Coping with the cost of pertussis vaccine
Hospitals begin widespread vaccination
Hospitals are wrestling with the cost of complying with recent guidelines from the Centers for Disease Control and Prevention in Atlanta on pertussis vaccination of health care workers.
The CDC recommends vaccinating health care workers who have direct patient contact "as soon as feasible" if it has been at least two years since their last tetanus booster. Other health care workers should gradually receive the acellular pertussis vaccine (known as Tdap) as their tetanus booster, the CDC says.1 The vaccine also contains tetanus and diphtheria toxoids, similar to the Td booster vaccine.
While many hospitals have not routinely paid for tetanus boosters for their staff, the CDC advises that Tdap should be offered free of charge. It costs about $30 per dose.
"It just requires planning, and it requires having the support of your administration," says Melanie Swift, MD, medical director of the Vanderbilt Occupational Health Clinic in Nashville, who estimates that Vanderbilt will spend $90,000 to vaccinate medical center and university employees. "We began planning for this when we first heard it was going to be approved. We put it in as a special budget proposal nine months before the upcoming fiscal year," she reports
A cost-benefit analysis showed that for every dollar spent on Tdap vaccination, hospitals would save $2.38, based on the costs of controlling an outbreak, says Katrina Kretsinger, MD, medical epidemiologist and lead author of the CDC recommendations. "Vaccination can avoid a lot of problems with outbreaks in health care settings and all the costs those entail," she says.
Many hospitals did not previously provide routine tetanus vaccines to their employees because it is not considered an occupational risk. However, studies show health care workers are at higher risk for pertussis than the general population, making the vaccine a benefit both for employee health and patient safety. Adacel, manufactured by sanofi pasteur in Toronto, has been approved for adults ages 19 to 64. (See summary of CDC recommendations below.)
Preventing Pertussis in Health Care Workers The Centers for Disease Control and Prevention offers this guidance for diagnosing and preventing pertussis among health care workers: Clinical Case Definition: A cough illness lasting at least two weeks with one of the following: paroxysms of coughing, inspiratory "whoop," or posttussive vomiting, and without other apparent cause (as reported by a health care professional). Laboratory Criteria for Diagnosis: Isolation of Bordetella pertussis from a clinical specimen, or positive polymerase chain reaction (PCR) assay for B. pertussis. Recommendation: Health care personnel in hospitals and ambulatory care settings who have direct patient contact should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap. An interval as short as two years because the last dose of Td is recommended. Other HCP should receive a single dose of Tdap according to the routine recommendation; they are encouraged also to receive Tdap at an interval as short as 2 years. Priority should be given to vaccination of HCP who have direct contact with infants aged <12 months. Hospitals and ambulatory care facilities should provide Tdap for HCP and use approaches that maximize vaccination rates Contraindications:
Precautions and reasons to defer Tdap:
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Protecting vulnerable patients
Most importantly, the cost of pertussis vaccination is weighed against the risk to vulnerable patients, particularly infants. CDC recommends prioritizing the vaccine by providing it first to health care workers who care for infants.
About 19% of pertussis cases and 92% of deaths occur among infants younger than one year old, the CDC reported. Infants receive the pertussis vaccine at 2, 4, and 6 months of age. "Until infants have finished those doses, they're quite vulnerable," Kretsinger says.
Because of concerns about the impact of a pertussis outbreak on vulnerable patients, some hospitals are considering making the Tdap vaccine mandatory. The American College of Occupational and Environmental Medicine has recommended vaccinating health care workers with direct patient contact "as soon as feasible," but did not address whether it should be voluntary or mandatory. (See www.acoem.org/guidelines.aspx.)
"There was a fatality in our system of a 5-month-old child," says Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety at the Marshfield (WI) Clinic. "It didn't come from a health care worker. But that's enough incentive to me right now that we should make it mandatory," he adds.
There are some practical reasons why hospitals have not yet made the Tdap vaccine mandatory. With a sudden surge in demand, hospitals have received limited supplies. For example, Vanderbilt has received 1,000 doses a month for employees and patients. It will take about 1,500 doses to cover employees who work in high-risk areas, such as obstetrics and pediatrics, estimates Swift. The university and medical center have about 20,000 employees.
"We are strongly encouraging health care workers in our children's hospital to participate," she says.
Yale-New Haven (CT) Hospital had planned to offer the Tdap vaccine in the fall along with the flu vaccine but was unable to receive sufficient supplies, says Mark Russi, MD, director of occupational health. Instead, employees are receiving the Tdap vaccine with their annual tuberculin skin testing, he says.
Do vaccinated HCWs shed virus?
Although the vaccine is considered to be about 85% effective at protecting health care workers from acquiring pertussis, there are not yet any data on whether exposed individuals could still shed virus. Therefore, CDC still recommends providing antibiotic prophylaxis to health care workers who are exposed to pertussis.
Vanderbilt is participating in a study to determine how to respond to pertussis exposures of vaccinated workers. Vaccinated employees will be randomized to receive either placebo or antibiotics after a pertussis exposure, says Swift.
"They'll be rigorously tested after the exposure to see if they're shedding pertussis and asked about symptoms on a daily basis," she says. "If they have symptoms of pertussis, they are removed from the workplace and placed on antibiotics for treatment."
If hospitals can forgo giving antibiotics after an exposure, that could represent a significant cost savings. Almost 500 employees have been exposed to pertussis in the past three years at Vanderbilt, Swift says.
"We typically see from 12-20 events where a patient exposes multiple health care workers each year," she says. "Every time there's an exposure, we contact all of the exposed health care workers, we interview them, and we prescribe them antibiotics to prevent them getting pertussis."
In its vaccination recommendations, CDC provides some leeway for hospitals that want to avoid antibiotic prophylaxis of vaccinated employees. Daily monitoring of health care workers for signs and symptoms for 21-28 days after exposure "might be a reasonable strategy for post-exposure management," CDC says, noting that hospitals should "maximize efforts" to prevent transmission to infants or other vulnerable patients.
"Hospitals can choose to modify their post-exposure prophylaxis guidelines based on their best judgment and risk assessment," Kretsinger says.
Reference
1. Centers for Disease Control and Prevention. Preventing tetanus, diphtheria, and pertussis among adults: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. MMWR 2006; 55(RR17):1-33.