The ins and outs of healthcare personnel vaccinations
After reading this article, you will be able to:
- Identify the five recommended immunizations needed for healthcare workers
- Describe necessary documentation that meets proof of immunity
The Immunization Action Coalition (IAC) in Saint Paul, MN, supported in part by the National Center for Immunization and Respiratory Diseases at the CDC, regularly provides advice on all aspects of immunizations.
Recently, the IAC compiled an "Ask the Experts" feature focusing on vaccinations for healthcare personnel and encouraged wide distribution of the content.
Here is what IAC experts-nurse educator Donna L. Weaver, RN, MN, and medical epidemiologists Andrew T. Kroger, MD, MPH, and William L. Atkinson, MD, MPH, National Center for Immunization and Respiratory Diseases, CDC-had to say on the subject.
Q Which vaccines does the Advisory Committee on Immunization Practices (ACIP) specifically recommend that healthcare personnel (HCP) receive in order to work in a healthcare setting?
A ACIP recommends that all HCP be vaccinated with:
- Two doses of MMR (measles-mumps-rubella) vaccine (or have evidence of measles, mumps, and rubella immunity)
- Annual influenza vaccination
- One dose of Tdap (especially to protect against pertussis)
- Three doses of hepatitis B vaccine for those who might be exposed to blood or body fluids at work
- Two doses of varicella vaccine (or have evidence of varicella immunity)
For definitions of evidence of immunity to MMR and varicella, please refer to "ACIP Provisional Recommendations for Measles-Mumps-Rubella (MMR) ‘Evidence of Immunity' Requirements for Healthcare Personnel" and "Varicella: Recommendations of the Advisory Committee on Immunization Practices," Morbidity and Mortality Weekly Report, June 22, 2007.
Q For which workers in healthcare settings does OSHA require that hepatitis B vaccine be provided?
A OSHA requires that hepatitis B vaccine be provided free of charge to HCP who have reasonably anticipated contact with blood or body fluids on the job. This requirement does not include HCP who would not be expected to have occupational risk, such as billing staff and general office workers.
Employers must ensure that workers who decline hepatitis B vaccination sign a declination form.
For a fact sheet about this OSHA requirement, search for "Hepatitis B Vaccination Protection" at www.osha.gov.
Q If an employee has two documented doses of MMR but has negative or equivocal titers for one or more of the antigens, what should we do? Same question if an employee has two documented doses of varicella vaccine but tests negative.
A Actually, ACIP does not recommend testing for immunity in such situations. For measles, mumps, and rubella, ACIP considers two documented doses of MMR vaccine given on or after age 1 year and at least 28 days apart to be evidence of immunity for HCP.
For varicella, ACIP considers two documented doses of vaccine to be evidence of immunity for HCP as long as doses are given no earlier than age 12 months, with at least three months between doses for children younger than age 13 years, or at least four weeks between doses for people age 13 years and older.
Because of the limitations of serologic testing, tests for even properly vaccinated individuals will often come back as negative or equivocal, putting the employee health service in the difficult position of having to do something (e.g., give additional doses, perform a follow-up titer).
If a healthcare worker does not have any documented doses of MMR and/or varicella vaccine, he or she can:
1.Be tested for immunity, or
2. Just be given two doses of MMR and/or varicella at least four weeks apart.
ACIP does not recommend serologic testing after vaccination.
Q How soon after a dose of Td can HCP receive a dose of Tdap?
A If they have not previously received Tdap, HCP in hospital, long-term care, and ambulatory care settings should receive a single dose of Tdap as soon as feasible and without regard to the dosing interval since the last Td dose. No minimum interval exists between receiving Td and Tdap.
Q Can Tdap be given to pregnant HCP?
A In June 2011, after studying new safety and efficacy data, ACIP voted to recommend that pregnant women who have never received the Tdap vaccine be vaccinated with Tdap during their third trimester or the second half of their second trimester (after 20 weeks gestation).
ACIP made this recommendation in response to the continuing pertussis outbreak, with the goal of protecting newborns with maternal antibodies and decreasing the risk of transmission from mother to infant after birth. If the vaccine is not given during pregnancy, it should be given immediately postpartum.
To view ACIP's provisional recommendation for use of Tdap in pregnant women, go to www.cdc.gov/vaccines/recs/provisional.
Q Can pregnant healthcare personnel administer live-virus vaccines?
A A pregnant staff member may administer any vaccine except smallpox vaccine.
Q Why does CDC recommend that we consider obtaining a signed declination from HCP who refuse influenza vaccination?
A Some studies have shown an increase in HCP influenza vaccine acceptance when decliners are required to sign such a statement. In addition, such statements can help a vaccination program assess the reasons for declination and plan future educational efforts.
Q Please tell me which professional associations have endorsed mandatory influenza vaccination for healthcare workers and have created policy statements.
A The following professional associations have issued policy statements supporting mandatory healthcare worker influenza vaccination:
- American Academy of Pediatrics
- American Medical Directors Association
- American Pharmacists Association
- American Public Health Association
- Association for Professionals in Infection Control and Epidemiology
- Infectious Diseases Society of America
- Society for Healthcare Epidemiology of America
You can find additional information about mandatory influenza vaccination for HCP including a list of more than 100 healthcare settings that have implemented mandatory vaccination programs. Access IAC's Honor Roll for Patient Safety Web section at www.immunize.org/honor-roll.
For more IAC "Ask the Experts" Q&As, go to www.immunize.org/askexperts.