Low tetanus-diphtheria-acellular pertussis (Tdap) vaccine coverage among healthcare workers in a quaternary university hospital in São Paulo, Brazil: need for continuous surveillance and implementation of active strategies

braz j infect dis 2 0 1 9;2 3(4):231–236 The Brazilian Journal of INFECTIOUS DISEASES www.elsevier.com/locate/bjid Original article Low tetanus-diphtheria-acellular pertussis (Tdap) vaccine coverage among healthcare workers in a quaternary university hospital in São Paulo, Brazil: need for continuous surveillance and implementation of active strategies Bruno Azevedo Randi a,b,∗ , Karina Takesaki Miyaji a , Amanda Nazareth Lara a , Karim Yaqub Ibrahim a , Vanessa Infante a,b , Camila Cristina Martines Rodrigues b , Marta Heloísa Lopes a,b , Ana Marli Christovam Sartori a,b a Hospital das Clinicas Divisão de Clinica de Molestias, Infecciosas e Parasitarias, Centro de Referencia para Imunobiologicos Especiais, São Paulo, SP, Brazil b Universidade de São Paulo, Faculdade de Medicina, Departamento de Molestias Infecciosas e Parasitarias, São Paulo, SP, Brazil a r t i c l e i n f o a b s t r a c t Article history: Introduction: Vaccination with tetanus-diphtheria-acellular pertussis (Tdap) has been rec- Received 26 February 2019 ommended for healthcare workers (HCWs) by Brazilian Ministry of Health since November Accepted 14 June 2019 2014. Available online 26 July 2019 Objective: To describe the strategies implemented to improve Tdap uptake, cumulative vac- Keywords: for non-vaccination among HCWs of the main building of a quaternary hospital attached to Pertussis vaccine the Sao Paulo University Medical School. cine coverage after each intervention, variables associated to Tdap vaccination, and reasons Diphtheria-tetanus-acellular Methods: A list of HCWs eligible for pertussis vaccination was generated. From April to pertussis vaccines December 2015, the following interventions were implemented: note on intern journal Bordetella pertussis reminding the importance of pertussis vaccination; email to the head nurses strengthen- Whopping cough ing vaccine recommendations; lectures on pertussis and Tdap for physicians of Obstetrics Health personnel and Neonatology Clinics; on-site vaccination by mobile teams at the Obstetrics, Neonatology, and Anesthesiology Clinics. Vaccine coverage was accessed at the end of each month. Multivariate Poisson regression model with a robust error variance was used to evaluate variables associated with Tdap vaccination. Reasons for non-vaccination were evaluated from January to May 2017 through phone calls for HCWs who had not received Tdap. ∗ Corresponding author at: Dr. Ovídio Pires de Campos Street, 225 — Cerqueira César, 05403-010, São Paulo, SP, Brazil. E-mail address: bruno (B.A. Randi). https://doi.org/10.1016/j.bjid.2019.06.007 1413-8670/© 2019 Sociedade Brasileira de Infectologia. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 232 b r a z j i n f e c t d i s . 2 0 1 9;2 3(4):231–236 Results: The study included 456 HCWs. After the interventions, Tdap coverage raised from 2.8% to 41.2%. In the multivariate analysis, occupation (physician), working place (obstetrics or anesthesiology) and influenza vaccination in 2015 were independently associated to Tdap vaccination. The main reason for non-vaccination was unawareness of Tdap recommendations. Conclusions: Tdap uptake among HCWs was low in our hospital. Providing vaccination at convenient places/times for HCW seems to be the most efficient strategy to increase vaccine uptake. © 2019 Sociedade Brasileira de Infectologia. Published by Elsevier España, S.L.U. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/ licenses/by-nc-nd/4.0/). Introduction Adult vaccination is difficult to implement. Most countries have low vaccine coverage among adults. Immunization of healthcare workers (HCWs) is challenging, as they usually show low perception of personal risk involved in their professional activities1,2 and hesitate in receiving vaccines. Fear of injections, misconceptions about vaccines efficacy and safety and lack of time are common reasons for non vaccination among HCWs.3 Vaccines recommended for HCWs include influenza, hepatitis B, measles-mumps-rubella, varicella, tetanusdiphtheria and, in some countries, adult tetanus-diphtheriapertussis acellular vaccine.4 Pertussis is caused by Bordetella pertussis, a Gram-negative bacillus transmitted by aerosol droplets.5,6 It affects people of all ages, but children aged less than one year are most affected.7 During the last decades, pertussis incidence raised globally, in spite of sustained high childhood vaccination coverage.6 Waning immunity after vaccination or infection, reduced effectiveness/duration of protection conferred by acellular pediatric vaccines, increased disease awareness, improved diagnoses and surveillance, and B. pertussis mutations allowing it to escape immunity conferred by vaccines have been proposed to explain pertussis reemergence.5,6 In Brazil, pertussis incidence increased from 0.3/100,000 persons in 2010 to 4/100,000 in 2014, despite high coverage with wholecell vaccines in children.8 Most cases occurred in infants among whom the incidence rate increased from 18/100,000 in 2010 to 152/100,000 in 2014, and who also had the highest case-fatality rate (4.6% among infants less than two months of age).8 Several Tdap vaccination strategies targeting adults to reduce pertussis among young infants have been proposed, including pregnant women vaccination, the cocooning strategy (vaccinating all newborns contacts), and vaccination of adolescents and adults, including HCWs.5 HCWs are at increased risk of acquiring pertussis through contact with infected patients and waning immunity following childhood vaccination or natural infection.9 Therefore, HCWs could be a source of pertussis nosocomial outbreaks.10 Recommendations on Tdap vaccination for HCWs vary by country. Some countries, such as the United States, Canada, Australia, Netherlands, Germany, and United Kingdom adopted Tdap vaccination for all HCWs, while others, such as Austria, Finland and Norway introduced Tdap only for HCWs who have contact with newborns and infants.11 In Brazil, Tdap was introduced into the Brazilian National Immunization Program (PNI) in November 2014, targeting pregnant women and HCWs who are in contact with newborns.12 The “Instituto Central do Hospital das Clinicas” (ICHC) is the main building of a quaternary teaching hospital attached to the Medical School of Sao Paulo University (FMUSP), which is the largest hospital in Latin America. ICHC has 850 beds. The “Centro de Referência para Imunobiológicos Especiais do Hospital das Clínicas” (CRIE-HC) is the immunization center of the complex and provides free vaccination as recommended by the PNI. In March 2015, four months after Tdap introduction, vaccine coverage among HCWs of the ICHC for whom the vaccine was recommended was very low (2.8%). This study describes the strategies implemented in 2015 to raise Tdap uptake, the cumulat (...truncated)