Vaccination of healthcare workers

1. IMMUNIZATIONS FOR HEALTH
CARE WORKERS
Dr. V. Anil Kumar MD
Infection Control Officer
Clinical Additional Professor
Microbiology,
Amrita Institute of Medical Sciences,
Kochi, Kerala.

2. Objectives
• Understand the importance of vaccines in
health care workers (HCWs)
• Review currently recommended vaccines
for HCWs
• Highlight recent vaccine updates for
HCWs

3. Definition of HCWs
Physicians, nurses, Nursing assistants, ward
boys, EMS personnel, dental care
professionals, students in the medical
setting, other hospital staff (custodians, food
service workers, volunteers, etc.)

5. Immunizations for HCWs
Recommendations based on:
• Nosocomial transmission documented
• HCWs at significant risk for acquiring or
transmitting infection

6. Recommendations
• Hepatitis B
• Influenza
• MMR (measles , mumps, rubella)
• Varicella (chickenpox)
• Tetanus, diphtheria, pertussis
• Meningococcal

7. Hepatitis B
• Why?
The Virus & Transmission dynamics
–Virus remains infectious for prolonged periods on
environmental surfaces
–Transmissible in the absence of visible blood
–Transmission risk 100X > than HIV
–5-10% infected become carriers
Morbidity and Mortality Weekly Report,Dec 2013

8. • The 3-dose at 0, 1, and 6 months produces a protective
antibody response in approximately 30%–55% of healthy
adults aged ≤40 years after the first dose, 75% after the
second dose, and >90% after the third dose .
• Protection against symptomatic and chronic HBV infection
has been documented to persist for ≥22 years in vaccine
responders .
• Immunocompetent persons who achieve anti-HBs
concentrations of ≥10 mIU/mL after preexposure
vaccination have protection against both acute disease and
chronic infection.
Hepatitis B Vaccine

9. Situation 1
If a person who works in a healthcare setting
had one dose only of hepatitis B vaccine 4
months ago, should the series be restarted?
• The hepatitis B vaccine series should not be restarted
when doses are delayed
• It should be continued from where it was stopped
• 1st and 2nd dose-4 weeks
• 2nd and 3rd dose gap-8 weeks
• 1st and 3rd dose gap-16 weeks

10. Which HCP need serologic testing after
receiving 3 doses of hepatitis B vaccine?
Situation 2
• All HCP
• Post vaccination testing should be done 1–2
months after the last dose of vaccine.
• Postvaccination testing for persons at low risk for
mucosal or percutaneous exposure to blood or
body fluids (e.g., public safety workers and HCP
without direct patient contact) likely is not cost-
effective
• Those who do not undergo postvaccination testing
should be counseled to seek immediate testing if
exposed.

11. • What should be done if a person’s
postvaccination anti-HBs test is non protective
(less on than10 mIU/mL) 1–2 months after the
last dose of vaccine?
Situation 3
• Repeat the 3 dose series
• Still negative?
• Test for HBsAg & Anti HBc--negative-Non
responder
• Positive HBsAg?
• Negative HBsAg;Positive anti HBc?

12. • How often should I test HCP after they’ve
received the hepatitis B vaccine series to make
sure they’re protected?
Situation 4
• Only once 1-2 months after last dose
• Should be performed for all HCP at high risk for
occupational percutaneous or mucosal exposure to
blood or body fluids.

13. • An employee thinks she had 3 doses of hepatitis B vaccine
in the past but has no documentation of receiving those
doses. Before reading the recommendations to revaccinate
her, we obtained an anti-HBs titer and the result was greater
than 10 mIU/mL. With this lab result,can't we assume she is
immune?
Situation 7
• No & Yes
– A positive anti-HBs indicates that the vaccinated person is
immune at the time the person was tested but does not
assure that the person has long-term immunity.
– Long-term immunity has been demonstrated only for people
attaining an adequate anti-HBs result of at least 10 mIU/mL
after completing a full vaccination series.

14. • I’m a nurse who received the hepatitis B vaccine
series more than 10 years ago and had a
positive follow-up titer (at least 10 mIU/mL). At
present, my titer is negative (less than 10
mIU/mL). What should I do now?
Situation 8
• Nothing
• Adults who respond to a 3-dose hepatitis B
vaccine series (anti-HBs of at least 10 mIU/ mL)
are protected from chronic HBV infection for at
least 22 years, even if there is no detectable
anti-HBs currently.
• Immunocompromised individuals: Booster doses
(esp dialysis patients and HIV positive)

15. • If an employee does not respond to hepatitis B
vaccination (employee has had two full series
of hepatitis B vaccine), does he need to be
removed from activities that expose him to
blood borne pathogens? Does the employer
have a responsibility in this area beyond
providing vaccine?
• Can a person with chronic HBV infection work
in a healthcare setting?
Situation 9

16. • There are no regulations that require
removal from job situations where
exposure to blood borne pathogens could
occur; this is an individual policy decision
within the organization
• HCP should not be discriminated against
because of their hepatitis B status

17. The Caveat
• HBV levels 1000 IU/mL or 5000 genomic
equivalents/mL or higher should not
perform exposure-prone procedures (e.g.,
gynecologic, cardiothoracic surgery)
–unless they have sought counsel from an
expert review panel
–and been advised under what circumstances,
if any, they may continue to perform these
procedures.

19. Achieving Immunity in Hepatitis B
Vaccine Non-responders
• Investigators in Sweden recently assessed the effectiveness of the
combined hepatitis A/B vaccine in 64 adults — 44 nonresponders
who had not developed protective anti-HBs levels after 4
intradermal doses of the Engerix-B recombinant hepatitis B vaccine
and 20 control participants who were not immune to hepatitis B virus
(HBV) or hepatitis A virus (HAV) and had never received the
hepatitis B vaccine. .
• All participants received 2 mL of combined hepatitis A/B vaccine at
0, 1, and 6 months; serum samples were obtained before each dose
and 1 month after the last two doses.
• Three double doses of the combined hepatitis A/B vaccine provided
protective HBV immunity in 95% of hepatitis B vaccine
nonresponders.
• All 20 controls attained such immunity (10%, 95%, and 100%,
respectively). Thirty-five of the 44 nonresponders (80%) developed
anti-HBs titers >100 IU/mL. The two persistent nonresponders were
smokers, and both smoking and high body-mass index were
associated with lower anti-HBs levels. All 64 participants developed
anti-HAV antibodies.
Published in Journal Watch Infectious Diseases July 2, 2008

20. Influenza - Disease
• Usually resolves after 3-7 days; cough and
malaise can persist for >2 weeks
• Can exacerbate underlying medical conditions
(e.g., pulmonary or cardiac disease), lead to
secondary bacterial pneumonia or primary
influenza viral pneumonia, or occur as part of a
coinfection with other viral or bacterial
pathogens

21. Influenza Vaccine
TIV: Inactivated vaccine
Contains killed viruses – does not cause influenza in recipient
Administered intramuscularly
Approved for use among persons aged >6 months, including
those who are healthy and those with chronic medical
conditions. Preferred in HCP working in transplant and
oncology units.
LAIV: Live attenuated vaccine
Contains live, attenuated viruses and, therefore, has a potential
to produce mild signs or symptoms related to influenza virus
infection
Administered intranasally
Approved only for non pregnant healthy HCP aged 5-49 yrs.

22. Influenza Vaccine
Both Vaccines:
• Contain strains of influenza viruses that are antigenically
equivalent to the annually recommended strains: one
influenza A (H3N2) virus, one A (H1N1) virus, and one B
virus
• Grown in eggs
• Administered annually to provide optimal protection
against influenza virus infection
• About 2 weeks after vaccination, antibodies that provide
protection against the influenza viruses in the vaccine
develop in the body.

23. Influenza Vaccine - HCWs
• Health care-associated transmission of influenza has been
documented among many patient populations in a variety of clinical
settings, and infections have been linked epidemiologically to
unvaccinated health care workers
• HCWs are included in the ―high risk‖ group for vaccination
• CDC - All health-care workers should be vaccinated against
influenza annually to protect themselves, their patients, and
communities
• Vaccination levels for health-care workers are typically <40%

24. Measles, Mumps, Rubella (MMR)
Transmission: Airborne/Droplet
Live virus vaccine
• 2 doses MMR for HCWs without serologic
evidence of immunity or prior vaccination
• For HCWs, immune if:
– Physician diagnosed disease
– Laboratory evidence of immunity
– Documentation of two doses MMR given on/after 1st
birthday separated by 28 days or more

25. Measles (Rubeola) - Disease
Serious, acute, highly communicable rash
illness which may result in ear infection
(7%-9%), diarrhea (8%), serious lung
infection such as pneumonia (1%-6%) or
inflammation of the brain (1 in 1,500)

26. Mumps - Disease
Complications:
• Can include deafness, inflammation of the
testicles, ovaries, or breasts respectively,
pancreatitis, meningitis, encephalitis, and
spontaneous abortion
• With the exception of deafness, complications
more common among adults than children

27. Rubella (German Measles)
Complications
• Congenital Rubella Syndrome (CRS)
• Occurs in up to 90% of infants born to mothers
infected with rubella during the first trimester of
pregnancy
• Results in heart defects, cataracts, mental
retardation, and deafness

28. Varicella (Chickenpox)
• Highly contagious viral disease
• Usually mild, but may be severe in some infants,
adolescents, and adults
Complications:
Secondary bacterial infections
Pneumonia
Central nervous system involvement

29. Varicella - HCWs
All HCWs should be immune to varicella
Immune if:
• 2 doses varicella given at least 28 days apart
• History of varicella or herpes zoster based on
physician diagnosis, laboratory evidence of
immunity, or laboratory confirmation of disease

30. Tetanus, diphtheria, pertussis
Pertussis Disease
• ―Whooping cough‖ - highly contagious
respiratory tract infection
• Initially resembles ordinary cold, may eventually
turn more serious, particularly in infants
• Characterized by irritating cough becoming
paroxysmal within 1-2 weeks and lasting 1-2
months or longer
• Best prevention is through vaccine

31. Tetanus-diphtheria-acellular pertussis-Vaccine (Tdap)
Licensed in 2005
Effectiveness: 92%
• Contain reduced pertussis antigen compared with
pediatric formula and similar amounts of tetanus and
diphtheria toxoids in adult dT booster
• Single dose booster for age 19-64
• HCWs working in hospitals or ambulatory care settings
and have direct patient contact should receive a single
dose of Tdap as soon as feasible if they have not
previously received Tdap
• Priority given to vaccination of HCWs with direct contact
with infants aged <12 months. Interval of 2 or more
years from the last dose of Td recommended for the
Tdap dose

32. Meningococcol Disease
• Acute bacterial disease caused by Neisseria
meningitidis characterized by:
– sudden onset of fever, intense headache,
nausea and often vomiting, stiff neck and
frequently a petechial rash
• The meningococcal disease is usually caused
by groups A, B, C, Y, and W-135 of the
meningococcus bacteria.
• Droplet spread

33. Meningococcol Vaccine - HCWs
• 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.
• N. meningitidis isolates pose a risk for
microbiologists and should be handled in a manner
that minimizes risk for exposure to aerosols or
droplets.

34. Meningococcol Vaccine
MPSV4: meningococcal polysaccharide vaccine
Ages 2-10 and >55
High risk need revaccination every 3–5 years
Not recommended and should not be administered
routinely for adolescents ages 11–12
MCV4: meningococcal conjugate vaccine Ages 11-55
Need for revaccination not yet known
Both current vaccines effective against A,C,Y and W-135.
Not effective against group B
Recommended for microbiologists who are routinely
exposed to isolates of N. meningitidis that might be
aerosolized

35. Pregnancy and Vaccination
• No live vaccines like MMR, influenza
• HBV vaccine not contraindicated.
• Td/Tdap should be given during each
pregnancy.

36. What about wearing masks?

39. Do Mandatory Immunization Programs for
HCWs Make Sense?
• Are their benefits for patients to having
healthcare workers immunized? YES
• Are their direct benefits to healthcare
workers from being immunized? YES
• Is it necessary for hospitals to require
healthcare workers to be immunized? YES
• Does it make sense to have non-
immunized clinical employees wear a
mask? YES

40. Why HCW decline flu vaccine
2005-2006 2006-2007
Allergy/Reaction 39 26
Rec’d vaccine elsewhere 36 6
Concern about side effects 34 193
Never get flu 9 27
Personal choice 119 53
Religious 1 0
Other 32 15
Pregnancy 11 5
Fear of needles 7 0
TOTAL 276 392

41. Influenza (H1N1), conjunctivitis, Chicken Pox

42. 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 influenza vaccine annually. Give inactivated
injectable vaccine intramuscularly or live attenuated influenza
vaccine (LAIV) intranasally.
MMR For healthcare personnel (HCP) born in 1957 or later without
serologic evidence of immunity or prior vaccination, give 2 doses
of MMR, 4 weeks apart. For HCP born prior to 1957, see below.
Give SC.
Varicella
(chickenpox)
For HCP who have no serologic proof of immunity, prior
vaccination, or history of varicella disease, give 2 doses of
varicella vaccine, 4 weeks apart. Give SC.
Tetanus,
diphtheria,
pertussis
Give a dose of Tdap as soon as feasible to all HCP who have not
received Tdap previously and to pregnant HCP with each
pregnancy (see below). Give Td boosters every 10 years thereafter.
Give IM.
Meningococcal Give 1 dose to microbiologists who are routinely exposed to
isolates of N. meningitidis and boost every 5 years if risk
continues. Give MCV4 IM; if necessary to use MPSV4, give SC.

43. Questions?
www.immunize.org/catg.d/p2109.pdf
CDC. Immunization of Health-Care Personnel:
Recommendations of the Advisory Committee on
Immunization Practices, MMWR, 2011; 60(7):1–
48, www.cdc.gov/mmwr/pdf/rr/rr6007.pdf
Immunization Action Coalition. ―Healthcare Personnel
Vaccination Recommendations,‖
www.immunize.org/catg.d/p2017.pdf