Table 3.

Postexposure management of HCP to infections transmitted by the airborne route.

Infection	Disease status of source patient	Disease status of exposed HCP and type of exposure	PEP regimen	Initial assessment and follow up of exposed HCP	Primary prevention	Adverse effects of PEP regimen
TB	Patients with untreated pulmonary or laryngeal TBa	All HCP with unprotected exposure, regardless of prior history of TB or vaccination with BCG	One of the following regimens for treatment of LTBI should be considered: Isoniazid 5 mg/kg/day orally PLUS vitamin B6 25–50 mg/day orally for 9 monthsb OR Rifampicin 10 mg/kg (maximum dose of 600 mg/day) orally for 4 months OR Isoniazid 900 mg orally once weekly PLUS vitamin B6 25–50 mg/day orally PLUS rifapentine 900 mg orally once weekly for 3 monthsc,d OR Isoniazid 5 mg/kg/day orally PLUS vitamin B6 25–50 mg/day orally for 6 months OR Isoniazid 900 mg orally twice weekly PLUS vitamin B6 25–50 mg/day orally for 9 monthsc OR Isoniazid 900 mg orally twice weekly PLUS vitamin B6 25–50 mg/day orally for 6 monthsc OR Rifampicin 10 mg/kg orally PLUS isoniazid 900 mg/kg orally twice weekly PLUS vitamin B6 25–50 mg/day orally for 3 monthsc	Notify infection control and occupational health departments to identify contacts of the index case Screen exposed HCP for symptoms and signs of TB disease Perform TST or IGRA in exposed HCP who have no history of prior positive TST or IGRAe Screen exposed HCP with prior positive TST or IGRA or documented history of LTBI or TB disease for symptoms and signs of TB disease and chest radiography Repeat TST or IGRA 8–12 weeks postexposure, if the initial test and screen for symptoms and signs of TB disease are negativee Rule out TB disease by symptom and sign screen and chest radiography, if initial or follow up TST or IGRA are positive Perform baseline and monthly liver function tests for HCP on treatment of LTBIf No work restriction or modification required for exposed asymptomatic HCP with or without LTBI or with extrapulmonary TB without lung or laryngeal involvement or draining lesions Symptomatic HCP with infectious pulmonary or laryngeal TB should be excluded immediately from work and can return to work when they are considered noninfectious by occupational health and infection control departmentsg	Patients with suspected or confirmed pulmonary laryngeal TB, or extrapulmonary TB with draining lesions should be placed in contact and airborne precautionsg Patients with extrapulmonary TB without draining lesions require only standard precautions	Isoniazid: nausea, vomiting, hepatotoxicity, and peripheral neuropathy Rifampin and rifapentine: nausea, vomiting, hepatotoxicity, red-orange discoloration of urine, tears, sweat, and stool, drugs interactions, thrombocytopenia, and rash
Varicella and disseminated herpes zoster (HZ)	Patients with active infection from 1–2 days before rash onset for varicella and from onset of rash for HZ until all lesions have crusted (for vesicular rash) or disappeared (for maculopapular rash)	Nonimmune HCP with direct, face-to-face contact, not transitory, with patients with varicella or disseminated HZ Immune HCP with direct, face-to-face contact, not transitory, with patients with varicella or disseminated HZh	Two doses of varicella vaccine 1 month apart SC for exposed immunocompetent HCP within 5 days of exposure A single dose of VariZIG 125 units/10 kg IM/IV (to a maximum of 625 units) for exposed pregnant or immunocompromised HCP as soon as possible, ideally within 96 hours of exposurei OR Immune globulin 400 mg/kg IV if VariZIG is not available OR Acyclovir 40–80 mg/kg orally in four divided doses, famciclovir 500 mg orally 3 times daily, or valacyclovir 1 g orally 3 times daily on postexposure days 3–22, or on postexposure days 3–28 in HCP who has received VariZIG or immunoglobulin PEP is not recommended	Monitor exposed HCP daily for fever, skin rash, or systemic symptoms from days 8–21 after exposure (from days 8–28, if they received VariZIG) No work restriction or modification for asymptomatic exposed immune HCP or recently vaccinated HCP Exposed HCP who are nonimmune, vaccinated with a single dose of varicella vaccine, or received the second dose of varicella vaccine >5 days postexposure should be excluded from work from days 8–21 (from days 8–28, if they received VariZIG) after last exposure Exposed symptomatic HCP should be excluded immediately from work until lesions are dry and crustedj	Patients with varicella or disseminated HZ, or immunocompromised patients with cutaneous HZ should be placed in contact and airborne precautions until all lesions are dry and crustedj Patients with cutaneous HZ should be placed in contact precautions with complete covering of skin lesions until crusting and dryness of all lesions All nonimmune HCP should receive two doses of varicella vaccine administered 4–8 weeks apart or a single dose of HZ vaccine if they are aged ≥60 years	Varicella vaccine: injection-site reactions (pain, tenderness, swelling), fever, rash, and thrombocytopenia VariZIG: injection-site reactions, headache, chills, anaphylactic/hypersensitivity reaction, and noncardiogenic pulmonary edema Acyclovir: nausea, vomiting, diarrhea, headache, acute renal failure, agitation, tremors, delirium, hallucinations, and myoclonus Famciclovir: nausea, malaise, rash, and headache Valacyclovir: nausea, headache, increased liver function tests, and thrombotic microangiopathy Varicella vaccine is contraindicated in HCP who are pregnant or might become pregnant within 4 weeks of vaccination and in immunocompromised HCP (with hematologic malignancies, or on immunosuppressive drugs such as such as systemic steroids >2 mg/kg body weight) Varicella vaccine can be administered to HIV-infected HCP with a CD4+ T-lymphocyte count ≥ 200 cells/mL or immunocompetent HCP with immunocompromised patients in their households Contraindications to VariZIG include history of anaphylactic or severe systemic reactions to human immunoglobulins, and IgA-deficient patients with antibodies against IgA and a history of hypersensitivity Acyclovir, famciclovir, and valacyclovir are classified as category B in the FDA use-in-pregnancy rating
Measles	Patients with active infection, from 4–5 days before appearance of the rash until 4 days after rash onset	Nonimmune HCP or documentation of 1 vaccine dose Immune contactsk	A single dose of immunoglobulin, 0.5 mg/kg IM (maximum dose 15 mL) or 400 mg/kg IV, for pregnant women or severely immunocompromised HCPL within 6 days of exposure Live measles virus-containing vaccine (MMR or MMRV) SC for exposed immunocompetent HCP within 3 days of exposure A single dose of immunoglobulin, 0.5 mg/kg IM (maximum dose 15 mL) or 400 mg/kg IV, exposed immunocompromised HCP within 6 days of exposurel	Give exposed immunocompetent HCP the second dose of live measles virus-containing vaccine, if indicated, at least 28 days after the first dose of MMR or at least 3 months after the first dose of MMRV No work restriction or modification for asymptomatic immune exposed HCP Exposed nonimmune HCP should be excluded from work from days 5–21 postexposure; HCP with a documented history of 1 vaccine dose may receive the second dose and remain at work Exposed symptomatic HCP should be excluded immediately from work until ≥4 days post-onset of rash	Patients with measles should be in airborne precautions until 4 days after onset of rash, or for duration of illness in immunocompromised individuals All nonimmune HCP should be vaccinated with two doses of live measles virus-containing vaccines (MMR, MMRV)	Live measles virus-containing vaccines (MMR, MMRV): pain, redness, or swelling at the injection site, fever, transient rashes, transient lymphadenopathy, arthralgia/transient arthritis, parotitis, thrombocytopenia, febrile seizures, and encephalitis Contraindications to live measles virus containing vaccines include history of anaphylactic reactions to neomycin, history of severe allergic reaction to any component of the vaccine, pregnancy, and immunosuppression MMR vaccine, not MMRV vaccine, can be administered to HIV-infected patients who are well controlled and on effective antiretroviral therapy Women should be counseled to avoid becoming pregnant for 28 days after receiving live measles virus-containing vaccine
MERS-CoV	Patients with MERS-CoV infection	HCP who have close contact with infectious patientsm	No PEP available	Consider excluding HCP with unprotected exposure to a MERS-CoV patient for 14 days following the last exposure; or HCP should wear a facemask at all times while in the healthcare facility HCP with unprotected exposure to a MERS-CoV patient should be monitored for fever and respiratory symptoms for 14 days after the last exposure	Patients with MERS-CoV infection should be placed in contact and airborne precautions Duration of precautions should be determined on a case-by-case basis, in conjunction with local and state public health authorities and CDC
Ebola	Symptomatic patients with Ebola	All HCP with high-risk exposure n	None	No work restriction for asymptomatic HCP during temperature surveillance period Check exposed HCP to other blood-borne infections such as HIV, HBV and HCV	see Table 1 footnote e	Consultation with expert, local or state health department, or CDC is strongly recommended; site and vaccine complications
Avian influenza (H5N1, H7N9)	Patients with symptomatic H5N1 or H7N9 infection	All HCP within moderate risk exposure groupo	One of the following regimens could be given within 48 hours of exposure: Oseltamivir 75 mg/day orally once for 7 days, if H5N1, or twice daily for 5 days for limited exposure and for 10 days for ongoing exposure if H7N9 (preferred regimen) OR Zanamivir 10 mg/day (2 inhalations) for 7 days, if H5N1, or twice daily for 5 days for limited exposure and for 10 days for ongoing exposure if H7N9 (alternative regimen)	Counsel HCP to measure temperature daily for 7–10 days following the last known exposure to the patient Consider excluding asymptomatic HCP from work for 10 days; if necessary to continue working, HCP should take PEP and wear a facemask for 10 days HCP who develop a temperature ≥38°C or other symptoms should be immediately excluded from work and promptly evaluated and tested for H5N1 or H7N9 influenza	Patients suspected of having avian influenza should be placed in contact and airborne precautions with face/eye protection

^aFor patients with AFB smear-positive pulmonary TB, the contagious period is considered to have begun 3 months prior to either symptom onset or first positive test result consistent with TB, whichever is longer and ends when the patient is placed under airborne precautions or on the date of collection for the first of consistently negative smear results. For patients with AFB smear-negative pulmonary TB, the contagious period is considered to have begun 1 month prior to onset of symptoms and ends when the patient is placed under airborne isolation.

^bStandard recommended regimen.

^cRegimens require directly observed therapy (DOT).

^dOnce weekly isoniazid and rifapentine is not recommended for HIV-infected patients receiving antiretroviral treatment, pregnant women or women expecting to become pregnant during treatment, and patients who are presumed to be infected with isoniazid or rifampicin-resistant strains.

^eIf the first and follow up TST or IGRA are both negative, the exposed person is classified as not infected with M. tuberculosis. However, if the first or follow up TST or IGRA are positive, the person is classified as infected with M. tuberculosis (either LTBI or TB disease).

^fLiver function tests are indicated for patients with preexisting liver disease/abnormal liver function tests, on hepatotoxic drugs or alcohol, pregnant or 3 months postpartum, and HIV-infected.

^gIsolation of confirmed TB patients can be discontinued if three consecutive sputum samples (collected on different days or 8–24 hours apart, with at least one being an early morning specimen) are AFB smear-negative, three consecutive cultures of the drainage are negative or drainage has ceased, and the patient is on effective therapy and is improving clinically.

^h HCP are considered immune to varicella or HZ if they meet any of the following criteria: documentation of vaccination with two doses of varicella vaccine; diagnosis or verification of history of varicella disease/HZ by a clinician; serologic evidence of either immunity or disease. HCP who previously received two doses of varicella vaccine or had a history of varicella/HZ and then become immunocompromised (e.g. solid organ transplant recipients) should be considered immune, except for hematopoietic stem cell transplant recipients who should be considered immune only if they developed varicella/HZ infection after transplantation or received two doses of varicella vaccine after transplantation.

ⁱVariZIG can be given up to 10 days after last exposure. For high-risk patients who have additional exposures to varicella-zoster virus ≥3 weeks after initial administration of VariZIG, a second dose should be considered.

^jFor immunocompromised patients with varicella pneumonia, airborne and contact precautions should be maintained for the duration of illness.

^kExposed HCP are considered immune if they meet one of the following criteria: documentation of vaccination with two doses of live measles virus-containing vaccine (with the first dose administered ≥12 months of age and the second dose at least 28 days after the first one), laboratory evidence of immunity (detection of measles immunoglobulin G in serum, with equivocal results considered negative), laboratory confirmation of disease, or birth before 1957. For HCP born before 1957, who lack the other criteria, facilities should consider vaccination with two doses of MMR vaccine at least 28 days apart.

^lSeverely immunocompromised individuals include the following: patients with severe primary immunodeficiency; patients who have received a peripheral stem cell transplant (until at least 12 months after completing all immunosuppressive treatment, or longer in patients who have developed graft-versus-host disease); patients with hematologic malignancies and lymphoma; patients on treatment for acute lymphoblastic leukemia and until at least 6 months after completion of immunosuppressive chemotherapy; persons receiving systemic immunosuppressive therapy, including corticosteroids ≥2 mg/kg of body weight or ≥20 mg/day of prednisone or equivalent for persons who weigh >10 kg, when administered for ≥2 weeks; and patients with a diagnosis of AIDS or HIV-infected persons with severe immunosuppression, defined as CD4 percentage <15% or CD4 count <200 lymphocytes/mm³ and those who have not received MMR vaccine since receiving effective antiretroviral agents.

^mClose contact is defined as being within ∼6 feet or within the room or care area for a prolonged period of time (not a brief interaction such walking by) or having direct contact with infectious secretions such respiratory while not wearing PPE.

ⁿHigh-risk exposures include: percutaneous (e.g. needle stick) or mucous membrane exposure to blood, body fluids (vomitus, urine, feces), or tissues from an infected symptomatic patient; direct skin contact with skin, blood, body fluids from an infected symptomatic patient; processing blood or body fluids from an infected symptomatic patient without appropriate PPE; direct contact with a dead body of an infected patient. Low-risk exposures include: HCP in facilities with infected patients who have been in care areas of infected patients without recommended PPE.

^oClose contact, particularly if at high risk of complications of avian influenza, within 6 feet with a confirmed or probable case during bronchoscopy or intubation; while performing tracheal suctioning, delivering nebulized drugs, or handling inadequately screened or sealed body fluids without use of recommended PPE; or following a recognized breach in PPE procedure or a laboratory workers with unprotected exposure to a virus-containing sample. If PEP cannot be started within 48 hours of exposure, antiviral treatment with oseltamivir 75 mg orally twice daily for 7 days can be given.

Abbreviations: AFB = Acid-fast bacilli; BCG = Bacillus Calmette-Guérin; CDC = Centers for disease control and prevention; HBV = Hepatitis B virus; HCP = Healthcare personnel; HCV = Hepatitis C virus; HZ = Herpes zoster; IGRA = Interferon-Gamma Release Assay; IM = Intramuscular; IV = Intravenous; LTBI = Latent tuberculosis infection; MERS-CoV = Middle East respiratory syndrome coronavirus; MMR = Measles, mumps, and rubella; MMRV = Measles, mumps, rubella, and varicella; PEP = Postexposure prophylaxis; SC = Subcutaneous; TB = Tuberculosis; TST = Tuberculin skin test; VariZIG = Varicella zoster immunoglobulin.

Information from references [1,4,5,21,22,28,29,31,32,36,39,41,45,48,50-52].