CDC guidance for 'non-routine' vaccines

The Centers for Disease Control and Preven tion has issued comprehensive guidelines for immunizing health care workers against occupational infections, including a section on vaccines that should be considered only in special circumstances.1

Every medical facility or health department that provides direct patient care is encouraged to formulate a comprehensive immunization policy for all health care workers, the CDC reminds. "Consistent immunization programs could substantially reduce both the number of susceptible health care workers in hospitals and health departments and the attendant risks for transmission of vaccine-preventable diseases to other workers and patients," the CDC emphasizes. "In addition to health care workers in hospitals and health departments, these recommendations apply to those in private physicians' offices, nursing homes, schools, and laboratories, and to first responders."

The recommendations for administration of vaccines and other immunobiologic agents are in three broad disease categories:

· those for which active immunization is strongly recommended because of special risks for health care workers (i.e., hepatitis B, influenza, measles, mumps, rubella, and varicella);

· those for which immunization of all adults is recommended (i.e., tetanus, diphtheria, and pneumococcal disease).

· those for which active and/or passive immunization of health care workers may be indicated in certain circumstances (i.e., tuberculosis, hepatitis A, meningococcal disease, typhoid, vaccinia).

Concerning the special circumstances category, the CDC guidance included the following recommendations:

Tuberculosis: BCG vaccination of health care workers should be considered on an individual basis in health care settings only when all of the following conditions are met:

· A high percentage of TB patients are infected with Mycobacterium tuberculosis strains that are resistant to both isoniazid and rifampin.

· Transmission of such drug-resistant M. tuberculosis strains to workers is likely.

· Comprehensive TB infection-control precautions have been implemented and have not been successful.

Vaccination with BCG should not be required for employment or for assignment in specific work areas. BCG is not recommended for use in HIV-infected people or people who are otherwise immunocompromised. Health care workers considered for BCG vaccination should be counseled regarding the risks and benefits of both BCG vaccination and preventive therapy.

Hepatitis A virus: Routine pre-exposure HAV vaccination of health care workers and routine immune globulin (IG) prophylaxis for hospital personnel providing care to patients with hepatitis A are not indicated. Rather, sound hygienic practices should be emphasized. Staff education should emphasize precautions regarding direct contact with potentially infective materials (e.g., hand washing). In documented outbreaks of hepatitis A, administration of IG to people who have close contact with infected patients (e.g., health care workers, other patients) is recommended. A single intramuscular dose (0.02 mL per kg) of IG is recommended as soon as possible and at two weeks after exposure. The usefulness of HAV vaccine in controlling outbreaks in health care settings has not been investigated.

Meningococcal disease: Routine vaccination of health care workers is not recommended. Health care workers who have intensive contact with oropharyngeal secretions of infected patients and who do not use proper precautions should receive antimicrobial prophylaxis with rifampin (or sulfonamides, if the organisms isolated are sulfonamide-sensitive). Ciprofloxacin and ceftriaxone are reasonable alternative drugs; ceftriaxone can be administered to pregnant women. Vaccination with quadrivalent polysaccharide vaccine should be used to control outbreaks of serogroup C meningococcal disease. Surveillance for serogroup C disease and calculation of attack rates can be used to identify outbreaks and determine whether use of meningococcal vaccine is warranted.

Vaccinia: Vaccinia vaccine is recommended only for the few people who work with ortho poxviruses such as laboratory workers who directly handle cultures or animals contaminated or infected with vaccinia. Physicians and nurses whose contact with these viruses is limited to contaminated materials (e.g., dressings) and who adhere to appropriate infection control measures are at lower risk for accidental infection than laboratory workers, but may be considered for vaccination. When indicated, vaccinia vaccine should be administered every 10 years. Vaccinia vaccine should not be administered to immunocompromised people (including people infected with HIV), people who have eczema or a history of eczema, or to pregnant women.

Reference

1. 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 1997; 46(No.RR-18)1-42.