INFECTION CONTROL NEWSLETTER

July 1997
written by and for Long Term Care Infection Control Nurses

Broad Street Solutions
James Marx, RN, MS, CIC Editor
P.O. Box 16557
San Diego, CA 92176
(619) 563-0274 Voice/FAX
jmarx@BroadStreetSolutions.com

VARICELLA VACCINATION PROGRAM: PART I

Varicella infection is manifested as chickenpox when a susceptible person first is exposed to the virus. The virus can again be manifested or reactivated in the form called herpes zoster or shingles. The exact mechanism for re-activation is unknown.

Shingles (herpes zoster) is a common disease of the elderly and others with immune compromise due to illness, stress, age, medication or co-infections. Approximately 15% of the population will experience herpes zoster during their lifetimes. The young, mostly female workforce in long term care facilities may be at risk of complications to themselves and, if they become pregnant, to their unborn children should they get exposed at work.

The CDC has published guidelines for vaccinating health care workers. All susceptible healthcare workers should ensure that they are immune to varicella. In healthcare facilities, serologic screening of personnel who have a negative or uncertain history of varicella is likely to be cost effective. A reliable history of varicella is a valid measure of immunity. Because the rash is distinctive and subclinical cases rarely occur, most parents know if their child has had varicella. A negative history of varicella substantiated by a parent may be more accurate than a self-reported negative history given by an adult. Serologic tests have been used to assess the accuracy of reported histories of varicella. In adults, a positive history of varicella is highly predictive of serologic immunity (97%‚99% of persons are seropositive); however, the majority of adults who have negative or uncertain histories are also seropositive (71%‚93%). ELISA tests, which are commercially available, range in sensitivity from 86% to 97% and range in specificity from 82% to 99% in detecting antibody after natural varicella infection.

Routine testing for varicella immunity after two doses of vaccine is not necessary for the management of vaccinated healthcare workers who may be exposed to varicella, because 99% of persons are seropositive after the second dose. Seroconversion, however, does not always result in full protection against disease. Testing vaccinees for seropositivity immediately after exposure to VZV is a potentially effective strategy for identifying persons who remain at risk for varicella. Varicella is unlikely to develop in persons who have detectable antibody; persons who do not have such antibody can be re-tested in 5‚6 days to determine if an anamnestic response is present, in which case development of disease is unlikely. Persons who remain susceptible may be relieved of work. Alternatively, persons can be monitored daily to determine clinical status and then sent home at the onset of manifestations of varicella. Facility guidelines are needed for the management of exposed vaccinees who do not have detectable antibody and for persons who develop clinical varicella. More information is needed concerning the risk for transmission of vaccine virus from vaccinees in whom varicella-like rash develops following vaccination. On the basis of available data, the risk appears to be minimal, and the benefits of vaccinating susceptible healthcare workers outweigh this potential risk. As a safeguard, facilities may wish to consider precautions for personnel in whom rash develops following vaccination and for other vaccinated personnel who will have contact with susceptible persons at high risk for serious complications. Vaccination should be considered for unvaccinated healthcare workers who are exposed to varicella and whose immunity is not documented. However, because the protective effects of postexposure vaccination are unknown, persons vaccinated after an exposure should be managed in the manner recommended for unvaccinated persons.

Screening should take place at the beginning of employment. If suspectable, vaccination should be given to direct care staff before initial assignment. The cost of vaccine is about $40.00 per dose. Screening test cost will vary depending on the laboratory.

For more information, see the recommednations from the CDC at Varicella Prevention Recommendations, July 12, 1996

LINEN HANDLING IN SKILLED NURSING FACILITIES

Linen handling is addressed in the federal regulations (HCFA), under F-tag 445. Clean and soiled linen should be kept separated during the cleaning and distribution process. There is no spacial separation requirement. Soiled linen should not be placed on the floor. Soiled diaper/briefs should never be rinsed in the resident's toilet, sink or bathtub. Soiled linen should be contained at the point of use in a container that will not break or leak when transported. If the laundry uses Universal Precautions, segregation of linen soiled based on type of soilage or isolation status is unnecessary. Laundry workers should all wear personnel protective equipment when handling soiled linen. Linen handling should be addressed in the Bloodborne Pathogens Exposure Control Plan.