Immunization of HCP Ed Septimus, MD, FACP, FIDSA, FSHEA Medical Director Infection Prevention and Epidemiology Clinical Services Group, HCA Professor Internal Medicine Texas A&M Professor, Distinguished Senior Fellow, School of Public Health, George Mason University
Approximate Basic Reproduction Numbers (in developed countries) and implied crude herd immunity thresholds (H, Calculated as (1-1/R 0 ) for common vaccine-preventable diseases) Infection Basic Reproduction Number (R 0 ) Diphtheria 6-7 85 Influenza 1.4-4 70-85 Measles 12-18 92-94 Mumps 4-7 75-86 Pertussis 12-17 92-94 Polio 2-15 50-93 Rubella 6-7 83-85 Smallpox 5-7 80-85 Crude Herd Immunity Threshold, H (%) Tetanus Not applicable Not applicable Tuberculosis?? Varicella 8-10? Plotkin, Orenstein and Offitt, Vaccines, 5 th edition, page 1577
Poster and Flyer http://www.cdc.gov/vaccines/pubs/flyers-brochures.htm Slide: 40
Vaccine Healthcare Personnel Vaccination Recommendations Recommendations in Brief Hepatitis B Give 3-dose series (dose #1 now, #2 in 1 month, #3 approximately 5 months after #2). Give IM. Obtain anti-hbs serologic testing 1-2 months after dose #3 Influenza MMR Give 1 dose of TIV or LAIV annually. Give TIV IM or ID or LAIV intranasally. HCP born in 1957 or later without evidence of immunity or prior vaccination, give 2 doses MMR, 4 weeks apart. Give SC. If born before 1957, 1 dose. Two doses for all HCP during mumps outbreak. Varicella Tetanus/diphtheria/ acellular pertussis Meningococcal HCP with no serologic proof of immunity, prior vaccination, or history of varicella disease, give 2 doses of varicella vaccine, 4 weeks apart. Give SC. All HCP need Td every 10 years after completing a primary series. Give 1 dose of Tdap IM, if direct patient contact, prioritize HCP in contact with pts. <12 mos. Give 1 dose to microbiologists who are routinely exposed to isolates of N. meningitidis. CDC Advisory Committee on Immunization Practices http://www.immunize.org/catg.d/p2017.pdf Slide: 51
Estimated Incidence of HBV Infections among HCW and General Population, United States, 1985-1999 Healthcare Personnel General U.S. Population
The Inconvenient Truths Influenza is the leading cause of vaccine-preventable deaths in the US Influenza vaccines are safe and effective Influenza can be transmitted by both symptomatic and asymptomatic healthcare workers (HCWs) Hospitalized patients can have increased length of stay and severe life-threatening illnesses as a result of influenza transmission from HCWs Up to 25% of HCWs have evidence of influenza each season 50% of HCWs who have influenza infections are asymptomatic or have only minor symptoms Influenza vaccination of HCWs has demonstrated decreased HCW illness, absenteeism, and mortality Influenza vaccination rates among HCWs remains unacceptably low
80 U.S. Data on Influenza Vaccination of Healthcare Workers(% vaccinated) 70 60 50 40 30 Overall Hospital Ambulatory 20 10 0 2004 2005 2006 2007 2008 2009 2010 MMWR 2011; 60:1073
2010-2011* 98 58 MMWR 2010; 59:357 *MMWR 2011; 60:1073
SHEA Position Paper: Influenza Vaccination of Healthcare Personnel Chairman: Members: Thomas R. Talbot MD, MPH Hillary Babcock MD, MPH Deborah Cotton MD, MPH Lisa L. Maragakis MD, MPH Gregory A. Poland MD Ed Septimus, MD Michael L. Tapper MD David J. Weber MD, MPH For the safety of both patients and HCP, SHEA endorses a policy in which annual influenza vaccination is a condition of both initial and continued HCP employment and/or professional privileges ICHE 2010; 31:987
Multi-faceted mandatory patient safety program associated with increased seasonal influenza vaccination of health care workers in community hospitals Authors: Edward J. Septimus, MD, FACP, FIDSA, FSHEA Jonathan B. Perlin, MD, PhD, MSHA, FACP, FACMI Scott B. Cormier, NREMT-P, IMRA-T Julia A. Moody, MS, SM(ASCP) Jason D. Hickok, MBA, RN JAMA 2011; 305;999
Seasonal Influenza vaccination rate and reasons for declination, 2009-2011 For season starting in 2009 2010 2011 Influenza Vaccination Rate (total) 94.7% 90.7% 92.3% Influenza Vaccination Rate (clinical employees) 95.5% 91.9% 93.0% Number of employees (total) 161,601 176,594 176,919 Number of clinical employees 109,209 121,656 124,588 Number of Declinations (all) 8,478 16,270 13,520 Reasons for Declination (%): Allergy 706 823 1,014 Contraindicated 376 403 521 Fear 231 576 702 Pregnancy 76 101 101 Religion 164 351 463 Other/No Reason 6,925 14,016 10,719 APIC 2012
Healthcare Facility HAI Reporting to CMS via NHSN Current Requirements (8/1/2011) HAI Event Facility Type Start Date CLABSI Acute Care Hospitals Adult, Pediatric, and Neonatal ICUs January 2011 CAUTI Acute Care Hospitals Adult and Pediatric ICUs January 2012 SSI Acute Care Hospitals Colon and abdominal hysterectomy procedures January 2012 MRSA Bacteremia Acute Care Hospitals Facility-wide January 2013 C. difficile LabID Event Acute Care Hospitals Facility-wide January 2013 HCW Influenza Vaccination Acute Care Hospitals, OP Surgery, ASCs January 2013
From Nature 485:11, 2012
MMWR 2011;
June 2012
Pertussis MMWR 2012; 59:1
DTaP INTRODUCTION OF ACELLULAR PERTUSSIS (ap) VACCINES: TIMELINE 1997: Children between the ages of 2 months and 6 years Tdap 2005: Adolescents (11-12 years of age with catch-up between 13-18 years); adults 19-64 years old; HCPs 2008: Post-partum women and people who have close contact with infants 2010: Adults 65 years old and children 7-10 years old who are not fully vaccinated 2011: Pregnant women Musher MD and Keitel WA. Hospital Practice 30:65, 1995
Mean Interval Between Clinical Presentation and Receipt of Last Acellular Pertussis Vaccine Clin Infect Dis 2012; 54:1730
Percentage of PCR Tests That Were Positive for Pertussis from January 2006 through June 2011, According to Age and Time since Vaccination. Klein NP et al. N Engl J Med 2012;367:1012-1019
Friday PM Call You are the director of employee health. A manager calls you and asks for your advise. One of your employees called you that she was diagnosed with varicella yesterday by a dermatologist. She worked Tuesday, Wednesday and half a day on Thursday. She started feeling ill on Tuesday, but came to work anyway and woke up Thursday with skin lesions. What would you advise?
Varicella Disease Considerations: Varicella disease is highly communicable Birth before 1980 is only presumptive evidence of immunity and does not apply to healthcare personnel Can be severe in persons with altered immunocompetence
Criteria for immunity Varicella Written documentation of 2 doses of vaccine Lab evidence of immunity or lab confirmation of disease Diagnosis of varicella by a HCP or diagnosis of zoster Susceptible HCP exposed to VZV are potentially infective from days 8-21after exposure and should be furloughed. Vaccination within 3-5 days of exposure may modify disease if infection occurs Persons exposed at risk for severe disease for whom vaccination is contraindicated(e.g. pregnancy or immunocompromised) VariZIG should be considered
The recipe for perpetual ignorance is: be satisfied with your opinions and content with your knowledge. Elbert Hubbard