Vaccinate health care workers first in pandemic flu outbreak
Vaccinate health care workers first in pandemic flu outbreak
HCWs are essential to maintain health care
If pandemic influenza strikes, health care workers with patient contact should be the top priority for vaccination, two federal advisory panels have recommended.
Keeping health care workers on the job will be critical if the nation’s health care system is stressed by a new influenza strain, the Advisory Committee on Immunization Practices (ACIP) and the National Vaccine Advisory Committee (NVAC) agreed in a July meeting. As Hospital Employee Health went to press, the final pandemic influenza preparedness plan was expected to be released soon.
"Our group really thought that preserving the health care worker work force was a key to reducing all types of mortality, not just influenza-related mortality," explains Michele Pearson, MD, medical epidemiologist at the Centers for Disease Control and Prevention (CDC) in Atlanta, who headed a subgroup of infection control experts who considered pandemic influenza vaccine priorities.
"Health care workers were really essential not only for taking care of influenza patients and reducing hospitalizations and deaths related to that, but also for other patients who may be in the hospital," she says.
The likely scenario for a pandemic is bleak. Some 25% to 30% of the U.S. population will become sick, influenza experts predict. Each wave of a flu outbreak in a community will last six to eight weeks, and there may be more than one wave.
The range of influenza-related hospitalizations and deaths could vary substantially, says Carolyn Bridges, MD, a CDC medical epidemiologist and flu expert. But the most vulnerable often are infants, the elderly, and those with more than one high-risk medical condition.
Yet as past pandemics have shown, healthy children and adults also can be stricken. "At the peak of a pandemic, 10% of workers or more may be out of work on a given day," Bridges says. The duration of illness for an uncomplicated case of influenza would be five days, she notes.
Antiviral medications will be an important component of a response to pandemic influenza, and again, health care workers will be a high- priority group. After all, although animal trials are under way in the development of a vaccine against avian influenza, H5N1, currently there is no vaccine available.
"It’s possible the pandemic may be going on for some time before we have vaccine available," Bridges adds.
Hospitals and public health departments will need an efficient mechanism for delivering the vaccine — if and when it becomes available.
About 9 million health care workers have direct patient contact or are involved in essential support positions and would need the vaccine, according to CDC estimates. They would require two doses to develop an immune response.
The NVAC agreed unanimously that the federal government should purchase all pandemic influenza vaccine to streamline access.
ACIP and NVAC approved a tiered priority schedule for vaccination, which assumes that limited vaccine would be available at the start of a pandemic. Only vaccine produced in the United States is expected to be used here, as other countries would seek to safeguard their supplies, Bridges explains.
The priorities are:
• Tier 1A: Health care workers with direct patient contact, as well as those personnel involved in manufacturing the vaccine. They include "essential support personnel" at hospitals, such as laboratory, dietary, and blood collection. Tiering assumes that two-thirds of health care workers would need to be vaccinated, which would require one month’s supply of the current manufacturing capability of influenza vaccine. FluMist, the intranasal vaccine that uses live, attenuated virus and is produced by Gaithersburg, MD-based MedImmune Inc., could be used by healthy health care workers.
• Tier 1B: Those 65 and older who have at least one high-risk medical condition and younger people with two or more high-risk conditions.
• Tier 1C: Household contacts of infants younger than 6 months and immunocompromised individuals and pregnant women.
• Tier 1D: Key public leaders.
• Tier 2A: All other high-priority groups — people older than 65 who do not have a high-risk medical condition or younger people with only one health risk.
• Tier 2C: People involved with key infrastructure, such as transportation, utilities, and public safety.
• Tier 3: Other key government decision makers and mortuary workers.
• Tier 4: The rest of the population, with the goal of providing vaccine to all Americans who want to be vaccinated.
Bridges notes that the 1918 pandemic, unlike epidemics or other pandemics, resulted in high mortality rates among young adults. "We may reorder any tier based on the epidemiology of the pandemic," she says.
Vaccination will not be the answer for everyone. In long-term care, infirm residents are at high risk, yet they may have a low immune response to the vaccine, influenza experts say. They will be a target for antiviral medications, the panels agreed.
Oseltamivir is effective in reducing complications and deaths related to influenza when administered within 24 hours of onset of symptoms, says NVAC member Andrew Pavia, MD, professor in the department of pediatrics, division of infectious diseases, at the University of Utah School of Medicine in Salt Lake City.
Patients hospitalized with influenza would be the top priority for antiviral treatment because of their risk of death from influenza complications, the NVAC agreed.
Because of the likely delay in vaccine availability, prophylactic use of antivirals could be a consideration for emergency department (ED), intensive care unit (ICU), and emergency medical service personnel, explains Ben Schwartz, MD, senior science adviser in the National Vaccine Program Office. To prevent pandemic influenza, health care workers would need a once-a-day treatment for six weeks.
But the supply of antivirals also will be a concern. The U.S. government stockpile contains only 2.3 million courses of treatment with oseltamivir (Tamiflu), a neuraminidase inhibitor that is considered more effective and less susceptible to resistance than older versions of antivirals. More has been ordered, but it’s not yet clear how large the stockpile will be, Schwartz adds.
"There is currently no production of neuraminidase inhibitors in the United States." He notes that domestic manufacture is expected by late 2005, but will produce only 15 million courses per year. "Stockpiled drugs will be the major source of supply," Schwartz adds.
Even if that stockpile is greatly expanded within the next year or two, it would not be sufficient to be used for prophylaxis and could not prevent the spread of influenza in the community, Pavia notes.
The second-highest priority for antiviral use would be for treatment of health care workers with direct patient contact and emergency medical service personnel who develop influenza symptoms.
Pavia adds that the prophylactic use of antivirals among health care workers ranked higher in Canadian preparedness plans. But in the U.S. priorities approved by NVAC, prophylactic treatment of ED and ICU staff would be the seventh priority level — only if enough antiviral medication was available.
"While you would lose a few days of productivity, you would likely prevent deaths and hospitalizations [due to pandemic influenza] very effectively," he explains.
While ACIP and NVAC set priorities for vaccination, logistical issues remain unanswered. For example, a representative of Becton, Dickinson & Co. of Northfield, IL, advised the panels that syringes currently are produced and supplied for just-in-time delivery. Stockpiling syringes and other ancillary products would be necessary to provide the supplies needed to administer millions of doses of vaccine.
If pandemic influenza strikes, health care workers with patient contact should be the top priority for vaccination, two federal advisory panels have recommended. Keeping health care workers on the job will be critical if the nations health care system is stressed by a new influenza strain, the Advisory Committee on Immunization Practices (ACIP) and the National Vaccine Advisory Committee (NVAC) agreed in a July meeting.Subscribe Now for Access
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