county of san diego, health and human services agency immunization branch protecting your patients...
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County of San Diego, Health and Human Services AgencyImmunization Branch
Protecting Your PatientsProtecting Your PatientsStarts WithStarts With
Protecting YourselfProtecting Yourself
Healthcare Personnel VaccinesHealthcare Personnel Vaccines
Protecting Your PatientsProtecting Your PatientsStarts WithStarts With
Protecting YourselfProtecting Yourself
Healthcare Personnel VaccinesHealthcare Personnel Vaccines
Jae L. Hansen, IMC, NREMT-P, FP-C (Ret.)
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Ask yourself…Ask yourself…
What can I do to protect myself?
What can I do to protect my patients?
What can I do to protect my family?
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Which HCP Need Vaccinations?Which HCP Need Vaccinations?
Includes physicians, nurses, nursing/medical assistants, therapists, technicians, EMTs/Paramedics, dental, pharmacists, laboratory personnel, autopsy, students, trainees, contract staff, persons potentially exposed to infectious agents that can be transmitted to and from HCP
Settings include hospitals, nursing homes, skilled nursing facilities, physicians’ offices, urgent care centers, outpatient clinics, home healthcare, and emergency medical services
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Adult Vaccines…Adult Vaccines… Shingles (Herpes Zoster)Shingles (Herpes Zoster)
One dose of Herpes Zoster Vaccine (Zostavax) at age 60 or older
Effective even if they’ve had a history of shingles
PneumococcalPneumococcal 40,000 deaths & 500,000 cases every year in the US One dose of PPV vaccine given at age 65 or older,
OR in presence of chronic health condition
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Adult Vaccines (cont.)Adult Vaccines (cont.) MMeasles, easles, MMumps, umps, RRubella (MMR)ubella (MMR)
Adults born before 1957 is considered immune to measles & mumps
2nd dose of MMR is recommended for HCP, or show lab evidence of immunity
MeaslesMeasles – Highly contagious virus found throughout the world, can remain airborne for up to 2 hours Transmission – coughing, sneezing or talking Symptoms – high fever, rash, runny nose, watery eyes, cough,
diarrhea & earache Incubation – 10 to 14 days
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Mumps Mumps – Acute viral disease, may spread even though they have no symptoms or their illness is mild
Transmission – coughing & sneezing
Symptoms – Low grade fever & swelling or tenderness of one or more salivary glands. In post pubertal males, up to 30% may experience testicular pain and swelling. May cause sterility in males.
Incubation – 12 to 25 days
Adult Vaccines (cont.)Adult Vaccines (cont.)
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RubellaRubella – (German Measles) is a virus If a woman gets rubella during the 1st trimester of
pregnancy, her baby is at risk of having serious birth defects Transmission – coughing or sneezing, direct contact
with nasal or throat secretions Symptoms – Rash, slight fever, aching joints, &
reddened eyes Many people with rubella have few or no symptoms, and
may not have rash
Incubation – 16 to 18 days
Adult Vaccines (cont.)Adult Vaccines (cont.)
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VaricellaVaricella – (Chickenpox) highly contagious disease caused by the Varicella-zoster virus Transmission – airborne & also spread through contact
with chickenpox blisters Symptoms – rash, body aches, fever, fatigue, irritability &
sore throat Hospitalization & death increases with adultsHospitalization & death increases with adults Incubation – 10 to 21 days If no lab evidence or history, 2 doses of Varicella vaccine
should be administered 4-8 weeks apart
Adult Vaccines (cont.)Adult Vaccines (cont.)
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Hepatitis A & Hepatitis BHepatitis A & Hepatitis B Hepatitis disease is a virus that affects the liver:
Hepatitis A is food-borne (oral-fecal)
Hepatitis B is blood-borne (blood to blood)
Hep A vaccine – common childhood and travel vaccine
Hep B vaccine – common childhood, travel vaccine and maybe required for healthcare personnel (HCP)
Vaccines given in multiple doses (plan ahead, e.g., travel, new job, etc.)
Combined in Twinrix® (2 shots in 1)
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HPVHPV
Human PapillomavirusHuman Papillomavirus
≥ 100 strains and types ≥ 40 strains and types are sexually transmitted
FDA recently approved vaccine for males
Approved for ages 9 – 26 yrs
Protects against viruses that can cause cervical, anal, penile & throat cancers
Source: CDC HPV Information
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also known as the “flu”also known as the “flu”
Influenza is a contagious viral infection of the Influenza is a contagious viral infection of the nose, throat and lungsnose, throat and lungs
36,000 deaths and over 200,000 hospitalizations per year 36,000 deaths and over 200,000 hospitalizations per year
InfluenzaInfluenzaInfluenzaInfluenza
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2007-2008 2007-2008 San Diego Influenza SeasonSan Diego Influenza Season
The first influenza detection occurred the second week of October
The peak flu season occurred mid February
A total of 9 influenza-related deaths
A total of 1,905 reports of influenza (lab results positive) were voluntarily reported to Public Health
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H1N1 in San DiegoH1N1 in San Diego
April 2009 – May 25, 2010 930 hospitalizations 56 deaths – San Diego residents 7 deaths – Visiting non-residents
Most recent death was a 22 y/o male with underlying condition
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Peak Influenza U.S. 1976-2006Peak Influenza U.S. 1976-2006
13%
19%
45%
13%
3% 3%3%
Source: MMWR 2007;56 (RR-6)
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Cold vs. FluCold vs. FluCan you tell the difference?Can you tell the difference?
Fever Rare in adults and older children,
but can be as high as 102 degrees in infants and small children
COLD OR FLU?
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COLDCOLD
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Cold vs. FluCold vs. FluCan you tell the difference?Can you tell the difference?
Headache
Sudden onset and can be severe
COLD OR FLU?
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FLUFLU
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Cold vs. FluCold vs. FluCan you tell the difference?Can you tell the difference?
Tiredness and weakness
Can last two or more weeks
COLD or FLU?
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FLUFLU
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Cold vs. FluCold vs. FluCan you tell the difference?Can you tell the difference?
Sneezing
Stuffy Nose
Sore Throat
COLD or FLU?
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COLDCOLD
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TirednessTiredness
HeadacheHeadacheFever & ChillsFever & Chills
Influenza SymptomsInfluenza Symptoms
Body AchesBody Aches
Chest DiscomfortChest Discomfort
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Flu PreventionFlu PreventionGet vaccinated!Get vaccinated! Your best protection!
Practice good hygienePractice good hygiene Wash hands often Cover your mouth/nose when you cough/sneeze Put used tissues in waste basket Clean your hands after you cough/sneeze Avoid touching your face, eyes, nose or mouth
If you are diagnosed with the fluIf you are diagnosed with the flu Stay home Avoid close contact with others, or wear a mask Get rest and drink plenty of fluids
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Transmission Respiratory route Direct contact Communicability – 1 to 2 days pre-onset to,
4 to 5 days post-onset Reservoir
Humans, swine (H1N1), and birds (H5N1) Geographic distribution
Global Incubation
1 to 5 days; usually 2 days
Influenza VirusInfluenza Virus
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Nosocomial InfluenzaNosocomial Influenza
Transmission that occurs in a healthcare setting
Can result from under-vaccinated healthcare personnel
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In a tertiary care facility from 1987 to 2000:
Staff influenza vaccination coverage 4% >>> 67%
Staff influenza disease 42% >>> 9%
Nosocomial Disease 32% >>> 0 cases
Salgado CD, Infection Control Hospital Epidemiology, 2004
Nosocomial InfluenzaNosocomial Influenza
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Healthcare personnel (HCP) can be infected by their patients
Prospective study vaccinated HCP:
30% fewer influenza like illness (ILI)
63% fewer illnesses with fever and cough
Wilde, JA, JAMA 1999
Nosocomial InfluenzaNosocomial Influenza
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Influenza in the ElderlyInfluenza in the Elderly
Kimura, et al. American Journal of Public Health, 2007
The elderly have The elderly have suboptimalsuboptimal immunologic immunologic response to the flu vaccine.response to the flu vaccine.
80% effective in preventing death 27% to 70% effective in preventing
hospitalizations and pneumonia 30% to 58% effective in preventing flu
The flu shot is about…
Despite high vaccination rates among residents, influenza Despite high vaccination rates among residents, influenza outbreaks still occur in LTCFs, triggered by unvaccinated HCP.outbreaks still occur in LTCFs, triggered by unvaccinated HCP.
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Influenza in LTCFInfluenza in LTCF
Influenza Attack Rates 25-60%
Case-fatality 10-20%
Randomized control study Staff vaccination led to a
43% decrease in ILI 44% decrease in
mortality
Potter J, et. Al. J Infectious Disease 1997
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Children between 6 months and 18 years of age
Healthcare personnel (HCP)Healthcare personnel (HCP)
Persons > 50 years
Nursing home & chronic care residents with chronic medical conditions
Persons with chronic pulmonary or cardiovascular disorders, including asthmatic children
Pregnant women
Persons with immunosuppression including HIV
Who’s at Risk?Who’s at Risk?
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Facts vs. MythsFacts vs. Myths I get sick from the vaccineI get sick from the vaccine
MythThe influenza vaccine is made from a DEAD virusYou cannot get sick from itYou cannot get sick from itSide effects may include a low-grade fever and
muscle achesThe flu shot can take up to two weeks to
become effective so you can still get the flu or a flu-like illness during this time
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Why I didn’t get a flu shot…Why I didn’t get a flu shot… My doctor didn’t recommend it
I am afraid of needlesThe flu shot is given with a relatively small needle. Check with your doctor to see if you are eligible to receive FluMist® - a vaccine that is sprayed into your nose and does not require needles.
The Flu isn’t that badInfluenza causes an average of 36,000 deaths and over 200,000 hospitalizations per year. Source: CDC Influenza Information
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Shot vs. Nasal SprayShot vs. Nasal SprayFlu Shot (TIV)Flu Shot (TIV) Injectable – Trivalent inactivated influenza vaccine 70-90% effective in healthy persons ≤65 yrs 50-60% effective in preventing hospitalization 80% effective in preventing death Few side effects (sore arm, general malaise)
Nasal Spray (LAIV) - FluMist®Nasal Spray (LAIV) - FluMist® Live attenuated influenza vaccine No needles – spray mist into the nose Approved for healthy persons ages 2-49 years of age Slightly more expensive
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also know asalso know as“Whooping Cough”“Whooping Cough”
is a highly contagious bacterial infection of the is a highly contagious bacterial infection of the lining and airways of the respiratory tract.lining and airways of the respiratory tract.
It is caused by the bacterium Bordetella pertussis.It is caused by the bacterium Bordetella pertussis.
PertussisPertussisPertussisPertussis
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Pertussis Cases in the U.S. Pertussis Cases in the U.S.
CDC. MMWR 1997;46(54):71-80. Murphy T. Data on file, personal communication, 2001. MMWR 2000;50:1175. MMWR 2001;50(33):725.MMWR 2002;51:723. MMWR 2003;52:747. Bacterial Vaccine Preventable Disease Branch, National Immunization Program, 2005.
Ca
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7,7966,586
4,570
11,647
9,771
0
4
8
12
16
24
20
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004
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Pertussis in S.D. County Pertussis in S.D. County Pertussis in S.D. County Pertussis in S.D. County
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County of San Diego Pertussis Cases by Month Reported, 2009 and 2010 (Jan - Apr)
0
5
10
15
20
25
30
35Ja
n
Feb
Mar
Apr
May Ju
n
Jul
Aug
Sep Oct
Nov
Dec
Month of Report
Num
ber o
f Cas
es
2009 2010
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Pertussis in the U.S.Pertussis in the U.S.
Güriş et al. Clin Infect Dis. 1999;28:1230-1237.CDC. MMWR. 2002;51:73-76, 2001;50(53):1-108, 2002;51(53):1-84, 2003;52(54):1-85
1990-1993 1990-1993 1994-1996 1994-1996 1997-2000 1997-2000 2001-20032001-2003 20042004
80008000
90009000
00
40004000
10001000
50005000
20002000
60006000
30003000
70007000
<1 yr<1 yr 1-4 yrs1-4 yrs 5-9 yrs5-9 yrs 10-19 yrs10-19 yrs 20+ yrs20+ yrs
Av
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Nu
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er
Av
era
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Nu
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Ca
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/ Y
ear
of
Ca
ses
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Age GroupAge Group
18.8 fold18.8 fold
15.5 15.5 foldfold
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Clinical Signs of PertussisClinical Signs of Pertussis Cough 97% 3 weeks,
52% 9 weeks Paroxysms 73% 3 weeks Whoop in 69% Post-tussive emesis in 65%
De Serres et al. J Infect Dis. 2000;182:174–9.
Teens missed average 5 days of school
Adults missed average 7 days of work Average 14 days of disrupted sleep
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3 Stages of Pertussis3 Stages of Pertussis CatarrhalCatarrhal
Runny nose, sneezing, low-grade fever, and a mild, nonproductive, occasional cough
Most infectious during the this period and the first 2 weeks after cough onset (approximately 21 days)
ParoxysmalParoxysmal Severe spasms of quick, short, coughs May gag, gasp and/or expel thick mucus “whoop” Following attack
Vomiting and exhaustionVomiting and exhaustion
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ConvalescentGradual recoveryCough frequency decreasesCough severity decreasesRecovery may be only partial
Source: www.pertussis.com
3 Stages of Pertussis3 Stages of Pertussis
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How is it diagnosed?How is it diagnosed? Multiple tests may be required to accurately
diagnose disease Frequent incorrect diagnoses:
Asthma Gastroesophageal reflux Post-viral bronchospasm Chronic sinusitis Tuberculosis
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Culture and PCRCulture and PCR
Nasopharyngeal (Dacron) swab or aspirate is the preferred sample
It’s the nasopharynx we’re after
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Pertussis in AdultsPertussis in AdultsAdultsAdults: Are the main reservoirs of disease in areas
with high immunization coverage rates
Transmit primarily to non-immune children (≤ 1 year of age) or to adults whose immunity has waned
Experience the longest recovery time (median 93 days)(median 93 days)
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15
7
3
0 0 0 0
1
12
5
0
1
0 00
2
4
6
8
10
12
14
16
0 1 2 3 4 5 6
age (months)
num
ber
of c
ases
Death Encephalopathy
The majority of severe pertussis disease complications occurred among infants 0-2 months of age, California 1995 - 2004
California Dept of Health ServicesImmunization Branch
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n=264 cases
Infant Pertussis: Infant Pertussis: Who Was the Source?Who Was the Source?
Bisgard, K. PIDJ. 2004;23:985-9..
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Costs of an OutbreakCosts of an Outbreak September 2003 – outbreak of pertussis in an
acute care facility 17 employees were infected Following a one-day exposure to an infant with
pertussis
Infection control measures were immediately implemented in hospital
Study examined outbreak-related costs and estimated possible benefits to vaccination
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Study ResultsStudy Results
Cost incurred by the hospital:
Cost incurred by the employees:
TOTAL COST incurred:
Cost of 1 dose of Tdap:
$74,870$74,870
$6,512$6,512
$81,382$81,382
$37.00$37.00
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CDC RecommendsCDC Recommends All HCP in hospitals, LTCF/SNF, ambulatory care and
emergency medical services (EMS) settings also receive Tdap in place of Td booster
Priority groups: HCP in contact with infants less than 12 months Emergency Departments Maternal/Child Health ICU/NICU Respiratory Therapy
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All adults receive Tdap in place of their tetanus booster
Postpartum mothers and/or primary caregivers receive Tdap
CDC RecommendsCDC Recommends
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Tdap VaccineTdap Vaccine
TTetanus etanus ddiphtheria iphtheria aacellular cellular ppertussisertussis
Licensed in 2005
Only one dose is required and it can be given in an interval as short as 2 years from the last Td booster
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Tdap Adverse ReactionsTdap Adverse Reactions
Localized pain, redness, swelling
Low-grade fever
Adverse reactions occur at approximately the same rate as Td alone
Source: CDC Pertussis InformationSource: CDC Pertussis Information
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A True Story…A True Story…
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ConclusionsConclusions Vaccinating ADULTS with Tdap:
85% protection with vaccine! Protect your family from pertussis Prevent an outbreak in workplace thereby reducing
costs and minimizing sick leave
Keeping adults up to date with their vaccines can minimize the effects of vaccine-preventable diseases
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ResourcesResourcesCounty of San Diego Immunization Branch
www.SDIZ.orgwww.SDIZ.org
Council of Community Clinics(Referral to low-cost immunizations)
((619) 542-4300619) 542-4300
Immunization Action Coalitionhttp://www.immunize.org/hcw/http://www.immunize.org/hcw/
Center for Disease Control and Preventionhttp://www.cdc.gov/ncidod/dhqp/wrkr_immune.htmlhttp://www.cdc.gov/ncidod/dhqp/wrkr_immune.html
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Jae L. Hansen, IMCJae L. Hansen, IMC(619) 692-6644(619) [email protected]@sdcounty.ca.gov
Thank you for your time.Thank you for your time.