Occupational Health Update: Approach to Evaluation of Health Care Personnel and Preexposure Prophylaxis.

An effective occupational health program is a key aspect of preventing exposure to infectious agents and subsequent infection, as well as evaluation and management of postexposure prophylaxis and infections in health care personnel (HCP) by educating HCP regarding proper handling of sharps, early identification and isolation of potentially infectious patients, implementation of standard and transmission-based precautions, and offering counseling of HCP regarding nonroutine prophylaxis. Occupational health services (OHS) must also apply standardized processes for determining when exposures have occurred and providing appropriate management, and provide immediate availability of a medical evaluation following a nonprotected exposure to an infectious disease.

Key points

Health care personnel (HCP) are at risk of exposure to infectious agents depending on their job duties and other factors.

Effective occupational health services (OHS) programs are a key aspect of preventing exposure to infectious agents and subsequent infection.

HCP must be educated on proper handling of sharps, early identification and isolation of potentially infectious patients, and implementation of standard and transmission-based precautions, including hand hygiene.

OHS must ensure immunity to vaccine-preventable diseases.

Risks to health care personnel and the role of occupational health services

Health care is one of the fastest-growing sectors of the US economy, employing more than 20 million persons. , Health care personnel (HCP) face a range of noninfectious hazards on the job, including back injuries, strains and sprains, latex allergy, violence, and stress. HCP are at risk of exposure to infectious agents depending on their job duties and other factors. Risks include percutaneous exposure to blood-borne pathogens (BBP) via sharp injuries (eg, human immunodeficiency virus [HIV], hepatitis B virus [HBV], hepatitis C virus HCV]); exposure by direct contact, droplet, or airborne-transmitted pathogens through direct patient care (eg, pertussis, meningococcal infections, tuberculosis); and indirect contact through transmission related to the contaminated health care environment (eg, Clostridioides difficile). Cases of nonfatal occupational injury and illness among HCP are among the highest of any industrial sector. Approaches to preventing occupational acquisition of infection by HCP have been reviewed, and include implementation of the Hierarchy of Controls to assess implementation of feasible and effective control solutions.4, 5, 6, 7 The Hierarchy of Controls (Fig. 1 ), developed by the National Institute of Occupational Health and Safety (NIOSH), is a framework to assess the effectiveness of interventions to reduce hazards in the workplace and the risks of injury or illness.

Fig. 1

The hierarchy of controls. Interventions at the top of the hierarchy can potentially be more effective than those at the bottom. Elimination and substitution strategies are highly effective but can be difficult to implement. An example of an effective elimination strategy is vaccination. Engineering controls are designed to remove a hazard before the hazard comes in contact with the worker. Use of airborne infection isolation rooms for airborne diseases such as measles is an example of engineering controls. Administrative controls, such as symptom screening of visitors, patients, and HCP, can be challenging to maintain over time. Use of personal protective equipment (PPE), although highly effective when used correctly and consistently, requires effort by HCP to achieve protection.

Minimizing the risk of communicable disease acquisition is based on 6 key recommended practices: (1) proper training of HCP at initiation of health care practice and annually (eg, infection prevention practices, sharp injury prevention, no eating or drinking in areas where care is delivered); (2) ensuring immunity to vaccine-preventable diseases , , , 9, 10, 11; (3) evaluation of HCP who were exposed to communicable diseases for receipt of postexposure prophylaxis (PEP) , , 12, 13, 14; (4) adherence to standard precautions when providing patient care, especially the performance of appropriate hand hygiene before and after patient care16, 17, 18; (5) rapid institution of appropriate transmission-based precautions for patients with a known or suspected communicable disease as part of the identify-isolate-inform framework19, 20, 21, 22, 23; and (6) proper use of personal protective equipment, such as surgical or procedural masks, N-95 respirators (including respiratory clearance and fit testing), eye protection, gloves, and gowns when caring for patients with potentially communicable diseases, based on the mode of transmission (Box 1 ). Prevention of clinical laboratory-acquired infection requires adherence to recommended administrative protocols (eg, no eating, drinking, or smoking in areas where microbiologic or pathologic samples are processed), engineering controls (eg, containment hoods), personal protective equipment (eg, N-95 respirators when culturing Mycobacterium tuberculosis), and appropriate immunizations. ,

Abbreviations: MRSA, methicillin-resistant Staphylococcus aureus; SARS-CoV-2, severe acute respiratory syndrome coronavirus-2.

Definitions

The following definitions are from the Centers for Disease Control and Prevention (CDC).

HCP refers to all paid and unpaid persons serving in health care settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances; contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. These HCP may include, but are not limited to, those listed in Box 2 . In general, HCP who have regular or frequent contact with patients, body fluids, or specimens have a higher risk of acquiring or transmitting infections than do HCP who have only brief contact with patients and their environment (eg, beds, food trays, medical equipment). However, all HCP who work within the confines of a health care facility should be covered by the occupational health service (OHS) and receive appropriate screening and preexposure prophylaxis even if they do not provide direct patient care. Recommendations for HCP who work in dental health care settings, autopsy personnel, and clinical laboratory personnel are addressed elsewhere.25, 26, 27

Emergency medical service personnel

Nurse and nursing assistants

Physicians

Technicians

Therapists (eg, occupational health, physical, respiratory care)

Phlebotomists

Pharmacists

Students and trainees

Contractual staff not employed by the health care facility

Persons not directly involved in patient care (for example, clerical, dietary, housekeeping, laundry, security, maintenance, engineering and facilities management, administrative, billing, volunteers, clinical laboratory personnel)

Note: HCP does not include dental health care personnel, autopsy personnel, and laboratory personnel, for whom recommendations are provided separately.25, 26, 27

Health care settings refer to locations where health care is delivered and includes, but is not limited to, acute care facilities, long-term acute care facilities, inpatient rehabilitation services, nursing homes and assisted living facilities, home health care, vehicles where care is delivered (eg, mobile clinics), and outpatient facilities such as dialysis centers and physician offices.

OHS refers to the group, department, or program that addresses many aspects of health and safety in the workplace for HCP, including the provision of clinical services for work-related injuries, exposures, and illnesses. In health care settings, OHS addresses workplace hazards, including communicable diseases; slips, trips, and falls; patient handling injuries; chemical exposures; HCP burnout; and workplace violence. Most commonly, OHS are provided on site within the health care facility in which HCP are performing patient care but may also be provided off site. Occupational health programs should include a variety of activities designed to minimize the risk for HCP to acquire an infectious disease, to evaluate HCP with a potential exposure to a communicable disease, and to evaluate HCP with a communicable disease (Box 3 ).

Medical evaluation of selected HCP

Table 1

Commonly cited references related to health care personnel occupational exposure

Author	Title	Most Recently Updated	Link
CDC, National Center for Emerging and Zoonotic Infectious Diseases, Division of Healthcare Quality and Promotion	Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services	2019	https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html
CDC	Recommended Vaccines for Healthcare Workers	2020	https://www.cdc.gov/vaccines/adults/rec-vac/hcw.html
ACIP	ACIP Vaccine Recommendations and Guidelines	2020	https://www.cdc.gov/vaccines/hcp/acip-recs/index.html
Society for Healthcare Epidemiology of America	Management of Healthcare Personnel Living With Hepatitis B, Hepatitis C, or Human Immunodeficiency Virus in US Healthcare Institutions	2020	http://www.shea-online.org/index.php/practice-resources

Abbreviation: ACIP, Advisory Committee on Immunization Practices.

Table 2

Methods of showing proof of immunity of health care personnel

Vaccine	Birth Before 1957	Physician Diagnosis	Positive Serology	Self-Report	Documented Appropriate Vaccine Seriesa
Mumps (MMR)	Yesb	Yesd	Yes	No	Yes
Measles (MMR)	Yesb	Yesc	Yes	No	Yes
Rubella (MMR)	Yesb,c	No	Yes	No	Yes
Varicella	No	Yes	Yes	Yese	Yes
Hepatitis B	No	—	>10 mIU/mLf	No	Yes
Influenza	No	No	No	No	Yes
SARS-CoV-2	No	No	No	No	Yes

“Yes” in any column is acceptable evidence of immunity.

Greater than 96% of HCP born before 1957 were shown to be immune to measles, mumps, and/or rubella.

Abbreviation: MMR, measles, mumps, rubella.

Written documentation (ie, signed by a health care provider).

Consider immunization of HCP born before 1957; recommend during an outbreak.

All HCP of child-bearing potential should be immunized.

Requires laboratory confirmation of infection.

Based on published literature: greater than 97% of HCP born before 1980 were shown to be immune to varicella in 2014.

Obtain anti–hepatitis B surface antibody (anti-HBs) titer, 1 to 2 months after the last vaccine dose; if immunization is remote and anti-HBs titer not available, see text for management.

Evaluation for tuberculosis

Allergy screening for common health care–associated products

Education

Review of immunity to vaccine-preventable diseases

Evaluation for possible communicable disease

Evaluation for postexposure prophylaxis

Evaluation of injured personnel (eg, strains, sprains, lacerations)

Abbreviations: IGRA, interferon gamma release assay; OSHA, Occupational Safety and Health Administration; TST, tuberculin skin test.

Occupational health programs should be aware of appropriate guidelines from the CDC and professional organizations. They should adhere to appropriate state and federal laws and regulations. Specific regulations promulgated by the US Occupational Safety and Health Administration (OSHA) related to HCP include BBP (1910.1030) and tuberculosis/respiratory protection (1910.134). The Federal Needlestick Safety and Prevention Act (HR5178), which was enacted in 2000, requires the use of safety engineered devices whenever possible to reduce the likelihood of sharp injuries. Commonly used references are provided in Table 1 .

Evaluation of health care personnel and preexposure prophylaxis

OHS either provide or refer newly hired HCP for preplacement medical evaluations before initiation of employment, and periodically as needed during the course of employment.

Preexposure Screening

All HCP should undergo a new personnel orientation on hire. As part of the orientation process, HCP should undergo screening and education directed at reducing the risk of acquisition of infection diseases by health care providers (Box 2). All information obtained should be entered into an electronic database. Access to this database may be prescribed by state law because some states treat HCP occupational health records as personnel records. If OHS records are part of the organization’s standard patient electronic medical records, unauthorized access of provider’s occupational health information by supervisors should be prohibited by the institutions privacy rules and periodically assessed.

Immunizations

General recommendations regarding vaccination of HCP have been published by the CDC, the Advisory Committee on Immunization Practices (ACIP) for HCP , as well as the general public and adults, and the American Academy of Pediatrics (AAP) for children. The most recent ACIP recommendations for adults, which are summarized yearly, should always be consulted. It is recommended that all HCP be immune to mumps, measles, rubella, varicella, influenza, and, in the context of the coronavirus disease 2019 (COVID-19) pandemic, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Depending on the vaccine-preventable disease, immunity may be ensured by several different measures (Table 2 ). HCP who are not immune should receive appropriate immunizations (Table 3 ). However, even if HCP are considered immune to a vaccine-preventable disease transmitted by the droplet (ie, pertussis, invasive meningococcal infection, mumps, rubella, SARS-CoV-2) or airborne (ie, varicella, measles) route, they should wear appropriate respiratory protection as per transmission-based precautions while providing care to a patient with confirmed or suspected disease because immunization is not 100% effective in preventing infection. Further, failure of any provider to wear the appropriate respiratory protection may lead nonimmune providers (eg, persons with a contraindication to vaccination) to mistakenly believe that the transmission-based precautions have been discontinued.

Table 3

Immunizations recommended for nonimmune health care personnel

Vaccine	Health Care Personnel	Comments
Mumps	All (2 doses)	Provide as MMR
Measles	All (2 doses)	Provide as MMR
Rubella	All (1 dose)	Provide as MMR
Varicella	All (2 doses)	—
Hepatitis B	HCP with potential exposure to blood or contaminated body fluids (2 or 3 doses depending on vaccine)	—
Meningococcal (serogroups A, C, Y, W)	Clinical microbiologists (1 dose; booster every 5 y)	All vaccines available are now conjugate products
Meningococcal (serogroup B)	Clinical microbiologists (2 or 3 doses, depending on manufacturer); booster every 2–3 y	MenB-FHbp and MenB-4C are not interchangeable
Influenza	All (1 dose each year)	HCP who care for severely immunocompromised persons who require care in a protected environment should receive IIV or RIV; HCP who receive LAIV should avoid providing care for severely immunocompromised persons (ie, persons receiving care in protected hospital unit such as BMTU) for 7 d after immunization
SARS-CoV-2	All (frequency of immunization not yet established)

Abbreviations: BMTU, bone marrow transplant unit; IIV, inactivated influenza vaccine; LAIV, live, attenuated influenza vaccine; RIV, recombinant influenza vaccine.

HCP should be provided with all vaccines that are recommended for adults, such as human papillomavirus, herpes zoster, Tdap (tetanus toxoid, diphtheria toxoid, acellular pertussis), and pneumococcal vaccines, or referred to their local medical providers for the same. In special circumstances, HCP should be offered immunization with other vaccines, including polio, rabies, hepatitis A, vaccinia (smallpox), Ebola virus, and anthrax (Box 4 ). HCP responding to an outbreak of Ebola virus disease (EVD), who work in one of the federally designated Ebola treatment centers in the United States, or work as laboratorians or other staff at biosafety level 4 facilities in the United States, are recommended for vaccination with EVD. In addition, HCP who are traveling outside the United States for work-related activities should be evaluated and provided with CDC-recommended immunizations such as typhoid, cholera, and Japanese encephalitis. ,

Anthrax: PEP, research, biothreat attack

Diphtheria (Tdap): outbreak

Ebola virus (Ervebo): adults who are responding, or may respond, to an outbreak of EVD, laboratorians or other staff working at biosafety level-4 facilities in the United States, or HCP working at federally designated Ebola treatment centers in the United States

Hepatitis A: PEP, outbreak, travel

Hepatitis B: PEP, travel

Measles (MMR): PEP, outbreak

Meningococcal serotypes A, C, W, Y: outbreak, travel

Meningococcal serotype B: outbreak

Mumps (MMR): outbreak

Pertussis (Tdap): outbreak

Poliomyelitis: research, outbreak

Rabies: PEP, research, travel

Rubella (MMR): outbreak

Smallpox (vaccinia): PEP, research, biothreat attack

Tetanus (Tdap or Td): PEP

Varicella: PEP, outbreak

Abbreviation: Td, tetanus toxoid, diphtheria toxoid.

aAdditional vaccines may be recommended for researchers or travel, such as yellow fever, Japanese encephalitis, and cholera.

Vaccination for SARS-CoV-2 is recommended for HCP, including paid and unpaid personnel working in all health care settings. At this time, 2 vaccines, both messenger RNA (mRNA) vaccines, have been approved under Emergency Use Authorization: Pfizer-BioNTech’s COVID-19 vaccine and Moderna’s COVID-19 vaccine. Late-stage trials of additional vaccines are underway or planned (AstraZeneca, Janssen, and Novavax). There are few contraindications to vaccination. These contraindications include (1) severe allergic reaction (eg, anaphylaxis) after a previous dose of an mRNA COVID-19 vaccine or any of its components, (2) immediate allergic reaction of any severity to a previous dose of an mRNA COVID-19 vaccine or any of its components (including polyethylene glycol [PEG]), and (3) immediate allergic reaction of any severity to polysorbate (because of potential cross-reactive hypersensitivity with the vaccine ingredient PEG). Individuals in the last 2 categories should not receive mRNA COVID-19 vaccination unless they have been evaluated by an allergist-immunologist who has determined that the vaccine can be safely administered with adequate observation and support. Detailed guidance is provided by the CDC. Individuals with a history of immediate allergic reaction to any other vaccine or injectable therapy can receive mRNA COVID-19 vaccines but must have received counseling in advance regarding potential risk of severe allergic reaction. If vaccination proceeds in these instances, the observation period should be extended from 15 minutes to 30 minutes for individuals with a history of immediate allergic reaction of any severity to a vaccine or injectable therapy and persons with a history of anaphylaxis of any cause. Vaccination centers should have immediate availability of resuscitation equipment.

Immunocompromised Health Care Personnel

Immunocompromised HCP require special consideration in the provision of immunizations. First, live, attenuated virus vaccines (eg, measles-mumps-rubella; varicella; live, attenuated influenza) may be contraindicated. Second, vaccines not routinely recommended may be indicated (eg, pneumococcal, meningococcal, Haemophilus influenzae type b). Third, higher antigen doses (eg, hepatitis B vaccine in people with end-stage renal disease), additional doses of vaccine (eg, rabies vaccine in immunocompromised persons), or postimmunization serologic evaluation may be indicated (eg, antibody response to rabies vaccine) because immunization of immunocompromised people may elicit a lower antibody response. In addition, 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 (LAIV) should not work in a protected environment (ie, stem cell transplant unit) for 7 days postimmunization. ,

Pregnant Health Care Personnel

Pregnant HCP also require special consideration in the provision of immunizations. The risks from immunization during pregnancy are largely theoretic. The benefit of immunization among pregnant women usually outweighs the potential risks for adverse reactions, especially when the risk for disease exposure is high, infection would pose a special risk to the mother or fetus, and the vaccine is unlikely to cause harm.44, 45, 46, 47 Furthermore, newer information continues to confirm 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, COVID-19, hepatitis A, and hepatitis B as children or adolescents before becoming pregnant. Nevertheless, live, attenuated vaccines should be provided only to nonpregnant HCP and deferred during pregnancy. The ACIP has recommended administration of Tdap during all pregnancies, preferably during weeks 27 to 36. If not administered during pregnancy, Tdap should be administered immediately postpartum before discharge from the hospital or birthing center for new mothers who have never received Tdap before or whose vaccination status is unknown. 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, COVID-19, and poliovirus (inactivated) (see Box 3). Importantly, the indications for use of immunoglobulin preparations are the same in pregnant and nonpregnant women. Breastfeeding does not adversely affect the response to immunization and is not a contraindication for any of the currently routinely recommended routine vaccines.

Health Care Personnel with Contraindications or Precautions to Immunization

Before the administration of any vaccine, the HCP should be evaluated for the presence of conditions 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 health care provider and the patient. 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 fever 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; and family history of allergies, serious adverse reactions to vaccination, or seizures.

Routine Immunization as a Condition of Employment

Despite the benefits of vaccination, challenges remain in ensuring a fully vaccinated health care workforce. In February 2012, the National Vaccine Advisory Committee issued a statement that provided recommendations on how to achieve the Healthy People 2020 annual influenza vaccine coverage goal (ie, 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.” In the most recent season for which data are available, 80.6% of HCP reported receiving influenza vaccination during the 2019 to 2020 season. Among those who were required by their employer to receive the vaccination, compliance was higher at 94.4% compared with those without an employer mandate at 69.6%. In 2020, the Society for Healthcare Epidemiology of America (SHEA) recommended that only medical contraindications should be accepted as a reason for not receiving all routine immunizations as recommended by the CDC.

Evaluation of health care personnel with communicable diseases

HCP exposed to a communicable disease for which they are susceptible should be considered for work restrictions or furlough. Similarly, HCP ill with a communicable disease should be considered for work restrictions or furlough (Table 4 ). Importantly, infectious HCP have been the source for patient infection and the index case for outbreaks. , HCP-to-patient transmission has been well documented for HIV, HBV, and HCV, but has most commonly been reported with HBV. For this reason, infected HCP who perform invasive procedures should be evaluated by a special panel for the need for education, additional engineering controls, and/or work restrictions per current guidelines from the Society of Hospital Epidemiology of America and CDC.

Table 4

Recommended work restrictions for health care personnel colonized/exposed or infected with selected infectious agents

Infection or Infectious Agent	Exposed or Colonized	Infected (Duration of Restrictions)
Conjunctivitis (adenovirus)	Exposed; no restriction unless illness develops	Restrict from patient contact and contact with the patient’s environment (until discharge ceases)
Cytomegalovirus	No restriction	No restriction
Diarrheal diseases	No restriction unless illness develops	Acute disease: exclude from duty (until >48–72 h after symptoms resolve)Convalescent stage (Salmonella spp): restrict from care of high-risk patients and food handling (until symptoms resolve; consult local and state authorities for HCP/food handlers with Salmonella typhi)
Diphtheria	Exposed: no restriction unless illness develops	Exclude from duty (until antimicrobial therapy completed and 2 cultures obtained ≥24 h apart are negative)
Hepatitis A	Exposed: no restriction unless illness develops	Restrict from patient contact, contact with patient’s environment, and food handling (until 7 d after onset of jaundice)
Hepatitis B (chronic)	—	Restrictions based on review of only HCP who perform exposure-prone procedures by expert panel (see text)
Hepatitis C	—	Restrictions based on review of HCP who perform exposure-prone procedures by expert panel (see text)
Herpes simplex (genital)	—	No restriction
Herpes simplex (hands; herpetic whitlow)	—	Restrict from patient contact and contact with the patient’s environment (until lesions heal)
Herpes simplex (orofacial)	—	Evaluate for need to restrict from care of high-risk patients
HIV	—	Restrictions based on review of HCP who perform exposure-prone procedures by expert panel (see text)
Measles	Exposed (susceptible HCP): exclude from duty (from the fifth day after first exposure through 21st day after last exposure and/or after rash appears)	Exclude from duty (until 4 d after the rash appears)
Meningococcal infections	Exposed: no restriction unless illness developsColonized (unrelated to invasive case): no restriction	Exclude from duty (until 24 h after start of effective therapy)
Methicillin-resistant Staphylococcus aureus	Colonized: no restrictions unless or ill or epidemiologically/molecular test linked to patient infections	Allow to work provided lesions can be contained under a bandage and clothes; if lesions on exposed area (eg, hand/wrists, face/neck), exclude from duty (until lesions healed)
Mumps	Exposed (susceptible HCP): exclude from duty (from the 12th day after first exposure through 26th day after last exposure or after onset of parotitis)	Exclude from duty (until 9 d after onset of parotitis)
Pertussis	Exposure (asymptomatic): no restriction unless develops illness (PEP recommended)Exposed (symptomatic): per active disease	Exclude from duty (from beginning of catarrhal stage through third week after onset of paroxysms or until 5 d after start of effective antimicrobial therapy)
Rubella	Exposed (susceptible HCP): exclude from duty (from seventh day after first exposure through 21st day after last exposure)	Exclude from duty (until 5 d after rash appears)
Group A Streptococcus	Colonized: no restrictions unless or ill or epidemiologically/molecular test linked to patient infections	Restrict from patient care, contact with patient’s environment, or food handling (until 24 h after adequate treatment started)
Tuberculosis	Latent tuberculous infection: no restrictions	Active pulmonary tuberculosis; exclude from duty (until proved noninfectious)
Varicella	Exposed (susceptible): exclude from duty from 10th day after first exposure through 21st day (27th day if varicella immune globulin provided) after last exposure	Exclude from duty (until all lesions dried and crusted)
Zoster	Exposed (susceptible): same as varicella	Localized, in healthy HCP: allow to work provided lesions can be contained under a bandage and clothes; if lesions on exposed area (eg, hand/wrists, face/neck), exclude from duty (until lesions dried and crusted)Generalized or localized in immunosuppressed HCP: exclude from duty (until all lesions dried and crusted)
Viral respiratory tract infections (acute)	No restrictions unless illness developsa	Febrile: exclude from duty (until afebrile for >24 h)Afebrile: exclude from care of highly immunocompromised patients (ie, patients cared for in a protected environment) until afebrile for >24 h or 7 d since onset of symptoms, whichever is longer; HCP should wear a mask providing care until symptom free
SARS-CoV-2	Detailed recommendations related to HCP restrictions after exposure to SARS-CoV-2 are available

Consider restrictions if HCP exposed to highly contagious disease transmitted by the respiratory route or close contact (eg, MERS-CoV [Middle East respiratory syndrome coronavirus], Ebola).

Summary

Although HCP are at risk of exposure to communicable diseases, effective occupational health programs can mitigate risk through thorough evaluation of HCP, ensuring appropriate preexposure prophylaxis, and management of HCP with communicable diseases.

Clinics care points

On hire, HCP should undergo screening and education directed at reducing the risk of acquisition of infection diseases by health care providers.

Recommendations for immunization for HCP are provided by CDC and ACIP.

Before the administration of any vaccine, the HCP should be evaluated for the presence of conditions that are listed as a vaccine contraindication or precaution.

Airborne	Bites	Blood Borne	Contact (Direct and Indirect)	Droplet
• Measles • Tuberculosis (pulmonary, laryngeal) • Varicella zoster virus (primary varicella or disseminated herpes zoster)	• Rabies • Tetanus	• HBV • HCV • HIV	• Anthrax (cutaneous) • C difficile • Hepatitis A • MRSA • SARS-CoV-2 • Varicella zoster virus (herpes zoster) • Herpes simplex	• Diphtheria • Influenza • Invasive group A streptococcus • Invasive Neisseria meningitidis • Pertussis • Plague • SARS-CoV-2

At initial employment	1. Evaluation for ability to perform job functions 2. Screen for illicit drugs 3. Medical evaluation of selected HCPa. Department of transportation (required for use of certain motor vehicles) b. Flight physical (required of pilots) c. Police/security for use of weapons 4. Review of immunity to vaccine-preventable diseases (Tables 1 and 2) 5. Evaluation for tuberculosisa. Symptom review for active tuberculosis b. Testing for latent tuberculosis (TST or IGRA; IGRA preferred) 6. Allergy screening for common health care–associated productsa. Latex/natural rubber, germicides (antiseptics, disinfectants) 7. Counseling for pregnant or immunocompromised personnel (voluntary) 8. Educationa. Fire and electrical safety b. Prevention of sharps injury c. Appropriate hand hygiene and proper use of personal protective equipment d. Workplace violence e. Disaster planning: weather, bomb threats, biothreats, chemical spills f. Reporting infectious disease exposures, injuries, illnesses g. OSHA required (if applicable): blood-borne pathogens, tuberculosis/respiratory protection
Annual	1. Symptom evaluation for tuberculosis 2. Review of immunity to vaccine-preventable diseasesa. Influenza immunization
Miscellaneous	1. Hearing evaluation if part of OSHA-required hearing conservation program 2. Test for color blindness if performing high-level disinfection
Education	1. OSHA required (if applicable): blood-borne pathogens, tuberculosis/respiratory protection 2. Others as recommended/required by health care facility
When needed	1. Evaluation for possible communicable diseasea. Consideration for treatment and job restriction/furlough if disease poses threat to patients or other HCP 2. Evaluation for postexposure prophylaxisa. Consideration for treatment and job restriction/furlough if disease poses threat to patients or other HCP 3. Evaluation of injured personnel (eg, strains, sprains, lacerations)a. Provide first aid b. Refer to emergency department or specialized clinic for severe injuries c. Provide long-term care d. Communicate with worker’s compensation department 4. Return-to-work evaluation for non–work-related injuries/illnesses 5. Fit-for-duty examination (may include drug and alcohol testing)