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Healthcare Personnel
Immunization
Recommendations:
2011 Update
Kathleen Harriman, PhD, MPH, RN
Vaccine Preventable Disease Epidemiology Section
California Department of Public Health
Immunization Branch
[email protected]
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
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
Vaccination Programs
1. Maintenance of complete immunization records
2. Policies for catch-up vaccination
3. Work restrictions for exposed susceptible
employees
4. Control of outbreaks
5. 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)
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
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
Newest ACIP Recommendations
for HCP, 2011
Most Recent ACIP
Recommendations
Immunization of healthcare personnel, 2011
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm
Hepatitis B, 2006
http://www.cdc.gov/mmwr/PDF/rr/rr5516.pdf
Influenza, 2011
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a3.htm
Influenza vaccine, healthcare personnel, 2006
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm
Diphtheria, tetanus, pertussis, 2006
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm
Measles, mumps, rubella, 1998 and 2009 update
http://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm
http://www.cdc.gov/vaccines/recs/provisional/downloads/mmr-evidence-immunity-Aug2009508.pdf
Mumps, 2006
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5522a4.htm
Varicella, 2007
http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdf
Vaccines that might be indicated for adults, based
on medical and other indications --- United States, 2011
2011 ACIP adult immunization recommendations
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6004a10.htm?s_cid=mm6004a10_e&source=govdelivery
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
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
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.
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
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
Vaccines that are required to be
offered* per the ATD standard
Vaccine
Schedule
•
•
•
•
•
•
•
•
•
•
Influenza
Measles
Mumps
Rubella
Tetanus, diphtheria, and
acellular pertussis (Tdap)
• Varicella-zoster (VZV)
One dose annually
Two doses
Two doses
One dose
One dose, booster
as recommended
• Two doses
* To all susceptible employees who might be exposed.
If vaccine is declined, a declination form must be signed.
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
Seasonal
Influenza
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??
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 to work in hospital
• 32% decrease (to 0) of nosocomial influenza in a
hospital with vaccination increase from 4 to >67%
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_014
http://www.thecommunityguide.org/worksite/flu-hcw.html
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
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
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
Joint Commission
Standard IC.02.04.01: The organization offers
vaccination against influenza to licensed independent
practitioners and staff.
1. The hospital establishes an annual influenza vaccination
program that is offered to licensed independent practitioners
and staff.
2. 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.
3. The hospital provides influenza vaccination at sites accessible
to licensed independent practitioners and staff.
4. The hospital annually evaluates vaccination rates and the
reasons given for declining the influenza vaccination.
5. The hospital takes steps to increase influenza vaccination rates.
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
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
from intranasal 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
Hepatitis B
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
Estimated # of Infections
Estimated Number of Acute HBV Infections Due
to Occupational Exposures, U.S., 1983-2002
12,000
10,000
OSHA
Requirements
8,000
6,000
4,000
2,000
Vaccine
Recommended
for HCP
0
1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002
Year
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
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
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
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
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-forManagement-of-Healthcare-Workers-Who-Are-Infected-with-Hepatitis-B-Virus-Hepatitis-C-V.aspx
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
Measles
Measles
• In the decade before the measles vaccine was
licensed in 1963, ~3–4 million people were
infected in the U.S. each year
 400–500 died
 48,000 were hospitalized
 1,000 developed chronic disability from measles
encephalitis
 Epidemics occurred every 2-3 years
• Widespread use of measles vaccine led to a
greater than 99% reduction in measles cases in
the U.S. compared with the pre-vaccine era
Measles—United States, 1950-2005
900
800
700
600
500
30000
Vaccine
Licensed
1963
20000
Measles
declared
eliminated
15000
10000
5000
0
1980
400
300
200
100
0
1950
Endemic
transmission
interrupted
25000
Cases
Cases (thousands)
2nd dose
1989
1960
1970
1980
1985
1990
1990
1995
2000
2005
2000
Measles
• Elimination of endemic measles in North and South America
was achieved in 2002 and is a public health success model
for 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 vaccine in 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
control to be sustained, two-dose vaccination strategy with
very high coverage 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
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
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 acceptable evidence 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.
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
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
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
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
Mumps
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
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
Mumps Vaccination
• All persons who work in healthcare facilities
should be immune to mumps
HCP born during or after 1957  2 doses
No vaccination/immunity  2 doses (>28 days apart)
Only 1 dose previously  second dose
Birth before 1957 only presumptive evidence of
immunity; consider 1 dose for unvaccinated workers
without laboratory evidence of immunity
 During an outbreak, 2 doses of vaccine recommended
for workers born before 1957 who do not have
evidence of immunity




Mumps Epidemiology
• Post-licensure studies of 1 dose of mumps vaccine
showed it was 78%-91% effective in preventing clinical
mumps
• Late 1980s - early 1990s, mumps outbreaks observed in
schools with extremely high (>95%) vaccination
coverage, suggesting that 1 dose of mumps vaccine is
insufficient to prevent mumps outbreaks in schools
• Since the 1989 2-dose MMR requirement, incidence of
mumps disease has decreased and studies of vaccine
effectiveness during outbreaks suggest substantially
higher levels of protection with a second dose of MMR
Mumps Prevention and Control
• During an outbreak, healthcare facilities should
strongly consider recommending 2 doses of mumps
vaccine to unvaccinated workers born before 1957
who do not have evidence of mumps immunity
• Reviewing HCP immune status for mumps and
providing serologic testing and vaccine during an
outbreak is difficult
• Facilities might consider reviewing immune status of
HCP routinely and providing appropriate vaccinations,
including a second dose of mumps vaccine, in
conjunction with annual activities such as influenza
vaccination or tuberculin testing
http://www.cdc.gov/mumps/prev-control-settings/index.html
Rubella
Rubella Epidemiology
• Rubella vaccines were first licensed in 1969 and
rubella was declared eliminated in the U.S. in
2004
• Rubella cases in the U.S. are now imported from
regions of the world where rubella is not
controlled
Presumptive Evidence of
Immunity to Rubella
• Documented administration of one dose of live
rubella virus vaccine; or
• Laboratory evidence of immunity or laboratory
confirmation of disease; or
• Born before 1957 (except premenopausal
women who could become pregnant)
Documentation of physician-diagnosed rubella is
no longer acceptable evidence of immunity
Presumptive Evidence of
Immunity to Rubella, continued
• HCP who can provide documentation of
serological evidence of rubella immunity (e.g.,
via prenatal testing) do not need to be retested
and should be considered immune
• The principle of “once immune, always immune”
also applies to measles, mumps and hepatitis B
MMR Vaccination for HCP
Born Before 1957
• HCP born before 1957 are generally presumed to be
immune to measles, mumps, and rubella, but not all are
• Consider recommending 2 doses of MMR vaccine
routinely for unvaccinated HCP born before 1957 who
lack laboratory evidence of measles, mumps or rubella
immunity or laboratory confirmation of disease
• During an outbreak of measles or mumps, two doses of
MMR vaccine are recommended for unvaccinated HCP
born before 1957 who lack laboratory evidence of
immunity or laboratory confirmation of disease; one
dose of MMR recommended during a rubella outbreak
Measles, Mumps and Rubella
Immunity Testing
• Testing for serologic evidence of immunity to
measles, mumps or rubella is not recommended for
HCP who have two documented doses of MMR
vaccine or other acceptable evidence of immunity
• If testing is inadvertently performed on HCP with
documentation of vaccination and the worker is IgG
negative for measles, mumps or rubella, ACIP
recommends that test be assumed to be falsely
negative and that the worker should be presumed
immune for the purposes of preplacement screening
• If such a worker has an exposure to measles, CDPH
recommends treating as susceptible
Varicella
Varicella Among HCP
• Nosocomial transmission of is varicella is wellrecognized
• Sources
 Patients, hospital staff, and visitors with varicella or
herpes zoster
• Airborne transmission of varicella has been
demonstrated
 Varicella has occurred in susceptible persons who
had no direct contact with index case-patient
 Virus detected in air
 Herpes zoster may also be airborne (?)
2007 ACIP Recommendations
• Serologic screening before vaccination
 Testing unvaccinated HCP with a negative or uncertain
history of varicella is likely to be cost-effective; or
 Test all HCP, because small proportion with positive
history of disease might be susceptible
• Routine testing after 2 doses of vaccine is not
recommended
 Available commercial assays not sensitive enough and
are likely to be falsely negative
 In sensitive tests, 99% of adults develop antibodies
after 2nd dose
 If testing is done, IgG+ results can be relied upon
http://www.cdc.gov/mmwr/pdf/rr/rr5604.pdf
Evidence of Immunity to
Varicella in HCP
• Documentation of two doses of vaccine
• Laboratory evidence of immunity or laboratory
confirmation of disease
• Diagnosis or verification of history of varicella
disease or history of herpes zoster (shingles)
by a healthcare provider
 If an employee states they have had varicella or
herpes zoster in the past, a healthcare provider can
interview the employee to determine if their history
is compatible with one of these diagnoses; if so,
this is considered evidence of immunity
Evidence of Immunity to
Varicella
• Serologic evidence of VZV infection in 96%-97% of
U.S.-born adults aged 20-29 years and in 97%-99% of
adults aged >30 years tested during 1998-1999
• U.S. birth before 1980 considered evidence of immunity
except for HCP, pregnant women, and
immunocomprised people
• For these three groups, certainty regarding immunity is
desirable because of the possibility of nosocomial
transmission to high-risk patients; transmission of the
virus to the fetus, which might result in congenital
varicella syndrome; and possibility of severe disease
Respiratory Protection
• Regardless of immune status, all HCP must
use respiratory protection at least as effective
as an N95 respirator when in contact with
varicella patients
Varicella Exposure to
Vaccinated HCP
• 2 doses - monitor daily during days 10-21 to
determine clinical status, place on sick leave
immediately if symptoms occur
• 1 dose – give 2nd dose <3-5 days of exposure
 After vaccination, management is similar to 2-dose
• Unvaccinated HCP without immunity –
postexposure vaccination and furlough days
10-21 after exposure
Transmission of Vaccine Virus
from Vaccine Recipients with Rash
• Risk low; transmission has been documented
after exposures in households and long-term
care facilities
• No cases documented after vaccination of HCP
• Consider precautions for HCP in whom rash
occurs after vaccination
 Avoid contact with persons without evidence of
immunity at risk for severe disease and complications
until all lesions resolve (i.e., are crusted over or fade
away) or no new lesions appear in a 24-hour period
Varicella Postexposure
Prophylaxis
• Varicella vaccine is effective in preventing illness
or modifying varicella severity if administered to
unvaccinated children within 3 days, and
possibly up to 5 days, of exposure
• Studies only in children
• Although postexposure use of varicella vaccine
has potential applications in hospital settings,
pre-exposure vaccination preferred
Pertussis
Pertussis in the United States
• Least well controlled vaccine preventable disease
• Cyclical with peaks every 2-5 years – in 2010, California
experienced an epidemic with >9,000 cases & 10 deaths
• Most severe disease occurs among infants <6 months of
age; almost all deaths are in infants <3 months of age
• Studies have shown that ~half of the infants with
pertussis were infected by a household member, most
often their mother
• Immunity via vaccine or disease wanes over time; most
children last vaccinated at kindergarten are susceptible
again by middle school
• Almost all adults are susceptible; only ~6% of adults
have received Tdap, which was licensed in 2005
Number of reported pertussis cases by year of
onset ― California, 1914-2010*
25000
Cases per 100,000
20000
DTP
widely
used
15000
PCR
available
10000
Acellular
DTaP
licensed
5000
Tdap
licensed
0
Year
* Includes cases reported to CDPH as of 3/9/2011
Number of reported pertussis cases by
year of onset -- California 1945-2010*
16000
160
Cases
Rate per 100,000
140
Previous peak in 1945
number of cases: 13,845
12000
120
10000
100
cases
9,477 cases
8000
80
6000
24.2/100,000
Previous peak in 1958
incidence: 26.0/100,000
60
4000
40
2000
20
0
1945
1950
1955
1960
1965
1970
1975
1980
year
1985
1990
1995
2000
2005
cases per 100,000
14000
0
2010*
*As of 3/9/2011; data for 2010 are still preliminary
Pertussis Among HCP
• Nosocomial spread of pertussis documented
 Hospitals and EDs (pediatric and adult), clinics, LTCFs
• Sources
 Patients, HCP with hospital or community-acquired
pertussis, visitors or family members; up to 80
infections per index case
• Incidence in HCP currently ~7% per year
• 90% pediatric hospitals reported HCP exposures
over 5-year period; 11% reported infected
physicians
Costs of Controlling Pertussis
• $74,870-$174,327 per outbreak
• $42,000-$98,000/year for pertussis exposures
 Include identifying contacts among HCP and patients,
providing postexposure prophylaxis for asymptomatic
close contacts, and evaluating, treating, and placing
symptomatic HCP on administrative leave until they
have received effective treatment
MMWR December 15, 2006;55(RR17)
http://www.cdc.gov/mmwr/PDF/rr/rr5517.pdf
Tdap Vaccine
• In 2005, a vaccine containing tetanus and diphtheria
toxoids and acellular pertussis vaccine (Tdap) was licensed
in the U.S. for persons aged 11-64 years (ADACEL®)
– pertussis is not available as a single vaccine
• In 2006, ACIP recommended that HCP in hospitals and
ambulatory care settings with direct patient contact
receive a single dose of Tdap as soon as feasible if they
have not previously received it – this was re-emphasized
in 2011 “all HCP should receive Tdap as soon as feasible”
• HCP who have direct contact with infants <12 months of
age or pregnant women should be strongly encouraged to
be vaccinated
• Regardless of age, HCP without documentation of Tdap
immunization should receive it – there is no minimum
interval between the last dose of Td and Tdap
Implementing Hospital
Tdap Program
• Infrastructure for vaccination exists in most
hospitals
 New HCP screened and vaccinated on employment
 Can be given at same time as influenza vaccine
 Tiered approach option: priority given to HCP with
contact with infants aged <12 months, other
vulnerable groups of patients
 As Tdap vaccination coverage in general population
increases, many new HCP will already have received
dose of Tdap
• Birth hospitals should also promote Tdap
vaccination of new mothers
• Emergency departments should use Tdap
2011 ACIP Recommendations on Pertussis
Postexposure Prophylaxis for Vaccinated HCP
• Data on the need for postexposure prophylaxis
in Tdap-vaccinated HCP are inconclusive
• Postexposure prophylaxis is recommend for all
HCP who have unprotected exposure to
pertussis and are likely to expose a patient at
risk for severe pertussis (e.g., hospitalized
neonates)
• Other HCP should either receive postexposure
prophylaxis or be monitored for 21 days after
pertussis exposure and treated at the onset of
signs and symptoms of pertussis
Meningococcal Disease
Meningococcal Disease
• Caused by the bacterium N. meningitidis
• ~185 cases/year in California; peaks in winter
• Even with proper treatment, it may progress
rapidly and result in death; 10-20% survivors
have sequelae
• Most cases are caused by five N. meningitidis
serogroups: A, B, C, W-135 and Y
• Serogroup B is not contained in the vaccine;
> 1/3 of cases in California are serogroup B and
are not vaccine preventable
Meningococcal disease by month of onset –
California 2009-2011
Meningococcal Vaccine
• Microbiologists routinely exposed to isolates of N.
meningitdis are considered to be at increased risk for
meningococcal disease and are recommended to receive
vaccine
• Two types of quadrivalent meningococcal vaccine are
available – both protect against infection with
serogroups A, C, W-135 and Y (not against B)
 Meningococcal conjugate vaccine (MCV4) for workers
through 55 years of age
 Meningococcal polysaccharide vaccine (MPSV4) for
workers over 55 years of age
 Employees >55 years who have received MPSV4 3-5
years previously should be revaccinated with MCV4 if
still at increased risk
http://www.cdc.gov/mmwr/pdf/rr/rr5407.pdf
New ACIP Recommendations
• HCP with anatomic or functional asplenia,
persistent complement component deficiencies,
or HIV should now receive a 2-dose primary
series of meningococcal conjugate vaccine
• Those HCP who remain in groups at high-risk
are recommended to be revaccinated every 5
years
Other Resources for
Occupational Health
• Medical center occupational and employee
health issues (MCOH-EH) listserv
 http://mylist.net/listinfo/mcoh-eh
• American College of Occupational and
Environmental Medicine
 http://www.acoem.org