IMMUNIZATIONS FOR HEALTH CARE WORKERS

Fran Ircink RN, NP

Clinic Manager

Employee Health Service

February 20, 2008

Objectives

• Understand the importance of vaccines in general

• Review currently recommended vaccines for health care workers (HCWs)

• Highlight recent vaccine updates for HCWs

Vaccine History

“The impact of vaccination on the health

of the world’s peoples is hard to exaggerate.

With the exception of safe water, no other

modality, not even antibiotics, had had such

a major effect on mortality reduction and

population growth.”

(Plotkin)

Definition of HCWs

Physicians, nurses, NAs, MAs, EMS

personnel, dental care professionals,

students in the medical setting, other

hospital staff (custodians, food service

workers, volunteers, etc.)

Immunizations for HCWs

Recommendations based on:

• Nosocomial transmission documented

• HCWs at significant risk for acquiring or transmitting infection

Recommendations

• Hepatitis B

• Influenza

• MMR (measles , mumps, rubella)

• Varicella (chickenpox)

• Tetanus, diphtheria, pertussis

• Meningococcal

Hepatitis B Disease• Virus affecting the liver• Can cause acute and chronic liver disease• Can cause liver cancer• Incubation period: 6 weeks – 6 months

• > 2 billion persons worldwide infected with the hepatitis B virus at some time in their lives– 350 million life-long carriers of disease and

can transmit virus to others– One million carriers die each year from liver

disease and liver cancer

Hepatitis B Disease

• Number of new infections per year declined from average of 450,000 in the 1980s to about 80,000 in 1999

• Greatest decline occurred among children and adolescents due to routine hepatitis B vaccination

Hepatitis B Transmission

Transmission via blood/body fluid via

mucocutaneous and contaminated sharps

exposures

• 30% of infected without identifiable risk factors• 5-10% infected become chronic carriers• Transmission risk 100X > than HIV

Hepatitis B Transmission

• Risk of infection related to degree of contact with blood in the work place and to hepatitis B e antigen (HBeAg) status of source person

• HBV can survive in dried blood at room temperature on environmental surfaces for at least 1 week

• Potential for HBV transmission through contact with environmental surfaces has been demonstrated in investigations of HBV outbreaks among patients and staff of hemodialysis units

Hepatitis B - HCWs

• HBV infection a well recognized occupational risk for HCP

• Prior to 1987 - 1997 100-200 HCWs died annually due to hepatitis B infection

• The annual number of occupational infections decreased 95% since hepatitis B vaccine became available in 1982, from >10,000 in 1983 to <400 in 2001.

Hepatitis B Vaccine

Recombinant vaccine licensed in 1986Effectiveness: 95% in adults who completed 3

dose series• Immunity probably lifelong

OSHA Blood Borne Pathogen Standard (1991)• Mandates that hepatitis B vaccine be made

available at the employer’s expense to all HCWs who are occupationally exposed to blood or other potentially infectious materials

Hepatitis B Vaccine

Post vaccine series antibody testing for HCWsrecommended

• Check titer 1-2 months after dose #3

– If positive/immune – no need for future doses or periodic blood tests to check for immunity

• 100% effective when develop positive antibody response after vaccination

– If negative/not immune – repeat 3 dose series• If positive/immune – done• If negative/not immune – non-responder-susceptible to hepatitis

B

Influenza - DiseaseTwo types - A and B that cause epidemic human disease

• Causes 36,000 deaths and over 200,000 hospitalizations on average in the United States annually

• Incubation period 1-4 days. Can be infectious from the day before symptoms begin through approximately 5 days after illness onset

• Characterized by the abrupt onset of fever, myalgia, headache, malaise, nonproductive cough, sore throat, and rhinitis

Influenza - Disease

• Usually resolves after 3-7 days; cough and malaise can persist for >2 weeks

• Can exacerbate underlying medical conditions (e.g., pulmonary or cardiac disease), lead to secondary bacterial pneumonia or primary influenza viral pneumonia, or occur as part of a coinfection with other viral or bacterial pathogens

Influenza - Transmission

Influenza viruses spread from person to

person, primarily through respiratory droplet

transmission (cough, sneeze) in close

proximity to an uninfected person

Influenza Vaccine - TIVLicensed in 1945Inactivated vaccineEffectiveness: 70%-90% in adults < 65 yrs of age

• Contains killed viruses – does not cause influenza in recipient

• Administered intramuscularly

• Approved for use among persons aged >6 months, including those who are healthy and those with chronic medical conditions

Influenza Vaccine - LAIV

Licensed in 2007Live attenuated vaccineEffectiveness: 92 %

• Contains live, attenuated viruses and, therefore, has a potential to produce mild signs or symptoms related to influenza virus infection

• Administered intranasally

• Approved only for use among healthy persons aged 5-49 yrs of age

Influenza Vaccine

Both Vaccines:

• contain strains of influenza viruses that are antigenically equivalent to the annually recommended strains: one influenza A (H3N2) virus, one A (H1N1) virus, and one B virus

• grown in eggs

• administered annually to provide optimal protectionagainst influenza virus infection

• A cost-benefit economic study estimated an average annual savings of $13.66/person vaccinated

Influenza Vaccine - HCWs

• Health care-associated transmission of influenza has been documented among many patient populations in a variety of clinical settings, and infections have been linked epidemiologically to unvaccinated health care workers

• HCWs are included in the “high risk” group for vaccination

• CDC - All health-care workers should be vaccinated against influenza annually to protect themselves, their patients, and communities

• Vaccination levels for health-care workers are typically <40%

Influenza Vaccine - UWHC

Influenza Vaccine Usage in UWHC Employees in 2007• Patient Care Titles: 64%• Non – Patient Care Titles: 62%

EHS Survey 2006: Reasons for not taking flu shot• Received a flu shot elsewhere: 28%• Fear of injections: 6%• I never get the flu-don’t need the shot: 39%• Contraindication to receiving flu shot: 4%• Fear of getting flu from the vaccine: 12%• Fear of side effects: 11%

Influenza Vaccine - UpdateNew JCAHO Standard – Effective 1/1/07 requiresorganizations to:

• Establish annual influenza vaccination program that includes at least staff and licensed independent practitioners

• Provide influenza vaccinations on-site

Influenza Vaccine - Update

• Educate staff about flu vaccination; non-vaccine control measures (i.e., use of appropriate precautions); and diagnosis, transmission and potential impact of influenza

• Annually evaluate vaccination rates and reasons for non-participation in the organization’s immunization program

• Implement enhancements to program to increase participation

Influenza Vaccine - Update

Infectious Disease Society of America (1/24/07) • The top professional society of infectious diseases experts is

insisting that all physicians, nurses, and other health workers caring for patients be vaccinated against influenza each year or decline in writing

• In 2005:– 7 states had legislation requiring annual influenza

vaccination of health-care workers or the signing of an informed declination

– 15 states had regulations regarding vaccination of health-care workers in long-term--care facilities

• Future Considerations:– Mandatory / Declination Waivers

Influenza - Update

Flu Outbreak in 11 states• New strain emerging not targeted by this year’s vaccine

– H3N2/Brisbane-like emerged near end of Australia’s flu season, too late to be included in the US vaccine

• So far, majority of flu cases caused by strains that are a good match to the vaccine and should provide some cross-protection against the new strain

• Not too late to get influenza vaccine

Measles, Mumps, Rubella (MMR)

Licensed in 1971Live virus vaccine

• 2 doses MMR for HCWs born in 1957 or later without serologic evidence of immunity or prior vaccination

• For HCWs born prior to 1957, immune if:– Physician diagnosed disease– Laboratory evidence of immunity– Documentation of two doses MMR given on/after 1st birthday

separated by 28 days or more

Measles (Rubeola) - Disease

Serious, acute, highly communicable rash

illness which may result in ear infection

(7%-9%), diarrhea (8%), serious lung

infection such as pneumonia (1%-6%) or

inflammation of the brain (1 in 1,500)

Measles – DiseaseWorldwide

• One of the most infectious diseases in the world– > 90% of people who are not immune get

measles if exposed to the virus

– > 20 million people get sick with measles each year, nearly 345,00 cases are fatal

Measles Rubeola - Disease

U.S.

• Before measles immunization available, nearly everyone in the U.S. got measles. Average of 450 measles-associated deaths reported each year between 1953 and 1963

• Up to 20 percent of persons with measles are hospitalized

• 3 of every 1,000 persons with measles will die in the U.S.

• Since 1997, < 150 cases reported annually

• 85% of cases in 2004 were imported

Measles - Transmission

• Spread by droplet and airborne (less common) routes

• Incubation period from exposure to rash 7-18 days

• Contagious from 4 days before until 4 days after onset of rash

Measles - Vaccine

Licensed in U.S. in 1963Live-virus vaccineEffectiveness - 95% one dose; 99+% two doses

Given as single antigen or part of MMR vaccine• 2 doses if born after 1956 given on/after 1st birthday• In U.S., widespread use of vaccine led to a > 99%

reduction in measles compared with the pre-vaccine era. • If immunization stopped, measles would increase to pre-

vaccine levels.

Mumps - Disease

• Acute viral disease characterized by fever, swelling and tenderness of one or more of the salivary glands. Usually mild viral disease

• Incubation period range; 12-25 days

• Estimated 212,000 cases occurred in the U.S. in 1964

• Annual reported cases in U.S. below 300 between 2001- 2005

• 2006 multistate outbreak (mainly in Midwest) > 4,000 cases reported

Mumps - Disease

Complications: • Can include deafness, inflammation of the

testicles, ovaries, or breasts respectively, pancreatitis, meningitis, encephalitis, and spontaneous abortion

• With the exception of deafness, complications more common among adults than children

Mumps - Transmission

• Airborne transmission

• Droplet spread

• Direct contact with saliva of infected person

• Contact with contaminated fomites

Mumps Vaccine

Licensed in 1967Live virus vaccine

• Effectiveness – 78%-91% one dose; 90 + % two doses

• In 1986 and 1987; resurgence of mumps with 12,848 cases reported in 1987

• Since 1989, incidence of mumps declined with 266 reported cases in 2001

Mumps Vaccine

• Recent mumps decrease probably due to children having received a second dose of mumps vaccine (as part of 2nd MMR) and the eventual development of immunity in those who did not gain protection after the first mumps vaccination

• If vaccination against mumps stopped, expected number of cases to climb back to pre-vaccine levels since mumps easily spread among unvaccinated persons

Mumps - Update

• “It’s the largest mumps epidemic in this country in more than two decades, with confirmed cases in at least eight states, most in the Midwest. The bulk of the cases are in Iowa, where up to 975 people have been affected, and the virus is spreading.”

Online News Hours, April 20th 2006

Mumps Vaccine -Update

• All persons who work in health-care facilities should be immune to mumps

• Adequate mumps vaccination for health-care workers born in or after 1957 consists of 2 doses of a mumps vaccine

• HCWs with no history of mumps vaccination and no other evidence of immunity should receive 2 doses (at a minimum interval of 28 days between doses)

Mumps Vaccine -Update

• HCWs who have received only 1 dose previously should receive a second dose

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

Rubella (German Measles)

• Mild febrile viral disease with a diffuse maculopapular rash resembling measles or scarlet fever

• Since 1996, > 50% of the reported rubella cases have been among adults

• Since 2004 no longer endemic in U.S but still common in many parts of the world

Rubella (German Measles)

Complications • Congenital Rubella Syndrome (CRS)

• Occurs in up to 90% of infants born to mothers infected with rubella during the first trimester of pregnancy

• Results in heart defects, cataracts, mental retardation,

and deafness

• From 1998 through 2004 93% of infants born with CRS were born to foreign-born mothers

Rubella - Transmission

• Contact with nasopharyngeal secretions of infected people

• Droplet spread or direct contact with patients

Rubella - Vaccine

Licensed in 1969Live – virus vaccineEffectiveness – 95+% 1st dose

• In 1964-1965, before rubella immunization was used routinely in the U.S., an epidemic of rubella resulted in– estimated 20,000 infants born with CRS

– 2,100 neonatal deaths

– 11,250 miscarriages

– Of the 20,000 infants born with CRS, 11,600 were deaf, 3,580 were blind, and 1,800 were mentally retarded

Rubella Vaccine

• Since 2001, fewer than 25 cases of rubella reported annually (99.8% decline compared with pre-vaccine era)

• Since 2001 an average of 1 case of CRS reportedannually in the U.S.

• If stopped rubella immunization, immunity would decline and rubella would once again return, resulting in pregnant women becoming infected with rubella and then giving birth to infants with CRS

Rubella - HCW

Department of Health and Family Services

Chapter 124 – Hospitals

• Protection against rubella – the hospital’s employee health program shall include vaccination or confirmed immunity against rubella for everyone who has direct contact with rubella patients, pediatric patients or female patients of childbearing age

Varicella (Chickenpox)

• Highly contagious viral disease

• Prior to varicella vaccine almost all persons in the U.S. had suffered from chickenpox by adulthood

• Usually mild, but may be severe in some infants, adolescents, and adults

Varicella (Chickenpox)

Complications:

• Secondary bacterial infections

• Pneumonia

• Central nervous system involvement

Varicella - Transmission

Person to person by:

• Direct contact– Droplet– Airborne spread of vesicle fluid of patients with

shingles (zoster)

• Indirect contact:– articles freshly soiled by discharges from vesicles and

mucous membranes of infected people

Varicella - Vaccine

Licensed in 1995

Live – virus vaccine

Effectiveness – 80% - 90% 1st dose: 98% 2nd dose

Past Recommendations:• One dose 12 months – 12 years • 2 doses age 13 or older

Varicella - Vaccine

New Recommendations:

• All children <13 years of age should be administered routinely two doses of varicella-containing vaccine

• Second dose catch-up varicella vaccination is recommended for children, adolescents, and adults who previously had received one dose to improve individual protection against varicella

Varicella - HCWs

All HCWs should be immune to varicella

Immune if:

• 2 doses varicella given at least 28 days apart

• History of varicella or herpes zoster based on physician diagnosis, laboratory evidence of immunity, or laboratory confirmation of disease

Tetanus, diphtheria, pertussis

Pertussis Disease

• “Whooping cough” - highly contagious respiratory tract infection

• Initially resembles ordinary cold, may eventually turn more serious, particularly in infants

• Characterized by irritating cough becoming paroxysmal within 1-2 weeks and lasting 1-2 months or longer

• Best prevention is through vaccine

Tetanus, diphtheria, pertussis

Pertussis Disease

• Immunity from prior illness or childhood vaccine is not lifelong

• In recent years in U.S., pertussis recognized with increasing frequency in adolescents and adults

• 1010 cases reported in 1976 ; 25,287 cases reported in 2004

Tetanus, diphtheria, pertussis

Pertussis Transmission

• Direct contact with discharges from respiratory mucous membranes of infected persons by the airborne and droplet routes usually through coughing and sneezing

• Incubation period 7-20 days

• Most contagious before the coughing starts and contagious for weeks after

• Secondary attack rates 50% - 100% in close contacts

Tetanus, diphtheria, pertussis

Pertussis Complications

• Bacterial pneumonia and rib fracture

• Infants are at highest risk for apnea, pneumonia, seizures, encephalopathy, and death

Tetanus, diphtheria, pertussis

Pertussis – HCWs

• Health care environments - setting for a number of pertussis outbreaksresulting in transmissions to HCWs, vulnerable infants and other patients

• In last decade numerous nosocomial outbreaks reported

Tetanus-diphtheria-acellular pertussis-Vaccine (Tdap)

Licensed in 2005Effectiveness: 92%

• Contain reduced pertussis antigen compared with pediatric formula and similar amounts of tetanus and diphtheria toxoids in adult dT booster

• Single dose booster for age 19-64

• HCWs working in hospitals or ambulatory care settings and have direct patient contact should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap

• Priority given to vaccination of HCWs with direct contact with infants aged <12 months. Interval of 2 or more years from the last dose of Td recommended for the Tdap dose

Meningococcol Disease

• Acute bacterial disease caused by Neisseria Meningitidis characterized by:– sudden onset of fever, intense headache,

nausea and often vomiting, stiff neck and frequently a petechial rash

• In the U.S., meningococcal disease is usually caused by groups A, B, C, Y, and W-135 of the meningococcus bacteria

Meningococcol Disease

• Approximately 2,600 cases of meningococcal meningitis in the U.S. each year – mainly in children less than five years old

• Children younger than two years old have the highest incidence, with a second peak incidence between 15 to 24 years of age

Meningococcol Disease

• 11-19% of survivors – deafness, other neurologic impairment, and impaired circulation leading to gangrene and amputation of limbs

• Death occurs in 10% to 14% of people with meningococcal disease – highest in infants and adolescents

Meningococcol Transmission

• Close contact with direct contact including respiratory droplets from aerosols and secretions from nose and throat of infected

people (patients or asymptomatic carriers)

• Incubation period: 2-10 days, commonly 3-4 days

Meningococcol Vaccine - HCWs

• Although N. meningitidis regularly isolated in clinical laboratories, it has infrequently been reported as a cause of laboratory-acquired infection

• Two probable cases of fatal laboratory-acquired meningococcal disease and the results of an inquiry to identify previously unreported cases reported

• The findings indicate that N. meningitidis isolates pose a risk for microbiologists and should be handled in a manner that minimizes risk for exposure to aerosols or droplets

Meningococcol Vaccine

MPSV4: Licensed in 1981: Ages 2-10 and >55

• 85%-100% protection for 3–5 years in older children and adults

• High risk need revaccination every 3–5 years

• Not recommended and should not be administered routinely for adolescents ages 11–12 or for adolescents entering high school. Adolescents in these age groups are recommended only to receive MCV4

• An acceptable alternative for persons at elevated risk ages 11–54 years where MCV4 is not available

Meningococcol Vaccine

MCV4: Licensed in 2005: Ages 11-55

• Need for revaccination not yet known

• Higher production of antibodies and longer duration of protection and similar efficacy compared to MPSV4 expected in adolescents and adults

• Both current vaccines effective against A,C,Y and W-135. Not effective against group B

• Recommended for microbiologists who are routinely exposed to isolates of N. meningitidis that might be aerosolized

Immunizations of HCWs - UWHC

• Immunization recommendations have become more comprehensive and standardized over the years

• All new applicants screened for appropriate immunizations

• “Old timers” may not be up to date

• Catch ups via: periodic chart audits;

episodic visits

Future Considerations

• Greater emphasis on making sure HCWs adhere to current vaccine recommendations

• Better documentation of HCWs vaccination status