PAGE 1 OF 8
MANAGEMENT OF ILLNESS OR EXPOSURE
TO COMMUNICABLE/INFECTIOUS DISEASE
TABLE OF CONTENTS
Procedure for Reporting Exposure or Illness
Notification of Local Health Authority
Employees/Patients with a BBP Disease
Treatment of Exposure
TB Exposure
Chicken Pox/Varicella Zoster, Measles, or other Vaccine Preventable
Diseases Exposure
Meningitis Exposure
Pertussis Exposure
Influenza Exposure
Lice or Scabies Exposure
Bloodborne Pathogen (BBP) Exposure
Hazardous Substance Exposure
Summary of Recommendations for Personnel Exposed to Infectious Diseases
Tuberculosis Exposure Protocol
Varicella/Herpes Zoster Protocol
Measles, Mumps, Rubella and other Vaccine Preventable Diseases Protocol
Neisseria Meningitis Exposure Protocol
Pertussis Exposure Protocol
Influenza Exposure Protocol
Lice Exposure Protocol
Scabies Exposure Protocol
Bloodborne Pathogen (BB) Exposure Protocol
2-3
3
3-4
4
4-5
5
5-6
6
6
6-7
7
7-8
Attachment A
Attachment B
Attachment C
Attachment D
Attachment E
Attachment F
Attachment G
Attachment H
Attachment I
Attachment J
Management of Illness or Exposure to
Communicable/Infectious Disease
I.
EH8660-585
Revised: 12/13
Page 2 of 8
POLICY
Employees, Licensed Independent Practitioners (LIPs), students/trainees and volunteers will report to their
supervisor immediately if they have contracted and/or been exposed to infectious/communicable diseases
or are identified as potentially having an infectious disease. Employees will not report to work with
symptoms of illness, especially cough or sore throat with fever, rash, drainage from the eye, diarrhea with
fever or other undiagnosed potentially contagious illness.
Employees with, or exposed to, infectious/communicable diseases will be restricted as outlined in the table in
ATTACHMENT A.
Employees, LIPs, students, volunteers, other employers, patients, visitors, and contractors will be notified by
verbal or written notice if they have been exposed to a suspected or confirmed infectious disease case in the
course of their duties.
Employees of other agencies or organizations reporting to Lodi Health through the ED, Occupational Health
Medicine Clinic, the Urgent Care Clinic or other clinics within the Lodi Health organization with an exposure
will be treated according to established standards.
II.
PROCEDURE
A.
Employees, LIPs, students/trainees and volunteers, identified as potentially having an infectious disease
or illness, will be reported to and followed, as indicated, by the Employee Health Department. The
employee will be sent home immediately and instructed to contact the Employee Health Department by
telephone for instructions for return to work.
1.
2.
3.
Employees, LIPs, students/trainees and volunteers may be referred to the Employee Health
Nurse if assessment, testing, immunization and/or prophylaxis/treatment and counseling as
indicated.
The Employee Health Nurse in consultation with the Infection Preventionist and department
Medical Directors and Administration will monitor for trends, establish screens, and determine
testing and treatment as indicated by protocol, CDC, OSHA, Cal-OSHA, and/or the
Department of Public Health (California and Federal).
Return to work is based on ATTACHMENT A criteria.
B.
Employees, LIPs, students/trainees, volunteers and visitors, identified as potentially exposed to suspect
or confirmed infectious disease cases will be contacted and treated as indicated in the protocols (see
ATTACHMENTS B-J).
C.
The Employee Health Nurse, Infection Preventionist, or Department Director may determine if a release
to return to work is required.
1.
D.
A copy of the release will be sent to Employee Health and Human Resources.
Employees ill on the job may be seen by the Employee Health Nurse or Urgent Care/ED physician if
indicated.
Management of Illness or Exposure to
Communicable/Infectious Disease
E.
Employees will report any potentially communicable illnesses or any exposures to communicable
diseases to the Employee Health Department and Infection Prevention immediately.
1.
2.
3.
4.
5.
F.
2.
3.
4.
Initial screening and base line testing is provided at Lodi Health Laboratory free of charge to
LIP; all others are billed for the services.
Follow-up testing can be done through Lodi Health lab services but may be charged to nonemployee or sent to the clinicians worker’s compensation carrier.
Should the non-employee choose to use a lab service other than Lodi Health lab services, the
clinician will be financially responsible for that service.
The treating provider will give appropriate post-exposure counseling. The non-employee may
choose to continue with Lodi Health for follow-up counseling and testing or may go to their
own physician/occupational health service.
NOTIFICATION OF LOCAL HEALTH AUTHORITY
A.
Employee Health Services and/or the Infection Preventionist and/or the physician confirming a
diagnosis of a communicable disease is responsible for submitting the Confidential Morbidity Report
(C.M.R.) to the Preventive/Public Health Services, Morbidity Unit.
1.
2.
IV.
Employee Health Services will conduct an investigation when notification is received.
When indicated, the department director/supervisor will be contacted to generate a list of
employees, visitors, patients who may have been exposed.
The Employee Health Nurse and Infection Preventionist, if needed, will conduct follow-up
investigations on exposed contacts to ensure treatment/resolution.
An investigation will be conducted by Employee Health and Infection Prevention, if needed, to
determine the cause of the exposure and any practices that may require revision to prevent
future exposures.
Investigation and follow-up documentation will be completed by Employee Health Services to
include requirements outlined in CCR Title 8 § 5199. Documentation is completed utilizing:
a.
Exposure Analysis & Post Exposure Evaluation Form, and
b.
Exposure Incident Evaluation Form
Lodi Health will provide testing for Bloodborne Pathogen (BBP) exposure for non Lodi Health
Employees including: LIP, students, and pre-hospital personnel employees according to regulation and
established guidelines.
1.
III.
EH8660-585
Revised: 12/13
Page 3 of 8
If Employee Health Service is the diagnosing unit, they will file a C.M.R.
If the disease is diagnosed by a private physician, he/she will be responsible for filing the
C.M.R.
EMPLOYEES/PATIENTS WITH A BBP DISEASE
A.
Employees with AIDS, known to be HIV positive, a Hepatitis B carrier, Hepatitis C positive or other
potentially communicable disease will be evaluated according to the type of work performed including
direct patient contact.
1.
The Employee Health Nurse will review placement and precautions with the employee and
complete the Work Clearance and Counseling for Healthcare Workers with HCV, HBV and/or
HIV Form.
Management of Illness or Exposure to
Communicable/Infectious Disease
2.
V.
These employees will not be permitted to perform procedures or work in positions that require
working with sharps without the ability to see the sharp while it is in contact with the patient.
(Blind Procedures)
TREATMENT OF EXPOSURE
A.
Follow protocols for specific exposure. (ATTACHMENTS B-J)
1.
B.
C.
If there is no protocol, contact Employee Health or after hours the ER physician on duty for
immediate treatment needs.
Provide and/or ensure immediate first aid is given.
1.
VI.
EH8660-585
Revised: 12/13
Page 4 of 8
Eye wash, wash exposed area; remove from immediate danger, etc.
Compile a list of those potentially exposed.
TB
A.
Exposure is defined as contact within three feet of a patient diagnosed with pulmonary tubercle Bacillus
(tuberculosis) without using respiratory protection equal to or greater than an N95 respirator.
B.
Department Managers will have potentially exposed employees complete TB Exposure protocol
(ATTACHMENT B) and/or send list of names to Employee Health.
C.
Employee Health, in cooperation with affected Department Managers, will contact potentially exposed
employees.
D.
Upon receipt of employee contact list, Employee Health Services will:
1.
2.
3.
4.
5.
6.
7.
8.
9.
E.
Sends notices, protocol and testing forms to those potentially exposed informing them of the
exposure and the need for baseline and follow-up testing.
Instruct employees to report any symptoms as outlined on the TB surveillance form.
Do Baseline TSTs on employees who have not had a PPD in the last three months.
Do Follow-up TST at least 12 weeks post-exposure if confirmed positive TB.
Have employees with a history of a positive PPD test complete the TB History and Respiratory
Symptom Review portion of the Tuberculosis Surveillance Form.
Provide employee with conversion from a negative to a positive skin test, a PA and lateral chest
x-ray.
a.
Until the results are obtained, the employee may continue to work if they have no signs
or symptoms consistent with TB disease.
Offer counseling and treatment for latent TB according to CDC and PHD guidelines.
Report conversion to Public Health Department.
Record all procedures and results in Employee Health Record.
If an employee develops signs and symptoms consistent with TB disease, a posterior anterior and lateral
check x-ray will be done and the employee will be removed from work until a negative chest x-ray is
received.
Management of Illness or Exposure to
Communicable/Infectious Disease
1.
2.
VII.
If the chest x-ray is positive, the employee will be referred to a pulmonologist or other
appropriate medical doctor for diagnosis and treatment.
The employee will be able to return to work when they have completed two weeks of successful
drug therapy and are no longer symptomatic.
a.
A release from the treating physician must be provided prior to return.
F.
Post-exposure testing is done regardless of annual testing and does not change that mandated annual
date. Employees failing to comply with testing requirements within two weeks of notification will not
be allowed to work until testing and clearance is obtained.
G.
Employers of pre-hospital personnel are notified of potential exposure and positive culture results by
the Public Health Department, Employee Health, or the Infection Preventionist as needed.
CHICKEN POX/VARICELLA ZOSTER, MEASLES OR OTHER DISEASES FOR WHICH
IMMUNITY IS PRESENT IN MOST PEOPLE
A.
Have employee complete and follow the instructions on the protocol ATTACHMENT D.
1.
The Employee Health Nurse will review Employee Health Records to determine if the
employee has immunity to the specific disease.
B.
Employees with immunity are not considered exposed.
C.
Those employees without immunity, or those with no documentation of immunity, will be contacted and
immunization, testing or prophylaxis will be provided according to Lodi Health Policy, CDC, and/or
Public Health.
D.
Employee may be restricted from work based on CDC and Public Health guidelines and Lodi Health
policy. (ATTACHMENT A)
1.
VIII.
EH8660-585
Revised: 12/13
Page 5 of 8
Employee Health will adjust restrictions as indicated by the specific disease based on CDC and
Public Health guidelines.
MENINGITIS
A.
Exposure is defined as intensive contact with a patient with meningococcal disease (N. meningitides).
There is a negligible risk of disease following casual contact. Intensive contact would occur in
unprotected:
1.
2.
3.
4.
5.
6.
B.
Mouth to mouth resuscitation.
Suctioning without using proper precautions.
Participation in intubation.
Oral or fundoscopic examination.
Assisting with vomiting patient.
Other mucus membrane contact with respiratory secretions.
Have the employee complete and follow the instructions on the Meningitis Exposure Protocol Form.
(ATTACHMENT E)
Management of Illness or Exposure to
Communicable/Infectious Disease
C.
IX.
Inform the Pharmacy Department that there has been a confirmed exposure.
PERTUSSIS
A.
Exposure is defined as intensive contact with a patient with Pertussis. There is a negligible risk of
disease following casual contact. Intensive contact includes unprotected:
1.
2.
3.
4.
5.
6.
B.
2.
XI.
Mouth to mouth resuscitation.
Suctioning without using proper precautions.
Participation in intubation.
Oral or fundoscopic examination.
Assisting with vomiting patient.
Other mucus membrane contact with respiratory secretions.
Data on the need for post exposure antimicrobial prophylaxis in Tetanus Toxoid, Reduced Diphtheria
Toxoid and Acellular Pertussis Vaccine (Tdap)-vaccinated HCP are inconclusive. Some vaccinated
HCP are still at risk for B pertussis. Tdap vaccination may not preclude the need for post exposure
antimicrobial prophylaxis.
1.
X.
EH8660-585
Revised: 12/13
Page 6 of 8
Post exposure antimicrobial prophylaxis is recommended for all HCP who have unprotected
exposure to pertussis and are likely to expose a patient at risk for severe pertussis (e.g.,
hospitalized neonates and pregnant women).
Other HCP can receive post exposure antimicrobial prophylaxis or be monitored daily for 21
days after pertussis exposure and treated at the onset of signs and symptoms of pertussis.
C.
Have the employee complete and follow the instructions on the Pertussis Protocol Form.
(ATTACHMENT F)
D.
Inform the Pharmacy Department that there has been a confirmed exposure.
INFLUENZA EXPOSURE
A.
Large droplet spread through coughing and sneezing is believed to be the primary mode of
transmission. Contact with surfaces may also be a source of transmissible particles. Exposure is
defined as contact within three feet of a patient diagnosed with influenza without use of respiratory or
contact protection.
B.
Have the employee complete and follow the instructions on the Influenza Protocol Form.
(ATTACHMENT G)
C.
Inform the Pharmacy Department that there has been a confirmed exposure.
LICE OR SCABIES EXPOSURE AND TREATMENT
A.
Definition of exposure to LICE: Occurs when an employee comes into direct contact with another
person with lice. Contact must be close head to head, or sharing of same fabric covered chair, lab
coats, or other personal items. Time is not a factor to determine exposure.
Management of Illness or Exposure to
Communicable/Infectious Disease
B.
Definition of exposure to SCABIES: Occurs when an employee comes into direct skin to skin contact
with another person with scabies. Occasionally, transmission may occur when there is contact with
heavily contaminated clothing or bed sheets.
C.
Any employee, who suspects exposure by any source, will immediately notify their director or
supervisor.
D.
Provide the potentially exposed employee(s) with the Scabies or Lice protocol to complete and follow
the instructions. (ATTACHMENT H or I)
E.
If the source of exposure is a patient, the director or supervisor will:
1.
2.
3.
F.
XII.
Initiate isolation of the patient.
Notify Infection Prevention immediately with patient name and room number.
Have potentially exposed employees complete the protocol and follow the instructions.
a.
Contact the Pharmacy Department to let them know employees may be reporting for
medication.
Employees with lice or scabies are relieved from direct patient contact and patient care areas until 24
hours after effective treatment.
BLOODBORNE PATHOGEN (BBP) EXPOSURE
A.
Obtain and complete the BBP Exposure Protocol (ATTACHMENT J) for exposures that include:
1.
2.
3.
4.
XIII.
EH8660-585
Revised: 12/13
Page 7 of 8
Needle stick, cut or puncture with a device contaminated with another’s blood or bloody
fluid.
Mucous-membrane contact to eye, nose or mouth with another’s blood or bloody fluid.
Contact with large amounts of blood or prolonged contact with blood, or bloody fluids on
broken or non-intact skin.
Human bite if visibly bloody oral secretions and employee skin is broken.
B.
Provide employee with signed copies of handouts. Forward originals to Employee Health.
C.
Instruct the employee to call Employee Health the next work day.
HAZARDOUS SUBSTANCE EXPOSURE – CHEMICALS
OCCUPATIONALLY RELATED ALLERGIES AND/OR SKIN SENSITIVITIES
A.
Definition: Intermittent or chronic skin conditions, respiratory, or other condition, which may be
related to glove use, latex exposure, chemical use/exposure or other irritants in the work place.
B.
Employees who have been or feel they have been exposed to a hazardous substance, chemical or other
irritant in the workplace will immediately report to their supervisor or seek emergency treatment if in
distress.
Management of Illness or Exposure to
Communicable/Infectious Disease
C.
The supervisor/director will provide emergency care as indicated and have the employee report to the
Emergency Department or Urgent Care Clinic for evaluation and treatment.
1.
2.
D.
FORMULATED:
REVIEWED:
REVISED:
EH8660-585
Revised: 12/13
Page 8 of 8
Have the employee take a copy of the MSDS sheet for the hazardous substance for physician
information.
The physician can refer to MSDS sheet and/or call UC Davis Poison Control – 1-800-342-9293
for additional treatment and testing indicated for specific agents.
Employees with hand or skin related problems will report to their department director, manager or
supervisor for referral to Employee Health for evaluation and treatment.
APRIL, 1988
4/01, 4/04, 9/04, 10/07, 11/10, 6/11, 2/13
Management of Illness or Exposure to Communicable/Infectious Disease
EH-8660-585
ATTACHMENT A
Page 1 of 4
SUMMARY OF RECOMMENDATIONS AND WORK RESTRICTIONS
FOR PERSONNEL EXPOSED TO OR INFECTED WITH INFECTIOUS DISEASES
Disease / Problem
Restrict from
Direct Patient
Contact and
Patient
Environment
Restrict from Work
Duration
Until discharge ceases and 24 hours of effective
treatment.
Conjunctivitis, infectious
All
Yes
Cytomegalovirus infections
No
No
All
Yes
Until symptoms resolve and infection with
Salmonella is ruled out.
Immunocompromised
patients
No
Until symptoms resolve
All
Yes
Until antimicrobial therapy completed and 2
cultures obtained > 24 hours apart are negative.
Infants,
neonates, and
immunocompromised patients
and their
environments.
No
Until symptoms resolve.
*Diarrhea disease
Acute stage
(Diarrhea with other
symptoms; fever,
abdominal cramps,
bloody stools)
Convalescent stage
Salmonella spp.
Diphtheria
Enteroviral infections
Management of Illness or Exposure to Communicable/Infectious Disease
EH-8660-585
ATTACHMENT A
Page 2 of 4
Disease / Problem
Restrict from
Direct Patient
Contact and
Patient
Environment
Streptococcal infection, Group A
All
Yes
Until 24 hours after adequate treatment is started.
Hepatitis A
All
Yes
Until 7 days after onset of jaundice, showing
clinical improvement.
Hepatitis B
Acute
No
No exposure prone procedures may be performed.
Until antigenemia resolves.
Hepatitis B
Chronic antigenemia
No
Same as acute illness
Hepatitis C, NANB
No
Same as acute Hepatitis B
Herpes Simplex
Genital
No
No
All
No
Until lesions heal
Immunocompromised nursery,
OB, Peds,
Oncology, food
handling.
No
Until lesions heal
Hands (herpetic whitlow)
Orofacial
Restrict from Work
Human immunodeficiency virus
No
Same as acute Hepatitis B
Lice (Pediculosis)
Yes
Yes
Duration
Period of infectivity has not been determined.
Until treated and observed to be free of adult and
immature lice.
Management of Illness or Exposure to Communicable/Infectious Disease
Disease / Problem
Measles (Rubeola)
Active
Restrict from
Direct Patient
Contact and
Patient
Environment
Restrict from Work
EH-8660-585
ATTACHMENT A
Page 3 of 4
Duration
All
Yes
Until 7 days after the rash appears.
Post exposure
(Susceptible personnel)
All
Yes
From the 5th through the 21st day after 1st
exposure and/or 4 days after the rash appears.
Meningococcal infections
Mumps
Active
All
Yes
Until 24 hours after start of effective therapy.
All
Yes
Until 9 days after onset of parotitis.
All
Yes
From the 12th through the 26th day after exposure
or until 9 days after onset of parotitis.
All
Yes
No
No
From the beginning of the catarrhal stage through
the 3rd week after onset of paroxysms or until 5
days after start of effective antimicrobial therapy.
All
Yes
Until 5 days after start of effective antimicrobial
therapy.
Rubella
Active
Post exposure
(Susceptible personnel)
All
Yes
Until 5 days after the rash appears.
All
Yes
From the 7th to the 21st day after exposure and/or
5 days after rash appears.
Scabies
All
Yes
Until 24 hours after effective treatment.
Post exposure (susceptible
personnel)
Pertussis
Active
Post exposure
(Asymptomatic personnel)
Post exposure
(Symptomatic personnel)
Management of Illness or Exposure to Communicable/Infectious Disease
Disease / Problem
Staphylococcus aureus
(Active, draining skin
lesions.)
Restrict from
Direct Patient
Contact and
Patient
Environment
Restrict from Work
EH-8660-585
ATTACHMENT A
Page 4 of 4
Duration
All
No
All
No
Yes
No
All
Yes, personnel may not work with a temperature
of 100o or more and cough.
Until acute symptoms resolve and there is
temperature less than 100o for at least 24 hours
without antipyretics.
All
Yes
Until all vesicles dry and are crusted.
Post exposure (susceptible
personnel)
All
Yes
From the 10th through the 21st day after exposure
or if varicella occurs until all lesions dry and
crust.
Zoster (Shingles/Herpes)
Localized, in healthy person.
Immunocompromised patients
No, cover lesions.
Until lesions dry and crust.
Yes
Until lesions dry and crust.
Tuberculosis
Active
Latent (TST Conversion)
Viral respiratory infections,
acute febrile
Varicella (chickenpox)
Active
Generalized or localized in
immunosuppressed personnel.
2.
No
Until 3 cultures 24 hours apart are negative and
medically cleared.
From the 10th through the 21st day after exposure
or if varicella occurs until all lesions dry and
crust.
Centers for Disease Control and Prevention, Guidelines for Infection Control in Health Care Personnel, 1998: Recommendations of the Hospital
Infection Control Practices Advisory Committee.
Centers for Disease Control and Prevention, Immunization of Health-Care Workers: Recommendations of the Advisory Committee on Immunization
Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). MMWR, December 26, 1997. 46(RR-18):1-42.
Post exposure (susceptible
personnel)
1.
All
Until lesions resolve.
All
Management of Illness or Exposure to
Communicable/Infectious Disease
EH-8660-585
ATTACHMENT B
Tuberculosis Exposure Protocol
Print Name
Exposure Date
Dept.
MR#
Tuberculosis is caused by Mycobacterium tuberculosis, the tubercle bacillus. The mycobacteria can be found in many
organs but transmission occurs when it is present in the lungs or larynx. TB is spread when an infected person coughs, or
otherwise aerosolizes particles. Depending on the environment, these particles can remain suspended in the air for hours.
If another person inhales air containing the droplet nuclei, transmission may occur. People at highest risk of becoming
infected with TB are close contacts – persons who had prolonged, frequent or intense contact with a person with infectious
TB. Close contacts may be family members, roommates, friends, and coworkers. HIV immunocompromised contacts
have the strongest risk for development of TB if infected.
A TB skin test (TST) is performed to determine if a person has been infected with TB. If the skin test is positive, a chest
X-ray will be performed to determine if there is active TB disease. Only 10% of people infected with TB will develop
active disease. Employees at Lodi Health are tested annually and three months after an exposure to active TB.
Please answer the following questions and follow the instructions following.
YES
NO
NA
Was source patient's mouth and nose covered when coughing or creating droplets when
you were in the same room with him/her?
Did you wear a facemask or shield when within three feet of the patient?
Did you use a protective facemask if CPR was initiated?
If you have answered YES or NA to all of the above questions, you are not likely to have been exposed to TB. Please sign
below and return this form to Employee Health.
I have reviewed the above and do not meet the evaluation criteria for potential exposure to TB.
Employee Signature
Date
There is no vaccine available against TB. Early identification of TB through screening and timely evaluation and treatment
strategies for patients and health care workers with known or suspected TB is the main TB control strategy.
What will happen next:
If the source patient cultures are positive for Mycobacterium tuberculosis and if you answered NO to any of the questions
above:
a. If you have not had a TST done in the last three months, you will be contacted to have a baseline TST.
b. You will be contacted to have a TST three months after the last date of exposure.
References:
American Public Health Association, Control of Communicable Diseases Manual, 19 th ed.
Forward Completed Form to Employee Health
Management of Illness or Exposure to
Infectious/Communicable Disease
EH-8660-585
ATTACHMENT C
Varicella/Herpes Zoster (Chicken Pox/Shingles) Protocol
Print Name
Exposure Date
Dept.
MR#
Chicken Pox is a viral disease spread by direct contact with vesicular fluid, aerosolized vesicular fluid, secretions from
the respiratory tract or contact with objects soiled with vesicular fluid or secretions. Shingles is spread by much the
same route but because there are fewer vesicles there is a lower rate of transmission. Shingles are not transmitted by
contact with respiratory secretions.
You were tested for Chicken Pox antibodies prior to starting work at Lodi Health and were notified and offered two
doses of varicella vaccine if you were found to lack immunity. If you were offered vaccine but declined, please answer
the following questions and follow the instructions following.
YES
NO
NA
Was source patient's mouth and nose covered when coughing or creating droplets when
you were in the same room with him/her?
Did you wear a facemask or shield when within three feet of the patient?
Did you wear gloves for direct contact with respiratory, oral, nasal secretions, or
clothing?
Did you use a protective facemask if CPR was initiated?
If you have answered YES or NA to all of the above questions, you are not likely to have been exposed to Chicken Pox
or Shingles. Please sign below and return this form to Employee Health.
I have reviewed the above and do not meet the evaluation criteria for potential exposure to Chicken Pox or Shingles.
Employee Signature
Date
If you answered NO to any of the questions above, please complete the bottom section of this form.
If you do not have immunity, Varicella vaccine is effective in preventing or modifying the severity of chicken pox if given
within three-five days of initial exposure. Please report to Employee Health or obtain vaccine from pharmacy and have
administered by licensed healthcare provider.
Please read and initial the following:
I am not pregnant or lactating.
I do not have an immunosuppressive disease.
I have received and reviewed the medication information sheet.
I understand I must monitor for an elevated temperature and rash for 10-21 days from last exposure.
I understand if I develop a fever or rash during the 10-21 days, I must not come to work or expose
others.
Varicella Vaccine .5cc, sq, Site _______ Lot # ______________ Exp Date _______ By _______________________
Employee Signature
References:
Date
American Public Health Association, Control of Communicable Diseases Manual, 19 th ed.
Forward Completed Form to Employee Health
Management of Illness or Exposure to
Communicable/Infectious Disease
EH-8660-585
ATTACHMENT D
Measles, Mumps, Rubella (MMR) and other Vaccine Preventable Diseases Protocol
Print Name
Exposure Date
Dept.
MR#
Vaccine preventable diseases such as Measles, Mumps, or Rubella are rarely a risk for healthcare workers. If a potential
exposure occurs, have potentially exposed employees complete this form and return it to Employee Health.
Employee Health will determine if there are any potentially exposed employees who may require additional
immunization. Please advise employees they will be contacted by Employee Health if treatment is indicated.
You were tested for MMR antibodies prior to starting work at Lodi Health and were notified and offered vaccine if you
were found to lack immunity. If you were offered vaccine but declined, please answer the following questions and
follow the instructions following.
YES
NO
NA
Was source patient's mouth and nose covered when coughing or creating droplets when
you were in the same room with him/her?
Did you wear a facemask or shield when within three feet of the patient?
Did you use a protective facemask if CPR was initiated?
If you have answered YES or NA to all of the above questions, you are not likely to have been exposed. Please sign
below and return this form to Employee Health.
I have reviewed the above and do not meet the evaluation criteria for potential exposure.
Employee Signature
Date
If you answered NO to any of the questions above, please complete the bottom section of this form.
If you do not have immunity, MMR vaccine is effective in preventing or modifying the severity of MMR if given within
three-five days of initial exposure. Please report to Employee Health or obtain vaccine from pharmacy and have
administered by licensed healthcare provider.
Please read and initial the following:
I am not pregnant or lactating. DO NOT GET MMR if you are pregnant or planning to become
pregnant within the next three months.
I do not have an immunosuppressive disease.
I have received and reviewed the medication information sheet.
I understand I must monitor for an elevated temperature and rash for 5-14 days from last exposure.
I understand if I develop a fever or rash during the 5-14 days, I must not come to work or expose others.
MMR .5cc, sq, Site _______ Lot # ______________ Exp Date _______ By _______________________
Employee Signature
References:
Date
American Public Health Association, Control of Communicable Diseases Manual, 19th ed.
Forward Completed Form to Employee Health
Management of Illness or Exposure to
Communicable/Infectious Disease
EH-8660-585
ATTACHMENT E
Neisseria Meningitis Exposure Protocol
Print Name
Exposure Date
Dept.
MR#
Neisseria meningitidis is transmitted through close contact with the respiratory secretions of patients with
meningococcemia or meningococcal meningitis, or through handling laboratory specimens. The risk of acquiring disease
from casual contact, routine patient care, cleaning patient room, delivering food trays, etc. it is negligible.
YES
NO
NA
Was source patient's mouth and nose covered when coughing or creating droplets when
you were within three feet of him/her? (Respiratory Droplets)
Did you wear a facemask or shield when within three feet of the patient?
Did you use a protective facemask if CPR was initiated?
If you have answered YES or NA to all of the above questions, you are not likely to have been exposed to meningitis.
Please sign below and return this form to Employee Health. I have reviewed the above and do not meet the evaluation
criteria for potential exposure to meningitis.
Employee Signature
Date
If you answered NO to any of the questions above, read the information below, complete the bottom section of
this form and if you decide to take the medication, take this completed form to Pharmacy.
Ciprofloxacin or Rifampin is the recommended medication for prophylactic treatment for Neisseria meningitidis.
Please read and initial the following:
I am not pregnant or lactating.
I do not have liver disease and do not take hepatotoxic agents.
I do not have renal disease.
I do not have an immunosuppressive disease.
I understand thrombocytopenia has occurred with high dose intermittent therapy.
I understand that repeated doses of antibiotics can reduce sensitivity.
I understand that the therapeutic effects of other drugs may be decreased while taking antibiotics.
I understand that while taking this medication my urine, feces, saliva, sweat and tears may be redorange and can cause staining of contact lenses.
I have received and reviewed the medication information sheet.
I understand the above information and (circle one) consent/decline to take Ciprofloxacin or Rifampin as a prophylactic
treatment for meningitis exposure.
Employee Signature
Date
Take this form to Pharmacy to receive prophylactic medication: If pregnant, employee must contact OB/GYN for
script.
Pharmacy please dispense the following:
Ciprofloxacin 500 mg PO x 1 dose - Contraindicated in Pregnancy-Refer to OB/GYN
OR - If allergy to Ciprofloxacin
Rifampin 600 mg PO q 12 hours x 2 days - Contraindicated in Pregnancy-Refer to OB/GYN
Pharmacist Signature: _________________________________
References:
American Public Health Association, Control of Communicable Diseases Manual, 19 th ed.
Forward Completed Form to Employee Health
Management of Illness or Exposure to
Communicable/Infectious Disease
EH-8660-585
ATTACHMENT F
Pertussis (Whooping Cough) Exposure Protocol
Print Name
Exposure Date
Dept.
MR#
Pertussis (Whooping Cough) is caused by the bacteria Bordetella pertussis and is transmitted by direct contact with
discharges from respiratory mucous membranes of infected people, by droplets during coughing, medical procedures,
etc. It is rarely spread through the air or contaminated objects.
To evaluate your level of exposure please answer the following questions and follow the instructions following.
YES
NO
NA
Was source patient's mouth and nose covered when coughing or creating droplets when
you were within three feet of him/her? (Respiratory Droplets)
Did you wear a facemask or shield when within three feet of the patient?
Did you wear gloves for direct contact with respiratory, oral, or nasal secretions?
Did you use a protective facemask if CPR was initiated?
Have you had the Tetanus with Pertussis vaccine within the last 10 years?
Do you work in an area other than OB?
If you have answered YES or NA to all of the above questions, you are not likely to have been exposed to Pertussis.
Please sign below and return this form to Employee Health.
I have reviewed the above and do not meet the evaluation criteria for potential exposure to Pertussis.
Employee Signature
Date
If you answered NO to any of the questions above, read the information below, complete the bottom section of
this form and if you decide to take the medication, take this completed form to Pharmacy.
Zithromax (Azithromycin), Erythromycin or Clarithromycin are the recommended medication for prophylactic treatment for
Pertussis.
Please read and initial the following:
I am not pregnant or lactating.
I do not have liver disease and do not take hepatotoxic agents.
I do not have renal disease.
I do not have an immunosuppressive disease.
I understand that repeated doses of antibiotics can reduce sensitivity.
I understand that the therapeutic effects of other drugs may be decreased while taking antibiotics.
I have received and reviewed the medication information sheet.
I understand the above information and (circle one) consent/decline to take the prophylactic treatment for this pertussis
exposure.
Employee Signature
Date
Take this form to Pharmacy to receive prophylactic medication: if pregnant, employee must contact OB/GYN for
script.
Pharmacy please dispense the following:
Zithromax 500 mg by mouth for one day, 250 mg by mouth for four days.
OR - If allergy to Zithromax
Erythromycin 500 mg by mouth four times a day for 14 days - Contraindicated in Pregnancy-Refer to OB/GYN
Pharmacist Signature: _____________________________________________
References:
American Public Health Association, Control of Communicable Diseases Manual, 19 th ed.
Forward Completed Form to Employee Health
Management of Illness or Exposure to
Communicable/Infectious Disease
EH-8660-585
ATTACHMENT G
Page 1 of 2
Influenza Exposure Protocol
Print Name
Exposure Date
Dept.
MR#
Influenza is an acute viral disease of the respiratory tract characterized by fever, cough (usually dry), headache, body
aches, extreme fatigue, stuffiness, and sore throat. Cough is usually severe and can last two weeks, other symptoms
resolve in two-five days. It is believed the primary spread is by coughing and sneezing by infected persons. The human
influenza virus may persist for hours on solid surfaces, particularly in cold, dry climates. Communicability is greatest in
the first three-five days of illness but is longer in children and immunocompromised persons.
To evaluate your level of exposure please answer the following questions and follow the instructions following.
YES
NO
NA
Was source patient's mouth and nose covered when coughing or creating droplets when
you were within six feet of him/her? (Respiratory Droplets)
Did you wear a facemask or shield when within six feet of the patient?
Did you wear gloves for direct contact with respiratory, oral, or nasal secretions?
Did you use a protective facemask if CPR was initiated?
If you have answered YES or NA to all of the above questions, you are not likely to have been exposed to Influenza.
Please sign below and return this form to Employee Health.
I have reviewed the above and do not meet the evaluation criteria for potential exposure to influenza.
Employee Signature
Date
If you answered NO to any of the questions above, read the information below.
GET VACCINATED
If you did not receive the seasonal influenza, it is advised you receive it. The vaccine is effective in preventing or modifying
the severity of influenza if given within three-five days of initial exposure. If you decide to get the vaccine, please complete
the information below and report to Employee Health or obtain vaccine from pharmacy and have administered by licensed
healthcare provider.
Please read and initial the following:
I have never had a serious allergic reaction or other problem after receiving the vaccine.
I have not had Guillain-Barre syndrome within six weeks following a previous dose of influenza
vaccine.
I understand I must monitor for an elevated temperature and cough for five-seven days from last
exposure.
I understand if I develop a fever and cough, I must not come to work or expose others.
Influenza Vaccine .5cc, sq, Site _______ Lot # ______________ Exp Date _______ By _______________________
I consent to receive the vaccine: Employee Signature
Date
Management of Illness or Exposure to
Communicable/Infectious Disease
EH-8660-585 (EH)
ATTACHMENT G
Page 2 of 2
MONITOR FOR SYMPTOMS
Report to Employee Health and your manager the abrupt onset of fever >101oF, body aches, headache, extreme tiredness,
dry cough, sore throat, and runny nose. STAY HOME.
IF YOU HAVE A HIGH RISK CONDITION, GET PROPHYLAXIS WITHIN 48 HRS OF EXPOSURE OR
ILLNESS
CDC does not recommend routine prophylaxis following influenza exposure. Antiviral agents to reduce the duration and
severity of symptoms are recommended for those with conditions that confer a higher risk of severe influenza. Conditions
include: chronic pulmonary or cardiovascular (not hypertension), renal, hepatic, neurological, hematologic, metabolic
disorders including diabetes mellitus, immunosuppressive illness, pregnancy or morbid obesity (BMI >39).
Employee Signature
Date
Take this form to Pharmacy to receive medication: if pregnant, contact OB/GYN for script.
Pharmacy, please dispense the following:
Tamiflu 75 mg twice daily for five days if symptoms present and within two days of onset
OR
Tamiflu 75 mg once daily for 10 days if no symptoms, has high risk condition and within two days of
exposure.
Pharmacist Signature: _____________________________________________
References:
American Public Health Association, Control of Communicable Diseases Manual, 19 th ed.
Forward Completed Form to Employee Health
Management of Illness or Exposure to
Communicable/Infectious Disease
EH-8660-585 (EH)
ATTACHMENT H
Lice Exposure Protocol
Print Name
Exposure Date
Dept.
MR#
Lice: Head lice are small insects that live in people's hair and feed on their blood. Lice glue their eggs, or "nits," to hair
so that the nits do not get brushed off. Lice die quickly (within two days) without feeding so they cannot live very long
away from a person. Nits take six to nine days to hatch, and seven or more days for the lice to become egg-laying
adults. People can give head lice to each other when they share combs, hats, clothing, barrettes, helmets, scarves,
headphones, or other personal items. There is no preventive treatment for lice; a health care worker must observe for
symptoms and be treated if they occur. To evaluate your level of exposure, please answer the following questions and
follow the instructions following.
YES
NO
NA
Did you have direct unprotected skin-to-skin contact with the infested patient?
Did you handle the infested clothing or bedding of an infested patient?
Do you have visible lice or nits?
If you have answered NO or NA to all of the above questions, you are not likely to have been exposed to Lice nor are
you currently infested. Please monitor for symptoms AND REPORT TO Employee Health if they should develop.
Please sign below and return this form to Employee Health.
I have reviewed the above and do not meet the evaluation criteria for potential exposure to lice.
Employee Signature
Date
If you answered Yes to the last two questions above, read the information below, complete the bottom section of
this form and if you decide to take the medication, take this completed form to Pharmacy.
Permethrin 5% topical solution is the recommended medication for treatment of Lice.
Please read and initial the following:
I am not pregnant or lactating. This medication is deemed safe during pregnancy and lactation.
I understand all household members must be treated at the same time to prevent re-infestation.
I understand all bedding and worn clothing must be changed and washed after treatment.
I understand itching will persist for up to two weeks and does not mean treatment has failed.
I understand that over treatment should be avoided as some of these medications are toxic.
I understand treatment may need to be repeated.
I have received and reviewed the medication information sheet.
I understand the above information and (circle one) consent/decline to treat my self and household for lice.
Employee Signature
Date
Take this form to Pharmacy to receive the medication:
Pharmacy dispenses the following:
Permethrin 5% topical solution for employee and household contacts
Pharmacist Signature; _____________________________________________
References:
American Public Health Association, Control of Communicable Diseases Manual, 19 th ed.
Forward Completed Form to Employee Health
Management of Illness or Exposure to
Communicable/Infectious Disease
EH-8660-585
ATTACHMENT I
Scabies Exposure Protocol
Print Name
Exposure Date
Dept.
MR#
Scabies is an infestation of the skin with the microscopic mite Sarcoptes scabiei. Infestation is common, found
worldwide and affects people of all races and social classes. Scabies spreads under crowded conditions where there is
frequent skin-to-skin contact. Healthcare workers are at risk when there is direct skin-to-skin contact with an infested
patient or handling infested clothing or bedding. There is no prophylaxis to prevent infestation, the healthcare worker
must observe for symptoms and be treated if they occur.
To evaluate your level of exposure, please answer the following questions and follow the instructions following.
YES
NO
NA
Did you have direct unprotected skin-to-skin contact with the infested patient?
Did you handle the infested clothing or bedding of an infested patient?
Do you have red pimple like irritation, burrows, or rash of the skin, especially in the
webbing between fingers, toes, skin folds or shoulder blades?
Do you have intense itching over the most of the body, especially at night?
If you have answered NO or NA to all of the above questions, you are not likely to have been exposed to scabies nor are
you currently infested. Please sign below and return this form to Employee Health.
I have reviewed the above and do not meet the evaluation criteria for potential exposure to scabies.
Employee Signature
Date
If you answered Yes to the last two questions above, read the information below, complete the bottom section of
this form and if you decide to take the medication, take this completed form to Pharmacy.
Permethrin 5% topical solution is the recommended medication for treatment scabies.
Please read and initial the following:
I am not pregnant or lactating. This medication is deemed safe during pregnancy and lactation.
I understand all household members must be treated at the same time to prevent re-infestation.
I understand all bedding and worn clothing must be changed and washed after treatment.
I understand itching will persist for up to two weeks and does not mean treatment has failed.
I understand that over treatment should be avoided as some of these medications are toxic.
I understand treatment may need to be repeated.
I have received and reviewed the medication information sheet.
I understand the above information and (circle one) consent/decline to treat my self and household for scabies.
Employee Signature
Date
Take this form to Pharmacy to receive the medication:
Pharmacy dispenses the following:
Permethrin 5% topical solution for employee and household contacts
Pharmacist Signature; _____________________________________________
References:
American Public Health Association, Control of Communicable Diseases Manual, 19 th ed.
Forward Completed Form to Employee Health
Management of Employee Illness or Exposure
to Communicable/Infectious Disease
EH-8660-585
ATTACHMENT J
Page 1 of 2
Bloodborne Pathogen Exposure Protocol
Employee Name
Exposure Date ________________
Home Dept.
Source Name _____________________ MR# _________
EXPOSED EMPLOYEE
Immediately:
 Wash punctures or cuts with soap and water.
 Flush splash to the nose, mouth, or skin with water.
 Irrigate eyes with clean water, saline or sterile irrigates.
Do not squeeze or milk wound as it may cause an immune response that increases the risk of HIV multiplication. Using a caustic
agent such as bleach or hydrogen peroxide is not recommended.
Did you get stuck or cut by a sharp object that had been in contact with another person’s body fluids or did
YES NO
another person’s body fluids come in contact with your non-intact skin or mucous membranes (nose, mouth or
eyes)?
Was the body fluid, blood, or cerebrospinal, synovial, pleural, peritoneal, pericardial, amniotic or other fluid
YES NO
visibly bloody?
If you answered NO to either of these questions, this is not considered an exposure to bloodborne pathogens (BBP). No further
testing or treatment related to BBP is indicated.
If you answered YES to either question. contact your Shift Supervisor or the Hospital Supervisor for evaluation and treatment.
SUPERVISOR
Identify source and obtain verbal consent for testing and complete Source Risk Assessment
(L:\LMH\FORMS\Employee Health\Attachment J Forms\Source Risk Assessment.doc).
 If the patient declines, use blood already in the lab.
 If the source is a baby, the mother is tested.
Contact Registration to create Employee Health accounts for Employee and Source.
Order: Exposure Panel-Source L:\LMH\FORMS\Employee Health\Attachment J Forms\Exposure Source Lab
Form.doc
Exposure Panel-Employee L:\LMH\FORMS\Employee Health\Attachment J Forms\Exposed Employee
Lab Form.doc
Complete BBP Exposure Report/Log with exposed employee. (L:\LMH\FORMS\Employee Health\Attachment J
Forms\Exposure Log Incident Report.doc.) Print and send to EH.
Print CDC document: Exposure to Blood – What Healthcare Personnel Need to Know.
(L:\LMH\FORMS\Employee Health\Attachment J Forms\Exp_to_Blood.pdf.) Give to Employee.
Obtain Source Rapid HIV results
 If source patient is HIV negative and no HIV exposure in the last 6 weeks, post-exposure prophylaxis
(PEP) is not indicated. Contact the employee and let them know the results and that Employee Health
will contact them with the remaining test results (Hepatitis B & C).
 If source patient HIV results are positive:
 Speak to employee face to face to discuss post-exposure prophylaxis (PEP) and complete PEP
Information and Consent Form. (L:\LMH\FORMS\Employee Health\Attachment J Forms\PEP
Consent and Side Effects.doc)
 Contact National HIV/AIDS Clinicians’ Consultation Center PEPline 1-888-448-4911 with any
questions regarding PEP. They are an awesome resource and are happy to talk to you and the
employee 24/7.
 If employee agrees to PEP, take this protocol to pharmacy, obtain meds and have them take the first
dose. Enough medicine will be provided to get them through a long weekend. (4 Days). Employee
Health will contact the employee on the next business day.
Have the Employee sign the bottom of this form and return all documents to Employee Health.
Completed?
YES
NO
YES
YES
YES
NO
NO
NO
YES
YES
NO
NO
HIV Results
Neg
Pos
Source Pos
and EE Wants
PEP?
YES
NO
PEP Provided?
YES
NO
Management of Employee Illness or Exposure
to Communicable/Infectious Disease
EH-8660-585
ATTACHMENT J
Page 2 of 2
PHARMACIST: Please dispense per BBP Protocol.
Raltegravir 400 mg po twice daily #8
Truvada Take 1 tablet po once daily #4
Please provide written and verbal instructions. Pharmacist Signature:
EXPOSED EMPLOYEE
I have been advised of the risks and benefits of PEP for HIV exposure and have been advised that the exposure I sustained:
Warrants taking the medication. I
will
will not take it for the prescribed time.
Does not warrant taking the medication.
I understand Employee Health will contact me with the remaining source results and any further tests or treatment.
Employee signature: _________________________________________________ Date: ___________________________
Return Completed Forms to Employee Health Services for Follow up