IMMUNIZATIONS FOR HEALTH

CARE WORKERS

Dr. V. Anil Kumar MD

Infection Control Officer

Clinical Additional Professor

Microbiology,

Amrita Institute of Medical Sciences, Kochi, Kerala.

Objectives

• Understand the importance of vaccines in

health care workers (HCWs)

• Review currently recommended vaccines

for HCWs

• Highlight recent vaccine updates for

HCWs

Definition of HCWs

Physicians, nurses, Nursing assistants, ward

boys, 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 • Why?

The Virus & Transmission dynamics

–Virus remains infectious for prolonged periods on

environmental surfaces

–Transmissible in the absence of visible blood

–Transmission risk 100X > than HIV

–5-10% infected become carriers

Morbidity and Mortality Weekly Report,Dec 2013

• The 3-dose at 0, 1, and 6 months produces a protective

antibody response in approximately 30%–55% of healthy

adults aged ≤40 years after the first dose, 75% after the

second dose, and >90% after the third dose .

• Protection against symptomatic and chronic HBV infection

has been documented to persist for ≥22 years in vaccine

responders .

• Immunocompetent persons who achieve anti-HBs

concentrations of ≥10 mIU/mL after preexposure

vaccination have protection against both acute disease and

chronic infection.

Hepatitis B Vaccine

Situation 1 If a person who works in a healthcare setting

had one dose only of hepatitis B vaccine 4

months ago, should the series be restarted?

• The hepatitis B vaccine series should not be restarted

when doses are delayed

• It should be continued from where it was stopped

• 1st and 2nd dose-4 weeks

• 2nd and 3rd dose gap-8 weeks

• 1st and 3rd dose gap-16 weeks

Which HCP need serologic testing after

receiving 3 doses of hepatitis B vaccine?

Situation 2

• All HCP

• Post vaccination testing should be done 1–2 months after the last dose of vaccine.

• Postvaccination testing for persons at low risk for mucosal or percutaneous exposure to blood or body fluids (e.g., public safety workers and HCP without direct patient contact) likely is not cost-effective

• Those who do not undergo postvaccination testing should be counseled to seek immediate testing if exposed.

• What should be done if a person’s

postvaccination anti-HBs test is non protective

(less on than10 mIU/mL) 1–2 months after the

last dose of vaccine?

Situation 3

• Repeat the 3 dose series

• Still negative?

• Test for HBsAg & Anti HBc--negative-Non

responder

• Positive HBsAg?

• Negative HBsAg;Positive anti HBc?

• How often should I test HCP after they’ve

received the hepatitis B vaccine series to make

sure they’re protected?

Situation 4

• Only once 1-2 months after last dose

• Should be performed for all HCP at high risk for

occupational percutaneous or mucosal exposure to

blood or body fluids.

• An employee thinks she had 3 doses of hepatitis B vaccine

in the past but has no documentation of receiving those

doses. Before reading the recommendations to revaccinate

her, we obtained an anti-HBs titer and the result was greater

than 10 mIU/mL. With this lab result,can't we assume she is

immune?

Situation 7

• No & Yes

– A positive anti-HBs indicates that the vaccinated person is

immune at the time the person was tested but does not

assure that the person has long-term immunity.

– Long-term immunity has been demonstrated only for people

attaining an adequate anti-HBs result of at least 10 mIU/mL

after completing a full vaccination series.

• I’m a nurse who received the hepatitis B vaccine

series more than 10 years ago and had a

positive follow-up titer (at least 10 mIU/mL). At

present, my titer is negative (less than 10

mIU/mL). What should I do now?

Situation 8

• Nothing • Adults who respond to a 3-dose hepatitis B

vaccine series (anti-HBs of at least 10 mIU/ mL) are protected from chronic HBV infection for at least 22 years, even if there is no detectable anti-HBs currently.

• Immunocompromised individuals: Booster doses (esp dialysis patients and HIV positive)

• If an employee does not respond to hepatitis B

vaccination (employee has had two full series

of hepatitis B vaccine), does he need to be

removed from activities that expose him to

blood borne pathogens? Does the employer

have a responsibility in this area beyond

providing vaccine?

• Can a person with chronic HBV infection work

in a healthcare setting?

Situation 9

• There are no regulations that require

removal from job situations where

exposure to blood borne pathogens could

occur; this is an individual policy decision

within the organization

• HCP should not be discriminated against

because of their hepatitis B status

The Caveat

• HBV levels 1000 IU/mL or 5000 genomic

equivalents/mL or higher should not

perform exposure-prone procedures (e.g.,

gynecologic, cardiothoracic surgery)

–unless they have sought counsel from an

expert review panel

–and been advised under what circumstances,

if any, they may continue to perform these

procedures.

Achieving Immunity in Hepatitis B

Vaccine Non-responders

• Investigators in Sweden recently assessed the effectiveness of the combined hepatitis A/B vaccine in 64 adults — 44 nonresponders who had not developed protective anti-HBs levels after 4 intradermal doses of the Engerix-B recombinant hepatitis B vaccine and 20 control participants who were not immune to hepatitis B virus (HBV) or hepatitis A virus (HAV) and had never received the hepatitis B vaccine. .

• All participants received 2 mL of combined hepatitis A/B vaccine at 0, 1, and 6 months; serum samples were obtained before each dose and 1 month after the last two doses.

• Three double doses of the combined hepatitis A/B vaccine provided protective HBV immunity in 95% of hepatitis B vaccine nonresponders.

• All 20 controls attained such immunity (10%, 95%, and 100%, respectively). Thirty-five of the 44 nonresponders (80%) developed anti-HBs titers >100 IU/mL. The two persistent nonresponders were smokers, and both smoking and high body-mass index were associated with lower anti-HBs levels. All 64 participants developed anti-HAV antibodies.

Published in Journal Watch Infectious Diseases July 2, 2008

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 Vaccine

TIV: Inactivated vaccine

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. Preferred in HCP working in transplant and oncology units.

LAIV: Live attenuated vaccine

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 non pregnant healthy HCP aged 5-49 yrs.

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 protection

against influenza virus infection

• About 2 weeks after vaccination, antibodies that provide protection against the influenza viruses in the vaccine develop in the body.

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%

Measles, Mumps, Rubella (MMR)

Transmission: Airborne/Droplet

Live virus vaccine

• 2 doses MMR for HCWs without serologic evidence of immunity or prior vaccination

• For HCWs, 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)

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

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

Varicella (Chickenpox)

• Highly contagious viral disease

• Usually mild, but may be severe in some infants,

adolescents, and adults

Complications:

Secondary bacterial infections

Pneumonia

Central nervous system involvement

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-acellular pertussis-Vaccine (Tdap)

Licensed in 2005

Effectiveness: 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

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

• Droplet spread

Meningococcol Vaccine - HCWs

• HCP with anatomic or functional asplenia or persistent complement component deficiencies should now receive a 2-dose series of meningococcal conjugate vaccine.

• HCP with HIV infection who are vaccinated should also receive a 2 dose series.

• Those HCP who remain in groups at high risk are

recommended to be revaccinated every 5 years.

• 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: meningococcal polysaccharide vaccine Ages 2-10 and >55

High risk need revaccination every 3–5 years

Not recommended and should not be administered routinely for adolescents ages 11–12

MCV4: meningococcal conjugate vaccine Ages 11-55

Need for revaccination not yet known

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

Pregnancy and Vaccination

• No live vaccines like MMR, influenza

• HBV vaccine not contraindicated.

• Td/Tdap should be given during each

pregnancy.

What about wearing masks?

Do Mandatory Immunization Programs for

HCWs Make Sense?

• Are their benefits for patients to having

healthcare workers immunized? YES

• Are their direct benefits to healthcare

workers from being immunized? YES

• Is it necessary for hospitals to require

healthcare workers to be immunized? YES

• Does it make sense to have non-

immunized clinical employees wear a

mask? YES

Why HCW decline flu vaccine

2005-2006 2006-2007

Allergy/Reaction 39 26

Rec’d vaccine elsewhere 36 6

Concern about side effects 34 193

Never get flu 9 27

Personal choice 119 53

Religious 1 0

Other 32 15

Pregnancy 11 5

Fear of needles 7 0

TOTAL 276 392

Influenza (H1N1), conjunctivitis, Chicken Pox

Hepatitis B Give 3-dose series (dose #1 now, #2 in 1 month, #3 approximately

5 months after #2). Give IM. Obtain anti- HBs serologic testing 1–

2 months after dose #3.

Influenza Give 1 dose of influenza vaccine annually. Give inactivated

injectable vaccine intramuscularly or live attenuated influenza

vaccine (LAIV) intranasally.

MMR For healthcare personnel (HCP) born in 1957 or later without

serologic evidence of immunity or prior vaccination, give 2 doses

of MMR, 4 weeks apart. For HCP born prior to 1957, see below.

Give SC.

Varicella

(chickenpox)

For HCP who have no serologic proof of immunity, prior

vaccination, or history of varicella disease, give 2 doses of

varicella vaccine, 4 weeks apart. Give SC.

Tetanus,

diphtheria,

pertussis

Give a dose of Tdap as soon as feasible to all HCP who have not

received Tdap previously and to pregnant HCP with each

pregnancy (see below). Give Td boosters every 10 years thereafter.

Give IM.

Meningococcal Give 1 dose to microbiologists who are routinely exposed to

isolates of N. meningitidis and boost every 5 years if risk

continues. Give MCV4 IM; if necessary to use MPSV4, give SC.

Questions?

www.immunize.org/catg.d/p2109.pdf

CDC. Immunization of Health-Care Personnel:

Recommendations of the Advisory Committee on

Immunization Practices, MMWR, 2011; 60(7):1–

48, www.cdc.gov/mmwr/pdf/rr/rr6007.pdf

Immunization Action Coalition. ―Healthcare Personnel

Vaccination Recommendations,‖

www.immunize.org/catg.d/p2017.pdf