Tdap for Health Care Workers

By Carol A. Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center.

Dr. Kemper does research for Abbott Laboratories and Merck. This article originally appeared in the August 2011 issue of Infectious Disease Alert. At that time it was peer reviewed by Timothy Jenkins, MD, Assistant Professor of Medicine, University of Colorado, Denver Health Medical Center. Dr. Jenkins reports no financial relationship to this field of study.

Source: ACIP Provisional recommendations for health care personnel on use of tetanus toxoid, reduced diptheria toxoid, and acellular pertussis vaccine (Tdap) and use of post-exposure antimicrobial prophylaxis. Available at: www.cdc.gov/vaccines/recs/provisional/default/htm.

Add Tdap to the growing list of recommended (and often required) vaccinations for health care workers (HCWs) in hospital, including MMR, hepatitis B, influenza, and possibly varicella. In April, the American College of Immunization Practices (ACIP) issued provisional recommendations for pertussis vaccination (Tdap) of all hospital HCWs, regardless of age and prior vaccine history (i.e., regardless of the time since last Td dose). Current hospital employees (and future hires) should receive a single dose of vaccine now, in one broad sweep to provide blanketed coverage of every hospital, and then continue to receive the usual booster vaccine recommended for adults.

Pertussis appears to be cycling up in our communities, especially in California, where 8,383 cases were reported in 2010, including 10 deaths in infants. Neonates and infants < 12 months of age are at the greatest risk for severe infection. For this reason, initial ACIP recommendations were to provide vaccination to all caregivers of small children, thus providing a protective "cocoon" of immunogenic individuals. The current recommendations expand on this philosophy, especially to physicians and nurses who provide care for infants and small children.

HCWs are at risk for pertussis exposure — both from their patients and fellow colleagues. Outbreaks of pertussis in the hospital setting can rapidly evolve, resulting in significant hours and effort to provide post-exposure prophylaxis to everyone exposed. Those who develop symptoms of pertussis are required to receive antibacterial therapy and are furloughed for a minimum of 5 days. In two separate outbreaks in Minnesota, 12% and 52% of cases occurred in HCWs who were exposed to either an ill index case or to each other. At our county hospital in the 1990s, an outbreak of a pertussis-like illness (pre-PCR test availability) necessitated the administration of chemoprophylaxis to more than 400 HCWs; a supreme effort over a Memorial Day weekend, with significant cost to the hospital.1

HCWs who have received Tdap vaccine nonetheless require close monitoring for signs and symptoms for 21 days after pertussis exposure. Post-exposure prophylaxis is still recommended for vaccinated HCWs with documented exposure. Even mild respiratory symptoms (e.g., runny nose, sneezing, low grade fever, or cough) should prompt PCR testing for pertussis, receipt of antibiotics, and furlough from work for 5 days. The paroxysmal stage of pertussis, with the characteristic cough, generally only begins 1-2 weeks into the illness.

Reference

1. Martinez SM, et al. Azithromycin prophylaxis during a hospitalwide outbreak of a pertussis-like illness. Infect Control Hosp Epidemiol 2001;22:781-783.