ACIP: Vaccinate all HCWs against pertussis

Monitoring OK for some exposed HCWs

Hospitals should provide pertussis vaccines to their health care workers free of charge, but should still treat employees with antibiotics if they have unprotected exposure to patients with pertussis and work with patients at high risk, such as young infants, a federal vaccine advisory panel says.

This recommendation represents a re-emphasis of the importance of vaccination and post-exposure prophylaxis of health care workers. "I think the big message to hospitals is to get your health care personnel vaccinated against pertussis. It's a very effective vaccine," says Alexis Elward, MD, assistant professor of pediatrics at the Washington University School of Medicine in St. Louis and a representative of the Healthcare Infection Control Practices Advisory Committee (HICPAC) to the Advisory Committee on Immunization Practices (ACIP).

ACIP had previously expanded its Tdap recommendations to include children aged 7 to 10 who aren't fully immunized and adults 65 and older who care for children. The idea is to "cocoon" infants among people who are all immunized against pertussis.

In addition, the American Nurses Association launched an awareness effort and rallied a coalition of nine leading professional organizations, including the American Medical Association and the American College of Pediatrics. They are urging family members, caregivers and health care providers of infants to receive the pertussis vaccine.

A study of two outbreaks in Minnesota found that health care workers are at risk from exposures, as well. In one outbreak, only 12% of cases were among health care personnel, but many of the exposed employees had received prophylaxis. In another outbreak, 52% of cases were among health care workers who contracted the disease from co-workers or patients. There were no cases identified of transmission from health care workers to patients.1

Pertussis epidemics are cyclical, and the disease is particularly dangerous for neonates who have not yet had their first pertussis vaccine. The Centers for Disease Control and Prevention noted the "continued resurgence of pertussis" in a February "Health Alert" that advised health care providers on using PCR tests to confirm the diagnosis. In 2010, there were 8,383 cases in California alone, including 10 deaths of infants. There also were significant outbreaks in Michigan and Ohio.

The expanded recommendations encompass all health care workers, regardless of age or when they received their last tetanus booster. Vaccination should include volunteers, especially those working in pediatric hospitals or with pediatric patients, says Elward. Tdap is recommended for women who are immediately postpartum but not for pregnant women.

Yet even vaccinated health care workers need to be evaluated for post-exposure prophylaxis, ACIP decided. An exposure is defined as being within six feet of coughing patients with pertussis for five minutes without wearing a mask.

Exposed, vaccinated health care workers can be monitored daily for 21 days for signs and symptoms rather than receiving post-exposure prophylaxis if they do not have contact with at-risk patients. Even slight respiratory symptoms should be considered a possible symptom of pertussis, says Elward. The employee would then need to be furloughed from work for five days and put on antibiotics, ACIP said.

Many hospitals may find it simpler to provide post-exposure prophylaxis to anyone who has an unprotected exposure, says William Schaffner, MD, an infectious disease expert who is chairman of the Department of Preventive Medicine at Vanderbilt University in Nashville, TN, and an ACIP representative from the National Foundation for Infectious Diseases.

There's no booster for Tdap, and it's not clear how long immunity lasts after vaccination, he notes. The bottom line: "Vaccinate everybody and if you have an exposure, give prophylaxis," Schaffner says.

Reference

1. Leekha S, Thompson RL, and Sampathkumar P. Epidemiology and control of pertussis outbreaks in a tertiary care center and the resource consumption associated with these outbreaks. Infect Control Hosp Epidemiol 2009; 30:467-473.