[Federal Register Volume 62, Number 173 (Monday, September 8, 1997)]
[Notices]
[Pages 47276-47327]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 97-23677]
[[Page 47275]]
_______________________________________________________________________
Part V
Department of Health and Human Services
_______________________________________________________________________
Centers for Disease Control and Prevention
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Draft Guideline for Infection Control in Health Care Personnel, 1997;
Notice
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 /
Notices
[[Page 47276]]
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
Draft Guideline for Infection Control in Health Care Personnel,
1997
AGENCY: Centers for Disease Control and Prevention (CDC), Department of
Health and Human Services (DHHS).
ACTION: Notice.
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SUMMARY: This notice is a request for review of and comment on the
Draft Guideline for Infection Control in Health Care Personnel, 1997.
The guideline consists of two parts: Part 1. ``Infection Control Issues
for Health Care Personnel, an Overview'' and Part 2. ``Recommendations
for Prevention of Infections in Health Care Personnel'', and was
prepared by the Hospital Infection Control Practices Advisory Committee
(HICPAC), the National Center for Infectious Diseases (NCID), the
National Immunizations Program, and the National Institute of
Occupational Safety and Health (NIOSH), CDC.
DATES: Written comments on the draft document must be received on or
before October 17, 1997.
ADDRESSES: Comments on this document should be submitted in writing to
the CDC, Attention: PHG Information Center, Mailstop E-68, 1600 Clifton
Road, N.E., Atlanta, Georgia 30333. To order copies of the Federal
Register containing the document, contact the U.S. Government Printing
Office, Order and Information Desk, Washington, DC 20402-9329,
telephone (202) 512-1800. In addition, the Federal Register containing
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FOR FURTHER INFORMATION CONTACT: The CDC Fax Information Center,
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information, call the PH Guideline Information Center, telephone (888)
232-3228, then press 2, 2, 3, 2, 2, 1, 5 to go directly to the
guideline information.
SUPPLEMENTARY INFORMATION: This 2-part document updates and replaces
the previously published CDC Guideline for Infection Control in
Hospital Personnel (Infect Control 1983 [Special Supplement]; 4
[Suppl]: 326-349). Part 1, ``Infection Control Issues for Health Care
Personnel, an Overview'' serves as the background for the consensus
recommendations of the Hospital Infection Control Practices Advisory
Committee (HICPAC) that are contained in Part 2, ``Recommendations for
Prevention of Infections in Health Care Personnel''.
HICPAC was established in 1991 to provide advice and guidance to
the Secretary and the Assistant Secretary for Health, DHHS; the
Director, CDC, and the Director, NCID regarding the practice of
hospital infection control and strategies for surveillance, prevention,
and control of nosocomial infections in U.S. hospitals. The committee
also advises CDC on periodic updating of guidelines and other policy
statements regarding prevention of nosocomial infections.
The Guideline for Infection Control in Hospital Personnel, 1997 is
the fourth in a series of CDC guidelines being revised by HICPAC and
NCID, CDC.
Dated: September 2, 1997.
Joseph R. Carter,
Acting Associate Director for Management and Operations, Centers for
Disease Control and Prevention (CDC).
Draft Guideline for Infection Control in Health Care Personnel,
1997
Executive Summary
This guideline updates and replaces the previous edition of the CDC
Guideline for Infection Control in Hospital Personnel published in
1983. The revised guideline, designed to provide methods for reducing
the transmission of infections from patients to health care personnel
and from personnel to patients, also provides an overview of the
evidence for recommendations considered prudent by consensus of the
Hospital Infection Control Practices Advisory Committee members. A
working draft of this guideline was also reviewed by experts in
infection control, occupational health, and infectious diseases;
however, all recommendations contained in the guideline may not reflect
the opinion of all reviewers.
This document focuses on the epidemiology of and preventive
strategies for infections known to be transmitted in health care
settings and those for which there are adequate scientific data on
which to base recommendations for prevention. The prevention strategies
addressed in this document include immunizations for vaccine
preventable diseases; isolation precautions to prevent exposures to
infectious agents; management of health care personnel exposures to
infected persons, including postexposure prophylaxis; and work
restrictions for exposed or infected health care personnel. In
addition, because latex barriers are frequently used to protect
personnel against transmission of infectious agents, this guideline
also addresses issues related to latex hypersensitivity and provides
recommendations to prevent sensitization and reactions among health
care personnel.
Part I. Infection Control Issues for Health Care Personnel, an
Overview
A. Introduction
In the United States, there are an estimated 8.8 million persons
who work in health care professions and about 6 million persons work in
more than 6,000 hospitals. However, health care is increasingly being
provided outside of hospitals in facilities such as nursing homes,
freestanding surgical and outpatient centers, emergency care clinics,
and in patients, homes or during pre-hospital emergency care. Hospital-
based personnel and personnel who provide health care outside of
hospitals may acquire infections from or transmit infections to
patients or other personnel, household members, or other community
contacts.
In this document, the term health care personnel refers to all paid
and unpaid persons working in health care settings who have the
potential for exposure to infectious materials, including body
substances, contaminated medical supplies and equipment, contaminated
environmental surfaces, or contaminated air. These personnel may
include, but are not limited to, emergency medical service personnel,
dental personnel, laboratory personnel, mortuary personnel, nurses,
nursing assistants, physicians, technicians, students and trainees,
contractual staff not employed by the health care facility, and persons
not directly involved in patient care (e.g., clerical, dietary,
housekeeping, maintenance, and volunteer personnel) but potentially
exposed to infectious agents. In general, health care personnel, in or
outside of hospitals, who have contact with patients, body fluids, or
specimens have a higher risk of acquiring or transmitting infections
than do other health care personnel who have only brief casual contact
with patients and their environment.
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Throughout this document terms are used to describe routes of
transmission of infections. These terms have been fully described in
the Guideline for Isolation Precautions in Hospitals (1). They are
summarized as follows: direct contact refers to body surface-to-body
surface contact and physical transfer of microorganisms between a
susceptible host and an infected or colonized person (e.g., while
bathing, performing procedures); indirect contact refers to contact of
a susceptible host with a contaminated object (e.g., instruments,
hands); droplet contact refers to conjunctival, nasal, or oral mucosa
contact with droplets containing microorganisms generated from an
infected person (by coughing, sneezing, and talking or during certain
procedures such as suctioning and bronchoscopy) that are propelled a
short distance; airborne transmission refers to contact with droplet
nuclei containing microorganisms that can remain suspended in the air
for long periods of time or dust particles containing an infectious
agent that can be widely disseminated by air currents; and finally,
common vehicle transmission refers to contact with contaminated items
such as food, water, medications, devices, and equipment.
In 1983, the Centers for Disease Control and Prevention (CDC)
published the Guideline for Infection Control in Hospital Personnel
(2). The document focused on the prevention of infections known to be
transmitted to and from health care personnel. This revision of the
Guideline has been expanded to include (a) recommendations for non-
patient care personnel, both in and outside of hospitals; (b)
management of exposures; (c) prevention of transmission of infections
in microbiologic and biomedical laboratories; and, (d) because of the
common use of latex barriers to prevent infections, prevention of latex
hypersensitivity reactions. As in the 1982 Guideline, readers are
frequently referred to the Guideline for Isolation Precautions in
Hospitals (1) and other published guidelines and recommendations for
precautions that health care personnel may use when caring for
patients, or handling patient equipment or specimens (3, 4).
B. Infection Control Objectives for a Personnel Health Service
The infection control objectives of the personnel health service
should be an integral part of a health care organization's general
program for infection control. The objectives usually include the
following: (a) Educating personnel about the principles of infection
control and stressing individual responsibility for infection control;
(b) collaborating with the infection control department in monitoring
and investigating potentially harmful infectious exposures and
outbreaks among personnel; (c) providing care to personnel for work-
related illnesses or exposures; (d) identifying work-related infection
risks and instituting appropriate preventive measures; and (e)
containing costs by preventing infectious diseases that result in
absenteeism and disability. These objectives cannot be met without the
support of the health care organization's administration, medical
staff, and other health care personnel.
C. Elements of a Personnel Health Service for Infection Control
Certain elements are necessary to attain the infection control
goals of a personnel health service: (a) Coordination with other
departments; (b) medical evaluations; (c) health and safety education;
(d) immunization programs; (e) management of job-related illnesses and
exposures to infectious diseases, including policies for work
restrictions for infected or exposed personnel; (f) counseling services
for personnel on infection risks related to employment or special
conditions; and (g) maintenance and confidentiality of personnel health
records.
The organization of a personnel health service may be influenced by
the size of the institution, the number of personnel, and the services
offered. Personnel with specialized training and qualifications in
occupational health can facilitate the provision of effective services.
1. Coordination With Other Departments
For infection control objectives to be achieved, the activities of
the personnel health service must be coordinated with infection control
and other departmental personnel. This coordination will help ensure
adequate surveillance of infections in personnel and provision of
preventive services. Coordinating activities will also help to ensure
that investigations of exposures and outbreaks are conducted
efficiently and preventive measures implemented promptly.
2. Medical Evaluations
Medical evaluations before placement can ensure that personnel are
not placed in jobs that would pose undue risk of infection to them,
other personnel, patients, or visitors. An important component of the
placement evaluation is a health inventory. This usually includes
determining immunization status and obtaining histories of any
conditions that might predispose personnel to acquiring or transmitting
communicable diseases, e.g., history of chickenpox, rubella, measles,
mumps, hepatitis, immunodeficiency, dermatologic conditions (including
chronic draining or open wounds), and risk factors or treatment for
tuberculosis. This information will assist in decisions about
immunizations or postexposure management.
A physical examination, another component of the medical
evaluation, can be used to screen personnel for conditions that might
increase the risk of transmitting or acquiring work related diseases
and can serve as a baseline for determining whether future diseases are
work related. However, the cost-effectiveness of routine physical
examinations, including laboratory testing (such as complete blood
counts, serologic tests for syphilis, urinalysis, chest x-rays) or
screening for enteric or other pathogens for infection control
purposes, has not been demonstrated. Conversely, screening for some
vaccine-preventable diseases, such as hepatitis B, measles, mumps,
rubella, or varicella, may be cost-effective. In general, the health
inventory can be used to guide decisions regarding physical
examinations or laboratory tests. However, some local public health
ordinances may mandate that certain screening procedures be used.
Periodic evaluations may be done as indicated for job reassignment,
ongoing programs (e.g., tuberculosis screening), or for evaluation of
work-related problems.
3. Personnel Health and Safety Education
Personnel are more likely to comply with an infection control
program if they understand its rationale. Thus, personnel education is
a cardinal element of an effective infection control program. Clearly
written policies, guidelines, and procedures ensure uniformity,
efficiency, and effective coordination of activities. However, since
the risk of infection varies by job category, infection control
education should be modified accordingly. In addition, some personnel
may need specialized education on infection risks related to their
employment, and of preventive measures that will reduce those risks.
Furthermore, educational materials need to be appropriate in content
and vocabulary to the educational level, literacy, and language of the
employee. All health care personnel need to be educated about the
[[Page 47278]]
organization's infection control policies and procedures.
4. Immunization Programs
Ensuring that personnel are immune to vaccine-preventable diseases
is an essential part of successful personnel health programs. Optimal
use of vaccines can prevent transmission of vaccine-preventable
diseases and eliminate unnecessary work restriction. Preventing illness
through comprehensive personnel immunization programs is far more cost-
effective than case management and outbreak control. Mandatory
immunization programs, which include both newly hired and currently
employed persons, are more effective than voluntary programs in
ensuring that susceptible persons are vaccinated (5). Also, programs in
which the employer bears the cost of vaccination have had higher
personnel vaccination rates than have programs without such support.
National guidelines for immunization of and postexposure
prophylaxis for health care personnel are provided by the U.S. Public
Health Service's Advisory Committee on Immunization Practices (ACIP)
(Table 1) (6, 7). ACIP guidelines also contain (a) detailed information
on the epidemiology of vaccine-preventable diseases; (b) data on the
safety and efficacy of vaccines and immune globulin preparations (6-
20); and (c) recommendations for immunization of immunocompromised
persons (Table 2) (14, 21). The recommendations in this guideline have
been adapted from the ACIP recommendations (7). In addition, individual
states and professional organizations have regulations or
recommendations on the vaccination of health care personnel (22).
Decisions about which vaccines to include in immunization programs
have been made by considering (a) the likelihood of personnel exposure
to vaccine-preventable diseases and the potential consequences of not
vaccinating personnel; (b) the nature of employment (i.e., type of
contact with patients and their environment); and (c) the
characteristics of the patient population within the health care
organization. Immunization of personnel before they enter high-risk
situations is the most efficient and effective use of vaccines in
health care settings.
Screening tests are available to determine susceptibility to
certain vaccine-preventable diseases (e.g., hepatitis B, measles,
mumps, rubella, and varicella). Such screening programs need to be
combined with tracking systems to ensure accurate maintenance of
personnel immunization records. Accurate immunization records ensure
that susceptible personnel are promptly identified and appropriately
vaccinated.
5. Management of Job-Related Illnesses and Exposures
Primary functions of the personnel health service are to arrange
for prompt diagnosis and management of job-related illnesses and to
provide appropriate postexposure prophylaxis following job-related
exposures.
It is the responsibility of the health care organization to
implement measures to prevent further transmission of infection, which
sometimes warrants exclusion of personnel from work or patient contact.
Decisions on work restrictions are based on the mode of transmission
and the epidemiology of the disease (Table 3). Exclusion policies
should include a statement of authority defining who may exclude
personnel. The policies also need to be designed to encourage personnel
to report their illnesses or exposures and not to penalize them with
loss of wages, benefits, or job status. In addition, exclusion policies
must be enforceable, and all personnel, especially department heads,
supervisors, and nurse managers, should know which infections may
warrant exclusion and where to report the illnesses 24 hours a day.
Health care personnel who have contact with infectious patients outside
of hospitals also need to be included in the postexposure program.
Notification of emergency response personnel possibly exposed to
selected infectious disease is mandatory (1990 Ryan White Act, Subtitle
B, 42 U.S.C 300ff-80).
6. Health Counseling
Access to adequate health counseling for personnel is another
crucial element of an effective personnel health service. Health
counseling allows personnel to receive individualized information
regarding (a) the risk and prevention of occupationally acquired
infections; (b) the risk of illness or other adverse outcome following
exposures; (c) management of exposures, including the risks and
benefits of postexposure prophylaxis regimens; (d) the potential
consequences of exposures or communicable diseases for family members,
patients, or other personnel, both inside and outside the health care
facility.
7. Maintenance of Records, Data Management, and Confidentiality
Maintenance of records on medical evaluations, immunizations,
exposures, postexposure prophylaxis, and screening tests in a
retrievable, preferably computerized, data base allows efficient
monitoring of the health status of personnel. Such record keeping also
helps to ensure that the organization will provide consistent and
appropriate services to health care personnel.
Individual records for all personnel should be maintained in
accordance with the Occupational Safety and Health Administration
(OSHA) record-keeping requirements for occupational injuries and
illnesses (23). In addition, the 1991 OSHA Occupational Exposure to
Bloodborne Pathogens; Final Rule (24) requires employers, including
health care facilities, to establish and maintain an accurate record
for each employee with occupational exposure to bloodborne pathogens.
The standard also requires that each employer ensure that the employee
medical records are (a) kept confidential; (b) not disclosed or
reported without the employee's express written consent to any person
within or outside the workplace except as required by law; and (c)
maintained by the employer for at least the duration of the worker's
employment plus 30 years.
More recently, OSHA developed enforcement policies that require the
recording and reporting of positive tuberculin skin test results (25).
It would be beneficial to health care organizations and personnel if
the principles of record keeping and confidentiality mandated by OSHA
were expanded to other work-related exposures and incidents,
immunizations, tuberculosis screening, and investigation and management
of nosocomial outbreaks.
D. Epidemiology and Control of Selected Infections Transmitted Among
Health Care Personnel and Patients
Almost any transmissible infection may occur in the community at
large or within health care organizations and can affect both personnel
and patients. However, only those infectious diseases that occur
frequently in the health care setting or are most important to
personnel are discussed below.
1. Bloodborne Pathogens
a. Overview. Assessment of the risk and prevention of transmission
of bloodborne pathogens, such as hepatitis B virus (HBV), hepatitis C
virus (HCV), and human immunodeficiency virus (HIV) in health care
settings is based upon information from a variety of sources, including
surveillance and investigation of suspected cases of transmission to
health care personnel and patients, seroprevalence surveys of health
care personnel and patients, and
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studies of the risk of seroconversion after exposure to blood or other
body fluids from infected persons. In this document, the emphasis of
the discussion of bloodborne pathogens will be on patient-to-personnel
transmission.
CDC has periodically issued and updated recommendations for
prevention of transmission of bloodborne pathogens in health care
settings that provide detailed information and guidance (26-36). Also,
in 1991, OSHA published a bloodborne pathogen standard, based on the
concept of Universal Precautions, to prevent occupational exposure to
bloodborne pathogens (24). In essence, the use of Standard Precautions
(which incorporates Universal Precautions), including appropriate
handwashing and barrier precautions to prevent contact with blood and
body fluids and using techniques and devices that reduce percutaneous
injury, will reduce the risk of transmission of bloodborne pathogens
(1, 27, 37-42).
The risk posed to patients from health care personnel infected with
bloodborne pathogens such as HBV and HIV has been the subject of much
concern and debate. There are no data to indicate that infected workers
who do not perform invasive procedures pose a risk to patients.
Consequently, work restrictions for these workers are not appropriate.
However, the extent to which infected workers who perform certain types
of invasive procedures pose a risk to patients and the restrictions
that should be imposed on these workers have been much more
controversial. In 1991, CDC recommendations on this issue were
published (43). Subsequently, Congress mandated that each state
implement the CDC guidelines or equivalent as a condition for continued
federal public health funding to that state. While all states have
complied with this mandate, there is a fair degree of state-to-state
variation regarding specific provisions. Local or state public health
officials should be contacted to determine the regulations or
recommendations applicable in a given area. CDC is currently in the
process of reviewing relevant data regarding health care personnel to
patient transmission of bloodborne pathogens.
b. Hepatitis B. Nosocomial transmission of HBV is a serious risk
for health care personnel (44-48). Approximately 1,000 health care
personnel were estimated to have become infected with HBV in 1994. This
is a 90% decline since 1985, attributable to the use of vaccine and
adherence to other preventive measures (e.g., Standard Precautions)
(49). During the past decade, an estimated 100 to 200 health care
personnel have died annually from HBV infection (49). The risk of
acquiring HBV infection from occupational exposure is dependent on the
nature and frequency of exposure to blood or body fluids containing
blood (44, 48). The risk of infection is at least 30% after a
percutaneous exposure to blood from a hepatitis B e antigen-positive
source (49).
HBV is transmitted by percutaneous or mucosal exposure to blood and
serum-derived body fluids from persons who either are have acute or
chronic HBV infection. The incubation period is 45 to 180 days. Any
person with blood positive for hepatitis B surface antigen (HBsAg) is
potentially infectious.
Hepatitis B vaccination of health care personnel who have contact
with blood and body fluids can prevent transmission of HBV and is
strongly recommended (7, 8, 36). The OSHA bloodborne pathogen standard
mandates that hepatitis B vaccine be made available, at the employer's
expense, to all health care personnel with occupational exposure to
blood or other potentially infectious materials (24). Provision of
vaccine during training for health care professions before such blood
exposure occurs may increase the vaccination rates among personnel and
prevent infection among trainees who are at increased risk of
unintentional injuries while learning techniques.
Prevaccination serologic screening for susceptibility to HBV
infection is not indicated for persons being vaccinated, unless the
health care organization considers screening to be cost-effective.
Postvaccination screening for antibody to HBsAg (anti-HBs) is advised
for personnel at ongoing risk of blood exposure, to determine if
response to vaccinations has occurred and to aid in determining the
appropriate postexposure prophylaxis or the need for revaccination.
Personnel who do not respond to or do not complete the primary
vaccination series should be revaccinated with a second three-dose
vaccine series or be evaluated to determine if they are HBsAg positive.
Revaccinated persons should be tested for anti-HBs at the completion of
the second vaccine series (7). If they do not respond, no further
vaccination series should be given and they should be evaluated for the
presence of HBsAg (e.g., possible chronic HBV infection).
Vaccine-induced antibodies decline gradually over time, and up to
60% of those who initially respond to vaccination will lose detectable
anti-HBs over 12 years (50). Booster doses of vaccine are not
recommended because persons who respond to the initial vaccine series
remain protected against clinical hepatitis and chronic infection even
when their anti-HBs levels become low or undetectable (51).
The need for postexposure prophylaxis and/or vaccination depends on
the HBsAg status of the source of the exposure as well as the
immunization status of the person exposed (Table 4) (36). Vaccine
should be offered following any exposure in an unvaccinated person,
and, if the source is known to be HBsAg positive, hepatitis B immune
globulin (HBIG) should be given, preferably within 24 hours. The
effectiveness of HBIG given >7 days after HBV exposure is unknown (6,
8, 36). If the exposed person is known not to have responded to a 3
dose vaccine series, a single dose of HBIG and a dose of hepatitis B
vaccine needs to be given as soon as possible after the exposure. If
the exposed person is known not to have responded to a 3 dose vaccine
series or to revaccination, two doses of HBIG need to be given, one
doses as soon as possible after exposure and the second dose 1 month
later.
c. Hepatitis C. HCV is the etiologic agent in most cases of
parenterally transmitted non-A, non-B hepatitis in the United States
(52,53). During the past decade, the annual number of newly acquired
HCV infections has ranged from an estimated 180,000 in 1984 to an
estimated 28,000 in 1995. Of these, an estimated 2%-4% occurred among
health care personnel who were occupationally exposed to blood (53).
A case-control study of patients with acute non-A, non-B hepatitis,
conducted before the identification of HCV, showed a significant
association between acquiring disease and health care employment,
specifically, patient care or laboratory work (54). Seroprevalence
studies among hospital-based health care personnel have shown anti-HCV
seroprevalence rates of 1% to 2% (55-58). In a study that assessed risk
factors for infection in health care personnel, a history of accidental
needlesticks was independently associated with anti-HCV positivity
(55).
Several case reports have documented transmission of HCV infection
from anti-HCV-positive patients to health care personnel as a result of
accidental needlesticks or cuts with sharp instruments (59, 60). In
follow-up studies of health care personnel who sustained percutaneous
exposures to blood from anti-HCV positive patients, the incidence of
anti-HCV seroconversion averaged 1.8% (range, 0%-7%) (61-64). In a
study in which HCV RNA polymerase chain reaction methods were used to
measure HCV
[[Page 47280]]
infection, the incidence of HCV infection was 10% (64).
The incubation period for hepatitis C is 6-7 weeks, and nearly all
persons with acute infection develop chronic HCV infection with
persistent viremia and have the potential for transmission of HCV to
others.
Serologic assays to detect antibody to HCV (anti-HCV) are
commercially available. The interpretation of anti-HCV test results is
limited by several factors: (a) These assays will not detect anti-HCV
in approximately 5% of persons infected with HCV; (b) these assays do
not distinguish between acute, chronic, or past infection; (c) there
may be a prolonged interval between the onset of acute illness with HCV
and seroconversion; and (d) when the assays are used in populations
with a low prevalence of HCV infection, commercial screening assays for
anti-HCV yield a high proportion (up to 50%) of false-positive results
(30, 53). Although no true confirmatory test has been developed,
supplemental tests for specificity are available and should be used to
judge the validity of repeatedly reactive results by screening assays.
Although the value of immune globulin (IG) for postexposure
prophylaxis after occupational exposure to hepatitis C virus has been
difficult to assess (65-67), postexposure prophylaxis with IG does not
appear to be effective in preventing HCV infection. Current IG
preparations are manufactured from plasma that has been screened for
HCV antibody; positive lots are excluded from use. An experimental
study in chimpanzees found that IG manufactured from anti-HCV-screened
plasma and administered one hour after exposure to HCV did not prevent
infection or disease (68). Thus, available data do not support the use
of IG for postexposure prophylaxis of hepatitis C and its use is not
recommended. There is no information regarding the use of antiviral
agents, such as alpha interferon, in the postexposure setting, and such
prophylaxis is not recommended (33, 69).
Health care institutions should consider implementing recommended
policies and procedures for follow-up for HCV infection after
percutaneous or mucosal exposures to blood (69).
d. Human Immunodeficiency Virus. Nosocomial transmission of HIV
infection from patients to health care personnel may occur following
percutaneous or, infrequently, mucocutaneous, exposure to blood or body
fluids containing blood. Based on prospective studies of health care
personnel percutaneously exposed to HIV-infected blood, the average
risk for HIV infection has been estimated to be 0.3% (70-74). A
retrospective case-control study to identify risk factors for HIV
seroconversion among health care personnel after a percutaneous
exposure to HIV-infected blood found that they were more likely to
become infected if they were exposed to a larger quantity of blood,
represented in the study as presence of visible blood on the device
prior to injury; a procedure that involved a needle placed directly in
the patient's vein or artery; or deep injury. Transmission of HIV
infection also was associated with injuries in which the source patient
was terminally ill with acquired immunodeficiency syndrome (AIDS); this
may be attributable to the increased titer of HIV in blood that is
known to accompany late stages of illness, or possibly other factors,
such as the presence of syncytia-inducing strains of HIV in these
patients. In addition, the findings of this study suggested that the
use of zidovudine postexposure may be protective for health care
personnel (71).
Factors that determine health care personnel's risk of infection
with HIV include the prevalence of infection among patients, the risk
of infection transmission after an exposure, and the frequency and
nature of exposures (75). Most personnel who acquire infection
following percutaneous exposure develop HIV antibody within 6 months of
exposure. HIV-infected persons are likely to transmit virus from the
time of early infection throughout life.
In 1990, CDC published guidelines for postexposure management of
occupational exposure to HIV (29). In 1996, provisional recommendations
for postexposure chemoprophylaxis were published, reflecting current
scientific knowledge on the efficacy of postexposure prophylaxis and
the use of antiretroviral therapies (76). The U.S. Public Health
Service will periodically review scientific information on
antiretroviral therapies and will publish updated recommendations for
their use as postexposure prophylaxis as necessary.
2. Conjunctivitis
Conjunctivitis can be caused by a variety of bacteria and viruses.
However, adenovirus has been the primary cause of nosocomial outbreaks
of conjunctivitis. Nosocomial outbreaks of conjunctivitis caused by
other pathogens are rare.
Adenoviruses, which can cause respiratory, ocular, genitourinary,
and gastrointestinal infections, are a major cause of epidemic
keratoconjunctivitis (EKC) in the community and health care settings.
Nosocomial outbreaks have primarily occurred in eye clinics or offices,
but have also been reported in newborn intensive care units and long
term care facilities (77-81). Patients and health care personnel have
acquired and transmitted EKC during these outbreaks. The incubation
period ranges from 5 to 12 days and shedding of virus occurs from late
in the incubation period up to 14 days after onset of disease (78).
Adenovirus survives for long periods on environmental surfaces;
ophthalmologic instruments and equipment can become contaminated and
transmit infection. Contaminated hands are also a major source of
person-to-person transmission of adenovirus, both from patients to
health care personnel and from health care personnel to patients.
Handwashing, glove use, and disinfection of instruments can prevent the
transmission of adenovirus (77, 78).
Infected personnel should not provide patient care for the duration
of symptoms following onset of EKC (77, 78) or purulent conjunctivitis
caused by other pathogens.
3. Cytomegalovirus
There are two principal reservoirs of cytomegalovirus (CMV) in
health care institutions: (a) Infants and young children infected with
CMV, and (b) immunocompromised patients, such as those undergoing
solid-organ or bone-marrow transplantation or persons with AIDS (82-
88). However, personnel who provide care to such high-risk patients
have a rate of primary CMV infection that is no higher than that among
personnel without such patient contact (3% versus 2%) (89-95). In areas
where there are patient populations with high prevalence of CMV,
seroprevalence studies and epidemiologic investigations have also
demonstrated that personnel who care for patients have no greater risk
of acquiring CMV than do personnel who have no patient contact (87, 89-
92, 94, 96-99). In addition, epidemiologic studies that included DNA
testing of viral strains have demonstrated that personnel who acquired
CMV infection while providing care to CMV-infected infants did not
acquire their infection from the CMV-infected patients (83, 87, 90,
100-102).
CMV transmission appears to occur directly either through close,
intimate contact with an excreter of CMV or through contact with
contaminated secretions or excretions, especially saliva or urine (95,
103-106). Transmission via the hands of personnel or infected person(s)
also has been suggested (87, 107). The incubation period for person-to-
person transmission is not known. Although
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CMV can survive on environmental surfaces and other objects for short
periods of time (108), there is no evidence that the environment plays
a role in the transmission of infection (87).
Because infection with CMV during pregnancy may have adverse
effects on the fetus, protecting women of childbearing age from persons
who are excreting the virus is of primary concern. However, the risk of
occupational transmission to female health care personnel is no greater
than the risk among the general public (89, 96, 109). While a majority
of fetal infections follow primary maternal infection, fetal infection
may follow maternal reinfection or reactivation. Serologic or virologic
screening programs to identify CMV-infected patients or seronegative
female personnel of childbearing age are impractical and costly for the
following reasons: (a) The virus can be intermittently shed (110);
repeated screening tests may be needed to identify shedders; (b)
seropositivity for CMV does not offer complete protection against
maternal reinfection or reactivation and subsequent fetal infection
(109, 111); (c) no currently available vaccines (112-115) or
prophylactic therapy (116-120) can provide protection against primary
infection; and (d) no studies clearly indicate that personnel may be
protected by transfer to areas with less contact with patients likely
to be reservoirs for CMV infection (83, 87, 89-91, 96, 99, 121).
Counseling of female personnel of childbearing age on the risk of
transmission of CMV in both nonoccupational and occupational
environments may help allay their fears (122).
Work restrictions for personnel who contract CMV illnesses are not
necessary; the risk of transmission of CMV can be reduced by careful
adherence to handwashing and Standard Precautions. (1, 109, 123).
4. Diphtheria
Nosocomial transmission of diphtheria among patients and personnel
has been reported (124-126). Diphtheria is currently a rare disease in
the United States; during 1980-1994 only 41 diphtheria cases were
reported (127), however, community outbreaks of diphtheria have
occurred in the past (128), and clusters of infection may occur in
communities where diphtheria was previously endemic (129). In addition
diphtheria epidemics have been occurring since 1990 in the New
Independent States of the former Soviet Union (130-132) and in Thailand
(133). At least 20 imported cases of diphtheria have been reported in
countries in Europe (132, 134) and two cases occurred in U.S. citizens
visiting or working in the Russian Federation and Ukraine (135). Health
care personnel are not at substantially higher risk than the general
adult population for acquiring diphtheria; however, there is the
potential for sporadic or imported cases to require medical care in the
United States.
Diphtheria, caused by Corynebacterium diphtheriae, is transmitted
by contact with respiratory droplets or contact with skin lesions of
infected patients. The incubation period is usually 2-5 days. Patients
with diphtheria are usually infectious for 2 weeks, but
communicability can persist for several months (136). Droplet
precautions are recommended for patients with pharyngeal symptoms, and
contact precautions are recommended for patients with cutaneous
lesions. Precautions need to be maintained until antibiotic therapy is
completed and two cultures taken 24 hours apart are negative
(1).
Limited serosurveys conducted since 1977 in the United States
indicate that 22%-62% of adults 18-39 years of age may lack protective
diphtheria antibody levels (137-141). Prevention of diphtheria is best
accomplished by maintaining high levels of diphtheria immunity among
children and adults (17, 130, 131). Immunization with tetanus and
diphtheria toxoid (Td) is recommended every 10 years for all adults who
have completed the primary immunization series (7, 17) (Table 1).
Health care personnel need to consider obtaining Td immunization from
their health care providers (7).
To determine if health care personnel directly exposed to oral
secretions of patients infected with toxigenic strains of C.
diphtheriae are carriers, cultures of the nasopharynx may be obtained.
Exposed personnel need to be evaluated for evidence of disease daily
for 1 week (142). Although the efficacy of antimicrobial prophylaxis in
preventing secondary disease has not been proven, prophylaxis with
either a single IM injection of benzathine penicillin (1.2 million
units) or oral erythromycin (1 g/day) for 7 days has been recommended
(17). Follow-up nasopharyngeal cultures for C. diphtheriae need to be
obtained after antimicrobial therapy is completed. If the organism has
not been eradicated, a 10-day course of erythromycin needs to be given
(142). In addition, previously immunized, exposed personnel need to
receive a dose of Td if they have not been vaccinated within the
previous 5 years (17).
Exclusion from duty is indicated for personnel with C. diphtheriae
infection or those identified as asymptomatic carriers until
antimicrobial therapy is completed and nasopharyngeal cultures are
negative.
5. Gastrointestinal Infections
Acute gastrointestinal infections may be caused by a variety of
agents, including bacteria, viruses, and protozoa. However, only a few
agents have been documented in nosocomial transmission (Table 5) (143-
161). Nosocomial transmission of agents that cause gastrointestinal
infections usually results from contact with infected individuals (143,
154, 156, 162); from consumption of contaminated food, water, or other
beverages (143, 159, 162); or from exposure to contaminated objects or
environmental surfaces (145, 146, 163). Airborne transmission of small
round-structured viruses (Norwalk-like viruses) has been postulated but
not proven (157, 158, 164-167). Inadequate handwashing by health care
personnel (168) and inadequate sterilization or disinfection of
patient-care equipment and environmental surfaces increase the
likelihood of transmission of agents that cause gastrointestinal
infections. Generally, adherence to good personal hygiene by personnel
before and after all contacts with patients or food and to either
Standard or Contact Precautions (1) will minimize the risk of
transmitting enteric pathogens (160, 169).
Laboratory personnel who handle infectious materials may also be at
risk for occupational acquisition of gastrointestinal infections, most
commonly with Salmonella typhi. Although the incidence of laboratory-
acquired S. typhi infection has decreased substantially since 1955,
infections continue to occur among laboratory workers, particularly
those performing proficiency exercises or research tests (144, 155).
Several typhoid vaccines are available for use in laboratory workers
who regularly work with cultures or clinical materials containing S.
typhi (170). The oral live-attenuated Ty21a vaccine, the IM Vi capsular
polysaccharide (ViCPS) vaccine, or the subcutaneous inactivated vaccine
may be given (170) (Table 1). Booster doses of vaccine are required at
2- to 5-year intervals, depending on the preparation used. The live-
attenuated Ty21a vaccine should not be used for immunocompromised
persons, including those known to be infected with HIV(170).
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Personnel who develop an acute gastrointestinal illness, defined as
vomiting and/or diarrhea (i.e., 3 loose stools in a 24-hour
period) with or without associated symptoms such as fever, nausea, and
abdominal pain, are likely to have high concentrations of the infecting
agent in their feces (bacteria, viruses, and parasites) or vomitus
(viruses and parasites) (158, 171, 172). It is important to determine
the etiology of gastrointestinal illness in health care personnel who
care for patients at high risk for severe disease (e.g., newborns, the
elderly, and immunocompromised patients). The initial evaluation of
personnel with gastroenteritis needs to include a thorough history and
determination of the need for specific laboratory tests such as stool
or blood cultures, staining procedures, and serologic or antigen/
antibody tests (155, 163, 173, 174).
After resolution of some acute bacterial gastrointestinal
illnesses, some personnel may have persistent carriage of the
infectious agent. However, once the person has clinically recovered and
is having formed stools, the risk of transmission of enteric pathogens
is minimal when there is adherence to Standard Precautions (1, 160). In
addition, appropriate antimicrobial therapy may eradicate fecal
carriage of Shigella (175) or Campylobacter (176). However,
antimicrobial or antiparasitic therapy may not eliminate carriage of
Salmonella (177) or Cryptosporidium. Moreover, antimicrobials may
prolong excretion of Salmonella (178) and lead to emergence of
resistant strains (179). However, transmission of Salmonella to
patients from personnel who are asymptomatic carriers of Salmonella has
not been well documented (160). In general, antimicrobial therapy is
not recommended unless the person is at high risk for severe disease
(180). When antibiotics are given, stool cultures should be obtained
48 hours after completion of antibiotic therapy.
Restriction from patient care or food-handling is indicated for
personnel with diarrhea or acute gastrointestinal symptoms, regardless
of the causative agent (1, 163). Some local and state agencies have
regulations that require work exclusion for health care personnel and/
or food handlers who have gastrointestinal infections caused by
Salmonella or Shigella. These regulations may require that such
personnel be restricted from duty until 2 consecutive stool
cultures obtained 24 hours apart are negative.
6. Hepatitis A
Nosocomial hepatitis A occurs infrequently and transmission to
personnel usually occurs when the source patient has unrecognized
hepatitis and is fecally incontinent or has diarrhea (181-190). Other
risk factors for hepatitis A virus (HAV) transmission to personnel
include activities that increase the risk of fecal-oral contamination,
such as (a) eating or drinking in patient-care areas (181, 183, 185,
191); (b) not washing hands after handling an infected infant (183,
191, 192) and (c) sharing food, beverages, or cigarettes with patients,
their families, or other staff (181, 183);.
HAV is transmitted primarily by the fecal-oral route. It has not
been reported to occur after inadvertent needlesticks or other contact
with blood, but has rarely been reported to be transmitted by
transfusion of blood products (185, 193, 194). The incubation period
for HAV is 15-50 days. Fecal excretion of HAV is greatest during the
incubation period of disease before the onset of jaundice (195). Once
disease is clinically obvious, the risk of transmitting infection is
decreased. However, some patients admitted to the hospital with HAV,
particularly immunocompromised patients, may still be shedding virus
because of prolonged or relapsing disease and they are potentially
infective (182, 195). Fecal shedding of HAV, formerly believed to
continue only for up to 2 weeks after onset of dark urine (195), has
been shown to occur for up to 6 months after diagnosis of infection in
premature infants (181). Anicteric infection is typical in young
children and infants (196).
Personnel can protect themselves and others from infection with HAV
by following Standard Precautions (1). Foodborne transmission of
hepatitis A is not discussed in this guideline, but has occurred in
health care settings (197, 198).
Two inactivated hepatitis A vaccines, HAVRIX and
VAQTA, are now available and provide long-term preexposure
protection against clinical infection with >94% efficacy (196).
Serologic surveys among health care personnel have not shown an
elevated prevalence of HAV infection compared with control populations
(47, 184, 199, 200); therefore, routine administration of vaccine in
health care personnel is not recommended. Vaccine may be useful for
personnel working in areas where HAV is highly endemic and is indicated
for personnel who handle HAV infected primates or are exposed to HAV in
a research laboratory. The role of hepatitis A vaccine in controlling
outbreaks has not been adequately investigated (7). Immune globulin
(IG) given within 2 weeks following an HAV exposure is >85% effective
in preventing hepatitis A virus infection (196) and may be advisable in
some outbreak situations (7, 196).
Restriction from patient care or food-handling is indicated for
personnel with HAV infection. They may return to regular duties 1 week
following onset of illness (7).
7. Herpes Simplex
Nosocomial transmission of herpes simplex viruses (HSV) is rare.
Nosocomial transmission has been reported in nurseries (201-203) and
intensive care units (204, 205) where high-risk patients (e.g.,
neonates, patients with severe malnutrition, patients with severe burns
or eczema, and immunocompromised patients) are located. Nosocomial
transmission of HSV occurs primarily through contact with either
primary or recurrent lesions or from virus-containing secretions, such
as saliva, vaginal secretions, or amniotic fluid (202, 204, 206).
Exposed areas of skin are the most likely sites of nosocomial
infection, particularly when minor cuts, abrasions, or other skin
lesions are present (205). The incubation period of HSV is 2-14 days
(207). The duration of viral shedding has not been well defined (208).
Personnel may develop an herpetic infection of the fingers
(herpetic whitlow or paronychia) from exposure to contaminated oral
secretions (205, 206). Such exposures are a distinct hazard for nurses,
anesthesiologists, dentists, respiratory care personnel, and other
personnel who have direct (usually hand) contact with either oral
lesions or respiratory secretions from patients (205). Less frequently,
personnel may develop mucocutaneous infection on other body sites from
contact with infectious body secretions (209).
Personnel with active infection of the hands (herpetic whitlow) can
potentially transmit HSV infection to patients with whom they have
contact (206). Transmission of HSV from personnel with orofacial HSV
infection to patients has also been infrequently documented (201);
however, the magnitude of the risk is unknown (203, 210). Although
asymptomatic infected persons can shed the virus, they are less
infectious than persons with active lesions (208, 211).
Personnel can protect themselves from acquiring HSV by adhering to
Standard Precautions (1). The risk of transmission of HSV from
personnel with orofacial infections to patients can be reduced by
handwashing before all patient care and by the use of appropriate
barriers, such as a mask or
[[Page 47283]]
gauze dressing, to prevent hand contact with the lesion.
Because personnel with orofacial lesions may touch their lesions
and potentially transmit infections, excluding them from the care of
patients at high risk for serious disease (e.g., neonates, patients
with severe malnutrition, patients with severe burns or eczema, and
immunocompromised patients) should be considered. Personnel with HSV
infections of the fingers or hands can more easily transmit infection
and, therefore, need to be excluded from patient care until their
lesions have crusted. In addition, herpetic lesions may be secondarily
infected by Staphylococcus and Streptococcus and personnel with such
infections should be evaluated to determine if they need to be excluded
from patient contact until the secondary infection has resolved. There
have been no reports that personnel with genital HSV infections have
transmitted HSV to patients; therefore, work restrictions for personnel
with genital herpes are not indicated.
8. Measles
Nosocomial transmission of measles virus (sporadic and epidemic)
has been well described (212-221). From 1985 through 1991,
approximately 3,000 (4%) of all reported episodes of measles in the
United States were probably acquired in a medical facility; of these,
>700 (25%) occurred in health care personnel, many of whom were not
vaccinated (7). Data have suggested that health care personnel have a
13-fold greater risk of measles compared with the general population
(7). Of the 2,765 episodes of measles reported during 1992-95, 385
(13.9%) occurred in health care settings (213, 222).
Measles is transmitted both by large droplets during close contact
between infected and susceptible persons and by the airborne route
(221, 223). Measles is highly transmissible and frequently misdiagnosed
during the prodromal stage. The incubation period for measles is 5-21
days. Immunocompetent persons with measles shed the virus from the
nasopharynx, beginning with the prodrome until 3-4 days after rash
onset; immunocompromised persons with measles may shed virus for
extended periods of time (224).
Strategies to prevent nosocomial transmission of measles include
(a) documentation of measles immunity in health care personnel; (b)
prompt identification and isolation of persons with fever and rash; (c)
adherence to airborne precautions for suspected and proven cases of
measles (1); and (d) vaccination of patients in medical settings,
especially emergency rooms.
It is essential that all personnel have documentation of measles
immunity regardless of their length of employment or whether they are
involved in patient care. Furthermore, some states have regulations
requiring measles immunity for health care personnel. Although persons
born before 1957 are generally considered to be immune to measles,
serologic studies indicate that 5%-9% of health care personnel born
before 1957 may not be immune (225, 226). Furthermore, during 1985-
1989, 29% of all measles cases in U.S. health care personnel occurred
in those born before 1957 (213). Consideration should be given to
recommending a dose of measles-mumps-rubella trivalent vaccine (MMR) to
personnel born before 1957 who are unvaccinated and who lack (a) a
history of prior measles disease; (b) documentation of receipt of one
dose of live measles vaccine; or (c) serologic evidence of measles
immunity (7). Health care personnel born during or after 1957 should be
considered immune to measles when they have (a) documentation of
physician-diagnosed measles; (b) documentation of two doses of live
measles vaccine on or after their first birthday; or (c) serologic
evidence of measles immunity (persons with an ``indeterminate'' level
of immunity upon testing should be considered susceptible). Persons
born between 1957 and 1984 who received childhood measles immunization
were given only one dose of vaccine in their infancy and may require a
second dose of vaccine (6).
Serologic screening for measles immunity is not necessary prior to
administering measles vaccine unless the medical facility considers it
cost-effective or the person to be vaccinated requests it (227-229).
When serologic screening before vaccination is done, tracking systems
are needed to ensure that those identified as susceptibles are
subsequently vaccinated in a timely manner (229). During measles
outbreaks, serologic screening before vaccination is not necessary. In
outbreak situations, prompt administration of vaccine is necessary to
halt disease transmission.
Work restrictions are necessary for personnel who develop measles;
they need to be excluded from duty for 4 days after the rash appears.
Likewise, personnel nonimmune to measles need to be excluded from duty
for 5 days after the first exposure to 21 days following the last
exposure to measles.
9. Meningococcal Disease
Community-acquired meningococcal disease typically is caused by a
variety of serogroups of Neisseria meningitidis; Serogroups B and C
cause 46% and 45% of the endemic cases, respectively. Serogroups A, Y,
and W-135 account for nearly all the remaining endemic cases (13). In
contrast, epidemic meningococcal disease has, since the early 1990s,
been caused increasingly by Serogroup C (13, 230, 231).
Nosocomial transmission of N. meningitidis is uncommon. In rare
instances, when proper precautions were not used, N. meningitidis has
been transmitted from patient to personnel, through contact with the
respiratory secretions of patients with meningococcemia or
meningococcal meningitis (1, 232-234) or through handling laboratory
specimens (235). Lower respiratory infections caused by N. meningitidis
may present a greater risk of transmission than either meningococcemia
or meningitis (234, 236), especially if the patient has an active,
productive cough (236). The risk of personnel acquiring meningococcal
disease from casual contact (e.g., cleaning rooms or delivering food
trays) appears to be negligible (236).
N. meningitidis infection is likely transmitted by large droplets;
the incubation period is from 2-10 days and patients infected with N.
meningitidis are rendered noninfectious by 24 hours of effective
therapy. Personnel who care for patients with suspected N. meningitidis
infection can decrease their risk of infection by adhering to Droplet
Precautions (1).
Postexposure prophylaxis is advised for persons who have had
intensive, unprotected contact (i.e., without wearing a mask) with
infected patients (e.g., intubating, resuscitating, or closely
examining the oropharynx of patients) (13). Antimicrobial prophylaxis
can eradicate carriage of N. meningitidis and prevent infections in
personnel who have unprotected exposure to patients with meningococcal
infections (237,238).
Because secondary cases of N. meninigitidis occur rapidly (within
the first week) following exposure to persons with meningococcal
disease (239), it is important to begin prophylactic therapy
immediately after an intensive, unprotected exposure, often before
results of antimicrobial testing are available. Prophylaxis
administered >14 days after exposure is probably of limited or no value
(13). Rifampin (600 mg orally every 12 hours for 2 days) is effective
in eradicating nasopharyngeal carriage of N.
[[Page 47284]]
meningitidis (237). Ciprofloxacin ( 500 mg orally) and ceftriaxone (250
mg IM) in single-dose regimens are also effective in reducing
nasopharyngeal carriage of N. meningitidis and are reasonable
alternatives to the multidose rifampin regimen (13, 238). These
antimicrobials may be useful in situations where infections are caused
by rifampin-resistant meningococci or when rifampin is contraindicated.
Rifampin and ciprofloxacin are not recommended for pregnant women (13,
240, 241).
The quadrivalent A,C,Y,W-135 polysaccharide vaccine has been used
successfully to control community outbreaks caused by Serogroup C (13,
230, 231, 240), but its use is not recommended for postexposure
prophylaxis in health care settings (13). However, preexposure
vaccination may be considered for laboratory personnel who routinely
handle soluble preparations of N. meningitidis (13, 235).
In the absence of exposures to patients with N. meningitidis
infection, personnel who are asymptomatic carriers need not be
identified, treated, or removed from patient-care activities. Healthy
persons may have nasopharyngeal carriage of N. meningitidis (237, 242-
244). Nosocomial transmission from carriers to personnel has not been
reported.
10. Mumps
Mumps transmission has occurred in hospitals and long-term-care
facilities housing adolescents and young adults (245, 246). Most cases
of mumps in health care personnel have been community acquired.
Mumps is transmitted by contact with virus-containing respiratory
secretions, including saliva; the portals of entry are the nose and
mouth. The incubation period varies from 12 to 25 days and is usually
16-18 days. The virus may be present in saliva for 6-7 days before
parotitis and may persist for up to 9 days after onset of disease.
Exposed personnel may be infectious for 12-25 days after their exposure
and many infected persons remain asymptomatic (247). Droplet
precautions are recommended for patients with mumps; such precautions
should be continued for 9 days after the onset of parotitis (1).
An effective vaccination program is the best approach to preventing
nosocomial mumps transmission (10). Vaccination with mumps virus
vaccine is recommended, unless otherwise contraindicated, for all those
who are susceptible to mumps (10, 248); combined MMR vaccine is the
vaccine of choice (249), especially when the recipient also is likely
to be susceptible to measles, rubella, or both.
Personnel should be considered immune to mumps if they have: (a)
Documentation of physician-diagnosed mumps; (b) documentation of
receipt of one dose of live mumps vaccine on or after their first
birthday; or (c) serologic evidence of immunity (individuals who have
an ``indeterminate'' antibody level should be considered susceptible)
(10). Most persons born before 1957 are likely to have been infected
naturally and may be considered to be immune, even if they may not have
had clinically recognized mumps. Outbreaks among highly vaccinated
populations have occurred and have been attributed to primary vaccine
failure (250).
Work restrictions are necessary for personnel who develop mumps;
such restrictions should be imposed for 9 days after the onset of
parotitis. Likewise, susceptible personnel who are exposed to mumps
need to be excluded from duty from the 12th day after the first
exposure until the 26th day after the last exposure.
11. Parvovirus
Human parvovirus B19 (B19) is the cause of erythema infectiosum
(fifth disease), a common rash illness that is usually acquired in
childhood. Immunocompetent persons infected with B19 may develop an
acute, self-limited arthropathy with or without a rash or anemia of
short duration. However, patients with preexisting anemia (e.g.,
patients with sickle cell anemia or thalassemia) may develop aplastic
crisis. Immunodeficient patients (e.g., patients with leukemia or AIDS)
may become chronically infected with B19 and develop chronic anemia
(251, 252).
Transmission of B19 to health care personnel from infected patients
appears to be rare. In two investigations of health care personnel
exposures to B19, the rate of infection among exposed nurses was not
higher than the rate among unexposed controls (253, 254). In another
investigation of health care personnel exposed to an undetected patient
with chronic B19 infection, none of the susceptible employees became
infected (255). Personnel have acquired infection while working in
laboratories or during the care of patients with B19-associated sickle
cell aplastic crises (256-261).
B19 may be transmitted via contact with infected persons, fomites,
or large droplets (253, 262, 263). The incubation period is variable,
depending on the clinical manifestation of disease, and ranges from 6-
10 days (252). The period of infectivity also varies depending on the
clinical presentation or stage of disease. Persons with erythema
infectiosum are infectious before the appearance of the rash; those
with infection and aplastic crises, up to 7 days after onset of
illness; and persons with chronic infection, for years.
Pregnant personnel are at no greater risk of acquiring B19
infection than are nonpregnant personnel; however, if a pregnant woman
does acquire B19 infection during the first half of pregnancy, the risk
of fetal death (fetal hydrops, spontaneous abortion, and stillbirth) is
increased (264, 265). Because of the seriousness of consequences for
the fetus, female personnel of childbearing age need to be counseled
regarding the risk of transmission of B19 and appropriate infection
control precautions (1).
Isolation precautions are not indicated for most patients with
erythema infectiousum because they are past their period of
infectiousness at the time of clinical illness (259, 264). However,
patients in aplastic crisis due to B19 or patients with chronic B19
infection may transmit the virus to susceptible health care personnel
or other patients; therefore, patients with preexisting anemia who are
admitted to the hospital with febrile illness and transient aplastic
crises should remain on Droplet Precautions for 7 days and patients
known or suspected to be chronically infected with B19 should be placed
on Droplet Precautions on admission and for the duration of
hospitalization (1, 256). Work restrictions are not necessary for
personnel exposed to B19.
12. Pertussis
Nosocomial transmission of Bordetella pertussis has involved both
patients and personnel; unimmunized children are at greatest risk (266-
270). Serologic studies of health care personnel indicate that
personnel may be exposed to and infected with pertussis much more
frequently than indicated by the occurrence of recognized clinical
illness (267, 269, 271, 272). In one such study, the level of pertussis
agglutination antibodies was found to correlate with the degree of
patient contact; the prevalence of such antibody was highest in
pediatric housestaff (82%) and ward nurses (71%) and lowest in nurses
with administrative responsibilities (35%) (267).
Pertussis is highly contagious: Secondary attack rates exceed 80%
in susceptible household contacts (273-275). B. pertussis transmission
occurs by contact with respiratory secretions or large aerosol droplets
from the
[[Page 47285]]
respiratory tract of infected persons. The incubation period is usually
7-10 days. The period of communicability starts at the onset of the
catarrhal stage and extends into the paroxysmal stage. Preventing
secondary transmission of pertussis is especially difficult during the
early stages of the disease because pertussis is highly communicable in
the catarrhal stage when the symptoms are nonspecific and the diagnosis
is uncertain.
During nosocomial pertussis outbreaks, the risk of acquiring
infection among patients or personnel is often difficult to quantify
because exposure is not easily determined. Furthermore, clinical
symptoms in adults are less severe than in children and may not be
recognized as pertussis. Pertussis should be considered for any person
presenting with an acute cough lasting 7 days, particularly
if accompanied by paroxysms of coughing, inspiratory whoop, or post-
tussive vomiting (270, 271).
Prevention of transmission of B. pertussis in health care settings
involves (a) early diagnosis and treatment of patients with clinical
infection; (b) implementation of Droplet Precautions for infectious
patients (1); (c) exclusion of infectious personnel from work; and (d)
administration of postexposure prophylaxis to persons exposed to
infectious patients (269). Patients with suspected or confirmed
pertussis who are admitted to the hospital need to be placed on Droplet
Precautions until they improve clinically and have received
antimicrobial therapy for at least 5 days.
Vaccination of adolescents and adults with whole-cell B. pertussis
vaccine is not recommended (17) because local and systemic reactions
have been observed more frequently in these groups than in children.
Acellular pertussis vaccine is immunogenic in adults and has a lower
risk of adverse events than does whole-cell vaccine (270, 276).
However, the acellular vaccine has not been licensed for use in persons
7 years old. Because immunity among vaccine recipients wanes
5-10 years after the last vaccine dose (usually given at 4-6 years of
age), personnel may play an important role in transmitting pertussis to
susceptible infants. However, additional studies are needed to assess
whether booster doses of acellular vaccines are indicated for adults.
Postexposure prophylaxis is indicated for personnel exposed to
pertussis; a 14 -day course of either erythromycin (500 mg qid po) or
trimethoprim-sulfamethoxazole (1 tablet bid) has been used for this
purpose. The efficacy of such prophylaxis has not been well documented,
but studies suggest that it may minimize transmission (17, 269, 277,
278). There are no data on the efficacy of newer macrolides
(clarithomycin or azithromycin) for prophylaxis of persons exposed to
pertussis.
Restriction from duty is indicated for personnel with pertussis,
from the beginning of the catarrhal stage through the third week after
onset of paroxysms or until 5 days after the start of effective
antimicrobial therapy. Exposed personnel do not need to be excluded
from duty.
13. Poliomyelitis
The last case of indigenously acquired wild-virus poliomyelitis
occurred in the United States in 1979. Since then, all of the cases of
endemic poliomyelitis reported in the United States (5-10 endemic
cases/year) have been related to the administration of oral polio
vaccine (OPV) (19). Although, the risk of transmission of poliovirus in
the United States is very low, wild poliovirus may potentially be
introduced into susceptible populations with low immunization levels.
Poliovirus is transmitted through contact with feces or urine of
infected persons, but can be spread by contact with respiratory
secretions and, in rare instances, through items contaminated with
feces. The incubation period for nonparalytic poliomyelitis is 3 to 6
days, and usually 7 to 21 days for paralytic polio (279).
Communicability is greatest immediately before and after the onset of
symptoms, when the virus is in the throat and excreted in high
concentration in feces. The virus can be recovered from the throat for
1 week and from feces for several weeks to months following onset of
symptoms.
Vaccine-associated poliomyelitis may occur in the recipient (7-21
days after vaccine administration) or susceptible contacts of the
vaccine recipient (20-29 days after vaccine administration) (280).
Adults have a slightly increased risk of vaccine-associated paralytic
polio after receipt of OPV; therefore, inactivated poliovirus vaccine
(IPV) should be used when adult immunization is warranted (6, 14, 19).
Also, because immunocompromised persons may be at greater risk for
developing polio after exposure to vaccine virus, IPV, rather than OPV,
is recommended when vaccinating pregnant or immunocompromised personnel
or personnel who may have contact with immunocompromised patients (6,
14, 19, 279).
Health care personnel who may have contact with patients excreting
wild virus (e.g., imported poliomyelitis case) and laboratory personnel
handling specimens containing poliovirus should receive a complete
series of polio vaccine, or if previously vaccinated, they may require
a booster dose of either IPV or OPV (6, 19). For situations where
immediate protection is necessary (e.g., an imported case of wild-virus
poliomyelitis requiring care), additional doses of OPV should be given
to adults if they have previously completed a polio vaccine series
(19).
14. Rabies
Human rabies cases occur primarily from exposure to rabid animals.
Cases of human rabies have increased in the United States during the
1990s (281). Laboratory and animal care personnel who are exposed to
infected animals, their tissues and excretions are at risk for the
disease. Also, rabies transmission to laboratory personnel has been
reported in vaccine production and research facilities following
exposure to high-titered infectious aerosols (282, 283). Theoretically,
rabies may be transmitted to health care personnel from exposures (bite
and non-bite) to saliva from infected patients, but no cases have been
documented following these types of exposures (284).
It is also possible that rabies can be transmitted when other
potentially infectious material (such as brain tissue) comes in contact
with nonintact skin or mucous membranes. Bites that penetrate the skin,
especially bites to the face and hands, pose the greatest risk of
transmission of rabies virus from animals to humans (20). The
incubation period for rabies is usually 1 to 3 months but longer
periods have been reported (285).
Exposures to rabies can be minimized by adhering to Standard
Precautions when caring for persons with suspected or confirmed rabies
(1) and by using proper biosafety precautions in laboratories (3).
Preexposure vaccination has been recommended for all personnel who (a)
work with rabies virus or infected animals; or (b) engage in
diagnostic, production, or research activities with rabies virus (3,
20). Consideration also may be given to providing preexposure
vaccination to animal handlers when research animals are obtained from
the wild, rather than from a known supplier who breeds the animals.
Postexposure prophylaxis has been administered to health care
personnel following exposures to patients with rabies (285-287) (Table
1) but decisions regarding postexposure prophylaxis should be made on a
case-by-case basis
[[Page 47286]]
after discussion with public health authorities (20).
15. Rubella
Nosocomial transmission of rubella has occurred from both male and
female personnel to other susceptible personnel and patients as well as
from patients to susceptible personnel and other patients (288-295).
Rubella is transmitted by contact with nasopharyngeal droplets from
infected persons. The incubation period is variable but may range from
12 to 23 days; most persons develop the rash 14-16 days after exposure.
The disease is most contagious when the rash is erupting, but virus may
be shed from 1 week before to 5-7 days after the onset of the rash
(296). Rubella in adults is usually a mild disease, lasting only a few
days; 30% to 50% of cases may be subclinical or inapparent.
Droplet Precautions are used to prevent transmission of rubella.
Infants with congenital rubella may excrete virus for months to years;
therefore, when caring for such patients it is advisable to use Contact
Precautions for the first year of life, unless nasopharyngeal and urine
cultures are negative for rubella virus after 3 months of age (1).
Ensuring immunity among all health care personnel (male and female)
is the most effective way to eliminate nosocomial transmission of
rubella (6, 7, 12, 248, 297). Persons should be considered susceptible
to rubella if they lack (a) documentation of one dose of live rubella
vaccine on or after their first birthday; or (b) laboratory evidence of
immunity (persons with indeterminate levels are considered
susceptible). A history of past rubella infection is unreliable and
should not be considered indicative of immunity to rubella. Although
birth before 1957 is generally considered acceptable evidence of
rubella immunity, a dose of MMR has been recommended for those health
care personnel that do not have laboratory evidence of immunity (7). In
addition, birth before 1957 is not considered acceptible evidence of
rubella immunity for women of childbearing age (7). Voluntary
immunization programs are usually inadequate to ensure personnel
protection (298, 299). Because many health departments mandate rubella
immunity for health care personnel, personnel health programs should
consult with their local or state health departments before
establishing policies for their facilities.
Serologic screening of personnel for immunity to rubella need not
be done before vaccinating against rubella unless the medical facility
considers it cost-effective or the person getting vaccinated requests
it (227-229). When serologic screening before vaccination is done,
tracking systems are needed to ensure that those identified as
susceptible are subsequently vaccinated in a timely manner (229).
Likewise, during rubella outbreaks, serologic screening is not
necessary. The ACIP states that rubella vaccination is contraindicated
among pregnant women, but administering rubella vaccine to women not
known to be pregnant is justifiable without prevaccination screening
(12); pregnant women who are already immune to rubella are not at
increased risk for adverse advents (300). MMR trivalent vaccine is the
vaccine of choice for rubella, especially when the recipient also is
likely to be susceptible to measles and/or mumps (Table 2).
Work restrictions are necessary for personnel who develop rubella;
ill personnel need to be excluded from duty for 5 days after the rash
appears. Likewise, personnel susceptible to rubella require exclusion
from duty from the 7th day after the first exposure through the 21st
day after the last exposure (Table 3).
16. Scabies and Pediculosis
a. Scabies. Scabies is caused by infestation with the mite
Sarcoptes scabiei. The conventional (typical) clinical presentation of
scabies includes intense pruritus and cutaneous tracks, where mites
have burrowed into the skin. Crusted or ``Norwegian'' scabies may
develop among immunocompromised and elderly individuals because their
skin may become hyperkeratotic, and pruritus may not be present, which
also makes diagnosis difficult. In conventional scabies 10-15 mites are
present, while in crusted scabies thousands of mites are harbored in
the skin, increasing the potential for transmission (301, 302).
Nosocomial outbreaks of scabies have occurred in a variety of
health care settings including intensive care units (303),
rehabilitation centers (304), long-term care facilities (305-307),
hospital wards (308, 309), and a health care laundry (310). In recent
years there has been an increase in the occurrence of crusted scabies
among immunocompromised patients, particularly persons with HIV, which
has led to the transmission of scabies among personnel, patients and
their families (303, 304, 306-308, 310-315).
Nosocomial transmission of scabies occurs primarily through skin-
to-skin contact with an infested person (301, 316, 317). Personnel have
acquired scabies while performing patient-care duties such as sponge-
bathing, lifting, or applying body lotions (301, 302, 312, 318).
Transmission by casual contact, such as by holding hands, or via
innaminate objects, such as infested bedding, clothes, or other
fomites, has been reported infrequently (310, 319, 320).
The use of Contact Precautions when taking care of infested
patients prior to application of scabicides can decrease the risk of
transmission to personnel (1, 302). Routine cleaning of the environment
of patients with typical scabies, especially bed linens and upholstered
furniture, will aid in eliminating the mites. Additional environmental
cleaning procedures may be warranted for crusted scabies (301, 302,
321, 322).
Recommendations for treatment and control of scabies in health care
institutions have been published previously (301, 302, 321-325). The
recommended topical scabicides include permethrin cream (5%),
crotamiton (10%), or lindane (1%) lotion; resistance to lindane has
been reported (321, 324). Single-dose oral ivermectin has recently been
shown to be an effective therapy for scabies (313, 325, 326), but has
not received Federal Drug Administration approval for this purpose.
Most infested health care workers have typical scabies with low
mite loads (311, 327); a single correct application of a scabicide is
adequate and immediately decreases the risk of transmission (316-318,
328-331). If personnel remain symptomatic after initial treatment, a
repeat application of scabicide may be needed in 7-10 days. Persistent
symptoms likely represent newly hatched mites rather than new
infestation. Patients with crusted scabies may require repeated
treatments and should be observed for recurrence of the mite
infestation (301, 302, 306, 321). Personnel who are exposed to scabies,
but lack signs of infestation, do not require prophylactic treatment
with scabicides.
Restrictions from patient care are indicated for personnel infested
with scabies until after they receive initial treatment. They should be
advised to report for further evaluation if symptoms do not subside.
b. Pediculosis. Pediculosis infestation is caused by three species
of lice: Pediculus humanus capitus (human head louse), Pediculus
humanus corporis (human body louse), or Phthirus pubis (pubic or crab
louse).
Head lice are transmitted by head-to-head contact or by contact
with infested fomites such as hats, combs, or brushes.
[[Page 47287]]
Nosocomial transmission, while not common, has occurred (301).
Body lice are usually associated with poor hygiene and overcrowded
conditions. Transmission occurs by contact with the skin or clothing of
an infested person. Nosocomial transmission is unlikely.
Pubic lice are primarily found in the pubic hair but can be found
in the axilla, eyelashes or eyebrows. Transmission occurs primarily
through intimate physical or sexual contact. Transmission by fomites,
such as toilet seats or bedding, is uncommon. Nosocomial transmission
is very unlikely.
Recommendations for control of pediculosis have been published
previously (301, 322, 332). The drugs recommended for treatment include
permethrin cream 1%, pyrethrins with piperonyl butoxide, malathion
0.5%, or lindane 1% (323-325, 332). Health care personnel exposed to
patients with pediculosis do not require treatment unless they show
evidence of infestation.
Restriction from patient care is indicated for personnel infested
with pediculosis until after they receive initial treatment. If
symptoms do not subside following initial treatment, they should be
advised to report for further evaluation.
17. Staphylococcus aureus Infection and Carriage
Staphylococcal carriage and infection occur frequently in humans.
In hospitals the most important sources of S. aureus are infected and
colonized patients. Previously, methicillin-susceptible (but
penicillin-resistant) S. aureus (MSSA) accounted for most
staphylococcal infections. However, in recent years, methicillin-
resistant S. aureus (MRSA) has accounted for approximately 80% of all
S. aureus isolates reported to the National Nosocomial Surveillance
System (333-335). The epidemiology of MRSA does not appear to differ
from that of MSSA, except that outbreaks of MRSA tend to occur more
frequently among elderly or immunocompromised patients or among
patients with severe underlying conditions (333, 336).
Nosocomial transmission of S. aureus occurs primarily via the hands
of personnel, which can become contaminated by contact with the
colonized or infected body sites of patients (333, 337). Hospital
personnel who are infected or colonized with S. aureus also can serve
as reservoirs and disseminators of S. aureus (338-341) and infected
dietary personnel have been implicated in staphylococcal food poisoning
(342). The role of contaminated environmental surfaces in transmission
of S. aureus remains controversial, although heavy contamination of
fomites may facilitate transmission to patients via personnel hands
(333).
The incubation period for S. aureus infections varies by type of
disease: foodborne illness is 30 minutes to 6 hours; bullous impetigo
is 1-10 days; toxic-shock syndrome is usually 2 days; and other types
of infections it is variable (343).
Carriage of S. aureus is most common in the anterior nares, but
other sites, such as the hands, axilla, perineum, nasopharynx and
oropharynx may also be involved (333). The frequency of nasal carriage
of S. aureus among health care personnel ranges between 20% and 90%,
but fewer than 10% of healthy nasal carriers disperse the organisms
into the air (339). Nasal carriers with upper respiratory symptoms can
disseminate the organism more effectively (339). Carriage of S. aureus
in the nares has been shown to correspond to hand carriage (334) and
persons with skin lesions caused by S. aureus are more likely than
asymptomatic nasal carriers to disseminate the organism.
Culture surveys of personnel can detect carriers of S. aureus but
do not indicate which carriers are likely to disseminate organisms.
Thus, such surveys are not cost-effective and may subject personnel
with positive cultures to unnecessary treatment and removal from duty.
A more reasonable approach is to conduct active surveillance for
nosocomial S. aureus infections. Culture surveys may be indicated if,
after a thorough epidemiologic investigation, personnel are linked to
infections. Such implicated personnel can then be removed from clinical
duties until carriage is eradicated (333, 338, 344-346).
Several antimicrobial regimens have been used successfully to
eradicate staphylococcal carriage in health care personnel. These
regimens include orally administered antimicrobial agents (e.g.,
rifampin, clindamycin, or ciprofloxacin) alone or in combination with
another oral (e.g., trimethoprim sulfamethoxazole) or topical
(mupirocin) antimicrobial (345, 347-358). Resistant S. aureus strains
have emerged following the use of the above oral or topical
antimicrobial agents for eradication of S. aureus colonization (16,
202, 345, 349, 359-361). Thus, antimicrobial treatment to eradicate
carriage may be best if limited to personnel carriers who are
epidemiologically linked to disease transmission. Nosocomial
transmission of S. aureus can be prevented by adherence to Standard
Precautions and other forms of transmission based precautions, as
needed (1).
Restriction from patient-care activities or food-handling is
indicated for personnel who have draining skin lesions that are
infected with S. aureus until they have received appropriate therapy
and the infection has resolved. No work restrictions are necessary for
personnel who are colonized with S. aureus, unless they have been
epidemiologically implicated in S. aureus transmission within the
facility.
18. Streptococcus, Group A
Group A Streptococcus (GAS) has been transmitted from infected
patients to health care personnel following contact with infected
secretions (362-364), and the infected personnel have subsequently
developed a variety of GAS-related illnesses (e.g., toxic-shock-like
syndrome, cellulitis, lymphangitis, and pharyngitis). Health care
personnel who were GAS carriers have infrequently been linked to
sporadic outbreaks of surgical site, postpartum or burn wound
infections (365-371) and foodborne transmission of GAS causing
pharyngitis (372). In these outbreaks GAS carriage was documented in
the pharynx (364, 367, 373), the skin (364, 365), the rectum (364,
370), and the female genital tract of the infected personnel (364, 369,
374).
The incubation period for GAS pharyngitis is 2-5 days, and is 7-10
days for impetigo. The incubation period is variable for other GAS
infections (375).
Culture surveys to detect GAS carriage among personnel are not
warranted unless personnel are epidemiologically linked to cases of
nosocomial infection (373). In instances where thorough epidemiologic
investigation has implicated personnel in nosocomial transmission,
cultures may be obtained from skin lesions, the pharynx, rectum, and
vagina; GAS isolates obtained from personnel and patients can be
serotyped to determine strain relatedness (368). Treatment of personnel
carriers needs to be individualized because (a) experience is limited
regarding the treatment of personnel carriers implicated in GAS
outbreaks; and (b) carriage of the organism by personnel may be
recurrent over long periods of time (364-366, 369). Contact is the
major mode of transmission of GAS in these health care settings.
Airborne transmission during outbreaks has been suggested by several
investigators, and some have demonstrated that exercising and changing
of clothing can lead to airborne dissemination of GAS from
[[Page 47288]]
rectal and vaginal carriage (364, 369, 370, 374). Nosocomial
transmission of GAS to personnel can be prevented by adherence to
Standard Precautions or other transmission-based precautions as needed
(1).
Restriction from patient-care activities and food-handling is
indicated for personnel with GAS infections until 24 hours after they
have received appropriate therapy. However, no work restrictions are
necessary for personnel who are colonized with GAS, unless they have
been epidemiologically linked to transmission of infection within the
facility.
19. Tuberculosis
Nosocomial transmission of tuberculosis (TB) is well documented,
but such transmission in the United States is generally low. However,
the risk may be increased in health care facilities located in
communities with (a) high rates of HIV; (b) high numbers of persons
from TB-endemic countries; and (c) communities with a high prevalence
of TB infection (376, 377). In some areas in the USA, the incidence and
prevalence of multidrug-resistant Mycobacterium tuberculosis (MDR-TB)
also have increased, and nosocomial MDR-TB outbreaks have occurred
(378-384). The increased risk of occupational acquisition of TB by
health care personnel has been reported for decades and it dramatically
decreased following the introduction of effective antituberculous drugs
(385, 386). Skin-test conversion rates among health care personnel
following routine skin testing have ranged from 0.11 % to 10%. Among
health care personnel with known exposure to an infectious TB patient
or involved in prolonged nosocomial outbreaks of TB, the skin-test
conversion rates have ranged from 18% to 55% (378-380, 383, 384, 386-
393).
The transmission of TB in health care facilities has been primarily
caused by incomplete implementation of recommended TB infection control
measures (388). In 1994, CDC published detailed recommendations for the
prevention of transmission of TB in health care settings, Guidelines
for Preventing the Transmission of Mycobacterium tuberculosis in Health
Care Facilities, 1994 (377). A summary of the recommendations
pertaining to personnel health follow.
a. Strategies for prevention of transmission of TB. The risk of
transmission of TB to or from personnel in a health care facility
varies according to the type and size of the facility, the prevalence
of TB in the community, the patient population served by the facility,
the occupational group the person represents, the area of the facility
where the person works, and the effectiveness of the facility's TB-
control program. A detailed risk assessment is essential in identifying
the nature of TB control measures that are appropriate for a particular
facility as well as for specific areas and occupational groups within a
facility (377, 394). A risk assessment should include the following:
(a) Review of the community TB profile; (b) review of the number of TB
patients who were treated in each area of the facility; (c) review of
the drug-susceptibility patterns of TB isolates from patients treated
in the facility; (d) an analysis of purified protein derivative (PPD)
skin-test results of health care personnel by work area or occupational
group; (e) an evaluation of infection control parameters including
isolation policies, laboratory diagnostic capabilities, and
antitubercular therapy regimens; (f) an observational review of TB
infection control practices; and (g) evaluation of the function and
maintenance of environmental controls (377).
Transmission of TB can be minimized by developing and implementing
an effective TB-control program based on a hierarchy of controls,
namely, (a) administrative controls, (b) engineering controls, and (c)
personal respiratory protection (377, 379, 381, 386, 388, 394, 395).
b. TB screening program. A tuberculosis screening program for
personnel is an integral part of a health care facility's comprehensive
TB control program. The screening program should be based on the
facility specific risk assessment.
Baseline PPD testing of all personnel [including personnel with a
history of Bacille Calmette-Guerin vaccination (BCG)] during their pre-
employment physical examination or when applying for hospital
privileges will identify personnel who have been previously infected.
For the baseline testing a two-step procedure can be used to minimize
the likelihood of confusing reactivity from an old infection (boosting)
with reactivity from a recent infection (conversion). Criteria used for
interpretation of a PPD test reaction may vary depending on the (a)
purpose (diagnostic or epidemiologic) of the test; (b) prevalence of TB
infection in the population being tested; (c) immune status of the
host; and (d) previous receipt of TB immunization. Detailed
recommendations have been published for performing and interpreting
skin tests (377, 396, 397).
c. Follow-up evaluation. The risk assessment will identify which
health care personnel have the potential for exposure to M.
tuberculosis and determine how frequently they should receive PPD
testing. At minimum, annual PPD testing is indicated for personnel with
the potential for exposure to TB.
It is also important to obtain an initial chest x-ray on personnel
with positive PPD-test reactions, documented PPD-test conversions, or
pulmonary symptoms suggestive of TB. There are no data to support the
use of routine chest x-ray examinations on asymptomatic PPD test-
negative personnel. In addition, personnel who have positive PPD-test
reactions but also received adequate preventive treatment do not need
repeat chest films unless they have pulmonary symptoms suggestive of
TB. Repeat chest x-ray examinations of such persons have not been shown
to be beneficial or cost-effective in monitoring persons for
development of disease. However, more frequent monitoring for symptoms
of TB may be considered for personnel who convert their PPD test; those
persons, if infected, are at increased risk of developing active TB
(e.g., HIV-infected or otherwise severely immunocompromised persons).
d. Management of personnel after exposure to TB. It is important to
perform PPD tests on personnel as soon as possible after TB exposures
are recognized. Such immediate PPD testing establishes a baseline by
which to monitor subsequent PPD tests. A PPD test, performed 12 weeks
after the last exposure, will indicate if infection has occurred.
Persons already known to have reactive PPD tests need not be retested.
Personnel with evidence of new infection (i.e., PPD-test conversions)
need to be evaluated for active TB. If active TB is not diagnosed,
preventive therapy should be considered (377).
e. Preventive therapy. For workers with positive PPD tests who were
likely exposed to drug-susceptible TB, preventive therapy with
isoniazid is indicated, unless there are contraindications to such
therapy (377, 397). Alternative preventive regimens have been proposed
for persons who have positive PPD tests following exposure to drug-
resistant TB (398).
f. Work restrictions. Personnel with active pulmonary or laryngeal
TB may be highly infectious; exclusion from duty is indicated until
they are noninfectious. If personnel are excluded from duty because of
active TB, the facility should have documentation from their health
care providers that personnel are noninfectious before they are allowed
to return to duty. The
[[Page 47289]]
documentation needs to include evidence that (a) adequate therapy is
being received; (b) the cough has resolved; and (c) three consecutive
sputum acid-fast-bacilli (AFB) smears, collected on different days, are
negative. After personnel resume duty and while they remain on anti-TB
therapy, periodic documentation from their health care providers is
needed to show that effective drug therapy is being maintained for the
recommended time period and that their sputum AFB smears continue to be
negative.
Work restrictions are not necessary for personnel receiving
preventive treatment for latent TB (positive PPD test without active
disease) or for personnel with latent TB who do not accept preventive
therapy. However, these personnel should be instructed to seek
evaluation promptly if they develop symptoms suggestive of TB.
g. Considerations for Bacille Calmette-Guerin Vaccine. BCG has not
been routinely used in the United States to protect health care
personnel. Nevertheless, because of the resurgence of TB in the United
States and new information about the protective effect of BCG (399,
400), the role of BCG vaccination in the prevention and control of TB
in the country has been re-evaluated (401). The following is a summary
of the joint statement by the Advisory Council for the Elimination of
Tuberculosis and ACIP regarding the use of BCG in health care
personnel.
Two recent meta-analyses of 18 and 26 BCG studies, respectively,
indicate that the efficacy of BCG vaccine in preventing serious TB in
children is high (>80%) and suggested 50% efficacy in adults (399,
400); however, the protective efficacy of the vaccine in adolescents
and adults, including health care personnel and HIV-infected children
and adults, has not been determined (401).
BCG vaccination may be indicated for health care personnel in a few
geographic areas where the prevalence of MDR-TB is high, transmission
of TB is likely, and TB infection control measures have not been
successful in controlling nosocomial transmission (401). BCG
vaccination often results in local adverse effects (such as muscular
soreness, erythema, purulent drainage, axillary or cervical
lymphadenopathy for as long as 3 months after vaccination); serious
long-term complications (such as musculoskeletal lesions, multiple
lymphadenitis, and disseminated BCG disease) are infrequent (402-404).
The safety of BCG vaccination in immunocompromised populations (i.e.,
immunocompromised from immune deficiency diseases, HIV infection,
leukemia, lymphoma, or generalized malignancy, or immunosuppressed as a
result of therapy with corticosteroids, alkylating drugs,
antimetabolites, or radiation) has not been determined by adequate
epidemiologic studies. However, because of the possibility of
disseminated BCG infection in such persons (405-408), BCG vaccination
is not recommended for immunocompromised personnel (401).
PPD testing is not contraindicated for persons who have received
BCG vaccine and can be used to support or exclude the diagnosis of
infection with M. tuberculosis (401). PPD-test reactivity caused by BCG
vaccination wanes with time (409-411) and is unlikely to persist >10
years after vaccination in the absence of infection with M.
tuberculosis (409, 410). After a person has been vaccinated with BCG,
the presence or size of a PPD-test reaction cannot be used as a
predictor of BCG vaccine efficacy in the vaccine recipient (412, 413),
or as a determinant as to whether the reaction is caused by infection
with M. tuberculosis or the prior BCG vaccination (414). However, a
BCG-vaccinated person who has a PPD test reaction of 10 mm
induration is considered infected with TB, especially if the vaccinee
is a contact of a person with infectious TB, is from a country with
high prevalence of TB, or is continually exposed to populations in
which the prevalence of TB is high (401).
20. Vaccinia (Smallpox)
Because of the effective use of smallpox vaccine (vaccinia virus
vaccine), the World Health Organization declared the world free of
smallpox in 1980. The smallpox vaccine licensed for use in the United
States is derived from infectious vaccinia virus. After vaccination,
the virus can be cultured from the vaccination site until the scab has
separated from the skin (2-21 days after vaccination); thus,
susceptible persons may acquire vaccinia from a recently vaccinated
person (415-418). Covering the vaccination site and washing hands
following contact with the vaccination site (including bandages) will
prevent transmission. Recently, recombinant vaccinia viruses have been
engineered. There is a theoretical risk that transmission could occur
from contact with contaminated dressings or by contact with recombinant
vaccine, but no such transmission has been reported among personnel who
provide care to the recombinant vaccine recipients. Infections also
have been reported among laboratory personnel who handle viral cultures
or materials contaminated with vaccinia or recombinant viruses (16,
155).
Smallpox vaccination is indicated for personnel who work directly
with orthopox viruses (e.g., monkeypox, vaccinia, variola) or in
animal-care areas where orthopox-viruses are studied. In selected
instances, vaccination may be considered for personnel who provide care
to recipients of recombinant vaccinia vaccine (7, 16). Personnel who
receive the vaccine may continue to have contact with patients if the
vaccination site is covered and handwashing is maintained (16).
21. Varicella
Nosocomial transmission of varicella-zoster virus (VZV) is well
recognized (419-430). Sources for nosocomial exposures have included
patients, health care personnel, and visitors (including the children
of personnel) with either varicella or herpes zoster.
All susceptible adults in health care settings are at risk for
varicella and its complications. However, certain persons are at higher
risk for severe disease and secondary complications; they include
pregnant women, premature infants born to varicella-susceptible
mothers; infants born at <28 weeks="" gestation="" or="" weighing="" 1000="" grams,="" regardless="" of="" maternal="" immune="" status;="" and="" immunocompromised="" patients="" (11).="" during="" 1990-1994,="" while=""><5% of="" varicella="" cases="" occurred="" among="" adults="" 20="" years="" old,="" they="" accounted="" for="" 55%="" of="" varicella-related="" deaths.="" the="" incubation="" period="" for="" varicella="" is="" usually="" 14="" to="" 16="" days,="" but="" may="" be="" from="" 10="" to="" 21="" days="" after="" exposure.="" in="" persons="" who="" receive="" postexposure="" varicella-zoster="" immune="" globulin="" the="" incubation="" period="" may="" be="" up="" to="" 28="" days="" after="" exposure.="" transmission="" of="" infection="" may="" occur="" from="" 2="" days="" before="" onset="" of="" rash="" and="" usually="" up="" to="" 5="" days="" after="" rash="" onset,="" although,="" in="" immunocompromised="" persons="" transmission="" may="" occur="" during="" the="" period="" of="" eruption="" of="" lesions="" (431).="" it="" is="" generally="" advisable="" to="" allow="" only="" personnel="" who="" are="" immune="" to="" varicella="" to="" take="" care="" of="" patients="" with="" vzv.="" because="" of="" the="" possibility="" of="" transmission="" to="" and="" development="" of="" severe="" illness="" in="" high-risk="" patients,="" personnel="" with="" localized="" zoster="" should="" not="" take="" care="" of="" such="" patients="" until="" all="" lesions="" are="" dry="" and="" crusted="" (11,="" 432).="" personnel="" with="" localized="" zoster="" may="" not="" transmit="" infection="" to="" immunocompetent="" patients="" if="" their="" lesions="" can="" be="" covered.="" however,="" some="" institutions="" may="" exclude="" personnel="" with="" zoster="" from="" work="" until="" their="" lesions="" dry="" and="" crust="" (428).="" [[page="" 47290]]="" vzv="" is="" transmitted="" by="" the="" contact="" with="" infected="" lesions="" and,="" in="" hospitals,="" airborne="" transmission="" from="" patients="" with="" varicella="" or="" zoster="" to="" susceptible="" persons="" who="" had="" no="" direct="" contact="" with="" the="" infected="" patient="" has="" occurred="" (432-436).="" adherence="" to="" airborne="" and="" standard="" precautions="" when="" caring="" for="" patients="" with="" known="" or="" suspected="" vzv="" infection="" can="" reduce="" the="" risk="" of="" transmission="" to="" personnel="" (1).="" management="" of="" clusters="" of="" vzv="" infection="" in="" health="" care="" settings="" also="" generally="" includes="" (a)="" isolation="" of="" patients="" with="" varicella="" and="" of="" exposed="" susceptible="" patients="" (1);="" and="" (b)="" control="" of="" air="" flow="" (negative="" pressure)="" in="" isolation="" rooms="" (435-437).="" a.="" varicella="" screening="" and="" vaccination.="" serologic="" tests="" have="" been="" used="" to="" assess="" the="" accuracy="" of="" reported="" histories="" of="" chickenpox="" (299,="" 429,="" 438-440).="" in="" adults,="" a="" history="" of="" varicella="" is="" highly="" predictive="" of="" serologic="" immunity="" (97%="" to="" 99%="" seropositive).="" the="" majority="" of="" adults="" who="" have="" negative="" or="" uncertain="" histories="" of="" varicella="" are="" also="" seropositive="" (71%="" to="" 93%).="" in="" health="" care="" institutions,="" serologic="" screening="" of="" personnel="" who="" have="" negative="" or="" uncertain="" histories="" is="" likely="" to="" be="" cost="" effective,="" depending="" on="" the="" relative="" costs="" of="" the="" test="" and="" vaccine="" (7,="" 11).="" a="" variety="" of="" methods="" have="" been="" used="" for="" detecting="" of="" varicella="" antibody,="" but="" a="" commercially="" available="" latex="" agglutination="" test="" will="" provide="" prompt,="" sensitive="" and="" specific="" serologic="" results="" at="" a="" reasonable="" cost.="" routine="" testing="" for="" varicella="" immunity="" following="" vaccination="" is="" not="" necessary="" because="" 99%="" of="" persons="" are="" seropositive="" after="" the="" second="" dose.="" moreover,="" seroconversion="" does="" not="" always="" result="" in="" full="" protection="" against="" disease.="" however,="" testing="" vaccinees="" following="" exposures="" may="" be="" warranted.="" in="" addition,="" vaccinated="" persons="" who="" are="" exposed="" to="" varicella="" but="" lack="" antibody="" may="" be="" retested="" in="" 5-6="" days="" to="" determine="" if="" they="" are="" antibody="" positive="" after="" the="" second="" test="" and,="" therefore,="" unlikely="" to="" develop="" varicella="" (11).="" in="" march="" 1995,="" a="" live="" attenuated="" varicella="" vaccine="" was="" licensed="" for="" use="" in="" the="" united="" states.="" administration="" of="" varicella="" vaccine="" is="" recommended="" for="" all="" susceptible="" health="" care="" personnel,="" especially="" those="" who="" will="" have="" close="" contact="" with="" persons="" at="" high="" risk="" for="" serious="" complications="" (11,="" 293,="" 441,="" 442).="" effective="" varicella="" vaccination="" programs="" require="" two="" doses="" of="" vaccine="" to="" achieve="" high="" seroconversion="" rates="" in="" adults="" (441);="" the="" need="" for="" and="" response="" to="" booster="" doses="" of="" vaccine="" are="" unknown.="" vaccination="" provides="" approximately="" 70%="" protection="" against="" infection="" and="" 95%="" protection="" against="" severe="" disease="" in="" follow-="" up="" from="" 7-10="" years="" after="" vaccination="" (11).="" cases="" of="" varicella="" have="" occurred="" among="" vaccinees="" following="" exposure="" to="" wild-type="" virus="" (``breakthrough="" infection'').="" data="" from="" vaccine="" trials="" indicate="" that="" 1%="" to="" 4%="" of="" vaccine="" recipients="" per="" year="" develop="" chickenpox,="" depending="" on="" the="" vaccine="" lot="" and="" interval="" following="" vaccination="" (7,="" 11).="" however,="" vaccinated="" persons="" have="" milder="" disease="" (e.g.,="" afebrile;="" a="" mean="" of="" 50="" skin="" lesions="" which="" are="" often="" not="" vesicular;="" and="" shorter="" duration="" of="" illness)="" compared="" with="" unvaccinated="" individuals="" (e.g.,="" febrile="" with="" several="" hundred="" vesicular="" lesions)="" (443,="" 444),="" and="" are="" less="" likely="" to="" transmit="" disease="" than="" unvaccinated="" persons.="" the="" rate="" of="" transmission="" of="" disease="" from="" vaccinees="" who="" contract="" varicella="" is="" low="" for="" vaccinated="" children,="" but="" has="" not="" been="" studied="" in="" adults.="" active="" surveillance="" for="" 1="" to="" 8="" years="" following="" vaccination="" of="" 2141="" children="" between="" 1981="" and="" 1989="" in="" 10="" different="" trials="" (7)="" resulted="" in="" reports="" of="" breakthrough="" infections="" in="" 78="" children,="" which="" further="" resulted="" in="" secondary="" cases="" in="" 12.2%="" (11/90)="" of="" vaccinated="" siblings.="" illness="" was="" mild="" in="" both="" index="" and="" secondary="" cases.="" there="" also="" has="" been="" a="" report="" of="" transmission="" from="" a="" vaccinated="" child,="" in="" whom="" breakthrough="" disease="" occurred,="" to="" a="" susceptible="" mother="" (7).="" all="" information="" currently="" available="" on="" vaccine="" efficacy="" and="" the="" persistence="" of="" antibody="" in="" vaccinees="" is="" based="" on="" research="" conducted="" in="" settings="" where="" infection="" is="" highly="" prevalent="" and="" not="" affected="" by="" the="" wide="" use="" of="" vaccine.="" thus,="" the="" extent="" to="" which="" the="" protection="" provided="" by="" vaccination="" has="" been="" increased="" by="" boosting="" from="" exposure="" to="" natural="" virus="" and="" whether="" longer="" term="" immunity="" may="" wane="" as="" the="" prevalence="" of="" natural="" vzv="" decreases="" are="" unknown.="" b.="" transmission="" of="" vaccine="" virus.="" in="" clinical="" trials,="" 3.8%="" of="" children="" and="" 5.5%="" of="" adolescents="" and="" adults="" developed="" a="" non-localized="" rash="" (median,="" 5="" lesions)="" after="" the="" first="" injection,="" and="" 0.9%="" of="" adolescents="" and="" adults="" developed="" a="" non-localized="" rash="" after="" the="" second="" injection.="" available="" data="" suggest="" that="" healthy="" children="" have="" limited="" potential="" to="" transmit="" vaccine="" virus="" to="" susceptible="" contacts="" (estimated="" to="" be=""><1%), but="" that="" the="" risk="" of="" transmission="" from="" immunocompromised="" vaccinees="" is="" higher="" and="" possibly="" related="" to="" the="" occurrence="" of="" rash="" following="" vaccination="" (445,="" 446).="" tertiary="" transmission="" of="" vaccine="" virus="" to="" a="" second="" healthy="" sibling="" of="" a="" vaccinated="" leukemic="" child="" has="" also="" occurred="" (99).="" these="" data="" suggest="" that="" healthy="" vaccinated="" individuals="" have="" a="" very="" small="" risk="" of="" transmitting="" vaccine="" virus="" to="" their="" contacts;="" this="" risk="" may="" be="" higher="" in="" those="" who="" develop="" a="" varicella-like="" rash="" following="" vaccination.="" although="" the="" risk="" of="" transmission="" of="" vaccine="" virus="" from="" vaccinees="" is="" not="" known,="" the="" risk,="" if="" any,="" appears="" to="" be="" very="" low="" and="" the="" benefits="" of="" vaccinating="" susceptible="" health="" care="" personnel="" clearly="" outweigh="" this="" potential="" risk.="" as="" a="" safeguard,="" institutions="" may="" wish="" to="" consider="" precautions="" for="" vaccinated="" personnel="" who="" develop="" a="" rash="" or="" who="" will="" have="" contact="" with="" susceptible="" persons="" at="" high="" risk="" for="" serious="" complications.="" c.="" management="" of="" health="" care="" personnel="" exposed="" to="" varicella.="" when="" unvaccinated="" susceptible="" personnel="" are="" exposed="" to="" varicella,="" they="" are="" potentially="" infective="" 10="" to="" 21="" days="" after="" exposure="" and="" exclusion="" from="" duty="" is="" indicated="" from="" the="" 10th="" day="" after="" the="" first="" exposure="" through="" the="" 21st="" day="" after="" the="" last="" exposure,="" or="" if="" varicella="" occurs,="" until="" all="" lesions="" dry="" and="" crust="" (table="" 3)="" (248).="" if="" vaccinated="" health="" care="" personnel="" are="" exposed="" to="" varicella,="" they="" may="" be="" serotested="" immediately="" after="" exposure="" to="" assess="" the="" presence="" of="" antibody="" (442).="" if="" they="" are="" seronegative="" they="" may="" be="" excluded="" from="" duty="" or="" monitored="" daily="" for="" development="" of="" symptoms.="" exclusion="" from="" duty="" is="" indicated="" if="" symptoms="" (fever,="" upper="" respiratory,="" and/or="" rash)="" develop.="" vaccination="" should="" be="" considered="" for="" exposed="" unvaccinated="" health="" care="" personnel="" without="" documented="" immunity="" (430,="" 442).="" however,="" because="" the="" efficacy="" of="" postexposure="" vaccination="" is="" unknown,="" persons="" vaccinated="" following="" an="" exposure="" should="" be="" managed="" as="" previously="" recommended="" for="" unvaccinated="" persons.="" the="" use="" of="" postexposure="" varicella="" zoster="" immune="" globulin="" (vzig)="" is="" not="" recommended="" for="" routine="" use="" among="" immunocompetent="" health="" care="" personnel="" (11).="" vzig="" can="" be="" costly,="" does="" not="" necessarily="" prevent="" varicella,="" and="" may="" prolong="" the="" incubation="" period="" by="" a="" week="" or="" more,="" thus="" extending="" the="" time="" that="" personnel="" will="" be="" restricted="" from="" duty.="" the="" use="" of="" vzig="" may="" be="" considered="" for="" immunocompromised="" (e.g.,="" hiv-="" infected)="" or="" pregnant="" health="" care="" personnel="" (11,="" 447).="" postexposure="" use="" of="" acyclovir="" may="" be="" effective="" and="" less="" costly="" than="" the="" use="" of="" vzig="" in="" some="" susceptible="" persons="" (447).="" however,="" additional="" data="" concerning="" the="" efficacy="" of="" acyclovir="" for="" postexposure="" prophylaxis="" are="" needed="" before="" such="" use="" can="" be="" recommended="" (7,="" 11,="" 430,="" 448).="" 22.="" viral="" respiratory="" infections="" viral="" respiratory="" infections="" are="" common="" problems="" in="" health="" care="" [[page="" 47291]]="" settings.="" nosocomial="" respiratory="" infections="" can="" be="" caused="" by="" a="" number="" of="" viruses,="" including="" adenoviruses,="" influenza="" virus,="" parainfluenza="" viruses,="" respiratory="" syncytial="" virus="" (rsv),="" and="" rhinoviruses.="" because="" influenza="" and="" rsv="" substantially="" contribute="" to="" the="" morbidity="" and="" mortality="" associated="" with="" viral="" pneumonia="" and="" both="" have="" been="" well="" studied="" epidemiologically,="" this="" section="" focuses="" on="" prevention="" of="" these="" two="" viral="" infections="" among="" personnel.="" additional="" information="" on="" influenza="" and="" rsv="" can="" be="" found="" in="" the="" guideline="" for="" prevention="" of="" nosocomial="" pneumonia="" (449).="" a.="" influenza.="" nosocomial="" transmission="" of="" influenza="" has="" been="" reported="" in="" acute="" and="" long-term="" care="" facilities="" (450-455).="" transmission="" has="" occurred="" from="" patients="" to="" health="" care="" personnel="" (452,="" 454),="" from="" health="" care="" personnel="" to="" patients="" (456),="" and="" among="" health="" care="" personnel="" (455,="" 457-462)="" .="" influenza="" is="" believed="" to="" be="" transmitted="" from="" person="" to="" person="" by="" direct="" deposition="" of="" virus="" laden="" large="" droplets="" onto="" the="" mucosal="" surfaces="" of="" the="" upper="" respiratory="" tract="" of="" an="" individual="" during="" close="" contact="" with="" an="" infected="" person,="" as="" well="" as="" by="" droplet="" nuclei="" or="" small-="" particle="" aerosols="" (19,="" 279,="" 463).="" while="" the="" extent="" of="" transmission="" by="" virus-contaminated="" hands="" or="" fomites="" is="" not="" known,="" it="" is="" not="" the="" primary="" mode="" of="" transmission="" (463).="" the="" incubation="" period="" of="" influenza="" is="" usually="" 1-5="" days,="" and="" the="" period="" of="" greatest="" communicability="" is="" during="" the="" first="" 3="" days="" of="" illness.="" however,="" virus="" can="" be="" shed="" before="" the="" onset="" of="" symptoms="" and="" up="" to="" 7="" days="" after="" illness="" onset="" (464-466).="" persons="" at="" greatest="" risk="" for="" influenza-related="" complications="" include="" (a)="" persons="">65 years
of age; (b) residents of nursing homes and other chronic-care
facilities; (c) persons with chronic pulmonary or cardiovascular
conditions; and (d) persons with diabetes mellitus (15). Adherence to
Droplet Precautions may prevent nosocomial transmission (1).
Administration of influenza vaccine to health care personnel,
including pregnant women (7), before the beginning of each influenza
season can help to (a) reduce the risk of influenza infection to health
care personnel; (b) prevent transmission of influenza from personnel to
persons at high risk of complications; and (c) reduce personnel
absenteeism during community outbreaks. Innovative methods may be
needed to increase influenza immunization rates among health care
personnel (467). Immunization rates may also be increased by providing
data to health care personnel on the low rates of systemic reactions to
influenza vaccine among healthy adults (468).
During institutional outbreaks of influenza, prophylactic antiviral
agents (e.g., amantadine and rimantadine) may be used in conjunction
with influenza vaccine to reduce the severity and duration of illness
among unvaccinated health care personnel. Amantadine and rimantadine
may be administered for 2 weeks following personnel vaccination or, in
unvaccinated personnel, for the duration of influenza activity in the
community (15, 449, 469, 470).
b. Respiratory Syncytial Virus (RSV). Nosocomial transmission of
RSV is greatest during the early winter when community RSV outbreaks
occur; patients, visitors, and health care personnel may transmit the
virus in the health care setting. RSV infection is most common among
infants and children, who are likely to develop more severe disease.
Because RSV infection can also occur simultaneously with other
respiratory viruses, it may go unrecognized (471, 472). Nosocomial
transmission has been reported most frequently among newborn and
pediatric patients (473, 474), but outbreaks associated with
substantial morbidity and mortality have been reported among adults in
bone marrow transplant centers (475), intensive care units (476), and
long-term care facilities (477, 478).
RSV is present in large numbers in the respiratory secretions of
symptomatic persons infected with the virus and can be transmitted
directly via large droplets during close contact with such persons, or
indirectly via hands or fomites that are contaminated with RSV. Hands
can become contaminated through handling of infected persons'
respiratory secretions or contaminated fomites, and transmit RSV by
touching the eyes or nose (449). The incubation period ranges from 2-8
days; 4-6 days is most common. In general, infected persons shed the
virus for 3-8 days, but young infants may shed virus for as long as 3-4
weeks. Adherence to Contact Precautions effectively prevents nosocomial
transmission.
c. Work restrictions. Because large numbers of personnel may have
viral respiratory illnesses during the winter, it may not be possible
to restrict infected personnel from all patient-care duties.
Nevertheless, it may be prudent to restrict personnel with acute viral
respiratory infections from the care of high-risk patients during
community outbreaks of RSV and influenza (479, 480).
E. Pregnant Personnel
Immunologic changes occur during pregnancy, primarily depression of
certain aspects of cell-mediated immunity such as decreased levels of
helper T cells. These changes permit fetal development without
rejection but generally do not increase maternal susceptibility to
infectious diseases. Occupational acquisition of infections is of
special concern to female health care personnel of childbearing age for
several reasons. Some infections, such as varicella, may be more severe
during pregnancy. Transplacental infection with viruses such as
parvovirus, varicella, and rubella has been associated with abortion,
congenital anomaly, and mental retardation. Other diseases in which the
infectious agent may be transmitted to the fetus include
cytomegalovirus, hepatitis B, herpes simplex, influenza, and measles.
In addition, certain drugs used to treat or prevent some infections,
for example tuberculosis, may be contraindicated during pregnancy.
In general, pregnant health care personnel do not have an increased
risk of acquiring infections in the workplace. The risks to pregnant
personnel and methods for prevention are discussed in the various
sections of this document and are summarized in Table 6. Female
personnel of childbearing age should be strongly encouraged to receive
immunizations for vaccine-preventable diseases prior to pregnancy. Such
personnel may also decrease their risk of acquiring infection by
adhering to appropriate infection control practices, including Standard
Precautions when caring for all patients. Additional information on
occupational risks for pregnant health care personnel has been
published elsewhere (480-482).
F. Laboratory Personnel
Despite the availability of improved engineering controls, work
practices, and personal protective equipment, laboratory personnel
remain at risk for occupational acquisition of infectious agents (3,
16, 48, 144, 155, 235, 483, 484). Furthermore, newer technologies that
require the use of large and/or concentrated specimens may further
increase the risk of occupationally acquired infections among
laboratory personnel (485).
In a review of laboratory-acquired infections from 1950-1974 >4000
laboratory associated infections were documented in the United States
(483) the 10 most commonly reported infections were brucellosis, Q
Fever, hepatitis, especially hepatitis B, typhoid fever, tularemia,
tuberculosis,
[[Page 47292]]
dermatomycosis, venezuelan equine encephalitis, psittacosis, and
coccidioidomycosis. However, laboratory-associated infections also have
been due to a wide variety of other pathogens (155, 483, 484). More
recently, viral agents have accounted for a larger proportion of
laboratory associated infections than have bacterial infections (484-
489).
Laboratory personnel may acquire infection by aerosolization of
specimens, mouth pipetting, or percutaneous injury. Information on the
risks of laboratory-associated infections and appropriate biosafety
procedures and precautions for laboratories have been published (3, 4,
485, 490-492).
In addition to biosafety precautions, preventive measures (e.g.,
immunizations and postexposure prophylaxis) also may be indicated for
laboratory personnel who handle infectious agents. In this document,
disease specific information and guidance are provided for prevention
of laboratory-associated infections and for management of laboratory
personnel exposed to infectious agents. Health care institutions need
to ensure that laboratory personnel who may be exposed to infectious
agents are well informed about the risks of acquiring infections and
biosafety procedures to prevent transmission of infectious agents.
G. Emergency Response Personnel
Emergency medical technicians, firemen, policemen, and others who
attend to and transport patients to the hospital may be exposed to
recognized or undiagnosed transmissible infectious diseases in the
patients with whom they come in contact. Subtitle B (42 U.S.C. 300ff-
80) of the 1990 Ryan White Comprehensive AIDS Resources Emergency Act
requires the establishment of notification systems in each State to
ensure that emergency response employees (including emergency medical
technicians, firefighters, and the like) are informed when they have
been exposed to an emergency medical patient with an infectious,
potentially fatal disease such as HIV or meningococcemia. CDC published
a list of diseases for which emergency response employees must be
informed of an exposure (493).
H. Latex Hypersensitivity
Since the introduction of Universal Precautions, the use of latex
gloves has become commonplace in health care settings (494, 495). The
increased use of latex gloves has been accompanied by increasing
reports of allergic reactions to natural rubber latex among health care
personnel (496-501).
Natural rubber latex is a combination of heat and water-soluble
proteins derived from the tree Hevea braziliensis. However, total
protein concentrations and allergenicity are not always directly
correlated (502), suggesting that total protein concentrations are not
necessarily a measure of the allergenic properties of latex gloves.
Latex gloves may be labeled ``hypoallergenic'', but this designation
refers to nonlatex additives in gloves and does not reflect reduced
allergenicity to latex (503). In one study, nearly 50% (11/24) of the
lots of hypoallergenic gloves tested had measurable latex allergen
(504). The FDA has proposed labeling of all the medical devices that
contain natural rubber latex (505). Also, the total protein content of
latex gloves may vary considerably from brand to brand and lot to lot
(502, 504). Currently, the amount of latex allergen exposure required
to produce sensitization or to elicit reactions in previously
sensitized persons is unknown.
Another recognized contributor to latex sensitization and reactions
is the powder or cornstarch used as a lubricant for gloves. Levels of
extractable protein and allergen in a given glove have been shown to be
correlated with the presence of powder. Powdered gloves have higher
levels of these proteins than powder-free gloves. Also, investigators
have demonstrated that latex proteins adhere to the powder on gloves
and that aerosolized latex protein-powder particles can provoke
allergic respiratory symptoms if inhaled by a latex-sensitive
individuals (506); similar adherence has not been detected with
powdered vinyl gloves. In one study, personnel wearing powdered latex
gloves had a significantly higher rate of reaction than did workers who
wore washed latex gloves, from which the powder had been removed (60%
vs 28%); none of these workers had positive skin-test reactions to
industrial or commercial cornstarch or powder (497). Although many
health care personnel or clinicians may implicate the powder or
cornstarch on gloves as the cause of their reactions, documented
reactions to cornstarch powder are rare.
Reactions to latex gloves may be localized or systemic and include
dermatitis, conjunctivitis, rhinitis, urticaria, angioedema, asthma,
and anaphylaxis (507-510). The majority of local reactions associated
with latex glove use are not immunologically mediated and result from
chemicals (e.g., thiurams, carbamates, mercaptobenzothiazole,
phenylenediamine), accelerants or antioxidants added to gloves during
manufacturing (495, 500, 511-513). It may be difficult to differentiate
irritant reactions from allergic contact dermatitis reactions. Both may
be manifested by itching, dryness, erythema, bleeding, or scaling of
the hands. Nevertheless, neither of the types of local reactions to
latex gloves are good predictors of latex allergy (496, 514); only a
subset of health care personnel reporting glove-associated skin
irritation will have immunoglobulin E (IgE) antibodies specific for
latex (511, 515-517).
In contrast, systemic reactions to natural rubber latex, including
urticaria, are mediated by anti-latex IgE antibodies (507, 518, 519)
and may result from direct skin contact or from exposure to airborne
latex allergen adsorbed to glove powder. Occupational asthma from latex
is becoming increasingly recognized (518, 520-522). Asthmatic responses
to latex may occur early (<8 hours)="" or="" late="" (="">8 hours) following
exposure (523-525).
Local reactions (i.e., irritant or allergic contact dermatitis)
account for the majority of reported reactions among health care
personnel (496, 499). The risk of progression from localized to
systemic reactions is unknown.
a. Prevalence and risk factors. In studies of health care
personnel, the reported prevalence of IgE-mediated allergy to latex
vary considerable ranging from 2.9%-17%. The broad range of prevalence
rates reported likely represent differences in the personnel groups
studied and the methods used for estimating sensitization or allergy
(516, 517, 520, 526, 527). The prevalence detected in some studies also
has been biased by enrollment or testing of only symptomatic personnel
(497, 501). However, it is estimated that a minority of health care
personnel, even if symptomatic, seek medical evaluation or treatment
for latex-allergic conditions. Thus, the true prevalence of these
reactions among health care personnel is unknown.
The prevalence of sensitization to latex among health care
personnel has been shown to vary by job category and by location within
a facility (499, 527). In one study of 224 health care personnel, the
overall prevalence of skin-prick reactivity to latex was 17%, but
ranged from 0% (0/17) among housekeepers/clerical workers to 38% (5/13)
among dental residents/assistants (499). In another survey of 512
health care personnel, the prevalence among physicians (6.5% [7/108])
was greater than that among nurses (2.2% [7/325]) or other hospital
personnel (1.3% [1/79]). Also, operating room personnel
[[Page 47293]]
(6.2% [9/145]) were significantly more likely to be sensitized than
were personnel assigned to general wards or laboratories (1.6% [6/
367]); operating room nurses had a four fold higher prevalence than did
general ward nurses (5.6% vs 1.2%) (527). Measurable levels of latex
aeroallergen have been detected in the breathing zones of operating
room personnel and may vary as much as 100-fold, depending on the
invasiveness of the procedure and frequency of glove changes (528).
Several factors have been linked with latex sensitization among
health care personnel, including the presence of other allergic
conditions (e.g., asthma, eczema, hay fever) (496, 514, 516, 517, 520,
526, 527), nonwhite race (79, 526), elevated total IgE levels (517),
allergy to cosmetic powders or foods (529), years or status (full vs
part-time) of employment, and frequency and/or duration of glove use
(496, 514, 520, 527). Coexistent allergy to certain fruits (e.g.,
bananas [(530, 531)], avocados [(532, 533), pears, and chestnuts (534))
also has been described in latex-allergic health care personnel.
Skin irritation, eczematous dermatitis (514, 527) (conditions that
may allow passage of latex proteins through the skin), and use of other
latex products (e.g., condoms, diaphragms) have not been consistently
linked to latex sensitization in health care personnel.
b. Diagnosis/identification. Diagnosis of personnel with latex
allergy relies largely on a clinical history of symptoms elicited by
exposure to latex products (e.g., balloons, gloves). Clinical symptoms,
such as urticaria, may be good predictors of IgE-medicated allergy
(514, 517).
A variety of methods have been used to aid in the identification of
latex-allergic persons; most are experimental and have not been
approved for clinical use. Skin-prick testing (SPT) may be the most
sensitive method for diagnosis of IgE-mediated allergy, but no
standardized FDA-approved antigen is currently available in the United
States for detection of latex-specific IgE antibodies. Moreover, the
use of some skin test reagents in highly sensitized persons have been
associated with adverse outcomes (535), suggesting that these
nonstandardized reagents may not be safe for routine use. In Europe,
where a standardized SPTallergen has been developed, SPT has been used
successfully.
Currently, only one immunoassay has been FDA approved for detection
of latex-specific IgE antibodies in blood. The FDA has recommended that
this assay be used as a confirmatory test, rather than screening, for
persons in whom latex allergy is suspected, based on clinical history
and findings. Levels of detectable antibody appear to be associated
with symptoms (497, 517), but, as with other allergens, the correlation
between serum concentrations of latex-specific IgE antibodies and
symptom severity is unpredictable (497, 514). Clinical screening, in
which the worker is questioned about allergy to latex products and risk
factors for latex allergy, may help to identify those in whom further
diagnostic testing should be considered.
c. Prevention strategies. Avoiding latex products remains the
cornerstone of preventing sensitization (primary prevention) and
reactions (secondary prevention) to natural rubber latex products.
Proposed strategies to reduce the risk of reactions to natural rubber
latex have included the use of the following: (a) nonlatex (e.g.,
vinyl) products alone or in combination (with vinyl or cloth liners)
with latex gloves; (b) powder-free latex gloves; (c) powdered latex
gloves washed to remove powder; and (d)''low protein'' latex gloves.
However, none of these interventions has been prospectively studied in
controlled trials to assess its cost-effectiveness or efficacy in
preventing sensitization or reactions.
Because latex proteins can be aerosolized when powdered gloves are
donned or removed, systemic symptoms caused by latex aeroallergens may
not be alleviated by simply avoiding latex products, particularly if
co-workers of the affected worker continue to use powdered latex
gloves. Although the risk of a worker's exposure is greatest when
gloves are donned or removed, allergenic proteins also may settle on
environmental surfaces, surgical gowns, or other clothing and become
resuspended. The use of powder-free or low protein gloves appears to
more effective and less costly than either laminar flow or high-
efficiency particulate air-filtered glove-changing stations in reducing
latex aeroallergens (528). For personnel with systemic manifestations
to latex, workplace restriction or reassignment may be necessary.
I. The Americans With Disabilities Act
The Americans with Disabilities Act (ADA) provides guidelines for
hiring and placing employees with disabilities as defined in the Act
(536-539). In general, employers must assess applicants for their
qualifications to perform the tasks inherent to the job for which the
employee is being considered. Applicants may be asked about their
ability to perform specific job functions, but may not be asked about
the existence, nature, or severity of a disability. Employers must make
a ``reasonable accommodation'' to allow an individual to perform the
essential functions of a job unless the employer can prove this would
create undue hardship because of significant difficulty or expense.
The provisions of the ADA need to be incorporated into infection
control policies for health care personnel. For example, applicants
with a communicable disease spread by aerosol could justifiably be
denied employment (until they are no longer infectious) because they
could pose a direct threat to others. On the other hand, applicants who
are immunocompromised may not necessarily be excluded because of an
increased risk of acquiring an infection in the hospital if the
employer can make reasonable accommodations that prevent exposure.
Health care personnel who are known to be immunocompromised need to be
referred to personnel health professionals who can individually counsel
the employees on their risk for infection. Upon the request of the
immunocompromised health care personnel, employers should offer, but
not compel, a work setting in which health care personnel would have
the lowest possible risk for occupational exposure to infectious
agents. Evaluation of individual situations need also to include
consideration of the provisions of other applicable federal, state, and
local laws.
Part II. Recommendations for Prevention of Infections in Health Care
Personnel
A. Introduction
In this document, the term health care personnel refers to all the
paid and unpaid persons working in health care settings who have the
potential for exposure to infectious materials including body
substances, contaminated medical supplies and equipment, contaminated
environmental surfaces, or contaminated air. These personnel may
include, but are not limited to, physicians, nurses, technicians,
nursing assistants, laboratory personnel, mortuary personnel, emergency
medical service personnel, dental personnel, students and trainees,
contractual staff not employed by the health care facility, and persons
not directly involved in patient care (e.g., volunteer, dietary,
housekeeping, maintenance, and clerical personnel) but potentially
exposed to infectious agents.
[[Page 47294]]
As in previous CDC guidelines, each recommendation is categorized
on the basis of existing scientific data, theoretical rationale,
applicability, and economic impact. The system for categorizing
recommendations is as follows:
Category IA. Strongly recommended for all hospitals and strongly
supported by well-designed experimental or epidemiologic studies.
Category IB. Strongly recommended for all hospitals and reviewed as
effective by experts in the field and a consensus of Hospital Infection
Control Practices Advisory Committee members based on strong rationale
and suggestive evidence, even though definitive scientific studies have
not been done.
Category II. Suggested for implementation in many hospitals.
Recommendations may be supported by suggestive clinical or
epidemiologic studies, a strong theoretical rationale, or definitive
studies applicable to some, but not all, hospitals.
No Recommendation, Unresolved Issue. Practices for which
insufficient evidence or consensus regarding efficacy exists.
B. Elements of a Personnel Health Service for Infection Control
1. Coordinated Planning and Administration
a. Coordinate policy-making and planning among the hospital
administration, personnel health service, infection control personnel,
clinical services and various other hospital departments, and relevant
external agencies. Include paid and nonpaid personnel (e.g.,
volunteers, trainees, physicians, out-of-hospital and contractual
personnel, and emergency responders) in the plan. Category IB
b. Establish an active system and develop a written policy for
notifying infection control personnel of (1) infections in personnel
(including volunteers, trainees, contractual personnel, and out-of-
hospital personnel) that require work restrictions or exclusion from
work; (2) clearance for work after an infectious illness that required
work restrictions or exclusion; (3) other work-related infections and
exposures; and (4) when appropriate, results of epidemiologic
investigations. Category IB
c. Develop protocols to assure coordination between the personnel
health program and the infection control program of the institution.
Category IB
2. Placement evaluation
a. Before personnel begin duty or are given a new work assignment,
obtain their health inventories. Include in the inventories the
following: (1) immunization status or history of vaccine preventable
diseases (e.g., chickenpox, measles, mumps, rubella, hepatitis B); (2)
history of any conditions that may predispose personnel to acquiring or
transmitting infectious diseases (e.g., immunosuppressive condition or
therapy, tuberculosis, dermatologic conditions, chronic draining
infections or open wounds, or chronic infections). Category IB
b. For infection control, perform directed physical and laboratory
examinations on personnel, as may be determined from the results of the
health inventory. Include examinations to detect conditions that might
increase the likelihood of transmitting disease to patients, or unusual
susceptibility to infection, and to serve as a baseline for determining
whether any future problems are work related. Category IB
c. Conduct personnel health assessments other than placement
evaluations on an as-needed basis for example, as required to evaluate
work-related illness or exposures to infectious diseases. Category IB
d. Do not perform routine cultures on personnel (e.g., cultures of
the nose, throat, or stool) as part of the placement evaluation (540).
Category IB
e. Conduct routine screening for tuberculosis by using the
intradermal (Mantoux), intermediate strength (5 TU) PPD test on
personnel who have potential for exposure to TB. Category II
f. Conduct routine serologic screening for some vaccine-preventable
diseases, such as hepatitis B, measles, mumps, rubella, or varicella,
if deemed to be cost-effective to the hospital and beneficial to the
health care personnel. Category II
3. Personnel Health and Safety Education
a. Include the infection control aspects of personnel health and
the proper use of the personnel health service in the initial job
orientation and ongoing in-service education of personnel. Category IB
(1) Ensure that the following topics are included in the initial
training on infection control: (a) handwashing; (b) modes of
transmission of infection and importance of complying with standard and
isolation precautions; (c) importance of reporting certain illnesses or
conditions (whether work related or acquired outside the hospital),
such as generalized rash or skin lesions that are vesicular, pustular,
or weeping; jaundice; illnesses that do not resolve within a designated
period of time (e.g., a cough that persists for >2 weeks,
gastrointestinal illness, or febrile illness with fever of >103 deg.F
lasting more than 2 days) and hospitalizations resulting from febrile
or other contagious diseases; (d) tuberculosis control; (e) importance
of complying with Standard Precautions and reporting exposure to blood
and body fluids to prevent transmission of bloodborne pathogens; (g)
importance of cooperating with infection control personnel during
outbreak investigations; and (h) importance of personnel screening and
immunization programs. Category IB
(2) Ensure that all personnel know that if they have medical
conditions (e.g., immunosuppression) or receive medical treatment that
render them more susceptible to or more likely to transmit infections,
they can follow recommendations to greatly reduce their risk for
transmitting or acquiring infections, e.g., request for work
reassignment. Category IB
b. Make specific written policies and procedures for control of
infections in health care personnel readily available. Category IB
c. Provide personnel, annually, and whenever the need arises, with
in-service training and education on infection control that are
appropriate and specific for their work assignments so that personnel
can maintain accurate and up-to-date knowledge about the essential
elements of infection control. Category IB
d. Provide educational information appropriate, in content and
vocabulary, to the educational level, literacy, and language of the
employee. Category IB
4. Job-Related Illnesses and Exposures
a. Maintain a record on health care personnel that includes
information obtained during the medical evaluation, immunization
records, results of tests obtained in any screening or control
programs, and reports of work-related illnesses or exposures in
accordance with state and federal regulatory requirements. Category IB
b. Establish a readily available mechanism for personnel to obtain
advice about illnesses they may acquire from or transmit to patients.
Category IB
c. Evaluate job-related and community-acquired illnesses or
important exposures and postexposure prophylaxis, when indicated.
Category IB
d. Develop written protocols for handling job-related and
community-acquired infectious diseases or important exposures. Record
the occurrences of job-related infectious diseases or important
exposures in the person's record and, when applicable,
[[Page 47295]]
notify appropriate infection control personnel and members of the
personnel health service. Category IB
5. Record-Keeping, Data Management, and Confidentiality
a. Establish and keep an updated record for all personnel and
maintain the confidentiality of their records while ensuring that they
receive appropriate therapeutic or prophylactic management for
illnesses caused by or following exposures to transmissible infections.
Ensure that individual records for volunteers, trainees, contractual
personnel, and personnel who provide care outside of hospitals are
similarly kept and maintained. Category IB
b. Ensure that when data on personnel health are made public, the
individual's confidentiality is maintained, for example, by releasing
only aggregate numbers. Category IB
c. Maintain a personnel data base, preferably computerized, that
allows tracking of personnel immunizations, screening tests, and
assessment of trends of infections and diseases in personnel. Copies of
these records are to be available to the individual. Category IB
d. Periodically review and assess data gathered on personnel health
(e.g., rates of PPD-test conversion) to determine the need for action.
Category IB
e. Ensure that all federal, state, local, and community standards
on medical record keeping and confidentiality are met (23, 24).
Category IB
C. Protection of Personnel and Other Patients From Patients With
Infections
Apply precautions described in the current Guideline for Isolation
Precautions in Hospitals (1) and other guidelines (377). Category IB
D. Immunization of Health Care Personnel, General Recommendations
1. Ensure that persons administering immunizing agents are: (a)
familiar with the general ACIP recommendations and recommendations on
immunizing adults; (b) well informed about indications, storage,
dosage, preparation, side effects, and contraindications for each of
the vaccines, toxoids, and immune globulins used (6, 7, 22); and (c)
kept updated on professional organization recommendations regarding
vaccination of health care personnel (Tables 1 and 2). Category IB
2. Ensure that immunization product information is available at all
times and that a pertinent health history, especially a history of
allergy and potential vaccine contraindications, is obtained from each
person before an agent is given (Table 2). Category IB
3. Ensure that persons administering immunizing agents are familiar
with state and local regulations regarding vaccinations for health care
personnel. Category IB
4. Formulate a written comprehensive policy on immunizing health
care personnel. Category IB
5. Develop a data base of employee specific information on history
of vaccine preventable diseases and status of vaccine administration.
Category IB
6. Develop a list of needed immunizations for each employee during
screening and an individual plan to provide the necessary vaccines.
Category IB
7. In the absence of a known occupational exposure, provide
personnel with on-site service or refer personnel to their own health
care providers for routine non-occupation-related immunizations against
diphtheria, pneumococcal disease, hepatitis A, or tetanus (Table 1).
Category IB
8. Provide vaccine to personnel who may have occupational exposure
to uncommon diseases such as plague, typhus, or yellow fever, or refer
them to their own health care providers. Category IB
E. Prophylaxis and Follow-Up After Exposure, General Recommendations
1. Ensure that when personnel are offered necessary prophylactic
treatment with drugs, vaccines, or immune globulins, they are informed
of (a) options for prophylaxis; (b) the risk (if known) of infection
when treatment is not accepted; (c) the degree of protection provided
by the therapy; and (d) the potential side effects of the therapy.
Category IB
2. Ensure that when personnel are exposed to particular infectious
agents, they are informed of (a) the recommended follow-up based on
current knowledge about the epidemiology of the infection; (b) the risk
(if known) of transmitting the infection to patients, other personnel,
or other contacts; and (c) the methods of preventing transmission of
the infection to other persons. Category IB
F. Personnel Restriction Because of Infectious Illnesses or Special
Conditions, General Recommendations
1. Develop well-defined policies concerning contact of personnel
with patients when personnel have potentially transmissible conditions.
These policies should govern (a) personnel responsibility in using the
health service and reporting illness; (b) removal of personnel from
contact with patients; and (c) clearance for work after an infectious
disease that required work restriction. Category IB
2. Identify the persons with authority to relieve personnel of
duties. Category IB
3. Develop work-exclusion policies that encourage personnel to
report their illnesses or exposures and that do not penalize them with
loss of wages, benefits, or job status. Category IB
4. Educate and encourage personnel who have signs and symptoms of a
transmissible infectious disease to report their condition promptly to
their supervisor and occupational health. Category IB
5. Provide appropriate education for personnel on the importance of
good hygienic practices, especially handwashing and covering the nose
and mouth when coughing and sneezing. Category IB
G. Prevention of Nosocomial Transmission of Selected Infections
1. Bloodborne Pathogens, General Recommendation
a. Ensure that health care personnel are familiar with precautions
to prevent occupational transmission of bloodborne pathogens (1, 4, 26,
27, 35). Category IA
b. Follow state and federal guidelines and strategies for
determining the need for work restrictions for health care personnel
infected with bloodborne pathogens (43). Category IB
a. Hepatitis B. (1) Administer hepatitis B vaccine to personnel who
perform tasks involving routine and inadvertent (e.g., as with
housekeepers) contact with blood, other body fluids (including blood-
contaminated fluids), and sharp medical instruments or other sharp
objects (7, 8, 36). Category IA
(2) Before vaccinating personnel, do not routinely perform
serologic screening for hepatitis B vaccine unless the health care
organization considers screening cost-effective or the potential
vaccinee requests it (7). Category IA
(3) Conduct post vaccination screening for immunity to hepatitis B
within 1 to 2 months after the administration of the third vaccine dose
to personnel who perform tasks involving contact with blood, other body
fluids (including blood-contaminated fluids), and sharp medical
instruments or other sharp objects. Category IA
(4) Revaccinate persons not found to have an antibody response
after the initial hepatitis B vaccine series with a second three dose
vaccine series. If persons still do not respond after
[[Page 47296]]
revaccination, refer them for evaluation for lack of response,
(e.g.,possible chronic HBV infection) (7) (Tables 1 and 4). Category IB
(5) Test staff in chronic dialysis centers who do not respond to
the hepatitis B vaccine for hepatitis B surface antigen (HBsAg) and
antibody to hepatitis B surface antigen (anti-HBs) semi-annually (541).
Category IA
(6) Use both passive immunization with hepatitis B immune globulin
and active immunization with hepatitis B vaccine for postexposure
prophylaxis in susceptible personnel who have had a needlestick,
percutaneous, or mucous membrane exposure to blood known or suspected
to be at high risk for being HBsAg positive (Table 6). Category IA
(7) Follow current recommendations for postexposure prophylaxis
following percutaneous or mucous membrane exposure to blood and body
fluids that is known or suspected to be at high risk for being HBsAg-
positive (Table 4) (36). Category IA
b. Hepatitis C. (1) Do not administer immune globulin (IG) to
personnel who have exposure to blood or body fluids positive for
antibody to hepatitis C virus (33, 69). Category IB
(2) Consider implementing policies for postexposure follow-up for
health care personnel who have had a percutaneous or mucosal exposure
to blood containing antibody to hepatitis C virus at baseline and 6
months (69). Category IB
c. Human Immunodeficiency Virus (HIV). Follow current
recommendations for postexposure prophylaxis following percutaneous or
mucocutaneous exposure to suspected or known HIV-infected blood or body
fluids containing blood (29, 76). Category IB
2. Conjunctivitis
Restrict personnel with epidemic keratoconjunctivitis caused by
adenovirus or purulent conjunctivitis caused by other microorganisms
from patient care for the duration of symptoms. If symptoms persist >5-
7 days, refer personnel to an ophthalmologist for evaluation of
continued infectiousness. Category IB
3. Cytomegalovirus (CMV)
a. Do not restrict personnel from work who contract illnesses
suspected or proven to be due to CMV (109). Category IB
b. Educate all patient-care personnel about careful handwashing and
exercising care to prevent their body fluids from contacting other
persons to reduce their risk of transmitting infections such as CMV to
patients or other personnel (89, 123). Category IA
c. Ensure that pregnant personnel are aware of the risks associated
with CMV infection and infection control procedures to prevent
transmission when working with high-risk patient groups (Table 6).
Category IA
4. Diphtheria
a. Encourage vaccination with tetanus and diphtheria toxoid (Td)
every 10 years for health care personnel (7, 17) (Table 1). Category IB
b. Obtain nasopharyngeal cultures from exposed personnel and
monitor for signs and symptoms of diphtheria for 7 days (156). Category
IB
c. Administer antimicrobial prophylaxis to personnel who have
contact with respiratory droplets or cutaneous lesions of patients
infected with diphtheria. Also administer a dose of Td to previously
immunized personnel who have not been vaccinated within the previous 5
years (17, 156) (Table 1). Category IB
d. Repeat nasopharyngeal cultures of personnel found to have
positive cultures at 2 weeks following completion of
antimicrobial therapy. Repeat antimicrobial therapy if personnel remain
culture positive (156). Category IB
e. Exclude exposed personnel and those identified as asymptomatic
carriers from duty until antimicrobial therapy is completed and two
nasopharyngeal cultures obtained 24 hours apart are negative
(156) (Table 3). Category IB
5. Gastroenteritis
a. Vaccinate and provide booster doses of vaccine, following
published guidelines, to microbiology laboratory personnel who work
with Salmonella typhi on a regular basis (144, 155). Category II
b. Pending their evaluation, exclude personnel with acute
gastrointestinal illnesses (vomiting or diarrhea, with or without other
symptoms such as nausea, fever, or abdominal pain) that may be
accompanied by other symptoms (such as fever, abdominal cramps, or
bloody stools), from contact with patients or food-handling (1, 163)
(Table 3). Category IB
c. Consult local and state health authorities regarding regulations
for the exclusion of patient-care personnel or food-handlers with
enteric infections from contact with patients or food-handling,
respectively. Category IB
d. Determine the etiology of gastrointestinal illness among
personnel who care for patients at high risk of severe disease.
Category IB
e. Allow personnel infected with enteric pathogens to return to
work after their symptoms resolve if local regulations do not require
exclusion from duty for designated pathogens for specified time periods
or until negative cultures are available. Category II
f. Ensure that personnel, including those who are
immunocompromised, returning to work after a gastrointestinal illness
practice good hygienic practices, especially handwashing, to reduce or
eliminate the risk of transmission of the infecting agents (160, 542).
Category IB
g. Do not routinely perform follow-up cultures or examinations of
stool for enteric pathogens other than Salmonella to determine when the
stool is free of the infecting organism, unless local regulations
require such procedures. Category IB
h. Do not perform routine stool cultures on asymptomatic health
care personnel unless required by state and local regulations. Category
IB
6. Hepatitis A (HAV)
a. Do not routinely administer inactivated hepatitis A vaccine to
health care personnel. Susceptible personnel working in areas where
hepatitis A is highly endemic should be vaccinated to prevent
acquisition of community acquired infection (7, 196). Category IB
b. Do not routinely administer immune globulin (IG) as prophylaxis
for personnel providing care or who are exposed to a patient with
hepatitis A (196). Category IB
c. Administer IG (0.02 ml/kg) to personnel who have had oral
exposure to fecal excretions from a person acutely infected with
hepatitis A virus (196) (Table 1). Category IA
d. In documented outbreaks involving transmission of HAV from
patient to patient or from patient to health care worker, use of IG in
persons with close contact with infected persons may be indicated.
Contact the local health department regarding control measures (Table
1). Category IB
e. Exclude personnel who have acute hepatitis A from work until 1
week after the onset of jaundice (Table 3). Category IA
7. Herpes Simplex Virus
a. Exclude personnel with primary or recurrent orofacial herpes
simplex infections from the care of high-risk patients, including
newborns, intensive care unit patients, patients with severe burns or
eczema, or severely immunocompromised patients, until the lesions are
crusted (201, 210) (Table 3). Category IB
b. Exclude personnel with herpes simplex infections of the fingers
or hands (herpetic whitlow) from contact
[[Page 47297]]
with patients until their lesions are healed (206). Category IB
8. Measles
a. Ensure that all personnel have documented immunity to measles.
(1) Consider administering measles vaccine* to persons born in 1957
or later unless they have evidence of measles immunity. Category IA
---------------------------------------------------------------------------
* (Measles-mumps-rubella [MMR] trivalent vaccine is the vaccine
of choice. If the recipient is known to be immune to one or more of
the components, monovalent or bivalent vaccines may be used.)
---------------------------------------------------------------------------
(2) Administer measles vaccine* to personnel born before 1957 if
they do not have evidence of measles immunity and are at risk of
occupational exposure to measles (6, 213, 225, 226) (Table 1). Category
IA
(3) Do not routinely perform serologic screening for measles before
administering measles vaccine * to personnel unless the health care
employer considers screening cost-effective or the potential vaccinee
requests it (6, 9, 227-229, 543). Category IA
(4) Administer postexposure measles vaccine* to measles-susceptible
personnel who have contact with persons with measles, within 72 hours
after the exposure. During the period 5 days after the first exposure
until 21 days after the last exposure, exclude exposed, vaccinated
personnel from duty (6) (Tables 1-3). Category IA
b. Exclude exposed unvaccinated personnel from duty from the 5th
day after the first exposure until the 21st day after the last exposure
to measles, regardless of whether they receive postexposure vaccine, if
they do not have documented immunity to measles (9, 229) (Table 3).
Category IB
c. Exclude personnel who develop measles from patient contact for 4
days after rash develops or for the duration of their acute illness,
whichever is longer (9, 229) (Table 3). Category IB
9. Meningococcal Disease
a. Do not administer routinely meningococcal vaccine to health care
personnel (13). Category IB
b. Consider vaccination of laboratory personnel who are routinely
exposed to Neisseria meninigitidis in solutions that may be aerosolized
(13) (Table 1). Category IB
c. Immediately offer antimicrobial prophylaxis to personnel who
have had any of the following types of contact with a patient with
meningococcal disease prior to administration of antibiotics: (a)
Intensive, unprotected (i.e., without the use of proper precautions),
close, face-to-face contact with a patient with meningococcal disease;
(b) contact with the patient's oropharyngeal secretions; or (c) a
needlestick from a patient with meningococcal disease (13) (Table 1).
Category IB
d. Do not routinely give quadrivalent A,C,Y, W-135 meningococcal
vaccines for postexposure prophylaxis (13) (Table 1). Category II
e. Administer meningococcal vaccine to personnel (and other persons
likely to have contact with infected persons) to control Serogroup C
outbreaks following consultation with public health authorities (13).
Category IB
f. Consider preexposure vaccination of personnel who routinely
handle soluble preparations in N. meningitidis (13). Category II
10. Mumps
a. Administer mumps vaccine* to all personnel without documented
evidence of mumps immunity unless otherwise contraindicated (7, 250)
(Table 1). Category IA
---------------------------------------------------------------------------
* (Measles-mumps-rubella [MMR] trivalent vaccine is the vaccine
of choice. If the recipient is known to be immune to one or more of
the components, monovalent or bivalent vaccines may be used.)
---------------------------------------------------------------------------
b. Before vaccinating personnel with mumps vaccine,* do not
routinely perform serologic screening for mumps unless the health care
employer considers screening cost-effective or it is requested by the
potential vaccinee (10). Category IB
c. Exclude susceptible personnel who are exposed to mumps from duty
from the 12th day after the first exposure through the 26th day after
the last exposure or if symptoms develop, until 9 days after the onset
of parotitis (7, 544) (Table 3). Category IB
11. Parvovirus
a. Ensure that pregnant personnel are aware of the risks associated
with parvovirus infection and of infection control procedures to
prevent transmission when working with high-risk patient groups (264,
265) (Table 6). Category IB
b. Do not routinely exclude pregnant personnel from caring for
patients with parvovirus B19. Category IB
12. Pertussis
a. Do not administer whole-cell pertussis vaccine to personnel
(Table 1). Category IB
b. No Recommendation for routine administration of an acellular
pertussis vaccine to health care personnel. Unresolved Issue
c. Immediately offer antimicrobial prophylaxis against pertussis to
personnel who have had unprotected (i.e., without the use of proper
precautions), intensive (i.e., close, face-to-face) contact with a
patient who has a clinical syndrome highly suggestive of pertussis and
whose cultures are pending; discontinue prophylaxis if cultures or
other tests are negative for pertussis and the clinical course is
suggestive of an alternate diagnosis (277, 278) (Table 1). Category II
d. Exclude personnel who develop symptoms (e.g., unexplained
rhinitis or acute cough) following known exposure to pertussis from
patient care until 5 days after the start of appropriate therapy (Table
3). Category IB
13. Poliomyelitis
a. Determine whether the following personnel have completed a
primary vaccination series: (1) Persons who may have contact with
patients or the secretions of patients who may be excreting wild
polioviruses; or (2) laboratory personnel who handle specimens that
might contain wild polioviruses or who do cultures to amplify virus
(19) (Table 1). Category IA
b. For personnel above, including pregnant personnel or personnel
with an immunodeficiency, who have no proof of having completed a
primary series of polio immunization, administer the enhanced
inactivated poliovirus vaccine (IPV) rather than oral polio vaccine
(OPV) for completion of the series (19) (Table 1). Category IB
c. When a case of wild-type poliomyelitis infection is detected or
an outbreak of poliomyelitis occurs, contact the CDC through the state
health department. Category IB
14. Rabies
a. Provide pre-exposure vaccination to personnel who work with
rabies virus or infected animals in rabies diagnostic or research
activities with rabies virus (3, 20) (Table 1). Category IA
b. After consultation with public health authorities, give a full
course of anti-rabies treatment to personnel who either have been
bitten by a human with rabies or have scratches, abrasions, open
wounds, or mucous membranes contaminated with saliva or other
potentially infective material from a human with rabies. In those
previously vaccinated individuals, postexposure therapy is abbreviated
to only include a single dose of vaccine on days 0 and 3 (285-287)
(Table 1). Category IB
15. Rubella
a. Vaccinate all personnel without documented immunity to rubella
with
[[Page 47298]]
rubella vaccine.* (7, 300) (Table 1) Category IA
---------------------------------------------------------------------------
* (Measles-mumps-rubella [MMR] trivalent vaccine is the vaccine
of choice. If the recipient is known to be immune to one or more of
the components, monovalent or bivalent vaccines may be used.)
---------------------------------------------------------------------------
b. Consult local and state health departments regarding regulations
for rubella immunity in health care personnel. Category IA
c. Do not perform serologic screening for rubella before
vaccinating personnel with rubella vaccine,* unless the health care
employer considers it cost-effective or the potential vaccinee requests
it (229). Category IB
d. Do not administer rubella vaccine* to susceptible personnel who
are pregnant or might become pregnant within 3 months of vaccination
(7) (Table 1). Category IA
e. Administer rubella vaccine* in the postpartum period to female
personnel not known to be immune. Category IA
f. Exclude personnel who are exposed to rubella from duty from the
7th day after the first exposure through the 21st day after the last
exposure (Table 3). Category IB
g. Exclude personnel who develop rubella from duty until 7 days
after the beginning of the rash (Table 3). Category IB
16. Scabies and Pediculosis
a. Evaluate exposed personnel for signs and symptoms of mite
infestation and provide appropriate therapy for confirmed or suspected
scabies (302). Category IA
b. Evaluate exposed personnel for louse infestation and provide
appropriate therapy for confirmed pediculosis (325). Category IA
c. Do not routinely provide prophylactic scabicide treatment of
personnel who have had contact with patients or other persons with
scabies (301, 302, 308, 321, 329) (Table 1). Category II
d. Do not routinely provide prophylactic pediculicide treatment of
personnel who have had contact with patients or other persons with
pediculosis. Category II
e. Exclude personnel with either confirmed or suspected scabies or
lice infestation from contact with patients until after they receive
appropriate initial treatment or are found not to have scabies or
pediculosis, respectively (302) (Table 3). Exclude personnel with
confirmed scabies from the care of immunocompromised patients until
after the second treatment, unless they wear gowns and gloves for
patient contact. Category IB
17. Staphylococcal Disease or Carriage
a. Obtain appropriate cultures and exclude personnel from patient
care or food handling if they have a draining lesion suspected to be
due to Staphylococcus aureus, until the infections have been ruled out
or personnel have received adequate therapy and their infections have
resolved (Table 3). Category IB
b. Do not routinely exclude personnel with suspected or confirmed
carriage of S. aureus (on nose, hand, or other body site), from patient
care or food-handling unless it is shown epidemiologically that the
person is responsible for disseminating the organism in the health care
setting (Table 3). Category IB
18. Group A Streptococcal Disease or Carriage
a. Obtain appropriate cultures, and exclude personnel from patient
care or food handling if they have draining lesions that are suspected
to be due to Streptococcus, until streptococcal infection has been
ruled out or the worker has received adequate therapy for 24 hours
(364-366, 369) (Table 3). Category IB
b. Do not routinely exclude personnel with suspected or confirmed
carriage of group A Streptococcus from patient care or foodhandling
unless it is shown epidemiologically that the person is responsible for
disseminating the organism in the health care setting (Table 3).
Category IB
19. Tuberculosis
a. General Recommendations. (1) Educate all health care personnel
regarding the recognition, transmission, and prevention of TB. Category
IB
( 2) Follow current recommendations outlined in the Guidelines for
Preventing the Transmission of Mycobacterium tuberculosis in Health-
Care Facilities, 1994 (377). Category IB
b. TB Screening Program. (1) Include all health care personnel who
have potential for exposure to M. tuberculosis in a purified protein
derivative (PPD) skin-test program (377). Category IA
(2) Maintain confidentiality regarding the medical condition of
personnel. Category IA
(3) Administer PPD tests by using the intracutaneous (Mantoux)
method of administration of 5 tuberculin units (0.1 ml) of purified
protein derivative (377, 397). Category IB
(4) Do not use the Tine or other tests to administer PPD (397).
Category IB
(5) Test personnel known to have conditions that cause severe
suppression of cell-mediated immunity (such as HIV-infected persons
with lowered CD4+ counts and organ-transplant recipients receiving
immunosuppressive therapy) for cutaneous anergy at the time of PPD
testing (377). Category IB
(6) Ensure that the administration, reading, and interpretation of
PPD tests are performed by specified trained personnel. Category IA
c. Baseline PPD. (1) Perform baseline PPD tests on health care
personnel who are new to a facility and who have potential for exposure
to M. tuberculosis. Include those with a history of BCG vaccination
(377). Category IB
(2) Perform two-step, baseline PPD tests on newly employed health
care personnel who are negative on initial PPD testing and have not had
a documented negative PPD-test result during the preceding 12 months,
unless the institution has determined that two-step testing is not
warranted in their facility (377). Category II
(3) Interpret baseline PPD-test results as outlined in the
Guidelines for Preventing the Transmission of Mycobacterium
tuberculosis in Health-Care Facilities, 1994 (377). Category IB
d. Follow-up (Repeat) PPD. (1) Perform periodic follow-up PPD tests
on all health care personnel (with negative baseline PPD test result)
who have the potential for exposure to M. tuberculosis (377). Category
IA
(2) Base the frequency of repeat PPD testing on the hospital's risk
assessment, as described in the Guidelines for Preventing the
Transmission of Mycobacterium tuberculosis in Health-Care Facilities,
1994 and as provided by federal, state, and local regulations (377).
Category IB
(3) Exempt from follow-up-PPD tests: personnel with documented
history of positive baseline PPD test result or adequate treatment for
tuberculosis (377). Category IB
(4) Interpret follow-up-PPD test results as outlined in the
Guidelines for Preventing the Transmission of Mycobacterium
tuberculosis in Health-Care Facilities, 1994 (377). Category IB
(5) Management of PPD-positive personnel.
(a) Promptly evaluate personnel with positive PPD test results for
active disease and obtain an adequate history on TB exposure to help
determine whether the infection is occupational or community acquired
(377). Category IB
(b) Perform chest x-ray examinations on personnel with a positive
PPD-test result as part of the evaluation for active TB (377). Category
IB
(c) Do not repeat chest x-rays unless symptoms suggestive of TB
develop, if
[[Page 47299]]
the initial chest x-ray examination is negative (377). Category IB
(d) Periodically remind all personnel, especially those with
positive PPD-test results, about the symptoms of TB and the need for
prompt evaluation of any pulmonary symptoms suggestive of TB (377).
Category IB
(e) Do not require routine chest x-rays for asymptomatic, PPD-
negative workers (377). Category IB
e. Preventive therapy. 1) Offer preventive therapy to the following
personnel, regardless of age, who convert their PPD test (a) recent
converters; (b) close contacts of persons with active TB; (c) those
with medical conditions that increase their risk for active TB; (d)
those with HIV infection; or (e) injecting-drug users (377, 397).
Category IB
(2) Offer preventive therapy to personnel with positive PPD
reactions who do not have the above risk factors, if they are <35 years="" of="" age="" (397).="" category="" ia="" (3)="" provide="" preventive="" therapy="" to="" personnel="" through="" the="" occupational="" health="" service="" or="" refer="" them="" to="" the="" health="" department="" or="" other="" health="" care="" provider,="" as="" appropriate.="" category="" ib="" f.="" postexposure="" management="" of="" personnel.="" 1)="" as="" soon="" as="" possible="" after="" an="" exposure="" to="" tb="" (i.e.,="" exposure="" to="" a="" person="" with="" pulmonary="" or="" laryngeal="" tb="" for="" whom="" proper="" isolation="" precautions="" were="" not="" implemented),="" conduct="" ppd="" testing="" on="" personnel="" who="" are="" known="" to="" have="" negative="" ppd-skin="" test="" results.="" when="" the="" result="" of="" this="" ppd="" test="" is="" negative,="" administer="" a="" second="" test="" 12="" weeks="" after="" the="" exposure="" (377).="" category="" ib="" (2)="" do="" not="" perform="" ppd="" tests="" or="" chest="" x-rays="" on="" personnel="" with="" prior="" positive="" ppd-test="" results="" unless="" they="" have="" symptoms="" suggestive="" of="" active="" tb="" (377).="" category="" ib="" (3)="" consider="" retesting="" immunocompromised="" health="" care="" personnel="" who="" are="" potentially="" exposed="" to="" m.="" tuberculosis="" at="" least="" every="" 6="" months="" (377).="" category="" ii="" g.="" workplace="" restrictions.="" (1)="" exclude="" personnel="" with="" infectious="" pulmonary="" or="" laryngeal="" tb="" from="" the="" workplace="" until="" the="" facility="" has="" documentation="" from="" their="" health="" care="" provider="" that="" they="" are="" receiving="" adequate="" therapy,="" their="" coughs="" have="" resolved,="" and="" that="" there="" have="" been="" three="" consecutive="" sputum="" smears="" collected="" on="" different="" days="" negative="" for="" acid-fast="" bacilli="" (afb).="" after="" personnel="" return="" to="" work,="" obtain="" periodic="" documentation="" from="" their="" health="" care="" provider="" that="" effective="" drug="" therapy="" has="" been="" maintained="" for="" the="" recommended="" time="" period="" and="" that="" sputum="" smears="" remain="" afb="" negative="" (377)="" (table="" 3).="" category="" ib="" (2)="" promptly="" evaluate="" for="" infectiousness,="" those="" personnel="" with="" active="" tb="" who="" discontinue="" treatment="" before="" they="" are="" cured.="" exclude="" from="" duty="" those="" who="" are="" found="" to="" remain="" infectious="" until="" (a)="" treatment="" is="" resumed;="" (b)="" an="" adequate="" response="" to="" therapy="" is="" documented;="" and="" (c)="" sputum="" smears="" are="" afb="" negative="" (377).="" category="" ib="" (3)="" consider="" directly="" observed="" therapy="" for="" personnel="" with="" active="" tb="" who="" have="" not="" been="" compliant="" with="" drug="" regimens.="" category="" ib="" (4)="" do="" not="" exclude="" personnel="" from="" the="" workplace="" who="" have="" tb="" only="" at="" sites="" other="" than="" the="" lung="" and/or="" larynx.="" category="" ib="" (5)="" do="" not="" restrict="" personnel="" from="" their="" usual="" work="" activities="" if="" they="" are="" receiving="" preventive="" therapy="" because="" of="" positive="" ppd="" tests="" (377).="" category="" ib="" (6)="" do="" not="" exclude="" personnel="" from="" the="" workplace="" who="" have="" positive="" ppd-test="" results="" and="" cannot="" take="" or="" do="" not="" accept="" or="" complete="" a="" full="" course="" of="" preventive="" therapy.="" instruct="" them="" to="" seek="" prompt="" evaluation="" if="" symptoms="" suggestive="" of="" tb="" develop="" (377).="" category="" ib="" h.="" immunocompromised="" personnel.="" (1)="" refer="" personnel="" who="" are="" known="" to="" be="" immunocompromised="" to="" personnel="" health="" professionals="" who="" can="" individually="" counsel="" them="" regarding="" their="" risk="" for="" tb="" (377).="" category="" ii="" (2)="" upon="" the="" request="" of="" immunocompromised="" personnel,="" offer,="" but="" do="" not="" compel,="" reasonable="" accommodations="" for="" work="" settings="" in="" which="" they="" would="" have="" the="" lowest="" possible="" risk="" for="" occupational="" exposure="" to="" m.="" tuberculosis.="" consider="" the="" provisions="" of="" the="" americans="" with="" disabilities="" act="" of="" 1990="" and="" other="" federal,="" state="" and="" local="" regulations="" in="" evaluating="" these="" situations="" (377).="" category="" ii="" i.="" bcg="" vaccination.="" 1)="" in="" settings="" associated="" with="" high="" risk="" for="" m.="" tuberculosis="" transmission:="" (a)="" consider="" bcg="" vaccination="" of="" personnel="" on="" an="" individual="" basis,="" and="" only="" in="" settings="" where="" 1)="" a="" high="" proportion="" of="" isolates="" of="" m.="" tuberculosis="" are="" resistant="" to="" isoniazid="" and="" rifampin;="" (2)="" there="" is="" a="" strong="" likelihood="" of="" transmission="" and="" infection="" with="" such="" drug-="" resistant="" organisms;="" and="" (3)="" comprehensive="" infection="" control="" precautions="" have="" been="" implemented="" and="" have="" failed="" to="" halt="" nosocomial="" transmission="" of="" tb="" (401).="" consult="" with="" the="" local="" and="" state="" health="" departments="" in="" making="" this="" determination.="" category="" ii="" (b)="" do="" not="" require="" bcg="" vaccination="" for="" employment="" or="" for="" assignment="" of="" personnel="" in="" specific="" work="" areas="" (401).="" category="" ii="" (2)="" counsel="" health="" care="" personnel="" who="" are="" being="" considered="" to="" receive="" bcg="" vaccination="" about="" the="" risks="" and="" benefits="" of="" both="" bcg="" vaccination="" and="" preventive="" therapy,="" including="" (a)="" the="" variable="" data="" on="" the="" efficacy="" of="" bcg="" vaccination;="" (b)="" the="" potentially="" serious="" complications="" of="" bcg="" vaccine="" in="" immunocompromised="" individuals,="" such="" as="" those="" with="" hiv="" infection;="" (c)="" the="" lack="" of="" information="" on="" chemoprophylaxis="" for="" multi-drug="" resistant="" tb="" infections;="" (d)="" the="" risks="" of="" drug="" toxicity="" with="" multi-drug="" prophylactic="" regimens;="" and="" (e)="" the="" fact="" that="" bcg="" vaccination="" interferes="" with="" the="" diagnosis="" of="" newly="" acquired="" tb="" infection="" (401).="" category="" ib="" (3)="" do="" not="" administer="" bcg="" vaccine="" to="" personnel="" in="" settings="" associated="" with="" a="" low="" risk="" for="" m.="" tuberculosis="" transmission.="" category="" ib="" (4)="" do="" not="" administer="" bcg="" vaccine="" to="" pregnant="" or="" immunocompromised="" persons="" with="" negative="" baseline="" ppd="" test="" results.="" category="" ii="" 20.="" vaccinia="" a.="" ensure="" that="" smallpox="" vaccination="" is="" current="" to="" within="" 10="" years="" for="" personnel="" who="" directly="" handle="" cultures="" of="" or="" animals="" contaminated="" or="" infected="" with="" vaccinia,="" recombinant="" vaccinia="" viruses,="" or="" other="" orthopox-viruses="" (e.g.,="" monkeypox,="" cowpox)="" that="" infect="" humans="" (7,="" 16)="" (table="" 1).="" category="" ib="" b.="" consider="" administering="" vaccinia="" vaccine="" to="" personnel="" who="" provide="" clinical="" care="" to="" recipients="" of="" recombinant="" vaccinia="" virus="" vaccines="" (7,="" 16)="" (table="" 1).="" category="" ii="" c.="" do="" not="" administer="" vaccinia="" vaccine="" to="" personnel="" with="" immunosuppression="" or="" eczema,="" or="" who="" are="" pregnant="" (tables="" 1="" and="" 2).="" category="" ib="" d.="" do="" not="" exclude="" from="" duty,="" personnel="" who="" receive="" the="" vaccine,="" if="" they="" keep="" the="" vaccination="" site="" covered="" and="" they="" follow="" handwashing="" practices="" (16).="" category="" ib="" 21.="" varicella="" a.="" administer="" varicella="" vaccine="" to="" susceptible="" personnel,="" especially="" those="" that="" will="" have="" contact="" with="" persons="" at="" high="" risk="" for="" serious="" complications="" (7,="" 11)="" (table="" 1).="" category="" ia="" b.="" before="" vaccinating="" personnel="" with="" varicella="" vaccine,="" do="" not="" perform="" serologic="" screening="" for="" varicella="" of="" persons="" with="" negative="" or="" uncertain="" history="" of="" varicella,="" unless="" the="" institution="" considers="" it="" cost-effective="" (7).="" category="" ib="" c.="" do="" not="" routinely="" perform="" post="" vaccination="" testing="" of="" personnel="" for="" antibodies="" to="" varicella="" (133).="" category="" ib="" [[page="" 47300]]="" d.="" no="" recommendation="" for="" administering="" postexposure="" varicella="" vaccination="" for="" the="" protection="" of="" exposed,="" susceptible="" personnel="" (7).="" unresolved="" issue="" e.="" develop="" guidelines="" for="" managing="" health="" care="" personnel="" who="" receive="" varicella="" vaccine,="" e.g.,="" consider="" precautions="" for="" personnel="" who="" develop="" a="" rash="" following="" their="" receipt="" of="" varicella="" vaccine="" and="" for="" other="" health="" care="" personnel="" who="" receive="" varicella="" vaccine="" and="" will="" have="" contact="" with="" susceptible="" persons="" at="" high="" risk="" for="" serious="" complications="" from="" varicella.="" category="" ib="" f.="" develop="" written="" guidelines="" for="" postexposure="" management="" of="" vaccinated="" or="" susceptible="" personnel="" who="" are="" exposed="" to="" wild-type="" varicella="" (7).="" category="" ib="" g.="" exclude="" personnel="" from="" work="" who="" have="" onset="" of="" varicella="" or="" zoster="" at="" least="" until="" all="" lesions="" have="" dried="" and="" crusted="" (1)="" (table="" 3).="" category="" ib="" h.="" exclude="" personnel="" from="" duty,="" following="" exposure="" to="" varicella="" or="" zoster,="" who="" are="" not="" known="" to="" be="" immune="" to="" varicella="" (by="" history="" or="" serology),="" beginning="" on="" the="" 10th="" day="" after="" the="" first="" exposure="" until="" the="" 21st="" day="" after="" the="" last="" exposure="" (7)="" (table="" 3).="" category="" ib="" i.="" perform="" serologic="" screening="" for="" immunity="" to="" varicella="" on="" exposed="" personnel="" who="" have="" not="" had="" varicella="" or="" are="" unvaccinated="" against="" varicella="" (7,="" 16).="" category="" ib="" j.="" consider="" performing="" serologic="" screening="" for="" immunity="" to="" varicella="" on="" exposed,="" vaccinated="" personnel="" whose="" antibody="" status="" is="" not="" known.="" if="" the="" test="" is="" negative,="" retest="" 5-6="" days="" following="" exposure="" for="" anamnestic="" response.="" category="" ib="" k.="" consider="" excluding="" vaccinated="" personnel="" from="" work,="" beginning="" on="" the="" 10th="" day="" after="" the="" first="" exposure="" through="" the="" 21st="" day="" after="" the="" last="" exposure,="" if="" they="" do="" not="" have="" detectable="" antibodies="" to="" varicella,="" or="" screen="" daily="" for="" symptoms="" of="" varicella="" (7)="" (table="" 3).="" category="" ib="" l.="" do="" not="" routinely="" give="" varicella-zoster="" immune="" globulin="" (vzig)="" to="" exposed="" personnel="" unless="" immunosuppressed,="" hiv="" infected,="" or="" pregnant.="" if="" vzig="" is="" given,="" exclude="" personnel="" from="" duty="" from="" the="" 10th="" day="" after="" the="" first="" exposure="" through="" the="" twenty-eighth="" day="" after="" the="" last="" exposure="" (7,="" 16)="" (tables="" 1="" and="" 3).="" category="" ib="" 22.="" viral="" respiratory="" infections="" a.="" administer="" influenza="" vaccine="" annually="" to="" all="" personnel,="" including="" pregnant="" women,="" before="" the="" influenza="" season,="" unless="" otherwise="" contraindicated="" (7,="" 15)="" (table="" 1).="" category="" ib="" b.="" consider="" the="" use="" of="" antiviral="" postexposure="" prophylaxis="" for="" unvaccinated="" health="" care="" personnel="" during="" institutional="" or="" community="" outbreaks="" of="" influenza="" for="" the="" duration="" of="" influenza="" activity,="" and="" vaccination="" of="" personnel="" who="" did="" not="" receive="" vaccine="" prior="" to="" influenza="" infections="" in="" the="" community="" in="" conjunction="" with="" antiviral="" postexposure="" prophylaxis="" for="" 2="" weeks="" following="" vaccination="" (1,="" 449)="" (table="" 1).="" category="" ib="" c.="" consider="" excluding="" personnel="" with="" acute="" febrile="" respiratory="" infections,="" or="" with="" laboratory="" evidence="" of="" epidemiologically="" significant="" viruses="" from="" the="" care="" of="" high-risk="" patients="" (e.g.,="" neonates,="" young="" infants,="" patients="" with="" chronic="" obstructive="" lung="" disease,="" and="" immunocompromised="" patients)="" during="" community="" outbreaks="" of="" influenza="" or="" rsv="" infections="" (1)="" (table="" 3).="" category="" ib="" h.="" special="" issues="" 1.="" pregnancy="" a.="" counsel="" pregnant="" women="" and="" women="" of="" childbearing="" age="" regarding="" the="" risk="" of="" transmission="" of="" particular="" infectious="" diseases="" (e.g.,="" cmv,="" hepatitis,="" herpes="" simplex,="" hiv,="" parvovirus,="" rubella)="" that,="" if="" acquired="" during="" pregnancy,="" may="" have="" adverse="" effects="" on="" the="" fetus,="" whether="" the="" infection="" is="" acquired="" in="" non-occupational="" or="" occupational="" environments="" (122).="" provide="" such="" women="" with="" information="" on="" standard="" and="" transmission-based="" precautions="" appropriate="" for="" each="" infection="" (1,="" 123)="" (table="" 6).="" category="" ib="" b.="" do="" not="" routinely="" exclude="" women,="" on="" the="" basis="" only="" of="" their="" pregnancy="" or="" intent="" to="" be="" pregnant,="" from="" the="" care="" of="" patients="" with="" particular="" infections="" that="" have="" potential="" to="" harm="" the="" fetus,="" (e.g.,="" cmv,="" hiv,="" hepatitis,="" herpes="" simplex,="" parvovirus,="" rubella,="" and="" varicella)="" (480-482)="" (table="" 6).="" category="" ib="" 2.="" emergency="" response="" employees="" ensure="" that="" emergency="" response="" employees="" are="" routinely="" notified="" of="" infectious="" diseases="" in="" patients="" they="" have="" cared="" for="" or="" transported,="" in="" accordance="" with="" the="" mandates="" of="" the="" 1990="" ryan="" white="" comprehensive="" aids="" resources="" emergency="" act="" (subtitle="" b="" 42="" u.s.c.="" 300ff-80).="" category="" ia="" 3.="" personnel="" linked="" to="" outbreaks="" of="" bacterial="" infection="" a.="" perform="" cultures="" and="" organism="" typing="" only="" on="" personnel="" who="" are="" linked="" epidemiologically="" to="" an="" increase="" in="" bacterial="" infections="" caused="" by="" a="" pathogen="" associated="" with="" a="" carrier="" state;="" if="" cultures="" are="" positive,="" exclude="" personnel="" from="" patient="" contact="" until="" carriage="" is="" eradicated="" or="" the="" risk="" of="" disease="" transmission="" is="" eliminated.="" category="" ib="" b.="" do="" not="" perform="" routine="" surveillance="" cultures="" of="" health="" care="" personnel="" for="" bacteria="" or="" multidrug-resistant="" organisms="" in="" the="" absence="" of="" a="" cluster="" or="" epidemic="" of="" bacterial="" infections="" in="" which="" personnel="" are="" implicated.="" category="" ia="" c.="" do="" not="" exclude="" personnel="" from="" duty="" who="" are="" colonized="" by="" bacteria,="" including="" multidrug-resistant="" bacteria,="" who="" are="" not="" epidemiologically="" linked="" to="" an="" increase="" in="" infections.="" category="" ib="" 4.="" latex="" hypersensitivity="" a.="" develop="" an="" institutional="" protocol="" for="" (1)="" evaluating="" and="" managing="" personnel="" with="" suspected="" or="" known="" latex="" allergy;="" (2)="" establishing="" surveillance="" for="" latex="" reactions="" within="" the="" facility;="" and="" (3)="" measuring="" the="" impact="" of="" preventive="" measures.="" educational="" materials="" and="" activities="" should="" be="" provided="" to="" inform="" personnel="" about="" the="" manifestations="" and="" potential="" risk="" of="" latex="" allergy.="" category="" ib="" b.="" purchasers="" should="" consider="" barrier="" effectiveness="" and="" worker="" acceptance="" (e.g.,="" comfort,="" fit)="" when="" selecting="" gloves="" for="" use="" in="" the="" health="" care="" organization.="" when="" nonlatex="" gloves="" are="" selected,="" they="" should="" have="" comparable="" barrier="" effectiveness="" to="" latex="" gloves="" (494).="" category="" ib="" c.="" provide="" workers="" with="" a="" list="" of="" nonlatex="" glove="" alternatives="" or,="" if="" possible,="" low-allergen="" latex="" gloves="" that="" are="" available="" within="" the="" organization.="" category="" ib="" d.="" question="" all="" personnel="" for="" symptoms="" suggestive="" of="" latex="" allergy="" (e.g.,="" localized="" dermatitis,="" workplace-related="" asthma)="" during="" preemployment="" and="" periodic="" evaluations="" (520).="" use="" serologic="" tests="" only="" for="" confirmation="" in="" those="" who,="" based="" on="" clinical="" history,="" are="" suspected="" to="" be="" latex="" allergic.="" category="" ib="" e.="" avoid="" the="" use="" of="" all="" latex="" products="" in="" personnel="" with="" a="" history="" of="" systemic="" reactions="" to="" latex.="" category="" ib="" f.="" use="" nonlatex="" gloves="" or="" powder-free="" latex="" gloves,="" or="" double-glove="" with="" cloth="" or="" vinyl="" gloves="" beneath="" latex="" gloves="" for="" personnel="" with="" localized="" reactions="" to="" latex="" (e.g.,="" irritant="" or="" allergic="" contact="" dermatitis).="" category="" ib="" g.="" consider="" targeted="" substitution="" of="" nonlatex="" gloves="" and/or="" powder-="" free="" latex="" gloves="" in="" areas="" of="" the="" facility="" or="" among="" groups="" where="" glove="" use="" is="" high="" (e.g.,="" operative="" suite,="" nursing)="" or="" in="" areas="" where="" large="" numbers="" of="" personnel="" have="" developed="" latex="" allergy="" (499,="" 527,="" 528).="" category="" ib="" [[page="" 47301]]="" h.="" no="" recommendation="" for="" institution-wide="" substitution="" of="" nonlatex="" products="" in="" health="" care="" facilities="" to="" prevent="" sensitization="" to="" latex="" among="" health="" care="" personnel.="" unresolved="" issue="" i.="" no="" recommendation="" for="" the="" routine="" use="" of="" environmental="" abatement="" interventions="" such="" as="" laminar="" flow="" to="" reduce="" latex="" aeroallergens.="" unresolved="" issuereferences="" 1.="" garner="" js,="" hospital="" infection="" control="" practices="" advisory="" committee.="" guideline="" for="" isolation="" precautions="" in="" hospitals.="" infect="" control="" hosp="" epidemiol="" 1996;="" 17:53-80.="" 2.="" williams="" ww.="" cdc="" guideline="" for="" infection="" control="" in="" hospital="" personnel.="" infect="" control="" 1983;="" 4:326-349.="" 3.="" cdc/national="" institutes="" for="" health.="" biosafety="" in="" microbiological="" and="" biomedical="" laboratories.="" 3rd="" ed.="" u.s.="" government="" printing="" office,="" 1993.="" 4.="" national="" committee="" for="" clinical="" laboratory="" standards.="" protection="" of="" laboratory="" workers="" from="" infectious="" disease="" transmitted="" by="" blood,="" body="" fluids,="" and="" tissue:="" tentative="" guideline.="" nccls="" document="" m29-t2="" 1991;="" 11(no.14):1-214.="" 5.="" heseltine="" pnr,="" ripper="" m,="" wohlford="" p.="" nosocomial="" rubella--="" consequences="" of="" an="" outbreak="" and="" efficacy="" of="" a="" mandatory="" immunization="" program.="" infect="" control="" 1997;="" 6:371-374.="" 6.="" centers="" for="" disease="" control="" and="" prevention.="" update="" on="" adult="" immunization:="" recommendations="" of="" the="" immunization="" practices="" advisory="" committee="" (acip).="" mmwr="" 1991;="" 40(rr-12):1-94.="" 7.="" centers="" for="" disease="" control="" and="" prevention,="" advisory="" committee="" on="" immunization="" practices="" and="" the="" hospital="" infection="" control="" practices="" advisory="" commitee.="" immunization="" of="" health="" care="" workers.="" mmwr="" 1997;="" in="" press.="" 8.="" centers="" for="" disease="" control.="" protection="" against="" viral="" hepatitis:="" recommendations="" of="" the="" advisory="" committee="" on="" immunization="" practices="" (acip).="" mmwr="" 1990;="" 39(rr-2):1-27.="" 9.="" centers="" for="" disease="" control.="" measles="" prevention:="" recommendations="" of="" the="" advisory="" committee="" on="" immunization="" practices="" (acip).="" mmwr="" 1989;="" 38(s-9):1-18.="" 10.="" centers="" for="" disease="" control.="" mumps="" prevention:="" recommendations="" of="" the="" immunization="" practices="" advisory="" committee="" (acip).="" mmwr="" 1989;="" 38:388-392-397-400.="" 11.="" centers="" for="" disease="" control="" and="" prevention.="" prevention="" of="" varicella:="" recommendations="" of="" the="" advisory="" committee="" on="" immunizations="" practices="" (acip).="" mmwr="" 1996;="" 45(rr-1):1-36.="" 12.="" centers="" for="" disease="" control.="" rubella="" prevention:="" recommedations="" of="" the="" advisory="" committee="" on="" immunization="" practices="" (acip).="" mmwr="" 1990;="" 39(rr-15):1-18.="" 13.="" centers="" for="" disease="" control="" and="" prevention.="" control="" and="" prevention="" of="" meningococcal="" disease:="" evaluation="" and="" management="" of="" suspected="" outbreaks;="" and="" control="" and="" prevention="" of="" serogroup="" c="" meningococcal="" disease:="" evaluation="" and="" management="" of="" suspected="" outbreaks:="" recommendations="" of="" the="" advisory="" committee="" on="" immunization="" practices="" (acip).="" mmwr="" 1997;="" 46(rr-5):1-21.="" 14.="" centers="" for="" disease="" control="" and="" prevention.="" update:="" vaccine="" side="" effects,="" adverse="" reactions,="" contraindications,="" and="" precautions:="" recommendations="" of="" the="" advisory="" committee="" on="" immunization="" practices="" (acip).="" mmwr="" 1996;="" 45(rr-12):1-35.="" 15.="" centers="" for="" disease="" control="" and="" prevention.="" prevention="" and="" control="" of="" influenza:="" recommendations="" of="" the="" advisory="" committee="" on="" immunization="" practices="" (acip).="" mmwr="" 1997;="" 46(rr-9):1-25.="" 16.="" centers="" for="" disease="" control.="" vaccinia="" (smallpox)="" vaccine:="" recommendations="" of="" the="" immunization="" practices="" advisory="" committee="" (acip).="" mmwr="" 1991;="" 40(rr-14):1-10.="" 17.="" centers="" for="" disease="" control.="" diphtheria,="" tetanus,="" pertussis:="" recommendations="" for="" vaccine="" use="" and="" other="" preventive="" measures:="" recommendations="" of="" the="" immunization="" practices="" advisory="" committee="" (acip).="" mmwr="" 1991;="" 40(rr-10):1-28.="" 18.="" centers="" for="" disease="" control="" and="" prevention.="" prevention="" of="" pneumococcal="" disease:="" recommendations="" of="" the="" advisory="" committee="" on="" immunization="" practices="" (acip).="" mmwr="" 1997;="" 46(rr-8):1-24.="" 19.="" centers="" for="" disease="" control="" and="" prevention.="" poliomyelitis="" prevention="" in="" the="" united="" states:="" introduction="" of="" a="" sequential="" vaccination="" schedule="" of="" inactivated="" poliovirus="" vaccine="" followed="" by="" oral="" poliovirus="" vaccine:="" recommendations="" of="" the="" advisory="" committee="" on="" immunization="" practices="" (acip).="" mmwr="" 1997;="" 46(rr-3):1-25.="" 20.="" centers="" for="" disease="" control.="" rabies="" prevention--united="" states,="" 1991:="" recommendations="" of="" the="" immunizations="" practices="" advisory="" committee="" (acip).="" mmwr="" 1991;="" 40(rr-3):1-19.="" 21.="" centers="" for="" disease="" control="" and="" prevention.="" recommedations="" of="" the="" advisory="" committee="" on="" immunization="" practices="" (acip):="" use="" of="" vaccines="" and="" immune="" globulins="" in="" persons="" with="" altered="" immunocompetence.="" mmwr="" 1993;="" 42(rr-4):1-18.="" 22.="" american="" college="" of="" physicians="" task="" force="" on="" adult="" immunization="" and="" infectious="" diseases="" society="" of="" america.="" guide="" for="" adult="" immunization.="" 3rd="" ed.="" philadelphia:="" american="" college="" of="" physicians,="" 1994.="" 23.="" anonymous.="" record="" keeping="" guidelines="" for="" occupational="" injuries="" and="" illnesses:="" the="" occupational="" safety="" and="" health="" act="" of="" 1970="" and="" 29="" cfr="" 1904.omb="" no.="" 120-0029.="" 1986;="" washington,="" dc:="" 24.="" department="" of="" labor.occupational="" safety="" and="" health="" administration.="" occupational="" exposure="" to="" bloodborne="" pathogens;="" final="" rule.="" fed="" reg="" 1991;="" 56:64004-64182.="" 25.="" u.s.department="" of="" labor.,="" occupational="" safety="" and="" health="" administration.="" enforcement="" procedures="" and="" scheduling="" for="" occupational="" exposure="" to="" tuberculosis.="" osha="" instruction="" 1996;="" cpl="" 2.106:="" 26.="" centers="" for="" disease="" control.="" recommendations="" for="" prevention="" of="" hiv="" transmission="" in="" health-care="" settings.="" mmwr="" 1987;="" 36(s-2):1s-="" 18s.="" 27.="" centers="" for="" disease="" control.="" update:="" universal="" precautions="" for="" prevention="" of="" tranmission="" of="" human="" immunodeficiency="" virus,="" hepatitis="" b="" virus,="" and="" other="" bloodborne="" pathogens="" in="" health-care="" settings.="" mmwr="" 1988;="" 37:377-382,="" 387-388.="" 28.="" centers="" for="" disease="" control.="" guidelines="" for="" prevention="" of="" transmission="" of="" human="" immunodeficiency="" virus="" and="" hepatitis="" b="" virus="" to="" health-care="" and="" public-safety="" workers.="" mmwr="" 1989;="" 38(s-6):1-36.="" 29.="" centers="" for="" disease="" control.="" public="" health="" service="" statement="" on="" management="" of="" occupational="" exposure="" to="" human="" immunodeficiency="" virus,="" including="" considerations="" regarding="" zidovudine="" postexposure="" use.="" mmwr="" 1990;="" 39(rr-1):1-14.="" 30.="" centers="" for="" disease="" control.="" public="" health="" service="" inter-="" agency="" guidelines="" for="" screening="" donors="" of="" blood,="" plasma,="" organs,="" tissues,="" and="" semen="" for="" evidence="" of="" hepatitis="" b="" and="" hepatitis="" c.="" mmwr="" 1991;="" 40(rr-4):13-14.="" 31.="" centers="" for="" disease="" control="" and="" prevention.="" recommended="" infection="" control="" practices="" for="" dentistry.="" mmwr="" 1993;="" 42(rr-8):1-12.="" 32.="" centers="" for="" disease="" control="" and="" prevention.="" human="" immunodeficiency="" virus="" transmission="" in="" household="" settings-united="" states.="" mmwr="" 1994;="" 43:347-353,="" 356.="" 33.="" centers="" for="" disease="" control="" and="" prevention.="" risk="" of="" acquiring="" hepatitis="" c="" for="" health-care="" workers="" and="" recommendations="" for="" prophylaxis="" and="" follow-up="" after="" occupational="" exposure.="" hepatitis="" surveillance="" report="" 1996;="" 56:3-7.="" 34.="" cdc/national="" institutes="" for="" health.="" agent="" summary="" statement:="" retroviruses,="" including="" human="" and="" simian="" immunodeficiency="" viruses.="" in:="" richmond="" jy,="" mckinney="" rw,="" editors.="" biosafety="" in="" microbiological="" and="" biomedical="" laboratories.="" 3rd="" ed.="" washington,="" d.c.="" u.s.="" government="" printing="" office,="" 1993:116-121.="" 35.="" centers="" for="" disease="" control="" and="" prevention.="" occupationally="" acquired="" human="" immunodeficiency="" virus="" infections="" in="" laboratories="" producing="" virus="" concentrates="" in="" large="" quantities:="" conclusions="" and="" recommendations="" of="" an="" expert="" team="" convened="" by="" the="" director="" of="" the="" national="" institutes="" of="" health="" (nih).="" mmwr="" 1988;="" 37="" (s-4):19-22.="" 36.="" centers="" for="" disease="" control.="" hepatitis="" b="" virus:="" a="" comprehensive="" strategy="" for="" eliminating="" transmission="" in="" the="" united="" states="" through="" universal="" childhood="" vaccination="" recommendations="" of="" the="" immunization="" practices="" advisory="" committee="" (acip).="" mmwr="" 1991;="" 40(rr-13):1-25.="" 37.="" centers="" for="" disease="" control="" and="" prevention.="" evaluation="" of="" safety="" devices="" for="" preventing="" percutaneous="" injuries="" among="" health-="" care="" workers="" during="" phlebotomy="" procedures--minneapolis-st.paul,="" new="" york="" city,="" and="" san="" francisco,="" 1993-1995.="" mmwr="" 1997;="" 46:21-25.="" 38.="" centers="" for="" disease="" control="" and="" prevention.="" evaluation="" of="" blunt="" suture="" needles="" in="" preventing="" percutaneous="" injuries="" among="" health-care="" workers="" during="" gynecologic="" surgical="" 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omitted]="" tn08se97.003="" [[page="" 47316]]="" [graphic]="" [tiff="" omitted]="" tn08se97.004="" [[page="" 47317]]="" [graphic]="" [tiff="" omitted]="" tn08se97.005="" [[page="" 47318]]="" [graphic]="" [tiff="" omitted]="" tn08se97.006="" [[page="" 47319]]="" [graphic]="" [tiff="" omitted]="" tn08se97.007="" [[page="" 47320]]="" [graphic]="" [tiff="" omitted]="" tn08se97.008="" [[page="" 47321]]="" [graphic]="" [tiff="" omitted]="" tn08se97.009="" [[page="" 47322]]="" [graphic]="" [tiff="" omitted]="" tn08se97.010="" [[page="" 47323]]="" [graphic]="" [tiff="" omitted]="" tn08se97.011="" [[page="" 47324]]="" [graphic]="" [tiff="" omitted]="" tn08se97.012="" [[page="" 47325]]="" [graphic]="" [tiff="" omitted]="" tn08se97.013="" [[page="" 47326]]="" [graphic]="" [tiff="" omitted]="" tn08se97.014="" [[page="" 47327]]="" [graphic]="" [tiff="" omitted]="" tn08se97.015="" [fr="" doc.="" 97-23677="" filed="" 9-5-97;="" 8:45="" am]="" billing="" code="" 4163-18-c="">