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Healthcare Personnel
Vaccines:
CDC Recommendations
&
Why They are Important
Jae L. Hansen, IMC, NREMT-P, FP-C (Ret.)
County of San Diego, Health and Human Services Agency
Immunization Branch
Ask yourself…
 What can I do to protect myself?
 What can I do to protect my patients?
 What can I do to protect my family?
Which HCP Need Vaccinations?
 Includes physicians, nurses, nursing/medical
assistants, therapists, technicians,
EMTs/Paramedics, dental, pharmacists, laboratory
personnel, autopsy, students, trainees, contract
staff, persons potentially exposed to infectious
agents that can be transmitted to and from HCP
 Settings include hospitals, nursing homes, skilled
nursing facilities, physicians’ offices, urgent care
centers, outpatient clinics, home healthcare, and
emergency medical services
Adult Vaccines…
 Shingles (Herpes Zoster)
 One dose of Herpes Zoster Vaccine (Zostavax) at age
60 or older
 Effective even if they’ve had
a history of shingles
 Pneumococcal
 40,000 deaths & 500,000 cases every year in the US
 One dose of PPV vaccine given at age 65 or older,
OR in presence of chronic health condition
Adult Vaccines (cont.)
 Measles, Mumps, Rubella (MMR)
 Adults born before 1957 is considered immune to measles &
mumps
 2nd dose of MMR is recommended for HCP, or show lab
evidence of immunity
 Measles – Highly contagious virus found throughout the world,
can remain airborne for up to 2 hours
 Transmission – coughing, sneezing or talking
 Symptoms – high fever, rash, runny nose, watery eyes, cough,
diarrhea & earache
 Incubation – 10 to 14 days
Adult Vaccines (cont.)
 Mumps – Acute viral disease, may spread even
though they have no symptoms or their illness is
mild
 Transmission – coughing & sneezing
 Symptoms – Low grade fever & swelling or
tenderness of one or more salivary glands. In post
pubertal males, up to 30% may experience testicular
pain and swelling. May cause sterility in males.
 Incubation – 12 to 25 days
Adult Vaccines (cont.)
 Rubella – (German Measles) is a virus
 If a woman gets rubella during the 1st trimester of
pregnancy, her baby is at risk of having serious birth
defects
 Transmission – coughing or sneezing, direct contact
with nasal or throat secretions
 Symptoms – Rash, slight fever, aching joints, &
reddened eyes
 Many people with rubella have few or no symptoms, and
may not have rash
 Incubation – 16 to 18 days
Adult Vaccines (cont.)
 Varicella – (Chickenpox) highly contagious disease
caused by the Varicella-zoster virus
 Transmission – airborne & also spread through contact
with chickenpox blisters
 Symptoms – rash, body aches, fever, fatigue, irritability &
sore throat
 Hospitalization & death increases with adults
 Incubation – 10 to 21 days
 If no lab evidence or history, 2 doses of Varicella vaccine
should be administered 4-8 weeks apart
Hepatitis A & Hepatitis B
 Hepatitis disease is a virus that affects the liver:
 Hepatitis A is food-borne (oral-fecal)
 Hepatitis B is blood-borne (blood to blood)
 Hep A vaccine – common childhood and travel vaccine
 Hep B vaccine – common childhood, travel vaccine
and maybe required for healthcare personnel (HCP)
 Vaccines given in multiple doses
(plan ahead, e.g., travel, new job, etc.)
 Combined in Twinrix® (2 shots in 1)
HPV
Human Papillomavirus
 ≥ 100 strains and types
 ≥ 40 strains and types are sexually transmitted
 FDA recently approved vaccine for males
 Approved for ages 9 – 26 yrs
 Protects against viruses that can cause
cervical, anal, penile & throat cancers
Source: CDC HPV Information
Influenza
also known as the “flu”
Influenza is a contagious viral infection of the
nose, throat and lungs
36,000 deaths and over 200,000 hospitalizations per year
2007-2008
San Diego Influenza Season
 The first influenza detection occurred the
second week of October
 The peak flu season occurred mid February
 A total of 9 influenza-related deaths
 A total of 1,905 reports of influenza (lab results
positive) were voluntarily reported to Public
Health
H1N1 in San Diego
April 2009 – January 20, 2010
 829 hospitalizations
 55 deaths – San Diego residents
 7 deaths – Visiting non-residents
 Most recent death is a 29 y/o female with
no underlying condition
Peak Influenza U.S. 1976-2006
45%
19%
13%
3%
13%
3%
3%
Source: MMWR 2007;56 (RR-6)
Cold vs. Flu
Can you tell the difference?
Fever
Rare in adults and older children,
but can be as high as 102 degrees in infants
and small children
COLD OR FLU?
COLD
Cold vs. Flu
Can you tell the difference?
Headache
Sudden onset and can be severe
COLD OR FLU?
FLU
Cold vs. Flu
Can you tell the difference?
Tiredness and weakness
Can last two or more weeks
COLD or FLU?
FLU
Cold vs. Flu
Can you tell the difference?
Sneezing
Stuffy Nose
Sore Throat
COLD or FLU?
COLD
Influenza Symptoms
Fever & Chills
Headache
Body Aches
Chest Discomfort
Tiredness
Flu Prevention
Get vaccinated!
 Your best protection!
Practice good hygiene





Wash hands often
Cover your mouth/nose when you cough/sneeze
Put used tissues in waste basket
Clean your hands after you cough/sneeze
Avoid touching your face, eyes, nose or mouth
If you are diagnosed with the flu
 Stay home
 Avoid close contact with others, or wear a mask
 Get rest and drink plenty of fluids
Influenza Virus
 Transmission
 Respiratory route
 Direct contact
 Communicability – 1 to 2 days pre-onset to,
4 to 5 days post-onset
 Reservoir
 Humans, swine (H1N1), and birds (H5N1)
 Geographic distribution
 Global
 Incubation
 1 to 5 days; usually 2 days
Nosocomial Influenza
 Transmission that occurs in a
healthcare setting
 Can result from under-vaccinated
healthcare personnel
Nosocomial Influenza
In a tertiary care facility from 1987 to 2000:
 Staff influenza vaccination coverage
 4% >>> 67%
 Staff influenza disease
 42% >>> 9%
 Nosocomial Disease
 32% >>> 0 cases
Salgado CD, Infection Control Hospital Epidemiology, 2004
Influenza in the Elderly
The elderly have suboptimal immunologic
response to the flu vaccine.
The flu shot is about…
 80% effective in preventing death
 27% to 70% effective in preventing
hospitalizations and pneumonia
 30% to 58% effective in preventing flu
Despite high vaccination rates among residents, influenza
outbreaks still occur in LTCFs, triggered by unvaccinated HCP.
Kimura, et al. American Journal of Public Health, 2007
Influenza in LTCF
 Influenza Attack Rates
25-60%
 Case-fatality 10-20%
Randomized control study
 Staff vaccination led to a
43% decrease in ILI
 44% decrease in
mortality
Potter J, et. Al. J Infectious Disease 1997
Who’s at Risk?

Children between 6 months and 18 years of age

Healthcare personnel (HCP)

Persons > 50 years

Nursing home & chronic care residents with chronic
medical conditions

Persons with chronic pulmonary or cardiovascular
disorders, including asthmatic children

Pregnant women

Persons with immunosuppression including HIV
Facts vs. Myths
 I get sick from the vaccine
Myth
The influenza vaccine is made from a DEAD virus
 You cannot get sick from it
 Side effects may include a low-grade fever and
muscle aches
 The flu shot can take up to two weeks to
become effective so you can still get the flu
or a flu-like illness during this time
Why I didn’t get a flu shot…
 My doctor didn’t recommend it
 I am afraid of needles
The flu shot is given with a relatively small needle. Check
with your doctor to see if you are eligible to receive
FluMist® - a vaccine that is sprayed into your nose and
does not require needles.
 The Flu isn’t that bad
Influenza causes an average of 36,000 deaths and over
200,000 hospitalizations per year.
Source: CDC Influenza Information
Shot vs. Nasal Spray
Flu Shot (TIV)





Injectable – Trivalent inactivated influenza vaccine
70-90% effective in healthy persons ≤65 yrs
50-60% effective in preventing hospitalization
80% effective in preventing death
Few side effects (sore arm, general malaise)
Nasal Spray (LAIV) - FluMist®




Live attenuated influenza vaccine
No needles – spray mist into the nose
Approved for healthy persons ages 2-49 years of age
Slightly more expensive
Novel H1N1 Vaccine
Who should receive the vaccine?
How much will it cost?
•
•
•
•
•
•
•
EMS and HCP
Pregnant women
Caregivers of <6 months
6 mon – 24 yrs, 25 – 64 yrs w/
underling chronic conditions
Now open to everyone
How safe is the vaccine?
•
Where can I get it?
•
•
Your physicians office
Local PHC, Mass Vax Clinics
How many doses will I need?
•
Only one dose for 10 yrs and older
Free – Feds paid for all doses
Nominal administration fee
Extremely safe! It is made using the
same processes & facilities as the
seasonal flu vaccine. It is very much
like the seasonal flu vaccine.
Should I get the vaccine if I think
I’ve already been infected?
•
Yes, the flu symptoms you had may
not have been caused by the H1N1
virus.
Pertussis
also know as
“Whooping Cough”
is a highly contagious bacterial infection of the
lining and airways of the respiratory tract.
It is caused by the bacterium Bordetella pertussis.
Pertussis Cases in the U.S.
25,827
24
Cases (Thousands)
20
16
12
11,647
8
6,586
7,796
9,771
4,570
4
0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
CDC. MMWR 1997;46(54):71-80. Murphy T. Data on file, personal communication, 2001. MMWR 2000;50:1175. MMWR 2001;50(33):725.
MMWR 2002;51:723. MMWR 2003;52:747. Bacterial Vaccine Preventable Disease Branch, National Immunization Program, 2005.
Pertussis in S.D. County
400
350
300
250
200
150
Cases
100
Deaths
50
0
19971998
1999 2000
2001 2002
2003 2004
2005 2006
2007 2008
2009 2010
Pertussis in the U.S.
1990-1993
1994-1996
1997-2000
2001-2003
9000
2004
18.8 fold
Average Number
of Cases / Year
8000
7000
15.5
fold
6000
5000
4000
3000
2000
1000
0
<1 yr
1-4 yrs
5-9 yrs
10-19 yrs
Age Group
Güriş et al. Clin Infect Dis. 1999;28:1230-1237.
CDC. MMWR. 2002;51:73-76, 2001;50(53):1-108, 2002;51(53):1-84, 2003;52(54):1-85
20+ yrs
Clinical Signs of Pertussis
 Cough 97%  3 weeks,
52%  9 weeks
 Paroxysms 73%  3 weeks
 Whoop in 69%
 Post-tussive emesis in 65%
 Teens missed average 5 days of school
 Adults missed average 7 days of work
 Average 14 days of disrupted sleep
De Serres et al. J Infect Dis. 2000;182:174–9.
Catarrhal
3 Stages of Pertussis
 Runny nose, sneezing, low-grade fever, and a mild,
nonproductive, occasional cough
 Most infectious during the this period and the first 2 weeks
after cough onset (approximately 21 days)
Paroxysmal




Severe spasms of quick, short, coughs
May gag, gasp and/or expel thick mucus
“whoop”
Following attack
 Vomiting and exhaustion
3 Stages of Pertussis
Convalescent
 Gradual recovery
 Cough frequency decreases
 Cough severity decreases
 Recovery may be only partial
Source: www.pertussis.com
How is it diagnosed?
 Multiple tests may be required to accurately
diagnose disease
 Frequent incorrect diagnoses:
 Asthma
 Gastroesophageal reflux
 Post-viral bronchospasm
 Chronic sinusitis
 Tuberculosis
Culture and PCR
 Nasopharyngeal
(Dacron) swab or
aspirate is the
preferred sample
 It’s the nasopharynx
we’re after
Pertussis in Adults
Adults:
 Are the main reservoirs of disease in areas
with high immunization coverage rates
 Transmit primarily to non-immune children
(≤ 1 year of age) or to adults whose immunity
has waned
 Experience the longest recovery time
(median 93 days)
The majority of severe pertussis disease complications occurred among infants
0-2 months of age, California 1995 - 2004
16
15
Death
Encephalopathy
14
12
number of cases
12
10
8
7
6
5
4
3
2
1
1
0
0
0
0
0
0
0
0
0
1
2
3
4
5
6
age (months)
California Dept of Health Services
Immunization Branch
Infant Pertussis:
Who Was the Source?
Bisgard, K. PIDJ. 2004;23:985-9.
n=264 cases
Costs of an Outbreak
 September 2003 – outbreak of pertussis in an
acute care facility
 17 employees were infected
 Following a one-day exposure to an infant with
pertussis
 Infection control measures were immediately
implemented in hospital
 Study examined outbreak-related costs and
estimated possible benefits to vaccination
Study Results
 Cost incurred by the hospital: $74,870
 Cost incurred by the employees: $6,512
 TOTAL COST incurred: $81,382
 Cost of 1 dose of Tdap: $37.00
Estimated Benefits of
Vaccination
 Study model predicts:
 Vaccinating employees in hospital against
pertussis would prevent ≥ 46% of exposures
 Cost of vaccination to benefit ratio is 2.38 : 1
CDC Recommends
 All HCP in hospitals, LTCF/SNF, ambulatory care and
emergency medical services (EMS) settings also
receive Tdap in place of Td booster
 Priority groups:
 HCP in contact with infants less than 12 months
 Emergency Departments
 Maternal/Child Health
 ICU/NICU
 Respiratory Therapy
CDC Recommends
 All adults receive Tdap in place of their
tetanus booster
 Postpartum mothers and/or primary
caregivers receive Tdap
Tdap Vaccine
 Tetanus diphtheria acellular pertussis
 Licensed in 2005
 Only one dose is required and it can be
given in an interval as short as 2 years from
the last Td booster
Tdap Adverse Reactions
 Localized pain, redness, swelling
 Low-grade fever
 Adverse reactions occur at
approximately the same rate as Td
alone
Source: CDC Pertussis Information
A True Story…
Conclusions
 Vaccinating ADULTS with Tdap:
 85% protection with vaccine!
 Protect your family from pertussis
 Prevent an outbreak in workplace thereby reducing
costs and minimizing sick leave
 Keeping adults up to date with their vaccines can
minimize the effects of vaccine-preventable
diseases
Resources
County of San Diego Immunization Branch
www.SDIZ.org
Council of Community Clinics
(Referral to low-cost immunizations)
(619) 542-4300
Immunization Action Coalition
http://www.immunize.org/hcw/
Center for Disease Control and Prevention
http://www.cdc.gov/ncidod/dhqp/wrkr_immune.html
Thank you for your time.
Jae L. Hansen, IMC
(619) 692-6644
[email protected]