Health care workers, vaccination

People who can transmit flu to others at high risk for complications. Any person in close contact with someone in a high-risk group should get vaccinated. This includes all health care workers, household contacts, and out-of-home caregivers of children 0 to 23 months of age and adults 65 years of age and older. 

Most health care workers are at risk for exposure to many diseases in the normal course of their work. Additionally, health care workers may transmit vaccine-preventable diseases to their patients. At the time of employment and on a regular basis, health care workers should be screened for immunity to measles, rubella, and varicella if found to be non-immune, the measles, mumps, and rubella, and varicella vaccines should be administered. The hepatitis B series should be given if not already completed. Tetanus should be updated and given every 10 years. Health care personnel in hospitals and ambulatory settings with direct patient contact should receive Tdap if not already received an interval as short as 2 years from the last tetanus-containing vaccine should be used. Priority for receiving Tdap should be given to personnel with direct contact with infants less than 12 months of age. 

Influenza vaccine is recommended annually for children aged >59 months with certain risk factors, health-care workers, and other persons (including household members) in dose contact with persons in groups at high risk. SeeMW/ 2006 55(No. RR-10) 1-41. 

The last known naturally occurring case of smallpox occurred in Somalia in 1977. In May 1980, the World Health Assembly certified that the world was free of naturally occurring smallpox. By the 1960s, because of vaccination programs and quarantine regulations, the risk for importation of smallpox into the United States had been reduced. As a result, recommendations for routine smallpox vaccination were rescinded in 1971. In 1976, the recommendation for routine smallpox vaccination of health-care workers was also discontinued. In 1982, the only active licensed producer of vaccinia vaccine in the United States discontinued production for general use, and in 1983, distribution to the civilian population was discontinued. All military personnel continued to be vaccinated, but that practice ceased in 1990. Since January 1982, smallpox vaccination has not been required for international travelers, and International Certificates of Vaccination forms no longer include a space to record smallpox vaccination. 

Yes. Vaccinia vaccine is recommended for laboratory workers who directly handle cultures, animals contaminated or infected with, nonhighly attenuated vaccinia virus, recombinant vaccinia viruses derived from nonhighly attenuated vaccinia strains, or other orthopoxviruses that infect humans. These would include monkeypox, cowpox, vaccinia, and variola. Other health-care workers, such as physicians and nurses whose contact with nonhighly attenuated vaccinia viruses is limited to contaminated materials such as medical dressings but who adhere to appropriate infection control measures, are at lower risk for accidental infection than laboratory workers. However, because a theoretical risk for infection exists, vaccination can be offered to this group. Vaccination is not recommended for people who do not directly handle nonhighly attenuated virus cultures or materials or who do not work with animals contaminated or infected with these viruses. 

Postexposure prophylaxis is not recommended for contacts of patients infected with B. anthracis, or for health care workers who may treat anthrax patients. It is also not recommended for the prophylaxis of cutaneous anthrax. It is currently only indicated for persons who may have been exposed to airspace contaminated with aerosolized B. anthracis (Bell, Kozarsky, Stephens, 2002). The duration of therapy is generally determined to be 60 days of either ciprofloxacin or doxy-cycline, with amoxicillin as an option for children and pregnant or lactating women. The U.S. Department of Health and Human Services has recently announced additional options for prophylaxis of inhalational anthrax, especially for those in whom inhalational exposure may have been significant. These options include 60 or 100 days of prophylaxis, as well as 100 days of prophylaxis plus anthrax vaccine as an investigational agent (GDG, 2001a Nass, 2002). 

Health care workers and public health personnel involved in the distribution of vaccine or prophylactic medication. 

Available but currently restricted in use to military and laboratory personnel. Plans to vaccinate U.S. health care workers are pending. Vaccinia Immune Globulin (VIG) 0.6 ml /kg IM may be given for complications of vaccine. 

Vaccinated health care workers can continue to work after receiving the vaccine. However, to protect patients, they should keep the site covered with gauze or some other absorbent material, and in turn, cover this dressing with a semiper-meable dressing. Several products combining an absorbent underlayer with an overlaying semipermeable layer are now available. 

In addition to the smallpox response teams, ACIP and HICPAC have recommended that every acute-care hospital identify and vaccinate a team of health care workers who might provide direct care for the first smallpox patients requiring admission or who might manage suspected case patients in emergency departments. When possible, to reduce the potential for adverse reactions to the vaccine, designated health care workers should be those who previously received smallpox vaccinations. 

In the event of an outbreak, these teams would provide care 24 h d for the first 2 days until additional health care workers receive vaccinations. Until vaccinated, other health care workers would be restricted from caring for patients with smallpox, or under emergency conditions, would be required to wear PPE (32). The ACIP and HICPAC recommend that smallpox health care teams include ... 

The recommendations state that hospitals should vaccinate enough staff in each category to ensure continuity of care (32). Health care workers performing the vaccinations should first receive the vaccine to minimize the consequences of inadvertent inoculation. Laboratory workers are not included in the recommendations because the quantity of smallpox virus likely to be present in clinical specimens is low. 

In addition to the patient population, many health care workers have conditions or therapy associated with immunosuppression who could be at risk for complications following exposure to staff who had received the vaccine. 

Physician concerns about the vaccine were similar to those of other health care workers and hospital administrators. A physician survey at Yale University, conducted in the spring of 2003, revealed that fewer than 3% of physicians offered the vaccine choose to receive it. Factors associated with physician refusal included concerns that the vaccine was unnecessary without a detailed description of the risk of a smallpox attack, physicians wanted to wait and see how safe the vaccine was. In addition, some physicians, primarily those who worked in the emergency department, had concerns about compensation for time off and liability for adverse reactions (33). 

Although Section 304 satisfied some of the liability concerns, it failed to address health care worker worries about compensation for lost wages due to side effects of the vaccine (27). In addition. Section 304 did not address hospital and health care worker concerns about whether compensation would be adequate for victims of vaccine complications, including victims, such as household contacts, who were not vaccine recipients. Consequently, on April 30, 2003, the President signed a law to compensate health care workers or first responders injured by the preevent smallpox vaccination program. The law established a no-fault fund that had the following provisions (35) ... 

In spite of these provisions, many hospitals and health care workers were not satisfied by the compensation provisions. By October 31, 2005, only 39,608 civilians had received the smallpox vaccine (http //www.cdc.gov/od/oc/media/pressrel/ smallpox/sp vaccin. httn). 

Adult immunizations are important to document as well and include vaccines such as pneumococcusl (for elderly and those at risk for pneumonia), influenza, hepatitis B, and tetanus. Although not an immunization, skin testing for tuberculosis might also be included under this section in high-risk patients (elderly, health care worker, or immunocompromised patient). 

In addition to vaccinating health care workers against hepatitis B, other infection control practices are important in preventing transmission of the virus because up to 10% of people do not develop an adequate antibody response to the vaccine. The most important infection control measure is the use of universal precautions. These precautions prevent exposure to blood and blood-derived body fluids via use of a variety of barrier precautions, measures to prevent needlesticks, environmental control measures, and good hand-washing techniques. However, if a worker is exposed to material that potentially contains HBV, recommendations for percutaneous exposure to HBV should be followed (see Table 40-7). ... 

The booster effect occurs in patients who do not respond to an initial skin test but show a positive reaction if retested about a week later. Patients with past M. tuberculosis infection and some patients with past immunization with bacillus Calmette-Guerin (BCG) vaccine or past infection with other mycobacteria may boost with a second skin test. Individuals who require periodic skin testing, such as health care workers, should receive a two-stage test initially. Once they are shown to be skin-test-negative, any positive skin test later shows recent infection, and this requires treatment. 

Poland GA. Hepatitis B immunization in health care workers Deahng with vaccine nonresponse. Am J Prev Med 1998 15 73-77. 

Alimonos K, Nafziger AN, Murray J, Bertino JS Jr. Prediction of response to hepatitis B vaccine in health care workers Whose titers of antibody to hepatitis B surface antigen should be determined after a three-dose series, and what are the imphcations in terms of cost-effectiveness Chn Infect Dis 1998 26 566-571. 

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