Adults whose occupations place them in contact with patients with contagious diseases are at increased risk of contracting vaccine-preventable diseases and, if infected, transmitting them to their patients. All health care personnel should protect themselves and susceptible patients by receiving appropriate immunizations. Physicians, health care facilities, and schools for health care professionals should play an active role in implementing policies to maximize immunization of health care personnel. Vaccine-preventable diseases of special concern to people involved in the health care of children are as follows (see the disease-specific chapters in Section 3 for further recommendations).

• Rubella . Outbreaks of rubella among health care personnel have been reported. Although the disease is mild in adults, the risk to a fetus necessitates documentation of rubella immunity in health care personnel of both sexes. People should be considered immune on the basis of a positive serologic test result for rubella antibody or documented proof of rubella immunization on or after the first birthday. A history of rubella disease is unreliable and should not be used in determining immune status. All susceptible people should be immunized with MMR and varicella vaccines before initial or continuing contact with pregnant patients.


• Measles . Because measles in health care personnel has contributed to spread of this disease during outbreaks, evidence of immunity to measles should be required for health care personnel. Proof of immunity is established by physician-documented measles, a positive serologic test result for measles antibody, or documented receipt of 2 doses of live virus-containing measles vaccine, the first of which is given on or after the first birthday. Health care personnel born before 1957 generally have been considered immune to measles. However, because measles cases have occurred in health care personnel in this age group, health care facilities should consider offering at least 1 dose of measles-containing vaccine to health care personnel who lack proof of immunity to measles, particularly in communities with documented measles outbreaks.


• Mumps . Transmission of mumps in health care facilities can be disruptive and costly. All people who work in health care facilities should be immune to mumps. Adequate mumps immunization for health care personnel born during or after 1957 consists of 2 doses of MMR vaccine. Health care personnel with no history of mumps immunization and no other evidence of immunity should receive 2 doses (at a minimum interval of 28 days between doses) of MMR. Health care personnel who have received only 1 dose previously should receive a second dose. Because birth before 1957 is only presumptive evidence of immunity, health care facilities should consider recommending 1 dose of MMR vaccine for unimmunized health care personnel born before 1957 who do not have a history of physician-diagnosed mumps or laboratory evidence of mumps immunity.¹


• Hepatitis B . Vaccine is recommended for all health care personnel who are likely to be exposed to blood or blood-containing body fluids. The Occupational Safety and Health Administration of the US Department of Labor issued a regulation requiring employers of personnel at risk of occupational exposure to HBV to offer hepatitis B immunization to personnel at the employer's expense. Personnel who refuse recommended immunizations should sign a refusal document.
  
  In some cases, susceptible health care personnel immunized appropriately with hepatitis B vaccines fail to develop serologic evidence of immunity (antibody to HBsAg [anti-HBs]). Serologic evidence of immunity is defined as serum anti-HBs concentration ≥10 mIU/mL. People who do not respond to the primary immunization series should complete a second 3-dose vaccine series with reevaluation of anti-HBs titers 1 to 2 months after the series is completed. People who do not respond to the second series and are HBsAg negative should be considered susceptible to HBV infection and will need to receive HBIG prophylaxis after any known or probable exposure to blood or body fluids infected with HBV.²


• Influenza . Because health care personnel can transmit influenza to their patients and because health care-associated outbreaks do occur, influenza immunization should be recommended and encouraged for all hospital personnel and other health care personnel with direct patient contact. Health care personnel should be educated about the benefits of influenza immunization and the potential health consequences of influenza illness for themselves and patients at their facilities. Influenza vaccine should be offered at no cost annually to all eligible people and should be available to personnel on all shifts in a convenient manner and location, such as through use of mobile immunization carts. A signed refusal document should be obtained from personnel who decline for reasons other than medical contraindications.³ Inactivated vaccine or live-attenuated vaccine (according to age and health status limitations) is appropriate. Live-attenuated vaccine should not be used for personnel who have direct contact with severely immunocompromised people, such as hematopoietic stem cell recipients.


• Varicella . Proof of varicella immunity is recommended for all health care personnel. In health care institutions, serologic screening of personnel who have an uncorroborated negative or uncertain history of varicella before immunization is likely to be cost-effective but need not be performed. All health care personnel without evidence of immunity to varicella should receive 2 doses of varicella vaccine. Evidence of immunity to varicella in adults includes any of the following: (1) documentation of 2 doses of varicella vaccine at least 4 weeks apart; (2) having been born in the United States before 1980 (although for health care personnel and pregnant women, having been born in the United States before 1980 should not be considered definitive evidence of immunity); (3) history of varicella diagnosed or verified by a health care professional (for a patient reporting a history of or presenting with an atypical case, a mild case, or both, health care professionals should seek either an epidemiologic link with a typical varicella case or evidence of laboratory confirmation, if it was performed at the time of acute disease); (4) history of herpes zoster diagnosed by a health care professional; or (5) laboratory evidence of immunity or laboratory confirmation of disease.


• Pertussis . Pertussis outbreaks involving adults occur in the community and the workplace. Health care personnel frequently are exposed to Bordetella pertussis and have substantial risk of illness and can be sources for spread of infection to patients, colleagues, their families, and the community. Health care personnel in hospitals or ambulatory-care settings who have direct patient contact should receive a single dose of Tdap as soon as is feasible if they have not previously received Tdap. An interval as short as 2 years from the last dose of Td is recommended. Other health care personnel should receive a single dose of Tdap to replace the next scheduled Td dose. Hospitals and ambulatory-care facilities should provide Tdap for health care personnel using approaches that maximize immunization rates.¹


• Tuberculosis . Early detection and Treatment of patients (or visitors) with communicable tuberculosis is recommended to prevent tuberculosis infection in health care personnel. The risk of transmission of tuberculosis in hospitals varies greatly and is determined by multiple factors (eg, the community profile of tuberculosis disease and the types of environmental controls in place). Policies for tuberculin skin testing for health care personnel should conform to CDC guidelines.² Each health care setting should have a tuberculosis infection-control plan based on initial and ongoing evaluations of the risk for transmission of Mycobacterium tuberculosis in the specific setting. The need for screening and frequency of screening should be based on the risk classification (ie, low, moderate, or high). Most pediatric settings will be low risk; more details are available in the CDC guidelines. Even in a low-risk setting, all health care personnel should receive baseline tuberculosis screening using a 2-step tuberculin skin test or a single blood assay for M tuberculosis .¹