Vaccines for Healthcare Personnel

Healthcare personnel (HCP) are at risk of exposure to infectious agents in the workplace setting. The risks and methods of preventing occupational acquisition of infection by HCP have been reviewed. Minimizing the risk of disease acquisition is based on correct and consistent adherence to five key recommended interventions: (a) adherence to Standard Precautions when providing patient care, especially the performance of appropriate hand hygiene before and after patient care, (b) rapid institution of appropriate transmission-based precautions for patients with known or suspected communicable diseases, ^, ^, ^, (c) proper use of personal protective equipment (PPE), such as facemasks, N-95 respirators, eye protection, and gowns when caring for patients with potentially communicable diseases based on mode of transmission, ^, ^, (d) evaluation of HCP who have confirmed exposures to communicable diseases for receipt of postexposure prophylaxis, ^, ^, and (e) appropriate immunizations as part of both pre-exposure prophylaxis and, in some cases, postexposure prophylaxis. ^, ^, ^, Laboratory personnel, including hospital personnel working in microbiology laboratories, are also at risk for acquiring infectious diseases. Prevention of laboratory-acquired infection requires adherence to recommended administrative protocols (e.g., no eating, drinking, or smoking in areas where microbiologic or pathologic samples are processed), engineering controls (e.g., containment hoods), personal protective equipment (e.g., N-95 respirators when culturing Mycobacterium tuberculosis ), and appropriate immunizations. ^, Vaccine-preventable diseases may be classified by their route(s) of transmission and include airborne (e.g., varicella, measles), droplet (e.g., influenza, pertussis, meningococcal infection, COVID-19), contact (e.g., hepatitis A from contact with feces), and parenteral or mucosal exposure to blood or contaminated body fluids (e.g., hepatitis B).

Immunization of HCP should be included by all healthcare facilities as part of a comprehensive occupational health program. Ensuring that HCP are immune to vaccine-preventable diseases is important because it protects HCP from infections that cause potentially serious complications when acquired as an adult (e.g., rubella, varicella, hepatitis B, COVID-19) and prevents the HCP from serving as a source leading to possible exposure of patients, especially immunocompromised patients, with diseases that may lead to serious morbidity or even death (e.g., varicella, measles, COVID-19). ^, For this reason, all HCP should receive a prompt review of their immunization status against vaccine-preventable diseases on hire and immunization status should be reviewed yearly. Other important occupational health interventions include accessible health services, baseline and periodic symptom screening and testing for tuberculosis (i.e., purified protein derivative skin test or interferon-γ release assay blood test), evaluation of HCP ill with potential communicable diseases to provide appropriate treatment and work restrictions, evaluation of HCP after infectious disease exposures for possible postexposure prophylaxis and work restrictions, and education of HCP in infection prevention and control in addition to Occupational Safety and Health Administration (OSHA)-mandated training in the prevention of bloodborne pathogens (BBP), tuberculosis, and COVID-19.

Recommendations for HCP who work in dental healthcare settings, autopsy personnel, and clinical laboratory personnel are addressed elsewhere. ^, ^, In this chapter, we focus on immunizations for HCP working in the United States.

VACCINES RECOMMENDED FOR HEALTHCARE PERSONNEL

General Guidelines

General recommendations regarding vaccination of HCP have been published by the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), ^, ^, the American Academy of Pediatrics, the Association for Professionals in Infection Control and Epidemiology, and infectious disease experts. ^, ^, ^, ^, It is recommended that all HCP be immune to mumps, measles, rubella, varicella, pertussis, influenza, and COVID-19 ( Table 72.1 ). ^, ^, ^, ^, Depending on the vaccine, preventable disease immunity may be assured by several different measures, or assumed based upon receipt of vaccine or completion of series, as applicable. All HCP with potential exposure to blood or body fluids should be immune to hepatitis B. Influenza vaccine should be offered to all HCP yearly. In the past few years, editorials and commentaries have recommended that yearly influenza immunization (unless contraindicated) should be a condition of employment for HCP. Policy statements from professional societies have endorsed the requirement for yearly influenza immunization, including the American Academy of Pediatrics, Association for Professionals in Infection Control, Infectious Diseases Society of America, American College of Physicians, and the Society of Healthcare Epidemiologists of America. ^, In February 2012, the National Vaccine Advisory Committee issued a statement which provided recommendations on how to achieve the Healthy People 2020 annual influenza vaccine coverage goal (i.e., 90%) for HCP; for facilities that have implemented the recommended initial strategies but have “not consistently achieved the Healthy People goal for vaccination coverage of HCP in an efficient and timely manner” it was recommended that they should “strongly consider an employer requirement for influenza immunization.” Some of these policy statements allow HCP to opt out if they sign a declination statement, have religious or personal objections, or agree to wear a facemask while working in a clinical area during influenza season. Detailed recommendations have been published regarding mumps, measles and rubella, varicella, hepatitis B, influenza, Tdap (tetanus toxoid, reduced diphtheria toxoid, acellular pertussis), and COVID-19 vaccines. ^, All HCP should be subject to these recommendations, including personnel with direct patient care responsibilities (e.g., nurses, respiratory technicians, physical therapists, physicians, students and other trainees), personnel without direct patient care responsibilities (e.g., environmental service workers, security), contract workers, volunteers, and emergency medical personnel. HCP should be provided vaccines that are recommended for adults, ^, such as human papillomavirus, herpes zoster, and pneumococcal vaccines, and referred to their local medical provider. In special circumstances, HCP or laboratory personnel should be offered immunization with other vaccines, including polio, ^, quadrivalent (A, C, Y, W135) meningococcal (polysaccharide, conjugate) and meningococcal serogroup B vaccines, ^, rabies, ^, typhoid, hepatitis A, anthrax, vaccinia (smallpox), and Ebola ( Table 72.2 ).

TABLE 72.1

Vaccines Recommended for All Healthcare Personnel ^a : Demonstration of Immunity, Administration, and Major Contraindications and Precautions

Vaccine	Demonstration of Immunity ^b	Administration ^c	Major Contraindications and Precautions ^c
Measles	1. Documented administration of two doses of live measles virus vaccine (MMR) ^d or 2. Laboratory evidence of immunity or laboratory confirmation of disease or 3. Born before 1957 ^e or 4. Physician diagnosed disease with laboratory confirmation	0.5 mL SC, second dose at least 1 month later	History of anaphylaxis to gelatin or neomycin; pregnancy; immunocompromised disorder, ^f recent (<11 months) receipt of antibody-containing blood product; need for tuberculin skin testing in next 4 weeks unless performed simultaneously with vaccine administration; moderate or severe acute illness with or without fever
Mumps	1. Documented administration of two doses of live mumps virus vaccine (MMR) ^d ^, ^g or 2. Laboratory evidence of immunity or laboratory confirmation of disease o r 3. Born before 1957 ^e or 4. Physician diagnosed disease with laboratory confirmation	0.5 mL SC, second dose at least 1 month later	As for measles (above) if provided as MMR
Rubella	1. Documented administration of one dose of live rubella virus vaccine (MMR)e or 2. Laboratory evidence of immunity or laboratory confirmation of disease or 3. Born before 1957 (except women of childbearing age who could become pregnant)f	0.5 mL SC, no additional doses	As for measles (above) if provided as MMR
Varicella	1. Documented receipt of two doses of varicella vaccine or 2. Laboratory evidence of immunity ^h or laboratory confirmation of disease or 3. Physician diagnosed varicella or zoster ⁱ	0.5 mL SC, second dose 4–8 weeks later	History of anaphylaxis to gelatin or neomycin; pregnancy; immunocompromised disorder, ^f recent (<11 months) receipt of antibody containing blood product; moderate or severe acute illness with or without fever
Hepatitis B ^j	Laboratory evidence of immunity unless last dose of series provided >6 months prior to evaluation, prior receipt of complete course of vaccine with appropriate schedule	Recombivax HB® or Engerix-B® 0.5 mL IM at 0, 1, and 6 months; Heplisav-B 0.5 mL at 0 and 1 month ^k	Severe allergic reaction, such as anaphylaxis, after a previous dose of any hepatitis B vaccine or to any vaccine component, including yeast.
Influenza	Yearly immunization needed	See individual vaccines for dose requirementsz	History of anaphylaxis to eggs; LAIV contraindicated in HCP who work with patients housed in a “protected environment,” pregnancy, immunocompromising disorderf or medications, ≥50 years of age (See post-exposure prophylaxis section on influenza vaccine in this chapter for further details.)
Tdap	1 dose Tdap then Td or Tdap recommended every 10 years (Tdap recommended by authors for all HCP)	0.5 mL IM	Progressive or unstable neurologic disorder or progressive encephalopathy, Guillain-Barré syndrome <6 weeks after a previous dose of a tetanus toxoid-containing vaccine, moderate or severe acute illness with or without fever
COVID-19	Receipt of complete COVID-19 vaccine series	Pfizer, 0.3 mL IM with second dose 21 days later; Moderna, 0.5 mL IM with second dose 28 days later; note that for HCP who are moderately to severely immunocompromised the primary vaccination series includes 3 doses of mRNA vaccine, with the third dose 28 days after the second. Johnson & Johnson/Jannsen: 0.5 mL IM x 1	See FDA authorized package inserts; severe reaction to a previous vaccine dose or vaccine constituent

a Healthcare personnel (HCP) are defined as persons who provide healthcare to patients or who work in institutions that provide healthcare (e.g., physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, hospital volunteers, and administrative and support staff in healthcare institutions).

b Written documentation should be required.

c The package insert and Centers for Disease Control and Prevention (CDC)/Advisory Committee on Immunization Practices (ACIP) should always be consulted for specific recommendations regarding indications, storage, administration, precautions, and contraindications. Doses listed are for adults; CDC/ACIP guidelines should be consulted when providing vaccines for children.

d The first dose should be administered on or after the first birthday; the second dose of measles and mumps-containing vaccine should be administered no earlier than 1 month (i.e., a minimum of 28 days) after the first dose. Combined MMR vaccine generally should be used whenever any of its component vaccines is indicated.

e For unvaccinated personnel born before 1957 who lack laboratory evidence of immunity to measles, mumps, and/or rubella or laboratory confirmation of disease, healthcare facilities should consider vaccinating personnel with two doses of MMR vaccine at the appropriate interval (for measles and mumps) or one dose of MMR vaccine (for rubella), respectively. For unvaccinated personnel born before 1957 who lack laboratory evidence of measles, mumps, and/or rubella immunity or laboratory confirmation of disease, healthcare facilities should recommend two doses of MMR vaccine during an outbreak of measles or mumps and one dose during an outbreak of rubella

f Persons immunocompromised because of immune deficiency diseases, human immunodeficiency virus infection, leukemia, lymphoma, or generalized malignancy, or immunosuppressed as a result of therapy with corticosteroids (i.e., >2 mg/kg body weight or 20 mg/day of prednisone for >2 weeks), alkylating drugs, antimetabolites, or radiation. Also see Table 72.2 .

g In cases of outbreaks and with consultation of the local public health department, consider a 3 ^rd dose of mumps (MMR) vaccine

h Commercial assays can be used to assess disease-induced immunity, but they often lack sensitivity to detect vaccine-induced immunity (i.e., they might yield false-negative results).

i Verification of history or diagnosis of typical disease can be provided by any healthcare provider (e.g., a school or occupational clinic nurse, nurse practitioner, physician assistant, or physician). For persons reporting a history of, or reporting with, atypical or mild cases, assessment by a physician or their designee is recommended, and one of the following should be sought: (1) an epidemiologic link to a typical varicella case or to a laboratory-confirmed case or (2) evidence of laboratory confirmation if it was performed at the time of acute disease. When such documentation is lacking, persons should not be considered as having a valid history of disease because other diseases might mimic mild atypical varicella. For persons born during or after 1998, history of disease is no longer considered as evidence of immunity, unless the illness was laboratory confirmed.

j Immunize all healthcare personnel with potential exposure to blood or contaminated body fluids.

k Immunity should be assessed 1–2 months after the last dose in the vaccine series; if not immune, an additional vaccine series should be provided and immunity reassessed; if not immune, test for HBsAg, and if HBsAg is absent, provide hepatitis B immunoglobulin as postexposure prophylaxis when indicated. Immunity is indicated by an anti-HBsAg titer of 10 mIU/mL. FDA, US Food and Drug Administration; HBsAg, hepatitis B surface antigen; HCP, healthcare personnel; IM, intramuscularly; LAIV, live attenuated influenza vaccine; MMR, measles-mumps-rubella; SC, subcutaneously; Tdap, tetanus toxoid, diphtheria toxoid, acellular pertussis.

TABLE 72.2

Vaccines Available Recommended for Select HCP ^a , Indications, Administration, and Major Contraindications and Precautions for Healthcare and Laboratory Personnel in Special Circumstances

Vaccines	Indications ^b	Administration ^b	Major Contraindications and Precautions ^b
Anthrax (AVA)	Laboratory personnel or researchers engaged in work involving production quantities or concentrations of Bacillus anthracis culture or in activities with a high potential for aerosol production. HCP exposed as a result of a biothreat attack.	See CDC/ACIP recommendations for pre-exposure prophylaxis. ^c Postexposure prophylaxis consists of a course of antibiotics PLUS vaccine, 0.5 mL SC at 0, 2, and 4 weeks.	History of anaphylaxis to a previous dose of vaccine or a vaccine component.
Ebola	HCP responding to an outbreak of Ebola virus disease and HCP at federally designated Ebola treatment centers in the United States	Single 1 mL IM dose.	See CDC/ACIP recommendations for vaccine precautions. ^d
Hepatitis A	Not routinely indicated for HCP. May be useful in outbreak settings (administer within 2 weeks of exposure or use Ig 0.02 mL/kg)	1.0 mL IM x 2 or 3 (follow FDA approved package insert for dosing).	History of anaphylaxis to a previous dose of vaccine or a vaccine component. Precautions: pregnancy, moderate or severe illness
Meningococcal quadrivalent (MEN ACWY) and meningococcal serogroup B (MenB)	Clinical and research microbiologists who work routinely with isolates of Neisseria meningitides . Others: HCP with asplenia, persistent complement deficiencies, travel to an endemic area	Microbiologists: One dose of MenACWY-D or MenACWY-CRM or MenACWY-TT; booster (if HCP remains at increased risk), single dose at 5 years after primary vaccination and every 5 years thereafter. PLUS 3 doses of MenB-FH at 0, 1–2, and 6 months or 2 doses MenB-4C > 1 month apart; booster (if HCP remains at risk), single dose at 1yr after completion of primary vaccination and every 2–3 years thereafter (note: MenB-FHbp and MenB-4C are NOT interchangeable)	History of anaphylaxis to a previous dose of vaccine or a vaccine component. Precautions: moderate or severe illness
Pneumococcal	Not routinely recommended for HCP. May be used in an outbreak situation.	See FDA approved package insert	History of anaphylaxis to a previous dose of vaccine or a vaccine component.
Polio (IPV)	Laboratory personnel or researchers who frequently work with polio. HCP who have close contact with patients who may be excreting wild poliovirus, including HCP who travel to work in areas where polioviruses are circulating	Unimmunized adults, 3 doses 0.5 mL IM or SC (0, 4–8 weeks, 6–12 months). Immunized, one dose 0.5 mL IM or SC	History of anaphylaxis to a previous dose of vaccine or a vaccine component. Precautions: pregnancy, moderate or severe illness
Rabies	Laboratory personnel or researchers who work with rabies virus or potentially infected animals; PEP may be required for potential exposure despite primary immunization	Preexposure, HDCV or PCEC 3 1.0 mL IM doses at 0, 7, and 21 or 28 days Postexposure (not previously vaccinated), HDCV or PCEC, 4 1.0 mL IM doses at 0, 3, 7, and 14 days (plus day 28 if immunocompromised) PLUS 1 dose Rabies Immune Globulin 20 IU/kg body weight (infiltrate at bite site, if possible; remainder IM)	History of anaphylaxis to a previous dose of vaccine or a vaccine component
Typhoid	Laboratory personnel or researchers who frequently work with Salmonella Typhi and travelers to endemic areas	Four oral doses (Ty21a; 1 capsule taken every other day) or one 0.5 mL-dose IM (ViCPS). Booster doses per CDC recommendations.	History of anaphylaxis to a previous dose of vaccine or a vaccine component. Ty21a: receipt of antibiotics or antimalarials (delay for >3 days posttherapy). Precautions: pregnancy, immunocompromised (Ty21a)c
JYNNEOS, ACAM2000	HCP or researchers who directly handle cultures or animals contaminated with recombinant vaccinia or orthopox viruses (Monkeypox, cowpox) that infection humans (preexposure prophylaxis), or HCP with high risk exposure to patients with Monkeypox (postexposure prophylaxis); preexposure or postexposure prophylaxis for biothreat use of variola (smallpox)	JYNNEOS vaccine is preferred. JYNNEOS vaccine, two dose subcutaneous; boosters as recommended by CDC – ACAM2000, one dose administered with a bifurcated needle; boosters as recommended by CDC.	JYNNEOS vaccine, anaphylaxis to a prior dose of vaccine or a vaccine component. ACAM2000, discuss with public health authorities prior to administration. Contraindications: pregnancy, immunocompromised state in vaccine recipient or household contact, history of eczema in HCP or family contact, other acute or chronic exfoliative skin conditions.

b The package insert and Centers for Disease Control and Prevention (CDC)/Advisory Committee on Immunization Practices (ACIP) should always be consulted for specific recommendations regarding indications, storage, administration, precautions, and contraindications. Doses listed are for adults; CDC/ACIP guidelines should be consulted when providing vaccines for children. ACIP, Advisory Committee on Immunization Practices; AVA, anthrax vaccine absorbed; CDC, Centers for Disease Control and Prevention; HCP, healthcare personnel; HDCV, human diploid cell vaccine; HRIG, human rabies immunoglobulin; Ig, immunoglobulin; IM, intramuscular; IND, investigational new drug; IPV, inactivated polio vaccine; PCEC, purified chick embryo cell vaccine; PEP, postexposure prophylaxis; SC, subcutaneous; ViCPS, Vi capsular polysaccharide.

Immunocompromised HCP

Immunocompromised HCP require special consideration in the provision of immunizations ( Table 72.3 ). ^, ^, ^, First, live virus vaccines (e.g., measles-mumps-rubella [MMR], varicella, live attenuated influenza) may be contraindicated. Second, vaccines not routinely recommended for HCP may be indicated (e.g., pneumococcal, meningococcal, Haemophilus influenzae type b). Third, higher antigen doses (e.g., hepatitis B vaccine in people with end-stage renal disease), additional doses of vaccine (e.g., rabies vaccine in immunocompromised persons), or postimmunization serologic evaluation may be indicated (e.g., anti-hepatitis B surface antigen titer after hepatitis B vaccine, antibody response to rabies vaccine) because immunization of immunocompromised people may elicit a lower antibody response. Finally, such personnel should be individually evaluated for reassignment (with the consent of the employee) depending on their job duties. Of importance, caring for an immunocompromised patient is not a contraindication to receipt of a live attenuated vaccine, although HCP receiving live attenuated influenza vaccine should not work in a protected environment (i.e., stem cell transplant unit) for 7 days postimmunization. ^,

Table 72.3

Recommended Adult Immunizations by Medical Condition and Other Indications, US, 2021 ^a

Vaccine	Pregnancy	Immunocompromised (excluding HIV infection)	HIV infectionCD4 count		Asplenia, complement deficiencies	End-stage renal disease; or on hemodialysis	Heart or lung disease, alcoholism1	Chronic liver disease	Diabetes	Health care personnel2	Man who have sex with men
Vaccine	Pregnancy	Immunocompromised (excluding HIV infection)	<200 mm3	≥200 mm3	Asplenia, complement deficiencies	End-stage renal disease; or on hemodialysis	Heart or lung disease, alcoholism1	Chronic liver disease	Diabetes	Health care personnel2	Man who have sex with men
IIV or RIV4	1 dose annually
LAIV4	Nor Recommended					Precaution				1 dose annually
Tdap or Td	1 dose Tdap each pregnancy	1 dose Tdap, then Td or Tdap booster every 10 years
MMR	NotRecommended*	Nor Recommended		1 or 2 doses depending on indication
VAR	NotRecommended*	Nor Recommended			2 doses
RZV					2 doses at age ≥50 years
HPV	NotRecommended*	3 doses through age 26 years			2 or 3 doses through age 26 years depending on age at initial vaccination or condition
PCV13
PPSV23
HepA
HepB									<60 years
HepB									≥60 years
MenACWY
MenB	Precaution
Hib		3 doses HSCT3recipients only
Recommended vaccination for adults who meet age requirement, lack documentation of vaccination, or lack evidence of past infection		Recommended vaccination for adults with an additional risk factor or another indication		Precaution—vaccination might be indicated if benefit of protection outweighs risk of adverse reaction		Recommended vaccination based on shared clinical decision-making		Not recommended/contraindicated—vaccine should not be administered. * Vaccinate after pregnancy.		No recommendation/Not applicable

1. Precaution for LAIV4 does not apply to alcoholism. 2. See notes for influenza; hepatitis B; measles, mumps, and rubella; and varicella vaccinations. 3. Hematopoietic stem cell transplant.

a Advisory Committee on Immunization Practices. Note that details regarding optimizing use of vaccines are available. See ACIP https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html

Pregnant HCP

Pregnant HCP also require special consideration in the provision of immunizations. The risks from immunization during pregnancy are largely theoretical. The benefit of immunization among pregnant women usually outweighs the potential risks for adverse reactions, especially when the risk for disease exposure is high, or infection would pose a special risk to the mother or fetus, or the vaccine is unlikely to cause harm. ^, ^, Furthermore, data continue to accrue confirming the safety of vaccines given inadvertently during pregnancy. Ideally, women of childbearing age, including HCP, should have been immunized against measles, mumps, rubella, varicella, tetanus, diphtheria, pertussis, meningococcus, polio, hepatitis A, and hepatitis B as children or adolescents before becoming pregnant. However, because this may not have occurred, it is especially important that all HCP be screened for rubella immunity (by serology because history is often unreliable) because of the consequences of infection for the developing fetus. Nevertheless, attenuated vaccines (mumps, measles, rubella, and varicella) or live attenuated influenza vaccine should be provided only to nonpregnant HCP and deferred for pregnant women. The ACIP has recommended that Tdap be administered during all pregnancies, preferably after 20 weeks’ gestation, during weeks 27–36. If not administered during pregnancy, Tdap should be administered immediately postpartum. Women who are pregnant during respiratory virus season should receive inactivated influenza immunization. ^, ^, There is no convincing evidence of risk from immunizing pregnant women with other inactivated virus or bacterial vaccines, or toxoids. Susceptible pregnant women at high risk for specific infections should receive, as indicated, the following vaccines: hepatitis A, hepatitis B, pneumococcal polysaccharide, meningococcal, rabies, and poliovirus (inactivated). In addition, pregnant and lactating HCP should be offered the COVID-19 vaccine (although they may wish to discuss the pros and cons of receiving a COVID-19 vaccine with their health care provider). ^, Several vaccines or immunoglobulins (Igs) are recommended as part of postexposure prophylaxis, including hepatitis A (Ig), hepatitis B immunoglobulin (HBIG), and rabies immunoglobulin (RIG). The indications for use are the same in pregnant and nonpregnant women. Pregnant women should be immunized with meningococcal vaccine when there is a substantial risk of infection, such as during epidemics. Breastfeeding does not adversely affect the response to immunization and is not a contraindication for any of the currently routinely recommended vaccines.

Underlying Conditions and Contraindications to Immunization

Before the administration of any vaccine, the HCP should be evaluated for the presence of condition(s) that are listed as a vaccine contraindication or precaution. If such a condition is present, the risks and benefits of vaccination need to be carefully weighed by the healthcare provider and the HCP. The most common contraindication is a history of an anaphylactic reaction to a previous dose of the vaccine or to a vaccine component. Factors that are not contraindications to immunization include the following: household contact with a pregnant woman; breastfeeding; reaction to a previous vaccination, consisting only of mild to moderate local tenderness, swelling, or both, or a fever of less than 40.5°C; mild acute illness with or without low-grade fever; current antimicrobial therapy (except for oral typhoid vaccine) or convalescence from a recent illness; personal history of allergies except a history of an anaphylactic reaction to a vaccine component (e.g., people with a history of anaphylaxis to neomycin should not receive the MMR vaccine); and family history of allergies, serious adverse reactions to vaccination, or seizures.

Postexposure Prophylaxis

All HCP potentially exposed to a communicable disease should be evaluated by the institution’s occupational health service as soon as possible to determine if an exposure has occurred and to establish a plan for management. General guidelines for a postexposure evaluation of HCP have been published. ^, ^, ^, In brief, the following steps should be undertaken:

Confirm that the source has a communicable disease.
Determine that potential transmission could have taken place (e.g., close contact for transmission of Neisseria meningitidis or Bordetella pertussis ).
Determine that the exposed HCP was not protected by the use of personal protective equipment (e.g., N-95 respirator for airborne transmitted diseases).
Determine that the exposed HCP is susceptible to infection (this may require laboratory evaluation).
Determine if effective postexposure prophylaxis is available and recommended.
Determine that the HCP has no contraindications to use of the recommended prophylaxis.
If the HCP has a contraindication to the recommended prophylaxis, determine if an alternative exists and is safe to use.
Inform the HCP of the risk of disease transmission, signs and symptoms of infection, and risks and benefits of prophylaxis.
Obtain informed consent for prophylaxis, if indicated
Obtain baseline laboratory tests, if indicated (e.g., anti-hepatitis B surface antigen [anti-HBsAg] titer).
Assess whether the HCP’s work activities should be restricted, including furlough
Arrange follow-up evaluations.

Vaccines that may be indicated for postexposure prophylaxis include tetanus toxoid (Tdap preferred), hepatitis B, and rabies ( Tables 72.4 and 72.5 ). The CDC states that “unvaccinated HCP who have no other evidence of immunity and who are exposed to varicella-zoster virus (VZV; varicella, disseminated herpes zoster, and uncovered lesions of a localized herpes zoster) are potentially infective from days 8 to 21 after exposure and should be furloughed during this period. They should receive postexposure vaccination as soon as possible. Vaccination within 3–5 days of exposure to rash might modify the disease if infection occurred. Vaccination more than 5 days postexposure is still indicated because it induces protection against subsequent exposures (if the current exposure did not cause infection).” HCP who have received one dose of vaccine and who are exposed to VZV (varicella, disseminated herpes zoster, and uncovered lesions of a localized herpes zoster in the community or healthcare setting/workplace) should receive the second dose within 3–5 days after exposure to rash (provided 4 weeks have elapsed after the first dose).

TABLE 72.4

Postexposure Prophylaxis for Vaccine-Preventable Diseases

Disease	Definition of Exposure	Prophylaxis ^a	Comments
Hepatitis A	Ingestion of contaminated food; contact with feces from a hepatitis A-infected patient	GammaSTAN human immune globulin 0.1 mL/kg IM within 2 weeks of exposure PLUS 1 dose of hepatitis A vaccine ^b	Vaccine and IG should be administered simultaneously in a different anatomic site (e.g., separate limbs).
Hepatitis B	Contact with HBsAg-positive blood (or body fluid) via percutaneous, mucous membrane, or nonintact skin exposure	See Table 72.5	HCP who have completed a full course of a hepatitis B vaccine and ever demonstrated an anti-HBsAg titer ≥10 mIU/mL do not require postexposure prophylaxis
Influenza A or B	Cohabiting confined air space or face-to-face contact in an open area (nonimmunized HCP)	Zanamivir 10 mg by inhaler once daily or oseltamivir 75 mg orally once daily may be used; both for 7 days or baloxavir one oral dose (weight <40 kg: 40 mg: weights >80 kg: 80 mg)	Zanamivir, avoid if asthmatic; Oseltamivir, associated with gastrointestinal toxicity (≈5–10%)
Measles ^c	Cohabiting confined air space or face-to-face contact in an open area (nonimmune HCP)	Susceptible HCP should receive immunoglobulin 0.50 mL/kg (maximum 15 mL) IM or IV within 6 days of exposure or measles vaccine	Susceptible HCP should be furloughed from days 5–21 postexposure or for 7 days after the rash appears
Meningococcus (invasive) ^c	Direct contact with respiratory secretions (e.g., resuscitating intubating, or closely examining the oropharynx) of infected persons with invasive disease (sepsis, meningitis)	Ciprofloxacin, 1 dose 500 mg orally; ceftriaxone 1 dose 250 mg IM; rifampin, 600 mg orally every 12 hours for 2 days (4 doses); azithromycin 1 dose 500 mg orally (not recommended routinely). Avoid ciprofloxacin if resistant strains reported in the community	Home contacts of exposed HCP do not need to receive prophylaxis unless the HCP develops infection; rifampin and ciprofloxacin not recommended in pregnancy
Pertussis ^c	Direct contact with respiratory secretions or droplets from the respiratory tract of infected persons	Exposed HCP should receive azithromycin orally (500 mg day 1, 250 mg days 2–5) or trimethoprim-sulfamethoxazole orally 1 tablet bid for 14 days	Other acceptable alternatives are erythromycin (14 days) and clarithromycin (7 days)
Varicella ^cc	Cohabiting confined air space or face-to-face contact in an open area with a patient with active lesions or within 48 hours before the development of lesions (nonimmune HCP)	For susceptible employees, VariZIG 125 U/10 kg IM (maximum dose 625U) is indicated for immunocompromised or pregnant adults (within 10 days of exposure but it should be administered as soon as possible after exposure)	Susceptible employees should be furloughed from days 8–21 postexposure (employees who receive VariZIG should be furloughed from days 8–28 postexposure)
Zoster ^c	Cohabiting confined air space or face-to-face contact in an open area with a patient with uncovered active lesions (disseminated zoster or immunocompromised patient) (nonimmune HCP)	As for varicella	Same as varicella exposure

a The latest guidelines from the Centers for Disease Control and Prevention should always be consulted.

b A second dose of HepA vaccine is not required for postexposure prophylaxis; however, for long-term immunity, the vaccination series should be completed with a second dose at least 6 months after the first dose.

c HCP who was wearing a mask (surgical facemask or N-95 respirator) is not considered exposed. bid, Twice a day; HBsAg, hepatitis B surface antigen; HCP, healthcare personnel; Ig, immunoglobulin; IM, intramuscular; MMR, measles, mumps, and rubella; VariZIG varicella-zoster immunoglobulin.

Table 72.5

Postexposure Management of Healthcare Personnel After Occupational Percutaneous or Mucosal Exposure to Blood or Body Fluids, by healthcare Personnel HepB vaccination and response status

	Postexposure Testing		Postexposure prophylaxis
HCP Status	Source Patient (HBsAg)	HCP Testing (Anti-HBs)	HBIG	Vaccination	Postvaccination Serologic Testing
Documented responder after complete series			No action needed
Documented nonresponder after two complete series	Positive/Unknown Negative	– ^a	HBIG x 2, separated by 1 month	–	N/A
Documented nonresponder after two complete series	Positive/Unknown Negative	– ^a	No action needed		N/A
Response unknown after complete series	Positive/Unknown Negative Any result	<10 mIU/mL <10 mIU/mL > 10 mIU/mL	HBIG x 1 None	Initiate revaccinationInitiate revaccination	YesYes
Response unknown after complete series	Positive/Unknown Negative Any result	<10 mIU/mL <10 mIU/mL > 10 mIU/mL	No action needed		YesYes
Unvaccinated/incompletely vaccinated or vaccine refusers	Positive/unknown Negative	– –	HBIG x 1 None	Complete vaccination Complete vaccination	Yes Yes

anti-HBs, antibody to hepatitis B surface antigen; HBIG, hepatitis B immune globulin; HBsAg, hepatitis B surface antigen; HCP, healthcare personnel; N/A = not applicable.

a Not indicated.

The ACIP now recommends that for healthy persons 12 months to 40 years of age, single-antigen hepatitis A vaccine at the age-appropriate dose is preferred to immunoglobulin for postexposure prophylaxis for persons exposed to hepatitis A virus because of vaccine advantages that include long-term protection and ease of administration. Currently, there are no data regarding the relative efficacy of vaccine compared with immunoglobulin postexposure prophylaxis for persons older than 40 years of age or for those with underlying medical conditions; consequently, the ACIP states that decisions to use vaccine or immunoglobulin should take into account patient characteristics associated with severe manifestations of hepatitis A, including older age and chronic liver disease. Several vaccines have been provided to persons without known direct exposure to an infected case to help contain community-wide or institutional transmission events and outbreaks, including hepatitis A, meningococcal vaccine, and pertussis vaccine. Immunoglobulin preparations may be indicated as part of postexposure prophylaxis for exposure to hepatitis A (immunoglobulin), hepatitis B (HBIG), measles (immunoglobulin), rabies (RIG), tetanus (tetanus immunoglobulin), varicella (varicella-zoster immunoglobulin [VariZIG]), and vaccinia immunoglobulin). All HCP who are exposed to a communicable disease or with symptoms of an infectious disease should be evaluated with the consideration of whether work restriction or furlough is required to reduce the risk of exposure to others in the healthcare facility ( Table 72.6 ).

Table 72.6

Healthcare Personnel ^a Work Restrictions for Vaccine Preventable Diseases

Disease	Work Restriction	Duration
Hepatitis A	Relieve from direct patient contact and food handling	Until 7 days after onset of jaundice
Hepatitis B, acute	Relieve from direct patient contact	Until jaundice resolves
Hepatitis B, chronic	No restriction unless demonstrated to transmit infection to patients or unable to practice appropriate infection prevention. Restrictions should be considered by SHEA guideline for personnel performing invasive procedures	Counsel regarding need to follow standard precautions. Periodic reevaluation per SHEA guideline.
Influenza A and B	Furlough from healthcare facility	Until fever resolves off antipyretics or 5 days (whichever is longer)
Measles, Active	Furlough from healthcare facility	Until 4 days after rash appears
Measles, Postexposure (susceptible HCP)	Furlough from healthcare facility	From the 5th day after the first exposure through the 21st day after the last exposure or 4 days after the rash appears
Mumps, Active	Furlough from healthcare facility	Until 9 days after onset of parotitis
Mumps, Postexposure (susceptible HCP)	Furlough from healthcare facility	From the 12th day after the first exposure through the 26th day after the last exposure or 9 days after the onset of parotitis
Pertussis, Active	Furlough from healthcare facility	From the beginning of the catarrhal stage through the third week after the onset of paroxysms or until 5 days after start of effective antimicrobial therapy
Pertussis, Postexposure (asymptomatic) ^b	No restriction, if on prophylactic antimicrobial therapy	—
Pertussis, Postexposure (symptomatic) ^b	Furlough from healthcare facility	Same as active pertussis
Rubella, Active	Furlough from healthcare facility	Until 5 days after rash appears
Rubella, Postexposure (susceptible)	Furlough from healthcare facility	From the 7th day after the first exposure through the 21st day after the last exposure or 5–7 days after the rash appears
Varicella, Active	Furlough from healthcare facility	Until the lesions are dried and crusted
Varicella, Postexposure (susceptible personnel)	Furlough from healthcare facility	From the 8th day after the first exposure through the 21st day (28th day if VariZIG given) after the last exposure or if varicella occurs, until all lesions are dried and crusted
Zoster, Localized (nonexposed area of skin); in a normal host)	Cover lesions; relieve from care of immunocompromised patients	Until the lesions are dried and crusted
Zoster, Localized Localized (exposed area of the skin); localized in immunocompromised host; generalized	Furlough from healthcare facility	Until the lesions are dried and crusted
Zoster, Postexposure (susceptible personnel)	Furlough from healthcare facility	From the 8th day after the first exposure through the 21st day (28th day if VariZIG given) after the last exposure or if varicella occurs, until all lesions are dried and crusted
COVID-19	Follow recommendations of Centers for Disease Control and Prevention	Follow CDC recommendations

b Provide antibiotic prophylaxis or therapy regardless of pertussis vaccine status

Postexposure Prophylaxis for Bioterrorism Agents

Before the intentional release of anthrax in the United States in 2001, several publications highlighted the concern about the potential for biologic terrorism, and recognition of the need to ensure preparedness since the 2001 attacks could continue. The CDC has categorized several agents as “high priority” because they can be easily disseminated or transmitted person-to-person, cause high morbidity and mortality, have limited therapeutic options, and are likely to cause public panic and social disruption. These agents include Bacillus anthracis (anthrax), Yersinia pestis (plague), variola major (smallpox), Clostridium botulinum toxin (botulism), Francisella tularensis (tularemia), filoviruses (Ebola virus disease, Marburg disease), and arenaviruses (Lassa [Lassa hemorrhagic fever], Junin [Argentine hemorrhagic fever], and related viruses). Characteristics of these high-priority agents include the following: they are infectious via aerosol (i.e., infections transmitted by exhaled infectious particles; subdivided into “droplet” (<6 feet) and “airborne” ( > 6 feet) transmission by CDC depending on the primary distance of transmission), the organisms are fairly stable in aerosol form, there are susceptible civilian populations, infection is associated with high morbidity and mortality, several exhibit person-to-person transmission (i.e., cutaneous anthrax, pneumonic plague, smallpox, and Ebola, Marburg, Lassa, and Junin viruses), they are difficult to diagnose and/or treat, and most have previously been developed as biologic weapons. General reviews of bioterrorist agents have been published, ^, as well as detailed management recommendations for anthrax, botulism, plague, smallpox, tularemia, and viral hemorrhagic fever.

Key aspects of the management of patients infected with bioterrorism agents include decontamination before medical evaluation, appropriate implementation of Standard and Transmission-based precautions, rapid diagnosis with appropriate therapy, appropriate management of patient generated medical waste and handling of laboratory specimens (as indicated), and postexposure prophylaxis of exposed persons, as indicated. HCP may be exposed and acquire infection from patients via contaminated clothes (i.e., smallpox, Q fever, plague, and anthrax) or via patient-to-HCP transmission. In the event of an attack with mass casualties and widespread exposures, vaccines likely will play an important adjunctive role in limiting the impact of anthrax and the critical role in containing smallpox. Currently preexposure use of anthrax vaccine is recommended only for laboratory workers or researchers at risk for anthrax exposure (see Table 72.2 ). Vaccinia vaccine is effective as postexposure prophylaxis after smallpox exposure when used within 4 days. If vaccines now in development for bioterrorist agents (e.g., vaccines for C. botulinum, F. tularensis, Y. pestis ) become available, HCP may be included in both preexposure and postexposure recommendations.

PROVIDING VACCINES FOR HEALTHCARE PERSONNEL

All HCP should be screened for immunity to vaccine-preventable diseases at the time of hire. HCP should be appropriately immunized based on the occupational health evaluation. In general, serologic screening for immunity before immunization is neither necessary nor cost-effective. Each healthcare facility, however, needs to evaluate the cost-effectiveness of screening. Factors that determine the effectiveness of serologically screening HCP for immunity include the cost of the screening test, the cost of the vaccine, and the prevalence of immunity in the population. The prevalence of immunity in the population likely depends on age, gender, race, place of birth, and socioeconomic status. In addition, the sensitivity and specificity of the screening test must be considered.

The immunization status of all HCP should be recorded in their medical record, which should be maintained by the institution’s occupational health service. HCP should be provided the CDC Vaccine Information Statements, and this noted in the medical record. When vaccines are provided, appropriate information should be recorded in the HCP’s medical record ( Box 72.1 ). All institutions should develop a readily available HCP medical record that includes the HCP immune status to vaccine-preventable diseases.

Box 72.1

Information That Should Be Obtained When Providing Vaccines to Healthcare Personnel ^a

Name
Identification number
Date of birth or age
Date of immunization
Potential contraindications to vaccine:
Anaphylaxis to a previous dose of vaccine
Allergy to vaccine constituent
For live attenuated vaccines: pregnancy, immunocompromising conditions/medications
Vaccine-specific contraindications
Vaccine provided
Name of vaccine manufacturer
Lot number of vaccine
Site of immunization
Route of immunization
Date for additional immunizations (if required)
Complications (if any)
Name of person providing vaccine
Medical record note should include that HCP was provided the required Vaccine Information Statement (available at: https://www.cdc.gov/vaccines/hcp/vis/current-vis.html )

^a Healthcare personnel (HCP) are defined as persons who provide healthcare to patients or who work in institutions that provide healthcare (e.g., physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, hospital volunteers, and administrative and support staff in healthcare institutions).

IMPROVING VACCINE COVERAGE OF HEALTHCARE PERSONNEL

Despite strong recommendations from the CDC and professional organizations that HCP in the United States be immune to vaccine-preventable diseases, studies continue to demonstrate that substantial numbers of HCP lacked evidence of immunity to these diseases and that many HCP refuse immunization. The proportion of U.S. HCP with direct patient care that have received vaccine has been reported as the following: hepatitis B, 75.3% (2018), Tdap, 60.2% (2018), and influenza, 80.6% (2019–20 season). Coverage for all three vaccines was higher in HCP with direct versus without direct patient care responsibilities. By occupation, influenza vaccine coverage was highest among physicians (96.7%), nurses (91.8%), pharmacists (91.5%), nurse practitioners/physician assistants (91.0%), and other clinical professionals (85.8%). Influenza vaccine coverage was lowest among administrative and nonclinical support HCP (75.5%) and assistants or aides (72.5%). By work setting, influenza vaccine coverage was highest among HCP working in hospitals (93.2%) and lowest among HCP working in long-term care facilities (69.3%). Serologic studies of hospital-based HCP indicate that 2–9% of those born before 1957 lack antibodies to measles virus. Although most U.S. schools training nurses and physicians required immunity to MMR and hepatitis B (i.e., >95%), less require immunity to varicella (physicians, >95%; registered nurses, ∼90%), and even less to Tdap (∼89%), and influenza (<20%). Schools training allied HCP (e.g., occupational therapists) less often require immunity to vaccine-preventable diseases. Vaccination policies in other areas of the world, such as Europe, are less likely than the United States to require or recommend immunity to vaccine-preventable diseases for HCP. A recent review of vaccine coverage of HCP which focused on influenza and hepatitis B vaccine coverage around the world reported, in general, very low rates of coverage.

Barriers to receiving influenza vaccine commonly reported by HCP have included desire to avoid medications, inconvenient vaccine administration, concern about side effects, belief that influenza can be caused by the vaccine, belief that they are at low risk of infection, doubt that influenza is a serious disease, and belief that the vaccine is ineffective. Similar concerns are voiced about hepatitis B vaccine, including the desire to avoid medications, perception that the HCP is at low risk for occupationally acquired hepatitis B virus (HBV) infection, and concern about side effects. Barriers to acceptance of influenza vaccine and measures to improve influenza vaccine compliance among HCP have been reviewed. Interventions that have been demonstrated to improve vaccine uptake have included the use of mobile carts, ^, incentive programs, educational campaigns that focus on the seriousness of influenza and address misconceptions about the vaccine, providing vaccine at multiple sites and on the wards, and weekly feedback to the HCP. An analysis of 50 hospitals during the 2007–2008 influenza season revealed that programs with the following components had significantly higher vaccination rates: weekend provision of vaccine, report of vaccination rates to administrators or board of trustees, a letter sent to HCP emphasizing the importance of vaccination, and any form of visible leadership support. The use of a signed declination form for HCP who refuse vaccination was not associated with an improved frequency of influenza immunization, and although some studies have demonstrated that the use of a signed declination form was associated with improved influenza coverage among HCP, a systematic review found only “modest” benefit. As noted above, multiple professional organizations have endorsed the position that employment for HCP should be conditional on receipt (unless contraindicated) of influenza vaccine. A systematic review of mandatory influenza vaccine for HCP reviewed eight observational studies; influenza vaccine rates in all studies exceeded 94%. The National Vaccine Advisory Committee statement provides an excellent summary of strategies for improving influenza coverage of HCP.

Barriers to receiving COVID-19 vaccines and how to improve coverage have been reviewed.

RECOMMENDATIONS FOR THE USE OF SELECTED VACCINES

Measles-Mumps-Rubella Vaccine

Epidemiology

The incidence of mumps, measles, and rubella has decreased dramatically since the widespread use of MMR vaccine. Cases reported to the CDC in 2019 were as follows: mumps, 3780 (0.07 per 100,000 population); measles, 1282 (0.02 per 100,000 population) of which ∼7.0% were imported; rubella six cases, and congenital rubella, one case The number of measles cases in the United States in 2019 was the greatest since 1992. The majority of cases were among people who were not vaccinated against measles. The cases reported for 2021 (mumps: 144, measles 47, rubella 6) and as of 29 October 2022 (mumps: 220, measles 35, rubella 8) are much lower than those reported in 2019. This likely reflects the impact of COVID-19 mitigation strategies (e.g., closure of day care centers, masking, physical distancing, etc.) and potentially decreased surveillance. In any given year, major reasons for U.S. cases are an increase in the number of travelers who acquire measles abroad and bring it into the United States, and/or further spread of measles in U.S. communities from foreign introductions within domestic pockets of unvaccinated people. All three diseases represent an important health hazard for HCP for the following reasons. First, all three are transmitted by the droplet route (measles is also transmitted by the airborne route). Second, in all three diseases, persons become infectious before developing a clinically recognizable illness. Third, a history of prior disease may be unreliable for determining whether HCP actually suffered a vaccine-preventable disease in the past. Hence, many unimmunized HCPs may falsely believe themselves immune.

Rubella is of special concern because of its ability to cause congenital abnormalities in up to 90% of women with confirmed infection in the first trimester of pregnancy and a substantial proportion of HCP are females of childbearing age. Infants with congenital rubella may be contagious until they are at least 1 year old and therefore can expose HCP.

Lessons From Nosocomial Transmission Events

Nosocomial transmission of mumps has been reported infrequently, but transmission from patient-to-patient ^, ^, ^, and from patient-to-HCP has been reported. ^, In one case, it was suggested that an asymptomatically infected nurse introduced mumps into a children’s hospital. Community outbreaks have led to nosocomial exposures. For example, during the widespread epidemic of mumps in Tennessee from 1986 to 1987, six HCP in three different hospitals developed mumps after nosocomial exposure. Men, including male HCP, are at higher risk of complications from mumps (such as orchitis) than are children. Orchitis has been reported among male HCP who developed mumps as a result of healthcare exposure. Because of the potential for nosocomial transmission of mumps, the ACIP now recommends that HCP receive two doses of MMR vaccine.

Nosocomial measles is well documented in the literature and may contribute to propagation of community outbreaks. ^, ^, ^, ^, Analyses of measles cases reported to the CDC revealed acquisition in a medical setting for 241 people (1.1% of all cases) between 1980 and 1984 ¹⁶⁷ and for 1,209 people (3.5% of all cases) between 1985 and 1989. Investigations of individual outbreaks, however, have reported that 17–59% of cases were acquired in a medical setting. ^, ^, ^, ^, ^, ^, ^, ^, ^, Acquisition of measles has occurred in outpatient settings, including emergency departments and physician offices, and has involved patient-to-patient, patient-to-HCP, and HCP-to-patient transmission. In one community outbreak, the relative risk of measles in HCP compared to community adults was 18.6. Transmission in the outpatient setting has occurred even though the index/source cases had left the waiting or examination room up to 75 minutes earlier. ^, ^, ^, ^, ^, Case-control studies have demonstrated that persons who visited an emergency department had a 4.9-fold to 5.2-fold higher risk of developing measles one incubation period later compared with those who did not have such visits during a time when measles was circulating in the community. In inpatient settings, transmission has occurred between patients, from patients to HCP, and from infected HCP to patients. Nosocomial outbreaks have led to hospitalization of infected HCP, ^, ^, severe complications in infected patients, and, occasionally, death of patients. ^, ^, Healthcare environments can amplify transmission, with multiple generations of nosocomial cases arising from single transmission events. The cost of controlling single past outbreaks has been reported to range from US$28,000 to more than US$100,000. ^, As noted above, although measles is an uncommon disease, there have been an increased number of cases in recent years often import-related and propagated by unimmunized or under-immunized persons.

There has been no documented transmission of rubella to HCP or other HCP or patients in U.S. healthcare facilities since the elimination of rubella was announced in 2004. However, as with mumps and measles, nosocomial rubella is well documented in the literature. Sources of rubella infection have included not only persons with acute infection, but also infants with congenital rubella. ^, ^, Healthcare-acquired infection of pregnant HCP has led to the termination of pregnancy. ^,

Several valuable lessons have been learned from the outbreaks. First, it appears that mumps and rubella are acquired mainly via droplet transmission. Measles, however, may be acquired via airborne transmission. Furthermore, measles transmission may occur for more than an hour after an infected case has left an enclosed area. Second, history of prior disease is unreliable for determining whether HCP actually contracted measles in the past, and hence many HCP falsely believe they are immune from past illness and fail to take appropriate precautions. Third, failure to institute a mandatory program requiring immunity results in a subpopulation of susceptible HCP capable of propagating epidemics. In multiple outbreaks, three to more than five generations of disease transmission occurred. Fourth, the cost of outbreaks for these diseases is high in both monetary terms and human suffering. Fifth, patients with congenital rubella are capable of transmitting rubella to susceptible adults.

Preexposure Prophylaxis

All HCP should be immune to mumps, measles, and rubella. Immunity may be demonstrated by meeting one of the following criteria: (a) birth before 1957 (rubella except women with childbearing potential who could become pregnant, although pregnancy in this age group would be exceedingly rare), (b) laboratory evidence of immunity (persons with indeterminate levels are considered susceptible), (c) laboratory confirmation of disease, or (d) evidence of appropriate immunizations (see Table 72.1 ). ^, Physician-diagnosed disease is no longer considered adequate evidence of immunity. Appropriate immunization consists of documented administration of two doses of live measles virus vaccine, two doses of live mumps virus vaccine, and one dose of live rubella virus vaccine (use of MMR is preferred). Birth before 1957 provides only presumptive evidence of immunity to measles, mumps, and rubella, although more than 95% of newly hired HCP born prior to 1957 will demonstrate serologic immunity. For unvaccinated HCP born before 1957 who lack laboratory evidence of measles, mumps, and/or rubella immunity or laboratory confirmation of disease, the ACIP recommends that healthcare facilities should consider vaccinating personnel with two doses of MMR vaccine at the appropriate interval (for measles and mumps) and one dose of MMR vaccine (for rubella), respectively. If a healthcare facility chooses not to assure immunity of HCP born before 1957 to mumps, measles, and rubella, the ACIP states that healthcare facilities should recommend two doses of MMR vaccine during an outbreak of measles or mumps and one dose during an outbreak of rubella. The American Academy of Pediatrics recommends that all HCP, including those born before 1957 who lack serologic evidence of immunity to rubella, be immunized regardless of gender. The American Academy of Pediatrics also states that healthcare facilities should consider recommending two doses of MMR for HCP born before 1957 without other evidence of immunity to mumps or measles. The provision of a third dose of mumps vaccine (MMR) may be considered as part of outbreak control with consultation of the local public health department.

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