Immunization Update 2012 Richard M. Lampe M.D.
Immunization Update List the Vaccines recommended for Health Care Personnel Explain why Health Care Personnel are at risk Recognize the importance of these 6 vaccinations to Recognize the importance of these 6 vaccinations to protect Health Care Personnel and patients in health care settings.
HealthCare Personnel Vaccination Recommendations MMWR 2011 Hepatitis B Influenza MMR Varicella (chickenpox) Tetanus, diphtheria, pertussis Meningococcal
Influenza Background Respiratory virus spread person to person, coughing, sneezing, and respiratory droplet contamination of surfaces. Highly contagious, patients may become infectious 24 hours before the onset of symptoms, cough, fever, body aches. Viral shedding peaks in first 3 days up to 7 days in normal patients Immunity afterward; therefore vaccines Yearly epidemics, shifts and drifts, Influenza A, B, Hemagglutinin H, Neuraminidase N (H1 N1), (H3 N2) necessitate yearly vaccines
Not Just a Bad Cold! 6
How Many Health Care Workers Got Vaccinated Last Season? During the 2010-2011 influenza season, coverage for influenza vaccination among health care workers was estimated at 63.5%. Coverage was 98.1% among health care workers who had an employer requirement for vaccination. In the absence of requirements, increased vaccination coverage was associated with employers offering vaccination onsite, free of charge, for multiple days. During the 2009-2010 influenza season, an estimated 61.9% of health care workers received seasonal influenza vaccine.
Influenza vaccine Why? Health care workers who get vaccinated help to reduce the following: transmission of influenza staff illness and absenteeism influenza-related illness and death, especially among people at increased risk for severe influenza illness Higher vaccination levels among staff have been associated with a lower risk of nosocomial (hospital-acquired) influenza cases. Influenza outbreaks in hospitals and long-term care facilities have been attributed to low influenza vaccination coverage among health care workers in those facilities. Higher influenza vaccination levels among health care workers can reduce influenza-related illness, and even deaths, in settings like nursing homes.
Flu Vaccine Facts The 2011-12 flu vaccine provides protection against the three main viruses that research indicates will cause the most illness this season. The 2011-12 flu vaccine will protect against an influenza A (H3N2) virus, an influenza B virus, and the 2009 H1N1 virus that caused so much illness during the 2009-10 influenza season. Flu vaccines CANNOT cause the flu. The viruses in flu vaccines are either killed (the flu shot) or weakened (the nasal-spray vaccine). Flu vaccines are safe. Serious problems from the flu vaccine are very rare. The most common side effect that a person is likely to experience is soreness where the injection was given. This is generally mild and usually goes away after a day or two.
There are two types of flu vaccines The first flu shot an inactivated vaccine (killed virus) that is given IM, usually in the arm. This flu vaccine is approved for use in people older than 6 months, including healthy people and people with chronic medical conditions. There are three different flu vaccines available: a regular flu shot approved for people ages 6 months and older a high-dose flu shot approved for people 65 and older, and an intradermal flu shot approved for people 18 to 64 years of age.
There are two types of flu vaccines: The second vaccine is made with live, weakened flu viruses that is given as a nasal spray (sometimes called LAIV for Live Attenuated Influenza Vaccine ) the nasal-spray flu vaccine. The viruses in the nasal spray vaccine do not cause the flu. LAIV is approved for use in healthy* people 2 through 49 years of age who are not pregnant. Nearly all healthy, non-pregnant health care workers, may receive LAIV if eligible, including those who come in contact with newborn infants (e.g., persons working in the neonatal intensive care unit, or NICU), pregnant women, persons with a solid organ transplant, persons receiving chemotherapy, and persons with HIV/AIDS. However, health care providers should not get LAIV if they are providing medical care for patients who require special environments in the hospital because they are profoundly immunocompromised, for example if they work in bone marrow transplant units. Theoretical risk.
Influenza Vaccine On February 23, 2012 the World Health Organization (WHO) recommended that the Northern Hemisphere's 2012-2013 seasonal influenza vaccine contain the following three vaccine viruses: A/California/7/2009 (H1N1)pdm09-like virus; A/Victoria/361/2011 (H3N2)-like virus; B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses). While the H1N1 virus is the same, the H3N2 and B vaccine viruses are different from those that were selected for the Northern Hemisphere for the 2011-2012 influenza vaccine.
Influenza take home message All HCP, not just those with direct patient care duties, should receive an annual influenza vaccination. Comprehensive programs to increase vaccine coverage among HCP are needed Influenza vaccination rates among HCP within facilities should be measured and reported regularly.
HEPATITIS B Hepatitis B virus Cirrhosis and hepatocellular cancer from chronic Hepatitis B
Hepatitis B background HBV transmitted by blood or body fluids (semen, saliva, wound exudates) to skin with breaks (percutaneous) or mucosa. Environmentally stable, infectious, on surfaces for 7 days. Estimated 10,000 infections in HCP in 1982 reduced to 304 in 2004 due to pre exposure vaccination and infection-control precautions
How is HBV transmitted? HBV is transmitted through activities that involve percutaneous (i.e., puncture through the skin) or mucosal contact with infectious blood or body fluids (e.g., semen, saliva), including Sex with an infected partner Injection drug use that involves sharing needles, syringes, or drugpreparation equipment Birth to an infected mother Contact with blood or open sores of an infected person Needle sticks or sharp instrument exposures Sharing items such as razors or toothbrushes with an infected person HBV is not spread through food or water, sharing eating utensils, breastfeeding, hugging, kissing, hand holding, coughing, or sneezing.
Has the rate of new HBV infections in the United States declined? The rate of new HBV infections has declined by approximately 82% since 1991, when a national strategy to eliminate HBV infection was implemented in the United States. The decline has been greatest among children born since 1991, when routine vaccination of children was first recommended.
How serious is acute HBV infection? Acute infection ranges from asymptomatic or mild disease to rarely fulminant hepatitis. Disease is more severe among adults aged >60 years. The fatality rate among acute cases reported to CDC is 0.5% 1%.
How likely is HBV infection to become chronic? The risk for chronic infection varies according to the age at infection and is greatest among young children. Approximately 90% of infants and 25% 50% of children aged 1 5 years will remain chronically infected with HBV. By contrast, approximately 95% of adults recover completely from HBV infection and do not become chronically infected.
How serious is chronic HBV infection? Approximately 25% of those who become chronically infected during childhood and 15% of those who become chronically infected after childhood die prematurely from cirrhosis or liver cancer, and the majority remain asymptomatic until onset of cirrhosis or end-stage liver disease. In the United States, chronic HBV infection results in an estimated 2,000 4,000 deaths per year.
Hepatitis B Vaccine Health-care personnel and public-safety workers who are exposed to blood or other potentially infectious body fluids Three dose series 0,1, 6 months, may repeat if non-responder, tested 1-2 months following. Don t test previously vaccinated HCP. HCP born in Asia, Africa or pacific islands or regions with >2% Hbsag prevalence
Hepatitis B take home message HCP and trainees in certain populations at high risk for chronic hepatitis B (e.g., those born in countries with high and intermediate endemicity) should be tested for HBsAg and anti-hbc/anti-hbs to determine infection status.
MEASLES, MUMPS, RUBELLA Measles Mumps Rubella Congenital Rubella Syndrome Congenital cataracts from congenital rubella
Measles Mumps and Rubella Respiratory virus droplet exposure Eliminated in US in 2000 (2 dose vaccine and measles control) 2001-2008, 557 cases due to importation; 126 hospitalized. ER, Hospital or health care facility $800,000 2 Arizona hospitals in 2008, reviewing measles documentation, providing 4,500 emergency vaccinations and checking serology of 1,583 who were not vaccinated and who had no documentation of immunity.
Measles Patients with measles are infectious 4 days before rash and for 4 days after the rash All persons who work in health-care facilities should have presumptive evidence of immunity to measles. This information should be documented and readily available at the work location. Recently vaccinated HCP do not require any restriction in their work activities.
Measles Vaccine Safe and effective as live attenuated vaccine MMR 2 dose series
Measles Presumptive evidence of immunity to measles for persons who work in health-care facilities includes any of the following Written documentation of vaccination with 2 doses of live measles or MMR vaccine administered at least 28 days apart Laboratory evidence of immunity or confirmation of disease (Igg) Birth before 1957.
Measles vaccination The majority of persons born before 1957 are likely to have been infected naturally and may be presumed immune, depending on current state or local requirements. For unvaccinated personnel born before 1957 who lack laboratory evidence of measles immunity or laboratory confirmation of disease, health-care facilities should consider vaccinating personnel with 2 doses of MMR vaccine at the appropriate interval.
Measles Mumps and Rubella Respiratory virus spread by droplet HealthCare associated transmission of Mumps infrequent 2006 Kansas Hospital $98,000 controlling outbreak 2006 Chicago Hospital $262,000 cost of evaluation of outbreak.
Mumps Vaccination Vaccine live attenuated virus as part of MMR All persons who work in health-care facilities should have presumptive evidence of immunity to mumps. This information should be documented and readily available at the work location. Recently vaccinated HCP do not require any restriction in their work activities
Mumps Vaccination Presumptive evidence of immunity to mumps for persons who work in health-care facilities includes any of the following: written documentation of vaccination with 2 doses of live mumps or MMR vaccine administered at least 28 days apart Laboratory evidence of immunity or confirmation of disease Birth before 1957.
Mumps vaccination The majority of persons born before 1957 are likely to have been infected naturally between birth and 1977, the year that mumps vaccination was recommended for routine use, and may be presumed immune, even if they have not had clinically recognizable mumps disease. (This might vary depending on current state or local requirements.) For unvaccinated personnel born before 1957 who lack laboratory evidence of mumps immunity or laboratory confirmation of disease, health-care facilities should consider vaccinating personnel with 2 doses of MMR vaccine at the appropriate interval
Measles Mumps and Rubella Rubella (German Measles) respiratory virus acquired by direct tor droplet exposure from nasopharyngeal secretions. Clinical diagnosis unreliable Immunity= Rubella IgG Contagious a few days before rash, maximum during rash and up to 7 days thereafter. Rubella outbreak in 1964-1965 12.5 million cases of rubella
Rubella 20,000 cases of congenital rubella syndrome Vaccine 1969 children 1977 post pubertal girls 1989 2 dose MMR in response to measles outbreaks US Rubella free since 2004 Only 4 CRS case since 2005 ; 3 imported
Rubella Vaccination All persons who work in health-care facilities should have presumptive evidence of immunity to rubella. Adequate rubella vaccination for HCP consists of 1 dose of MMR vaccine. However, because of the 2- dose vaccination requirements for measles and mumps, the use of the combined MMR vaccine will result in the majority of HCP receiving 2 doses of rubella-containing vaccine, which should provide an additional safeguard against primary rubella vaccine failure. Recently vaccinated HCP do not require any restriction in their work activities.
Rubella Vaccination Presumptive evidence of immunity to rubella for persons who work in health-care facilities includes any of the following: Written documentation of vaccination with 1 dose of live rubella or MMR vaccine, Laboratory evidence of immunity, or rubella infection or disease rubella IgG Birth before 1957 (except women of childbearing potential who could become pregnant, although pregnancy in this age group would be exceedingly rare).
MMR take home message History of disease is no longer considered adequate presumptive evidence of measles or mumps immunity for HCP Laboratory confirmation of disease was added as acceptable presumptive evidence of immunity. History of disease has never been considered adequate evidence of immunity for rubella. Recommendations for personnel born before 1957 in routine and outbreak contexts. Specifically, guidance is provided for 2 doses of MMR for measles and mumps protection and 1 dose of MMR for rubella protection.
VARICELLA Varicella in a school aged child Varicella with oral lesions Fatal hemorrhagic Varicella
Varicella Virus, highly infectious, person to person contact; inhalation aerosols from vesicular fluid Patients contagious 1-2 days before rash and 4-7 days after rash onset Vaccine (1995) has changed epidemiology Breakthrough varicella, milder, <50 lesions, less fever, still infectious Costly $ to evaluate VZV exposures Diagnosis of varicella still clinical but lab confirmation likely in future due to less experienced observers
Varicella Vaccination Health-care institutions should ensure that all HCP have evidence of immunity to varicella. Evidence of immunity for HCP includes any of the following written documentation of vaccination with 2 doses of varicella vaccine, laboratory evidence of immunity or confirmation of disease diagnosis or verification of a history of varicella or zoster by a health-care provider
Varicella Vaccine Efficacy proven in children 1 shot 80-85% reduction all disease and 95% moderate and severe disease. 2 shots even better Specific Cell mediated immunity protection to Specific Cell mediated immunity protection to vaccinated adults even without antibody
Varicella take home message Criteria for evidence of immunity to varicella were established. For HCP they include written documentation with 2 doses of vaccine, laboratory evidence of immunity or confirmation of disease, Diagnosis of history of varicella or herpes zoster by health-care provider
Pertussis Highly contagious bacteria Bordatella pertussis Secondary attack rate to household contacts 80% Communicable in catarrhal stage (URI) till paroxysmal stage Immunity wanes 5-10 years, very young susceptible Need for Tdap ; immunization rates Adol 68.7% 2010 Adult <7% 2009 HCP 17% 2009
Hospital transmission Visitors to patients HCP to patients Patients to HCP Pertussis $ Diagnostic testing, antibiotics, exclusion from work Cost benefit of Tdap program for every $1.00 invested $2.38 saved
Pertussis vaccine Vaccine killed components of acellular Pertussis toxins Efficacy 92% Post licensure efficacy 66-78% Safe, duration One dose for now, future? Antibiotic still for post exposure prophylaxis with prior Tdap; 2%with ABX 10% without HCP not at greater risk for diphtheria or tetanus Serologic testing not recommended serologic correlates of protection not well established
Pertussis take home message HCP, regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap. The minimal interval was removed, and Tdap can now be administered regardless of interval since the last tetanus or diphtheria-containing vaccine. Hospitals and ambulatory-care facilities should provide Tdap for HCP and use approaches that maximize vaccination rates.
Meningococcal Disease Meningococcal disease is rare among adults in the United States and incidence has decreased to historic lows Routine vaccination with meningococcal Routine vaccination with meningococcal conjugate vaccine is recommended by ACIP for adolescents aged 11--18 years, with the primary dose at age 11--12 years and the booster dose at age 16 years. In 2010, coverage with meningococcal conjugate vaccine among persons aged 13--17 years was 62.7%
Meningococcal Disease Nosocomial transmission of Neisseria meningitidis is rare, but HCP have become infected after direct contact with respiratory secretions of infected persons (e.g., managing of an airway during resuscitation) and in a laboratory setting. HCP can decrease the risk for infection by adhering to precautions to prevent exposure to respiratory droplets and by taking antimicrobial chemoprophylaxis if exposed directly to respiratory secretions.
Vaccine Effectiveness, Immunity, and Safety Two quadrivalent (A, C, W-135, Y) conjugate meningococcal vaccines (MCV4) are licensed for persons aged through 55 years). Both protect against 75% of disease among adults in the United States. The majority of persons do not have enough circulating functional antibody to be protected 5 years after a single dose of MCV4. Both vaccines had similar safety profiles in clinical trials. Quadrivalent (A, C, W-135, Y) meningococcal polysaccharide vaccine (MPSV4) is available for use in persons aged >55 years. No vaccine for group B meningococcal disease in the US
Meningococcal take home message MCV4 is not recommended routinely for all HCP HCP with anatomic or functional asplenia or persistent complement component deficiencies should now receive a 2-dose series of meningococcal conjugate vaccine. HCP with HIV infection who are vaccinated should also receive a 2 dose series. Those HCP who remain in groups at high risk are recommended to be revaccinated every 5 years.
Summary Hepatitis B HCP and trainees in certain populations at high risk for chronic hepatitis B (e.g., those born in countries with high and intermediate endemicity) should be tested for HBsAg and anti-hbc/anti-hbs to determine infection status. Influenza Emphasis that all HCP, not just those with direct patient care duties, should receive an annual influenza vaccination Comprehensive programs to increase vaccine coverage among HCP are needed; influenza vaccination rates among HCP within facilities should be measured and reported regularly. Measles, mumps, and rubella (MMR) History of disease is no longer considered adequate presumptive evidence of measles or mumps immunity for HCP; laboratory confirmation of disease was added as acceptable presumptive evidence of immunity. History of disease has never been considered adequate evidence of immunity for rubella. The footnotes have been changed regarding the recommendations for personnel born before 1957 in routine and outbreak contexts. Specifically, guidance is provided for 2 doses of MMR for measles and mumps protection and 1 dose of MMR for rubella protection.
Summary Pertussis HCP, regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap. The minimal interval was removed, and Tdap can now be administered regardless of interval since the last tetanus or diphtheria-containing vaccine. Hospitals and ambulatory-care facilities should provide Tdap for HCP and use approaches that maximize vaccination rates. Varicella Criteria for evidence of immunity to varicella were established. For HCP they include written documentation with 2 doses of vaccine, laboratory evidence of immunity or laboratory confirmation of disease, diagnosis of history of varicella disease by health-care provider, or diagnosis of history of herpes zoster by health-care provider.
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