[MCOH-EH] [EXTERNAL] Re: Vaccination practice

[Swift, Melanie D., M.D., MPH]

Hi Tracey,

For individuals without any documentation available of prior vaccination or positive serology to all 3 diseases, you definitely have a choice. In general, experts recommend vaccination in these cases: https://www.immunize.org/catg.d/p2017.pdf but there are good reasons facilities might choose to offer serologic testing. Just be aware of pros and cons of each approach and select the approach that works best for you. There are no concerns with revaccinating an adult who might have already been vaccinated, provided they don’t have a current medical contraindication to the vaccine.

Postvaccination serology for measles, mumps and rubella is not recommended because the available antibody tests don’t assess immune status very well. Individuals who were actually fully vaccinated but have a negative IgG probably do have immune memory (cellular immunity) but aren’t pumping out antibodies that can be detected on the day you test them. Seronegativity after vaccination can be expected in some proportion of people, with the lowest rates of seronegativity in rubella and the highest in mumps (up to 17% in one study<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8226533/>!) The risk of having one of the 3 antibodies return as negative depends on the sensitivity of the serologic assay your lab uses.

So the one thing that really is a strong recommendation is do not check serology if you have the vaccination record. Post vaccination serology is definitely not recommended, and additional doses of MMR are not recommended if postvaccination serology is done and is negative, so it just generates unnecessary cost and confusion. However, we often have new hires with no documentation of their prior vaccine, but they believe that they did receive routine childhood vaccination.

To figure out which approach is best for your institution, considering the following:

  *   IgG sensitivity for the measles, mumps and rubella assays used in your lab (consult your immunology lab director)
  *   Cost of doing 2 MMR vaccines for everyone without vaccine records
  *   Cost of phlebotomy plus all 3 antibody tests for everyone without vaccine records, plus 2 MMR vaccines for the expected number of people with at least one negative serology
  *   Feasibility and timeliness of recalling those with a negative antibody test for vaccination (the first dose provides some degree of temporary protection so if you can do the first dose before they start and the second one in a month, they have minimal time of being completely susceptible. If it takes a month or two to track them down to even start the series, they are at risk for longer.)
  *   Feasibility/complexity of customizing the approach depending on how many antibody tests they need (i.e. if they present with a positive rubella IgG done for a previous pregnancy, you only need to check 2 labs which lowers your cost.)

Obviously if someone has a contraindication to MMR, checking serology has a reasonable chance of resolving their immunity status. If they have a religious objection to vaccination, serology is an easy first step, since they might “test out” of needing the vaccine.
If your lab costs allow you the latitude to test people, and you have a good system for recalling them quickly to vaccinate if needed, there’s nothing wrong with doing serology as a first step. Vaccination is the general public health recommendation for these folks and as a bonus it ensures they have a vaccine record in the state IIS for any further reference.

I hope this helps. There are so many little nuances to HCP vaccination programs! Here is a paper Dr. Behrman and I wrote on the topic if you have interest in some of the nuances: https://pubmed.ncbi.nlm.nih.gov/31515104/

All my best,

Melanie

From: Tracey O'Neal Hooker <toneal10 at gmail.com>
Sent: Thursday, October 19, 2023 6:47 PM
To: MCOH-EH <mcoh-eh at mylist.net>
Cc: Swift, Melanie D., M.D., M.P.H. <Swift.Melanie at mayo.edu>
Subject: [EXTERNAL] Re: [MCOH-EH] Vaccination practice

Melanie
Why do you vaccinate rather than check titers/look for need?  My group tends to check titers. Are there any concerns with revaccinating older adults any reason to avoid?
Thanks for the conversation.

Tracey O'Neal Hooker D.O.
ThedaCare at Work
Appleton WI

On Thu, Oct 19, 2023 at 5:01 PM Swift, Melanie D., M.D., MPH via MCOH-EH <mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>> wrote:
Tdap is offered/encouraged but not mandatory for any group of employees. It is an indicator on the USNWR survey for children’s hospitals so it’s helpful to optimize vaccination rates there if nowhere else. However the USNWR metric has remained (so far) limited to just one adult dose of Tdap, which could have been as long ago as 2005 when the vaccine came out!

MMR and varicella vaccination/immunity are required, with an exemption process for people unable to be vaccinated who lack evidence of immunity. In the absence of vaccination records, we recommend/prefer to vaccinate the person rather than check serology.

Melanie

Melanie Swift, MD, MPH
(She/her)
Vice Chair, Division of Public Health, Infectious Diseases and Occupational Medicine
Medical Director, Mayo Clinic Physician Health Center<https://www.mayoclinic.org/departments-centers/preventive-occupational-aerospace-medicine/physician-health-center/referrals>
Associate Medical Director, Occupational Health Service
Phone 507.284.2560
_______________________________
Mayo Clinic
200 First Street SW
Rochester, MN 55905
www.mayoclinic.org<http://www.mayoclinic.org/>


From: MCOH-EH <mcoh-eh-bounces+swift.melanie=mayo.edu at mylist.net<mailto:mayo.edu at mylist.net>> On Behalf Of Carr, Jennifer L.
Sent: Monday, October 16, 2023 12:27 PM
To: 'MCOH-EH' <mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>>
Subject: [EXTERNAL] [MCOH-EH] Vaccination practice

Team,
I am looking to assess the industry practice regarding vaccine requirements.
Do you require all employees to be up to date with TDAP? Do you require those not immune or with low titers to receive MMR, Varicella?
Thank you,
Jennifer
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