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Continuing Education Examination available at http://www.cdc.gov/mmwr/cme/conted.html.

Immunization of Health-Care PersonnelRecommendations of the Advisory Committee on

Immunization Practices (ACIP)

Morbidity and Mortality Weekly Report

Recommendations and Reports / Vol. 60 / No. 7 November 25, 2011

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
http://www.cdc.gov/mmwr/cme/conted.htmlhttp://www.cdc.gov/mmwr/cme/conted.html


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Recommendations and Reports

On the cover:An adult emale health-care proessional receiving an intramuscular vaccination into her let shoulder muscle rom a nurse.

Disclosure of Relationship

CDC, our planners, and our content experts wish to disclose thathey have no inancial interests or other relationships with themanuacturers o commercial products, suppliers o commerciaservices, or commercial supporters. This report will not includeany discussion o the unlabeled use o a product or a product undeinvestigational use with the exception o the ollowing situations:

1. For varicella postexposure prophylaxis or persons withouevidence o immunity who have contraindications orvaccination and who are at risk or severe disease andcomplications, the product currently used in the United StatesVariZIG (Cangene Corporation, Winnipeg, Canada), iavailable under an Investigational New Drug ApplicationExpanded Access Protocol.

2. The interval between administration o Td and Tdap might be


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MMWR / November 25, 2011 / Vol. 60 / No. 7 1

Immunization of Health-Care Personnel

Recommendations of the Advisory Committee on Immunization Practices(ACIP)Prepared by

Abigail Sheer, MD1William Atkinson, MD1

Carole Friedman, DO1*David T. Kuhar, MD2

Gina Mootrey, DO1

Stephanie R. Bialek, MD1

Amanda Cohn, MD1

Anthony Fiore, MD3Lisa Grohskop, MD1

Jennier L. Liang, DVM1

Suchita A. Lorick, DO1

Mona Marin, MD1

Eric Mintz, MD2

Trudy V. Murphy, MD4

Anna Newton, MPH2

Amy Parker Fiebelkorn, MSN, MPH1

Jane Seward, MBBS1

Gregory Wallace, MD11National Center for Immunization and Respiratory Diseases

2National Center for Emerging and Zoonotic Infectious Diseases3Center for Global Health

4National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention*Deceased.

Summary

This report updates the previously published summary of recommendations for vaccinating health-care personnel (HCP) inthe United States (CDC. Immunization of health-care workers: recommendations of the Advisory Committee on ImmunizationPractices [ACIP] and the Hospital Infection Control Practices Advisory Committee [HICPAC]. MMWR 1997;46[No. RR-18]).This report was reviewed by and includes input from the Healthcare (formerly Hospital) Infection Control Practices AdvisoryCommittee. These updated recommendations can assist hospital administrators, infection-control practitioners, employee healthclinicians, and HCP in optimizing infection prevention and control programs. The recommendations for vaccinating HCP arepresented by disease in two categories: 1) those diseases for which vaccination or documentation of immunity is recommended becauseof risks to HCP in their work settings for acquiring disease or transmitting to patients and 2) those for which vaccination mightbe indicated in certain circumstances. Background information for each vaccine-preventable disease and specific recommendationsfor use of each vaccine are presented. Certain infection-control measures that relate to vaccination also are included in this report.In addition, ACIP recommendations for the remaining vaccines that are recommended for certain or all adults are summarized,as are considerations for catch-up and travel vaccinations and for work restrictions. This report summarizes all current ACIPrecommendations for vaccination of HCP and does not contain any new recommendations or policies.

The material in this report originated in the National Center or

Immunization and Respiratory Diseases, Anne Schuchat, MD,Director.Corresponding preparer: Abigail Sheer, MD, National Center orImmunization and Respiratory Diseases, 1600 Cliton Rd., MS A-19,

Atlanta, GA 30333. Telephone: 404-639-8233; Fax: 404-417-0791;E-mail: [email protected].

The recommendations provided in this report apply,

but are not limited, to HCP in acute-care hospitals; long-termcare facilities (e.g., nursing homes and skilled nursingfacilities); physicians offices; rehabilitation centers; urgentcare centers, and outpatient clinics as well as to persons whoprovide home health care and emergency medical services.
mailto:ams7%40cdc.gov?subject=mailto:ams7%40cdc.gov?subject=


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2 MMWR / November 25, 2011 / Vol. 60 / No. 7

IntroductionThis report updates the previously published summary

o recommendations o the Advisory Committee onImmunization Practices (ACIP) and the Healthcare (ormerlyHospital) Inection Control Practices Advisory Committee

(HICPAC) or vaccinating health-care personnel (HCP) inthe United States (1). The report, which was reviewed byand includes input rom HICPAC, summarizes all currentACIP recommendations or vaccination o HCP and doesnot contain any new recommendations or policies that havenot been published previously. These recommendations canassist hospital administrators, inection-control practitioners,employee health clinicians, and HCP in optimizing inectionprevention and control programs.

HCP are deined as all paid and unpaid persons workingin health-care settings who have the potential or exposureto patients and/or to inectious materials, including body

substances, contaminated medical supplies and equipment,contaminated environmental suraces, or contaminated air.HCP might include (but are not limited to) physicians,nurses, nursing assistants, therapists, technicians, emergencymedical service personnel, dental personnel, pharmacists,laboratory personnel, autopsy personnel, students and trainees,contractual sta not employed by the health-care acility, andpersons (e.g., clerical, dietary, housekeeping, laundry, security,maintenance, administrative, billing, and volunteers) notdirectly involved in patient care but potentially exposed toinectious agents that can be transmitted to and rom HCPand patients (2).

Because o their contact with patients or inective materialrom patients, many HCP are at risk or exposure to (and possibletransmission o) vaccine-preventable diseases. Employers andHCP have a shared responsibility to prevent occupationallyacquired inections and avoid causing harm to patients by takingreasonable precautions to prevent transmission o vaccine-preventable diseases. Vaccination programs are thereore anessential part o inection prevention and control or HCP.Optimal use o recommended vaccines helps maintain immunityand saeguard HCP rom inection, thereby helping protectpatients rom becoming inected; pertinent ACIP statementson various individual vaccines and diseases have been published(Table 1). Nationwide, ongoing implementation o these vaccinerecommendations through well-managed vaccination programscould substantially reduce both the number o susceptible HCPin any setting in which they interact with patients and their risksor transmitting vaccine-preventable diseases to patients, otherHCP, and other contacts (3).

HICPAC and CDC have recommended that secure,preerably computerized, systems should be used to manage

vaccination records or HCP so records can be retrieved easilyas needed (3). Each record should relect immunity statusor indicated vaccine-preventable diseases (i.e., documenteddisease, vaccination history, or serology results) as well asvaccinations administered during employment and anydocumented episodes o adverse events ater vaccination (4)

For each vaccine, the record should include date o vaccineadministration (including or those vaccines that might havebeen received prior to employment), vaccine manuacturerand lot number, edition and distribution date o the languageappropriate Vaccine Inormation Statement (VIS) providedto the vaccinee at the time o vaccination, and the nameaddress, and title o the person administering the vaccine(4). Accurate vaccination records can help to rapidly identiysusceptible HCP (i.e., those with no history o vaccinationor lack o documentation o immunity) during an outbreaksituation and can help reduce costs and disruptions to health-care operations (57). HCP should be provided a copy otheir vaccination records and encouraged to keep it with theirpersonal health records so they can readily be made availableto uture employers.

HICPAC has encouraged any acility or organization thaprovides direct patient care to ormulate a comprehensivevaccination policy or all HCP (3). The American HospitaAssociation has endorsed the concept o vaccination programor both hospital personnel and patients (8). To ensure that allHCP are up to date with respect to recommended vaccinesacilities should review HCP vaccination and immunity statusat the time o hire and on a regular basis (i.e., at least annually)

with consideration o oering needed vaccines, i necessary, inconjunction with routine annual disease-prevention measures(e.g., inluenza vaccination or tuberculin testing). Theserecommendations (Tables 2 and 3) should be consideredduring policy development. Several states and health-careacilities have established requirements relating to assessmento vaccination status and/or administration o one or morevaccines or HCP (9,10). Disease-speciic outbreak contromeasures are described in this report and elsewhere (3,11,12)All HCP should adhere to all other recommended inectioncontrol guidelines, whether or not they are individuallydetermined to have immunity to a vaccine-preventable disease

MethodsIn 2008, the ACIP Immunization o Health-Care Personne

Work Group (the Work Group) was ormed as a subgroup othe ACIP Adult Immunization Work Group to update thepreviously published recommendations or immunizationo HCP. The Work Group comprised proessionals rom


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academic medicine (pediatrics, amily medicine, internalmedicine, occupational and environmental medicine, andinectious disease); ederal and state public health proessionals;and liaisons rom the Society or Healthcare Epidemiologyo America and HICPAC. The Work Group met monthly,developed an outline or the report, worked closely with subject

matter experts at CDC (who developed, revised, and updatedsections o the report), and provided subsequent critical reviewo the drat documents. The approach o the Work Group wasto summarize previously published ACIP recommendationsand not to make new recommendations or policies; acomprehensive list o publications containing the variousvaccine-speciic recommendations is provided (Table 1). InFebruary 2011, the updated report was presented to ACIP,which voted to approve it.

The recommendations or vaccination o HCP are presentedbelow by disease in two categories: 1) those diseases orwhich routine vaccination or documentation o immunity isrecommended or HCP because o risks to HCP in their worksettings and, should HCP become inected, to the patients theyserve and 2) those diseases or which vaccination o HCP mightbe indicated in certain circumstances. Vaccines recommendedin the irst category are hepatitis B, seasonal inluenza, measles,mumps, and rubella, pertussis, and varicella vaccines. Vaccinesin the second category are meningococcal, typhoid, and poliovaccines. Except or inluenza, all o the diseases prevented bythese vaccines are notiiable at the national level (13). Mainchanges rom the 1997 ACIP recommendations have beensummarized (Box).

Diseases for Which Vaccination IsRecommended

On the basis o documented nosocomial transmission,HCP are considered to be at substantial risk or acquiringor transmitting hepatitis B, inluenza, measles, mumps,rubella, pertussis, and varicella. Current recommendations orvaccination are provided below.

Hepatitis B

Background

Epidemiology and Risk Factors

Hepatitis B is an inection caused by the hepatitis B virus(HBV), which is transmitted through percutaneous (i.e.,breaks in the skin) or mucosal (i.e., direct contact withmucous membranes) exposure to inectious blood or bodyluids. The virus is highly inectious; or nonimmune persons,

disease transmission rom a needlestick exposure is up to100 times more likely or exposure to hepatitis B e antigen(HBeAg)positive blood than to HIV-positive blood (14)HBV inection is a well recognized occupational risk or U.SHCP and globally. The risk or HBV is associated with degreeo contact with blood in the work place and with the hepatitis B

e-antigen status o the source persons (15). The virus is alsoenvironmentally stable, remaining inectious on environmentasuraces or at least 7 days (16).

In 2009 in the United States, 3,371 cases o acute HBVinection were reported nationally, and an estimated 38,000new cases o HBV inection occurred ater accounting ounderreporting and underdiagnosis (17). O 4,519 personsreported with acute HBV inection in 2007, approximately40% were hospitalized and 1.5% died (18). HBV can leadto chronic inection, which can result in cirrhosis o the liverliver ailure, liver cancer, and death. An estimated 800,0001.4million persons in the United States are living with chronicHBV inection; these persons serve as the main reservoir orcontinued HBV transmission (19).

Vaccines to prevent hepatitis B became available in theUnited States in 1981; a decade later, a national strategy toeliminate HBV inection was implemented, and the routinevaccination o children was recommended (20). During 19902009, the rate o new HBV inections declined approximately84%, rom 8.5 to 1.1 cases per 100,000 population (17); thedecline was greatest (98%) among persons aged


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training period and can vary throughout a persons career (1).

Depending on the tasks perormed, health-care or publicsaety personnel might be at risk or HBV exposure; inaddition, personnel providing care and assistance to personsin outpatient settings and those residing in long-termcareacilities (e.g., assisted living) might be at risk or acquiring oracilitating transmission o HBV inection when they perormprocedures that expose them to blood (e.g., assisted blood-glucose monitoring and wound care) (3234).

A Federal Standard issued in December 1991 under

the Occupational Saety and Health Act mandates thathepatitis B vaccine be made available at the employers expenseto all health-care personnel who are exposed occupationallyto blood or other potentially inectious materials (35). TheFederal Standard deines occupational exposure as reasonablyanticipated skin, eye, mucous membrane, or parenteracontact with blood or other potentially inectious materialsthat might result rom the perormance o an employeeduties (35). Occupational Saety and Health Administration

BOX. Summary of main changes* from 1997 Advisory Committee on Immunization Practices/Hospital (now Healthcare) Infection ControPractices Advisory Committee recommendations for immunization of health-care personnel (HCP)

Hepatitis B HCPandtraineesincertainpopulationsathighriskforchronichepatitisB(e.g.,thosebornincountrieswithhighand

intermediate endemicity) should be tested or HBsAg and anti-HBc/anti-HBs to determine inection status.

Influenza EmphasisthatallHCP,notjustthosewithdirectpatientcareduties,shouldreceiveanannualinfluenzavaccination ComprehensiveprogramstoincreasevaccinecoverageamongHCPareneeded;influenzavaccinationratesamongHCP

within acilities should be measured and reported regularly.

Measles, mumps, and rubella (MMR) HistoryofdiseaseisnolongerconsideredadequatepresumptiveevidenceofmeaslesormumpsimmunityforHCP;

laboratory conirmation o disease was added as acceptable presumptive evidence o immunity. History o disease hasnever been considered adequate evidence o immunity or rubella.

Thefootnoteshavebeenchangedregardingtherecommendationsforpersonnelbornbefore1957inroutineandoutbreak contexts. Speciically, guidance is provided or 2 doses o MMR or measles and mumps protection and 1 doseo MMR or rubella protection.

Pertussis HCP,regardlessofage,shouldreceiveasingledoseofTdapassoonasfeasibleiftheyhavenotpreviouslyreceivedTdap. Theminimalintervalwasremoved,andTdapcannowbeadministeredregardlessofintervalsincethelasttetanusor

diphtheria-containing vaccine. Hospitalsandambulatory-carefacilitiesshouldprovideTdapforHCPanduseapproachesthatmaximizevaccinationrates.

VaricellaCriteria or evidence o immunity to varicella were established. For HCP they include writtendocumentationwith2dosesofvaccine, laboratoryevidenceofimmunityorlaboratoryconfirmationofdisease, diagnosisofhistoryofvaricelladiseasebyhealth-careprovider,ordiagnosisofhistoryofherpeszosterbyhealth-care

provider.

Meningococcal HCPwithanatomicorfunctionalaspleniaorpersistentcomplementcomponentdeficienciesshouldnowreceivea2-dose series o meningococcal conjugate vaccine. HCP with HIV inection who are vaccinated should also receive a 2dose series.

ThoseHCPwhoremainingroupsathighriskarerecommendedtoberevaccinatedevery5years.

Abbreviations: HBsAg = Hepatitis B surace antigen; anti-HBc = hepatitis B core antibody; anti-HBs = hepatitis B surace antibody; Tdap = tetanus toxoid,reduced diptheria toxoid and acellular pertussis vaccine; HIV = human immunodeiciency virus.* Updated recommendations made since publication o the 1997 summary o recommendations (CDC Immunization o health-care workers: recommendations

o the Advisory Committee on Immunization Practices [ACIP] and the Hospital Inection Control Practices Advisory Committee [HICPAC]. MMWR1997;46[No. RR-18]).


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(OSHA) vaccination practice requirements (e.g., preexposureand postexposure antibody testing) are based on current ACIPrecommendations. OSHA regulations might have acceleratedthe use o hepatitis B vaccine in HCP (36).

Data rom a national, cross-sectional survey demonstratedthat during 20022003, an estimated 75% o HCP had

received the 3-dose hepatitis B vaccination series (37). Since2002, rates o 1-dose and 3-dose vaccination coverage haveremained stable. Data obtained through the National HealthInterview Survey (NHIS) in 2009 demonstrated a 1-dosecoverage rate o 75%77% and a 3-dose rate o 67%68%among HCP aged 1849 years (23). Similarly, data obtainedthrough the National Immunization SurveyAdult (NIS-Adult) in 2007 demonstrated a 3-dose coverage o 62%among HCP aged 1864 years (38). The Healthy People2020 goal (objective no. IID-15.3) o a hepatitis B vaccinationcoverage rate o 90% among HCP (39) has not been achieved.

Vaccine Effectiveness, Duration of Immunity, andVaccine Safety

Vaccine Effectiveness

The 3-dose vaccine series administered intramuscularly at0, 1, and 6 months produces a protective antibody responsein approximately 30%55% o healthy adults aged 40 yearsater the irst dose, 75% ater the second dose, and >90%ater the third dose (4042). Ater age 40 years, 99.9 F(>37.7C) (1%6%) (6467). However, in placebo-controlledstudies, these side eects were reported no more requentlyamong persons receiving hepatitis B vaccine than amongpersons receiving placebo (40,41,6467). Revaccination is noassociated with an increase in adverse events.

Hepatitis B vaccination is contraindicated or persons with ahistory o hypersensitivity to yeast or any vaccine componen(4,6466). Persons with a history o serious adverse events (e.g.anaphylaxis) ater receipt o hepatitis B vaccine should noreceive additional doses. As with other vaccines, vaccination opersons with moderate or severe acute illness, with or withouever, should be deerred until illness resolves (4). Vaccination

is not contraindicated in persons with a history o multiplesclerosis, Guillain-Barr Syndrome, autoimmune disease(e.g., systemic lupus erythematosis and rheumatoid arthritis)or other chronic diseases. Pregnancy is not a contraindicationto vaccination; limited data suggest that developing etusesare not at risk or adverse events when hepatitis B vaccine isadministered to pregnant women (4,68). Available vaccinescontain noninectious hepatitis B surace antigen (HBsAgand do not pose any risk or inection to the etus.


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Recommendations

Two single-antigen hepatitis B vaccines, Recombivax HB(Merck & Co., Inc., Whitehouse Station, New Jersey) andEngerix-B (GlaxoSmithKline Biologicals, Rixensart, Belgium)and one combination hepatitis A and hepatitis B vaccine,Twinrix (GlaxoSmithKline Biologicals), are available in theUnited States. Primary vaccination consists o 3 intramusculardoses o hepatitis B vaccine or o the combined hepatitis A andhepatitis B vaccine. The hepatitis vaccine series does not needto be restarted i the second or third dose is delayed. Detailedvaccination recommendations are available in previouslypublished guidelines (52). Vaccine schedules are available athttp://www.cdc.gov/vaccines/recs/schedules/adult-schedule.htm#HCWs. In adults, hepatitis B vaccine always should beadministered into the deltoid muscle. Longer needles (up to1.5 inches in length) might be required or obese adults (4).

Preexposure

Unvaccinated and Incompletely Vaccinated HCPand Trainees: Pre- and Postvaccination Serologic Testing

Prevaccinationserologictestingforpreviousinfectionisnot indicated or the majority o persons being vaccinatedbecause o occupational risk unless the hospital or health-care organization considers such testing cost-eective(3,52,6972). However, such testing is indicated or HCPand is cost-eective in certain high-risk populations (seeHCP and Trainees at Additional Risk), regardless ovaccination status (71,73).

Allunvaccinatedpersonswhosework-andtraining-relatedactivities involve reasonably anticipated risk or exposureto blood or other inectious body luids (e.g., HCP, long-termcare acility sta, and public saety workers) shouldbe vaccinated with the complete, 3-dose hepatitis Bvaccine series.

Personswithan incomplete seriesarenot consideredprotected and should complete the 3-dose series.

Becausehigherriskhasbeenreportedduringtheproessional training period, the vaccination series shouldbe completed beore trainees have contact with blood;vaccination should be oered in schools o medicine,

dentistry, nursing, laboratory technology, and other alliedhealth proessions. Todeterminethe need forrevaccinationandto guide

postexposure prophylaxis, postvaccination serologic testingshould be perormed or all HCP at high risk oroccupational percutaneous or mucosal exposure to bloodor body luids. Postvaccination serologic testing isperormed 12 months ater administration o the lastdose o the vaccine series using a method that allows

detection o the protective concentration o anti-HB(10 mIU/mL). Persons determined to have anti-HBsconcentrations o 10 mIU/mL ater receipt o the primaryvaccine series are considered immune, and the resultshould be documented. Immunocompetent persons havelong-term protection and do not need urther periodic

testing to assess anti-HBs levels. Postvaccination testingor persons at low risk or mucosal or percutaneousexposure to blood or body luids (e.g., public saetyworkers and HCP without direct patient contact) likelyis not cost eective (52); however, persons who do notundergo postvaccination testing should be counseled toseek immediate testing i exposed.

Personsdeterminedtohaveanti-HBsconcentrationsof


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postexposure prophylaxis should be based on the HBsAg statuso the source and the vaccination history and vaccine-responsestatus o the exposed HCP (Table 4) (72).

Unvaccinated and Incompletely Vaccinated HCPand Trainees

Unvaccinatedor incompletelyvaccinatedpersonswhoexperience a workplace exposure rom persons known tobe HBsAg-positive should receive 1 dose o hepatitis Bimmune globulin HBIG (i.e., passive vaccination) as soonas possible ater exposure (preerably within 24 hours).The eectiveness o HBIG when administered >7 daysater percutaneous or permucosal exposures is unknown(Table 4).

HepatitisBvaccineshouldbeadministeredinthedeltoidmuscle as soon as possible ater exposure; HBIG shouldbe administered at the same time at another injection site.The 3-dose hepatitis B vaccine series should be completed

or previously unvaccinated and incompletely vaccinatedpersons who have needlestick or other percutaneousexposures, regardless o the HBsAg status o the sourceand whether the status o the source is known. Todocument protective levels o anti-HBs (10mIU/mL),postvaccination testing o persons who received HBIG orpostexposure prophylaxis should be perormed ater anti-HBs rom HBIG is no longer detectable (46 months ateradministration).

Vaccinated HCP and Trainees

VaccinatedHCPwithdocumentedimmunity(anti-HBs

concentrations o 10 mIU/mL) require no postexposureprophylaxis, serologic testing, or additional vaccination.

VaccinatedHCPwithdocumentednonresponse to a3-dose vaccine series should receive 1 dose o HBIG anda second 3-dose vaccine series i the source is HBsAg-positive or known to be at high risk or carrying hepatitis.I the source is known or determined to be HBsAg-negative, these previously nonresponding HCP shouldcomplete the revaccination series and undergopostvaccination testing to ensure that their response statusis documented (Table 4). Postvaccination testing o

persons who received HBIG or PEP should be perormedater anti-HBs rom HBIG is no longer detectable (46months ater administration).

VaccinatedHCPwithdocumentednonresponsetotwo3-dose vaccine series should receive 2 doses o HBIG, 1month apart i the source is HBsAg-positive or known tobe at high risk or carrying hepatitis; no additionalvaccination is necessary. I the source is known ordetermined to be HBsAg-negative, these previously

nonresponding HCP need no additional testing ortreatment (Table 4).

VaccinatedHCPwithnodocumentationofpostvaccinationserologic response who are exposed to an HBsAg-positivesource should have serum obtained or anti-HBs testingimmediately. Those determined to have protective levels

o antibody (anti-HBs 10 mIU/mL) require no additionatreatment; those with concentrations


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o HCP and inectious disease specialists) regarding theprocedures that they can perorm saely. They should notbe excluded rom work (69). Additional inormationregarding prevaccination testing or HCP with otherhepatitis B risk actors and or pregnant women has beenpublished previously (52,71). HCP receiving hemodialysis

should be provided annual anti-HBs testing and should beadministered a booster dose o vaccine when anti-HBs levelsdecline to 200,000hospitalizations and 3,00049,000 deaths annually in theUnited States (7476). The majority o inluenza-relatedsevere illnesses and deaths occur among persons with chronicmedical conditions, inants and young children, seniors, andpregnant women (7478). Reducing the risk or inluenzaamong persons at higher risk or complications is a major ocuso inluenza prevention strategies (77).

Influenza Transmission in Health-Care Settings

HCP are exposed to patients with inluenza in the workplaceand are thus at risk o occupationally acquired inluenza and o

transmitting inluenza to patients and other HCP. In a cross-sectional survey o hospital house sta (physicians in training)37% reported inluenza-like illness during SeptemberApriland 9% reported more than one respiratory illness. Length oillness varied (range: 110 days; mean: 7 days), as did days owork missed (range: 010 days; mean: 0.7 days) (79). Inected

HCP who continue to work while ill might transmit inluenzato patients, many o whom are at increased risk or severeoutcomes rom inluenza. HCP are thereore recommendedor routine annual inluenza vaccination (77).

Few randomized trials o the eect that inluenza vaccinationhas on illness in HCP have been conducted. In one randomizedtrial o 427 HCP, inluenza vaccination o HCP ailed todecrease episodes o respiratory inection or duration o illnesbut was associated with a 28% decrease in absenteeism (rom1.4 days to 1.0 day) attributable to respiratory inections (80)No laboratory conirmation o inluenza was obtained in thisstudy. In another randomized trial among HCP, vaccinationwas associated with a signiicantly lower rate o serologicaevidence o inluenza inection, with a vaccine eicacy rate o88% or inluenza A and 89% or inluenza B (p


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allergic reactions to prior inluenza vaccination), patientswho respond poorly to vaccination (e.g., persons aged 85years and immune-compromised persons), and persons orwhom antiviral treatment is not available (e.g., persons withmedical contraindications). Although annual vaccination haslong been recommended or HCP and is a high priority or

reducing morbidity associated with inluenza in health-caresettings (98100), national survey data have demonstratedthat the vaccination coverage level during the 200809 seasonwas 52.9% (101).

Considerations Regarding Influenza Vaccinationof HCP

Barriers to HCP aceptance o inluenza vaccination haveincluded ear o vaccine side eects (particularly inluenza-like symptoms), insuicient time or inconvenience, perceivedineectiveness o the vaccine, perceived low likelihood ocontracting inluenza, avoidance o medications, and ear o

needles (79,102109). Factors demonstrated to increase vaccineacceptance include a desire or sel-protection, previous receipto inluenza vaccine, a desire to protect patients, and perceivedeectiveness o vaccine (79,105,106,109112). Strategiesthat have demonstrated improvement in HCP vaccinationrates have included campaigns to emphasize the beneits oHCP vaccination or sta and patients, vaccination o seniormedical sta or opinion leaders, removing administrativebarriers (e.g., costs), providing vaccine in locations and attimes easily accessible by HCP, and monitoring and reportingHCP inluenza vaccination rates (99,113120). Intranasallyadministered live attenuated inluenza vaccine (LAIV) is anoption or healthy, nonpregnant adults aged 70%80% (99,115,121123). Institutionsthat require declination statements rom HCP who reuseinluenza vaccination should educate and counsel these HCPabout beneits o the vaccine.

Each health-care acility should develop a comprehensiveinluenza vaccination strategy that includes targeted education

about the disease, including disease risk among HCP andpatients, and about the vaccine. In addition, the programshould establish easily accessible vaccination sites and inormHCP about their locations and schedule. Facilities thatemploy HCP should provide inluenza vaccine at no cost topersonnel (124). The most eective combination o approachesor achieving high inluenza vaccination coverage amongHCP likely varies by institution. Hospitals and health-care

organizations in the United States traditionally have employedan immunization strategy that includes one or more o theollowing components: education about inluenza, easy accesto vaccine, incentives to encourage immunization, organizedcampaigns, institution o declination policies, and legislativeand regulatory eorts (e.g., vaccination requirements) (99

115, 121126).Beginning January 1, 2007, the Joint Commission on

Accred itat ion o Heal th-Care Organizations requiredaccredited organizations to oer inluenza vaccinations to staincluding volunteers and licensed independent practitionersand to report coverage levels among HCP (127). Standardsare available or measuring vaccination coverage amongHCP as a measure o program perormance within a healthcare setting (128). Beginning January 2013, the Centers orMedicaid Services will require acute care hospitals to reportHCP inluenza vaccine as part o its hospital inpatient qualityreporting program.*

Vaccine Effectiveness, Duration of Immunity, andVaccine Safety

Eectiveness o inluenza vaccines varies rom year to yeaand depends on the age and health status o the person gettingthe vaccine and the similarity or match between the virusesor virus in the vaccine and those in circulation. Vaccine strainare selected or inclusion in the inluenza vaccine every yeabased on international surveillance and scientists estimationabout which types and strains o viruses will circulate in agiven year. Annual vaccination is recommended because thepredominant circulating inluenza viruses typically changerom season to season and, because immunity declines overtime postvaccination (77).

In placebo-controlled studies among adults, the mostrequent side eect o vaccination was soreness at thevaccination site (aecting 10%64% o patients) that lasted


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Recommendations

Vaccination

Annual inluenza vaccination is recommended or all personsaged 6 months who have no medical contraindication;thereore, vaccination o all HCP who have no contraindications

is recommended. The inluenza vaccine is evaluated annuallywith one or more vaccine strains updated almost every year.In addition, antibody titers decline during the year atervaccination. Thus, annual vaccination with the currentseasons ormulation is recommended. Annual vaccination isappropriate and sae to begin as early in the season as vaccineis available. HCP should be among the groups considered orprioritized receipt o inluenza vaccines when vaccine supplyis limited.

Two types o inluenza vaccines are available. LAIV isadministered intranasally and is licensed or use in healthynonpregnant persons aged 249 years. The trivalent inactivated

vaccine (TIV) is administered as an intramuscular injectionand can be given to any person aged 6 months. Both vaccinetypes contain vaccine virus strains that are selected to stimulatea protective immune response against the wild-type virusesthat are thought to be most likely in circulation during theupcoming season. Use o LAIV or HCP who care or patientshoused in protective inpatient environments has been atheoretic concern, but transmission o LAIV in health-caresettings has not been reported. LAIV can be used or HCPwho work in any setting, except those who care or severelyimmunocompromised hospitalized persons who require care

in a protective environment. HCP who themselves have acondition that coners high risk or inluenza complications,who are pregnant, or who are aged 50 years should not receiveLAIV and should be administered TIV instead. An inactivatedtrivalent vaccine containing 60 mcg o hemagglutinin antigenper inluenza vaccine virus strain (Fluzone High-Dose [sanoipasteur]) is an alternative inactivated vaccine or persons aged65 years. Persons aged 65 years may be administered anyo the standard-dose TIV preparations or Fluzone High-Dose(77). The majority o TIV preparations are administeredintramuscularly. An intradermally administered TIV waslicensed in May 2011 and is an alternative to other TIV

preparations or persons aged 1864 years (131).Use of Antiviral Drugs for Treating Exposed Personsand Controlling Outbreaks

Use o antiviral drugs or chemoprophylaxis or treatment oinluenza is an adjunct to (but not a substitute or) vaccination.Oseltamivir or zanamivir are recommended currently orchemoprophylaxis or treatment o inluenza (132,133). TIV

can be administered to exposed, unvaccinated HCP at thesame time as chemoprophylaxis, but LAIV should be avoidedbecause the antiviral medication will prevent viral replicationneeded to stimulate a vaccine response (77). Antivirals areused oten among patients during outbreaks in closed settingssuch as long-termcare acilities but also can be administered

to unvaccinated HCP during outbreaks, when an exposureto a person with inluenza occurs, or ater exposure whenvaccination is not thought to be protective against the strainto which a vaccinated HCP was exposed. Chemoprophylaxiconsists o 1 dose (o either antiviral drug) daily or 10 daysand treatment consists o 1 dose twice daily or 5 days. Inmany instances o HCP exposure, watchul waiting and earlyinitiation o treatment i symptoms appear is preerred rathethan use o antiviral chemoprophylaxis immediately aterexposure. The intensity and duration o the exposure and theunderlying health status o the exposed worker are importanactors in clinical judgments about whether to providechemoprophylaxis. I chemoprophylaxis is used, the providershould base choice o the agent on whether the circulatingstrain or strains o inluenza have demonstrated resistance toparticular antivirals.

Program Evaluation

Health-care administrators should include influenzavaccination coverage among HCP as a measure o qualityo care (124).

InfluenzavaccinationratesamongHCPwithinfacilitiesshould be regularly measured and reported, and ward-unit-, and specialty-speciic coverage rates should beprovided to sta and administration (124). Suchinormation might be useul to promote compliance withvaccination policies.

Measles

Background


Measles is a highly contagious rash illness that is transmitted byrespiratory droplets and airborne spread. Severe complicationswhich might result in death, include pneumonia andencephalitis. Beore the national measles vaccination programwas implemented in 1963, almost every person acquiredmeasles beore adulthood; an estimated 34 million personin the United States acquired measles each year (134)Approximately 500,000 persons were reported to have hadmeasles annually, o whom 500 persons died, 48,000 were


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hospitalized, and another 1,000 had permanent brain damagerom measles encephalitis (134).

Through a successul 2-dose measles vaccination program(i.e., a irst dose at age 1215 months and a second dosebetween ages 46 years) (135) and better measles controlthroughout the region o the Americas (136), endemic

transmission o measles was interrupted in the United States,and measles was declared eliminated rom the country in 2000(137). However, measles remains widespread in the majority ocountries outside the Western Hemisphere, with an estimated20 million measles cases occurring worldwide (138) andapproximately 164,000 related deaths (139). Thus, the UnitedStates continues to experience international importations thatmight lead to transmission among U.S. residents and limitedoutbreaks, especially in unvaccinated populations (140143).

During 20012008, a total o 557 conirmed measles caseswere reported in the United States rom 37 states and the Districto Columbia (annual median: 56; range: 37 in 2004 to 140 in2008), representing an annual incidence o less than one case permillion population (144). O the 557 reported case-patients, 126(23%) were hospitalized (annual median: 16; range: 529); othese, at least ive case-patients were admitted to intensive care.Two deaths were reported, both in 2003 (144).

O the 557 reported case-patients during 20012008, atotal o 223 (40%) were adults, including 156 (28%) aged2039 years and 67 (12%) aged 40 years. O the 438 measlescases among U.S. residents, 285 (65%) cases were consideredpreventable (i.e., occurred among persons who were eligibleor vaccination but were unvaccinated) (144). The remaining

153 (35%) cases were considered nonpreventable. Cases weredeined as nonpreventable i they occurred among U.S. residentcase-patients who had received 1 dose o measles-containingvaccine, i patients were vaccinated as recommended i travelinginternationally, or i they were not vaccinated but had otherevidence o immunity (i.e., were born beore 1957 andthereore presumed immune rom natural disease in childhood,had laboratory evidence o immunity, or had documentationo physician-diagnosed disease) or or whom vaccination is notrecommended. During 20012008, a total o 12.5% (one oeight) o measles cases reported to CDC among HCP occurredin persons born beore 1957; the other seven cases occurred

among HCP born ater 1957.Measles-mumps-rubella (MMR) vaccination policies have

been enorced with variable success in United States health-care acilities over the past decade. Even though medicalsettings were a primary site o measles transmission duringthe 19891991 measles resurgence (145,146), as o September

2011, only three states (New York, Oklahoma, and RhodeIsland) had laws mandating that all hospital personnel haveproo o measles immunity and did not allow or religious orphilosophic exemptions (147).

Vaccine coverage in the United States is high; in 2010, a totao 91.5% o children aged 1935 months had received 1 dose

o MMR vaccine (21); during 20092010, a total o 94.8%o kindergartners had evidence o 2 doses (148); and in 2010a total o 90.5% o adolescents had evidence o 2 doses (22)Nationally representative data on MMR vaccine coverage oU.S. HCP are not available.

Measles Transmission and the Costs of MitigatingMeasles Exposures in Health-Care Settings

Health-careassociated cases o measles are o public healthconcern. Because o the severity o measles, inected personare likely to seek medical care in primary health-care acilitiesemergency departments, or hospitals (141,149,150). Medicasettings played a prominent role in perpetuating outbreaks omeasles transmission during the 19891991 measles resurgence(145,146) and were a primary site o measles transmission in ahealth-careassociated outbreak in 2008 (149). During 20012008, a total o 27 reported measles cases were transmitted inU.S. health-care acilities, accounting or 5% o all reportedU.S. measles cases.

Because o the greater opportunity or exposure, HCP are ahigher risk than the general population or becoming inectedwith measles. A study conducted in 1996 in medical acilitiein a county in Washington state indicated that HCP were 19

times more likely to develop measles than other adults (151)During 20012008, in the 23 health-care settings in whichmeasles transmission was reported, eight cases occurred amongHCP, six (75%) o whom were unvaccinated or had unknownvaccination status. One health-care provider was hospitalizedin an intensive care unit or 6 days rom severe measlescomplications (142). During a health-careassociated measlesoutbreak in Arizona in 2008 with 14 cases, six cases wereacquired in hospitals, and one was acquired in an outpatientsetting. One unvaccinated health-care worker developedmeasles and inected a hospital emergency room patientwho required intensive care ollowing hospital admission o

measles (149).High costs also are involved in evaluating and containing

exposures and outbreaks in health-care acilities, as well asa substantial disruption o regular hospital routines whencontrol measures are instituted, especially i hospitals do nothave readily available data on the measles immunity status


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o their sta and others included in the acility vaccinationprogram. In 2005 in Indiana, one hospital spent more than$113,000 responding to a measles outbreak (142), and in 2008in Arizona, two hospitals spent $799,136 responding to andcontaining cases in their acilities (149). The Arizona outbreakresponse required rapid review o measles documentation o

14,844 HCP at seven hospitals and emergency vaccinationo approximately 4,500 HCP who lacked documentation omeasles immunity. Serologic testing at two hospitals among1,583 HCP without documented history o vaccination orwithout documented laboratory evidence o measles immunityrevealed that 138 (9%) o these persons lacked measles IgGantibodies (149).

Vaccine Effectiveness, Duration of Immunity andSeroprevalence Studies, and Vaccine Safety


MMR vaccine is highly eective in preventing measles witha 1-dose vaccine eectiveness o 95% when administered onor ater age 12 months and a 2-dose vaccine eectiveness o99% (135).

Duration of Immunity and Seroprevalence Studies

Two doses o live measles vaccine are considered to providelong-lasting immunity (135). Although antibody levels declineollowing vaccination, a study examining neutralizing antibodylevels up to 10 years ollowing the second dose o MMR vaccinein children indicates that antibodies remain above the levelconsidered protective (152).

Studies among HCP in the United States during the measlesresurgence in the late 1980s through early 1990s demonstratedthat 4%10% o all HCP lacked measles IgG antibodies(153156). During the 2008 Arizona outbreak, o the 1,077health-care providers born during or ater 1957 withoutdocumented measles immunity, 121 (11%) were seronegative(149). In a study o measles seroprevalence among 469 newlyhired HCP at a hospital in North Carolina who were bornbeore 1957, and thus considered immune by age, who couldnot provide written evidence o immunity to measles, serologictesting indicated that six (1.3%) lacked measles IgG antibodies(157). Other serologic studies o hospital-based HCP indicate

that 2%9% o those born beore 1957 lacked antibodies tomeasles (156,158160).

A sur ve y co nd uc te d dur ing 19 99 20 04 oun d aseroprevalence o measles antibodies o 95.9% among personsin the U.S. population aged 649 years (161). The survey

indicated that the lowest prevalence, 92.4%, was amongadults born during 19671976 (161). A 1999 study o U.Sresidents aged 20 years determined that 93% had antibodieto measles virus (162).

Vaccine Safety

Measles vaccine is administered in combination with themumps and rubella components as the MMR vaccine in theUnited States. Monovalent measles vaccine rarely has beenused in the United States in the past 2 decades and is no longeravailable. Ater decades o use, evidence demonstrates thaMMR vaccine has an excellent saety proile (134).

The majority o documented adverse events occur inchildren. In rare circumstances, MMR vaccination o adultshas been associated with the ollowing adverse eventsanaphylaxis (approximately 1.03.5 occurrences per milliondoses administered) (134), thrombocytopenia rom the measlescomponent or rubella component (a rate o three to our case

or every 100,000 doses) (134), and acute arthritis rom therubella component (arthralgia develops among approximately25% o rubella-susceptible postpubertal emales ater MMRvaccination, and approximately 10% have acute arthritis-likesigns and symptoms) (135). When joint symptoms occur, theygenerally persist or 1 day3 weeks and rarely recur (135)Chronic joint symptoms attributable to the rubella componento the MMR vaccine are reported very rarely, i they occur aall. Evidence does not support an association between MMRvaccination and any o the ollowing: hearing loss, retinopathyoptic neuritis, Guillain-Barr Syndrome, type 1 diabetesCrohns disease, or autism (135,163169).

A woman can excrete the rubella vaccine virus in breast milkand transmit the virus to her inant, but the inection remainasymptomatic (135). Otherwise, persons who receive MMRor its component vaccines do not transmit measles, rubellaor mumps vaccine viruses (135). No transmission o MMRvaccine virus in a health-care setting has been documented.

Recommendations

Vaccination

All persons who work in hea lth-care acil ities shouldhave presumptive evidence o immunity to measles. This

inormation should be documented and readily available atthe work location. Recently vaccinated HCP do not requireany restriction in their work activities.

Presumptive evidence o immunity to measles or personswho work in health-care acilities includes any o the ollowing


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writtendocumentationofvaccinationwith2dosesoflivemeasles or MMR vaccine administered at least 28 daysapart,

laboratoryevidenceofimmunity,

laboratoryconfirmationofdisease,or birthbefore1957.

Prevaccination Testing

Prevaccination antibody screening beore MMR vaccinationor an employee who does not have adequate presumptiveevidence o immunity is not necessary unless the medicalacility considers it cost eective (134,170172) althoughno recent studies have been conducted. For HCP who have2 documented doses o MMR vaccine or other acceptableevidence o immunity to measles, serologic testing or immunityis not recommended. In the event that a HCP who has 2documented doses o MMR vaccine is tested serologically anddetermined to have negative or equivocal measles titer results, it

is not recommended that the person receive an additional doseo MMR vaccine. Such persons should be considered to havepresumptive evidence o measles immunity. Documented age-appropriate vaccination supersedes the results o subsequentserologic testing. Because rapid vaccination is necessary to haltdisease transmission, during outbreaks o measles, serologicscreening beore vaccination is not recommended.

Use of Vaccine and Immune Globulin for TreatingExposed Persons and Controlling Outbreaks

Following airborne inectioncontrol precautions andimplementing other inection-control measures are important

to control the spread o measles but might ail to preventall nosocomial transmission, because transmission to othersusceptible persons might occur beore illness is recognized.Persons inected with measles are inectious 4 days beore rashonset through 4 days ater rash onset.

When a person who is suspected o having measles visitsa health-care acility, airborne inectioncontrol precautionsshould be ollowed stringently. The patient should be askedimmediately to wear a medical mask and should be placed

in an airborne-inection isolation room (i.e., a negative airpressure room) as soon as possible. I an airborne-inectionisolation room is not available, the patient should be placedin a private room with the door closed and be asked to weara mask. I possible, only sta with presumptive evidence oimmunity should enter the room o a person with suspect or

conirmed measles. Regardless o presumptive immunity statusall sta entering the room should use respiratory protectionconsistent with airborne inectioncontrol precautions (i.e., useo an N95 respirator or a respirator with similar eectivenesin preventing airborne transmission) (3,150).

Because o the possibility, albeit low (~1%), o measlesvaccine ailure in HCP exposed to inected patients (173)all HCP should observe airborne precautions in caring orpatients with measles. HCP in whom measles occurs shouldbe excluded rom work until 4 days ollowing rash onsetContacts with measles-compatible symptoms should beisolated, and appropriate inection-control measures (e.g., rapidvaccination o susceptible contacts) should be implemented toprevent urther spread (174).

I measles exposures occur in a health-care acility, all contactsshould be evaluated immediately or presumptive evidence omeasles immunity. HCP without evidence o immunity shouldbe oered the irst dose o MMR vaccine and excluded romwork rom day 521 ollowing exposure (135). HCP withouevidence o immunity who are not vaccinated ater exposureshould be removed rom all patient contact and excluded romthe acility rom day 5 ater their irst exposure through day 21ater the last exposure, even i they have received postexposure

intramuscular immune globulin o 0.25 mL/kg (40 mg IgGkg) (135). Those with documentation o 1 vaccine dose mayremain at work and should receive the second dose.

Case-patient contacts who do not have presumptiveevidence o measles immunity should be vaccinated, oeredintramuscular immune globulin o 0.25 mL/kg (40 mg IgGkg), which is the standard dosage or nonimmunocompromisedpersons (135), or quarantined until 21 days ater theirexposure to the case-patient. Contacts with measles-compatiblesymptoms should be isolated, and appropriate inection-control measures should be implemented to prevent urtherspread. I immune globulin is administered to an exposed

person, observations should continue or signs and symptomso measles or 28 days ater exposure because immune globulinmight prolong the incubation period.

Available data suggest that live virus measles vaccine, iadministered within 72 hours o measles exposure, will preventor modiy disease (134). Even i it is too late to provide eectivepostexposure prophylaxis by administering MMR, the vaccine canprovide protection against uture exposure to all three inectionsIdentiying persons who lack evidence o measles immunity during

The irst dose o measles-containing vaccine should be administered on or aterthe irst birthday; the second dose should be administered no earlier than 28

days ater the irst dose. Measles immunoglobulin (IgG) in the serum; equivocal results should beconsidered negative.

The majority o persons born beore 1957 are likely to have been inectednaturally and may be presumed immune, depending on current state or localrequirements. For unvaccinated personnel born beore 1957 who lack laboratoryevidence o measles immunity or laboratory conirmation o disease, health-careacilities should consider vaccinating personnel with 2 doses o MMR vaccineat the appropriate interval. For unvaccinated personnel born beore 1957 wholack laboratory evidence o measles immunity or laboratory conirmation odisease, health-care acilities should recommend 2 doses o MMR vaccine duringan outbreak o measles.


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contact investigations provides a good opportunity to oer MMRvaccine to protect against measles as well as mumps and rubella,not only or HCP who are part o an organizations vaccinationprogram, but also or patients and visitors. I an exposed person isalready incubating measles, MMR vaccination will not exacerbatesymptoms. In these circumstances, persons should be advised that

a measles-like illness occurring shortly ater vaccination could beattributable either to natural inection or to the vaccine strain.In such circumstances, specimens should be submitted or viralstrain identiication.

Mumps

Background


Mumps is an acute viral inection characterized by ever andinlammation o the salivary glands (usually parotitis) (175).

The spectrum o illness ranges rom subclinical inection (20%40%) to nonspeciic respiratory illness, sialadenitis includingclassic parotitis, deaness, orchitis, and meningoencephalitis;severity increases with age (175). In the prevaccine era, mumpswas a common childhood illness, with approximately 186,000mumps cases reported in the United States per year (176). Aterthe introduction o the Jeryl Lynn strain mumps vaccine in1967 and the implementation o the 1-dose mumps vaccinepolicy or children in 1977 (177), reports o mumps cases inthe United States declined 99% (178). During 19861987, anincrease in reported mumps cases occurred, primarily aectingunvaccinated adolescents and young adults. In the late 1980s,sporadic outbreaks continued to occur that aected bothunvaccinated and 1-dose vaccinated adolescents and youngadults (178). In 1989, a second dose o MMR vaccine wasrecommended nationwide or better measles control amongschool-aged children (179). Historically low rates o mumpsollowed with only several hundred reported cases per year inthe United States during 20002005.

In 1998, a national goal to eliminate mumps was set or 2010(180). However, in 2006, a total o 6,584 mumps cases werereported in the United States, the largest U.S. mumps outbreakin nearly 20 years (181183). Whereas overall national mumps

incidence was 2.2 per 100,000 population, eight states inthe Midwest were the most aected, with 2.566.1 cases per100,000 population (183). The highest incidence (31.1 casesper 100,000 population) was among persons aged 1824years (e.g., college-aged students), the majority o whom hadreceived 2 doses o mumps-containing vaccine. O the 4,017case-patients or whom age and vaccination status were known,1,786 (44%) were aged 25 years (incidence: 7.2 cases per100,000 persons); o these 1,786 patients, 351 (20%) received

at least 2 doses, 444 (25%) received 1 dose, 336 (19%) wereunvaccinated, and 655 (37%) had unknown vaccination status

Since the 2006 resurgence, two additional large U.S. mumpsoutbreaks have occurred, both during 20092010, one amongmembers o a religious community with cases occurringthroughout the northeastern United States (184) and the other

in Guam (185); both outbreaks primarily aected childrenand adolescents in crowded environments who had received2 doses o vaccine.

Vaccine coverage in the United States is high; in 2010approximately 91.5% o children aged 1935 months hadreceived 1 dose o MMR vaccine (21); during 20092010, atotal o 94.8% o kindergartners had evidence o 2 doses (148)In 2010, a total o 90.5% o adolescents had evidence o 2doses (22). Nationally representative data on MMR vaccinecoverage o U.S. HCP are not available.

Mumps Transmission and the Costs of Mitigating

Mumps Exposures in Health-care SettingsAlthough health-careassociated transmission o mumps

is inrequent, it might be underreported because o the highpercentage (~20%40%) o inected persons who might beasymptomatic (186189). In a survey o 9,299 adults indierent proessions conducted in 1968, beore vaccine wasused routinely, the rate o mumps acquisition was highestamong dentists and HCP, with rates o 18% among dentistsand 15% among physicians (37% or pediatricians), comparedwith 9% among primary and secondary school teachers and2% among university sta members (190).

In the postvaccine era, mumps transmission also hasbeen documented in medical settings (191193). During aTennessee mumps outbreak during 19861987, a total o 17(12%) o 146 hospitals and three (50%) o six long-termcareacilities reported one or more practices that could contributeto the spread o mumps, including not isolating patients withmumps, assigning susceptible sta to care or patients withmumps, and not immunizing susceptible employees. Healthcareassociated transmission resulted in six cases o mumpsinections among health-care providers and nine cases omumps inections among patients (191). In Utah in 1994two health-care providers in a hospital developed mumps ate

they had contact with an inected patient (192). During the2006 outbreak, one health-care acility in Chicago experiencedongoing mumps transmission lasting 4 weeks (193).

During the 2006 multistate U.S. outbreak, 144 (8.5%)o 1,705 adult case-patients in Iowa or whom occupationwas known were health-care providers (Iowa Departmento Public Health, unpublished data, 2006). Whethertransmission occurred rom patients, coworkers, or persons in


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the community is unknown. During the 20092010 outbreakin the northeastern region o the United States, seven (0.2%)o the 3,400 case-patients were health-care providers, six owhom likely were inected by patients because they had noother known exposure.

Exposures to mumps in health-care settings also can result

in added economic costs because o urlough or reassignmento sta members rom patient-care duties or closure o wards(194). In 2006, a Kansas hospital spent $98,682 containing amumps outbreak (195). During a mumps outbreak in Chicagoin 2006, one health-care acility spent $262,788 controllingthe outbreak (193).



MMR vaccine has a 1-dose vaccine eectiveness in preventing

mumps o 80%85% (range: 75%91%) (175,196199) anda 2-dose vaccine eectiveness o 79%95% (199202). In astudy conducted on two Iowa college campuses during the2006 mumps outbreak among a population that was primarilyvaccinated with 2 doses, 2-dose vaccine eectiveness rangedrom 79% to 88% (202).


Mumps antibody levels wane over time ollowing the irstor second dose o vaccination (203,204), but the correlateso immunity to mumps are poorly understood and thesigniicance o these waning antibody levels is unclear. A

study on a university campus in Nebraska in 2006 indicatedlower levels o mumps neutralizing antibodies among studentswho had been vaccinated with a second MMR dose >15years previously than among those who had been vaccinated15 years previously, but the dierence was not statisticallysigniicant (p>0.05) (205). In a 2006 study on a universitycampus in Kansas, students with mumps were more likelyto have received a second dose o MMR vaccine 10 yearspreviously than were their roommates without mumps (206).However, another 2006 study rom an Iowa college campusidentiied no such association (202).

During 19992004, national seroprevalence or mumps

antibodies or persons aged 649 years was 90% (95%conidence interval [CI]: 88.891.1) (207). In the Nebraskastudy, 414 (94%) o the 440 participants were seropositive ormumps antibodies (205). A study in Kansas in 2006 indicatedthat 13% o hospital employees lacked antibodies to the mumpsvirus (195). In a recent study on mumps seroprevalence among381 newly hired health-care personnel at a hospital in NorthCarolina who were born beore 1957 and thus considered

immune by age and who could not provide written evidenceo immunity to mumps, serologic testing indicated that 14(3.7%) lacked IgG antibodies to mumps (157).

Vaccine Safety

Mumps vaccine is administered in combination with the

measles and rubella components as the MMR vaccine in theUnited States. Monovalent mumps vaccine has rarely beenused in the United States in the past 2 decades and is no longeravailable. Ater decades o use, evidence demonstrates thaMMR vaccine has an excellent saety proile. The most commonadverse reactions to the mumps component o the MMR vaccineare parotitis 1014 days ater vaccination and low-grade ever(175). On the basis o biologic plausibility, orchitis, arthritisor sensorineural deaness might rarely ollow vaccination (175)

The majority o documented adverse events occur inchildren. In rare circumstances, MMR vaccination oadults has been associated with anaphylaxis (approximately

1.03.5 occurrences per million doses administered) (134)thrombocytopenia rom the measles component or rubellacomponent (rate: three to our cases or every 100,000doses) (134), and acute arthritis rom the rubella component(arthralgia develops among approximately 25% o rubellasusceptible postpubertal emales ater MMR vaccinationand approximately 10% have acute arthritis-like signs andsymptoms) (135). When joint symptoms occur, they generallypersist or 1 day3 weeks and rarely recur (135). Chronic jointsymptoms attributable to the rubella component o the MMRvaccine are reported rarely, i they occur at all. Evidence doesnot support a link between MMR vaccination and hearing lossretinopathy, optic neuritis, Guillain-Barr Syndrome, type 1diabetes, Crohns disease, or autism (135,163169).


Recommendations

Vaccination

All persons who work in hea lth-care acil ities shouldhave presumptive evidence o immunity to mumps. Thisinormation should be documented and readily available atthe work location. Recently vaccinated HCP do not requireany restriction in their work activities.

Presumptive evidence o immunity to mumps or personwho work in health-care acilities includes any o the ollowing


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writtendocumentationofvaccinationwith2dosesoflivemumps or MMR vaccine administered at least 28 daysapart,**

laboratoryevidenceofimmunity,

laboratoryconfirmationofdisease,or birthbefore1957.


For HCP who do not have adequate presumptive evidenceo mumps immunity, prevaccination antibody screeningbeore MMR vaccination is not necessary (135,175). ForHCP who have 2 documented doses o MMR vaccine orother acceptable evidence o immunity to mumps, serologictesting or immunity is not recommended. In the eventthat a health-care provider who has 2 documented doseso MMR vaccine is tested serologically and determined tohave negative or equivocal mumps titer results, it is notrecommended that the person receive an additional dose o

MMR vaccine. Such persons should be considered immune tomumps. Documented age-appropriate vaccination supersedesthe results o subsequent serologic testing. Likewise, duringoutbreaks o mumps, serologic screening beore vaccinationis not recommended because rapid vaccination is necessary tohalt disease transmission.

Controlling Mumps Outbreaks in Health-Care Settings

Placing patients in droplet precautions and implementingother inection-control measures is important to control thespread o mumps but might ail to prevent all nosocomialtransmission, because transmission to other susceptible persons

might occur beore illness is recognized (208). When a personsuspected o having mumps visits a health-care acility, onlyHCP with adequate presumptive evidence o immunityshould be exposed to the person, and in addition to standardprecautions, droplet precautions should be ollowed. The indexcase-patient should be isolated, and respiratory precautions

(gown and gloves) should be used or patient contact. Negativepressure rooms are not required. The patient should be isolatedor 5 days ater the onset o parotitis, during which timeshedding o virus is likely to occur (209).

I mumps exposures occur in a health-care acility, all contactsshould be evaluated or evidence o mumps immunity. HCP

with no evidence o mumps immunity who are exposed topatients with mumps should be oered the irst dose o MMRvaccine as soon as possible, but vaccine can be administeredat any interval ollowing exposure; they should be excludedrom duty rom day 12 ater the irst unprotected exposurethrough day 25 ater the most recent exposure. HCP withdocumentation o 1 vaccine dose may remain at work andshould receive the second dose. HCP with mumps should beexcluded rom work or 5 days rom the onset o parotitis (209)

Antibody response to the mumps component o MMRvaccine generally is believed not to develop soon enoughto provide eective prophylaxis ater exposure to suspectedmumps (191,210), but data are insuicient to rule oua prophylactic eect. Nonetheless, the vaccine is notrecommended or prophylactic purposes ater exposureHowever, identiying persons who lack presumptive evidenceo mumps immunity during contact investigations providesa good opportunity to oer MMR vaccine to protect againsmumps as well as measles and rubella, not only or HCP whoare part o an organizations vaccination program, but also opatients and visitors. I an exposed person already is incubatingmumps, MMR vaccination will not exacerbate the symptomsIn these circumstances persons should be advised that a

mumps-like illness occurring shortly ater vaccination is likelyto be attributable to natural inection. In such circumstancesspecimens should be submitted or viral strain identiicationto dierentiate between vaccine and wild type virus. Immuneglobulin is not routinely used or postexposure protection rommumps because no evidence exists that it is eective (135).

Rubella

Background


Rubella (German measles) is a viral disease characterizedby rash, low-grade ever, lymphadenopathy, and malaise(211). Although rubella is considered a benign diseasetransient arthralgia and arthritis are observed commonly ininected adults, particularly among postpubertal emalesChronic arthritis has been reported ater rubella inectionbut such reports are rare, and evidence o an association isweak (212). Other complications that occur inrequently

** The irst dose o mumps-containing vaccine should be administered on orater the irst birthday; the second dose should be administered no earlier than28 days ater the irst dose.

Mumps immunoglobulin (IgG) in the serum; equivocal results should beconsidered negative.

The majority o persons born beore 1957 are likely to have been inectednaturally between birth and 1977, the year that mumps vaccination wasrecommended or routine use, and may be presumed immune, even i theyhave not had clinically recognizable mumps disease. (This might varydepending on current state or local requirements.) For unvaccinated personnelborn beore 1957 who lack laboratory evidence o mumps immunity orlaboratory conirmation o disease, health-care acilities should considervaccinating personnel with 2 doses o MMR vaccine at the appropriate interval;or unvaccinated personnel born beore 1957 who lack laboratory evidenceo mumps immunity or laboratory conirmation o disease, health-care acilitiesshould recommend 2 doses o MMR vaccine during an outbreak o mumps.


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are thrombocytopenia and encephalitis (211). Inection isasymptomatic in 25%50% o cases (213). Clinical diagnosiso rubella is unreliable and should not be considered inassessing immune status. Many rash illnesses might mimicrubella inection and many rubella inections are unrecognized.The only reliable evidence o previous rubella inection is the

presence o serum rubella IgG antibody (211).O primary concern are the eects that rubella can have

when a pregnant woman becomes inected, especially duringthe irst trimester, which can result in miscarriages, stillbirths,therapeutic abortions, and congenital rubella syndrome(CRS), a constellation o birth deects that oten includesblindness, deaness, mental retardation, and congenital heartdeects (211,213). Postnatal rubella is transmitted throughdirect or droplet contact rom nasopharyngeal secretions. Theincubation period ranges rom 12 to 23 days (214,215). Anill person is most contagious when the rash irst appears, butthe period o maximal communicability extends rom a ewdays beore to 7 days ater rash onset (213). Rubella is lesscontagious than measles.

In the prevaccine era, rubella was an endemic disease globallywith larger epidemics that occurred; in the United States,rubella epidemics occurred approximately every 7 years (211).During the 19641965 global rubella epidemic, an estimated12.5 million cases o rubella occurred in the United States,resulting in approximately 2,000 cases o encephalitis, 11,250etal deaths attributable to spontaneous or surgical abortions,2,100 inants who were stillborn or died soon ater birth, and20,000 inants born with CRS. The economic impact o this

epidemic in the United States alone was estimated at $1.5billion in 1965 dollars ($10 billion in 2010 dollars) (216).Ater the rubella vaccine was licensed in the United States in

1969, reported rubella cases decreased rom 57,686 in 1969to 12,491 in 1976 (216), and CRS cases reported nationwidedecreased rom 68 in 1970 to 23 in 1976 (217). Declinesin rubella age-speciic incidence occurred in all age groups,including adolescents and adults, but the greatest declines wereamong children aged 15years compared with 23% o cases during 19661968 (135).As a result o the change in the epidemiologic proile o rubella,in 1977, ACIP modiied its recommendations to include thevaccination o susceptible postpubertal girls and women. In1989, a second MMR vaccination dose was recommended inresponse to large measles outbreaks nationwide (179). During

20012004, the annual numbers o rubella and CRS caseswere extremely low, with 23 reported rubella cases in 2001a total o 18 in 2002, a total o 7 in 2003, and a total o 9 in2004 (219).

Rubella was declared eliminated rom the United States in2004 (219,220). During 20052009, a total o 54 cases o

rubella were reported; the majority o the cases occurred amongpersons aged >20 years. O the reported cases, 23 (43%) wereimport-associated; only two outbreaks o rubella were reportedduring this time, and both involved only three cases (CDCunpublished data, 2009). Since 2005, only our cases o CRShave been reported, with two cases reported in 2009; three(75%) cases were acquired internationally, and the other hadan unknown source (CDC, unpublished data, 2009). Rubellaimportations are expected to continue in the immediate uture

As o September 2011, only three states (i.e., New YorkOklahoma, and Rhode Island) had laws mandating that alhospital personnel have proo o rubella immunity and didnot allow or religious or philosophical exemptions (147)Additional states had requirements or speciic types o acilitieor or certain employees within those acilities, but they didnot have universal laws mandating proo o rubella immunityor all hospital personnel (147).

MMR vaccine coverage in the United States is high; in2010, an estimated 91.5% o children aged 1935 monthshad received 1 dose o MMR vaccine (21); during 20092010a total o 94.8% o kindergarteners had evidence o 2 dose(148); and in 2010, a total o 90.5% o adolescents hadevidence o 2 doses (22). Nationally representative data on

MMR vaccine coverage o U.S. HCP are not available.Rubella Transmission and the Costs of MitigatingRubella Exposures in Health-Care Settings

No documented transmission o rubella to HCP or otherhospital sta or patients in U.S. health-care acilities has occurredsince elimination was declared. However, in the decades beoreelimination, rubella transmission was documented in at least10 U.S. medical settings (221231) and led to outbreakswith serious consequences, including pregnancy terminationsdisruption o hospital routine, absenteeism rom work, expensivecontainment measures, negative publicity, and the threat o

litigation (232). In these outbreaks, transmission occurredrom HCP to susceptible coworkers and patients, as well arom patients to HCP and other patients. No data are availableon whether HCP are at increased risk or acquiring rubellacompared with other proessions.


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Vaccine eectiveness o the RA 27/3 rubella vaccine againstclinical rubella is 95% (85%99% CI) and >99% or clinical

laboratory conirmed rubella (211,233). Antibody responsesto rubella as part o MMR vaccine are equal (i.e., >99%) tothose seen ater the single-antigen RA 27/3 rubella vaccine(211,234).


In clinical trials, 97%99% o susceptible persons whoreceived a single dose o the RA 27/3 rubella vaccine whenthey were aged 12 months developed antibody (211,235,236).Two studies have demonstrated that vaccine-induced rubellaantibodies might wane ater 1215 years (237,238); however,rubella surveillance data do not indicate that rubella and CRS

are increasing among vaccinated persons.National seroprevalence or rubella antibodies among

persons aged 649 years during 19992004 was 91% (239).During 19861990, serologic surveys in one hospital indicatedthat 5% o HCP (including persons born in 1957 or earlier)did not have detectable rubella antibody (240). Earlier studiesindicated that up to 14%19% o U.S. hospital personnel,including young women o childbearing age, lacked detectablerubella antibody (225,241,242). In a recent study on rubellaseroprevalence among 477 newly hired HCP at a hospitalin North Carolina who were born beore 1957, and thusconsidered immune by age, who could not provide writtenevidence o immunity to rubella, serologic testing revealed that14 (3.1%) lacked detectable levels o antibody to rubella (157).

Because o the potential or contact with pregnant women inany type o health-care acility, all HCP should have documentedpresumptive evidence o immunity to rubella. History o diseaseis not considered adequate evidence o immunity.

Vaccine Safety

Rubella vaccine is administered in combination with themeasles and mumps components as the MMR vaccine inthe United States. Monovalent rubella vaccine has been usedrarely in the United States in the past 2 decades and is nolonger available. Ater decades o use, evidence demonstratesthat MMR vaccine has an excellent saety proile. The mostcommon adverse reactions to the rubella component o theMMR vaccine are transient rashes, which usually appear 710days ater vaccination in approximately 5% o vaccinatedpersons, or transient lymphadenopathy, ever, sore throat, andheadache (135,211).

The majority o documented adverse events occur inchildren. In rare circumstances, MMR vaccination o adultshas been associated with the ollowing adverse eventsanaphylaxis (approximately 1.03.5 occurrences per milliondoses administered) (134), thrombocytopenia rom the measlescomponent or rubella component (rate: three to our case

or every 100,000 doses) (134), and acute arthritis rom therubella component (arthralgia develops among approximately25% o rubella-susceptible postpubertal emales ater MMRvaccination, and approximately 10% have acute arthritis-like signs and symptoms rom the rubella component o thevaccine) (135). When joint symptoms occur, they generallypersist or 1 day3 weeks and rarely recur (135). Chronic joinsymptoms attributable to the rubella component o the MMRvaccine are very rarely reported, i they occur at all.

As a result o the theoretic risk to the etus, women shouldbe counseled to avoid becoming pregnant or 28 days aterreceipt o a rubella-containing vaccine (243). However, receipo rubella-containing vaccine during pregnancy should notbe a reason to consider termination o pregnancy; data rom18 years o ollowing to term 321 known rubella-susceptiblewomen who were vaccinated within 3 months beore or 3months ater conception indicated that none o the 324inants born to these mothers had malormations compatiblewith congenital rubella syndrome, but ive had evidence osubclinical rubella inection (244). The estimated risk oserious malormations to etuses attributable to the motherreceiving RA 27/3 vaccine is considered to range rom zeroto 1.6% (135,244).

Evidence does not support a link between MMR vaccinationand any o the ollowing: hearing loss, retinopathy, opticneuritis, Guillain-Barr Syndrome, type 1 diabetes, Crohnsdisease, or autism (135,163169).


Recommendations

VaccinationAll persons who work in health-care acilities should have

presumptive evidence o immunity to rubella. Adequate rubellavaccination or HCP consists o 1 dose o MMR vaccineHowever, because o the 2-dose vaccination requirements ormeasles and mumps, the use o the combined MMR vaccinewill result in the majority o HCP receiving 2 doses o rubellacontaining vaccine, which should provide an additional saeguard


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against primary rubella vaccine ailure. Recently vaccinated HCPdo not require any restriction in their work activities.

Presumptive evidence o immunity to rubella or personswho work in health-care acilities includes any o the ollowing:

writtendocumentationofvaccinationwith1doseofliverubella or MMR vaccine,

laboratoryevidenceofimmunity, laboratoryconfirmationofrubellainfectionordisease,or birthbefore1957*** (exceptwomenofchildbearing

potential who could become pregnant, although pregnancyin this age group would be exceedingly rare).


For HCP who do not have adequate presumptive evidenceo rubella immunity, prevaccination antibody screeningbeore MMR vaccination is not necessary unless the medicalacility considers it cost eective (135). For HCP who have1 documented dose o MMR vaccine or other acceptable

evidence o immunity to rubella, serologic testing or immunityis not recommended. In the event that a health-care providerwho has at least 1 documented dose o rubella-containingvaccine is tested serologically and determined to have negativeor equivocal rubella titer results, receipt o an additional dose oMMR vaccine or prevention o rubella is not recommended.Such persons should be considered immune to rubella.However, i the provider requires a second dose o measlesor mumps vaccine, then a second dose o MMR should beadministered. Documented age-appropriate vaccinationsupersedes the results o subsequent serologic testing. Likewise,during outbreaks o rubella, serologic screening beorevaccination is not recommended because rapid vaccination isnecessary to halt disease transmission.

Controlling Rubella Outbreaks

To prevent transmission o rubella in health-care settings,patients suspected to have rubella should be placed in privaterooms. In addition to standard precautions, droplet precautions

should be ollowed until 7 days ater onset o symptoms. Roomdoors can remain open, and special ventilation is not required

Any exposed HCP who do not have adequate presumptiveevidence o rubella immunity should be excluded rom dutybeginning 7 days ater exposure to rubella and continuingthrough either 1) 23 days ater the most recent exposure or

2) 7 days ater rash appears i the provider develops rubella(213215). Exposed HCP who do not have adequatepresumptive evidence o immunity who are vaccinatedpostexposure should be excluded rom duty or 23 days atethe most recent exposure to rubella because no evidence existsthat postexposure vaccination is eective in preventing rubellainection (244).

Neither rubella-containing vaccine (244) nor immuneglobulin (IG) (211,244) is eective or postexposureprophylaxis o rubella. Although intramuscular administrationo 20 mL o immune globulin within 72 hours o rubellaexposure might reduce the risk or rubella, it will not eliminatethe risk (135,245); inants with congenital rubella have beenborn to women who received IG shortly ater exposure (213)In addition, administration o IG ater exposure to rubellamight modiy or suppress symptoms and create an unwarrantedsense o security with respect to transmission.

I exposure to rubella does not cause inection, postexposurevaccination with MMR vaccine should induce protectionagainst subsequent inection o rubella, as well as measlesand mumps. I the exposure results in inection, no evidenceindicates that administration o MMR vaccine during thepresymptomatic or prodromal stage o illness increases the risk

or vaccine-associated adverse events (213).

Pertussis

Background


Pertussis is a highly contagious bacterial inection. Secondaryattack rates among susceptible household contacts exceed80% (246,247). Transmission occurs by direct contact withrespiratory secretions or large aerosolized droplets rom therespiratory tract o inected persons. The incubation period i

generally 710 days but can be as long as 21 days. The periodo communicability starts with the onset o the catarrhal stageand extends into the paroxysmal stage. Symptoms o earlypertussis (catarrhal phase) are indistinguishable rom otherupper respiratory inections.

Vaccinated adolescents and adults, whose immunity romchildhood vaccinations wanes 510 years ater the most recendose o vaccine (usually administered at age 46 years), are an

Rubella immunoglobulin (IgG) in the serum; equivocal results should beconsidered negative.

*** Depending on current state or local requirements, or unvaccinated personnelborn beore 1957 who lack laboratory evidence o rubella immunity orlaboratory conirmation o inection or disease, health-care acilities shouldconsider vaccinating personnel with one dose o MMR vaccine; orunvaccinated personnel born beore 1957 who lack laboratory evidence orubella immunity or laboratory conirmation o inection or disease, health-care acilities should recommend 1 dose o MMR vaccine during an outbreako rubella.

Because rubella can occur in some persons born beore 1957 and becausecongenital rubella and congenital rubella syndrome can occur in the ospringo women inected with rubella virus during pregnancy, birth beore 1957is not acceptable evidence o rubella immunity or women who could becomepregnant.


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important source o pertussis inection or susceptible inants.Inants too young to be vaccinated are at greatest risk or severepertussis, including hospitalization and death. The diseasecan be transmitted rom adults to close contacts, especiallyunvaccinated children.

Vaccination coverage among inants and children or

diphtheria and tetanus toxoids and acellular pertussis (DTaP)vaccine remains high. In 2010, coverage or children aged1935 months who have received 4 doses o DTaP/diphtheriaand tetanus toxoids and pertussis vaccine (DTP)/diphtheriaand tetanus toxoids vaccine (DT) was 84% (21). Amongchildren entering kindergarten or the 20092010 schoolyear, DTaP coverage was 93% (148). Vaccination coverageor tetanus toxoid, reduced diphtheria toxoid and acellularpertussis (Tdap) vaccine was 68.7% among adolescents in 2010and


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use approaches that maximize vaccination rates (e.g., educationabout the beneits o vaccination, convenient access, and theprovision o Tdap at no charge).


Prevaccination serologic testing is not recommended.

Demonstrating Immunity

Immunity cannot be demonstrated through serologictesting because serologic correlates o protection are not wellestablished.

Controlling Pertussis Outbreaks in Health-CareSettings

Prevention o pertussis transmission in health-care settingsinvolves diagnosis and early treatment o clinical cases, dropletisolation o inectious patients who are hospitalized, exclusionrom work o HCP who are inectious, and postexposure

prophylaxis. Early diagnosis o pertussis, beore secondarytransmission occurs, is diicult because the disease is highlycommunicable during the catarrhal stage, when symptoms arestill nonspeciic. Pertussis should be considered in the dierentialdiagnoses or any patient with an acute cough illness with severeor prolonged paroxysmal cough, particularly i characterizedby posttussive

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