[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]]

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Part V





Department of Health and Human Services





_______________________________________________________________________



Centers for Disease Control and Prevention



_______________________________________________________________________



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.

-----------------------------------------------------------------------

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 
this draft document may be viewed and photocopied at most libraries 
designated as U.S. Government Depository Libraries and at many other 
public and academic libraries that receive the Federal Register 
throughout the country. Addresses and telephone numbers of the U.S. 
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The Federal Register is also available online on the Superintendent of 
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FOR FURTHER INFORMATION CONTACT: The CDC Fax Information Center, 
telephone (888) 232-3299 and order document number 370160 or, for voice 
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.

[[Page 47277]]

    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

[[Page 47279]]

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

[[Page 47281]]

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 <gr-thn-eq>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 <gr-thn-eq>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).

[[Page 47282]]

    Personnel who develop an acute gastrointestinal illness, defined as 
vomiting and/or diarrhea (i.e., <gr-thn-eq>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 
<gr-thn-eq>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 <gr-thn-eq>2 consecutive stool 
cultures obtained <gr-thn-eq>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<SUP></SUP> and 
VAQTA<SUP></SUP>, 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 <gr-thn-eq>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 
<gr-thn-eq>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 <gr-thn-eq>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

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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 <gr-thn-eq>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 <gr-thn-eq>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 <gr-thn-eq>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. 
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