Kathleen Harriman, PhD, MPH, RNVaccine Preventable Disease Epidemiology SectionCalifornia Department of Public HealthImmunization Branchkathleen.harriman@cdph.ca.gov

Healthcare PersonnelImmunization

Recommendations:2011 Update

Background

• Ensuring that healthcare personnel (HCP) are immune to vaccine preventable diseases (VPDs) is an essential part of occupational health programs Prevent transmission of VPDs and eliminate

unnecessary work restrictions Safeguards health of workers and protects

patients from exposure to infected workers Substantially reduces both number of

susceptible HCP and risks for transmission of VPDs to other workers and patients

Rationale

• Prevention of illness through comprehensive employee immunization programs is far more cost-effective than case management and outbreak control

• Mandatory immunization programs, which include both newly hired and currently employed persons, are more effective than voluntary programs in ensuring that susceptible persons are vaccinated

Vaccination Programs

1. Maintenance of complete immunization records

2. Policies for catch-up vaccination3. Work restrictions for exposed susceptible

employees4. Control of outbreaks5. Additional vaccines may be indicated for

laboratories 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 from?

• 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 recommendations

• 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 contraindications

• Recommends immunizations for healthcare personnel

Advisory Committee on Immunization Practices (ACIP)

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 within the organization

Newest ACIP Recommendations for HCP, 2011

Most Recent ACIP Recommendations

Immunization of healthcare personnel, 2011http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htmHepatitis B, 2006 http://www.cdc.gov/mmwr/PDF/rr/rr5516.pdf

Influenza, 2011http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a3.htmInfluenza vaccine, healthcare personnel, 2006http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm

Diphtheria, tetanus, pertussis, 2006http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm

Measles, mumps, rubella, 1998 and 2009 updatehttp://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htmhttp://www.cdc.gov/vaccines/recs/provisional/downloads/mmr-evidence-immunity-Aug2009-508.pdf

Mumps, 2006 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5522a4.htm

Varicella, 2007http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdf

2011 ACIP adult immunization recommendationshttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm6004a10.htm?s_cid=mm6004a10_e&source=govdelivery

Vaccines that might be indicated for adults, based on medical and other indications --- United States, 2011

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

Vaccine that is required to be offered* per the Cal/OSHA 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.

Which employees are covered by the Cal/OSHA ATD standard?• 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

http://www.dir.ca.gov/Title8/5199.html

Occupational Exposure• In each included work setting covered by

the standard, it is presumed that some employees have occupational exposure; for a particular employee it depends on tasks, activities, and the environment

• 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 measures

Vaccines that are required to be offered* per the ATD standard

Vaccine • Influenza • Measles• Mumps• Rubella • Tetanus, diphtheria,

and acellular pertussis (Tdap)

• Varicella-zoster (VZV)

Schedule• One dose

annually• Two doses• Two doses• One dose• One dose,

booster as recommended

• Two doses* To all susceptible employees who might be exposed. If vaccine is declined, a declination form must be signed.

Diseases covered by the ATD standard

• Applies to diseases classified by CDC’s 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://www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html

† http://www.cdph.ca.gov/HealthInfo/Documents/Reportable_Diseases_Conditions.pdf

Seasonal Influenza

Annual Influenza Vaccination

• Offer to all eligible HCP at no cost• Educate re: vaccination benefits and

consequences of influenza illness for themselves and their patients

• Obtain signed declination forms• Monitor coverage including ward, unit,

and specialty-specific coverage rates• Use HCP coverage as a measure of

patient safety quality program• Mandate vaccination??

Influenza – the Numbers• 15% of persons ill during average influenza

season

• 23% of HCP had documented serologic evidence of influenza infection after mild influenza season; 59% could not recall having influenza

• >75% of HCP with influenza-like illness (ILI) continued to work in hospital

• 32% decrease (to 0) of nosocomial influenza in a hospital with vaccination increase from 4 to >67%

Barriers to Influenza Vaccination • Fear of vaccine side effects (particularly influenza-

like illness symptoms)

• Perceived ineffectiveness of the vaccine

• Medical contraindication (not always valid)

• Perceived low likelihood of contracting influenza

• Fear of needles

• Insufficient time or inconvenience

• Similar barriers may apply to Tdap

CDC influenza vaccine information for HCP: http://www.cdc.gov/flu/HealthcareWorkers.htm?s_cid=ccu091310_014 http://www.thecommunityguide.org/worksite/flu-hcw.html

Strategies Used by Nursing Homes to Encourage Influenza Vaccination Among

Their Employees

§ Strategies associated with LTCF staff influenza vaccination rates >60%

SOURCE: National Nursing Home Survey; 2004

Available at: http://www.cdc.gov/nchs/nnhs.htm

Mandatory Influenza Vaccination• Seattle: Virginia Mason – first U.S. hospital to mandate

influenza vaccination or mask wearing during influenza season

• St. Louis: Barnes-Jewish – first U.S. hospital to mandate influenza vaccination and terminate noncompliant employees

• New York: 2009 emergency regulation (later withdrawn) required seasonal and pandemic H1N1 vaccination of personnel in hospitals, home care, hospice, and diagnostic/treatment facilities http://www.health.state.ny.us/diseases/communicable/influenza/seasonal/providers/

2009-08-26_health_care_worker_mandatory_influenza_immunization.htm

• 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 CDC’s National Healthcare

Safety Network (NHSN) required Some hospitals began mandating vaccination or mask wearing in

2009

National Organization Influenza Vaccination Recommendations

• APIC 2011: Acute care hospitals, long-term care and other facilities that employ HCP should require annual influenza immunization as a condition of employment unless there are compelling medical contraindications. Unvaccinated HCP may be required to wear a mask when contact with patients or susceptible employees is likely.

• SHEA 2010: Endorses a policy in which annual influenza vaccination is a condition of both initial and continued HCP employment and/or professional privileges.

• IDSA 2009: Mandatory vaccination or mask wearing.

• ACIP 2007: Level of vaccination coverage among HCP to be one measure of a patient safety quality program. Implement policies to encourage HCP vaccination (e.g., obtaining signed statements from HCP who decline influenza vaccination).

• Most unions oppose mandatory vaccination

Joint CommissionStandard IC.02.04.01: The organization offers vaccination against influenza to licensed independent practitioners and staff.

1. The hospital establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff.

2. The hospital educates licensed independent practitioners and staff about, at a minimum, the influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza.

3. The hospital provides influenza vaccination at sites accessible to licensed independent practitioners and staff.

4. The hospital annually evaluates vaccination rates and the reasons given for declining the influenza vaccination.

5. The hospital takes steps to increase influenza vaccination rates.

Medical Conditions that Confer a Higher Risk of Severe Influenza• Chronic pulmonary disorders (including asthma) • Cardiovascular disorders (except hypertension) • Renal disorders• Hepatic disorders• Cognitive disorders*• Neurologic/neuromuscular disorders*• Hematologic disorders• Metabolic disorders (including diabetes mellitus)• Immunosuppression (including

immunosuppression caused by medications or by HIV)

*that can compromise respiratory function, the handling of respiratory secretions, or increase the risk for aspiration

Can HCP taking antivirals receive influenza vaccine?• Antivirals do not interfere with the development of

immunity from inactivated (injectable) influenza vaccine

• Antivirals may interfere with the development of immunity from intranasal live attenuated influenza vaccine (LAIV)

• LAIV should not be administered until 48 hours after the cessation of antiviral therapy and antivirals should not be administered until two weeks after administration of LAIV unless medically indicated

• If antivirals and LAIV are given concomitantly, HCP should be revaccinated when appropriate

 

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

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm

0

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1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

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Estimated Number of Acute HBV Infections Due to Occupational Exposures, U.S., 1983-2002

Vaccine Recommended for HCP

OSHA Requirement

s

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 >10 mIU/mL = immune

Hepatitis B Testing After Vaccination• Anti-HBs <10 mIU/mL revaccinate

3 doses followed by testing after third dose more practical than testing after 1 or more doses of vaccine

• Anti-HBs <10 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 blood

• Periodic titers or booster doses of vaccine not recommended - protection is long lasting

Previously Vaccinated HCP Without Evidence of Immunity• 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

• An ACIP workgroup is currently discussing recommendations for HCP who were immunized as children

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 B

HIV-positive HCP HCP who disclose having engaged in or currently

engaging in high-risk sexual or substance abuse behaviors

HCP who require immunosuppressive therapy or who are on hemodialysis http://www.cdc.gov/mmwr/pdf/rr/rr5516.pdf

Hepatitis B Infected HCP

• Chronic hepatitis B infection is not grounds for exclusion from healthcare practice or training

• See the Society for Healthcare Epidemiology of America’s “Guideline for Management of Healthcare Workers Who Are Infected with Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus” at: http://www.shea-online.org/GuidelinesResources/Guidelines/Guideline/ArticleId/46/Guideline-for-Management-of-Healthcare-Workers-Who-Are-Infected-with-Hepatitis-B-Virus-Hepatitis-C-V.aspx

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. MMWR 50 (RR11) - 6/29/01

Measles

Measles • In the decade before the measles vaccine

was licensed in 1963, ~3–4 million people were infected in the U.S. each year 400–500 died 48,000 were hospitalized 1,000 developed chronic disability from

measles encephalitis Epidemics occurred every 2-3 years

• 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

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Measles—United States, 1950-2005

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2nd dose1989

Endemictransmission interrupted

Measlesdeclared

eliminated

Measles• Elimination of endemic measles in North and South

America was achieved in 2002 and is a public health success model for immunization programs in the developed world

• 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 2000: “Measles is no longer endemic in the U.S.”

• As evidenced by recent outbreak activity in Europe, for control to be sustained, two-dose vaccination strategy with very high coverage is needed

• Measles continues to be imported to the U.S. and California by travelers from parts of the world where measles is not controlled

Measles Transmission • Measles is transmitted via the airborne

route and is thought to be the most infectious communicable disease

• 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• Documented administration of two doses of

live measles virus vaccine on or after the first birthday and at least 28 days apart; or

• Laboratory evidence of immunity or laboratory confirmation of disease; or

• Birth before 1957*

Documentation of physician-diagnosed measles is no longer acceptable evidence of immunity

* Since ~5% of people born before 1957 are susceptible to measles, CDPH recommends that immunity be assessed if such HCP are exposed to measles. During an outbreak, 2 doses of MMR are recommended for unvaccinated HCP without evidence of immunity.

Respiratory Protection

• Regardless of 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

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 pediatrician’s 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 >1957 and 18 (4%) of 506 HCPs born <1957 were seronegative, including 1 who acquired measles

• Two hospitals spent ~$800,000 responding to and containing the seven measles cases in their facilities

Mumps

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

Presumptive Evidence of Immunity to Mumps

• Documented administration of two doses of live mumps virus vaccine; or

• Laboratory evidence of immunity or laboratory confirmation of disease; or

• Born before 1957

Documentation of physician-diagnosed mumps is no longer acceptable evidence of 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 (>28 days

apart) Only 1 dose previously second dose Birth before 1957 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 (>95%) 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

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 tuberculin testing http://www.cdc.gov/mumps/prev-control-settings/index.html

Rubella

Rubella Epidemiology

• Rubella vaccines were first licensed in 1969 and rubella was declared eliminated in the U.S. in 2004

• Rubella cases in the U.S. are now imported from regions of the world where rubella is not controlled

Presumptive Evidence of Immunity to Rubella• Documented administration of one dose of

live rubella virus vaccine; or

• Laboratory evidence of immunity or laboratory confirmation of disease; or

• Born before 1957 (except premenopausal women who could become pregnant)

Documentation of physician-diagnosed rubella is no longer acceptable evidence of immunity

Presumptive Evidence of Immunity to Rubella, continued• 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 disease

• 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

Measles, Mumps and Rubella Immunity Testing• Testing for serologic evidence of immunity to

measles, mumps or rubella is not recommended for HCP who have two documented doses of MMR vaccine or other acceptable evidence of immunity

• If testing is inadvertently performed on HCP with documentation of vaccination and the worker is IgG negative for measles, mumps or rubella, ACIP recommends that test be assumed to be falsely negative and that the worker should be presumed immune for the purposes of preplacement screening

• If such a worker has an exposure to measles, CDPH recommends treating as susceptible

Varicella

Varicella Among HCP

• Nosocomial transmission of is varicella is well-recognized

• Sources Patients, hospital staff, and visitors with

varicella or herpes zoster

• Airborne transmission of varicella has been demonstrated Varicella has occurred in susceptible persons

who had no direct contact with index case-patient

Virus detected in air Herpes zoster may also be airborne (?)

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 recommended 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 upon

http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdf

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 history of 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 immunity

Evidence of Immunity to Varicella• Serologic evidence of VZV infection in 96%-97% of

U.S.-born adults aged 20-29 years and in 97%-99% of adults aged >30 years tested during 1998-1999

• U.S. birth before 1980 considered evidence of immunity except for HCP, pregnant women, and immunocomprised 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

• 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 Exposure to Vaccinated HCP

• 2 doses - monitor daily during days 10-21 to determine clinical status, place on sick leave immediately if symptoms occur

• 1 dose – give 2nd dose <3-5 days of exposure After vaccination, management is similar to 2-

dose

• Unvaccinated HCP without immunity – postexposure vaccination and 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 facilities

• 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

Varicella Postexposure Prophylaxis

• Varicella vaccine is effective in preventing illness or modifying varicella severity if administered to unvaccinated children within 3 days, and possibly up to 5 days, of exposure

• Studies only in children

• Although postexposure use of varicella vaccine has potential applications in hospital settings, pre-exposure vaccination preferred

Pertussis

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 >9,000 cases & 10 deaths

• Most severe disease occurs among infants <6 months of age; almost all deaths are in infants <3 months of age

• Studies have shown that ~half of the infants with pertussis were infected by a household member, most often their mother

• Immunity via vaccine or disease wanes over time; most children last vaccinated at kindergarten are susceptible again by middle school

• Almost all adults are susceptible; only ~6% of adults have received Tdap, which was licensed in 2005

Number of reported pertussis cases by year of onset ― California, 1914-2010*

* Includes cases reported to CDPH as of 3/9/2011

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licensed

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Number of reported pertussis cases by year of onset -- California 1945-2010*

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case

s p

er 1

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00

case

s

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Cases

Rate per 100,000

*As of 3/9/2011; data for 2010 are still preliminary

9,477 cases

Previous peak in 1945 number of cases: 13,845

Previous peak in 1958 incidence: 26.0/100,000

24.2/100,000

Pertussis Among HCP• Nosocomial spread of pertussis documented

Hospitals and EDs (pediatric and adult), clinics, LTCFs

• Sources Patients, HCP with hospital or community-acquired

pertussis, visitors or family members; up to 80 infections per index case

• Incidence in HCP currently ~7% per year

• 90% pediatric hospitals reported HCP exposures over 5-year period; 11% reported infected physicians

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, 2006;55(RR17)

http://www.cdc.gov/mmwr/PDF/rr/rr5517.pdf

Tdap Vaccine • In 2005, a vaccine containing tetanus and diphtheria

toxoids and acellular pertussis vaccine (Tdap) was licensed in the U.S. for persons aged 11-64 years (ADACEL®) – pertussis is not available as a single vaccine

• 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 <12 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 Tdap

Implementing Hospital Tdap Program • Infrastructure for vaccination exists in

most hospitals New HCP screened and vaccinated on

employment Can be given at same time as influenza vaccine Tiered approach option: priority given to HCP

with contact with infants aged <12 months, other vulnerable groups of patients

As Tdap vaccination coverage in general population increases, many new HCP will already have received dose of Tdap

• Birth hospitals should also promote Tdap vaccination of new mothers

• Emergency departments should use Tdap

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

Meningococcal Disease

Meningococcal Disease • Caused by the bacterium N. meningitidis

• ~185 cases/year in California; peaks in winter

• Even with proper treatment, it 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 vaccine; > 1/3 of cases in California are serogroup B and are not vaccine preventable

Meningococcal disease by month of onset – California 2009-2011

Meningococcal Vaccine• Microbiologists routinely exposed to isolates of N.

meningitdis are considered to be at increased risk for meningococcal disease and are recommended to receive vaccine

• Two types of quadrivalent meningococcal vaccine are available – both protect against infection with serogroups A, C, W-135 and Y (not against B) Meningococcal conjugate vaccine (MCV4) for

workers through 55 years of age Meningococcal polysaccharide vaccine (MPSV4) for

workers over 55 years of age Employees >55 years who have received MPSV4 3-

5 years previously should be revaccinated with MCV4 if still at increased risk

http://www.cdc.gov/mmwr/pdf/rr/rr5407.pdf

New ACIP Recommendations• HCP with anatomic or functional asplenia,

persistent complement component deficiencies, or HIV should now receive a 2-dose primary series of meningococcal conjugate vaccine

• Those HCP who remain in groups at high-risk are recommended to be revaccinated every 5 years

Other Resources for Occupational Health

• Medical center occupational and employee health issues (MCOH-EH) listserv http://mylist.net/listinfo/mcoh-eh

• American College of Occupational and Environmental Medicine http://www.acoem.org