Do we practice what we preach? Health care worker screening and vaccination

Do we practice what we preach? Health care worker screening and vaccination Julia M. L. Brotherton, B Med (Hons), MPH (Hons)a,b Mark J. Bartlett, MPH, Grad Dip App Epi, Dip Ed RNa,b David J. Muscatello, MPH, Grad Dip App Epia,b Sue Campbell-Lloyd, RNc Kim Stewart, BA, M Health Adminc Jeremy M. McAnulty, MBBS, MPHa New South Wales, Australia Objective: To describe the current screening and immunization practices in New South Wales (NSW) hospitals and the experience of NSW nurses in relation to screening and immunization and to identify areas that can be targeted for improvement. Design: This was a cross-sectional survey. Setting: The study was performed in NSW, Australia. Methods: We used a written questionnaire to survey the infection control/occupational health coordinators of all of the 85 private hospitals and 204 eligible public hospitals in NSW and 800 randomly sampled registered nurses. Results: Response rates were high (hospitals [90%], nurses [70%]). Hospitals almost universally offered hepatitis B vaccination to nurses (251/261, 96%), but more than one quarter (132/473, 28%) of nurses reported incomplete vaccination. Provision to physicians was relatively poor (142/261, 54%). The majority of nurses (> 80%) had been vaccinated with bacille CalmetteGuérin vaccine, but hospitals reported variable tuberculosis screening practices. Both hospitals and nurses reported low rates (< 30%) of screening and vaccination provision for varicella and measles-mumps-rubella. Two thirds of NSW hospitals (174/261, 67%) provided annual influenza vaccination. Conclusions: Even though hepatitis B immunization programs were widespread, their effectiveness could be improved by ensuring that vaccination schedules are completed and by targeting physicians. Varicella and measles-mumps-rubella screening and immunization programs are currently lacking. Better strategies are needed to improve the implementation of health care worker protection guidelines in hospitals. (Am J Infect Control 2003;31:144-50.)

Health care workers, by virtue of their exposure to patients and to blood and other body substances, are at increased risk of acquiring infectious diseases.1,2 From the Communicable Diseases Surveillance and Control Branch,a New South Wales Public Health Officer Training Program,b and AIDS and Infectious Diseases Branch,c New South Wales Health Department. This study was funded by the New South Wales Department of Health. Reprint requests: Julia M. L. Brotherton, B Med (Hons), MPH (Hons), New South Wales Public Health Officer Training Program, New South Wales Health Department, LMB 961, North Sydney 2059, New South Wales, Australia. Copyright © 2003 by the Association for Professionals in Infection Control and Epidemiology, Inc. 0196-6553/2003/$30.00 + 0 doi:10.1067/mic.2003.24

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Some infections are preventable through vaccination (eg, hepatitis B,3 varicella,4 and measles5) and others through the adherence to Standard Precautions (eg, hepatitis C and HIV6). Likewise, patients may sometimes acquire infectious diseases from health care workers.7-9 Prevention of these infections requires effective occupational safety programs. Recommendations for health care worker screening and vaccination are set out in both state guidelines,10,11 which relate particularly to tuberculosis (TB) and hepatitis B programs, and in national guidelines.12,13 In New South Wales (NSW), hospitals employ nurses, allied health professionals, and resident physicians. They also employ consultant medical staff on a contract basis. We aimed to describe the current screening and immunization practices in NSW health care facilities and the experience of NSW nurses in relation to screening and

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immunization and to identify areas that can be targeted for improvement.

Table 1. Characteristics of surveyed health care facilities (n = 261)

METHODS

Characteristic

In December 1999 we conducted the following 2 surveys: a hospital survey and a nurse survey. The Statewide Health Confidentiality and Ethics Committee gave ethical approval for the study.

No. of beds 25 or fewer 26-50 51-100 >100 Data missing Location Sydney metropolitan Other metropolitan* Rural Public hospital classification Principal referral Specialist acute Major acute District acute Community acute Community nonacute Psychiatric Other nonacute

Hospital survey We used a postal questionnaire to survey the infection control/occupational health coordinator of all of the 85 private hospitals and 204 eligible public hospitals on an NSW Department of Health mailing list. Eligible health care facilities were those with inpatient beds that were not solely a nursing home or mothercraft facility (ie, tertiary referral services that provide intensive specialist support and care for complex parenting issues). The questionnaire requested information about bed numbers, preemployment staff screening, storage of staff screening/immunization records, documentation of consent or refusal for screening/immunization, provision of vaccinations to staff, postvaccination serologic tests and education by occupational grouping, and the use of staff subcontracted through private employment agencies. Each questionnaire was accompanied by an introductory letter signed by the NSW chief health officer. We also sent a letter informing each area health service’s chief executive officer about the questionnaire.

Nurse survey A random sample of 500 registered nurses (RNs) employed at public hospitals and 300 RNs employed at private hospitals was identified through the NSW Nurses Registration Board (NRB) workforce database. According to the database, more RNs in NSW are employed in public hospitals (ratio, 5:1 over private hospitals); therefore, we oversampled nurses employed in private hospitals to obtain a large enough sample for statistical purposes. A uniquely numbered questionnaire was sent to these nurses, whose names and mailing details were kept confidential by the NRB, along with an introductory letter from the NSW chief health officer. The questionnaire requested demographic information such as age; sex; year of first registration; years worked as an RN; current employment status; area of work; and information about employerprovided screening and immunization against and past infection with hepatitis B, TB, hepatitis A,

Public hospital (n = 182)

51 49 29 45 8

Private hospital (n = 79)

(28%) (27%) (16%) (25%) (4%)

37 (20%) 25 (14%) 120 (66%) 12 4 20 38 33 44 4 27

(7%) (2%) (11%) (21%) (18%) (24%) (2%) (15%)

2 22 31 15 9

(2%) (28%) (39%) (19%) (11%)

52 (66%) 13 (16%) 14 (18%) N/A

N/A, Categorization not applicable. *Located in the Illawarra, Central Coast, or Hunter regions.

measles-mumps-rubella (MMR), varicella, influenza, and polio. Reminder letters were sent to nonresponders (identified by questionnaire number) on 2 occasions. Follow-up was completed in March 2000. Univariate analysis and multivariate logistic regression analyses were performed with Epi-Info (Centers for Disease Control and Prevention, Atlanta, Georgia) and SAS Statistical Software (version 6.12, Cary, NC). Univariate analyses used the χ2 and Mantel-Haenszel (MH) χ2 tests for test of trend. When respondents answered “don’t know” or did not respond, they were excluded from the denominator when odds ratios were calculated. Adjusted odds ratios were calculated with use of logistic regression.

RESULTS Hospital survey After the survey, an updated mailing list identified 12 eligible public hospitals that had not been surveyed (coverage 204/216; 94%). Of those hospitals surveyed, the overall response rate was 90% (private hospitals, 93% [79/85], and public hospitals, 89% [182/204]). Characteristics of the surveyed hospitals are listed in Table 1. Public hospitals ranged in size from 5 funded beds to 1020 funded beds. Two thirds

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Table 2. Screening and immunization practices of NSW hospitals (n = 261) Practice

Public hospitals (n = 182)

Pre-employment screening for the following:* Nurses Physicians Nonpatient care staff Keep records of the following: • Staff vaccinations • Postvaccination test results Hepatitis B Provide staff vaccination • To nurses • To physicians • To nonpatient care staff Provide follow-up serologic tests Formally document vaccine refusal Provide inservice education • To nurses • To physicians • To nonpatient care staff Provide hepatitis A vaccination Assess measles immunity Provide MMR vaccination Provide annual influenza vaccination‡ Provide tetanus vaccination Screen staff for previous varicella infection TB Inservice education • To nurses • To physicians • Nonpatient care staff Have TB screening program Provide BCG vaccination if indicated Mantoux screening of unvaccinated staff in high-risk areas

Private hospitals (n = 79)

Total (n = 261)

91 (50%) 43 (24%) 73 (40%)

46 (58%) 8 (10%) 41 (52%)

137 (52%) 51 (20%) 114 (44%)

178 (98%) 166 (91%)

76 (96%) 74 (94%)

254 (97%) 240 (92%)

177 175 111 156 171 126

(97%) (99%)† (63%)† (88%)† (97%)† (71%)

76 76 31 69 73 70

(96%) (100%)† (41%)† (91%)† (96%)† (92%)

253 251 142 225 244 196

(97%) (96%) (54%) (86%) (93%) (77%)

156 59 121 58 43 34 138 80 53

(86%) (32%) (67%) (32%) (24%) (19%) (76%) (44%) (29%)

74 15 68 23 22 2 36 17 23

(94%) (19%) (86%) (29%) (28%) (2.5%) (46%) (22%) (29%)

230 74 189 81 65 36 174 97 76

(88%) (28%) (72%) (31%) (25%) (14%) (67%) (37%) (29%)

106 43 70 119 115 93

(58%) (24%) (38%) (65%) (63%) (51%)

44 6 33 33 38 18

(56%) (8%) (42%) (42%) (48%) (23%)

150 49 103 152 153 111

(57%) (19%) (39%) (58%) (59%) (43%)

*For example, immunization history, disease history, results of screening/blood tests. †Of hospitals providing staff hepatitis B vaccination. ‡Ninety-one percent of vaccinating hospitals reported vaccinating all staff groups against influenza.

of public hospitals were located in rural areas, whereas two thirds of private hospitals were located within the Sydney metropolitan region. Hospitals in rural areas were generally smaller, with 72% (97/134) having 50 or fewer beds. In contrast, only 30% (38/127) of metropolitan hospitals had 50 or fewer beds.

Screening and recordkeeping. Screening and immunization practices are summarized in Table 2. About half of surveyed hospitals reported that they performed pre-employment screening (ie, immunization and diseases history) of nurses, but far fewer (20%) reported screening physicians before employment. Records of pre-employment screening were kept in paper form by most hospitals (64%), in both paper and electronic form by 29% of hospitals, and in only electronic form by 7% of hospitals. The vast majority of NSW hospitals (> 90%) reported that they kept records of staff vaccinations and test results.

Hepatitis B vaccination and education. Almost all NSW hospitals (97%) reported that they have a staff hepatitis B vaccination program. However, nurses were routinely offered hepatitis B vaccination by employers (96%) far more commonly than were physicians (54%). Similarly, physicians were less likely to be provided with inservice education about hepatitis B and TB than were other staff.

Other infections. The routine assessments of staff immunity to measles and varicella were both relatively uncommon practices (<30%). Acute care public hospitals were significantly more likely than nonacute care public hospitals to screen their staff for varicella (varicella screening was reported by 43/104 [41%] of acute care hospitals compared with 10/75 [13%] of nonacute care hospitals; OR, 4.6 [95% CI, 2.0-10.7] and P = .00005). Similarly, TB screening programs were reported significantly more often by

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acute care hospitals (81/105, 77%) than nonacute care hospitals (38/73, 52%) (OR, 3.1; 95% CI, 1.6-6.3; P = .0005). Few hospitals (14%) had elected to provide MMR vaccination to staff, although metropolitan hospitals outside of Sydney were significantly more likely to provide MMR vaccination, even after adjusting for acute/private status and presence of a pediatric ward in a logistic regression analysis (MMR vaccine provision reported by 12/35 [34%] of metropolitan hospitals outside of Sydney compared with 7/86 [8%] of hospitals in Sydney and 17/131 [13%] of rural hospitals [adjusted OR, 4.5; 95% CI, 1.3-14.8; P = .005]). In contrast to the generally poor provision of MMR vaccine, two thirds of hospitals reported providing their staff with an annual influenza vaccination. There were some significant differences in reported practices between private and public hospitals. In a multivariate logistic regression analysis, private hospitals were significantly less likely to provide influenza vaccination to staff, even after adjusting for location (Sydney, other metropolitan, or rural), size, and presence of a pediatric ward (OR, 0.3; 95% CI, 0.2-0.8; P = .008). Similarly, private hospitals were significantly less likely to provide MMR vaccination (OR, 0.04; 95% CI, 0.005-0.3; P < .0001) or tetanus vaccine (OR, 0.3; 95% CI, 0.1-0.7; P = .02) after adjustment for location, size, and presence of a pediatric ward. In contrast, private hospitals were significantly more likely to formally document hepatitis B vaccine refusal by staff (OR, 3.5; 95% CI, 1.5-8.0; P = .0009).

Nurse survey Of the nurses selected from the NRB list of nurses employed in a public hospital, 350 responded to the survey (350/500, 70%). The response rate for nurses employed in private hospitals was 71% (212/300). Nurses who were not currently working were excluded (n = 31 [17 public, 14 private]). For the purposes of analysis, only nurses who identified that their place of work was predominantly in the public/private hospital category from which they had been selected were included. This led to the exclusion of an additional 29 nurses who had been recruited as public hospital nurses but reported that they worked elsewhere and 29 nurses selected as private hospital nurses but who were currently working elsewhere. Characteristics of the responders are given in Table 3. Most nurses were women, and 70% of public hospital nurses and 64% of private hospital nurses were aged 40 years or older. Just fewer than half of the nurses employed in pub-

Table 3. Demographic characteristics of responders to the nurse survey

Characteristic

Public hospital nurses (n = 304) N (% [95% CI])

Sex Woman 284 Man 18 Data missing 2 Age group 20-29 y 21 30-39 y 72 40-49 y 115 50 y and older 96 Year of first registration Before 1970 56 1970 to 1979 104 1980 to 1989 112 1990 to 1997 26 Data missing 6 Current work status Full time 164 Part time 140 Data missing 0 Field of work Midwifery 52 Surgical ward 21 General medical ward 40 Medical subspecialty 30 Operating room 18 Pediatrics/neonatal 29 Intensive care 25 Psychiatry/mental health 12 Orthopedics/rehabilitation 13 Emergency department 13 Nonclinical 18 Other 32 Data missing 1

(93 [91-96]) (6 [3-9]) (1 [0-2])

Private hospital nurses (n = 169) N (% [95% CI])

165 (98 [95-100]) 3 (2 [0-4]) 1 (0.6 [0-2])

(7 [4-10]) (24 [19-29]) (38 [32-43]) (32 [26-37])

5 55 63 46

(3 [0-6]) (33 [26-40]) (37 [30-45]) (27 [21-34])

(18 [14-23]) (34 [29-40]) (37 [31-42]) (9 [5-12]) (2 [0-4])

29 53 59 27 1

(17 [12-23]) (31 [24-38]) (35 [28-42]) (16 [11-22]) (0.6 [0-2])

(54 [48-60]) (46 [40-52])

(17 [13-21]) (7 [4-10]) (13 [9-17]) (10 [7-13]) (6 [3-9]) (10 [6-13] (8 [5-11]) (4 [2-6]) (4 [2-7]) (4 [2-7]) (6 [3-9]) (10 [7-14]) (0.3 [0-1])

56 (33 [26-40]) 112 (66 [59-73]) 1 (0.6 [0-2]) 25 38 16 6 32 4 6 6 11 1 13 11 0

(15 [9-20]) (22 [16-29]) (9 [5-14]) (4 [1-6]) (19 [13-25]) (2 [0-5]) (4 [1-6]) (4 [1-6]) (7 [3-10]) (0.6 [0-2]) (8 [4-12]) (7 [3-10])

lic hospitals were working on a part-time basis, whereas two thirds of the nurses employed in private hospitals worked part time. Nurses reported a wide range of specialty areas of work; the most common specialty area among public hospital nurses surveyed was midwifery and among private hospital nurses was operating rooms. Key findings are summarized in Tables 4 and 5 for the 473 nurses included in the analysis.

Hepatitis B vaccination, screening, and education. Although fewer than half of public hospital nurses reported having been educated about hepatitis B on commencement of employment or being asked about their immunity to hepatitis B, most

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Table 4. Findings from nurse survey: Nurse’s experiences (n = 473)

Experience Inservice education at commencement with current employer about the following: Hepatitis B TB Asked about immune status to the following: Hepatitis B TB Measles Rubella Varicella Ever offered vaccination by current employer against the following: Hepatitis B TB (BCG) MMR Hepatitis A Influenza in 1999

Public hospital nurses (n = 304) N (% [95% CI])

Table 5. Reported immunity (previous infection or vaccination) of respondents

Private hospital nurses (n = 169) N (% [95% CI])

132 (43 [38-49]) 98 (32 [27-38])

89 (53 [45-60]) 49 (29 [22-36])

127 149 75 86 61

92 68 29 32 23

270 160 50 74 205

(42 (49 (25 (28 (20

(89 (53 (16 (24 (67

[36-47]) [43-55]) [20-30]) [23-33]) [16-25])

[85-92]) [47-58]) [12-21]) [20-29]) [62-73])

142 50 3 26 82

(54 (40 (17 (19 (14

[47-62]) [33-48]) [12-23]) [13-25]) [8-19])

(84 [79-90]) (30 [23-37]) (2 [0-4]) (15 [10-21]) (49 [41-56])

(89%) reported having been offered vaccination against hepatitis B by their current employer. Private hospital nurses were just as likely as public hospital nurses to report having been offered hepatitis B vaccine (OR, 0.7; 95% CI, 0.4-1.4; P = .35), and private hospital nurses were more likely than public hospital nurses to report having been asked about their hepatitis B status at employment (OR, 1.6; 95% CI, 1.05-2.5; P = .03) (see Table 4). Although most nurses in both public and private hospitals reported receiving at least 1 vaccination against hepatitis B, more than one quarter in each group could be categorized as “not known to be immune” because of inadequate compliance with the 3-dose schedule (see Table 5). Among public hospital nurses, there was evidence of a strong association between adequate immunization against hepatitis B and age group (χ23, 12.9; P = .005). This association took the form of a trend with decreasing probability of adequate hepatitis B immunization with increasing age group (χ2, 7.13; P = .008). A similar association was observed among private hospital nurses but was not statistically significant (P = .15).

Other infections. About one quarter of public hospital nurses reported that they had been asked

Disease status

Public hospital nurses (n = 304) N (% [95% CI])

Hepatitis B Previous infection 6 Ever immunized 274/304 1 dose only 13/274 2 doses only 33/274 3 + doses 217/274 Unsure about 11/274 number of doses Not known to be 82/304 immune* TB Previous infection 6 Immunized with BCG 254 Measles Previous infection 193 Immunized 95 Not known to be 62 immune Rubella Previous infection 103 Immunized 176 Not known to be 70 immune Hepatitis A Previous infection 15 Immunized 71 Not known to be 220 immune Polio Previous infection 1 Immunized 263 Not known to be 40 immune

Private hospital nurses (n = 169) N (% [95% CI])

(2 [0-4]) 0 (90 [87-94]) 158/169 (93 [90-97]) (5 [2-7]) 9/158 (6 [2-9]) (12 [8-16]) 24/158 (15 [10-21]) (79 [74-84]) 119/158 (75 [69-82]) (4 [2-6]) 6/158 (4 [1-7]) (27 [22-32])

50/169 (30 [23-37])

(2 [0-4]) (84 [79-88])

2 (1 [0-3]) 140 (83 [77-89])

(63 [58-69]) (31 [26-37]) (20 [16-25])

97 (57 [50-65]) 63 (37 [30-45]) 39 (23 [17-29])

(34 [29-39]) (58 [52-63]) (23 [18-28])

51 (30 [23-37]) 120 (71 [64-78]) 26 (15 [10-21])

(5 [3-7]) (23 [19-28]) (73 [67-77])

9 (5 [2-9]) 36 (21 [15-28]) 125 (74 [67-81])

(0.4 [0-1]) (87 [83-90]) (13 [9-17])

0 149 (88 [83-93]) 20 (12 [7-17])

*Neither previous infection nor vaccination reported; some nurses reported both previous infection and vaccination. For hepatitis B immunity, those who had received fewer than 3 doses were considered to be nonimmune.

about their immunity to measles or rubella by their employer, and fewer had been asked about varicella immunity. Private hospital nurses reported even lower rates of inquiry into their immunity to these diseases by their employers. Only 16% of public hospital nurses and 2% of private hospital nurses recalled having been offered MMR vaccination by their current employer (see Table 4). Two thirds of public hospital nurses and almost half of private hospital nurses had been offered influenza vaccination by their employer in 1999. Among the nurses who reported either “yes” or “no” (as opposed to being uncertain), those

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employed in private hospitals were significantly less likely than those in public hospitals to report having been offered vaccination with hepatitis A vaccine by their current employer (18% vs 29%; OR, 0.5 [0.30.9]; P = .02), bacille Calmette-Guérin (BCG) vaccine (33% vs 60%; OR, 0.3 [0.2-0.5]; P < .0001), MMR vaccine (2% vs 19%; OR, 0.08 [0.02-0.3]; P < .0001), or influenza vaccine in 1999 (50% vs 71%; OR, 0.4 [0.3-0.6]; P < .0001). On the basis of self-report, significant numbers of nurses may not be immune to measles and rubella because they reported neither previous infection nor immunization (see Table 5). In both public and private hospital nurse groups, age was significantly associated with immunization against rubella (public, P = .001; private, P = .001) and measles (public, P = .001; private, P = .04), with a trend of decreasing probability of immunization with increasing age. According to the MH trend test, this trend in relation to measles immunization for public nurses was significant at P = .001 and for private nurses at P = .01; the MH trend test for rubella immunization was significant at P = .001 in both groups.

DISCUSSION This large survey of NSW hospitals and nurses revealed a broad cross section of practices and experiences in relation to health care worker screening and immunization in NSW. We found the following: hospitals almost universally offered hepatitis B vaccination programs but the provision to physicians was relatively poor and more than one quarter of nurses did not report completed vaccination; most hospitals in NSW maintain records of staff screening and immunization; the majority of nurses (> 80%) were vaccinated with BCG; and hospitals report variable TB screening practices and low rates of screening and vaccination provision for varicella and MMR. Much of the variation in practices is likely due to the variation in risk according to the population served by the hospitals and by job description (eg, not all hospitals serve populations that put health care workers at risk for hepatitis A or TB). Thus, decisions are made at the local level as to the applicability of screening and vaccination of health care workers for specific infections. However, in other instances, for example, in the area of hepatitis B education and staff vaccination, the survey indicates that there is a need for targeted strategies to ensure that health care workers are protected. A hospital survey undertaken in Victoria in 1995-1996

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also demonstrated the widespread existence of hospital-based hepatitis B programs and similar variability in terms of who was offered vaccination.14 A US survey found a similar rate of completed hepatitis B vaccination (75%) among nurses, and in that survey, nurses had the highest completion rate of all health care worker groups surveyed.3 Data from the NRB indicate that our nurse respondents were older than expected when compared with all nurses registered in NSW (public hospital nurses [expected, 49% for those older than 40 years; observed, 70%] and private hospital nurses [expected, 51% for those older than 40 years; observed, 64%]). Estimates of vaccination uptake may therefore have been underestimated in our survey because we found that increasing age was negatively associated with hepatitis B, measles, and rubella immunization. An important implication of the inverse relationship between increasing age and completed hepatitis B immunization among nurses is that hospitals should consider a targeted campaign to identify and vaccinate unprotected older staff members. The response rate from hospitals in our survey was high and provided a good basis for identifying areas that need particular attention or clarification. In particular, because immunization schedules and recommendations are not static, the survey provided a reference point for asking, “Where are we now?” and identifying problem areas. There are undoubtedly difficulties for employers caused by the existence of varying international recommendations15 and both commonwealth and state guidelines surrounding recommended practice in screening and immunization. Overall the immunization and screening experiences reported by nurses appeared consistent with practices reported by hospitals. Strengths of existing hospital programs included that almost all hospitals were providing hepatitis B staff vaccination programs, including follow-up serologic tests, and were documenting staff vaccinations. It is also encouraging that so many public hospitals were already providing staff with annual influenza vaccination. In contrast, hospitals will need to revisit the importance of undertaking an assessment of staff immunity to measles, rubella, and varicella, particularly now that a varicella vaccine is available. The hospital survey also suggested that physicians were relatively overlooked compared with other

150 Vol. 31 No. 3 staff groups in regard to both education about and vaccination against hepatitis B. The unstated assumption that physicians will themselves ensure that they are adequately immunized has, unfortunately, been refuted in other surveys.16-18 Although there is no doubt that the screening and immunization of resident medical staff are the responsibility of the employing hospital, it remains less clear how hospitals can best facilitate the screening and immunization of contract medical staff. In 2001, the NSW Health Department19 released a new policy on health care worker screening and immunization to provide clearer guidance to NSW health care facilities. The policy contains new recommendations, including an annual influenza vaccination of health care workers who have patient contact and the assessment of patient care staff for previous varicella, with provision of vaccination for those subsequently demonstrated serologically to be nonimmune. The new policy also emphasizes the importance of ensuring that all staff involved in patient care, especially those whose work includes exposureprone procedures, convey to their employer their hepatitis B immune status. It is only with adequate knowledge about a health care worker’s susceptibility to hepatitis B that employers can provide vaccination when required and postexposure protection for those who are identified as being nonimmune. Infectious diseases are still a problem for the community and health care workers. Employers have a duty of care to staff and patients by providing them with protection against these diseases when it is available. In 2002, we still have a way to go to implement health care worker screening and vaccination recommendations in an effective way. References 1. Sepkowitz KA. Occupationally acquired infection in health care workers. Part I. Ann Intern Med 1996;125:826-34. 2. Sepkowitz KA. Occupationally acquired infection in health care workers. Part II. Ann Intern Med 1996;125:917-28. 3. Mahoney FJ, Stewart K, Hu H, Coleman P, Alter MJ. Progress toward the elimination of hepatitis B virus transmission among health care workers in the United States. Arch Intern Med 1997;157:2601-5.

Brotherton et al 4. Tennenberg AM, Brassard JE,Van Lieu J, Drusin LM.Varicella vaccination for health care workers at a university hospital: an analysis of costs and benefits. Infect Control Hosp Epidemiol 1997;18: 405-12. 5. Stover BH, Adams G, Kuebler CA, Cost KM, Rabalais GP. Measles-mumps-rubella immunization of susceptible hospital employees during a community measles outbreak: cost effectiveness and protective efficacy. Infect Control Hosp Epidemiol 1994; 15:18-21. 6. Bell DM. Human immunodeficiency virus transmission in health care settings: risk and risk reduction. Am J Med 1991;91(suppl 3B):294S-300S. 7. Ross RS, Viazov S, Gross T, Hofmann F, Seipp HM, et al. Transmission of hepatitis C virus from a patient to an anesthesiology assistant to five patients [brief report]. N Engl J Med 2000; 343(25):1851-4. 8. Poland GA, Nichol KL. Medical students as sources of rubella and measles outbreaks. Arch Intern Med 1990;150:44-6. 9. Ciesielski C, Marianos D, Ou CY, Dumbaugh R, Witte J, Berkelman R, et al. Transmission of human immunodeficiency virus in a dental practice. Ann Intern Med 1992;116:798-805. 10. New South Wales Health Department. Health care worker screening and protection. Circular No. 94/95. Available at: www.health.nsw.gov.au. 11. New South Wales Health Department. Hepatitis B and health care workers. Circular No. 96/40. Available at: www.health.nsw. gov.au. 12. National Health and Medical Research Council. Infection control in the health care setting: guidelines for the prevention of transmission of infectious diseases. Canberra, Australia: Australian Government Publishing Service; 1996. 13. National Health and Medical Research Council. The Australian immunisation handbook. 7th ed. Canberra, Australia: Australian Government Publishing Service; 2000. 14. Thompson SC, Norris M. Hepatitis B vaccination of personnel employed in Victorian hospitals: are those at risk adequately protected? Infect Control Hosp Epidemiol 1999;20:51-4. 15. Centers for Disease Control and Prevention. Immunization of health-care workers: recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC). Morb Mortal Wkly Rep MMWR 1997;46(RR-18):1-42. 16. Patterson JM, Noval CB, Mackinnon SE, Patterson GA. Surgeon’s concern and practices of protection against blood borne pathogens. Ann Surg 1998;228:266-72. 17. Morrisey J, Bek MD.A survey of hepatitis B vaccination and immunity among health care workers at the Canterbury Hospital: a report to the South Sydney Area Health Service. Sydney,Australia: Southern Sydney Area Health Service; March 1995. 18. Rosen E, Rudensky B, Paz E, Isacsohn M, Jerassi Z, et al.Ten-year follow-up study of hepatitis B virus infection and vaccination status in hospital employees. J Hosp Infect 1999;41:245-50. 19. New South Wales Health Department. Occupational screening and vaccination of health care workers against infectious diseases. Circular No. 2001/91. Available at: www.health.nsw.gov.au.