Draft Guideline for Infection Control in Health Care Personnel, 1997

SUMMARY: This notice is a request for review of and comment on the

Draft Guideline for Infection Control in Health Care Personnel, 1997.

The guideline consists of two parts: Part 1. ``Infection Control Issues

for Health Care Personnel, an Overview'' and Part 2. ``Recommendations

for Prevention of Infections in Health Care Personnel'', and was

prepared by the Hospital Infection Control Practices Advisory Committee

(HICPAC), the National Center for Infectious Diseases (NCID), the

National Immunizations Program, and the National Institute of

Occupational Safety and Health (NIOSH), CDC.

DATES: Written comments on the draft document must be received on or

before October 17, 1997.

ADDRESSES: Comments on this document should be submitted in writing to

the CDC, Attention: PHG Information Center, Mailstop E-68, 1600 Clifton

Road, N.E., Atlanta, Georgia 30333. To order copies of the Federal

Register containing the document, contact the U.S. Government Printing

Office, Order and Information Desk, Washington, DC 20402-9329,

telephone (202) 512-1800. In addition, the Federal Register containing

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FOR FURTHER INFORMATION CONTACT: The CDC Fax Information Center,

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guideline information.

SUPPLEMENTARY INFORMATION: This 2-part document updates and replaces

the previously published CDC Guideline for Infection Control in

Hospital Personnel (Infect Control 1983 [Special Supplement]; 4

[Suppl]: 326-349). Part 1, ``Infection Control Issues for Health Care

Personnel, an Overview'' serves as the background for the consensus

recommendations of the Hospital Infection Control Practices Advisory

Committee (HICPAC) that are contained in Part 2, ``Recommendations for

Prevention of Infections in Health Care Personnel''.

HICPAC was established in 1991 to provide advice and guidance to

the Secretary and the Assistant Secretary for Health, DHHS; the

Director, CDC, and the Director, NCID regarding the practice of

hospital infection control and strategies for surveillance, prevention,

and control of nosocomial infections in U.S. hospitals. The committee

also advises CDC on periodic updating of guidelines and other policy

statements regarding prevention of nosocomial infections.

The Guideline for Infection Control in Hospital Personnel, 1997 is

the fourth in a series of CDC guidelines being revised by HICPAC and

NCID, CDC.

Dated: September 2, 1997.

Joseph R. Carter,

Acting Associate Director for Management and Operations, Centers for

Disease Control and Prevention (CDC).

Draft Guideline for Infection Control in Health Care Personnel,

1997

Executive Summary

This guideline updates and replaces the previous edition of the CDC

Guideline for Infection Control in Hospital Personnel published in

1983. The revised guideline, designed to provide methods for reducing

the transmission of infections from patients to health care personnel

and from personnel to patients, also provides an overview of the

evidence for recommendations considered prudent by consensus of the

Hospital Infection Control Practices Advisory Committee members. A

working draft of this guideline was also reviewed by experts in

infection control, occupational health, and infectious diseases;

however, all recommendations contained in the guideline may not reflect

the opinion of all reviewers.

This document focuses on the epidemiology of and preventive

strategies for infections known to be transmitted in health care

settings and those for which there are adequate scientific data on

which to base recommendations for prevention. The prevention strategies

addressed in this document include immunizations for vaccine

preventable diseases; isolation precautions to prevent exposures to

infectious agents; management of health care personnel exposures to

infected persons, including postexposure prophylaxis; and work

restrictions for exposed or infected health care personnel. In

addition, because latex barriers are frequently used to protect

personnel against transmission of infectious agents, this guideline

also addresses issues related to latex hypersensitivity and provides

recommendations to prevent sensitization and reactions among health

care personnel.

Part I. Infection Control Issues for Health Care Personnel, an

Overview

A. Introduction

In the United States, there are an estimated 8.8 million persons

who work in health care professions and about 6 million persons work in

more than 6,000 hospitals. However, health care is increasingly being

provided outside of hospitals in facilities such as nursing homes,

freestanding surgical and outpatient centers, emergency care clinics,

and in patients, homes or during pre-hospital emergency care. Hospital-

based personnel and personnel who provide health care outside of

hospitals may acquire infections from or transmit infections to

patients or other personnel, household members, or other community

contacts.

In this document, the term health care personnel refers to all paid

and unpaid persons working in health care settings who have the

potential for exposure to infectious materials, including body

substances, contaminated medical supplies and equipment, contaminated

environmental surfaces, or contaminated air. These personnel may

include, but are not limited to, emergency medical service personnel,

dental personnel, laboratory personnel, mortuary personnel, nurses,

nursing assistants, physicians, technicians, students and trainees,

contractual staff not employed by the health care facility, and persons

not directly involved in patient care (e.g., clerical, dietary,

housekeeping, maintenance, and volunteer personnel) but potentially

exposed to infectious agents. In general, health care personnel, in or

outside of hospitals, who have contact with patients, body fluids, or

specimens have a higher risk of acquiring or transmitting infections

than do other health care personnel who have only brief casual contact

with patients and their environment.

[[Page 47277]]

Throughout this document terms are used to describe routes of

transmission of infections. These terms have been fully described in

the Guideline for Isolation Precautions in Hospitals (1). They are

summarized as follows: direct contact refers to body surface-to-body

surface contact and physical transfer of microorganisms between a

susceptible host and an infected or colonized person (e.g., while

bathing, performing procedures); indirect contact refers to contact of

a susceptible host with a contaminated object (e.g., instruments,

hands); droplet contact refers to conjunctival, nasal, or oral mucosa

contact with droplets containing microorganisms generated from an

infected person (by coughing, sneezing, and talking or during certain

procedures such as suctioning and bronchoscopy) that are propelled a

short distance; airborne transmission refers to contact with droplet

nuclei containing microorganisms that can remain suspended in the air

for long periods of time or dust particles containing an infectious

agent that can be widely disseminated by air currents; and finally,

common vehicle transmission refers to contact with contaminated items

such as food, water, medications, devices, and equipment.

In 1983, the Centers for Disease Control and Prevention (CDC)

published the Guideline for Infection Control in Hospital Personnel

(2). The document focused on the prevention of infections known to be

transmitted to and from health care personnel. This revision of the

Guideline has been expanded to include (a) recommendations for non-

patient care personnel, both in and outside of hospitals; (b)

management of exposures; (c) prevention of transmission of infections

in microbiologic and biomedical laboratories; and, (d) because of the

common use of latex barriers to prevent infections, prevention of latex

hypersensitivity reactions. As in the 1982 Guideline, readers are

frequently referred to the Guideline for Isolation Precautions in

Hospitals (1) and other published guidelines and recommendations for

precautions that health care personnel may use when caring for

patients, or handling patient equipment or specimens (3, 4).

B. Infection Control Objectives for a Personnel Health Service

The infection control objectives of the personnel health service

should be an integral part of a health care organization's general

program for infection control. The objectives usually include the

following: (a) Educating personnel about the principles of infection

control and stressing individual responsibility for infection control;

(b) collaborating with the infection control department in monitoring

and investigating potentially harmful infectious exposures and

outbreaks among personnel; (c) providing care to personnel for work-

related illnesses or exposures; (d) identifying work-related infection

risks and instituting appropriate preventive measures; and (e)

containing costs by preventing infectious diseases that result in

absenteeism and disability. These objectives cannot be met without the

support of the health care organization's administration, medical

staff, and other health care personnel.

C. Elements of a Personnel Health Service for Infection Control

Certain elements are necessary to attain the infection control

goals of a personnel health service: (a) Coordination with other

departments; (b) medical evaluations; (c) health and safety education;

(d) immunization programs; (e) management of job-related illnesses and

exposures to infectious diseases, including policies for work

restrictions for infected or exposed personnel; (f) counseling services

for personnel on infection risks related to employment or special

conditions; and (g) maintenance and confidentiality of personnel health

records.

The organization of a personnel health service may be influenced by

the size of the institution, the number of personnel, and the services

offered. Personnel with specialized training and qualifications in

occupational health can facilitate the provision of effective services.

1. Coordination With Other Departments

For infection control objectives to be achieved, the activities of

the personnel health service must be coordinated with infection control

and other departmental personnel. This coordination will help ensure

adequate surveillance of infections in personnel and provision of

preventive services. Coordinating activities will also help to ensure

that investigations of exposures and outbreaks are conducted

efficiently and preventive measures implemented promptly.

2. Medical Evaluations

Medical evaluations before placement can ensure that personnel are

not placed in jobs that would pose undue risk of infection to them,

other personnel, patients, or visitors. An important component of the

placement evaluation is a health inventory. This usually includes

determining immunization status and obtaining histories of any

conditions that might predispose personnel to acquiring or transmitting

communicable diseases, e.g., history of chickenpox, rubella, measles,

mumps, hepatitis, immunodeficiency, dermatologic conditions (including

chronic draining or open wounds), and risk factors or treatment for

tuberculosis. This information will assist in decisions about

immunizations or postexposure management.

A physical examination, another component of the medical

evaluation, can be used to screen personnel for conditions that might

increase the risk of transmitting or acquiring work related diseases

and can serve as a baseline for determining whether future diseases are

work related. However, the cost-effectiveness of routine physical

examinations, including laboratory testing (such as complete blood

counts, serologic tests for syphilis, urinalysis, chest x-rays) or

screening for enteric or other pathogens for infection control

purposes, has not been demonstrated. Conversely, screening for some

vaccine-preventable diseases, such as hepatitis B, measles, mumps,

rubella, or varicella, may be cost-effective. In general, the health

inventory can be used to guide decisions regarding physical

examinations or laboratory tests. However, some local public health

ordinances may mandate that certain screening procedures be used.

Periodic evaluations may be done as indicated for job reassignment,

ongoing programs (e.g., tuberculosis screening), or for evaluation of

work-related problems.

3. Personnel Health and Safety Education

Personnel are more likely to comply with an infection control

program if they understand its rationale. Thus, personnel education is

a cardinal element of an effective infection control program. Clearly

written policies, guidelines, and procedures ensure uniformity,

efficiency, and effective coordination of activities. However, since

the risk of infection varies by job category, infection control

education should be modified accordingly. In addition, some personnel

may need specialized education on infection risks related to their

employment, and of preventive measures that will reduce those risks.

Furthermore, educational materials need to be appropriate in content

and vocabulary to the educational level, literacy, and language of the

employee. All health care personnel need to be educated about the

[[Page 47278]]

organization's infection control policies and procedures.

4. Immunization Programs

Ensuring that personnel are immune to vaccine-preventable diseases

is an essential part of successful personnel health programs. Optimal

use of vaccines can prevent transmission of vaccine-preventable

diseases and eliminate unnecessary work restriction. Preventing illness

through comprehensive personnel immunization programs is far more cost-

effective than case management and outbreak control. Mandatory

immunization programs, which include both newly hired and currently

employed persons, are more effective than voluntary programs in

ensuring that susceptible persons are vaccinated (5). Also, programs in

which the employer bears the cost of vaccination have had higher

personnel vaccination rates than have programs without such support.

National guidelines for immunization of and postexposure

prophylaxis for health care personnel are provided by the U.S. Public

Health Service's Advisory Committee on Immunization Practices (ACIP)

(Table 1) (6, 7). ACIP guidelines also contain (a) detailed information

on the epidemiology of vaccine-preventable diseases; (b) data on the

safety and efficacy of vaccines and immune globulin preparations (6-

20); and (c) recommendations for immunization of immunocompromised

persons (Table 2) (14, 21). The recommendations in this guideline have

been adapted from the ACIP recommendations (7). In addition, individual

states and professional organizations have regulations or

recommendations on the vaccination of health care personnel (22).

Decisions about which vaccines to include in immunization programs

have been made by considering (a) the likelihood of personnel exposure

to vaccine-preventable diseases and the potential consequences of not

vaccinating personnel; (b) the nature of employment (i.e., type of

contact with patients and their environment); and (c) the

characteristics of the patient population within the health care

organization. Immunization of personnel before they enter high-risk

situations is the most efficient and effective use of vaccines in

health care settings.

Screening tests are available to determine susceptibility to

certain vaccine-preventable diseases (e.g., hepatitis B, measles,

mumps, rubella, and varicella). Such screening programs need to be

combined with tracking systems to ensure accurate maintenance of

personnel immunization records. Accurate immunization records ensure

that susceptible personnel are promptly identified and appropriately

vaccinated.

5. Management of Job-Related Illnesses and Exposures

Primary functions of the personnel health service are to arrange

for prompt diagnosis and management of job-related illnesses and to

provide appropriate postexposure prophylaxis following job-related

exposures.

It is the responsibility of the health care organization to

implement measures to prevent further transmission of infection, which

sometimes warrants exclusion of personnel from work or patient contact.

Decisions on work restrictions are based on the mode of transmission

and the epidemiology of the disease (Table 3). Exclusion policies

should include a statement of authority defining who may exclude

personnel. The policies also need to be designed to encourage personnel

to report their illnesses or exposures and not to penalize them with

loss of wages, benefits, or job status. In addition, exclusion policies

must be enforceable, and all personnel, especially department heads,

supervisors, and nurse managers, should know which infections may

warrant exclusion and where to report the illnesses 24 hours a day.

Health care personnel who have contact with infectious patients outside

of hospitals also need to be included in the postexposure program.

Notification of emergency response personnel possibly exposed to

selected infectious disease is mandatory (1990 Ryan White Act, Subtitle

B, 42 U.S.C 300ff-80).

6. Health Counseling

Access to adequate health counseling for personnel is another

crucial element of an effective personnel health service. Health

counseling allows personnel to receive individualized information

regarding (a) the risk and prevention of occupationally acquired

infections; (b) the risk of illness or other adverse outcome following

exposures; (c) management of exposures, including the risks and

benefits of postexposure prophylaxis regimens; (d) the potential

consequences of exposures or communicable diseases for family members,

patients, or other personnel, both inside and outside the health care

facility.

7. Maintenance of Records, Data Management, and Confidentiality

Maintenance of records on medical evaluations, immunizations,

exposures, postexposure prophylaxis, and screening tests in a

retrievable, preferably computerized, data base allows efficient

monitoring of the health status of personnel. Such record keeping also

helps to ensure that the organization will provide consistent and

appropriate services to health care personnel.

Individual records for all personnel should be maintained in

accordance with the Occupational Safety and Health Administration

(OSHA) record-keeping requirements for occupational injuries and

illnesses (23). In addition, the 1991 OSHA Occupational Exposure to

Bloodborne Pathogens; Final Rule (24) requires employers, including

health care facilities, to establish and maintain an accurate record

for each employee with occupational exposure to bloodborne pathogens.

The standard also requires that each employer ensure that the employee

medical records are (a) kept confidential; (b) not disclosed or

reported without the employee's express written consent to any person

within or outside the workplace except as required by law; and (c)

maintained by the employer for at least the duration of the worker's

employment plus 30 years.

More recently, OSHA developed enforcement policies that require the

recording and reporting of positive tuberculin skin test results (25).

It would be beneficial to health care organizations and personnel if

the principles of record keeping and confidentiality mandated by OSHA

were expanded to other work-related exposures and incidents,

immunizations, tuberculosis screening, and investigation and management

of nosocomial outbreaks.

D. Epidemiology and Control of Selected Infections Transmitted Among

Health Care Personnel and Patients

Almost any transmissible infection may occur in the community at

large or within health care organizations and can affect both personnel

and patients. However, only those infectious diseases that occur

frequently in the health care setting or are most important to

personnel are discussed below.

1. Bloodborne Pathogens

a. Overview. Assessment of the risk and prevention of transmission

of bloodborne pathogens, such as hepatitis B virus (HBV), hepatitis C

virus (HCV), and human immunodeficiency virus (HIV) in health care

settings is based upon information from a variety of sources, including

surveillance and investigation of suspected cases of transmission to

health care personnel and patients, seroprevalence surveys of health

care personnel and patients, and

[[Page 47279]]

studies of the risk of seroconversion after exposure to blood or other

body fluids from infected persons. In this document, the emphasis of

the discussion of bloodborne pathogens will be on patient-to-personnel

transmission.

CDC has periodically issued and updated recommendations for

prevention of transmission of bloodborne pathogens in health care

settings that provide detailed information and guidance (26-36). Also,

in 1991, OSHA published a bloodborne pathogen standard, based on the

concept of Universal Precautions, to prevent occupational exposure to

bloodborne pathogens (24). In essence, the use of Standard Precautions

(which incorporates Universal Precautions), including appropriate

handwashing and barrier precautions to prevent contact with blood and

body fluids and using techniques and devices that reduce percutaneous

injury, will reduce the risk of transmission of bloodborne pathogens

(1, 27, 37-42).

The risk posed to patients from health care personnel infected with

bloodborne pathogens such as HBV and HIV has been the subject of much

concern and debate. There are no data to indicate that infected workers

who do not perform invasive procedures pose a risk to patients.

Consequently, work restrictions for these workers are not appropriate.

However, the extent to which infected workers who perform certain types

of invasive procedures pose a risk to patients and the restrictions

that should be imposed on these workers have been much more

controversial. In 1991, CDC recommendations on this issue were

published (43). Subsequently, Congress mandated that each state

implement the CDC guidelines or equivalent as a condition for continued

federal public health funding to that state. While all states have

complied with this mandate, there is a fair degree of state-to-state

variation regarding specific provisions. Local or state public health

officials should be contacted to determine the regulations or

recommendations applicable in a given area. CDC is currently in the

process of reviewing relevant data regarding health care personnel to

patient transmission of bloodborne pathogens.

b. Hepatitis B. Nosocomial transmission of HBV is a serious risk

for health care personnel (44-48). Approximately 1,000 health care

personnel were estimated to have become infected with HBV in 1994. This

is a 90% decline since 1985, attributable to the use of vaccine and

adherence to other preventive measures (e.g., Standard Precautions)

(49). During the past decade, an estimated 100 to 200 health care

personnel have died annually from HBV infection (49). The risk of

acquiring HBV infection from occupational exposure is dependent on the

nature and frequency of exposure to blood or body fluids containing

blood (44, 48). The risk of infection is at least 30% after a

percutaneous exposure to blood from a hepatitis B e antigen-positive

source (49).

HBV is transmitted by percutaneous or mucosal exposure to blood and

serum-derived body fluids from persons who either are have acute or

chronic HBV infection. The incubation period is 45 to 180 days. Any

person with blood positive for hepatitis B surface antigen (HBsAg) is

potentially infectious.

Hepatitis B vaccination of health care personnel who have contact

with blood and body fluids can prevent transmission of HBV and is

strongly recommended (7, 8, 36). The OSHA bloodborne pathogen standard

mandates that hepatitis B vaccine be made available, at the employer's

expense, to all health care personnel with occupational exposure to

blood or other potentially infectious materials (24). Provision of

vaccine during training for health care professions before such blood

exposure occurs may increase the vaccination rates among personnel and

prevent infection among trainees who are at increased risk of

unintentional injuries while learning techniques.

Prevaccination serologic screening for susceptibility to HBV

infection is not indicated for persons being vaccinated, unless the

health care organization considers screening to be cost-effective.

Postvaccination screening for antibody to HBsAg (anti-HBs) is advised

for personnel at ongoing risk of blood exposure, to determine if

response to vaccinations has occurred and to aid in determining the

appropriate postexposure prophylaxis or the need for revaccination.

Personnel who do not respond to or do not complete the primary

vaccination series should be revaccinated with a second three-dose

vaccine series or be evaluated to determine if they are HBsAg positive.

Revaccinated persons should be tested for anti-HBs at the completion of

the second vaccine series (7). If they do not respond, no further

vaccination series should be given and they should be evaluated for the

presence of HBsAg (e.g., possible chronic HBV infection).

Vaccine-induced antibodies decline gradually over time, and up to

60% of those who initially respond to vaccination will lose detectable

anti-HBs over 12 years (50). Booster doses of vaccine are not

recommended because persons who respond to the initial vaccine series

remain protected against clinical hepatitis and chronic infection even

when their anti-HBs levels become low or undetectable (51).

The need for postexposure prophylaxis and/or vaccination depends on

the HBsAg status of the source of the exposure as well as the

immunization status of the person exposed (Table 4) (36). Vaccine

should be offered following any exposure in an unvaccinated person,

and, if the source is known to be HBsAg positive, hepatitis B immune

globulin (HBIG) should be given, preferably within 24 hours. The

effectiveness of HBIG given >7 days after HBV exposure is unknown (6,

8, 36). If the exposed person is known not to have responded to a 3

dose vaccine series, a single dose of HBIG and a dose of hepatitis B

vaccine needs to be given as soon as possible after the exposure. If

the exposed person is known not to have responded to a 3 dose vaccine

series or to revaccination, two doses of HBIG need to be given, one

doses as soon as possible after exposure and the second dose 1 month

later.

c. Hepatitis C. HCV is the etiologic agent in most cases of

parenterally transmitted non-A, non-B hepatitis in the United States

(52,53). During the past decade, the annual number of newly acquired

HCV infections has ranged from an estimated 180,000 in 1984 to an

estimated 28,000 in 1995. Of these, an estimated 2%-4% occurred among

health care personnel who were occupationally exposed to blood (53).

A case-control study of patients with acute non-A, non-B hepatitis,

conducted before the identification of HCV, showed a significant

association between acquiring disease and health care employment,

specifically, patient care or laboratory work (54). Seroprevalence

studies among hospital-based health care personnel have shown anti-HCV

seroprevalence rates of 1% to 2% (55-58). In a study that assessed risk

factors for infection in health care personnel, a history of accidental

needlesticks was independently associated with anti-HCV positivity

(55).

Several case reports have documented transmission of HCV infection

from anti-HCV-positive patients to health care personnel as a result of

accidental needlesticks or cuts with sharp instruments (59, 60). In

follow-up studies of health care personnel who sustained percutaneous

exposures to blood from anti-HCV positive patients, the incidence of

anti-HCV seroconversion averaged 1.8% (range, 0%-7%) (61-64). In a

study in which HCV RNA polymerase chain reaction methods were used to

measure HCV

[[Page 47280]]

infection, the incidence of HCV infection was 10% (64).

The incubation period for hepatitis C is 6-7 weeks, and nearly all

persons with acute infection develop chronic HCV infection with

persistent viremia and have the potential for transmission of HCV to

others.

Serologic assays to detect antibody to HCV (anti-HCV) are

commercially available. The interpretation of anti-HCV test results is

limited by several factors: (a) These assays will not detect anti-HCV

in approximately 5% of persons infected with HCV; (b) these assays do

not distinguish between acute, chronic, or past infection; (c) there

may be a prolonged interval between the onset of acute illness with HCV

and seroconversion; and (d) when the assays are used in populations

with a low prevalence of HCV infection, commercial screening assays for

anti-HCV yield a high proportion (up to 50%) of false-positive results

(30, 53). Although no true confirmatory test has been developed,

supplemental tests for specificity are available and should be used to

judge the validity of repeatedly reactive results by screening assays.

Although the value of immune globulin (IG) for postexposure

prophylaxis after occupational exposure to hepatitis C virus has been

difficult to assess (65-67), postexposure prophylaxis with IG does not

appear to be effective in preventing HCV infection. Current IG

preparations are manufactured from plasma that has been screened for

HCV antibody; positive lots are excluded from use. An experimental

study in chimpanzees found that IG manufactured from anti-HCV-screened

plasma and administered one hour after exposure to HCV did not prevent

infection or disease (68). Thus, available data do not support the use

of IG for postexposure prophylaxis of hepatitis C and its use is not

recommended. There is no information regarding the use of antiviral

agents, such as alpha interferon, in the postexposure setting, and such

prophylaxis is not recommended (33, 69).

Health care institutions should consider implementing recommended

policies and procedures for follow-up for HCV infection after

percutaneous or mucosal exposures to blood (69).

d. Human Immunodeficiency Virus. Nosocomial transmission of HIV

infection from patients to health care personnel may occur following

percutaneous or, infrequently, mucocutaneous, exposure to blood or body

fluids containing blood. Based on prospective studies of health care

personnel percutaneously exposed to HIV-infected blood, the average

risk for HIV infection has been estimated to be 0.3% (70-74). A

retrospective case-control study to identify risk factors for HIV

seroconversion among health care personnel after a percutaneous

exposure to HIV-infected blood found that they were more likely to

become infected if they were exposed to a larger quantity of blood,

represented in the study as presence of visible blood on the device

prior to injury; a procedure that involved a needle placed directly in

the patient's vein or artery; or deep injury. Transmission of HIV

infection also was associated with injuries in which the source patient

was terminally ill with acquired immunodeficiency syndrome (AIDS); this

may be attributable to the increased titer of HIV in blood that is

known to accompany late stages of illness, or possibly other factors,

such as the presence of syncytia-inducing strains of HIV in these

patients. In addition, the findings of this study suggested that the

use of zidovudine postexposure may be protective for health care

personnel (71).

Factors that determine health care personnel's risk of infection

with HIV include the prevalence of infection among patients, the risk

of infection transmission after an exposure, and the frequency and

nature of exposures (75). Most personnel who acquire infection

following percutaneous exposure develop HIV antibody within 6 months of

exposure. HIV-infected persons are likely to transmit virus from the

time of early infection throughout life.

In 1990, CDC published guidelines for postexposure management of

occupational exposure to HIV (29). In 1996, provisional recommendations

for postexposure chemoprophylaxis were published, reflecting current

scientific knowledge on the efficacy of postexposure prophylaxis and

the use of antiretroviral therapies (76). The U.S. Public Health

Service will periodically review scientific information on

antiretroviral therapies and will publish updated recommendations for

their use as postexposure prophylaxis as necessary.

2. Conjunctivitis

Conjunctivitis can be caused by a variety of bacteria and viruses.

However, adenovirus has been the primary cause of nosocomial outbreaks

of conjunctivitis. Nosocomial outbreaks of conjunctivitis caused by

other pathogens are rare.

Adenoviruses, which can cause respiratory, ocular, genitourinary,

and gastrointestinal infections, are a major cause of epidemic

keratoconjunctivitis (EKC) in the community and health care settings.

Nosocomial outbreaks have primarily occurred in eye clinics or offices,

but have also been reported in newborn intensive care units and long

term care facilities (77-81). Patients and health care personnel have

acquired and transmitted EKC during these outbreaks. The incubation

period ranges from 5 to 12 days and shedding of virus occurs from late

in the incubation period up to 14 days after onset of disease (78).

Adenovirus survives for long periods on environmental surfaces;

ophthalmologic instruments and equipment can become contaminated and

transmit infection. Contaminated hands are also a major source of

person-to-person transmission of adenovirus, both from patients to

health care personnel and from health care personnel to patients.

Handwashing, glove use, and disinfection of instruments can prevent the

transmission of adenovirus (77, 78).

Infected personnel should not provide patient care for the duration

of symptoms following onset of EKC (77, 78) or purulent conjunctivitis

caused by other pathogens.

3. Cytomegalovirus

There are two principal reservoirs of cytomegalovirus (CMV) in

health care institutions: (a) Infants and young children infected with

CMV, and (b) immunocompromised patients, such as those undergoing

solid-organ or bone-marrow transplantation or persons with AIDS (82-

88). However, personnel who provide care to such high-risk patients

have a rate of primary CMV infection that is no higher than that among

personnel without such patient contact (3% versus 2%) (89-95). In areas

where there are patient populations with high prevalence of CMV,

seroprevalence studies and epidemiologic investigations have also

demonstrated that personnel who care for patients have no greater risk

of acquiring CMV than do personnel who have no patient contact (87, 89-

92, 94, 96-99). In addition, epidemiologic studies that included DNA

testing of viral strains have demonstrated that personnel who acquired

CMV infection while providing care to CMV-infected infants did not

acquire their infection from the CMV-infected patients (83, 87, 90,

100-102).

CMV transmission appears to occur directly either through close,

intimate contact with an excreter of CMV or through contact with

contaminated secretions or excretions, especially saliva or urine (95,

103-106). Transmission via the hands of personnel or infected person(s)

also has been suggested (87, 107). The incubation period for person-to-

person transmission is not known. Although

[[Page 47281]]

CMV can survive on environmental surfaces and other objects for short

periods of time (108), there is no evidence that the environment plays

a role in the transmission of infection (87).

Because infection with CMV during pregnancy may have adverse

effects on the fetus, protecting women of childbearing age from persons

who are excreting the virus is of primary concern. However, the risk of

occupational transmission to female health care personnel is no greater

than the risk among the general public (89, 96, 109). While a majority

of fetal infections follow primary maternal infection, fetal infection

may follow maternal reinfection or reactivation. Serologic or virologic

screening programs to identify CMV-infected patients or seronegative

female personnel of childbearing age are impractical and costly for the

following reasons: (a) The virus can be intermittently shed (110);

repeated screening tests may be needed to identify shedders; (b)

seropositivity for CMV does not offer complete protection against

maternal reinfection or reactivation and subsequent fetal infection

(109, 111); (c) no currently available vaccines (112-115) or

prophylactic therapy (116-120) can provide protection against primary

infection; and (d) no studies clearly indicate that personnel may be

protected by transfer to areas with less contact with patients likely

to be reservoirs for CMV infection (83, 87, 89-91, 96, 99, 121).

Counseling of female personnel of childbearing age on the risk of

transmission of CMV in both nonoccupational and occupational

environments may help allay their fears (122).

Work restrictions for personnel who contract CMV illnesses are not

necessary; the risk of transmission of CMV can be reduced by careful

adherence to handwashing and Standard Precautions. (1, 109, 123).

4. Diphtheria

Nosocomial transmission of diphtheria among patients and personnel

has been reported (124-126). Diphtheria is currently a rare disease in

the United States; during 1980-1994 only 41 diphtheria cases were

reported (127), however, community outbreaks of diphtheria have

occurred in the past (128), and clusters of infection may occur in

communities where diphtheria was previously endemic (129). In addition

diphtheria epidemics have been occurring since 1990 in the New

Independent States of the former Soviet Union (130-132) and in Thailand

(133). At least 20 imported cases of diphtheria have been reported in

countries in Europe (132, 134) and two cases occurred in U.S. citizens

visiting or working in the Russian Federation and Ukraine (135). Health

care personnel are not at substantially higher risk than the general

adult population for acquiring diphtheria; however, there is the

potential for sporadic or imported cases to require medical care in the

United States.

Diphtheria, caused by Corynebacterium diphtheriae, is transmitted

by contact with respiratory droplets or contact with skin lesions of

infected patients. The incubation period is usually 2-5 days. Patients

with diphtheria are usually infectious for 2 weeks, but

communicability can persist for several months (136). Droplet

precautions are recommended for patients with pharyngeal symptoms, and

contact precautions are recommended for patients with cutaneous

lesions. Precautions need to be maintained until antibiotic therapy is

completed and two cultures taken 24 hours apart are negative

(1).

Limited serosurveys conducted since 1977 in the United States

indicate that 22%-62% of adults 18-39 years of age may lack protective

diphtheria antibody levels (137-141). Prevention of diphtheria is best

accomplished by maintaining high levels of diphtheria immunity among

children and adults (17, 130, 131). Immunization with tetanus and

diphtheria toxoid (Td) is recommended every 10 years for all adults who

have completed the primary immunization series (7, 17) (Table 1).

Health care personnel need to consider obtaining Td immunization from

their health care providers (7).

To determine if health care personnel directly exposed to oral

secretions of patients infected with toxigenic strains of C.

diphtheriae are carriers, cultures of the nasopharynx may be obtained.

Exposed personnel need to be evaluated for evidence of disease daily

for 1 week (142). Although the efficacy of antimicrobial prophylaxis in

preventing secondary disease has not been proven, prophylaxis with

either a single IM injection of benzathine penicillin (1.2 million

units) or oral erythromycin (1 g/day) for 7 days has been recommended

(17). Follow-up nasopharyngeal cultures for C. diphtheriae need to be

obtained after antimicrobial therapy is completed. If the organism has

not been eradicated, a 10-day course of erythromycin needs to be given

(142). In addition, previously immunized, exposed personnel need to

receive a dose of Td if they have not been vaccinated within the

previous 5 years (17).

Exclusion from duty is indicated for personnel with C. diphtheriae

infection or those identified as asymptomatic carriers until

antimicrobial therapy is completed and nasopharyngeal cultures are

negative.

5. Gastrointestinal Infections

Acute gastrointestinal infections may be caused by a variety of

agents, including bacteria, viruses, and protozoa. However, only a few

agents have been documented in nosocomial transmission (Table 5) (143-

161). Nosocomial transmission of agents that cause gastrointestinal

infections usually results from contact with infected individuals (143,

154, 156, 162); from consumption of contaminated food, water, or other

beverages (143, 159, 162); or from exposure to contaminated objects or

environmental surfaces (145, 146, 163). Airborne transmission of small

round-structured viruses (Norwalk-like viruses) has been postulated but

not proven (157, 158, 164-167). Inadequate handwashing by health care

personnel (168) and inadequate sterilization or disinfection of

patient-care equipment and environmental surfaces increase the

likelihood of transmission of agents that cause gastrointestinal

infections. Generally, adherence to good personal hygiene by personnel

before and after all contacts with patients or food and to either

Standard or Contact Precautions (1) will minimize the risk of

transmitting enteric pathogens (160, 169).

Laboratory personnel who handle infectious materials may also be at

risk for occupational acquisition of gastrointestinal infections, most

commonly with Salmonella typhi. Although the incidence of laboratory-

acquired S. typhi infection has decreased substantially since 1955,

infections continue to occur among laboratory workers, particularly

those performing proficiency exercises or research tests (144, 155).

Several typhoid vaccines are available for use in laboratory workers

who regularly work with cultures or clinical materials containing S.

typhi (170). The oral live-attenuated Ty21a vaccine, the IM Vi capsular

polysaccharide (ViCPS) vaccine, or the subcutaneous inactivated vaccine

may be given (170) (Table 1). Booster doses of vaccine are required at

2- to 5-year intervals, depending on the preparation used. The live-

attenuated Ty21a vaccine should not be used for immunocompromised

persons, including those known to be infected with HIV(170).

[[Page 47282]]

Personnel who develop an acute gastrointestinal illness, defined as

vomiting and/or diarrhea (i.e., 3 loose stools in a 24-hour

period) with or without associated symptoms such as fever, nausea, and

abdominal pain, are likely to have high concentrations of the infecting

agent in their feces (bacteria, viruses, and parasites) or vomitus

(viruses and parasites) (158, 171, 172). It is important to determine

the etiology of gastrointestinal illness in health care personnel who

care for patients at high risk for severe disease (e.g., newborns, the

elderly, and immunocompromised patients). The initial evaluation of

personnel with gastroenteritis needs to include a thorough history and

determination of the need for specific laboratory tests such as stool

or blood cultures, staining procedures, and serologic or antigen/

antibody tests (155, 163, 173, 174).

After resolution of some acute bacterial gastrointestinal

illnesses, some personnel may have persistent carriage of the

infectious agent. However, once the person has clinically recovered and

is having formed stools, the risk of transmission of enteric pathogens

is minimal when there is adherence to Standard Precautions (1, 160). In

addition, appropriate antimicrobial therapy may eradicate fecal

carriage of Shigella (175) or Campylobacter (176). However,

antimicrobial or antiparasitic therapy may not eliminate carriage of

Salmonella (177) or Cryptosporidium. Moreover, antimicrobials may

prolong excretion of Salmonella (178) and lead to emergence of

resistant strains (179). However, transmission of Salmonella to

patients from personnel who are asymptomatic carriers of Salmonella has

not been well documented (160). In general, antimicrobial therapy is

not recommended unless the person is at high risk for severe disease

(180). When antibiotics are given, stool cultures should be obtained

48 hours after completion of antibiotic therapy.

Restriction from patient care or food-handling is indicated for

personnel with diarrhea or acute gastrointestinal symptoms, regardless

of the causative agent (1, 163). Some local and state agencies have

regulations that require work exclusion for health care personnel and/

or food handlers who have gastrointestinal infections caused by

Salmonella or Shigella. These regulations may require that such

personnel be restricted from duty until 2 consecutive stool

cultures obtained 24 hours apart are negative.

6. Hepatitis A

Nosocomial hepatitis A occurs infrequently and transmission to

personnel usually occurs when the source patient has unrecognized

hepatitis and is fecally incontinent or has diarrhea (181-190). Other

risk factors for hepatitis A virus (HAV) transmission to personnel

include activities that increase the risk of fecal-oral contamination,

such as (a) eating or drinking in patient-care areas (181, 183, 185,

191); (b) not washing hands after handling an infected infant (183,

191, 192) and (c) sharing food, beverages, or cigarettes with patients,

their families, or other staff (181, 183);.

HAV is transmitted primarily by the fecal-oral route. It has not

been reported to occur after inadvertent needlesticks or other contact

with blood, but has rarely been reported to be transmitted by

transfusion of blood products (185, 193, 194). The incubation period

for HAV is 15-50 days. Fecal excretion of HAV is greatest during the

incubation period of disease before the onset of jaundice (195). Once

disease is clinically obvious, the risk of transmitting infection is

decreased. However, some patients admitted to the hospital with HAV,

particularly immunocompromised patients, may still be shedding virus

because of prolonged or relapsing disease and they are potentially

infective (182, 195). Fecal shedding of HAV, formerly believed to

continue only for up to 2 weeks after onset of dark urine (195), has

been shown to occur for up to 6 months after diagnosis of infection in

premature infants (181). Anicteric infection is typical in young

children and infants (196).

Personnel can protect themselves and others from infection with HAV

by following Standard Precautions (1). Foodborne transmission of

hepatitis A is not discussed in this guideline, but has occurred in

health care settings (197, 198).

Two inactivated hepatitis A vaccines, HAVRIX and

VAQTA, are now available and provide long-term preexposure

protection against clinical infection with >94% efficacy (196).

Serologic surveys among health care personnel have not shown an

elevated prevalence of HAV infection compared with control populations

(47, 184, 199, 200); therefore, routine administration of vaccine in

health care personnel is not recommended. Vaccine may be useful for

personnel working in areas where HAV is highly endemic and is indicated

for personnel who handle HAV infected primates or are exposed to HAV in

a research laboratory. The role of hepatitis A vaccine in controlling

outbreaks has not been adequately investigated (7). Immune globulin

(IG) given within 2 weeks following an HAV exposure is >85% effective

in preventing hepatitis A virus infection (196) and may be advisable in

some outbreak situations (7, 196).

Restriction from patient care or food-handling is indicated for

personnel with HAV infection. They may return to regular duties 1 week

following onset of illness (7).

7. Herpes Simplex

Nosocomial transmission of herpes simplex viruses (HSV) is rare.

Nosocomial transmission has been reported in nurseries (201-203) and

intensive care units (204, 205) where high-risk patients (e.g.,

neonates, patients with severe malnutrition, patients with severe burns

or eczema, and immunocompromised patients) are located. Nosocomial

transmission of HSV occurs primarily through contact with either

primary or recurrent lesions or from virus-containing secretions, such

as saliva, vaginal secretions, or amniotic fluid (202, 204, 206).

Exposed areas of skin are the most likely sites of nosocomial

infection, particularly when minor cuts, abrasions, or other skin

lesions are present (205). The incubation period of HSV is 2-14 days

(207). The duration of viral shedding has not been well defined (208).

Personnel may develop an herpetic infection of the fingers

(herpetic whitlow or paronychia) from exposure to contaminated oral

secretions (205, 206). Such exposures are a distinct hazard for nurses,

anesthesiologists, dentists, respiratory care personnel, and other

personnel who have direct (usually hand) contact with either oral

lesions or respiratory secretions from patients (205). Less frequently,

personnel may develop mucocutaneous infection on other body sites from

contact with infectious body secretions (209).

Personnel with active infection of the hands (herpetic whitlow) can

potentially transmit HSV infection to patients with whom they have

contact (206). Transmission of HSV from personnel with orofacial HSV

infection to patients has also been infrequently documented (201);

however, the magnitude of the risk is unknown (203, 210). Although

asymptomatic infected persons can shed the virus, they are less

infectious than persons with active lesions (208, 211).

Personnel can protect themselves from acquiring HSV by adhering to

Standard Precautions (1). The risk of transmission of HSV from

personnel with orofacial infections to patients can be reduced by

handwashing before all patient care and by the use of appropriate

barriers, such as a mask or

[[Page 47283]]

gauze dressing, to prevent hand contact with the lesion.

Because personnel with orofacial lesions may touch their lesions

and potentially transmit infections, excluding them from the care of

patients at high risk for serious disease (e.g., neonates, patients

with severe malnutrition, patients with severe burns or eczema, and

immunocompromised patients) should be considered. Personnel with HSV

infections of the fingers or hands can more easily transmit infection

and, therefore, need to be excluded from patient care until their

lesions have crusted. In addition, herpetic lesions may be secondarily

infected by Staphylococcus and Streptococcus and personnel with such

infections should be evaluated to determine if they need to be excluded

from patient contact until the secondary infection has resolved. There

have been no reports that personnel with genital HSV infections have

transmitted HSV to patients; therefore, work restrictions for personnel

with genital herpes are not indicated.

8. Measles

Nosocomial transmission of measles virus (sporadic and epidemic)

has been well described (212-221). From 1985 through 1991,

approximately 3,000 (4%) of all reported episodes of measles in the

United States were probably acquired in a medical facility; of these,

>700 (25%) occurred in health care personnel, many of whom were not

vaccinated (7). Data have suggested that health care personnel have a

13-fold greater risk of measles compared with the general population

(7). Of the 2,765 episodes of measles reported during 1992-95, 385

(13.9%) occurred in health care settings (213, 222).

Measles is transmitted both by large droplets during close contact

between infected and susceptible persons and by the airborne route

(221, 223). Measles is highly transmissible and frequently misdiagnosed

during the prodromal stage. The incubation period for measles is 5-21

days. Immunocompetent persons with measles shed the virus from the

nasopharynx, beginning with the prodrome until 3-4 days after rash

onset; immunocompromised persons with measles may shed virus for

extended periods of time (224).

Strategies to prevent nosocomial transmission of measles include

(a) documentation of measles immunity in health care personnel; (b)

prompt identification and isolation of persons with fever and rash; (c)

adherence to airborne precautions for suspected and proven cases of

measles (1); and (d) vaccination of patients in medical settings,

especially emergency rooms.

It is essential that all personnel have documentation of measles

immunity regardless of their length of employment or whether they are

involved in patient care. Furthermore, some states have regulations

requiring measles immunity for health care personnel. Although persons

born before 1957 are generally considered to be immune to measles,

serologic studies indicate that 5%-9% of health care personnel born

before 1957 may not be immune (225, 226). Furthermore, during 1985-

1989, 29% of all measles cases in U.S. health care personnel occurred

in those born before 1957 (213). Consideration should be given to

recommending a dose of measles-mumps-rubella trivalent vaccine (MMR) to

personnel born before 1957 who are unvaccinated and who lack (a) a

history of prior measles disease; (b) documentation of receipt of one

dose of live measles vaccine; or (c) serologic evidence of measles

immunity (7). Health care personnel born during or after 1957 should be

considered immune to measles when they have (a) documentation of

physician-diagnosed measles; (b) documentation of two doses of live

measles vaccine on or after their first birthday; or (c) serologic

evidence of measles immunity (persons with an ``indeterminate'' level

of immunity upon testing should be considered susceptible). Persons

born between 1957 and 1984 who received childhood measles immunization

were given only one dose of vaccine in their infancy and may require a

second dose of vaccine (6).

Serologic screening for measles immunity is not necessary prior to

administering measles vaccine unless the medical facility considers it

cost-effective or the person to be vaccinated requests it (227-229).

When serologic screening before vaccination is done, tracking systems

are needed to ensure that those identified as susceptibles are

subsequently vaccinated in a timely manner (229). During measles

outbreaks, serologic screening before vaccination is not necessary. In

outbreak situations, prompt administration of vaccine is necessary to

halt disease transmission.

Work restrictions are necessary for personnel who develop measles;

they need to be excluded from duty for 4 days after the rash appears.

Likewise, personnel nonimmune to measles need to be excluded from duty

for 5 days after the first exposure to 21 days following the last

exposure to measles.

9. Meningococcal Disease

Community-acquired meningococcal disease typically is caused by a

variety of serogroups of Neisseria meningitidis; Serogroups B and C

cause 46% and 45% of the endemic cases, respectively. Serogroups A, Y,

and W-135 account for nearly all the remaining endemic cases (13). In

contrast, epidemic meningococcal disease has, since the early 1990s,

been caused increasingly by Serogroup C (13, 230, 231).

Nosocomial transmission of N. meningitidis is uncommon. In rare

instances, when proper precautions were not used, N. meningitidis has

been transmitted from patient to personnel, through contact with the

respiratory secretions of patients with meningococcemia or

meningococcal meningitis (1, 232-234) or through handling laboratory

specimens (235). Lower respiratory infections caused by N. meningitidis

may present a greater risk of transmission than either meningococcemia

or meningitis (234, 236), especially if the patient has an active,

productive cough (236). The risk of personnel acquiring meningococcal

disease from casual contact (e.g., cleaning rooms or delivering food

trays) appears to be negligible (236).

N. meningitidis infection is likely transmitted by large droplets;

the incubation period is from 2-10 days and patients infected with N.

meningitidis are rendered noninfectious by 24 hours of effective

therapy. Personnel who care for patients with suspected N. meningitidis

infection can decrease their risk of infection by adhering to Droplet

Precautions (1).

Postexposure prophylaxis is advised for persons who have had

intensive, unprotected contact (i.e., without wearing a mask) with

infected patients (e.g., intubating, resuscitating, or closely

examining the oropharynx of patients) (13). Antimicrobial prophylaxis

can eradicate carriage of N. meningitidis and prevent infections in

personnel who have unprotected exposure to patients with meningococcal

infections (237,238).

Because secondary cases of N. meninigitidis occur rapidly (within

the first week) following exposure to persons with meningococcal

disease (239), it is important to begin prophylactic therapy

immediately after an intensive, unprotected exposure, often before

results of antimicrobial testing are available. Prophylaxis

administered >14 days after exposure is probably of limited or no value

(13). Rifampin (600 mg orally every 12 hours for 2 days) is effective

in eradicating nasopharyngeal carriage of N.

[[Page 47284]]

meningitidis (237). Ciprofloxacin ( 500 mg orally) and ceftriaxone (250

mg IM) in single-dose regimens are also effective in reducing

nasopharyngeal carriage of N. meningitidis and are reasonable

alternatives to the multidose rifampin regimen (13, 238). These

antimicrobials may be useful in situations where infections are caused

by rifampin-resistant meningococci or when rifampin is contraindicated.

Rifampin and ciprofloxacin are not recommended for pregnant women (13,

240, 241).

The quadrivalent A,C,Y,W-135 polysaccharide vaccine has been used

successfully to control community outbreaks caused by Serogroup C (13,

230, 231, 240), but its use is not recommended for postexposure

prophylaxis in health care settings (13). However, preexposure

vaccination may be considered for laboratory personnel who routinely

handle soluble preparations of N. meningitidis (13, 235).

In the absence of exposures to patients with N. meningitidis

infection, personnel who are asymptomatic carriers need not be

identified, treated, or removed from patient-care activities. Healthy

persons may have nasopharyngeal carriage of N. meningitidis (237, 242-

244). Nosocomial transmission from carriers to personnel has not been

reported.

10. Mumps

Mumps transmission has occurred in hospitals and long-term-care

facilities housing adolescents and young adults (245, 246). Most cases

of mumps in health care personnel have been community acquired.

Mumps is transmitted by contact with virus-containing respiratory

secretions, including saliva; the portals of entry are the nose and

mouth. The incubation period varies from 12 to 25 days and is usually

16-18 days. The virus may be present in saliva for 6-7 days before

parotitis and may persist for up to 9 days after onset of disease.

Exposed personnel may be infectious for 12-25 days after their exposure

and many infected persons remain asymptomatic (247). Droplet

precautions are recommended for patients with mumps; such precautions

should be continued for 9 days after the onset of parotitis (1).

An effective vaccination program is the best approach to preventing

nosocomial mumps transmission (10). Vaccination with mumps virus

vaccine is recommended, unless otherwise contraindicated, for all those

who are susceptible to mumps (10, 248); combined MMR vaccine is the

vaccine of choice (249), especially when the recipient also is likely

to be susceptible to measles, rubella, or both.

Personnel should be considered immune to mumps if they have: (a)

Documentation of physician-diagnosed mumps; (b) documentation of

receipt of one dose of live mumps vaccine on or after their first

birthday; or (c) serologic evidence of immunity (individuals who have

an ``indeterminate'' antibody level should be considered susceptible)

(10). Most persons born before 1957 are likely to have been infected

naturally and may be considered to be immune, even if they may not have

had clinically recognized mumps. Outbreaks among highly vaccinated

populations have occurred and have been attributed to primary vaccine

failure (250).

Work restrictions are necessary for personnel who develop mumps;

such restrictions should be imposed for 9 days after the onset of

parotitis. Likewise, susceptible personnel who are exposed to mumps

need to be excluded from duty from the 12th day after the first

exposure until the 26th day after the last exposure.

11. Parvovirus

Human parvovirus B19 (B19) is the cause of erythema infectiosum

(fifth disease), a common rash illness that is usually acquired in

childhood. Immunocompetent persons infected with B19 may develop an

acute, self-limited arthropathy with or without a rash or anemia of

short duration. However, patients with preexisting anemia (e.g.,

patients with sickle cell anemia or thalassemia) may develop aplastic

crisis. Immunodeficient patients (e.g., patients with leukemia or AIDS)

may become chronically infected with B19 and develop chronic anemia

(251, 252).

Transmission of B19 to health care personnel from infected patients

appears to be rare. In two investigations of health care personnel

exposures to B19, the rate of infection among exposed nurses was not

higher than the rate among unexposed controls (253, 254). In another

investigation of health care personnel exposed to an undetected patient

with chronic B19 infection, none of the susceptible employees became

infected (255). Personnel have acquired infection while working in

laboratories or during the care of patients with B19-associated sickle

cell aplastic crises (256-261).

B19 may be transmitted via contact with infected persons, fomites,

or large droplets (253, 262, 263). The incubation period is variable,

depending on the clinical manifestation of disease, and ranges from 6-

10 days (252). The period of infectivity also varies depending on the

clinical presentation or stage of disease. Persons with erythema

infectiosum are infectious before the appearance of the rash; those

with infection and aplastic crises, up to 7 days after onset of

illness; and persons with chronic infection, for years.

Pregnant personnel are at no greater risk of acquiring B19

infection than are nonpregnant personnel; however, if a pregnant woman

does acquire B19 infection during the first half of pregnancy, the risk

of fetal death (fetal hydrops, spontaneous abortion, and stillbirth) is

increased (264, 265). Because of the seriousness of consequences for

the fetus, female personnel of childbearing age need to be counseled

regarding the risk of transmission of B19 and appropriate infection

control precautions (1).

Isolation precautions are not indicated for most patients with

erythema infectiousum because they are past their period of

infectiousness at the time of clinical illness (259, 264). However,

patients in aplastic crisis due to B19 or patients with chronic B19

infection may transmit the virus to susceptible health care personnel

or other patients; therefore, patients with preexisting anemia who are

admitted to the hospital with febrile illness and transient aplastic

crises should remain on Droplet Precautions for 7 days and patients

known or suspected to be chronically infected with B19 should be placed

on Droplet Precautions on admission and for the duration of

hospitalization (1, 256). Work restrictions are not necessary for

personnel exposed to B19.

12. Pertussis

Nosocomial transmission of Bordetella pertussis has involved both

patients and personnel; unimmunized children are at greatest risk (266-

270). Serologic studies of health care personnel indicate that

personnel may be exposed to and infected with pertussis much more

frequently than indicated by the occurrence of recognized clinical

illness (267, 269, 271, 272). In one such study, the level of pertussis

agglutination antibodies was found to correlate with the degree of

patient contact; the prevalence of such antibody was highest in

pediatric housestaff (82%) and ward nurses (71%) and lowest in nurses

with administrative responsibilities (35%) (267).

Pertussis is highly contagious: Secondary attack rates exceed 80%

in susceptible household contacts (273-275). B. pertussis transmission

occurs by contact with respiratory secretions or large aerosol droplets

from the

[[Page 47285]]

respiratory tract of infected persons. The incubation period is usually

7-10 days. The period of communicability starts at the onset of the

catarrhal stage and extends into the paroxysmal stage. Preventing

secondary transmission of pertussis is especially difficult during the

early stages of the disease because pertussis is highly communicable in

the catarrhal stage when the symptoms are nonspecific and the diagnosis

is uncertain.

During nosocomial pertussis outbreaks, the risk of acquiring

infection among patients or personnel is often difficult to quantify

because exposure is not easily determined. Furthermore, clinical

symptoms in adults are less severe than in children and may not be

recognized as pertussis. Pertussis should be considered for any person

presenting with an acute cough lasting 7 days, particularly

if accompanied by paroxysms of coughing, inspiratory whoop, or post-

tussive vomiting (270, 271).

Prevention of transmission of B. pertussis in health care settings

involves (a) early diagnosis and treatment of patients with clinical

infection; (b) implementation of Droplet Precautions for infectious

patients (1); (c) exclusion of infectious personnel from work; and (d)

administration of postexposure prophylaxis to persons exposed to

infectious patients (269). Patients with suspected or confirmed

pertussis who are admitted to the hospital need to be placed on Droplet

Precautions until they improve clinically and have received

antimicrobial therapy for at least 5 days.

Vaccination of adolescents and adults with whole-cell B. pertussis

vaccine is not recommended (17) because local and systemic reactions

have been observed more frequently in these groups than in children.

Acellular pertussis vaccine is immunogenic in adults and has a lower

risk of adverse events than does whole-cell vaccine (270, 276).

However, the acellular vaccine has not been licensed for use in persons

7 years old. Because immunity among vaccine recipients wanes

5-10 years after the last vaccine dose (usually given at 4-6 years of

age), personnel may play an important role in transmitting pertussis to

susceptible infants. However, additional studies are needed to assess

whether booster doses of acellular vaccines are indicated for adults.

Postexposure prophylaxis is indicated for personnel exposed to

pertussis; a 14 -day course of either erythromycin (500 mg qid po) or

trimethoprim-sulfamethoxazole (1 tablet bid) has been used for this

purpose. The efficacy of such prophylaxis has not been well documented,

but studies suggest that it may minimize transmission (17, 269, 277,

278). There are no data on the efficacy of newer macrolides

(clarithomycin or azithromycin) for prophylaxis of persons exposed to

pertussis.

Restriction from duty is indicated for personnel with pertussis,

from the beginning of the catarrhal stage through the third week after

onset of paroxysms or until 5 days after the start of effective

antimicrobial therapy. Exposed personnel do not need to be excluded

from duty.

13. Poliomyelitis

The last case of indigenously acquired wild-virus poliomyelitis

occurred in the United States in 1979. Since then, all of the cases of

endemic poliomyelitis reported in the United States (5-10 endemic

cases/year) have been related to the administration of oral polio

vaccine (OPV) (19). Although, the risk of transmission of poliovirus in

the United States is very low, wild poliovirus may potentially be

introduced into susceptible populations with low immunization levels.

Poliovirus is transmitted through contact with feces or urine of

infected persons, but can be spread by contact with respiratory

secretions and, in rare instances, through items contaminated with

feces. The incubation period for nonparalytic poliomyelitis is 3 to 6

days, and usually 7 to 21 days for paralytic polio (279).

Communicability is greatest immediately before and after the onset of

symptoms, when the virus is in the throat and excreted in high

concentration in feces. The virus can be recovered from the throat for

1 week and from feces for several weeks to months following onset of

symptoms.

Vaccine-associated poliomyelitis may occur in the recipient (7-21

days after vaccine administration) or susceptible contacts of the

vaccine recipient (20-29 days after vaccine administration) (280).

Adults have a slightly increased risk of vaccine-associated paralytic

polio after receipt of OPV; therefore, inactivated poliovirus vaccine

(IPV) should be used when adult immunization is warranted (6, 14, 19).

Also, because immunocompromised persons may be at greater risk for

developing polio after exposure to vaccine virus, IPV, rather than OPV,

is recommended when vaccinating pregnant or immunocompromised personnel

or personnel who may have contact with immunocompromised patients (6,

14, 19, 279).

Health care personnel who may have contact with patients excreting

wild virus (e.g., imported poliomyelitis case) and laboratory personnel

handling specimens containing poliovirus should receive a complete

series of polio vaccine, or if previously vaccinated, they may require

a booster dose of either IPV or OPV (6, 19). For situations where

immediate protection is necessary (e.g., an imported case of wild-virus

poliomyelitis requiring care), additional doses of OPV should be given

to adults if they have previously completed a polio vaccine series

(19).

14. Rabies

Human rabies cases occur primarily from exposure to rabid animals.

Cases of human rabies have increased in the United States during the

1990s (281). Laboratory and animal care personnel who are exposed to

infected animals, their tissues and excretions are at risk for the

disease. Also, rabies transmission to laboratory personnel has been

reported in vaccine production and research facilities following

exposure to high-titered infectious aerosols (282, 283). Theoretically,

rabies may be transmitted to health care personnel from exposures (bite

and non-bite) to saliva from infected patients, but no cases have been

documented following these types of exposures (284).

It is also possible that rabies can be transmitted when other

potentially infectious material (such as brain tissue) comes in contact

with nonintact skin or mucous membranes. Bites that penetrate the skin,

especially bites to the face and hands, pose the greatest risk of

transmission of rabies virus from animals to humans (20). The

incubation period for rabies is usually 1 to 3 months but longer

periods have been reported (285).

Exposures to rabies can be minimized by adhering to Standard

Precautions when caring for persons with suspected or confirmed rabies

(1) and by using proper biosafety precautions in laboratories (3).

Preexposure vaccination has been recommended for all personnel who (a)

work with rabies virus or infected animals; or (b) engage in

diagnostic, production, or research activities with rabies virus (3,

20). Consideration also may be given to providing preexposure

vaccination to animal handlers when research animals are obtained from

the wild, rather than from a known supplier who breeds the animals.

Postexposure prophylaxis has been administered to health care

personnel following exposures to patients with rabies (285-287) (Table

1) but decisions regarding postexposure prophylaxis should be made on a

case-by-case basis

[[Page 47286]]

after discussion with public health authorities (20).

15. Rubella

Nosocomial transmission of rubella has occurred from both male and

female personnel to other susceptible personnel and patients as well as

from patients to susceptible personnel and other patients (288-295).

Rubella is transmitted by contact with nasopharyngeal droplets from

infected persons. The incubation period is variable but may range from

12 to 23 days; most persons develop the rash 14-16 days after exposure.

The disease is most contagious when the rash is erupting, but virus may

be shed from 1 week before to 5-7 days after the onset of the rash

(296). Rubella in adults is usually a mild disease, lasting only a few

days; 30% to 50% of cases may be subclinical or inapparent.

Droplet Precautions are used to prevent transmission of rubella.

Infants with congenital rubella may excrete virus for months to years;

therefore, when caring for such patients it is advisable to use Contact

Precautions for the first year of life, unless nasopharyngeal and urine

cultures are negative for rubella virus after 3 months of age (1).

Ensuring immunity among all health care personnel (male and female)

is the most effective way to eliminate nosocomial transmission of

rubella (6, 7, 12, 248, 297). Persons should be considered susceptible

to rubella if they lack (a) documentation of one dose of live rubella

vaccine on or after their first birthday; or (b) laboratory evidence of

immunity (persons with indeterminate levels are considered

susceptible). A history of past rubella infection is unreliable and

should not be considered indicative of immunity to rubella. Although

birth before 1957 is generally considered acceptable evidence of

rubella immunity, a dose of MMR has been recommended for those health

care personnel that do not have laboratory evidence of immunity (7). In

addition, birth before 1957 is not considered acceptible evidence of

rubella immunity for women of childbearing age (7). Voluntary

immunization programs are usually inadequate to ensure personnel

protection (298, 299). Because many health departments mandate rubella

immunity for health care personnel, personnel health programs should

consult with their local or state health departments before

establishing policies for their facilities.

Serologic screening of personnel for immunity to rubella need not

be done before vaccinating against rubella unless the medical facility

considers it cost-effective or the person getting vaccinated requests

it (227-229). When serologic screening before vaccination is done,

tracking systems are needed to ensure that those identified as

susceptible are subsequently vaccinated in a timely manner (229).

Likewise, during rubella outbreaks, serologic screening is not

necessary. The ACIP states that rubella vaccination is contraindicated

among pregnant women, but administering rubella vaccine to women not

known to be pregnant is justifiable without prevaccination screening

(12); pregnant women who are already immune to rubella are not at

increased risk for adverse advents (300). MMR trivalent vaccine is the

vaccine of choice for rubella, especially when the recipient also is

likely to be susceptible to measles and/or mumps (Table 2).

Work restrictions are necessary for personnel who develop rubella;

ill personnel need to be excluded from duty for 5 days after the rash

appears. Likewise, personnel susceptible to rubella require exclusion

from duty from the 7th day after the first exposure through the 21st

day after the last exposure (Table 3).

16. Scabies and Pediculosis

a. Scabies. Scabies is caused by infestation with the mite

Sarcoptes scabiei. The conventional (typical) clinical presentation of

scabies includes intense pruritus and cutaneous tracks, where mites

have burrowed into the skin. Crusted or ``Norwegian'' scabies may

develop among immunocompromised and elderly individuals because their

skin may become hyperkeratotic, and pruritus may not be present, which

also makes diagnosis difficult. In conventional scabies 10-15 mites are

present, while in crusted scabies thousands of mites are harbored in

the skin, increasing the potential for transmission (301, 302).

Nosocomial outbreaks of scabies have occurred in a variety of

health care settings including intensive care units (303),

rehabilitation centers (304), long-term care facilities (305-307),

hospital wards (308, 309), and a health care laundry (310). In recent

years there has been an increase in the occurrence of crusted scabies

among immunocompromised patients, particularly persons with HIV, which

has led to the transmission of scabies among personnel, patients and

their families (303, 304, 306-308, 310-315).

Nosocomial transmission of scabies occurs primarily through skin-

to-skin contact with an infested person (301, 316, 317). Personnel have

acquired scabies while performing patient-care duties such as sponge-

bathing, lifting, or applying body lotions (301, 302, 312, 318).

Transmission by casual contact, such as by holding hands, or via

innaminate objects, such as infested bedding, clothes, or other

fomites, has been reported infrequently (310, 319, 320).

The use of Contact Precautions when taking care of infested

patients prior to application of scabicides can decrease the risk of

transmission to personnel (1, 302). Routine cleaning of the environment

of patients with typical scabies, especially bed linens and upholstered

furniture, will aid in eliminating the mites. Additional environmental

cleaning procedures may be warranted for crusted scabies (301, 302,

321, 322).

Recommendations for treatment and control of scabies in health care

institutions have been published previously (301, 302, 321-325). The

recommended topical scabicides include permethrin cream (5%),

crotamiton (10%), or lindane (1%) lotion; resistance to lindane has

been reported (321, 324). Single-dose oral ivermectin has recently been

shown to be an effective therapy for scabies (313, 325, 326), but has

not received Federal Drug Administration approval for this purpose.

Most infested health care workers have typical scabies with low

mite loads (311, 327); a single correct application of a scabicide is

adequate and immediately decreases the risk of transmission (316-318,

328-331). If personnel remain symptomatic after initial treatment, a

repeat application of scabicide may be needed in 7-10 days. Persistent

symptoms likely represent newly hatched mites rather than new

infestation. Patients with crusted scabies may require repeated

treatments and should be observed for recurrence of the mite

infestation (301, 302, 306, 321). Personnel who are exposed to scabies,

but lack signs of infestation, do not require prophylactic treatment

with scabicides.

Restrictions from patient care are indicated for personnel infested

with scabies until after they receive initial treatment. They should be

advised to report for further evaluation if symptoms do not subside.

b. Pediculosis. Pediculosis infestation is caused by three species

of lice: Pediculus humanus capitus (human head louse), Pediculus

humanus corporis (human body louse), or Phthirus pubis (pubic or crab

louse).

Head lice are transmitted by head-to-head contact or by contact

with infested fomites such as hats, combs, or brushes.

[[Page 47287]]

Nosocomial transmission, while not common, has occurred (301).

Body lice are usually associated with poor hygiene and overcrowded

conditions. Transmission occurs by contact with the skin or clothing of

an infested person. Nosocomial transmission is unlikely.

Pubic lice are primarily found in the pubic hair but can be found

in the axilla, eyelashes or eyebrows. Transmission occurs primarily

through intimate physical or sexual contact. Transmission by fomites,

such as toilet seats or bedding, is uncommon. Nosocomial transmission

is very unlikely.

Recommendations for control of pediculosis have been published

previously (301, 322, 332). The drugs recommended for treatment include

permethrin cream 1%, pyrethrins with piperonyl butoxide, malathion

0.5%, or lindane 1% (323-325, 332). Health care personnel exposed to

patients with pediculosis do not require treatment unless they show

evidence of infestation.

Restriction from patient care is indicated for personnel infested

with pediculosis until after they receive initial treatment. If

symptoms do not subside following initial treatment, they should be

advised to report for further evaluation.

17. Staphylococcus aureus Infection and Carriage

Staphylococcal carriage and infection occur frequently in humans.

In hospitals the most important sources of S. aureus are infected and

colonized patients. Previously, methicillin-susceptible (but

penicillin-resistant) S. aureus (MSSA) accounted for most

staphylococcal infections. However, in recent years, methicillin-

resistant S. aureus (MRSA) has accounted for approximately 80% of all

S. aureus isolates reported to the National Nosocomial Surveillance

System (333-335). The epidemiology of MRSA does not appear to differ

from that of MSSA, except that outbreaks of MRSA tend to occur more

frequently among elderly or immunocompromised patients or among

patients with severe underlying conditions (333, 336).

Nosocomial transmission of S. aureus occurs primarily via the hands

of personnel, which can become contaminated by contact with the

colonized or infected body sites of patients (333, 337). Hospital

personnel who are infected or colonized with S. aureus also can serve

as reservoirs and disseminators of S. aureus (338-341) and infected

dietary personnel have been implicated in staphylococcal food poisoning

(342). The role of contaminated environmental surfaces in transmission

of S. aureus remains controversial, although heavy contamination of

fomites may facilitate transmission to patients via personnel hands

(333).

The incubation period for S. aureus infections varies by type of

disease: foodborne illness is 30 minutes to 6 hours; bullous impetigo

is 1-10 days; toxic-shock syndrome is usually 2 days; and other types

of infections it is variable (343).

Carriage of S. aureus is most common in the anterior nares, but

other sites, such as the hands, axilla, perineum, nasopharynx and

oropharynx may also be involved (333). The frequency of nasal carriage

of S. aureus among health care personnel ranges between 20% and 90%,

but fewer than 10% of healthy nasal carriers disperse the organisms

into the air (339). Nasal carriers with upper respiratory symptoms can

disseminate the organism more effectively (339). Carriage of S. aureus

in the nares has been shown to correspond to hand carriage (334) and

persons with skin lesions caused by S. aureus are more likely than

asymptomatic nasal carriers to disseminate the organism.

Culture surveys of personnel can detect carriers of S. aureus but

do not indicate which carriers are likely to disseminate organisms.

Thus, such surveys are not cost-effective and may subject personnel

with positive cultures to unnecessary treatment and removal from duty.

A more reasonable approach is to conduct active surveillance for

nosocomial S. aureus infections. Culture surveys may be indicated if,

after a thorough epidemiologic investigation, personnel are linked to

infections. Such implicated personnel can then be removed from clinical

duties until carriage is eradicated (333, 338, 344-346).

Several antimicrobial regimens have been used successfully to

eradicate staphylococcal carriage in health care personnel. These

regimens include orally administered antimicrobial agents (e.g.,

rifampin, clindamycin, or ciprofloxacin) alone or in combination with

another oral (e.g., trimethoprim sulfamethoxazole) or topical

(mupirocin) antimicrobial (345, 347-358). Resistant S. aureus strains

have emerged following the use of the above oral or topical

antimicrobial agents for eradication of S. aureus colonization (16,

202, 345, 349, 359-361). Thus, antimicrobial treatment to eradicate

carriage may be best if limited to personnel carriers who are

epidemiologically linked to disease transmission. Nosocomial

transmission of S. aureus can be prevented by adherence to Standard

Precautions and other forms of transmission based precautions, as

needed (1).

Restriction from patient-care activities or food-handling is

indicated for personnel who have draining skin lesions that are

infected with S. aureus until they have received appropriate therapy

and the infection has resolved. No work restrictions are necessary for

personnel who are colonized with S. aureus, unless they have been

epidemiologically implicated in S. aureus transmission within the

facility.

18. Streptococcus, Group A

Group A Streptococcus (GAS) has been transmitted from infected

patients to health care personnel following contact with infected

secretions (362-364), and the infected personnel have subsequently

developed a variety of GAS-related illnesses (e.g., toxic-shock-like

syndrome, cellulitis, lymphangitis, and pharyngitis). Health care

personnel who were GAS carriers have infrequently been linked to

sporadic outbreaks of surgical site, postpartum or burn wound

infections (365-371) and foodborne transmission of GAS causing

pharyngitis (372). In these outbreaks GAS carriage was documented in

the pharynx (364, 367, 373), the skin (364, 365), the rectum (364,

370), and the female genital tract of the infected personnel (364, 369,

374).

The incubation period for GAS pharyngitis is 2-5 days, and is 7-10

days for impetigo. The incubation period is variable for other GAS

infections (375).

Culture surveys to detect GAS carriage among personnel are not

warranted unless personnel are epidemiologically linked to cases of

nosocomial infection (373). In instances where thorough epidemiologic

investigation has implicated personnel in nosocomial transmission,

cultures may be obtained from skin lesions, the pharynx, rectum, and

vagina; GAS isolates obtained from personnel and patients can be

serotyped to determine strain relatedness (368). Treatment of personnel

carriers needs to be individualized because (a) experience is limited

regarding the treatment of personnel carriers implicated in GAS

outbreaks; and (b) carriage of the organism by personnel may be

recurrent over long periods of time (364-366, 369). Contact is the

major mode of transmission of GAS in these health care settings.

Airborne transmission during outbreaks has been suggested by several

investigators, and some have demonstrated that exercising and changing

of clothing can lead to airborne dissemination of GAS from

[[Page 47288]]

rectal and vaginal carriage (364, 369, 370, 374). Nosocomial

transmission of GAS to personnel can be prevented by adherence to

Standard Precautions or other transmission-based precautions as needed

(1).

Restriction from patient-care activities and food-handling is

indicated for personnel with GAS infections until 24 hours after they

have received appropriate therapy. However, no work restrictions are

necessary for personnel who are colonized with GAS, unless they have

been epidemiologically linked to transmission of infection within the

facility.

19. Tuberculosis

Nosocomial transmission of tuberculosis (TB) is well documented,

but such transmission in the United States is generally low. However,

the risk may be increased in health care facilities located in

communities with (a) high rates of HIV; (b) high numbers of persons

from TB-endemic countries; and (c) communities with a high prevalence

of TB infection (376, 377). In some areas in the USA, the incidence and

prevalence of multidrug-resistant Mycobacterium tuberculosis (MDR-TB)

also have increased, and nosocomial MDR-TB outbreaks have occurred

(378-384). The increased risk of occupational acquisition of TB by

health care personnel has been reported for decades and it dramatically

decreased following the introduction of effective antituberculous drugs

(385, 386). Skin-test conversion rates among health care personnel

following routine skin testing have ranged from 0.11 % to 10%. Among

health care personnel with known exposure to an infectious TB patient

or involved in prolonged nosocomial outbreaks of TB, the skin-test

conversion rates have ranged from 18% to 55% (378-380, 383, 384, 386-

393).

The transmission of TB in health care facilities has been primarily

caused by incomplete implementation of recommended TB infection control

measures (388). In 1994, CDC published detailed recommendations for the

prevention of transmission of TB in health care settings, Guidelines

for Preventing the Transmission of Mycobacterium tuberculosis in Health

Care Facilities, 1994 (377). A summary of the recommendations

pertaining to personnel health follow.

a. Strategies for prevention of transmission of TB. The risk of

transmission of TB to or from personnel in a health care facility

varies according to the type and size of the facility, the prevalence

of TB in the community, the patient population served by the facility,

the occupational group the person represents, the area of the facility

where the person works, and the effectiveness of the facility's TB-

control program. A detailed risk assessment is essential in identifying

the nature of TB control measures that are appropriate for a particular

facility as well as for specific areas and occupational groups within a

facility (377, 394). A risk assessment should include the following:

(a) Review of the community TB profile; (b) review of the number of TB

patients who were treated in each area of the facility; (c) review of

the drug-susceptibility patterns of TB isolates from patients treated

in the facility; (d) an analysis of purified protein derivative (PPD)

skin-test results of health care personnel by work area or occupational

group; (e) an evaluation of infection control parameters including

isolation policies, laboratory diagnostic capabilities, and

antitubercular therapy regimens; (f) an observational review of TB

infection control practices; and (g) evaluation of the function and

maintenance of environmental controls (377).

Transmission of TB can be minimized by developing and implementing

an effective TB-control program based on a hierarchy of controls,

namely, (a) administrative controls, (b) engineering controls, and (c)

personal respiratory protection (377, 379, 381, 386, 388, 394, 395).

b. TB screening program. A tuberculosis screening program for

personnel is an integral part of a health care facility's comprehensive

TB control program. The screening program should be based on the

facility specific risk assessment.

Baseline PPD testing of all personnel [including personnel with a

history of Bacille Calmette-Guerin vaccination (BCG)] during their pre-

employment physical examination or when applying for hospital

privileges will identify personnel who have been previously infected.

For the baseline testing a two-step procedure can be used to minimize

the likelihood of confusing reactivity from an old infection (boosting)

with reactivity from a recent infection (conversion). Criteria used for

interpretation of a PPD test reaction may vary depending on the (a)

purpose (diagnostic or epidemiologic) of the test; (b) prevalence of TB

infection in the population being tested; (c) immune status of the

host; and (d) previous receipt of TB immunization. Detailed

recommendations have been published for performing and interpreting

skin tests (377, 396, 397).

c. Follow-up evaluation. The risk assessment will identify which

health care personnel have the potential for exposure to M.

tuberculosis and determine how frequently they should receive PPD

testing. At minimum, annual PPD testing is indicated for personnel with

the potential for exposure to TB.

It is also important to obtain an initial chest x-ray on personnel

with positive PPD-test reactions, documented PPD-test conversions, or

pulmonary symptoms suggestive of TB. There are no data to support the

use of routine chest x-ray examinations on asymptomatic PPD test-

negative personnel. In addition, personnel who have positive PPD-test

reactions but also received adequate preventive treatment do not need

repeat chest films unless they have pulmonary symptoms suggestive of

TB. Repeat chest x-ray examinations of such persons have not been shown

to be beneficial or cost-effective in monitoring persons for

development of disease. However, more frequent monitoring for symptoms

of TB may be considered for personnel who convert their PPD test; those

persons, if infected, are at increased risk of developing active TB

(e.g., HIV-infected or otherwise severely immunocompromised persons).

d. Management of personnel after exposure to TB. It is important to

perform PPD tests on personnel as soon as possible after TB exposures

are recognized. Such immediate PPD testing establishes a baseline by

which to monitor subsequent PPD tests. A PPD test, performed 12 weeks

after the last exposure, will indicate if infection has occurred.

Persons already known to have reactive PPD tests need not be retested.

Personnel with evidence of new infection (i.e., PPD-test conversions)

need to be evaluated for active TB. If active TB is not diagnosed,

preventive therapy should be considered (377).

e. Preventive therapy. For workers with positive PPD tests who were

likely exposed to drug-susceptible TB, preventive therapy with

isoniazid is indicated, unless there are contraindications to such

therapy (377, 397). Alternative preventive regimens have been proposed

for persons who have positive PPD tests following exposure to drug-

resistant TB (398).

f. Work restrictions. Personnel with active pulmonary or laryngeal

TB may be highly infectious; exclusion from duty is indicated until

they are noninfectious. If personnel are excluded from duty because of

active TB, the facility should have documentation from their health

care providers that personnel are noninfectious before they are allowed

to return to duty. The

[[Page 47289]]

documentation needs to include evidence that (a) adequate therapy is

being received; (b) the cough has resolved; and (c) three consecutive

sputum acid-fast-bacilli (AFB) smears, collected on different days, are

negative. After personnel resume duty and while they remain on anti-TB

therapy, periodic documentation from their health care providers is

needed to show that effective drug therapy is being maintained for the

recommended time period and that their sputum AFB smears continue to be

negative.

Work restrictions are not necessary for personnel receiving

preventive treatment for latent TB (positive PPD test without active

disease) or for personnel with latent TB who do not accept preventive

therapy. However, these personnel should be instructed to seek

evaluation promptly if they develop symptoms suggestive of TB.

g. Considerations for Bacille Calmette-Guerin Vaccine. BCG has not

been routinely used in the United States to protect health care

personnel. Nevertheless, because of the resurgence of TB in the United

States and new information about the protective effect of BCG (399,

400), the role of BCG vaccination in the prevention and control of TB

in the country has been re-evaluated (401). The following is a summary

of the joint statement by the Advisory Council for the Elimination of

Tuberculosis and ACIP regarding the use of BCG in health care

personnel.

Two recent meta-analyses of 18 and 26 BCG studies, respectively,

indicate that the efficacy of BCG vaccine in preventing serious TB in

children is high (>80%) and suggested 50% efficacy in adults (399,

400); however, the protective efficacy of the vaccine in adolescents

and adults, including health care personnel and HIV-infected children

and adults, has not been determined (401).

BCG vaccination may be indicated for health care personnel in a few

geographic areas where the prevalence of MDR-TB is high, transmission

of TB is likely, and TB infection control measures have not been

successful in controlling nosocomial transmission (401). BCG

vaccination often results in local adverse effects (such as muscular

soreness, erythema, purulent drainage, axillary or cervical

lymphadenopathy for as long as 3 months after vaccination); serious

long-term complications (such as musculoskeletal lesions, multiple

lymphadenitis, and disseminated BCG disease) are infrequent (402-404).

The safety of BCG vaccination in immunocompromised populations (i.e.,

immunocompromised from immune deficiency diseases, HIV infection,

leukemia, lymphoma, or generalized malignancy, or immunosuppressed as a

result of therapy with corticosteroids, alkylating drugs,

antimetabolites, or radiation) has not been determined by adequate

epidemiologic studies. However, because of the possibility of

disseminated BCG infection in such persons (405-408), BCG vaccination

is not recommended for immunocompromised personnel (401).

PPD testing is not contraindicated for persons who have received

BCG vaccine and can be used to support or exclude the diagnosis of

infection with M. tuberculosis (401). PPD-test reactivity caused by BCG

vaccination wanes with time (409-411) and is unlikely to persist >10

years after vaccination in the absence of infection with M.

tuberculosis (409, 410). After a person has been vaccinated with BCG,

the presence or size of a PPD-test reaction cannot be used as a

predictor of BCG vaccine efficacy in the vaccine recipient (412, 413),

or as a determinant as to whether the reaction is caused by infection

with M. tuberculosis or the prior BCG vaccination (414). However, a

BCG-vaccinated person who has a PPD test reaction of 10 mm

induration is considered infected with TB, especially if the vaccinee

is a contact of a person with infectious TB, is from a country with

high prevalence of TB, or is continually exposed to populations in

which the prevalence of TB is high (401).

20. Vaccinia (Smallpox)

Because of the effective use of smallpox vaccine (vaccinia virus

vaccine), the World Health Organization declared the world free of

smallpox in 1980. The smallpox vaccine licensed for use in the United

States is derived from infectious vaccinia virus. After vaccination,

the virus can be cultured from the vaccination site until the scab has

separated from the skin (2-21 days after vaccination); thus,

susceptible persons may acquire vaccinia from a recently vaccinated

person (415-418). Covering the vaccination site and washing hands

following contact with the vaccination site (including bandages) will

prevent transmission. Recently, recombinant vaccinia viruses have been

engineered. There is a theoretical risk that transmission could occur

from contact with contaminated dressings or by contact with recombinant

vaccine, but no such transmission has been reported among personnel who

provide care to the recombinant vaccine recipients. Infections also

have been reported among laboratory personnel who handle viral cultures

or materials contaminated with vaccinia or recombinant viruses (16,

155).

Smallpox vaccination is indicated for personnel who work directly

with orthopox viruses (e.g., monkeypox, vaccinia, variola) or in

animal-care areas where orthopox-viruses are studied. In selected

instances, vaccination may be considered for personnel who provide care

to recipients of recombinant vaccinia vaccine (7, 16). Personnel who

receive the vaccine may continue to have contact with patients if the

vaccination site is covered and handwashing is maintained (16).

21. Varicella

Nosocomial transmission of varicella-zoster virus (VZV) is well

recognized (419-430). Sources for nosocomial exposures have included

patients, health care personnel, and visitors (including the children

of personnel) with either varicella or herpes zoster.

All susceptible adults in health care settings are at risk for

varicella and its complications. However, certain persons are at higher

risk for severe disease and secondary complications; they include

pregnant women, premature infants born to varicella-susceptible

mothers; infants born at 65 years

of age; (b) residents of nursing homes and other chronic-care

facilities; (c) persons with chronic pulmonary or cardiovascular

conditions; and (d) persons with diabetes mellitus (15). Adherence to

Droplet Precautions may prevent nosocomial transmission (1).

Administration of influenza vaccine to health care personnel,

including pregnant women (7), before the beginning of each influenza

season can help to (a) reduce the risk of influenza infection to health

care personnel; (b) prevent transmission of influenza from personnel to

persons at high risk of complications; and (c) reduce personnel

absenteeism during community outbreaks. Innovative methods may be

needed to increase influenza immunization rates among health care

personnel (467). Immunization rates may also be increased by providing

data to health care personnel on the low rates of systemic reactions to

influenza vaccine among healthy adults (468).

During institutional outbreaks of influenza, prophylactic antiviral

agents (e.g., amantadine and rimantadine) may be used in conjunction

with influenza vaccine to reduce the severity and duration of illness

among unvaccinated health care personnel. Amantadine and rimantadine

may be administered for 2 weeks following personnel vaccination or, in

unvaccinated personnel, for the duration of influenza activity in the

community (15, 449, 469, 470).

b. Respiratory Syncytial Virus (RSV). Nosocomial transmission of

RSV is greatest during the early winter when community RSV outbreaks

occur; patients, visitors, and health care personnel may transmit the

virus in the health care setting. RSV infection is most common among

infants and children, who are likely to develop more severe disease.

Because RSV infection can also occur simultaneously with other

respiratory viruses, it may go unrecognized (471, 472). Nosocomial

transmission has been reported most frequently among newborn and

pediatric patients (473, 474), but outbreaks associated with

substantial morbidity and mortality have been reported among adults in

bone marrow transplant centers (475), intensive care units (476), and

long-term care facilities (477, 478).

RSV is present in large numbers in the respiratory secretions of

symptomatic persons infected with the virus and can be transmitted

directly via large droplets during close contact with such persons, or

indirectly via hands or fomites that are contaminated with RSV. Hands

can become contaminated through handling of infected persons'

respiratory secretions or contaminated fomites, and transmit RSV by

touching the eyes or nose (449). The incubation period ranges from 2-8

days; 4-6 days is most common. In general, infected persons shed the

virus for 3-8 days, but young infants may shed virus for as long as 3-4

weeks. Adherence to Contact Precautions effectively prevents nosocomial

transmission.

c. Work restrictions. Because large numbers of personnel may have

viral respiratory illnesses during the winter, it may not be possible

to restrict infected personnel from all patient-care duties.

Nevertheless, it may be prudent to restrict personnel with acute viral

respiratory infections from the care of high-risk patients during

community outbreaks of RSV and influenza (479, 480).

E. Pregnant Personnel

Immunologic changes occur during pregnancy, primarily depression of

certain aspects of cell-mediated immunity such as decreased levels of

helper T cells. These changes permit fetal development without

rejection but generally do not increase maternal susceptibility to

infectious diseases. Occupational acquisition of infections is of

special concern to female health care personnel of childbearing age for

several reasons. Some infections, such as varicella, may be more severe

during pregnancy. Transplacental infection with viruses such as

parvovirus, varicella, and rubella has been associated with abortion,

congenital anomaly, and mental retardation. Other diseases in which the

infectious agent may be transmitted to the fetus include

cytomegalovirus, hepatitis B, herpes simplex, influenza, and measles.

In addition, certain drugs used to treat or prevent some infections,

for example tuberculosis, may be contraindicated during pregnancy.

In general, pregnant health care personnel do not have an increased

risk of acquiring infections in the workplace. The risks to pregnant

personnel and methods for prevention are discussed in the various

sections of this document and are summarized in Table 6. Female

personnel of childbearing age should be strongly encouraged to receive

immunizations for vaccine-preventable diseases prior to pregnancy. Such

personnel may also decrease their risk of acquiring infection by

adhering to appropriate infection control practices, including Standard

Precautions when caring for all patients. Additional information on

occupational risks for pregnant health care personnel has been

published elsewhere (480-482).

F. Laboratory Personnel

Despite the availability of improved engineering controls, work

practices, and personal protective equipment, laboratory personnel

remain at risk for occupational acquisition of infectious agents (3,

16, 48, 144, 155, 235, 483, 484). Furthermore, newer technologies that

require the use of large and/or concentrated specimens may further

increase the risk of occupationally acquired infections among

laboratory personnel (485).

In a review of laboratory-acquired infections from 1950-1974 >4000

laboratory associated infections were documented in the United States

(483) the 10 most commonly reported infections were brucellosis, Q

Fever, hepatitis, especially hepatitis B, typhoid fever, tularemia,

tuberculosis,

[[Page 47292]]

dermatomycosis, venezuelan equine encephalitis, psittacosis, and

coccidioidomycosis. However, laboratory-associated infections also have

been due to a wide variety of other pathogens (155, 483, 484). More

recently, viral agents have accounted for a larger proportion of

laboratory associated infections than have bacterial infections (484-

489).

Laboratory personnel may acquire infection by aerosolization of

specimens, mouth pipetting, or percutaneous injury. Information on the

risks of laboratory-associated infections and appropriate biosafety

procedures and precautions for laboratories have been published (3, 4,

485, 490-492).

In addition to biosafety precautions, preventive measures (e.g.,

immunizations and postexposure prophylaxis) also may be indicated for

laboratory personnel who handle infectious agents. In this document,

disease specific information and guidance are provided for prevention

of laboratory-associated infections and for management of laboratory

personnel exposed to infectious agents. Health care institutions need

to ensure that laboratory personnel who may be exposed to infectious

agents are well informed about the risks of acquiring infections and

biosafety procedures to prevent transmission of infectious agents.

G. Emergency Response Personnel

Emergency medical technicians, firemen, policemen, and others who

attend to and transport patients to the hospital may be exposed to

recognized or undiagnosed transmissible infectious diseases in the

patients with whom they come in contact. Subtitle B (42 U.S.C. 300ff-

80) of the 1990 Ryan White Comprehensive AIDS Resources Emergency Act

requires the establishment of notification systems in each State to

ensure that emergency response employees (including emergency medical

technicians, firefighters, and the like) are informed when they have

been exposed to an emergency medical patient with an infectious,

potentially fatal disease such as HIV or meningococcemia. CDC published

a list of diseases for which emergency response employees must be

informed of an exposure (493).

H. Latex Hypersensitivity

Since the introduction of Universal Precautions, the use of latex

gloves has become commonplace in health care settings (494, 495). The

increased use of latex gloves has been accompanied by increasing

reports of allergic reactions to natural rubber latex among health care

personnel (496-501).

Natural rubber latex is a combination of heat and water-soluble

proteins derived from the tree Hevea braziliensis. However, total

protein concentrations and allergenicity are not always directly

correlated (502), suggesting that total protein concentrations are not

necessarily a measure of the allergenic properties of latex gloves.

Latex gloves may be labeled ``hypoallergenic'', but this designation

refers to nonlatex additives in gloves and does not reflect reduced

allergenicity to latex (503). In one study, nearly 50% (11/24) of the

lots of hypoallergenic gloves tested had measurable latex allergen

(504). The FDA has proposed labeling of all the medical devices that

contain natural rubber latex (505). Also, the total protein content of

latex gloves may vary considerably from brand to brand and lot to lot

(502, 504). Currently, the amount of latex allergen exposure required

to produce sensitization or to elicit reactions in previously

sensitized persons is unknown.

Another recognized contributor to latex sensitization and reactions

is the powder or cornstarch used as a lubricant for gloves. Levels of

extractable protein and allergen in a given glove have been shown to be

correlated with the presence of powder. Powdered gloves have higher

levels of these proteins than powder-free gloves. Also, investigators

have demonstrated that latex proteins adhere to the powder on gloves

and that aerosolized latex protein-powder particles can provoke

allergic respiratory symptoms if inhaled by a latex-sensitive

individuals (506); similar adherence has not been detected with

powdered vinyl gloves. In one study, personnel wearing powdered latex

gloves had a significantly higher rate of reaction than did workers who

wore washed latex gloves, from which the powder had been removed (60%

vs 28%); none of these workers had positive skin-test reactions to

industrial or commercial cornstarch or powder (497). Although many

health care personnel or clinicians may implicate the powder or

cornstarch on gloves as the cause of their reactions, documented

reactions to cornstarch powder are rare.

Reactions to latex gloves may be localized or systemic and include

dermatitis, conjunctivitis, rhinitis, urticaria, angioedema, asthma,

and anaphylaxis (507-510). The majority of local reactions associated

with latex glove use are not immunologically mediated and result from

chemicals (e.g., thiurams, carbamates, mercaptobenzothiazole,

phenylenediamine), accelerants or antioxidants added to gloves during

manufacturing (495, 500, 511-513). It may be difficult to differentiate

irritant reactions from allergic contact dermatitis reactions. Both may

be manifested by itching, dryness, erythema, bleeding, or scaling of

the hands. Nevertheless, neither of the types of local reactions to

latex gloves are good predictors of latex allergy (496, 514); only a

subset of health care personnel reporting glove-associated skin

irritation will have immunoglobulin E (IgE) antibodies specific for

latex (511, 515-517).

In contrast, systemic reactions to natural rubber latex, including

urticaria, are mediated by anti-latex IgE antibodies (507, 518, 519)

and may result from direct skin contact or from exposure to airborne

latex allergen adsorbed to glove powder. Occupational asthma from latex

is becoming increasingly recognized (518, 520-522). Asthmatic responses

to latex may occur early (8 hours) 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

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(6.2% [9/145]) were significantly more likely to be sensitized than

were personnel assigned to general wards or laboratories (1.6% [6/

367]); operating room nurses had a four fold higher prevalence than did

general ward nurses (5.6% vs 1.2%) (527). Measurable levels of latex

aeroallergen have been detected in the breathing zones of operating

room personnel and may vary as much as 100-fold, depending on the

invasiveness of the procedure and frequency of glove changes (528).

Several factors have been linked with latex sensitization among

health care personnel, including the presence of other allergic

conditions (e.g., asthma, eczema, hay fever) (496, 514, 516, 517, 520,

526, 527), nonwhite race (79, 526), elevated total IgE levels (517),

allergy to cosmetic powders or foods (529), years or status (full vs

part-time) of employment, and frequency and/or duration of glove use

(496, 514, 520, 527). Coexistent allergy to certain fruits (e.g.,

bananas [(530, 531)], avocados [(532, 533), pears, and chestnuts (534))

also has been described in latex-allergic health care personnel.

Skin irritation, eczematous dermatitis (514, 527) (conditions that

may allow passage of latex proteins through the skin), and use of other

latex products (e.g., condoms, diaphragms) have not been consistently

linked to latex sensitization in health care personnel.

b. Diagnosis/identification. Diagnosis of personnel with latex

allergy relies largely on a clinical history of symptoms elicited by

exposure to latex products (e.g., balloons, gloves). Clinical symptoms,

such as urticaria, may be good predictors of IgE-medicated allergy

(514, 517).

A variety of methods have been used to aid in the identification of

latex-allergic persons; most are experimental and have not been

approved for clinical use. Skin-prick testing (SPT) may be the most

sensitive method for diagnosis of IgE-mediated allergy, but no

standardized FDA-approved antigen is currently available in the United

States for detection of latex-specific IgE antibodies. Moreover, the

use of some skin test reagents in highly sensitized persons have been

associated with adverse outcomes (535), suggesting that these

nonstandardized reagents may not be safe for routine use. In Europe,

where a standardized SPTallergen has been developed, SPT has been used

successfully.

Currently, only one immunoassay has been FDA approved for detection

of latex-specific IgE antibodies in blood. The FDA has recommended that

this assay be used as a confirmatory test, rather than screening, for

persons in whom latex allergy is suspected, based on clinical history

and findings. Levels of detectable antibody appear to be associated

with symptoms (497, 517), but, as with other allergens, the correlation

between serum concentrations of latex-specific IgE antibodies and

symptom severity is unpredictable (497, 514). Clinical screening, in

which the worker is questioned about allergy to latex products and risk

factors for latex allergy, may help to identify those in whom further

diagnostic testing should be considered.

c. Prevention strategies. Avoiding latex products remains the

cornerstone of preventing sensitization (primary prevention) and

reactions (secondary prevention) to natural rubber latex products.

Proposed strategies to reduce the risk of reactions to natural rubber

latex have included the use of the following: (a) nonlatex (e.g.,

vinyl) products alone or in combination (with vinyl or cloth liners)

with latex gloves; (b) powder-free latex gloves; (c) powdered latex

gloves washed to remove powder; and (d)''low protein'' latex gloves.

However, none of these interventions has been prospectively studied in

controlled trials to assess its cost-effectiveness or efficacy in

preventing sensitization or reactions.

Because latex proteins can be aerosolized when powdered gloves are

donned or removed, systemic symptoms caused by latex aeroallergens may

not be alleviated by simply avoiding latex products, particularly if

co-workers of the affected worker continue to use powdered latex

gloves. Although the risk of a worker's exposure is greatest when

gloves are donned or removed, allergenic proteins also may settle on

environmental surfaces, surgical gowns, or other clothing and become

resuspended. The use of powder-free or low protein gloves appears to

more effective and less costly than either laminar flow or high-

efficiency particulate air-filtered glove-changing stations in reducing

latex aeroallergens (528). For personnel with systemic manifestations

to latex, workplace restriction or reassignment may be necessary.

I. The Americans With Disabilities Act

The Americans with Disabilities Act (ADA) provides guidelines for

hiring and placing employees with disabilities as defined in the Act

(536-539). In general, employers must assess applicants for their

qualifications to perform the tasks inherent to the job for which the

employee is being considered. Applicants may be asked about their

ability to perform specific job functions, but may not be asked about

the existence, nature, or severity of a disability. Employers must make

a ``reasonable accommodation'' to allow an individual to perform the

essential functions of a job unless the employer can prove this would

create undue hardship because of significant difficulty or expense.

The provisions of the ADA need to be incorporated into infection

control policies for health care personnel. For example, applicants

with a communicable disease spread by aerosol could justifiably be

denied employment (until they are no longer infectious) because they

could pose a direct threat to others. On the other hand, applicants who

are immunocompromised may not necessarily be excluded because of an

increased risk of acquiring an infection in the hospital if the

employer can make reasonable accommodations that prevent exposure.

Health care personnel who are known to be immunocompromised need to be

referred to personnel health professionals who can individually counsel

the employees on their risk for infection. Upon the request of the

immunocompromised health care personnel, employers should offer, but

not compel, a work setting in which health care personnel would have

the lowest possible risk for occupational exposure to infectious

agents. Evaluation of individual situations need also to include

consideration of the provisions of other applicable federal, state, and

local laws.

Part II. Recommendations for Prevention of Infections in Health Care

Personnel

A. Introduction

In this document, the term health care personnel refers to all the

paid and unpaid persons working in health care settings who have the

potential for exposure to infectious materials including body

substances, contaminated medical supplies and equipment, contaminated

environmental surfaces, or contaminated air. These personnel may

include, but are not limited to, physicians, nurses, technicians,

nursing assistants, laboratory personnel, mortuary personnel, emergency

medical service personnel, dental personnel, students and trainees,

contractual staff not employed by the health care facility, and persons

not directly involved in patient care (e.g., volunteer, dietary,

housekeeping, maintenance, and clerical personnel) but potentially

exposed to infectious agents.

[[Page 47294]]

As in previous CDC guidelines, each recommendation is categorized

on the basis of existing scientific data, theoretical rationale,

applicability, and economic impact. The system for categorizing

recommendations is as follows:

Category IA. Strongly recommended for all hospitals and strongly

supported by well-designed experimental or epidemiologic studies.

Category IB. Strongly recommended for all hospitals and reviewed as

effective by experts in the field and a consensus of Hospital Infection

Control Practices Advisory Committee members based on strong rationale

and suggestive evidence, even though definitive scientific studies have

not been done.

Category II. Suggested for implementation in many hospitals.

Recommendations may be supported by suggestive clinical or

epidemiologic studies, a strong theoretical rationale, or definitive

studies applicable to some, but not all, hospitals.

No Recommendation, Unresolved Issue. Practices for which

insufficient evidence or consensus regarding efficacy exists.

B. Elements of a Personnel Health Service for Infection Control

1. Coordinated Planning and Administration

a. Coordinate policy-making and planning among the hospital

administration, personnel health service, infection control personnel,

clinical services and various other hospital departments, and relevant

external agencies. Include paid and nonpaid personnel (e.g.,

volunteers, trainees, physicians, out-of-hospital and contractual

personnel, and emergency responders) in the plan. Category IB

b. Establish an active system and develop a written policy for

notifying infection control personnel of (1) infections in personnel

(including volunteers, trainees, contractual personnel, and out-of-

hospital personnel) that require work restrictions or exclusion from

work; (2) clearance for work after an infectious illness that required

work restrictions or exclusion; (3) other work-related infections and

exposures; and (4) when appropriate, results of epidemiologic

investigations. Category IB

c. Develop protocols to assure coordination between the personnel

health program and the infection control program of the institution.

Category IB

2. Placement evaluation

a. Before personnel begin duty or are given a new work assignment,

obtain their health inventories. Include in the inventories the

following: (1) immunization status or history of vaccine preventable

diseases (e.g., chickenpox, measles, mumps, rubella, hepatitis B); (2)

history of any conditions that may predispose personnel to acquiring or

transmitting infectious diseases (e.g., immunosuppressive condition or

therapy, tuberculosis, dermatologic conditions, chronic draining

infections or open wounds, or chronic infections). Category IB

b. For infection control, perform directed physical and laboratory

examinations on personnel, as may be determined from the results of the

health inventory. Include examinations to detect conditions that might

increase the likelihood of transmitting disease to patients, or unusual

susceptibility to infection, and to serve as a baseline for determining

whether any future problems are work related. Category IB

c. Conduct personnel health assessments other than placement

evaluations on an as-needed basis for example, as required to evaluate

work-related illness or exposures to infectious diseases. Category IB

d. Do not perform routine cultures on personnel (e.g., cultures of

the nose, throat, or stool) as part of the placement evaluation (540).

Category IB

e. Conduct routine screening for tuberculosis by using the

intradermal (Mantoux), intermediate strength (5 TU) PPD test on

personnel who have potential for exposure to TB. Category II

f. Conduct routine serologic screening for some vaccine-preventable

diseases, such as hepatitis B, measles, mumps, rubella, or varicella,

if deemed to be cost-effective to the hospital and beneficial to the

health care personnel. Category II

3. Personnel Health and Safety Education

a. Include the infection control aspects of personnel health and

the proper use of the personnel health service in the initial job

orientation and ongoing in-service education of personnel. Category IB

(1) Ensure that the following topics are included in the initial

training on infection control: (a) handwashing; (b) modes of

transmission of infection and importance of complying with standard and

isolation precautions; (c) importance of reporting certain illnesses or

conditions (whether work related or acquired outside the hospital),

such as generalized rash or skin lesions that are vesicular, pustular,

or weeping; jaundice; illnesses that do not resolve within a designated

period of time (e.g., a cough that persists for >2 weeks,

gastrointestinal illness, or febrile illness with fever of >103 deg.F

lasting more than 2 days) and hospitalizations resulting from febrile

or other contagious diseases; (d) tuberculosis control; (e) importance

of complying with Standard Precautions and reporting exposure to blood

and body fluids to prevent transmission of bloodborne pathogens; (g)

importance of cooperating with infection control personnel during

outbreak investigations; and (h) importance of personnel screening and

immunization programs. Category IB

(2) Ensure that all personnel know that if they have medical

conditions (e.g., immunosuppression) or receive medical treatment that

render them more susceptible to or more likely to transmit infections,

they can follow recommendations to greatly reduce their risk for

transmitting or acquiring infections, e.g., request for work

reassignment. Category IB

b. Make specific written policies and procedures for control of

infections in health care personnel readily available. Category IB

c. Provide personnel, annually, and whenever the need arises, with

in-service training and education on infection control that are

appropriate and specific for their work assignments so that personnel

can maintain accurate and up-to-date knowledge about the essential

elements of infection control. Category IB

d. Provide educational information appropriate, in content and

vocabulary, to the educational level, literacy, and language of the

employee. Category IB

4. Job-Related Illnesses and Exposures

a. Maintain a record on health care personnel that includes

information obtained during the medical evaluation, immunization

records, results of tests obtained in any screening or control

programs, and reports of work-related illnesses or exposures in

accordance with state and federal regulatory requirements. Category IB

b. Establish a readily available mechanism for personnel to obtain

advice about illnesses they may acquire from or transmit to patients.

Category IB

c. Evaluate job-related and community-acquired illnesses or

important exposures and postexposure prophylaxis, when indicated.

Category IB

d. Develop written protocols for handling job-related and

community-acquired infectious diseases or important exposures. Record

the occurrences of job-related infectious diseases or important

exposures in the person's record and, when applicable,

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notify appropriate infection control personnel and members of the

personnel health service. Category IB

5. Record-Keeping, Data Management, and Confidentiality

a. Establish and keep an updated record for all personnel and

maintain the confidentiality of their records while ensuring that they

receive appropriate therapeutic or prophylactic management for

illnesses caused by or following exposures to transmissible infections.

Ensure that individual records for volunteers, trainees, contractual

personnel, and personnel who provide care outside of hospitals are

similarly kept and maintained. Category IB

b. Ensure that when data on personnel health are made public, the

individual's confidentiality is maintained, for example, by releasing

only aggregate numbers. Category IB

c. Maintain a personnel data base, preferably computerized, that

allows tracking of personnel immunizations, screening tests, and

assessment of trends of infections and diseases in personnel. Copies of

these records are to be available to the individual. Category IB

d. Periodically review and assess data gathered on personnel health

(e.g., rates of PPD-test conversion) to determine the need for action.

Category IB

e. Ensure that all federal, state, local, and community standards

on medical record keeping and confidentiality are met (23, 24).

Category IB

C. Protection of Personnel and Other Patients From Patients With

Infections

Apply precautions described in the current Guideline for Isolation

Precautions in Hospitals (1) and other guidelines (377). Category IB

D. Immunization of Health Care Personnel, General Recommendations

1. Ensure that persons administering immunizing agents are: (a)

familiar with the general ACIP recommendations and recommendations on

immunizing adults; (b) well informed about indications, storage,

dosage, preparation, side effects, and contraindications for each of

the vaccines, toxoids, and immune globulins used (6, 7, 22); and (c)

kept updated on professional organization recommendations regarding

vaccination of health care personnel (Tables 1 and 2). Category IB

2. Ensure that immunization product information is available at all

times and that a pertinent health history, especially a history of

allergy and potential vaccine contraindications, is obtained from each

person before an agent is given (Table 2). Category IB

3. Ensure that persons administering immunizing agents are familiar

with state and local regulations regarding vaccinations for health care

personnel. Category IB

4. Formulate a written comprehensive policy on immunizing health

care personnel. Category IB

5. Develop a data base of employee specific information on history

of vaccine preventable diseases and status of vaccine administration.

Category IB

6. Develop a list of needed immunizations for each employee during

screening and an individual plan to provide the necessary vaccines.

Category IB

7. In the absence of a known occupational exposure, provide

personnel with on-site service or refer personnel to their own health

care providers for routine non-occupation-related immunizations against

diphtheria, pneumococcal disease, hepatitis A, or tetanus (Table 1).

Category IB

8. Provide vaccine to personnel who may have occupational exposure

to uncommon diseases such as plague, typhus, or yellow fever, or refer

them to their own health care providers. Category IB

E. Prophylaxis and Follow-Up After Exposure, General Recommendations

1. Ensure that when personnel are offered necessary prophylactic

treatment with drugs, vaccines, or immune globulins, they are informed

of (a) options for prophylaxis; (b) the risk (if known) of infection

when treatment is not accepted; (c) the degree of protection provided

by the therapy; and (d) the potential side effects of the therapy.

Category IB

2. Ensure that when personnel are exposed to particular infectious

agents, they are informed of (a) the recommended follow-up based on

current knowledge about the epidemiology of the infection; (b) the risk

(if known) of transmitting the infection to patients, other personnel,

or other contacts; and (c) the methods of preventing transmission of

the infection to other persons. Category IB

F. Personnel Restriction Because of Infectious Illnesses or Special

Conditions, General Recommendations

1. Develop well-defined policies concerning contact of personnel

with patients when personnel have potentially transmissible conditions.

These policies should govern (a) personnel responsibility in using the

health service and reporting illness; (b) removal of personnel from

contact with patients; and (c) clearance for work after an infectious

disease that required work restriction. Category IB

2. Identify the persons with authority to relieve personnel of

duties. Category IB

3. Develop work-exclusion policies that encourage personnel to

report their illnesses or exposures and that do not penalize them with

loss of wages, benefits, or job status. Category IB

4. Educate and encourage personnel who have signs and symptoms of a

transmissible infectious disease to report their condition promptly to

their supervisor and occupational health. Category IB

5. Provide appropriate education for personnel on the importance of

good hygienic practices, especially handwashing and covering the nose

and mouth when coughing and sneezing. Category IB

G. Prevention of Nosocomial Transmission of Selected Infections

1. Bloodborne Pathogens, General Recommendation

a. Ensure that health care personnel are familiar with precautions

to prevent occupational transmission of bloodborne pathogens (1, 4, 26,

27, 35). Category IA

b. Follow state and federal guidelines and strategies for

determining the need for work restrictions for health care personnel

infected with bloodborne pathogens (43). Category IB

a. Hepatitis B. (1) Administer hepatitis B vaccine to personnel who

perform tasks involving routine and inadvertent (e.g., as with

housekeepers) contact with blood, other body fluids (including blood-

contaminated fluids), and sharp medical instruments or other sharp

objects (7, 8, 36). Category IA

(2) Before vaccinating personnel, do not routinely perform

serologic screening for hepatitis B vaccine unless the health care

organization considers screening cost-effective or the potential

vaccinee requests it (7). Category IA

(3) Conduct post vaccination screening for immunity to hepatitis B

within 1 to 2 months after the administration of the third vaccine dose

to personnel who perform tasks involving contact with blood, other body

fluids (including blood-contaminated fluids), and sharp medical

instruments or other sharp objects. Category IA

(4) Revaccinate persons not found to have an antibody response

after the initial hepatitis B vaccine series with a second three dose

vaccine series. If persons still do not respond after

[[Page 47296]]

revaccination, refer them for evaluation for lack of response,

(e.g.,possible chronic HBV infection) (7) (Tables 1 and 4). Category IB

(5) Test staff in chronic dialysis centers who do not respond to

the hepatitis B vaccine for hepatitis B surface antigen (HBsAg) and

antibody to hepatitis B surface antigen (anti-HBs) semi-annually (541).

Category IA

(6) Use both passive immunization with hepatitis B immune globulin

and active immunization with hepatitis B vaccine for postexposure

prophylaxis in susceptible personnel who have had a needlestick,

percutaneous, or mucous membrane exposure to blood known or suspected

to be at high risk for being HBsAg positive (Table 6). Category IA

(7) Follow current recommendations for postexposure prophylaxis

following percutaneous or mucous membrane exposure to blood and body

fluids that is known or suspected to be at high risk for being HBsAg-

positive (Table 4) (36). Category IA

b. Hepatitis C. (1) Do not administer immune globulin (IG) to

personnel who have exposure to blood or body fluids positive for

antibody to hepatitis C virus (33, 69). Category IB

(2) Consider implementing policies for postexposure follow-up for

health care personnel who have had a percutaneous or mucosal exposure

to blood containing antibody to hepatitis C virus at baseline and 6

months (69). Category IB

c. Human Immunodeficiency Virus (HIV). Follow current

recommendations for postexposure prophylaxis following percutaneous or

mucocutaneous exposure to suspected or known HIV-infected blood or body

fluids containing blood (29, 76). Category IB

2. Conjunctivitis

Restrict personnel with epidemic keratoconjunctivitis caused by

adenovirus or purulent conjunctivitis caused by other microorganisms

from patient care for the duration of symptoms. If symptoms persist >5-

7 days, refer personnel to an ophthalmologist for evaluation of

continued infectiousness. Category IB

3. Cytomegalovirus (CMV)

a. Do not restrict personnel from work who contract illnesses

suspected or proven to be due to CMV (109). Category IB

b. Educate all patient-care personnel about careful handwashing and

exercising care to prevent their body fluids from contacting other

persons to reduce their risk of transmitting infections such as CMV to

patients or other personnel (89, 123). Category IA

c. Ensure that pregnant personnel are aware of the risks associated

with CMV infection and infection control procedures to prevent

transmission when working with high-risk patient groups (Table 6).

Category IA

4. Diphtheria

a. Encourage vaccination with tetanus and diphtheria toxoid (Td)

every 10 years for health care personnel (7, 17) (Table 1). Category IB

b. Obtain nasopharyngeal cultures from exposed personnel and

monitor for signs and symptoms of diphtheria for 7 days (156). Category

IB

c. Administer antimicrobial prophylaxis to personnel who have

contact with respiratory droplets or cutaneous lesions of patients

infected with diphtheria. Also administer a dose of Td to previously

immunized personnel who have not been vaccinated within the previous 5

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

d. Repeat nasopharyngeal cultures of personnel found to have

positive cultures at 2 weeks following completion of

antimicrobial therapy. Repeat antimicrobial therapy if personnel remain

culture positive (156). Category IB

e. Exclude exposed personnel and those identified as asymptomatic

carriers from duty until antimicrobial therapy is completed and two

nasopharyngeal cultures obtained 24 hours apart are negative

(156) (Table 3). Category IB

5. Gastroenteritis

a. Vaccinate and provide booster doses of vaccine, following

published guidelines, to microbiology laboratory personnel who work

with Salmonella typhi on a regular basis (144, 155). Category II

b. Pending their evaluation, exclude personnel with acute

gastrointestinal illnesses (vomiting or diarrhea, with or without other

symptoms such as nausea, fever, or abdominal pain) that may be

accompanied by other symptoms (such as fever, abdominal cramps, or

bloody stools), from contact with patients or food-handling (1, 163)

(Table 3). Category IB

c. Consult local and state health authorities regarding regulations

for the exclusion of patient-care personnel or food-handlers with

enteric infections from contact with patients or food-handling,

respectively. Category IB

d. Determine the etiology of gastrointestinal illness among

personnel who care for patients at high risk of severe disease.

Category IB

e. Allow personnel infected with enteric pathogens to return to

work after their symptoms resolve if local regulations do not require

exclusion from duty for designated pathogens for specified time periods

or until negative cultures are available. Category II

f. Ensure that personnel, including those who are

immunocompromised, returning to work after a gastrointestinal illness

practice good hygienic practices, especially handwashing, to reduce or

eliminate the risk of transmission of the infecting agents (160, 542).

Category IB

g. Do not routinely perform follow-up cultures or examinations of

stool for enteric pathogens other than Salmonella to determine when the

stool is free of the infecting organism, unless local regulations

require such procedures. Category IB

h. Do not perform routine stool cultures on asymptomatic health

care personnel unless required by state and local regulations. Category

IB

6. Hepatitis A (HAV)

a. Do not routinely administer inactivated hepatitis A vaccine to

health care personnel. Susceptible personnel working in areas where

hepatitis A is highly endemic should be vaccinated to prevent

acquisition of community acquired infection (7, 196). Category IB

b. Do not routinely administer immune globulin (IG) as prophylaxis

for personnel providing care or who are exposed to a patient with

hepatitis A (196). Category IB

c. Administer IG (0.02 ml/kg) to personnel who have had oral

exposure to fecal excretions from a person acutely infected with

hepatitis A virus (196) (Table 1). Category IA

d. In documented outbreaks involving transmission of HAV from

patient to patient or from patient to health care worker, use of IG in

persons with close contact with infected persons may be indicated.

Contact the local health department regarding control measures (Table

1). Category IB

e. Exclude personnel who have acute hepatitis A from work until 1

week after the onset of jaundice (Table 3). Category IA

7. Herpes Simplex Virus

a. Exclude personnel with primary or recurrent orofacial herpes

simplex infections from the care of high-risk patients, including

newborns, intensive care unit patients, patients with severe burns or

eczema, or severely immunocompromised patients, until the lesions are

crusted (201, 210) (Table 3). Category IB

b. Exclude personnel with herpes simplex infections of the fingers

or hands (herpetic whitlow) from contact

[[Page 47297]]

with patients until their lesions are healed (206). Category IB

8. Measles

a. Ensure that all personnel have documented immunity to measles.

(1) Consider administering measles vaccine* to persons born in 1957

or later unless they have evidence of measles immunity. Category IA

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

* (Measles-mumps-rubella [MMR] trivalent vaccine is the vaccine

of choice. If the recipient is known to be immune to one or more of

the components, monovalent or bivalent vaccines may be used.)

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

(2) Administer measles vaccine* to personnel born before 1957 if

they do not have evidence of measles immunity and are at risk of

occupational exposure to measles (6, 213, 225, 226) (Table 1). Category

IA

(3) Do not routinely perform serologic screening for measles before

administering measles vaccine * to personnel unless the health care

employer considers screening cost-effective or the potential vaccinee

requests it (6, 9, 227-229, 543). Category IA

(4) Administer postexposure measles vaccine* to measles-susceptible

personnel who have contact with persons with measles, within 72 hours

after the exposure. During the period 5 days after the first exposure

until 21 days after the last exposure, exclude exposed, vaccinated

personnel from duty (6) (Tables 1-3). Category IA

b. Exclude exposed unvaccinated personnel from duty from the 5th

day after the first exposure until the 21st day after the last exposure

to measles, regardless of whether they receive postexposure vaccine, if

they do not have documented immunity to measles (9, 229) (Table 3).

Category IB

c. Exclude personnel who develop measles from patient contact for 4

days after rash develops or for the duration of their acute illness,

whichever is longer (9, 229) (Table 3). Category IB

9. Meningococcal Disease

a. Do not administer routinely meningococcal vaccine to health care

personnel (13). Category IB

b. Consider vaccination of laboratory personnel who are routinely

exposed to Neisseria meninigitidis in solutions that may be aerosolized

(13) (Table 1). Category IB

c. Immediately offer antimicrobial prophylaxis to personnel who

have had any of the following types of contact with a patient with

meningococcal disease prior to administration of antibiotics: (a)

Intensive, unprotected (i.e., without the use of proper precautions),

close, face-to-face contact with a patient with meningococcal disease;

(b) contact with the patient's oropharyngeal secretions; or (c) a

needlestick from a patient with meningococcal disease (13) (Table 1).

Category IB

d. Do not routinely give quadrivalent A,C,Y, W-135 meningococcal

vaccines for postexposure prophylaxis (13) (Table 1). Category II

e. Administer meningococcal vaccine to personnel (and other persons

likely to have contact with infected persons) to control Serogroup C

outbreaks following consultation with public health authorities (13).

Category IB

f. Consider preexposure vaccination of personnel who routinely

handle soluble preparations in N. meningitidis (13). Category II

10. Mumps

a. Administer mumps vaccine* to all personnel without documented

evidence of mumps immunity unless otherwise contraindicated (7, 250)

(Table 1). Category IA

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

* (Measles-mumps-rubella [MMR] trivalent vaccine is the vaccine

of choice. If the recipient is known to be immune to one or more of

the components, monovalent or bivalent vaccines may be used.)

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

b. Before vaccinating personnel with mumps vaccine,* do not

routinely perform serologic screening for mumps unless the health care

employer considers screening cost-effective or it is requested by the

potential vaccinee (10). Category IB

c. Exclude susceptible personnel who are exposed to mumps from duty

from the 12th day after the first exposure through the 26th day after

the last exposure or if symptoms develop, until 9 days after the onset

of parotitis (7, 544) (Table 3). Category IB

11. Parvovirus

a. Ensure that pregnant personnel are aware of the risks associated

with parvovirus infection and of infection control procedures to

prevent transmission when working with high-risk patient groups (264,

265) (Table 6). Category IB

b. Do not routinely exclude pregnant personnel from caring for

patients with parvovirus B19. Category IB

12. Pertussis

a. Do not administer whole-cell pertussis vaccine to personnel

(Table 1). Category IB

b. No Recommendation for routine administration of an acellular

pertussis vaccine to health care personnel. Unresolved Issue

c. Immediately offer antimicrobial prophylaxis against pertussis to

personnel who have had unprotected (i.e., without the use of proper

precautions), intensive (i.e., close, face-to-face) contact with a

patient who has a clinical syndrome highly suggestive of pertussis and

whose cultures are pending; discontinue prophylaxis if cultures or

other tests are negative for pertussis and the clinical course is

suggestive of an alternate diagnosis (277, 278) (Table 1). Category II

d. Exclude personnel who develop symptoms (e.g., unexplained

rhinitis or acute cough) following known exposure to pertussis from

patient care until 5 days after the start of appropriate therapy (Table

3). Category IB

13. Poliomyelitis

a. Determine whether the following personnel have completed a

primary vaccination series: (1) Persons who may have contact with

patients or the secretions of patients who may be excreting wild

polioviruses; or (2) laboratory personnel who handle specimens that

might contain wild polioviruses or who do cultures to amplify virus

(19) (Table 1). Category IA

b. For personnel above, including pregnant personnel or personnel

with an immunodeficiency, who have no proof of having completed a

primary series of polio immunization, administer the enhanced

inactivated poliovirus vaccine (IPV) rather than oral polio vaccine

(OPV) for completion of the series (19) (Table 1). Category IB

c. When a case of wild-type poliomyelitis infection is detected or

an outbreak of poliomyelitis occurs, contact the CDC through the state

health department. Category IB

14. Rabies

a. Provide pre-exposure vaccination to personnel who work with

rabies virus or infected animals in rabies diagnostic or research

activities with rabies virus (3, 20) (Table 1). Category IA

b. After consultation with public health authorities, give a full

course of anti-rabies treatment to personnel who either have been

bitten by a human with rabies or have scratches, abrasions, open

wounds, or mucous membranes contaminated with saliva or other

potentially infective material from a human with rabies. In those

previously vaccinated individuals, postexposure therapy is abbreviated

to only include a single dose of vaccine on days 0 and 3 (285-287)

(Table 1). Category IB

15. Rubella

a. Vaccinate all personnel without documented immunity to rubella

with

[[Page 47298]]

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

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

* (Measles-mumps-rubella [MMR] trivalent vaccine is the vaccine

of choice. If the recipient is known to be immune to one or more of

the components, monovalent or bivalent vaccines may be used.)

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

b. Consult local and state health departments regarding regulations

for rubella immunity in health care personnel. Category IA

c. Do not perform serologic screening for rubella before

vaccinating personnel with rubella vaccine,* unless the health care

employer considers it cost-effective or the potential vaccinee requests

it (229). Category IB

d. Do not administer rubella vaccine* to susceptible personnel who

are pregnant or might become pregnant within 3 months of vaccination

(7) (Table 1). Category IA

e. Administer rubella vaccine* in the postpartum period to female

personnel not known to be immune. Category IA

f. Exclude personnel who are exposed to rubella from duty from the

7th day after the first exposure through the 21st day after the last

exposure (Table 3). Category IB

g. Exclude personnel who develop rubella from duty until 7 days

after the beginning of the rash (Table 3). Category IB

16. Scabies and Pediculosis

a. Evaluate exposed personnel for signs and symptoms of mite

infestation and provide appropriate therapy for confirmed or suspected

scabies (302). Category IA

b. Evaluate exposed personnel for louse infestation and provide

appropriate therapy for confirmed pediculosis (325). Category IA

c. Do not routinely provide prophylactic scabicide treatment of

personnel who have had contact with patients or other persons with

scabies (301, 302, 308, 321, 329) (Table 1). Category II

d. Do not routinely provide prophylactic pediculicide treatment of

personnel who have had contact with patients or other persons with

pediculosis. Category II

e. Exclude personnel with either confirmed or suspected scabies or

lice infestation from contact with patients until after they receive

appropriate initial treatment or are found not to have scabies or

pediculosis, respectively (302) (Table 3). Exclude personnel with

confirmed scabies from the care of immunocompromised patients until

after the second treatment, unless they wear gowns and gloves for

patient contact. Category IB

17. Staphylococcal Disease or Carriage

a. Obtain appropriate cultures and exclude personnel from patient

care or food handling if they have a draining lesion suspected to be

due to Staphylococcus aureus, until the infections have been ruled out

or personnel have received adequate therapy and their infections have

resolved (Table 3). Category IB

b. Do not routinely exclude personnel with suspected or confirmed

carriage of S. aureus (on nose, hand, or other body site), from patient

care or food-handling unless it is shown epidemiologically that the

person is responsible for disseminating the organism in the health care

setting (Table 3). Category IB

18. Group A Streptococcal Disease or Carriage

a. Obtain appropriate cultures, and exclude personnel from patient

care or food handling if they have draining lesions that are suspected

to be due to Streptococcus, until streptococcal infection has been

ruled out or the worker has received adequate therapy for 24 hours

(364-366, 369) (Table 3). Category IB

b. Do not routinely exclude personnel with suspected or confirmed

carriage of group A Streptococcus from patient care or foodhandling

unless it is shown epidemiologically that the person is responsible for

disseminating the organism in the health care setting (Table 3).

Category IB

19. Tuberculosis

a. General Recommendations. (1) Educate all health care personnel

regarding the recognition, transmission, and prevention of TB. Category

IB

( 2) Follow current recommendations outlined in the Guidelines for

Preventing the Transmission of Mycobacterium tuberculosis in Health-

Care Facilities, 1994 (377). Category IB

b. TB Screening Program. (1) Include all health care personnel who

have potential for exposure to M. tuberculosis in a purified protein

derivative (PPD) skin-test program (377). Category IA

(2) Maintain confidentiality regarding the medical condition of

personnel. Category IA

(3) Administer PPD tests by using the intracutaneous (Mantoux)

method of administration of 5 tuberculin units (0.1 ml) of purified

protein derivative (377, 397). Category IB

(4) Do not use the Tine or other tests to administer PPD (397).

Category IB

(5) Test personnel known to have conditions that cause severe

suppression of cell-mediated immunity (such as HIV-infected persons

with lowered CD4+ counts and organ-transplant recipients receiving

immunosuppressive therapy) for cutaneous anergy at the time of PPD

testing (377). Category IB

(6) Ensure that the administration, reading, and interpretation of

PPD tests are performed by specified trained personnel. Category IA

c. Baseline PPD. (1) Perform baseline PPD tests on health care

personnel who are new to a facility and who have potential for exposure

to M. tuberculosis. Include those with a history of BCG vaccination

(377). Category IB

(2) Perform two-step, baseline PPD tests on newly employed health

care personnel who are negative on initial PPD testing and have not had

a documented negative PPD-test result during the preceding 12 months,

unless the institution has determined that two-step testing is not

warranted in their facility (377). Category II

(3) Interpret baseline PPD-test results as outlined in the

Guidelines for Preventing the Transmission of Mycobacterium

tuberculosis in Health-Care Facilities, 1994 (377). Category IB

d. Follow-up (Repeat) PPD. (1) Perform periodic follow-up PPD tests

on all health care personnel (with negative baseline PPD test result)

who have the potential for exposure to M. tuberculosis (377). Category

IA

(2) Base the frequency of repeat PPD testing on the hospital's risk

assessment, as described in the Guidelines for Preventing the

Transmission of Mycobacterium tuberculosis in Health-Care Facilities,

1994 and as provided by federal, state, and local regulations (377).

Category IB

(3) Exempt from follow-up-PPD tests: personnel with documented

history of positive baseline PPD test result or adequate treatment for

tuberculosis (377). Category IB

(4) Interpret follow-up-PPD test results as outlined in the

Guidelines for Preventing the Transmission of Mycobacterium

tuberculosis in Health-Care Facilities, 1994 (377). Category IB

(5) Management of PPD-positive personnel.

(a) Promptly evaluate personnel with positive PPD test results for

active disease and obtain an adequate history on TB exposure to help

determine whether the infection is occupational or community acquired

(377). Category IB

(b) Perform chest x-ray examinations on personnel with a positive

PPD-test result as part of the evaluation for active TB (377). Category

IB

(c) Do not repeat chest x-rays unless symptoms suggestive of TB

develop, if

[[Page 47299]]

the initial chest x-ray examination is negative (377). Category IB

(d) Periodically remind all personnel, especially those with

positive PPD-test results, about the symptoms of TB and the need for

prompt evaluation of any pulmonary symptoms suggestive of TB (377).

Category IB

(e) Do not require routine chest x-rays for asymptomatic, PPD-

negative workers (377). Category IB

e. Preventive therapy. 1) Offer preventive therapy to the following

personnel, regardless of age, who convert their PPD test (a) recent

converters; (b) close contacts of persons with active TB; (c) those

with medical conditions that increase their risk for active TB; (d)

those with HIV infection; or (e) injecting-drug users (377, 397).

Category IB

(2) Offer preventive therapy to personnel with positive PPD

reactions who do not have the above risk factors, if they are <35 years

of age (397). Category IA

(3) Provide preventive therapy to personnel through the

occupational health service or refer them to the health department or

other health care provider, as appropriate. Category IB

f. Postexposure management of personnel. 1) As soon as possible

after an exposure to TB (i.e., exposure to a person with pulmonary or

laryngeal TB for whom proper isolation precautions were not

implemented), conduct PPD testing on personnel who are known to have

negative PPD-skin test results. When the result of this PPD test is

negative, administer a second test 12 weeks after the exposure (377).

Category IB

(2) Do not perform PPD tests or chest x-rays on personnel with

prior positive PPD-test results unless they have symptoms suggestive of

active TB (377). Category IB

(3) Consider retesting immunocompromised health care personnel who

are potentially exposed to M. tuberculosis at least every 6 months

(377). Category II

g. Workplace restrictions. (1) Exclude personnel with infectious

pulmonary or laryngeal TB from the workplace until the facility has

documentation from their health care provider that they are receiving

adequate therapy, their coughs have resolved, and that there have been

three consecutive sputum smears collected on different days negative

for acid-fast bacilli (AFB). After personnel return to work, obtain

periodic documentation from their health care provider that effective

drug therapy has been maintained for the recommended time period and

that sputum smears remain AFB negative (377) (Table 3). Category IB

(2) Promptly evaluate for infectiousness, those personnel with

active TB who discontinue treatment before they are cured. Exclude from

duty those who are found to remain infectious until (a) treatment is

resumed; (b) an adequate response to therapy is documented; and (c)

sputum smears are AFB negative (377). Category IB

(3) Consider directly observed therapy for personnel with active TB

who have not been compliant with drug regime

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