Transcript IMMUNIZATIONS FOR HEALTH CARE WORKERS

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 1986
Effectiveness: 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 HCWs
recommended
• 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-respondersusceptible to hepatitis B
Influenza - Disease
Two 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 - TIV
Licensed in 1945
Inactivated vaccine
Effectiveness: 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 2007
Live attenuated vaccine
Effectiveness: 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 protection
against 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 - Update
New JCAHO Standard – Effective 1/1/07 requires
organizations 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 1971
Live 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 – Disease
Worldwide
• 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 1963
Live-virus vaccine
Effectiveness - 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 prevaccine 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 1967
Live 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 physiciandiagnosed 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 1969
Live – virus vaccine
Effectiveness – 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 reported
annually 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 varicellacontaining 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 outbreaks
resulting in transmissions to HCWs,
vulnerable infants and other patients
• In last decade numerous nosocomial
outbreaks reported
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
• 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