1、,Kathleen Harriman, PhD, MPH, RN Vaccine Preventable Disease Epidemiology Section California Department of Public Health Immunization Branch kathleen.harrimancdph.ca.gov 510-620-3767,Immunization Recommendations for Employees Covered by the ATD Standard,Which employees are covered by the ATD standar
2、d?,Employees whose exposure from work activity or working conditions is reasonably anticipated to create an elevated risk of contracting any disease caused by aerosol-transmissible pathogens if protective measures are not in place “Elevated” risk means higher than what is considered ordinary for emp
3、loyees having direct contact with the general public outside of the facilities, service categories, and operations listed in the standard,http:/www.dir.ca.gov/Title8/5199.html,Work settings covered by the ATD standard,Applies in health care settings, such as: Hospitals Long Term Health Care Faciliti
4、es Primary Care Emergency MedicalApplies in other high risk environments Corrections Homeless shelters Drug treatment programs First receivers Laboratories,Occupational Exposure,In each included work setting covered by the standard, it is presumed that some employees have occupational exposure; for
5、a particular employee it depends on tasks, activities, and the environmentIncludes having contact with, or being within exposure range of cases or suspected cases of aerosol-transmissible diseasesEmployers must identify employees with occupational exposure in order to take protective measures,Exampl
6、es of Possible Occupational Exposures,Intake or triage of patients Providing care to influenza patients Testing people for TB Taking a throat swab for strep Cleaning patient rooms Transporting patients,Where do U.S. immunization recommendations come from?,15 experts selected by the U.S. Secretary of
7、 HHS to provide advice and guidance to CDC on the control of vaccine preventable diseases; the only entity in the federal government that makes such recommendationsDevelops written recommendations for routine administration of vaccines to children and adults in the civilian population; recommendatio
8、ns include age for vaccine administration, number of doses/dosing intervals, and precautions and contraindications Recommends immunizations for healthcare personnel,Advisory Committee on Immunization Practices (ACIP),ACIP Recommendations for Healthcare Personnel (HCP),Employer decisions about which
9、ACIP recommended vaccines to include in HCP immunization programs have typically been made by considering the: Likelihood of HCP exposure to vaccine preventable diseases and the potential consequences of not vaccinating HCP Nature of employment (type of contact with patients/residents and their envi
10、ronment) Characteristics of the patient/resident population within the organization,CDC Definition of HCP,All paid and unpaid persons working in healthcare settings who have the potential for exposure to patients with influenza, infectious materials, including body substances, contaminated medical s
11、upplies and equipment, or contaminated environmental surfaces. HCP might include (but are not limited to):physicians, nurses, nursing assistants, therapists, technicians, emergency medical service personnel, dental personnel, pharmacists, laboratory personnel, autopsy personnel, students and trainee
12、s, contractual staff not employed by the health-care facility, and persons (e.g., clerical, dietary, housekeeping, maintenance, and volunteers) not directly involved in patient care but potentially exposed to infectious agents that can be transmitted to and from HCP,ACIP Recommended Immunizations fo
13、r U.S. HCP,All HCP who are not vaccinated:Tdap (tetanus, diphtheria, and acelluar pertussis) vaccine Hepatitis B vaccine Influenza vaccine All HCP who are not immune:MMR (measles, mumps, and rubella) vaccine Varicella vaccine (two doses),Required Immunizations for California HCP,There are no federal
14、 or California state requirements for immunization or immunity to vaccine preventable diseasesSome healthcare facilities require immunizations/immunity as a condition of employment,2010 ACIP adult immunization recommendations http:/www.cdc.gov/vaccines/recs/schedules/downloads/adult/2010/adult-sched
15、ule.pdf,Vaccine that is required to be offered* per the Cal/OSHA Bloodborne Pathogen standard,Hepatitis B vaccine three doses,* To all employees who are exposed to blood or otherpotentially infectious materials as part of their job duties. If vaccine is declined, a declination form must be signed.,V
16、accines that are required to be offered* per the Cal/OSHA Aerosol Transmissible Disease (ATD) standard as of September 1, 2010,Vaccine Influenza Measles Mumps Rubella Tetanus, diphtheria, and acellular pertussis (Tdap) Varicella-zoster (VZV),Schedule One dose annually Two doses Two doses One dose On
17、e dose, booster as recommended Two doses,* To all susceptible employees who might be exposed. If vaccine is declined, a declination form must be signed. Seasonal vaccine was required to be offered in 2009.,Diseases covered by the ATD standard,Applies to diseases classified by CDCs Healthcare Infecti
18、on Control Advisory Committee (HICPAC) as either droplet or airborne*Novel or unknown pathogens considered airborne Only “reportable diseases” under Title 17 require exposure investigation,* 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
19、 http:/www.cdc.gov/hicpac/2007IP/2007isolationPrecautions.html http:/www.cdph.ca.gov/HealthInfo/Documents/Reportable_Diseases_Conditions.pdf,Influenza Vaccine,Annual Influenza Vaccination,Offer to all employees covered under the ATD standard at no costEducate employees about vaccination benefits and
20、 consequences of influenza illness for themselves and their patientsObtain signed declination forms for those who choose to declineMonitor coverage including ward, unit, and specialty-specific coverage ratesYears of efforts to increase uptake have not increased rates significantly in most facilities
21、 - mandate vaccination?,Healthy People 2010 Goal = 60% Voluntary rates are suboptimal despite years of efforts to increase them,Barriers to Influenza Vaccination,Fear of vaccine side effects (particularly influenza-like illness symptoms)Perceived ineffectiveness of the vaccine Medical contraindicati
22、on (not always valid)Perceived low likelihood of contracting influenzaFear of needles Insufficient time or inconvenienceSimilar barriers may apply to Tdap,Mandatory Influenza Vaccination,Seattle: Virginia Mason first U.S. hospital to mandate influenza vaccination or mask wearing during influenza sea
23、son St. Louis: Barnes-Jewish first U.S. hospital to mandate influenza vaccination and terminate noncompliant employees New York: 2009 emergency regulation (that was withdrawn) required seasonal and pandemic H1N1 vaccination of personnel in hospitals, home care, hospice, and diagnostic/treatment faci
24、lities http:/www.health.state.ny.us/diseases/communicable/influenza/seasonal/providers/ 2009-08-26_health_care_worker_mandatory_influenza_immunization.htm California: hospitals must offer vaccine at no cost to employees Vaccination or written declination required per SB 739 and the ATD standard Publ
25、ic reporting of vaccination rates via CDCs National Healthcare Safety Network (NHSN) required Some hospitals mandated vaccination or mask wearing in 2009,National Organization Influenza Vaccination Recommendations,IDSA 2009 Mandatory vaccination or mask wearingAPIC 2008 Supports requiring influenza
26、immunization for all HCP who have direct patient contact Also recommends that healthcare facilities obtain informed statements acknowledging the risk to patients from employees who decline the vaccine for other than medical reasonsACIP 2007 Level of vaccination coverage among HCP to be one measure o
27、f a patient safety quality program Implement policies to encourage HCP vaccination (e.g., obtaining signed statements from HCP who decline influenza vaccination)SHEA 2005 Vaccination or declinationMost unions oppose mandatory vaccination,Joint Commission,Standard IC.02.04.01: The organization offers
28、 vaccination against influenza to licensed independent practitioners and staff.The hospital establishes an annual influenza vaccination program that is offered to licensed independent practitioners and staff. The hospital educates licensed independent practitioners and staff about, at a minimum, the
29、 influenza vaccine; non-vaccine control and prevention measures; and the diagnosis, transmission, and impact of influenza. The hospital provides influenza vaccination at sites accessible to licensed independent practitioners and staff. The hospital annually evaluates vaccination rates and the reason
30、s given for declining the influenza vaccination. The hospital takes steps to increase influenza vaccination rates.,Hepatitis B,Hepatitis B Vaccination,Any person who performs tasks involving contact with blood, blood contaminated body fluids, other body fluids, or sharps should be vaccinated against
31、 hepatitis B Highly immunogenic seroconversion 95% Incidence of hepatitis B among HCP since mid-1990s is lower than general population due to vaccination and standard precautions,Updated U.S. P.H.S. Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for
32、Post-exposure Prophylaxis. MMWR 50 (RR11) - 6/29/01 http:/www.cdc.gov/mmwr/preview/mmwrhtml/rr5011a1.htm,Estimated Number of Acute HBV Infections Due to Occupational Exposures, United States, 1983-2002,Vaccine Recommended for HCP,OSHA Requirements,Hepatitis B,Employees with potential for exposure to
33、 blood or body fluids should be immunized for hepatitis B with 3-dose vaccine series if they have not already received itTest newly immunized employees 1-2 months after the last dose of vaccine series to determine if immuneEmployees with written documentation of a complete vaccine series but without
34、 postvaccination testing do not need immunity testing unless they have an exposure to blood or body fluidsPeriodic titers or booster doses of vaccine not recommended - protection is long lasting,Measles,Measles,Control and virtual elimination of measles in the U.S. is a public health success model f
35、or immunization programs in the developed worldLast nationwide outbreak 1988-1991Introduction of 2nd dose of vaccine in 1989 2000: “measles is no longer endemic in the U.S.”Concern about measles being introduced into the U.S. via travelers from parts of the world where measles is not controlled,Vacc
36、ine Licensed 1963,MeaslesUnited States, 1950-2005,Measles Transmission,Measles is transmitted via the airborne route and is thought to be the most infectious communicable disease Indigenous transmission of measles in the U.S. was declared eliminated in 2000; concern over recent imported cases Measle
37、s transmission has been documented in physician offices, emergency rooms, and hospital wards; HCP have been infected in recent outbreaks Good documentation and high levels of immunity minimize the amount of follow-up that needs to be done in the event of an exposureRecord review for hundreds to thou
38、sands staff Serologic testing and vaccination,Presumptive Evidence of Immunity to Measles,Documented administration of two doses of live measles virus vaccine on or after the first birthday and at least 28 days apart; or Laboratory evidence of immunity or laboratory confirmation of disease; or Birth
39、 before 1957* Documentation of physician-diagnosed measles is no longer acceptable evidence of immunity,* Since 5% of people born before 1957 are susceptible to measles, CDPH recommends that immunity be assessed if such HCP are exposed to measles. During an outbreak, 2 doses of MMR are recommended f
40、or unvaccinated HCP without evidence of immunity.,MMR Vaccination for HCP Born Before 1957,HCP born before 1957 are generally presumed to be immune to measles, mumps, and rubella, but not all are Consider recommending 2 doses of MMR vaccine routinely for unvaccinated HCP born before 1957 who lack la
41、boratory evidence of measles, mumps or rubella immunity or laboratory confirmation of diseaseDuring an outbreak of measles or mumps, two doses of MMR vaccine are recommended for unvaccinated HCP born before 1957 who lack laboratory evidence of immunity or laboratory confirmation of disease; one dose
42、 of MMR recommended during rubella outbreaks,Mumps,Presumptive Evidence of Immunity to Mumps,Documented administration of two doses of live mumps virus vaccine; or Laboratory evidence of immunity or laboratory confirmation of disease; or Born before 1957 Documentation of physician-diagnosed mumps is
43、 no longer acceptable evidence of immunity,Mumps Vaccination,All persons who work in healthcare facilities should be immune to mumps HCP born during or after 1957 2 doses No vaccination/immunity 2 doses (28 days apart) Only 1 dose previously second dose Birth before 1957 only presumptive evidence of
44、 immunity; consider 1 dose for unvaccinated workers without laboratory evidence of immunity During an outbreak, 2 doses of vaccine recommended for workers born before 1957 who do not have evidence of immunity,Nosocomial Transmission of Measles and Mumps in Healthcare Facilities,During 2001-8, 27 rep
45、orted measles cases were transmitted in healthcare settings, accounting for 5% of all reported U.S. measles cases (CDC, unpublished data) In 2008, 11% of cases; considerable economic cost and public health effort to contain ($100,000 to $400,000)In Arizona in 2008, the largest nosocomial U.S. measle
46、s outbreak (14 cases) occurred in 20 years At 3 hospitals, almost 8000 HCP were exposed; 25% had no documentation of immunity so were serologically tested 30% were born before 1957 ( 5% susceptible) 70% born 1957 (11% susceptible)In Tennessee in 1986-87, nosocomial transmission of mumps occurred in
47、2 hospital ERs infecting 6 HCP and in 2 long-term care facilities infecting 9 patients,www.cdc.gov/vaccines/vpd-vac/mumps/outbreak/control-hcw.htm,Rubella,Presumptive Evidence of Immunity to Rubella,Documented administration of one dose of live rubella virus vaccine; or Laboratory evidence of immuni
48、ty or laboratory confirmation of disease; or Born before 1957 (except premenopausal women who could become pregnant) HCP who can provide documentation of serological evidence of rubella immunity (e.g., via prenatal testing) do not need to be retested and should be presumed to be immune,Varicella,Var
49、icella Among HCP,Nosocomial transmission of is varicella (chickenpox) is well-recognizedSources Patients, hospital staff, and visitors with varicella or herpes zoster (shingles)Airborne transmission of varicella has been demonstrated Varicella has occurred in susceptible persons who had no direct co
50、ntact with index case-patient Virus detected in air Herpes zoster may also be airborne,Evidence of Immunity to Varicella in HCP,Documentation of two doses of vaccineLaboratory evidence of immunity or laboratory confirmation of diseaseDiagnosis or verification of history of varicella disease by a healthcare providerDiagnosis or verification of a history of herpes zoster (shingles) by a healthcare provider,
