Occupational Health Services

David T. Kuhar

Elise M. Beltrami

Elizabeth A. Bolyard

Healthcare personnel (HCP) are at risk of exposure to infectious pathogens in both the workplace and the community. If they develop an infection, they may pose a risk for transmission of that infectious pathogen to patients, other HCP, members of their households, or other community contacts. In this chapter, the term HCP refers to all paid and unpaid persons working in healthcare settings who have the potential for exposure to infectious materials, including body substances, contaminated medical supplies or equipment, contaminated environmental surfaces, or contaminated air. HCP include, but are not limited to, physicians, nurses, nursing assistants, therapists, technicians, emergency medical personnel, dental personnel, pharmacists, students and trainees, contractual personnel, home healthcare personnel, and persons not directly involved in patient care (e.g., clerical, dietary, house-keeping, laundry, security, maintenance, billing, chaplains, and volunteers) but potentially exposed to infectious agents that can be transmitted to and from HCP and patients. Healthcare settings include, but are not limited to, acute-care hospitals; long-term care facilities, such as nursing homes and skilled nursing facilities; physicians’ offices; urgent-care centers; outpatient clinics; and home healthcare. In general, HCP inside or outside hospitals who have contact with patients, body fluids, or specimens have a higher risk of acquiring or transmitting pathogens than do other HCP who have only brief casual contact with patients and their environment (e.g., beds, furniture, bathrooms, food trays, or medical equipment).

This chapter outlines the infection control elements of an occupational health service and discusses important aspects of selected transmissible diseases excluding hepatitis B virus (HBV) infection, hepatitis C virus (HCV) infection, and human immunodeficiency virus (HIV) infection, which are discussed in Chapter 42.

INFECTION CONTROL ELEMENTS OF AN OCCUPATIONAL HEALTH SERVICE

Whether performed “in house” or contracted out, certain elements are necessary for the appropriate functioning of an occupational health service: (a) coordination with other departments, (b) preplacement medical evaluations, (c) health and safety education, (d) immunization programs, (e) management of job-related illnesses and exposures to infectious pathogens, 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 individual health records.

The organization of an occupational health service can be influenced by the size of the institution, the number of HCP, and the services offered. To ensure that contractual HCP who are not paid by the healthcare facility receive appropriate occupational health services, contractual agreements with their employers should contain provisions consistent with the policies of the facility that uses those HCP. Experts with specialized training and qualifications in occupational health can facilitate the provision of effective services.

COORDINATION WITH OTHER DEPARTMENTS

For infection prevention (IP) objectives to be achieved, the activities of the occupational health service must be coordinated with IP and other appropriate departmental staff. This coordination will help ensure adequate surveillance of infections in HCP and provision of appropriate preventive services. Coordination of activities also will help to ensure that investigations of exposures and outbreaks are conducted efficiently and preventive measures implemented promptly.

PREPLACEMENT MEDICAL EVALUATIONS

Medical evaluations before placement can help ensure that HCP are not placed in jobs that would pose undue risk of infection to them, other HCP, patients, or visitors. An important component of the preplacement evaluation is a health inventory. This includes determining immunization status and obtaining histories of any conditions that could predispose HCP to acquiring or transmitting infectious diseases.

A physical examination can be used to screen HCP for conditions that could increase the risk of transmitting pathogens 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 routine laboratory testing (e.g., complete blood cell counts, urinalysis, and chest radiographs) and screening for enteric or other pathogens for IP purposes, has not been demonstrated. Conversely, serologic screening for some vaccine-preventable diseases, such as HBV, 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 use of certain screening procedures. Periodic evaluations may be done as indicated for job reassignment, for ongoing programs (e.g., tuberculosis [TB] screening), or for evaluation of work-related problems.

HEALTH AND SAFETY EDUCATION

HCP are more likely to comply with an IP program if they understand its rationale. Thus, education is an important element of an effective IP program for HCP. Clearly written policies, guidelines, and procedures ensure uniformity, efficiency, and effective coordination of activities. However, because the risk of infection varies by job category, IP education should be tailored accordingly. HCP in some jobs may need specialized education on infection risks related to their employment and on 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. The training should comply with existing federal, state, and local regulations regarding requirements for employee education and training. All HCP need to be educated about the organization’s IP policies and procedures.

IMMUNIZATION PROGRAMS

Ensuring that HCP have evidence of immunity to selected vaccine-preventable diseases is an essential part of successful occupational health programs. Optimal use of vaccines can help prevent transmission of vaccine-preventable diseases and limit the need to apply work restrictions. Prevention of illness among HCP through comprehensive occupational immunization programs is far more cost-effective than case management and outbreak control. In particular, interventions to increase influenza vaccination of HCP have been shown to be effective (1). Hospitals and other healthcare organizations in the United States traditionally have employed an influenza immunization strategy that includes one or more of the following components: education about influenza, easy access to vaccine, incentives to encourage immunization, organized campaigns, institution of declination policies, and legislative and regulatory efforts (e.g., vaccination requirements) (2,3,4,5,6,7,8,9).

National guidelines for immunization of and postexposure prophylaxis (PEP) for HCP are provided by the U.S. Public Health Service’s Advisory Committee on Immunization Practices (ACIP) (9,10,11,12,13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31).

Screening tests are available to determine evidence of immunity to certain vaccine-preventable diseases (e.g., HBV, measles, mumps, rubella, and varicella). Such screening programs should be combined with tracking systems to ensure accurate maintenance of HCP immunization records. Accurate immunization records ensure that susceptible personnel are promptly identified and appropriately vaccinated. For more details about vaccinations for HCP, see Vaccinations in Patients and Healthcare Workers.

MANAGEMENT OF JOB-RELATED ILLNESSES AND EXPOSURES

Primary functions of the occupational health service are to arrange for prompt diagnosis and management of job-related illnesses and to provide appropriate PEP after job-related exposures. The healthcare organization is responsible for implementing measures to prevent further transmission of pathogens, which sometimes warrants exclusion of personnel from work or patient contact (32). Decisions about work restrictions are based on the mode of transmission and the epidemiology of the disease (Table 4.1). The term “exclude from duty” in this

chapter should be interpreted as exclusion from the healthcare facility and from healthcare activities outside the facility. HCP who are excluded should avoid contact with susceptible persons both in the facility and in the community. Exclusion policies should include a statement of authority defining who may exclude HCP. The policies also need to be designed to encourage personnel to report their illnesses or exposures, not to penalize them with loss of wages, benefits, or job status. While workers’ compensation laws cover occupationally acquired infections, they do not cover exclusion from duty based solely on exposures to infectious diseases; therefore, policies should include a method for providing wages during the period that HCP are not permitted to work. In addition, exclusion policies must be enforceable, and all HCP, especially department heads, supervisors, and nurse managers, should know which infections and exposures warrant exclusion and where to report the illnesses 24 hours a day, 7 days a week. HCP who have contact with infectious persons outside the healthcare setting also need to be included in a postexposure program and encouraged to report any suspected or known exposures promptly.

TABLE 4.1 Summary of Suggested Work Restrictions for Healthcare Personnel Exposed to or Infected with Infectious Diseases of Importance in Healthcare Settings, in the Absence of State and Local Regulations

Disease/Problem		Work Restriction	Duration
Conjunctivitis		Restrict from patient contact and contact with the patient’s environment	Until discharge ceases
Cytomegalovirus infections		No restriction
Diarrheal diseases
	Acute stage (diarrhea with other symptoms)	Restrict from patient contact, contact with the patient’s environment, or food handling	Until at least 48 hours after resolution of symptoms consistent with norovirus infection
	Convalescent stage, Salmonella spp.	Restrict from care of high-risk patients	Until symptoms resolve; consult with local and state health authorities regarding need for negative stool cultures
Group A streptococcal infections		Restrict from patient care, contact with the patients environment, or food handling	Until 24 hours after adequate treatment started
Hepatitis A		Restrict from patient contact, contact with patient’s environment, and food handling	Until 7 days after onset of jaundice
Herpes simplex hands (herpetic whitlow)		Restrict from patient contact and contact with the patient’s environment	Until lesions have crusted
Measles active		Exclude from duty	Until 4 days after the rash appears
	Postexposure (HCP without evidence of immunity)	Exclude from duty	From the 5th day after the 1st exposure through the 21st day after last exposure
Meningococcal infections		Exclude from duty	Until 24 hours after start of effective therapy
Mumps active		Exclude from duty	Until 5 days after onset of parotitis
	Postexposure (HCP without evidence of immunity)	Exclude from duty	From 12th day after 1st exposure through until 25 days after last exposure or until 5 days after onset of parotitis
Pertussis active		Exclude from duty	From beginning of catarrhal stage through 3rd week after onset of paroxysms or until 5 days after start of effective antimicrobial therapy
	Postexposure (asymptomatic personnel-HCP likely to expose a patient at risk for severe pertussis)	No restriction from duty; on antimicrobial prophylactic therapy
	Postexposure (asymptomatic personnel-other HCP)	No restriction, can receive PEP or be monitored for 21 days after exposure
	Postexposure (symptomatic personnel)	Exclude from duty	Until 5 days after start of effective antimicrobial therapy
Rubella Active		Exclude from duty	Until 7 days after rash appears
Postexposure (HCP without evidence of immunity)		Exclude from duty	From 7th day after 1st exposure through 23rd day after last exposure
Staphylococcus aureus infection
	Acute, active, draining skin lesions	Restrict from contact with patients and patient’s environment or food handling	Until lesions have resolved
	Chronic, draining skin lesions	Restrict from contact with patients and patient’s environment or food handling	Until lesions have resolved, though considerations for earlier return to work could include the location of the provider’s infection, if the lesion can be completely covered, the hand hygiene and infection prevention practices of the individual provider, and others.
Tuberculosis
	Active disease	Exclude from duty	Until proved noninfectious
	TST or IGRA converter	No restriction
Varicella active		Exclude from duty	Until all lesions dry and crust. If only lesions that do not crust (i.e., macules or papules), until no new lesions appear within a 24-hour period.
	Postexposure (HCP without evidence of immunity)	Exclude from duty until receipt of the second dose of varicella vaccine within 3-5 days of exposure	From 8th day after 1st exposure through 21st day (28th day if VariZIG given) after last exposure; if varicella occurs, until all lesions dry and crust or, if only lesions that do not crust (i.e., macules or papules), until no new lesions appear within a 24-hour period
Viral respiratory infections, acute febrile		Exclude from duty	Until afebrile for greater than 24 hours (without the use of fever-reducing medications, such as acetaminophen)
			Consider for temporary reassignment or exclusion from work for 7 days from symptom onset or until the resolution of symptoms, whichever is longer, if returning to care for patients in a protective environment, such as hematopoetic stem cell transplant patients.
Zoster
	Localized, in immunocompetent HCP	Cover lesions; restrict from care of high-risk patients (pregnant women, neonates, and immunocompromised patients of any age)	Until all lesions dry and crust
	Disseminated or localized in immunosuppressed HCP	Exclude from duty	Until all lesions dry and crust
	Postexposure (HCP without evidence of immunity-dissem inated zoster or localized zoster with uncontained/uncovered lesions)	Exclude from duty unless receipt of the second dose of varicella vaccine within 3-5 days after exposure	From 8th day after 1st exposure through 21st day (28th day if VariZIG given) after last exposure or, if varicella occurs, until all lesions dry and crust or if only lesions that do not crust (i.e., macules and papules), until no new lesions appear within a 24-hour period
	Postexposure (HCP without evidence of immunity-localized zoster with contained/covered lesions)	For HCP with at least one dose of varicella vaccine, no work restrictions. For HCP with no doses of varicella vaccine, restrict from patient contact	From 8th day after 1st exposure through 21st day (28th day if VariZIG given) after last exposure or, if varicella occurs, until all lesions dry and crust or if only lesions that do not crust (i.e., macules and papules), until no new lesions appear within a 24-hour period
Modified from Bolyard EA, Tablan OC, Williams WW, et al. Guideline for infection control in healthcare personnel, 1998. Infect Control Hosp Epidemiol. 1998;19:407-463.

HEALTH COUNSELING

Access to adequate health counseling for HCP is another crucial element of an effective occupational health service. Health counseling allows HCP to receive individually targeted information regarding (a) the risk and prevention of occupationally acquired infections, (b) the risk of illness or other adverse outcome after exposure, (c) management of exposure, including the risks and benefits of PEP regimens, and (d) the potential consequences of exposure or communicable disease for family members, patients, or other persons, both inside and outside the healthcare facility.

MAINTENANCE OF RECORDS, DATA MANAGEMENT, AND CONFIDENTIALITY

Maintenance of records related to medical evaluations, evidence of immunity, immunizations, exposures, PEP, and screening tests in a retrievable, preferably computerized, database allows efficient monitoring of the health status of HCP. Such record keeping also helps to ensure that the organization will provide consistent and appropriate services to HCP.

Individual records for all HCP should be maintained in accordance with the Occupational Safety and Health Administration (OSHA) medical records standard, which requires the employer to retain records, maintain employee confidentiality, and provide records to employees when they ask to review them (33). In addition, the OSHA “Occupational Exposure to Bloodborne Pathogens; Final Rule” (34) requires employers, including healthcare facilities, to establish and maintain an accurate, confidential record for each employee with occupational exposure to bloodborne pathogens. The standard also requires that each employer ensures that he or she maintains employee medical records for at least the duration of the worker’s employment plus 30 years.

Occupational health departments need to protect and safeguard protected health information as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the American Disabilities Act (ADA) (35). Disclosure of such information to public health authorities is permitted for the purpose of preventing or controlling disease, injury, or disability.

EPIDEMIOLOGY AND CONTROL OF SELECTED INFECTIONS TRANSMITTED AMONG HCP AND PATIENTS

The following section provides more detail about selected infectious pathogens and conditions that can be transmitted in the healthcare setting. Bloodborne pathogens, including HBV, HCV, and HIV, are not included here but are discussed in Chapter 43.

CONJUNCTIVITIS

Although conjunctivitis can be caused by a variety of bacteria and viruses, adenovirus has been the primary cause of healthcare-associated outbreaks of conjunctivitis. Healthcare-associated outbreaks of conjunctivitis caused by adenovirus have primarily occurred in eye clinics or offices, but also have been reported in neonatal intensive care units and long-term care facilities (36,37,38,39,40). The incubation period ranges from 2 to 12 days, and shedding of virus occurs from late in the incubation period to as long as 14 days after onset of disease (37,41). Adenovirus survives for long periods on environmental surfaces; ophthalmologic instruments and equipment can become contaminated and be a source of transmission. Contaminated hands also are a major source of person-to-person transmission of adenovirus, both from patients to HCP and from HCP to patients. Hand hygiene, glove use, and disinfection of instruments can prevent the transmission of adenovirus (36,37). Infected personnel should not provide patient care for the duration of symptoms after onset of purulent conjunctivitis caused by adenovirus or other pathogens (37,38).

CYTOMEGALOVIRUS

There are two principal reservoirs of cytomegalovirus (CMV) in healthcare institutions: (a) infants and young children infected with CMV and (b) immunocompromised patients; for example, those undergoing solid-organ or bone-marrow transplantation or those with acquired immunodeficiency syndrome (AIDS) (42,43). However, HCP 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% vs. 2%) (44,45,46,47,48).

CMV transmission appears to occur directly either through close, intimate contact with a person excreting CMV or through contact with contaminated secretions or excretions, especially saliva or urine (47,49,50). Transmission by the hands of HCP or infected persons also has been suggested (43,51). The incubation period for person-to-person transmission is not known. Although CMV can survive on environmental surfaces and other objects for short periods (52,53), there is no evidence that the environment plays a role in the transmission of this pathogen (43).

Because infection with CMV during pregnancy may have adverse effects on the fetus, women of childbearing age need to be counseled regarding the risks and prevention of transmission of CMV in both nonoccupational and occupational settings (54). No studies clearly indicate that seronegative HCP can be protected from infection by transfer to areas with less contact with patients likely to be reservoirs for CMV (42,43,44,48). Workplace reassignment should not be routinely used as a method to reduce CMV exposures among seronegative pregnant HCP.

Serologic or virologic screening programs to identify CMV-infected patients or seronegative female personnel of childbearing age are impractical and costly because (a) virus shedding can be intermittent (55), and thus repeated screening tests could be needed to identify shedders, (b) seropositivity for CMV does not offer complete protection against maternal re-infection or reactivation and subsequent fetal infection (42), and (c) no currently available vaccines or prophylactic therapy for HCP can provide protection against primary infection.

Work restrictions for personnel who contract CMV illnesses are not necessary. The risk of transmission of CMV can be reduced by careful adherence to hand hygiene and standard precautions (42,56).

DIPHTHERIA

Healthcare-associated transmission of diphtheria among patients and HCP has been reported (57,58,59). HCP are not at substantially higher risk than the general adult population for acquiring diphtheria.

Prevention of diphtheria is best accomplished by maintaining high levels of diphtheria immunity among children and adults (21,60,61). Immunization with tetanus and diphtheria toxoid (Td) is recommended every 10 years for all adults who have completed the primary immunization series (9,21). Persons without documentation of having received Td vaccination should receive a series of three vaccinations with Td-containing vaccine. Preferably, the first dose of this series should be administered as Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine (see Pertussis). HCP directly exposed to oral secretions of patients infected with Corynebacterium diphtheriae should be evaluated in consultation with local public health authorities.

GASTROENTERITIS

Gastrointestinal infections may be caused by a variety of agents, including bacteria, viruses, and protozoa. However, only a few agents have been documented in healthcare-associated transmission, such as Salmonella typhimurium, Yersinia enterocolitica, Escherichia coli, and norovirus (62,63,64,65,66,67,68,69,70,71,72,73,74,75). Few episodes of healthcare-associated Clostridium difficile infection (CDI) among HCP have been reported (76), and increased risk of CDI among HCP has not been clearly demonstrated. Healthcare-associated transmission of agents that cause gastrointestinal infections usually results from contact with infected individuals (62,68,77), from consumption of contaminated food, water, or other beverages (62,77,78), or from exposure to contaminated objects or environmental surfaces (63,79). Inadequate HCP hand hygiene (80) 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 proper hand hygiene by HCP before and after all contacts with patients and food, and to either standard or contact precautions (56) will minimize the risk of transmitting enteric pathogens (70,81).

HCP who acquire an acute infectious gastrointestinal illness (defined as vomiting, diarrhea, or both, 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). Determining the etiology of gastrointestinal illness is important in affected HCP who care for patients at high risk for severe disease (e.g., neonates, elderly persons, and immunocompromised patients). The initial evaluation of HCP with gastroenteritis needs to include a thorough history, physical exam, and determination of the need for specific laboratory tests (69,79,82,83,84,85).

Restriction from patient care and the patient’s environment or from food handling is indicated for HCP with diarrhea or acute gastrointestinal symptoms regardless of the causative agent (56,79). Work exclusion for a minimum of 48 hours after resolution of symptoms for HCP with symptoms consistent with norovirus infection has been recommended (85). Some local and state agencies have regulations that require work exclusion for HCP, food handlers, or both who have gastrointestinal infections caused by specified organisms (e.g. Salmonella or Shigella spp.). These regulations may require such personnel to be restricted from duty until results of at least two consecutive stool cultures obtained at least 24 hours apart are negative.

HEPATITIS A VIRUS

Healthcare-associated hepatitis A virus (HAV) infections occur infrequently, and transmission to HCP usually occurs when the source-patient has unrecognized hepatitis and is fecally incontinent or has diarrhea (86,87,88,89,90,91,92,93). Other risk factors for HAV transmission to HCP include activities that increase the risk of fecal-oral contamination such as (a) eating or drinking in patient-care areas (86,88,90,94), (b) not performing hand hygiene after caring for an infected infant (88,94,95), and (c) sharing food, beverages, or cigarettes with patients, their families, or other staff members (86,88).

HAV is transmitted primarily by the fecal-oral route. The incubation period for HAV is 15 to 50 days. Fecal excretion of HAV is greatest during the incubation period of disease before the onset of jaundice. Once disease is clinically obvious, the risk of pathogen transmission is decreased. However, some patients admitted to the hospital with HAV, particularly premature infants or immunocompromised patients, can still shed virus because of prolonged or relapsing disease, and such patients are potentially infectious (87). Fecal shedding of HAV, formerly believed to continue only as long as 2 weeks after onset of dark urine, has been shown to occur as late as 6 months after diagnosis of infection in premature infants (86). Anicteric infection is typical in young children and infants (96).

HCP can protect themselves and others from infection with HAV by adhering to standard precautions (56).

Three inactivated HAV vaccines are now available and provide long-term preexposure protection against clinical infection with >94% efficacy (96). Routine administration of HAV vaccine in HCP is not recommended because HCP have not been demonstrated to be at increased risk for HAV infection due to occupational exposure. However, vaccine may be useful for HCP working or living in areas where HAV is highly endemic and is indicated for individuals who handle HAV-infected primates or are exposed to HAV in a research laboratory. The role of HAV vaccine in controlling outbreaks has not been adequately investigated (96). Immune globulin given within 2 weeks after an HAV exposure is 80% to 90% effective in preventing HAV infection and may be advisable in some outbreak situations (96).

Restriction from patient-care areas or food handling is indicated for HCP with HAV infection. They may return to regular duties 1 week after onset of the illness.

HERPES SIMPLEX VIRUS

Healthcare-associated transmission of herpes simplex virus (HSV) is rare. It has been reported in nurseries (97,98,99) and intensive care units (100,101) where high-risk patients (e.g., neonates, patients with severe malnutrition, patients with severe burns or eczema, and immunocompromised patients) are located. Healthcare-associated transmission of HSV occurs primarily through contact either with primary or recurrent lesions or with virus-containing secretions, such as saliva, vaginal secretions, or amniotic fluid (98,100,102). Exposed areas of skin are the most likely sites of infection, particularly when minor cuts, abrasions, or other skin lesions are present (101). The incubation period of HSV is 2 to 14 days (103). The duration of viral shedding has not been well defined (104).

HCP can acquire a herpetic infection of the fingers (herpetic whitlow or paronychia) from exposure to contaminated oral secretions (101,102). Such exposures are a distinct hazard for nurses, anesthesiologists, dentists, respiratory care personnel, and other personnel who have ungloved direct (usually hand) contact with either oral lesions or respiratory secretions from patients (101). Less frequently, HCP may acquire mucocutaneous infection on other body sites from contact with infectious body secretions (105).

HCP with active HSV infection of the hands (herpetic whitlow) can potentially transmit the pathogen to patients with whom they have contact (102). Transmission of HSV from HCP with orofacial HSV infection to patients also has been infrequently documented (97); however, the magnitude of this risk is unknown (99,106). Although asymptomatic HSV-infected persons can shed the virus, they are less infectious than persons with active lesions (104,107).

HCP can protect themselves from acquiring HSV by adhering to standard precautions (56). The risk of transmission of HSV from personnel with orofacial infections to patients can be reduced by performing hand hygiene before all patient care and by the use of appropriate barriers (e.g., a mask or gauze dressing) to prevent hand contact with the lesions.

Because HCP with orofacial lesions could touch their lesions and potentially transmit HSV, they should be evaluated to determine their potential for transmitting HSV to patients at high risk for serious disease (e.g., neonates, patients with severe malnutrition, patients with severe burns or eczema, and immunocompromised patients) and excluded from the care of such patients as indicated. The evaluation also should consider the extent of the lesion and the severity of illness in the patient population that personnel will contact. HCP with HSV infections of the fingers or hands can more easily transmit HSV and therefore need to be excluded from patient care until their lesions have crusted. In addition, herpetic lesions can be secondarily infected by Staphylococcus or Streptococcus spp., and HCP with such infections should be evaluated to determine whether they need to be excluded from patient contact until the secondary infection has resolved. There have been no reports that HCP with genital HSV infections have transmitted HSV to patients; therefore, work restrictions for HCP with genital herpes are not indicated.

MEASLES

Healthcare-associated transmission of measles virus has been well described (108,109,110,111,112,113,114,115) and responding to measles exposures in hospital settings can be very costly and disruptive (116). Measles is transmitted both by large droplets during close contact between infected and susceptible persons and by the airborne route (117). Measles is highly transmissible and frequently misdiagnosed during the prodromal stage. The incubation period for measles is 7 to 21 days. Immunocompetent persons with measles shed the virus from the nasopharynx, beginning with the prodrome until 4 days after rash onset; immunocompromised persons with measles could shed virus for extended periods (118).

Strategies to prevent healthcare-associated transmission of measles include (a) documentation of evidence of measles immunity in HCP, (b) prompt identification and isolation of persons with fever and rash, and (c) adherence to airborne precautions for suspected and proven patients with measles (56).

Documentation of evidence of measles immunity is essential for all HCP, regardless of their length of employment or whether they are involved in patient care. Presumptive evidence of immunity to measles for persons who work in healthcare facilities includes those (a) with written documentation of vaccination with two doses of live measles or Measles-Mumps-Rubella (MMR) vaccine administered at least 28 days apart, (b) with laboratory evidence of immunity (“equivocal” results should be considered nonimmune), (c) laboratory confirmation of disease, or (d) born before 1957. Although persons born before 1957 are generally considered to be immune to measles, serologic studies indicate that 2% to 9% of HCP born before 1957 may not be immune (9,119,120). During 2001 to 2008, a total of 12.5% (1 of 8) measles cases reported to the Centers for Disease Control and Prevention (CDC) among HCP occurred in persons born before 1957 (9). For unvaccinated personnel born before 1957 who lack laboratory evidence of measles immunity or laboratory confirmation of disease, healthcare facilities should consider vaccinating personnel with two doses of the MMR vaccine at the appropriate interval, absent a measles outbreak. During an outbreak of measles, two doses of the MMR vaccine are recommended for these personnel (9).

Work restrictions are necessary for HCP who acquire measles; they need to be excluded from duty for 4 days after the rash appears. Likewise, HCP without presumptive evidence of immunity to measles need to be excluded from duty from 5 days after the first exposure through 21 days after the last exposure to measles.

MENINGOCOCCAL DISEASE

Healthcare-associated transmission of Neisseria meningitidis is rare. When proper precautions were not used, N. meningitidis

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