Vaccination of Healthcare Personnel



Vaccination of Healthcare Personnel


Kap Sum Foong

Hilary M. Babcock



The availability of vaccination has changed the landscape of many communicable diseases.1,2 Smallpox, one of the most devastating infections, was declared eradicated in 1980 through a global surveillance and immunization campaign led by the World Health Organization (WHO).3 Similar widespread and successful national vaccination programs in the United States (USA) have led to the elimination of measles, rubella, and poliomyelitis.4,5,6 Nevertheless, outbreaks of these vaccine-preventable diseases still occur, usually following international importation and particularly among undervaccinated communities.7,8,9

In 2018, a wave of measles outbreaks spread rapidly across international boundaries, creating a national public health emergency and jeopardizing the measles elimination status of the United States.9,10 The rise of vaccine misinformation campaigns and vaccine hesitancy was labeled one of the top 10 threats to global health in 2019 by the WHO.11

Healthcare personnel (HCP) are at risk of exposure to patients infected with contagious vaccine-preventable infections such as hepatitis B, influenza, measles, mumps, rubella, pertussis, and varicella.12 The term “HCP” includes a very broad range of job functions, including but not limited to physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care but still with occupational exposure risk to infectious agents such as clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel.12

HCP without immunity to vaccine-preventable diseases can serve as a vehicle of transmission of communicable infections to patients, colleagues, and other contacts (eg, visitors). Therefore, HCP vaccination is recognized as an essential component of an effective infection prevention program. By achieving and maintaining high vaccination rates, occupational health programs not only protect HCP but also safeguard vulnerable patients from becoming infected, reduce HCP absenteeism, and minimize productivity loss.

However, low uptake of recommended vaccines remains a challenge in many healthcare settings. The U.S. Centers for Disease Control and Prevention (CDC) estimated ˜79% of HCP reported having received an influenza vaccination during the 2017-2018 season,13 which was below the Healthy People 2020’s target goal of >90% vaccination among HCP.14 According to the National Health Survey in 2017, the vaccination rate for tetanus, diphtheria, and acellular pertussis (Tdap) among HCP was 61.8% and for hepatitis B was 69.8%.15 Immunization rates for measles, mumps, and rubella (MMR), varicella, and meningococcus among HCP are not well reported. Hepatitis B vaccine uptake rose substantially in the 1980s and has remained stable; influenza vaccine uptake among HCP has also been rising in the last decade.16,17,18,19 Both employers and HCP share the responsibility to ensure all HCP receive the full schedule of appropriate vaccinations in accordance with recommendations by U.S. Advisory Committee on Immunization Practices (ACIP) and the Healthcare Infection Control Practices Advisory Committee (HICPAC).


ORGANIZATION OF THE HCP IMMUNITY PROGRAM

A successful HCP vaccination program relies on the collaboration of multiple people (eg, institutional leadership, infectious diseases physicians, occupational health professionals, infection preventionists, managers) and organizations (eg, state and local health departments) to ensure its effectiveness. HICPAC guidance includes recently updated (2019) recommendations for establishment of an effective occupational infection prevention program and incorporation of HCP vaccines into routine practice.20,21 Utilization of secure and computerized systems is also recommended to manage HCP vaccination records.

All HCP new to a healthcare facility should receive a prompt review of their immune status for all recommended vaccines. The record should be regularly updated to reflect the HCP’s current status for each indicated vaccine-preventable disease. Criteria for immunity are specific to each vaccine-preventable disease and are published and maintained by ACIP.21 Immunity is most commonly demonstrated by written documentation of immunizations received. Verbal report of vaccination and a presumption that “most children” have received childhood vaccines is insufficient. HCP come from many different countries, and many children may inadvertently miss some vaccinations. For those reporting immunity on the basis of natural infection, self-report of disease without physician documentation is no longer considered adequate evidence of
immunity, and serologic documentation of immunity may still be prudent as the predictive value of a physician diagnosis may be less reliable than previously, given the current rarity of these diseases. Unless documented to be immune, all HCP without medical contraindications should receive appropriate immunizations when hired and as needed (eg, annually for influenza). As a general rule, serologic screening for those with unknown immune status before immunization is neither necessary nor cost-effective. However, some healthcare facilities might find certain screening programs to be cost-effective, taking into account the cost of the screening test, the cost of the vaccine, and the prevalence of immunity in the local HCP population.

All healthcare organizations should make all recommended vaccines easily available to HCP, at no cost to the HCP. Multiple studies have evaluated interventions to improve HCP vaccine uptake, most frequently for the influenza vaccine. While making the vaccine easily accessible at multiple times and locations, with leadership support and even incentives, have all shown benefits in increasing vaccination rates. The most effective method to achieve and maintain high vaccination rates (>90%) is through a mandatory program in which receipt of recommended vaccines is a condition of employment, volunteering, receiving training, or providing services in the absence of a medical contraindication.21 Some programs allow religious accommodations as well, although many professional medical organizations (eg, IDSA, AMA, SHEA, APIC) have officially recommended that only medical contraindications should preclude immunization of susceptible HCP. For physicians or other nonemployed providers, immunity can be a requirement for continued hospital or facility privileges.

When vaccines are provided, appropriate information should be recorded in the HCP medical record (Table 37-1). Clinically significant or unexpected adverse events occurring after immunization should be reported to the Vaccine Adverse Events Reporting System, as should any event listed by the vaccine manufacturer as a contraindication to subsequent doses of vaccine and any event listed in the Reportable Events Table (available at www.vaers.hhs.gov/reportable.htm) that occurs within the specified time period after vaccination. Accurate and computerized records can greatly facilitate record retrieval and identification of susceptible HCP in the event of an exposure or outbreak, thereby reducing cost and disruption of healthcare operation.








TABLE 37-1 Data to Record When Providing Vaccines to HCP





























HCP name


HCP identification number


Date of birth


Signed informed consent (or refusal, if relevant)


Date of immunization (or refusal)


Vaccine provided (or declined)


Name of vaccine manufacturer


Lot number of vaccine


Site of immunization


Route of immunization


Date of next scheduled dose or booster (if applicable)


Adverse events (if any)


Name, title of person providing vaccine





USE OF VACCINES FOR POSTEXPOSURE PROPHYLAXIS OR OUTBREAK CONTROL

HCP are at increased risk of exposure to communicable diseases at the workplace and especially during healthcareassociated outbreaks. Rapid identification of HCP immune status during an outbreak is critical to expedite appropriate control measures such as postexposure prophylaxis (eg, vaccine, immune globulin, or chemoprophylaxis) for susceptible contacts and exclusion of exposed nonimmune HCP from the facility.20 Ensuring appropriate immunity of all HCP and readily accessible documentation before an exposure or an outbreak is highly preferable. Management of postexposure vaccination in accordance with the CDC and ACIP recommendations is summarized in Table 37-4; see also Chapter 40: Exposures to Contagious Infectious Diseases.


GUIDELINES FOR THE USE OF SELECTED VACCINES

The following subsections provide additional information regarding the vaccine-preventable diseases for which immunization of HCP is recommended, either universally (Table 37-2) or in special circumstances (Table 37-3). For each vaccine, administration schedules and contraindications are summarized in these tables, and recommendations concerning immunization of HCP with special conditions are provided in Table 37-5. Management of the vaccine-preventable diseases themselves and management of exposures to those diseases (other than postexposure vaccination) are covered in detail in other chapters.


Hepatitis B Vaccine

Background Since the implementation of national hepatitis B vaccination program for all newborns, the incidence of acute hepatitis B virus (HBV) infection in the United States has declined markedly. From 1990 to 2009, the rate of new HBV infections declined ˜84%, from 8.5 to 1.1 cases per 100 000 population.44 The current incidence of acute HBV infection in the United States has been fluctuating around 3000 cases annually since 2012 with an estimate of 1.0 reported cases per 100 000 population.45 Chronic HBV infection remains a public health challenge with an estimated prevalence as high as 2.2 million in the United States.46

Healthcare-Associated Exposures HBV has long been recognized as an occupational hazard for HCP in the United States and globally. Occupational transmission of HBV infection to HCP generally occurs through percutaneous, mucosal, and nonintact skin exposures to infected blood or other infectious body fluids.47,48 It is estimated that 385 000 percutaneous injuries occur in US hospitals each year.47 Previous studies found the risks of developing clinical hepatitis and serologic evidence of HBV infection among HCP who sustained a needle injury were 22%-31% and 37%-62%, respectively, if exposed to needles contaminated with blood positive for both hepatitis B surface antigen (HBsAg) and hepatitis B e-antigen (HBeAg).48,49,50 By comparison, the risk of developing clinical hepatitis and serologic evidence of HBV infection was lower, 1%-6% and 23%-37%, respectively, if exposed to blood positive for HBsAg and negative for HBeAg.48,49,50 Contaminated environmental surfaces and medical instruments have also been reported as potential sources for occupational transmission of HBV.48,49,51,52,53,54 HBV can persist well in the environment, able to survive drying and storage at 25°C and 42% relative humidity for at least 1 week.51 The virus is transmissible even in the absence of visible blood.48

Many outbreaks of healthcare provider-to-patient transmission of hepatitis B have been described.55,56,57,58,59,60 Transmission typically occurred during an invasive procedure, with the most important risk factors being HBeAg positivity of the HCP, degree of invasiveness of the procedure, the infected HCP not wearing gloves, or injury (often inapparent) to the infected HCP.

Vaccination Hepatitis B vaccines currently licensed in the United States are single-antigen hepatitis B vaccines, which include two conventional recombinant HBsAg vaccines (ie, Recombivax-HB and Engerix-B) and a new recombinant HBsAg vaccine with a novel immunostimulatory adjuvant (ie, Heplisav-B). The usual vaccination schedule consists of a three-dose series of Recombivax HB or Engerix-B at 0, 1, and 6 months or a two-dose series of Heplisav-B at 0 and 1 month.12,23,24 The conventional hepatitis B vaccines are equally immunogenic and are interchangeable; either can be used (in its recommended dose) to complete an immunization series begun with the other.61 Studies have shown Heplisav-B vaccine is more immunogenic; 90%-100% achieved seroprotective hepatitis B surface antibody (anti-HBs) levels as compared to 70%-90% with Engerix-B vaccine.62,63,64 However, there were higher rates of cardiovascular and immune-mediated adverse events associated with Heplisav-B vaccine. Immunogenicity is not reduced when hepatitis B vaccine is given with other vaccines. Pregnancy is not a contraindication to hepatitis B vaccine. In general, seroprotective titers for hepatitis B develop after vaccination in 92% of HCP aged <40 years and 84% aged ≥40 years.12,23,49

A U.S. Federal Standard issued under OSHA in 1991, based on ACIP recommendations, mandated that all HCP with risks for occupational exposure be offered hepatitis B immunization at the employer’s expense.12,23,49 Employees may refuse immunization but must sign a declination form. Employees who decline hepatitis B vaccine cite a desire to avoid medications, the perception that they are at low risk for occupationally acquired HBV infection, and
concern about vaccine side effects.65 Availability of educational materials directed at these issues may be helpful in addressing concerns that could lead to refusal.

The use of HBV vaccine among HCP, coupled with improved infection prevention practices through institution of Standard Precautions and other preventive measures such as needleless devices and safety needles and syringes (eg, self-sheathing needles), has markedly reduced the risk of occupational acquisition of HBV infection.66 The revised Needlestick Safety and Prevention Act of 2001 by the OSHA requiring evaluation, identification, and implementation of safer medical devices has decreased percutaneous injuries from 39.6 injuries per 100 occupied beds in 1999 to 19.5 injuries per 100 occupied beds in 2011.52,53 The number of occupational HBV infections among HCP has declined ˜98%, from an estimated 17 000 in 1983 to 263 cases of acute HBV infection in 2010.49,50

All unvaccinated HCP, or those with incomplete hepatitis B vaccine series, who are at risk for exposure to blood or infectious body fluids should receive a complete hepatitis B vaccine series.12 HCP at ongoing risk for percutaneous or mucosal exposures should have an anti-HBs titer obtained 1-2 months after the final dose of vaccine. A postvaccination anti-HBs titer of ≥10 mIU/mL is considered immune. Postvaccination serologic antibody testing for HCP at low risk for HBV exposure may not be cost-effective; they can be tested at the time of an exposure.

For HCP who did not respond (anti-HBs titers <10 mIU/mL) to a primary vaccination series, revaccination with an additional vaccine dose followed by anti-HBs testing in 1-2 months is recommended. If postvaccination anti-HBs titers remain <10 mIU/mL after the receipt of an additional vaccine dose, two additional vaccine doses should be provided followed by serologic antibody testing in 1-2 months after the last dose of vaccine.49 An adequate antibody response rate was seen in 15%-25% and in ˜50% after one and three additional doses, respectively.67 If seroprotection is not achieved following the revaccination series, the HCP should be considered a nonresponder. The ACIP does not recommend more than two vaccine series in nonresponders. Nonresponders should have HBsAg and hepatitis B core antibody (anti-HBc) testing to ensure not HBV infected.49 Nonresponders who are not HBV infected are considered to be susceptible to HBV infection, but no work restrictions are needed. If HCP are found to be HBsAg positive, they should be counseled on prevention of HBV transmission and referred for further evaluation. Recommendations for management of HCP infected with a bloodborne pathogen have been made by the CDC, the Society for Healthcare Epidemiology of America (SHEA), and the Public Health Agency of Canada.49,68,69

Postexposure Vaccination Evaluation of the need for postexposure prophylaxis in HCP should be performed immediately after any percutaneous, mucosal, or nonintact skin exposure to blood or body fluids in the workplace.23 For HCP with a complete vaccine series and a documented anti-HBs ≥10 mIU/mL, no postexposure vaccine or hepatitis B immune globulin (HBIG) is indicated regardless of the source patient’s HBsAg status.23

For HCP who are nonresponders after two complete hepatitis B vaccine series, two doses of HBIG (given 4 weeks apart) are recommended after an unprotected exposure to blood or body fluid from a source patient with a positive HBsAg.23

HCP with an unknown response after a complete hepatitis B vaccine series should be tested for anti-HBs titers at the same time as source patient testing to determine source patient’s HBsAg status.23 If HCP have an anti-HBs <10 mIU/mL and source patient’s HBsAg is positive, one dose of HBIG and revaccination with a complete hepatitis B vaccine series are recommended. Postvaccination anti-HBs serologic testing should be performed 1-2 months after the final dose of vaccine. If HCP have an anti-HBs <10 mIU/mL and the source patient is HBsAg-negative, an additional hepatitis B vaccine is recommended followed by postvaccination anti-HBs serologic testing 1-2 months later so that the HCP immune status will be known for subsequent exposures.23 For HCP with anti-HBs ≥10 mIU/mL, no postexposure prophylaxis is necessary regardless of the source HBsAg status.23

For unvaccinated HCP or those with incomplete vaccination series, postexposure serology testing of anti-HBs status is not recommended. If the source patient is HBsAg positive, one dose of HBIG and revaccination with a complete hepatitis B vaccine series are recommended.23 Postvaccination anti-HBs serologic testing should be performed 1-2 months after the final dose of vaccine. If the source patient is HBsAg negative, HCP should still complete the hepatitis B vaccine series according to the ACIP vaccine schedule, followed by anti-HBs serologic testing 1-2 months after the final vaccine dose.23


Influenza Vaccine

Background The annual burden of influenza disease in the United States is estimated using a mathematical model by the CDC.70 Since 2010, influenza epidemics caused a range of 9.3-49.0 million illnesses, 140 000-960 000 hospitalizations, and 12 000-79 000 deaths each year.71 The epidemics are typically associated with a U-shaped age curve, with higher attack rates in the young and higher mortality rates among elderly. Excess morbidity and mortality are also seen in those with certain underlying comorbid conditions such as chronic cardiopulmonary disorders, diabetes mellitus, pregnancy, and immunosuppression.72,73,74

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Jun 8, 2021 | Posted by in INFECTIOUS DISEASE | Comments Off on Vaccination of Healthcare Personnel
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