Take a sneak peek at updated vaccination guide

CDC to publish immunization recommendations

Guidelines for immunizing health care workers are being updated by the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, and by the CDC’s Hospital Infection Control Practices Advisory Committee.

While the guidelines will not be published until later this year, Hospital Employee Health has gleaned a preliminary view of the standards, based on information from Raymond A. Strikas, MD, a medical epidemiologist in the CDC’s National Immunization Program, and from a published report on the standards.1

One major change is that HCWs born before 1957 no longer are automatically considered immune to measles.

Following are three sections of the guidelines and the preliminary recommendations:

Section 1 — Diseases for which immunization is strongly recommended (because HCWs are at significant risk for acquiring or transmitting these diseases)

Hepatitis B: The federal Occupational Safety and Health Administration’s bloodborne pathogens standard requires that hepatitis B vaccine be made available free of charge to HCWs with "reasonably anticipated ... contact with blood or other potentially infectious materials."2

Preliminary recommendations for this section include:

• Vaccinate HCWs who have contact with blood or blood-contaminated body fluids, other body fluids, or sharps.

• Ideally, vaccination should be completed during professional training.

• Prevaccination serologic screening is not indicated unless considered cost-effective.

• Hepatitis B immune globulin (IG) prophylaxis and vaccine should be used when indicated (e.g., following needlesticks).

• Post-vaccination serologic testing to determine response is recommended.

Influenza:

• Offer vaccine before influenza season to all personnel who attend high-risk patients.

• Particularly emphasize care providers to high-risk groups, such as adults and neonatal intensive care units and medical/surgical units.

• Vaccinate workers with high-risk conditions.

Measles, mumps, rubella (MMR):

• All HCWs with patient contact should be immune.

• Most people born before 1957 probably are immune, but up to 9.3% of hospital workers have been documented as susceptible to measles. From the 1985-1989 time span, 29% of all HCW measles cases were among persons born before 1957.

• All HCWs are considered immune to measles and mumps only if they have documented physician-diagnosed disease, or laboratory evidence of immunity, or documented two doses of live measles vaccine, or documented one dose of live mumps vaccine.

• All HCWs are considered immune to rubella only if they have documented laboratory evidence of immunity or documented one dose of live rubella vaccine.

• Hospitals should consider recommending a dose of MMR vaccine to unvaccinated workers born before, in, and after 1957 who cannot provide the documentation specified above.

Varicella:

• Vaccinate susceptible HCWs who have close contact with people at high risk for serious complications, such as immunocompromised people, premature infants born to susceptible mothers, and infants born at less than 28 weeks’ gestation or who weigh 1,000 grams or less.

• Serologic screening before vaccinating is not recommended unless considered cost-effective.

• Routine post-vaccination testing is not recommended.

• Develop guidelines for managing vaccinated HCWs following exposure to natural varicella.

• Develop guidelines for managing vaccinees due to the risk for transmitting vaccine virus.

Tuberculosis and hepatitis C also are discussed in separate categories. Here are those preliminary findings:

Tuberculosis:

• Consider giving bacille Calmette-Guerin (BCG) vaccine on an individual basis when there is a high percentage of TB patients infected with strains resistant to isoniazid and rifampin, transmission of drug-resistant strains to HCWs and infection are likely, or comprehensive TB infection control precautions have not been successful.

• BCG is not recommended for HIV-infected workers.

• Counsel HCWs considered for vaccination on the following points: the risks and benefits of BCG vaccination and preventive therapy, variable data on vaccine efficacy, interference with diagnosing newly acquired infection, possible serious complications in immunocompromised people, lack of efficacy data on preventive therapy for multidrug-resistant TB, and risks of drug toxicity with multidrug regimens.

Hepatitis C:

• No vaccine against hepatitis C is currently available.

• Immune globulin does not protect against HCV infection and is not recommended postexposure.

• Provide HCWs up-to-date information on the risks and prevention of all bloodborne pathogens.

• Consider policies/procedures for HCW follow-up after exposures to anti-HCV-positive blood.

• No current recommendations exist regarding restriction of HCV-infected HCWs.

Section 2 — Other diseases for which immunoprophylaxis is or may be indicated

Hepatitis A:

• Routine hepatitis A vaccination is not indicated.

• Routine IG prophylaxis of HCWs providing care to patients with HAV infection is not indicated.

• In outbreaks, use IG in workers who have close contact with infected patients.

Meningococcal disease:

• Routine vaccination is not recommended.

• HCWs who have intensive contact with oropharyngeal secretions of infected patients and who do not use proper precautions should receive antimicrobial prophylaxis with rifampin.

• Meningococcal immunization should be used to control serogroup C outbreaks whenever unusual disease clustering occurs.

Pertussis:

• Vaccines currently are licensed only for use in children six weeks to six years old.

• If acellular pertussis vaccines become licensed for adults, booster doses of adult formulations may be recommended for HCWs.

Vaccinia:

• Vaccine is recommended only for those working with orthopoxviruses, but may be considered for other HCWs whose contact with those viruses is limited to contaminated materials.

• Vaccine should not be used for immunocompromised workers, workers with eczema or a history of eczema, or pregnant workers.

Section 3 — Other vaccine-preventable diseases

Tetanus, diphtheria, and pneumococcal disease:

• HCWs are not at substantially greater risk than the general population for acquiring these diseases.

• If immunizations are administered, it should be through the HCW’s primary provider.

Immunization of immunocompromised HCWs is also addressed in the guidelines. Killed or inactivated vaccines generally are considered safe, but live virus or live bacterial vaccines should not be given. Unless severely immunosuppressed, workers with HIV infection should be given MMR vaccine if needed.

It is recommended that non-immune HCWs be relieved from direct patient care following exposure to hepatitis B, upper respiratory infections, measles, mumps, rubella, pertussis, varicella, and zoster.

Also discussed are outbreak control, with a recommendation for developing comprehensive policies/protocols for management and control; catch-up vaccination programs, which should be considered for HCWs already employed; and immunization records, which are necessary for all HCWs and should be regularly updated to document illnesses and immunizations.

The complete guidelines will be published in an upcoming Morbidity and Mortality Weekly Report.

References

1. Richards CA. ACIP adopts guidelines on immunizing HCWs. Infect Dis Child 1997; 10:29,34.

2. U.S. Department of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens; Final rule. 56 Fed Reg 64,004-64,182 (1991).