County of San Diego, Health and Human Services AgencyImmunization Branch

Protecting Your PatientsProtecting Your PatientsStarts WithStarts With

Protecting YourselfProtecting Yourself

Healthcare Personnel VaccinesHealthcare Personnel Vaccines

Protecting Your PatientsProtecting Your PatientsStarts WithStarts With

Protecting YourselfProtecting Yourself

Healthcare Personnel VaccinesHealthcare Personnel Vaccines

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

Ask yourself…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?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…Adult Vaccines… Shingles (Herpes Zoster)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

PneumococcalPneumococcal 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.)Adult Vaccines (cont.) MMeasles, easles, MMumps, umps, RRubella (MMR)ubella (MMR)

Adults born before 1957 is considered immune to measles & mumps

2nd dose of MMR is recommended for HCP, or show lab evidence of immunity

MeaslesMeasles – 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

Mumps 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.)Adult Vaccines (cont.)

RubellaRubella – (German Measles) is a virus If a woman gets rubella during the 1st trimester of

pregnancy, her baby is at risk of having serious birth defects 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.)Adult Vaccines (cont.)

VaricellaVaricella – (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 adultsHospitalization & 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

Adult Vaccines (cont.)Adult Vaccines (cont.)

Hepatitis A & Hepatitis BHepatitis 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)

HPVHPV

Human PapillomavirusHuman 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

also known as the “flu”also known as the “flu”

Influenza is a contagious viral infection of the Influenza is a contagious viral infection of the nose, throat and lungsnose, throat and lungs

36,000 deaths and over 200,000 hospitalizations per year 36,000 deaths and over 200,000 hospitalizations per year

InfluenzaInfluenzaInfluenzaInfluenza

2007-2008 2007-2008 San Diego Influenza SeasonSan 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 DiegoH1N1 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. 1976-2006Peak Influenza U.S. 1976-2006

13%

19%

45%

13%

3% 3%3%

Source: MMWR 2007;56 (RR-6)

Cold vs. FluCold vs. FluCan you tell the difference?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?

COLDCOLD

Cold vs. FluCold vs. FluCan you tell the difference?Can you tell the difference?

Headache

Sudden onset and can be severe

COLD OR FLU?

FLUFLU

Cold vs. FluCold vs. FluCan you tell the difference?Can you tell the difference?

Tiredness and weakness

Can last two or more weeks

COLD or FLU?

FLUFLU

Cold vs. FluCold vs. FluCan you tell the difference?Can you tell the difference?

Sneezing

Stuffy Nose

Sore Throat

COLD or FLU?

COLDCOLD

TirednessTiredness

HeadacheHeadacheFever & ChillsFever & Chills

Influenza SymptomsInfluenza Symptoms

Body AchesBody Aches

Chest DiscomfortChest Discomfort

Flu PreventionFlu PreventionGet vaccinated!Get vaccinated! Your best protection!

Practice good hygienePractice 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 fluIf you are diagnosed with the flu Stay home Avoid close contact with others, or wear a mask Get rest and drink plenty of fluids

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

Influenza VirusInfluenza Virus

Nosocomial InfluenzaNosocomial Influenza

Transmission that occurs in a healthcare setting

Can result from under-vaccinated healthcare personnel

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 InfluenzaNosocomial 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

Nosocomial InfluenzaNosocomial Influenza

Influenza in the ElderlyInfluenza in the Elderly

Kimura, et al. American Journal of Public Health, 2007

The elderly have The elderly have suboptimalsuboptimal immunologic immunologic response to the flu vaccine.response to the flu vaccine.

80% effective in preventing death 27% to 70% effective in preventing

hospitalizations and pneumonia 30% to 58% effective in preventing flu

The flu shot is about…

Despite high vaccination rates among residents, influenza Despite high vaccination rates among residents, influenza outbreaks still occur in LTCFs, triggered by unvaccinated HCP.outbreaks still occur in LTCFs, triggered by unvaccinated HCP.

Influenza in LTCFInfluenza 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

Children between 6 months and 18 years of age

Healthcare personnel (HCP)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

Who’s at Risk?Who’s at Risk?

Facts vs. MythsFacts vs. Myths I get sick from the vaccineI get sick from the vaccine

MythThe influenza vaccine is made from a DEAD virusYou cannot get sick from itYou cannot get sick from itSide effects may include a low-grade fever and

muscle achesThe 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…Why I didn’t get a flu shot… My doctor didn’t recommend it

I am afraid of needlesThe 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 badInfluenza causes an average of 36,000 deaths and over 200,000 hospitalizations per year. Source: CDC Influenza Information

Shot vs. Nasal SprayShot vs. Nasal SprayFlu Shot (TIV)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®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

also know asalso know as“Whooping Cough”“Whooping Cough”

is a highly contagious bacterial infection of the is a highly contagious bacterial infection of the lining and airways of the respiratory tract.lining and airways of the respiratory tract.

It is caused by the bacterium Bordetella pertussis.It is caused by the bacterium Bordetella pertussis.

PertussisPertussisPertussisPertussis

Pertussis Cases in the U.S. Pertussis Cases in the U.S.

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.

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Pertussis in S.D. County Pertussis in S.D. County Pertussis in S.D. County Pertussis in S.D. County

County of San Diego Pertussis Cases by Month Reported, 2009 and 2010 (Jan - Apr)

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Pertussis in the U.S.Pertussis in the U.S.

Güriş 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

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18.8 fold18.8 fold

15.5 15.5 foldfold

Clinical Signs of PertussisClinical Signs of Pertussis Cough 97% 3 weeks,

52% 9 weeks Paroxysms 73% 3 weeks Whoop in 69% Post-tussive emesis in 65%

De Serres et al. J Infect Dis. 2000;182:174–9.

Teens missed average 5 days of school

Adults missed average 7 days of work Average 14 days of disrupted sleep

3 Stages of Pertussis3 Stages of Pertussis CatarrhalCatarrhal

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)

ParoxysmalParoxysmal Severe spasms of quick, short, coughs May gag, gasp and/or expel thick mucus “whoop” Following attack

Vomiting and exhaustionVomiting and exhaustion

ConvalescentGradual recoveryCough frequency decreasesCough severity decreasesRecovery may be only partial

Source: www.pertussis.com

3 Stages of Pertussis3 Stages of Pertussis

How is it diagnosed?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 PCRCulture and PCR

Nasopharyngeal (Dacron) swab or aspirate is the preferred sample

It’s the nasopharynx we’re after

Pertussis in AdultsPertussis in AdultsAdultsAdults: 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)(median 93 days)

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The majority of severe pertussis disease complications occurred among infants 0-2 months of age, California 1995 - 2004

California Dept of Health ServicesImmunization Branch

n=264 cases

Infant Pertussis: Infant Pertussis: Who Was the Source?Who Was the Source?

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

Costs of an OutbreakCosts 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 ResultsStudy Results

Cost incurred by the hospital:

Cost incurred by the employees:

TOTAL COST incurred:

Cost of 1 dose of Tdap:

$74,870$74,870

$6,512$6,512

$81,382$81,382

$37.00$37.00

CDC RecommendsCDC 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

All adults receive Tdap in place of their tetanus booster

Postpartum mothers and/or primary caregivers receive Tdap

CDC RecommendsCDC Recommends

Tdap VaccineTdap Vaccine

TTetanus etanus ddiphtheria iphtheria aacellular cellular ppertussisertussis

Licensed in 2005

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

Tdap Adverse ReactionsTdap Adverse Reactions

Localized pain, redness, swelling

Low-grade fever

Adverse reactions occur at approximately the same rate as Td alone

Source: CDC Pertussis InformationSource: CDC Pertussis Information

A True Story…A True Story…

ConclusionsConclusions 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

ResourcesResourcesCounty of San Diego Immunization Branch

www.SDIZ.orgwww.SDIZ.org

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

((619) 542-4300619) 542-4300

Immunization Action Coalitionhttp://www.immunize.org/hcw/http://www.immunize.org/hcw/

Center for Disease Control and Preventionhttp://www.cdc.gov/ncidod/dhqp/wrkr_immune.htmlhttp://www.cdc.gov/ncidod/dhqp/wrkr_immune.html

Jae L. Hansen, IMCJae L. Hansen, IMC(619) 692-6644(619) 692-6644Jae.Hansen@sdcounty.ca.govJae.Hansen@sdcounty.ca.gov

Thank you for your time.Thank you for your time.