It has been said that sanitation and vaccination have made the two greatest contributions to the health of mankind. This importance is mirrored within healthcare institutions. For healthcare personnel (HCP) and for their patients, sanitation (better known within hospitals as hygiene or infection control) may be the first line of defense against infectious agents, but HCP vaccination is an essential second line of defense to prevent spread of infection from patients to HCP, among HCP, and from HCP to patients.
Accordingly, ensuring the immunity of HCP to infection or disease caused by relevant infectious agents is an essential component of any healthcare institution’s occupational health program, to accomplish two fundamental legal and moral duties: protection of the workers from the risks of the workplace, and protection of the patients from the risks posed by infectious HCP.
High rates of immunity among HCP are required if patients are to be protected from infection spread by HCP, as even a single infected worker can expose many patients. Unfortunately, it has proven impossible to attain the necessary high vaccination rates through purely voluntary programs. Screening has repeatedly shown substantial proportions of hospital staff to be susceptible to vaccinepreventable diseases, in the absence of a policy requiring immunity. For example, numerous studies of hospital workers in the early 1990s showed that 5% to 10% were susceptible to measles, despite national recommendations regarding measles immunity (1, 2, 3, 4and5). Indeed, the last major outbreaks of measles in the United States were predominantly fueled by spread within healthcare institutions. As cohorts born after the disappearance of epidemic measles enter the workforce, the proportion susceptible will increase unless immunity is confirmed and vaccinations provided to the susceptible. For example, a recent study reported that 9% of adult HCP hired at a cancer hospital between 1998 and 1999 were seronegative for measles antibody, compared with 4% of those of the same age hired between 1983 and 1988 (6).
The problem of continued HCP susceptibility to vaccinepreventable diseases is not, of course, limited to measles. Even following adoption by the Occupational Safety and Health Administration (OSHA) of the Bloodborne Hazard Standard, with its requirement to offer hepatitis B vaccine to all exposed workers, substantial numbers of healthcare workers (HCWs) remain susceptible (particularly physicians, who typically are not employees and thus not subject to the standard). Similarly, surveys of HCP have reported low rates of acceptance of influenza immunization. Selected studies of hepatitis B and influenza vaccine coverage rates are shown in Table 75-1 (7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22and23,24,25,26,27).
Many institutions (and some jurisdictions) have adopted policies requiring the demonstration of immunity to selected diseases as a condition of service in various capacities or units. Although the proportion of institutions with such policies continues to increase, as recently as 1995, a survey of children’s hospitals showed the following frequency of policies requiring measles, mumps, rubella, and varicella vaccination: medical students, 47% to 74%; resident physicians, 70% to 91%; hospital-based physicians, 40% to 55%; and private or community-based physicians, only 15% to 26% (28).
Although one might argue that it is the worker’s right to decline vaccination and accept the risk of infection, no one would argue that the worker has a right to infect patients. Accordingly, we consider “informed refusal” of vaccination to be permissible only for infections that are not expected to place the patient at jeopardy. (For employees, hepatitis B has been placed in this category as a matter of law by the Bloodborne Hazards Standard, despite numerous outbreaks of healthcare provider-topatient transmission of hepatitis B; but physicians typically are not employees, and vaccination can be made a condition of admitting or other privileges, even if not a condition of employment.) For those vaccine-preventable infections among HCP that place patients at risk, we urge the adoption of policies that make demonstrated immunity (or valid medical waiver) a condition of employment (or privileges) in positions that would place the patient at risk in the event of HCP infection.
ORGANIZATION OF THE IMMUNITY (VACCINATION) PROGRAM
As alluded to above, it is important that the occupational health team understand that they need to operate an immunity program, not simply a vaccination program. The goal is to identify the susceptibilities of the workers to relevant infections and to take such steps (typically, vaccination) as may be appropriate to ensure their continued immunity.
TABLE 75-1 Hepatitis B and Influenza Vaccine Coverage of HCP: Selected Studies
The services provided by the institution, and the characteristics of the patient populations served, need to be considered in determining these policies. Some infections (e.g., rubella and varicella) are much more likely to be associated with serious complications in adult HCP, and at the same time some infections that are common and often minor among HCP can be life threatening to patients with underlying chronic illnesses (e.g., influenza), immunosuppression (e.g., vaccinia), etc. The presence of special programs or populations (e.g., transplant units) will further alter the nature and scope of the vaccination and immunity policies. With these considerations in mind, the institution must decide which of the infections with potential for spread to, or through, HCP, warrant monitoring of HCP immunity; which warrant offering of immunization to the susceptible (with the option to decline); and which warrant mandatory immunization (or demonstrated immunity).
The institution has no obligation under the Occupational Safety and Health Act with respect to workers (e.g., volunteers, medical or other students, contract workers, etc.) who are not employees. Unfortunately, because microbes are unaware of this legal nuance, patient protection requires that the institution’s vaccination and immunity policy apply to all workers, irrespective of their employment status, including workers with direct patient care responsibilities (e.g., nurses, respiratory technicians, physical therapists, physicians, students), workers without direct patient care responsibilities (e.g., environmental service workers, security), contract or service workers, and emergency medical personnel.
All HCP new to a healthcare facility should receive a prompt review (within 10 working days) of their immunity with respect to vaccine-preventable diseases. Immunity is most commonly demonstrated by written documentation of immunization; for those persons requesting exemption on the basis of natural infection, serologic documentation of immunity should be required (the predictive value of a physician diagnosis is no longer adequate, given the current rarity of these diseases). Unless immune, the HCP should be appropriately immunized. As a general rule, serologic screening for immunity before immunization is neither necessary nor cost-effective. However, healthcare facilities might find certain screening programs to be costeffective, given the cost of the screening test, the cost of the vaccine, and the prevalence of immunity in the local HCP population. In addition, facilities might wish to permit screening at the worker’s request (either at the institution’s or the worker’s expense).
The institution may also wish to make available to HCP vaccinations that are not necessary for the protection of patients but that are indicated for other reasons. For example, the establishment and maintenance of immunity to diphtheria and tetanus toxins is universally recommended, and ensuring the timely provision of tetanus and diphtheria toxoid (Td; or, if not previously received, tetanus, diphtheria, and acellular pertussis [Tdap]) boosters through the occupational health service will eliminate concerns about tetanus prophylaxis in the event of (possibly unreported) occupational injury.
When vaccines are provided, appropriate information should be recorded in the employee’s medical record (Table 75-2) and tracked electronically (either through a computerized employee vaccination registry or an electronic medical record). Computerized records greatly facilitate recall for boosting and identification of susceptibles in the event of an exposure or outbreak. Signed informed consent (or refusal, if appropriate) specific to each vaccine should be obtained before immunization. Vaccine information statements (29) must be provided for vaccines covered by the National Childhood Vaccine Injury Act (including measles, mumps, rubella, polio, diphtheria, tetanus, pertussis, hepatitis A, hepatitis B, Haemophilus influenzae type b, influenza, human papillomavirus, meningococcal conjugate, pneumococcal conjugate, and varicella vaccines). Vaccine information statements are also available for yellow fever and smallpox vaccines. Clinically significant or unexpected adverse events occurring after immunization should be reported to the Vaccine Adverse Events Reporting System (30), as should any event listed by the vaccine manufacturer as a contraindication to subsequent doses of vaccine OR any event listed in the Reportable Events Table (available at http://www.vaers.hhs.gov/reportable.htm) that occurs within the specified time period after vaccination.
TABLE 75-2 Data to Record When Providing Vaccines to HCP
Employee name
Employee identification number
Date of birth
Signed informed consent (or refusal, if relevant)
Date of immunization (or refusal)
Vaccine provided (or declined)
Name of vaccine manufacturer
Lot number of vaccine
Site of immunization
Route of immunization
Date of next scheduled dose or booster (if applicable)
Adverse events (if any)
Name, title, and address of person providing vaccine
The immunization status of all HCP should be recorded in their employee medical record. A mechanism should be established to track immune status, including the need for and timing of repeat immunization, with effective recall and enforcement provisions.
VACCINES RECOMMENDED FOR HEALTHCARE WORKERS: GENERAL GUIDELINES
Recommendations regarding the vaccination of HCP have been issued by the Centers for Disease Control and Prevention (CDC) and its advisory bodies, the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC) (31, 32, 33, 34, 35, 36 and 37), the American College of Physicians (ACP) (38), the American Academy of Pediatrics (39), and others (40, 41and42,43). Many of these recommendations are updated periodically (see Table 75-3 for online sources of information).
All HCP should be immune to mumps, measles, rubella, varicella, and pertussis, and all HCP with potential exposure to blood or body fluids should be immune to hepatitis B (Table 75-4). Influenza vaccine should be offered to all HCP yearly (and strongly encouraged, if not mandated). In special circumstances, HCP or laboratory personnel should be offered immunization with other vaccines, including (no longer recommended) hepatitis A, quadrivalent meningococcal, inactivated poliomyelitis, rabies, typhoid, and vaccinia (Table 75-5).
Before the administration of any vaccine, the HCP should be evaluated for the presence of any condition that is listed as a vaccine contraindication or precaution (44). If such a condition is present, the risks and benefits of vaccination need to be carefully weighed by the healthcare provider and the employee. The most common contraindication is a history of an anaphylactic reaction to a previous dose of the vaccine or to a vaccine component. Factors that are not contraindications to immunization include the following: breast-feeding or household contact with a pregnant woman (exception: vaccinia); reaction to a previous vaccination consisting only of mild-to-moderate local tenderness, swelling, or both, or fever less than 40.5°C; mild acute illness with or without low-grade fever; current antimicrobial therapy (except for oral typhoid vaccine) or convalescence from a recent illness; personal history of allergies (except a history of an anaphylactic reaction to a vaccine component); and family history of allergies, adverse reactions to vaccination, or seizures (38).
TABLE 75-3 Online Sources for Current Vaccine Information and Vaccination Recommendations
General Information Concerning Vaccines and Vaccine-Preventable Diseases
CDC: http://www.cdc.gov/nip/vaccines
Allied Vaccine Group: http://www.vaccine.org/
American Academy of Pediatrics Childhood Immunization Support Program: http://www.cispimmunize.org/index.html
ACIP, Advisory Committee on Immunization Practices; CDC, Centers for Disease Control and Prevention; HICPAC, Hospital Infection Control Practices Advisory Committee.
Special Conditions
HCP who are immunocompromised, pregnant, or have certain underlying chronic diseases can pose special considerations in the provision of immunizations (Table 75-6) (45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58and59). Some routinely recommended vaccines (especially live virus vaccines such as measles, mumps, rubella, and varicella) may be contraindicated, and some vaccines that are not routinely recommended for HCP may be indicated (e.g., pneumococcal, meningococcal, and H. influenzae type b vaccines). In addition, for some indicated vaccines, higher antigen doses or postimmunization serologic evaluation may be indicated (e.g., hepatitis B vaccine in people with renal failure). When an otherwise mandatory vaccine is contraindicated for a given HCP, the worker should be individually evaluated for the possibility of altering his or her assignment to reduce risk to patients or to the HCP. The decision to reassign such a worker should be made in consultation with the employee.
Pregnancy Immunization of pregnant HCP raises a number of issues. For some live-attenuated and all inactivated or toxoid vaccines, the risks from immunization during pregnancy are largely theoretical (36,38). For such vaccines, the benefit of immunization outweighs the potential risks for adverse reactions, especially when the risk of exposure is high, infection would pose a special risk to the mother or fetus, and the vaccine is unlikely to cause harm. Furthermore, newer information continues to confirm the safety of vaccines given inadvertently during pregnancy.
No reliance should be placed on the presumption that certain vaccines “must have” been given in childhood or adolescence. HCP come from many countries, with differing vaccination programs; many children fail to receive various “routine” vaccinations, either through inadvertence or deliberate avoidance; and even if vaccinated, immunity may not have been produced. Accordingly, reliance should be placed only on objectively verifiable records of vaccination or serological assay. It is especially important that serological proof of immunity be obtained for all HCP without documentation of two separate vaccinations with rubella-containing vaccine, given the concern for both the worker and the patient populations regarding the consequences of this infection on the fetus.
Because of the theoretical risks, live attenuated viral vaccines (mumps, measles, rubella, and varicella) should be deferred for pregnant women. Pregnant HCWs may receive combined tetanus and Td (36,60). All women who are pregnant or will be pregnant during influenza season should receive influenza immunization (61). If otherwise indicated, susceptible pregnant women may receive hepatitis A, hepatitis B, inactivated influenza, meningococcal, pneumococcal, rabies, typhoid Vi polysaccharide, and inactivated poliomyelitis vaccines (formulations containing trace or no thimerosal are preferable, when available) (36). Breast-feeding does not adversely affect the response to immunization and is not a contraindication for any of the currently recommended vaccines. The indications for using immune globulins in pregnant women are the same as those for women who are not pregnant.
USE OF VACCINES FOR POSTEXPOSURE PROPHYLAXIS OR OUTBREAK CONTROL
Those who have had to respond to the spread within their institution of a vaccine-preventable illness understand quite clearly how preferable it is to have previously vaccinated their HCP. The virtual impossibility of identifying and immunizing susceptible HCP sufficiently rapidly during an outbreak of measles, mumps, rubella, or varicella to avoid spread to another generation of susceptible HCP or patients offers a powerful inducement for policies requiring immunity before assignment to duty. Moreover, these vaccines are not known to provide protection when given to a susceptible person following exposure. In contrast, tetanus toxoid (Tdap is preferred, if not previously received) (62,63), hepatitis B vaccine (64), vaccinia (53), and rabies vaccine (49) are effective when given promptly following exposure, and hepatitis A vaccine may provide at least partial protection (65). Varicella vaccine may provide protection if given within 72 hours of exposure, but it should not be relied on to prevent further transmission by exposed HCP because of incomplete efficacy (66). Immunization of HCP with hepatitis A, meningococcal, or acellular pertussis vaccine may be indicated to control an institutional or community outbreak. In the event of widespread influenza activity, additional supplies of influenza vaccine may be difficult to obtain, adding further importance to a robust annual influenza vaccination program. Outbreaks of measles or polio are now highly unlikely (except, perhaps, in distinct communities that reject vaccination), but either would trigger large-scale immunization drives. Finally, passive vaccination with immunoglobulin is useful for postexposure prophylaxis for hepatitis A, hepatitis B, measles, rabies, tetanus, varicella, and vaccinia. Unfortunately, postexposure prophylaxis (vaccine and/or immunoglobulin) is not available to prevent rubella or mumps following an exposure.
TABLE 75-4 Vaccines Strongly Recommended for All Persons Who Provide Healthcare to Patients or Who Work in Institutions that Provide Healthcare
Vaccine
Recommendation
Schedule (Adults)
Major Contraindications
Special Considerations
Hepatitis B
All HCPs at risk for exposure to blood or body fluids. Vaccinate unless laboratory evidence of immunity or prior receipt of three doses of vaccine with an appropriate schedule is documented.
1.0 mL IM (deltoid) at 0, 1, 6 mo; booster doses not necessary
Hypersensitivity to common baker’s yeast.
Prevaccination serologic screening is not necessary. Perform postvaccination serologic testing for HCPs at high risk for continued exposure. HCPs who have contact with patients or blood should be tested 1-2 mo after vaccination to determine response (see text).
Influenza
All HCPs should receive annual seasonal influenza vaccine. Consideration should be given to requiring vaccination (unless appropriately exempted) as a condition of presence within the healthcare institution. The Schedule and Contraindications shown are for trivalent inactivated vaccine (see Special Considerations).
0.5 mL IM yearly
Hypersensitivity to eggs (or thimerosal, for formulations containing thimerosal). No evidence exists of risk to mother or fetus when the vaccine is administered to a pregnant woman.
Trivalent inactivated vaccine is preferred over live attenuated intranasal vaccine for immunization of HCPs, due to the theoretical risk of spread to immunosuppressed and other at-risk patients.
Measles
All HCPs (including those born before 1957) who cannot document either receipt of two doses of live vaccine on or after their first birthday or laboratory evidence of immunity should receive a total of two doses of vaccine. MMR is preferred unless immunity to mumps and rubella is documented.
0.5 mL SC, second dose at least 1 mo later
Pregnancy; hypersensitivity to gelatin, neomycin, or eggs; immunocompromised statea; recent receipt of immunoglobulin.
Persons vaccinated during 1963-1967 with a killed measles vaccine alone, killed vaccine followed by live vaccine, or with a vaccine of unknown type should be revaccinated with 2 doses of live measles virus vaccine.
Mumps
Vaccinate (2 doses) unless born before 1957, laboratory evidence of immunity or laboratory confirmation of disease, or prior receipt of 2 doses of vaccine is documented. MMR preferred unless contraindicated or immunity to measles and rubella is documented.
0.5 mL SC, no booster
Pregnancy; hypersensitivity to gelatin, neomycin, or eggs; immunocompromised statea; recent receipt of immunoglobulin.
For unvaccinated personnel born before 1957 who lack laboratory evidence of mumps immunity or laboratory confirmation of disease, healthcare facilities should consider (and during an outbreak should require) 2 doses of vaccine.
Pertussis
Recommended for all persons aged 11-65 who have not yet received a dose. All HCP with direct patient contact should receive Tdap as soon as feasible.
0.5 mL IM. Booster schedule not yet determined, but likely will be similar to Td.
Hypersensitivity to any component of the vaccine.
Rubella
Vaccinate unless male born before 1957b, laboratory evidence of immunity or laboratory confirmation of disease, or prior receipt of vaccine. MMR is preferred unless contraindicated or immunity to measles and mumps is documented.
0.5 mL SC, no booster
Pregnancy; hypersensitivity to gelatin or neomycin; immunocompromised statea; recent receipt of immunoglobulin.
For unvaccinated personnel born before 1957 who lack laboratory evidence of rubella immunity or laboratory confirmation of disease, healthcare facilities should consider (and during an outbreak should require) 1 dose of vaccine.
Varicella
All personnel should have evidence of immunity (see Special Considerations). Vaccinate unless physician-diagnosed disease, laboratory evidence of immunity or disease, or prior receipt of vaccine is documented. A personal history of disease is not acceptable unless reviewed and confirmed as unambiguous by a healthcare professional.
0.5 mL SC, second dose 4-8 wk later if ≥13 y of age
Pregnancy; hypersensitivity to gelatin or neomycin; immunocompromised statea; recent receipt of immunoglobulin. Avoid salicylate use for 6 wk after vaccination.
Susceptibles can be identified by serotesting all HCPs or only those with a negative or uncertain history of chickenpox; or, institutions may simply immunize all those with a negative or uncertain history.
Note: The package insert and ACIP recommendations should be consulted for specific guidance regarding indications, storage, administration, precautions, and contraindications.
aPersons immunocompromised because of immune deficiency diseases, human immunodeficiency virus infection, leukemia, lymphoma or generalized malignancy, or immunosuppressed as a result of therapy with corticosteroids (i.e., ≥2 mg/kg body weight or 20 mg/day of prednisone for ≥2 wk, alkylating drugs, antimetabolites, or radiation). Also see Table 75-6.
bMany authorities would also vaccinate males born before 1957 unless immunity is demonstrated.
IM, intramuscularly; MMR, measles, mumps, and rubella vaccine; SC, subcutaneously.
The following subsections provide additional information regarding the vaccine-preventable diseases for which immunization of HCP is recommended, either universally (Table 75-4) or in special circumstances (Table75-5). For each vaccine, administration schedules and contraindications are summarized in these tables, and recommendations concerning immunization of healthcare workers with special conditions are provided in Table 75-6. Management of the vaccine-preventable diseases themselves and management of exposures to those diseases (other than postexposure vaccination) are covered in detail in other chapters, to which readers will be referred.
TABLE 75-5 Vaccines that May Be Indicated for HCP or Laboratory Personnel
Vaccine
Recommendation
Schedule
Major Contraindications
Special Considerations
BCG (for tuberculosis prevention)
Indicated for HCPs only in localities where
(a) multidrug-resistant tuberculosis is prevalent;
(b) ongoing transmission to HCPs exists; and (c) full implementation of infection control precautions has been inadequate in controlling the spread of infection.
One percutaneous dose of 0.2-0.3 mL, given by multipuncture device; no booster recommendation
BCG vaccination of US HCP is discouraged as it would interfere with subsequent PPD screening programs and can result in complications.
Hepatitis A
Not routinely indicated for HCP. Persons who work with HAV-infected primates or with HAV in a research laboratory setting should be vaccinated.
Two 1.0-mL doses IM, 6-18 mo apart (Vaqta) or 6-12 mo apart (Havrix)
History of anaphylaxis to a previous dose; hypersensitivity to latex or neomycin.
Meningococcal (serogroups A, C, Y, W135)
Not routinely indicated for HCP except personnel with laboratory or industrial exposure to N. meningitidis aerosols. May be useful during an outbreak due to a type included in the vaccine. Conjugate preferred (see Special Considerations).
0.5 mL IM; consider booster dose within 3 (polysaccharide) to 5 (conjugate) y if exposure continues
Conjugate: known history of Guillain-Barré Syndrome or latex allergy.
Polysaccharide: Sensitivity to thimerosal (used in multidose presentation only) or to latex.
Although conjugate vaccines are not yet licensed for those >55 y, they have important immunological advantages and off-label use should be considered.
Poliomyelitis
All persons should be immune. Immune status should be confirmed for HCPs in close contact with people who may be excreting wild virus and laboratory personnel handling specimens that may contain wild virus.
Unimmunized adults: two doses of IPV given SC 4-8 wk apart, followed by a third dose at 6-12 mo
Hypersensitivity to 2-phenoxyethanol, formaldehyde, neomycin, streptomycin, or polymyxin B.
Use only IPV. OPV can, rarely, result in paralysis of recipients or their contacts (OPV is not available in the United States).
Rabies
Not routinely indicated for HCP except personnel working with rabies virus or infected animals in diagnostic or research activities
Preexposure: 1.0 mL IM on days 0, 7, and 21 or 28. Follow standard guidelines for postexposure prophylaxis
Imovax: None.
RabAvert (PCEC):
Hypersensitivity to bovine gelatin, chicken protein, neomycin, chlortetracycline, or amphotericin B.
Postexposure prophylaxis boosters may be required despite primary immunization
Typhoid
Not routinely indicated for HCP except laboratory personnel who frequently work with Salmonella typhi
One 0.5-mL dose IM (Vi polysaccharide vaccine); booster doses of 0.5 mL every 2 y; or
Four oral doses (Ty21a) on alternate days; revaccinate with the entire 4-dose series every 5 yr
History of severe local reaction or anaphylaxis to a previous dose of vaccine. Ty21a should not be administered to immunosuppresseda persons or to persons receiving antimicrobials.
Do not use the killed whole-cell vaccine.
The Vi polysaccharide vaccine (Typhim VI) may be preferable because Ty21a (Vivotif) is a live attenuated product that poses a theoretical risk of transmission to patients by recently immunized HCPs.
Vaccinia
Not routinely indicated for HCP except personnel who directly handle cultures or animals contaminated with recombinant vaccinia or orthopox viruses (monkeypox, cowpox) that infect humans, or as part of “Pre-Event Vaccination Program” (see Special Considerations).
One dose administered with a bifurcated needle; boosters every 10 y
Pregnancy; breastfeeding; history of eczema in worker or close family contacts; other acute, chronic, or exfoliative skin conditions; immunosuppression in vaccine recipient or household contact; hypersensitivity to polymyxin B, streptomycin, tetracycline, neomycin, glycerin, or phenol.
Vaccine is available only from CDC Drug Services.
A bioterrorism-related “Pre-Event Vaccination Program” was conducted among HCP in 2002 and early 2003 but is currently inactive.
Notes:
1. Excluded are vaccines not currently available in the United States for civilian use (e.g., anthrax, plague).
2. This table only considers indications related to occupational exposures of HCPs; these and other (e.g., Td, pneumococcal, etc.) vaccines may be indicated for persons, whether HCP or not, who meet certain exposure or risk criteria.
3. ACIP recommendations and the current package insert for the selected product should be consulted for specific guidance regarding indications, storage, administration, precautions, and contraindications.
aPersons immunocompromised because of immune deficiency diseases, human immunodeficiency virus infection, leukemia, lymphoma or generalized malignancy, or immunosuppressed as a result of therapy with corticosteroids (i.e., ≥2 mg/kg body weight or 20 mg/day of prednisone for ≥2 wk, alkylating drugs, antimetabolites, or radiation).
(Adapted from Centers for Disease Control and Prevention. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 1997; 46(RR-18):7-9.)
In addition to those vaccines discussed below, there are other vaccines that are indicated only in certain parts of the world (e.g., Japanese encephalitis, tick-borne encephalitis, yellow fever) or that have no recognized application for HCWs (Hib, HPV, rotavirus); they are not discussed further.
Hepatitis A Vaccine
Background Hepatitis A virus (HAV) is highly endemic in the United States, with 13,397 cases (4.91 cases per 100,000) reported to the CDC in 1999 (67), a figure that probably represents <10% of actual infections. The incidence of HAV varies by race (among US residents highest in Native Americans and Native Alaskans), location (in the United States higher west of the Mississippi River), and age. Globally, incidence and median age of onset are closely related to socioeconomic and developmental status, with higher rates and lower median ages of onset in less-developed countries. In the United States, schoolchildren 5 to 14 years of age have the highest reported incidence. However, infection in infants and young children often is asymptomatic, so the age distribution of reported cases may not be representative of the underlying age distribution of infection. Sources of infection include household or sexual contact with a person with HAV (22-26% of reported cases), with a child or employee in a day-care center (14-16%), or with an international traveler (4-6%) (68). The majority of cases are sporadic, with no identified source. Food- or waterborne outbreaks classically account for only 2% to 3% of cases, but are becoming more common with globalization of the US food supply.
Hepatitis A results in substantial morbidity with significant costs caused by medical care and lost work time. Approximately 11% to 22% of people who develop recognized hepatitis A require hospitalization (54). In the United States, an estimated 100 deaths per year are attributable to acute hepatitis A (there is no chronic infection).
Healthcare-Associated Outbreaks Although several cohort studies have failed to demonstrate HCP to be at increased risk for hepatitis A compared with control populations (69, 70, 71and72), some European researchers have reported that HCP had higher than expected rates of seropositivity to hepatitis A (73,74). A number of healthcare-associated outbreaks of HAV have been reported (75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90and91). These reports suggest a common set of circumstances: a source patient who was not jaundiced, in whom hepatitis was not suspected, and who had fecal incontinence or diarrhea. Risk factors for HAV transmission to personnel include activities that increase the risk of fecal-oral contamination, including caring for a person with unrecognized HAV infection (77, 78, 79, 80, 81, 82, 83and84); sharing food, beverages, or cigarettes with patients, their families, or the staff (78,84, 85and86); nail biting; handling bile without proper precautions (84); and not washing hands or wearing gloves when providing care to an infected patient (81,82,84,85) (see also Chapters 46 and 73).
TABLE 75-6 Recommendations Concerning Immunization of HCP with Special Conditions
Note: The package insert and ACIP recommendations should be consulted for specific guidance regarding indications, precautions, and contraindications.
aSevere immunosuppression can be the result of congenital immunodeficiency; HIV infection, leukemia, lymphoma, generalized malignancy, or therapy with alkylating agents, antimetabolites, radiation, or large amounts of corticosteroids.
bRecommendation is based on the person having the indicated underlying condition, not their status as HCP.
cRecommended for all women who are pregnant or will be pregnant at any time during the influenza season.
dBecause of the theoretical risk of transmission to patients of the live attenuated agent contained in this vaccine, use of the alternative inactivated vaccine is preferred.
eGenerally contraindicated in persons with HIV infection; recommended for children (no official recommendation for serosusceptible adults) with CD4+ >200/µL; consider reimmunization if initial immunization was given when CD4+ <200/µL and if CD4+ increases to ≥200 µL due to highly active antiretroviral therapy.
fAll persons, whether HCP or not, should be immune unless specifically contraindicated.
gImmunization with IPV is recommended for unvaccinated HCP who have close contact with persons who may be excreting wild poliovirus.
HCP who have a primary series of OPV or IPV who are directly involved with the provision of care to patients who may be excreting poliovirus may receive another dose of IPV. Except in the context of mass immunization to control circulating wild polio, use only IPV; OPV can, rarely, result in paralysis of recipients or their contacts (OPV is not available in the United States).
BCG, bacille Calmette-Guérin; HIV, human immunodeficiency virus; IPV, inactivated poliovirus vaccine; MMR, measles-mumps-rubella vaccine; R, recommended; C, contraindicated; UI, use if indicated.
(Adapted and expanded from Centers for Disease Control and Prevention. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR Recomm Rep 1997;46(RR-18):30.)
Vaccination Although current recommendations do not support routine immunization of United States HCP except in areas where hepatitis A is highly endemic (31), costbenefit analyses have suggested that the cost of hepatitis A vaccination in HCP, per life-year saved, was similar to that of other standard medical interventions (92). As with other special use vaccines, HCP should be encouraged to review with their local medical provider their own risks and benefits for hepatitis A vaccine.
Hepatitis B Vaccine
Background Exposure to blood-borne pathogens via parenteral or mucosal contact can expose HCP to the risk of acquiring numerous infections, foremost among these (in terms of risk, prevalence, and aggregate burden) being hepatitis B. Seroprevalence surveys conducted prior to the availability of hepatitis B virus (HBV) vaccine showed HCP to be at threefold to fivefold higher risk of HBV infection than the general US population (93, 94, 95and96), with the risk of infection proportionate to the extent and duration of blood contact. The use of HBV vaccine among HCP, coupled with the institution of Universal (now Standard) Precautions and other preventive measures such as needleless devices and safety needles and syringes (e.g., self-sheathing needles), has markedly reduced that risk. Mahoney et al. (12) reported that HBV infection among HCP declined from 17,000 in 1983 to 400 in 1995. This 95% decline in incidence observed among HCP was 1.5-fold greater than the reduction in incidence in the general US population during the same time period.
Healthcare-Associated Exposures HCP are at risk of hepatitis B acquisition for several reasons. First, HCP have high rates of exposure to blood (97). For example, a 1988 survey of New York City surgeons found that 86% had at least one puncture injury in the preceding year (98). A survey of US and Canadian orthopedic surgeons in 1991 found that 87.4% had a blood-skin contact and 39.2% a percutaneous blood contact in the previous month (99). Second, the virus can persist in the environment, being able to survive drying and storage at 25°C and 42% relative humidity for at least 1 week (100). Third, HBV is highly transmissible; the titer of infectious particles is extraordinarily high in the blood of actively infected persons. Consequently, rates of disease transmission after a percutaneous injury with a contaminated sharp range from 6% to 30% (101, 102and103). HBV infection also can be acquired via mucosal exposure, exposure to nonintact skin, or ocular exposure (68), and has been transmitted to patients by a worker with severe exudative dermatitis while obtaining arterial blood gases (104). Fourth, a substantial number of patients have inapparent infections; for example, a study of consecutive blood samples submitted to the chemistry laboratory of an urban hospital in 1987 revealed that only 28% of hepatitis B surface antigen (HBsAg)-positive specimens were labeled with a biohazard label as required (105). Finally, many HCP remain unimmunized.
Many outbreaks of healthcare provider-to-patient transmission of hepatitis B have been described (106, 107, 108, 109and110). Transmission typically occurs during an invasive procedure, with the most important risk factors being e-antigen positivity of the HCP, degree of invasiveness of the procedure, the infected HCP not wearing gloves, or injury (often inapparent) to the infected HCP (see also Chapters 46, 73, and 76).
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