Immunization for Special Populations

Transcription

1 Newfundland and Labradr Immunizatin Manual Sectin 8 Immunizatin fr Special Ppulatins 8.1 Immunizatin Pst Bne Marrw Transplant/Stem Cell Transplant Immunizatin f Asplenic Ppulatin Immunizatin Recmmendatins fr Patients with Chrnic Kidney Disease Guideline fr the Preplacement Cmmunicable Disease Screening f Healthcare Wrkers Immunizatin fr Individuals New t Canada 5-1

2 8.1 Immunizatin Pst Bne Marrw Transplant/Stem Cell Transplant Plicy Allgenic and autlgus bne marrw transplant (BMT) r stem cell transplant (SCT) recipients frequently lse specific prtective immunity t diseases preventable by rutine immunizatins, therefre re-immunizatin may be necessary. This is rganized by the nclgy clinic and public health nurses may be requested t participate in immunizatin. Prcedure 1. The Onclgy Nurse Crdinatr/designate will prvide ral and written infrmatin n immunizatin t the patient/parents/family. (Fact Sheet Appendix A). A recrd will be prvided fr the dcumentatin f the vaccines. There is a schedule fr children under 7 years and ne fr children 7 years including Adults. 2. The Onclgy Nurse Crdinatr/designate will ntify the reginal Cmmunicable Disease Cntrl Crdinatr f the required vaccinatins utilizing the Request fr Immunizatin Pst Bne Marrw/Stem Cell Transplant Frm (Appendix B r Appendix C). 3. Multiple vaccines can be given at each visit. 4. Live vaccines must nt be administered if evidence f graft versus hst disease (GVHD) r cntinued immunsupressin is present. 5. Live vaccines must be given at the same time r at a minimum f 28 days apart. The public health nurse is t cntact the Onclgy Nurse crdinatr/designate t verify that the live vaccines are rdered by the Haematlgist/Onclgist. 6. If there has been a change in the recipient s health status since last immunizatin clinic appintment please cnfirm the client s eligibility t cntinue with the scheduled vaccines by cntacting the Onclgy Nurse Crdinatr/designate. 7. Varicella vaccine recipients shuld avid the use f salicylates fr 6 weeks after vaccinatin. 8. Please refer t the Canadian Immunizatin Guide and the Prvincial Immunizatin Manual fr specific infrmatin n vaccines and their administratin. 9. The attached guidelines and appendix B and C have been develped t assist the immunizer with the scheduling f the immunizatins. The decisin when t cmmence the prgram is dne by nclgy/transplant specialist r designate. Immunizatins fr Special Ppulatins 8.1-1

3 10. Guidelines fr inactivated vaccines pst-transplant: a) Influenza vaccine (Inf) Can cmmence at 6 mnths pst-transplant Given yearly in the fall prir t the influenza seasn Children less than 9 years receiving the vaccine fr the first time require tw dses ne mnth apart b) Rutine immunizatins Children less than 7 years Diphtheria txid, tetanus txid, acellular pertussis, inactivated pli and Haemphilus influenza (DTaP-IPV-Hib). Three dses shuld be given t all clients Can cmmence at 6-12 mnths pst-transplant Give at 12 mnths, 14 mnths, and 20 mnths pst-transplant fr cnvenience f scheduling Children greater than r equal t 7 years <18 years Tetanus txid, diphtheria txid and acellular pertussis (Tdap) Three dses shuld be given t all clients Can cmmence at 6-12 mnths pst-transplant Give at 12 mnths 14 mnths, and 20 mnths pst-transplant fr cnvenience f scheduling Haemphilus influenzae type b cnjugate vaccine (Hib) Three dses shuld be given t all clients Can cmmence at 6-12 mnths pst-transplant Give at 12 mnths, 14 mnths and 20 mnths pst-transplant fr cnvenience f scheduling Inactivated pli vaccine (IPV) Three dses shuld be given t all clients Can cmmence at 6-12 mnths pst-transplant Give at 12 mnths, 14 mnths and 20 mnths pst-transplant fr cnvenience f scheduling Adults 18 years Tetanus txid, diphtheria txid and acellular pertussis (Tdap ) (Td) Can cmmence at 6-12 mnths pst-transplant Give ne dse Tdap at 12 mnths Give 2 dses f Td at 14 mnths and 20 mnths Immunizatins fr Special Ppulatins 8.1-2

4 Haemphilus influenzae type b cnjugate vaccine (Hib) Three dses shuld be given t all clients Can cmmence at 6-12 mnths pst-transplant Give 3 dses at 12 mnths, 14 mnths and 20 mnths pst-transplant fr cnvenience f scheduling Inactivated pli vaccine (IPV) Three dses shuld be given t all clients Can cmmence at 6-12 mnths pst-transplant Give at 12 mnths, 14 mnths and 20 mnths pst-transplant fr cnvenience f scheduling c) Pneumcccal vaccine Pneumcccal cnjugate vaccine (Pneu-C-13) Three dses shuld be given t all clients Can cmmence at 3-6 mnths pst-transplant Regardless f age pneumcccal cnjugate vaccine 3 dses f Pneu-C-13, 4 weeks apart. Give at 6 mnths,7 mnths and 8 mnths pst-transplant fr cnvenience f scheduling Pneumcccal plysaccharide vaccine (Pneu-P-23) All transplant patients give 6 mnths after last dse f Pneu-C- 13 r when recipient reaches age 2. A single re-immunizatin with pneumcccal plysaccharide 23 is recmmended: 5 years after the initial dse in thse aged <11years at time f initial vaccine and 3 years after the initial dse in thse 10 years at the time f the initial vaccine d) Meningcccal vaccine Children greater than 12 mnths f age t age 10 years Meningcccal C cnjugate vaccine (Men- C-C) Can cmmence 6-12 mnths pst-transplant Give 1 dse 12 mnths pst-transplant fr cnvenience f scheduling. Meningcccal quadrivalent cnjugate vaccine (Men-C- ACYW135) Give 1 dse t when child is in grade 4 with schl prgram (8 weeks frm Men-C-C) Children 11 years t Adults Meningcccal quadrivalent cnjugate vaccine (Men-C- ACYW135) 1 dse 12 mnths pst-transplant Immunizatins fr Special Ppulatins 8.1-3

5 e) Hepatitis B vaccine (HB) Three dses shuld be given t all patients Can cmmence at 6-12 mnths pst-transplant Give at 12 mnths, 14 mnths and 20 mnths pst-transplant fr cnvenience f scheduling Administer duble dse µg that is recmmended fr age at time f administratin 11. Guidelines fr Live Vaccines Pst Transplant a) Measles, mumps and rubella Vaccine (MMR) This is a live vaccine which must nt be given befre 24 mnths psttransplant Recipient must be deemed immuncmpetent by specialist N GVHD present Give ne dse f MMR Check serlgic respnse after 1 st dse If n sercnversin 2 nd dse can be given in 3 mnths b) Varicella vaccine This is a live vaccine which must nt be given befre 24 mnths psttransplant Recipient must be deemed immuncmpetent by specialist N GVHD present Check serlgic status prir t vaccinatin Administer ne dse f VAR t serlgical susceptible patients. c) Other live vaccines Bacille-Calmette Guerin, Yellw Fever, Oral Typhid Vaccine Cntraindicated 12. Recmmendatins fr all husehld cntacts f immunsuppressed patients Annual influenza vaccine Nn-immune husehld cntact shuld be immunized against measles, mumps, rubella and varicella IPV and hepatitis A vaccine shuld be administered if there is an utbreak Immunizatins fr Special Ppulatins 8.1-4

6 References British Clumbia Centre fr Disease Cntrl (2010) Cmmunicable Disease Cntrl Immunizatin Prgrams. Sectin III-Immunizatin f Special Ppulatins. Centers fr Disease Cntrl and Preventin. (2000). Guidelines fr preventing pprtunistic infectin amng hematpietic stem cell transplant recipients. MMWR, 49(RR-10), King, SM., Saunders, EF., Petric, M., & Gld, R. (1996). Respnse t measles, mumps and rubella vaccine in pediatric bne marrw transplant recipients. Bne Marrw Transplant, 17(4), Mlrine, DC (2003). Recmmendatins fr immunizatins in stem cell transplantatins. Pediatric Transplantatin, 7(Suppl 3): S Mrrine DC, & Hibberd, PL. (2001). Vaccine fr transplant recipients. Infectius Disease Clinics f Nrth America, 15(1), Natinal Advisry Cmmittee n Immunizatin (2012). Canadian Immunizatin Guide (EvergreenEditin).OttawaONhttp:// Natinal Advisry Cmmittee n Immunizatin. Statement n the use f Pneumcccal Cnjugated Vaccines. (Nvember 2010) Natinal Advisry Cmmittee n Immunizatin. Supplement Statement n the use f Quadrivalent Cnjugated Meningcccal Vaccines. (January 2010) Prvincial Infectin Cntrl TB subcmmittee (2010) TB Management Spulu, V., Giannaki M., Vunatsu, M., Baklula, C., & Grafaks, S. (2004). Lng-term immunity t measles, mumps and rubella after MMR vaccinatin amng children with bne marrw transplants. Bne Marrw Transplant, 33(12), Immunizatins fr Special Ppulatins 8.1-5

7 Appendix A IMMUNIZATIONS AFTER BONE MARROW/STEM CELL TRANSPLANT FACT SHEET Why mre immunizatins are needed Mst patients wh have had a bne marrw r stem cell transplant lse the immunity they had frm previus vaccinatins and sme childhd diseases. Als because the immune system is suppressed after the transplant, a persn is at a higher risk fr infectins. T gain prtectin frm these illnesses it is imprtant t get re-immunized accrding t a set recmmended schedule. Keeping track f the immunizatins A recrd will indicate when the immunizatins are due. It is imprtant t get the immunizatins n time and t have them recrded n the immunizatin card by the Cmmunity Health Nurse. It is necessary t bring the card t the dctr s ffice fr review at fllw-up appintments. Getting the vaccines The Haematlgy/Onclgy Team will infrm the Cmmunity Health Nurse in yur area f the vaccine requirements. Yu can cntact the Cmmunity Health Nurse and set up an appintment fr the immunizatins. The nurse will recrd the vaccines n the card and will als maintain a recrd in the ffice. The fllwing immunizatins are recmmended: a) Influenza Vaccine (Flu vaccine Flu Sht ) The influenza viruses usually are the main cause f serius respiratry disease each year. The vaccine helps prevent chest infectins and shuld be administered prir t the start f the influenza seasn. All husehld cntacts wh are ver the age f six mnths shuld als receive this vaccine. b) Rutine Immunizatins In early childhd, children receive prtectin against diphtheria, tetanus, pli, pertussis and Haemphilus influenzae type b diseases. These vaccines shuld be re-administered pst-transplant and can be started at 6-12 mnths pst-transplant. c) Pneumcccal Vaccine Pneumcccal bacteria can cause infectins such as pneumnia, bldstream infectins and meningitis. This vaccine shuld be started at 3-6 mnths psttransplant. d) Meningcccal Cnjugate Vaccine This vaccine prevents invasive infectins such as meningitis and bldstream infectins. This vaccine can be started at 6-12 mnths pst-transplant. Immunizatins fr Special Ppulatins 8.1-6

8 e) Hepatitis B Vaccine This vaccine prevents bld brne infectins frm Hepatitis. It can be administered at 6-12 mnths pst-transplant. It is a three-dse vaccine given at 12 mnths, 14 mnths and 20 mnths pst-transplant. f) Live Vaccines Measles, mumps, and rubella (MMR) and Varicella vaccine shuld nt be given befre 24 mnths pst-transplant. PHN must cnsult with the pediatric r adult nurse transplant cnsultant t verify yur health status and eligibility t receive a live vaccine. Measles is a viral infectin that can prduce encephalitis and which is fatal in 1/3,000 cases. Spread by cntact with naspharyngeal secretins. Mumps is a viral infectin that can lead t rchitis, deafness, and meningitis. Spread by cntact with naspharyngeal secretins and saliva. Rubella is a viral infectin that prduces mild disease; it is teratgenic if cntracted by mther during first trimester f pregnancy. Spread via cntact with naspharyngeal secretins and saliva. Varicella (chickenpx) is a viral infectin that causes an itchy rash that blisters. Chickenpx can cause serius illnesses in children; such as encephalitis and pneumnia. Chickenpx is spread by cntact with blisters r frm secretins frm the nse r muth. If yu require mre infrmatin abut immunizatins, please cntact the Cmmunity Health Nurse in yur area. Immunizatins fr Special Ppulatins 8.1-7

9 Appendix B Wrksheet fr Immunizatin Pst Bne Marrw/Stem cell transplant fr children less than 7 years Client s name: Age: DOB: Parent s name: Schl: MCP: Address: : Date f BMT/SCT: Type: Start Date: Physicians signature: Prir t giving live vaccines CHN must cnsult with Transplant Nurse Cnsultant t verify client s eligibility status. Cntact Numbers: Pediatric nclgy/transplant Nurse Cnsultant: Adult Onclgy/transplant Nurse Cnsultant: Please cmplete this sheet and fax t the CDCN Crdinatr. Thank yu # f mnth pst-transplant 6 mnths Pneu-C-13 1 Inf (yearly) 3 7 mnths Pneu-C mnths Pneu-C mnths DTaP-IPV-Hib 2 Men-C-C 4 HB 5 14 mnths Pneu-P Vaccine/s Date Signature Next Dse Date HB 5 DTaP-IPV-Hib 2 20 mnths DTaP-IPV-Hib 2 HB 5 24 mnths MMR 6 Var 7 *27 mnths MMR 6 50 Mnths Pneu-P Ftntes 1. Pneumcccal cnjugate vaccine (Pneu- C-13) three dses ne mnth apart regardless f age. Pneumcccal plysaccharide (Pneu-P-23) vaccine shuld be given 6 mnths after 3rd Pneu-C-13 r when child reaches age tw. Bster dse f Pneu-P-23 3 years after initial dse. 5. Administer duble µg dse fr healthy child f same age fr hepatitis B vaccine. 2. Diphtheria txid, tetanus txid, acellular pertussis (DTaP) inactivated pli (IPV), Haemphilus influenzae type b (Hib. 3.Influenza children < than 9 years ld receiving the Inf vaccine fr the first time require 2 dses ne mnth apart 6. Measles,Mumps and rubella (MMR) vaccine: CHN must cnsult with Transplant Nurse Cnsultant t verify client s eligibility status prir t administering live vaccine, *Secnd dse f MMR is nly given if there is n sercnversin. 4. Meningcccal cnjugate vaccine Men-C-C, child will receive meningcccal quadrivalent Men-C- ACYW135 with schl prgram in grade fur. 7. Varicella (Var) Serlgic status prir t immunizatin must be checked. Only administer t susceptible individuals whse eligibility status has been cnfirmed. Immunizatins fr Special Ppulatins 8.1-8

10 Appendix C Wrksheet fr Immunizatin Pst Bne Marrw/Stem Cell Transplant fr Children 7 Years and Adults Client s name: Age: DOB: Parent s name: Schl: MCP: Address: : Date f BMT/SCT: Type: Start Date: Physicians signature: Prir t giving live vaccines CHN must cnsult with Transplant Nurse Cnsultant t verify client s eligibility status. Cntact Numbers: Pediatric nclgy/transplant Nurse Cnsultant: Adult Onclgy/Transplant Nurse Cnsultant: Please cmplete this sheet and fax t the CDCN Crdinatr. Thank yu Cmmence Date Vaccine/s Date Signature Date f next dse 6 mnths Pneu-C-13 1 Inf (yearly ) 2 7 mnths Pneu-C mnths Pneu-C mnths Hib 3 HB 4 Men-C-C 10 yrs r Men-C-ACYW yrs 5 Tdap/IPV 6 14 mnths Tdap/IPV r Td/ IPV 6 Hib 3 HB 4 Pneu-P mnths HB 4 Men-C-ACYW135 4 ( 10 yrs nly) 20mnths Hib 3 Tdap/IPV r Td/ IPV 6 24 mnths MMR 7 Var 8 *27 mnths MMR 7 50 r 72 mnths Pneu-P-23 1 Ftntes 1. Pneumcccal cnjugate vaccine (Pneu-C-13) Give 3 dses 4 weeks apart. Pneumcccal plysaccharides (Pneu-P-23) give 6 mnths pst-transplant. Bster dse f Pneu-P-23 3 r 5 years after initial dse age dependent. 5. Meningcccal cnjugate vaccine Men-C-C ne dse age 10 years and under fllwed by Men C-ACYW135 when child is in grade 4. Individuals age 11 and lder receive ne dse f Men C-ACYW Measles,Mumps and rubella (MMR) CHN must cnsult with Transplant Nurse Cnsultant t verify client s eligibility status prir t administering live vaccine,*secnd dse f MMR is nly given if there is n sercnversin. 2.Influenza children < than 9 years ld receiving the Inf vaccine fr the first time require 2 dses ne mnth apart 3. Haemphilus influenzae type b vaccine (Hib) 3 dses at separated by minimum f 4 weeks. 4. Administer duble the µg dse fr healthy child f same age up t & including age 19.Thse 20 years and lder give 40 µg (adult frmulatin). 5. Diphtheria txid, tetanus txid, acellular pertussis (Tdap) inactivated pli (IPV) r Tetanus txid diphtheria txid ( Td).The recmmendatins fr the use f Tdap/IPV r Td/IPV prduct is age dependent. See plicy sectin b. fr details as t which prduct t use. 7. Varicella (Var) CHN must cnsult with Transplant Nurse Cnsultant t verify client s eligibility status prir t administering live vaccine. Check serlgic status prir t immunizatin nly administer t susceptible clients. Nte: HPV vaccine may be added t schedule but eligibility is defined by birth year and sex. Immunizatins fr Special Ppulatins 8.1-9

11 8.2 Immunizatin f Asplenic Ppulatin Backgrund The spleen is the rgan that frms part f the hem-lympatic system. It plays an imprtant rle in regulating immunity, particularly fr encapsulated bacteria such as Neisseria meningitidis, Haemphilus influenzae type b and Streptcccus pneumniae. Asplenia may be anatmic r functinal in nature. The asplenia patient is at risk fr develping infectins frm encapsulated bacteria sme f which are vaccine preventable. Individuals underging elective and/r emergency spleenectmy, as are thse whse asplenic cnditin is cngenital r functinal in nature are eligible fr vaccines t decrease the risk f infectin. Definitins Asplenia: is the absence f the nrmal functin f the spleen. The cnditin may be, functinal, cngenital r the result f surgical remval. Anatmic asplenia surgical remval r cngenital absence f the spleen Cngenital asplenia: (rare) may be due t a genetic disrder and can include absent r defective splenic functin Functinal asplenia: ccurs when splenic tissue is present but des nt wrk well, e.g., sickle-cell disease, plysplenia; such patients are managed as if asplenic. Surgical asplenia: Surgical remval f the spleen (spleenectmy) which may be elective r an emergency Guidelines fr all Asplenic Patients The attending physician will: Advise the patient/parent/family f the vaccine requirements Prvide ral and written infrmatin n the required vaccines Refer the patient/parent /family t the Public Health Nurse fr Immunizatin Cngenital asplenia Vaccine schedule t be initiated at tw mnths even if infant hspitalized vaccinatin is t be started as per apprpriate schedule. Functinal asplenia Thse wh have been diagnsed with functinal asplenia shuld be immunized as sn as their cnditin is identified. Immunizatins fr Special Ppulatins 8.2-1

12 Surgical asplenia If elective spleenectmy, the vaccines shuld be given 2 weeks prir t the remval f the spleen. If an emergency spleenectmy the vaccines shuld be given tw weeks after the surgery. If hspital discharge is delayed then the vaccines can be given befre discharge r as sn as the patient is stable. The Public Health Nurse will: Review the immunizatin status f the patient and update as per schedule r recmmendatins fr age. Multiple vaccines can be given at each visit. Guidelines fr Vaccines All rutine vaccines shuld be administered accrding t the recmmended immunizatin schedule fr the individual s age, if nt previusly immunized. If the asplenic individual is up-t-date with rutine vaccinatins there is n need t reimmunize. Unimmunized individuals wh have had a spleenectmy in the past r wh have functinal asplenia shuld be immunized as sn as their cnditin is identified. Recmmended vaccines fr thse with anatmic r functinal asplenia All rutine immunizatins Immunize accrding t rutine schedule Hib vaccine All individuals greater than 5 years f age require ne dse regardless f immunizatin histry Meningcccal vaccine Meningccal quadrivalent cnjugate vaccine fr thse 2 mnths f age. Reinfrcement dses(s) recmmended Pneumcccal vaccine Cnjugate and/ r plysaccharide vaccine depending n age Influenza vaccine Immunize yearly ( all thse 6 mnths f age) (1) Haemphilus influenzae type b (Hib) vaccine: Children less than 5 years Vaccinate with age apprpriate primary series Primary series 2, 4, 6 & 18 mnths Children greater than and equal t 5 years adults Give ne dse f Hib (2) Meningcccal Vaccine Children age 2 mnths t 11 mnths Men-C ACYW135-CRM (Menve*) 2 r 3 dses given 8 weeks apart. 3rd r 4 th dse at mnths Revaccinatin** Immunizatins fr Special Ppulatins 8.2-2

13 Children 12 t 23 mnths 2 dses f Men-C ACYW135-CRM (Menve*) at least 8 weeks apart Revaccinatin** Children age 24 mnths t Adult If nt previusly vaccinated with Men C-ACYW135 give 2 dses administered 8 weeks apart (either prduct) Revaccinatin ** * Menve is nt authrized fr use in children less than 2 years f age; there are n authrized schedules fr thse children. The schedule in this plicy and in CIG are based n thse used in clinical trials and the recmmendatin that a dse f meningcccal cnjugate vaccine be given in the secnd year f life ( 12 t 23 mnths) fr children vaccinated at less than 1 year f age. ** Revaccinatin with Men-C-ACYW-135 A bster dse shuld be given every 3 t 5 years if vaccinated at 6 years f age r yunger and every 5 years fr thse vaccinated at 7 years and lder. (3) Pneumcccal Vaccine Children and Adults Individuals will receive cnjugate and/ r plysaccharide vaccine depending n age. Infants Rutine immunizatin with pneumcccal cnjugate 13 valent (Pneu-C-13) Give at 2, 4, 6 & 12 mnths At 24 mnths give pneumcccal plysaccharide 23 valent (Pneu-P-23) ne dse at least 8 weeks pst Pneu C- 13. Children 24 mnths - 59 mnths Children nt previusly vaccinated with pneumcccal vaccine r wh have nt cmpleted a series Pneu-C-13 1 dse Pneu-P-23 1 dse at least 8 weeks after Pneu-C-13 Children wh have cmpleted pneumcccal series but wh have nt previusly received Pneu-C-13 Pneu-C-13 1 dse If nt previusly immunized with Pneu-P-23; Pneu-P-23 1 dse 8 weeks after Pneu-C-13 Immunizatins fr Special Ppulatins 8.2-3

14 Adults Pneu-C-13 1 dse Pneu-P-23 1 dse a minimum f 8 weeks later Revaccinatin Pneu-P-23 Revaccinate nce in 5 years if at the time f initial Pneu-P-23 the client was greater than r equal t 10 years f age. Revaccinate nce in 3 years fr thse wh received initial Pneu-P-23 less than r equal t 10 years f age. (4) Influenza vaccine Immunize yearly all thse > than 6 mnths Children less than 9 years receiving influenza vaccine fr the first time require tw dses ne mnth apart References British Clumbia Centre fr Disease Cntrl (2010) Cmmunicable Disease Cntrl Immunizatin Prgrams. Sectin III-Immunizatin f Special Ppulatins. Public Health Agency f Canada. (2006). Canadian Immunizatin Guide (Seventh Editin. Public Health Agency f Canada Statement n the use f Pneumcccal Cnjugated Vaccines. (Nvember 2010) Public Health Agency f Canada Supplement Statement n the use f Quadrivalent Cnjugated Meningcccal Vaccines. (January 2010) Immunizatins fr Special Ppulatins 8.2-4

15 8.3 Immunizatin Recmmendatins fr Patients with Chrnic Kidney Disease Backgrund Patients with chrnic kidney disease are at increased risk fr infectin due t underlying cnditins such as diabetes, inadequate calrie and prtein intake due t pr appetite and t invasive devices such as dialysis access catheters. Many f these infectins are vaccine preventable such as influenza, pneumcccal infectin, varicella and hepatitis B. Research has shwn that the earlier in the curse f kidney disease that patients are vaccinated the mre likely they are t btain an adequate immune respnse. Recmmendatins 1. All patients with chrnic kidney disease shuld have their immunizatin status reviewed by their physician at the time f the diagnsis. The assessment fr hepatitis B immunizatin fr patients requiring dialysis mdalities can be dne by the Prgressive Renal Insufficiency (PRI) staff in cnsultatin with the Cmmunicable Disease Cntrl Nurse (CDCN). Serlgy will be requested and mnitred by the PRI r Dialysis staff. Vaccinatin, if indicated, can be crdinated by the PRI staff r a referral can be made t the CDCN. 2. The recmmended vaccines are included in Table 1: Table 1: Vaccines fr thse with chrnic kidney disease Vaccine Recmmendatins 1 All rutine vaccines Immunize accrding t rutine schedule Live vaccines shuld nt be given t patients when Pneumcccal vaccine significant immunsuppressin is present Cnjugate r plysaccharide vaccine depending n the age and risk 1 A single re-immunizatin with pneumcccal plysaccharide 23 is recmmended: 5 years after the initial dse in thse aged >11 years at the time f the initial vaccine and 3 years after the initial dse in thse 10 years at the time f the initial vaccine Influenza vaccine Annual vaccine in the fall; husehld members shuld als be vaccinated Varicella vaccine Nt rutinely recmmended Varicella vaccine shuld be cnsidered fr susceptible (as determined by serlgy) transplant candidates befre transplantatin because varicella is a significant cause f mrbidity and mrtality and is cntraindicated after 1 Refer t the Newfundland and Labradr Immunizatin Manual fr specific infrmatin n immunizatin requirements available at Immunizatins fr Special Ppulatins 8.3-5

16 transplantatin Hepatitis A vaccine Susceptible dialysis patients with chrnic liver disease shuld be administered the vaccine Hepatitis B vaccine Discussed in detail in #3. 3. Hepatitis Screening The first step in the prcess f evaluating the need fr hepatitis B vaccine is screening fr previus hepatitis expsure which includes serlgy fr hepatitis A, hepatitis B and hepatitis C. The fllwing serlgy shuld be requested: Hepatitis A Antibdy t hepatitis A virus (Anti-HAV) Hepatitis B Hepatitis B surface antigen (HBsAg) Antibdy t hepatitis B surface antigen (Anti-HBs) and Antibdy t hepatitis B cre antigen (Anti-HBc) Hepatitis C Antibdy t hepatitis C virus (Anti-HCV) See Appendix A - Table 2 & 3, & 4 fr the pssible serlgy results. 4. Hepatitis B Immunizatin The hepatitis B serlgy results, interpretatin and vaccinatin recmmendatins are prvided in Appendix A, Table 3. The dse and schedule fr hepatitis B prducts are prvided in Appendix B, Table Patients given the primary series f hepatitis B vaccine shuld have serlgy fr anti- HBs dne ne t six mnth after the final dse f the series. If the anti-hbs 10 Internatinal Units per Liter (IU/L) cnsider immune If anti-hbs is less than <10 IU/L a secnd three dse series must be administered and testing fr anti-hbs shuld be dne ne t six mnth after the last dse i. If the anti-hbs remains <10 IU/L fllwing the secnd series, cnsider the patient a nn-respnder ii. A nn-respnder is a patient wh has received the HB vaccine series twice (6 dses) and the anti-hbs remains < 10 IU/L Annual testing fr hepatitis B iii. Respnders (patients wh have munted a respnse 10 IU/L) are tested annually fr anti-hbs t ensure cntinued immunity iv. Nn-respnders shuld be tested annually (fr infectin) HBsAg and Anti-HBc Immunizatins fr Special Ppulatins 8.3-6

17 References 1. BC Centre fr Disease Cntrl Cmmunicable Disease Cntrl Immunizatin Prgram. Sectin 3: Immunizatin f Special Ppulatins Nvember Retrieved May 28, 2013 frm C797C76C2BCB/0/SectinIII_ImmunizatinfSpecialPpulatinsFeb2013.pdf 2. Centers fr Disease Cntrl and Preventin. (2001). Recmmendatins fr Preventing Transmissin f Infectins Amng Chrnic Heamdialysis Patients. MMWR, 50, CHICA-Canada Dialysis Special Interest Grup. (July 5, 2007). Infectin Preventin and Cntrl Measures t prevent transmissin f Hepatitis B amng Hemdialysis Patients. Retrieved May 28, 2013 frm 4. DaRza G, Lewen A, et al. (2003). Stage f Chrnic Kidney Disease Predicts Sercnversin After Hepatitis B Immunizatin: Earlier Is Better. American Jurnal f Kidney Diseases, 42(6), Dinits-Pensy M, Graeme N, Frrest MD, et al. (2005). The use f vaccines in adult patients with renal disease. American Jurnal f Kidney Diseases, 46(6), Fabrizi F, Vivek D et al. (January, 2011). The impact f diabetes mellitus n the immunlgical respnse t hepatitis B virus vaccine in dialysis patients: Metaanalysis f clinical trials. Alimentary Pharmaclgy & Therapeutics, Public Health Agency f Canada. (2013).Canadian Immunizatin Guide. Retrieved May 28, 2013 frm 8. Sheth R. (January 1, 2009). "A retrspective chrt study f the duratin f hepatitis B vaccine immunity and assciated factrs in pediatric dialysis patients" (January 1, 2009). Texas Medical Center Dissertatins (via PrQuest). Paper AAI Immunizatins fr Special Ppulatins 8.3-7

18 Appendix A Table 2: Baseline serlgy fr hepatitis A Hepatitis A Anti-HAV Interpretatin NR Susceptible; if patient has chrnic liver disease, vaccinate N further testing required R Immune N further testing required Table 3: Serlgy results fr hepatitis B and vaccinatin prtcls HBs Ag Anti-HBs IU/L Anti- HBc Clinical status Interpretatin Vaccinatin Prtcl NR <10 NR N prir histry f Susceptible Vaccinate with hepatitis B primary series (3 dses) vaccinatin Test Anti-HBs ne t six mnths Incmplete vaccinatin after last dse f series NR 10 NR Results after primary series NR < 10 NR Results after primary series Immune Test Anti-HBs annually Susceptible Revaccinate with 3 dses f hepatitis B vaccine Test anti-hbs ne six mnths after last dse If anti-hbs remains <10 N further vaccine Cnsider nn-respnder Test HBsAg and Anti-HBc annually NR 10 R Past infectin Immune N vaccinatin Refer fr medical evaluatin Testing as recmmended by physician NR < 10 NR Results f annual testing and a previus prtective respnse May be susceptible Give ne bster dse and retest anti-hbs in ne mnth NR <10 R Maybe recvering frm acute HBV infectin Maybe immune, with a lw level f anti-hbs (frm past infectin) May be susceptible with false psitive anti-hbc Maybe chrnically infected with an undetectable level f HBsAg R NR R Acute hepatitis B infectin r Chrnic carrier Fllw up with Anti-HBe and HBeAg t clarify infectin status Refer fr medical evaluatin and vaccine recmmendatins N vaccinatin Refer fr medical evaluatin Immunizatins fr Special Ppulatins 8.3-8

19 Table 4: Baseline serlgy fr hepatitis C Hepatitis C Anti-HCV Interpretatin NR Dcument N further testing required R Refer fr medical evaluatin Legend: Acrnym Interpretatin R Reactive NR Nn-reactive < Less than Greater than r equal t Primary Three r fur dses f hepatitis B hepatitis B vaccine as per series recmmendatins in Appendix B IU/L Internatinal units per litre Immunizatins fr Special Ppulatins 8.3-9

20 Appendix B Table 5: Dse and schedule fr hepatitis B-cntaining vaccines fr patients with chrnic renal failure requiring dialysis. Mnvalent hepatitis B Recipients Recmbivax HB Engerix Dse Schedule Mnths: 1 st dse=mnth Dse 0 0 Dialysis and chrnic renal failure under 16 years f age Dialysis and chrnic renal failure years f age Dialysis and chrnic renal failure, 20 years f age and lder Duble the micrgram (µg) dse fr healthy child f same age Duble the µg dse fr health child f same age 40 µg (adult frmulatin) 3 r 4 dse schedule Duble the µg dse fr healthy child f same age 3 r 4 dse schedule 40 µg 0, 1, and 6 mnths Schedule Mnths: 1 st dse=mnth 3 r 4 dse schedule 0, 1, 2, 6 mnths 40 µg 0, 1, 2, 6 mnths Immunizatins fr Special Ppulatins

21 8.4 Guideline fr the Pre-placement Assessment f Healthcare wrkers fr Cmmunicable Disease The purpse f this guideline is t prvide a cmprehensive, cnsistent prvincial apprach t the pre-placement assessment f healthcare wrkers (HCWs) fr specific cmmunicable diseases and t prvide evidence based recmmendatins fr the immunizatin f HCWs fr vaccine preventable diseases. These recmmendatins are intended t minimize the risk f ccupatinally acquired cmmunicable diseases t the HCWs and the HCWs families, t prtect patients and ther staff frm expsure t infected wrkers, and t sustain the wrk frce during utbreaks f cmmunicable diseases. Healthcare wrkers are at risk f expsure t and pssible transmissin f vaccine preventable disease because f their cntact with patients r infective materials frm patients. Additinally, patients, residents and ther HCWs may be placed at risk if healthcare wrkers are nt adequately assessed and immunized against vaccine preventable diseases. Maintenance f immunity against vaccine-preventable diseases is identified as an integral part f the infectin preventin Occupatinal Health (OH) Prgram in the Reginal Health Authrities. All rutine vaccines and vaccines fr high risk individuals are the respnsibility f the emplyee r emplyers. As an emplyer, gvernment prvides these vaccines fr their emplyees. In private industry the emplyer r emplyee is respnsible fr any csts related t immunizatin prgrams. This guideline was riginally develped by the Department f Health & Cmmunity Services, Cmmunicable Disease Cntrl Divisin, in cllabratin with a prvincial ad hc cmmittee with representatives frm the Medical Officers f Health, Infectin Cntrl, Cmmunicable Disease Cntrl, Occupatinal Health and the Public Health Labratry. It will be updated by the Cmmunicable Disease Cntrl Divisin t reflect changes in immunizatin recmmendatins. Immunizatins fr Special Ppulatins 8.4-1

22 Definitins Bacille Calmette-Guerin (BCG) - A vaccine used t prevent Mycbacterium tuberculsis in infants and yung children. It is mainly used in cuntries with a high prevalence f TB. Drplet Precautins - Precautins required when the infectius rganism is transmitted thrugh large drplets frm the infected persn during cughing r sneezing. Mre infrmatin n Drplet Precautins is available in the Public Health Agency Guideline (2013). Expsure The state f being expsed t an infectius agent. It can ccur via cntact expsure such as when the infectius agent is transferred thrugh physical cntact between an infected surce and a hst r thrugh the passive transfer f the infectius agent t a hst via an intermediate bject. Expsure prne prcedures (EPPs) Prcedures where transmissin f HBV, HIV r HCV frm a HCW t a patient is mre likely t ccur and may include the fllwing: digital palpatin f a needle tip in a bdy cavity (a hllw space within the bdy r ne f its rgans) r the simultaneus presence f the HCW's fingers and a needle r ther sharp instrument r bject in a blind r highly cnfined anatmic site, e.g., during majr abdminal, cardithracic, vaginal and/r rthpedic peratins, r repair f majr traumatic injuries, r majr cutting r remval f any ral r periral tissue, including tth structures, during which there is a ptential fr the patient's pen tissues t be expsed t the bld f an injured HCW (PHAC, 1998, SHEA, 2010). Healthcare settings A variety f healthcare settings including hspitals, ambulatry care facilities, ut-patient clinics, child health clinics, hme care settings, lng-term care r residential facilities and medical areas f crrectinal facilities. Healthcare wrkers (HCWs) Individuals wh prvide health care r supprt services such as nurses, physicians, dentists, nurse practitiners, paramedics and smetimes emergency first respnders, allied health prfessinals, unregulated healthcare prviders, clinical instructrs and students in health care disciplines, vlunteers and husekeeping staff. Healthcare wrkers have varying degrees f respnsibility related t the health care they prvide, depending n their level f educatin and their specific jb/respnsibilities. Immunizatin requirements will be determined by their specific jb and respnsibilities. (PHAC, 2013) Interfern gamma release assay (IGRA) A test fr cell mediated immunity respnses t antigens that simulate mycbacterial prteins. The prteins used in IGRA are absent frm all BCG strains. Latent tuberculsis infectin (LTBI) The presence f latent r drmant infectin with Mycbacterium tuberculsis with n evidence f clinically active disease. Individuals with LTBI are nn-infectius. Immunizatins fr Special Ppulatins 8.4-2

23 Nntuberculus mycbacteria (NTM) These are all mycbacterial species except thse that cause tuberculsis. Patient Fr the purpse f this dcument this term will be used t identify the individual (patient, client r resident) wh receives care in a healthcare facility r in the cmmunity. Rutine Practices - Rutine Practices are the infectin preventin and cntrl practices fr use in the rutine care f all patients, at all times, in all healthcare settings and are determined by the circumstances f the patient, the envirnment and the task t be perfrmed (PHAC, 2013). Tuberculin skin test (TST) A diagnstic tl used t identify peple infected with Mycbacterium tuberculsis (TB). It is a measure f cell mediated immune respnsiveness and pssible infectin with the TB rganism. It is the intradermal injectin f five tuberculin units (TU) f purified prtein derivative (PPD) int the anterir aspect f the frearm (Mantux technique). Tw-step TST A prcedure used fr the baseline skin testing f persns wh will receive serial TSTs t reduce the likelihd f mistaking a bsted reactin fr a new infectin. If an initial TST result is classified as negative, a secnd step f a tw-step TST shuld be administered ne fur weeks after the first TST was read. There is n indicatin fr tw-step TST testing in the setting f a cntact investigatin (PIC-NL, 2010). Immunizatins fr Special Ppulatins 8.4-3

24 1. Respnsibilities 1.1. Emplyers Implement and maintain an infectius disease assessment, educatin, and immunizatin prgram fr emplyees, including new hires Prvide emplyees with adequate infrmatin t make infrmed decisins abut assessment results, screening prcesses and recmmended immunizatins Establish guidelines fr the placement f HCWs wh remain nn-immune due t: failure t sercnvert, medical cntraindicatins t immunizatin, r immunizatin refusal Maintain a database/file that cntains details f HCW vaccine preventable disease histry, serlgical test results, immunizatins received, cnsents, and refusals Ensure that the database/file is maintained in a cnfidential manner and is accessible by authrized persnnel when needed Ensure that all newly emplyed HCWs are immunized against vaccine preventable diseases fr which they are at risk f expsure Cnsider a catch-up prgram fr ther HCWs emplyed in departments deemed high risk fr specific cmmunicable disease; wrkplaces may vary in hw they put this int peratin Activate an expert panel when a HCW wh perfrms expsure-prne prcedures is fund t be infected with a bldbrne pathgen 1.2. Occupatinal Health Nurses/Designate Cmplete a pre-placement assessment f all HCWs Prvide HCWs with the apprpriate educatin regarding the recmmended vaccines and administer them Fllw the Newfundland and Labradr (NL) Immunizatin Manual fr the latest recmmendatins n immunizatins available at: Prvide HCWs, deemed t have high risk cnditins, with the recmmended vaccines Obtain infrmed cnsent r refusal fr recmmended screening and immunizatins Dcument screening and immunizatins in the HCWs cnfidential health file/database Prvide HCWs with a recrd f all screening results and immunizatins cmpleted Immunizatins fr Special Ppulatins 8.4-4

25 1.3. Healthcare Wrkers Prvide previus recrds f health assessment and immunizatin histry t OH prir t placement Cmply with the emplyer s screening, educatin, immunizatin prgram, and acknwledge in writing either cnsent fr immunizatins r refusal f immunizatins Infrm OH f any expsure t an infectius disease Abide by the recmmendatin f OH regarding wrk restrictin due t an infectius disease 2. Assessment Prtcl 2.1 Preplacement Assessment OH will perfrm the fllwing assessment: Cmplete a health and immunizatin histry Review dcumented recrds f immunizatins Utilize serlgy t determine antibdy status Dcument the immune status Determine if the HCW has any cntraindicatins t vaccines r previus adverse reactins t vaccines 2.2 Cnsent An infrmed written cnsent must be btained frm the HCW prir t screening and immunizatin Cnsent must be dcumented n the HCW s health screening recrd If recmmended vaccines are refused, a signed dcumentatin f refusal must be btained including evidence that the HCW understands the implicatin invlved in refusal (e.g., wrk restrictins) 2.3 Persnal Immunizatin Recrd HCWs will be prvided with a cpy f his/her immunizatins 2.4 Cnfidentiality OH/Designate staff wrk within strict guidelines f cnfidentiality OH/Designate staff are bliged ethically and prfessinally nt t release infrmatin withut the infrmed written cnsent f the HCW, except when required by law Immunizatins fr Special Ppulatins 8.4-5

26 3. Disease Specific Recmmendatins 3.1 Diphtheria/Tetanus/Pli Ensure that HCWs have cmpleted a primary series f three dses f a cmbined tetanus txid-reduced diphtheria txid and inactivated pli vaccine Administer vaccine t cmplete the primary series Prvide a bster dse f tetanus txid-reduced diphtheria txid (Td) every 10 year; replace ne f the Td dses with Tdap (see pertussis recmmendatin) 3.2 Hepatitis B All HCWs at risk f expsure t bld and bld-cntaminated bdy fluids shuld be vaccinated against hepatitis B infectin The assessment prtcl fr hepatitis B is available in Appendix A Rutine bster dses are nt necessary fr HCWs fllwing achievement f serlgical cnfirmed immunity After dcumentatin f anti-hbs level f 10 IU/L antibdy levels d nt require mnitring If any emplyee is infectius with hepatitis B he/she must nt perfrm EPP 3.3 Influenza Cnsider HCWs t be susceptible t influenza if they have nt received the current seasn s vaccine Educate HCWs n the imprtance f annual influenza vaccine Offer all HCWs the influenza vaccine prir t/during influenza seasn 3.4 Measles Cnsider HCWs immune t measles if they have ne f the fllwing: Labratry evidence f immunity Histry f labratry cnfirmed measles disease Written dcumentatin f immunizatin with tw dses f measles cntaining vaccine administered at least fur weeks apart (first dse given n r after the first birthday) Any HCW withut written dcumentatin f immunizatin with tw dses f measles vaccine {usually given as measles, mumps and rubella (MMR)} shuld be prvided vaccine t ensure tw dses have been received These HCWs d nt need t have serlgy perfrmed t determine immunity either prir t immunizatin r fllwing immunizatin Immunizatins fr Special Ppulatins 8.4-6

27 D nt exclude frm wrk recently vaccinated HCW wh develp a vaccine-related rash Advise susceptible HCWs that they must nt wrk with patients suspected r cnfirmed t have measles In circumstances where this is unavidable, Airbrne Precautins must be fllwed; a respiratr must be wrn 3.5 Meningcccal Disease Immunize clinical micrbilgists, research micrbilgists and clinical labratry persnnel wh prcess cultures f Neisseria meningitides n a regular basis with ne dse f quadrivalent meningcccal cnjugate (Men-C-ACYW135) vaccine The vaccine des nt prvide cmplete prtectin, therefre, labratry safety practices must be maintained Prvide bster dses as per the NL Immunizatin Manual Prvide the vaccine t HCWs with high risk medical cnditins as recmmended in the NL Immunizatin Manual Rutine meningcccal vaccine is nt recmmended fr all HCWs 3.6 Mumps Cnsider HCWs immune t mumps if they have ne f the fllwing: Histry f labratry cnfirmed mumps disease Written dcumentatin f immunizatin with tw dses f mumps cntaining vaccine administered at least fur weeks apart (first dse given n r after the first birthday) Any HCW withut written dcumentatin f immunizatin with tw dses f mumps cntaining vaccine shuld be prvided vaccine (MMR) t ensure tw dses have been received These HCWs d nt need t have serlgy perfrmed t determine immunity either prir t immunizatin r fllwing immunizatin Advise HCWs wh are susceptible that they must nt wrk with patients suspected r cnfirmed t have mumps In circumstances where this is unavidable, Drplet Precautins must be fllwed; facial prtectin (a mask and gggles) shuld be wrn 3.7 Pertussis Cnsider HCWs susceptible t pertussis since natural and acquired immunity wanes Prvide a single dse f pertussis-cntaining vaccine (Tdap) t all healthcare wrkers regardless f age if nt vaccinated with Tdap in adulthd (i.e., 18 years) Immunizatins fr Special Ppulatins 8.4-7

28 Give the adult Tdap ten years after the adlescent Tdap bster dse Refer schl aged vlunteers t the Public Health Nurse if they have nt received the adlescent dse f Tdap Advise HCWs they must fllw Drplet Precautins if caring fr patient with pertussis 3.8 Pneumcccal plysaccharide vaccine Prvide pneumcccal vaccine t HCWs with high risk cnditins as identified in the NL Immunizatin Manual 3.9 Rubella Cnsider HCWs immune t rubella if they have ne f the fllwing: Labratry evidence f immunity Histry f labratry cnfirmed rubella disease Written dcumentatin f immunizatin with ne dse f rubella cntaining vaccine administered n r after the first birthday Any HCW withut written dcumentatin f immunizatin shuld receive ne dse r rubella cntaining vaccine Due t the tw dse requirement fr measles and mumps, the use f MMR will result in the majrity f HCWs receiving tw dses f rubella-cntaining vaccine These HCWs d nt need t have serlgy perfrmed t determine immunity either prir t immunizatin r fllwing immunizatin Advise susceptible HCWs that they must nt wrk with patients suspected r cnfirmed t have rubella In circumstances where this is unavidable, Drplet Precautins must be fllwed; facial prtectin (mask and gggles) shuld be wrn 3.10 Tuberculsis All HCWs must be assessed fr tuberculsis (TB) The assessment prtcl is utlined in Appendix B HCWs with active TB must be excluded frm wrk until: Three AFB smears are negative with substantial imprvement in symptms Clearance frm the Occupatinal Health Nurse is required befre returning t wrk HCWs with extrapulmnary TB may wrk if cncurrent pulmnary tuberculsis has been excluded HCWs with latent tuberculsis infectin (LTBI) can reprt t wrk unless symptms develp Immunizatins fr Special Ppulatins 8.4-8

29 3.11 Typhid Fever Immunize micrbilgists and thers wh wrk frequently with Salmnella (S.) Typhi Typhid is rare in Canada, s rutine micrbilgy labratries prcess S. Typhi nly rarely, i.e., nt frequently 3.12 Varicella Cnsider HCWs immune t varicella if they have ne f the fllwing: Labratry evidence f immunity Histry f a labratry cnfirmed varicella infectin Healthcare prvider diagnsis f varicella r herpes zster A reliable self-reprted histry f varicella Written dcumentatin f immunizatin with tw dses f varicella cntaining vaccine administered at least six weeks apart (first dse given n r after first birthday) A secnd dse f varicella vaccine shuld be ffered t HCWS wh have received nly ne dse f vaccine These HCWS d nt need t have serlgy perfrmed t determine immunity either prir t r fllwing the immunizatin OH shuld exclude HCWs with a pst immunizatin varicella-like rash, fr the duratin f the rash, if the rash cannt be cvered and if the HCWs are invlved in the care f high-risk patients, e.g., immuncmprmised and newbrn patients, Obtain recmmendatins fr the immunizatin f a susceptible immuncmprmised HCW frm his/her attending physician Advise HCWs wh are susceptible that they must nt wrk with patients suspected r cnfirmed t have varicella r zster In circumstances where this is unavidable, Airbrne Precautins must be fllwed; a respiratr shuld be wrn Immunizatins fr Special Ppulatins 8.4-9

30 References Natinal Advisry Cmmittee n Immunizatin. (2010). Supplement: Guidelines fr the preventin and cntrl f mumps utbreaks in Canada. CDDR; 36S1, Natinal Advisry Cmmittee n Immunizatins. (2013). Update n the use f quadrivalent cnjugage meningcccal vaccines. Retrieved March 25, 2014, frm eng.pdf PICNet BC. (2010). Interim guidelines fr baseline assessment and management f healthcare wrkers (HCWs) wh are cases r cntacts f measles (Rubela). Retrieved January 6, 2012 frm Newfundland and Labradr Immunizatin Manual. (2013). Retrieved May 22, 2013 frm Public Health Agency Canada. (2002). Infectin Cntrl Guidelines: Preventin f ccupatinal infectins in health care. CCDR, 28S1-March, Public Health Agency Canada. (1998). Prceeding f the cnsensus cnference n infected health care wrkers: Risk fr transmissin f bldbrne pathgens. CCDR, 24S4-July. Public Health Agency f Canada.(2013). Part 4: Active Vaccines. Canadian Immunizatin Guide (8 th ed.). Retrieved May 22, 2013 frm Public Health Agency Canada. (2013). Rutine practices and additinal precautins fr preventing the transmissin f infectin in healthcare settings. Retrieved May 21, 2013 frm PIC-NL Tuberculsis Subcmmittee. (2010). Guideline fr preventing the transmissin f Mycbacterium tuberculsis acrss the cntinuum f care. Retrieved January 5, 2012 frm Pai M, Kunimt D, Jamiesn F, & Menzies D. (2013). Diagnsis f latent tuberculsis infectin. In Canadian Tuberculsis Standards ( 7 th ed.). Retrieved March 27, 2014, frm Sciety fr Healthcare Epidemilgy f America (SHEA). (2010). SHEA guideline fr management f healthcare wrkers wh are infected with hepatitis B virus, hepatitis C virus, and/r human immundeficiency virus. ICHE, 31(3), Immunizatins fr Special Ppulatins

31 Appendix A Table 1: Healthcare wrker baseline assessment and testing fr Hepatitis B Hepatitis B immunizatin status N hepatitis B vaccine, r 1 r 2 dses f series received Dcumented HB vaccine series Pst immunizatin anti-hbs serlgy is 10 IU/L Dcumented HB vaccine series N pst immunizatin anti-hbs dcumented Unsure if HB vaccine series cmpleted Tw hepatitis B series cmpleted Anti-HBs <10 IU/L Actin Cmplete a three dse hepatitis B series Test fr anti-hbs 1-6 mnths after final dse N further actin Test fr anti-hbs Pssible Results: anti-hbs 10 IU/L n further actin anti-hbs < 10 IU/L Actin 1 r 2 Actin 1 Actin 2 If anti-hbs testing dne 1-6 mnths after series cmpleted administer a secnd HB series retest in 1-6 mnths If anti-hbs remains<10 IU/L cnsider a nn-respnder If anti-hbs testing dne > 6 mnths after series cmpleted administer ne dse f vaccine retest in ne mnth if still <10 IU/L cmplete series Test fr anti-hbs If anti-hbs < 10 IU/ml - vaccinate with hepatitis B series If anti-hbs 10 IU/ml - n further actin Dcument as nn-respnder N further dses recmmended Pst expsure prphylaxis required HBsAg psitive Refer t expert review cmmittee if HCW perfrming EPP Legend Anti-HBs = antibdy t hepatitis B HBsAg = hepatitis B surface antigen Primary hepatitis B series = 3 dses f vaccine IU/L=Internatinal Units per Liter Immunizatins fr Special Ppulatins