Jae L. Hansen, IMC, NREMT-P, FP-C (Ret.) Healthcare Personnel Vaccines: CDC Recommendations & Why They are Important Hello – my name is Jae Hansen and I am the Project Coordinator for the San Diego Healthcare Professionals Immunization Initiative of the County of San Diego Immunization Branch. (NEED to change this intro to employees) …where we once primarily focused on improving influenza immunization rates in healthcare workers, we are now expanding our focus to include the new Tdap recommendations for HCP. Today we will discuss – Tdap for HCP, the new recommendations and why they’re important in the hospital. Jae L. Hansen, IMC, NREMT-P, FP-C (Ret.)

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? As we go through this presentation I want you to ask yourself these simple questions.

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 This is now the CDC’s definition of a HCP.

Adult Vaccines… Shingles (Herpes Zoster) Pneumococcal 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 These are recommended vaccines for adults.

Adult Vaccines (cont.) Measles, Mumps, Rubella (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 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 Talk about the Measles outbreak in San Diego that occurred early 2008. 12 people where infected, and over 70 people where quarantined.

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 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.) 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 – January 20, 2010 829 hospitalizations 55 deaths – San Diego residents 7 deaths – Visiting non-residents Most recent death is a 29 y/o female with no underlying condition

Peak Influenza U.S. 1976-2006 45% 19% 13% 13% 3% 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? We are going to play a little game. Can you guess what this is, cold or flu?

COLD With a common cold people rarely get fevers. With the flu, adults may have a fever above 100.3 degrees, and children will have a fever above 102 degrees.

Cold vs. Flu Can you tell the difference? Headache Sudden onset and can be severe COLD OR FLU?

FLU With the flu, you’ll have a sudden onset of a severe headache. With the common cold you generally don’t get a severe headache. Some people may have sinus pressure, but not a headache.

Cold vs. Flu Can you tell the difference? Tiredness and weakness Can last two or more weeks COLD or FLU? With the common cold, you generally start feeling better about 3 – 4 days into it. With the flu, you are tired and weak for two or more weeks.

FLU

Cold vs. Flu Can you tell the difference? Sneezing Stuffy Nose Sore Throat COLD or FLU? This is a tricky one… the key words here are “can become severe”. Keep in mind that the flu is a respiratory illness and could cause a severe cough.

COLD With a common cold people rarely get fevers. With the flu, adults may have a fever above 100.3 degrees, and children will have a fever above 102 degrees. 22

Influenza Symptoms Fever & Chills Headache Body Aches Tiredness Chest Discomfort

Flu Prevention Get vaccinated! Practice good hygiene 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

This illustrates what happens when someone sneezes This illustrates what happens when someone sneezes. As you can see at the edge of the photograph those droplets are showing no sign of falling to the ground. These viruses and bacteria’s live in these droplets. This is why it’s so important to cover your cough and sneezes. “Please ask the students to show you the proper way to cover your cover/sneezes.”

Influenza Virus Transmission Reservoir Geographic distribution 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 infection means the infection occurred in the healthcare setting.

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 The numbers don’t lie… this proves the the vaccine works and works well. Salgado CD, Infection Control Hospital Epidemiology, 2004

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 LTCF residents should receive the influenza vaccination annually; however, in contrast to healthy adults, the elderly have suboptimal immunologic response to the influenza vaccine. Although the vaccine efficacy is estimated to be 80% in preventing death and 50% to 60% in preventing hospitalizations and pneumonia among LTCF residents, the vaccine is only 30% to 40% effective in preventing influenza infection. Thus, despite generally high vaccination rates among residents, influenza outbreaks still occur in LTCFs, sometimes triggered by illness among unvaccinated HCP. HCP vaccination has been shown to reduce morbidity and mortality among the elderly in long-term care settings. 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 29

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 Our nursing home patients have a tough time with influenza. They tend to die when infected. 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 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) Nasal Spray (LAIV) - FluMist® 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 Attenuated means weakened. It is impossible to get sick from the LAIV.

Novel H1N1 Vaccine Who should receive the vaccine? Where can I get it? EMS and HCP Pregnant women Caregivers of <6 months 6 mon – 24 yrs, 25 – 64 yrs w/ underling chronic conditions Now open to everyone Where can I get it? Your physicians office Local PHC, Mass Vax Clinics How many doses will I need? Only one dose for 10 yrs and older How much will it cost? Free – Feds paid for all doses Nominal administration fee How safe is the vaccine? Extremely safe! It is made using the same processes & facilities as the seasonal flu vaccine. It is very much like the seasonal flu vaccine. Should I get the vaccine if I think I’ve already been infected? Yes, the flu symptoms you had may not have been caused by the H1N1 virus.

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 is a bit different than influenza. Pertussis is a bacteria and not a virus. With pertussis, the infection releases toxin that infect the epiglottis which constricts the upper airway. The name “whooping cough” refers to the sound a person make when they try to inhale after an attack. This is not a pediatric disease, this affects everyone!

Pertussis Cases in the U.S. Here is a picture of what has been happening. This graph demonstrates the reports of pertussis in the United States from 1980-2004. As you can see, over the last 25 years there has been a very real increase in reported pertussis cases, particularly in the last couple of years. But it's not only an increase in reports; we have also seen a change in the age distribution. Pertussis Cases in the U.S. 25,827 24 20 16 12 11,647 Cases (Thousands) 9,771 7,796 8 6,586 4,570 4 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 Here is some data specific to San Diego. Highlight the two deaths related to the disease.

Average Number of Cases / Year You can see here the different time periods – 1990 through 1993, '94 through '96, '97 through 2000 and then in green, 2001 through 2003. The bars for the different age groups represents the average number of cases per year during each of those time periods. And you can see that for each age group there has been an increase in pertussis. The most dramatic increases have been among adolescents and adults – approximately a 15-fold increase for both adolescents and adult case reports of pertussis during this time frame. Pertussis in the U.S. 1990-1993 1994-1996 1997-2000 2001-2003 2004 18.8 fold 15.5 fold 9000 8000 7000 6000 Average Number of Cases / Year 5000 4000 3000 2000 1000 <1 yr 1-4 yrs 5-9 yrs 10-19 yrs 20+ yrs Age Group 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

Clinical Signs of Pertussis Cough 97%  3 weeks, 52%  9 weeks Paroxysms 73%  3 weeks Whoop in 69% Post-tussive emesis in 65% So – what is pertussis and what does it look like in adults or adolescents? If any of you have ever experienced pertussis – either personally or in treating someone – you already know, it’s much worse than just a “really bad cough.” It’s spread via respiratory droplets and… Over 97% of those diagnosed with pertussis will cough for 3 or more weeks, some for 9 or more weeks. Close to 70% also experience the classic “whoop” associated with this disease – although it may not always be present in an adult case. As if the coughing weren’t bad enough… the majority of those ill with pertussis also experience paroxysms and post-tussive emesis. All of this coughing and these secondary symptoms tend to be quite disruptive to an individual’s sleep schedule and consequently school and work attendance. 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.

3 Stages of Pertussis Catarrhal Paroxysmal 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 So, when a person first gets sick with pertussis – especially as an adult – symptoms are relatively vague. A runny nose, sneezing and a non-productive, occasional cough would lead someone to believe that they have just come down with a common cold – this is what is called the “Catarrhal” stage. Incubation period ranges from 4-21 days, typically lasting about 5-10 days. You are most infectious during this period. The single best way to protect yourself, your patients and your family is to get vaccinated. It isn’t until a week or two later – after you’ve already been symptomatic and contagious, that the more classic symptoms appear – the paroxysms, the frequent/severe coughing, a whooping sound – this is where an individual strains to inhale leading to a “high-pitch” whoop, and even the post-tussive vomiting. This is the “Paroxysmal” stage – and a person can be stuck in this stage, as we’ve already learned, for weeks – typically 1-6 weeks. To illustrate what pertussis sounds like in an adult…this is the sound of a man who is about 40 years old who has had a cough for about 3 weeks. A week ago, it started to sound like this. The coughing time is relatively short before giving a loud whoop. This is repeated about 3 times before he retches severely and the paroxysm ends.

3 Stages of Pertussis Convalescent Gradual recovery Cough frequency decreases Cough severity decreases Recovery may be only partial Source: www.pertussis.com The convalescent stage marks a period of gradual recovery – while in this stage a patient may continue to have coughing attacks – this can last anywhere from a few days to a few months, but in general the frequency and severity of the cough decreases. Another hallmark of pertussis is that although the cough can subside, a future illness can potentially reactivate the cough and at the same level of frequency and/or severity as previously experienced.

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 Read slide

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) So what about pertussis in adults? Here are a few bullets…read slide

This is a video of a child with pertussis This is a video of a child with pertussis. Listen for the classic “whoop” sound and then the barking sound following the attack, that’s the paroxysms. Check out how much energy is spent and how exhausted the boy is after the attack.

This graph illustrates how serious this disease is in infants and small children.

Infant Pertussis: Who Was the Source? And to complement the last point - this slide is a great graphic that sums up a recent study published in the Pediatric Infectious Disease Journal, done on pertussis by Dr. Bisgard - an epidemiologist with the CDC. She and her colleagues from state health departments in Georgia, Illinois, Massachusetts and Minnesota tracked the source of infection for infants to find out how they acquired pertussis and found that 75% of the time the source was a family member: 32% of the cases were from mom, 15% from dad, 20% of the time a sibling, and 8% of the time it was a grandparent. This just further emphasizes how imperative it is for HCP to be up to date with their Tdap – not only can a HCP be potentially infected at work and spread disease to co-workers at work, but they can also bring it home and infect family members. n=264 cases Bisgard, K. PIDJ. 2004;23:985-9.

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 When implementing a new program, it’s always important to evaluate its cost-effectiveness. There was a study conducted of a pertussis outbreak in a hospital that occurred in September, 2003. It measured both the direct and indirect costs associated with the outbreak and estimated benefits of vaccination.

Study Results Cost incurred by the hospital: Cost incurred by the employees: TOTAL COST incurred: Cost of 1 dose of Tdap: $74,870 $6,512 $81,382 After looking at billing records, interviewing both the affected HCP and the infection control practitioners involved, researchers presented the following information: -the cost incurred by the hospital was nearly $75,000 -the cost incurred by the HCP was over $6500 -the total cost was over $80,000 So, what would it cost to give one dose of Tdap? 2007 data from the CDC say $37.00. And we’ll see the significance of this more on the next slide. $37.00

Estimated Benefits of Vaccination Study model predicts: Vaccinating employees in hospital against pertussis would prevent ≥ 46% of exposures Cost of vaccination to benefit ratio is 2.38 : 1 In summary, this study predicts that vaccinating HCP against pertussis would prevent over 46% of exposures. It also states the benefits of giving HCP Tdap are 2.38 times the dollar amount invested in vaccinating HCP. So, clearly implementing a Tdap program can result in savings to everyone involved – both financially and personally with respect to work-time lost, sick-time, etc.

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 So, what can be done? The CDC is now recommending Tdap for HCP in hospitals and/or ambulatory care settings and pre-hospital care in place of their Td booster. Specifically the CDC has highlighted the following as PRIORITY groups: -HCP in contact with infants less than 12 months of age -and those who work in the ED, Maternal/Child health, -Respiratory and ICU departments For those HCP that may have recently received their Td booster, Tdap can be administered in an interval as short as 2 years from the last Td.

CDC Recommends All adults receive Tdap in place of their tetanus booster Postpartum mothers and/or primary caregivers receive Tdap The CDC is now recommending that all adults receive Tdap in place of their Td booster, and postpartum mothers and primary caregivers as well.

Tdap Vaccine Tetanus diphtheria acellular pertussis 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 was licensed for use in the US in 2005, and they are composed of the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed. Only one dose is required.

Tdap Adverse Reactions Localized pain, redness, swelling Low-grade fever Adverse reactions occur at approximately the same rate as Td alone Adverse reactions are very similar to Td with localized pain, redness, and swelling and/or a low-grade fever. Incidence rates for these reactions were similar to Td. Source: CDC Pertussis Information

A True Story… Now having said all of this, let’s hear what a colleague has to say about pertussis and how much of an impact it can actually have…

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 I think that basically sums it up – vaccinating HCP with Tdap can protect not just the HCP but also their patients and family.

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 Here are a few resources available. Please visit our website for the latest information.

Thank you for your time. Jae L. Hansen, IMC (619) 692-6644 Jae.Hansen@sdcounty.ca.gov