You will notice during the course of this course that we vary from a very practical, at times, approach, and you will have some very nuts-and-bolts conversations. You will also have some more thought-provoking and esoteric and foundational kind of talks. So you'll see an example of many of these. Our next speaker is gifted with the ability of blending these styles and taking the most complex information and a tremendous fund of knowledge and distilling it into what you need to know and implement on the front lines. So it is my honor and privilege to introduce to you my dear friend and colleague, Dr. Amy Berman, who is an emergency physician first in her career and then an occupational physician. She's the Division Chief of Occupational Medicine and Professor of Emergency Medicine at Perelman School of Medicine at the University of Pennsylvania. She's the immediate past chair of the Medical Center Occupational Health Section, and she'll be speaking with us this morning about vaccine-preventable diseases. Dr. Berman. Thank you very much, Dr. Swift. This will be kind of a nuts-and-bolts basics course, and I will try to read your faces and not be too elementary, but I'm going to talk about immunization, immunity, and health care personnel, and really on a fairly granular level. How do we prevent these vaccine-preventable diseases? How do we manage them when they happen in terms of exposures? How do we manage them when the health care personnel themselves become ill with these diseases, if we don't manage to prevent them? And although in some ways, I was thinking last night, this is a fairly mundane topic in the sense of being a daily, a quotidian thing that we do. It's the, at least as I look at what our staff, mainly nurses, do. It is far and away the most common, the most numerous, the most frequent of encounters. It's just the immunizations, day in, day out, new hires, old hires, flu, COVID. And I would put it to you that it's the most important thing that we do. So as I go through this, please do bear in mind the more erudite and kind of elemental talks that preceded me, both in terms of how this bears on workplace safety, how it bears on our present moment and historic record of controlling outbreaks and epidemics, and how we can use these principles to best serve our own patients, and by extension, their patients. So now I will launch into the basics. I'm going to talk about the principles and practice that we follow, knowing that it is primarily your nurses who are hands on with this, but that they are looking to all of us for guidance in the unusual circumstances that do come up. We'll look at what constitutes current standards for immunity for each of these diseases, how we are currently trying to prevent them from being transmitted from infected patients, and how to manage the exposures when they actually happen. I won't be talking about tuberculosis or TB vaccines. I won't be talking about bloodborne pathogens or hepatitis B vaccine. And this won't deal with research pathogens. I refer you to that wonderful book that was just published, edited by Dr. Roussey and Dr. Harbour and Dr. Baker. Why is this important? Well, it's certainly important to protect our patients and to protect our health care personnel. But because of where we function, because of where they function, it is equally important to protect their patients, as well as their families and their communities, from transmission in either direction. So just a quick photo of vulnerable patients and then we will launch. So when we think about vaccine encounters or immunity evaluations, the golden opportunity, the easiest, the most effective, the least labor-intensive moment that you have to do this is when somebody comes in as a new hire and they sit down and whatever the onboarding process is in your institution with whatever person, a nurse, a nurse practitioner, sometimes a doctor deals with this, and you can hold that person still and get their records and figure out if they're up to date or not and all the things that you were worried about. Urge your staff to look at all possible prior documentation. If you don't need to re-immunize someone, that's wonderful. Look almost everybody who comes before us in medical center occupational health has had multiple interactions with immunizers, vaccinators in the past, at their prior jobs, at their training, whether that's medical school, nursing school, high school, college, they have had encounters and they have documentation and they can do the work for you of finding it. We are delighted to get information from people's records, from our state and city IISs, that's the word, IISs, from prior military records and from prior pediatric records. All of these things are wonderful. I actually have more faith in old baby book pediatrics records than I do in a record that's been repeated and retyped over and over through multiple EMRs, so accept what looks legitimate and document it and move on. This is your opportunity to update any missing doses for people who never went back for that third hepatitis B, Regenerix hepatitis B, or never actually got their second varicella shot. You've got them. They're not working, or at least they're not working at your hospital. You can hold them still and do what needs to be done. You can educate them about the importance of ongoing adult vaccination, including everything we do in the workplace, and you can form a kind of a caregiving relationship with your new hires or your nurses can do this that will pay off at many times in the future. First future is follow-up doses. If you get somebody in who still needs a COVID vaccine or still needs an MMR, let me tell you it's a lot harder to get them back to you after they have started their residency or are working as a nurse in the intensive care unit or even are working from home as a billing administrator. That's where the effort comes in, and that's where the effort comes in. Then our third opportunity is to vaccinate people in seasonal or recurrent vaccines. Obviously, I'm thinking about influenza and COVID, and that presents its own set of challenges. How many people in the room have experienced, probably everybody, running large or consulting for large immunization clinics in a lobby or in a cafeteria or in a non-traditional space that's not a clinic room? These are essential to our functioning. You might be doing these in a tent, in a courtyard, in any place in your hospital that has enough room. We've done it in the auditoriums. These places are not designed as healthcare sites, and they have their own challenges in terms of safety and vaccine safety. I worked for several years with CDC and Immunization Action Group, putting together an OR-style safety checklist for immunizations. Great principle. We ended up with a very—I'm going to be honest—difficult-to-use six-page checklist tool that has not really caught on because—six pages. I actually boiled this down to ten principles, and these are available online. You have the link in the references. I think they're actually worth sharing with the folks who will be actually running the clinics. In addition to your own staff, it's almost impossible to run these big seasonal clinics without bringing in surge staffing. These will be nurses or vaccinators, pharmacists, sometimes even trainees who do not have the extensive experience that our medical center occupational health employee health nurses have. They need to be brought up to date. It may have been a year since they gave their last IM injection. They need to be—you need to have—ideally, to have a rapid training and safety program in place for them. Maybe you can get it into your learning management system. You need to make sure that the vaccine is being transported to these sites in a safe and temperature-controlled way, just as you would do if you were doing it in a parking lot at a community flu event. It can be quite a ways from your pharmacy and your pharmacy refrigerators to the cafeteria where you're giving these shots or the tent where you're giving these shots. It's super important to make sure that these surge staffing vaccinators understand ergonomics to protect themselves, that they're going to be hunched over for eight hours at a time doing 100 vaccines an hour. That's a real challenge. And it's even more important for them to understand exactly, exactly what the anatomic landmarks are so that we do not end up with a surge of shoulder injuries from inappropriate vaccination technique at the same time that we're doing surge vaccinations. So that is an important principle of these things. I just kind of reworded them into plainer, clearer English, just common sense things that often get lost in the sauce of a very hurried clinic. I actually suspect this will be one of the advantages of COVID is that we were all forced to develop even more pristine methods of mass vaccination in multiple settings, and that's something we will carry with us for future epidemic control. So kind of bringing this back down to the more particulars, I really do think passionately that what we do with workplace vaccines is the single most effective thing we can do to protect people. It doesn't mean that your engineering and administrative controls are not important. Obviously they are. Hand hygiene, crucial. Do you know your hand hygiene rates for the various clinical units in your hospitals? Because I do, and I know that the places that are the highest risk, like say the emergency department, have the pathetically lowest hand washing observation measures. So anything that you can do that lets people's immune systems function without conscious control like a vaccine is a wonderful thing. You may have to, I don't, I know we're kind of moving along quickly here. I'm guessing this is a group from all over the country. You may have individual state, Department of Health, and institutional regulations that may differ somewhat between us, but the basic guidance is consensus and is listed at the national level from the CDC and from the Joint Commission and is easily accessible. We do need to remember, if we ever forgot it, this past two years have been a lesson in the fact that vaccine recommendations do evolve over time, not just for COVID but for other things as well. So I've tried throughout my slides, which will be available to you, to mainly use live links that get updated, but do be aware of that. Final principle of vaccination on this page, for every single vaccine that I'm going to talk about, and pretty much every one we use in a hospital set, in a medical center, a health setting, late doses are not a problem. You do not need to start series over. Just pick it up and keep going. It doesn't matter if that MMR is a month later, a year later, a decade later, just keep going with the series. In fact, there's actually a fair amount of evidence that our immune systems may process the second and third doses better with some extended timing. Know your key collaborators for managing exposures when they do happen. No surprises here, hospital epidemiology and infection prevention, your safety managers, the people that Dr. Hodgson was just touching on, human resources to hopefully be your partners for providing free access to sick time and furlough time for people who need it so they won't work when they're contagious, your ID consultants, your nursing and medical leadership, and critically, your local public health authorities, whether that's city, county, state, or national, to be your partners and your guides in knowing what's going on regionally. I'm going to skip to the bottom and just say, you know, a final principle that you can support your institution in is to not, you're going to be taking care of the healthcare personnel to encourage them to be as syndromic as possible in their thinking so that they do not think, oh, a COVID case, I should isolate that person, but rather they think, oh, fever and a cough, I should isolate that person. They might have, they probably have COVID, but they might have TB. They might have, they might have flu. The key thing is to get them into isolation and transmission-based precautions before anybody gets exposed. I'm going to talk through a bunch of vaccines. I kind of put them in colors just because I like colors. The ones in red are pretty much vaccines that we can deal with upfront at the onboarding appointment or shortly after. Then there are the recurrent vaccines, most notably influenza and COVID, and then there are the special population vaccines that are not necessary, that are not needed for all clinicians or all healthcare personnel, but are relevant to smaller subsets, and we'll try to get to those. Launching right in and keeping an eye on my time, let's talk about measles for a minute. Curious, has anyone in the room ever seen a case of measles? And I'm not counting when you might've been a kid and you're, have you as an adult healthcare worker seen a case of measles? Not a lot of hands. Thankfully, there hasn't been a lot of measles in most of our practicing lifetimes, but I think there will be. Measles is having a big comeback globally. I want to just flip back and forth a little bit. The most recent numbers I came up with in a quick glance at WHO are that more than 200,000 people, mainly small children, are dying annually right now of measles, a completely vaccine-preventable disease. The last time I gave this talk, four years ago, that number was 140,000. And I don't know how completely accurate any of these numbers are, but we're clearly going the wrong direction. I am unfortunately confident that the terrible conflict in the Ukraine will drive this up higher. The Ukraine was already not in good shape in terms of childhood vaccines and measles, especially. The refugee camps are going to be a driver. So the chances are that, you know, especially those younger among us here, your hospital may see measles. Hopefully you won't personally, but you may see this. It is critical that we keep up our MMR vaccines to the highest possible level. The great news is that the vaccine is incredibly effective, incredibly contagious disease, a killer especially of children, but absolutely a terrific vaccine. And keep an eye on this. You will see the world and our country see outbreaks based often among, often seeded from unimmunized travelers, whether they are U.S. citizens returning from recreational travel, probably not military, but volunteers or visitors to the country or immigrants. And then they often spread, at least in my experience, in unvaccinated, sometimes religious communities. And then they can show up to you and to your healthcare personnel. So assess that immunity on higher, make really 100% sure that everybody has gotten their two doses for measles. This is a spectacularly effective vaccine. It's fine to use Ig and ELISA and IgG to establish immunity, especially in those of us born before 1957 who have excellent natural immunity for the most part. I put a little kind of pale pink language on that slide, which you'll see. I put that up when I really don't want people to pay attention to it, but it's actually in the CDC guidance. So you can potentially assume immunity in persons born before 1957 and earlier, but I wouldn't. I think it's much simpler and more effective to treat everybody the same and to simply make sure that everybody's got a titer or evidence of two vaccines. What if you have evidence of two vaccines for measles or mumps or any of the other things we're going to talk about, but the titer's negative? How do you do that? Don't do anything. The commercially available ELISAs do not detect all vaccine-induced immunity for measles, mumps, rubella, or varicella. If you believe your prior vaccine records, if they look legit, if you have confidence in them, just move on. Vaccines to the, you know, if given in a complete series for whatever illness, trump the negative titers. Don't worry about it. vaccines and don't lose sleep if you have a low titer that somebody else did for you. There are vaccines, and hep B is the poster child for them, for which having a documented titer is absolutely crucial in an occupational setting, but right now, we're not talking about that particular vaccine. These are live virus vaccines, MMR, varicella. You will have people who may not be immune and cannot be vaccinated because they are immunocompromised, or even more frequently because they are pregnant. That's OK. Just at least in our setting, what we do is we restrict them from these fairly rare patient interactions until or unless they reach a point in their own lives where it is safe and reasonable to vaccinate them. So took a while on that, but I'm going to touch briefly on what you do if there is an exposure and then race through mumps and rubella. So get this all set up before the exposure happens, if you can. If you didn't, or you have a temp staff who got missed, or somebody who was pregnant and never came back for their updated MMR, do it as soon as possible, and all the time, but particularly if you have an admission that looks like they really do have measles. Good idea to be aware of the basic presentation of these diseases so that you may be the person who spots them first. It certainly has happened. You heard from Dr. Rusci that there's going to be probably some significant updating of transmission-based precautions. But I'll just say here that there's no harm in treating all of these things as airborne, but certainly measles is a magnificently airborne pathogen. If you do have non-immune staff who are exposed in any kind of significant way, there's a substantial furlough period, which is absolutely necessary, days 5 to 21. Strongly consider post-disposal prophylaxis. Vaccinate anybody who isn't up to date as soon as you can get your hands on them, but don't think that'll get them back to work sooner. It won't. It will just hopefully protect them. And some very fragile health care personnel may benefit from immune globulin. At that point, I think you'll be talking to your ID staff. So how about mumps? Same vaccine, different disease, very different presentation. There have been periodic US and international outbreaks. These actually often tend to happen among fully vaccinated individuals because the mumps moiety of the MMR vaccine is the least immunogenic. So you will see people who either drop their titers if you're unfortunately checking their titers, or more importantly, are actually vulnerable and may have, hopefully, a relatively mild case. This is something, if you're practicing on a campus with a lot of young people around in congregate living, that'll often drive your mumps cases. These are continuing to occur episodically. They've actually dropped, at least in the US, over the last two years because source control works. That's probably the most important thing we can all say to each other today. Source control works, and COVID precautions have probably cut back on these mumps cases. So you know what to do, how to prevent it. You know you're going to treat your older people just the same as your younger people. And that you're going to protect people who cannot be vaccinated from dealing with these patients. Although generally considered to be a droplet spread disease, mumps is also incredibly contagious. So if you do have non-immune staff or non-immune community members, and they have any type of significant contact, they probably will get sick. Same contraindications as for measles because it's the same vaccine. And just a word of talking point, if you have to deal with people who are vaccine-averse and have somehow gotten to you without their MMRs. This is not a benign disease in adults. And I'm not going to speak to the pediatric presentations. But it is associated with ovarian and testicular involvement, with secondary infertility, and at least, I will say, with small children with deafness and encephalitis. So it's not completely benign. Keep an eye on your furlough periods if you do have someone who slipped by and is vulnerable. It stays 12 to 25. And although there is no post-exposure prophylaxis recommended for non-immune exposed persons, there is a recommendation from the ACIP to consider or just use third doses in outbreak situations. Hopefully, you won't encounter that in a hospital situation. But you probably will encounter it in a campus situation if you help out your local university. Rubella. Hopefully, none of us have ever seen rubella because that is the most immunogenic portion of the MMR vaccine. And in fact, we have reached elimination status actually almost 20 years ago in the US, and in fact, most of the world for rubella. Truly, God forbid this ever comes back. It was a relatively mild disease in children and adults, but devastating for unborn children with congenital rubella syndrome, accounting for a great deal of cardiac, ocular, auditory, and developmental devastation in the pre-vaccine era. There have been imported cases. They have involved health care personnel in the last 10 years. All of those persons were unimmunized. You only need one dose of MMR to get there. And nobody should leave our offices without this unless they are truly unable to receive the vaccine. It's also listed at this point as a droplet precaution for isolation. I'm not going to dwell here because hopefully we'll never see it, but there is a significant furlough period if you ever do have to deal with it. Or perhaps if you are in a setting where this might come up, I'm thinking of friends who are working in refugee camps. You know what, all of these things are poised to make a bit of a comeback in the COVID-19 era. How about chickenpox? Now, here is a vaccine-preventable disease that you will see in the hospital setting. The vaccine was developed more recently. There's a large pool of non-immune adults, and they are able to transmit it with appalling results, usually to immune-compromised patients and or immune-compromised health care personnel as well. It often presents atypically in immune-compromised folks so that we see cases missed in the emergency department, in dermatology, even in transplant. I think the last two exposures I saw, which were within the last six months, actually occurred in transplant patients in transplant clinic. People don't know what this disease looks like anymore because we don't see it so much. If you see a typical case, it's a kind of striking vesicular pustular rash where you see the lesions in many stages of maturity. But in those immune-compromised populations, it may present in a much more innocuous or maculopapular way, and it simply gets missed. Critical to have our health care personnel immune, both for their own sake, for their family's sakes, and also for their vulnerable patients' sakes. I can't imagine you could practice in basically any hospital for any period of time and not see one of these exposures. It comes up all the time. So absolutely assess immunity on hire. Don't worry about the negative titers if you've got good documentation of vaccines. And I would say do not depend on a physician history or even documentation of disease, and certainly don't depend on the health care worker's story belief that they had varicella. You've got to prove it. You either have to have the laboratory diagnostics for prior disease or the documentation of titer or vaccines. You can't take any chances with this one. There's also live vaccine, of course. You will have people who can't be made immune, and they really need to be, in my opinion, to be restricted from dealing with these patients if at all possible. And it usually is possible. This is one unusual thing about the vaccine is that it needs to be stored frozen. You may get people in your clinic who are 50 and older and have actually had doses of Shingrix, the wonderful, currently recommended shingles vaccine, but do not have evidence of prior immunization or titers. You still got to do primary varicella vaccination with them. I'm sorry, but that's what the CDC says at this point. Can you see vaccine-induced varicella? You can. It's usually very mild, and it is extremely rarely transmissible. So persons who develop a vaccine-induced rash should be followed carefully, and I wouldn't let them work, but I actually think the risk is fairly low. Otherwise, there are no restrictions to work after any of the vaccines I'm going to talk about, even with the most vulnerable of populations. For varicella exposures, if you read the fine print, those of us who have natural immunity really do have natural immunity. Those of us who have vaccine-induced immunity are probably a little less robust and should self-monitor themselves for 21 days after exposure. I don't actually pay a lot of attention to this because I think everyone should be self-monitoring for febrile rash illnesses, and nobody should be working with a febrile rash illness or even with a disseminated rash of any kind. Rather, they should be coming to you for evaluation. I'm going to actually just kind of skip over this slide. I think I've pretty much touched on everything except the bullets under furlough. So absolutely, this is a strict furlough for people days 8 to 21 if they are not fully immune by one technique or by titer or by vaccine. If you do have people, health care personnel, with disseminated varicella or with primary varicella or with shingles that cannot be fully covered or is more than one dermatome, those people must be excluded from work with vulnerable patients until they have fully crusted. We allow single dermatome shingles employees to work if they're comfortable enough to do so and if the lesions are fully covered and if it's a single dermatome and if they're immune-competent. Racing onward, keeping an eye on my time, pertussis, another disease that's made a significant comeback over the last 20 years. It is primarily a miserable disease of small children. It definitely can affect adults. Most healthy adults have relatively mild disease, but not everybody. And the complications can include significant exacerbations of underlying lung disease, chest pain from coughing up to and including rib fractures, and especially in more frail or very, very young patients, hypoxic encephalopathy, vomiting, seizures, and the fatalities that you see are mostly in patients. Oh, excuse me, mostly in infants. Sorry, mostly in infant patients. The healthy adult course is usually described in three phases, a relatively mild cariza, mild cough phase, catarrhal, paroxysmal phase of strong coughing, and then a convalescent phase. Unfortunately, infectivity is probably greatest before people really escalate their symptoms. And in fact, a healthy young house officer may never get particularly sick, but he or she will be incredibly contagious throughout this first three to four weeks of infection. So you will see these exposures if people are looking for them. It's important to immediately isolate any patient or provider who's thought to be infected. Diagnosis is actually a little tricky. You need to do a nasopharyngeal swab and send it for PCR and or culture, and to be precautionary in terms of excluding the patients and the providers from contact with others while you're trying to figure it out. The vaccine obviously exists. There's been an adult licensed booster vaccine, Tdap, following childhood vaccination with DTaP for heading up for 20 years now. It's recommended as a single adult booster, and we certainly should take advantage of our onboarding to make sure we actually do bring people up to that level. No doubt, this effective immunity wanes sharply over the first year or two. That's why pregnant women are vaccinated with every pregnancy, even if that means every year. So you do not assume, unlike MMR and V, you do not assume that people who have been vaccinated are immune, they're probably not. Give a Tdap whenever you can. If you have somebody coming in with a percutaneous injury or any other reason to be boosted, don't use Td, use Tdap. Get that little extra boost from the booster, but it's not actually a great boost. And for that reason, when you have exposures, everybody should be offered post-exposure prophylaxis. Everybody, it doesn't matter whether they're vaccinated or not. I've put the basic regimens up here, and I'll say that if you've got everything in line, if it's a healthy healthcare worker and they have zero symptoms and they've been vaccinated and they're on post-exposure prophylaxis, they can absolutely work, at least unless they develop subsequent symptoms, basically like COVID. People who are unvaccinated, we furlough until they have completed five days of PEP. And if they don't wanna take the antibiotics, then they are gonna be out of work for 21 days, which is probably the peak of their potential incubation period. It'd be a little bit longer than that. Okay, I think we've addressed that. Now, I actually wasn't gonna deal with diphtheria, except for the fact that the HICPAC, who Dr. Rusci brought up, actually updated their infection control paper in November of this year, and actually did deal with diphtheria. And since we're seeing recrudescence of vaccine-preventable diseases, I'm gonna touch on it briefly. Disease that I hope none of us ever see, a very serious upper airway illness transmitted by respiratory droplets and also contact with secretions or even fomites. It may be imported. It's been rare here for many, many years because actually the vaccine DTaP and Tdap are very, very effective. I did find a picture of one of the horrible, thick, highly adherent membranes that diphtheria produces. If you try to pull them off, the person will bleed and bleed. People actually sometimes die of airway obstruction from this illness. Again, hopefully none of us will ever see it, but we should at least be aware of it, and we should, of course, make sure that, to the extent possible, our healthcare personnel are immunized against it. Very straightforward, Td or Tdap will do that. If you have a patient or a patient who is a healthcare worker who might have diphtheria, it is absolutely crucial to start treating them with appropriate antibiotics as soon as possible. Again, a rare thing, at least in a non-existent thing, in my clinical experience, but we are seeing the old diseases come back. So if you do have someone who's been exposed, no matter what their vaccine history, when that diagnosis in the source patient is confirmed, beg your healthcare personnel to take the prophylaxis, to update their diphtheria vaccine, and to accept the antibiotics that are recommended. We don't wanna see that as an outbreak. So I'm gonna change gears completely here and talk about flu and COVID briefly. I actually think it's fun to talk about flu for a long time, but we're just gonna accept the fact here that flu is really maybe similar to COVID, but except very different from everything I talked about so far, has multiple hosts, multiple mammals, multiple non-mammalian species. Its genome is divided into multiple segments. Multiple strains can infect the same host, and they can trade their little gene segments around like they were a deck of cards. And the bottom line is that because of both reassortment and recombination, you will see, we all see different strains of flu circulating, multiple strains per year, different strains on different years. It's very, very difficult to create vaccines that can keep up with this. And for this reason, in dramatic contrast to all of the prior vaccine preventable illnesses, the vaccine effectiveness is much lower for this illness. But it's still honestly the best thing we've got because people are not awesome at always wearing respiratory protection and always washing their hands when they might be around a symptomatic or an asymptomatic infectious person with influenza. Maybe you will see in your working lifetimes a more effective or even a universal flu vaccine. It's a lot of work being done. It definitely does not exist yet. I do wanna mention here that in addition to droplets and fomites and aerosols, children are a great driver of influenza epidemics. And you should just bear them in mind if you have hospital settings where children are present, either as visitors or as patients. So this is actually one of the more, up until COVID, probably one of the more complex things we dealt with in medical center occupational health vaccine programs and employee health. And it's definitely a surge staffing recurrent annual vaccine program. Groups of healthcare personnel have been more and less accepting of these vaccine programs. Most notably, staff in long-term care facilities, if you care for them, there's excellent evidence for last 20 years that they are vaccinated at lower rates and that their patients die at higher rates of nosocomial influenza. So that's really a group to look out for. I would say that our decades of work in communicating about flu vaccine and effectively administering flu vaccine really were incredibly helpful for the pandemic that we're in now. I don't know how, it would have been much more difficult to put together our COVID vaccine programs without having flu vaccine programs as a training field previously. Contraindications to these vaccines are rare with, as far as I know, only one exception. These are all non-live vaccines. Certainly, people can be allergic, but it is rare. Certainly, people can have history of vaccine-induced Guillain-Barre syndrome, but it's very rare. You are going to see this in health care personnel. We should all be prepared to diagnose it and to make arrangements to furlough infected staff. This has changed significantly in practice, I think, over the last couple of years with consistent use of source control for health care personnel. But people who are clinically ill with flu, obviously, should not work. I think the consistent with CDC guidance and the rule in our hospital is that they have to be well enough to work, afebrile off antipyretics for at least 24 hours, and with improving respiratory symptoms. And that seems to work pretty well. If you do have an exposure, and you probably will, consider offering people post-exposure prophylaxis. I've listed all four of the currently licensed anti-influenza medications, but realistically, the only one that's practical to give is oral Tamiflu, Oseltamivir, which, in my opinion, should be made available to health care personnel, potentially through your office, if not through their primary care providers, particularly if they're unvaccinated for one reason or another, particularly if they are themselves fragile or at risk for complications, if they're asthmatic or diabetic or immune-compromised, and maybe in a year where there's a particularly poor vaccine match, like this year, for instance. So keeping an eye on my time, Melanie, I'm going to race ahead to COVID. You've got 15 minutes. OK, but I have lots to say. So when I was asked to give this talk this year, of course, the COVID-19 vaccines are new, since the last time we all gathered together for AOHC, much less the last time we had this course. I know that everybody in this room has been reading and grappling and administering and embracing COVID vaccines for the last year and a half. I don't want to bore you. I actually figured that the older vaccine-preventable diseases were probably going to be less at the front of everybody's mind. And I wanted to find a way to talk about things that might benefit us going forward, as opposed to going backward with the COVID vaccines. So this is going to be a little more ad hoc. And you can please feel free to just stand up or raise a hand and redirect me if you think that would be useful. Have anybody here been doing medical center or occupational health for more than two years? When COVID hit, when I think back to just over two years ago, it was really obvious that this was an existential threat, not only to our societies and the globe, but in particular to our patients, our health care personnel, our colleagues, our friends, and of course, all of their families as well. The stress and the pain and the sorrow of dealing with that first year, 2020 in particular, is so great that I at least find myself just not thinking about it, because it's so horrible to think about the people who died, the people who had a stroke in the ICU and will never be able to return to their teaching or their surgery or their lives, basically. And when the vaccines came along in December of 2020, I will just say for myself that the sun came out. I mean, the excitement and just the joy of running those first voluntary vaccine clinics brings tears to my eyes even now. Everybody has these pictures. This is just our little vaccine group at the end of one busy day in the end of December 2020. And just buzzing with happiness. Now, at that point, with the strains that were circulating at that point, we had every reason to be happy, because we were not only preventing hospitalization, death, and serious illness, we were actually preventing transmission until the variants got a bit ahead of the vaccine. But it's still probably the most important thing that all of us are doing. And I suspect that many of you could say that the programs that you set up for your health care personnel were then used as models in your community to reach out to the vulnerable people in the general population who got vaccinated. I know that's true for us. We simply took the model that we evolved and offered it to the community in our hospital settings, moved it out to schools, moved it out to parking lots and everything else. And it's tremendously gratifying. There are many COVID vaccines that are WHO approved and FDA approved, either fully or an EUA at this point. In practical terms, we are dealing day to day with the two currently licensed messenger RNA vaccines from Pfizer and from Moderna, adenovirus vaccines, Johnson & Johnson in this country. But we have many, many people coming in with the AstraZeneca version. And we're looking forward to the protein subunit vaccines, most notably from Novavax, that I believe is actually pending at this point. I wonder, looking at you, Ken, if there's someone in the room who knows more than I do about its status. But it's not out yet. But we do have options. And I hope that we are all using them. When I was thinking about what data to bring to you out of the incredibly rich, but also incredibly extensive, literature that has been pumped out over the last 2 and 1 half years, I finally decided that I would just go and pull the most recent ACIP presentations. This is from roughly two weeks ago, April 20. All of this is in the public domain. Some of it's actually been published. Some of it hasn't. And I'd like to make it super clear that the next six or seven slides I'm showing are not my slides. These are from the ACIP, Dr. Daly and Dr. Grohl, I believe. All of this is online. All you have to do is Google it. I actually don't think I put this into the references. But it was kind of good to look at the data that we've been looking at from other countries and see what the same kind of analysis looks like in US cases. And this slide, obviously cases on one side, deaths on the other, is just no surprises. Three curves, the most awful one in the unvaccinated, the middle one in people who've had two doses and are technically fully vaccinated, but are not up to date. The lowest line in both of those cases and the deaths is folks who are up to date or boosted. I think we could clean up our nomenclature a little bit. But it simply really drives home the point that, frankly, everybody should be boosted. We do not, at least in this setting, have a shortage. And we have tremendous transmission. Not necessarily thinking of AOHC. I'm just saying everybody should be boosted. This is just another way of looking at very similar data, vaccine effectiveness for hospitalization, looking at two doses and three doses. The green dots on the right are people with normal immune status. And the purple dots on the left are the immune compromised. In every single case, no surprises. We know that people whose immune systems are not up to snuff do not get the same degree of protection, but they get some. And people with good immune systems really get quite robust protection against significant illness, even in the current era. And this data goes through, all right, it's no longer last month, but through March of 2022. So, well through the Omicron, at least the BA1 Omicron surge. Still looking wonderful. They are the best tools that we have to prevent hospitalization and death. This is a slightly different slide looking at booster effectiveness against just symptomatic infection. Not necessarily serious, but enough symptoms to be tested. And also showing that in, if I really boil this down, that boosters are important and that boosters work, especially with the strains that we have circulating now. If you drill into this, there is, it's kind of, it's very interesting to look both in our data and in the European and British data at what mixing and matching vaccines for primary series and boosters does. Long story short, I would say that three doses are important, that at least some of those, hopefully most of them will be messenger, at least in the context of what we have available in this country, will be messenger RNA vaccines, but that it's perfectly reasonable to mix and match, Jay, thank you so much, J and J with the messenger RNA vaccines. And there's even a suggestion that the cell-mediated immunity from that approach may become more impressive as we have more time and more data. So, in summary, and again, this is still from the ACIP presentations on April 20th, which were wonderful, just looking down at the bottom half of that, the vaccine effectiveness with three doses is looking robust and persistent against hospitalization and significant disease, and certainly has some effect in terms of milder infections. That's not to say two doses is useless, but three doses is really significantly better at this time with these variants. And this is a slightly busy slide looking at kind of the current recommendations that the CDC has out, including the potential for fourth doses. I think we are all aware that relatively recently, the FDA authorized second boosters or fourth doses for immune-competent people with a pretty lenient approach to age, and that these, frankly, are freely available. As we sit here, as we stand here, as we speak, there's really no vaccine shortages in this country. In essence, I think that the recommendation now should be read as what we used to call shared decision-making, and that if you're adding that final dose, it's probably not necessary to protect immune-competent people against severe disease at this time. However, if you know that they are going to become immune-compromised, if you know that they're going to go into a congregate setting or a very high-risk occupational setting, or maybe a medical meeting where people are coming together from all over the country and all over the world, I think that it should be, in my opinion, at this time, a relatively individualized decision. And I have to say, I'm kind of seeing and hearing that. I got my dose two weeks ago, and I did it explicitly for this purpose. I'm seeing elderly patients, co-workers, and friends time their fourth doses to anticipated travel, especially if it's for family gatherings like this. So I think that's not a straightforward — it's a great question without a straightforward answer, and at this time, you can be kind of selective about it. I do want to say that bringing this back to how we manage our own practices, our own clinics, our own responsibilities in hospital settings, vaccine status does make a difference, both in the CDC guidance — and then I just switched here to what we have posted on our own website — in terms of how you manage people with high-risk exposures. And absolutely, people who are not fully vaccinated up-to-date with that first booster, that third shot, or the booster after their primary series, if you're in conventional status by CDC and, in our case, Department of Health criteria, you will be furloughing or quarantining those people, whereas you will not be doing that for your fully vaccinated, boosted, up-to-date staff. So it really does make a difference in terms of workforce readiness at this point. I couldn't help it. I'm being asked, like, every night by my hospital epi folks to look at what's going on with our own healthcare personnel. So this may not apply to you. I hope it doesn't. But this is what's going on right now at my hospital. We've had roughly a — this goes over three weeks. We've had about a 400 percent increase in healthcare worker cases over the last month. It's not going in the right direction, far exceeding the identified cases in the community and far exceeding the admitted cases in the hospital. People are mostly doing well, but I do wonder how that will bear both on our decisions about which status to remain under in terms of bringing people back in contingency or crisis staffing when we know they're probably contagious and possibly in terms of moving forward with our vaccine mandates. It's going to take just the last couple minutes here to talk about vaccine mandates, a perennially touchy subject, particularly, I think, applicable to COVID vaccines in healthcare settings. Super briefly, because I can never resist putting up historical pictures, this is not a new discussion. It's a discussion that's going on for hundreds of years, not just decades. I think most people accept that the first workplace immunization or inoculation mandate was George Washington's in 1777 because he was worried about smallpox outbreaks. And he was actually also worried that the British might do some germ warfare with infected bodies among our troops. And he successfully implemented inoculation and secondary quarantine for the troops. May have helped. It probably did help. Vaccine mandates have remained part of society over, you know, since that time, most commonly in terms of those required for school children. So these are not new things. Many, many hospitals. This just happens to be my hospital's data in the red line overlaid with the curves of vaccine, influenza vaccine rates among various sectors of healthcare personnel. Basically, they look great for hospital based folks and not so based so great for ambulatory folks and particularly not so great for long term care facility healthcare personnel, whether or not. And I know there is there is profound and heartfelt disagreement about whether there should be mandates. They clearly work in terms of bring in terms of improving compliance. There's just no evidence from every part of the world that if you have a mandate, you will vaccinate more people. Now, influenza vaccine, as we have said, is highly variable in terms of its effectiveness. The covid vaccines are better vaccines, even with all of our concerns, our very legitimate concerns about new variants and about asymptomatic spread for both covid and influenza among vaccinated staff. Still in all, they save lives and certainly covid vaccine stays lives. Dr. Swift and myself kind of summarized this, I think, relatively effectively a few months ago in a webinar and looked at how the ethics and the practicalities as well as the the evidence for using mandates in our our settings was applicable to covid vaccines over the last year and a half. And to make a long story short, I personally feel strongly that this is the right way to go and that it is the effective way to go. That's funny. Okay. So so we still have we have vaccines that are still effective. We have covid still killing hundreds of thousands of people. We know how to use vaccine mandates. We know that there are people who cannot be vaccinated for any vaccine. There's always going to be exceptions and you have to provide for their safety. I would say that if the hardest part of running a mandatory vaccine program is dealing with the exemption request, the more standardized, the more consistent, the more the more compassionate that you can be, the more effective you will also be. I also want to say that you need those relationships with your allergist, your allergy consultants, with HR to help actually implement the program and frankly, with your general counsel to protect you as well as your patients are crucial to doing this without undue stress. A couple more lines in here just about the legalities of what you can and cannot do in terms of both EUA and fully FDA approved vaccines. But the long story short is that I think this is the time to use these mandates. And in fact, our organization, not necessarily with a complete consensus, has come out in support of vaccine mandates for healthcare personnel for COVID-19. And I will basically stop there and not go on to my special populations of meningococcal vaccine, which you should make available to microbiology lab workers. The details are in the handouts. The details are in the slides, which you will have access to. It really is very important and utterly vaccine preventable. There are a couple other special groups that you might want to think about. People who are in, if you have a city where there's a ton of Hepatitis A and Hep A patients, it's reasonable to offer that a terrific vaccine. There is some discussion among the people who do, for instance, laser, excuse me, laser fulguration of genital warts as to whether they might be at risk of aerosol transmission of human papillomavirus. Never been shown, but there is a good vaccine, not ACIP approved for this purpose. But actually, most of these folks will fall into an age range where you can actually vaccinate them and offer them other adult vaccines at the same time. If you're in a situation where you have a special pathogen unit in your hospital, as of just a month ago, I think, the ACIP has approved the VSV Ebola vaccine for these groups on a voluntary basis. And other than that, I left you with selected references and my traditional Oslo quote. Thank you. Thank you.

vaccine-preventable diseases

measles

mumps

rubella

varicella

pertussis

diphtheria

flu

COVID-19