ACIP urges pertussis vaccination for health workers

Feb 23, 2011 (CIDRAP News) – In the wake of a bad year for pertussis (whooping cough) in 2010, the federal Advisory Committee on Immunization Practices (ACIP) recommended today that healthcare personnel (HCP) get vaccinated against the disease and that employers should foot the bill.

The ACIP, whose decisions shape national immunization recommendations from the Centers for Disease Control and Prevention (CDC), also advised today that HCP who have been exposed to pertussis should be treated with antibiotics to help prevent spread of the illness to vulnerable patients such as newborns.

The committee also approved the first update of its general immunization recommendations for healthcare workers since 1997.

CDC officials at the meeting said provisional data show that more than 21,000 pertussis cases were reported in the United States last year, with 26 deaths. With more reports still likely to come in, that was the highest total since 2005, when there were about 25,000 cases.

About 95% of children have had at least three doses of pertussis vaccine, but adult immunization rates are much lower, because no vaccine for adolescents and adults was available until 2005, according to an Associated Press report published today.

The recommendation on HCP vaccination was approved unanimously except for one abstention. It says that:

  • HCP of all ages should receive a single dose of tetanus, diphtheria and pertussis (Tdap) vaccine as soon as is feasible if they have not previously received it, regardless of the time since the last tetanus-diphtheria (Td) vaccine dose.
  • After receiving Tdap, which is not approved for multiple doses, personnel should receive routine booster shots against tetanus and diphtheria as recommended by existing guidelines.
  • Hospitals and outpatient clinics should provide Tdap for HCP and take steps to maximize coverage, such as education, convenient access, and not charging for it.

In discussing the recommendation, which was proposed by the ACIP's pertussis working group, ACIP member Dr. Renee Jenkins asked if there were any estimates of the cost burden for hospitals if they supply the vaccine for free. Dr. Jennifer Liang of the CDC replied that the group talked about the cost issue but did not review data on it.

An ACIP liaison member asked if the group considered how the recommendation would be implemented, noting that for some diseases, staff members are tested for immunity.

Liang replied, "There are no serologic correlates of protection for pertussis, so it's based on vaccine history."

ACIP Chair Carol J. Baker, MD, of Baylor College of Medicine in Houston, commented, "At our medical school, we ask people about Tdap, and usually they don't remember, so they just get [the vaccination]."

In another pertussis-related step, after considerable discussion the committee approved a recommendation on postexposure prophylaxis (PEP) for HCP who might spread the disease to vulnerable patients.

The recommendation says:

  • Healthcare facilities should maximize efforts to prevent transmission of Bordetella pertussis, including respiratory precautions.
  • Data on the need for postexposure antimicrobial prophylaxis in Tdap-vaccinated HCP are inconclusive. Some vaccinated workers are still at risk for the disease, so Tdap may not preclude the need for PEP with antimicrobials.
  • Postexposure antimicrobial prophylaxis is recommended for all HCP who have unprotected exposure to pertussis and are likely to expose a patient at risk for severe pertussis (eg, hospitalized neonates and pregnant women). Other vaccinated personnel should either receive PEP or be monitored daily for 21 days after pertussis exposure and treated at the onset of signs and symptoms of pertussis.

Baker commented that the early symptoms of pertussis resemble the common cold, adding, "I don't know of any convincing data that antibiotic treatment will modify the course, but it'll clearly decrease transmission to others."

ACIP member S. Michael Marcy, MD, of Southern California Permanente Medical Group in Los Angeles, questioned the recommendation to monitor signs and symptoms for some personnel. "If you're monitoring signs and symptoms, you're closing the door after the cow is out," he said.

Member Mark H. Sawyer, MD, of the University of California San Diego, commented, "The language presented to you was based on the practical experience of many people on the working group who have seen such problems where workers are monitored by occupational health, and if they have symptoms they are treated and excluded from work for 5 days. This approach, though imperfect, has worked in many institutions."

In later action, the ACIP discussed and approved a revision of the general immunization recommendations for HCPs, after dropping a clause calling for documenting immunity to hepatitis B in workers who are exposed to blood and other bodily fluids. CDC officials said the revision was needed because several new and expanded recommendations have been made since 1997.

The report was prepared by an ACIP subcommittee and presented by Dr. Harry Keyserling, MD, an Emory University pediatrician and ACIP liaison member who represents the Society for Healthcare Epidemiology of America.

He said the group decided to change the term for the target population from "healthcare workers" to "healthcare personnel," because the aim is to include anyone who would be in a healthcare environment, such as custodians and volunteers. The guidance is intended for outpatient clinics, nursing homes, and home health care agencies, as well as hospitals.

ACIP members received a draft of the report earlier this month and submitted comments. In response to the comments, the working group made a number of minor editorial changes, Keyserling said.

Regarding hepatitis B, Keyserling said the landscape has changed since 20 years ago, when the ACIP first recommended immunization for infants. Most people now have a childhood history of immunization but may not have documentation, he said.

"We do want to document immunity to hepatitis B for individuals exposed to blood and other body fluids," he said. "ACIP hasn't addressed this specifically, but healthcare facilities are now faced with making decisions."

Several members questioned the recommendation about documenting hepatitis B immunity. Dr. Jim Turner, ACIP liaison from the American College Health Association, said all students entering his medical school have been vaccinated in childhood, and the screening test costs $116. "I've got some concerns about that [recommendation] showing up even as an option now," he said.

The committee passed a motion by Sawyer to approve the report while deleting the recommendation about testing staff for hepatitis B immunity. He suggested that the committee's hepatitis B working group should discuss the issue.

On other immunizations covered in the report, Keyserling said it recommends flu vaccination for all HCP and discusses practices to increase vaccination coverage but does not call for mandatory flu vaccination, which a growing number of institutions are embracing.

He said many ACIP members thought the document should "weigh in on mandatory flu vaccination as a condition of employment."

"From my perspective, OSHA [the Occupational Safety and Health Administration] mandates and ACIP recommends," he said. "We do discuss in the document that many professional organization have endorsed the concept of mandatory immunization, and in 2007 the Joint Commission [an accreditation body] started asking hospitals to report their immunization coverage, so I think we're in the process of bringing immunization up to where it should be."

See also:

Feb 23-24 ACIP agenda

ACIP main page

Oct 27, 2010, CIDRAP News story "CDC advisors recommend steps to fill pertussis vaccine gaps"

ACIP members

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