106.

Pregnant Healthcare Personnel | Infection Prevention for Occupational Health | Table of Contents | APIC 12/30/20, 3:51 PM

Pregnant Healthcare Personnel

Author(s): Vicki Allen, MSN, RN, CIC, FAPIC
Director, Infection Prevention & Control

CaroMont Regional Medical Center

Gastonia, NC

Published: October 3, 2014

Abstract
Following Standard Precautions (i.e., consider all body fluids except
sweat potentially infectious, and use personal protective equipment
when exposure to blood or body fluids is anticipated), as
recommended by the Centers for Disease Control and Prevention for
all healthcare personnel, will protect pregnant healthcare personnel
against most infectious agents to which they may be exposed.
However, because some infectious agents can cause congenital
syndromes in the fetus when primary infection is acquired during
pregnancy, there are additional concerns in pregnant or potentially
pregnant healthcare personnel. For practical purposes, immunologic
function is normal during pregnancy, and an otherwise healthy woman
is not considered to be an immunocompromised host. Pregnancy
does not increase the risk of acquisition of infections and, for most
infectious agents, clinical manifestations of infections are no more
severe in pregnant women than in those who are not pregnant. In
view of the routes of transmission and ubiquity of some infectious
agents (e.g., cytomegalovirus), restricting pregnant women from caring
for patients with potentially transmissible infections is considered only

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for patients infected with parvovirus B19 and for patients with
respiratory syncytial virus infections who are receiving ribavirin aerosol.
Because patients with vaccine-preventable diseases should be cared
for by only immune healthcare personnel, it is especially important for
women contemplating pregnancy to obtain the needed vaccines
before conception. Similar to nonpregnant healthcare personnel,
susceptible pregnant healthcare personnel should be restricted from
contact with patients with rubeola, rubella, varicella, and smallpox.
Much anxiety among pregnant healthcare personnel results from
misinformation concerning epidemiology and transmission of infectious
agents. The emphasis must be on education of all healthcare
personnel of childbearing age, ideally before pregnancy, or at least as
soon as pregnancy is diagnosed. It is important to note that the
incidence of cytomegalovirus and parvovirus infection is not increased
among healthcare personnel compared with other occupations,
especially day care center staff and school teachers.

Key Concepts
Consistent adherence of pregnant healthcare personnel to the
practices of Standard Precautions, especially hand hygiene, will
protect against most exposures to infectious agents of concern
during pregnancy.
Healthcare personnel should be immunized against vaccine-
preventable diseases before conception. Once pregnancy occurs,
most missed immunizations may still be provided but should occur
only after consultation with the healthcare personnel's obstetrician.
However, influenza vaccine is recommended for routine
administration to pregnant women at any trimester if they will be
pregnant during the influenza season, including the first trimester.
Although live virus vaccines are not recommended during
pregnancy, inadvertent administration of live attenuated virus
vaccines (rubella, rubeola, varicella, smallpox) has not been
associated with adverse outcomes as tracked in national registries.
The exposure of nonimmunized pregnant healthcare personnel to
varicella zoster virus presents a primary risk to the mother and
fetus-neonate.
Immunization during pregnancy and before conception provides
benefit from the disease to the mother during pregnancy and
benefit to the neonate by passive antibodies during the first 4 to 6
months of life.

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Reviewing the patient's immunization status before attempts to

conceive is prudent.
There are few healthcare exposures that will be associated with
adverse outcomes for pregnant healthcare personnel or her fetus.

Background
Consistent adherence to Standard Precautions (i.e., consider all bodily
fluids except sweat potentially infectious and use personal protective
equipment [PPE] when exposure to blood and body fluid is
anticipated), as recommended by the Centers for Disease Control and
Prevention (CDC), provides pregnant healthcare personnel (HCP) and
all HCP the optimal protection from exposure to infectious agents.
Increased adherence to recommended precautions has been
demonstrated for pregnant individuals when compared with
nonpregnant individuals. Pregnant HCP have the additional concern of
coming into contact with an infectious agent that may cause serious
illness in the mother and may cause a congenital syndrome or some
adverse pregnancy outcome. In general, maternal immune function is
normal, but there is some decrease in cell-mediated immunity in the
third trimester to viruses and pathogenic fungi.

HCP protection against vaccine-preventable diseases should be

achieved by prepregnancy immunization. Immunization of pregnant
HCP is indicated either to protect the mother, as is the case with the
influenza vaccine, or to ensure the transfer of maternal antibody to
the fetus, as with tetanus and influenza. The benefits of preventing
disease during pregnancy clearly outweigh concerns about the safety
of vaccines or immunoglobulins because no definable risks have been
described.

Basic Principles
Patients who may be shedding certain infectious agents for which
there is no vaccine may cause the pregnant HCP to be concerned
regarding her safety and the safety of her fetus. These may include
patients with cytomegalovirus (CMV), parvovirus B19, herpes simplex
virus, syphilis, and rubeola, rubella, and varicella if not immune (Table
106-1). Although respiratory syncytial virus (RSV) infection does not
have an adverse effect on the pregnant woman, exposure to the
ribavirin aerosol used for treatment of RSV is contraindicated during

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pregnancy based on theoretical, but unproven, adverse effects during

pregnancy. It is essential that all HCP practice Standard Precautions
to optimize their personal protection when caring for patients. If
Standard Precautions are used, restriction of patient care
responsibilities for pregnant HCP is rarely indicated. Despite this fact,
one cannot underestimate the importance of recognizing the
emotional aspects of pregnancy and the real potential for exposures
to infectious agents. It may be prudent to consider alterations in
patient care activities if fear of safety cannot be adequately
addressed and adequate numbers of staff are available to allow such
modifications. Such decisions are best made in collaboration with the
healthcare management, the occupational health, and infection
prevention and control departments, as well as the individual pregnant
HCP. However, it is important to recognize that removing pregnant
HCP from caring for the patient known to be infected with an agent
of concern may result in re-assignment to a patient in whom an
infection may be present but not yet identified, and adherence to
Standard Precautions may be less likely. For example, 70 percent of
children who attend day care centers may be shedding CMV and may
be asymptomatic.

Table 106-1 Infectious Agents of Concern to the Pregnant Healthcare

Personnel According to Risk of Transmission Associated With Delivery
of Healthcare and Available Preventive Measures
Healthcare- Healthcare- Infection Postexposure
associated associated Prevention Chemoprophylaxis
Acquisition Acquisition Precautions Effective
Possible and Unlikely are the
Prevented by Only
Pre-exposure Preventive
Vaccine Measures

Anthrax* HSV CMV HIV

HAVa Toxoplasmosis HCV Neisseria meningitis

HBV Parvovirus
B19

Influenza Tuberculosis Syphilis

N. meningitis†

Pertussis

Rubella

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Rubeola

Varicella

Tetanus

Diphtheria

Smallpox

*Rare.
†Considered for
laboratory workers,
for college freshmen
living in dormitories,
or during a
community outbreak.

Pregnant HCP should have been immunized according to the

schedule for adult immunization. Immunizations should include
poliomyelitis; measles, mumps, rubella (MMR); varicella; tetanus; and
diphtheria, or there should be a reliable history of having had the
disease before becoming pregnant (Table 106-2). Pneumococcal
vaccine should be administered preconceptually or during pregnancy
in the second or third trimesters, especially if high-risk conditions are
present (e.g., metabolic diseases such as diabetes mellitus or thyroid
dysfunction; pulmonary, renal, or cardiac diseases; asthma; smoking;
or functional or anatomic asplenia). Unfortunately, many adults do not
have reliable records or memory of childhood vaccines or illnesses. In
addition, HCP generally have access to information about vaccines
and vaccine-preventable diseases but may not consider the benefits
to themselves during pregnancy or to their newborn infant during the
first 6 months of life. Healthcare institutions should mandate that HCP
must complete the proper vaccine program as a condition of
employment.

Table 106-2 Vaccination of Pregnant Women

Vaccine General Contraindicated
Recommendations During
for Use in Pregnancy
Pregnant Women

Hepatitis A Recommended if
otherwise indicated

Hepatitis B Recommended in

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some circumstances

Human papillomavirus (HPV) Not

recommended

Influenza inactivated Recommended

Influenza (LAIV)* Contraindicated

Measles, mumps, rubella (MMR) Contraindicated

Meningococcal conjugate May be used if

(MCV4/MenACWY) otherwise indicated

Pneumococcal conjugate (PCV13) Inadequate data for

specific
recommendation

Pneumococcal polysaccharide (PPSV23) Inadequate data for

specific
recommendation

Polio (inactivated poliovirus vaccine [IPV]) May be used if

needed

Tetanus and diphtheria (Td) Should be used if

otherwise indicated

Tetanus, diphtheria, and pertussis (Tdap)†‡ Recommended

Varicella Contraindicated

Zoster (shingles) Contraindicated

Travel and Other Vaccines

Anthrax High risk of Low risk of

exposure: May be exposure: Not
used recommended

Bacille Calmette-Guérin (BCG) Contraindicated

Japanese encephalitis Inadequate data for

specific
recommendation

Meningococcal polysaccharide (MPSV4) May be used if

otherwise indicated

Rabies May be used if

otherwise indicated

Typhoid Inadequate data for

specific
recommendation

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Vaccinia (smallpox) Postexposure: Preexposure:

recommended contraindicated

Yellow fever May be used if

benefit outweighs
risk

*LAIV: Do not administer LAIV to

pregnant women (Centers for Disease
Control and Prevention [CDC]. Guidelines
for Vaccinating Pregnant Women.CDC
website. 2013. Available
at:http://www.cdc.gov/vaccines/pubs/preg-
guide.htm).
†For women not previously vaccinated
with Tdap. If Tdap is not administered
during pregnancy, Tdap should be
administered immediately postpartum.
‡Wound management: If a Td booster is
indicated for a pregnant HCP, healthcare
providers should administer Tdap.

From Centers for Disease Control and

Prevention. Updated recommendations for
use of tetanus toxoid, reduced diphtheria
toxoid, and acellular pertussis vaccine
(Tdap) in pregnant women – Advisory
Committee on Immunization Practices
(ACIP), 2012. MMWR Morb Mortal Wkly
Rep2013;62 (No. 7):131–135.

No evidence exists for risk from vaccinating pregnant women with

inactivated vaccines or toxoids. In addition, pregnancy registries have
demonstrated no harmful fetal effects when polio, rubella, varicella,
and smallpox vaccines have been administered inadvertently to
women who did not know they were pregnant. Benefits of maternal
vaccination include protecting the mother from disease and protecting
the neonate from disease for the first 3 to 6 months of life by
passively transferred antibody via the umbilical cord.

DISEASE AND PREGNANT HEALTHCARE

PERSONNEL
There are numerous questions regarding occupational exposures to
infectious agents (Table 106-3). This table lists many of the infectious
agents pregnant HCP may encounter during employment or in
nonoccupational activities.

Table 106-3 Pregnant Healthcare Worker: Guide to Management of

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Occupational Exposure
Agent In-hospital Source Potential Rate of
Effect on the Perinatal
Fetus Transmission

Anthrax

CMV Urine, blood, semen,

vaginal secretion, Classic Primary
immunosuppressed cytomegalic infection
transplant, dialysis, inclusion (25 to 50
day care disease percent)
(5 to 10
percent)* Recurrent
infants
Hearing loss (52 percent)
(10 to 15
percent) Symptomatic
(<5 to 15
percent)

HAV Feces (most No fetal None

common), blood transmission
(rare) described;
transmission
may occur at
the time of
delivery if
women still in
the infectious
phase and
cause hepatitis

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HBV Blood, bodily fluids, Hepatitis, early

vaginal secretions, onset HbsAg + 10
semen hepatocellular percent
carcinoma
HbeAg + 90
percent

HCV Blood, sexual Hepatitis 5 percent (0

to 25 percent)

HSV Vesicular fluid, Sepsis,

oropharyngeal and encephalitis, Primary
vaginal secretions meningitis, genital
mucocutaneous (33 to 50
lesions, percent)
congenital
malformation Recurrent
(rare) genital
(1 to 2
percent)

HIV Blood, bodily fluids, No congenital

vaginal secretions, syndrome. If Depends on
semen fetus infected, HIV viral titer
AIDS in 2 to 4
years. If titer <1,000
virus; rate, 2
percent

If titer
≥10,000; rate
up to 25
percent

Influenza Sneezing and No congenital Rare

coughing, respiratory syndrome:
tract secretions Influenza in
mother could
cause hypoxia
in fetus

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Measles (rubeola) Respiratory secretion Prematurity Rare

coughing spontaneous
abortion no
congenital
syndrome

N. meningitidis Respiratory secretion Unknown

of untreated patients Sepsis
or those who have
received No congenital
antimicrobials for syndrome
<24 hours

Parvovirus B19 Respiratory secretion, Fetal hydrops, Approximately

blood, stillbirth, no 25 percent;
immunocompromised congenital fetal death
patients syndrome <10 percent

Rubella Respiratory Congenital

secretions syndrome 90 percent in
first trimester

40 to 50
percent
overall

Smallpox (vaccinia) Respiratory Fetal vaccinia,

secretions, contents premature
of pustular-vesicular delivery,
lesions spontaneous
abortion, and
perinatal death

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Syphilis Blood, lesion, fluid, Congenital Variable 10 to

amniotic fluid syndrome 90 percent
depends on
stage of
maternal
disease and
trimester of
the infection

Tuberculosis Sputum, skin lesions Neonatal Rare

tuberculosis;
liver most
frequently
infected

Varicella zoster Droplet or airborne Malformations Total 25

spread of vesicle (skin, limb, percent:
fluid or secretions of CNS, eye); congenital
the respiratory tract chickenpox syndrome
(scabs are not (0 to 4
infective) percent)

TIV, trivalent
inactivated.

*Congenital
syndrome: varying
combinations of
jaundice,
hepatosplenomegaly,
microcephaly,
thrombocytopenia,
anemia, retinopathy,
and skin and bone
lesions.
†Live virus vaccine
given before or after
pregnancy.

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Counsel pregnant women and women of childbearing age regarding

the risk of transmission of infectious diseases (e.g., CMV, hepatitis,
HIV, parvovirus, rubella) that, if acquired during pregnancy, may have
adverse effects on the fetus, whether the infection is acquired in
nonoccupational or occupational environments. Information regarding
occupational exposure to infectious agents including preventive
measures such as Standard and Transmission-based Precautions is
included in Table 106-3 and should be accessible and provided to
pregnant HCP. It is not necessary to routinely exclude women strictly
on the basis of their pregnancy, or intent to become pregnant, from
the care of patients with particular infections that have potential to
harm the fetus.

CYTOMEGALOVIRUS
No vaccine is available for CMV and consistent adherence to
Standard Precautions is the only preventive measure. The clinical
entity, cytomegalic inclusion disease, was described in 1950. This
generalized congenital infection was associated with cytomegalic
cells, and typical intranuclear inclusions were found in multiple
organs. The virus was grown on cultured human cells in 1956 and is
now recognized as the most frequent congenitally and perinatally
acquired viral disease known in humans. It is the single most
important infectious cause of mental retardation and congenital
deafness in the United States.

CMV infection is restricted to humans. The virus is widespread, and

infection is more common than disease. By serology, 80 to 90 percent
of individuals are exposed during their lifetime. Seropositivity among
women in the reproductive years (15 to 35) is approximately 50
percent in middle and upper socioeconomic groups and 90 percent in
the lower socioeconomic groups.

CMV is transmitted most frequently by sexual contact or by direct

contact with infected urine, saliva, semen, vaginal secretions, or
breast milk. Major risks for primary infections among seronegative
women include the following:

1. Age <25 years

2. Multiple sexual partners
3. Exposure to young children (especially those who attend day
care) at home and in the work place; for example, day care
centers and schools

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The rate of seroconversion in seronegative women is 1 to 3 percent

per year, but is as high as 10 to 20 percent in women who work in
day care centers, and approaches 50 percent when an infected child
younger than 2 years of age is present in the home. HCP do not have
an increased risk of acquisition of CMV infection.

CMV crosses the placenta with relative ease, and congenital infection
occurs in 1 to 2 percent of all pregnancies. Perinatal infections are
acquired by exposure to the mother's infected genitourinary tract and
by ingestion of breast milk from an infected mother. Organ
transplants, blood transfusions, and dialysis centers are other sources
of infections. The spread of CMV among the general population is
facilitated by asymptomatic primary and recurrent infections, multiple
sites of excretion, prolonged and intermittent excretion, and excretion
of virus despite the presence of specific immunity. Asymptomatic
transmission further supports the need for adherence to Standard
Precautions among all HCP when in contact with all patients.

CMV infections are considered congenital if virus excretion or

serological evidence (CMV immunoglobulin M [IgM]) is found in the
infant within the first 2 weeks of life. Transmission of CMV to the
fetus can occur during primary and recurrent infections despite
maternal antibody. Although maternal immunity is not completely
protective, it plays a major role in reducing the virulence of infection
and the severity of the clinical manifestations in the fetus or newborn.
The frequency of congenitally infected infants among seropositive
women is 2 to 3 percent, whereas primary maternal infections carry
an overall risk to the fetus of 25 to 50 percent. Ninety percent of
congenitally infected infants will shed virus at birth and do so for 6
years or longer, even in the presence of antibody.

Congenital infections range from asymptomatic and unrecognized (90

percent) to multiple organ system involvement that is sometime
incompatible with life in 10 percent or less. Most of the asymptomatic
infections do not endanger life, but 10 to 15 percent of these infants
are at risk for long-term sequelae, such as progressive sensorineural
hearing loss, chorioretinitis, and dental abnormalities.

Approximately 5 to 10 percent of congenitally infected infants will

have significant stigmata of infection at birth. Approximately half will
have classic cytomegalic inclusion disease, and half will have atypical
involvement. All infants will excrete CMV at birth. The rate of mortality
infections in infants in this group is 20 to 30 percent. Children are
most severely affected as a result of primary maternal infections that

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occur early in pregnancy.

Acquisition of CMV in the neonatal period is common, but the

consequences of perinatally acquired infections are considerably less
serious than for congenital infections. Incubation time from exposure
to infection (asymptomatic or symptomatic) is 4 to 12 weeks, and
greater than 50 percent will be asymptomatic. Blood transfusion was
the source of most perinatal CMV infections before there were
recommendations for using specially treated blood in low-birth-weight
neonates.

Preventing primary infections in seronegative women during

pregnancy would be valuable. Because CMV is ubiquitous, there is no
treatment available, and the incidence of congenital CMV syndrome
with its devastating neurologic effects is rare. Serologic screening is
not offered to women routinely. Although transfer to a presumed
lower-risk patient care unit is an appealing option, it is difficult to
identify such an area in most acute care hospitals or healthcare
institutions that care for toddlers.

HEPATITIS A VIRUS
Hepatitis A virus (HAV) infection used to be one of the most
frequently reported vaccine-preventable diseases. However, with more
widespread use of HAV vaccine in populations defined by higher
disease prevalence rates, there has been a 97 percent decrease in
the incidence of this infection in the United States. HAV replicates in
the liver, is excreted in the bile, and is shed in the stool. Peak
infectivity occurs during the 2 weeks before the onset of jaundice or
elevation of hepatic transaminases, when the viral concentration in
the stool is greatest. Chronic shedding does not occur, and viremia is
present only soon after infection and persists through the time of
hepatic transaminase elevation.

Transmission is primarily from exposure to contaminated feces, but

blood can be a source for a short period of time. Maternal HAV
transmission to the fetus has not been established. HAV infection
during pregnancy can cause an increased risk of severe systemic
infections, spontaneous abortion, and preterm delivery. Hepatitis A is
an inactivated vaccine and, similar to Hepatitis B vaccines, is
recommended if another high-risk condition or other indication is
present.

HEPATITIS B VIRUS
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Hepatitis B virus (HBV) infection during pregnancy can result in severe

disease for the mother, fetal loss, or chronic infection of the neonate
if born alive. The prolonged HBV viremia may persist from weeks to
months and provides adequate time for vertical transmission. Chronic
HBV infections occur in 1 to 5 percent of adults with acute HBV
infection. However, in neonates, as many as 90 percent will manifest
chronic infection; 50 percent of infected infants and 20 percent of
infected young children will develop chronic infection. This
demonstrates the importance of an effective HBV immunization
program in the maternal and child health areas within healthcare
facilities.

Pregnancy is not a contraindication to vaccination. Limited data

suggest that developing fetuses are not at risk for adverse events
when Hepatitis B vaccine is administered to pregnant women.
Available vaccines contain noninfectious Hepatitis B surface antigen
(HBsAg) and should cause no risk of infection to the fetus.

POSTEXPOSURE PROPHYLAXIS FOR HBV DURING PREGNANCY

No apparent risk exists for adverse effects to developing fetuses
when Hepatitis B vaccine is administered to pregnant women (CDC,
unpublished data, 1990). The vaccine contains noninfectious HBsAg
particles and should pose no risk to the fetus. HBV infection during
pregnancy might result in severe disease for the mother and chronic
infection for the newborn. Therefore, neither pregnancy nor lactation
should be considered a contraindication to vaccination of women.
Hepatitis B immunoglobulin (HBIG) is not contraindicated for pregnant
or lactating women.

HBV vaccine should be administered in pregnancy when a high-risk

indication is present. See 99. Viral Hepatitis, and 103 Immunization
of Healthcare Personnel, for all indications for HBV vaccine.

All pregnant women should be screened for HBsAg early in pregnancy

and later in pregnancy if indicated by participation in high-risk
activities such as multiple sexual partners, illicit drug abuse, and
acquisition of another sexually transmitted infection.

Previously unvaccinated women who are HBsAg-negative should

receive the HBV vaccine series (0, 1, 6 to 12 months). Infants of
HBsAg-negative mothers should receive HBV vaccine at birth,
whereas infants of HBsAg-positive women should receive HBIG in
addition to the first dose of vaccine as soon as possible and ideally

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within 12 hours of birth.

HEPATITIS C VIRUS
Hepatitis C virus (HCV) may be transmitted sexually, by exposure to
blood via transfusion, sharing needles for intravenous drug use,
percutaneous injury, and, rarely, perinatal exposure. Transmission via
blood transfusion is prevented by screening blood donors for
laboratory evidence of HCV infection. No vaccine and no effective
therapy during pregnancy or the postnatal period exist at the current
time. In fact, it has not been determined if postexposure prophylaxis
(PEP) with antiviral agents is beneficial, because it may inhibit the
natural protective immune response. Therefore, preventing
occupational exposure is by avoiding percutaneous blood exposures
via the use of safety devices and wearing gloves.

The epidemiology of HCV resembles HBV. The prevalence of HCV in

the United States is 1.5 percent, but is higher in African Americans
and inner city pregnant women. Injectable drug use is the major mode
of transmission. Both sexual and maternal-fetal transmission have
been described, but with low frequencies. Studies of pregnant women
who are HCV seropositive suggest that injectable drug use and sexual
contact with injectable drug users are the major risk factors
responsible for HCV infection in women. The risk of developing
chronic HCV infection without evidence of active liver disease is
higher than for HBV infection, approaching 75 percent. The incubation
period is 15 to 160 days with a peak at 50 days.

The maternal-fetal transmission risk in an HCV seropositive mother is

10 percent, and infection rates can be correlated with the level of
maternal viremia. Studies have shown that acute HCV infection in the
first and second trimesters causes fetal hepatic injury, whereas acute
HCV infection in the third trimester results in serum transaminase
elevations without jaundice or evidence of hepatitis in the neonate.

HERPES SIMPLEX VIRUS

No vaccine is currently available for herpes simplex virus (HSV), and
prevention is by adhering to Standard Precautions. Healthcare-
associated HSV infection is most likely to manifest as a herpetic
whitlow, is prevented by the use of gloves for contact with mucous
membranes, and is unlikely to affect the genital tract or the fetus.

There are two major types of HSV: HSV-1 and HSV-2, with multiple
strains of each. HSV-1 and HSV-2 share approximately 50 percent of

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their DNA sequences. Viral replication occurs in the cell nucleus with
production of virus within 10 to 14 hours after infection.

Transmission of HSV occurs by intimate contact, such as oral-oral,

oral-genital, and genital-genital contact. Transmission by fomites
contaminated by body fluids has been documented. Humans are the
sole natural host for HSV, and 55 to 90 percent of the general
population has antibodies to HSV-1, HSV-2, or both. In the United
States, serologic evidence of infection with HSV-2 ranges from less
than 1 percent in those aged 15 years or younger to greater than 25
percent in those aged 30 years. Two-thirds of individuals who are
seropositive for HSV-2 report no clinical history or exposure to
another infected person.

HUMAN IMMUNODEFICIENCY VIRUS

No vaccine is currently available for HIV; however, chemoprophylaxis
is available for occupational exposures. Handling PEP is covered in
103. Occupational Exposure to Bloodborne Pathogens.

HIV infection causes destruction of the immune system, particularly

CD4 cells, and can result in the clinical acquired immunodeficiency
syndrome (AIDS). The risk factors for women or their sexual partners
for acquiring HIV infection are as follows:

Illicit drug use; especially injectable drug use

Current or previous multiple sexual partners
Trading sex for drugs
Transfusion of blood products before 1985
Bisexual activity
Residence in or origin from HIV-endemic areas
Symptoms of HIV-related illnesses
History of current sexually transmitted infection

In addition to those listed, risk factors for acquiring HIV are as

follows:

Maternal-fetal transmission
Transplantation of organs
Artificial insemination
Breastfeeding

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Maternal-fetal transmission may occur transplacentally in utero or

perinatally. The rate of transmission is determined by the viral titer in
the mother. Studies in the United States have indicated that the
transmission rate in nontreated women is 25 percent, whereas those
receiving antiretroviral chemotherapy have a transmission rate of 1 to
8 percent. In Africa, breastfeeding appears to account for 7 to 22
percent of all HIV transmission. When safer forms of nutrition are
available, breastfeeding is contraindicated in HIV-infected mothers.
Management of the HIV-infected pregnant woman includes
antiretroviral therapy during pregnancy, during labor, and after delivery
for the neonate. Maternal antiretroviral therapy is continued after
delivery.

Despite the increasing use of safety devices, occupational exposures

will occur and the seroconversion after percutaneous exposure is 0.3
percent, whereas seroconversion after mucous membrane, nonintact
skin exposure is 0.09 percent. Risk of percutaneous transmission is
increased with hollow-bore needles and when an increased volume of
blood is injected. Consistent adherence to Standard Precautions and
use of needleless systems and other safety needles will decrease the
risk of exposure.

PEP FOR PREGNANT HCP

If the exposed person is pregnant, the evaluation of risk of infection
and need for PEP should be approached as with any other person
who has had an HIV exposure. However, the decision to use any
antiretroviral drug during pregnancy should involve discussion
between the HCP and her healthcare provider(s) regarding the
potential benefits and risks to her and her fetus. Certain drugs should
be avoided in pregnant women—another reason for involving the
pregnant HCP healthcare provider—and, therefore, expert consultation
for HIV PEP is advised for known or suspected pregnancy in the
exposed person.

HUMAN PAPILLOMAVIRUS
Human papillomavirus (HPV) vaccines are not recommended for use
in pregnant women. If a woman is found to be pregnant after initiating
the vaccination series, the remainder of the three-dose series should
be delayed until completion of pregnancy.

INFLUENZA
Influenza is an acute respiratory illness characterized by myalgias,

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laryngotracheal bronchitis, fever with a nonproductive cough, and

acute and chronic debilitation. In the United States, seasonal
epidemics of influenza typically occur during October to March.
During 30 seasons from the 1976 to 1977 season through the 2005 to
2006 season, estimated influenza-associated deaths ranged from
3,000 to 49,000 annually. Increased severity of influenza among
pregnant women was reported during the pandemics of 1918 to 1919,
1957 to 1958, and 2009 to 2010. Pregnant women are at increased
risk for severe illness from influenza because of physiologic changes
during pregnancy.

Influenza is transmitted in most instances via respiratory secretions

from sneezing and coughing (e.g., droplet transmission). Although
airborne transmission via small droplet nuclei has been documented
(rarely) under certain conditions, large droplet transmission within 3
feet is the primary means of transmission. Influenza vaccination is the
best method of preventing influenza and its complications. The
Advisory Committee on Immunization Practices (ACIP) recommends
routine annual influenza vaccination for all persons aged ≥6 months
that do not have contraindications. Recommendations pertaining to
the use of specific vaccines and populations can be found in the
annual Morbidity and Mortality Weekly Reporton prevention and
control of seasonal influenza with vaccines.

It is important to note that when there are shortages in vaccine

supply, as in the 2004 to 2005 season, vaccine is recommended only
for those who are pregnant, those with high-risk conditions, all
persons age 65 years or greater (instead of 50 years), HCP with direct
face-to-face or hands-on contact with patients, and close household
contacts or out-of-home caregivers of infants younger than 6 months
of age.

Influenza is a common viral disease, and pregnant HCP can be a

vector to patients and become infected with the influenza virus
herself. The risk of hospitalization for a pregnant woman with
influenza during the second and third trimesters is equivalent to that
of nonpregnant individuals with underlying cardiopulmonary disease.
All HCP should be immunized with influenza vaccine on a yearly basis
to protect themselves, their patients, and their families. Currently, the
live attenuated influenza vaccine is not recommended during
pregnancy.

MEASLES, MUMPS, AND RUBELLA

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A highly effective vaccine exists for measles, and all HCP should have
received immunization before having patient contact. The measles-
mumps-rubella (MMR) vaccine combines measles, mumps, and rubella
vaccines and is highly effective.

The MMR vaccine and its component vaccines should not be

administered to women known to be pregnant. Because a risk to the
fetus from administration of these live virus vaccines cannot be
excluded for theoretical reasons, women should be counseled to
avoid becoming pregnant for 28 days after vaccinations with measles
or mumps vaccines or MMR or other rubella-containing vaccines.

All women of childbearing age, including those who grew up outside

the United States in areas where routine rubella vaccination might not
occur, should be vaccinated with one dose of MMR vaccine or have
other acceptable evidence of rubella immunity. Nonpregnant women
of childbearing age who do not have documentation of rubella
vaccination, serologic evidence of rubella immunity, or laboratory
confirmation of rubella disease should be vaccinated with MMR
vaccine. Birth before 1957 is not acceptable evidence of rubella
immunity for women who could become pregnant.

Measles occurs primarily in late winter and spring. Transmission is

primarily person-to-person via droplet and airborne routes. Measles is
highly contagious, with a secondary household attack rate of 90
percent. Death is usually from pneumonia or acute encephalitis and
occurs in 1 to 2 of 1,000 cases, which constitutes the main rationale
for universal immunization. MMR is not indicated during pregnancy
because it contains three live attenuated vaccines, but it should be
given postpartum to the nonimmune woman. This demonstrates the
importance of ensuring that an effective postpartum immunization
program exists in the maternal and child health areas in healthcare
facilities.

Rubella (German measles) is a mild, exanthematous viral infection that

primarily affects children. Except for rubella infecting pregnant
women, there are practically no complications.

The disease is transmitted by respiratory secretions, and the

incubation period is 10 to 14 days. The patient infected with rubella
should be placed on Droplet Precautions. The maculopapular rash
spreads from the thorax and face to the extremities. A low-grade
fever and posterior auricular lymphadenopathy are frequently present.
The viremia can persist for as long as 46 days after initial infection.

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Ensuring immunity of HCP in obstetrical clinics and offices is

especially important because transmission of this virus from HCP to
pregnant women in these settings has been associated with
congenital rubella syndrome.

The presentation of the infection in the newborn may range from no

symptoms to the multi-organ system involvement that characterizes
the congenital rubella syndrome. The syndrome includes a growth-
restricted infant who has a chronic infection with this virus. The
gestational age of the infection determines the severity of the
syndrome. Maternal infection at less than 8 weeks causes 85 percent
fetal infection rate, whereas maternal infection at 20 weeks causes a
fetal infection rate of 10 percent. Babies born with congenital rubella
should be placed on Contact Precautions.

The signs of infection may be so nonspecific that rubella

immunoglobin (Ig) G serology is necessary to confirm infection. All
pregnant women should be screened for rubella IgG at a
preconception visit or early in pregnancy. If the person is rubella
nonimmune, the appropriate time to vaccinate the patient is
postpartum with MMR vaccine.

PARVOVIRUS B19
Parvovirus B19 was discovered in 1975 and is the causative agent of
erythema infectiosum (also known as fifth disease), a common
childhood illness. This agent is of concern to pregnant HCP because
B19 can cause infection of fetal red blood cell precursors and lead to
severe anemia and high-output cardiac failure in the fetus, hydrops
fetalis, and fetal death. Parvovirus B19 infection of patients with
hemolytic anemia (e.g., sickle cell disease) can be associated with a
transient aplastic crisis and with a prolonged anemia in
immunodeficient hosts (e.g., HIV-infected patients, patients receiving
chemotherapy).

Respiratory secretions transmit parvovirus B19 during close contact.

Patients infected with parvovirus B19 should be placed on Droplet
Precautions. However, the period of infectivity is over by the time the
rash of fifth disease has occurred; these patients need not be placed
on Droplet Precautions. Transmission will occur in 10 to 60 percent of
school contacts. The viral infection is characterized by a facial rash
that resembles a slapped cheek and a reticular pattern of rash on the
arms. The virus may persist for a prolonged period of time in
immunocompromised patients, and the duration of infectivity is not

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known. However, transmission of infection may occur as long as the

blood polymerase chain reaction (PCR) remains positive.

B19 infection can be diagnosed by B19 IgM serology after the third
day of the rash and is present for 30 to 60 days. B19 IgG is present
within 7 days and remains detectable for years. PCR may be used to
detect parvovirus B19 in the blood.

The major effect of B19 infection is fetal hydrops and death. The
likelihood of fetal death after maternal B19 infection is less than 10
percent. Diagnostic ultrasound is the most widely available test to
detect fetal hydrops; this may resolve spontaneously or may be
treated via intrauterine digoxin. Thus, fetal infection with parvovirus
B19 is not an indication for interruption of pregnancy.

Parvovirus B19 infection in a pregnant woman represents a risk to the

unborn child. It therefore makes sense to establish a woman's
immunological status early in pregnancy. Five percent of infections in
the first 20 weeks of pregnancy will result in fetal death. These are
often early miscarriages.

PERTUSSIS
Pertussis is an acute respiratory infection caused by Bordetella
pertussis. The organism produces multiple toxins that damage
respiratory epithelium and can have systemic effects including the
promotion of lymphocytosis.

The incubation period for pertussis is 7 to 10 days (range: 5 to 21

days). Classic pertussis is characterized by three phases: catarrhal,
paroxysmal, and convalescent. The catarrhal phase lasts 1 to 2 weeks
and consists of infection of the conjunctiva, frequent sneezing, a
watery nasal discharge, and frequent cough. The cough suggesting
tracheal irritation is short, hacking, isolated, and present equally day
or night. Fever is uncommon during any phase.

The paroxysmal phase lasts 4 to 6 weeks. During this phase, the

patient has intermittent periods of intense coughing (paroxysmal) with
periods when the patient lives well. The paroxysms are characterized
by severe spasms of coughing, choking, post-tussive, and an
inspiratory whoop. Adults with pertussis make repeated visits for
medical care and miss work and school.

Pertussis is transmitted from person to person via large respiratory

droplets generated by coughing or sneezing. Reports suggest

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pertussis could be recovered from dry mucus up to 3 days. Persons

with pertussis are highly infectious: Attack rates among exposed
nonimmune households are as high as 80 to 90 percent. The most
infectious periods are the catarrhal and early paroxysmal phases.
Patients can remain infectious for 6 weeks or more.

The source of pertussis for infected pregnant women has not been
systematically studied. In one study of 111 adults aged 18 to 29
years, the source was a person in the household (25 percent), at work
or school (25 percent), a relative (7 percent), a friend (5 percent), and
unknown (37 percent). In another study of adults aged 30 to 39 years,
the source was a person in the household (44 percent), at school or
work (17 percent), a relative (4 percent), a friend (5 percent), and
unknown (31 percent).

Although the mortality and morbidity in pregnant women are similar to

disease in the nonpregnant woman, the disease in the infant can be
severe. Infants aged younger than 12 months and especially age
younger than 3 months are most likely to have severe pertussis,
require hospitalization, and have respiratory and other complications
of pertussis. Most deaths due to pertussis occur in infants less than 2
months of age.

Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis

(Tdap) vaccine is recommended before pregnancy, during pregnancy,
or immediately postpartum. The value of antepartum administration is
to protect the mother from disease, but also to provide the neonate
with passive antibodies for protection from disease until the infant's
active immunity occurs. Infant immunization with DTaP (the childhood
form of the pertussis vaccine) occurs at 2, 4, and 6 months of life,
and the infant is not protected until 6 months of life.

Pertussis is another serious infectious disease that pregnant HCP are

susceptible to and can transmit to patients. Only 2 percent of adults
in the United States are protected against pertussis so there is a high
probability that most HCP are not only susceptible to infection but
also can transmit pertussis to their patients, family, or neonate.

In October 2011, in an effort to reduce the burden of pertussis in

infants, ACIP recommended that unvaccinated pregnant women
receive a dose of Tdap. Vaccination of women with Tdap during
pregnancy is expected to provide some protection to infants from
pertussis until they are old enough to be vaccinated themselves. Tdap
given to pregnant women will stimulate the development of maternal

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antipertussis antibodies, which will pass through the placenta, likely

providing the newborn with protection against pertussis in early life,
and will protect the mother from pertussis around the time of delivery,
making her less likely to become infected and transmit pertussis to
her infant. The 2011 Tdap recommendation did not call for
vaccinating pregnant women previously vaccinated with Tdap. On
October 24, 2012, ACIP voted to recommend use of Tdap during
every pregnancy.

PREGNANT WOMEN DUE FOR TETANUS BOOSTER

If a tetanus and diphtheria booster vaccination is indicated during
pregnancy (i.e., .10 years since previous Td), then Tdap should be
administered. Optimal timing is between 27 and 36 weeks' gestation
to maximize the maternal antibody response and passive antibody
transfer to the infant.

WOUND MANAGEMENT FOR PREGNANT WOMEN

As part of standard wound management to prevent tetanus, a tetanus
toxoid-containing vaccine might be recommended for wound
management in a pregnant woman if ≥5 years have elapsed since the
previous Td booster. If a Td booster is recommended for a pregnant
woman, healthcare providers should administer Tdap.

PREGNANT WOMEN WITH UNKNOWN OR INCOMPLETE TETANUS

VACCINATION
To ensure protection against maternal and neonatal tetanus, pregnant
women who never have been vaccinated against tetanus should
receive three vaccinations containing tetanus and reduced diphtheria
toxoids. The recommended schedule is 0, 4 weeks, and 6 through 12
months. Tdap should replace one dose of Td, preferably between 27
and 36 weeks' gestation to maximize the maternal antibody response
and passive antibody transfer to the infant.

SMALLPOX (VACCINIA)
Because of the limited risk but severe consequences of fetal infection,
smallpox vaccine should not be administered in a pre-event setting to
pregnant women or to women who are trying to become pregnant.

Smallpox is a severe, disseminated viral disease with a characteristic

vesicular-pustular rash distributed over the extremities, palms, and
soles. It is caused by variola minor and variola major viruses, and

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was associated with mortality rates as high as 30 percent. The last

naturally acquired infection occurred in Somalia in 1977, and global
eradication was declared in 1980. Routine vaccination was stopped in
the United States in 1972. Smallpox caused excessive mortality in
pregnant women: a 33 percent case fatality rate, with 27 percent
among vaccinated pregnant women and 61 percent among
unvaccinated pregnant women. Excessive rates of premature delivery,
spontaneous abortion, and perinatal death were associated with
smallpox during pregnancy. Although vaccinia virus used for smallpox
vaccination is not teratogenic, fetal vaccinia was a rare complication
of vaccination of the pregnant woman, with less than 30 cases
reported in the world's literature from 1932 to 1978. Estimated
incidence has been 1 of 10,000 exposed, but no cases were
observed when approximately 173,000 pregnant women were
vaccinated in New York City in 1947.

A targeted smallpox vaccination program (∼700,000 military personnel

and 40,000 civilians who would serve as members of emergency
response teams) was initiated in the United States in December 2002
and January 2003 in response to the perceived threat of smallpox as
a bioweapon. Because of potential adverse effects of vaccinia on the
fetus, pregnancy was considered a contraindication to receiving the
vaccine in this program, and all women in the childbearing age group
were screened with a questionnaire and counseled to prevent fetal
exposure to vaccinia. As of June 2004, 236 vaccinia-exposed
pregnancies were reported to the National Smallpox Vaccine in
Pregnancy Registry. Analysis available in June 2004 revealed the
following: (1) pregnancy occurred less frequently in vaccinia-exposed
women compared with the expected rate of pregnancy in unscreened
women of childbearing age; (2) no excess adverse effects were
observed in the vaccinia-exposed pregnancy; and (3) 75 percent of
the women in the registry were exposed to vaccinia before a
pregnancy test could have been positive. Thus, the screening program
used was effective in preventing fetal exposure to vaccinia and should
be included in all pre-event smallpox vaccination programs. However,
if inadvertent vaccination during pregnancy does occur, adverse
outcome due to exposure to vaccinia virus is unlikely.

SYPHILIS
Syphilis is a complex, chronic sexually transmitted infection that can
have profound effects on pregnancy. It is characterized by a 3-week
incubation stage; a primary stage with a single-cutaneous lesion and

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regional lymphadenopathy; a secondary stage with mucocutaneous

lesions, lymphadenopathy, and spirochetemia; a latent period of
variable length; and, finally, a progression to serious systemic
manifestations. It is acquired by the fetus transplacentally at any time
during pregnancy and can be treated successfully with penicillin.

Syphilis can be acquired by intimate sexual contact and direct,

unprotected contact with primary or secondary lesions on mucous
membranes or skin. Healthcare-associated acquisition of syphilis is
highly unlikely because, according to Standard Precautions, HCP
would be wearing gloves for contact with any suspicious lesions or
blood of patients with suspected syphilis. If a significant exposure
does occur (e.g., percutaneous or mucocutaneous exposure to blood
or fluid in lesions before or within the first 24 hours of treatment), PEP
should be initiated with penicillin as soon as possible. Fetal risks for
infection are directly proportional to the degree of maternal
spirochetemia and the duration of the untreated maternal infection.
The highest rates of congenital syphilis occur in women with
secondary syphilis. Fifty percent of infants born to women with
untreated primary or secondary syphilis will have congenital infection
at birth. The remainder will be infected at delivery. Only 6 to 14
percent of fetuses of women in the late latent stage will be affected.

Serologic tests for antibody production allow the clinician to make the
diagnosis. The nontreponemal test, rapid plasma reagin (RPR) test, or
Venereal Disease Research Laboratory (VDRL) test can be used to
screen for disease and follow response to therapy. Treponemal tests
are used for confirmation if the VDRL or RPR is positive. Common
treponemal tests are the microhemagglutination assay for antibodies
(MHA-TP) or the fluorescent treponemal antibody-absorption (FTA-
ABS).

The efficacy of the currently recommended treatment regimens for

adult or antepartum early syphilis is 98 percent; most treatment
failures are reinfections. Penicillin is the drug of choice during
pregnancy. Treatment failures can occur with penicillin treatment but
are more likely to occur if treatment is later in pregnancy, if a drug
other than penicillin is used, in the presence of higher treponemal
loads characteristic of secondary and early latent syphilis, in the
presence of very high VDRL titers at treatment and at delivery, or if
delivery occurs within 30 days treatment.

All pregnant women should be screened for syphilis early in

pregnancy at the first prenatal visit and at 36 weeks' gestation or at

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delivery. An additional screening at 28 weeks is recommended for

populations with a high prevalence of syphilis or for individuals at
high risk.

TUBERCULOSIS
Tuberculosis is a major world health problem, and the World Health
Organization (WHO) estimates one-third of the world's population is
infected with Mycobacterium tuberculosis (M. tuberculosis). The
prevalence in the United States is 4 to 6 percent. However, many
international travelers and immigrants enter the United States each
year, so the prevalence may vary.

Transmission of tuberculosis occurs almost exclusively as a result of

inhaling infectious particles. These particles are produced when an
infected person sneezes and coughs. These particles are 1 to 10 mm
in size and remain airborne for prolonged periods of time. Pregnant
HCP must be aware of the airborne route of transmission and know
that using respiratory protection (e.g., N95 respirator or higher level of
respiratory protection) when caring for a patient with suspected or
proven tuberculosis will protect her. A pregnant woman is not at
increased risk of developing active disease after exposure compared
with nonpregnant women.

Currently, the standard screening test for latent tuberculosis infection

exposure is the intradermal injection of 0.1 mL of fluid containing five
tuberculin units of purified protein derivative (PPD), also known as the
tuberculin skin test (TST). Tuberculosis will trigger a delayed
hypersensitivity reaction and cause induration. The site is examined
48 to 72 hours after placement. Induration of 5 mm is considered
positive in high-risk populations or individuals who have had recent
exposure or clinical manifestations highly suggestive of tuberculosis.
An induration of 15 mm or more is considered positive in a low-risk
population. Induration of 10 mm or more in HCP is considered
reactive and requires investigation. An alternative test that would
involve serology instead of the intradermal injection is currently under
review. The whole-blood interferon gamma release assay is a U.S.
Food and Drug Administration (FDA)-approved in vitro cytokine-based
assay for cell-mediated immune reactivity to M. tuberculosisand might
be used instead of TST in tuberculosis screening programs for HCP.
This IGRA is an example of a blood assay for M. tuberculosis(BAMT).
Additional information can be obtained in the chapter that discusses
tuberculosis ( 97. Tuberculosis and Other Mycobacteria). Neither
pregnancy nor a history of having received bacillus Calmette-Guérin is

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a contraindication to the use of TST for screening; the frequency of

screening is based on the risk assessment for the healthcare
institution.

VARICELLA ZOSTER VIRUS

Varicella (chickenpox) and herpes zoster are different manifestations of
the same virus. The primary infection is chickenpox when varicella
zoster virus (VZV) first infects humans. VZV remains latent for a
variable period of time and, when it is reactivated, it presents as
shingles or herpes zoster infection.

Because the effects of the varicella virus on the fetus are unknown,
pregnant women should not be vaccinated. Nonpregnant women who
are vaccinated should avoid becoming pregnant for 1 month after
each injection. For persons without evidence of immunity, having a
pregnant household member is not a contraindication for vaccination.

Varicella zoster viral particles are transmitted from the respiratory tract
via the airborne route, from vesicular lesions by the contact route, or,
rarely, by the airborne route with aerosolized vesicular lesions. The
infection is highly contagious (90 percent transmission rate to
susceptible household contacts) from 1 day before the outbreak of
the rash and lasts until the lesions have dried completely. Although
this is a disease of children, infection may occur in susceptible
adults, and second cases of chickenpox have been documented in
the elderly. Apparently 5 cases of varicella per 100,000 pregnancies
were expected in the prevaccine era. Incubation period varies from 10
to 21 days for immunocompetent individuals; the average is
approximately 14 days after exposure. Fever occurs and is followed
by a rash that begins on the face and scalp. It then becomes
randomly distributed to the trunk; the palms and soles are spared.
New crops continue to appear for 5 days and are present in varying
stages.

Chickenpox pneumonia is the most common complication and is

expected to occur in 15 to 50 percent of adults when no antiviral
treatment is given. Chickenpox pneumonia in pregnancy is more
severe than in the nonpregnant adult, with a maternal mortality rate of
41 to 46 percent compared with 11 percent in the nonpregnant adult.
Bacterial superinfection of skin lesions, most frequently with group A
streptococcus or Staphylococcus aureus, may be associated with
serious invasive disease, including toxic shock syndrome. Treatment
with acyclovir is recommended for the pregnant woman who develops

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chickenpox.

Fetal death is the result of severe maternal varicella infection, usually

accompanied with pneumonia. It has not been shown that the virus
causes fetal death or first trimester wastage.

Varicella embryopathy is rare with fewer than 20 cases reported in the

literature. The syndrome may include fetal growth restrictions, aplasia
of a single limb or chest wall, cicatrization of the skin, and neurologic
and ocular abnormalities. In none of the cases has virus been
cultured.

HCP without a reliable history of disease should receive the varicella

vaccine before pregnancy. Household contacts of pregnant women
may receive the varicella vaccine because transmission of the
attenuated vaccine virus has not been associated with adverse fetal
effects.

A newly released vaccine is now available for prevention of shingles

(herpes zoster). It is indicated for persons aged 60 years or greater. It
has a 66 percent efficacy in preventing shingles and post hepatic
neuropathy. It is contraindicated in immunosuppressed persons.

In December 2012, the FDA approved VariZIG, a varicella zoster

immunoglobulin preparation (Cangene Corporation, Winnipeg, Canada)
for use in the United States for PEP of varicella for persons at high
risk for severe disease who lack evidence of immunity to varicella*
and for whom varicella vaccine is contraindicated. Previously available
under an investigational new drug (IND) expanded access protocol,
VariZIG, a purified immunoglobulin preparation made from human
plasma containing high levels of anti-varicella zoster virus antibodies
(immunoglobulin G), is the only varicella zoster immunoglobulin
preparation currently available in the United States. VariZIG is now
approved for administration as soon as possible following varicella
zoster virus exposure, ideally within 96 hours (4 days) for greatest
effectiveness. The CDC recommends the use of VariZIG for pregnant
women without evidence of immunity.

Zoster (shingles) vaccine is not recommended for use in pregnant

women. Women should avoid becoming pregnant for 4 weeks
following zoster vaccination.

Conclusions
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Pregnant and nonpregnant HCP are exposed to the same possible

infectious agents. For some infectious agents, vaccines are available,
and prudent HCP will become immunized before conception. It is
important that employee health services departments educate all
women of childbearing age on how to protect themselves before
considering pregnancy and educate all pregnant HCP on how to
protect themselves and their fetuses. Immunized, pregnant HCP will
then protect herself and pass antibodies to her neonate to protect the
neonate for 3 to 6 months.

For some infectious agents, there is no vaccine available, and

pregnant HCP must rely on Standard Precautions, including the
appropriate use of hand hygiene, masks, gown, glove and eye
protection, and respiratory protection, when exposure to potentially
infectious blood and body fluids is likely. Restricting pregnant HCP
from caring for patients with certain known infections (e.g., CMV) is
not recommended.

Future Trends
There are currently a number of vaccines under development that will
be of importance to HCP who are pregnant or contemplating
pregnancy. These include HSV-2 vaccine, CMV vaccine, RSV vaccine,
and group B streptococcus vaccine.

International Perspective
Globalization will continue to require that immunization against
vaccine-preventable diseases be emphasized. It is especially
important to recognize the variations in immunization practices among
all countries. When providing medical care for immigrants and
international travelers, it is important to be aware of this potential lack
of immunization and, in many cases, presume that the individual is
vaccine na&iuml;ve and proceed with the primary series of indicated
vaccines. In addition, increasing international travel can be expected
to result in new types of infection that may affect the health and
safety of pregnant and nonpregnant HCP. Emphasis on the health and
safety of the pregnant woman, as well as the fetus, must include
immunization as an effort to reduce illness in the newborn.

* Evidence of immunity to varicella includes (1) documentation of age-

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appropriate vaccination with varicella vaccine, (2) laboratory evidence

of immunity or laboratory confirmation of disease, (3) birth in the
United States before 1980 (except for healthcare personnel, pregnant
women, and immunocompromised persons), or (4) healthcare provider
diagnosis or verification of a history of varicella or herpes zoster. For
immunocompromised children aged 12 months to 6 years, two doses
of varicella vaccine are considered age-appropriate vaccination.

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