Taking Care of Business-- Protecting Healthcare Workers with Immunizations

1. Taking Care of Business--Protecting Healthcare Workerswith Immunizations Maggi Gallaher, MD, MPH February 7, 2008

2. Protecting Employees • Increased likelihood of exposure to infection • Increased risk of transmission should the employee become ill • Protect the worker before they are exposed • Protects workers • Protects patients

3. Define Healthcare Worker • Doctors • Nurses • Lab personnel • Dentists • Students • Administrative staff • Volunteers

4. Direct Patient Care(Department of Health) • Hands on or face-to-face contact with patients as part of routine activities • Does NOT include staff working primarily in office settings where clients are not present, even if the office is located in a health office or facility

5. Protecting Employees • Immunizations—before exposures • Other infection control measures • Education • Gloves • Masks • Other • Post-exposure prophylaxis

6. Hepatitis B--Rationale • Exposure to blood and body fluids, greatly increases risk of Hep B infection • 5-10% of HBV infected workers become chronically infected • Risk of HBV infection related to percutaneous and permucosal exposures

7. Hepatitis B--Indications • All staff whose work-related activities involve exposure to blood or other potentially infectious body fluids • Infrequent exposure—timely post-exposure prophylaxis may be more cost effective

8. Hepatitis B--Approach • Assess history • Education of staff • HBV vaccine—3 doses– IM in deltoid • Reminders and tracking for follow up doses • Prevaccination Serology • Not indicated for those vaccinated for occupational risk

9. Hepatitis B—Approach Postvaccination Serology • Indicated for those with occupational risk • 1-2 months after 3rd dose • Revaccinate if HBsAb levels low • 3 dose schedule • Retest • If HBsAb remains low, test for HBsAg

10. Hepatitis B--Approach • Employees with documentation of completed series, but not post-vacc. serology—screening not recommended • No need for periodic screening after vaccination • Up to 60% of vaccinated persons lose detectable antibodies but still protected • Booster doses not recommended for persons with normal immune status

11. Hepatitis B--Approach • No evidence of adverse effects on developing fetus—Pregnancy not a contraindication • No risk with vaccinating HBV-infected persons

12. Influenza--Rationale • Nosocomial transmission occurs during community outbreaks • Serosurveys of healthcare personnel suggest asymptomatic infections occur: • 23% + antibodies for influenza infection • 59% did not recall having influenza • 28% did not recall respiratory infection

13. Influenza—RationaleAbsenteeism • 2 Randomized, placebo-controlled trials • 28% fewer lost work days for resp illness • Vaccinated staff had markedly lower incidence of influenza (1.7% vs. 13.4%) • Cross sectional study--Vaccinated housestaff had: • 23% fewer influenza-like illnesses • 27% fewer days of illness • 59% reduction in illness during vacation time

14. Influenza--Rationale • Long term care facilities • High staff vaccination protects patients

15. Does the influenza vaccine decrease mortality? Influenza vaccine status +HCW/+pt +HCW/-pt -HCW/+pt -HCW/-pt death 10.9% 9.6% 18.2% 16.1% death-LRI 4.3% 5.8% 7.8% 8.8% pts with flu 0.9% 7.7% 6.2% 8.8% like illness pts with LRI 3.0% 5.4% 5.2% 6.9% Potter et al., JID 1997;175:1

16. Influenza--Indications • All staff who do not have a contraindication • Every year

17. Influenza--Approach • Education—promote vaccination • Role models—Vaccinate senior staff or opinion leaders • Ease of access—readily available, free • Signed declination • Identify issues for education • Identify staff for targeted interventions

18. Measles--Rationale • Measles transmission has been documented in offices, EDs, hospital wards • While the number of measles cases is decreasing (average 82 cases/year in US), the proportion in healthcare settings is increasing

19. Measles--Rationale CDC. MMWR, December 26, 1997

20. Measles--Indications • Staff with direct patient contact who do not have evidence of immunity

21. Measles--Approach • MMR is vaccine of choice • Serology pre-vaccination is not indicated • Those born before 1957 presumed immune • 5-9% are susceptible

22. Measles--Approach • Those born 1957 or later • Physician diagnosis of measles • Lab evidence of immunity • 2 doses of MMR on or after 1st birthday, and at least 28 days apart • Those vaccinated 1963-1967 with a killed measles vaccine alone or unknown vaccine type—2 doses of MMR

23. Measles--Approach • Contraindicated if • Pregnant • Severely immunocompromised • Recently received IG, or other live virus vaccine within past month

24. Mumps--Rationale • Outbreaks of mumps documented on college campuses and in workplace • Outbreaks seen in highly vaccinated populations • Attributed to vaccine failure • Increasing incidence in those >15 years • Nearly 6,000 cases reported in 2006

25. Mumps--Indications • Staff with direct patient contact that do not have evidence of immunity

26. Mumps--Approach • Born before 1957—presumed immune • Consider a single dose of MMR if no physicians diagnosis or lab evidence • Born 1957 or later • Physician diagnosis of mumps • Laboratory evidence of immunity • 2 doses of MMR on or after 1st birthday, and at least 28 days apart

27. Rubella--Rationale • Nosocomial outbreaks involving health care workers and patients have been documented • Overall risk for rubella has decreased with vaccination, 10-15% of young adults are still susceptible • Transmitted effectively by males and females

28. Rubella--Indications • Staff with direct patient contact unless pregnant without evidence of immunity

29. Rubella--Approach • “1957” rule does not apply to rubella • Evidence of immunity: • Physician diagnosis • Laboratory evidence of immunity • 2 doses of MMR on or after 1st birthday, and at least 28 days apart

30. Varicella--Rationale • Nosocomial infections are well-recognized • Source=patients, staff, visitors • Airborne transmission as well • Varicella or zoster implicated • Susceptible adults at risk of severe disease and complications, especially: • Pregnant women • Premature infants • Immunocompromised persons

31. Varicella--Indication • Staff with direct patient contact without evidence of immunity

32. Varicella--Approach • Reliable history of varicella or herpes zoster—consider immune • 97-99% of those with history are immune • Unknown or negative history of varicella • Do serology to assess immunity • 71-93% of those with equivocal history are immune

33. Varicella Vaccine • 2 doses given SC at least 28 days apart • Use single antigen varicella vaccine, not MMRV • Contraindicated • Pregnant • Immunocompromised • No current recommendations for Zostavax

34. Pertussis--Rationale • One of the most common vaccine-preventable diseases • In 2004, over 25,000 cases were reported in U.S. – a 40 year high • 27% were among adults • Currently about 20 infant deaths per year

35. Pertussis--Rationale • Endemic in U.S. despite routine childhood vaccination • Immunity to pertussis wanes 5-10 years after vaccination • Causes serious morbidity and mortality in young children • Attack rates among exposed, non-immune household contacts—80-90%

36. Pertussis--Rationale • Nosocomial transmission documented • Early symptoms are difficult to differentiate from other respiratory illnesses • Delays use of PPE by workers • Delays isolation of patient • Post-exposure management costly and time-consuming

37. Pertussis--Indications • Staff <65 years of age with direct patient contact • If they have not previously received Tdap • Have completed the primary series of Td • Can be given at an interval as short as 2 years since last Td

38. Pertussis--Approach • Age <65 years • Vaccination history • Primary Td series? • Previously received Tdap • Date of last Td booster • If 2 years or more, vaccinate • Single dose only to replace 1 Td booster

39. Immunizations not Routinely Recommended • Hepatitis A • Diphteria/Tetanus • Meningococcal (A, C, Y, W-135) • Pneumococcal • Typhoid • Vaccinia (Smallpox)

40. TB--Rationale • 13,779 cases (4.6 per 100,000 persons) in 2006 • NM—2006 48 cases (2.5/100,000) • NM—2007 52 cases (2.7/100,000)* • Multidrug resistant TB is growing concern • Complexity of cases in NM— • Homelessness • Substance Use • Immigrant status • Co-morbidities *2007 preliminary data

41. TB--Rationale • No immunization available— • Two priorities to prevent transmission • Early diagnosis and treatment of disease • Investigation, evaluation and treatment of contacts

42. TB--Rationale • TB spread by airborne route; droplets. Affected by: • Infectiousness of patient • Characteristics of exposed person • Previous MTB infection • Immunocompetence • Characteristics of exposure • Frequency and duration • Volume • Ventilation • Virulence of MTB strain • Most exposed persons do not become infected

43. TB Control • Administrative • Environmental • Respiratory Protection

44. TB—Indications for Screening • Staff with direct patient contact • “Paid and unpaid working in healthcare settings who have the potential for exposrue to TB through shared air space with an infected patient” • Includes part-time, full-time, temporary and contract staff • All workers whose duties involve face-to-face contact with suspected or confirmed TB should be in a TB screening program

45. TB--Approach • Perform TB risk assessments in all settings • Low • Medium • Potential ongoing transmission

46. TB--Approach • Some organizations can be divided by • Geography • Functional units • Patient populations • Job type or location within the setting

47. TB—Risk Assessment • Determines the types of administrative, environmental, and respiratory-protection controls needed for a setting • Serves as an ongoing evaluation tool • Quality of TB infection control • Identifies needed improvements • Should be done annually

48. TB—Risk Assessment • Factors included in assessment: • Incidence of TB in community • Type of setting—Outpatient, inpatient, lab, etc • Number of patients with suspected/confirmed TB encountered • Patient volume • TST/BAMT* conversions among staff or clients • Plan for triaging clients with suspected TB *BAMT=Blood assay for MTB

49. TB—Employee Screening • Low risk setting • All staff with direct patient contact should receive baseline two-step TST or BAMT If documented negative TST in last 12 months—single TST • TB Screening questionnaire—all staff • Baseline • Staff with + or newly + TST—CXR and clinical evaluation to exclude TB disease • History of +TST without prior treatment for LTBI should be further evaluated

50. TB—Employee Screening • Medium risk setting • All staff with direct patient contact should receive baseline two-step TST or BAMT • Baseline TST/BAMT was negative • TST annually • Symptom screen annually • Baseline + or previous treatment for LTBI/TB • Periodic symptom screen only • +TST or BAMT on followup—Refer for evaluation