47276 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

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

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receive the Federal Register throughout

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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. Hospitalbased 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.
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 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 nonpatient 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 workrelated 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 costeffectiveness 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 vaccinepreventable 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
47278 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

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 jobrelated 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) recordkeeping 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
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 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 antigenpositive 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 antiHBs 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 hospitalbased 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
47280 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

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 antiHCV 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 antiHCV 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 antiHCV-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 casecontrol 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 bonemarrow 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 CMVinfected 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
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 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 ≥2

weeks, but communicability can persist

for several months (136). Droplet

precautions are recommended for

patients with pharyngeal symptoms,

and contact precautions are

recommended for patients with

cutaneous lesions. Precautions need to

be maintained until antibiotic therapy is

completed and two cultures taken ≥24

hours apart are negative (1).

Limited serosurveys conducted since

1977 in the United States indicate that

22%–62% of adults 18–39 years of age

may lack protective diphtheria antibody

levels (137–141). Prevention of

diphtheria is best accomplished by

maintaining high levels of diphtheria

immunity among children and adults

(17, 130, 131). Immunization with

tetanus and diphtheria toxoid (Td) is

recommended every 10 years for all

adults who have completed the primary

immunization series (7, 17) (Table 1).

Health care personnel need to consider

obtaining Td immunization from their

health care providers (7).

To determine if health care personnel

directly exposed to oral secretions of

patients infected with toxigenic strains

of C. diphtheriae are carriers, cultures of

the nasopharynx may be obtained.

Exposed personnel need to be evaluated

for evidence of disease daily for 1 week

(142). Although the efficacy of

antimicrobial prophylaxis in preventing

secondary disease has not been proven,

prophylaxis with either a single IM

injection of benzathine penicillin (1.2

million units) or oral erythromycin (1 g/

day) for 7 days has been recommended

(17). Follow-up nasopharyngeal cultures

for C. diphtheriae need to be obtained

after antimicrobial therapy is

completed. If the organism has not been

eradicated, a 10-day course of

erythromycin needs to be given (142). In

addition, previously immunized,

exposed personnel need to receive a

dose of Td if they have not been

vaccinated within the previous 5 years

(17).

Exclusion from duty is indicated for

personnel with C. diphtheriae infection

or those identified as asymptomatic

carriers until antimicrobial therapy is

completed and nasopharyngeal cultures

are negative.

5. Gastrointestinal Infections

Acute gastrointestinal infections may

be caused by a variety of agents,

including bacteria, viruses, and

protozoa. However, only a few agents

have been documented in nosocomial

transmission (Table 5) (143–161).

Nosocomial transmission of agents that

cause gastrointestinal infections usually

results from contact with infected

individuals (143, 154, 156, 162); from

consumption of contaminated food,

water, or other beverages (143, 159,

162); or from exposure to contaminated

objects or environmental surfaces (145,

146, 163). Airborne transmission of

small round-structured viruses

(Norwalk-like viruses) has been

postulated but not proven (157, 158,

164–167). Inadequate handwashing by

health care personnel (168) and

inadequate sterilization or disinfection

of patient-care equipment and

environmental surfaces increase the

likelihood of transmission of agents that

cause gastrointestinal infections.

Generally, adherence to good personal

hygiene by personnel before and after

all contacts with patients or food and to

either Standard or Contact Precautions

(1) will minimize the risk of

transmitting enteric pathogens (160,

169).

Laboratory personnel who handle

infectious materials may also be at risk

for occupational acquisition of

gastrointestinal infections, most

commonly with Salmonella typhi.

Although the incidence of laboratoryacquired 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 liveattenuated 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).
47282 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

Personnel who develop an acute

gastrointestinal illness, defined as

vomiting and/or diarrhea (i.e., ≥3 loose

stools in a 24-hour period) with or

without associated symptoms such as

fever, nausea, and abdominal pain, are

likely to have high concentrations of the

infecting agent in their feces (bacteria,

viruses, and parasites) or vomitus

(viruses and parasites) (158, 171, 172).

It is important to determine the etiology

of gastrointestinal illness in health care

personnel who care for patients at high

risk for severe disease (e.g., newborns,

the elderly, and immunocompromised

patients). The initial evaluation of

personnel with gastroenteritis needs to

include a thorough history and

determination of the need for specific

laboratory tests such as stool or blood

cultures, staining procedures, and

serologic or antigen/antibody tests (155,

163, 173, 174).

After resolution of some acute

bacterial gastrointestinal illnesses, some

personnel may have persistent carriage

of the infectious agent. However, once

the person has clinically recovered and

is having formed stools, the risk of

transmission of enteric pathogens is

minimal when there is adherence to

Standard Precautions (1, 160). In

addition, appropriate antimicrobial

therapy may eradicate fecal carriage of

Shigella (175) or Campylobacter (176).

However, antimicrobial or antiparasitic

therapy may not eliminate carriage of

Salmonella (177) or Cryptosporidium.

Moreover, antimicrobials may prolong

excretion of Salmonella (178) and lead

to emergence of resistant strains (179).

However, transmission of Salmonella to

patients from personnel who are

asymptomatic carriers of Salmonella has

not been well documented (160). In

general, antimicrobial therapy is not

recommended unless the person is at

high risk for severe disease (180). When

antibiotics are given, stool cultures

should be obtained ≥48 hours after

completion of antibiotic therapy.

Restriction from patient care or foodhandling is indicated for personnel with

diarrhea or acute gastrointestinal

symptoms, regardless of the causative

agent (1, 163). Some local and state

agencies have regulations that require

work exclusion for health care

personnel and/or food handlers who

have gastrointestinal infections caused

by Salmonella or Shigella. These

regulations may require that such

personnel be restricted from duty until

≥2 consecutive stool cultures obtained

≥24 hours apart are negative.

6. Hepatitis A

Nosocomial hepatitis A occurs

infrequently and transmission to

personnel usually occurs when the

source patient has unrecognized

hepatitis and is fecally incontinent or

has diarrhea (181–190). Other risk

factors for hepatitis A virus (HAV)

transmission to personnel include

activities that increase the risk of fecaloral contamination, such as (a) eating or

drinking in patient-care areas (181, 183,

185, 191); (b) not washing hands after

handling an infected infant (183, 191,

192) and (c) sharing food, beverages, or

cigarettes with patients, their families,

or other staff (181, 183);.

HAV is transmitted primarily by the

fecal-oral route. It has not been reported

to occur after inadvertent needlesticks

or other contact with blood, but has

rarely been reported to be transmitted

by transfusion of blood products (185,

193, 194). The incubation period for

HAV is 15–50 days. Fecal excretion of

HAV is greatest during the incubation

period of disease before the onset of

jaundice (195). Once disease is

clinically obvious, the risk of

transmitting infection is decreased.

However, some patients admitted to the

hospital with HAV, particularly

immunocompromised patients, may still

be shedding virus because of prolonged

or relapsing disease and they are

potentially infective (182, 195). Fecal

shedding of HAV, formerly believed to

continue only for up to 2 weeks after

onset of dark urine (195), has been

shown to occur for up to 6 months after

diagnosis of infection in premature

infants (181). Anicteric infection is

typical in young children and infants

(196).

Personnel can protect themselves and

others from infection with HAV by

following Standard Precautions (1).

Foodborne transmission of hepatitis A is

not discussed in this guideline, but has

occurred in health care settings (197,

198).

Two inactivated hepatitis A vaccines,

HAVRIX and VAQTA, are now

available and provide long-term

preexposure protection against clinical

infection with >94% efficacy (196).

Serologic surveys among health care

personnel have not shown an elevated

prevalence of HAV infection compared

with control populations (47, 184, 199,

200); therefore, routine administration

of vaccine in health care personnel is

not recommended. Vaccine may be

useful for personnel working in areas

where HAV is highly endemic and is

indicated for personnel who handle

HAV infected primates or are exposed to

HAV in a research laboratory. The role

of hepatitis A vaccine in controlling

outbreaks has not been adequately

investigated (7). Immune globulin (IG)

given within 2 weeks following an HAV

exposure is >85% effective in

preventing hepatitis A virus infection

(196) and may be advisable in some

outbreak situations (7, 196).

Restriction from patient care or foodhandling 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
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 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 costeffective 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.
47284 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

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, selflimited 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
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 47285

respiratory tract of infected persons. The

incubation period is usually 7–10 days.

The period of communicability starts at

the onset of the catarrhal stage and

extends into the paroxysmal stage.

Preventing secondary transmission of

pertussis is especially difficult during

the early stages of the disease because

pertussis is highly communicable in the

catarrhal stage when the symptoms are

nonspecific and the diagnosis is

uncertain.

During nosocomial pertussis

outbreaks, the risk of acquiring infection

among patients or personnel is often

difficult to quantify because exposure is

not easily determined. Furthermore,

clinical symptoms in adults are less

severe than in children and may not be

recognized as pertussis. Pertussis

should be considered for any person

presenting with an acute cough lasting

≥7 days, particularly if accompanied by

paroxysms of coughing, inspiratory

whoop, or post-tussive vomiting (270,

271).

Prevention of transmission of B.

pertussis in health care settings involves

(a) early diagnosis and treatment of

patients with clinical infection; (b)

implementation of Droplet Precautions

for infectious patients (1); (c) exclusion

of infectious personnel from work; and

(d) administration of postexposure

prophylaxis to persons exposed to

infectious patients (269). Patients with

suspected or confirmed pertussis who

are admitted to the hospital need to be

placed on Droplet Precautions until they

improve clinically and have received

antimicrobial therapy for at least 5 days.

Vaccination of adolescents and adults

with whole-cell B. pertussis vaccine is

not recommended (17) because local

and systemic reactions have been

observed more frequently in these

groups than in children. Acellular

pertussis vaccine is immunogenic in

adults and has a lower risk of adverse

events than does whole-cell vaccine

(270, 276). However, the acellular

vaccine has not been licensed for use in

persons ≥7 years old. Because immunity

among vaccine recipients wanes 5–10

years after the last vaccine dose (usually

given at 4–6 years of age), personnel

may play an important role in

transmitting pertussis to susceptible

infants. However, additional studies are

needed to assess whether booster doses

of acellular vaccines are indicated for

adults.

Postexposure prophylaxis is indicated

for personnel exposed to pertussis; a 14

-day course of either erythromycin (500

mg qid po) or trimethoprimsulfamethoxazole (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 nonbite) 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
47286 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

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 costeffective 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), longterm 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-tohead contact or by contact with infested

fomites such as hats, combs, or brushes.
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 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-shocklike 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
47288 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

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). Skintest 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 skintest 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-Gue ́rin 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 twostep 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 PPDtest 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 costeffective 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
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 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 CalmetteGue ́rin 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 reevaluated (401). The following is a

summary of the joint statement by the

Advisory Council for the Elimination of

Tuberculosis and ACIP regarding the

use of BCG in health care personnel.

Two recent meta-analyses of 18 and

26 BCG studies, respectively, indicate

that the efficacy of BCG vaccine in

preventing serious TB in children is

high (>80%) and suggested 50% efficacy

in adults (399, 400); however, the

protective efficacy of the vaccine in

adolescents and adults, including health

care personnel and HIV-infected

children and adults, has not been

determined (401).

BCG vaccination may be indicated for

health care personnel in a few

geographic areas where the prevalence

of MDR–TB is high, transmission of TB

is likely, and TB infection control

measures have not been successful in

controlling nosocomial transmission

(401). BCG vaccination often results in

local adverse effects (such as muscular

soreness, erythema, purulent drainage,

axillary or cervical lymphadenopathy

for as long as 3 months after

vaccination); serious long-term

complications (such as musculoskeletal

lesions, multiple lymphadenitis, and

disseminated BCG disease) are

infrequent (402–404). The safety of BCG

vaccination in immunocompromised

populations (i.e., immunocompromised

from immune deficiency diseases, HIV

infection, leukemia, lymphoma, or

generalized malignancy, or

immunosuppressed as a result of

therapy with corticosteroids, alkylating

drugs, antimetabolites, or radiation) has

not been determined by adequate

epidemiologic studies. However,

because of the possibility of

disseminated BCG infection in such

persons (405–408), BCG vaccination is

not recommended for

immunocompromised personnel (401).

PPD testing is not contraindicated for

persons who have received BCG vaccine

and can be used to support or exclude

the diagnosis of infection with M.

tuberculosis (401). PPD-test reactivity

caused by BCG vaccination wanes with

time (409–411) and is unlikely to persist

>10 years after vaccination in the

absence of infection with M.

tuberculosis (409, 410). After a person

has been vaccinated with BCG, the

presence or size of a PPD-test reaction

cannot be used as a predictor of BCG

vaccine efficacy in the vaccine recipient

(412, 413), or as a determinant as to

whether the reaction is caused by

infection with M. tuberculosis or the

prior BCG vaccination (414). However, a

BCG-vaccinated person who has a PPD

test reaction of ≥10 mm induration is

considered infected with TB, especially

if the vaccinee is a contact of a person

with infectious TB, is from a country

with high prevalence of TB, or is

continually exposed to populations in

which the prevalence of TB is high

(401).

20. Vaccinia (Smallpox)

Because of the effective use of

smallpox vaccine (vaccinia virus

vaccine), the World Health Organization

declared the world free of smallpox in

1980. The smallpox vaccine licensed for

use in the United States is derived from

infectious vaccinia virus. After

vaccination, the virus can be cultured

from the vaccination site until the scab

has separated from the skin (2–21 days

after vaccination); thus, susceptible

persons may acquire vaccinia from a

recently vaccinated person (415–418).

Covering the vaccination site and

washing hands following contact with

the vaccination site (including

bandages) will prevent transmission.

Recently, recombinant vaccinia viruses

have been engineered. There is a

theoretical risk that transmission could

occur from contact with contaminated

dressings or by contact with

recombinant vaccine, but no such

transmission has been reported among

personnel who provide care to the

recombinant vaccine recipients.

Infections also have been reported

among laboratory personnel who handle

viral cultures or materials contaminated

with vaccinia or recombinant viruses

(16, 155).

Smallpox vaccination is indicated for

personnel who work directly with

orthopox viruses (e.g., monkeypox,

vaccinia, variola) or in animal-care areas

where orthopox-viruses are studied. In

selected instances, vaccination may be

considered for personnel who provide

care to recipients of recombinant

vaccinia vaccine (7, 16). Personnel who

receive the vaccine may continue to

have contact with patients if the

vaccination site is covered and

handwashing is maintained (16).

21. Varicella

Nosocomial transmission of varicellazoster 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 varicellasusceptible 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 varicellazoster 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).
47290 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

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 wildtype 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
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 47291

settings. Nosocomial respiratory

infections can be caused by a number of

viruses, including adenoviruses,

influenza virus, parainfluenza viruses,

respiratory syncytial virus (RSV), and

rhinoviruses. Because influenza and

RSV substantially contribute to the

morbidity and mortality associated with

viral pneumonia and both have been

well studied epidemiologically, this

section focuses on prevention of these

two viral infections among personnel.

Additional information on influenza

and RSV can be found in the Guideline

for Prevention of Nosocomial

Pneumonia (449).

a. Influenza. Nosocomial transmission

of influenza has been reported in acute

and long-term care facilities (450–455).

Transmission has occurred from

patients to health care personnel (452,

454), from health care personnel to

patients (456), and among health care

personnel (455, 457–462) .

Influenza is believed to be transmitted

from person to person by direct

deposition of virus laden large droplets

onto the mucosal surfaces of the upper

respiratory tract of an individual during

close contact with an infected person, as

well as by droplet nuclei or smallparticle aerosols (19, 279, 463). While

the extent of transmission by viruscontaminated hands or fomites is not

known, it is not the primary mode of

transmission (463).

The incubation period of influenza is

usually 1–5 days, and the period of

greatest communicability is during the

first 3 days of illness. However, virus

can be shed before the onset of

symptoms and up to 7 days after illness

onset (464–466). Persons at greatest risk

for influenza-related complications

include (a) persons ≥65 years of age; (b)

residents of nursing homes and other

chronic-care facilities; (c) persons with

chronic pulmonary or cardiovascular

conditions; and (d) persons with

diabetes mellitus (15). Adherence to

Droplet Precautions may prevent

nosocomial transmission (1).

Administration of influenza vaccine

to health care personnel, including

pregnant women (7), before the

beginning of each influenza season can

help to (a) reduce the risk of influenza

infection to health care personnel; (b)

prevent transmission of influenza from

personnel to persons at high risk of

complications; and (c) reduce personnel

absenteeism during community

outbreaks. Innovative methods may be

needed to increase influenza

immunization rates among health care

personnel (467). Immunization rates

may also be increased by providing data

to health care personnel on the low rates

of systemic reactions to influenza

vaccine among healthy adults (468).

During institutional outbreaks of

influenza, prophylactic antiviral agents

(e.g., amantadine and rimantadine) may

be used in conjunction with influenza

vaccine to reduce the severity and

duration of illness among unvaccinated

health care personnel. Amantadine and

rimantadine may be administered for 2

weeks following personnel vaccination

or, in unvaccinated personnel, for the

duration of influenza activity in the

community (15, 449, 469, 470).

b. Respiratory Syncytial Virus (RSV).

Nosocomial transmission of RSV is

greatest during the early winter when

community RSV outbreaks occur;

patients, visitors, and health care

personnel may transmit the virus in the

health care setting. RSV infection is

most common among infants and

children, who are likely to develop

more severe disease. Because RSV

infection can also occur simultaneously

with other respiratory viruses, it may go

unrecognized (471, 472). Nosocomial

transmission has been reported most

frequently among newborn and

pediatric patients (473, 474), but

outbreaks associated with substantial

morbidity and mortality have been

reported among adults in bone marrow

transplant centers (475), intensive care

units (476), and long-term care facilities

(477, 478).

RSV is present in large numbers in the

respiratory secretions of symptomatic

persons infected with the virus and can

be transmitted directly via large droplets

during close contact with such persons,

or indirectly via hands or fomites that

are contaminated with RSV. Hands can

become contaminated through handling

of infected persons’ respiratory

secretions or contaminated fomites, and

transmit RSV by touching the eyes or

nose (449). The incubation period

ranges from 2–8 days; 4–6 days is most

common. In general, infected persons

shed the virus for 3–8 days, but young

infants may shed virus for as long as 3–

4 weeks. Adherence to Contact

Precautions effectively prevents

nosocomial transmission.

c. Work restrictions. Because large

numbers of personnel may have viral

respiratory illnesses during the winter,

it may not be possible to restrict

infected personnel from all patient-care

duties. Nevertheless, it may be prudent

to restrict personnel with acute viral

respiratory infections from the care of

high-risk patients during community

outbreaks of RSV and influenza (479,

480).

E. Pregnant Personnel

Immunologic changes occur during

pregnancy, primarily depression of

certain aspects of cell-mediated

immunity such as decreased levels of

helper T cells. These changes permit

fetal development without rejection but

generally do not increase maternal

susceptibility to infectious diseases.

Occupational acquisition of infections is

of special concern to female health care

personnel of childbearing age for several

reasons. Some infections, such as

varicella, may be more severe during

pregnancy. Transplacental infection

with viruses such as parvovirus,

varicella, and rubella has been

associated with abortion, congenital

anomaly, and mental retardation. Other

diseases in which the infectious agent

may be transmitted to the fetus include

cytomegalovirus, hepatitis B, herpes

simplex, influenza, and measles. In

addition, certain drugs used to treat or

prevent some infections, for example

tuberculosis, may be contraindicated

during pregnancy.

In general, pregnant health care

personnel do not have an increased risk

of acquiring infections in the workplace.

The risks to pregnant personnel and

methods for prevention are discussed in

the various sections of this document

and are summarized in Table 6. Female

personnel of childbearing age should be

strongly encouraged to receive

immunizations for vaccine-preventable

diseases prior to pregnancy. Such

personnel may also decrease their risk

of acquiring infection by adhering to

appropriate infection control practices,

including Standard Precautions when

caring for all patients. Additional

information on occupational risks for

pregnant health care personnel has been

published elsewhere (480–482).

F. Laboratory Personnel

Despite the availability of improved

engineering controls, work practices,

and personal protective equipment,

laboratory personnel remain at risk for

occupational acquisition of infectious

agents (3, 16, 48, 144, 155, 235, 483,

484). Furthermore, newer technologies

that require the use of large and/or

concentrated specimens may further

increase the risk of occupationally

acquired infections among laboratory

personnel (485).

In a review of laboratory-acquired

infections from 1950–1974 >4000

laboratory associated infections were

documented in the United States (483)

the 10 most commonly reported

infections were brucellosis, Q Fever,

hepatitis, especially hepatitis B, typhoid

fever, tularemia, tuberculosis,
47292 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

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
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 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 latexallergic 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.
47294 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

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 workrelated 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 °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 inservice 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 communityacquired infectious diseases or

important exposures. Record the

occurrences of job-related infectious

diseases or important exposures in the

person’s record and, when applicable,
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 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-occupationrelated 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 bloodcontaminated 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
47296 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

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 HIVinfected blood or body fluids containing

blood (29, 76). Category IB

2. Conjunctivitis

Restrict personnel with epidemic

keratoconjunctivitis caused by

adenovirus or purulent conjunctivitis

caused by other microorganisms from

patient care for the duration of

symptoms. If symptoms persist >5–7

days, refer personnel to an

ophthalmologist for evaluation of

continued infectiousness. Category IB

3. Cytomegalovirus (CMV)

a. Do not restrict personnel from work

who contract illnesses suspected or

proven to be due to CMV (109). Category

IB

b. Educate all patient-care personnel

about careful handwashing and

exercising care to prevent their body

fluids from contacting other persons to

reduce their risk of transmitting

infections such as CMV to patients or

other personnel (89, 123). Category IA

c. Ensure that pregnant personnel are

aware of the risks associated with CMV

infection and infection control

procedures to prevent transmission

when working with high-risk patient

groups (Table 6). Category IA

4. Diphtheria

a. Encourage vaccination with tetanus

and diphtheria toxoid (Td) every 10

years for health care personnel (7, 17)

(Table 1). Category IB

b. Obtain nasopharyngeal cultures

from exposed personnel and monitor for

signs and symptoms of diphtheria for 7

days (156). Category IB

c. Administer antimicrobial

prophylaxis to personnel who have

contact with respiratory droplets or

cutaneous lesions of patients infected

with diphtheria. Also administer a dose

of Td to previously immunized

personnel who have not been

vaccinated within the previous 5 years

(17, 156) (Table 1). Category IB

d. Repeat nasopharyngeal cultures of

personnel found to have positive

cultures at ≥2 weeks following

completion of antimicrobial therapy.

Repeat antimicrobial therapy if

personnel remain culture positive (156).

Category IB

e. Exclude exposed personnel and

those identified as asymptomatic

carriers from duty until antimicrobial

therapy is completed and two

nasopharyngeal cultures obtained ≥24

hours apart are negative (156) (Table 3).

Category IB

5. Gastroenteritis

a. Vaccinate and provide booster

doses of vaccine, following published

guidelines, to microbiology laboratory

personnel who work with Salmonella

typhi on a regular basis (144, 155).

Category II

b. Pending their evaluation, exclude

personnel with acute gastrointestinal

illnesses (vomiting or diarrhea, with or

without other symptoms such as nausea,

fever, or abdominal pain) that may be

accompanied by other symptoms (such

as fever, abdominal cramps, or bloody

stools), from contact with patients or

food-handling (1, 163) (Table 3).

Category IB

c. Consult local and state health

authorities regarding regulations for the

exclusion of patient-care personnel or

food-handlers with enteric infections

from contact with patients or foodhandling, 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
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 47297

* (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.)

* (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.)

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

(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 costeffective 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

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 highrisk 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, faceto-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
47298 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

* (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.)

rubella vaccine.* (7, 300) (Table 1)

Category IA

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 HealthCare 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 organtransplant 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 twostep 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 HealthCare 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 HealthCare 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 HealthCare 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
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 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
47300 Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices

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 varicellazoster 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, workplacerelated 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
Federal Register / Vol. 62, No. 173 / Monday, September 8, 1997 / Notices 47301

h. No Recommendation for

institution-wide substitution of nonlatex

products in health care facilities to

prevent sensitization to latex among

health care personnel. Unresolved Issue

i. No Recommendation for the routine

use of environmental abatement

interventions such as laminar flow to

reduce latex aeroallergens. Unresolved

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