Home care providers (HCP) are exposed to many different situations as they perform home visits. Living conditions vary from home to home, ranging from clean to filthy, and we care for patients in the home setting with every imaginable disease, some of which are contagious. In order for home health providers to be protected and prevent disease transmission, the Centers for Disease Control (CDC ) recommends a number of routine vaccinations for health care providers. Most vaccinations can be obtained from local health departments at a very nominal charge if any.
The CDC definition of healthcare provider has broadened to include all paid and unpaid people who may have contact with patients, body substances, or contaminated equipment. In home care and hospice this includes a variety of people, who go into the home or come into contact with patients in other ways. This includes all staff, including people who are in direct healthcare positions such as nurses, home health aides, therapists, social workers, and family educators. It also includes students, trainees, volunteers, transportation personnel, hospice volunteers, home meal delivery staff, and anyone else coming into contact with patients. The goal is to protect both HCP and patients from preventable infection.[i]
Vaccines recommended for HCP include: Hepatitis B, Seasonal influenza, measles, mumps, Rubella, Pertussis, and Varicella and in certain circumstances Meningococcal. Of these vaccines, only Hepatitis B is mandated to be made available at the employer’s expense. However, state and local requirements may vary and should be reviewed before updating immunization policies.
The CDC has recommended that all HCP receive an annual influenza vaccination since 2006. In addition, they encourage healthcare agencies to institute programs to increase the flu vaccination rate by providing influenza vaccine at no cost to personnel, and to monitor and report staff influenza vaccination rates regularly. Not only is influenza an occupational hazard but HCP are also considered a source of disease transmission to all patients, especially to the vulnerable including those who cannot be vaccinated, those who respond poorly to vaccine, or those for whom antiviral medication is contraindicated. [ii]
Regardless of vaccination history, HCP and trainees at high risk for chronic Hepatitis B should be tested for Hepatitis B surface antigen (HBsAg) and Hepatitis B core antibody/Hepatitis B surface antibody to determine infection status. People with chronic Hepatitis B virus (HBV) are the main reservoir for continued transmission in the United States. Testing for HBsAg is the primary means to identify chronic HBV infection. High risk for chronic infection would include people born in geographic regions with HBsAg prevalence of ≥2%, born in United States but not vaccinated as infants and whose parents were born in geographic regions with HBsAg prevalence of ≥8%, injection-drug users, men who have sex with men, and those with elevated liver blood tests of unknown etiology. For those who are unvaccinated, blood should be drawn for testing before the first dose of vaccine is administered, and vaccination should be administered during the same health-care visit. Despite Occupational Safety and Health Administration-mandated availability, the Hepatitis B vaccination rate among HCP is only about 75%.[iii]
HCP are at higher risk of infection with measles, and healthcare sites have been associated with measles outbreaks in recent years. Therefore, it is recommended that all HCP have presumptive evidence of immunity to measles, mumps, and rubella documented and available at the worksite. Evidence for measles and mumps includes two doses of measles, mumps, rubella (MMR) at least 28 days apart (or live measles and live mumps vaccine), or laboratory evidence of immunity or confirmation of disease. Birth before 1957 had been considered presumptive evidence of immunity but research suggests some HCP born before 1957 lack measles immunity. Therefore, the current recommendation is HCP born before 1957 that lack laboratory evidence of disease or immunity should consider vaccination with two doses of MMR. History of measles is no longer presumptive evidence of immunity. HCP born before 1957 without laboratory evidence of mumps immunity or disease are also recommended two doses of MMR. Presumptive evidence of rubella immunity includes only one dose of MMR, or laboratory evidence of immunity, or laboratory evidence of disease, or birth before 1957.[iv]
Pertussis is a highly contagious disease that can infect people of any age. Immunity to the Pertussis vaccine normally wanes within 5 to 10 years from the most recent dose. A single dose of Tdap (tetanus–diphtheria–Pertussis) should be administered as soon as possible to HCP of any age who have not previously received it regardless of the date of any prior tetanus/diphtheria (Td) vaccinations. Thereafter, Td would be administered every 10 years for booster vaccination against tetanus and diphtheria because Tdap is not licensed for multiple administrations. Recent epidemics demonstrate the need for Pertussis immunity. The CDC warns that Pertussis is endemic in the United States with periodic epidemics every 3 to 5 years and frequent outbreaks.[v]
HCP should have evidence of immunity to Varicella documented at the worksite. Criteria for immunity to Varicella were recently established and include documentation of two doses of vaccine, laboratory evidence of disease or immunity, or documented diagnosis of Varicella or shingles by a healthcare provider.
HCP with certain splenic disorders, clotting deficiencies, or HIV infection should receive two doses of meningococcal vaccine. Some HCP at high risk will need revaccination every 5 years.
Providers should review the CDC recommendations and their policies and procedures to ensure compliance with these very important guidelines. As Health care providers we have a solemn responsibility to the patients we serve to be vaccinated and safe. They are entrusting their care to us.
[i] Home Healthcare Nurse: November/December 2012 – Volume 30 – Issue 10 – p 596–600doi: 10.1097/NHH.0b013e3182705ccc
[ii] Centers for Disease Control and Prevention. (2006). Influenza vaccination of health care personnel: Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 55(RR-10), 1–42. Retrieved from https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5510a1.htm
[iii] Institute of Medicine. (2010). Hepatitis and liver cancer: A national strategy for prevention and control of Hepatitis B and C. Washington, DC: National Academics Press.
[iv] Centers for Disease Control and Prevention. (2011a). Immunization of health-care personnel: Recommendations of the Advisory committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 60(7), 1–45. Retrieved from https://www.cdc.gov/mmwr/pdf/rr/rr6007.pdf
[v] Centers for Disease Control and Prevention. (2011d). Pertussis (whooping cough) outbreaks. Retrieved from https://www.cdc.gov/pertussis/outbreaks.html