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Infection Control in Health Care Personnel

[1] Introduction

The CDC's "Guideline for Infection Control in Healthcare Personnel, 1998," which updates and replaces the 1983 "Guideline for Infection Control in Hospital Personnel," contains recommendations for reducing the transmission of infections from patients to health care personnel and from personnel to patients (Infect Control Hosp Epidemiol. 1998;19:407-463). The revised guideline also incorporates recommendations of the Advisory Committee on Immunization Practices and the Hospital Infection Control Practices Advisory Committee for the use of vaccines for specific disease categories.

The guideline focuses on the epidemiology of and preventive strategies for infections known to be transmitted in health care settings. According to the CDC, such prevention strategies include the following:

  • Immunizations for vaccine preventable diseases

  • Isolation precautions to prevent exposures to infectious agents

  • Management of health care personnel exposures to infected persons, including post-exposure prophylaxis

  • Work restrictions for exposed or infected health care personnel

Employee health service. The guideline emphasizes the importance of using an employee health service (EHS) to attain infection control goals through programs and services such as coordination with other departments; medical evaluations; health and safety education; immunization programs; management of job-related illnesses and exposures to infectious diseases, including policies for work restrictions for infected or exposed personnel; counseling services for personnel on infection risks related to employment or special conditions; and maintenance and confidentiality of personnel health records. (For more information on developing an EHS, see Employee Health Services.)

Work Restriction Policies

The CDC's 1998 infection control guideline provides an overview of the symptoms, treatment, and work restrictions for diseases that are of particular concern to hospital personnel because of the possibility of transmission.

Special guidance on work restrictions for HIV-infected health care workers is included in the CDC's "Recommendations for Preventing Transmission of Human Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone Invasive Procedures."

The Society for Healthcare Epidemiology of America (SHEA) also has issued recommendations for the management of health care workers infected with HBV, HCV, HIV, or other bloodborne pathogens (see box, "SHEA Infection Management Recommendations").

[2] Applicability

The CDC's guideline for infection control applies to all 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. The guideline focuses on infection control issues related to personnel directly involved with patient care (e.g., nurses, physicians, technicians, etc.) and those not directly involved in patient care but potentially exposed to infectious agents (e.g., housekeeping staff, maintenance workers, volunteers, etc.). The CDC notes that, in general, health care personnel in or outside hospitals who have contact with patients, body fluids, or specimens have a higher risk of acquiring or transmitting infections than do other health care workers who have only brief casual contact with patients and their environment.

In addition to infection control measures for health care workers in general, the CDC guideline addresses the following special categories of workers:

  • Pregnant employees. The CDC recommends that employee health services should counsel pregnant women and women of childbearing age regarding the risk of transmission of particular infectious diseases (e.g., cytomegalovirus, various forms of hepatitis, herpes simplex viruses, HIV, parvovirus, rubella). If acquired during pregnancy, such diseases may have adverse effects on the fetus, whether the infection is acquired in nonoccupational or occupational environments. Information should be provided to such women on standard and transmission-based precautions appropriate for each infection. Women should not be routinely excluded, on the basis only of their pregnancy or intent to be pregnant, from the care of patients with particular infections that have potential to harm the fetus, according to the CDC.

  • Emergency response employees. The CDC recommends that emergency response employees should be routinely notified of infectious diseases in patients they have cared for or transported, in accordance with the mandates of the 1990 Ryan White Comprehensive AIDS Resources Emergency (CARE) Act.

  • Personnel linked to outbreaks of bacterial infection. Cultures and organism typing should be performed only on personnel who are linked epidemiologically to an increase in bacterial infections caused by a pathogen associated with a carrier state, the CDC recommends. If cultures are positive, personnel should be excluded from patient contact until carriage is eradicated or the risk of disease transmission is eliminated. Routine surveillance cultures of health care personnel should not be performed for bacteria or multidrug-resistant organisms in the absence of a cluster or epidemic of bacterial infections in which personnel are implicated. Personnel who are colonized by bacteria, including multidrug-resistant bacteria, but who are not epidemiologically linked to an increase in infections, should not be excluded from duty, according to the CDC.

  • Workers with latex hypersensitivity. Because latex barriers frequently are used to protect personnel against transmission of infectious agents, the guideline addresses issues related to latex hypersensitivity and provides recommendations to prevent sensitization and reactions among health care personnel.

The CDC recommends that health care facilities develop an institutional protocol for evaluating and managing personnel with suspected or known latex allergy, establishing surveillance for latex reactions within the facility, and measuring the impact of preventive measures. Educational materials and activities should be provided to inform personnel about the manifestations and potential risk of latex allergy.

For more information on the prevention of latex hypersensitivity, seePersonal Protective Equipment-In General

[3] Acquired Immune Deficiency Syndrome

Human immunodeficiency virus, the virus that causes AIDS, is known to be transmitted through sexual contact, exposure to infected blood or blood components, and perinatally from mother to neonate, according to the CDC. Nosocomial transmission of HIV infection from patients to health care personnel may occur after percutaneous or, infrequently, mucocutaneous exposure to blood or body fluids containing blood. Factors that determine a health care worker'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.

The OSHA bloodborne pathogens standard requires health care workers to take steps that include use of gloves and other PPE to prevent exposure to HIV and hepatitis B virus (see Bloodborne Pathogens-Personal Protective Equipment). Both OSHA and the CDC recommend that health care workers take extraordinary care to avoid accidental wounds from sharp instruments contaminated with blood or other potentially infectious material. In addition, all workers should comply with current CDC guidelines for disinfection and sterilization of reusable devices used in invasive procedures.

The risk of an infected health care worker transmitting HIV to a patient in the normal course of care-i.e., non-invasive procedures-is thought to be very small, and generally does not warrant work restrictions unless the worker is suffering from a secondary infection. Health care workers who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient care equipment and devices used in performing invasive procedures until the condition resolves, according to the CDC.

Work restrictions. Restrictions are warranted for HIV-infected health care personnel who perform "exposure-prone" invasive procedures, where a small risk of HIV transmission from worker to patient is thought to be present, according to the CDC. Reported examples include certain oral, cardiothoracic, colorectal, and obstetric gynecological procedures where the health care worker's hands may come in close contact with a needle or other sharp instrument in a highly confined or otherwise poorly visualized body cavity or internal area. Workers who are infected with HIV or HBV (and are HBsAg positive) generally should not perform such procedures.

Post-exposure prophylaxis. The CDC recommends that health care workers follow current recommendations for post-exposure prophylaxis after percutaneous or mucocutaneous exposure to blood or body fluids containing blood from a source suspected or known to be HIV-infected.

For more information on HIV post-exposure prophylaxis, see Bloodborne Pathogens-Vaccination and Post-Exposure Follow-up.

[4] Cytomegalovirus

Although the risk of health care personnel acquiring cytomegalovirus (CMV) from patients appears to be small, the virus can cause damage to unborn fetuses, according to the CDC. Patients known to be infected with CMV can be identified, and this information used in counseling pregnant personnel and determining their work assignments. Generally, personnel who contract illnesses thought to be due to CMV need not be restricted from work. They can reduce the risk of transmission to patients and others by careful handwashing and exercising care to prevent their body fluids from contacting other persons.

The CDC makes the following recommendations regarding the nosocomial transmission of CMV:

  • Do not restrict personnel from work who contract CMV-related illnesses

  • 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

  • Do not routinely use workplace reassignment as a method to reduce CMV exposures among seronegative pregnant personnel

[5] Gastrointestinal Infections

Acute gastrointestinal infections may be caused by a variety of agents, including bacteria, viruses, and protozoa, according to CDC guidelines. However, only a few agents have been documented in nosocomial transmission. Nosocomial transmission of agents that cause gastrointestinal infections usually results from contact with infected individuals; from consumption of contaminated food, water, or other beverages; or from exposure to contaminated objects or environmental surfaces. Airborne transmission of small round-structured viruses (Norwalk-like viruses) has been postulated but not proven. Inadequate handwashing by health care personnel 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 will minimize the risk of transmitting enteric pathogens.

To prevent the transmission of gastroenteritis, the CDC recommends the following:

  • Vaccinate microbiology laboratory personnel who work with Salmonella typhi on a regular basis

  • 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

  • Consult local and state health authorities regarding work restrictions for patient-care personnel or food handlers with enteric infections

  • Determine the etiology of gastrointestinal illness among personnel who care for patients at high risk of severe disease

  • Allow personnel infected with enteric pathogens to return to work after their symptoms resolve, unless local regulations require exclusion from duty

  • Ensure that personnel returning to work after a gastrointestinal illness follow good hygienic practices, especially handwashing, to reduce or eliminate the risk of transmission of the infecting agents

  • 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

  • Do not perform routine stool cultures on asymptomatic health care personnel, unless required by state and local regulations

[6] Hepatitis B Virus

According to the CDC, the transmission of hepatitis B virus to health care workers has been documented as occurring through accidental needlesticks and broken skin or mucous membrane contact with infective material-e.g., blood or serum. Patient contact without physical exposure to blood has not been documented to be a risk factor.

An increased risk of contracting HBV is found in those work locations and occupational categories that put workers in frequent contact with blood from infected patients. Such work locations include blood banks, clinical laboratories, dental clinics, dialysis wards, emergency rooms, hematology/oncology wards, operating and recovery rooms, and pathology laboratories.

Requirements for protecting workers from exposure to HBV are mandated by OSHA. These include use of universal precautions, provision of the HBV vaccine, and post-exposure follow-up requirements. See Bloodborne Pathogens-General Requirements for more information.

Special precautions against HBV transmission in hemodialysis centers are described in the CDC's Control Measures for Hepatitis B in Dialysis Centers.

Pregnant employees who contract hepatitis B during pregnancy are at risk of bearing a child that develops neonatal hepatitis. Thus, the CDC recommends that such employees be educated on the dangers of working in high-risk departments, appropriate precautions, and the benefits of the hepatitis B vaccine.

For protection against hepatitis B virus, the CDC makes the following recommendations:

  • 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.

  • 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.

  • Conduct post-vaccination screening for immunity to hepatitis B within one to two 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.

  • Revaccinate persons not found to have an antibody response after the initial hepatitis B vaccine series with a second three-dose vaccine series. If the persons still do not respond after revaccination, refer them for evaluation for lack of response, (e.g., possible chronic HBV infection).

  • Semiannually test for HBsAg and anti-HBs staff in chronic dialysis centers who do not respond to the hepatitis B vaccine.

  • Use both passive immunization with hepatitis B immune globulin and active immunization with hepatitis B vaccine for post-exposure 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 seropositive.

  • Follow current recommendations for post-exposure prophylaxis after percutaneous or mucous membrane exposure to blood and body fluids known or suspected to be at high risk for being HBsAg seropositive.

Hepatitis B Carriers

[7] Other Forms of Viral Hepatitis

Aside from hepatitis B, other forms of viral hepatitis include hepatitis A virus (HAV) and the one or more viruses currently designated non-A, non-B (NANB). Health care workers should practice universal precautions to reduce their risk of exposure to HAV and NANB, according to the CDC.

Hepatitis A virus. The primary mode of transmission of hepatitis A virus is fecal/oral, making good personal hygiene and thorough handwashing central to preventing its spread. The risk of transmitting HAV is highest in the earliest stages of the disease, before the illness has become clinically obvious. In most persons, HAV transmission risk becomes low or negligible about seven days after the onset of jaundice. HAV has not been reported to occur after inadvertent needlesticks or contact with infected blood. It may, however, be spread via blood transfusion.

To protect workers from hepatitis A virus, the CDC recommends the following:

  • 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.

  • Do not routinely administer immune globulin as prophylaxis for personnel providing care or who are exposed to a patient with hepatitis A.

  • Administer immune globulin (0.02 mL/kg) to personnel who have had oral exposure to fecal excretions from a person acutely infected with hepatitis A virus.

  • In documented outbreaks involving transmission of HAV from patient to patient or from patient to health care worker, use of immune globulin may be indicated in persons with close contact with infected persons. Contact the local health department regarding control measures.

  • Exclude personnel who have acute hepatitis A from duty until one week after the onset of jaundice.

Hepatitis C virus. Health care workers, emergency response personnel, and others who have exposure to blood in the workplace are at risk for being infected with hepatitis C virus, according to the CDC's "Recommendations for Prevention and Control of Hepatitis C Virus (HCV) Infection and HCV-Related Chronic Disease" (MMWR. 1998;47(RR-19):1-39).

Although no recommendations currently exist to restrict professional activities of health care workers with HCV infection, the CDC does recommend that HCV-positive workers should follow strict aseptic procedures and standard precautions (e.g., proper handwashing techniques, proper disposal techniques for needles and other sharps).

The CDC does not recommend the administration of immune globulin and antiviral agents (e.g., interferon) for post-exposure prophylaxis of hepatitis C. While limited data indicate that antiviral therapy might be beneficial when started early in the course of HCV infection, no guidelines currently exist for administration of therapy during the acute phase of infection. When HCV infection is identified early, however, the CDC recommends that the individual be referred to a specialist knowledgeable in the area of HCV infection and appropriate counseling, testing, and medical follow-up.

For HCV post-exposure follow-up of health care workers, the CDC recommends the following:

  • For the source, baseline testing for antibody to HCV.

  • For the person exposed to an HCV-positive source, baseline and follow-up testing including baseline testing for anti-HCV and alanine aminotransferase (ALT) activity and follow-up testing for anti-HCV (e.g., at 4-6 months) and ALT activity. (If earlier diagnosis of HCV infection is desired, testing for HCV ribonucleic acid may be performed at 4-6 weeks.)

  • Confirmation by supplemental anti-HCV testing of all anti-HCV results reported as positive by enzyme immunoassay.

The CDC recommendations also include guidelines for hemodialysis-specific practices, testing for HCV infection, and training of health care workers.

For more information on the CDC's HCV recommendations, seeBloodborne Pathogens-Vaccination and Post-Exposure Follow-up.

[8] Herpes Simplex Viruses

Herpes simplex viruses can be transmitted among personnel and patients through skin lesions or through secretions (e.g., saliva, vaginal secretions, infected amniotic fluid) that contain the virus when no lesions are apparent. Direct contact with lesions or infected secretions is the principal mode of spread. Health care workers sometimes develop an infection of the fingers (herpetic whitlow or paronychia) from exposure to contaminated oral secretions.

Workers can protect themselves from such infections by avoiding direct contact with lesions, wearing gloves on both hands or using a "no-touch" technique for all contact with oral or vaginal secretions, and through thorough handwashing after patient contact. There is no evidence that health care workers with genital infections pose a high risk to patients as long as the workers follow good patient care practices. Persons with oral infections can reduce the risk of infecting patients by wearing a mask, gauze dressing, or other barrier to prevent hand contact with the lesion, washing hands well before patient care, and not being assigned to care for patients at high risk of infections such as neonates, patients with severe malnutrition or severe burn injuries, and patients in immunodeficient states.

The CDC recommends the following actions to prevent the transmission of herpes simplex viruses:

  • Evaluate personnel with primary or recurrent orofacial herpes simplex infections on a case-by-case basis to assess the potential for transmission to high-risk patients (e.g., neonates, intensive-care-unit patients, patients with severe burns or eczema, and severely immunocompromised patients) and the need for exclusion from the care of such patients

  • Counsel personnel with orofacial herpes simplex to cover and not touch the infected lesions, to observe handwashing policies, and not to allow the lesions to touch patients with dermatitis

  • Exclude personnel with herpes simplex infections of the fingers or hands (herpetic whitlow) from contact with patients until their lesions are healed

[9] Measles, Mumps, and Rubella

Measles. 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, the CDC recommends. Further more, some states have regulations requiring measles immunity for health care personnel.

The CDC recommends the following:

  • Ensure that all personnel have documented immunity to measles. Administer measles vaccine to persons born in 1957 or later unless they have evidence of measles immunity and to personnel born before 1957 if they do not have evidence of measles immunity and are at risk of occupational exposure to measles. Administer post-exposure measles vaccine to measles-susceptible personnel who have contact with persons with measles within 72 hours after the exposure.

  • Exclude exposed personnel who do not have documented immunity to measles from duty from the fifth day after the first exposure until the 21st day after the last exposure to measles, regardless of whether they receive post-exposure vaccine.

  • Exclude personnel who acquire measles from duty for seven days after rash develops or for the duration of their acute illness, whichever is longer.

Mumps. An effective vaccination program is the best approach to preventing nosocomial mumps transmission, according to the CDC. Vaccination with mumps virus vaccine is recommended, unless otherwise contraindicated. The CDC recommends the following:

  • Administer mumps vaccine to all personnel without documented evidence of mumps immunity unless otherwise contraindicated

  • Before vaccinating personnel with mumps vaccine, do not routinely perform serologic screening for mumps unless the healthcare employer considers screening cost-effective or it is requested by the potential vaccinee

  • 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 nine days after the onset of parotitis

On May 17, 2006 the Advisory Committee on Immunization Practices (ACIP) issued updated criteria for mumps immunity and updated mumps vaccination recommendations.

For healthcare workers born in or after 1957, adequate mumps vaccination consists of two doses of a live mumps virus vaccine. Healthcare workers with no history of mumps vaccination and no other evidence of immunity should receive two doses (at a minimum interval of 28 days between doses). Healthcare workers who have received only one dose previously should receive a second dose.

Healthcare facilities should consider recommending one dose of a live mumps virus vaccine for unvaccinated workers born before 1957 who do not have a history of physician-diagnosed mumps or laboratory evidence of mumps immunity.

Key Changes to 1998 ACIP Recommendations on Mumps

Rubella. Ensuring immunity among all health care personnel is the most effective way to eliminate nosocomial transmission of rubella, the CDC says. Persons should be considered susceptible to rubella if they lack documentation of one dose of live rubella vaccine on or after their first birthday or laboratory evidence of immunity (persons with indeterminate levels are considered susceptible).

The CDC recommends the following:

  • Vaccinate all personnel without documented immunity to rubella with rubella vaccine

  • Consult local and state health departments regarding regulations for rubella immunity in health care personnel

  • 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

  • Do not administer rubella vaccine to susceptible personnel who are pregnant or might become pregnant within three months of vaccination

  • Administer rubella vaccine in the postpartum period to female personnel not known to be immune

  • Exclude personnel who are exposed to rubella from duty from the seventh day after the first exposure through the 21st day after the last exposure

  • Exclude personnel who develop rubella from duty until seven days after the beginning of the rash

[10] Meningococcal Disease

According to CDC guidelines, it is uncommon for health care workers to contract Neisseria meningititis from patients with meningococcemia, meningococcal meningitis, or lower respiratory infections, but it has occurred in rare instances. Meningococcal lower respiratory infections may present a greater risk in cases where the patient has an active, productive cough.

Antimicrobial prophylaxis can eradicate the virus and prevent infections in persons who have had unprotected exposure. When medically necessary, such treatment should begin immediately and may be necessary before antimicrobial test results are available.

To prevent the transmission of meningococcal disease, the CDC recommends the following:

  • Do not routinely administer meningococcal vaccine to health care personnel.

  • Consider vaccination of laboratory personnel who are routinely exposed to Neisseria meningitidis in solutions that may be aerosolized.

  • Immediately offer antimicrobial prophylaxis to personnel who have had intensive, close contact (e.g., mouth-to-mouth resuscitation, endotracheal intubation, endotracheal-tube management) with a patient with meningococcal disease without the use of proper precautions before administration of antibiotics.

  • Do not routinely give quadrivalent meningococcal vaccines for post-exposure prophylaxis.

  • Administer meningococcal vaccine to personnel (and other persons likely to have contact with infected persons) to control outbreaks after consultation with public health authorities.

  • Consider pre-exposure vaccination of laboratory personnel who routinely handle soluble preparations of N. meningitidis.

  • Exclude personnel with N. meningitidis infections from duty until 24 hours after the start of effective therapy. Do not routinely exclude personnel from duty who only have nasopharyngeal carriage of N. meningitidis.

[11] Pertussis

Nosocomial transmission of pertussis has been reported only infrequently, even though the disease, caused by Bordetella pertussis, is considered highly communicable, according to the CDC. Infection occurs less commonly in adults and may be limited to mild respiratory illness.

Routine vaccination of health care workers is not considered warranted. Nevertheless, during an outbreak the CDC recommends the removal of workers with cough or upper respiratory symptoms from patient care duties.

For protection from pertussis transmission, the CDC recommends the following:

  • Do not administer whole-cell pertussis vaccine to personnel.

  • 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.

  • Exclude personnel in whom symptoms develop (e.g., cough for seven days or more, particularly if accompanied by inspiratory whoop or post-tussive vomiting) after known exposure to pertussis from patient care areas until five days after the start of appropriate therapy.

Vancomycin Resistance

[12] Staphylococcus and Streptococcus

Staphylococcus carriage or infection occurs frequently in humans and is spread most commonly through direct contact. The CDC advises that infected health care workers not be allowed to engage in direct patient care until skin infection caused by this organism is resolved. If certain personnel are epidemiologically linked to an increased number of infections, these persons can be cultured and, if positive, removed from patient contact until carriage is eradicated.

For protection against staphylococcal infection or carriage, the CDC recommends the following:

  • Obtain appropriate cultures and exclude personnel from patient care or food handling if they have a draining lesion suspected to be due to S. aureus, until the infections have been ruled out or personnel have received adequate therapy and their infections have resolved.

  • 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 they are responsible for disseminating the organism in the health care setting.

Streptococcus can cause outbreaks of surgical wound infections. Otherwise, pharyngeal and skin infections are the most common manifestations of the bacteria, which is transmitted by direct contact and, possibly, via airborne transmission. Increased incidence of surgical wound infections due to streptococcus should be followed up with an immediate search for a carrier. Implicated personnel should be cultured and, if positive, removed from patient contact until treated.

For protection against streptococcus transmission, the CDC recommends the following:

  • Obtain appropriate cultures and exclude personnel from patient care or food handling if they have draining lesions that are suspected to be caused by streptococcus. Work restrictions should be maintained until streptococcal infection has been ruled out or personnel have received adequate therapy for 24 hours.

  • Do not routinely exclude personnel with suspected or confirmed carriage of streptococcus from patient care or food handling unless it is shown epidemiologically that they are responsible for disseminating the organism in the health care setting.

[13] Tuberculosis

Transmission of tuberculosis infection in the hospital is most likely to occur in cases where a patient or employee has unsuspected pulmonary or laryngeal TB, has bacilli-laden sputum or respiratory secretions, and is coughing or sneezing into air that remains in circulation.

Health care facilities should assess the risk of TB transmission in all areas and implement appropriate controls to prevent such transmission, according to the CDC's "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." Recommended controls include such preventive measures as early identification and isolation of TB patients, proper use of ventilation and other engineering controls, use of respirators by workers who have exposure to TB, and employee training and skin-testing programs. For more information on CDC recommendations and OSHA requirements, see Tuberculosis-In General.

The general CDC infection control guideline makes the following recommendations to protect health care workers from tuberculosis infection:

  • Educate all health care personnel regarding the recognition, transmission, and prevention of TB

  • Follow current recommendations outlined in the "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005."

In addition to the general recommendations, the CDC infection control guideline provides specific guidance for the following:

  • TB screening programs

  • Baseline PPD tests

  • Follow-up (repeat) PPD

  • Management of PPD-positive personnel

  • Preventive therapy

  • Post-exposure management of personnel

  • Workplace restrictions

  • Immunocompromised personnel

  • Administration of Bacille Calmette-GuĂ©rin vaccination

[14] Varicella Zoster Virus

Varicella-zoster virus (VZV), which causes chicken pox and shingles, is well-known as a source of nosocomial infection among both personnel and patients. Generally, appropriate isolation of hospitalized patients known or suspected to have the disease and restriction of susceptible health care workers should help reduce the risk of transmission.

Only health care workers who have had varicella or who demonstrate serologic evidence of immunity should be assigned to care for these patients. In facilities where varicella is more prevalent, it may be advisable to screen personnel for the presence of serum antibodies to VZV to document susceptibility or immunity. Persons who have been exposed to varicella are potentially infective to others during the latter part of the incubation period, which lasts 10 to 21 days. Transmission of the disease is possible until all skin lesions are dry and crusted. Susceptible exposed personnel should be evaluated for exclusion from patient care duties.

To prevent the nosocomial transmission of VZV, the CDC recommends the following:

  • Administer varicella vaccine to susceptible personnel, especially those who will have contact with persons at high risk for serious complications.

  • Do not perform serologic screening of personnel with negative or uncertain history of varicella before administering varicella vaccine, unless the institution considers it cost-effective.

  • Do not routinely perform post-vaccination testing of personnel for antibodies to varicella.

  • Develop guidelines for managing health care personnel who receive varicella vaccine. For example, consider precautions for personnel who acquire a rash after receipt of varicella vaccine and for other health care personnel who receive varicella vaccine and will have contact with susceptible persons at high risk for serious complications from varicella.

  • Develop written guidelines for post-exposure management of vaccinated or susceptible personnel who are exposed to wild-type varicella.

  • Exclude personnel from work who have onset of varicella until all lesions have dried and crusted.

  • Exclude from duty after exposure to varicella personnel who are not known to be immune to varicella (by history or serology) beginning on the 10th day after the first exposure until the 21st day after the last exposure (28th day if varicella-zoster immune globulin [VZIG] was given).

  • Restrict immunocompetent personnel with localized zoster from the care of high-risk patients until lesions are crusted; allow them to care for other patients with lesions covered.

  • Restrict immunocompromised personnel with zoster from contact with patients until their lesions are crusted.

  • Restrict susceptible health care personnel exposed to varicella-zoster virus from duty from the 10th day after the first exposure through the 21st day after the last exposure (28th day if VZIG was given).

  • Perform serologic screening for immunity to varicella on exposed personnel who have not had varicella or are unvaccinated against varicella.

  • Consider performing serologic screening for immunity to varicella on exposed, vaccinated personnel whose antibody status is not known. If the initial test result is negative, retest five to six days after exposure to determine whether an immune response occurred.

  • Consider excluding vaccinated personnel from work, beginning on the 10th day after the first exposure through the 21st day after the last exposure, if they do not have detectable antibodies to varicella, or screen daily for symptoms of varicella.

  • Do not routinely give VZIG to exposed susceptible personnel, unless immunosuppressed, HIV-infected, or pregnant. If VZIG is given, exclude personnel from duty from the 10th day after the first exposure through the 28th day after the last exposure.

SHEA Infection Management Recommendations

[15] Viral Respiratory Infections

Viral respiratory infections are common problems for infection control programs. Hospital personnel, patients, and visitors all are important sources of the viruses-via airborne droplets emitted during sneezing, coughing, and talking or via direct physical contact with infected persons or contaminated objects (see Updated Infection Control Measures for the Prevention and Control of Influenza in Healthcare Facilities, and, Interim Guidance on Planning for the Use of Surgical Masks and Respirators in Health Care Settings during an Influenza Pandemic).

Pandemic influenza event will quickly overwhelm the healthcare system locally, regionally, and nationally. An increased number of sick individuals will seek healthcare services. In addition, the number of healthcare workers available to respond to these increased demands will be reduced by illness rates similar to pandemic influenza attack rates affecting the rest of the population. OSHA's Pandemic Influenza Guidance for Healthcare Workers and Healthcare Employers provides resources for planning and responding to such an emergency situation.

Supply Checklists for Pandemic Planning

The CDC makes recommendations for each influenza season (see Prevention and Control of Influenza ). One recommendation is the annual vaccination of all healthcare workers. Also, the CDC encourages health care facilities to provide vaccines to workers by using approaches that maximize vaccination rates. This will protect health care workers, their patients, and communities; will improve patient safety and prevention of influenza-associated disease; and reduce disease burden.

Physicians, nurses, and other workers in both hospital and outpatient care settings, including medical emergency response workers (e.g., paramedics and emergency medical technicians), should be vaccinated.

Beginning January 2007, staff influenza vaccination programs will become an infection control standard (IC.4.15) for accreditation of critical access hospitals, hospitals, and long-term care facilities by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Currently, there is no specific vaccination to prevent avian influenza, or "bird flu." Avian influenza is a contagious disease among animals that is caused by viruses that normally infect only birds and, less commonly, pigs. Avian influenza viruses are highly species-specific, but have, on rare occasions, crossed the species barrier to infect humans. The CDC regularly updates a Web page devoted to avian influenza developments at www.cdc.gov/flu/avian. OSHA has issued (Guidance for Healthcare Workers Who Treat Patients with Known or Suspected Avian Influenza) and (Guidance on Protecting Laboratory Employees from Avian Influenza). All employees with potential occupational exposure, as described in these documents, should be trained on the hazards associated with exposure to avian influenza and be familiar with the protocols in place at their facility to isolate and report cases or reduce exposures.

ACIP/HICPAC Immunization Recommendations

JCAHO Standard for Immunization against Influenza

Declination of Influenza Vaccination