JEMS Clinical Review Features
This clinical review feature article is presented in conjunction with the Department of Emergency Medicine Education at the University of Texas Southwestern Medical Center, Dallas.
- List the vaccines and immunizations currently recommended for all health-care workers.
- Describe the steps taken when an employee/volunteer chooses not to take a recommended vaccine.
- Describe the administration and/or testing guidelines for hepatitis B, tetanus/diptheria boosters, measles/mumps/rubella, varicella, influenza and tuberculosis.
- Discuss the cost benefits of establishing immunity status for all new hires/volunteers.
- Describe employer requirements for and documentation of employee immunization, vaccinations and testing for infectious diseases.
Immunization:The process of obtaining immunity to a specific disease. Active immunity is established with a specific agent to stimulate immune response, and passive immunity is achieved by administering serum from immune persons.
Live attenuated vaccine:Vaccine that delivers an attenuated (weakened) virus, a strain of live virus that has undergone physical and chemical processes to lower its virulence (power to produce disease). These changes disable the virus from causing disease while allowing it
to create protective immunity.
Non-responder:An individual who does not develop protective antibodies after the administration of a vaccine and/or vaccine series.
Pandemic:A disease which occurs throughout the population of a country, a people or the world.
Titer (antibody):The amount of a specific antibody present in the serum as a result of an acquired infection or vaccine induced immunity.
Universal vaccination:Vaccinations given at varying but specific ages to protect a whole population, country or world from specific infectious diseases and, in some cases, to abolish the disease.
Vaccination:The administration of antigenic material to produce immunity to a disease.
Most providers consider personal protective equipment (PPE) the primary means ofprotecting against communicable diseases. But vaccines and immunizations are just as important. Once you have immunity to a disease, the risk for acquiring it is eliminated. This isa simple concept.
Back in 1982, the Centers for Disease Control and Prevention (CDC) released their "Recommendation of the Immunization Practices Advisory Committee (ACIP)." It was the first published recommendation for the vaccination of health-care workers for protection against hepatitis B viral (HBV) infection. In 1990, the recommendations were expanded to include newborns, and in 2000, middle school, high school and college students were also added. This"universal vaccination"approach has led to an 82% decrease in HBV cases in the U.S. as of 2007. Currently, almost all health-care workers are vaccinated for HBV before entering the workplace, and the budget allocation for employer-funded HBV vaccine programs has diminished.
Although we_ve made great progress for reduction of HBV, it_s just one of the diseases that poses an occupational health risk. Older diseases that many thought wouldn_t reappear in the U.S.ƒmumps, measles, rubella, pertussis (whooping cough) and chickenpoxƒare making a comeback. In 2008 in the U.S., there were 800 cases of mumps reported, 131 cases of measles, 9,499 cases of pertussis and 26,489 cases of chickenpox. The problem is many health-care workers have not been vaccinated against these communicable diseases.
It_s a Fact
With these facts and statistics in mind, it_s clear that EMS leaders should makeimmunizationandvaccinationof personnel a top priority. Immunization standards for this group should be addressed in accordance with the CDC guidelines, the National Fire Protection Association (NFPA) 1581 Infection Control Standard, and the Occupational Safety and Health Administration (OSHA) standard 1910.1030 addressing protection of workers from bloodborne pathogens.
At first glance, this goal may seem expensive, but the long-term savings make up for it. It_s less costly to vaccinate up front than to pay for one post-exposure event, estimatedat $1,200Ï$6,000 or more.
It_s currently recommended that all health-care workers (including EMS personnel) get immunized or vaccinated for hepatitis B, measles/mumps/rubella (MMR), varicella (chickenpox), tetanus/diphtheria/pertussis and annual influenza. Testing for exposure to tuberculosis (TB) is also an important component of a comprehensive vaccine/immunization program.
It_s important to note that OSHA is enforcing the 2005 CDC guidelines on prevention of transmission of TB in the health-care setting, the CDC hepatitis B vaccine recommendations and, by reference, the CDC- guidelines for vaccinations and immunization of health-care workers. The CDC guidelines and recommendations set the medical standard of care.
Under the guidelines, vaccines and immunizations are to be offered to personnel. If an employee/volunteer chooses not to take a vaccine, then they are to sign a declination form. The NFPA standard 1581 (2005 version) refers to the CDC guidelines for vaccination and immunization recommendations and the need for declination forms.
Employees can obtain vaccine/immunization records and health history information from previous employers or from their high school or college records. The employee needs to request the records in writing. Each employer is to maintain records for the duration of employment, plus 30 years. Departments may want to consider supplying vaccine/immunization record copies to members of the department to assist in ensuring availability and access.
Recommendations for EMS
It should be noted that hepatitis A, meningitis and polio vaccinesarenotrecommended for health-care providers, including EMS personnel. Here is a list of the vaccines and immunizations thatare recommended:
Hepatitis B vaccine:This is recommended (and OSHA enforced) to be offered to all health-care personnel who perform tasks/procedures that involve blood or bodily fluids. The vaccine is a three-dose series given over a six-month time frame. It_s important to complete all three doses to achieve protection. If the series is not completed in the recommended time frame, there_s no need to start the series all over again. Just pick up where the employee left off and complete the series. There_s no requirement for a booster for this vaccine. It appears that there_s lifelong protection.
Titertesting to determine response to the vaccine is to be done one to two months after completion of the three-dose series. If this time frame is missed, it_s too late to do a titer. Tracking employee participation is an OSHA requirement. Tracking is important to ensure that all three doses are completed and that the titer is performed in a timely manner.
If a titer performed after completion of the vaccine program does not document adequate response to the vaccine (10 mIU/mL or higher), then the full series should be repeated and another titer performed. If no response is noted, then the employee is a"non-responder"and needs to be counseled that they_re not protected. If an exposure occurs in a non-responder, reporting is critical, as there_s a specific treatment protocol for this situation.
If there_s a positive titer, no further titer testing needs to be performed, even if an exposure occurs. Having these records readily available is essential. The designated infection control officer for the department should be able to access this information 24/7.
For persons who received their vaccine series and never had a titer, one should not be performed. A titer should be performed only if an exposure to a HBV-positive patient occurs. This is because this vaccine has a unique property, "immunologic memory." Titers go into a "sleep mode"; even if a titer testing were to show negative on hire, the employee is still protected. This is why routine titer testing is not recommended and never has been.
Public safety departments can purchase the HBV vaccine using the CDC contract price of $26.70 per dose.
Tetanus/diphtheria boosters:These are recommended for all health-care workers every 10 years. However, due to the rise of pertussis (whooping cough) in adults, the CDC has recommended that all health-care providers who deliver direct patient care should receive a one-time dose of tetanus, diphtheriaand the acellular pertussis (Tdap) vaccine. The average cost for Tdap is approximately $27.52 per dose. The list cost of Td is about $13.25 per dose.
Measles/mumps/rubella (MMR) immunity:All personnel who provide direct patient care should provide proof of this immunization. Generally, health-care workers born in 1957 or later can be considered immune if they have documentation. Documentation includes physician diagnoses, a laboratory titer showing immunity, or vaccination documentation with live MMR vaccine. People born before 1957, when there was no vaccine, are generally considered to be immune. However, one dose of MMR vaccine is recommended if there_s an outbreak.
A titer could also be performed before vaccination, but this decision should be based on a cost-benefit analysis. Sometimes, it_s more expensive to titer than to just vaccinate. Currently, the MMR vaccine costs about $48.31 for a one-dose vial.
Since 2001, measles outbreaks have been reported in Virginia, Michigan, New York and California. In Virginia, one case of measles triggered a visit from the CDC, because this disease is rarely seen in the U.S. This single case of measles resulted in eight EMS personnel being exposed. No records of immunity for these individuals were readily available, and post-exposure prophylaxis needed to happen quickly.
In this case, the eight staff members had to remain off duty for 36 hours post exposure. Replacement staff was necessary, and titer testing needed to be performed. The designated infection control officer stated that the final cost for this one exposure incident was $14,400. Had immunity been established on hire and records been readily available, the cost would have been minimalƒthe price of one or two doses of vaccine per exposed employee. Two doses of vaccine times eight employees equals $772.96.
The CDC has stated that "health-care personnel place themselves and their patients at risk if th ey_re not protected against measles. In accordance with current recommendations, health-care personnel should have documented evidence of measles immunity readily available at their work location."
Varicella (chickenpox) vaccine:This vaccine is recommended for all non-immune health-care workers. Documentation of immunity is noted by record of two doses of varicella vaccine, history of varicella or herpes zoster (shingles) based on physician diagnosis or a titer showing immunity. The CDC first published the need for employee screening programs in 1997, but few employers took notice. Screening should be a standard step in the hiring process.
Currently, the vaccine costs $161.50 per dose and is given as a two-dose series, one month apart. If there_s a non-immune employee exposure, costs will include the medical fees, laboratory testing (titer), and vaccine administration. In addition, the employee will need to be off duty from day 10 following the exposure to day 28.
Influenza vaccine:It_s recommended that all health-care providers receive this vaccine annually. It was listed as a recommendation in the first version of NFPA 1581, which was published in 1989.
There are many benefits to employers and employees alike in establishing an annual influenza vaccine. First, the program will assist in the reduction of absenteeism. Second, the employee will develop protective antibodies against more strains of influenza virus by taking the vaccine every year. And, third, this is part ofpandemicplanning. As the incidence rate of seasonal flu declines, this will assist in the more rapid identification of a pandemic.
Influenza vaccines can be administered at a price as low as $9.75Ï$13.25 per dose. The cost of the nasal spray has been lowered to be more in line with the injectable form, about $19.70 per dose.
The influenza vaccine can be offered in two forms: the inactivated vaccine by injection or theliveattenuated vaccinein a nasal spray. The nasal spray can be administered to persons ages two to 49. The nasal spray is not recommended for pregnant women because it_s alive virus vaccine.TB testing:TB testing should be performed on hire to establish a baseline. If the employee has not been tested in the previous 12 months, then two-step testing should be performed. Two-step testing involves an initial skin test, and if the result is negative, the test is repeated in one to two weeks.
An alternative to skin testing is the blood test, QuantiFERON-TB Gold In-Tube. Blood is drawn and sent to the lab for testing, and the results are back in a couple of days. This testing has been determined to be more accurate than skin testing and is recommended by the CDC.
tThere_s also documentation to support that the blood test is more cost effective than skin testing. This can be computed by adding up the cost of the skin test, the price of staffing to cover the personnel going to get the test, the cost of staffing to cover the personnel going back to get the test read, and then the cost of the second test in one to two weeks. There_s also bound to be a number of employees who do not make it back for evaluation during the proper time frame (between 24 and 48 hours). This means the process must take place all over again, which means more costs.
The decision as to whether to perform annual TB testing on employees should be based on a TB risk assessment conducted every year. A department will fall into either the low-risk or medium-risk category, depending on the number of active untreated TB patients transported by the department in the previous year. If the number is less than three, the department is in the low-risk category and TB testing is not recommended on an annual basis. If the number is three or more, then the department falls into the medium-risk category and annual testing is recommended. The National Institute for Occupational Safety & Health (NIOSH) also stated this in a report following an investigation of positive skin tests in a Mississippi fire department.
Compliance with current requirements, recommendations and standards for immunization and vaccination can actually be cost effective. Each department should have a comprehensive program to assess the immunity status of all new hires/volunteers, as well as current members. Immunity documentation should be readily available at the station and directly available to the designated officer 24/7 to assist with exposure situations.JEMS
Katherine West,BSN, MSEd, CIC, is an infection control consultant with Infection Control/Emerging Concepts Inc. and a JEMS editorial board member. Contact her at email@example.com.
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- Centers for Disease Control & Prevention: "Summary of Notifiable DiseasesƒUnited States, 2008." MMWR. 57(53):1420Ï1431, 2009.
- "Immunization of health-care workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC)." MMWR. 46(RR-18):1Ï42, 1997.
- National Fire Protection Association: "NFPA 1581: Standard on Fire Department Infection Control Program." 2005 Guidelines.
- Centers for Disease Control and Prevention: "Immunization Recommendations for Disaster Responders."www.bt.cdc.gov/disasters/disease/responderimmun.asp
- Mast EE, Weinbaum CM, Fiore AE, et al: "Comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP)." MMWR. 55(RR-16):1Ï33, 2006.
- Personal Communication. Hepatitis B Vaccine Branch, Centers for Disease Control and Prevention. January 25, 2006.
- CPL 2-2.69. Enforcement procedures for Occupational Exposure to Bloodborne Pathogens. November 27, 2001.
- U.S. Public Health Service: "Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis." MMWR. 50(RR-11):1Ï52, 2001.
- "Preventing tetanus, diphtheria and pertussis among adults: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine." MMWR. 55(RR-17):1Ï37, 2006.
- Centers for Disease Control and Prevention: "CDC Vaccine Price List."http://cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm.
- Centers for Disease Control and Prevention. "MeaslesƒUnited States, January 1ÏApril 25, 2008." MMWR. 57(18):494Ï498, 2008.
- Centers for Disease Control and Prevention: "Prevention and control of influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2008." MMWR. 57(RR-7):1Ï60, 2008.
- Mazurek GH, Jereb J, Lobue P, et al: "Guidelines for using the QuantiFERON-TB Gold test for detecting mycobacterium TB infection, United States." MMWR. 54(RR-15):49Ï55, 2005.
- Jensen PA, Lambert LA, Iademarco MF, et al: "Guidelines for preventing the transmission of mycobacterium tuberculosis in health-care settings, 2005." MMWR.54(RR-17):1Ï141, 2005.
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- Centers for Disease Control and Prevention: "Evaluation of results from occupational tuberculin skin testsƒMississippi, 2006." MMWR. 56(50):1316Ï1318, 2007.
- Occupational Safety & Health Administration: "Standard on Access to Employee Exposure and Medical Records (29 CFR 1910.1020)."www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=18046
HEALTH-CAREPersonnel Vaccination Recommendations
Hepatitis BGive 3-dose series (dose #1 now, #2 in 1 month, #3 approximately 5 months after #2).
Give IM. Obtain anti-HBs serologic testing 1Ï2 months after dose #3.
Tetanus,pertussis, diphtheriaGive all HCP a Td booster dose every 10 years, following the completion of the primary 3-dose series. Give a 1-time dose of Tdap to all HCP younger than age 65 years withdirect patient contact. Give IM.
MMRFor healthcare personnel (HCP) born in 1957 or later without serologic evidence of immunity or prior vaccination, give 2 doses of MMR, 4 weeks apart. For HCP born
prior to 1957, are considered to be immune. Give SC.
VaricellaFor HCP who have no serologic proof of immunity, prior vaccination, or history of(chickenpox)varicella disease, give 2 doses of varicella vaccine, 4 weeks apart. Give SC.
Influenza Give 1 dose of TIV or LAIV annually. Give TIV intramuscularly or LAIV intranasally.
Source:Center for Disease Control and Prevention.