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 http://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

VACCINES RECOMMENDED FOR HEALTHCARE PERSONNEL: GENERAL GUIDELINES

Recommendations regarding the vaccination of HCP have been issued by the CDC and its advisory bodies, ACIP, and HICPAC²²^,²³^,²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²^,³³^,³⁴^,³⁵ and are summarized in Table 37-2. These recommendations are updated periodically. All HCP should be immune to mumps, measles, rubella, varicella, and pertussis, and all HCP with potential exposure to blood or body fluids should be immune to hepatitis B. Influenza vaccine should be given to all HCP annually.

In special circumstances, HCP or laboratory personnel should be offered immunization with other vaccines, including quadrivalent meningococcal (two vaccines are available ACWY and B; both may be indicated), inactivated poliomyelitis, rabies, typhoid, and vaccinia (Table 37-3), and vaccines may also have a role in postexposure management (Table 37-4) and outbreak control.

Before the administration of any vaccine, HCP should be evaluated for the presence of any condition that is listed as a vaccine contraindication or precaution.²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²^,³³^,³⁴^,³⁵^,³⁶^,³⁷^,³⁸^,³⁹ If such a condition is present, the risks and benefits of vaccination need to be carefully weighed by the HCP and the employee. The most common contraindication is a history of an anaphylactic reaction to a previous dose of the vaccine or to any vaccine component. Factors that are not contraindications to immunization include the following: breast-feeding or household contact with a pregnant woman (except for vaccinia vaccine); reaction to a previous vaccination consisting only of mild-to-moderate local tenderness or swelling, or fever <40.5°C; mild acute illness with or without low-grade fever; current antimicrobial therapy (except for oral typhoid vaccine) or influenza antiviral therapy; convalescence from a recent illness; and family history of allergies, adverse reactions to vaccination, or seizures.⁴⁰

Special Conditions

HCP who are immunocompromised, are pregnant, or have certain underlying chronic diseases can pose challenges in the provision of immunizations (Table 37-5).²⁴^,²⁵^,²⁶^,²⁸^,²⁹^,³²^,³³^,³⁴^,³⁶^,³⁷^,³⁸^,⁴¹^,⁴²^,⁴³ Some routinely recommended vaccines (especially live virus vaccines such as measles, mumps, rubella, varicella, and live-attenuated influenza) may be contraindicated, and some vaccines that are not routinely recommended for HCP may be indicated (eg, pneumococcal, meningococcal, and Haemophilus influenzae type b vaccines) based on their underlying medical condition. In addition, for some indicated vaccines, higher antigen doses or postimmunization serologic evaluation may be indicated (eg, hepatitis B vaccine in people with renal failure). When an otherwise mandatory vaccine is contraindicated, HCP should be individually evaluated for the possibility of altering their assignments, work practices, or use of personal protective equipment to reduce risk to patients and to other HCP. The decision to reassign such HCP, or recommend other work practice adaptations, should be made in consultation with the individual.

TABLE 37-2 Vaccines Recommended for All HCP

*Vaccine*	*Recommendation*	*Schedule (adults)*	*Major contraindications (check full vaccine info for precautions)*	*Special considerations*
Hepatitis B	Vaccinate all HCP at risk for exposure to blood or body fluids, unless serologic evidence of immunity or prior documented evidence of a complete hepatitis B vaccine series.	A 3-dose series of Recombivax HB or Engerix-B (at 0, 1, 6 mo) or a 2-dose series of Heplisav-B (at 0, 1 mo).	Severe hypersensitivity (eg, anaphylaxis) after a previous dose; to any component of the vaccine; or to common baker’s yeast.	Prevaccination serologic screening is not necessary. Perform postvaccination serologic testing 1-2 mo after the final dose for HCP at risk for continued exposure.
Influenza	Vaccinate all HCP annually with seasonal influenza vaccine. Consideration should be given to requiring vaccination (with appropriate exemptions) as a condition of working within the healthcare institution.	One dose annually	Severe hypersensitivity (eg, anaphylaxis) after a previous dose or to any component of the vaccine. LAIV is contraindicated for immunocompromised and pregnant HCP.	IIV and RIV4 are preferred over LAIV for immunization of HCP. HCP who receive LAIV should avoid providing care for patients requiring a protective environment for 7 d after vaccination.
MMR	Vaccinate all HCP without presumptive evidence of immunity: either (1) written documentation of 2-dose MMR vaccination series; (2) laboratory evidence of immunity; or (3) laboratory confirmation of disease.	Two-dose MMR vaccine series given at least 28 d apart for measles and mumps. At least 1-dose MMR vaccine for rubella.	Severe hypersensitivity (eg, anaphylaxis) after a previous dose or to any component of the vaccine; pregnancy; severe immunodeficiency^a; family history of altered immunocompetence^b.	HCP born before 1957 who lack presumptive evidence of immunity should be vaccinated. HCP with postvaccination rash can continue to work.
Tdap	Vaccinate all HCP who have not previously received Tdap, regardless of when the last dose of Td vaccine received.	One dose of Tdap followed by Td (or Tdap) booster every 10 y thereafter.	Severe hypersensitivity (eg, anaphylaxis) after a previous dose or to any component of the vaccine or encephalopathy (eg, coma, decreased level of consciousness, or prolonged seizure) not attributable to other cause and within 7 d of administration of Tdap.	One dose of Tdap should be given during each pregnancy.
Varicella	Vaccinate all HCP without evidence of immunity against varicella: (1) written documentation of 2-dose vaccination series; (2) laboratory evidence of immunity; or (3) clinician verification of disease.	A 2-dose vaccine series, given at least 4 wk apart.	Severe hypersensitivity (eg, anaphylaxis) after a previous dose or to any component of the vaccine; pregnancy; severe immunodeficiency; family history of altered immunocompetence^b. Avoid aspirin or aspirin-containing product use for 6 wk after vaccination.	Prevaccination serology may be considered for HCP without evidence of immunity. Postvaccination serology is not recommended. HCP who develop rash following vaccination should avoid contact with persons without evidence of immunity, until all lesions are resolved (crusted) or no new lesions appear for 24 h.
Note: The package insert for the selected product and ACIP recommendations should be consulted for specific guidance regarding indications, storage, administration, precautions, and contraindications.
^aIndividuals are immunocompromised because of immunodeficiency diseases, human immunodeficiency virus infection, leukemia, lymphoma or generalized malignancy, or immunosuppressed as a result of therapy with corticosteroids (ie, ≥2 mg/kg body weight or 20 mg/d of prednisone for ≥2 weeks), alkylating drugs, antimetabolites, or radiation. ^bFamily history of congenital or hereditary immunodeficiency in first-degree relatives, unless the immune competence of the potential vaccine recipient has been substantiated clinically or verified by a laboratory.
Abbreviations: HCP, health care personnel; HIV, human immunodeficiency virus; IIV, inactivated influenza vaccine; RIV4, quadrivalent recombinant influenza vaccine; LAIV, live attenuated influenza vaccine; MMR, measles, mumps, and rubella; Tdap, tetanus, diphtheria, and acellular pertussis; Td, tetanus and diphtheria. Data from Refs.^{12,22,23,24,25,26,27,28,31,36}

TABLE 37-3 Vaccines that May Be Indicated for select HCP or Laboratory Personnel

*Vaccine*	*Recommendation*	*Schedule (adults)*	*Major contraindications (check full vaccine info for precautions)*	*Special considerations*
BCG (for tuberculosis prevention)	Indicated for HCP only in localities where (1) multidrug-resistant tuberculosis is prevalent; (2) ongoing transmission to HCP exists; and (3) full implementation of infection control precautions has been inadequate in controlling the spread of infection	One intradermal dose of 0.2-0.3 mL, given by multipuncture device; no boosters recommended	Immunocompromised state^a or pregnancy	BCG vaccination of HCP is not recommended in the United States as TB not endemic, it may complicate subsequent PPD screening and can result in complications.
Meningococcus	Not routinely indicated for HCP except for microbiologists with routine exposure to Neisseria meningitidis isolates	One dose of quadrivalent meningococcal (MenACWY) and of serogroup B meningococcal (MenB) vaccines. A booster of quadrivalent meningococcal vaccine every 5 y if exposure risk continues.	Severe hypersensitivity (eg, anaphylaxis) after a previous dose or to any component of the vaccine
Poliomyelitis	Not routinely indicated for HCP except for laboratory workers who handle specimens that might contain polioviruses or HCP with close contact with patients who might be excreting wild polioviruses	If completed childhood vaccine series, give a single booster IPV dose. If unvaccinated, give a 2-dose IPV vaccine series, given 4-8 wk apart, followed by a third dose at 6-12 mo after the second dose.	Severe hypersensitivity (eg, anaphylaxis) after a previous dose or to any component of the vaccine	Only IPV is licensed in the United States.
Rabies	Not routinely indicated for HCP except for laboratory workers working with rabies virus or infectious materials or specimens	A 3-dose vaccine series on d 0, 7, and 21 or 28. HCP with ongoing occupational exposure risk should have serum-neutralizing antibody for rabies virus tested every 6 mo to guide the need for booster.	Severe hypersensitivity (eg, anaphylaxis) after a previous dose or to any component of the vaccine	Exposure to rabies before the completion of preexposure prophylaxis series should transition to a postexposure vaccine regimen.
Typhoid	Not routinely indicated for HCP except for laboratory personnel with routine exposure to Salmonella enterica serotype Typhi isolates	Either 1 dose of Vi polysaccharide vaccine and booster every 2 y for those remaining at risk, or 4 oral doses of Ty21a vaccine on alternate days and revaccinate with the entire 4-dose series every 5 y for those remaining at risk	Severe hypersensitivity (eg, anaphylaxis) after a previous dose or to any component of the vaccine for both Vi polysaccharide and Ty21a vaccines. Ty21a vaccine is contraindicated in immunocompromised individuals.	HCP receiving antimicrobial treatment should postpone the use of Ty21a live vaccine until at least 3 d after the last dose of antimicrobial agent.
Vaccinia	Not routinely indicated for HCP except for personnel who directly handle cultures or animals contaminated with recombinant vaccinia or orthopoxviruses (monkeypox, cowpox) that infect humans	One dose administered with a bifurcated needle; boosters every 10 y	Atopic dermatitis; exfoliative skin conditions (vaccine recipient or household contact); immunosuppressed state^a (vaccine recipient or household contact); autoimmune disease with immunodeficiency; pregnancy; breast-feeding; severe allergic reaction (eg, anaphylaxis) to any component of the vaccine; known underlying heart disease; or three or more cardiac risk factors	Vaccine is available only from CDC Drug Services.
Notes: (1) Excluded are vaccines not currently available in the United States for civilian use (eg, anthrax, plague). (2) This table only considers indications related to occupational exposures of HCP; these and other (eg, Td, pneumococcal, etc.) vaccines may be indicated for persons, whether HCP or not, who meet certain exposure or risk criteria. (3) The package insert for the selected product and ACIP recommendations should be consulted for specific guidance regarding indications, storage, administration, precautions, and contraindications
^aIndividuals are immunocompromised because of immune deficiency diseases, human immunodeficiency virus infection, leukemia, lymphoma or generalized malignancy, or immunosuppressed as a result of therapy with corticosteroids (ie, ≥2 mg/kg body weight or 20 mg/d of prednisone for ≥2 weeks), alkylating drugs, antimetabolites, or radiation. Abbreviation: BCG, bacillus Calmette-Guérin; CDC, Centers for Disease Control and Prevention; HCP, health care personnel; IPV, inactivated poliovirus vaccine; PPD, purified protein derivative (tuberculin); TB, tuberculosis; USA, United States.
Data from Refs.^{12,24,28,29,30,32,33,34,38,42}

TABLE 37-4 Recommendations for Postexposure Vaccination for HCP or Laboratory Personnel

*Exposure or outbreak*	*HCP’s immune status*	*Recommendation*	*Special considerations*
Hepatitis B	Adequate response^a after a complete series	No action needed regardless of the source HBsAg status
	Documented nonresponder^b after two complete series	If source HBsAg-positive/unknown (high risk), give 2 doses of HBIG separated by 1 mo. If source HBsAg-negative, no action needed
	Unknown antibody response after a complete series	Test HCP anti-HBs status. If HCP’s anti-HBs titer <10 mIU/mL and source HBsAg-positive/unknown (high risk), give 1 dose of HBIG and initiate revaccination. If HCP anti-HBs titer <10 mIU/mL and source HBsAg-negative, initiate revaccination. If HCP anti-HBs titer ≥10 mIU/mL, no action needed regardless of the source HBsAg status.	Perform postvaccination serologic testing 1-2 mo after the final dose of vaccine.
	Previously unvaccinated or incomplete vaccine series	If source HBsAg-positive or unknown (high risk), give 1 dose of HBIG and complete revaccination. If source HBsAg-negative, complete vaccination	Perform postvaccination serologic testing 1- 2 mo after the final dose of vaccine.
Measles	Documented presumptive evidence of immunity	No action is needed.	Symptom monitoring still recommended day 5-21 after exposure; no work restriction.
	Previously unvaccinated or without presumptive evidence of immunity	One dose of MMR if no CI within 72 h of exposure or IG^c within 6 d after exposure	MMR vaccine should not be coadministered with IG. HCP should be excluded from duty from day 5 after first exposure to day 21 after last exposure, regardless of postexposure vaccine.
	Documented 1 dose of MMR	Give a second dose of MMR if no CI. Meningococcal Chemoprophylaxis is recommended for HCP who have close, face-to-face unprotected contact with Neisseria meningitidis, regardless of vaccination status.	HCP who otherwise are not indicated for meningococcal vaccination may be considered for vaccination in the setting of an outbreak caused by the serogroup contained in the vaccine.
Mumps	Previously unvaccinated or without presumptive evidence of immunity	Initiate vaccine series.	HCP should be excluded from work from day 12 after first exposure through day 25 after the last exposure.
	Documented 1 dose of MMR	Give a second dose of MMR.
	Documented 2 doses of MMR	No action needed	A third dose of MMR may be considered for individuals who are identified by public health authorities at increased risk for mumps infection during an outbreak.
Pertussis		Chemoprophylaxis is recommended for certain HCP with unprotected exposure to pertussis, regardless of the vaccination status. Close symptom monitoring is also recommended.	Exclude symptomatic HCP with known or suspected pertussis from work for 21 d from the onset of cough or until 5 d after the start of an effective antimicrobial treatment.
Rabies	Previously unvaccinated	Give 1 dose of rabies IG and a 4-dose vaccination regimen (at day 0, 3, 7, and 14) of HDCV or PCECV.
	Previously vaccinated or documented adequate antibody response^d	Give 2-dose vaccination regimen (at day 0 and 3) of HDCV or PCECV.
Rubella		No evidence has shown that postexposure vaccination or IG is effective in preventing rubella infection postexposure.	If an exposure to rubella does not cause infection, postexposure vaccination can provide protection against subsequent exposure to rubella, as well as measles and mumps.
Varicella	Documented presumptive evidence of immunity	No action is needed.	Monitor for symptoms of varicella during days 8-21 after exposure.
	Unvaccinated or without presumptive evidence of immunity	Give 1 dose of varicella vaccine if no CI within 3-5 d after exposure^e or give varicella-zoster IG^c.	HCP should be excluded from work from day 8 after first exposure to day 21 (day 28 if given IG) after the last exposure.
	Documented 1 dose of varicella	Give a second dose of varicella vaccine if no CI.
Note: The package insert and ACIP recommendations should be consulted for specific guidance regarding indications, storage, administration, precautions, and contraindications.
^aIndividuals are considered immune to hepatitis B if anti-HBs ≥10 mIU/mL. ^bHepatitis B nonresponders have documented anti-HBs <10 mIU/mL despite the receipt of two complete hepatitis B vaccine series. ^cImmune globulin may be considered for pregnant women and immunocompromised individuals (eg, hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, longterm immunosuppressive therapy, or HIV infection with CD4 count <200 cells/µL), who otherwise contraindicated for receiving live vaccines. ^dThe ACIP recommends complete neutralization of rabies virus at a 1:5 serum dilution, by rapid fluorescent focus inhibition test, as minimum evidence of circulating rabies virus-neutralizing antibodies. ^ePostexposure vaccination can be administered after day 5 of an exposure to provide protection against future exposure to varicella.
Abbreviations: Anti-HBs, hepatitis B surface antibody; CI, contraindication; HBIG, hepatitis B immune globulin; HBsAg, hepatitis B surface antigen; HCP, health care personnel; HDCV, human diploid cell vaccine; IG, immune globulin; MMR, measles, mumps, and rubella; PCECV, purified chick embryo cell vaccine. Data from Refs.^{12,20,22,23,24,26,27,28,29,31,38}

TABLE 37-5 Recommendations Concerning Immunization of HCP with Special Conditions

*Vaccine*	*Pregnancy*	*HIV infection*	*Severe immunosuppression^a*	*Asplenia*	*ESRD on HD*	*Diabetes mellitus*	*Chronic liver disease*
BCG	CI	CI	CI	UI	UI	UI	UI
Hepatitis B	UI	R	UI	UI	R	R	R
Influenza, inactivated R^b	R	R	R	R	R	R
LAIV	CI^c	CI^c	CI^c	CI	UI^d	UI^d	UI^d
Measles, mumps, and rubella	CI^c	R^e	CI^c	R	R	R	R
MenACWY	UI	R	UI^f	R	UI	UI	UI
MenB	UI	UI	UI^f	R	UI	UI	UI
Tdap or Td	R	R	R	R	R	R	R
Poliovirus, inactivated	UI	UI	UI	UI	UI	UI	UI
Rabies	UI	UI	UI	UI	UI	UI	UI
Typhoid, Vi polysaccharide	UI	UI	UI	UI	UI	UI	UI
Typhoid, Ty21a^d	CI	CI	CI	UI	UI	UI	UI
Varicella	CI^c	R^g	CI^c	R	R	R	R
Vaccinia	CI	CI	CI	UI	UI	UI	UI
Note: The package insert for the selected product and ACIP recommendations should be consulted for specific guidance regarding indications, warning, precautions, and contraindications.
^aSevere immunosuppression can be the result of hematologic and solid tumors, receipt of chemotherapy, congenital immunodeficiency, long-term immunosuppressive therapy, or immunosuppressed as a result of therapy with corticosteroids (ie, ≥2 mg/kg body weight or 20 mg/d of prednisone for ≥2 weeks), alkylating drugs, antimetabolites, or radiation. ^bRecommended for all women who are pregnant or will be pregnant at any time during the influenza season. ^cBecause of the theoretical risk of transmission to patients of the live attenuated agent contained in this vaccine, use of the alternative inactivated vaccine is preferred. ^dThese underlying medical conditions are precautions for use of live attenuated vaccine. Inactivated influenza vaccine is preferred over live formulation in these individuals. ^eContraindicated in HIV-infected individuals with CD4 count <200 cells/µL. MMR vaccination is indicated in all HIV-infected individuals with CD4 ≥200 cells/µL for at least 6 months and lack of evidence of immunity against MMR. ^fVaccination is indicated in individuals who are taking eculizumab. ^gContraindicated in HIV-infected individuals with CD4 count <200 cells/µL. Varicella vaccination is indicated in all HIV-infected individuals with CD4 ≥200 cells/µL and lack of evidence of immunity against varicella.
Abbreviations: BCG, bacillus Calmette-Guérin; CI, contraindicated; ESRD, end-stage renal disease; HCP, healthcare personnel; HD, hemodialysis; HIV, human immunodeficiency virus; LAIV, live attenuated influenza vaccine; R, recommended; Tdap, tetanus, diphtheria, and acellular pertussis; Td, tetanus and diphtheria; UI, use if otherwise indicated. Data from Refs.^{20,21,22,23,24,25,26,28,29,32,33,34,36,39}

Pregnancy Immunization of pregnant and breast-feeding HCP is important but can pose challenges. Inactivated vaccines, including influenza and Tdap, are specifically recommended during pregnancy due to risk infection can pose to the mother and fetus.²⁴^,²⁵^,²⁸^,³¹ Because of the potential risks from live vaccines, live attenuated viral vaccines (eg, mumps, measles, rubella, live attenuated influenza, and varicella) should be deferred during pregnancy.²²^,²⁴^,²⁵^,²⁶^,²⁸^,³⁹

If indicated, susceptible HCP may also receive hepatitis A, hepatitis B, meningococcal, pneumococcal, rabies, typhoid Vi polysaccharide, and inactivated poliomyelitis vaccines during pregnancy.²⁴^,²⁸ Breast-feeding does not adversely affect the response to immunization and is not a contraindication for any of the currently recommended vaccines (except for vaccinia 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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