Transcript this presentation (Pt. 2) - cacuss/aseucc 2007

Health Care Professionals
and Immunization
Ben J. K. Tan, MD, FRCPC
Assoc Prof, University of Saskatchewan
Infectious Diseases, RUH
Saskatoon, SK
Declaration:
Not speaking as a member of NACI
“Organized” Immunization
Occupational Health
Infection Control
Infectious Diseases
Outbreaks
Patients
HCW
|
Student
Public Health
Family Physician
Pediatrician
University/College
Student Health
Physician/Nurse
Immunization Schedule, Child (mod from CIG 2006)
Vaccines
B
2m
4m
6m
#1
#2
#3
12m
18m
23m
2y
DTaP-IPV (im)
4y
9y
12y
14y
18y
#5
#4
Hib (im)
Tdap (im)
#1
Pneu-C-7 (im)
#1
#2
[#3]
Men-C-C (im)
#1
#2
#3
#4
#1
Var (sc)
#1
3d, preferably @ B,1m,6m
HPV (im, females)
OR
#2
CU – 1 dose (if susceptible)
CU-2 doses
Yearly doses for HR, rest encouraged
OR
2-3d
3 doses @ 0, 2m, 6m
RV (po)
HAV (im, HR com)
#2
2d in 1st yr, 1d in 2nd yr
Inf (im)
BCG (id, HR com)
CU – 1 dose
or#1
MMR (sc)
HBV (im)
1d (HR)
#1
#2
#3
Do NOT use RV after 32 wks of age
#1
2 doses 6m apart (HR)
Pneu-P-23 (sc)
2 doses, 3-5y apart (HR)
Men-C-ACWY (sc)
Single dose after 2 yrs of age (HR)
Immunization Schedule, Adult (mod from CIG 2006)
Vaccines
18y
24y
26y
30y
35y
Tdap (im)
Single dose (if not received in Gr 8) to replace one Td booster
Td (im)
50y
Single dose for HR under 65y
Inf (im)
Var (sc) susceptible
45y
Yearly dose for HR, rest encouraged
Men-C-ACYW (im)
55y
60y
65y
70y
#1
#2
Yearly
3 doses @ 0,2m,6m
CU – 2 doses, 4w apart
Zos (sc) N/A as yet
Men-C-C (im)
54y
Booster doses q10y
Pneu-P-23 (im)
HPV (im, females)
40y
Single dose
CU–1 dose
Single dose after 2 yoa (HR or based on disease epid)
Vaccines below the gray line are either:
- Not yet available in Canada.
- Not publicly-funded by most provinces or territories.
- Meant for high-risk (HR) persons.
CU = catch-up (if not previously immunized)
http://www.phac-aspc.gc.ca/im/ptimprog-progimpt/table-1_e.html
http://www.who.int/immunization_monitoring/en/globalsummary/scheduleselect.cfm
Factors to consider in HCW vaccination
• HCW is member of the general public:
– General population risk for infectious diseases.
– No risk for diseases which occur only/mainly in childhood.
• Vaccinate to prevent waning immunity (maintaining high
immunity levels).
• Risk of:
– Exposure to infected patients (differs in various health-care
professions).
– Infecting others, including patients and own family
members.
SK cohorts reaching 20 yrs of age q5y
# vaccine doses
2000
2005
2010
2015
Diph-Tet (1959)
6
6
6
6
Pert (aP 97;ap 01)
wP-5
wP-5
wP-5; ap-1
wP-4;aP-1;ap-1
Polio (IPV 6/94)
OPV-5; IPV-1
OPV-5
OPV-5
IPV-5
Hib (5/88-5/92)
0
0-1
1-4
4
Men-CC (10/04)
0
0
0
0
Pneum-C7 (4/05)
0
0
0
0
MMR (79-96-01)
MMR-1
Var (12/98-1/05)
0
0
0 (1-self)
0 (1-self)
HBV (9/95)
0
3
3
2-3
HAV (8/96 HR)
0
0
0
0
Inf (10/05)
BCG (HR only)
MMR-1; MR-1 MMR-1; MR-1
MMR-2
Depends whether opted to get yearly dose(s)
0 (1-HR)
0 (1-HR)
0 (1-HR)
0 (1-HR)
HCW immunity/immunization requirements
College
Medical
Nursing
Lab Tech
Dental
Vet
MMR
+
+
+
+
-
Var
+
+
+
+
-
HBV
+
+
+
+
-
Inf
+
+
+
+
-
IPV
+
+
+
+
-
Rabies
-
-
±
-
+
Td + ap
+
+
+
+
+
Pneu-23
-
-
-
-
-
Men-C
-
-
-
-
-
BCG
-
-
±
-
-
Entering health-care colleges
• Ensuring all recommended/required immunizations are
completed.
• Screening for infectious diseases prior to entry:
– HBsAb, [HBsAg, HBc-Ab(IgG+IgM)].
• Policies (?) regarding:
– Those who decline catch-up immunizations, and
– Those previously infected with bloodborne infections.
Hepatitis B virus
• Hep B immune:
– HBsAb +ve (≥ 10 mIU/ml) documented at least once (even
if subsequent level falls below 10 IU/ml).
– May develop HBsAb in response to either previous
vaccination or infection (with loss of HBsAg but retaining
HBcAb).
Hepatitis B virus
• Student previously unimmunized:
– 2-3 doses HB vaccine.
– HBsAb, [HBsAg, HBc-Ab].
• Student previously immunized in school:
– HBsAb, [HBsAg, HBc-Ab].
• If HBsAb –ve, single dose HB vaccine and retest.
– If still HBsAb –ve, 2 more doses of HB vaccine to
complete second series and retest; if still HBsAb –ve, stop.
• If HBsAg +ve, stop (refer back to college for counselling).
Hepatitis B markers (recovered, non-carrier)
HBsAg
HBcAb(IgM)
HBcAb(IgG)
HBeAg
HBsAb
HBeAb
Hepatitis B markers (chronic carrier, HBeAg+)
HBsAg
(May become –ve
in 10-25 years)
HBcAb(IgM)
HBcAb(IgG)
Symptoms
HBeAg
(HBsAb)
Hepatitis B markers (vaccinated)
Peak HBsAb
HBV vaccination @ 0,1,6 m
Slower HBsAb 
Faster HBsAb 
10
mIU/ml
[Infected  HBcAb(IgG)]
Hepatitis B profile in healthcare students
Interpretation
HBsAg
HBeAg
HBeAb
HBcIgM HBcIgG
HBsAb
Acutely infected
+
±
–
+
–
–
Previously infected,
chronic carrier,
infectious, immune
+
–/+
+/–
–
+
–/+
(<10)
Previously infected,
non-carrier, immune
–
–
±
–
+
+ (≥10)
Never infected,
vaccinated, immune
–
–
–
–
–
+ (≥10)
Never infected,
vaccinated, never
immune
–
–
–
–
–
– or +
(<10)
Never infected,
vaccinated, immune,
waning HBsAb
–
–
–
–
–
+ (≥10,
later <10)
Varicella zoster virus
• Varicella immune:
– Documentation of physician-diagnosed varicella or zoster
(need letter).
– Self-reported history of varicella or zoster (difficult to
verify, so best to screen serum for VZV-IgG).
– Documentation of varicella vaccination (screening for
VZV-IgG post-vaccination is not necessary):
• 1 dose administered at 1-12 yrs of age (ACIP requires 2
doses; under review in Canada at present).
• 2 doses 4-6 wks apart administered at ≥ 13 yrs of age.
Varicella zoster virus
• Student unimmunized or non-immune (negative VZV-IgG):
– 2 doses of varicella vaccine, 4-6 wks apart.
– Do not check serology after vaccination (VZV-IgG test is
not sensitive enough to detect antibody post-vaccination).
• Do not vaccinate:
– Pregnant students; defer until post-partum.
– If student has immunodeficiency disease.
– If student has anaphylaxis to vaccine component(s).
– If patient is on long term ASA therapy.
MMR
• Measles-immune:
– Born before 1970, or
– Born in or after 1970 with:
• 2 doses measles-containing vaccine, or
• (Physician)/Lab-diagnosed measles infection, or
• Measles IgG positive.
• Mumps-immune:
– Born before 1970 (controversial), or
– Born in or after 1970 with:
• At least 1 dose mumps-containing vaccine, or
• (Physician)/Lab-diagnosed mumps infection, or
• Mumps IgG positive.
MMR
• Rubella-immune:
– Born in any year:
• At least 1 dose rubella-containing vaccine, or
• Rubella IgG positive once.
• Note difference between NACI and ACIP (CDC, USA)
recommendations for mumps:
– ACIP requires 2 doses mumps-containing vaccine for
college students and HCWs as proof of immunity, whereas
NACI currently requires 1 dose (pending investigation of
2007 mumps outbreak in NS/NB/PEI).
MMR
• If immune by criteria to all three, no need to provide MMR.
• If non-immune to mumps or rubella according to NACI
criteria, OR previously received only 1 dose of measlescontaining vaccine:
– Provide a single dose of MMR (pending outcome of
mumps outbreak investigation in NS).
• If non-immune to measles, regardless of mumps and rubella
status:
– Provide 2 doses of MMR 4-8 wks apart.
• No need to document measles, mumps or rubella IgG if above
vaccinations are completed.
Tetanus-diphtheria ± pertussis
• Tetanus-immune:
– Completed primary series (≥ 3 doses) & booster doses at 10 yr
intervals (can be verified by tetanus antitoxin level).
• Diphtheria-immune:
– All considered susceptible to infection, even if fully immunized;
vaccine protects against the toxin, not infection (can be verified
by diphtheria antitoxin level).
• Pertussis:
– All considered susceptible since immunity wanes; last pertussis
vaccine (whole cell or acellular) dose typically at preschool,
unless received Tdap in adolescence.
Tetanus-diphtheria ± pertussis
• Previously unimmunized:
– 3 doses of Td (first one as Tdap) @ 0, 2, 6-12 mos; issue is cost
of the Tdap dose (not covered by prov/univ).
• Completed primary series, last booster of Td ≥ 10 yrs
previously:
– Single dose of Td (preferably as Tdap for additional protection
against pertussis).
• If last booster of Td was 2-9 yrs ago, and HCW wishes the
additional protection against pertussis:
– Single dose of Tdap (but may have greater local swelling and
pain, which reportedly does not affect limb function).
Polio
• Polio-immune:
– Documented primary series of poliovirus vaccine (≥ 4
doses in childhood; ≥ 3 doses in adolescence/adulthood).
– Serology for poliovirus serotypes 1, 2, 3 is available, but
not routinely recommended as proof of immunity.
• Boosters of IPV no longer recommended for adults residing in
N. America, as the western hemisphere was declared free of
wild poliovirus in 1991.
– Booster only recommended for travellers to endemic areas
and possibly virology lab staff.
Polio
• Previously unvaccinated:
– 3 doses of IPV @ 0, 2, 6-12 mos.
– No need to check serology post-vaccination.
Influenza
• Influenza-immune:
– Seasonal yearly immunization with the NACI/WHOrecommended trivalent influenza vaccine (A-H1N1, AH3N2 and B) confers 6 month efficacy of 70-80% against
infection by the vaccine strains (including some crossprotection against drifted A strains).
• Recommend yearly vaccination of all HCW for self-protection
and protection of patient-contacts.
Rabies
• Rabies-immune:
– Completed 3 doses of rabies vaccine pre-exposure, with
further 2 doses upon exposure to persons/animals with
rabies (inducing adequate antibody titer).
• Not recommended for all HCW; priority for virology lab techs,
vet students.
HCW and Mantoux skin testing
• Different policies in various colleges, universities and health
regions (provinces) as to:
– Frequency of Mantoux skin testing.
– Single-step skin-test, versus two-step (boosted) skin-test.
• TB service and OH in Saskatoon requires baseline single step
skin-test for HCW, plus:
– Yearly test for high-risk areas (with CXR if skin-test positive) 
ER, ICUs, ORs, RRs, RT/PT, Path/Micro Lab Techs, Residents,
Air Ambulance, Ambulatory/Medical Daycare).
– Repeat skin test on-exposure and F/U skin test 6 wks later.
Health care workers/students – references 1
• Health Canada, Infection Control – Prevention and Control of
Occupational Infections in Health Care.
– Canada Commun Dis Report Vol 28S1, Mar 2002:27-188.
– Weblink  http://www.phac-aspc.gc.ca/publicat/ccdrrmtc/02pdf/28s1e.pdf
• The Hospital Infection Control Practices Advisory Committee Guideline for infection control in health-care personnel
– Am J Infect Control 1998;26:289-354.
– Weblink  http://www.cdc.gov/mmwr/PDF/rr/rr5502.pdf
• Advisory Committee on Immunization Practices, CDC – Influenza
vaccination of health-care personnel.
– MMWR 24 Feb 2006, Vol 55, RR02.
– Weblink  http://www.cdc.gov/mmwr/PDF/rr/rr5502.pdf
Health care workers/students – references 2
• National Advisory Committee on Immunizations, Public Health
Agency of Canada – Canadian Immunization Guide, 7th Ed, 2006.
– Weblink  http://www.phac-aspc.gc.ca/publicat/ciggci/index.html
• Advisory Committee on Immunization Practices, CDC Immunization of Health-Care Workers.
– MMWR 26 Dec 1997; Vol 46, RR18.
– Weblink  http://www.cdc.gov/mmwr/PDF/rr/rr4618.pdf
HCW immunizations algorithm
Student health (A)?
Review college-entry immunization requirements:
- All recommended home provincial/territorial childhood vaccines.
- Varicella immunity = clinical status/previous immunization.
Student health (B)
Serological screen/Skin test:
- HBsAg, HBsAb, HBcAb (IgG and IgM); policy regarding HBsAg+.
- Varicella IgG (if status unclear).
- Mantoux test.
Student health (C)
Arrange follow-up immunizations:
- Catch-up missing childhood immunizations.
- HBV booster or whole series (if non-immune).
- Varicella immunization (if non-immune).
- Next tetanus, diphtheria booster = Tdap (with acellular pertussis).
- Encourage yearly influenza vaccination.
Vaccine-preventable disease risks to HCW
Faculty
Medicine
Nursing
Lab Med
RT
PT/OT
VPD
Route of
infection
Need
immunity
Exposure risk in general
community (SK)
Diphtheria
Resp
Yes
Very rare
HAV
Fecal-oral
Not routine
Rare, unless travelling
HBV
Needles, sex
Yes
Rare, contact of carrier/IDU
Hib
Resp
No
Very rare in adults (ped disease)
HPV
Sex
Yes-Female
Common, personal sex contacts
Influenza
Resp
Yes
Very common in flu season
Measles
Resp
Yes
Rare, imported case
Meningo
Resp
Not routine
Uncommon
Mumps
Resp
Yes
Uncommon, US/NS outbreaks
Vaccine-preventable disease risks to HCW
Faculty
Medicine
Nursing
Lab Med
RT
PT/OT
VPD
Occupational risk
Risk to family & patients
Diphtheria
Rare, from imported case
During acute illness
HAV
Rare, jaundiced patient
During acute illness
HBV
Up to 30% w/ needlestick
Acutely ill/chronic carrier
Hib
No, but may carry in NP
May infect children
HPV
No!
No!
Influenza
Common, in flu season
During flu illness
Measles
Rare, from imported case
Yes, if contact susceptible
Meningo
Rare (intubating)
Unknown/possible
Mumps
During acute illness
Yes, if contact susceptible
Vaccine-preventable disease risks to HCW
Faculty
Medicine
Nursing
Lab Med
RT
PT/OT
VPD
Route of
infection
Need
immunity
Exposure risk in general
community (SK)
Pertussis
Resp
Yes
Increasingly common in adults
Pneumoc
Resp
No/Yes
Common, esp w/ risk factors
Polio
Fecal-oral
Yes
No wild-type dis in western hem
Rabies
Wound
No
Rare (zoonoses-rac, bats, skunks)
Rotavirus
Fecal-oral
Not feasible
Common; vaccine not for adults
Rubella
Resp
Yes
Rare, recent ON cluster
Tetanus
Wound
Yes
Rare, if one maintains immunity
TB
Resp
No BCG
Common in high-risk groups
Varicella
Resp
Yes
Common, decline after vaccin
Vaccine-preventable disease risks to HCW
Faculty
VPD
Occupational risk
Risk to family & patients
Pertussis
During acute illness
First 1-3 wks of acute illness
Pneumoc
Unlikely/unknown
Unlikely/unknown
Polio
Medicine
Nursing
Lab Med
RT
PT/OT
Rare, from imported case Possible even if asymptomatic
Rabies
No, unless bitten
Possible (bite, saliva)
Rotavirus
During acute illness
During acute illness
Rubella
Rare, from imported case
Yes, if contact susceptible
Tetanus
No, unless bitten
No
TB
If actively coughing AFB
Only if coughing AFB
Varicella
Common, if susceptible
Yes, if contact susceptible
STOP!
Questions?