# Presentation: 640791

- Current Issues in Immunization NetConference** **

**Education, Information, and Partnership Branch of the**
**Immunization Services Division**
**National Center for Immunization and Respiratory Diseases**

## Judy V. Schmidt, Ed.D., MSN, MA, RN

**Public Health Educator**
**Immunization Services Division**
**Centers for Disease Control and Prevention**

- Today's  Presenter

## Healthcare PersonnelWhat Immunizations are Advised?

**NetConference – July 12, 2007**

**Notes:**
Thanks Rick, and I also welcome you to today’s discussion on Healthcare Personnel, What Immunizations are Advised?

## Why Increased Attention to Healthcare Personnel (HCP)?

**More reports of hospital-acquired infection**
**New findings regarding transmission and lack of immunity against some vaccine-preventable diseases**
**New vaccines; new recommendations**
**Low HCP vaccination rates for some recommended vaccines**

**Notes:**
The increased attention to healthcare personnel comes from reports of hospital-acquired infections and transmission of vaccine-preventable diseases involving non-immune healthcare personnel.  Recent outbreaks of pertussis and mumps and suspected transmission include healthcare personnel. With the recent availability of new vaccines and new schedule recommendations healthcare personnel can not only reduce their own disease risk, but they can reduce the risks to patients to whom they provide care.  One other reason for increased attention is because of the low vaccination rates for diseases such as influenza.

## Overview

**Review recent recommendations for HCP **
**Rationale**
**Issues and responsibilities**
**Summary of “old” recommendations**

**Notes:**
In addition to reviewing the recommendations and rationale, we will talk about healthcare personnel responsibilities and review the “old” recommendations for healthcare personnel.

## Which HCP are Affected by the Recommendations?

**In addition to healthcare personnel in hospitals and health departments, recommendations apply to HCP in private physicians’ offices, nursing homes, schools, laboratories, and first responders.**
**Any medical facility or health department that provides direct patient care is encouraged to formulate a comprehensive immunization policy for all healthcare personnel.**

**Notes:**
Immunizations are for more than hospital personnel.  Transmission of vaccine-preventable diseases by healthcare personnel has included those who work in outpatient health settings as well as long term care facilities.  In fact, any medical facility or health department providing direct patient care is encouraged to formulate an immunization policy for healthcare personnel.

## HCP Vaccination: More than Personal Health

**HCPs have direct patient contact and can transmit disease from patient to patient**
**HCPs contact infected material from patients**
**Transmission of disease throughout healthcare setting—patients, staff, visitors **
**HCPs immunity essential to infection prevention and control programs**

**Notes:**
We often hear our colleagues talk about deciding on immunizations based upon how healthy or susceptible to disease they believe they are. Studies have shown that HCPs often come to work even when not feeling well.  A mild or moderate illness for a working person may be transmitted to a patient who is less able to tolerate the same illness such as pertussis or influenza.
Transmission of disease can be from infected materials not handled properly, poor handwashing after handling the materials as well as from other patients or visitors.  
When the link of transmission is broken because healthcare personnel are immune, everyone benefits—the patient, the healthcare staff, and the community!  This makes an immunization program essential.

## http://www.cdc.gov/vaccines/pubs/flyers-brochures.htmPoster and Flyer

**Notes:**
There is a poster on the left and a flyer on the right that are posted on our cdc vaccines website.  We would especially encourage occupational health personnel and employers to post and distribute these reminders.

## Recommendations for Healthcare Personnel VaccinationWhat’s New?

**Hepatitis B - same**
**MMR –new mumps recommendation added**
**Varicella – no longer depends on clinical specialty **
**Td/Tdap  - new recommendation for Tdap **
**Influenza – old recommendation with new strategies and 2007 JCAHO criteria**

**Notes:**
Let’s look more closely at specific vaccines and the recommendations that pertain to healthcare settings.
Hepatitis B recommendations are unchanged, but there are changes in the other vaccines that may affect you and necessitate some action on your part.
The MMR recommendations now include mumps vaccine for personnel of all ages.
Varicella immunity is recommended for all  healthcare personnel
Tdap is a newer vaccine with recommendations for healthcare personnel, and
Influenza vaccine is an old recommendation with new JCAHO criteria.

## Hepatitis B Vaccine Recommendation

**Personnel performing tasks involving exposure to blood or blood-contaminated body fluids should be vaccinated**
**December 1991, Occupational Safety and Health Administration (OSHA) mandates availability of hepatitis B vaccine to all healthcare personnel with occupational exposure**

**Notes:**
Personnel who may have contact with blood or blood-contaminated body fluids should receive hepatitis B vaccine.  This OSHA Federal standard was instituted in 1991 and requires employers to offer hepatitis B vaccine free of charge to employees who are occupationally exposed to blood or other potentially infectious materials.

## Hepatitis B Vaccine Recommendation

**Occupational exposure is: “...reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.”**
**Postvaccination testing for anti-HBs response is indicated for HCP 1-2 months after series completion**

**Notes:**
An occupational exposure is defined as a “reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious materials that may result from the performance of an employee’s duties.”
If you are receiving your hepatitis B immunization series, keep in mind that postvaccination testing for antibodies to hepatitis B surface antigen is indicated for healthcare personnel within 1-2 months of completing the series.  

## Facts: 
 Risk of transmission from needlestick exposure   6%-30%
 17,000 infections in 1983
 400 infections in 1995
 5%-10% of acute infections lead to chronic    infection
	Protect HCP, their patients, and colleagues 	from becoming infected through  exposure to infection

** ****Risk of transmission from needlestick exposure****   6%-30%**
** ****17,000 infections in 1983**
** ****400 infections in 1995**
** ****5%-10% of acute infections lead to chronic****    infection**
**	****Protect HCP, their patients, and colleagues ****	****from becoming infected through****  exposure to infection**

**Rationale for Hepatitis B Vaccine**

**Notes:**
Hepatitis B disease and transmission has been reduced significantly since the OSHA requirements for this vaccine were implemented. Compare the 17,000 infections acquired in 1983 with the 400 infections 1995.
It’s obvious that protection for staff and patients has greatly improved, but it is not perfect.

## Common Questions about Hepatitis B Vaccine Series

**Notes:**
Even though employers have been required to offer hepatitis B vaccine to healthcare personnel for some time, we get frequent questions about the immunization process.
Let’s talk about some of the frequent questions.

##  What if a HCP tests non-immune 1-2 months after completing the hepatitis B vaccine series 

**Postvaccination Testing and ****Vaccine Nonresponder**

**Notes:**
What if a HCP tests non-immune 1-2 months after completing the hepatitis B vaccine series ?
One to two months is the appropriate time frame for serologic testing after completing the series. If the serology reports a nonimmune status, a complete second series is recommended followed by retesting in 1-2 months.

## 	Complete another 3-dose series and test again in 1-2 months
 30%-50% will respond after three 	  			 additional doses 

-  30%-50% will respond after three 	  			 additional doses

**Hepatitis B Vaccine Non-responder**

**Notes:**
If the results are non-immune, a complete second series is recommended followed by retesting in 1-2 months.
You can expect that 30-50% of revaccinated personnel will respond to the second series.  
A complete second series of three doses is recommended as only 15-25% will respond after one additional dose.

##  What if a HCP does not respond to 6 doses (2 complete series) of hepatitis B vaccine?

**Persistent Non-responder to Hepatitis B Vaccine**

**Notes:**
What if a healthcare person does not respond to 6 doses of hepatitis B vaccine?  There will be a few who still do not respond to a second series. 

##  What if a HCP does not respond to 6 doses (2 complete series) of hepatitis B vaccine?
  ACIP recommends no further vaccine.  
	Treat as a nonresponder (susceptible) following hepatitis B exposure.

*  **ACIP recommends no further vaccine.  *
*	**Treat as a nonresponder (susceptible) following hepatitis B exposure***.**

**Persistent Nonresponder to Hepatitis B Vaccine**

**Notes:**
If this is the case, ACIP recommends no further vaccine be given as it is unlikely they will convert with additional doses.
It is important to test for hepatitis B surface antigen in this situation to assess if these people are already infected.
If the surface antigen is negative and the antibody to surface antigen is also negative, these healthcare personnel should be considered a nonresponder and susceptible to hepatitis B and treated as such for any subsequent direct, known exposures.  
Usually a known, direct exposure indicates a need for immunoglobulin following the exposure protocol of the healthcare facility.

## 	If the hepatitis B vaccine series is interrupted do we restart the series or add extra doses?

**Interruption of Vaccine Series**

**Notes:**
If the hepatitis B vaccine series is interrupted do we restart the series or add extra doses? There are persons who start a series and do not complete the series on the recommended schedule.  This can present a dilemma unless you know that most vaccine doses do not have a maximum interval.

## 	 	If the vaccine series is interrupted do we       	restart the series or add extra doses?
No – just complete the remaining doses of the series

**No – ****just complete the remaining doses of the series**

**Interruption of Vaccine Series**

**Notes:**
So, the only action needed is to continue the series with the remaining doses needed.  You do not need to restart the series.
Even if the next dose is years late, just continue to complete the series.

## Measles and Rubella Vaccine Recommendation

**Persons who work in medical facilities should be immune to measles and rubella.**
**All medical institutions--inpatient and outpatient, public and private--should ensure that those who work in their facilities are immune to measles and rubella. **
**Likewise, HCP have a responsibility to avoid causing harm to patients by preventing transmission of these diseases.**

**Notes:**
Measles and rubella are our next topics.
The ACIP healthcare recommendations state that persons who work in medical facilities should be immune to measles and rubella
This recommendation includes both inpatient and outpatient facilities.  
Likewise, healthcare personnel have a responsibility to avoid causing harm to patients by preventing transmission of these diseases.

## Measles Vaccine Rationale

**Nosocomial measles transmission has been documented in the offices of private physicians, in emergency rooms, and on hospital wards**
**Risk of measles infection in medical personnel estimated to be 13-fold greater than in general population**
**13.9% of cases during 1992-1995 occurred in medical settings **
**Current risk exists - 2005 Indiana outbreak of 34 cases resulted from 1 imported case**

**Notes:**
Nosocomial infections are not limited to hospital facilities; they can occur in outpatient settings too.
Measles infection is highly contagious and risks to medical personnel are about 13-fold higher than the general population.  This is supported by studies during outbreaks when cases occurred in medical settings.  Remember that measles virus is transmitted 3-4 days BEFORE as well as after the rash appears. Consider how many measles cases could be transmitted by one medical person before they become obviously ill.

The 2005 Indiana outbreak of 34 measles cases resulted from one case imported from Europe.  

## HCP Immunity to Measles and Rubella

**	****If born in or after 1957, immunity is:**
**Physician-diagnosed measles [not rubella]; OR**
**Documentation of laboratory evidence of measles and rubella immunity (****equivocal result = nonimmune status****); OR **
**Two doses of MMR (or 1 rubella, 2 measles) given at least 28 days apart**
**	****If born before 1957 and unvaccinated, consider a dose of MMR vaccine if no history of measles disease or no laboratory evidence of immunity – ****5-9% tested as nonimmune**

**Notes:**
If you were born in or after 1957, you were probably required to meet one of the immunity criteria listed on the bullets of this slide.
Physician-diagnosed measles [not rubella]; OR
Documentation of laboratory evidence of measles and rubella immunity (equivocal result = nonimmune status); OR 
Two doses of MMR (or 1 rubella, 2 measles) given at least 28 days apart

If you were born BEFORE 1957 with a history of measles and unvaccinated, you were considered to have presumptive immunity to measles and rubella.  You should now consider having a dose of MMR for more than one reason.  The first reason for a dose of MMR is that 5-9% of those tested were non-immune.

## Newsweek: May 2006 Dubuque, Iowa

**Newsweek: May 2006 Dubuque, Iowa**

**1956 Philadelphia**

**Notes:**
Now, about mumps--
In May, 2006, there was an outbreak of mumps primarily in young adults with a few additional cases in middle-aged adults. These two pictures from 1956 and 2006 remind us that we have had periodic outbreaks of mumps for many years in this country.

## Findings of 2006 Mumps Outbreak 

**2,597 cases of mumps in 11 states and ****5,783 in 45 states by October**
**U.S. mumps vaccine efficacy data**
- 70%-80% after one dose
- 90%-95% after two doses
**Finland eliminated mumps through high and sustained coverage using 2 doses MMR vaccine**

**Notes:**
Usually there are 250-300 cases of mumps reported each year.  In 2006 the outbreak began in Iowa and spread to 11 states infecting more than 2,500 people by April and 5,783 by October 7, 2006. 
Historically, the ACIP recommendation for mumps vaccine was just one dose.  In 2006 ACIP changed the recommendation to two doses of mumps vaccine because of the improved efficacy of two doses, and because of the observed success of countries such as Finland.

## Mumps – United States, 1980- 2003

**2-dose measles schedule with MMR**

**Notes:**
We know of the improved efficacy because of the combination MMR vaccine and the two doses recommended for measles immunity.  When a 2-dose schedule of MMR was introduced in 1989, children began receiving two doses of mumps.  
This likely has played a part in the continuing decline of mumps and the absence of large mumps outbreaks in recent years.
However, the outbreak that occurred in 2006 was primarily in the age group that would have had only one dose of mumps vaccine.

## Rationale for Updated 2006 Mumps Vaccine Recommendation

**Infection-control failures resulting in nosocomial transmission have occurred during mumps outbreaks involving hospitals and long-term-care facilities **
**Exposures to mumps in healthcare settings add economic costs – e.g., furlough or reassignment of staff members, or closure of wards **
**Persons with only one dose of mumps-containing vaccine are more susceptible to mumps disease**

**Notes:**
During outbreaks there were nosocomial cases of mumps in hospitals and even long-term-care facilities.  If nonimmune medical personnel are exposed to mumps, costly and inconvenient action is taken as they are furloughed or reassigned.  It is known that hospital wards have been closed due to staff illness or risk of transmission of disease.
Two doses of mumps confers 90-95% immunity for vaccinated staff, significantly lowering the risk to patients and others.

## Mumps ImmunityDefinition

**History of physician-diagnosed mumps OR **
**Laboratory evidence of mumps immunity OR**
**Appropriate vaccine doses **

**Notes:**
Mumps immunity is also defined.  Notice that between each criterion is the word “or”  Only one criterion needs to be met.

## Mumps Vaccine Recommendations for HCP

**All persons who work in healthcare facilities should be immune to mumps**
**If born in or after 1957 and with no history or evidence of immunity - 2 doses of live mumps virus vaccine recommended**
**If 1 dose previously, should receive a second dose**
**If born **_**before**_** 1957 & no history or evidence of immunity – consider 1 dose**

**Notes:**
This is the new ACIP recommendation for healthcare personnel. All persons who work in healthcare facilities should be immune to mumps. You need one or two doses of mumps virus vaccine depending upon your birth year and disease history.  For many healthcare personnel born before 1957 or maybe even after 1957, this recommendation will lead to receiving a dose of MMR vaccine.

## ACIP Changes – May 2006Mumps Virus Vaccine

**Documentation of 2 doses of vaccine for school-age children, K-12, and adults at risk e.g., HCP, students at post-high school education facilities, international travelers**
**Outbreak settings – If 1-4 yrs of age or low- risk adult with 1 dose, consider 2****nd**** dose**
**HCP during outbreak, **_**strongly consider 2 doses**_** vaccine to unvaccinated workers born before 1957 without evidence of mumps immunity.**

**Notes:**
Notice that two doses of mumps vaccine are recommended for routine immunization.  Those who were immunized after 1989 are likely to have two documented doses of MMR.  During an outbreak of mumps disease, adults without disease history even if born before 1957 should receive two doses of vaccine.  Children 1-4 years of age also need another dose during an outbreak.

## Mumps Vaccine Strategies for HCP

**An effective MMR vaccination program prevents nosocomial transmission **
**New recommendations offer increased protection during an outbreak**
**Record review and vaccination of HCP during an outbreak may be impractical or inefficient**
**Consider record review and vaccination for 2****nd**** dose of mumps vaccine when completing other annual programs such as CPR or tuberculin testing**

**Notes:**
ACIP recommends each medical facility have a program for MMR vaccine for healthcare personnel.
This will help protect staff and patients during an outbreak.  It may be impractical to provide the second dose during an outbreak.  It is suggested that during annual requirements such as for CPR or TB testing, vaccine status and immune status should be assessed and needed vaccines be given.

## 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**

**Notes:**
Now, let’s review a few facts about varicella.  We know it is a highly communicable disease.  The presumptive immunity criterion of birth before 1980 does NOT include healthcare personnel.  
And we know that varicella can be severe in persons who are not immunocompetent.  This fact is significant when considering the potential risk of transmission by healthcare personnel. Varicella is one of the diseases in which the virus can be transmitted before symptoms appear.

## Risks of Hospital-Acquired Infection

- Varicella – transmitted in hospitals by patients, staff, and visitors.
- Varicella infection reported in 4 medical students; probable transmission during autopsy of infected patient

**Notes:**
There are reports of varicella transmission in hospitals even without direct exposure to infected persons, probably from airborne sources. The  virus can be transmitted for two days before illness occurs.  A rather unusual report of 4 medical students infected during an autopsy of an infected patient is described in Clinical Infectious Diseases, September 2006. Blood splatter transmission was suspected in this case.
_________________________________________
4 students infected by blood splashes when liver dissected.  No effort to immediately wash off blood or to question students about their varicella history.

Clinical Infectious Diseases 2006; 43:599–601
 2006 by the Infectious Diseases Society of America. All rights reserved.

## Varicella Immunity for HCPDefinition

**HCP should have:**
**Serologic proof of immunity, OR **
**Prior vaccination with **_**2**_** doses, OR **
**‘****Verified history of varicella disease”, OR**
**History of herpes zoster (shingles)**
**If not, give 2 doses of varicella vaccine,at least 4 weeks apart**

**Notes:**
Varicella immunity is defined for healthcare personnel.  Again, notice the word “or” appears and only one of the criterion need to be met to determine immunity.  A person who meets none of the criteria needs two doses of varicella vaccine given at least 28 days or 4 weeks apart.

## What is “Verified History of Varicella Disease?”

**Typical disease - can be diagnosed by any healthcare provider**
**School or occupational nurse, nurse practitioner, physician assistant, physician**
**Atypical and mild varicella cases - verified by physician or designee **_**with**_** one of these:**
**Epidemiologic link to typical case**
**Evidence of laboratory confirmation**
**If no disease documentation, consider person susceptible**
**Other diseases mimic mild atypical varicella**

**Notes:**
What is “verified history of varicella disease?”
The new varicella recommendations describe “verified history.”  Most of the varicella rashes today are atypical or mild types that must be laboratory verified or linked epidemiologically to a laboratory diagnosed case.  Remember that other rash illnesses can mimic varicella.

## ACIP Now Recommends Two Doses of Varicella Vaccine for All Ages

**Dose #1  at 12-15 months of age**
**Dose #2 at 4-6 years of age**
**If 12 months-12 years of age, separate two doses by 3 months**
**If older than 13 yrs, separate the two doses by at least 4-8 weeks**

**Notes:**
Persons of all ages now need two doses of varicella vaccine.  The difference is in the recommended interval for those older and younger than 13 years of age.  Those who are 12 months to 12 years of age should have the doses separated by 3 months while those older than 13 years need only 4-8 weeks between the two doses.

## Varicella Vaccine Rash Transmission

**Risk of transmission if vaccine rash develops, but risk is low**
**Consider precautions if rash develops**
**Avoid contact with susceptible persons who are at risk for severe disease**
**Avoid contact until all lesions crusted over or fade away or no new lesions for 24 hours**

**Notes:**
A small percentage of vacinees develop a vaccine rash following varicella vaccine.  Disease transmission from this rash is possible although no cases have been documented after vaccination of HCP. Therefore, if a medical staff member has a vaccine rash they should avoid contact with susceptible persons who have risk of severe disease until the lesions are resolved.

## Varicella Serology

**Prevaccination serologic screening to detect past disease is not necessary, but may be cost-effective**
**Postvaccination testing should not be done – assays not adequately sensitive**

**Notes:**
Prevaccination serology for varicella is not necessary, but some employers do serologies for cost-effective purposes.
Postvaccination serology should not be done as the assays for vaccine immunity are not adequately sensitive.

## Pertussis Paroxysmal Cough

**Notes:**
Pertussis also known as whooping cough has been diagnosed more frequently in recent years along with increased incidence of disease.
As a result, there are now several changes in the status of pertussis.  Let review them.

## Facts Related to Pertussis

**Adolescents and adults transmit pertussis to infants **
**Pertussis immunity wanes in 5-10 years, **_**both**_** vaccine and disease immunity**
**Historical underdiagnosis of adolescents and adults**
**Increased awareness of pertussis disease leads to earlier and better diagnosis**
**May have had incomplete immunization as a child**

**Notes:**
We now know that adolescents and adults often transmit pertussis to infants.  What has been learned is that immunity to pertussis wanes in 5 to 10 years whether the person was previously immune from natural disease or the vaccine.  
Pertussis has been under-diagnosed in adolescents and adults.  In the past, providers ruled out a nagging, prolonged cough in adults thinking that pertussis is only a childhood disease.  As awareness of the disease in adults and adolescents has occurred, diagnosis improves, and reported cases increase. 
Waning immunity is also attributed to the fact that some children are incompletely immunized for pertussis. In other words, they had fewer doses of pertussis containing vaccine. These facts account for some, but certainly not all of the increase in reported pertussis disease.

## Pertussis Outbreaks

**Pertussis outbreaks are regularly documented in schools and healthcare settings**
**Nosocomial spread of pertussis has been documented in various healthcare settings serving pediatric and adult patients**
**Pertussis among HCP and patients can result in substantial morbidity**
**Infants with nosocomial pertussis are at substantial risk**

**Notes:**
Outbreaks have occurred in schools and healthcare settings.  Several nosocomial outbreaks in hospitals and healthcare settings have been documented which lead to serious disease.  Infected infants are at serious risk as they are often too young to have received their immunization series for pertussis.

## Pertussis in Infants

**Smaller infants may be unable to “whoop” and will have apnea or respiratory distress symptoms**

**Notes:**
Infants may be too young or too ill to have the characteristic cough.  Diagnosis of a nosocomial pertussis infection could be misdiagnosed as generalized respiratory distress or apnea.

## Pertussis in Healthcare Settings

**Numerous studies and case reports document pertussis transmission among HCP in healthcare settings**
**1 infected infant – 17 HCP infected; ****307 contacts treated**
**1 infected HCP – 87 cases; 626 contacts**
**HCP, patients, visitors have been the “source case” of pertussis in healthcare settings**
**HCP immunity is essential for infection prevention and control efforts**

**Notes:**
There are examples of documented pertussis transmission in healthcare settings. These include the infection of 17 healthcare persons by one infected infant.  Prophylaxis treatment had to be given to 307 contacts.  In another situation, one healthcare provider was related to 87 cases and 626 contacts.  
Immunity to pertussis is now considered to be essential for healthcare personnel.

## Tdap Recommendation for HCP

**For HCP who provide direct patient care, ACIP recommends 1 dose of Tdap as soon as feasible; **
**Prioritize Tdap vaccine to HCP who care for patients younger than 12 months of age**

**Notes:**
Whether or not a healthcare person has a history of pertussis, ACIP recommends that those who provide direct patient care should get a Tdap vaccine as soon as feasible.  If you provide care to patients younger than 12 months of age, you are considered a high priority to receive the Tdap vaccine.  It does not matter when you received your last Td vaccine.

## Are the mother, grandmother, nurse, and babysitter immune to pertussis?

**Are the mother, grandmother, nurse, and babysitter immune to pertussis?**

**Notes:**
Because our awareness of pertussis disease has changed, when the infant is immunized we must ask if the mother, the healthcare provider, the babysitter, and close household contacts of the infant (including siblings) have been immunized in the last 5 years.
__________________________________

At one ACIP meeting when the pertussis vaccine recommendations were on the agenda, a mother came during the public comment session and related her story of having an annoying cough immediately after giving birth.  She unknowingly had pertussis and her infant became ill too.  She was fortunate that her infant survived after a long hospitalization including ventilation.  We heard other stories from persons who were not as fortunate.

## Slide 45

**Notes:**
Be sure you know the difference between these vials. The formulations are very different for pediatric patients. There is only one type of Tdap vaccine, Adacel by sanofi pasteur, that can be given to adults.

## Influenza Vaccine Recommendations for Healthcare Personnel

**Offer annual influenza vaccination to all HCP, including night and weekend staff **
**Prioritize vaccination to HCP who care for high-risk groups**
**Provide education to HCP about vaccine benefits and potential health consequences of influenza illness for patients, self, family**
**Provide convenient access to influenza vaccine at the work site, free of charge**

**Notes:**
Let’s review influenza vaccine for healthcare personnel. The ACIP recommendations for influenza vaccination of healthcare personnel are very specific and are closely aligned with recommendations from The American Medical Association and Influenza Summit.
The vaccine should be offered to all healthcare personnel every year with priority given to those who care for high-risk groups. We would be concerned about priority only when vaccine is in limited supply or delayed.
It is important that education about the vaccine, its benefits and potential consequences be reviewed.
Of course, access to the vaccine at the worksite is important.

## Risks of Influenza Outbreaks in Healthcare Settings

**Influenza transmission in healthcare settings is linked to unvaccinated HCP**
**Long-term-care facility death rates are affected by influenza infection and HCP vaccination rates**
**All healthcare personnel, employees in residences for persons at high risk of influenza, household contacts, home care- givers should be vaccinated annually**

**Notes:**
Influenza outbreaks in hospitals and long-term-care facilities have been associated with low vaccination rates among HCP. The reverse is also true, higher vaccination levels among staff have been associated with a lower incidence of nosocomial influenza cases. This was shown in a study that followed a large tertiary facility for 12 influenza seasons.  Staff vaccination rate progressed from 4% to 67% and the laboratory-confirmed cases of influenza dropped from 42% to 9% suggesting that staff vaccination contributed to the decline in nosocomial influenza cases.(1) 

Two studies have shown a decrease in the mortality rates in long-term-care facilities when healthcare personnel are also vaccinated.(2) All of these studies are referenced in the February 2006 MMWR on Influenza Vaccination of Healthcare Personnel.
All healthcare personnel should be vaccinated against influenza annually whether they are employed in inpatient or outpatient facilities. Employees in long-term-care and residences should be vaccinated as well.
_____________________________
Referenced in February 2006 MMWR Influenza Vaccination of Healthcare Personnel:
Salgado CD, Giannetta ET, Hayden FG, Farr BM. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004;25:923--8. 

Cunney RJ, Bialachowski A, Thornley D, Smaill FM, Pennie RA. An outbreak of influenza A in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2000;21:449--54. 

## Table of Priority Groups for Inactivated Influenza Vaccine

**Priority Group 1C**

**Notes:**
This priority table would be used only in years when there is a shortage or delay of vaccine production. I wanted to show it to you because of the higher priority given to healthcare personnel for influenza vaccine.  Note that healthcare personnel are in group 1—specifically group 1C.  

## HCP Transmission of Influenza

**Virus is shed one day before symptoms**
**Some HCP are asymptomatic but still transmit virus to others**
**Mild cases are still contagious**
**HCP tend to work when ill**
**3 of 5 HCP put themselves, their families, patients at risk of infection**

**Notes:**
This slide lists some facts about influenza transmission that all healthcare personnel should consider in protecting patients and preventing nosocomial transmission. The virus is shed one day before symptoms appear.  If an asymptomatic or mild infection occurs, the virus will still be transmitted to others.
It is a well known and documented fact that healthcare personnel often work when they are ill.
Using the 40% healthcare personnel vaccination rate, this means that 3 of 5 healthcare personnel will put themselves and others at risk of infection.
___________________
(Infect Control Hosp Epidemiol 2005;26:882-890).Nov2005
Another concern is the self-reported percentage of HCWs who work while ill with an influenza-like illness, reaching 76.6% in one study.53 In another study, 36.7% of housestaff self-reported the development of an influenza like illness during the influenza season and worked a mean of 2.5 days while ill.55 HCWs, as with other healthy adults, may have minimal or no symptoms during their influenza infection but still shed the virus, thus potentially exposing their patients and colleagues.

SHEA Position Paper  Influenza Vaccination of Healthcare Workers and Vaccine Allocation for Healthcare Workers During Vaccine Shortages
Thomas R. Talbot, MD, MPH; Suzanne F. Bradley, MD; Sara E. Cosgrove, MD, MS; Christian Ruef, MD;
Jane D. Siegel, MD; David J. Weber, MD, MPH

## HCP Transmission of Influenza

**23% HCP had serologic evidence of influenza infection after a mild influenza season; **
**59% could not recall having influenza, **
**28% could not recall any respiratory infection, suggesting a high proportion of asymptomatic illness **
**Mortality rates were 42% lower among nursing home residents where staff had higher vaccination coverage**

**Notes:**
One study reported that 23% of healthcare personnel had serologic evidence of influenza even during a mild influenza season.(1)
When interviewed, 59% did not recall having influenza and 28% did not remember any respiratory infection.
One study reported that when a nursing home immunized staff who provide patient care, their mortality rates were 42% lower. (2)  These studies from JAMA and Infection Control in Hospital Epidemiology are also referenced in the February 2006 MMWR Influenza Vaccination of Healthcare Personnel

________________
Referenced in MMWR February 2006 Influenza Vaccination of Healthcare Personnel:
Wilde JA, McMillan JA, Serwint J, Butta J, O'Riordan MA, Steinhoff MC. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA 1999;281:908--13. 

Salgado CD, Giannetta ET, Hayden FG, Farr BM. Preventing nosocomial influenza by improving the vaccine acceptance rate of clinicians. Infect Control Hosp Epidemiol 2004;25:923--8. Cunney RJ, Bialachowski A, Thornley D, Smaill FM, Pennie RA. An outbreak of influenza A in a neonatal intensive care unit. Infect Control Hosp Epidemiol 2000;21:449--54. 

## ...unvaccinated health care workers can be the index case for influenza in a facility, potentially posing a threat to high-risk patients and other workers.

**...unvaccinated health care workers can be the index case for influenza in a facility, potentially posing a threat to high-risk patients and other workers.**
**                                                                                ****May 2004,32(3)**

**Notes:**
As this article states: Healthcare personnel can be an index case for influenza and pose a threat to others.

## Slide 52

**Notes:**
As of January 2007, the Joint Commission on Accreditation of Healthcare Organizations issued a standard for accredited organizations in providing influenza vaccine to their staff, volunteers, and licensed independent practitioners who have patient contact.

## JCAHO Standard Requirements

**Establish an annual influenza vaccination program**** that includes at least staff and licensed independent practitioners**
**Provide access to influenza vaccinations on-site**
**Educate**** staff and licensed independent practitioners about flu vaccination; nonvaccine control measures (precautions); and diagnosis, treatment, and potential impact of influenza**
**Annually evaluate vaccination rates and reasons for non-participation**** in the organization’s immunization program**
**Implement enhancements to the program to increase participation**

**Notes:**
Here are the primary criteria in the JCAHO standards. They include establishing an annual influenza vaccination program, providing access to vaccines on-site, educating healthcare personnel about the vaccine, control measures, and influenza disease.  Every year the facility must evaluate their vaccine coverage and reasons for nonparticipation.  One way facilities meet this criteria is by requesting “a declination form” that contains the required educational information and verifies refusal of the vaccine.  Finally, JCAHO requires action to enhance the influenza vaccination program.

## Influenza Vaccine for HCP

-  Inactivated influenza vaccine contains only noninfectious fragments of influenza virus. It is given intramuscularly.
-  Nasal spray is a live, attenuated vaccine and does not replicate systemically.
-  Healthcare personnel _can_ receive LAIV
-  Influenza vaccines cannot cause influenza disease.
-  It takes about 2 weeks for the vaccine to become fully effective

**Notes:**
Inactivated flu vaccine is made of noninfectious fragments of the influenza virus. The nasal spray is a live, attenuated vaccine known as LAIV and does not replicate in the body.  It can be given to persons who are healthy and younger than 50 years of age. It is important to remember that you cannot get the flu from either vaccine. Finally, remember that it takes about two weeks for the influenza vaccines to become fully effective.
So, considering that there is only a 1-2 day incubation period for transmission of the influenza virus, you could conceivably be exposed to the virus close to the time of receiving the vaccine before it has an opportunity to produce immunity. Consider this the next time someone says that they “got the flu” after they had the vaccine.

## Live Attenuated Influenza Vaccine

**Healthy persons younger than 50 years of age can receive LAIV**
**Eligible HCP should use LAIV**
**Noneligible HCP can administer LAIV (e.g., those who are diabetic, asthmatic, pregnant)**

**Notes:**
LAIV is a relatively new vaccine given by nasal spray.  If you are healthy and younger than 50 years of age you can receive the vaccine; in fact, you should receive the vaccine especially if the supply of injectable vaccine is limited or delayed.
One question that comes up frequently is who can administer the vaccine.  You may not be eligible to receive the vaccine, but you can administer the vaccine even if you are diabetic, asthmatic, or pregnant.

## Influenza Vaccination of Health Care Workers

**Excuse:**
**“****Influenza vaccine always gives**
**  ****me the flu...”**

**Notes:**
Let’s review a myth of influenza vaccine that becomes an excuse. “Influenza vaccine always gives me the flu..”

## Influenza Vaccine Adverse Reactions

**Local reactions-TIV****	****15%-20%**
**Fever, malaise****	****	****uncommon**
**Allergic reactions****	****	****rare**
**Neurological****	****	****	****very rare**** reactions**
**Inactivated (TIV) ****	****	****NEVER causes flu**
**LAIV****	****	****	****	****Won’t cause flu**** ****	****	****	****	****	****	****	****	****	**

**Notes:**
The adverse reactions of influenza are few, if any.  Help us dispel these myths as you talk with your colleagues.

## Influenza Vaccination of HCWs

**Excuse:**
**“****Influenza vaccine doesn’t work...”**

**Notes:**
Here’s another excuse.  We know that the efficacy of the vaccine is 70% to 90% among persons younger than 65 years of age.
Also, other illnesses that are not actually influenza are often referred to as influenza. There are other benefits of influenza vaccine.

## Influenza Vaccine Benefits Healthcare Personnel

**28% fewer lost work days due to respiratory infections **
**28% fewer days HCP felt unable to work**
**Lower incidence of influenza, 1.7%; compared to controls 13.4%**
**Fewer respiratory illnesses than controls; 28.7 vs. 40.6 per 100 persons **
**Fewer days of lost work than control groups; 9.9 vs. 21.1 per 100 persons **

**Notes:**
Studies have documented the benefits of the vaccine for healthcare personnel.  Not only does vaccination reduce transmission of influenza in health-care settings but also staff illness and absenteeism and influenza-related morbidity and mortality are lower in those at severe risk of disease.  The study reported in JAMA is also referenced in the 2006 MMWR.

_______________
Referenced in February 2006 MMWR 

(1) Wilde JA, McMillan JA, Serwint J, Butta J, O'Riordan MA, Steinhoff MC. Effectiveness of influenza vaccine in health care professionals: a randomized trial. JAMA 1999;281:908--13. 

## Pandemic Strain Emergence: Reassortment of Influenza A Viruses

**Avian **
**Reservoir**

**Avian **
**virus**

**Human**
** ****virus**

**Pandemic Strain Emergence: Reassortment ****of Influenza A Viruses**

**Notes:**
This slide is to remind you that conceivably you could acquire the seasonal influenza virus and other virus such as avian influenza.  
*We used to think of other mammals as the source of a new virus, *but a healthcare person could actually serve as the mixing vessel for a *new reassorted virus that is easily transmitted to others.  A new virus for which there is no immunity could be disastrous!

## Healthcare Personnel Vaccination Recommendations

| Vaccine | 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 | Give 1 dose of TIV or LAIV annually.  Give TIV intramuscularly or LAIV intranasally. |
| MMR | 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 | 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. |
| Tetanus/diph-theria/ acellular pertussis | 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.   |
| Meningococcal | Give 1 dose to microbiologists who are routinely exposed to isolates of N. meningitidis. |

**http://www.immunize.org/catg.d/p2017.pdf**

**Notes:**
In case you want an easy-to-use, current reference on vaccines for healthcare personnel, there is one available online. Note the website at the bottom of the slide.  At the actual website you will also find footnotes that accompany this table.

## Immunization Contact Information National Center for Immunization and Respiratory Diseases - NCIRD

**Hotline****	****	****800.CDC.INFO**
- 			800-232-4636
**Email****	****	****	**_**nipinfo**__**[@cdc.gov](mailto:vaccines@cdc.gov)**_
**Website****	****	**_**www.cdc.gov/vaccines**__** **_

**Notes:**
If you have questions, please contact us or visit our website.

## FINISH

**FINISH**

**Notes:**
That’s all I have for now, and I’ll turn the conference back to Rick.