County of San Diego, Health and Human Services AgencyImmunization Branch

Healthcare Personnel Vaccines:

CDC Recommendations&

Why They are Important

Jae L. Hansen, IMC, NREMT-P, FP-C (Ret.)

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?

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

Adult Vaccines… 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

Pneumococcal 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

Adult Vaccines (cont.) Measles, Mumps, Rubella (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

Measles – 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

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.)

Rubella – (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.)

Varicella – (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 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.)

Hepatitis 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)

HPV

Human 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

also known as the “flu”

Influenza is a contagious viral infection of the nose, throat and lungs

36,000 deaths and over 200,000 hospitalizations per year

Influenza

2007-2008 San 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

H1N1 in San Diego

April 2009 – January 20, 2010 829 hospitalizations 55 deaths – San Diego residents 7 deaths – Visiting non-residents

Most recent death is a 29 y/o female with no underlying condition

Peak Influenza U.S. 1976-2006

13%

19%

45%

13%

3% 3%3%

Source: MMWR 2007;56 (RR-6)

Cold vs. FluCan 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?

COLD

Cold vs. FluCan you tell the difference?

Headache

Sudden onset and can be severe

COLD OR FLU?

FLU

Cold vs. FluCan you tell the difference?

Tiredness and weakness

Can last two or more weeks

COLD or FLU?

FLU

Cold vs. FluCan you tell the difference?

SneezingStuffy NoseSore ThroatCOLD or FLU?

COLD

Tiredness

HeadacheFever & Chills

Influenza Symptoms

Body Aches

Chest Discomfort

Flu PreventionGet vaccinated! Your best protection!

Practice 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 flu Stay home Avoid close contact with others, or wear a mask Get rest and drink plenty of fluids

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 Virus

Nosocomial Influenza

Transmission that occurs in a healthcare setting

Can result from under-vaccinated healthcare personnel

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 Influenza

Influenza in the Elderly

Kimura, et al. American Journal of Public Health, 2007

The elderly have suboptimal immunologic 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 outbreaks still occur in LTCFs, triggered by unvaccinated HCP.

Influenza 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

Children between 6 months and 18 years of age 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?

Facts vs. Myths I get sick from the vaccine

MythThe influenza vaccine is made from a DEAD virusYou 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

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

Shot vs. Nasal SprayFlu 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® Live attenuated influenza vaccine No needles – spray mist into the nose Approved for healthy persons ages 2-49 years of age Slightly more expensive

Novel H1N1 VaccineWho should receive the vaccine?• EMS and HCP• Pregnant women• Caregivers of <6 months• 6 mon – 24 yrs, 25 – 64 yrs w/ underling chronic conditions• Now open to everyone

Where can I get it?• Your physicians office• Local PHC, Mass Vax Clinics

How many doses will I need?• Only one dose for 10 yrs and older

How much will it cost?• Free – Feds paid for all doses• Nominal administration fee

How safe is the vaccine?• Extremely safe! It is made using the

same processes & facilities as the seasonal flu vaccine. It is very much like the seasonal flu vaccine.

Should I get the vaccine if I think I’ve already been infected?

• Yes, the flu symptoms you had may not have been caused by the H1N1 virus.

also know as“Whooping Cough”

is a highly contagious bacterial infection of the lining and airways of the respiratory tract.

It is caused by the bacterium Bordetella pertussis.

Pertussis

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.

Cas

es (T

hous

ands

)

7,7966,586

4,570

11,6479,771

25,827

0

4

8

12

16

24

20

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004

Pertussis in S.D. County

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

0

50

100

150

200

250

300

350

400

CasesDeaths

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 1994-1996 1997-2000 2001-2003 2004

8000

9000

0

4000

1000

5000

2000

6000

3000

7000

<1 yr 1-4 yrs 5-9 yrs 10-19 yrs 20+ yrs

Aver

age

Num

ber

of C

ases

/ Ye

ar

Age Group

18.8 fold

15.5 fold

Clinical 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

3 Stages of Pertussis Catarrhal

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)

Paroxysmal Severe spasms of quick, short, coughs May gag, gasp and/or expel thick mucus “whoop” Following attack

Vomiting and exhaustion

ConvalescentGradual recoveryCough frequency decreasesCough severity decreasesRecovery may be only partial

Source: www.pertussis.com

3 Stages of Pertussis

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

Culture and PCR

Nasopharyngeal (Dacron) swab or aspirate is the preferred sample

It’s the nasopharynx we’re after

Pertussis in AdultsAdults: 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)

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 o

f cas

es

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

n=264 cases

Infant Pertussis: Who Was the Source?

Bisgard, K. PIDJ. 2004;23:985-9.

Costs 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

Study Results

Cost incurred by the hospital:

Cost incurred by the employees:

TOTAL COST incurred:

Cost of 1 dose of Tdap:

$74,870

$6,512

$81,382

$37.00

Estimated Benefits of Vaccination

Study model predicts:

Vaccinating employees in hospital against pertussis would prevent ≥ 46% of exposures

Cost of vaccination to benefit ratio is 2.38 : 1

CDC 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

All adults receive Tdap in place of their tetanus booster

Postpartum mothers and/or primary caregivers receive Tdap

CDC Recommends

Tdap Vaccine

Tetanus diphtheria acellular pertussis 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

Tdap Adverse Reactions

Localized pain, redness, swelling Low-grade fever Adverse reactions occur at

approximately the same rate as Td alone

Source: CDC Pertussis Information

A True Story…

Conclusions 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

ResourcesCounty of San Diego Immunization Branch

www.SDIZ.org

Council of Community Clinics(Referral to low-cost immunizations)

(619) 542-4300

Immunization Action Coalitionhttp://www.immunize.org/hcw/

Center for Disease Control and Preventionhttp://www.cdc.gov/ncidod/dhqp/wrkr_immune.html

Jae L. Hansen, IMC(619) 692-6644Jae.Hansen@sdcounty.ca.gov

Thank you for your time.