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Healthcare Workers Immunization

Update
Rontgene M. Solante, MD., FPCP, FPSMID
Phillipine Hospital Infection Control Society
Annual Convention
Crowne Plaza Hotel
May 27, 2016

Rontgene M. Solante, MD
Phil Society for Microbiology and Infectious Diseases (PSMID), Past
President
Global Steering Committee Member , MEDSCAPE for Pneumococcal
Disease Prevention and Education thru vaccination
Asian Advisory Board , Community Acquired Pneumonia Immunization Trial
Adults (CAPiTA) 2015
Chairman, Fellowship Program Adult Infectious Disease and Tropical
Medicine- San Lazaro Hospital
Medical Specialist III , National Reference Laboratory for HIV/AIDS San
Lazaro Hospital
Infection Control Chair: ManilaMed MCM, San Lazaro Hospital
Assistant Professor , UERMMMC
Fellow, Philippine College of Physicians and PSMID

Disclosure
Pfizer vaccines , Asian and local advisory board member
MSD vaccines Phil advisory board member
Sanofi Pasteur Phil advisory board

Objectives
Discuss the following:
Why vaccinate healthcare workers?
What are the currently recommended vaccines?

Definition: Healthcare personnel

Definition: Healthcare personnel


all paid and unpaid persons working in health-care settings who
have the potential for exposure to patients and/or to infectious
materials, including body substances, contaminated medical
supplies and equipment, contaminated environmental surfaces, or
contaminated air.
include (but are not limited to) the following
physicians, nurses, nursing assistants, therapists, technicians,
emergency medical service personnel, dental personnel, pharmacists,
laboratory personnel, autopsy personnel, students and trainees,
contractual staff
clerical, dietary, housekeeping, laundry, security, maintenance,
administrative, billing, and volunteers
risk for exposure to (and possible transmission of) vaccine-preventable diseases
1.US Department of Health and Human Services. Definition of health- care personnel (HCP). Available at
http://www.hhs.gov/ash/programs/ initiatives/vacctoolkit/definition.html. Accessed October 5, 2011

Definition: Healthcare worker

2012 Recommended Immunization for Filipino Healthcare Workers


PSMID-PHICS-PFV

Vaccines important for the HCW?


PUBLIC

PRIVATE

Informal survey conducted during the HcW annual conventions (AMHOP, PHICS)

Why vaccinate healthcare personnel?


1. Protection against vaccine preventable
diseases/infections including its complications
protection for healthy HCP
protection of at-risk HCPs (e.g. diabetes,
immunocompromised, chronic conditions)

2. Prevent transmission of VPDs to patients and other


HCPs
3. Minimize absenteeism and work flow disruption
4. Added cost for contact investigation, source of
infection, diagnostics, and antibiotic treatment and
prophylaxis

5 key recommended interventions preventing


occupational acquisition of infection by HCP
(1) adherence to standard precautions
(2) rapid institution of appropriate isolation
precautions
(3) proper use of personal protective equipment
(4) evaluation of personnel with exposure to
communicable diseases for receipt of PEP
(5) appropriate immunizations

Vaccines 6th ed. 2013 Chap 66 pp 1290-1308

Healthcare risk of vaccine preventable infections


Infectious Diseases

Healthcare risk

Hepatitis B

dependent on the frequency of percutaneous and


mucosal exposures to blood or body fluids
transmission from a needlestick exposure is up to
100 times more likely for exposure to HBeAg
positive blood than to HIV-positive blood
HBV can lead to chronic infection, which can result
in cirrhosis of the liver, liver failure, liver cancer,
and death

Influenza

risk of occupationally acquired influenza


transmitting influenza to patients and other HCP
increased risk for severe outcomes from influenza
outbreaks in hospitals and long-term care
facilities have been associated with low vaccination
rates among HCP

SAGE recommendations for


influenza vaccination (2012)
5 recommended priority groups for countries
using or considering introduction of seasonal
influenza vaccination.

Pregnant women highest priority group.


Health-care workers
Children under 5 (particularly 6-23 months)
Elderly
Underlying health conditions

Healthcare risk of vaccine preventable infections


Infectious Diseases

Healthcare risk

Measles

highly contagious transmitted by respiratory


droplets and airborne spread
severe complications, which might result in death,
include pneumonia and encephalitis
WHO estimated 20 million measles cases
occurring worldwide and approximately 164,000
related deaths
Medical settings played a prominent role in
perpetuating outbreaks of measles transmission
(1989-1991 outbreaks ; 2008 outbreaks)

Presumptive evidence of immunity to measles :


written documentation of vaccination with 2 doses of live measles or MMR
laboratory evidence of immunity
laboratory confirmation of disease, or
birth before 1957
MMWR Recommendations and Reports / Vol. 60 / No. 7 November 25, 2011

Healthcare risk of vaccine preventable infections


Infectious Diseases

Healthcare risk

Mumps

health-careassociated transmission of mumps is


infrequent, it might be underreported
added economic costs because of furlough or
reassignment of staff members from patient-care
duties or closure of wards

Pertussis

transmission has occurred from hospital visitors to


patients, from HCP to patients, and from patients
to HCP
documented outbreaks were costly and disruptive
-diagnostic testing, prophylactic antibiotics, and
exclusion from work

MMWR Recommendations and Reports / Vol. 60 / No. 7 November 25, 2011

Healthcare risk of vaccine preventable infections


Infectious Diseases

Healthcare risk

Varicella

higher proportion of VZV infections are acquired


later in life among 3rd world countries
nosocomial transmission of VZV is well recognized
and can be life-threatening to certain patients
airborne transmission from patients with either
varicella or HZ has resulted in varicella in HCP and
patients
risk for severe varicella disease with complications
pregnant women, premature infants and
immunocompromised pts

Evidence of immunity
for HCP

written documentation of vaccination with 2 doses of


laboratory evidence of immunity
laboratory confirmation of disease,
diagnosis or verification of a history of varicella disease by a
health-care provider
Diagnosis or verification of a history of HZ by a healthcareprovider

MMWR Recommendations and Reports / Vol. 60 / No. 7 November 25, 2011

Healthcare risk of vaccine preventable infections


Infectious Diseases

Healthcare risk

Meningococcal Disease

Nosocomial transmission of Neisseria meningitidis


is rare
HCP increased risk after direct contact with
respiratory secretions of infected persons (e.g.,
managing of an airway during resuscitation) and in
a laboratory setting
HCP with known HIV infection are at increased risk
for meningococcal disease

Typhoid Fever

transmitted nosocomially via the hands of infected


persons

Hepatitis A

HCP not at increased risk for hepatitis A virus infection


because of occupational exposure

MMWR Recommendations and Reports / Vol. 60 / No. 7 November 25, 2011

Guidelines and recommendations


2011 Advisory Committee Immunization
Practices (ACIP) Immunization of Health-Care
Personnel
2012 PSMID PHICS PFV Recommended
immunization for healthcare workers
2016 ACIP Updated Recommendations

2011 Immunization of Health-Care Personnel


Advisory Committee on Immunization Practices (ACIP)
Diseases for Which Vaccination Is Recommended
Hepatitis B
Influenza
Measles Mumps Rubella (MMR)
Pertussis
Varicella

Diseases for Which Vaccination Might Be Indicated in Certain Circumstances


Meningococcal
Typhoid Fever
Pneumococcal
Tetanus and Diphtheria
Human papilloma virus

Zoster

MMWR Recommendations and Reports / Vol. 60 / No. 7 November 25, 2011

2012 Healthcare Workers Vaccination Guide


Strongly recommended
Hepatitis B
Influenza
Measles Mumps Rubella (MMR)
Tetanus, Diphtheria, acellular Pertussis (Tdap)
Varicella
Recommended
Pneumococcal
Recommended for selected HCW
Hepatitis A
Meningococcal vaccine
Rabies
Typhoid vaccine

2012 Recommended immunization for healthcare workers


PSMID PHICS and PFV

2012 Healthcare Workers Vaccination Guide

2016 ACIP Healthcare personnel Vaccination Guide


Recommended
Hepatitis B
Influenza
Measles Mumps Rubella (MMR)
Tetanus, Diphtheria, acellular Pertussis (Tdap)
Varicella
HPV * (male thru age 26 years; female thru age 21 years old)
Zoster *
Recommended
Pneumococcal (PCV13; PPV23)
Hepatitis A
Meningococcal vaccine ((MenACWY) /(MPSV4)
Haemophilus influenzae type b (Hib)
Recommended for all persons who meet the age
requirement, lack documentation of vaccination, or lack
evidence of past infection; zoster vaccine is
recommended regardless of past episode of zoster

Recommended for persons with a risk


factor (medical, occupational, lifestyle,
or other indication)

2012 PSMID-PFV-PHICS

2016 ACIP

Routinely Recommended
Hepatitis B

Hepatitis B

Influenza

Influenza

Measles Mumps Rubella (MMR)

Measles Mumps Rubella (MMR)

Tetanus, Diphtheria, acellular Pertussis (Tdap)

Tetanus, Diphtheria, acellular Pertussis (Tdap)

Varicella

Varicella
Human Papilloma virus
Zoster

Not Routine Recommended but based on Risk


Pneumococcal (PPV23)

Pneumococcal (PCV13; PPV23)

Hepatitis A

Hepatitis A

Meningococcal

Meningococcal

Rabies

Hemophilic influenzae type b (Hib)

Typhoid

Recommendations on Immunization of Health Care Personnel


with Special Conditions
Pregnancy

HIV
infection
CD4 <200

Immunocom
promising
conditions

Chronic
liver ,heart
and lung
dses and
alcoholism

Asplenia and
complement
component
deficiencies

Kidney
failure, endstage renal
disease,
receipt of
hemodialysis

Diabetes

Men sex
with
men
MSM)

Influenza
Tdap
Varicella
HPV
Rabies
Zoster
MMR
Pneumococcal (PCV13
Pneumococcal (PPV23)

Hepatitis A
Hepatitis B
Meningococcal

R- recommended;

UI-use if indicated; C-contraindicated

Vaccines 6th ed. 2013 Chap 66 pp 1290-1308

Vaccine with specific indications on selected


healthcare personnel
Vaccine

Specific indications

Typhoid vaccine

Food handlers, dieticians, cooks, nutritionist


microbiologist

Meningococcal

Clinical and research microbiologists who


may be routinely exposed to isolates of
Neisseria meningitides

Rabies

Laboratory personnel or researchers who


work with rabies virus of potentially infected
animals;
PEP may be required for potential exposure
despite primary immunization

veterinarians and veterinary students,


health care workers directly involved in care of
rabies patients
individuals directly involved in rabies control, field
workers)
Vaccines 6th ed. 2013 Chap 66 pp 1290-1308

Vaccine schedule

ROUTINE ADULT VACCINATION

HEPATITIS B
Vaccine type:
Inactivated vaccine
intramuscularly (IM)
3 doses :0,1,6-12 months
Accelerated schedule
Days 0, 7, 21-30,
and at 12 months
Booster is not routinely
recommended
Vaccine efficacy:
>90% after the 3rd dose
40 y.o., <90%
60 y.o, 75%

Target individuals
Those without documented evidence of immunity to
Hepatitis B
All healthcare workers
Sexually active persons, MSMs, IV drug users,
Clients and staff members of institutions for persons
with disabilities
Travelers to countries with high or intermediate
prevalence of chronic Hepatitis B infection
Diabetics, Persons with HIV/AIDS
Chronic liver disease, Hemodialysis patients
Household contacts of HBV carrier
Recipients of blood products
Immigrants from areas of high HBsAg endemicity

2015 Schedule of Adult Immunization


Philippine Society for Microbiology and Infectious Disease (PSMID) and Philippine Foundation for Vaccination (PFV)

HEPATITIS B and HCPs


Pre-exposure

Pre-vaccination serologic testing is


indicated for HCP and is cost-effective in
certain high-risk populations regardless of
vaccination status
Post-vaccination serologic testing should be
performed for all HCP at high risk for
occupational percutaneous or mucosal
exposure to blood or body fluids
Post-vaccination serologic testing is
performed 12 months after administration
of the vaccine series
Persons determined to have anti-HBs
concentrations of 10 mIU/mL are
considered immune
If anti-HBs concentrations <10
,administration a second 3-dose series on an
appropriate schedule, followed by anti-HBs
testing 12 months
If no response, test for HBsAg and anti-HBc

Post-exposure

Vaccinated HCP with documented immunity


(anti-HBs concentrations of 10 mIU/mL)
require no postexposure prophylaxis,
serologic testing, or additional vaccination
Vaccinated HCP with documented
nonresponse to a 3-dose vaccine series
should receive 1 dose of HBIG and a second
3-dose vaccine series if the source is HBsAgpositive or known to be at high risk for
carrying hepatitis
Vaccinated HCP with documented
nonresponse to two 3-dose vaccine series
should receive 2 doses of HBIG, 1 month
apart if the source is HBsAg-positive or
known to be at high risk for carrying
hepatitis

MMWR Recommendations and Reports / Vol. 60 / No. 7 November 25, 2011

Pre-exposure
Management for
Healthcare Personnel
with a Documented
Hepatitis B Vaccine
Series Who Have Not
Had Post- vaccination
Serologic Testing

INFLUENZA
Vaccine type and schedule
2 types:
trivalent inactivated
quadrivalent inactivated
IM route
Southern Hemisphere strain
February to June, but maybe
given throughout the year.

Vaccine efficacy:
varies from year to year
age and health status of the person
similarity match between the
viruses or virus in the vaccine and
those in circulation

WHO 2016 Recommendation


It is recommended that trivalent vaccines for use
in the 2016 influenza season (southern
hemisphere ) contain the following:
an A/California/7/2009 (H1N1)pdm09-like
virus;
an A/Hong Kong/4801/2014 (H3N2)-like virus;
a B/Brisbane/60/2008-like virus.
It is recommended that quadrivalent vaccines
containing two influenza B viruses contain the
above three viruses and a B/Brisbane/60/2008like virus.

The Rationale For Quadrivalent


Influenza Vaccines (QIV)

Why is it important that an


additional B strain be added to
trivalent influenza vaccines?

Circulating Influenza B lineages


Philippines 2003-2013 and Vaccine mismatch

Source: Flunet, http://apps.who.int/globalatlas/dataQuery/default.asp, accessed January 2014

Vaccine type/route
MEASLES, MUMPS, RUBELLA (MMR)
live attenuated, SQ

Schedule
2 doses
0, 1 month interval

2-dose vaccine effectiveness of 99%


(Measles) 75-95% (Mumps), 95%
(rubella)
Tetanus, Diphtheria, acellular
Pertussis (Tdap)
- inactived, IM route

3 doses (1 Tdap + 2 Td):


0,1,6-12 months
Booster every 10 years with Td

vaccine effectiveness at 66%- 78%


VARICELLA
live attenuated, SQ
vaccine effectiveness 80% 85%

2 doses
0, 1-2 months
Post-exposure Prophylaxis
Given within 72 hours of exposure;
Single dose

2015 Schedule of Adult Immunization


Philippine Society for Microbiology and Infectious Disease (PSMID) and Philippine Foundation for Vaccination (PFV)

HUMAN PAPILLOMAVIRUS (HPV)


Vaccine type

Target individuals

Inactivated

Recommended for:
Females: 9-55 years old
Males: 10-26 years old

1. Bivalent (Types 16,18)


Females only
2. Quadrivalent (Types
(6,11,16,18)
Females and males

May be given as catch up vaccination to 13-21


years old who have not been previously vaccinated
or who have not completed the 3-dose series

Schedules
Bivalent for females only
2 doses: 9 to 13 years old, (0, 6 or 12 months)
3 doses: >13 years old, (0, 1, 6 months)
Quadrivalent - for males and females
3 doses 0,2,6 months
Females: 14 to 45 years old
Males: 14 to 26 years old

2 doses: Female 9-13 years old. 0, 6 or 12 months


2015 Schedule of Adult Immunization
Philippine Society for Microbiology and Infectious Disease (PSMID) and Philippine Foundation for Vaccination (PFV)

Vaccine type

Pneumococcal vaccine
(inactivated)
Polysaccharide (PPSV23)
IM or SQ
Conjugate (PCV13) IM route
Sequential pneumococcal
vaccination (PCV13-PPV23)

Meningococcal Vaccine
Polysaccharide (MPSV): SQ/IM

Conjugate (MCV4) : IM

Hepatitis A
IM; Single antigen or in
combination with Hepatitis B

Indications and schedule


For elderly (>50 yo), immunocompetent
PCV13 then PPSV23 in 6-12 months
For immunocompromised
PCV13 then PPSV23 at least 8 weeks
For those previously received 1 or 2 doses PPV23
Give PCV13 12 months after the most recent dose
of 23vPPV
Revaccination
Single dose PPV23 after 5 months
For immunocompetent, single dose 0.5 ml no
revaccination
For immunocompromised, single dose 0.5 ml,
revaccination after 5 years
For monovalent: 2 doses at 0, 6-12 months
In combination with hepatitis B:
0,1,6 months

2015 Schedule of Adult Immunization


Philippine Society for Microbiology and Infectious Disease (PSMID) and Philippine Foundation for Vaccination (PFV)

HERPES ZOSTER
Vaccine type:
Live, attenuated VZV
vaccine
single-dose 0.65 ml SQ
Prevention of herpes zoster (HZ)
Prevention of postherpetic
neuralgia (PHN)
Reduction of acute and chronic
HZ-associated pain

Target individuals
Adults 60 years old with or without a prior
episode of herpes zoster
Persons with history of zoster
Men sex with men (MSMs)
Persons with chronic medical conditions
chronic renal failure
diabetes mellitus
rheumatoid arthritis
Heart disease, chronic lung and
chronic liver disease
healthcare workers
Asplenia

2015 Schedule of Adult Immunization


Philippine Society for Microbiology and Infectious Disease (PSMID) and Philippine Foundation for Vaccination (PFV)

Vaccine type/route

Schedule

TYPHOID
IM,
VI capsular polysaccharide

For primary and booster single 0.5 ml


M dose on the deltoid

RABIES
IM/Intradermal
(HDCV , PVRV, PCECV)

Pre-exposure:
3 injections on days 0, 7 & 21 or 28
Post-exposure :

2015 Schedule of Adult Immunization


Philippine Society for Microbiology and Infectious Disease (PSMID) and Philippine Foundation for Vaccination (PFV)

IMPACT OF VACCINES

Johnson DR, et al. Am J Med 2008;121:S28-S35

JAMA. 2007;298(18):2155-2163
CDC. MMWR January 7, 2011;59(52);1704-1716.

IMPACT OF VACCINES

*? ?JAMA. 2007;298(18):2155-2163
?CDC. Active Bacterial Core surveillance Report; S. pneumoniae 2008.
?2008 Active Bacterial Core surveillance
?CDC. MMWR. February 6, 2009 / 58(RR02); 1-25
?New Vaccine Surveillance Network

Barriers for Vaccination


PUBLIC

PRIVATE

Both Private and Public HcW views vaccines as


expensive increasing barriers for vaccination despite the
need.

PATIENT
AWARENESS/B
ELIEFS

MYTHS

PHYSICIAN
RESOURCES /
KNOWLEDGE

INFRASTRUCTURE

BARRIER
S

National Foundation for Infectious Diseases. Call To Action: Adult Vaccination Saves Lives.
Bethesda, MD, 2012.

Steps in the process of implementing a vaccination policy


for HCWs

H.C. Maltezou, G.A. Poland / Vaccine 32 (2014) 48764880

Measures should be taken to ensure


healthcare workers are provided
convenient access to vaccine.
Employers of healthcare workers
need to commit resources toward
institutionalizing immunization in
the workplace
They need to demonstrate that
immunization is an employee and
patient safety PRIORITY.
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KEY CHALLENGE

THE BIGGEST CHALLENGE IS THE


CHALLENGE OF CHANGING
SOMEONES MIND

-- Paul Sax, MD

http://www.vaccines.gov/basics/protection/

Add perspective: Herd Immunity

http://www.vaccines.gov/basics/protection/

Before you vaccinate adults, consider their


H-A-L-O!
H-A-L-O checklist of factors that indicate a possible need for adult
vaccination

Technical content reviewed by the Centers for Disease Control and


Prevention www.immunize.org/catg.d/p3070.pdf

Thank you
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