Immunizations for Health Care Workers

Transcription

1 Immunizations for Health Care Workers Tanisha Taylor, MD, MPH Senior Medical Director Barnabas Health Corporate Care

2 Tanisha Taylor MD, MPH Senior Medical Director Barnabas Health Corporate Care CDC

3 Immunizations for HCWs Protect the individual who is vaccinated Decrease exposure to patients and co-workers Reduce the cost and disruption in health-care facilities and other institutional settings

4 WHO definition of HCWs Health workers are all people whose main activities are aimed at enhancing health. They include the people who provide health services --such as doctors, nurses, pharmacists, laboratory technicians --and management and support workers such as financial officers, cooks, drivers and cleaners.

5 Immunizations for HCWs General Principles Proper storage, reconstitution, needle size and mode of administration It is not necessary to restart the series or add doses because of an extended interval between doses

6 Immunizations for HCWs General Principles All vaccines can be administered at the same visit Interference can occur between two live vaccines given < 28 days apart If two live parenteral vaccines, or live intranasal influenza vaccine, given < 28 days apart, the vaccine given second should be repeated*

7 Recommendations of vaccines for HCWs VACCINE MMR (Measles,Mumps & Rubella) Varicella Hepatitis B Tdap(Tetanus, Diphtheria, Pertussis) Flu Meningococcal CDC yes yes yes yes yes yes CDC

8 Hepatitis B Blood or body fluids : percutaneous, mucosal serum, semen 30% risk of infection if source HBsAg+ Sexual Perinatal

9 Hepatitis B Vaccine Single antigen: recombinant HBsAg

10 Hepatitis B vaccination schedules 3 IM injections: 0, 1, and 6 months 0, 1, and 4 months 0, 2, and 4 months Antibody response: # % #2-75% #3 - >90%

11 Hepatitis B Vaccine Adverse Events Pain at injection site Low grade fever Anaphylaxis Contraindications Hypersensitivity to yeast or other vaccine component Serious adverse event to previous dose Hepatitis B vaccine

12 Hepatitis B vaccine: causes of decreased antibody response Older age Smoking Obesity Genetic factors Immune suppression

13 Hepatitis B vaccine : OSHA: specifies HCWs previous Hepatitis B vaccine series (3 doses) history of Hepatitis B infection give Hepatitis B vaccine series(3 doses) sign declination form

14 CDC for HCWs HepB vaccine x3 positive HBsAb negative 2 nd series HepB x3 PROTECTED HBsAB positive negative PROTECTED STOP NON-RESPONDER

15 DNA Core Protein HBcAg HBsAb + HBcAb + DNA polymerase Surface Protein HBsAg HBsAb +

16 HBsAb+ HBcAb- HBsAg- 3+ doses Hep B vaccine PROTECTED <3 doses Hep B vaccine PROTECTED (complete initial series)

17 HBcAb+ HBsAb+/- PROTECTED - natural immunity from previous infection HBsAg- not infectious HBsAg + infectious HBeAg, HBeAb, HepB by PCR

18 HBsAg- HBsAb- HBcAb - <3 doses complete initial Hep B vaccine series check HBsAb(6 8 weeks) PROTECTED 2 nd series HepB vaccine check HBsAb(6-8weeks) PROTECTED NOT PROTECTED STOP

19 HBsAg- HBsAb- HBcAb - 3 doses give 4 th dose HepB vaccine check HBsAb(6 8 weeks) PROTECTED give doses #5 and #6 Hep B vaccine check HBsAb(6-8weeks) PROTECTED NOT PROTECTED STOP

20 Hepatitis B vaccine Booster Booster doses not recommended for persons with normal immune status who have developed HBsAb after Hepatitis B vaccine series B and T cells have memory even if lost HBsAb Protected for ~ 30 years

21 Exposure to Hepatitis B Unprotected HCW HBIG ml/kg (screened for HBsAg, HIV, Hep C) Hepatitis B vaccine series if never received previously

22 Tetanus, Diphtheria and Pertussis (Tdap) DPT 1940 s DTap 1990 s dt booster every 10 y - 5y if deep/dirty wound Large increase # reported cases pertussis ~ >25,000 U.S. Pertussis: >300,000 deaths annually worldwide

23 Tdap Tetanus toxoid same amount Diphtheria toxoid reduced amount Pertussis toxin same five antigens, reduced amount

24 Tdap Single dose booster 0.5 ml given IM Age Contraindications: previous severe allergic reaction to any component encephalopathy following previous dose of pertussis Precautions: pregnancy unstable neurologic condition history or Arthus-type reaction following tetanus vaccine history of Guillain-Barre following tetanus vaccine

25 Tdap Adverse effects: Local pain, swelling, erythema, underarm lymph node swelling Systemic fever, headache, myalgias, arthralgias, tiredness, chills, nausea, diarrhea, vomiting, rash Serious events within 6 months neuropathic (migraine with unilateral facial paralysis, nerve compression in neck)

26 Tdapfor HCWs Initially, >2 y since last dt, now ASAP for HCWs At time of pertussisexposure if no previous Tdap Begin vaccination program of HCWs with contact with infants and young children How often booster needed? Every 5 or 10 years?

27 Pertussisexposure PPE N95 respirators if suspect Pertussis Locate and prophylax contacts Furlough (administrative leave) for HCWs HCW with Tdap antibiotic PEP or symptom monitoring Antimicrobial agents Azithromycin(500mg day 1, 250mg days 2-5) Erythromycin (500mg qid X 14d) Clarithromycin(500mg bid X 7d) TMP-SMZ (160mg/800mg bid X 14d) Tdapif not already received

28 Measles, Mumps, Rubella (MMR) Vaccine Contains Live Attenuated Virus CONTRAINDICATIONS: Pregnancy (or expected pregnancy within 3 months) Immunosuppression Severe allergic reaction to vaccine component or following prior dose (neomycin, eggs)

29 MMR Adverse Reactions Fever 5%-15% Rash 5% Joint symptoms 25%

30 MMR Vaccine 0.5 ml SQ 1-dose efficacy varies from 80% (mumps) to 95% (measles and rubella) Duration of immunity probably lifelong

31 MMR Vaccine High risk (HCWs, military, university students, international travel) 2 doses MMR vaccine or other evidence of immunity (titers)

32 MMR flow chart Me, Ru, Mu titers positive negative < 1957 >1957 pregnancy test negative protected give 1-2 doses MMR MMR x2 MMR x1 protected protected give 2 nd MMR check titer positive negative protected not protected

33 Exposure to Measles, Mumps, Rubella unprotected HCW Vaccinate if not done previously Furlough: Measles : days 5 23 Mumps : days Rubella : days 7 21

34 VaricellaZoster Virus Varicella- primary infection with VZV - Chickenpox generalized vesicular eruption, constitutional symptoms more severe in very young and adolescents/adults Herpes Zoster - reactivation of VZV Shingles eruptions along nerve root can generalize in the immuno-compromised

35 VZV vaccines Varivax: Oka strain, live, attenuated VZV (single antigen) lyophilized must be kept frozen (5F /-15C), reconstituted and stored at room temperature maximum 30 minutes Zostavax: Herpes Zoster (Shingles) age 60>

36 VZV and Varivax Immunologic response after 2 nd dose 98% protection against all VZV, 100% protection against severe VZV

37 Varivax Storage frozen 5 deg F (-15 deg C) or colder Diluentstored separately at room temperature or in the refrigerator Reconstitute according to directions Should be used immediately to minimize loss of potency Discard if not used within 30 minutes of reconstitution

38 Varivaxfor HCWs Two doses 4 8 weeks apart (can be years) 0.5 ml SQ Not pregnant Avoid conception 1 month post vaccination Safe for breast feeding

39 Varivax-Contraindications Serious allergic reaction to vaccine component (gelatin, neomycin) Altered immunity - HIV, AIDS, hematopoetic/lymphatic malignancies, congenital/inherited immunodeficiency Pregnancy (no cases of varivax fetal syndrome) High dose systemic immunosuppressive therapy

40 Varivax-Adverse Events Pain and redness at injection site Fever Varicella-like rash at injection site or generalized Urticaria gelatin allergy

41 Varivaxfor HCWs If vesicles/rash develop avoid immunocompromised patients

42 VZV Exposure Furlough non-immune (no vaccine/ - titer) HCW days Monitor vaccinated (no titer) HCW closely days Varivax vaccine if not received previously Acyclovir synthetic nucleoside analog inhibits replication of human herpes viruses within 24 hours of vesicle appearance - not prophylaxis VZIG - passive immunization - if immunocompromised ASAP (<96 hours) protection ~ 3 weeks prophylaxis - not treatment once clinical symptoms appear

43 Meningococcal Vaccine IM or SQ Childhood primary vaccination Relatively safe in pregnancy Adverse effects: hypersensitivity, latex in stopper local swelling, pain, erythema headache, and fatigue, malaise arthralgia, diarrhea, anorexia chills, fever, vomiting, and rash

44 Meningococcal Vaccine Booster every 5 years for those with increased risk: - complement component deficiencies -prolonged exposure (microbiologists,military, college dorm, hyperendemicor epidemic area) - exposed to meningitis during an outbreak

45 Meningitis Exposure Ciprofloxacin 500mg orally as a single dose Rifampin600mg orally twice daily for two days Ceftriaxone250mg as a single intra-muscular injection

46 Vaccines HCWs Total Doses Ordered Cost per dose Total Doses 2014 Cost per Dose Total Doses 2015 Cost per dose Adult Influenza Vaccine - Trivalent 31,500 $ ,000 $10.70 dns DNS Adult Influenza Vaccine - Quadravalent dns 29,000 $ ,000 $17.00 dtap (Boostrix) 20,000 Flumist - Trivalent 60 Flumist - Quadravalent $ ,000 $ (proj) $31.00 $ $21.65 dns dns dns 100 $22.50 FluBlock dbs dns dns 110 $33.50 Hepatitis B Vaccine Adult* 5,000 Varicella Vaccine 300 MMR II 700 $ ,300 $ (proj) $22.00 $ $ (proj) $99.70 $ $ (proj) $55.00 CDC