Immunization of workers: Canadian Immunization Guide

For health professionals

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Introduction

Workers in a variety of settings may be exposed to vaccine-preventable diseases. Vaccination against specific vaccine-preventable diseases will protect the worker and/or reduce transmission of infection to others.

Vaccines recommended for workers (and people who are about to enter the workforce) include vaccines that are part of the routine immunization schedule and vaccines recommended for adults considered at-risk (refer to Recommended Immunization Schedules in Part 1), as well as vaccines recommended because of specific occupational risks. In addition, all employers and employees should consider annual influenza immunization for working adults, as this has been shown to decrease work absenteeism due to respiratory and other illnesses. When considering immunization of adult workers, their medical history will inform whether other immunizations are needed in addition to routinely recommended vaccines. Refer to Immunization of persons with chronic diseases and Immunization of immunocompromised persons in Part 3 for further information about how underlying medical conditions may modify immunization recommendations.

A detailed discussion of personal protective measures recommended for workers is beyond the scope of the Canadian Immunization Guide.

Health care workers

Health care workers (HCW), including hospital employees, other staff who work or study in hospitals (e.g., students in health care disciplines, contract workers, volunteers) and other health care personnel (e.g., those working in clinical laboratories, nursing homes, home care agencies and community settings) are at risk of exposure to communicable diseases because of their contact with patients/clients (diagnosed or undiagnosed) or their environment. There is also a risk that HCW could transmit an undiagnosed vaccine-preventable disease to others. Some health care institutions and jurisdictions are moving towards making vaccination a condition of employment for HCW.

HCW require assessment of immunization status, completion of routinely recommended vaccine series, and booster doses as necessary. In addition, HCW may require additional doses or booster doses of routine immunizations, or a change in the routine immunization schedule. Unimmunized or incompletely immunized HCW should receive routine immunizations as appropriate for age as well as vaccines recommended because of specific occupational risks. Refer to Table 1 for a summary of recommended immunizations for HCW.

Bacille Calmette-Guérin (BCG)

In general, HCW do not need BCG vaccine. Appropriate personal protection, environmental controls, treatment of the source, and tuberculosis (TB) screening and chemoprophylaxis of the exposed person as indicated are the typical approaches to TB control in HCW. If early identification and treatment of latent TB infection are not available, BCG vaccine may be considered for HCW who may be repeatedly exposed to persons with untreated, inadequately treated or drug-resistant active TB or tubercle bacilli in conditions where protective measures against infection are not feasible. Consultation with a TB and/or infectious disease expert is recommended. Refer to Bacille Calmette-Guérin (BCG) vaccine in Part 4 for additional information.

Diphtheria, tetanus

All HCW should have received a primary series of tetanus toxoid-diphtheria toxoid-containing vaccine. Tetanus toxoid-reduced diphtheria toxoid vaccine (Td) booster doses are indicated every 10 years. Tdap vaccine should be administered if a pertussis-containing vaccine was not received in adulthood. Tdap vaccine can be given even if Td vaccine was recently administered.

Hepatitis B

Immunization with hepatitis B (HB) vaccine and post-immunization serologic testing to assess vaccine response within 1 to 6 months of completion of the vaccine series are recommended for all HCW due to potential occupational exposure to blood, blood products and bodily fluids that may contain HB virus. Refer to Hepatitis B vaccine in Part 4 for additional information on management of non-responders.

Influenza

Influenza vaccination provides benefits to HCW and to the patients/clients they care for. Transmission of influenza between infected HCW and their vulnerable patients/clients results in significant morbidity and mortality. Randomized controlled trials conducted in geriatric long-term care settings have demonstrated that vaccination of HCW is associated with substantial decreases in morbidity and mortality in the residents. Influenza vaccination of HCW who have direct patient contact (i.e., activities that allow opportunities for influenza transmission between a HCW and a patient) is an essential component of the standard of care for the protection of patients. HCW who have direct patient contact should consider it their responsibility to provide the highest standard of care, which includes annual influenza vaccination. Refer to Influenza vaccine in Part 4 for additional information.

Measles

It is recommended that all HCW be immune to measles. HCW, regardless of their year of birth, should receive two doses of measles-mumps-rubella (MMR) vaccine if they do not have one or more of the following: documented evidence of receiving two doses of measles-containing vaccine on or after their first birthday or laboratory evidence of immunity; or a history of laboratory confirmed measles disease. Refer to Measles vaccine in Part 4 for additional information.

Meningococcal

Clinical laboratory personnel who handle Neisseria meningitidis specimens should be offered immunization with one dose of quadrivalent conjugate meningococcal vaccine. Re-vaccination is generally recommended every 5 years. Good laboratory practices should be employed at all times to minimize the risk of exposure in laboratory workers and post-exposure prophylaxis should be offered after recognized exposures. There is no evidence to recommend routine meningococcal immunization of other HCW. Nosocomial transmission of invasive meningococcal disease is very uncommon. Post-exposure chemoprophylaxis may be indicated for HCW who are close contacts of cases of invasive meningococcal disease. HCW are considered as close contacts only if they have had intensive, unprotected contact (without wearing a mask) with infected patients (e.g., intubating, resuscitating or closely examining the oropharynx). It is recommended that HCW use barrier precautions to avoid direct contact with respiratory secretions of patients with meningococcal disease until the patient has completed 24 hours of effective antibiotic therapy. Refer to Meningococcal vaccine in Part 4 for additional information.

Mumps

It is recommended that all HCW be immune to mumps. HCW, regardless of their year of birth, should receive two doses of MMR vaccine if they do not have one or more of the following: documented evidence of receiving two doses of mumps-containing vaccine on or after their first birthday; or laboratory evidence of immunity; or a history of laboratory confirmed mumps disease. Refer to Mumps vaccine in Part 4 for additional information.

Pertussis

All adult HCW, regardless of age, should receive a single dose of tetanus toxoid-reduced diphtheria toxoid-reduced acellular pertussis-containing vaccine (Tdap) for pertussis protection if not previously received in adulthood. The adult dose is in addition to the routine adolescent booster dose. Adolescent volunteers in health care settings should receive their routine booster dose of Tdap vaccine. Refer to Pertussis vaccine in Part 4 for additional information.

Polio

All HCW who have not received a primary series of poliomyelitis vaccine should receive a primary series of inactivated poliomyelitis vaccine.

Health care workers at highest risk for polio exposure, including those who have close contact with patients who might be excreting wild type virus (e.g., from travel abroad) or vaccine type poliovirus (e.g., infants who received oral polio vaccine abroad) and laboratory workers handling specimens that may contain poliovirus, should be particularly targeted for polio vaccination. HCW at highest risk for polio exposure should receive a single lifetime booster dose of inactivated poliomyelitis vaccine. If these HCW have not received a primary series, they should receive a full primary series and then receive a single lifetime booster dose after 10 years. Refer to Poliomyelitis vaccine in Part 4 for additional information.

Rubella

It is recommended that all HCW be immune to rubella. HCW, regardless of age, should receive one dose of MMR vaccine if they do not have one or more of the following: documented evidence of receiving one dose of rubella-containing vaccine on or after their first birthday; or laboratory evidence of immunity; or a history of laboratory confirmed rubella disease. Refer to Rubella vaccine in Part 4 for additional information.

Travel vaccines for health care providers working abroad

Health care providers working in cholera-endemic countries or areas where hepatitis A, typhoid, Japanese encephalitis, tick-borne encephalitis, or yellow fever are present may be at significantly increased risk of exposure and should be appropriately vaccinated. Re-vaccination may be recommended if risk of exposure is ongoing. Consultation with a travel medicine expert is advised. Refer to Immunization of travellers in Part 3 and vaccine-specific chapters in Part 4 for additional information.

Varicella

It is recommended that all HCW be immune to varicella. HCW are considered to be immune to varicella if they have documented evidence of immunization with 2 doses of a varicella-containing vaccine or laboratory evidence of immunity. For HCW who are currently or have previously been employed in a Canadian health care setting, a self-reported history or health care provider diagnosis is considered a reliable correlate of immunity if varicella infection occurred before the year of a one-dose vaccine program implementation (refer to Varicella (Chickenpox) vaccine in Part 4). In general, healthy adults 50 years of age and older, are presumed to be immune to varicella, even if the person does not remember having had chickenpox or herpes zoster (shingles, HZ).  All HCW should be immunized with two doses of univalent varicella vaccine when there is uncertainty about immunity to varicella.

Following the exposure of HCW to varicella within health care settings, verification of susceptibility to infection should be a part of post-exposure protocols. Refer to Varicella (Chickenpox) vaccine in Part 4 for additional information.

Laboratory Worker

Medical, research or industrial laboratory workers routinely handling a bacteria or virus that causes a vaccine preventable disease should be immunized against it. For example, anyone working with the influenza virus should receive influenza vaccine on an annual basis. Routine adult immunizations are also indicated. Refer to Table 2 for a summary of recommended immunization for research or industrial laboratory workers.

Hepatitis A, hepatitis B

Workers involved in research on hepatitis A (HA) or hepatitis B (HB) virus or production of HA and/or HB vaccine and who may be exposed to HA or HB viruses should receive HA and HB vaccine. Post-immunization serologic testing for HB should be done within 1 to 6 months of completion of the vaccine series to assess vaccine response. Refer to Hepatitis A vaccine and Hepatitis B vaccine chapters in Part 4 for dosing and additional information.

Meningococcal

Research and industrial laboratory personnel who handle N. meningitidis specimens should be offered immunization with one dose of quadrivalent conjugate meningococcal vaccine. Re-vaccination is generally recommended every 5 years. Good laboratory practices should be employed at all times to minimize the risk of exposure in laboratory workers and post-exposure prophylaxis should be offered after recognized exposures. Refer to Meningococcal vaccine in Part 4 for additional information.

Polio

Laboratory workers handling specimens that may contain poliovirus should be particularly targeted for polio vaccination. Laboratory workers at highest risk for polio exposure who have received a primary series of poliomyelitis vaccine should receive a single lifetime booster dose of inactivated poliomyelitis vaccine. If the worker has not received a primary series, they should receive a full primary series and then receive a single lifetime booster dose after 10 years. Refer to Poliomyelitis vaccine in Part 4 for additional information.

Rabies

Pre-exposure rabies immunization should be offered to workers at high risk of occupational exposure to potentially rabid animals or to the rabies virus. High risk individuals may include veterinarians, veterinary staff, animal control and wildlife workers, and laboratory workers exposed to the rabies virus.  Workers with ongoing high risk of exposure to the rabies virus require periodic serology testing following completion of a primary series to ensure the persistence of circulating antibodies. For workers at continuous risk of exposure (e.g., those who work with the rabies virus in a research laboratory or production of rabies vaccine) - obtain serology every 6 months. For those at frequent risk of exposure (e.g., rabies diagnostic laboratory workers) - obtain serology every 2 years. A booster dose of rabies vaccine is recommended if antibody levels fall below an acceptable concentration. Refer to Rabies vaccine in Part 4 for additional information.

Japanese encephalitis

Laboratory personnel who work with Japanese encephalitis (JE) virus should receive JE vaccine. Laboratory workers at continuous risk for acquiring JE should receive a booster dose 12 months after primary immunization. Data on the need for further booster doses are not available. Refer to Japanese encephalitis vaccine in Part 4 for additional information.

Yellow fever

Laboratory personnel who work with yellow fever virus should receive yellow fever vaccine. Re-immunization is recommended every 10 years if risk of exposure is ongoing. Refer to Yellow fever vaccine in Part 4 for additional information.

Typhoid

Typhoid vaccine is recommended for laboratory personnel regularly working with S. typhi. Re-vaccination at vaccine specific intervals is recommended if risk of exposure is ongoing. Technicians working in routine microbiology laboratories do not need to be vaccinated. Refer to Typhoid vaccine in Part 4 for additional information.

Smallpox and mpox

Smallpox vaccine, including Imvamune, may be indicated for certain workers at high risk of exposure, such as laboratory workers who handle vaccinia or other orthopoxviruses (including mpox and recombinant vaccinia vaccine products) in specialized reference or research facilities. Refer to Smallpox and mpox (monkeypox) vaccine in Part 4 for additional information.

Child Care Workers and Workers in Educational Setting

Child care workers and workers in educational settings are at risk of exposure to communicable diseases such as varicella, measles, mumps, rubella, influenza and pertussis because of their contact with young people. Child care workers are also capable of transmitting communicable diseases (such as influenza or pertussis) to young children. Child care workers should also receive all vaccines routinely recommended for adults.

Hepatitis A

Hepatitis A vaccine is recommended for post-exposure prophylaxis of workers if hepatitis A occurs in a group child care centre or kindergarten. Refer to Hepatitis A vaccine in Part 4 for additional information.

Hepatitis B

Workers in child care settings in which there is a child or worker who has acute HB or is a HB carrier should receive HB vaccine and post-immunization serologic testing within 1 to 6 months of completion of the vaccine series. As children with HB are usually asymptomatic and the HB status of children in child care settings is generally unknown, consider vaccination of all child care workers. Refer to Hepatitis B vaccine in Part 4 for additional information.

Influenza

Annual influenza immunization is recommended for people providing regular child care to children less than 60 months of age (whether in or out of the home) because these child care workers are capable of transmitting influenza to young children who are at high risk of influenza-related complications. Influenza vaccine is encouraged for all other adults. Refer to Influenza vaccine in Part 4 for additional information.

Measles, mumps, rubella

One dose of MMR vaccine is recommended for measles and/or mumps susceptible adults born in or after 1970; adults born before 1970 can be considered immune. One dose of MMR vaccine is recommended for rubella susceptible adults. Non-immune people who work with children (e.g., child care workers, teachers) and non-immune, non-pregnant female workers of childbearing age in educational settings are priorities for rubella immunization. Refer to Measles Vaccine, Mumps vaccine, Rubella vaccine in Part 4 for additional information.

Meningococcal

Staff members (regardless of immunization status) in contact with a case of invasive meningococcal disease in a child care or nursery school facility should receive chemoprophylaxis and, if the meningococcal serogroup identified in the case is vaccine preventable, should also be considered for immunoprophylaxis with an appropriate meningococcal conjugate vaccine. Refer to Meningococcal vaccine in Part 4 for additional information.

Pertussis

All child care workers and teachers, regardless of age, should receive a single dose of Tdap vaccine for pertussis protection if not previously received in adulthood. Adolescents providing child care should receive their routine booster dose of Tdap vaccine. Refer to Pertussis vaccine in Part 4 for additional information.

Varicella

Varicella outbreaks can occur in child care and educational settings where there are unimmunized children. Varicella susceptible child care workers and teachers of young children should receive two doses of univalent varicella vaccine. Refer to Varicella (Chickenpox) vaccine in Part 4 for additional information.

Workers with Occupational Exposure to Animals or Materials from Animal

Workers with occupational exposure to animals or materials from animals with infections (e.g., veterinarians and veterinary staff, animal control workers, wildlife workers, zoo-keepers, researchers, laboratory workers) may be at higher risk of exposure to diseases that can be transmitted from animals to humans, such as hepatitis A or rabies. These workers should also receive all vaccines routinely recommended for adults.

Hepatitis A

Zoo-keepers, veterinarians and researchers who handle non-human primates should receive two doses of hepatitis A vaccine. Refer to Hepatitis A vaccine in Part 4 for additional information.

Influenza

Annual seasonal influenza immunization is recommended for people in direct contact during culling operations with poultry infected with avian influenza. This is to reduce the potential for mixing of human and avian strains of influenza that may arise if workers become co-infected with seasonal and with avian influenza. Influenza vaccine is encouraged for all adults. Refer to Influenza vaccine in Part 4 for additional information.

Rabies

Pre-exposure rabies immunization should be offered to workers such as veterinarians, veterinary staff, animal control and wildlife workers at high risk of occupational exposure to potentially rabid animals or the rabies virus. Certain workers with ongoing high risk of exposure to the rabies virus require periodic serology testing following completion of the primary series to ensure the persistence of circulating antibodies. For workers at frequent risk of exposure (veterinarians, veterinary staff, animal control and wildlife workers in areas where rabies is enzootic) - obtain serology every 2 years. A booster dose of rabies vaccine should be given if antibody levels fall below an acceptable concentration. For workers at less frequent risk of exposure to potentially rabid animals and/or whose risk is likely to be from a recognized source (such as veterinarians, veterinary staff and students, and animal control officers who work with terrestrial animals in areas where rabies is uncommon) periodic serologic testing is not required. Refer to Rabies vaccine in Part 4 for additional information.

Tetanus

Persons handling animals may be at risk for tetanus from bite and other puncture wounds and should have up-to-date routine tetanus immunization.

Humanitarian Relief and Overseas Refugee Worker

Humanitarian relief workers are at risk of exposure to vaccine-preventable diseases such as cholera, diphtheria, ebola virus, hepatitis A, polio, TB, yellow fever, tick-borne encephalitis, Japanese encephalitis and typhoid when posted to endemic areas and may benefit from immunization. These workers should also have up-to-date routine adult immunizations prior to departure. Refer to Immunization of travellers in Part 3 and vaccine-specific chapters in Part 4 for additional information.

Polio

Humanitarian relief workers in refugee camps in areas where poliovirus is known or suspected to be circulating or who come in close contact with those who may be excreting poliovirus should be particularly targeted for polio vaccination. Relief workers at highest risk for polio exposure who have received a primary series of poliomyelitis vaccine should receive a single lifetime booster dose of inactivated poliomyelitis vaccine. If the worker has not received a primary series, he/she should receive a full primary series and then receive a single lifetime booster dose after 10 years. Refer to Poliomyelitis vaccine in Part 4 for additional information.

Travel vaccines for humanitarian relief and overseas refugee workers

Humanitarian relief and overseas refugee workers in cholera-endemic countries or areas where hepatitis A, typhoid, Japanese encephalitis, tick-borne encephalitis, or yellow fever are present may be at significantly increased risk of exposure and may benefit from immunization. Re-vaccination may be recommended if the risk of exposure is ongoing. Consultation with a travel medicine expert is advised.

Refugee Workers in Canada

People who plan to work with refugees in Canada should have up-to-date routine adult immunizations. In addition, prior to initiating work with refugees, the worker's risk of exposure to polio should be assessed.

Polio

People who work with refugees in Canada should be particularly targeted for polio vaccination because they may come in close contact with refugees who are excreting poliovirus. Refugee workers at highest risk for polio exposure who have received a primary series of poliomyelitis vaccine should receive a single lifetime booster dose of inactivated poliomyelitis vaccine. If the worker has not received a primary series, they should receive a full primary series and then receive a single lifetime booster dose after 10 years. Refer to Poliomyelitis vaccine in Part 4 for additional information.

Emergency Services Worker

Emergency service workers include police and fire fighters and any other front line workers who may need to respond to emergencies. For paramedical and ambulance workers refer to Health Care Workers. For other emergency service workers, routine adult immunizations should be up to date and hepatitis B and influenza vaccines are recommended.

Hepatitis B

Pre-exposure hepatitis B immunization and post-immunization serologic testing within 1 to 6 months of completion of the vaccine series are recommended for emergency services workers. These workers may be at higher risk of blood exposure and potential HB virus exposure, although there are no data to quantify their risk. Refer to Hepatitis B vaccine in Part 4 for additional information.

Influenza

Annual influenza immunization of emergency service workers is recommended because these workers provide essential community services. Refer to Influenza vaccine in Part 4 for additional information.

Workers in Institutions for the Developmentally Challenged or Correctional Facilities

Workers in institutions for the developmentally challenged or correctional facilities should receive all vaccines routinely recommended for adults including influenza vaccine. In addition, hepatitis B vaccine is recommended.

Hepatitis B

Pre-exposure hepatitis B immunization and post-immunization serologic testing within 1 to 6 months of completion of the vaccine series are recommended for workers in institutions for the developmentally challenged or correctional facilities because these workers are at higher risk of exposure to hepatitis B through bites or penetrating injuries, or exposure to blood or blood products. Refer to Hepatitis B vaccine in Part 4 for additional information.

Workers who Provide Services within Closed Setting

Workers who provide services within closed settings (e.g., crews on ships) should receive all vaccines routinely recommended for adults, including annual influenza vaccine.

Influenza

Annual influenza immunization is recommended for workers who provide services within closed or relatively closed settings to persons at high risk of influenza-related complications because these workers are capable of transmitting influenza to these high-risk individuals. Refer to Influenza vaccine in Part 4 for additional information.

Workers who Provide Essential Community Service

Workers who provide essential community services should receive all vaccines routinely recommended for adults, including annual influenza vaccine.

Influenza

Annual influenza immunization of workers who provide essential community services is recommended to minimize the disruption of routine activities during seasonal influenza epidemics. Refer to Influenza vaccine in Part 4 for additional information.

Workers in Shelters for the Homeless

Workers in shelters for the homeless should receive all vaccines routinely recommended for adults. In addition, hepatitis B vaccine is recommended if the worker is at risk of exposure to blood or body fluids.

Hepatitis B

Pre-exposure hepatitis B immunization and post-immunization serologic testing within 1 to 6 months of completion of the vaccine series are recommended for workers at risk of exposure to blood or body fluids. Refer to Hepatitis B vaccine in Part 4 for additional information.

Military Personnel

On enrolment into the Canadian Forces, the medical history and immunization records of recruits are reviewed and then vaccination, as required is offered during recruit training to boost or induce immunity against tetanus, diphtheria, measles, mumps, polio, pertussis, varicella, influenza, meningococcal disease, hepatitis A, and hepatitis B. The immunization status of personnel is reviewed throughout their service career and any required booster doses, as well as additional vaccines to address individual risks resulting from military occupations, lifestyle choices, travel plans, and deployments are offered.

The Canadian Forces immunization standards adopt the Canadian Immunization Guide, advisory statements of the National Advisory Committee on Immunization, and relevant statements of the Committee to Advise on Tropical Medicine and Travel, as guiding documents for use of immunizing agents. The Directorate of Force Health Protection at National Defence Headquarters in Ottawa adapts these national guidelines and produces advisories on the use of specific vaccines in the Canadian Forces, and provides the recommendations on vaccinations requirements for health protection at specific deployment locations.

Selected References

• Centers for Disease Control and Prevention. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2011;60(RR-7):1-45.
• Stewart AM. Mandatory vaccination of health care workers. N Engl J Med 2009 Nov 19;361(21):2015-7.

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