Protecting Your Patients

Starts With

Protecting Yourself

Healthcare Personnel Vaccines Jae L. Hansen, IMC, NREMT-P, FP-C (Ret.)

County of San Diego, Health and Human Services Agency Immunization Branch

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?

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

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

Adult Vaccines (cont.)



Measles, Mumps, Rubella (MMR)

 Adults born before 1957 is considered immune to measles & mumps 

2 nd 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

Adult Vaccines (cont.)

 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.)

  Rubella – (German Measles) is a virus If a woman gets rubella during the 1 pregnancy, her baby is at risk of having serious birth defects st trimester of  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.)

 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

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)

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

Influenza

also known as the “flu” Influenza is a contagious viral infection of the nose, throat and lungs 36,000 deaths and over 200,000 hospitalizations per year

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

H1N1 in San Diego

April 2009 – May 25, 2010

 930 hospitalizations  56 deaths – San Diego residents  7 deaths – Visiting non-residents  Most recent death was a 22 y/o male with underlying condition

Peak Influenza U.S. 1976-2006

45% 3% 13% 19% 13% 3% 3% Source: MMWR 2007;56 (RR-6)

Cold vs. Flu Can 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?

COLD

Cold vs. Flu Can you tell the difference?

Headache

Sudden onset and can be severe

COLD OR FLU?

FLU

Cold vs. Flu Can you tell the difference?

Tiredness and weakness

Can last two or more weeks

COLD or FLU?

FLU

Cold vs. Flu Can you tell the difference?

Sneezing Stuffy Nose Sore Throat

COLD or FLU?

COLD

Influenza Symptoms

Headache Body Aches Fever & Chills Tiredness Chest Discomfort

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

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

Nosocomial Influenza

 Transmission that occurs in a healthcare setting  Can result from under-vaccinated healthcare personnel

Nosocomial Influenza

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

Salgado CD, Infection Control Hospital Epidemiology, 2004

Nosocomial Influenza

Healthcare personnel (HCP) can be infected by their patients Prospective study vaccinated HCP:  30% fewer influenza like illness (ILI)  63% fewer illnesses with fever and cough

Wilde, JA, JAMA 1999

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

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

      

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

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

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

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

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.

Pertussis Cases in the U.S.

25,827 24 20 16 12 8 6,586 7,796 9,771 11,647 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.

Pertussis in S.D. County

15 10 5 0 35 30 25 20 County of San Diego Pertussis Cases by Month Reported, 2009 and 2010 (Jan - Apr) Month of Report 2009 2010

1990-1993

Pertussis in the U.S.

1994-1996 1997-2000 2001-2003 2004 9000 8000 7000 6000 5000 4000 3000 2000 1000 0 <1 yr 1-4 yrs 5-9 yrs Age Group 10-19 yrs G üriş 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 18.8 fold 20+ yrs 15.5 fold

Clinical Signs of Pertussis

  Cough 97%  52%  3 weeks, 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.

Catarrhal

3 Stages of Pertussis

 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

3 Stages of Pertussis

Convalescent  Gradual recovery  Cough frequency decreases  Cough severity decreases  Recovery may be only partial

Source: www.pertussis.com

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

Culture and PCR

 Nasopharyngeal (Dacron) swab or aspirate is the preferred sample  It’s the nasopharynx we’re after

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)

10 8 6 4 2 0 16 The majority of severe pertussis disease complications occurred among infants 0-2 months of age, California 1995 - 2004 15 Death Encephalopathy 14 12 12 0 1 7 1 3 2 5 0 0 3 age (months) 0 4 1 0 0 5 0 6 0 California Dept of Health Services Immunization Branch

Infant Pertussis: Who Was the Source?

Bisgard, K. PIDJ. 2004;23:985-9.

n=264 cases

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

Study Results

 Cost incurred by the hospital:

$74,870

 Cost incurred by the employees:

$6,512



TOTAL COST incurred:

$81,382

 Cost of 1 dose of Tdap:

$37.00

CDC Recommends

 All HCP in hospitals, LTCF/SNF, ambulatory care and emergency medical services (EMS) settings also receive Tdap in place of Td booster  Priority groups:  HCP in contact with infants less than 12 months  Emergency Departments  Maternal/Child Health  ICU/NICU  Respiratory Therapy

CDC Recommends

 All adults receive Tdap in place of their tetanus booster  Postpartum mothers and/or primary caregivers receive Tdap

Tdap Vaccine



Tetanus diphtheria acellular pertussis

 Licensed in 2005  Only one dose is required and it c an be given in an interval as short as 2 years from the last Td booster

Tdap Adverse Reactions

   Localized pain, redness, swelling Low-grade fever Adverse reactions occur at approximately the same rate as Td alone

Source: CDC Pertussis Information

A True Story…

Conclusions

 Vaccinating ADULTS with Tdap:  85% protection with vaccine!

 Protect your family from pertussis  Prevent an outbreak in workplace thereby reducing costs and minimizing sick leave  Keeping adults up to date with their vaccines can minimize the effects of vaccine-preventable diseases

Resources

County of San Diego Immunization Branch

www.SDIZ.org

Council of Community Clinics (Referral to low-cost immunizations)

( 619) 542-4300

Immunization Action Coalition

http://www.immunize.org/hcw/

Center for Disease Control and Prevention

http://www.cdc.gov/ncidod/dhqp/wrkr_immune.html

Thank you for your time.

Jae L. Hansen, IMC (619) 692-6644 [email protected]