|
HEALTH CARE WORKER IMMUNIZATION TO PROTECT PATIENTS
Position Paper from the Indiana Chapter of the American Academy of Pediatrics
September 2011
Introduction
A focus on patient safety includes the need to prevent the transmission of infectious diseases from health care workers (HCWs) to patients, including vaccine-preventable diseases. Vaccination is one of the most effective public health tools to accomplish this goal, along with consistent hand-washing. Health care-associated infections contribute to patient illness and deaths as well as posing a major financial impact on health care delivery systems.
Influenza
Young children, pregnant women, and the elderly experience the highest rates of serious influenza-related illness and death. There were 115 children in the U.S. who died from influenza during the 2010-11 flu season. Influenza is contagious through respiratory transmission of the virus, which begins one day before symptoms appear and can last for 5 to 7 days in a healthy person. Infected people without symptoms of influenza can transmit the virus to others.
Since vaccination is the most effective way to prevent influenza outbreaks, it is now recommended for everyone 6 months of age and older. When the vaccine strain is well-matched to the influenza strain of the outbreak, influenza cases are decreased by 70% to 90%.. Vaccination with influenza vaccine will prevent most cases of influenza in health care workers (HCWs) and thus prevent transmission of infection to patients with whom they are in contact.
Hospital workers provide care to the sickest patients, who are often vulnerable to complications of influenza infection. Thus, hospital workers must be certain that they are not responsible for transmitting influenza to patients. Similar to employees in many settings, health care workers may keep working even when they are feeling mildly ill (“presenteeism”).
Several studies document influenza transmission from personnel in hospital settings: In a NICU, 35% of infants (19/54) contracted influenza; 6 became ill and 1 died. Another study reported an outbreak of influenza in a bone marrow transplant unit where 6 patients developed pneumonia and 2 patients died related to 5 staff members having influenza.
The Rationale for Mandatory Vaccination of HCWs
It is estimated that vaccination rates of 80% or higher are necessary to achieve herd immunity to substantially reduce health care-associated influenza. Voluntary HCW influenza vaccination programs have been used in many hospitals but only achieve vaccination coverage levels of 70% at best. CDC published data showing that 63.5% of HCWs overall, and 71.1% of HCWs working in hospitals, received influenza vaccine in the 2010-11 season. HCW reluctance to be vaccinated stems around several misconceptions about the risk and benefit of vaccination. Mandatory health worker influenza vaccination programs demonstrate vaccination coverage rates of 88% to 99%. Medical and religious exemptions were used by only 1% to 2% of employees.
Mandatory immunization is not a new concept; hospitals require some specific vaccines and annual tuberculosis testing for patient protection just as schools require certain vaccinations to prevent the spread of some contagious diseases. Mandatory vaccination of HCWs is ethically justified as part of the professional obligation to act in the best interests of health of patients and is cost-effective.
Pertussis (Whooping Cough)
In Indiana, 744 cases of pertussis were reported to the Indiana State Department of Health in 2010, the most cases since the previous peak of 394 cases were reported in 2005.
Pertussis is an additional vaccine-preventable infection that should be considered important for HCW immunization programs. The pertussis bacteria is spread by respiratory transmission and is most serious when young infants are infected; 90% of deaths from pertussis occur in infants less than 6 months of age. The infant is usually infected from an adult who is unaware of having pertussis, but may have symptoms of a persistent cough. Similar to influenza, contagiousness occurs even in asymptomatic infected persons. Outbreaks of pertussis in both inpatient and outpatient settings from infected HCWs have been documented, including NICUs.
Since 2005, pertussis vaccination of adults and adolescents has been recommended with one dose of Tdap (tetanus, diphtheria, acellular pertussis) vaccine. However, less than 10% of adults have ever received a Tdap vaccination. All HCWs who have contact with infants less than one year of age should receive Tdap vaccine.
It is particularly important for people in contact with newborns (including family members and child care providers). Pregnant women can receive Tdap vaccine after 20 weeks of gestation. In recent years, some hospitals have begun providing Tdap vaccine to the new mother prior to hospital discharge, but it is often difficult to vaccinate all family members due to reimbursement issues.
Promotion of Tdap vaccination of HCWs in both hospital and ambulatory settings is an important step in controlling the spread of pertussis. All health care facilities should examine and update their policies regarding the need for Tdap vaccination of their employees in order to protect vulnerable young infants from this devastating infection.
References:
Policy Statement – Recommendation for Mandatory Influenza Immunization of All Health Care Personnel. Committee on Infectious Diseases of the American Academy of Pediatrics. Pediatrics, Vol. 126, No. 4, October 2010.
Influenza Vaccination Coverage Among Health-Care Personnel – United States, 2010-11 Influenza Season. Morbidity and Mortality Weekly Report, Vol. 60, No. 32 August 19, 2011.
Use of Models to Identify Cost-effective Interventions: Pertussis Vaccination for Pediatric Health Care Workers. Greer and Fishman. Pediatrics, Vol. 128, No. 3 September 2011.
The Indiana State Department of Health (ISDH) has issued new childhood and adult eligibility policies for publicly funded vaccines, affecting local health departments as of July 1, 2011. Local health departments are being advised to provide publicly funded vaccines to those residents who lack insurance coverage for vaccines in specified ways (see below). There are no changes in eligibility for children who have Medicaid or who have no health insurance (uninsured), i.e, those who receive VFC vaccines (federally funded).
The policy changes affect the definition of which children can be considered as underinsured; these will include ONLY those children with private insurance that:
A) does not include any vaccine coverage, or
B) specific vaccines are not covered under insurance, or
C) the yearly dollar cap in vaccine coverage has been met or exceeded.
The categories of children with private health insurance who will no longer be considered underinsured are: a) requires a high deductible, or b) has a preventable services component that pays for vaccines, or c) there is a co-pay required, or d) there is percentage based coverage (such as 80/20).
In the past, most local health departments provided immunizations to everyone, regardless of insurance status. Some local health departments may have a supply of "private stock" vaccine to use for children fully insured with private insurance; however, most children will need to receive immunizations from a health care provider in private practice. The rationale for this policy change is to better utilize the limited monies available for state-funded vaccines supplied to local health departments.
On April 22, 2011 the US Food and Drug Administration (FDA) granted licensure to expand the indication of Menactra vaccine to infants as young as 9 months of age. Since this is the first meningococcal vaccine indicated for infants in the US, the Advisory Committee on Immunization Practices (ACIP) has yet to make an official recommendation. A press release detailing this news has been issued by sanofi Pasteur.
Indication - Menactra vaccine is indicated for active immunization to prevent invasive meningococcal disease caused by N meningitidis serogroups A, C, Y, and W-135. Menactra vaccine does not prevent N. meningitidis serogroup B disease. Menactra vaccine is approved for use in individuals 9 -23 months of age, in addition to 2 through 55 years of age. Children 9-23 months of age should receive 2 doses (0.5 ml each) of vaccine given 3 months apart.
Safety Information -The most common local and systemic adverse reactions to Menactra vaccine include injection site pain, redness, and induration (all age groups); irritability, crying, drowsiness, loss of appetite, and diarrhea (infants and children); headache, fatigue, and malaise (adolescents and adults). Other adverse reactions may occur. Menactra vaccine is contraindicated in persons with known hypersensitivity to any component of the vaccine or to latex, which is used in the vial stopper. Guillain-Barré syndrome (GBS) has been reported in temporal relationship following administration of Menactra vaccine. Persons previously diagnosed with GBS should not receive Menactra vaccine. Vaccination with Menactra vaccine may not protect all individuals. Before administering Menactra vaccine, please see full Prescribing Information.
Adolescents age 11-12 years and previously unvaccinated 13-18 year-olds, and 19-21 year olds enrolling in college, should receive one dose of meningococcal conjugate vaccine (MCV4) as their primary series. For age 11-18 years, a booster dose of MCV4 is needed at age 16 years, if the primary dose was given at age 12 or younger, OR at ages 16-18, if the primary dose was given at ages 13-15. Likewise, those adolescents age 19-21 who will be attending college should receive a booster dose if the first dose was given before age 16. For 19-21 year-olds currently attending college, permissive use of the first dose and booster dose is recommended, i.e, the health care provider MAY give a primary dose if not previously received, and MAY give a booster dose, if the previous dose was received before age 16.
In addition, there are revised primary series and booster dose recommendations for patients with functional/anatomic asplenia and certain complement component deficiencies that apply to children age 2 years or older. These updated recommendations, as well as the situation of increased risk for exposure from travel or lab work, are available on the CDC/Vaccines website or the Immunization Action Coalition/Ask the Experts website.
CHIRP is the free and innovative online system that stores and updates immunization records of both children and adults in Indiana.
There has been some confusion about billing vaccine administration fees for Medicaid-eligible children when vaccines are administered during a visit for which an E&M code is billed. We have asked the OMPP Policy office for clarification of allowable charges, and this was reviewed during their recent policy meeting.
Their decision states that an administration fee for VFC vaccine may be billed (and reimbursed) up to $8.00 even if the vaccine is given at the time of another service for which and E&M code is billed.
If a provider is vaccinating Medicaid-eligible children outside the VFC program, a separate administration fee may not be billed.
Please click here to read the article
The Tdap project- music video and website - were created for the purpose of educating youth and their parents about the dangers of pertussis and the availability of a vaccine to prevent pertussis in adolescents and adults.
The idea of developing a music video to educate youth on this topic was conceived by INAAP member Charlene Graves, after reviewing vaccination videos available on YouTube in March of 2009. INAAP then secured funding for this project through a competitive process for immunization grants available from the Friends of Children Fund of the AAP. The concept of the grant proposes to widely disseminate the music video and website through social networking venues as well as to health care providers and school systems.
INAAP partnered with the Media Arts Department of Butler University in Indianapolis to produce the music video Tdap Vac and Friends Visit the Classroom. Faculty member Patrick Hurley composed the music and lyrics and produced the music video and designed the website. The video features a newly created character – rapper Tdap Vac – as the central focus of the video and the website. Utilizing humor and parody, along with a variety of rapidly paced musical performances, the music video provides a highly entertaining method of health education.
TdapVac and Friends Visit the Classroom is a unique educational offering. We urge you to explore the health information available through the www.TdapVac.com website (posters, fact sheets) and show the music video in pediatric offices and other sites. The music video can be obtained on a DVD (contact CGraves1203@aol.com) or downloaded from the website or from YouTube (search term Tdap Vac). Become a fan of Tdap Vac on Facebook! The music video will also be featured as a Video of the Week on the Immunization Action Coalition website (www.immunize.org) which has 38,000 subscribers. We can prevent pertussis infection if a large majority of teens and adults receive Tdap vaccine!
During the 2009 legislative session, Indiana Code 02-34-4-2 was revised, requiring the Indiana State Department of Health (ISDH) to "adopt rules under IC 4-22-2 to require school age children to receive additional immunizations...
See the videos at http://www.vaccinateyourbaby.org/news/videos/
|
