[MCOH-EH] MCOH-EH Digest, Vol 253, Issue 318 - varicella exposure

[Timothy Herrick]

The CDC is actually a bit more demanding on what constitutes a prior history of varicella, as opposed to what is stated in the cited documents. See below.
I feel that this is appropriate given the fact that many practicing providers at the present time have virtually no experience diagnosing varicella and frankly, I don't necessarily trust a provider diagnosis of varicella.

To verify a history of varicella, health care providers should inquire about:

  *   an epidemiologic link to another typical varicella case or to a laboratory confirmed case, or
  *   evidence of laboratory confirmation, if testing was performed at the time of acute disease
Persons who have neither an epidemiologic link nor laboratory confirmation of varicella should not be considered as having a valid history of disease. For these persons, a second dose of vaccine is recommended if they previously received only one dose. If a health care provider verifies the diagnosis based on the above criteria, then vaccination is not needed.
[from Assessing Immunity to Varicella from the current CDC website.]

Tim Herrick, MD
OHSU

From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Harriman, Kathleen at CDPH
Sent: Thursday, November 15, 2018 12:28 PM
To: mcoh-eh at mylist.net
Subject: Re: [MCOH-EH] MCOH-EH Digest, Vol 253, Issue 318 - varicella exposure

Hi Deanna,
Please see the section on Health Care Personnel in: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5604a1.htm; the quoted information below comes from this document. Also see,  https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/HCWIZRecs.pdf

Is there more information about the three employees with "low titers"? I ask, because serologic testing is not recommended for persons who were vaccinated for varicella because commercially available tests don't reliably detect vaccine-induced varicella immunity, ie, you can trust a positive result, but not necessarily a negative or equivocal result.
Routine testing for varicella immunity after 2 doses of vaccine is not recommended for the management of vaccinated HCP. Available commercial assays are not sensitive enough to detect antibody after vaccination in all instances. Sensitive tests have indicated that 99% of adults develop antibodies after the second dose. However, seroconversion does not always result in full protection against disease, and no data regarding correlates of protection are available for adults.

Here are the recommendations for HCWs with negative or equivocal varicella IgG results, who were not vaccinated and have no other evidence of immunity, eg, varicella scars or a legitimate history of previous shingles:
Unvaccinated HCP who have no other evidence of immunity who are exposed to VZV are potentially infective from days 10--21 after exposure and should be furloughed during this period. They should receive postexposure vaccination as soon as possible. Vaccination within 3--5 days of exposure to rash might modify the disease if infection occurred. Vaccination >5 days postexposure still is indicated because it induces protection against subsequent exposures (if the current exposure did not cause infection).

Here are the recommendations for exposed workers who have documentation of two doses of varicella vaccine:
HCP who have received 2 doses of vaccine and who are exposed to VZV should be monitored daily during days 10--21 after exposure through the employee health program or by an infection control nurse to determine clinical status (i.e., daily screen for fever, skin lesions, and systemic symptoms). Persons with varicella might be infectious up to 2 days before rash onset. In addition, HCP should be instructed to report fever, headache, or other constitutional symptoms and any atypical skin lesions immediately. HCP should be placed on sick leave immediately if symptoms occur. Health-care institutions should establish protocols and recommendations for screening and vaccinating HCP and for management of HCP after exposures in the work place.

With regard to HCWs who receive varicella vaccine (routinely, not a susceptible HCW vaccinated after an exposure) and work with immunocompromised patients:
The risk for transmission of vaccine virus from vaccine recipients in whom varicella-like rash occurs after vaccination is low and has been documented after exposures in households and long-term care facilities (140,146--148). No cases have been documented after vaccination of HCP. The benefits of vaccinating HCP without evidence of immunity outweigh this extremely low potential risk. As a safeguard, institutions should consider precautions for personnel in whom rash occurs after vaccination. HCP in whom a vaccine-related rash occurs should avoid contact with persons without evidence of immunity who are at risk for severe disease and complications until all lesions resolve (i.e., are crusted over or fade away) or no new lesions appear within a 24-hour period.

Kathleen Harriman
Immunization Branch
California Department of Public Health
Richmond, CA


Today's Topics:

   1. Re:  Varicella exposure (Tim Crump)

----------------------------------------------------------------------

Message: 1
Date: Thu, 15 Nov 2018 19:29:00 +0000
From: Tim Crump <crumpt at ohsu.edu<mailto:crumpt at ohsu.edu>>
To: MCOH/EH <mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>>
Subject: Re: [MCOH-EH] Varicella exposure

We generally let our Infection Prevention and Control Dept determine exposure criteria, but generally, my understanding is that even in immune compromised patients, if the shingles is restricted to a single dermatome, we are thinking about contact but not airborne exposures.

We had a disseminated case that affected a lot of staff.  We are strongly encouraging staff to address issues of immunity  prior to an exposure rather than in the midst of one.  Furlough is not a fun thing.  Best, Tim

Tim Crump, MSN, FNP
Family Nurse Practitioner
Multnomah Pavilion 1 SE, Suite 1110
Occupational Health
Healthcare Human Resources

Oregon Health & Science University
3181 SW Sam Jackson Park Rd
Mail code: UHN 89
Portland, OR 97239-3098
Department Phone: 503-494-5271
Office Phone: 503-346-1152
Fax: 503-494-4457
Email: crumpt at ohsu.edu<mailto:crumpt at ohsu.edu<mailto:crumpt at ohsu.edu%3cmailto:crumpt at ohsu.edu>>


From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of PRATER, DEANNA
Sent: Wednesday, November 14, 2018 4:24 PM
To: mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>
Subject: [MCOH-EH] Varicella exposure

I'm needing some help.  I'm new to the role of Employee Health.  Our Cancer Center reported 7 cases of shingles patients coming into their facility.  Some of these patients are sitting in a group setting, receiving chemo.  I made some inquiries about which employees had interaction with the shingles patients and requested either titer checks or records of titer checks.  There were 3 employees with low titers.  I have no idea what steps to take (in regards to the employees-I know concerns about the other patients is a whole other story).  I'm told all cases were non-disseminated.

If employees would request the vaccine, could they still work around these immunocompromised patients?

Also-if anyone has examples of exposure packets/algorhythms you use; I would greatly appreciate it.


-------------- next part --------------
An HTML attachment was scrubbed...
URL: <https://mylist.net/archives/mcoh-eh/attachments/20181119/ca5bd626/attachment.html>