Healthcare Personnel Vaccines: CDC Recommendations & Why They are Important

1. Healthcare Personnel Vaccines:CDC Recommendations&Why They are Important Jae L. Hansen, IMC, NREMT-P, FP-C (Ret.)

2. Ask yourself… What can I do to protect myself? What can I do to protect my patients? What can I do to protect my family?

3. Which HCP Need Vaccinations? Includes physicians, nurses, nursing/medical assistants, therapists, technicians, EMTs/Paramedics, dental, pharmacists, laboratory personnel, autopsy, students, trainees, contract staff, persons potentially exposed to infectious agents that can be transmitted to and from HCP Settings include hospitals, nursing homes, skilled nursing facilities, physicians’ offices, urgent care centers, outpatient clinics, home healthcare, and emergency medical services

4. Adult Vaccines… Shingles (Herpes Zoster) One dose of Herpes Zoster Vaccine (Zostavax) at age 60 or older Effective even if they’ve had a history of shingles Pneumococcal 40,000 deaths & 500,000 cases every year in the US One dose of PPV vaccine given at age 65 or older, OR in presence of chronic health condition

5. Adult Vaccines (cont.) Measles, Mumps, Rubella (MMR) Adults born before 1957 is considered immune to measles & mumps 2nd dose of MMR is recommended for HCP, or show lab evidence of immunity Measles– Highly contagious virus found throughout the world, can remain airborne for up to 2 hours Transmission – coughing, sneezing or talking Symptoms – high fever, rash, runny nose, watery eyes, cough, diarrhea & earache Incubation – 10 to 14 days

6. Mumps – Acute viral disease, may spread even though they have no symptoms or their illness is mild Transmission – coughing & sneezing Symptoms – Low grade fever & swelling or tenderness of one or more salivary glands. In post pubertal males, up to 30% may experience testicular pain and swelling. May cause sterility in males. Incubation – 12 to 25 days Adult Vaccines (cont.)

7. Rubella– (German Measles) is a virus If a woman gets rubella during the 1st trimester of pregnancy, her baby is at risk of having serious birth defects Transmission – coughing or sneezing, direct contact with nasal or throat secretions Symptoms – Rash, slight fever, aching joints, & reddened eyes Many people with rubella have few or no symptoms, and may not have rash Incubation – 16 to 18 days Adult Vaccines (cont.)

8. Varicella– (Chickenpox) highly contagious disease caused by the Varicella-zoster virus Transmission – airborne & also spread through contact with chickenpox blisters Symptoms – rash, body aches, fever, fatigue, irritability & sore throat Hospitalization & death increases with adults Incubation – 10 to 21 days If no lab evidence or history, 2 doses of Varicella vaccine should be administered 4-8 weeks apart Adult Vaccines (cont.)

9. Hepatitis A & Hepatitis B Hepatitis disease is a virus that affects the liver: Hepatitis A is food-borne (oral-fecal) Hepatitis B is blood-borne (blood to blood) Hep A vaccine – common childhood and travel vaccine Hep B vaccine – common childhood, travel vaccine and maybe required for healthcare personnel (HCP) Vaccines given in multiple doses (plan ahead, e.g., travel, new job, etc.) Combined in Twinrix® (2 shots in 1)

10. HPV • Human Papillomavirus • ≥ 100 strains and types • ≥ 40 strains and types are sexually transmitted • FDA recently approved vaccine for males • Approved for ages 9 – 26 yrs • Protects against viruses that can cause cervical, anal, penile & throat cancers Source: CDC HPV Information

11. also known as the “flu”Influenza is a contagious viral infection of the nose, throat and lungs36,000 deaths and over 200,000 hospitalizations per year Influenza

12. 2007-2008 San Diego Influenza Season The first influenza detection occurred the second week of October The peak flu season occurred mid February A total of 9 influenza-related deaths A total of 1,905 reports of influenza (lab results positive) were voluntarily reported to Public Health

13. H1N1 in San Diego April 2009 – January 20, 2010 • 829 hospitalizations • 55 deaths – San Diego residents • 7 deaths – Visiting non-residents • Most recent death is a 29 y/o female with no underlying condition

14. Peak Influenza U.S. 1976-2006 45% 19% 13% 13% 3% 3% 3% Source: MMWR 2007;56 (RR-6)

15. Cold vs. FluCan you tell the difference? Fever Rare in adults and older children, but can be as high as 102 degrees in infants and small children COLD OR FLU?

16. COLD

17. Cold vs. FluCan you tell the difference? Headache Sudden onset and can be severe COLD OR FLU?

18. FLU

19. Cold vs. FluCan you tell the difference? Tiredness and weakness Can last two or more weeks COLD or FLU?

20. FLU

21. Cold vs. FluCan you tell the difference? Sneezing Stuffy Nose Sore Throat COLD or FLU?

22. COLD

23. Influenza Symptoms Fever & Chills Headache Body Aches Tiredness Chest Discomfort

24. Flu Prevention Get vaccinated! Your best protection! Practice good hygiene Wash hands often Cover your mouth/nose when you cough/sneeze Put used tissues in waste basket Clean your hands after you cough/sneeze Avoid touching your face, eyes, nose or mouth If you are diagnosed with the flu Stay home Avoid close contact with others, or wear a mask Get rest and drink plenty of fluids

26. Influenza Virus • Transmission • Respiratory route • Direct contact • Communicability – 1 to 2 days pre-onset to, 4 to 5 days post-onset • Reservoir • Humans, swine (H1N1), and birds (H5N1) • Geographic distribution • Global • Incubation • 1 to 5 days; usually 2 days

27. Nosocomial Influenza  Transmission that occurs in a healthcare setting  Can result from under-vaccinated healthcare personnel

28. In a tertiary care facility from 1987 to 2000:  Staff influenza vaccination coverage 4% >>> 67%  Staff influenza disease 42% >>> 9%  Nosocomial Disease 32% >>> 0 cases Nosocomial Influenza Salgado CD, Infection Control Hospital Epidemiology, 2004

29. Influenza in the Elderly The elderly have suboptimal immunologic response to the flu vaccine. The flu shot is about… • 80% effective in preventing death • 27% to 70% effective in preventing hospitalizations and pneumonia • 30% to 58% effective in preventing flu Despite high vaccination rates among residents, influenza outbreaks still occur in LTCFs, triggered by unvaccinated HCP. Kimura, et al. American Journal of Public Health, 2007

30. Influenza in LTCF Influenza Attack Rates 25-60% Case-fatality 10-20% Randomized control study Staff vaccination led to a 43% decrease in ILI 44% decrease in mortality Potter J, et. Al. J Infectious Disease 1997

31. Who’s at Risk? • Children between 6 months and 18 years of age • Healthcare personnel (HCP) • Persons > 50 years • Nursing home & chronic care residents with chronic medical conditions • Persons with chronic pulmonary or cardiovascular disorders, including asthmatic children • Pregnant women • Persons with immunosuppression including HIV

32. Facts vs. Myths I get sick from the vaccine Myth The influenza vaccine is made from a DEAD virus You cannot get sick from it Side effects may include a low-grade fever and muscle aches The flu shot can take up to two weeks to become effective so you can still get the flu or a flu-like illness during this time

33. Why I didn’t get a flu shot… My doctor didn’t recommend it I am afraid of needles The flu shot is given with a relatively small needle. Check with your doctor to see if you are eligible to receive FluMist® - a vaccine that is sprayed into your nose and does not require needles. The Flu isn’t that bad Influenza causes an average of 36,000 deaths and over 200,000 hospitalizations per year. Source: CDC Influenza Information

34. Shot vs. Nasal Spray Flu Shot (TIV) Injectable – Trivalent inactivated influenza vaccine 70-90% effective in healthy persons ≤65 yrs 50-60% effective in preventing hospitalization 80% effective in preventing death Few side effects (sore arm, general malaise) Nasal Spray (LAIV) - FluMist® Live attenuated influenza vaccine No needles – spray mist into the nose Approved for healthy persons ages 2-49 years of age Slightly more expensive

35. Who should receive the vaccine? EMS and HCP Pregnant women Caregivers of <6 months 6 mon – 24 yrs, 25 – 64 yrs w/ underling chronic conditions Now open to everyone Where can I get it? Your physicians office Local PHC, Mass Vax Clinics How many doses will I need? Only one dose for 10 yrs and older How much will it cost? Free – Feds paid for all doses Nominal administration fee How safe is the vaccine? Extremely safe! It is made using the same processes & facilities as the seasonal flu vaccine. It is very much like the seasonal flu vaccine. Should I get the vaccine if I think I’ve already been infected? Yes, the flu symptoms you had may not have been caused by the H1N1 virus. Novel H1N1 Vaccine

36. Pertussis also know as“Whooping Cough”is a highly contagious bacterial infection of the lining and airways of the respiratory tract.It is caused by the bacterium Bordetella pertussis.

37. Pertussis Cases in the U.S. 25,827 24 20 16 12 11,647 Cases (Thousands) 9,771 7,796 8 6,586 4,570 4 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 CDC. MMWR 1997;46(54):71-80. Murphy T. Data on file, personal communication, 2001. MMWR 2000;50:1175. MMWR 2001;50(33):725. MMWR 2002;51:723. MMWR 2003;52:747. Bacterial Vaccine Preventable Disease Branch, National Immunization Program, 2005.

38. Pertussis in S.D. County

39. Pertussis in the U.S. 18.8 fold 15.5 fold 2004 1990-1993 1994-1996 1997-2000 2001-2003 9000 8000 7000 6000 Average Numberof Cases / Year 5000 4000 3000 2000 1000 0 <1 yr 1-4 yrs 5-9 yrs 10-19 yrs 20+ yrs Age Group Güriş et al. Clin Infect Dis. 1999;28:1230-1237. CDC. MMWR. 2002;51:73-76, 2001;50(53):1-108, 2002;51(53):1-84, 2003;52(54):1-85

40. Clinical Signs of Pertussis Cough 97%  3 weeks, 52%  9 weeks Paroxysms 73%  3 weeks Whoop in 69% Post-tussive emesis in 65% • Teens missed average 5 days of school • Adults missed average 7 days of work • Average 14 days of disrupted sleep De Serres et al. J Infect Dis. 2000;182:174–9.

41. 3 Stages of Pertussis Catarrhal Runny nose, sneezing, low-grade fever, and a mild, nonproductive, occasional cough Most infectious during the this period and the first 2 weeks after cough onset (approximately 21 days) Paroxysmal Severe spasms of quick, short, coughs May gag, gasp and/or expel thick mucus “whoop” Following attack Vomiting and exhaustion

42. Convalescent Gradual recovery Cough frequency decreases Cough severity decreases Recovery may be only partial Source: www.pertussis.com 3 Stages of Pertussis

43. How is it diagnosed? Multiple tests may be required to accurately diagnose disease Frequent incorrect diagnoses: Asthma Gastroesophageal reflux Post-viral bronchospasm Chronic sinusitis Tuberculosis

44. Culture and PCR • Nasopharyngeal (Dacron) swab or aspirate is the preferred sample • It’s the nasopharynx we’re after

45. Pertussis in Adults Adults: Are the main reservoirs of disease in areas with high immunization coverage rates Transmit primarily to non-immune children (≤ 1 year of age) or to adults whose immunity has waned Experience the longest recovery time (median 93 days)

48. Infant Pertussis: Who Was the Source? n=264 cases Bisgard, K. PIDJ. 2004;23:985-9.

49. Costs of an Outbreak September 2003 – outbreak of pertussis in an acute care facility 17 employees were infected Following a one-day exposure to an infant with pertussis Infection control measures were immediately implemented in hospital Study examined outbreak-related costs and estimated possible benefits to vaccination

50. Study Results Cost incurred by the hospital: Cost incurred by the employees: TOTAL COST incurred: Cost of 1 dose of Tdap: $74,870 $6,512 $81,382 $37.00