Carmen P. Hench

Standardized management of patients and employees exposed to pertussis

Waning pertussis immunity and spread of pertussis by asymptomatic adults contributes to increased pertussis exposures of vulnerable children. The Santa Clara Valley Medical Center had 49 pertussis exposures between July 1, 1989, and June 30, 1997, which originated in pediatric units or clinics and had an impact on the Employee Health Service (EHS) and Emergency Department (ED). We have developed a standardized protocol for management of employees and patients exposed to pertussis. The protocol includes a checklist for infection control staff; memoranda to exposed units conveying exposure information, instructions for employees to report to EHS or ED, and disease symptom information; written guidelines for physician management of patient exposures (prophylaxis and isolation) and EHS or ED management of employee exposures; and prophylaxis recommendations. We allow exposed employees to work while wearing a mask (worn until 5 days of prophylaxis are completed or for the entire potential contagious period if prophylaxis was refused). Employees who develop pertussis are restricted from work. Our protocol and standardized forms provide consistent management of pertussis exposures in both patients and employees.

Management of varicella-vaccinated patients and employees exposed to varicella in the healthcare setting.

Varicella exposures from patients, visitors, and staff continue to occur in healthcare facilities. In a recent report from the National Surveillance System for Health Care Workers, 9 participating hospitals reported 72 varicella exposures from 1996 to 1999, involving 1,111 healthcare workers.1 Depending on the patient and employee demographics for any particular healthcare institution, the number of these exposures can vary. Many healthcare facilities follow the guidelines of the Hospital Infection Control Practices Advisory Committee for non-immune employees exposed to varicella. These guidelines recommend that such employees be excluded from duty from 8 to 21 days after exposure to varicella.2 There is no standard definition of what constitutes exposure to varicella, which can result in employees’ being excluded from duty on one or more occasions without having contracted chickenpox. We previously reported our experience of allowing non-immune employees exposed to varicella to work while wearing masks, checking daily for prodromal symptoms, and excluding these employees from duty only if such symptoms occurred.3-6 Since our original report from 1994, we have continued this practice without adverse consequences. The varicella vaccine, a live-attenuated preparation licensed in 1995, alters the situation. The vaccine is recommended for administration to all immunocompetent susceptible healthcare workers.7,8 According to the Advisory Committee on Immunization Practices, the varicella vaccine is effective in preventing severe disease for 7 to 10 years after vaccination in 95% of recipients and provides approximately 70% to 90% protection against varicella infection.7 There is also evidence to support the use of the vaccine for unvaccinated individuals after exposure to prevent illness or modify its severity, if used within 3 days (possibly up to 5 days) after exposure.8-11 The purpose of this article is to identify issues involved with managing healthcare workers and patients exposed to varicella in light of the availability and administration of the varicella vaccine. We outline the issues, present the policy developed at our institution, and discuss the rationale for the policy decisions. Our algorithm-based policy is included as a reference.