Kathleen Harriman, PhD, MPH, RN Vaccine Preventable Disease Epidemiology Section California Department of Public Health

1. Healthcare Personnel Immunization Recommendations: 2011 Update Kathleen Harriman, PhD, MPH, RNVaccine Preventable Disease Epidemiology SectionCalifornia Department of Public HealthImmunization Branch kathleen.harriman@cdph.ca.gov

2. 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

3. 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

4. Vaccination Programs • Maintenance of complete immunization records • Policies for catch-up vaccination • Work restrictions for exposed susceptible employees • Control of outbreaks • 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)

5. Where do U.S. immunization recommendations come from? Advisory Committee on Immunization Practices (ACIP) • 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

6. 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

8. Most Recent ACIP Recommendations

9. Vaccines that might be indicated for adults, based on medical and other indications --- United States, 2011 2011 ACIP adult immunization recommendationshttp://www.cdc.gov/mmwr/preview/mmwrhtml/mm6004a10.htm?s_cid=mm6004a10_e&source=govdelivery

10. 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

11. 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

12. 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.

13. 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

14. 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

15. 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 Vaccines that are required to be offered* per the ATD standard * To all susceptible employees who might be exposed. If vaccine is declined, a declination form must be signed.

16. 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

17. Seasonal Influenza

19. 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??

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

21. 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_014http://www.thecommunityguide.org/worksite/flu-hcw.html

22. 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

23. 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

24. 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

25. Joint Commission Standard IC.02.04.01: The organization offers vaccination against influenza to licensed independent practitioners and staff. • The hospital establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff. • 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. • The hospital provides influenza vaccination at sites accessible to licensed independent practitioners and staff. • The hospital annually evaluates vaccination rates and the reasons given for declining the influenza vaccination. • The hospital takes steps to increase influenza vaccination rates.

26. 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

27. 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 fromintranasal 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

28. Hepatitis B

29. 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

30. Estimated Number of Acute HBV Infections Due to Occupational Exposures, U.S., 1983-2002 OSHA Requirements Vaccine Recommended for HCP

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. Measles

38. Measles • Elimination of endemic measles in North and South America was achieved in 2002 and is a public health success modelfor 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 vaccinein 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 controlto be sustained, two-dose vaccination strategy with very highcoverage 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

39. 2nd dose 1989 Endemic transmission interrupted Measles—United States, 1950-2005 Vaccine Licensed 1963 Measles declared eliminated

41. 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

42. 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 acceptableevidence 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.

43. 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

44. 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

45. 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

46. 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

47. Mumps

48. 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

50. 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