Health Care Professionalsand Immunization

Ben J. K. Tan, MD, FRCPC

Assoc Prof, University of Saskatchewan

Infectious Diseases, RUH

Saskatoon, SK

Declaration:

Not speaking as a member of NACI

“Organized” Immunization

Occupational HealthInfection Control

Infectious Diseases

University/CollegeStudent Health

Physician/Nurse

Public HealthFamily Physician

Pediatrician

HCW|

Student

Patients

Outbreaks

Immunization Schedule, Child (mod from CIG 2006)Vaccines B 2m 4m 6m 12m 18m 23m 2y 4y 9y 12y 14y 18y

DTaP-IPV (im)#1 #2 #3 #4

#5

Hib (im)

Tdap (im) #1

Pneu-C-7 (im) #1 #2 [#3] #4 1d (HR)

Men-C-C (im) #1 #2 #3 or#1 CU – 1 dose

MMR (sc) #1 #2 OR #2

Var (sc) #1 CU – 1 dose (if susceptible) CU-2 doses

Inf (im) 2d in 1st yr, 1d in 2nd yr Yearly doses for HR, rest encouraged

HBV (im) 3d, preferably @ B,1m,6m OR 2-3d

HPV (im, females) 3 doses @ 0, 2m, 6m

RV (po) #1 #2 #3 Do NOT use RV after 32 wks of age

BCG (id, HR com) #1

HAV (im, HR com) 2 doses 6m apart (HR)

Pneu-P-23 (sc) 2 doses, 3-5y apart (HR)

Men-C-ACWY (sc) Single dose after 2 yrs of age (HR)

Immunization Schedule, Adult (mod from CIG 2006)Vaccines 18y 24y 26y 30y 35y 40y 45y 50y 54y 55y 60y 65y 70y

Tdap (im) Single dose (if not received in Gr 8) to replace one Td booster

Td (im) Booster doses q10y

Pneu-P-23 (im) Single dose for HR under 65y #1 #2

Inf (im) Yearly dose for HR, rest encouraged Yearly

HPV (im, females)3 doses @ 0,2m,6m

Var (sc) susceptible CU – 2 doses, 4w apart

Zos (sc) N/A as yet Single dose

Men-C-C (im) CU–1 dose

Men-C-ACYW (im) Single dose after 2 yoa (HR or based on disease epid)

Vaccines below the gray line are either:- Not yet available in Canada.- Not publicly-funded by most provinces or territories.- Meant for high-risk (HR) persons. CU = catch-up (if not previously immunized)

http://www.phac-aspc.gc.ca/im/ptimprog-progimpt/table-1_e.html

http://www.who.int/immunization_monitoring/en/globalsummary/scheduleselect.cfm

Factors to consider in HCW vaccination• HCW is member of the general public:

– General population risk for infectious diseases.

– No risk for diseases which occur only/mainly in childhood.

• Vaccinate to prevent waning immunity (maintaining high immunity levels).

• Risk of:

– Exposure to infected patients (differs in various health-care professions).

– Infecting others, including patients and own family members.

SK cohorts reaching 20 yrs of age q5y# vaccine doses 2000 2005 2010 2015

Diph-Tet (1959) 6 6 6 6

Pert (aP 97;ap 01) wP-5 wP-5 wP-5; ap-1 wP-4;aP-1;ap-1

Polio (IPV 6/94) OPV-5; IPV-1 OPV-5 OPV-5 IPV-5

Hib (5/88-5/92) 0 0-1 1-4 4

Men-CC (10/04) 0 0 0 0

Pneum-C7 (4/05) 0 0 0 0

MMR (79-96-01) MMR-1 MMR-1; MR-1 MMR-1; MR-1 MMR-2

Var (12/98-1/05) 0 0 0 (1-self) 0 (1-self)

HBV (9/95) 0 3 3 2-3

HAV (8/96 HR) 0 0 0 0

Inf (10/05) Depends whether opted to get yearly dose(s)

BCG (HR only) 0 (1-HR) 0 (1-HR) 0 (1-HR) 0 (1-HR)

HCW immunity/immunization requirementsCollege Medical Nursing Lab Tech Dental Vet

MMR + + + + -

Var + + + + -

HBV + + + + -

Inf + + + + -

IPV + + + + -

Rabies - - ± - +

Td + ap + + + + +

Pneu-23 - - - - -

Men-C - - - - -

BCG - - ± - -

Entering health-care colleges

• Ensuring all recommended/required immunizations are completed.

• Screening for infectious diseases prior to entry:

– HBsAb, [HBsAg, HBc-Ab(IgG+IgM)].

• Policies (?) regarding:

– Those who decline catch-up immunizations, and

– Those previously infected with bloodborne infections.

Hepatitis B virus

• Hep B immune:

– HBsAb +ve (≥ 10 mIU/ml) documented at least once (even if subsequent level falls below 10 IU/ml).

– May develop HBsAb in response to either previous vaccination or infection (with loss of HBsAg but retaining HBcAb).

Hepatitis B virus

• Student previously unimmunized:– 2-3 doses HB vaccine.– HBsAb, [HBsAg, HBc-Ab].

• Student previously immunized in school:– HBsAb, [HBsAg, HBc-Ab].

• If HBsAb –ve, single dose HB vaccine and retest.– If still HBsAb –ve, 2 more doses of HB vaccine to

complete second series and retest; if still HBsAb –ve, stop.

• If HBsAg +ve, stop (refer back to college for counselling).

Hepatitis B markers (recovered, non-carrier)

HBsAg

HBeAg

HBcAb(IgM)

HBcAb(IgG)

HBsAb

HBeAb

Hepatitis B markers (chronic carrier, HBeAg+)

HBsAg

HBeAg

HBcAb(IgM)

HBcAb(IgG)

(HBsAb)

Symptoms

(May become –vein 10-25 years)

Hepatitis B markers (vaccinated)

Faster HBsAb

Peak HBsAb

Slower HBsAb

10mIU/ml

HBV vaccination @ 0,1,6 m

[Infected HBcAb(IgG)]

Hepatitis B profile in healthcare studentsInterpretation HBsAg HBeAg HBeAb HBcIgM HBcIgG HBsAb

Acutely infected + ± – + – –

Previously infected, chronic carrier, infectious, immune

+ – / + + / – – +– / + (<10)

Previously infected, non-carrier, immune

– – ± – + + (≥10)

Never infected, vaccinated, immune

– – – – – + (≥10)

Never infected, vaccinated, never immune

– – – – –– or + (<10)

Never infected, vaccinated, immune, waning HBsAb

– – – – –+ (≥10,

later <10)

Varicella zoster virus

• Varicella immune:

– Documentation of physician-diagnosed varicella or zoster (need letter).

– Self-reported history of varicella or zoster (difficult to verify, so best to screen serum for VZV-IgG).

– Documentation of varicella vaccination (screening for VZV-IgG post-vaccination is not necessary):

• 1 dose administered at 1-12 yrs of age (ACIP requires 2 doses; under review in Canada at present).

• 2 doses 4-6 wks apart administered at ≥ 13 yrs of age.

Varicella zoster virus

• Student unimmunized or non-immune (negative VZV-IgG):

– 2 doses of varicella vaccine, 4-6 wks apart.

– Do not check serology after vaccination (VZV-IgG test is not sensitive enough to detect antibody post-vaccination).

• Do not vaccinate:

– Pregnant students; defer until post-partum.

– If student has immunodeficiency disease.

– If student has anaphylaxis to vaccine component(s).

– If patient is on long term ASA therapy.

MMR• Measles-immune:

– Born before 1970, or – Born in or after 1970 with:

• 2 doses measles-containing vaccine, or• (Physician)/Lab-diagnosed measles infection, or• Measles IgG positive.

• Mumps-immune:– Born before 1970 (controversial), or– Born in or after 1970 with:

• At least 1 dose mumps-containing vaccine, or• (Physician)/Lab-diagnosed mumps infection, or• Mumps IgG positive.

MMR

• Rubella-immune:– Born in any year:

• At least 1 dose rubella-containing vaccine, or• Rubella IgG positive once.

• Note difference between NACI and ACIP (CDC, USA) recommendations for mumps:– ACIP requires 2 doses mumps-containing vaccine for

college students and HCWs as proof of immunity, whereas NACI currently requires 1 dose (pending investigation of 2007 mumps outbreak in NS/NB/PEI).

MMR• If immune by criteria to all three, no need to provide MMR.

• If non-immune to mumps or rubella according to NACI criteria, OR previously received only 1 dose of measles-containing vaccine:– Provide a single dose of MMR (pending outcome of

mumps outbreak investigation in NS).

• If non-immune to measles, regardless of mumps and rubella status:– Provide 2 doses of MMR 4-8 wks apart.

• No need to document measles, mumps or rubella IgG if above vaccinations are completed.

Tetanus-diphtheria ± pertussis

• Tetanus-immune:– Completed primary series (≥ 3 doses) & booster doses at 10 yr

intervals (can be verified by tetanus antitoxin level).

• Diphtheria-immune:– All considered susceptible to infection, even if fully immunized;

vaccine protects against the toxin, not infection (can be verified by diphtheria antitoxin level).

• Pertussis:– All considered susceptible since immunity wanes; last pertussis

vaccine (whole cell or acellular) dose typically at preschool, unless received Tdap in adolescence.

Tetanus-diphtheria ± pertussis

• Previously unimmunized:– 3 doses of Td (first one as Tdap) @ 0, 2, 6-12 mos; issue is cost

of the Tdap dose (not covered by prov/univ).

• Completed primary series, last booster of Td ≥ 10 yrs previously:– Single dose of Td (preferably as Tdap for additional protection

against pertussis).

• If last booster of Td was 2-9 yrs ago, and HCW wishes the additional protection against pertussis:– Single dose of Tdap (but may have greater local swelling and

pain, which reportedly does not affect limb function).

Polio

• Polio-immune:

– Documented primary series of poliovirus vaccine (≥ 4 doses in childhood; ≥ 3 doses in adolescence/adulthood).

– Serology for poliovirus serotypes 1, 2, 3 is available, but not routinely recommended as proof of immunity.

• Boosters of IPV no longer recommended for adults residing in N. America, as the western hemisphere was declared free of wild poliovirus in 1991.

– Booster only recommended for travellers to endemic areas and possibly virology lab staff.

Polio

• Previously unvaccinated:

– 3 doses of IPV @ 0, 2, 6-12 mos.

– No need to check serology post-vaccination.

Influenza

• Influenza-immune:

– Seasonal yearly immunization with the NACI/WHO- recommended trivalent influenza vaccine (A-H1N1, A-H3N2 and B) confers 6 month efficacy of 70-80% against infection by the vaccine strains (including some cross-protection against drifted A strains).

• Recommend yearly vaccination of all HCW for self-protection and protection of patient-contacts.

Rabies

• Rabies-immune:

– Completed 3 doses of rabies vaccine pre-exposure, with further 2 doses upon exposure to persons/animals with rabies (inducing adequate antibody titer).

• Not recommended for all HCW; priority for virology lab techs, vet students.

HCW and Mantoux skin testing

• Different policies in various colleges, universities and health regions (provinces) as to:– Frequency of Mantoux skin testing.

– Single-step skin-test, versus two-step (boosted) skin-test.

• TB service and OH in Saskatoon requires baseline single step skin-test for HCW, plus:– Yearly test for high-risk areas (with CXR if skin-test positive)

ER, ICUs, ORs, RRs, RT/PT, Path/Micro Lab Techs, Residents, Air Ambulance, Ambulatory/Medical Daycare).

– Repeat skin test on-exposure and F/U skin test 6 wks later.

Health care workers/students – references 1• Health Canada, Infection Control – Prevention and Control of

Occupational Infections in Health Care.– Canada Commun Dis Report Vol 28S1, Mar 2002:27-188.– Weblink

http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/02pdf/28s1e.pdf

• The Hospital Infection Control Practices Advisory Committee - Guideline for infection control in health-care personnel– Am J Infect Control 1998;26:289-354.– Weblink http://www.cdc.gov/mmwr/PDF/rr/rr5502.pdf

• Advisory Committee on Immunization Practices, CDC – Influenza vaccination of health-care personnel. – MMWR 24 Feb 2006, Vol 55, RR02. – Weblink http://www.cdc.gov/mmwr/PDF/rr/rr5502.pdf

Health care workers/students – references 2• National Advisory Committee on Immunizations, Public Health

Agency of Canada – Canadian Immunization Guide, 7th Ed, 2006.

– Weblink http://www.phac-aspc.gc.ca/publicat/cig-gci/index.html

• Advisory Committee on Immunization Practices, CDC - Immunization of Health-Care Workers.

– MMWR 26 Dec 1997; Vol 46, RR18.

– Weblink http://www.cdc.gov/mmwr/PDF/rr/rr4618.pdf

HCW immunizations algorithmReview college-entry immunization requirements:- All recommended home provincial/territorial childhood vaccines.- Varicella immunity = clinical status/previous immunization.

Serological screen/Skin test:- HBsAg, HBsAb, HBcAb (IgG and IgM); policy regarding HBsAg+.- Varicella IgG (if status unclear).- Mantoux test.

Arrange follow-up immunizations:- Catch-up missing childhood immunizations. - HBV booster or whole series (if non-immune).- Varicella immunization (if non-immune).- Next tetanus, diphtheria booster = Tdap (with acellular pertussis).- Encourage yearly influenza vaccination.

Student health (C)

Student health (B)

Student health (A)?

Vaccine-preventable disease risks to HCW

Faculty VPDRoute of infection

Need immunity

Exposure risk in general community (SK)

Medicine

Nursing

Lab Med

RT

PT/OT

Diphtheria Resp Yes Very rare

HAV Fecal-oral Not routine Rare, unless travelling

HBV Needles, sex Yes Rare, contact of carrier/IDU

Hib Resp No Very rare in adults (ped disease)

HPV Sex Yes-Female Common, personal sex contacts

Influenza Resp Yes Very common in flu season

Measles Resp Yes Rare, imported case

Meningo Resp Not routine Uncommon

Mumps Resp Yes Uncommon, US/NS outbreaks

Vaccine-preventable disease risks to HCW

Faculty VPD Occupational risk Risk to family & patients

Medicine

Nursing

Lab Med

RT

PT/OT

Diphtheria Rare, from imported case During acute illness

HAV Rare, jaundiced patient During acute illness

HBV Up to 30% w/ needlestick Acutely ill/chronic carrier

Hib No, but may carry in NP May infect children

HPV No! No!

Influenza Common, in flu season During flu illness

Measles Rare, from imported case Yes, if contact susceptible

Meningo Rare (intubating) Unknown/possible

Mumps During acute illness Yes, if contact susceptible

Vaccine-preventable disease risks to HCW

Faculty VPDRoute of infection

Need immunity

Exposure risk in general community (SK)

Medicine

Nursing

Lab Med

RT

PT/OT

Pertussis Resp Yes Increasingly common in adults

Pneumoc Resp No/Yes Common, esp w/ risk factors

Polio Fecal-oral Yes No wild-type dis in western hem

Rabies Wound No Rare (zoonoses-rac, bats, skunks)

Rotavirus Fecal-oral Not feasible Common; vaccine not for adults

Rubella Resp Yes Rare, recent ON cluster

Tetanus Wound Yes Rare, if one maintains immunity

TB Resp No BCG Common in high-risk groups

Varicella Resp Yes Common, decline after vaccin

Vaccine-preventable disease risks to HCW

Faculty VPD Occupational risk Risk to family & patients

Medicine

Nursing

Lab Med

RT

PT/OT

Pertussis During acute illness First 1-3 wks of acute illness

Pneumoc Unlikely/unknown Unlikely/unknown

Polio Rare, from imported casePossible even if asymptomatic

Rabies No, unless bitten Possible (bite, saliva)

Rotavirus During acute illness During acute illness

Rubella Rare, from imported case Yes, if contact susceptible

Tetanus No, unless bitten No

TB If actively coughing AFB Only if coughing AFB

Varicella Common, if susceptible Yes, if contact susceptible

STOP!Questions?