaccine
Preventable Disease Epidemiology
Section California Department of Public
Health Immunization Branch kathleen.harriman_at_cdph.
  • Ensuring that healthcare personnel (HCP) are
    protected against vaccine preventable diseases
    (VPDs) is an essential part of occupational
    health programs
  • Prevents transmission of VPDs and eliminates
    unnecessary work restrictions
  • Safeguards the health of HCP and protects
    patients from exposure to infected HCP
  • Reduces both number of susceptible HCP and risks
    for transmission of VPDs to other workers and

  • Prevention of illness through comprehensive
    employee immunization programs is far more
    cost-effective than case management and outbreak
  • Facility mandated immunization programs, which
    include both newly hired and currently employed
    persons, are more effective than voluntary
    programs in ensuring that susceptible persons are
  • There are no federal or California state rules
    mandating immunization of HCP

How vaccines have changed the world in one
graphic (2010 data)
Vaccination programs
  1. Maintenance of complete immunization records
  2. Policies for catch-up vaccination
  3. Work restrictions for exposed susceptible
  4. Control of outbreaks
  5. Additional vaccines may be indicated for
    laboratory employees or for employees who travel
    to other parts of the world to perform research
    or healthcare work (e.g., as medical volunteers
    in a humanitarian effort)

Where do U.S. immunization recommendations come
Advisory Committee on Immunization Practices
  • 15 experts selected by the U.S. Secretary of HHS
    to provide advice and guidance to CDC on the
    control of vaccine preventable diseases the only
    entity in the federal government that makes such
  • Develops written recommendations for routine
    administration of vaccines to children and adults
    in the civilian population recommendations
    include age for vaccine administration, number of
    doses/dosing intervals, and precautions and
  • Also makes immunization recommendations for HCP

ACIP recommendations for HCP
  • Employer decisions about which ACIP recommended
    vaccines to include in HCP immunization programs
    have typically been made by considering the
  • Likelihood of HCP exposure to vaccine preventable
    diseases and the potential consequences of not
    vaccinating HCP
  • Nature of employment (type of contact with
    patients/residents and their environment)
  • Characteristics of the patient/resident
    population the facility serves

Newest ACIP compendium of recommendations for
HCP, 2011
Most recent ACIP recommendations
Immunization of healthcare personnel, 2011 http//
Diphtheria, tetanus, pertussis, 2006 and 2011 update http// http//
A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United StatesPart 2 Immunization of Adults, 2006 http//
CDC Guidance for Evaluating Health-Care Personnel for Hepatitis B Virus Protection and for Administering Postexposure Management, 2013 http//
Prevention and Control of Seasonal Influenza with Vaccines, 2013 http//
Influenza vaccine, healthcare personnel, 2006 http//
Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013 http//
Prevention and Control of Meningococcal Disease, 2013 http//
Mumps, 2006 http//
Varicella, 2007 http//
Recommended vaccinations indicated for adults
based on medical and other indications U.S.,
2014 ACIP adult immunization
recommendations http//
CDC definition of HCP
  • All paid and unpaid persons working in healthcare
    settings who have the potential for exposure to
    patients with influenza, infectious materials,
    including body substances, contaminated medical
    supplies and equipment, or contaminated
    environmental surfaces.
  • HCP might include (but are not limited to)
  • physicians, nurses, nursing assistants,
    therapists, technicians, emergency medical
    service personnel, dental personnel, pharmacists,
    laboratory personnel, autopsy personnel, students
    and trainees, contractual staff not employed by
    the health-care facility, and persons (e.g.,
    clerical, dietary, housekeeping, maintenance, and
    volunteers) not directly involved in patient care
    but potentially exposed to infectious agents that
    can be transmitted to and from HCP

Required immunizations for
California HCP
  • There are no federal or California state
    requirements mandating immunization or immunity
    to VPDs
  • Some healthcare facilities require
    immunizations/immunity to specific VPDs as a
    condition of employment
  • Some California local health officers have
    written orders mandating influenza vaccine for
    HCP working in facilities in their jurisdictions

Cal/OSHA Bloodborne Pathogen standard
  • Vaccine that is required to be offered per the
    Bloodborne Pathogen Standard
  • Hepatitis B vaccine three doses

To all employees who are exposed to blood or
other potentially infectious materials as part
of their job duties. If vaccine is declined,
a declination form must be signed.
Cal/OSHA Aerosol Transmissible Diseases (ATD)
  • Which California employees are covered by the ATD
  • Employees whose exposure from work activity or
    working conditions is reasonably anticipated to
    create an elevated risk of contracting any
    disease caused by aerosol-transmissible pathogens
    if protective measures are not in place
  • Elevated risk means higher than what is
    considered ordinary for employees having direct
    contact with the general public outside of the
    facilities, service categories, and operations
    listed in the standard

Diseases covered by the ATD standard
  • Applies to diseases classified by CDCs
    Healthcare Infection Control Advisory Committee
    (HICPAC) as either droplet or airborne
  • Novel or unknown pathogens considered airborne
  • Only reportable diseases under Title 17
    require exposure investigation

2007 Guideline for Isolation Precautions
Preventing Transmission of Infectious Agents in
Healthcare Settings http//
7IP/2007isolationPrecautions.html California
reportable diseases http//
Occupational exposure
  • In each included work setting covered by the
    standard, it is presumed that some employees have
    occupational exposure to ATDs for a particular
    employee it depends on tasks, activities, and the
  • Includes having contact with, or being within the
    exposure range of cases or suspected cases of
    aerosol-transmissible diseases
  • Employers must identify employees with
    occupational exposure in order to take protective

Vaccines that are required to be offered per the
ATD standard
  • Vaccine
  • Influenza
  • Measles
  • Mumps
  • Rubella
  • Tetanus, diphtheria, and acellular pertussis
  • Varicella-zoster (VZV)
  • Schedule
  • One dose annually
  • Two doses
  • Two doses
  • One dose
  • One dose
  • Two doses

To all susceptible employees who might be
exposed. If vaccine is declined, a
declination form must be signed.
Seasonal Influenza
(No Transcript)
Annual influenza vaccination
  • Offer to all eligible HCP at no cost
  • Educate re vaccination benefits and consequences
    of influenza illness for themselves and their
  • Obtain signed declination forms
  • Monitor coverage including ward, unit, and
    specialty-specific coverage rates report
    vaccination rates to CDPH
  • Use HCP influenza vaccination coverage as a
    measure of patient safety quality program
  • Mandate vaccination??

Influenza and HCP
  • On average, 5 to 20 of the U.S. population
    becomes infected with influenza each year
  • 23 of HCP had documented serologic evidence of
    influenza infection after a mild influenza
    season 59 could not recall having influenza
  • gt75 of HCP with influenza-like illness (ILI)
    continued to work in hospital
  • Persons are infectious before the onset of
    influenza symptoms
  • Data for the 2013-2014 influenza season indicate
    that influenza vaccine effectiveness against
    influenza A was about 62 for all age groups

Barriers to influenza vaccination
  • Fear of vaccine side effects (particularly
    influenza-like illness symptoms)
  • Perceived ineffectiveness of the vaccine
  • Perceived medical contraindication (typically not
  • Perceived low likelihood of contracting influenza
  • Fear of needles
  • Insufficient time or inconvenience
  • CDC influenza vaccine information for HCP
    ccu091310_014 http//

Strategies used by nursing homes to encourage
influenza vaccination among their employees
Strategies associated with LTCF staff influenza
vaccination rates gt60 SOURCE National Nursing
Home Survey 2004 Available at
Mandatory influenza vaccination
  • Seattle Virginia Mason in 2005, first U.S.
    hospital to mandate influenza vaccination or mask
    wearing during influenza season
  • St. Louis Barnes-Jewish in 2008, first U.S.
    hospital system to mandate influenza vaccination
    and terminate noncompliant employees
  • New York in 2009, emergency regulation (later
    withdrawn) required seasonal and pandemic H1N1
    vaccination of personnel in hospitals, home care,
    hospice, and diagnostic/treatment facilities
  • California hospitals must offer vaccine at no
    cost to employees
  • Vaccination or written declination required per
    SB 739 and the ATD standard
  • Public reporting of vaccination rates via CDCs
    National Healthcare Safety Network (NHSN)
  • Some CA hospitals began mandating vaccination or
    mask wearing during the 2009 H1N1 pandemic
  • At least 23 CA local health officers have
    mandated influenza vaccine or mask wearing for
    HCP working in their jurisdictions

National organizations with position statements
on HCP influenza vaccine
  • American Academy of Family Physicians (AAFP)
    Mandatory Influenza Vaccination of Health Care
    Personnel, 2011
  • American Academy of Pediatrics (AAP) Policy
    StatementRecommendation for Mandatory Influenza
    Immunization of All Health Care Personnel, 2010
  • American Hospital Association (AHA) AHA Endorses
    Patient Safety Policies Requiring Influenza
    Vaccination of Health Care Workers, 2011
  • American Medical Directors Association (AMDA)
    Position Statement Mandatory Immunization for
    Long Term Care Workers, 2011
  • American Pharmacists Association (APhA)
    Requiring Influenza Vaccination for All Pharmacy
    Personnel, 2011
  • American Public Health Association (APHA) Policy
    Statement Annual Influenza Vaccination
    Requirements for Health Workers, 2010
  • Association for Professionals in Infection
    Control and Epidemiology, Inc. (APIC) Influenza
    Vaccination Should Be a Condition of Employment
    for Healthcare Personnel, Unless Medically
    Contraindicated, 2011
  • Infectious Diseases Society of America (IDSA)
    Policy on Mandatory Influenza Immunization of
    Heath Care Workers, 2010
  • National Association of County and City Health
    Officials (NACCHO) Influenza Vaccinations for
    Healthcare Personnel Policy, 2012
  • National Business Group on Health Hospitals
    Should Require Flu Vaccination for all Personnel
    to Protect Patients Health and Their Own Health,
  • National Foundation for Infectious Diseases
    (NFID), 2010
  • National Patient Safety Foundation (NPSF)
    Supports Mandatory Flu Vaccinations for
    Healthcare Workers, 2009
  • Society for Healthcare Epidemiology of America
    (SHEA) Position Paper Influenza Vaccination of
    Healthcare Personnel, 2010

Joint Commission - 2011
  • Standard IC.02.04.01 - The organization
  • establishes an annual influenza vaccination
    program that is offered to staff, including
    contracted staff
  • educates staff about, at a minimum, the influenza
    vaccine non-vaccine control and prevention
    measures and the diagnosis, transmission, and
    impact of influenza
  • sets incremental influenza vaccination goals,
    consistent with achieving the 90 rate
    established in the national influenza initiatives
    for 2020
  • measures vaccination rates and has a written
    description of the methodology used to determine
    rates (CDC/NQF measure does not include
    contracted staff)
  • collects and reviews the reasons given by staff
    for declining influenza vaccination at least
  • improves its vaccination rates according to its
    established, internal goals at least annually
  • Standard IC.02.04.01 does not mandate influenza
    vaccination for staff as a condition of Joint
    Commission accreditation

People at higher risk for developing influenza
related complications
  • Children younger than 5, but especially children
    younger than 2 years of age
  • Adults 65 years of age and older
  • Pregnant women
  • American Indians and Alaskan Natives
  • People with asthma, neurological and
    neurodevelopmental conditions, chronic lung
    disease, heart disease, blood, kidney, liver and
    metabolic disorders, weakened immune systems,
    morbid obesity (BMI 40) and people lt19 years of
    age who are receiving long-term aspirin therapy
  • particularly conditions that can compromise
    respiratory function, the
  • handling of respiratory secretions, or
    increase the risk for aspiration

Types of influenza vaccine
  • Inactivated influenza vaccine (IIV) may be
    trivalent 2 A strains and 1 B strain (IIV3) or
    quadrivalent 2 A strains and 2 B strains (IIV4).
  • Live attenuated influenza vaccine (LAIV)
    available vaccine is quadrivalent (LAIV4).
  • Recombinant influenza vaccine (RIV) available
    vaccine is trivalent (RIV3).
  • There are two antigenically distinct lineages of
    influenza B viruses and immunization against B
    virus strains of one lineage provides only
    limited cross-protection against strains in the
    other lineage.
  • Because of this and the difficulty of predicting
    which B virus lineage will predominate during a
    given season, quadrivalent vaccines have been

Other formulations of inactivated vaccines
  • All inactivated vaccine preparations contain the
    same quantity of hemagglutinin (15 µg per vaccine
    virus strain per 0.5 mL dose 45 µg total),
    except Fluzone Intradermal and Fluzone High-Dose
    (Sanofi Pasteur)
  • Fluzone Intradermal is indicated for persons aged
    18 through 64 years and contains 9 µg of
    hemagglutinin per vaccine virus strain (27 µg
    total) in a 0.1 mL dose
  • Fluzone High-Dose is indicated for persons aged
    65 years and contains 60 µg of hemagglutinin per
    vaccine virus strain (180 µg total) in a 0.5 mL
  • Within specified age indications, ACIP expresses
    no preference for any given IIV formulation over

Inactivated influenza vaccines (IIV) vs.
live attenuated influenza vaccine (LAIV)
  • Either IIV3 or IIV4 or LAIV can be used to reduce
    the risk for influenza among HCP
  • LAIV is approved for use only among nonpregnant
    healthy persons aged 5-49 years
    contraindications include
  • pregnancy, asthma, reactive airways disease or
    other chronic disorders of the pulmonary or
    cardiovascular systems other underlying medical
    conditions, including metabolic diseases such as
    diabetes, renal dysfunction, and
    hemoglobinopathies known or suspected
    immunodeficiency diseases or receipt of
    immunosuppressive therapies
  • Available data indicate that persons vaccinated
    with LAIV can shed vaccine viruses for gt2 days
    after vaccination
  • HCP who work with severely immunocompromised
    patients (e.g., hematopoietic stem cell
    transplant recipients) who require a protected
    environment should not receive LAIV (if given
    LAIV, HCP should have no contact with such
    patients for 7 days)

More on LAIV
  • Personnel who may administer LAIV
  • Severely immunosuppressed persons should not
    administer LAIV because introduction of low
    levels of vaccine virus into the environment
    probably cannot be avoided when administering
    LAIV. However, other persons with conditions
    placing them at high risk for influenza
    complications (e.g., pregnant women, persons with
    asthma, and persons aged gt50 years) may
    administer LAIV.
  • LAIV and the use of influenza antiviral
  • Because influenza antivirals reduce replication
    of influenza viruses, LAIV should not be
    administered until 48 hours after cessation of
    influenza antiviral therapy, and influenza
    antiviral medications should not be administered
    for 2 weeks after receipt of LAIV.

Influenza vaccination of persons with a history
of egg allergy - 1
  • Persons with a history of egg allergy who have
    experienced only hives after exposure to egg
    should receive influenza vaccine. Because
    relatively few data are available for use of LAIV
    in this setting, IIV or RIV should be used. RIV
    is egg-free and may be used for persons aged
    1849 years who have no other contraindications.
    However, IIV (egg- or cell-culture based) also
    may be used, with the following additional safety
  • Vaccine should be administered by a health-care
    provider who is familiar with the potential
    manifestations of egg allergy and
  • Vaccine recipients should be observed for at
    least 30 minutes for signs of a reaction after
    administration of each vaccine dose.
  • Other measures, such as dividing and
    administering the vaccine by a two-step approach
    and skin testing with vaccine, are not necessary.
  • Persons who report having had reactions to egg
    involving such symptoms as angioedema,
    respiratory distress, lightheadedness, or
    recurrent emesis or who required epinephrine or
    another emergency medical intervention,
    particularly those that occurred immediately or
    within a short time (minutes to hours) after egg
    exposure, are more likely to have a serious
    systemic or anaphylactic reaction upon
    re-exposure to egg proteins. These persons may
    receive RIV3, if aged 18 through 49 years and
    there are no other contraindications. If RIV3 is
    not available or the recipient is not within the
    indicated age range, such persons should be
    referred to a physician with expertise in the
    management of allergic conditions for further
    risk assessment before receipt of vaccine.

Influenza vaccination of persons with a history
of egg allergy - 2
  • All vaccines should be administered in settings
    in which personnel and equipment for rapid
    recognition and treatment of anaphylaxis are
    available. ACIP recommends that all vaccination
    providers should be familiar with the office
    emergency plan.
  • Some persons who report allergy to egg might not
    be egg-allergic. Those who are able to eat
    lightly cooked egg (e.g., scrambled egg) without
    reaction are unlikely to be allergic.
    Egg-allergic persons might tolerate egg in baked
    products (e.g., bread or cake). Tolerance to
    egg-containing foods does not exclude the
    possibility of egg allergy. Egg allergy can be
    confirmed by a consistent medical history of
    adverse reactions to eggs and egg-containing
    foods, plus skin and/or blood testing for
    immunoglobulin E antibodies to egg proteins.
  • For persons who have no known history of exposure
    to egg, but who are suspected of being
    egg-allergic on the basis of previously performed
    allergy testing, consultation with a physician
    with expertise in the management of allergic
    conditions should be obtained before vaccination.
    Alternatively, RIV3 may be administered if the
    recipient is aged 18 through 49 years.
  • A previous severe allergic reaction to influenza
    vaccine, regardless of the component suspected to
    be responsible for the reaction, is a
    contraindication to future receipt of any
    influenza vaccine.
  • Two adult vaccines that are manufactured using
    newer technologies that minimize or avoid
    entirely the use of eggs are now available
    Flucelvax, which is produced using cell culture
    technology, and FluBlok, which contains
    recombinant HA.

Recommendations on influenza vaccination
of persons who report allergy to eggs
Abbreviations IIV inactivated influenza
vaccine RIV3 recombinant influenza vaccine,
trivalent Persons with egg allergy might
tolerate egg in baked products (e.g. bread or
cake). Tolerance to egg-containing foods does not
exclude the possibility of egg allergy. For
persons who have no known history of exposure to
egg but who are suspected of being egg-allergic
on the basis of previously performed allergy
testing, consultation with a physician with
expertise in the management of allergic
conditions should be obtained prior to
vaccination. Alternatively, RIV3 may be
administered if the recipient is aged 18 through
49 years.
Contraindication and precautions
  • Contraindication
  • A previous severe allergic reaction to influenza
    vaccine, regardless of the component suspected to
    be responsible for the reaction
  • Precautions
  • Moderate or severe acute illness with or without
  • Guillain-Barré Syndrome within 6 weeks following
    a previous dose of influenza vaccine

Hepatitis B
Hepatitis B vaccination HCP
  • Any person who performs tasks involving contact
    with blood, blood-contaminated body fluids, other
    body fluids, or sharps should be vaccinated
    against hepatitis B
  • Highly immunogenic seroconversion 95
  • Incidence among HCP since mid-1990s is lower than
    general population due to vaccination and
    standard precautions

Updated U.S. P.H.S. Guidelines for the Management
of Occupational Exposures to HBV, HCV, and HIV
and Recommendations for Post-exposure
Prophylaxis. MMWR 50 (RR11) - 6/29/01
Estimated number of acute HBV infections due to
occupational exposures, U.S., 1983-2002
OSHA Requirements
Vaccine Recommended for HCP
Hepatitis B
  • HCP with potential for exposure to blood or body
    fluids should be immunized for hepatitis B with
    the 3-dose vaccine series if they have not
    already received it
  • Newly immunized HCP should be tested 1-2 months
    after the last dose of vaccine series to
    determine if they are immune
  • anti-HBs gt10 mIU/mL immune

Hepatitis B testing for immunity after vaccination
  • Anti-HBs lt10 mIU/mL ? revaccinate
  • 3 doses followed by testing after third dose more
    practical than testing after 1 or more doses of
  • Anti-HBs lt10 mIU/mL after revaccination ? test
    for HBsAg
  • HBsAg positive ? provide appropriate management
  • HBsAg negative ? susceptible to HBV infection
  • counsel re precautions to prevent HBV infection
  • HBIG postexposure prophylaxis for any known or
    likely parenteral exposure to HBsAg-positive
  • Periodic titers or booster doses of vaccine not
    recommended - protection is long lasting

Previously vaccinated HCP without evidence of
  • Over time, an increasing number of persons
    entering the healthcare workforce will have
    received routine vaccination as infants,
    children, or adolescents most will have no
    documentation of seroprotection
  • Persons immunized for hepatitis B in the past are
    less likely to have measurable anti-HBs than
    those vaccinated more recently
  • In 2013 CDC issued updated guidance on pre- and
    post-exposure testing and follow-up for hepatitis
    B, this guidance can be accessed at

2013 CDC guidance
  • HCP with documentation of 3 doses of hepatitis B
    vaccine, but no documentation of immunity may
    undergo anti-HBs testing upon hire or
  • This approach is most appropriate for settings
    with HCP-trainees and HCP in occupations with
    higher risk of exposure (e.g., surgeons), and
    when the prevalence of HBV is increased in the
    patient population served.
  • Alternatively, employers may choose to perform
    anti-HBs testing only if such HCP later report a
    blood or body fluid exposure. All employees
    should receive training to recognize and report

California hospital survey, 2012 How does your
institution currently manage new HCP who have
documentation of a complete hepatitis B vaccine
series but no documentation of post-vaccination
serologic testing?
Which do you think is the best approach?
Testing for hepatitis B infection
  • Regardless of immunization history, it may be
    prudent to test HCP and trainees in certain
    high-risk groups for HBsAg and anti-HBc/anti-HBs
    to determine their infection status
  • Those born in countries with high and
    intermediate endemicity for hepatitis B
  • Unvaccinated U.S.-born HCP whose parents were
    born in regions of high endemicity for hepatitis
  • HIV-positive HCP
  • HCP who disclose having engaged in or currently
    engaging in high-risk sexual or substance abuse
  • HCP who require immunosuppressive therapy or who
    are on hemodialysis

Hepatitis B infected HCP
  • Chronic hepatitis B infection is not grounds for
    exclusion from healthcare practice or training,
  • The Society for Healthcare Epidemiology of
    Americas Guideline for Management of Healthcare
    Workers Who Are Infected with Hepatitis B Virus,
    Hepatitis C Virus, and/or Human Immunodeficiency
    Virus at
  • http//
  • Updated CDC Recommendations for the Management of
    Hepatitis B VirusInfected Health-Care Providers
    and Students at http//

HBV postexposure prophylaxis
Updated U.S. Public Health Service Guidelines for
the Management of Occupational Exposures to HBV,
HCV, and HIV and Recommendations for
Post-exposure Prophylaxis. 2001. http//www.cdc.go

Measles - basics
  • Rash illness, historically a childhood infection
    with 2-4 year epidemic cycle most cases in
  • Complications may include otitis media,
    pneumonia, encephalitis, miscarriage, and death
  • No endemic transmission in the U.S. at this time

  • In the decade before measles vaccine was licensed
    in 1963, 34 million people were infected in the
    U.S. each year
  • 400500 died
  • 1,000 suffered permanent brain damage or deafness
  • 4,000 had encephalitis
  • 7,000 had seizures
  • 48,000 were hospitalized
  • 150,000 had respiratory complications (pneumonia)
  • Nearly all children were infected by the age of
  • Widespread use of measles vaccine led to a
    greater than 99 reduction in measles cases in
    the U.S. compared with the pre-vaccine era

(No Transcript)
MeaslesUnited States, 1950-2005
Measles declared eliminated 2000
  • Vaccine licensed
  • 1963

(No Transcript)
  • Elimination of endemic measles was achieved in
    the U.S. in 2000 and in North and South America
    in 2002 and is a public health success model for
    immunization programs in the developed world
  • The last nationwide outbreak in U.S. was
    1988-1991 when there were 17,000 cases in
    California with 70 deaths
  • Introduction of 2nd dose of vaccine in 1989 and
    federal Vaccines for Children program in 1993
  • Two doses of MMR vaccine offer gt99 protection
    from disease however because measles is so
    infectious, very high population immunity
    (92-95) is necessary to interrupt transmission

Measles - epidemiology
  • Currently, most U.S. measles cases are related to
    international travel or contact with ill
  • Measles is still endemic in Europe with large
    outbreaks in 2010-2011 including a large
    (gt15,000 cases) outbreak in France in 2011
  • During 2012, large measles outbreaks were
    reported by the Democratic Republic of the Congo,
    India, Indonesia, Ukraine, Somalia, Sudan,
    Pakistan, and Romania China reported 6183 cases,
    a historic low
  • In 2012, there were 226,722 cases worldwide with
    an estimated 122,000 deaths a 73 decrease in
    cases and a 78 decrease in deaths since 2000 as
    1 dose measles vaccine coverage increased from 73
    to 84

Measles transmission
  • Measles is transmitted via the airborne route and
    is thought to be the most infectious communicable
    disease R0 15-17
  • Measles transmission has been documented in
    physician offices, emergency rooms, and hospital
    wards HCP have been infected in recent outbreaks
  • Good documentation and high levels of immunity
    minimize the amount of follow-up that needs to be
    done in the event of an exposure
  • Record review for hundreds to thousands staff
  • Serologic testing and vaccination

Presumptive evidence of immunity to measles
  • Documentation of vaccination with 2 doses of live
    measles virus-containing vaccine, or
  • Laboratory evidence of immunity, or
  • Laboratory confirmation of disease, or
  • Birth before 1957
  • The first dose of MMR vaccine should be
    administered on or after age 12 months the
    second dose of measles- or mumps-containing
    vaccine should be administered no earlier than 28
    days after the first dose.
  • Measles IgG in serum equivocal results should
    be considered negative.
  • Since some persons born before 1957 will be
    susceptible to measles, CDPH recommends that
    immunity be assessed if such HCP are exposed to
    measles. During a measles outbreak, 2 doses of
    MMR are recommended for unvaccinated HCP born
    before 1957 who do not have evidence of measles

Respiratory protection
  • Per Cal/OSHA requirements, regardless of their
    immune status, all HCP must use respiratory
    protection at least as effective as an N95
    respirator when in contact with measles patients

Measles exposures
  • If an exposure to measles occurs in a healthcare
    facility CDPH recommends that all exposed HCP,
    regardless of age, have
  • serological evidence of immunity to measles
    (IgG) or
  • documentation of two doses of measles containing
    vaccine (preferably MMR) after first birthday
  • Reviewing HCP immune status for measles and
    testing for immunity/providing vaccine after an
    exposure results in considerable work for
    healthcare facilities

HCP measles exposure
  • MMR vaccine for postexposure prophylaxis
  • MMR may be given lt72 hours of exposure to those
    with 1 or no documented doses of MMR, if not
  • Immune globulin (IG) for postexposure prophylaxis
  • Pregnant women without evidence of measles
    immunity should receive 400 mg/kg of IG given
    intravenously (IGIV).
  • Severely immunocompromised persons, irrespective
    of evidence of measles immunity, should receive
    400 mg/kg of IGIV.
  • For persons who are already receiving IGIV
    therapy, gt400 mg/kg lt3 weeks before exposure
    should be sufficient to prevent infection.
  • IGIM (0.5 mL/kg of body weight maximum dose 15
    mL) can be given to other persons who do not have
    evidence of measles immunity, but priority should
    be given to persons exposed in settings with
    intense, prolonged, close contact (e.g.,
    household, child care, classroom, etc.).
  • Severely immunocompromised patients include
    patients with severe primary immunodeficiency
    patients who have received a bone marrow or stem
    cell transplant until at least 12 months after
    finishing all immunosuppressive treatment, or
    longer where the patient has developed
    graft-versus-host disease patients on treatment
    for ALL within and until at least six months
    after completion of immunosuppressive
    chemotherapy and patients with a diagnosis of
    AIDS or HIV-infected persons with CD4 percent
    lt15 (all ages) or CD4 lt200 lymphocytes /mm3 (age
    gt5 years) and those who have not received MMR
    vaccine since receiving effective ART some
    experts would include HIV-infected persons who
    lack recent confirmation of immunologic status or
    measles immunity. IG may be given to exposed
    susceptible people of any age lt6 days of
  • It is unknown if IG prolongs the incubation
    period. If measles symptoms occur lt28 days of
    exposure, persons who have received IG should
    self-isolate and contact their local health
  • One source of IG is FFF Enterprises, which can be
    reached 24/7 at 1-800-843-7477.

A high risk contact is defined as an exposed
contact who is at high risk of infection or
measles complications (pregnant or
immunocompromised) from measles or who works or
lives in a sensitive setting or a setting where
transmission is likely to occur (e.g.,
healthcare, child care, or congregate setting) or
who had significant exposure to the case
(household contact). Ensure documentation of
immunity (documented IgG or 2 documented doses
MMR) in all high risk persons. Postexposure
prophylaxis is either IG or MMR vaccine. IG may
be administered lt6 days of exposure to
susceptible contacts of any age who did not
receive MMR vaccine lt72 hours of exposure. MMR
vaccine should not be given until 5 months after
IG in healthy people and until 6 months after IG
in immunocompromised people. If it can be done
rapidly, we recommend testing healthy contacts
gt12 months of age for measles IgG prior to
administering IG. If symptoms consistent with
measles develop, exposed person should be
isolated. If there is concern about whether
measles symptoms will be reported or if there
will be compliance with quarantine, periodic
calls to the exposed person to monitor for
development of measles symptoms are recommended
(see above for symptom watch time period and
additional guidance). If an exposed person is
identified as susceptible through serologic
testing (measles IgG negative), then postexposure
prophylaxis should be offered if it is within the
recommended time period alternatively if immune
status is unknown and laboratory testing cannot
be done, postexposure prophylaxis can be
considered. If measles IgG status is unknown,
persons gt12 months of age who receive MMR vaccine
as postexposure prophylaxis
should have blood drawn and tested at the time of
MMR administration.
Category IgG testing Postexposure prophylaxis2 Quarantine3 Symptom watch
Two documented doses of MMR vaccine (1 will be susceptible) No No No Passive
Measles IgG positive (lt1 will be susceptible) No No No Passive
Have 1 documented dose of MMR vaccine (5 will be susceptible) or no documented doses of MMR Yes No4 Yes Active
Born before 1957 (5 will be susceptible) Yes No4 Yes Active
History of measles disease Yes No4 Yes Active
Unknown or no documentation of measles immunity status Yes No4 Yes Active
Measles IgG negative or known to be unvaccinated - Yes Yes Active
Received MMR vaccine lt72 hours of exposure5 - - Yes Active
Received immune globulin 6 days of exposure - - Yes Active
Healthcare-associated transmission of measles in
U.S. healthcare facilities
  • Healthcare-associated transmission of measles is
    well documented
  • Measles can be transmitted up to two hours after
    an infectious patient has left the area
  • 11 of 127 cases were transmitted in healthcare
    settings considerable economic cost and public
    health effort to contain (100,000 to 400,000)
  • Four cases of measles were acquired in a San
    Diego County pediatricians office
  • The largest nosocomial measles outbreak in 20
    years occurred in Arizona in 2008

Arizona measles outbreak, 2008
  • In February 2008, an infected Swiss traveler
    sparked a measles outbreak involving 14 cases, 7
    of whom were infected in healthcare facilities
    measles was not suspected until after she had
    been hospitalized, unisolated, for 2 days
  • Of the 11 secondary cases who accessed
    healthcare, 10 did not receive a prompt measles
    diagnosis after rash onset and only 1 was masked
    and isolated promptly
  • 8231 people were potentially exposed 4793 were
    hospital or clinic patients and 2868 were HCP
  • 25 of 7195 screened HCP lacked evidence of
    measles immunity 1583 underwent IgG testing and
    121 (11) of 1077 HCPs born gt1957 and 18 (4) of
    506 HCPs born lt1957 were seronegative, including
    1 who acquired measles
  • Two hospitals spent 800,000 responding to and
    containing the seven measles cases in their


Mumps in healthcare settings
  • In recent outbreaks involving hospitals and
    long-term care facilities with adolescent and
    young adult patients, infection control failures
    resulted in nosocomial transmission
  • Exposure to mumps in healthcare settings results
    in added economic costs associated with furlough
    or reassignment of staff members from
    patient-care duties or the closure of wards
  • In Tennessee in 1986-87, nosocomial transmission
    of mumps occurred in two hospital ERs infecting 6
    HCP and in two long-term care facilities
    infecting 9 patients

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Presumptive evidence of immunity to mumps
  • Documentation of vaccination with 2 doses of live
    mumps virus-containing vaccine, or
  • Laboratory evidence of immunity, or
  • Laboratory confirmation of disease, or
  • Birth before 1957
  • The first dose of MMR vaccine should be
    administered on or after age 12 months the
    second dose of measles- or mumps-containing
    vaccine should be administered no earlier than 28
    days after the first dose.
  • Mumps IgG in serum equivocal results should be
    considered negative.
  • Since some persons born before 1957 will be
    susceptible to mumps, CDPH recommends that
    immunity be assessed if such HCP are exposed to
    mumps. During a mumps outbreak, 2 doses of MMR
    are recommended for unvaccinated HCP born before
    1957 who do not have evidence of mumps immunity.

Mumps vaccination
  • All persons who work in healthcare facilities
    should be immune to mumps
  • HCP born during or after 1957 ? 2 doses
  • No vaccination/immunity ? 2 doses (gt28 days
  • Only 1 dose previously ? second dose
  • Birth before 1957 is only presumptive evidence of
    immunity consider 1 dose for unvaccinated
    workers without laboratory evidence of immunity
  • During an outbreak, 2 doses of vaccine
    recommended for workers born before 1957 who do
    not have evidence of immunity

Mumps epidemiology
  • Post-licensure studies of 1 dose of mumps vaccine
    showed it was 78-91 effective in preventing
    clinical mumps
  • Late 1980s - early 1990s, mumps outbreaks
    observed in schools with extremely high (gt95)
    vaccination coverage, suggesting that 1 dose of
    mumps vaccine is insufficient to prevent mumps
    outbreaks in schools
  • Since the 1989 2-dose MMR requirement, incidence
    of mumps disease has decreased and studies of
    vaccine effectiveness during outbreaks suggest
    substantially higher levels of protection with a
    second dose of MMR

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Mumps prevention and control
  • During an outbreak, healthcare facilities should
    strongly consider recommending 2 doses of mumps
    vaccine to unvaccinated workers born before 1957
    who do not have evidence of mumps immunity
  • Reviewing HCP immune status for mumps and
    providing serologic testing and vaccine during an
    outbreak is difficult
  • Facilities might consider reviewing immune status
    of HCP routinely and providing appropriate
    vaccinations, including a second dose of mumps
    vaccine, in conjunction with annual activities
    such as influenza vaccination or TB testing
  • Because not all people with 2 doses of mumps
    vaccine are protected, HCP should be advised to
    immediately exclude themselves from work if
    symptoms develop

HCP mumps exposure
  • HCP without presumptive evidence of immunity
  • There is no postexposure prophylaxis
  • Exclude from the 12th day after the first
    unprotected exposure through the 25th day after
    the last exposure
  • HCP with one dose of vaccine
  • May remain at work and should receive the second
    dose as soon as possible, but no sooner than 28
    days after the first
  • Should be educated about mumps symptoms,
    including non-specific presentations, and notify
    occupational health if symptoms develop
  • HCP with presumptive evidence of immunity
  • May remain at work, but because some vaccinated
    people develop infection, should be educated
    about mumps symptoms and notify occupational
    health if symptoms develop


Rubella epidemiology
  • Rubella vaccines were first licensed in 1969 and
    rubella was declared eliminated in the U.S. in
  • Rubella cases in the U.S. are now imported from
    regions of the world where rubella is not
  • Rubella is typically a mild illness the concern
    is harm (deafness, seizures, encephalitis, and
    developmental delays) to the developing fetus
    when pregnant women are infected
  • More than 20,000 babies were born in the U.S.
    with congenital rubella syndrome (CRS) during a
    1964-65 outbreak before the vaccine was licensed

Current rubella outbreak
  • The number of rubella cases in Japan, especially
    in Tokyo, has been increasing in 2013
  • Approximately 70 of reported cases of rubella
    involve middle-aged men, partly because boys were
    not vaccinated against rubella by the national
    immunization program until 1995
  • To prevent congenital rubella syndrome, the
    vaccination of women of childbearing age and
    their partners is currently a national priority

Rubella case Japan 2013
A 23-year-old unvaccinated woman presented to the
ED after 1 day of fever, sore throat, arthralgia,
and rash. Diffuse erythema (Panel A) that
blanched on pressure was noted over the face,
neck, trunk, and arms, along with posterior
cervical lymphadenopathy. The next day, the fever
and rash subsided, but she reported pain in the
oral cavity. Examination revealed petechial
hemorrhages on the soft palate (Panel B) that
disappeared spontaneously in 2 days.
Presumptive evidence of immunity to rubella
  • Documentation of vaccination with 1 dose of live
    rubella virus-containing vaccine, or
  • Laboratory evidence of immunity, or
  • Laboratory confirmation of disease, or
  • Birth before 1957 (except premenopausal women
    who could become pregnant)
  • The first dose of MMR vaccine should be
    administered on or after age 12 months the
    second dose of measles- or mumps-containing
    vaccine should be administered no earlier than 28
    days after the first dose.
  • Rubella IgG in serum equivocal results should
    be considered negative.
  • Since some persons born before 1957 will be
    susceptible to rubella, CDPH recommends that
    immunity be assessed if such HCP are exposed to
    rubella. During a rubella outbreak, 1 dose of MMR
    is recommended for unvaccinated HCP born before
    1957 who do not have evidence of rubella

Presumptive evidence of immunity to rubella,
  • HCP who can provide documentation of serological
    evidence of rubella immunity (e.g., via prenatal
    testing) do not need to be retested and should be
    considered immune
  • The principle of once immune, always immune
    also applies to measles, mumps and hepatitis B

MMR vaccination for HCP born before 1957
  • HCP born before 1957 are generally presumed to be
    immune to measles, mumps, and rubella, but not
    all are
  • Consider recommending 2 doses of MMR vaccine
    routinely for unvaccinated HCP born before 1957
    who lack laboratory evidence of measles, mumps or
    rubella immunity or laboratory confirmation of
  • During an outbreak of measles or mumps, two doses
    of MMR vaccine are recommended for unvaccinated
    HCP born before 1957 who lack laboratory evidence
    of immunity or laboratory confirmation of
    disease one dose of MMR recommended during a
    rubella outbreak

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Measles, mumps and rubella immunity testing
  • When testing immunity, please do not select a
    panel that includes IgM testing this results in
    false positives
  • Testing for serologic evidence of immunity to
    measles, mumps or rubella (IgG testing) is not
    recommended for HCP who have two documented doses
    of MMR vaccine or other acceptable evidence of
  • If testing is inadvertently performed on HCP with
    documentation of two doses of MMR vaccine and the
    worker is IgG negative or equivocal for measles,
    mumps or rubella, ACIP recommends that the test
    be assumed to be falsely negative and that the
    worker be presumed immune and not given another
    dose of MMR vaccine, i.e., documented
    age-appropriate vaccination supersedes the
    results of subsequent serologic testing

Varicella among HCP
  • Nosocomial transmission of is varicella is
  • Sources
  • Patients, hospital staff, and visitors with
    varicella or herpes zoster (shingles)
  • Airborne transmission of varicella has been
  • Varicella has occurred in susceptible persons who
    had no direct contact with index case
  • Virus detected in air
  • Herpes zoster may also be airborne (?)

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2007 ACIP recommendations
  • Serologic screening before vaccination
  • Testing unvaccinated HCP with a negative or
    uncertain history of varicella is likely to be
    cost-effective or
  • Test all HCP, because small proportion with
    positive history of disease might be susceptible
  • Routine testing after 2 doses of vaccine is not
  • Available commercial assays not sensitive enough
    and are likely to be falsely negative
  • In sensitive tests, 99 of adults develop
    antibodies after 2nd dose
  • If testing is done, IgG results can be relied
  • http//

Evidence of immunity to
varicella in HCP
  • Documentation of two doses of vaccine
  • Laboratory evidence of immunity or laboratory
    confirmation of disease
  • Diagnosis or verification of history of varicella
    disease or herpes zoster (shingles) by a
    healthcare provider
  • If an employee states they have had varicella or
    herpes zoster in the past, a healthcare provider
    can interview the employee to determine if their
    history is compatible with one of these
    diagnoses if so, this is considered evidence of
  • ACIP also states that Institutions may elect to
    test all HCP regardless of disease history
    because a small proportion of persons with a
    positive history of disease might be susceptible

Evidence of immunity to
varicella, continued
  • Serologic evidence of VZV infection in 96-97 of
    U.S.-born adults aged 20-29 years and in 97-99
    of adults aged gt30 years tested during 1998-1999
  • U.S. birth before 1980 considered evidence of
    immunity except for HCP, pregnant women, and
    immunocompromised people
  • For these three groups, certainty regarding
    immunity is desirable because of the possibility
    of nosocomial transmission to high-risk patients
    transmission of the virus to the fetus, which
    might result in congenital varicella syndrome
    and possibility of severe disease

Respiratory protection
  • Per Cal/OSHA requirements, regardless of immune
    status, all HCP must use respiratory protection
    at least as effective as an N95 respirator when
    in contact with varicella patients

Varicella postexposure prophylaxis for HCP
  • Varicella vaccine may be effective in preventing
    illness or modifying varicella severity if
    administered to unvaccinated persons within 3
    days, and possibly up to 5 days, of exposure
  • Although postexposure use of varicella vaccine
    has potential applications in hospital settings,
    pre-exposure vaccination preferred
  • Varicella Zoster Immune Globulin (VariZIG) is
    recommended for pregnant and immunocompromised
    contacts without evidence of immunity

HCP varicella exposure
  • HCP with 2 doses of varicella vaccine
  • Monitor daily during days 10-21 after exposure to
    determine clinical status
  • Place on sick leave immediately if symptoms occur
  • HCP with 1 dose of varicella vaccine
  • Give 2nd dose of vaccine lt3-5 days of exposure
  • After vaccination, management is similar to
  • HCP without evidence of immunity
  • Give 1st dose of vaccine lt3-5 days of exposure
  • Furlough days 10-21 after exposure

Transmission of vaccine virus from vaccine
recipients with rash
  • Risk low transmission has been documented after
    exposures in households and long-term care
  • No cases documented after vaccination of HCP
  • Consider precautions for HCP in whom rash occurs
    after vaccination
  • Avoid contact with persons without evidence of
    immunity at risk for severe disease and
    complications until all lesions resolve (i.e.,
    are crusted over or fade away) or no new lesions
    appear in a 24-hour period

Pertussis in the United States
  • Least well controlled vaccine preventable disease
  • Cyclical with peaks every 2-5 years in 2010,
    California experienced an epidemic with gt9,000
    cases 10 deaths
  • Most severe disease occurs among infants lt6
    months of age almost all deaths are in infants
    lt3 months of age
  • Studies have shown that half of the infants with
    pertussis were infected by a household member
  • Immunity via vaccine or disease wanes over time
    duration of protection from acellular pertussis
    vaccines wanes within several years disease gt
    whole cell vaccine gt acellular vaccine
  • Almost all adults are susceptible very few
    adults have received Tdap, which was licensed in

Incidence of reported pertussis cases by year of
onset California, 1914-2011
Includes cases reported to CDPH as of 2/6/2012
Number of reported pertussis cases by year of
onset -- California 1947-2013
Pertussis among HCP
  • Nosocomial spread of pertussis documented
  • Hospitals and EDs (pediatric and adult), clinics,
  • Sources
  • Patients, HCP with hospital or community-acquired
    pertussis, visitors or family members up to 80
    infections per index case
  • Incidence in HCP 7 per year
  • 90 of pediatric hospitals reported HCP exposures
    over 5-year period 11 reported infected

Costs of controlling pertussis
  • 74,870-174,327 per outbreak
  • 42,000-98,000/year for pertussis exposures
  • Include identifying contacts among HCP and
    patients, providing postexposure prophylaxis for
    asymptomatic close contacts, and evaluating,
    treating, and placing symptomatic HCP on
    administrative leave until they have received
    effective treatment

MMWR December 15, 200655(RR17) http//
Tdap vaccine
  • In 2005, Tdap (tetanus, diphtheria and acellular
    pertussis) vaccine was licensed in the U.S. no
    single antigen pertussis vaccine is available
  • In 2006, ACIP recommended that HCP in hospitals
    and ambulatory care settings with direct patient
    contact receive a single dose of Tdap as soon as
    feasible if they have not previously received it
    this was re-emphasized in 2011, all HCP should
    receive Tdap as soon as feasible
  • HCP who have direct contact with infants lt12
    months of age or pregnant women should be
    strongly encouraged to be vaccinated
  • Regardless of age, HCP without documentation of
    Tdap immunization should receive it there is no
    minimum interval between the last dose of Td and
  • Only one dose of Tdap is currently recommended,
    including for healthcare workers

Implementing a hospital Tdap program
  • Infrastructure exists in most hospitals
  • New HCP can be screened and vaccinated on
  • Tdap can be given at same time as influenza
  • Tiered approach option for existing HCP priority
    given to those with contact with infants lt12
    months of age or pregnant women
  • Pregnant women now recommended to receive Tdap
    during every pregnancy birth hospitals should
    provide Tdap to new mothers who were not
    vaccinated during pregnancy (and other contacts)
  • Emergency departments should use Tdap instead of
    Td for wound management

2011 ACIP recommendations on pertussis
postexposure prophylaxis for vaccinated HCP
  • Data on the need for postexposure prophylaxis in
    Tdap-vaccinated HCP are inconclusive
  • Postexposure prophylaxis is recommend for all HCP
    who have unprotected exposure to pertussis and
    are likely to expose a patient at risk for severe
    pertussis (e.g., hospitalized neonates)
  • Other HCP should either receive postexposure
    prophylaxis or be monitored for 21 days after
    pertussis exposure and treated at the onset of
    signs and symptoms of pertussis
  • The Minnesota Department of Health recently
    issued guidance on this topic http//

Diphtheria and tetanus protection also still
Chicago Department of Health WPA
Poster Collection Library of Congress, 1936-1941
Meningococcal Disease
Meningococcal disease
  • Caused by the bacterium N. meningitidis (gram
    negative diplococci)
  • 150-200 cases/year in California cases peak in
  • Even with proper treatment, infection may
    progress rapidly and result in death 10-20
    survivors have sequelae
  • Most cases are caused by five N. meningitidis
    serogroups A, B, C, W-135 and Y
  • Serogroup B is not contained in the quadrivalent
    (A, C, Y, W) vaccine 1/3 of California cases
    are serogroup B