Physician Protect Thyself (and Your Patients and Coworkers)!

By Stan Deresinski, MD, FACP, FIDSA, Clinical Professor of Medicine, Stanford University, Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center, is Editor for Infectious Disease Alert.

Source: Centers for Disease Control and Prevention. Immunization of Health-Care Personnel Recommendations of the Advisory Committee on Immunization Practices (ACIP). Recommendations and Reports. MMWR Morb Mortal Wkly Rep 2011:60 (RR07);1-45.

The Advisory Committee on Immunization Practices (ACIP) of the CDC has updated their recommendations for immunization of health care providers (HCP) against communicable infectious diseases.1 These recommendations apply, but are not limited, to HCP in acute-care hospitals, long-term-care facilities (e.g., nursing homes and skilled nursing facilities), physician's offices, rehabilitation centers, urgent care centers, and outpatient clinic,s as well as to persons who provide home health care and emergency medical services. Evidence indicates that HCP are considered to be at substantial potential risk for acquiring or transmitting hepatitis B, influenza, measles, mumps, rubella, pertussis, and varicella and much of the focus of the recommendations deals with these infections.

Vaccines for HCP Because of the Potential of Occupational Exposure of HCP or of Patients.

Recommendations for immunization of HCP were last published by CDC in 1997. The following is a summary of important changes made in the new document. The original document should be consulted for full details.

Hepatitis B Virus (HBV).

HCP and trainees in certain populations at high risk for chronic HBV infection (e.g., those born in countries with high and intermediate endemicity) should be tested for HBsAg and anti-HBc/anti-HBs to determine infection status.

Influenza.

Emphasis is placed on a recommendation that all HCP, not just those involved in direct patient care, should receive an annual influenza vaccination.

Institutions should develop comprehensive programs designed to increase vaccine coverage among HCP. Influenza vaccination rates among HCP within facilities should be measured and regularly reported.

Measles, Mumps, Rubella (MMR).

A history of prior infection in the absence of laboratory confirmation is no longer considered adequate presumptive evidence of measles or mumps immunity for HCP. Laboratory confirmation of disease was added as acceptable presumptive evidence of immunity. Of note is that a past history of disease has never been considered adequate evidence of immunity to rubella.

A change has been made in the footnotes regarding recommendations for personnel born before 1957 in both routine and outbreak contexts. Specifically, guidance is provided for 2 doses of MMR for measles and mumps protection and 1 dose of MMR for rubella protection in the absence of written documentation of vaccination adequate vaccination or laboratory evidence of immunity, or birth before 1957.

Pertussis.

HCP, regardless of age, should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap.

The previously recommended minimal interval was removed, and Tdap can now be administered regardless of the interval since the last receipt of tetanus or diphtheria-containing vaccines.

Hospitals and ambulatory-care facilities should provide Tdap for HCP and use approaches that maximize vaccination rates.

Varicella Zoster.

Criteria for evidence of immunity to varicella were established for HCP and they include

Written documentation of receipt of 2 doses of vaccine,

Laboratory evidence of immunity or laboratory confirmation of disease,

A documented diagnosis of a history of varicella disease made by a HCO, or diagnosis of history of herpes zoster by a HCP.

Meningococcus.

HCP with anatomic or functional asplenia or persistent complement component deficiencies should now receive a 2-dose series of meningococcal conjugate vaccine. HCP with HIV infection who are vaccinated should also receive a 2 dose series.

Those HCP who remain in groups at high risk should be revaccinated every 5 years.

Other Vaccines Recommended for Adults, Whether HCP or Not.

Certain vaccines are recommended for adults based on age or other individual risk factors but not because of occupational exposure and should be considered by HCP. Vaccine-specific ACIP recommendations should be consulted for details on schedules, indications, contraindications, and precautions for these vaccines. Thus, the infections prevented are not generally considered to cause significant risk of transmission from patient to HCP nor the reverse.

Pneumococcal polysaccharide vaccine (PPSV). PPSV is recommended for healthy persons aged ≥65 years. PPSV is also recommended for persons aged <65 years with certain underlying medical conditions, including anatomic or functional asplenia, immunocompromise (including HIV infection), chronic lung, heart or kidney disease, and diabetes.

Tetanus and diphtheria toxoids (Td). All adults should have documentation of having received an age-appropriate series of Td-containing vaccine and a routine booster dose every 10 years. Persons without documentation of having received a Td series should receive a 3-dose series. The first dose of the series should be administered as Tdap (see Pertussis above).

Human papillomavirus (HPV) vaccine. Either quadrivalent HPV vaccine (Gardasil) or bivalent HPV vaccine (Cervarix) is recommended for females at age 11 or 12 years with catch-up vaccination recommended through age 26 years. Quadrivalent HPV vaccine (Gardasil) may be administered to males aged 9-26 years.

Zoster vaccine. Zoster vaccine contains the same live attenuated varicella zoster virus as varicella vaccine but at a higher concentration (approximately 14 times more vaccine virus per dose). Zoster vaccine is recommended for the prevention of HZ (shingles) in persons aged ≥60 years. Transmission of vaccine virus from the recipient to a contact has not been reported. Consequently, limiting or restricting work activities for persons who recently received zoster vaccine is not necessary.

Hepatitis A vaccine. HCP have not been demonstrated to be at increased risk for hepatitis A virus infection because of occupational exposure, including persons exposed to sewage. Hepatitis A vaccine is recommended for person with chronic liver disease, international travelers, and certain other groups at increased risk for exposure to hepatitis A.

Catch-Up and Travel Vaccination

Programs should be implemented designed to enhance the safety of HCP and patients by systematically assuring that HCP are up-to-date on all vaccinations and that they receive appropriate preparation before travel to regions in which they may be at increased risk of certain infections.

Catch-Up Programs.

Managers of health-care facilities should implement catch-up vaccination programs for HCP who already are employed, in addition to developing policies for achieving high vaccination coverage among newly hired HCP. HCP vaccination records could be reviewed annually during the influenza vaccination season or concurrent with annual TB testing. This strategy could help prevent outbreaks of vaccine-preventable diseases. Because education, especially when combined with other interventions such as reminder/recall systems and low or no out-of-pocket costs, enhances the success of many vaccination programs, informational materials should be available to assist in answering questions from HCP regarding the diseases, vaccines, and toxoids as well as the program or policy being implemented. Conducting educational workshops or seminars several weeks before the initiation of a catch-up vaccination program might promote acceptance of program goals.

Travel.

Hospital personnel and other HCP who perform research or health-care work in foreign countries might be at increased risk for acquiring certain diseases that can be prevented by vaccines recommended in the United States (e.g., hepatitis B, influenza, MMR, Tdap, poliovirus, varicella, and meningococcal vaccines) and travel-related vaccines (e.g., hepatitis A, Japanese encephalitis, rabies, typhoid, or yellow fever vaccines). Elevated risks for acquiring these diseases might stem from exposure to patients in health-care settings (e.g., poliomyelitis and meningococcal disease) but also might arise from circumstances unrelated to patient care (e.g., in areas of high endemicity of hepatitis A or after exposure to arthropod-vector diseases [e.g., yellow fever]). All HCP should seek the advice of a health-care provider familiar with travel medicine at least 4-6 weeks before travel to ensure that they are up to date on routine vaccinations and that they receive vaccinations recommended for their destination. Although bacille Calmette-Guérin vaccination is not recommended routinely in the United States, HCP should discuss potential beneficial and other consequences of this vaccination with their health-care provider.

Work Restrictions of Susceptible HCP.

Work restrictions for susceptible HCP (i.e., no history of vaccination or documented lack of immunity) exposed to or infected with certain vaccine-preventable diseases can range from restricting individual HCP from patient contact to complete exclusion from duty. A furloughed employee should be considered in the same category as an employee excluded from the facility.

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 Morb Mortal Wkly Rep 1997;46(No.RR-18).

Summary of Recommendations
(For complete recommendations, see original publication)

Vaccination

Indications

HBV

Prexposure: HCP at risk for exposure to blood & body fluids; Postexposure for selected individuals

Influenza

All HCP (absent allergy to eggs or vaccine). HCP who care for severely immunosuppressed persons who require a protective environment should receive inactivated rather than live attenuated vaccine

Measles

Recommended for all HCP who lack presumptive evidence of immunity without contraindications including relevant severe allergy, pregnancy & immunocompromise; vaccination should be considered for those born before 1957

Mumps

Recommended for all HCP who lack presumptive evidence of immunity without contraindications including relevant severe allergy, pregnancy & immunocompromise

Rubella

Recommended for all HCP who lack presumptive evidence of immunity without contraindications including relevant severe allergy, pregnancy & immunocompromise

Tetanus, Diphtheria, Pertussis (Tdap)

Recommended for all HCP absent serious allergic reaction (i.e., anaphylaxis) to any component of Tdap

Varicella

Recommended for all HCP who lack presumptive evidence of immunity without contraindications including relevant severe allergy, pregnancy & immunocompromise. Avoid salicylate use for 6 weeks after vaccination.

Quadrivalent Meningococcal

Microbiologists with potential exposure

Typhoid

Microbiologists with potential exposure; no oral vaccine (Ty21a) for immunompromised or those receiving antibiotics

Inactivated Polio

Adults at increased risk of exposure absent allergy to components

Source: Centers for Disease Control and Prevention