VACCINES FOR HEALTHCARE WORKERS

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VACCINES FORHEALTHCARE WORKERS

• David Jay Weber, M.D., M.P.H.
• Professor of Medicine, Pediatrics, Epidemiology
• Associate Chief of Staff
• University of North Carolina at Chapel Hill

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VACCINE SUCCESS STORIES
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10 GREAT PUBLIC HEALTH ACHIEVEMENTS, US, 1900-1999

• Immunization
• Motor vehicle safety
• Safer workplaces
• Control of infectious diseases
• Decline in deaths from coronary artery disease
  and stroke
• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
• Recognition of tobacco use as a health hazard

CDC. MMWR 199948241-243
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VACCINE PREVENTABLE DISEASES
14 indigenous, 26 imported
MMWR 200857903-913
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INACTIVATED POLIO VACCINE(SALK) PROGRAM, 1955
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IMPACT OF DISCONTINUING A VACCINE PROGRAM
DIPHTHERIA IN THE RUSSIAN FEDERATION
Markina SS, et al. J Infect Dis 2000181(suppl
1)S27-34
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MAJOR INFECTIOUS RISKS FOR HEALTHCARE WORKERS

• Airborne or droplet transmitted diseases
• Varicella, pertussis, meningococcal infection,
  influenza, mumps, measles, others (e.g., RSV)
• Bloodborne pathogens
• Via percutaneous or mucosal exposure (gt30
  documented)
• Major risks HBV, HCV, HIV
• Contact transmitted diseases (direct, indirect)
• C. difficile, MRSA, herpes simplex, syphilis,
  adenovirus (keratoconjunctivitis)

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WHY IMMUNIZATION OF HEALTHCARE WORKERS IS SO
IMPORTANT!!!

• Infection introduced or propagated by infected
  HCWs leading to large outbreaks
• Mumps, measles, rubella, varicella, pertussis,
  influenza
• Asymptomatic or minimally symptomatic patients
  may transmit infection
• Influenza, chronic hepatitis B (gt25 outbreaks of
  HCW-to-patient transmission documented)
• Patients in prodromal phase of illness may
  transmit infection
• Measles, varicella

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WHY IMMUNIZATION OF HEALTHCARE WORKERS IS SO
IMPORTANT!!!

• HCWs may acquire infection entering room after
  the infectious patient has left
• Measles (up to 75 minutes)
• Aerosolization of infective fluids may lead to
  infection
• Meningococcus (spinning CSF in laboratory)
• Airborne infections may result from autopsies
  (source cadaver)
• Varicella (Paul N, Jacob ME. Clin Infect Dis
  200643599-601)

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UNC OHS EVALUATIONS, 2006-07
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PROTECTING HCWs

• Immunizations Pre- and post-exposure
• Hand hygiene Before and after direct patient
  contact
• Personal protective equipment Gloves, masks/N95
  respirators, gowns
• Patient isolation precautions
• Contact via direct or indirect contact gloves,
  gowns
• Droplet via large droplets (lt3 feet) mask,
  private room
• Airborne via small droplets (gt3 feet) N95
  respirator (TB) or surgical mask, private room,
  negative air pressure, gt12 air exchanges per
  hour, direct out exhausted air

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RECOMMENDED VACCINES FOR HCWs CDC, ACIP, HICPAC

• Measles (MMR preferred)
• Mumps (MMR preferred)
• Rubella (MMR preferred)
• Varicella (V)
• Hepatitis B (OHSA required)
• Influenza
• Tetanus (Tdap)
• Diphtheria (Tdap)
• Pertussis (Tdap)
• Required at UNC

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ASSURING HCW COVERAGE

• Healthcare facility employees - requirement for
  employment
• Medical staff - include in credentialing process
• Students - require for attending class
• Volunteers - require
• Contract workers - require in contract
• Emergency responders - require

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SPECIAL USE VACCINES IN HCWs

• Anthrax Post-exposure
• BCG Pre-exposure (high risk)
• Hepatitis A Post-exposure, outbreak, research,
  travel
• Japanese encephalitis Research, travel
• Meningococcal Outbreak, laboratory (spinning
  CSF), travel
• Polio Research, travel
• Rabies Post-exposure, research, travel
• Typhoid Research, travel
• Vaccinia Pre-exposure?, post-exposure, research
• Yellow fever Research, travel

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PROVIDING VACCINES

• Employee name and identification number
• Vaccine
• Dose, Site, Route of Administration
• Date given
• Manufacturer, Lot number
• Name, title, address of person providing vaccine
• Date next dose due
• Signed informed consent

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PROVIDING VACCINES SEROLOGIC TESTING

• Pre-immunization testing for immunity
• Do not obtain serological screening for immunity
  unless cost-effective or vaccine contraindicated
  (e.g., MMR, V)
• Post-immunization testing for immunity
• Indicated for hepatitis B (all HCWs), rabies
  (high risk exposure situation)
• Consider persons with an indeterminate antibody
  level susceptible

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PREGNANCY

• Pregnancy test prior to immunization not required
  (except for vaccinia)
• Indicated vaccines Influenza (inactivated), Td
  (Tdap?)
• Use if warranted (benefit exceeds risk)
• Inactivated vaccines (e.g., pneumococcal,
  hepatitis A, hepatitis B, meningococcal, rabies)
• Contra-indicated (No reports of fetal toxicity)
• Live attenuated vaccines Mumps, measles,
  rubella, varicella, influenza, typhoid
• Contra-indicated (Fetal toxicity reported)
• Vaccinia

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SPECIAL CONSIDERATIONS FOR HCWs WORK
RESTRICTIONS POST-IMMUNIZATON

• Live attenuated nasal influenza Restrict from
  working in a stem cell transplant unit (i.e.,
  protected environment) for 7 days
• Vaccinia Lesion must be maintained under a
  porous dressing and under clothes
• Varicella Furlough if generalized rash develops
• No other work restrictions recommended (i.e.,
  immunized employees may work with neonates,
  pregnant women, and immunocompromised patients)

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MUMPS

• Microbiology
• Paramyxovirus, genus rubulavirus (single-stranded
  RNA)
• Single antigenic type
• Epidemiology
• Incubation period 16-18 days (range, 14-25
  days)
• Prevalence Generally 200-300 cases in US per
  year
• Reservoir Humans only
• Distribution Worldwide
• Transmission Droplet contact (spread through
  contact with respiratory secretions and saliva or
  via fomites)

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MMWR 200655(No. 53)
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CDC. MMWR 200655366-68
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MUMPS VACCINE

• Universal vaccine (attenuated virus vaccine)
• Ages 12-15 months follow-up MMR at 4-6 years
• Immunity (HCWs)
• MD diagnosed disease, positive serology, 2 doses
  (1 dose if born before 1957, except in outbreak
  setting provide 2nd dose)
• Efficacy
• 1 dose 80 (range, 60-90) 2 doses 90
• Administration (MMR preferred)
• 0.5 mL SC
• Contraindications
• Pregnancy immunocompromised allergy to eggs,
  gelatin or neomycin

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MEASLES

• Microbiology
• Paramyxoviridae, genus morbillivirus (single
  stranded RNA)
• Single antigenic type
• Epidemiology
• Incubation period 10-14 days (range, 7-18 days)
• Prevalence lt100 cases per year (usually
  imported)
• Reservoir Humans only
• Distribution Worldwide
• Transmission Airborne

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MMWR 200655(No. 53)
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MEASLES OUTBREAKS

• More than 30 reports in the literature
• Between 1985 and 1989, 3.5 of all case acquired
  in a medical facility (Atkinson Wl, et al. Am J
  Med 199191(S 3B)320-24S
• Investigation of individual outbreaks has
  revealed that 17 to 53 were acquired in a
  medical facility)
• Nosocomial outbreaks have led to hospitalization
  of medical staff and severe complications in
  infected patients including death
• Cost of outbreaks has ranged from 28,000 to more
  than 100,000

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MEASLES VACCINE

• Universal vaccine (attenuated virus vaccine)
• Ages 12-15 months follow-up MMR at 4-6 years
• Immunity (HCWs)
• MD diagnosed disease, positive serology, 2 doses
• Administration (MMR preferred)
• 0.5 mL SC
• Contraindications
• Pregnancy immunocompromised allergy to eggs,
  gelatin, or neomycin

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RUBELLA

• Microbiology
• Togaviridae, genus rubivirus (small enveloped
  RNA)
• Single antigenic type
• Epidemiology
• Incubation period 14-17 days (range 14-21 days)
• Prevalence lt10 cases per year
• Reservoir Humans only
• Distribution Worldwide
• Transmission Droplet

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MMWR 200655(No. 53)
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RUBELLA VACCINE

• Universal vaccine (attenuated virus vaccine)
• Ages 12-15 months follow-up MMR at 4-6 years
• Immunity (HCWs)
• Positive serology, 1 dose
• Administration (MMR preferred)
• 0.5 mL SC
• Contraindications
• Pregnancy immunocompromised persons allergy to
  gelatin

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VARICELLA

• Microbiology
• Lipid enveloped DNA virus (pox virus)
• Single antigenic type
• Epidemiology
• Incubation period 14-16 days (range, 8-21 days)
• Prevalence Formerly near universal disease
  prior to vaccine 4 million cases per year with
  11,000 hospitalizations and 100 deaths (highest
  risk of death neonates and immunocompromised)
• Reservoir Humans only
• Distribution Worldwide
• Transmission Airborne

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DECLINING VZV IN THE US
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DECLINING VZV IN THE US
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ISSUES FOR HOSPITALS

• Multiple outbreaks reported in hospitals
• Airborne transmission
• Highly communicable
• Serious disease in immunocompromised persons
• Infection in pregnant woman may lead to
  congenital malformations
• Seropositivity lower in persons born in tropical
  countries
• For near future, how to manage HCWs with remote
  immunization

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CHICKENPOX FROM AN IMMUNO-SUPPRESSED INDEX CASE
WITH ZOSTER
Faizallah R, et al. BMJ 19822851022-1023
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Gustafson TL, et al. Pediatr 198270550-6
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VARICELLA VACCINE

• Universal vaccine (attenuated virus vaccine)
• Ages 12-15 months follow-up at 4-6 years
• Immunity (HCWs)
• MD diagnosed disease, immunization, positive
  serology, report of varicella or zoster?
• Administration
• 0.5 mL SC deltoid

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VARICELLA VACCINE IN HCWs

• To prevent disease and nosocomial spread of VZV,
  healthcare institutions should ensure that all
  HCWs have evidence of immunity to varicella
• Birth before 1980 is NOT considered evidence of
  immunity
• Serologic screening before vaccination of
  personnel who have a negative or uncertain
  history of varicella and are unvaccinated is
  likely to be cost effective
• Institutions may elect to test all HCWs
  regardless of disease history because a small
  proportion of persons with a positive history
  might be susceptible
• Institutions should consider precautions for
  personnel in whom rash occurs after vaccination.
  HCWs in who a vaccine related rash occurs should
  avoid contact with persons without evidence of
  immunity who are at risk for severe disease

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PROOF OF IMMUNITY
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HEPATITIS B

• Microbiology
• DNA virus
• Single antigenic type
• Impact Causes acute and chronic hepatitis
• Epidemiology
• Prevalence 1.2 million Americans have chronic
  HBV infection
• Reservoir Humans only
• Distribution Worldwide
• Transmission Blood (percutaneous, transfusion,
  organs), sexual, vertical (mother-to-child),
  horizontal

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HEPATITIS BISSUES FOR HEALTHCARE

• Hepatitis B stable in the environment for at
  least 1 week
• Highly infectious
• Risk via needlestick
• HBeAg positive source 22.0 to 30.0
• HBeAg negative source 1.0 to 6.0
• Examples of transmission
• Nurse with eczema while obtaining blood gases
• File cards used in a microbiology laboratory
  (paper cuts)
• Fomites Glucose measuring devices (multiple),
  multi-dose medication vials, vaccine
  administration devices

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Hepatitis B by Year, United States, 1966 - 2000
HBsAg screening of pregnant women recommended
Infant immunization recommended
Vaccine licensed
OSHA Rule enacted
Adolescent Immunization recommended
Decline among injecting drug users
Decline among MSM HCWs
Source NNDSS
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Estimated Incidence of HBV infections among HCP
and General Population, United States, 1985-1999
Healthcare Personnel
General U.S. Population
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HEPATITIS B VACCINE

• Dose Recombivax 1.0 ml (10 ug), Engerix 1.0 ml
  (20 ug)
• IM dose into deltoid 1-1.5 needle, 20-25 gauge
• May mix and match vaccine from different
  companies
• Schedule 0, 1, 6 mo OR 0, 1, 2, 12 mo (more
  rapid antibody rise)(Engerix)
• Prior to administration do not routinely perform
  serologic screening for hepatitis B unless cost
  effective
• After 3rd dose, test for immunity (i.e., gt10
  mIU/mL)OSHA required if inadequate provide 3
  more doses and test again for immunity if
  inadequate consider as nonresponder
• If non-immune after 6 (or 3) doses, test for HBsAg

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INFLUENZA

• Microbiology
• Single stranded RNA virus
• Types A (epidemic, pandemics), B (epidemics), C
  (mild)
• Epidemiology
• Incubation period 2 days (range, 1-4 days)
• Prevalence 10-20 attack rate each year
• Reservoir Birds, humans
• Distribution Worldwide
• Transmission Droplet contact

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Influenza Disease Burden to U.S. Societyin an
Average Year
Deaths 25,000 - 72,000
Hospitalizations 114,000 - 257,500
Physician visits 25 million
Infections and illnesses 50 - 60 million
Thompson WW et al. JAMA. 2003289179-86. Couch
RB. Ann Intern Med. 2000133992-8. Patriarca PA.
JAMA. 199928275-7. ACIP. MMWR.
200453(RR06)1-40.
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INFLUENZA VACCINE INDICATIONS

• Children aged 6 mo to 18 years
• Women who will be pregnant during influenza
  season
• Persons aged gt50 years
• Children (6 mo18 yr) receiving aspirin (risk for
  Reye syndrome)
• Adults and children with chronic
  cardio-respiratory illnesses
• Adults and children with chronic metabolic
  disorders, immune deficiencies, or
  immunosuppression
• Adults and children with any chronic condition
  that compromised respiratory tract function or at
  increased risk for aspiration
• Persons who live with people at high risk for
  influenza complications
• Residents of extended care facilities of any age
• Healthcare workers

CDC/ACIP. MMWR 200857(RR-7)
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INFLUENZA VACCINE STRAINS
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AVAILABLE INFLUENZA VACCINES
CDC. MMWR 200453
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AVAILABLE INFLUENZA VACCINES
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INFLUENZA VACCINE (Inactivated)CONTRAINDICATIONS
PRECAUTIONS

• Contraindication
• Hypersensitivity to eggs or vaccine components
• Precaution
• Moderate-to-severe acute febrile illness
  (postpone vaccine)
• Untrue (vaccine may be administered)
• Pregnancy or breastfeeding
• Nonsevere allergy (e.g., contact) to latex or
  thimerosal
• Concurrent administration of coumadin or
  aminophylline

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INFLUENZA VACCINE (Live)CONTRAINIDATIONS

• lt2 years or gt50 years of age
• Reactive airway disease, asthma, or chronic
  cardio-pulmonary disorders
• Children receiving aspirin
• Persons with a history of Guillain-Barre syndrome
• Pregnant women
• Hypersensitivity to eggs or vaccine components
• Persons with contact with severely
  immunocompromised persons in the next 7 days

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INFLUENZA IN HEALTHCARE FACILITIES

• More than 25 outbreaks described in literature in
  acute care hospitals
• Infected staff may initiate outbreak or aid in
  propagation
• HCW infection may lead to absenteeism and
  disruption of health care
• Attack rates in HCWs have ranged from 25 to 80
• More than 15 outbreaks described in literature in
  extended care facilities
• Important morbidity and mortality among residents
  may result
• High rates of immunization (gt60) among staff may
  lead to decreased attack rate in residents

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Indirect Benefits of Influenza Vaccination of
Health Care Workers
Mortality of residents was significantly reduced
(10 vs 17) in nursing homes where the staff
was vaccinated (SV) compared to facilities where
they were not (S0)
20
Vaccine groups
SV (n490) SO (n561)
(P0.0009)
Total patient mortality ()
10
0
0
20
40
60
80
100
120
140
Time in days
Potter J et al. J Inf Dis. 19971751-6.
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Indirect Benefits of Influenza Vaccination of
Health Care Workers

• 20 long-term care facilities, stratified cluster
  randomization staff influenza vaccination or not
  
• Resident mortality odds ratio 0.58 (95 CI 0.40,
  0.84) p0.014

Resident mortality ()
n 688
n 749
No significant difference in residents positive
for influenza Vaccine hospitals 5.4 no
vaccine hospitals 6.7
Carman WF et al. Lancet. 200035593-7.
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REDUCTION IN OUTCOMES IN HCWS RECEIVING INFLUENZA
VACCINE
Talbot TT, Weber DJ, et al. ICHE 200526882-890
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BARRIERS AND SOLUTIONS TO HCW INFLUENZA VACCINE
CONCERNS

• Access to vaccine, inconvenience
• Off-hours clinics
• Use of mobile vaccination carts
• Vaccination at staff and department meetings
• Cost
• Provision of vaccine free of charge
• Concerns for adverse events
• Targeted education, including specific
  information to dispel vaccine myths

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BARRIERS AND SOLUTIONS TO HCW INFLUENZA VACCINE
CONCERNS

• Fear of needles
• Use of LAIV for eligible HCWs
• Other
• Strong and visible leadership
• Visible vaccination of key leaders
• Surveillance of HCW-associated influenza
• Accurate tracking of individual and unit-based
  compliance
• Active declination for HCWs who do not wish to be
  or cannot be vaccinated

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ARGUMENTS IN FAVOR AND AGAINST CONDITIONAL
(MANDATORY) USE OF INFLUENZA VACCINE IN HCWs

• In favor of conditional vaccine use
• Key principle First do no harm (nosocomial
  transmission linked to infected staff)
• Protects the staff and their families
• Institutional benefit Decreased absenteeism,
  cost effective
• Against conditional vaccine use
• Feasibility Difficult to capture all employees
  each year
• May result in staff dissatisfaction
• Union concerns

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INFLUENZAHICPAC RECOMMENDATIONS, 2004

• Vaccinate per ACIP high risk groups in acute-care
  settings (IA)
• Vaccinate per ACIP residents of ECFs (IA)
• Place patients with influenza in private room
  (IB)
• Wear a mask with 3 feet of a patient with
  influenza (IB)
• Practice hand hygiene (IA)
• Use rapid tests on patients with suspected
  influenza (IB)
• Use antiviral as prophylaxis to all patients
  without illness during an outbreak for a minimum
  of 2 weeks (IA)
• Do not allow contact between persons at risk for
  influenza and patients or personnel taking
  antiviral prophylaxis during and for 2 days after
  therapy discontinued (IB)

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INFLUENZAHICPAC RECOMMENDATIONS - OHS, 2004

• Provide influenza vaccine to HCWs (IA)
• Offer antiviral prophylaxis to unvaccinated HCWs
  during an outbreak (IA)
• Consider antiviral prophylaxis to all HCWs,
  regardless of vaccination status, if outbreak
  caused by varient of influenza not well matched
  to vaccine (1B)
• Furlough employees with influenza (IB)

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Hampson AW, Mackenzie JS. MJA 2006185S39-43
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PANDEMIC INFLUENZA PLANNING CHALLENGES

• Pandemic strain unknown (likely H5N1 but many
  others possible)
• The ability of the virus to rapidly spread
  worldwide
• Simultaneous outbreaks throughout the US,
  limiting the ability of an jurisdiction to
  provide assistance to other areas
• People may be asymptomatic while infectious
• Long duration (gt2 years) and multiple waves
• Enormous demands on the healthcare system
• Need for surge capacity Medications,
  ventilators, beds, personnel
• Personnel Exhaustion, concerns about infection
• Maintaining social distancing
• Providing adequate antivirals including
  distribution/allocation
• Vaccine development and distribution/allocation

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DIFFERENCES BETWEEN SEASONALAND PANDEMIC
INFLUENZA
66
DIFFERENCES BETWEEN SEASONALAND PANDEMIC
INFLUENZA
Modified from www.pandemicflu.gov
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POTENTIAL USES OF VACCINESAND ANTIVIRALS

• Vaccines
• Develop vaccine when pandemic hits
• Pre-pandemic stockpile of likely strain
• Pre-pandemic primer
• Pre-pandemic primer and boost
• Early initiation of vaccine from stockpile

• Antivirals
• Treatment
• Post-exposure prophylaxis
• Seasonal prophylaxis

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HHS VACCINE PRIORITIES
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PERTUSSIS

• Microbiology
• Gram negative bacteria
• Epidemiology
• Incubation period 9-10 days (range, 6-20 days)
• Prevalence Most common vaccine preventable
  disease (estimated at gt1,000,000 cases per year)
• Reservoir Humans only
• Distribution Worldwide
• Transmission Droplet

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MMWR 200655(No. 53)
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Pertussis Stages, Communicability
period of communicability
Catarrhal runny nose, sneezing, low- grade
fever, mild cough Paroxysmal severe spasms of
cough, thick mucus, whoops, vomiting,
exhaustion Convalescent gradual recovery with
less frequent and less severe cough
paroxysmal cough onset
exposure
2
4
-1
1
3
5
6
8
9
10
11
12
-2
0
7
weeks of cough
catarrhal stage
paroxysmal stage
convalescent stage
CDC. Epidemiology and Prevention of
Vaccine-Preventable Diseases. PHF 2004
73
Pertussis Spectrum of Disease
CLASSIC
EXHAUSTION PROLONGED COUGH PAROXYSMAL COUGH
INSPIRATORY WHOOP POSTTUSSIVE VOMITING
Disease Severity
DIFFICULTY SLEEPING DIFFICULTY BREATHING POSTTUSSI
VE GAGGING
PERSISTENT COUGH WHOOP MAY BE
ABSENT INDISTINGUISHABLE FROM URI
MILD/ATYPICAL
Hewlett EL, Edwards KM. NEJM. 20053521215-1222.
Lee GM et al. CID. 2004391572-1580. Wirsing
von Konig CH et al. Lancet Infect Dis.
20022744-750. Centers for Disease Control and
Prevention. Epidemiology and Prevention of
Vaccine-Preventable Diseases. Atkinson W et al,
eds. 8th ed. 2004 75-76.
74
CDC. MMWR 2006(RR-17)
75
CDC. MMWR 2006(RR-17)
76
OUTBREAK MAYO CLINIC, ROCHESTER, MN
Leekha S, et al. SHEA (abstract), 2206
77
PERTUSSIS VACCINE

• Provided as Tdap for adolescents and adults
• Provide to HCWs unless Td within past 2 years or
  vaccine contra-indication
• Immunity (HCWs)
• Tdap vaccine within past 10 years
• Administration
• 0.5 mL IM

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VACCINIA

• Microbiology
• Exact source unclear
• Single antigenic type
• Epidemiology
• Prevalence Eradicated (potential bioterrorist
  agent)
• Reservoir Humans
• Distribution US, Russia, others?
• Transmission Airborne contact

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Airborne Spread of Smallpox in the Meschede
Hospital
Fenner. 1988.Fig. 4.9
80
VACCINIA VACCINE

• Special use vaccine
• Bioterrorist attack Pre- and post-exposure
• Care for patients with active vaccinia lesion
• Post-exposure prophylaxis for monkey pox exposure
• Immunity (HCWs)
• Proof of vaccination with 10 years
• Administration
• Vaccination

81
Portrait of Edward Jenner (1749-1823)
Ann Intern Med 1997127635-42
82
PROTECTIVE EFFECT OF INFANT IMMUNIZATION AGAINST
MORTALITY BY AGE OF INFECTION
Deaths per 100 Cases
Hanna, W. 1913, Studies in smallpox and
Vaccination. Bristol, Wright.
83
Vaccination With the Bifurcated Needle
Henderson JAMA 28119992127-2137
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EVOLVING PRIMARY VACCINATION
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VACCINIA VACCINEPRECAUTONS AND CONTRAINDICATIONS

• Severe allergic reaction to prior dose of vaccine
• History or presence of eczema, other skin
  conditions
• Pregnancy (children in the household is not a
  contraindication)
• Altered immocompetence
• HIV, Leukemia, lymphoma, generalized malignancy
• Solid organ transplant, BMT
• Corticosteroids, alkylating agents,
  antimetabolites, radiation
• Cardiac disease
• Allergies
• Neomycin, polymyxin b, tetracyclines, streptomycin

86
VACCINIA VACCINEPREVENTION OF CONTACT
TRANSMISSION

• Vaccinia virus can be cultured from primary
  vaccination site beginning at the time of
  development papule (2-5d after vaccination)
• Transmission via direct skin contact may occur
• Vaccination site should be covered with a porous
  bandage until scab has separated and underlying
  skin has healed (do not use an occlusive
  dressing)
• Use impermeable bandage when bathing
• Vaccinated HCWs may continue to work (vaccination
  site covered with sterile gauze and semipermeable
  dressing, and practice of good handwashing)

87
Adverse Reaction Rates
Adapted from CDC.Vaccinia (smallpox vaccine)
recommendations of the ACIP, 2001. MMWR
200150(RR-10)
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89
VACCINIA USE IN A HCWPREVENTION OF CONTACT
TRANSMISSION

• Vaccinia virus can be cultured from primary
  vaccination site beginning at the time of
  development papule (2-5d after vaccination)
• Transmission via direct skin contact may occur
• Vaccination site should be covered with a porous
  bandage until scab has separated and underlying
  skin has healed (do not use an occlusive
  dressing)
• Use impermeable bandage when bathing
• Vaccinated HCWs may continue to work (vaccination
  site covered with sterile gauze and semipermeable
  dressing, and practice of good handwashing)

90
ADVERSE EVENTS REPORT (AERs) FOLLOWING CIVILIAN
SMALLPOX VACCINATIONS
N37,802 immunizations
MMWR 200352639
91
MANAGEMENT OF EXPOSED, INCUBATING OR ILL EMPLOYEES
92
OCCUPATIONAL HEALTH MANAGEMENT

• Mumps
• Exposure Close patient contact (lt3 feet)
• Post-exposure Exclude from the 12th days from
  first exposure through 25th day after last
  exposure
• Active disease Exclude for 5 days from onset of
  parotitis
• Measles
• Exposure Within same room as infectious patient
• Post-exposure Exclude from the 5th day from
  first exposure through the 21st day after last
  exposure
• Active disease Exclude for 7 days after the rash
  appears

Serosusceptible and not wearing appropriate PPE
93
OCCUPATIONAL HEALTH MANAGEMENT

• Rubella
• Exposure Close patient contact (lt3 feet)
• Post-exposure Exclude from 7th day after first
  exposure through 21st day after last exposure
• Active disease Exclude until 5 days after rash
  appears
• Varicella
• Exposure Within same room as infectious patient
• Post-exposure Exclude from the 8th day after
  first exposure through 21st day after last
  exposure (28th day if VZIG provided)
• Active disease Exclude until lesions dried and
  crusted

Serosusceptible and not wearing appropriate PPE
94
OCCUPATIONAL HEALTH MANAGEMENT

• Zoster
• Exposure Within same room as patient (lesions
  not covered by an occlusive bandage) or direct
  contact with lesions
• Post-exposure Exclude from the 8th day after
  first exposure through 21st day after last
  exposure (28th day if VZIG provided)
• Active Allow to work if lesions can be covered
  with a sterile dressing and located under
  clothing (avoid working with severely
  immunocompromised patients)

Serosusceptible and not wearing appropriate PPE
95
OCCUPATIONAL HEALTH MANAGEMENT

• Hepatitis B
• Exposure Percutaneous, mucus membrane or
  non-intact skin exposure to a contaminated body
  fluid (blood, blood contaminated fluid, CSF,
  pleural, pericardial, semen, vaginal, amniotic,
  peritoneal not sweat, saliva, urine, stool,
  vomitus)
• Post-exposure No exclusion necessary
• Active disease While acutely ill
• Chronic carrier Set up expert panel (may be
  required by law) if performing invasive
  procedures (surgery, dentistry, obstetrics)

96
OCCUPATIONAL HEALTH MANAGEMENT

• Pertussis
• Exposure Close contact contact with
  respiratory secretions (e.g., intubation)immuniza
  tion not shown to be protective
• Post-exposure No exclusion necessary (if not
  symptomatic)
• Active disease For 5 days after beginning
  effective therapy
• Invasive meningococcal infection
• Exposure Close contact contact with
  respiratory secretions (e.g., intubation)immuniza
  tion not shown to be protective
• Post-exposure No exclusion necessary (if not
  symptomatic)
• Active disease For 24 hours after beginning
  effective therapy

Not wearing appropriate PPE
97
OCCUPATIONAL HEALTH MANAGEMENT

• Influenza
• Exposure Close patient contact (lt3 feet)
• Post-exposure No exclusion necessary (if not
  symptomatic)
• Active illness Exclude for 5-7 days

Not wearing appropriate PPE
98
VACCINES INDICATED FORPOST-EXPOSURE PROPHYLAXIS

• Mumps No post-exposure prophylaxis available
• Measles lt3 days post-exposure (alternative Ig)
• Rubella No post-exposure prophylaxis available
• Varicella lt4 days post-exposure (alternative
  VZIG or acyclovir)
• Hepatitis B lt7 days post-exposure /- HBIG
  (alternative HBIG)
• Influenza Vaccine not indicated may use
  oseltamivir or zanamivir x 5 days
• Pertussis Vaccine not indicated (use
  antibiotics azithromycin, TMP-SMX)
• Tetanus Post-wound /- TIG (no time limit
  Tdap preferred)
• Rabies Prior to symptoms /- RIG (avoid RIG if
  previously vaccinated)
• Vaccinia lt4 days post-exposure (may also be
  indicated for monkey pox)
• Outbreak control Hepatitis A, pertussis,
  meningococcal

May need to be provided with an immunoglobulin
preparation
99
USE OF IMMUNE GLOBULIN

• Hepatitis A (post-exposure)
• Immune serum globulin (IG) 0.02 mL/kg IM
• Measles (post-exposure, normal host)
• Immune serum globulin (IG) 0.25 mL/kg
• Rubella (post-exposure, pregnant female, abortion
  not acceptable)
• Immune serum globulin (IG) 20 mL
• Hepatitis B (post-exposure prophylaxis)
• Hepatitis B immune globulin (HBIG) 0.06 mL/kg
• Tetanus (post-exposure prophylaxis)
• Tetanus immune globulin (TIG) 250 units IM
• Varicella (post-exposure)
• Varicella immune globulin (VZIG)

100
VACCINIA IMMUNE GLOBULIN (VIG)

• Indicated
• Accidental implantation (extensive lesions)
• Eczema vaccinatum
• Generalized vaccinia (severe or recurrent)
• Progressive vaccinia
• Not recommended
• Accidental implantation (mild instances)
• Generalized vaccinia (mild or limited most
  cases)
• Post-vaccinial encephalitis
• Consider
• Vaccinia keratitis

101
VACCINIA IMMUNE GLOBULIN

• Indicated
• Accidental implantation (extensive lesions)
• Eczema vaccinatum
• Generalized vaccinia (severe or recurrent)
• Progressive vaccinia
• Not recommended
• Accidental implantation (mild instances)
• Generalized vaccinia (mild or limited most
  cases)
• Post-vaccinial encephalitis
• Consider
• Vaccinia keratitis

102
SELECTED REFERENCES

• Bolyard EA, et al. Guideline for infection
  control in health care personnel, 1998.
  www.cdc.gov/ncidod/dhqp/pdf/guidelines/InfectionCo
  ntrol98.pdf
• CDC. Immunization of health-care workers.
  199746(RR-18)
• Weber DJ, Rutala WA. Vaccines for health care
  workers. In Vaccines (Plotkin S, Orenstein W,
  Offit P, eds). 5th ed. Saunders, 2008.
• Decker MD, Weber DJ, Schaffner W. Vaccination of
  healthcare workers. In Hospital Epidemiology amd
  Infection Control (Mayhall CG,ed). 3rd ed.
  Lippencott Williams Wilkins, 2004.

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