IMMUNIZATIONS FOR DISASTER MANAGEMENT

11 September 2005

Katharine C. Rathbun, MD, MPH

Tetanus toxoid - A single dose of Tetanus/Diphtheria (Td) toxoid should be given to anyone who will be entering the disaster area if they have not received a booster within the last 5 years.  Wounds received in flood waters are not in fact tetanus prone, so individuals who are certain they have had a booster within the last 10 years may safely choose to decline another booster.  Single antigen tetanus should NOT be used unless Td is not available.

Hepatitis A - A single dose of Hepatitis A vaccine should be given to anyone (1) who is living or working in a shelter, (2) who is providing medical or personal care to survivors, (3) who is working in a jail, prison, detention center, or other law enforcement capacity, (4) who is working with the mentally handicapped, (5) who is functioning as a first responder, (6) who is working with bodies or in a mortuary, (7) or who is working preparing or handling food in a shelter.  This creates protective antibody in about 2 weeks.  A booster dose should be offered after 6 months to all those immunized to assure long-term immunity. Hepatitis A immunization is not indicated for those engaged in clean-up or those exposed to flood waters.  There is no increased risk of Hepatitis A in sewer workers or those working in flood waters.  If an individual has had a single dose of Hepatitis A vaccine more than 6 months ago, give the booster.  If the individual has had the 2 dose series, no booster is required.

Hepatitis B - Three doses of Hepatitis B vaccine are required to protect those at risk for exposure.  This includes anyone (1) who is providing medical care to anyone, (2) who is caring for the mentally or physically handicapped in a residential setting, (3) who is working in a refugee shelter and might be exposed to blood or body fluids, (4) who is functioning as a first responder, (5) who is working in law enforcement, (6) or who is working with bodies or in a mortuary.  The accelerated schedule should be used.  The immunizations are given on day 0, day 7 and day 21.  This provides immunity in approximately 1 month.  A booster dose should be given in one year to provide lasting immunity.  If the individual has previously completed a Hepatitis B vaccine series, no further treatment is needed.  If they have received only one previous hepatitis B vaccination, give a single booster dose.

Combined Hepatitis A & B - This vaccine may be used instead of the two separate vaccines.  It is given as a three shot series on day 0, day 7 and day 21 with a booster dose at one year.  Immunity develops in about a month.  The separate vaccines are preferred in a disaster situation since Hepatitis A immunity occurs earlier with the separate hepatitis A vaccine.

Rabies - A three dose series for pre-exposure immunization is needed for anyone who will be working directly with animals including those working in animal shelters and those capturing loose animals.  These are given on day 0, day 7 and day 21.  Start the series as soon as possible and schedule the next 2 doses accordingly.  Give a single booster dose if the person has had previous rabies immunization, but has not had a booster or antibody test within the last 5 years.  If an individual has pre-exposure immunization and is exposed to rabies, give an immediate booster and a second dose in 3 days to complete the 5 shot series for post-exposure treatment.  HRIG is not required if the person has ever received rabies immunization, even if the series is not complete.  If a partially immunized person is exposed to rabies, continue the series as post-exposure by counting the number of doses already given and completing the 5 doses by day 28.  Post-exposure is given on days 0, 3, 7, 14 and 28.

Influenza - As soon as it becomes available, influenza immunization should be given to the entire population of the disaster affected areas.  Because most of the displaced population has been absorbed into the community without an increase in housing stock, there is massive overcrowding in our homes and schools.  The opening of school always brings with it an increase in respiratory and infectious diseases.  This can be expected to be much worse in these crowded conditions.  Children, high risk adults, medical and relief workers and those in shelters or institutions should be the first to be immunized but the most effective situation would be to immunize as much of the population as possible to create herd immunity.

Measles - In other countries, it is standard practice to give a booster dose of measles vaccine to all children under age 15 who are residing in shelters or refugee camps.  There was a low rate of immunization in the state of Louisiana before the storm and the children in the shelters are less likely to have had their regular immunizations than the general population.  Everyone over the age of 12 months who is in a shelter or other crowded group setting should receive one dose of Measles, Mumps, Rubella (MMR) vaccine unless they have a documented record of 2 doses of MMR or were born before 1957.

Varicella - Everyone over the age of 12 months who is in a shelter or other crowded group setting should receive one dose of this vaccine unless they have a documented record of immunization or a reliable history of chickenpox.

Childhood Immunizations - It is extremely important that children continue to receive their standard childhood immunizations.  Crowded conditions increase their risk for serious illnesses, particularly Chicken Pox and Whooping Cough which are still endemic in our population.

Typhoid, Cholera, Yellow Fever - These vaccines are not useful and not indicated in a natural disaster situation in the United States.

RECORDS - Permanent medical records of all immunizations given should be created using standard forms and systems.  In addition, all persons given immunizations in a disaster area should be given a wallet-sized card that has their name and date of birth and the date of each immunization given.  Where a series of shots is required, such as Hepatitis B or Rabies, there should be blanks on the card for the number of shots in the series so that the documentation remains on one card.

NOTE - The recommendations for Hepatitis B and Rabies immunization are standard occupational medicine recommendations.  The change in disaster conditions is the use of the accelerated schedule for those not previously immunized.

References:

Adult Immunization: A Report By the National Vaccine Advisory Committee, January 1994, as reprinted by the US Department of Health and Human Services.

Centers for Disease Control and Prevention: Interim Immunization Recommendations for Emergency Responders: Hurricane Katrina

Centers for Disease Control and Prevention: Interim Immunization Recommendations for Evacuees of Hurricane Katrina.

Accelerated Vaccination Schedules Provide Protection Against Hepatitis A and B in Last-Minute Travelers; J Travel Med 11(4):260-262, 2004; Nothdurft et al.

Louisiana Office of Public Health; personal communication.

End of Document