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VACCINES AFFECTING HCW SAFETY

Kent A. Sepkowitz, MDMemorial Sloan-Kettering Cancer Center

Disclosure

Completely Free of All Human and Financial Conflict

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Are Hospitals Safe?

SARS, MERS, and Swine flu have demonstrated the risk to HCWs of caring for the contagious

How do healthcare workers prevent occupationally acquired infections?

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Diphtheria

Diphtheria etymology: “pair of leather scrolls”

Diphtheria

In early 1900s, diphtheria and scarlet fever accounted for half of all ID admissions

Occupational transmission to 5%

Gauze masks to prevent scarlet fever and vaccinations for diphtheria instituted

First attempts to protect HCW

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Strongly Recommended

Dead

Influenza

HBV

Pertussis

Alive

MMR

Varicella

Recommended: Specific Circumstances Only

Dead

Meningococcus (micro lab)

Typhoid (micro lab)

Polio (micro lab)

Alive

Smallpox

BCG

Typhoid oral (ditto)

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Not Specifically Recommended

Dead

Pneumococcus

Tetanus

Diphtheria

Hepatitis A

Alive

Shingles

LAIV (Flumist)

Occupationally-Acquired Infections in HCWVaccine Available

• BloodborneHIV, hepatitis B, hepatitis C, CMV

• Airborne or DropletTB, measles, varicella, pertussis, mumps, influenza, RSV, parvovirus B19, rubella, variola, SARS, MERS,meningococcus

• Fecal-Oralsalmonella, hepatitis A, helicobacter, Norwalk

• Directscabies, lice, herpes simplex

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Are Live Vaccines Safe to Give?

MMR

Varivax / Zostrix

Flumist

BCG

Vaccinia

Occupationally-Acquired Infections in HCW

Bloodborne

• HIV

• Hepatitis B

• Hepatitis C

• CMV

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How Long Does HBV Vaccine Work?

US does not recommend routine re-vaccination

Many countries re-vaccinate every 5-10 years or when titers fall below a certain level

What About Non-Converters?

Excellent data from Eskimo/Inuit cohort followed since 1981-2 after vaccine

Hyperendemic for HBV

Non-converters had no serious cases of acute HBV, though 3 had new HBcAb over 10 years

Non-converters may be protected

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Who Does Not Seroconvert?

Overall rate about 90+%

Overweight smoking older males have lower rates --60+%

Repeat 3-dose

series X 1 adds

30-50% conversion

Generation of vaxed

infants now of age

Dealing with Non-Convertors (if second series fails)

Intradermal series

Double-dose vaccination in a standard 3-dose series of combination hepatitis A and hepatitis B vaccine Among 44 nonresponders, protective anti-HBs levels

were found in 26 (59%) after the first dose and in 42 (95%) after the third dose. (Cardell, JID 2008)

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Scenario #1

You are called because a nurse stuck himself with a needle used to draw blood from a patient with HBsAg

The nurse “thinks he was vaccinated for the last job” 7 years ago

Scenario #1: You should

1. Initiate a 3-vaccine series

2. Give HBIG

3. Start vaccine AND give HBIG

4. Check the nurse’s serostatus

5. Turn off your beeper and go back to sleep

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Scenario #1: You should

1. Initiate a 3-vaccine series

2. Give HBIG

3. Start vaccine AND give HBIG

4. Check the nurse’s serostatus

5. Turn off your beeper and go back to sleep

What Do You DoPost HBsAg Exposure?

If established vaccine responder: Nothing

If unvaccinated or serostatus unknown: Vaccine and HBIG

Check serostatus

If vaccine non-responder: HBIG X 2 or vaccine and HBIG X 1

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Occupationally-Acquired Infections in HCW

TB

Measles*

Varicella

Pertussis

Mumps

Influenza*

RSV

Parvovirus B19

Rubella

Variola*

SARS

Meningococcus*

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Pertussis

‘100-day cough’

20% of adult population estimated to be susceptible

12-30% of all prolonged coughing illnesses in adults are pertussis

Our immunity is waning: Outbreaks reported every year

Pertussis, US: 1922-2005

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Mayo OutbreakICHE 2009, 30:467

Mayo OutbreakICHE 2009, 30:467

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Pertussis (Tdap)ACIP Recommendation, 2005

HCWs should receive Tdap every 10 years instead of Td Do not confuse Tdap with DTaP which has higher

concentrations of D and T (given to children)

ER’s often confuse these

Tdap hurts due to the toxoid part of the preparation

Acellular Pertussis Vaccine Combined with Tetanus and Diphtheria Toxoids

In the United States, there are two Tdap products ADACEL® licensed on June 10, 2005, for use in persons aged 11--64

years as a single dose active booster vaccination against tetanus, diphtheria, and pertussis.

Another Tdap product, BOOSTRIX® is just licensed for use in 10-64 year olds

Pediatric DTaP is DAPTACEL®

ADACEL® and DAPTACEL® contain the same five pertussis antigens

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Pertussis PEP Dosing

Azithromycin: 500mg day 1, then 250 for 4 more days (the Z-pack)

Erythromycin: 2 gms/d for 14d

Clarithromycin: 1gm/d for 7d

Bactrim: DSB BID for 14d

MMWR Dec 9, 2005;54 (RR14)

Scenario #2

The same nurse transferred to a pediatrics ward

He is exposed to a child with pertussis who had been treated for routine pneumonia in a non-isolation room

He was vaccinated with Tdap 2 years ago

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Scenario #2: You Should:

1. Not worry – he’s vaccinated

2. Give him PEP regardless of vaccine status

3. Give Tdap again

4. Check his pertussis serostatus

5. Turn off your beeper and go back to sleep

Scenario #2: You Should:

1. Not worry – he’s vaccinated

2. Give him PEP regardless of vaccine status

3. Give Tdap again

4. Check his pertussis serostatus

5. Turn off your beeper and go back to sleep

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Occupationally-Acquired Infections in HCW

TB

Measles

Varicella

Pertussis

Mumps

Influenza

RSV

Parvovirus B19

Rubella

Variola

SARS

Meningococcus

Meningococcus

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Meningococcus Vaccine

6 serogroups cause almost all human disease (different antigen on capsule)

Current MCV4 Prevents A, C, W-135, and Y

Does not prevent B or X

MCV4 covers 70% of cases seen in college students pre-vaccination rec

Mening belt is 80%+ Group A

Meningococcus Vaccine

HCWs without a spleen or with complement deficiency

Clinical and research microbiologists including technicians “who might be exposed routinely to N meningitidis”

Boost every 5 years

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Princeton, UCSB and B Vaccine

Occupationally-Acquired Infections in HCW

TB

Measles

Varicella

Pertussis

Mumps

Influenza

RSV

Parvovirus B19

Rubella

Variola

SARS

Meningococcus

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Measles

It’s 3-D and starts in “dandruff distribution”

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Measles: Koplik’s Spots

They appear opposite the molars as red spots with blue white centers

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Occupationally-Acquired Infections in HCW

TB

Measles

Varicella

Pertussis

Mumps

Influenza

RSV

Parvovirus B19

Rubella

Variola

SARS

Meningococcus

Influenza

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Influenza: Model for the Worst Possible Vaccine

Needs to be given annually

Covers anticipated strains only

Only 60-80%+ effective against selected strains

Hurts but does not cause influenza

Does not prevent other URI

© 2013 Lippincott Williams & Wilkins, Inc.  Published by Lippincott Williams & Wilkins, Inc. 2

Table 2

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Scenario #3

The same nurse transferred to the emergency room

He is exposed to a series of persons with influenza who were not isolated

Per EHS records, he was vaccinated for seasonal flu 2 months ago

Scenario #3: You Should:

1. Not worry – he’s vaccinated

2. Give him antiviral PEP regardless of vaccine status

3. Give him flu vaccination again

4. Check his influenza serostatus

5. Turn off your beeper and go back to sleep

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Scenario #3: You Should:

1. Not worry – he’s vaccinated

2. Give him antiviral PEP regardless of vaccine status

3. Give him flu vaccination again

4. Check his influenza serostatus

5. Turn off your beeper and go back to sleep

Occupationally-Acquired Infections in HCW

TB

Measles

Varicella

Pertussis

Mumps

Influenza

RSV

Parvovirus B19

Rubella

Variola

SARS

Meningococcus

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Vaccinia

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Benjamin Jesty62

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MyocarditisMilitary and civilian experience

About 1 per 1500 vaccinations

All male primary vaccinees in military Rate at 1 in 800

Mostly female revaccinees in civilian program

Most have recovered

Long-term consequences not known

Case definition remains very difficult

Vaccination Needs in HCW, 2012

• BloodborneHIV, hepatitis B, hepatitis C, CMV, Ebola

• Airborne or DropletTB, measles, varicella, pertussis, mumps, influenza, RSV, parvovirus B19, rubella, variola, SARS, meningococcus

• Fecal-Oralsalmonella, hepatitis A, helicobacter, Norwalk

• Directscabies, lice, herpes simplex

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Work Restrictions for HCW’s Exposed to or Infected with Vaccine-Preventable Diseases

Problem Restriction DurationMumpsActive Exclude 9 days after onset of parotitisExposure (Ab-) Exclude 12th day after initial exposure till

26thday after last exposure PertussisActive Exclude Beginning of catarrhal stage

through 3rd week after onsetof paroxysms or until 5 daysafter start of effective Abx

Exposure (Ab-)Symptoms Exclude 5 days after start of effective AbxNo symptom None If on Abx

Work Restrictions for HCW’s Exposed to or Infected with Vaccine-Preventable Diseases

Problem Restriction DurationRubellaActive Exclude 5 days after rash appears Exposure (Ab-) Exclude 7th day after initial exposure till 21st

day after last exposure VaricellaActive Exclude Until all lesions crust/dry Exposure (Ab-) Exclude 10th day after exposure till 21st day

(extend to 28d if VZIG used) ZosterActive Cover; no “high Same as varicella

-risk” patients Exposure (Ab-) Exclude Same as varicella

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Conclusions

Hospitals remain slightly unsafe places to work in

Healthcare workers do not avail themselves of useful vaccinations

There will always be another disease with potential risk