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This Viewpoint discusses the importance of preventive measures and supplies to reduce workplace COVID-19 transmission and calls for the US Occupational Safety a

This study characterizes the prevalence of antibodies against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) among hospital staff of a Belgian tertiary care center tested over 1 week in April 2020, and risk factors for seropositivity. ispartof: JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION vol:324 issue:2 pages:195-197 ispartof: location:United States status: published

This study aims to describe an association between the Pfizer-BioNTech (BNT162b2) vaccine and decreased risk of symptomatic and asymptomatic infections with SARS-CoV-2 in hospital employees.

This study examines the incidence of acute allergic reactions to mRNA COVID-19 vaccine administrations in health care employees in Massachusetts.

This Viewpoint discusses Kaiser Permanente in Northern California's transition from a containment strategy for coronavirus disease 2019 (COVID-19)-isolation or quarantine of exposed or infected patients-to a mitigation strategy comprising elements such as droplet and airborne precautions, telemedicine, staffing protocol revisions, and equipment allocation planning

Importance In China and other parts of the world, hospital personnel adherence to evidence-based stroke care is limited. Objective To determine whether a multifaceted quality improvement intervention can improve hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke (AIS) in China. Design, Setting, and Participants A multicenter, cluster-randomized clinical trial among 40 public hospitals in China that enrolled 4800 patients hospitalized with AIS from August 10, 2014, through June 20, 2015, with 12-month follow-up through July 30, 2016. Interventions Twenty hospitals received a multifaceted quality improvement intervention (intervention group; 2400 patients), including a clinical pathway, care protocols, quality coordinator oversight, and performance measure monitoring and feedback. Twenty hospitals participated in the stroke registry with usual care (control group; 2400 patients). Main Outcomes and Measures The primary outcome was hospital personnel adherence to 9 AIS performance measures, with co-primary outcomes of a composite of percentage of performance measures adhered to, and as all-or-none. Secondary outcomes included in-hospital mortality and long-term outcomes (a new vascular event, disability [modified Rankin Scale score, 3-5], and all-cause mortality) at 3, 6, and 12 months. Results Among 4800 patients with AIS enrolled from 40 hospitals and randomized (mean age, 65 years; women, 1757 [36.6%]), 3980 patients (82.9%) completed the 12-month follow-up of the trial. Patients in intervention group were more likely to receive performance measures than those in the control groups (composite measure, 88.2% vs 84.8%, respectively; absolute difference, 3.54% [95% CI, 0.68% to 6.40%], P = .02). The all-or-none measure did not significantly differ between the intervention and control groups (53.8% vs 47.8%, respectively; absolute difference, 6.69% [95% CI, −0.41% to 13.79%], P = .06). New clinical vascular events were significantly reduced in the intervention group compared with the control group at 3 months (3.9% vs 5.3%, respectively; difference, −2.03% [95% CI, −3.51% to −0.55%]; P = .007), 6 months (6.3% vs 7.8%, respectively; difference, −2.18% [95% CI, −4.0% to −0.35%]; P = .02) and 12 months (9.1% vs 11.8%, respectively; difference, −3.13% [95% CI, −5.28% to −0.97%]; P = .005). Conclusions and Relevance Among 40 hospitals in China, a multifaceted quality improvement intervention compared with usual care resulted in a statistically significant but small improvement in hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke when assessed as a composite measure, but not as an all-or-none measure. Further research is needed to understand the generalizability of these findings. Trial Registration ClinicalTrials.gov Identifier:NCT02212912

Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria.To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care.Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012.In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room.The primary outcome was acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care–associated infections, and adverse events.From the 26,180 patients included, 92,241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, −1.71 acquisitions per 1000 person-days, 95% CI, −6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference, 0.89 acquisitions per 1000 person-days; 95% CI, −4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, −2.98 acquisitions per 1000 person-days; 95% CI, −5.58 to −0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, −0.96; 95% CI, −1.71 to −0.21, P = .02), increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference, 15.4%; 95% CI, 8.99% to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, −15.7; 95% CI, −40.7 to 9.2, P = .24).The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions.clinicaltrials.gov Identifier: NCT0131821.

Automated external defibrillators (AEDs) improve survival from out-of-hospital cardiac arrests, but data on their effectiveness in hospitalized patients are limited.To evaluate the association between AED use and survival for in-hospital cardiac arrest.Cohort study of 11,695 hospitalized patients with cardiac arrests between January 1, 2000, and August 26, 2008, at 204 US hospitals following the introduction of AEDs on general hospital wards.Survival to hospital discharge by AED use, using multivariable hierarchical regression analyses to adjust for patient factors and hospital site.Of 11,695 patients, 9616 (82.2%) had nonshockable rhythms (asystole and pulseless electrical activity) and 2079 (17.8%) had shockable rhythms (ventricular fibrillation and pulseless ventricular tachycardia). AEDs were used in 4515 patients (38.6%). Overall, 2117 patients (18.1%) survived to hospital discharge. Within the entire study population, AED use was associated with a lower rate of survival after in-hospital cardiac arrest compared with no AED use (16.3% vs 19.3%; adjusted rate ratio [RR], 0.85; 95% confidence interval [CI], 0.78-0.92; P.001). Among cardiac arrests due to nonshockable rhythms, AED use was associated with lower survival (10.4% vs 15.4%; adjusted RR, 0.74; 95% CI, 0.65-0.83; P.001). In contrast, for cardiac arrests due to shockable rhythms, AED use was not associated with survival (38.4% vs 39.8%; adjusted RR, 1.00; 95% CI, 0.88-1.13; P = .99). These patterns were consistently observed in both monitored and nonmonitored hospital units where AEDs were used, after matching patients to the individual units in each hospital where the cardiac arrest occurred, and with a propensity score analysis.Among hospitalized patients with cardiac arrest, use of AEDs was not associated with improved survival.

To examine the impact of workplace smoking bans on smoking behavior of employees.A total of 1469 current or former smokers (intervention group) employed in smoke-free hospitals and 920 current or former smokers (comparison group) employed in non-smoke-free workplaces were surveyed to determine smoking behavior.This cross-sectional study is part of a larger, ongoing prospective study. The study design was quasi-experimental. We randomly selected sites consisting of a hospital and a corresponding community. Furthermore, we randomly selected subjects from hospitals and their corresponding communities.Postban quit ratio and progression along the stages-of-change continuum.The Cox proportional hazards model was used to compare the postban quit ratio between the intervention and comparison groups. The Cochran-Mantel-Haenszel analysis of variance statistic was used to compare groups on the stages-of-change variables.Beginning with the smoking ban and continuing for 5 years after implementation, statistically significant differences in the postban quit ratio were observed between employees of smoke-free hospitals who were smokers and counterparts in the community (P.001). Despite preban differences in smoking intensity, the overall difference in postban quit ratios remained significant even after multivariate adjustment for socioeconomic, demographic, and smoking intensity variables. For those sites that were 5 years postban, the quit ratio was 0.506 in smoke-free workplaces compared with 0.377 in workplaces where smoking was permitted. In all but 1 category, the intervention group was further along the stages-of-change continuum toward quitting smoking than the comparison group (P.001).American hospitals' experiences with smoking bans, which directly affect more than 5 million workers, should be examined by other industries as a method of improving employee health. Workplace smoking bans could also be effective in saving lives, reducing health care costs, addressing safety concerns, and decreasing operating and maintenance expenses of employers.

To examine health care workers' (HCWs') acceptance of and adherence to isoniazid preventive therapy in the setting of a comprehensive tuberculin skin-testing program.Descriptive case series.University-affiliated inner-city public hospital in Atlanta, Ga.A total of 125 HCWs (91 hospital employees and 34 house staff or medical students [the physician group]) who had a positive tuberculin skin test between July 1992 and January 1994 and were offered isoniazid preventive therapy.Health care workers with a recent tuberculin skin test conversion were required to have a chest x-ray performed and see a physician and were encouraged but not required to undergo preventive therapy.Acceptance and initiation of preventive therapy with isoniazid by HCWs, completion of at least 6 months of preventive therapy, and differences between the employee and physician groups.All 125 HCWs with a recent positive tuberculin skin test had a chest radiograph performed, 123 (98.4%) saw a physician, and 105 (84%) initiated preventive therapy. Sixty-nine (66%) of the 105off HCWs who initiated preventive therapy (55% of the 125 total) completed at least 6 months of isoniazid therapy. More of the physician group than of the employee group completed preventive therapy (25 of 34 [74%] vs 44 of 91 [48%], respectively; P.01). Of the 36 HCWs who started but did not complete preventive therapy, 12 discontinued therapy because of an adverse drug effect and 24 were nonadherent.Acceptance of tuberculosis preventive therapy by HCWs was high in the setting of a comprehensive tuberculin skin-testing program, and completion of therapy was much higher in the physician group than in previously reported series.

To evaluate the cost-effectiveness of voluntary counseling and testing of US hospital inpatients for the human immunodeficiency virus (HIV).Data for entry into the model were derived from a review of the literature, consultation with experts, and consensus of the authors.We rated our confidence in these probabilities and costs by grading the data inputs using methods adapted from those of the US Preventive Services Task Force.Decision analysis models were developed to evaluate two outcomes: (1) cost per health care worker (HCW) HIV infection averted if measures are taken by the HCW to reduce his or her risk of acquiring HIV; and (2) cost per inpatient HIV infection detected. Sensitivity analyses were also conducted. Using baseline input values, testing to avert HCW infection may prevent 3.6 HIV infections per year at a total program cost of $2.7 billion, or a cost of $753 million per infection averted. At baseline assumptions (seroprevalence = 1%), testing to detect inpatient HIV infection would cost $16,104 per year per infection detected. Cost-effectiveness at baseline drops to $8353 per HIV infection detected if the seroprevalence is 10%. If testing is limited to hospitals with inpatient seroprevalences of at least 1%, approximately 5400 persons per year will be falsely labeled HIV-positive.This analysis provides no justification for testing inpatients to prevent HIV infection of HCWs. Screening inpatients to detect HIV infection may be justified at seroprevalences exceeding 1%, but issues of medical or social discrimination, false-positive results, informed consent, and logistics must be resolved first.

To the Editor. —For many years the basis of hospital peer review has been internally driven by physicians and nurses reviewing one another. This has been accomplished by volunteer physicians through hospital committees at no cost to the institution. To our knowledge, the real cost in terms of person-hours has never been calculated, but it has never been a concern because of willing volunteerism. As public confidence in our ability to review ourselves has eroded, the concept of "external" peer review has developed. This has the obvious advantage of reviewers' not being personally involved with the "reviewees," but also has the major disadvantage of cost. We must consider that as physicians' incomes decrease with health system reform and as demands on our time increase, the willingness of physicians to volunteer this service may diminish. At some point, reviewers both internally and externally may demand payment for services rendered. Nevertheless, up

To test the effectiveness of vinyl and latex gloves as barriers to hand contamination with gram-negative organisms and enterococci during routine hospital procedures.We studied 137 procedures during which a health care worker's gloved hand contacted a patient's mucous membrane and was thus potentially contaminated with gram-negative rods or enterococci. Quantitative hand cultures were obtained from each health care worker before and after the gloved contact using a modified glove juice method, and the exterior glove surface was also quantitatively cultured after patient contact. Used gloves were then tested for leaks using the American Society for Testing and Materials' watertight test.Harborview Medical Center, a 330-bed city-county hospital and level I regional trauma and burn center, is both a teaching facility affiliated with the University of Washington and the major provider of care to indigent and uninsured persons in Seattle-King County, Washington.Respiratory therapists performing endotracheal tube care on intubated intensive care unit patients, registered nurses performing digital rectal stimulation for bowel training on patients with spinal cord injury in the rehabilitation ward, and dentists performing routine dental examinations and procedures on healthy outpatients in the dental clinic.Eighty-six of the 135 gloves cultured had gram-negative rods or enterococci on the external surface after use and were thus sources of potential hand contamination. Microbial contamination of the health care worker's hands occurred in 11 (13%; 95% confidence interval, 6% to 20%) of these 86 events, and was more frequent with vinyl (10 of 42) than latex (one of 44) gloves (P.01). After use, glove leaks were also more frequent in vinyl gloves (26 of 61) than with latex gloves (six of 70) (P.001). Even when leaks were present, gloves prevented hand contamination in 77% of instances and quantitative counts of microorganisms contaminating hands were 2 to 4 logs less than counts on external glove surfaces. Health care workers reported awareness of the presence of glove leaks in only seven (22%) of the 32 events in which leaks were subsequently demonstrated.Under conditions of routine use, gloves effectively function as a protective barrier even when leaks are present. Latex gloves were less frequently associated with leaks and hand contamination. Since hand contamination occurred after 13% of exposures and cannot be readily identified by health care workers, routine hand washing should be done after each patient contact.

To describe transmission of multidrug-resistant (MDR) Mycobacterium tuberculosis infection among patients and health care workers (HCWs) in a ward and clinic for human immunodeficiency virus (HIV)-infected patients in a hospital, four studies were conducted.Case patients and control patients were persons who had been treated in the HIV ward or clinic, whose clinical course was consistent with tuberculosis and who had at least one positive culture for M tuberculosis between January 1, 1988, and January 31, 1990, resistant to at least isoniazid and rifampin (case patients), or whose isolates were susceptible to all drugs tested (control patients). In the first study, case patients and control patients were compared to identify risk factors for MDR tuberculosis. In the second study, inpatient and outpatient days of MDR tuberculosis case patients were compared to determine whether acid-fast bacillus (AFB) smear-positivity or aerosolized pentamidine use was associated with higher numbers of subsequent MDR tuberculosis cases among exposed patients. In the third study, restriction fragment length polymorphism analysis was performed on available MDR and sensitive M tuberculosis isolates. In the fourth study, skin test conversion rates among HCWs in the HIV ward and clinic were compared with those of HCWs in another ward, and the strength of the associations between skin test conversions among HCWs on the HIV ward and the number of person-days that AFB smear-positive case patients and control patients were on this ward was estimated.Case patients were more likely than control patients to have been exposed on the HIV ward or clinic to an AFB smear-positive case patient (P less than .001). Inpatient and outpatient days of MDR tuberculosis case patients were associated with more subsequent cases of MDR tuberculosis if exposing case patients were smear-positive or if they received aerosolized pentamidine (P less than or equal to .01). Of 13 MDR isolates, all had one of two restriction fragment length polymorphism patterns; 10 sensitive isolates had restriction fragment length polymorphism patterns that were different from each other. The HCW skin test conversion rate was higher on the HIV ward and clinic than on the comparison ward (P less than .01). The risk of occupational acquisition of infection increased in direct proportion to the number of person-days that AFB smear-positive case patients were on the HIV ward (r = .75; P = .005), but did not increase in proportion to the number of person-days that AFB smear-positive control patients were there (r = -.36; P = NS). After isolation measures for AFB smear-positive tuberculosis patients were improved, MDR tuberculosis cases decreased to seven of 214 tuberculosis patients.Nosocomial transmission of MDR M tuberculosis infection to patients and HCWs occurred on the HIV ward and clinic. Infectiousness of MDR tuberculosis case patients was associated with AFB sputum-smear positivity. Case patients with MDR tuberculosis created a greater risk of skin test conversion for HCWs on the HIV ward than drug-susceptible control patients.

To assess nosocomial transmission of tuberculosis (TB).A historical cohort study of hospitalized patients with the human immunodeficiency virus (HIV) and a purified protein derivative (PPD) tuberculin skin test survey of health care workers (HCWs).A large public teaching hospital in San Juan, Puerto Rico.For the cohort study, a case patient was defined as any patient in the HIV unit at the hospital who developed culture-positive TB from 31 days or more after admission through December 31, 1989. For the PPD survey, of 1420 HCWs from the hospital, 908 agreed to participate and had sufficient data for analysis.For the cohort study, to compare the risk of developing active TB among patients who were exposed to hospital roommates with infectious TB and the risk among nonexposed patients. For the HCW PPD survey, to determine the prevalence of and risk factors for tuberculous infection.Eight of 48 (9.7/10,000 person-days) exposed case patients vs four of 192 (0.8/10,000 person-days) nonexposed case patients developed active TB (relative risk [RR] = 11; 95% confidence interval [CI], 2.3, 50.3). Positive PPDs (greater than or equal to 10 mm of induration) in HCWs were associated with older age (P = .0001) and with history of community TB exposure (P = .0002). In a multivariable logistic model that adjusted for these variables, HIV unit nurses (nine of 19) and nurses in the internal medicine ward (45 of 90) had a higher proportion of positive PPDs than the reference group (clerical personnel on other floors: 35 of 188, P = .0005).These data suggest that patient-to-patient transmission of TB in HIV units can occur and that HCWs are at risk of acquiring TB infection.

Three patients in a university hospital developed nosocomial infusion-related Pseudomonas pickettii bacteremia. Investigation identified six additional patients who had received intravenous fluid contaminated by P pickettii but did not become ill. All nine patients had had surgery, and each of these patients but only nine of 19 operated-on control patients had received intravenous fentanyl citrate in the operating room; the mean dose given to the nine case patients was far greater than that given to control patients. Fentanyl in 20 (40%) of 50 predrawn 30-mL syringes was shown to be contaminated by P pickettii. Contamination was caused by theft of fentanyl from predrawn synringes and replacement by distilled water contaminated by P pickettii. Narcotic theft by health care personnel may cause patients to suffer pain needlessly and can also result in dire unanticipated consequences, such as nosocomial bacteremia. Whereas drug testing in the workplace is highly controversial, we believe that testing of health care personnel is indicated when drug abuse or theft is suspected.

An analysis of the increase in expenditures for barrier isolation materials before and after the institution of universal precautions at our 900-bed university hospital was used to generate a national estimate of the cost of implementation of the new Centers for Disease Control guidelines. Following the institution of universal precautions, use of rubber gloves at our hospital increased from 1.64 million pairs of 2.81 million pairs annually. A 5-year review of hospital purchasing and supply records in both inpatient and outpatient areas indicated that the total annual costs for isolation materials increased by $350,900. This represented an increase from $13.70 to $22.89 per admission (60%) after adjustment for inflation. The cost of isolation materials increased from $98 to $215 per 1000 outpatient visits, an adjusted increase of 92%. Two thirds of the increase (64%) was due to rubber gloves and an additional 25% was due to disposable isolation gowns. Universal precautions are estimated to have cost at least $336 million in the United States in fiscal year 1989 after adjustment for inflation. If expenditures for isolation materials at our medical center are representative, previous estimates may have significantly underestimated costs nationwide.

Employees of a children's hospital were studied to determine the prevalence of antibody to cytomegalovirus (CMV) and the incidence of CMV infection between 1984 and 1988 in relation to patient contact. At enrollment, 783 (63%) of 1250 employees had antibody to CMV. By logistic regression analysis, age greater than 30 years, black race, fewer than 16 years of education, employment for more than 1 year, female sex, and being married were each associated with seropositivity at enrollment. Three hundred workers who were seronegative initially were followed up; 13 seroconverted over a median follow-up interval of 1.96 years, 2.2% per year. Administrative, patient-care, laboratory, and support personnel were included among seroconverters. There were no statistically significant differences in the incidence of CMV infection when employees were grouped by job type, number of hours per week of patient contact, or nursing unit. The incidence of CMV among employees of a children's hospital was similar to the rate expected for the general population. Risk of CMV infection was not increased by patient contact in this setting.

On August 17,1969, Hurricane Camille, the most destructive North American hurricane since 1937, made landfall on the Gulf Coast. The storm devastated coastal Mississippi, Louisiana, and Alabama and inland areas in the South. It killed between 250 and 400 people and caused damage estimated at $1 billion, a stunning sum at the time. The 25th anniversary of that catastrophe is cause enough to ask how much has been learned about disaster planning since; but the United States and its health care system have had several more recent unfortunate opportunities to consider the question. Among these trials have been Hurricane Andrew in south Florida on August 24,1992; Hurricane Iniki on the Hawaiian island of Kauai on September 11,1992; massive flooding in the Midwest in the summer of 1993; and the Northridge earthquake in the San Fernando Valley of southern California on January 17,1994. In each case, health care facilities suffered problems—in

To the Editor. — We would like to report the experience at the University of California, San Francisco, with aerosolized ribavirin. Ribavirin is a virostatic agent approved for the treatment of respiratory syncytial virus (RSV) in infants who do not require mechanical ventilation. While the drug currently is not approved for use in intubated patients, it has been administered via this route. However, considering the tendencies of the drug to crystallize in respiratory equipment, special care must be taken to ensure patency of the airway in these patients.1 Morbidity and mortality secondary to RSV primarily occurs in premature infants and in those with underlying cardiopulmonary abnormalities.2The early trials with ribavirin suggest subjective improvement in severity of illness. Some studies report improved arterial oxygen tension and a decrease in viral shedding in patients who receive ribavirin.3The drug has not been found to alter the mortality associated

We evaluated an eye-nose goggle to determine its usefulness in reducing nosocomial RSV infection in patients and staff members on our infant ward. During a community outbreak of RSV in 1984, infection was assessed by biweekly routine viral cultures on all ward personnel and patients and also by seroconversion in personnel. For three weeks staff members wore the goggles; two (5%) adults and one (6%) child acquired nosocomial infection. During the subsequent three-week study period, goggles were not used and 34% of personnel and 43% of susceptible infants became infected. The use of the disposable eye-nose goggles was associated with a significant decrease in nosocomial RSV infections (P less than .003 for staff and P less than .05 for contact infants).

We report a ten-year survey of clinical hepatitis B virus (HBV) infections in Minnesota hospital personnel. Between 1974 and 1983, a total of 561 personnel cases of viral hepatitis were identified. Four hundred twelve cases were diagnosed as type B, with 399 cases (97%) identified as work related. Of the 177 hospitals in the state, only 42 (24%) reported cases during the ten-year period. The highest annual incidence of type B cases was in 1975 (127/100,000 personnel) and decreased to the lowest incidence in 1983 (8/100,000 personnel). The incidence for personnel at hospitals with long-term hemodialysis decreased from 418/100,000 personnel in 1975 to 16/100,000 personnel in 1983, while the incidence for employees in hospitals without hemodialysis decreased from 16 to 5/100,000 personnel for the same time. The decrease in the incidence of hepatitis B in personnel occurred before the use of HBV vaccine. Our findings indicate that HBV seroprevalence studies significantly overestimate the current incidence of HBV infections among personnel in most hospital settings.

To determine the risk of hepatitis B virus infection for rural hospital employees, we obtained serum and a completed questionnaire from each of 2,064 employees of 11 rural hospitals. Only 96 (4.7%) employees had hepatitis B virus markers. Increased marker prevalence was significantly associated with prior residence in a city with a population of greater than 100,000 (odds ratio, 2.9; 95% confidence interval, 1.6 to 5.2) and increasing blood contact (odds ratio, 1.6; confidence interval, 1.2 to 2.3); however, the association with blood contact was not significant when we limited analysis to the 836 employees who had never lived in a city. We conclude that the risk of hepatitis B virus infection for these rural hospital employees is low, probably because the incidence of hepatitis B in rural areas is low.

We describe the management of an exposure to varicella in a neonatal intensive care unit. Thirty-seven hospital staff members with negative histories of varicella were tested by enzyme-linked immunosorbent assay for antibody to varicella zoster; all were seropositive. None were restricted from clinical duties, were given varicella-zoster immune globulin, or developed disease. Although only 1 of 38 cord serum samples from normal term infants was seronegative, 10 of 22 neonatal intensive care unit infants were seronegative. The high rate of seronegativity among these patients was related to chronological age older than 2 months and to multiple transfusions of packed red blood cells. This probably reflects natural catabolism of maternal antibody and loss of antibody in serum removed from these infants for diagnostic tests. Infants lacking antibody were given varicella-zoster immune globulin. Antibody levels following administration of varicella-zoster immune globulin were directly related to the dose administered.