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.) HCWs at UWHC covers many titles and employees Risk likely differs but disease transmission can occur to non “direct hands on providersHCWs at UWHC covers many titles and employees Risk likely differs but disease transmission can occur to non “direct hands on providers

5. Immunizations for HCWs Recommendations based on: Nosocomial transmission documented HCWs at significant risk for acquiring or transmitting infection Diseases for Which Immunization Is Strongly Recommended (CDC MMWR, 1997) On the basis of documented nosocomial transmission, HCWs are considered to be at significant risk for acquiring or transmitting hepatitis B, influenza, measles, mumps, rubella, and varicella. All of these diseases are vaccine-preventable JCAHO – What do to prevent transmission of diseases from HCWs to patients and vice versa? Immunizations is one part of the strategy ACIP = 15 experts in fields associated with immunization-selected by the Secretary of U. S. DHHS to provide advice and guidance to the Secretary, the Assistant Secretary for Health, and the Centers for Disease Control and Prevention (CDC) on the control of vaccine-preventable diseases. Committee develops written recommendations for the routine administration of vaccines to children and adults in the civilian population; recommendations include age for vaccine administration number of doses and dosing interval, and precautions and contraindications ACIP is the only entity in the federal government that makes such recommendations. Goals of the ACIP: 1) provide advice that leads to a reduction in the incidence of vaccine preventable diseases in US 2) Increase in safe use of vaccines and related biological productsDiseases for Which Immunization Is Strongly Recommended (CDC MMWR, 1997) On the basis of documented nosocomial transmission, HCWs are considered to be at significant risk for acquiring or transmitting hepatitis B, influenza, measles, mumps, rubella, and varicella. All of these diseases are vaccine-preventable JCAHO – What do to prevent transmission of diseases from HCWs to patients and vice versa? Immunizations is one part of the strategy ACIP = 15 experts in fields associated with immunization-selected by the Secretary of U. S. DHHS to provide advice and guidance to the Secretary, the Assistant Secretary for Health, and the Centers for Disease Control and Prevention (CDC) on the control of vaccine-preventable diseases. Committee develops written recommendations for the routine administration of vaccines to children and adults in the civilian population; recommendations include age for vaccine administration number of doses and dosing interval, and precautions and contraindications ACIP is the only entity in the federal government that makes such recommendations. Goals of the ACIP: 1) provide advice that leads to a reduction in the incidence of vaccine preventable diseases in US 2) Increase in safe use of vaccines and related biological products

6. Recommendations Hepatitis B Influenza MMR (measles , mumps, rubella) Varicella (chickenpox) Tetanus, diphtheria, pertussis Meningococcal Slide sequence: Disease;Transmission;HCWs;VaccineSlide sequence: Disease;Transmission;HCWs;Vaccine

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 Terms for “hepatitis B” for parenteral or serum hepatitis first introduced in 1947. First evidence hepatitis transmitted by direct inoculation of blood or blood products discovered when outbreak of hepatitis occurred after smallpox immunization campaign among shipyard workers in Bremen Germany in 1883 (Plotkin p. 299)Terms for “hepatitis B” for parenteral or serum hepatitis first introduced in 1947. First evidence hepatitis transmitted by direct inoculation of blood or blood products discovered when outbreak of hepatitis occurred after smallpox immunization campaign among shipyard workers in Bremen Germany in 1883 (Plotkin p. 299)

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 HBV infection is a well recognized occupational risk for HCP (25). Risk of HBV infection primarily related to the degree of contact with blood in the work place and to hepatitis B e antigen (HBeAg) status of the source person. All source patients tested for HBSAG In studies of HCP who sustained injuries from needles contaminated with blood containing HBV, the risk of developing clinical hepatitis if the blood was both hepatitis B surface antigen (HBsAg)- and HBeAg-positive was 22%--31%; the risk of developing serologic evidence of HBV infection was 37%--62%. By comparison, the risk of developing clinical hepatitis from a needle contaminated with HBsAg-positive, HBeAg-negative blood was 1%--6%, and the risk of developing serologic evidence of HBV infection, 23%--37% (26). Therefore, most body fluids are not efficient vehicles of transmission because they contain low quantities of infectious HBV, despite the presence of HBsAg 73 exposures to HBV at UWHC since 1981. Last 5 years we get 1-5 exposures per year. Only one of the 3 big blood borne pathogens that we have a vaccine for:HBV infection is a well recognized occupational risk for HCP (25). Risk of HBV infection primarily related to the degree of contact with blood in the work place and to hepatitis B e antigen (HBeAg) status of the source person. All source patients tested for HBSAG In studies of HCP who sustained injuries from needles contaminated with blood containing HBV, the risk of developing clinical hepatitis if the blood was both hepatitis B surface antigen (HBsAg)- and HBeAg-positive was 22%--31%; the risk of developing serologic evidence of HBV infection was 37%--62%. By comparison, the risk of developing clinical hepatitis from a needle contaminated with HBsAg-positive, HBeAg-negative blood was 1%--6%, and the risk of developing serologic evidence of HBV infection, 23%--37% (26). Therefore, most body fluids are not efficient vehicles of transmission because they contain low quantities of infectious HBV, despite the presence of HBsAg 73 exposures to HBV at UWHC since 1981. Last 5 years we get 1-5 exposures per year. Only one of the 3 big blood borne pathogens that we have a vaccine for:

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 Long lasting immunity – assumes 3 doses Can’t assume if only +anti-HB or less than 3 doses with + titer Serum based HBV vaccine out in 1981 – replaced with recombivant vaccine due to concerns about infectivity Long lasting immunity – assumes 3 doses Can’t assume if only +anti-HB or less than 3 doses with + titer Serum based HBV vaccine out in 1981 – replaced with recombivant vaccine due to concerns about infectivity

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 Won’t use at UWHC 2008 for logistical reasons – maybe next year Narrower applicability – age range and “healthy” Concern about live-virus transmission from HCW recipient to patients More in-depth screening questionnaire Won’t use at UWHC 2008 for logistical reasons – maybe next year Narrower applicability – age range and “healthy” Concern about live-virus transmission from HCW recipient to patients More in-depth screening questionnaire

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 Cost-Effectiveness of Influenza Vaccine Influenza vaccination can reduce both health-care costs and productivity losses associated with influenza illness. Studies flu vaccination of persons aged >65 years conducted in the United States have reported substantial reductions in hospitalizations and deaths(15,100,104). Studies of adults aged <65 years have indicated that vaccination can reduce both direct medical costs and indirect costs from work absenteeism (8,10--12,91,116). Reductions of 13%--44% in health-care--provider visits, 18%--45% in lost workdays, 18%--28% in days working with reduced effectiveness, and 25% in antibiotic use for influenza-associated illnesses have been reported (10,12,117,118). One cost-effectiveness analysis estimated a cost of approximately $60--$4,000/illness averted among healthy persons aged 18--64 years, depending on the cost of vaccination, the influenza attack rate, and vaccine effectiveness against influenza-like illness (ILI) (91). Another cost-benefit economic study estimated an average annual savings of $13.66/person vaccinated (119). In the second study, 78% of all costs prevented were costs from lost work productivity, whereas the first study did not include productivity losses from influenza illness. Economic studies evaluating the cost-effectiveness of vaccinating persons aged 50--64 years not available - number of studies that examine the economics of routinely vaccinating children with TIV or LAIV are limited (8,120--123). Cost-Effectiveness of Influenza Vaccine Influenza vaccination can reduce both health-care costs and productivity losses associated with influenza illness. Studies flu vaccination of persons aged >65 years conducted in the United States have reported substantial reductions in hospitalizations and deaths(15,100,104). Studies of adults aged <65 years have indicated that vaccination can reduce both direct medical costs and indirect costs from work absenteeism (8,10--12,91,116). Reductions of 13%--44% in health-care--provider visits, 18%--45% in lost workdays, 18%--28% in days working with reduced effectiveness, and 25% in antibiotic use for influenza-associated illnesses have been reported (10,12,117,118). One cost-effectiveness analysis estimated a cost of approximately $60--$4,000/illness averted among healthy persons aged 18--64 years, depending on the cost of vaccination, the influenza attack rate, and vaccine effectiveness against influenza-like illness (ILI) (91). Another cost-benefit economic study estimated an average annual savings of $13.66/person vaccinated (119). In the second study, 78% of all costs prevented were costs from lost work productivity, whereas the first study did not include productivity losses from influenza illness. Economic studies evaluating the cost-effectiveness of vaccinating persons aged 50--64 years not available - number of studies that examine the economics of routinely vaccinating children with TIV or LAIV are limited (8,120--123).

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% NHIS (National Health Interview Survey) 2004 survey data indicated a vaccination coverage level of only 42% among health-care workers (CDC, unpublished data, 2006). Vaccination of health-care workers has been associated with reduced work absenteeism (9) and fewer deaths among nursing home patients (144,145) and is a high priority for reducing the effect of influenza in health-care settings and for expanding influenza vaccine use (146,147). (MMWR July 28) Safe in pregnancy One of the national health objectives for 2010 is to achieve an influenza vaccination coverage level of 90% for persons aged >65 years Estimated national influenza vaccine coverage in 2004 among persons aged >65 years and 50--64 years was 65% and 36%, respectively, based on 2004 NHIS data (Table 3). The estimated vaccination coverage among adults with high-risk conditions aged 18--49 years and 50--64 years was 26% and 46%, respectively, substantially lower than the Healthy People 2000 and 2010 objective of 60% No goal set for HCWs – individual organizations set their own. UWHC? NHIS (National Health Interview Survey) 2004 survey data indicated a vaccination coverage level of only 42% among health-care workers (CDC, unpublished data, 2006). Vaccination of health-care workers has been associated with reduced work absenteeism (9) and fewer deaths among nursing home patients (144,145) and is a high priority for reducing the effect of influenza in health-care settings and for expanding influenza vaccine use (146,147). (MMWR July 28) Safe in pregnancy One of the national health objectives for 2010 is to achieve an influenza vaccination coverage level of 90% for persons aged >65 years Estimated national influenza vaccine coverage in 2004 among persons aged >65 years and 50--64 years was 65% and 36%, respectively, based on 2004 NHIS data (Table 3). The estimated vaccination coverage among adults with high-risk conditions aged 18--49 years and 50--64 years was 26% and 46%, respectively, substantially lower than the Healthy People 2000 and 2010 objective of 60% No goal set for HCWs – individual organizations set their own. UWHC?

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% 2% higher in each category than in 2006 Usage rates do not include non-empls (Fac MDs) Medical Residents: 77% (N=138) Pediatric Residents: 90% (N=49) TLC Nurses: 59% (N= 131) Pulmonary Inpt Nurses: 56% (N=82) N = 9582% higher in each category than in 2006 Usage rates do not include non-empls (Fac MDs) Medical Residents: 77% (N=138) Pediatric Residents: 90% (N=49) TLC Nurses: 59% (N= 131) Pulmonary Inpt Nurses: 56% (N=82) N = 958

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 What we do now How improve: expanded hours; offsite; on –unit; prizes: better education Best way – media hype Influenza immunization rates in hospitals has become a quality indicator: JCAHO; Leapfrog Gp; CMS -federal government could also force greater participation by linking mandatory healthcare worker vaccination to Medicare or Medicaid reimbursement What we do now How improve: expanded hours; offsite; on –unit; prizes: better education Best way – media hype Influenza immunization rates in hospitals has become a quality indicator: JCAHO; Leapfrog Gp; CMS -federal government could also force greater participation by linking mandatory healthcare worker vaccination to Medicare or Medicaid reimbursement

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 You are all taking care of and encouraging patients to get flu shots - Encourage your colleagues!You are all taking care of and encouraging patients to get flu shots - Encourage your colleagues!

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 Pushing flu shots for healthcare workers The strongest language in the IDSA's proposals aimed at boosting seasonal flu immunization rates among healthcare workers. The current rate for this group is about 40%, the ISDA report says. The IDSA recommends that healthcare workers be required to receive flu shots unless they decline, in writing, for religious or philosophical reasons or because of a medical contraindication In 2004, Virginia Mason Medical Center in Seattle became the first hospital in the nation to make vaccination a "fitness for duty" requirement for its employees. Kim Davis, communications director at Virginia Mason, told CIDRAP News that for the 2005-06 flu season the hospital's immunization rate for staff topped 98%, with the remainder of staff using masks. Declinication Waver: Hot Topic Pros: Bioethicists Arthur Caplan and David Curry supported mandatory vaccination for healthcare workers in a recent editorial in the San Jose Mercury News. "Choice is a key value for us all, but spreading infection among the sick is too high a price to pay for that choice," "We should not have to wonder whether the person taking care of us, our newborn, or our elderly parent has gotten a flu shot." (http://www.cidrap.umn.edu/apic/influenza/panflu/news/jan2507idsa.html) 1/25/07 Cons: Signing waiver has not shown evidence that increases immunization rates – hot topic In 2005, the American College of Occupational and Environmental Medicine (ACOEM) issued a consensus statement encouraging healthcare employees to be vaccinated but opposing a requirement. The ACOEM said that having employees decline the vaccine in writing has not been shown to improve overall vaccination rates. However, the Washington State Nurses Association (WSNA) opposed the plan. "We don't believe a mandate is the best method for compliance," Anne Tan Piazza, spokesperson for the WSNA, told the Spokane Spokesman Review. "We think you get the best results through education." Pushing flu shots for healthcare workers The strongest language in the IDSA's proposals aimed at boosting seasonal flu immunization rates among healthcare workers. The current rate for this group is about 40%, the ISDA report says. The IDSA recommends that healthcare workers be required to receive flu shots unless they decline, in writing, for religious or philosophical reasons or because of a medical contraindication In 2004, Virginia Mason Medical Center in Seattle became the first hospital in the nation to make vaccination a "fitness for duty" requirement for its employees. Kim Davis, communications director at Virginia Mason, told CIDRAP News that for the 2005-06 flu season the hospital's immunization rate for staff topped 98%, with the remainder of staff using masks. Declinication Waver: Hot Topic Pros: Bioethicists Arthur Caplan and David Curry supported mandatory vaccination for healthcare workers in a recent editorial in the San Jose Mercury News. "Choice is a key value for us all, but spreading infection among the sick is too high a price to pay for that choice," "We should not have to wonder whether the person taking care of us, our newborn, or our elderly parent has gotten a flu shot." (http://www.cidrap.umn.edu/apic/influenza/panflu/news/jan2507idsa.html) 1/25/07 Cons: Signing waiver has not shown evidence that increases immunization rates – hot topic In 2005, the American College of Occupational and Environmental Medicine (ACOEM) issued a consensus statement encouraging healthcare employees to be vaccinated but opposing a requirement. The ACOEM said that having employees decline the vaccine in writing has not been shown to improve overall vaccination rates. However, the Washington State Nurses Association (WSNA) opposed the plan. "We don't believe a mandate is the best method for compliance," Anne Tan Piazza, spokesperson for the WSNA, told the Spokane Spokesman Review. "We think you get the best results through education."

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 See changes below in this slide since Feb 9th report -Although influenza A (H1N1) viruses predominated through mid-January, an increasing proportion of subtyped influenza A viruses are influenza A (H3N2) viruses. During the week ending February 9, H3N2 became the predominant virus for the season overall. (CDC. MMWR-February 15, 2008 / 57 (Early Release);1-5 Update: Influenza Activity --- United States, September 30, 2007--February 9, 2008 H3N2/BRISBANE-LIKE STRAIN THAT NOW ACCOUNTS FOR THE LARGEST PORTION OF LAB-CONFIRMED CASES. This strain not matched in current vaccine. When the viruses are not closely matched, the vaccine can still protect many people and prevent flu-related complications. Such protection is possible because antibodies made in response to the vaccine can provide some protection (called cross-protection) against different, but related strains of influenza viruses. Vaccination remains the best method for preventing influenza and its potentially severe complications in children and adults even in years where there is a suboptimal match between vaccine and circulating strains of influenza viruses. (40% match with current vaccine strain (Maki) Above slide: CDC 2007-2008 Influenza Season Week 5, ending February 2, 2008 http://www.cdc.gov/flu/weekly/ During week 5 (January 27 – February 2, 2008), influenza activity continued to increase in the United States This week, the World Health Organization took the unusual step of recommending that next season's flu vaccine have a completely different makeup from this year's. (2/18/08 – Fox medical news)See changes below in this slide since Feb 9th report -Although influenza A (H1N1) viruses predominated through mid-January, an increasing proportion of subtyped influenza A viruses are influenza A (H3N2) viruses. During the week ending February 9, H3N2 became the predominant virus for the season overall. (CDC. MMWR-February 15, 2008 / 57 (Early Release);1-5 Update: Influenza Activity --- United States, September 30, 2007--February 9, 2008 H3N2/BRISBANE-LIKE STRAIN THAT NOW ACCOUNTS FOR THE LARGEST PORTION OF LAB-CONFIRMED CASES. This strain not matched in current vaccine. When the viruses are not closely matched, the vaccine can still protect many people and prevent flu-related complications. Such protection is possible because antibodies made in response to the vaccine can provide some protection (called cross-protection) against different, but related strains of influenza viruses. Vaccination remains the best method for preventing influenza and its potentially severe complications in children and adults even in years where there is a suboptimal match between vaccine and circulating strains of influenza viruses. (40% match with current vaccine strain (Maki) Above slide: CDC 2007-2008 Influenza Season Week 5, ending February 2, 2008 http://www.cdc.gov/flu/weekly/ During week 5 (January 27 – February 2, 2008), influenza activity continued to increase in the United States This week, the World Health Organization took the unusual step of recommending that next season's flu vaccine have a completely different makeup from this year's. (2/18/08 – Fox medical news)

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 Vaccine of choice over individual components Individual component shortages Issue is sometimes when have titers to some that are immune and could just get by with single dose antigen Effectiveness of individual vaccine components: see single dose antigen effectiveness UWHC Costs MMR: $42 Measles: $15 Mumps: $20 Rubella: $17Vaccine of choice over individual components Individual component shortages Issue is sometimes when have titers to some that are immune and could just get by with single dose antigen Effectiveness of individual vaccine components: see single dose antigen effectiveness UWHC Costs MMR: $42 Measles: $15 Mumps: $20 Rubella: $17

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. 2nd dose of MMR recommended for measles control in 19892nd dose of MMR recommended for measles control in 1989

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 Shortage of mumps vaccine MMR recommendedShortage of mumps vaccine MMR recommended

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