IMMUNIZATIONS FOR HEALTH CARE WORKERS

1. IMMUNIZATIONS FOR HEALTH CARE WORKERS Fran Ircink RN, NP Clinic Manager Employee Health Service February 20, 2008

2. Objectives • Understand the importance of vaccines in general • Review currently recommended vaccines for health care workers (HCWs) • Highlight recent vaccine updates for HCWs

3. 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)

4. 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.)

5. Immunizations for HCWs Recommendations based on: • Nosocomial transmission documented • HCWs at significant risk for acquiring or transmitting infection

6. Recommendations • Hepatitis B • Influenza • MMR (measles , mumps, rubella) • Varicella (chickenpox) • Tetanus, diphtheria, pertussis • Meningococcal

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. 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-responder-susceptible to hepatitis B

14. 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

15. 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

16. Influenza - Transmission Influenza viruses spread from person to person, primarily through respiratory droplet transmission (cough, sneeze) in close proximity to an uninfected person

17. 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

18. 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

19. 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

20. 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%

21. 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%

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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)

28. 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

29. 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

30. 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

31. 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 pre-vaccine levels.

32. 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

33. 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

34. Mumps - Transmission • Airborne transmission • Droplet spread • Direct contact with saliva of infected person • Contact with contaminated fomites

35. 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

36. 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

37. 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

38. 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)

39. 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 physician-diagnosed mumps or laboratory evidence of mumps immunity

40. 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

41. 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

42. Rubella - Transmission • Contact with nasopharyngeal secretions of infected people • Droplet spread or direct contact with patients

43. 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

44. 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

45. 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

46. 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

47. Varicella (Chickenpox) Complications: • Secondary bacterial infections • Pneumonia • Central nervous system involvement

48. 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

49. 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

50. Varicella - Vaccine New Recommendations: • All children <13 years of age should be administered routinely two doses of varicella-containing 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