David T. Kuhar

Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis

This report updates US Public Health Service recommendations for the management of healthcare personnel (HCP) who experience occupational exposure to blood and/or other body fluids that might contain human immunodeficiency virus (HIV). Although the principles of exposure management remain unchanged, recommended HIV postexposure prophylaxis (PEP) regimens and the duration of HIV follow-up testing for exposed personnel have been updated. This report emphasizes the importance of primary prevention strategies, the prompt reporting and management of occupational exposures, adherence to recommended HIV PEP regimens when indicated for an exposure, expert consultation in management of exposures, follow-up of exposed HCP to improve adherence to PEP, and careful monitoring for adverse events related to treatment, as well as for virologic, immunologic, and serologic signs of infection. To ensure timely postexposure management and administration of HIV PEP, clinicians should consider occupational exposures as urgent medical concerns, and institutions should take steps to ensure that staff are aware of both the importance of and the institutional mechanisms available for reporting and seeking care for such exposures. The following is a summary of recommendations: (1) PEP is recommended when occupational exposures to HIV occur; (2) the HIV status of the exposure source patient should be determined, if possible, to guide need for HIV PEP; (3) PEP medication regimens should be started as soon as possible after occupational exposure to HIV, and they should be continued for a 4-week duration; (4) new recommendation-PEP medication regimens should contain 3 (or more) antiretroviral drugs (listed in Appendix A ) for all occupational exposures to HIV; (5) expert consultation is recommended for any occupational exposures to HIV and at a minimum for situations described in Box 1 ; (6) close follow-up for exposed personnel ( Box 2 ) should be provided that includes counseling, baseline and follow-up HIV testing, and monitoring for drug toxicity; follow-up appointments should begin within 72 hours of an HIV exposure; and (7) new recommendation-if a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing of exposed HCP, HIV testing may be concluded 4 months after exposure ( Box 2 ); if a newer testing platform is not available, follow-up HIV testing is typically concluded 6 months after an HIV exposure.

Hospital-associated outbreak of Middle East Respiratory Syndrome Coronavirus: A serologic, epidemiologic, and clinical description

Novel serological tests allowed for the detection of otherwise unrecognized cases of Middle East respiratory syndrome coronavirus infection among contacts in a hospital-associated respiratory illness outbreak in Jordan in April 2012, resulting in a total of 9 test-positive cases.

Strategies to Prevent Methicillin-Resistant Staphylococcus aureus Transmission and Infection in Acute Care Hospitals: 2014 Update

Previously published guidelines are available that provide comprehensive recommendations for detecting and preventing healthcare-associated infections (HAIs). The intent of this document is to highlight practical recommendations in a concise format designed to assist acute care hospitals in implementing and prioritizing their methicillin-resistant Staphylococcus aureus (MRSA) prevention efforts. This document updates “Strategies to Prevent Transmission of Methicillin-Resistant Staphylococcus aureus in Acute Care Hospitals,” published in 2008. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Transmission of Middle East Respiratory Syndrome Coronavirus Infections in Healthcare Settings, Abu Dhabi.

Early detection and adherence to infection prevention recommendations are necessary to avoid transmission.

Health care worker contact with MERS patient, Saudi Arabia.

To investigate potential transmission of Middle East respiratory syndrome coronavirus (MERS-CoV) to health care workers in a hospital, we serologically tested hospital contacts of the index case-patient in Saudi Arabia, 4 months after his death. None of the 48 contacts showed evidence of MERS-CoV infection.

Lack of transmission among close contacts of patient with case of middle east respiratory syndrome imported into the United States, 2014

Despite 61 contacts with unprotected exposure, no secondary cases occurred.

Active Tracing and Monitoring of Contacts Associated With the First Cluster of Ebola in the United States

Context After confirmation of the first case of Ebola virus disease diagnosed in the United States, contact tracing and monitoring were instituted. Contribution Challenges included the need for rapid response in a setting of evolving knowledge, institution of direct active monitoring and movement restriction for a large number of contacts, and provision of mental health and other supports. Quarantine was necessary in only a few cases. Implication Contact tracing of the first case of U.S.-diagnosed case of Ebola was unprecedented in complexity. This experience may be useful in future instances of exposure to highly communicable diseases. Tracing and monitoring contacts exposed to patients with Ebola virus disease in past epidemics in Africa have been central to effective outbreak control by ensuring that persons at higher risk for infection are identified, isolated, and evaluated as soon as possible after symptom onset (13). Such contact tracing was challenging during the 2014 western Africa Ebola epidemic, particularly after the disease extended into dense urban areas of Guinea, Liberia, and Sierra Leone (4, 5). However, contact tracing and active monitoring were critical components of containment of Ebola importations into urban Nigeria and Senegal during the summer of 2014 (6, 7). Before 25 September 2014, 4 patients with Ebola had been treated in the United States; all of them were diagnosed in western Africa and evacuated to biocontainment facilities in the United States for care (8). On 25 September, a 45-year-old man (patient 1), who had arrived in the United States from Liberia 5 days earlier, presented to a Dallas, Texas, emergency department (ED) with a 1-day history of fever, abdominal pain, and headache (9). He was prescribed antibiotics for possible sinusitis and discharged a few hours later. On 28 September, he returned to the hospital by ambulance with persistent fever, abdominal pain, and intervening onset of diarrhea. Ebola was suspected, and he was placed in a private room under standard, droplet, and contact precautions. He was transferred to the hospitals medical intensive care unit on 29 September. Ebola was confirmed on 30 September, and the patient died on 8 October. On 11 October and 15 October, 2 health care personnel (HCP) (patients 2 and 3, respectively) who had cared for patient 1 were confirmed to have Ebola (10). This domestic cluster of Ebola provided the opportunity to assess implementation of contact tracing and monitoring approaches for this high-consequence disease in both community and health care settings for the first time in the United States. Methods Case and Contact Identification The case and contact definitions used at the outset of this investigation were the extant definitions from the Centers for Disease Control and Prevention (CDC), operational as of 28 September 2014; they have since been revised (11). Possible Ebola case-patients were persons with both potential Ebola epidemiologic risk factors and consistent symptoms. Potential Ebola exposure risk factors included contact with a patient who had laboratory-confirmed Ebola or who had traveled from countries affected by the Ebola outbreak. The extant symptom criteria included temperature of 101.5F or greater (38.6C); 1 or more of the following symptoms: severe headache, sore throat, malaise, muscle pain, diarrhea, vomiting, rash, or unexplained bleeding within 21 days after exposure or travel; and no alternative diagnosis. Confirmed patients had Ebola virus detected in a blood sample by real-time reverse-transcription polymerase chain reaction performed at the CDC (12). Contact tracing was initiated for possible and confirmed Ebola cases. A contact was defined as any person, irrespective of use of personal protective equipment, who touched the skin, blood, or other body fluid of a symptomatic patient with confirmed Ebola; had been within 3 feet of a symptomatic patient with Ebola for more than 15 minutes; or who interacted with a possibly contaminated health care environment. Contacts whose Ebola exposures occurred outside of health care settings were designated as community contacts. Community contacts who interacted with the patient between symptom onset and admission were identified by interviewing patients with Ebola, their household members, and other reported potential contacts. Identification and monitoring of additional possible community contacts of patient 3 from a visit to Ohio are described elsewhere (13, 14). Contacts whose Ebola exposures occurred during ambulance transport or at the hospital were designated as health care contacts. Ambulance transport contacts were identified through emergency medical services. The HCP contacts were identified through the hospitals human resources department from a combination of information provided by department managers, records of staff movement from location-tracking badge tags, security sign-in sheets, and prospective logs used to document HCP participating in the care of the patients with Ebola. Risk Classification and Monitoring of Contacts Standardized questionnaires on the nature and duration of potential exposures were administered to contacts to stratify them into exposure risk groups termed high risk, some risk, or no known exposure (Table 1). These groups were defined according to the extant CDC classification criteria, which have since been revised (15). The no known exposure category encompassed contacts without recognized unprotected exposures to Ebola, including HCP who used recommended personal protective equipment when caring for patients with Ebola. After confirmation of patient 2s Ebola diagnosis, additional subclassifications (higher risk, lower risk, and least risk) were created to further stratify risk levels within the no known exposure group and help guide heightened monitoring and movement restrictions (Table 1). Table 1. Ebola Exposure Categories to Determine Public Health ActionsDallas, Texas, 2014 All contacts received instruction about symptom monitoring and procedures to follow in the event of illness onset. Monitoring entailed twice-daily oral temperature measurement and checking for symptoms compatible with Ebola for 21 days from the date of last exposure. Contacts in the high risk and some risk groups underwent direct active monitoring, with at least 1 of their twice-daily symptom checks directly observed by a member of the investigation team at their place of lodging, and the second reported by phone. In accordance with the extant national guidance, twice-daily self-monitoring for fever and symptoms was initially recommended to the contacts in the no known exposure risk group. After patient 2s Ebola diagnosis, all HCP contacts in the no known exposure category were transitioned to direct active monitoring, with at least 1 in-person check daily onsite at the hospital. From 1 to 7 November, the last week of monitoring in Dallas County, alternatives, such as video chat, were used when in-person checks were not feasible. Data from EPI-Info 7 (CDC) was reentered into Microsoft Access 2010 (Microsoft Corp.) and later into Maven (Consilience Software) databases and analyzed using SAS software, version 9.3 (SAS Institute). Because this investigation was part of a public health response, it was determined to be nonresearch by the CDC and therefore was not subject to CDC institutional review board review. Movement Restrictions Movement restrictions were recommended to prevent possible spread should a contact become symptomatic. Contacts with high risk and some risk exposure levels were instructed to avoid travel by commercial conveyances and public transportation during their monitoring period (15). According to the extant CDC guidance for monitoring and movement of persons with Ebola exposures, contacts in the no known exposure risk category were not initially subject to movement restrictions; however, after patient 2s Ebola diagnosis, directives for controlled movement were also applied to this risk group. On 16 October, all contacts in the no known exposure category who had ever entered the index patients room were additionally restricted from direct care activities of other patients and from public gatherings. Public health control orders for quarantine were implemented whenever voluntary adherence to active monitoring or controlled movement directives could not be ensured. Investigation of Symptomatic Contacts Contacts of the 3 patients with Ebola reporting a temperature of 100.4F (38C) or greater, or compatible symptoms (severe headache, sore throat, malaise, muscle pain, diarrhea, vomiting, rash, or unexplained bleeding) were referred to the ED, isolated, and assessed to determine whether Ebola testing was warranted. If the result of an initial reverse-transcription polymerase chain reaction test for Ebola was negative, contacts with persistent symptoms and without an alternative diagnosis underwent additional Ebola testing 72 hours or more after symptom onset. Patients were eligible for discharge after improvement or resolution of symptoms for 24 hours or a negative Ebola test result obtained 72 hours or more after symptom onset. Results From 28 September to 16 October, more than 280 reported potential contacts of the 3 Ebola case-patients were investigated, of whom 179 were confirmed as contacts and monitored (Figure). Patient 1 had 139 contacts (17 community contacts and 122 health care contacts, 2 of whom became patients 2 and 3). Patients 2 and 3 had 73 contacts (3 community and 70 HCP contacts); 33 of their HCP contacts were also contacts of patient 1. Among the 3 patients who were part of this investigation, patient 1 had the longest period of symptoms before hospital admission (5 days; 2428 September) and the longest hospital stay (11 days; 28 September8 October). Patients 2 and 3 were each symptomatic for less than 24 hours in the Dallas community before admission, and their Dallas hospital stays were also shorter (7

First confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in the United States, updated information on the epidemiology of MERS-CoV infection, and guidance for the public, clinicians, and public health authorities - May 2014

Since mid-March 2014, the frequency with which cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection have been reported has increased, with the majority of recent cases reported from Saudi Arabia and United Arab Emirates (UAE). In addition, the frequency with which travel-associated MERS cases have been reported and the number of countries that have reported them to the World Health Organization (WHO) have also increased. The first case of MERS in the United States, identified in a traveler recently returned from Saudi Arabia, was reported to CDC by the Indiana State Department of Health on May 1, 2014, and confirmed by CDC on May 2. A second imported case of MERS in the United States, identified in a traveler from Saudi Arabia having no connection with the first case, was reported to CDC by the Florida Department of Health on May 11, 2014. The purpose of this report is to alert clinicians, health officials, and others to increase awareness of the need to consider MERS-CoV infection in persons who have recently traveled from countries in or near the Arabian Peninsula. This report summarizes recent epidemiologic information, provides preliminary descriptions of the cases reported from Indiana and Florida, and updates CDC guidance about patient evaluation, home care and isolation, specimen collection, and travel as of May 13, 2014.

Measles in Healthcare Facilities in the United States During the Postelimination Era, 2001–2014

Between 2001 and 2014, 78 reported measles cases resulted from transmission in US healthcare facilities, and 29 healthcare personnel were infected from occupational exposure, 1 of whom transmitted measles to a patient. The economic impact of preventing and controlling measles transmission in healthcare facilities was

Assessment of Management Policies and Practices for Occupational Exposure to Bloodborne Pathogens in Dialysis Facilities

19 000-