HCW pertussis vaccination lags
Outbreaks continue throughout U.S.
For the past 10 years, the United States has been wrestling with a resurgence of pertussis as outbreaks strike in different states. In 2013, cases subsided in most of Minnesota, but spiked in Texas and North Carolina, for example. California reported 2,372 cases, 132 hospitalizations and one death — of a two-month-old.
But one thing has changed little in the last few years: Pertussis vaccination of health care workers. By 2012, only about 31% of health care workers had received the recommended one-time booster Tdap, which protects against pertussis as well as tetanus and diphtheria.1 That was just a slight increase from a rate of 27% in 2011, as reported by the Centers for Disease Control and Prevention.2
"Every institution ought to think about this very seriously and ought to have a [pertussis vaccination] program," says William Schaffner, MD, professor of preventive medicine at Vanderbilt University in Nashville, TN, and past president of the National Foundation for Infectious Diseases. "At the least, emergency, pediatrics and obstetrics [personnel] ought to be thoroughly covered."
Schaffner notes that infants and children, who are the most vulnerable, may be seen in other units as well, such as orthopedics.
More than 24,000 pertussis cases were reported to CDC last year. But the American College of Occupational and Environmental Medicine (ACOEM) notes that those reports are "only the tip of the iceberg" and the actual number of annual cases is likely to be a million or more. In a position statement, ACOEM advised occupational health providers "to assign high priority to vaccinating health care workers as soon as feasible."
Should vaccination be mandatory?
Late last year, some leading infectious disease organizations raised the ante by stating that all recommended vaccines should be mandatory for health care workers if voluntary programs fail to achieve 90% vaccination coverage.
Citing the premise of "Do no harm," the organizations said that "Mandatory immunization programs are necessary where voluntary programs fail to maintain adequate HCP vaccination rates." The joint position statement was issued by the Infectious Diseases Society of America (IDSA), the Society for Healthcare Epidemiology of America (SHEA), and the Pediatric Infectious Diseases Society (PIDS). (See HEH, January 2014, p.1)
At about $40 a dose, a sudden move to mandatory vaccination of all employees could be quite expensive, particularly at a time of diminished resources. But some hospitals have begun to promote Tdap, with a special focus on units that treat pregnant women and children.
Tampa (FL) General Hospital offers Tdap to all newly hired employees and at each annual visit to employee health. Clinical employees who choose not to receive the vaccine must sign a declination. Last year alone, the hospital gave almost 1,000 Tdap vaccines.
JoAnn Shea, MSN, ARNP, director of employee health and wellness, promotes the vaccine in units that treat women and children, including labor & delivery, neonatal intensive care, and pediatrics. In those units, more than 70% of employees have had a Tdap booster.
"We tell employees that pertussis in children is normally acquired from an adult. They may be asymptomatic and not know they have pertussis," Shea says.
In Wisconsin, which had a major pertussis outbreak in 2012, the Marshfield Clinic made all recommended vaccines mandatory, with exceptions for medical contraindications and strongly held religious beliefs. The state reported almost 6,500 confirmed and probable cases of pertussis in 2012, including three infant deaths.
"We have all these facilities that are mandating flu [shots] but they’re not mandating pertussis," says Bruce Cunha, RN, MS, COHN-S, manager of Employee Health and Safety. "Why would you do one and not the other?"
Barriers to vaccination
Why don’t health care workers get the Tdap vaccine? The reasons may be similar to those who decline the influenza vaccine — fear of needles, concern about side effects, distrust of vaccines.3
A study of 2011 National Health Interview Survey data found that physicians were somewhat more likely than nurses to receive the pertussis vaccine (41.5% versus 36.5%). Vaccination rates varied from 30% to barely 12% for other health care workers.4
Educating employees and encouraging vaccination can be effective, says William Buchta, MD, MPH, medical director of the Employee Occupational Health Service at the Mayo Clinic in Rochester, MN, where about 80% of employees have received the pertussis vaccine.
He notes that pertussis is highly contagious — but not easily identified in adults. "It tends to look like any other respiratory illness during the time you’re infectious," he says. "For most adults, it’s a bad cold and a long cough."
The Tdap vaccine has a couple of caveats. Health care workers who have a known exposure to pertussis and contact with patients who are at risk of severe illness (such as pregnant women and infants) should receive post-exposure prophylaxis with antibiotics — even if they were vaccinated, CDC says. Other health care workers — vaccinated or not — should either receive post-exposure antibiotics or be monitored for symptoms and be treated, if necessary, for 21 days after exposure.
Meanwhile, CDC has been studying the Tdap effectiveness over time, in the wake of reports of waning immunity. Health care workers will likely need an additional Tdap booster at some interval, possibly every 10 years, the ACOEM statement says.
"Although we recognize that the vaccine has limitations, it remains the best way to prevent pertussis," Schaffner says.
- Centers for Disease Control and Prevention. Noninfluenza Vaccination Coverage Among Adults — United States, 2012. MMWR 2014; 63:95-102.
- CDC. Noninfluenza Vaccination Coverage Among Adults — United States, 2011. MMWR 2013; 62:66-72.
- Top KA, Halperin BA, Baxendale D, et al. Pertussis immunization in paediatric healthcare workers: Knowledge, attitudes, beliefs, and behavior. Vaccine 2010; 28:2169-2173.
- Lu PJ, Graitcer SB, O’Halloran A, et al. Tetanus, diphtheria and acellular pertussis (Tdap) vaccination among healthcare personnel-United States, 2011. Vaccine 2014; 32:572-578.