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ACIP Releases Recommendations for the Immunization of Health Care Workers

The Advisory Committee on Immunization Practices (ACIP), in consultation with the Hospital Infection Control Practices Advisory Committee (HICPAC), has released recommendations concerning the use of certain immunizing agents in health care workers in the United States. These guidelines are intended to help hospital administrators, infection control practitioners, employee health physicians and health care workers optimize infection prevention and control programs. The recommendations were published in the Recommendations and Reports series of the Morbidity and Mortality Weekly Report (December 26, 1997, vol. 46 [RR-18]:1-42).

Because of their contact with patients or infective material from patients, many health care workers are at risk of exposure to and possible transmission of vaccine-preventable diseases. The recommendations apply not only to health care workers in hospitals and health departments but also to those in private physicians' offices, nursing homes, schools and laboratories, and to emergency personnel.

The recommendations for administration of vaccines and other immunobiologic agents to health care workers are divided into the following three disease categories (see table):

• Those for which active immunization is strongly recommended because of special risk for health care workers (i.e., hepatitis B, influenza, measles, mumps, rubella and varicella).
• Those for which active and/or passive immunization of health care workers may be indicated in certain circumstances (i.e., tuberculosis, hepatitis A, meningococcal disease, typhoid fever and vaccinia) or in the future (i.e., pertussis).
• Those for which immunization of all adults is recommended (i.e., tetanus, diphtheria and pneumococcal disease).

Immunization That Is Strongly Recommended

ACIP strongly recommends that all health care workers be vaccinated against (or have documented immunity to) hepatitis B, influenza, measles, mumps, rubella and varicella.

Hepatitis B

Recommended Immunizations for Health Care Workers Immunizing agents strongly recommended for health care workers Hepatitis B recombinant vaccine Hepatitis B immune globulin Influenza vaccine (inactivated whole-virus and split-virus vaccines) Measles live-virus vaccine Mumps live-virus vaccine Rubella live-virus vaccine Varicella zoster live-virus vaccine Varicella zoster immune globulin BCG vaccination* Bacille Calmette-Guérin vaccine (tuberculosis) Other immunobiologics that are or may be indicate for health care workers Immune globulin (Hepatitis A) Hepatitis A vaccine Meningococcal polysaccharide vaccine (tetravalent A, C, W135, and Y) Typhoid vaccine, intramuscular, subcutaneous and oral Vaccinia vaccine (smallpox) Other vaccine-preventable diseases: Tetanus and diphtheria (toxoids) Pneumococcal polysaccharide vaccine (23 valent) *--Should be considered only for health care workers in areas where multi-drug tuberculosis is prevalent, a strong likelihood of infection exists, and where comprehensive precautions have failed to prevent tuberculosis transmission to health care workers. Adapted from the Centers for Disease Control and Prevention. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices and the Hospital Infection Control Practice Advisory Committee. MMWR 1997; 46(RR-18):4-9.

Any health care worker who performs tasks involving contact with blood, blood-contaminated body fluids, other body fluids or sharps should be vaccinated. Hepatitis B vaccine should be administered by the intramuscular route in the deltoid muscle with a needle 1.0 to 1.5 inches long.

One to two months after completion of the three-dose vaccination series, health care workers who have contact with patients or blood and are at ongoing risk for injuries with sharp instruments or needle sticks should be tested for antibody to hepatitis B surface antigen (anti-HBs). Persons who do not respond to the primary vaccine series should complete a second three-dose vaccine series or be evaluated to determine if they are positive to hepatitis B surface antigens (HBsAg). Revaccinated persons should be retested. Persons who prove to be HBsAg-positive should be counseled accordingly. Primary nonresponders to vaccination who are HBsAg-negative should be considered susceptible to hepatitis B virus infection and should be counseled regarding precautions to prevent hepatitis B virus infection and the need to obtain hepatitis B immune globulin prophylaxis for any known or probable parenteral exposure to HBsAg-positive blood. Booster doses of hepatitis B vaccine are not considered necessary, and periodic serologic testing to monitor antibody concentrations after completion of the vaccine series is not recommended.

Influenza
The following health care workers should be vaccinated against influenza in the fall of each year:

• Persons who take care of patients at high risk for complications of influenza (whether the care is provided at home or in a health care facility).
• Persons 65 years of age and older.
• Persons with certain chronic medical conditions.
• Pregnant women who will be in the second or third trimester of pregnancy during the influenza season.

Measles, Mumps and Rubella
Because any health care worker who is susceptible can, if exposed, contract and transmit measles or rubella, all medical institutions should ensure that those who work within their facilities are immune to measles and rubella. Immunity to mumps is also very desirable. In addition, health care workers have a responsibility to avoid causing harm to patients by preventing transmission of these diseases.

Measles-mumps-rubella (MMR) trivalent vaccine is the vaccine of choice. MMR or its component vaccines should not be administered to women who are pregnant. Women should be counseled to avoid pregnancy for 30 days after administration of monovalent measles or mumps vaccines and for three months after administration of MMR or other rubella-containing vaccines. If a pregnant woman is vaccinated or if a woman becomes pregnant within three months after vaccination, she should be counseled about the theoretical basis of concern for the fetus, but MMR vaccination during pregnancy should not ordinarily be a reason to consider termination of pregnancy. Measles vaccine is not recommended for HIV-infected persons with evidence of severe immunosuppression.

Varicella
All health care workers should ensure that they are immune to varicella. Immunization is particularly recommended for susceptible health care workers who have close contact with persons at high risk for serious complications. Routine postvaccination testing of health care workers for antibodies to varicella is not recommended.

Hospitals should develop guidelines for management of vaccinated health care workers who are exposed to natural varicella. Seroconversion after varicella vaccination does not always result in full protection against disease. Therefore, the following measures should be considered: serologic testing for varicella antibody immediately after varicella zoster virus exposure, retesting five to six days later, and possible furlough or reassignment of personnel who do not have detectable varicella antibody. It is not known if postexposure vaccination protects adults.

Hospitals also should have guidelines for managing health care workers after varicella vaccination because of the risk for transmission of vaccine virus.

Recommendations are also discussed for hepatitis C and other parenterally transmitted non-A, non-B hepatitis viruses; tuberculosis, hepatitis A, meningococcal disease, pertussis, typhoid, vaccinia, tetanus and diphtheria, and pneumococcal disease. ACIP does not recommend routine immunization of health care workers against tuberculosis, hepatitis A, pertussis, meningococcal disease, typhoid fever or vaccinia. However, immunoprophylaxis for these diseases may be indicated for health care workers in certain circumstances. There is also a discussion on immunization of immunocompromised health care workers.

A section on other considerations in vaccination of health care workers includes immunization records, catch-up vaccination programs, work restrictions for susceptible workers after exposure, outbreak control and vaccines indicated for foreign travel.

-- VERNA L. ROSE

Consensus Statement Focuses on Diagnosis and Treatment of Alzheimer's Disease and Related Disorders in Primary Care

The American Association for Geriatric Psychiatry, the Alzheimer's Association and the American Geriatrics Society convened a consensus conference on the diagnosis and treatment of Alzheimer's disease. The members of the consensus panel and expert presenters were from the fields of psychiatry, neurology, geriatrics, primary care, psychology, nursing, social work, occupational therapy, epidemiology, and public health policy. The 18-member panel was charged with the task of developing recommendations for the diagnosis and treatment of Alzheimer's disease in the primary care setting. Co-chairs of the panel were Gary W. Small, M.D., University of California at Los Angeles, and Peter V. Rabins, M.D., the Johns Hopkins University, Baltimore. A consensus statement titled "Diagnosis and Treatment of Alzheimer's Disease and Other Related Disorders" was prepared and published in the October 22/29, 1997, issue of JAMA.

According to the statement, Alzheimer's disease affects about 4 million persons in the United States. It is the most common of the dementing disorders. By the year 2040, an estimated 14 million persons in this country will have Alzheimer's disease.

The consensus statement addresses the following questions about the disease:

• How prevalent is Alzheimer's disease and what are its risk factors?
• What is its impact on society?
• What are the different forms of dementia and how can they be recognized?
• What constitutes safe and effective treatment for Alzheimer's disease?
• What management strategies are available to the primary care practitioner?
• What are the available medical specialty and community resources?
• What are the important policy issues and how can policy makers improve access to care for dementia patients?
• What are the most promising questions for future research?

The main risk factors, according to the statement, are age and family history. Approximately 6 to 8 percent of all persons older than 65 years have Alzheimer's disease. The panel reports that the prevalence of the disease doubles every five years after the age of 60 years. By the age of 90 years, some studies show that almost 50 percent of persons with a first-degree relative with Alzheimer's disease develop the disease themselves.

Alzheimer's disease is characterized by gradual onset and progressive decline in cognition. Changes in behavior and mood frequently occur. Motor skills, sensory function and social skills usually remain intact until late in the course of the disease.

The panel notes that recent progress in understanding the diagnosis and treatment of Alzheimer's disease has helped many patients and their caregivers. Treatments include pharmacologic and nonpharmacolgic methods, and the panel emphasizes that a nonpharmacologic approach is preferred. If nonpharmacologic therapy fails, pharmacologic therapy should be introduced. Pharmacologic therapy can also be used if there is a risk of danger or if the patient is very distressed. The statement discusses the use of cholinesterase inhibitors, such as tacrine and donepezil, and other agents, such as estrogen, nonsteroidal anti-inflammatory drugs and botanical agents, such as ginkgo biloba. Before any treatment is started, it is recommended that patients undergo a thorough medical examination.

Management Strategies

The panel lists a number of strategies available to the primary care practitioner to minimize the problems of function and independence and help the patient with a safe environment. The following five strategies are presented in the statement:

• Schedule regular patient surveillance and health maintenance visits every three to six months.
• Work closely with family and caregivers. This strategy includes a thorough discussion of long-term care and the necessary emotional adjustments.
• Establish programs to improve patient behavior and mood.
• Encourage caregivers to modulate the environment.
• Warn families of the hazards of the patient wandering and driving.

Conclusions and Recommendations

The following is a list of the conclusions and recommendations made by the expert panel:

• Alzheimer's disease is underreported and underrecognized. Patients often do not see their physician for an evaluation when they experience cognitive deficits. Also, physicians may not recognize the early signs of the disease. Because there is no definitive test for the disease, physicians must conduct a focused clinical assessment and interview with their patients who are suspected of having Alzheimer's disease.
• Diagnosis is primarily one of inclusion, not exclusion, and usually can be made using standardized clinical criteria. Physicians need to be alert to concerns about cognitive decline in their patients who present for treatment of another medical problem.
• Most cases of Alzheimer's disease can be managed in a primary care environment. Patients with severe impairment or those with complex comorbidity should be referred to a subspecialist. Regular health examinations are essential. Pharmacologic therapies for cognitive impairment and nonpharmacologic and pharmacologic treatments for behavioral problems can help the quality of life. Drug treatment should be used cautiously in elderly patients.
• Education, counseling and support for the family and/or caregivers is important. Some relatives may need their own neuropsychologic evaluation.
• The nation's current system of care for patients with Alzheimer's disease is inadequate and fragmented. New approaches need to be initiated to assure necessary medical, psychosocial and community resources.
• Future research should focus on barriers to care and improvement of diagnostic and therapeutic effectiveness.

-- VERNA L. ROSE

Patients, their caregivers and the general public can obtain information on Alzheimer's disease from the Alzheimer's Association (800-272-3900), the Geriatric Psychiatry Alliance (888-463-6472), the American Geriatrics Society (212-308-1414) and the Alzheimer's Disease Education and Referral Center (800-438-4380).

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Copyright © 1998 by the American Academy of Family Physicians.
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