Hospitals moving ahead with HCW pertussis shots

Hospitals moving ahead with HCW pertussis shots

Protect infants, prevent disruptive outbreaks

Hospitals have begun offering pertussis vaccines to their employees in an effort to protect vulnerable patients from a disease that is most contagious in its early stages, when it may go undetected.

The American College of Occupational and Environmental Medicine (ACOEM) urged hospitals to administer the vaccines "as soon as feasible" to health care workers with direct patient contact and noted that the costs will be more than offset by the benefits of preventing an outbreak. Two federal advisory panels have endorsed the vaccinations, and the Centers for Disease Control and Prevention has issued provisional recommendations for the vaccination of health care workers (www.cdc.gov/nip/vaccine/tdap/tdap_adult_recs.pdf).

"It's an expensive recommendation, but this is a disease that still kills infants in this country," says Mark Russi, MD, vice chair of ACOEM's medical center occupational health section and ACOEM liaison to the Healthcare Infection Control Practices Advisory Committee. HICPAC and the Advisory Committee on Immunization Practices endorsed the pertussis recommendation.

A recent outbreak at Dartmouth-Hitchcock Medical Center in Lebanon, NH, highlights the potential for hospital-based spread of pertussis. This spring, 135 hospital employees were diagnosed with pertussis after the disease spread from one department. The hospital responded with a mass vaccination program and intensive monitoring.

More than 1,500 physicians and staff were screened and tested for pertussis, and more than 5,000 physicians, staff members, medical students, and volunteers were immunized against the disease over a four-week period. Health care workers in high-risk areas (such as the intensive care nursery) who were identified as having pertussis or who were awaiting test results were furloughed from work.

That led to the temporary closure of some hospital beds and cutbacks on operating room hours. Even today, physicians and staff entering high-risk areas sign in at entrances acknowledging they are symptom-free, according to a hospital spokeswoman.

An outbreak also occurred at the hospital in 2003, triggered by a nurse who worked with a cough that persisted for four weeks. Her teenaged son, who also had a persistent cough, attended a school where pertussis cases had been identified. The hospital screened patients and employees and confirmed cases of pertussis in 10 of 117 employees in the hematology-oncology unit. Good infection control practices apparently prevented any of the unit's patients from contracting the disease.¹

A pertussis outbreak can place a significant burden on a hospital, notes Tejpratap Tiwari, MD, medical epidemiologist with the CDC's National Center for Immunizations and Respiratory Diseases.

"Currently, if health care personnel have pertussis or if they're suspected of having pertussis, the guidelines recommend that they stay away from work until at least five days of appropriate treatment are completed," he says. "Health care personnel who are exposed to pertussis and are without symptoms should receive post-exposure prophylaxis but are allowed to continue working.

"Since we do not know how well Tdap vaccination prevents transmission, health care personnel who have received the newly licensed Tdap vaccine and who have unprotected exposures to pertussis should be given prophylactic antimicrobials. Alternatively, if the infrastructure in hospitals exists, they should be monitored daily for pertussis symptoms for 21 days without a course of antimicrobials. If respiratory symptoms appear during this period, then they can be treated early," he says.

One study found that a Tdap vaccination program in hospitals is cost-saving, even when post-exposure prophylaxis is given to vaccinated health care personnel, he notes. The study estimated that for every dollar spent in a hospital vaccination program there will be a cost saving of $2.38.²

Targeting HCWs who care for infants

Hospitals are seeking to avoid outbreaks by offering the vaccine to employees. For example, Yale-New Haven (CT) Hospital has begun vaccinating new employees. "We've also targeted employees who have contact with infants as the highest priority group," says Russi, who is director of occupational health at the hospital and associate professor of medicine and public health at the Yale University School of Medicine. "Over the course of the year, we will add pertussis vaccine to the flu vaccine campaign and offer it to [employee health] clinic patients."

So far, employees have been receptive to the vaccine, he says, adding it is not associated with significant adverse effects. Marshfield (WI) Clinic budgeted almost $50,000 to vaccinate more than 1,500 employees at about $32 per shot. That will encompass employees who may have contact with infants, including general internal medicine, pediatrics, family practice, and obstetrics. Eventually, the clinic hopes to offer the vaccine to all 7,000 employees, says Bruce Cunha, RN, MS, COHN-S, manager of employee health and safety. Cunha is aware of the potential for hospital- or clinic-based outbreaks. "We have had cases of pertussis [among employees], but none of those were directly related to patient exposure," he reports.

Danville (VA) Regional Medical Center also is initially focusing on certain areas, include obstetrics, pediatrics, and neonatal units, the emergency department, outpatient clinics, laboratory, and the hospital's child care center. Employees have reported mild effects from the vaccine, including pain and redness at the vaccine site, and a little malaise and fever, says Jacob Moll, MD, MPH, medical director of outpatient clinics/employee health.

For now, the hospital is not vaccinating employees (or patients) 65 years or older unless there is a specific request from a physician, he says. ADACEL, the Tdap vaccine manufactured by Sanofi Pasteur is licensed by the FDA for use among adults ages 19 to 64.

The CDC is recommending the Tdap vaccine for employees who have not received the Td vaccine within the past two years. The recommendation involves only a one-time, single dose, but as more data become available, that recommendation may evolve and health care workers may eventually need another booster, Tiwari says.

Even employees who have had confirmed pertussis should be vaccinated, he says. "Neither pertussis vaccination nor previous disease confers lasting or lifelong protection," he says. "The immunity wanes over a five- to 10-year period."

Reference

1. Boulay BR, Murray CJ, Ptak J, et al. An outbreak of pertussis in a hematology-oncology care unit: Implications for adult vaccination policy. Infect Control Hosp Epidemiol 2006; 27:92-95.
2. Calugar A, Ortega-Sanchez IR, Tiwari T, et al. Nosocomial pertussis: Costs of an outbreak and benefits of vaccinating health care workers. Clin Infect Dis 2006; 42:981-988.