Morbidity and Mortality Weekly Report

www.cdc.gov/mmwr

Recommendations and Reports August 1, 2008 / Vol. 57 / No. RR-6

Recommendations for Postexposure Interventions to

Prevent Infection with Hepatitis B Virus, Hepatitis C
Virus, or Human Immunodeficiency Virus, and Tetanus
in Persons Wounded During Bombings and Similar
Mass-Casualty Events — United States, 2008
Recommendations of the Centers for Disease Control
and Prevention (CDC)

INSIDE: Continuing Education Examination

depar tment of health and human ser

department vices
services
vices

Centers for Disease Control and Prevention

Prevention

 MMWR

CONTENTS

The MMWR series of publications is published by the Coordinating

Center for Health Information and Service, Centers for Disease
Introduction .......................................................................... 1

Control and Prevention (CDC), U.S. Department of Health and

Human Services, Atlanta, GA 30333. Methods ............................................................................... 3

Suggested Citation: Centers for Disease Control and Prevention. Bloodborne Pathogens of Immediate Concern ..................... 3

[Title]. MMWR 2008;57(No. RR-#):[inclusive page numbers]. Tetanus ................................................................................ 6

Centers for Disease Control and Prevention Recommendations ................................................................ 8

Julie L. Gerberding, MD, MPH Vaccine and Antitoxin Supply ............................................. 11

Director
Tanja Popovic, MD, PhD Counseling ......................................................................... 11

Chief Science Officer Special Situations ............................................................... 11

James W. Stephens, PhD Responders and Other Personnel ....................................... 12

Associate Director for Science

Steven L. Solomon, MD Contraindications and Precautions ..................................... 13

Director, Coordinating Center for Health Information and Service Reporting Adverse Events ................................................... 13

Jay M. Bernhardt, PhD, MPH

Information Sources ........................................................... 14

Director, National Center for Health Marketing

Katherine L. Daniel, PhD Acknowledgments .............................................................. 14

Deputy Director, National Center for Health Marketing References ......................................................................... 14

Editorial and Production Staff Continuing Education Activity ......................................... CE-1

Frederic E. Shaw, MD, JD

Editor, MMWR Series
Susan F. Davis, MD
(Acting) Assistant Editor, MMWR Series
Teresa F. Rutledge
(Acting) Managing Editor, MMWR Series
David C. Johnson
Disclosure of Relationship
(Acting) Lead Technical Writer-Editor
Jeffrey D. Sokolow, MA CDC and our content experts wish to disclose that they have no financial
Project Editor interests or other relationships with the manufacturers of commercial
Peter M. Jenkins
products, suppliers of commercial services, or commercial supporters
(Acting) Lead Visual Information Specialist
discussed in these recommendations.
Lynda G. Cupell

Malbea A. LaPete
Information included in these recommendations might not represent
Visual Information Specialists FDA approval or approved labeling for the particular product or
Quang M. Doan, MBA
indications in question. Specifically, the terms “safe” and “effective”
Erica R. Shaver
might not be synonymous with the FDA-defined legal standard for
Information Technology Specialists product approval.
Editorial Board
This report does not include any discussion of the unlabeled use of a
William L. Roper, MD, MPH, Chapel Hill, NC, Chairman

Virginia A. Caine, MD, Indianapolis, IN

product or a product under investigational use with the exception of
David W. Fleming, MD, Seattle, WA
the discussions of:
William E. Halperin, MD, DrPH, MPH, Newark, NJ
1. use of antiretroviral medications for human immunodeficiency virus
Margaret A. Hamburg, MD, Washington, DC
postexposure prophylaxis.
King K. Holmes, MD, PhD, Seattle, WA
2. off-label use of tetanus toxoid, reduced diphtheria toxoid and acel­
Deborah Holtzman, PhD, Atlanta, GA
lular pertussis vaccine (Tdap) in the following situations:
John K. Iglehart, Bethesda, MD
a. the interval between tetanus and diphtheria toxoids vaccine (Td)
Dennis G. Maki, MD, Madison, WI
and Tdap might be shorter than the 5 years indicated in the pack­
Sue Mallonee, MPH, Oklahoma City, OK
age insert,
Stanley A. Plotkin, MD, Doylestown, PA

b. the interval between doses of Td might be shorter than the 5 years

Patricia Quinlisk, MD, MPH, Des Moines, IA

Patrick L. Remington, MD, MPH, Madison, WI

indicated in the package insert,
Barbara K. Rimer, DrPH, Chapel Hill, NC
c. a dose of Tdap may be administered to a person who has already
John V. Rullan, MD, MPH, San Juan, PR
received Tdap,
Anne Schuchat, MD, Atlanta, GA
d. a dose of Tdap may be administered to a person aged <7 years or
Dixie E. Snider, MD, MPH, Atlanta, GA
>64 years, and
John W. Ward, MD, Atlanta, GA
e. Tdap may be used as part of the primary series for tetanus and
diphtheria.
Vol. 57 / RR-6 Recommendations and Reports 1

Recommendations for Postexposure Interventions to Prevent

Infection with Hepatitis B Virus, Hepatitis C Virus, or Human

Immunodeficiency Virus, and Tetanus in Persons Wounded During

Bombings and Other Mass-Casualty Events — United States, 2008

Recommendations of the Centers for Disease Control and Prevention (CDC)

Prepared by

Louisa E. Chapman, MD1

Ernest E. Sullivent, MD2

Lisa A. Grohskopf, MD3

Elise M. Beltrami, MD4

Joseph F. Perz, DrPH5

Katrina Kretsinger, MD6

Adelisa L. Panlilio, MD4

Nicola D. Thompson, PhD5

Richard L. Ehrenberg, MD7

Kathleen F. Gensheimer, MD8,9

Jeffrey S. Duchin, MD10,11

Peter H. Kilmarx, MD3

Richard C. Hunt, MD2

1
Immunization Services Division, National Center for Immunizations and Respiratory Diseases,

2
Division of Injury Response, National Center for Injury Prevention and Control

3
Division of HIV/AIDS Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

4
Division of Healthcare Quality Promotion, National Center for Preparedness, Detection, and Control of Infectious Diseases

5
Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

6
Division of Bacterial Diseases, National Center for Immunizations and Respiratory Diseases

7
Office of Emergency Preparedness and Response, National Institute for Occupational Safety and Health

8
Council of State and Territorial Epidemiologists, Atlanta, Georgia

9
Maine Department of Health and Human Services, Augusta, Maine

10
National Association of County and City Health Officials, Washington, DC

11
Public Health – King County, Seattle, Washington

Summary
This report outlines recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C
virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings or other events resulting in mass
casualties. Persons wounded during such events or in conjunction with the resulting emergency response might be exposed to
blood, body fluids, or tissue from other injured persons and thus be at risk for bloodborne infections. This report adapts
existing general recommendations on the use of immunization and postexposure prophylaxis for tetanus and for occupational
and nonoccupational exposures to bloodborne pathogens to the specific situation of a mass-casualty event. Decisions regarding
the implementation of prophylaxis are complex, and drawing
parallels from existing guidelines is difficult. For any prophy-
The material in this report originated in the Coordinating Office for lactic intervention to be implemented effectively, guidance must
Terrorism Preparedness and Emergency Response, Rich Besser, MD, be simple, straightforward, and logistically undemanding.
Director; the National Center for Immunizations and Respiratory
Diseases, Anne Schuchat, MD, Director; the National Center for Critical review during development of this guidance was pro-
HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Kevin A. Fenton, vided by representatives of the National Association of County
MD, PhD, Director; the National Center for Preparedness, Detection, and City Health Officials, the Council of State and Territorial
and Control of Infectious Diseases, Rima Khabbaz, MD, Director;
the National Center for Injury Prevention and Control, Howard Epidemiologists, and representatives of the acute injury care,
Frumkin, MD, Director, Division of Injury Response, Richard Hunt, trauma and emergency response medical communities partici-
MD, Director; and the National Institute for Occupational Safety pating in CDC’s Terrorism Injuries: Information, Dissemina­
and Health, John Howard, MD, Director.
tion and Exchange (TIIDE) project. The recommendations
Corresponding preparer: Louisa Chapman, MD, National Center
for Immunizations and Respiratory Diseases, CDC, Mailstop D-68,
contained in this report represent the consensus of U.S. federal
1600 Clifton Road, N.E., Atlanta, GA 30333. Telephone: 404-639- public health officials and reflect the experience and input of

8921; Fax: 404-639-3500; E-mail: LChapman@cdc.gov.

public health officials at all levels of government and the acute
injury response community.
2 MMWR August 1, 2008

Introduction resulting from trauma cases not involving mass casualties,

including the risk for tetanus. In addition, exposure of
Public health authorities must consider how to provide
wounds, abraded skin, or mucous membranes to blood,
care to injured persons in the event of acts such as bomb­
body fluids, or tissue from other injured persons (includ­
ings that result in mass casualties. During 1980–2005, of
ing suicide bombers and bombing casualties) might carry
318 acts of terrorism investigated by the Federal Bureau of
a risk for infection with a bloodborne virus. Injured survi­
Investigation (FBI) in the United States or territories, 208
vors of mass-casualty events are at risk for infection with
(65%) involved attempted bombings; of these 208
HBV, hepatitis C virus (HCV), or human immunodefi­
attempts, 183 (88%) succeeded. The majority of these acts
ciency virus (HIV) and for tetanus.
were committed by domestic extremist groups that inten­
Decisions regarding the administration of prophylaxis after
tionally targeted property and did not cause deaths or
a mass-casualty event are complex, and drawing direct par­
injuries in persons; however, 19 bombings (10% of those
allels from existing guidelines regarding prophylaxis against
that were successful) resulted in 181 deaths and 1,967
bloodborne pathogens in occupational or nonoccupational
injured survivors. These figures do not include mass-
settings is difficult. Assessment of risk factors commonly
casualty incidents that occurred outside the United States
used to estimate the need for prophylactic intervention
and its territories or those that occurred on U.S. soil that
might not be possible in the setting of response to a mass-
were classified as crimes, accidents, unintended negligence,
casualty event because responses to such events might over­
or terrorist incidents other than bombings (e.g., the 2,972
whelm local emergency response facilities, and medical
persons killed as a result of the terrorist attacks of Septem­
response staff will be focused primarily on rendering life­
ber 11, 2001). A total of 1,967 (91%) persons injured
saving trauma treatments. Because no uniform guidance
during terrorist bombings in the United States and approxi­
existed for posstexposure interventions to prevent
mately 12,000 (80%) persons injured during the terrorist
bloodborne infections and tetanus among U.S. civilians or
attacks of September 11, 2001, survived (1).
military personnel wounded during mass-casualty event,
Military health-care providers frequently must respond
CDC convened a Working Group comprising experts in
to mass-casualty events. During October 7, 2001–March 1,
injury response, immunizations, bloodborne infections,
2008, of 35,630 casualties incurred by U.S. Department
tetanus, and federal-, state-, and local-level public health
of Defense forces involved in Operation Enduring Freedom
response to develop such guidance.
(OEF) in Afghanistan and Operation Iraqi Freedom in Iraq
The recommendations in this report pertain only to
(OIF), 27,441 (77%) resulted from mass-casualty events.
bombings and other mass-casualty events and are not meant
Explosive devices accounted for 23,277 (65%) of these
to supplant existing recommendations for other settings.
casualties. Of 27,441 persons wounded during OEF- and
In a situation involving a substantial number of casualties,
OIF-related mass-casualty events, 24,433 (89%) survived
the ability to assess medical and vaccination histories or
(U.S. Department of Defense, unpublished data, 2008).
the risks associated with the source of exposures might be
In August 2001, the Israeli health ministry announced
limited, as might the supply of biologics. For this reason,
that tissue from two suicide bombers had tested positive
in certain instances, the recommendations provided in this
for evidence of hepatitis B virus (HBV) (2). A 2002 case
report differ from standard published recommendations for
report from Israel described evidence of hepatitis B virus in
vaccination and prophylaxis in other settings. These rec­
a bone fragment that had traumatically implanted into a
ommendations are not meant to supplant existing recom­
bombing survivor (3). Traumatically implanted bone frag­
mendations for other settings and apply only to the specific
ments removed from five survivors of the 2005 London
situation of an event involving mass casualties. In addition,
bombings were taken directly to forensic custody without
the recommendations provided in this report are limited
testing for bloodborne pathogens (4) These observations
to issues regarding initial postexposure management for
support the potential for explosions to result in transmis­
bloodborne pathogens and tetanus prophylaxis. Other pro­
sion of infections among persons injured during the event
phylactic measures that might be appropriate (e.g., use of
and indicate that emergency responders and health-care
antibiotics for the prevention of bacterial infection) are not
providers in the United States need uniform guidance on
discussed in this report.
prophylactic interventions appropriate for persons injured
Federal law requires the use of a Vaccine Information State­
in bombings and other events resulting in mass casualties.
ment (VIS) before the administration of vaccines against
Wounds resulting from mass-casualty events require the
HBV or tetanus. VIS forms are available at http://
same considerations for management as similar injuries
Vol. 57 / RR-6 Recommendations and Reports 3

www.cdc.gov/vaccines/pubs/vis/default.htm. Whenever fea­ with experience in local and state level public health re­
sible, a VIS form should be provided to patients or guard­ sponse. This group worked through the draft section by
ians before vaccination. section to revise, update, and refine the recommendations;
Individual states set forth their own legal requirements this revised document was shared again with representa­
as to what constitutes the nature of informed consent that tives of the U.S. and international trauma response com­
might be required before certain medical interventions. In munity for additional comment during a meeting in Atlanta,
general, these statutes also provide for exemptions in emer­ Georgia, in August 2007. Because this guidance met the
gency circumstances. It is these state-specific laws that requirements established by the Office of Management and
should guide response when informed consent would be Budget (OMB) for a Highly Influential Scientific Assess­
applicable, but the circumstances of response to a mass- ment (HISA) (available at http://www.whitehouse.gov/
casualty event might preclude adherence to standard omb/memoranda/fy2005/m05-03.html), the recommen­
informed consent processes. Emergency responders and dations underwent a final process of external review in
health-care providers should consult with their legal coun­ addition to undergoing internal CDC review for scientific
sel for guidance regarding the relevant laws of their juris­ content. As part of the OMB HISA peer review, the docu­
dictions in advance of any mass-casualty event. ment was posted on CDC’s website for public comment.
An external expert panel subsequently reviewed and cri­
tiqued the document, the public comments, and CDC’s
Methods response to those comments, and the document was
This report was developed through consultation among revised a final time in response to the external review
persons with expertise in immunization and other prophy­ process.
lactic interventions against bloodborne and other infections,
physicians who specialize in acute injury-care medicine
(trauma and emergency medicine), and local, state, and Bloodborne Pathogens of

federal public health epidemiologists. Thus, the recommen­ Immediate Concern

dations in this report represent the best consensus judg­ Although transfusions and injuries from sharp objects
ment of expert opinion. (e.g., needlestick) have been associated with the transmis­
This report adapts existing recommendations on the use sion of multiple different pathogens (8,9), three bloodborne
of immunization and postexposure prophylaxis in response pathogens merit specific consideration in mass-casualty situ­
to occupational and nonoccupational exposures to ations: HBV, HCV, and HIV. All three viruses are endemic
bloodborne pathogens in the United States to the specific at low levels in the United States and can be transmitted
mass-casualty event setting while acknowledging the diffi­ by exposure of infectious blood to an open wound or, more
culty of drawing direct parallels. This adaptation also draws rarely, to skin abrasions or through exposure to intact
on guidance and practices developed previously and in use mucous membranes. These viruses also can be transmitted
in the United Kingdom and Israel (2,5–7). by similar exposures to other body fluids or tissues from
These recommendations were adopted through a process infected persons. Infection risks and options for
of expert consultation and consensus development. First, postexposure prophylaxis vary, depending on the virus and
CDC drafted proposed preliminary recommendations on the type of injury and exposure. Because hepatitis A virus
the basis of relevant existing U.S. guidance and practices of (HAV) is transmitted via the fecal-oral route and is not
Israel and the United Kingdom (2,5–7). These proposed considered a bloodborne pathogen (10), HAV prophylaxis
recommendations were discussed by representatives of the is not recommended during a mass-casualty event.
U.S. and international trauma response community at a The information typically used in occupational settings
May 2006 meeting in Atlanta, Georgia; following this dis­ to guide prophylactic intervention decisions (including the
cussion, the initial draft was revised. A working group then circumstances of the injury, background prevalence of dis­
was convened comprising CDC staff members with exper­ ease, or risk for infection of the source of exposure) might
tise in injury response, tetanus, viral hepatitis, HIV infec­ not be as clearly interpretable or as readily available in a
tion, immunization and postexposure prophylaxis, and mass-casualty setting. For example, both the extent of
occupational safety and health, and representatives of the exposed disrupted skin and the volume of blood contribut­
National Association of County and City Health Officials ing to the exposure might greatly exceed that of usual
and the Council of State and Territorial Epidemiologists occupational exposures. In addition, injured persons might
4 MMWR August 1, 2008

be exposed to blood from multiple other persons or to bio­ Both passive-active PEP with hepatitis B immune globu­
logic material from the body of a bomber or another lin (HBIG) combined with hepatitis B vaccine and active
injured person. The HBV, HCV, and HIV status of the PEP with hepatitis B vaccine alone have been demonstrated
source(s) usually will be unknown, and timely ascertain­ to be highly effective in preventing transmission after
ment might not be practical. If the circumstance in which exposure to HBV (12). HBIG alone has been demonstrated
each victim was injured can be characterized, this informa­ to be effective in preventing HBV transmission. However,
tion can be used to assess the likelihood that an injured since hepatitis B vaccine became available, HBIG is used
person was exposed to another person’s blood. However, typically (and preferentially) as an adjunct to vaccination
when such information is not readily available for persons (11). The major determinant of effectiveness of PEP is early
injured during blast-related mass-casualty events, such administration of the initial dose of vaccine (or HBIG).
blood exposure should be assumed. The effectiveness of PEP diminishes the longer after expo­
sure it is initiated (12). Studies are limited on the maxi­
Hepatitis B Virus mum interval after exposure during which PEP is effective,
but the interval is unlikely to exceed 7 days for perinatal
The prevalence of chronic HBV infection in the United
and needlestick exposures (12). No data are available on
States is approximately 0.4%. Prevalence varies by race,
the efficacy of HBsAg-containing combination vaccines
ethnicity, age group, geographic location, and individual
when used to complete the vaccine series for PEP, but the
history of risk behaviors (11).
efficacy of combination vaccines is expected to be similar
Newly acquired HBV infection often is asymptomatic;
to that of single-antigen vaccines because the HBsAg
only 30%–50% of children aged >5 years and adults have
component induces a comparable antibody response (12).
initial clinical signs or symptoms (11). The fatality rate
Antiviral PEP is not available for HBV.
among persons with reported cases of acute symptomatic
A policy of liberal use of hepatitis B vaccine for PEP after
hepatitis B is 0.5%–1.0% (11). No specific treatment
bombings or in other mass-casualty situations is recom­
exists for acute hepatitis B. Acute hepatitis B infection fails
mended because of the high concentration of HBV in blood
to resolve and instead progresses to chronic HBV infection
of infected persons, the durability of HBV in the environ­
in approximately 90% of those infected as infants, 30% of
ment, and the efficacy and relative ease of administration
children infected at age <5 years, and <5% of persons
of vaccine (11). Such use is consistent with existing recom­
infected at age >5 years (11). Overall, approximately 25%
mendations for administering the hepatitis B vaccine series
of persons who become chronically infected during child­
as PEP for persons (e.g., health-care personnel or sexual
hood and 15% of those who become chronically infected
assault victims) exposed to a source with unknown HBV
after childhood die prematurely from cirrhosis or liver can­
infection status (11,12). In general, PEP for HBV will be
cer (11). Therapeutic agents approved by the U.S. Food
warranted for previously unvaccinated persons if wounds,
and Drug Administration (FDA) for treating chronic hepa­
nonintact skin, or intact mucous membranes might have
titis B can achieve sustained suppression of HBV replica­
been exposed to blood or body fluids from another person
tion and remission of liver disease for certain persons (11).
or persons. In a mass-casualty setting, failure to provide
HBV is transmitted by percutaneous or mucosal expo­
hepatitis B vaccination when needed could result in pre­
sure to infectious blood or body fluids. Although hepatitis
ventable illness, whereas unnecessary vaccination is unlikely
B surface antigen (HBsAg) has been detected in multiple
to cause harm (11). Completion of primary vaccination at
body fluids, only serum, semen, and saliva have been dem­
the time of discharge or during follow-up visits should be
onstrated to be infectious (11). Serum has the highest con­
ensured for all persons who receive an initial hepatitis B
centration of HBV, with lower concentrations in semen and
vaccine dose as part of the acute response to a mass-
saliva. HBV remains viable for 7 days or longer on environ­
casualty event.
mental surfaces at room temperature (11). Among suscep­
If hepatitis B vaccine is in short supply, assessing how
tible health-care personnel, the risk for HBV infection after
likely a person is to have been vaccinated previously might
a needlestick injury involving an HBV-positive source is
be necessary. In general, hepatitis B vaccination rates are
23%–62% (12). Prompt and appropriate postexposure
highest among children aged <17 years (80%–90%) and
prophylaxis (PEP) intervention reduces this risk. Many
health-care personnel (approximately 80%) (Table 1)
infections that occurred before widespread vaccination of
(13–15) (see Pathogen-Specific Management Recommen­
health-care personnel probably resulted from unapparent
dations).
exposures (e.g., inoculation into cutaneous scratches, lesions,
or mucosal surfaces) (12).
Vol. 57 / RR-6 Recommendations and Reports 5

TABLE 1. Estimated percentage of persons vaccinated against hepatitis B virus infection, by age group and selected
characteristics — United States, 2001–2006
Group No. doses % vaccinated (95% CI*) Source
Infants aged 19–35 mos 3 93.4 (92.8–94) National Immunization Survey, 2001–2006†
Adolescents aged 13–17 yrs 3 81.3 (79.4–83.1) National Immunization Survey, 2001–2006§
Adults aged 18–49 yrs >1 34.6 (33.5–35.6) National Health Interview Survey, 2004¶
Health-care personnel >1 80.5 (77.3–83.4)
Police/firefighters >1 63.3 (56.6–70.1)
Adults at high risk** >1 45.4 (41.7–49.2)
* Confidence interval.
† CDC. National, state, and local area vaccination coverage among children aged 19–35 months—United States, 2006. MMWR 2007;56;880–5.

§ CDC. National vaccination coverage among adolescents aged 13–17 years—United States, 2006. MMWR 2007;56:885–8.

¶ CDC. Hepatitis B vaccination among adults—United States, 2004. MMWR 2006;55:509–11.

** Includes persons who reported having a sexually transmitted disease other than human immunodeficiency virus (HIV)/acquired immunodeficiency
syndrome during the previous 5 years, persons who consider themselves at high risk for HIV infection, and persons who reported any one of the
following risk factors: hemophilia with receipt of clotting factor concentrates, men who have sex with men, injection-drug use, trading sex for money
or drugs, testing positive for HIV, or having sex with someone with any of these risk factors.

Hepatitis C Virus intended to achieve early identification of infection and, if

present, referral for evaluation of treatment options. No
The prevalence of chronic HCV infection in the United
guidelines exist for administration of therapy during the
States is approximately 1.3% (16). Prevalence varies by race/
acute phase of HCV infection. However, limited data indi­
ethnicity, age group, geographic location, and individual
cate that antiviral therapy might be beneficial when started
history of risk behaviors (16,17).
early in the course of HCV infection. When HCV
Persons with acute HCV infection typically either are
seroconversion is identified early, the person should be
asymptomatic or have a mild clinical illness. Antibody to
referred for medical management to a knowledgeable
HCV (anti-HCV) can be detected in 80% of patients within
specialist (12,17).
15 weeks after exposure and in 97% of patients by 6 months
Testing is not routinely recommended in the absence of
after exposure. Chronic HCV infection develops in 75%–
a risk factor for infection or a known exposure to an HCV-
85% of infected persons. The majority remain asymptom­
positive source (17). However, current public health prac­
atic until onset of cirrhosis or end-stage liver disease, which
tice often does include advising testing for potential
develops within 20–30 years in approximately 10%–20%
exposures to unknown sources (e.g., playground incidents
of infected persons (17).
involving needlestick or health-care exposures involving
HCV is transmitted primarily through exposure to large
possible needle or syringe reuse or inadequately disinfected
amounts of blood or repeated direct percutaneous expo­
equipment). In the setting of a bombing or other mass-
sures to blood (i.e., transfusion or injection-drug use). HCV
casualty event, both the extent of exposed disrupted skin
is not transmitted efficiently through occupational expo­
and the volume of blood contributing to the exposure might
sures to blood; the average incidence of anti-HCV
greatly exceed that of usual occupational exposures. Thus,
seroconversion after accidental percutaneous exposure from
baseline and follow-up HCV testing should be considered
an HCV-positive source is 1.8% (range: 0–7%), with one
for persons injured during bombings or other mass-
study indicating that transmission occurred only from
casualty events whose penetrating injuries or nonintact skin
hollow-bore needles (17). Transmission rarely occurs
are suspected to have come into contact with another person’s
through mucous membrane exposures to blood, and in only
blood or body fluids (see Pathogen-Specific Management
one instance was transmission in a health-care provider
Recommendations).
attributed to exposure of nonintact skin to blood (18). The
risk for transmission from exposure to fluids or tissues other
than HCV-infected blood has not been quantified but is Human Immunodeficiency Virus
expected to be low. The exact duration of HCV viability in The overall prevalence of HIV infection in the United
the environment is unknown but is at least 16–23 hours States was estimated to be 311.5 per 100,000 population
(19,20). (0.31%) in 2005, with wide geographic variability (range:
Immune globulin and antiviral agents are not recom­ 26.4 per 100,000 population [0.03%] [North Dakota]–
mended for PEP after exposure to HCV-positive blood. No 2,060 per 100,000 population [2.06%] [Washington,
vaccine against HCV exists. In the absence of PEP for HCV, DC]) (21). Prevalence might vary greatly among subpopu­
recommendations for postexposure management are lations within the same communities (e.g., residents of a
6 MMWR August 1, 2008

nursing home compared with residents of transitional hous­ In the majority of instances involving bombings or other
ing associated with a drug treatment program). The prin­ mass-casualty events, the working group concluded that
cipal means of transmission in the United States is through the risk for exposure to HIV-infected materials probably is
sexual contact or through sharing of injection-drug use low and that therefore PEP is not indicated. On this basis,
equipment with an infected person (21). Exposures also PEP is not routinely recommended for treating persons
occur in occupational settings (principally among health- injured in mass-casualty settings in the United Kingdom
care personnel) and infrequently can result in transmission. (7). For the same reason, HIV PEP should not be adminis­
Guidelines for the use of antiretroviral PEP in both occu­ tered universally in mass-casualty settings in the United
pational and nonoccupational settings have been published States unless recommended by the local public health
previously (22–24), but these documents do not specifi­ authority. Such instances might occur for mass-casualty
cally address situations involving mass casualties. events in certain specific settings judged by public health
Potentially infectious materials include blood and visibly authorities to be associated with higher risk for HIV expo­
bloody body fluids, semen, and vaginal secretions. Cere­ sure (e.g., a research facility that contained a large archive
brospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, of HIV-infected blood specimens). In the rare situation in
pericardial fluid, and amniotic fluid also are considered which PEP is recommended, it should be initiated as soon
infectious, but the transmission risk associated with them as possible after exposure, and specimens from the exposed
is less well defined. Feces, nasal secretions, saliva, sputum, person should be collected for baseline HIV testing. How­
sweat, tears, urine, and vomitus are not considered infec­ ever, PEP should not be delayed for the results of testing. If
tious unless visibly bloody. Exposures that pose a risk for PEP is used, certain other laboratory studies also are indi­
transmission include percutaneous injuries, contact of cated. Consultation from health-care professionals knowl­
mucous membranes, or contact of nonintact skin with edgeable about HIV infection is ideal, and is particularly
potentially infected fluids (22–24). important for pediatric patients and pregnant women. All
In studies of health-care personnel, the average risk for persons for whom HIV PEP has been initiated should be
HIV transmission has been estimated to be approximately referred to a clinician experienced in HIV care for follow
0.3% (95% confidence interval [CI] = 0.2%–0.5%) after up.
a percutaneous exposure to HIV-infected blood and
approximately 0.09% (95% CI = 0.01%–0.5%) after a
mucous membrane exposure. Transmission risk from Tetanus
nonintact skin exposure has not been quantified but is esti­ Clostridium tetani, the causative agent of tetanus, is ubiq­
mated to be less than that for mucous membrane exposure. uitous in the environment and distributed worldwide. The
Risk following percutaneous exposure is correlated posi­ organism is found in soil and in the intestines of animals
tively with exposure to a larger quantity of blood, direct and humans. When spores of C. tetani are introduced into
penetration of a vein or artery, a deep tissue injury, or the anaerobic or hypoaerobic conditions found in wounds
exposure to blood from a source person with terminal or devitalized tissue, they germinate to vegetative bacilli
illness (25), presumably related to high viral load. that elaborate toxin and cause disease. This now infrequent
Use of PEP with antiretroviral medications, initiated as but often fatal disease has been associated with injuries to
soon as possible after exposure and continuing for 28 days, otherwise healthy persons, particularly during military con­
has been associated with a decreased risk for infection fol­ flicts. During 1998–2000, the case-fatality ratio for
lowing percutaneous exposure in health-care settings (22). reported tetanus in the United States was 18% (26).
PEP also is recommended following nonoccupational sexual Although tetanus is not transmitted from person to per­
and injection-drug use–related exposures (24). Because of son, contamination of wounds with debris might increase
the potential toxicities of antiretroviral drugs, PEP is rec­ the risk for tetanus among persons injured in mass-
ommended unequivocally only for exposures to sources casualty settings. Proper wound care and debridement play
known to be HIV-infected. The decision to use PEP fol­ a critical role in tetanus prevention.
lowing unknown-source exposures is to be made on a case- Serologic tests indicate that immunity to tetanus toxin is
by-case basis, considering the information available about not acquired naturally. However, protection against teta­
the type of exposure, known risk characteristics of the source, nus is achievable almost universally by use of highly
and prevalence in the setting concerned. immunogenic and safe tetanus toxoid–containing vaccines.
The disease now occurs almost exclusively among persons
Vol. 57 / RR-6 Recommendations and Reports 7

who were not vaccinated adequately or whose vaccination age-indicated by the standard childhood immunization
histories are unknown or uncertain (27,28). Universal pri­ table (pediatric diphtheria and tetanus toxoids and acellu­
mary vaccination, with subsequent maintenance of adequate lar pertussis vaccine [DTaP] if aged <7 years, Td if aged
antitoxin levels by means of appropriately timed boosters, 7–10 years, and Tdap if aged >11 years) (32,34).
protects persons among all age groups. ACIP recommends that patients without a complete pri­
The age distribution of recent cases and the results of mary tetanus series who sustain a tetanus-prone wound
serosurveys indicate that many U.S. adults are not protected routinely receive passive immunization with tetanus
against tetanus (29). The proportions of persons lacking immune globulin (TIG) and tetanus toxoid (33). In the
protective levels of circulating antitoxins against tetanus setting of acute response to a mass-casualty event, many
increase with age; at least 40% of persons aged >60 years wounded patients probably will be unable to confirm pre­
might lack protection. In the United States, tetanus is pri­ vious vaccination histories, and thus TIG normally would
marily a disease of older adults (27,28). Children are much be indicated. However, this might not be feasible in a mass-
more likely to have received age-appropriate vaccination; casualty setting if supplies of TIG are limited. All decisions
rates for receipt of 3 doses among children aged 19–35 to administer TIG depend on the number of casualties and
months exceed 96% (28). During 1992–2000, only 15 the readily available supply of TIG. If the supply of TIG is
cases of tetanus were reported in the United States among adequate, consideration might be given to providing both
children aged <15 years. Parental philosophic or religious tetanus toxoid and passive immunization with TIG at the
objection to vaccination accounted for the absence of time of management of tetanus-prone wounds. TIG is
immune protection for 12 (80%) affected children (30). indicated if completion of a primary vaccination series is
Foreign-born immigrants, especially those from regions uncertain for an adult or if prior receipt of age-appropriate
other than North America or Europe, also might be vaccinations is uncertain for a child. If TIG is in short sup­
relatively undervaccinated (29,31). ply, it should be reserved for patients least likely to have
Available evidence indicates that complete primary vac­ received adequate primary vaccination. In general, this group
cination with tetanus toxoid provides long-lasting protec­ includes persons aged >60 years and immigrants from
tion. After routine childhood tetanus vaccination, the regions other than North America or Europe who might
Advisory Committee on Immunization Practices (ACIP) be less likely to have adequate antitetanus antibodies and
recommends routine booster vaccination with tetanus who thus would derive the most benefit from TIG (32).
toxoid–containing vaccines every 10 years. For clean and The TIG prophylactic dose that is recommended cur­
minor wounds, a booster dose is recommended if the rently for wounds is 250 units administered intramuscu­
patient has not received a dose within 10 years. For all other larly (IM) for adult and pediatric patients. When tetanus
wounds, a booster is appropriate if the patient has not toxoid and TIG are administered concurrently, separate
received tetanus toxoid during the preceding 5 years. syringes and separate sites should be used (35). In circum­
In the setting of acute response to a mass-casualty event, stances in which passive protection is clearly indicated but
failure to provide a tetanus vaccination when needed could TIG is unavailable, intravenous immune globulin may be
result in preventable illness, whereas unnecessary vaccina­ substituted for TIG. Postexposure chemoprophylaxis with
tion is unlikely to cause harm (26–29,32,33). A substan­ antimicrobials against tetanus is not recommended.
tial proportion of patients in this setting might be unable ACIP recommends that adults and adolescents with a
to provide a history of vaccination or history of history of uncertain or incomplete primary vaccination com­
contraindications to tetanus toxoid–containing vaccines, plete a 3-dose primary series for tetanus, diphtheria, and
and the majority of wounds sustained will be considered pertussis (26,30–34). In the setting of acute response to a
tetanus-prone because they are likely to be exposed to dirt mass-casualty event, completion of the primary vaccina­
or feces. Thus, a wounded adult patient who cannot con­ tion series of any vaccine provided initially during acute
firm receipt of a tetanus booster during the preceding 5 years response during follow-up visits should be ensured at the
should be vaccinated with tetanus and diphtheria toxoids time of discharge for inadequately vaccinated patients of
vaccine (Td) or tetanus toxoid, reduced diphtheria toxoid, all ages. Special precautions regarding management of preg­
and acellular pertussis vaccine (Tdap); adults aged >65 years nant women in the setting of emergency delivery have been
should receive Td (26). Similarly, a child with an uncer­ identified (see Special Situations).
tain vaccination history should receive a tetanus booster as
8 MMWR August 1, 2008

Recommendations Pathogen-Specific Management

Recommendations
Risk Assessment
To determine appropriate actions in response to evalua­ Hepatitis B Virus
tion of casualties of bombings or other mass-casualty events, Unless an injured person who is unable to communicate
health-care providers should an accurate medical history or for whom medical records
• assess individual exposure risk by categorizing the are not readily available is accompanied by a person able to
patient into one of three exposure risk categories (Box 1) function as a health-care proxy, responders should assume
that are numbered sequentially from the highest (cat­ the absence of a reliable hepatitis B vaccination history and
egory 1) to the lowest (category 3) level of exposure no contraindication to vaccination with hepatitis B vaccine
risk and assign each person to the highest level risk (see Contraindications and Precautions). If administration
category for which he/she qualifies, of hepatitis B vaccine to a large number of persons after a
• identify the appropriate risk category- and pathogen- mass-casualty event is anticipated to result in shortages of
specific management recommendation(s) (Box 1), and hepatitis B vaccine products, or if such shortages already
• determine the appropriate action to take (see Patho­ exist, assistance with vaccine supply is available (see Vac­
gen-Specific Management Recommendations) in cine Supply).
response to management recommendations.
Recommendation: Intervene:
When evaluating management choices for casualties of
bombings or other mass-casualty events, health-care pro­ • Persons for whom neither a reliable history of completed
viders should assume that exposure to blood from other vaccination against HBV nor a known contraindica­
injured persons is likely unless available information on tion to vaccination against HBV exist should receive
the circumstances of injury suggests otherwise. Blast inju­ the first dose of the HBV vaccine series as soon as pos­
ries result occasionally in traumatic implantation of bone sible (preferably within 24 hours) and not later than
or other biologic material that is alien to the wounded per­ 7 days after the event.
son. Testing of such matter is not recommended as a useful • Persons who receive or are identified as candidates for a
adjunct for clinical management of wounded persons. Pub­ dose of hepatitis B vaccine while undergoing evalua­
lic health authorities can provide assistance in assessing tion or treatment in immediate response to a mass-
exposure risk for affected groups of injured persons. Teta­ casualty event should be discharged with referrals for
nus risk is not dependent upon blood exposure. follow-up and written information on predischarge

BOX 1. Recommended postexposure management by risk category and specific pathogen

Risk category HBV* HCV† HIV§ Tetanus

Category 1. Penetrating injuries or Consider Generally Intervene
nonintact skin exposures¶ Intervene testing no action
Category 2. Mucous membrane exposures** Intervene Generally Generally No action
no action no action
Category 3. Superficial exposure of intact skin†† No action No action No action No action
* Hepatitis B virus.
† Hepatitis C virus.
§ Human immunodeficiency virus.
¶ Penetration of skin by a sharp object that was in contact with blood, tissue, or other potential infectious body fluid (i.e., semen, vaginal fluid, cerebrospinal fluid,
synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid or any other visibly bloody body fluid or tissue) before penetration. Nonintact
skin exposure is defined as contact of nonintact skin with any of these potentially infectious tissues or fluids.
** Contact of mucous membranes (i.e., eyes, nose, mouth, or inner surfaces of the gut or genital areas) with blood, tissue, or other potential infectious body fluid
(i.e., semen, vaginal fluid, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid or any other visibly bloody body
fluid or tissue).
†† Superficial exposure of intact skin (but not of mucous membranes) with blood, tissue, or other potential infectious body fluid (i.e., semen, vaginal fluid,
cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid or any other visibly bloody body fluid or tissue).
Vol. 57 / RR-6 Recommendations and Reports 9

treatment to facilitate the ability of primary health- • However, in settings in which exposure to an HCV-
care providers to evaluate and, if appropriate, initiate infected source is known or thought to be highly likely,
or complete age-appropriate vaccinations or vaccina­ testing for early identification of HCV infection fol­
tion series (Appendix 1). lowing mucous membrane exposure may be consid­
ered. The decision to perform testing should be made
Recommendation: No action:
on the basis of the judgment of the treating physician
• No action is necessary to prevent HBV infection. and the preference of the individual patient.
Hepatitis C Virus Recommendation: No action
Recommendation: Consider testing: • No action is necessary to prevent HCV infection.
• Testing should be considered when an HCV-infected Human Immunodeficiency Virus
source is known or thought to be likely on the basis of
the setting in which the injury occurred or exposure to Recommendation: Generally no action:
blood or biologic material from a bomber or multiple • In general, HIV PEP is not warranted. HIV PEP might
other injured persons is suspected. be considered only in settings in which exposure to an
• Public health authorities can provide assistance in HIV-infected source is known or thought to be highly
assessing exposures and therefore treatment for affected likely (e.g., a blast injury incident that occurred in a
groups of injured persons. A decision to perform test­ research facility that contained a large archive of HIV
ing of specific persons might be made on the basis of infected blood specimens).
the judgment of the treating physician and the prefer­ • HIV PEP should not be administered universally in
ences of the individual patient; testing during a fol­ response to mass-casualty events unless recommended
low-up referral might be a more feasible logistical option by the local public health authority.
in the setting of response to a mass-casualty event. • In the rare event that HIV PEP is considered, it should
If a decision is made to perform testing: be initiated as soon as possible after exposure. The
• baseline testing for anti-HCV and alanine aminotrans­ patient should be counseled about the availability of
ferase (ALT) should be performed within 7–14 days of PEP and informed of the potential benefits and risks
the exposure; and the need for prompt initiation to maximize poten­
• follow-up testing for anti-HCV and ALT should be tial effectiveness. If PEP is thought to be indicated on
performed 4–6 months after exposure to assess the basis of exposure risk, administration should not
seroconversion, preferably arranged as part of discharge be delayed for HIV test results. Specific guidance on
planning; how to administer HIV PEP in unusual circumstances
• HCV RNA testing should be performed at 4–6 weeks when it is warranted is available (see Special Situations).
if an earlier diagnosis of HCV infection is desired; and • Persons who receive or are identified as candidates for
• positive anti-HCV with low signal-to-cutoff value HIV PEP while undergoing evaluation or treatment in
should be confirmed using a more specific supplemen­ immediate response to a mass-casualty event should be
tal assay before communicating the results to the discharged with referrals for urgent follow-up. Written
patient; and information on predischarge treatment should be pro­
• persons who are tested or are identified as a candidate vided to facilitate a primary health-care provider’s abil­
for testing regarding exposure to HCV while undergo­ ity to evaluate and, if appropriate, complete
ing evaluation or treatment in immediate response to a age-appropriate vaccinations or vaccination series
mass-casualty event should be discharged with a refer­ (Appendix 1).
ral for follow-up and written information on pre­ • In all health-care settings, opt-out screening for HIV
discharge treatment (Appendix 1). (performing HIV screening after notifying the patient
that the test will be performed, with assent inferred
Recommendation: Generally no action:
unless the patient declines or defers testing) is recom­
• Exposure of mucous membranes to blood from a source mended for all patients aged 13–64 years. In the set­
with unknown HCV status generally poses a minor risk ting of response to a mass-casualty event, testing during
for infection and does not require further action. a follow-up referral might be a more feasible logistic
10 MMWR August 1, 2008

option unless a decision to administer PEP has been • In a mass-casualty situation, unusually high demand
made (35). might result in shortages of age-specific vaccine formu­
lations, and logistic considerations might make differ­
Recommendation: No action:
entiating patients by age category prohibitive. If
• No action is necessary to prevent HIV infection. supplies of DTaP are inadequate, heath-care providers
Tetanus might consider substituting Tdap or Td for DTaP
because the amount of tetanus toxoid in all formula­
All persons who sustain tetanus-prone injuries in mass- tions is adequate to induce an immune response in a
casualty settings should be evaluated for the need for teta­ child. Similarly, if supplies of Td are inadequate, health-
nus prophylaxis. Tetanus-prone injuries include but are not care providers might consider substituting Tdap for Td
limited to puncture and other penetrating wounds with for persons aged >65 years. Pediatric DTaP generally is
the potential to result in an anaerobic environment (wounds not indicated in persons aged >7 years; the increased
resulting from projectiles or by crushing) and wounds, avul­ diphtheria toxoid content is associated with higher rates
sions, burns, or other nonintact skin that might be con­ of local adverse reactions in older persons (26,32).
taminated with feces, soil or saliva. However, in a mass-casualty setting, other options
All persons who are not accompanied by either medical might not exist.
records or a health-care proxy and whose ability to com­ • TIG might be indicated if completion of a primary
municate an accurate medical history is uncertain for any vaccination series is uncertain for an adult, or prior
reason should be deemed to lack a reliable tetanus toxoid receipt of age-appropriate vaccinations is uncertain for
vaccination history and to have no contraindication to vac­ a child.
cination with tetanus toxoid (see Contraindications and — If TIG is in short supply, use of TIG should be
Precautions). If compliance with recommendations is an­ reserved first for persons aged >60 years and for
ticipated to result in a shortage of tetanus toxoid products immigrants from regions other than North America
or TIG, assistance with product supplies is available (see or Europe. All decisions to administer TIG depend
Vaccine Supply). on the number of casualties and the readily avail­
Recommendation: Intervene: able supply of TIG.
— The recommended prophylactic dose of TIG is 250
• Appropriate wound care and debridement are critical
units IM for adult and pediatric patients. When
to tetanus prevention.
tetanus toxoid and TIG are administered concur­
• Age-appropriate vaccines should be used if possible.
rently, separate syringes and separate sites should
However, in a mass-casualty setting, this might not be
be used (34).
possible, and any tetanus vaccine formulation might
• Persons who receive or are identified as candidates for
be used, because the tetanus toxoid content is adequate
tetanus toxoid–containing products or TIG while
for tetanus prophylaxis in any age group. In this set­
undergoing evaluation or treatment in immediate re­
ting, the benefit of supplying tetanus prophylaxis out­
sponse to a mass-casualty event should be discharged
weighs the potential for adverse reactions from
with referrals for follow-up if possible. Written infor­
formulations from a different age indication.
mation on predischarge treatment should be provided
• Adult patients who cannot readily confirm receipt of a
to facilitate the ability of primary health-care providers
tetanus booster during the preceding 5 years and who
to evaluate and, if appropriate, complete age-
do not have known contraindication to tetanus vacci­
appropriate vaccinations or vaccination series
nation should be vaccinated with Tdap (or with Td if
(Appendix 1).
Tdap is unavailable) or with Td if aged >65 years.
• Pediatric patients with uncertain vaccination history Recommendation: No action:
and with no known contraindication to tetanus vacci­ • No action is necessary to prevent tetanus. Exposure to
nation should receive a tetanus booster according to blood or other bodily fluids generally is not considered
the following schedule: a risk factor for tetanus.
— DTaP if aged <7 years • However, responders or persons engaged in debris clean
— Td if aged 7–10 years up and construction are candidates for prophylaxis even
— Tdap (or Td if Tdap is unavailable) if aged >11 years. if they do not sustain any wounds. When feasible, as a
routine public health measure, tetanus toxoid vaccina­
Vol. 57 / RR-6 Recommendations and Reports 11

tion with Tdap or Td should be offered to all persons refrain from donating blood, plasma, organs, tissue, or
whose last tetanus toxoid–containing vaccine was semen until follow-up testing by the health-care provider
received >10 years previously and who either are has excluded seroconversion (12,17).
responders or are engaged in either debris clean-up or
construction and who thus might be expected to Human Immunodeficiency Virus
encounter further risk for exposure (36–39).
Persons known to be exposed to HIV should refrain from
blood, plasma, organ, tissue, or semen donation until follow-
Vaccine and Antitoxin Supply up testing by the health-care provider has excluded
seroconversion. In addition, measures to prevent sexual
Adherence to these recommendations might increase the transmission (e.g., abstinence or use of condoms) should
acute demand for tetanus toxoid–containing vaccine, TIG, be taken, and breastfeeding should be avoided until HIV
and hepatitis B vaccine beyond the available local supply. infection has been ruled out (22).
In that event, local authorities might have to rely on local
and state health departments, mutual aid agreements, or
commercial vendors to supplement the supply of needed Special Situations
biologic or pharmaceutical products. If a local authority’s
capacity to respond to an emergency is exceeded and other When HIV PEP is Initiated
local or regional resources are inadequate, local and state HIV PEP should be considered only under exceptional
public health jurisdictions can, through their established circumstances. In the rare event that HIV PEP is consid­
communication channels for health emergencies, work with ered, it should be initiated as soon as possible after expo­
CDC and others as appropriate to assist with product short­ sure. The patient should be counseled about the availability
ages. of PEP and informed about the potential benefits and risks
CDC’s Strategic National Stockpile (SNS) maintains bulk and the need for prompt initiation to maximize potential
quantities of pharmaceutical and nonpharmaceutical medi­ effectiveness. If PEP is thought to be indicated on the basis
cal supplies for use in a national emergency. Tetanus tox­ of exposure risk, administration should not be delayed for
oid, tetanus immune globulin, and hepatitis B vaccine are HIV test results.
not included in the stockpile formulary. However, SNS has In the rare event that HIV PEP is administered, speci­
purchasing agreements for acquiring medical materials in mens should be collected for baseline HIV testing on all
large quantities, subject to commercial availability. CDC patients provided with PEP using a blood or oral fluid rapid
maintains stockpiles of pediatric vaccine products purchased test if available; otherwise, conventional testing should be
by the Vaccines for Children Program that might be used used. Testing should be discussed with the patient if the
to assist state, territorial, and tribal health departments in patient’s medical condition permits. Procedures for testing
meeting emergent local demands for vaccines. CDC also should be in accordance with applicable state and local laws.
can work with manufacturers and with state and local health PEP can be initiated and test results reviewed at follow-up.
authorities to assist with supply of vaccines that are not If the HIV test result is positive, PEP can be discontinued
available in either the SNS or other CDC vaccine stock­ and the patient referred to a clinician experienced with HIV
piles. care for treatment.
If PEP is administered, the health-care provider also
should obtain baseline complete blood count, renal func­
Counseling tion, hepatic function tests, and, in women, a pregnancy
Hepatitis B and C Viruses test. Because efavireniz might be teratogenic, it should not
be administered until pregnancy test results are available
Persons undergoing postexposure management for pos­ (12,22). Otherwise, test results need not be available
sible exposure to HBV- or HCV-infected blood do not need before PEP initiation but should be reviewed in follow-up.
to take any special precautions to prevent secondary trans­ Selection of antiretroviral regimens should aim for sim­
mission during the follow-up period (12,17). The exposed plicity and tolerability. Because of the complexity of selec­
person does not need to modify sexual practices or refrain tion of HIV PEP regimens, consultation with persons having
from becoming pregnant. An exposed nursing mother might expertise in antiretroviral therapy and HIV transmission is
continue to breastfeed. However, exposed persons should
12 MMWR August 1, 2008

strongly recommended. Resources for consultation are avail­ Administration of Blood Products
able from the following sources:
The administration of hepatitis B vaccine or tetanus
• local infectious diseases, hospital epidemiology, or
toxoid–containing products does not need to be deferred
occupational health consultants;
in persons who have received a blood transfusion or other
• local, state, or federal public health authorities;
blood products.
• PEPline at http://www.nccc.ucsf.edu/Hotlines/
PEPline.html, telephone 888-448-4911;
• HIV/AIDS Treatment Information Service at http:// Pregnancy
aidsinfo.nih.gov; and Pregnancy is not a contraindication to vaccination against
• previously published guidance (see Information hepatitis B. Limited data suggest that a developing fetus is
Sources). not at risk for adverse events when hepatitis B vaccine is
Nevirapine should not be included in HIV PEP regi­ administered to a pregnant woman. Available vaccines con­
mens because of potential severe hepatic and cutaneous tain noninfectious HBsAg and should cause no risk for
toxicity. Efavirenz should not be used if pregnancy is known infection to the fetus (11).
or suspected because of potential teratogenicity (12,22). Pregnancy is not a contraindication for HIV PEP. How­
PEP should be started as soon after exposure as possible ever, use of efavirenz should be avoided when pregnancy is
and continue for 4 weeks. For ambulatory patients, a starter known or suspected (11,22).
pack of 5–7 days of medication should be provided, if pos­ Pregnant adolescents and adults who received the most
sible. Alternatively, for hospitalized patients, the first dose recent tetanus toxoid–containing vaccine >5 years previ­
should be taken in the emergency department, and follow- ously generally should receive Td in preference to Tdap
up orders should be written for completion of the course when possible (41).
in the hospital.
Patients on PEP should be reassessed for adherence, tox­
icity, and for follow-up of HIV testing (if rapid testing was Responders and Other Personnel
not available at baseline) within 72 hours by an infectious Responders and persons engaged in debris removal or
disease consultant. Patients continuing on PEP should have construction often are at risk for incurring wounds through­
follow-up laboratory evaluation as recommended previously out the duration of response and clean up work. As a rou­
(22–24), including a complete blood count and renal and tine public health measure, health-care providers should
hepatic function tests at baseline and at 2 weeks offer tetanus toxoid vaccination to all response workers who
postexposure, and HIV testing at baseline, 6 weeks, do not have a reliable history of receipt of a tetanus toxoid–
3 months, and 6 months postexposure. containing vaccine during the preceding 10 years, regard­
Persons begun on HIV PEP should be discharged with less of whether the health-care visit was for a wound (38,39).
written instructions and a referral to ensure follow-up care Such persons might encounter potential exposure situations
with a clinician experienced with HIV care and informa­ throughout the duration of their work in response to a mass-
tion on the age-appropriate dose and schedule (Appendix 1). casualty situation.
Health-care personnel, emergency response, public safety
Simultaneous Administration and other workers (e.g., construction workers and equip­
When tetanus toxoid and TIG are administered concur­ ment operators) who are injured and exposed to blood while
rently, separate syringes and separate anatomic sites should providing assistance after a mass-casualty event should be
be used (40). Hepatitis B vaccine and tetanus toxoid– managed according to existing guidelines and standards for
containing vaccines might be administered at the same time the management of occupational exposures (10,22,42).
using separate syringes and separate sites (36). Health-care personnel and first responders whose activities
Treatment with an antimicrobial agent generally is not a involve contact with blood or other body fluids should have
contraindication to vaccination (40). Antimicrobial agents been previously vaccinated against HBV and tetanus
have no effect on the responses to vaccines against tetanus (12,22).
or hepatitis B.
Vol. 57 / RR-6 Recommendations and Reports 13

Contraindications and Precautions the vaccine or any event listed in the Reportable Events
Table (available at http://vaers.hhs.gov/reportable.htm) that
Hepatitis B Vaccine occurs within the specified period after vaccination. VAERS
Hepatitis B vaccination is contraindicated for persons with reporting forms and information can be requested 24 hours
a history of anaphylactic allergy to yeast or any vaccine a day at telephone 800-822-7967 or by accessing VAERS
component (11). On the basis of CDC’s Vaccine Study at http://vaers.hhs.gov. Web-based reporting also is avail­
Datalink data, the estimated incidence of anaphylaxis among able, and providers are encouraged to report adverse events
children and adolescents who received hepatitis B vaccine electronically at http://secure.vaers.org/VaersDataEntryintro.
is 1 case per 1.1 million vaccine doses distributed (95% CI = htm.
0.1–3.9) (11). Persons with a history of serious adverse
events (e.g., anaphylaxis) after receipt of hepatitis B vac­ Reporting Adverse Events Associated
cine should not receive additional doses. Vaccination is not With Antiretroviral Drugs and TIG
contraindicated in persons with a history of multiple scle­
Unusual or severe toxicities believed to be associated with
rosis, Guillain-Barré syndrome, autoimmune disease (e.g.,
use of antiretroviral agents or TIG should be reported to
systemic lupus erythematosis or rheumatoid arthritis), or
FDA’s MEDWATCH program (http://www.fda.gov/
other chronic diseases (11).
medwatch) at MedWatch, HF-2, Food and Drug Admin­
istration, 5600 Fishers Lane, Rockville, MD 20857;
Antiretroviral Therapy telephone 800-332-1088.
Nevirapine should not be included in HIV PEP regi­
mens because of potential severe hepatic and cutaneous National Vaccine Injury Compensation
toxicity. Efavirenz should not be used if pregnancy is known Program
or suspected because of potential teratogenicity (12,22).
The National Vaccine Injury Compensation Program
(NVICP) was established by the National Childhood Vac­
Preparations Containing Tetanus Toxoid cine Injury Act and became operational on October 1, 1988.
The only contraindication to preparations containing Intended as an alternative to civil litigation under the tra­
tetanus toxoid (TT, Td, or Tdap) is a history of a neuro­ ditional tort system (in that negligence need not be proven),
logic or severe allergic reaction following a previous dose. NVICP is a no-fault system in which persons thought to
Local side effects alone do not preclude continued use have suffered an injury or death as a result of administra­
(26,30,31). If a person has a wound that is neither clean tion of a covered vaccine may seek compensation. Claims
nor minor and for which tetanus prophylaxis is indicated, may be filed on behalf of infants, children and adolescents,
but also a contraindication to receipt of tetanus toxoid– or by adults receiving VICP-covered vaccines. Other legal
containing preparations, only passive immunization using requirements (e.g., the statute of limitations for filing an
human TIG should be administered. injury or death claim) must be satisfied to pursue compen­
sation. Claims arising from covered vaccines must be adju­
dicated through the program before civil litigation can be
Reporting Adverse Events pursued. The program relies on a Reportable Events Table
listing the vaccines covered by the program and the inju­
Vaccine Adverse Events Reporting
ries, disabilities, illnesses, and conditions (including death)
System for which compensation might be awarded. Additional
Any clinically significant adverse events that occur after information about NVICP is available at http://
administration of any vaccine should be reported to the www.hrsa.gov/vaccinecompensation or from the National
Vaccine Adverse Events Reporting System (VAERS) even if Vaccine Injury Compensation Program, Health Resources
causal relation to vaccination is uncertain. The National and Services Administration, Parklawn Building, Room
Childhood Vaccine Injury Act requires health-care provid­ 11C-26, 5600 Fishers Lane, Rockville, MD 20857;
ers to report to VAERS any event listed by the vaccine telephone 800-338-2382.
manufacturers as a contraindication to subsequent doses of
14 MMWR August 1, 2008

Information Sources BOX 2. Online information sources

Recommendations for immediate prophylactic interven­ Vaccines
tions have been summarized (Table 2). Recommendations Advisory Committee on Immunization Practices
for issues that might arise in association with immediate (ACIP) recommendations, available at http://
www.cdc.gov/vaccines/pubs/ACIP-list.htm.
prophylactic intervention also have been summarized
(Table 3). CDC vaccines and immunization website, available
at http://www.cdc.gov/vaccines.
In addition to the guidance provided in these recom­
mendations, information on specific vaccines or other pro­ American Academy of Pediatrics (AAP) Red Book,
phylactic interventions also is available (Box 2). ACIP available at http://aapredbook.aappublications.org.
recommendations regarding vaccine use are published by Downloadable Vaccine Information Statements,
MMWR. Electronic subscriptions are available free of charge available at http://www.cdc.gov/vaccines/pubs/vis/
at http://www.cdc.gov/subscribe.html. Printed subscrip­ default.htm.
tions are available at Superintendent of Documents, U.S. Childhood, adolescent and adult immunization tables
Government Printing Office, Washington, D.C. 20402­ Harmonized childhood, adolescent and adult
9235, telephone 202-512-1800. immunization tables, available at http://www.cdc.gov/
vaccines/recs/schedules/default.htm.
Acknowledgments Postexposure prophylaxis (PEP) against HIV
Contributors to this report included the National Association of CDC. Antiretroviral postexposure prophylaxis after
County and City Health Officials, the Council of State and Territorial sexual, injection-drug use, or other nonoccupational
Epidemiologists, the Terrorism Injuries: Information Dissemination exposure to HIV in the United States. MMWR
and Exchange (TIIDE) partnership, and the following persons: Italo 2005;54(No. RR-2). Available at http://www.cdc.gov/
Subbarao, DO, Center for Public Health Preparedness and Disaster mmwr/preview/mmwrhtml/rr5402a1.htm.
Response, American Medical Association; Richard Sattin, MD, Division CDC. Updated U.S. Public Health Service guide­
of Injury Response, National Center for Injury Prevention and Control; lines for management of occupational exposures to
Richard McCluskey, MD, Coordinating Office for Terrorism HBV, HCV, and HIV and recommendations for
Preparedness and Emergency Response; Jeanne Santoli, MD, postexposure prophylaxis. MMWR 2001;50
Immunization Services Division, National Center for Immunizations (No. RR-11). Available at http://www.cdc.gov/
and Respiratory Diseases; William Atkinson, MD, Immunization mmwr/preview/mmwrhtml/rr5011a1.htm.
Services Division, National Center for Immunizations and Respiratory CDC. Updated U.S. Public Health Service guidelines
Diseases, CDC. for the management of occupational exposures to HIV
and recommendations for postexposure prophylaxis.
References MMWR 2005;54(No. RR-9). Available at http://
1. Federal Bureau of Investigation. Terrorism 2002–2005. Washington, www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm.
DC: US Department of Justice, Federal Bureau of Investigation; 2006.
CDC. Notice to readers: updated information
Available at http://www.fbi.gov/publications.terror/terrorism2002_2005.htm.
regarding antiretroviral agents used as HIV
2. Siegel-Itzkovich J. Israeli minister orders hepatitis B vaccine for survi­
postexposure prophylaxis for occupational HIV expo­
vors of suicide bomb attacks. BMJ 2001;323:417.
sures. MMWR 2007;56:1291–2. Available at http://
3. Braverman I, Wexler D, Oren M. A novel mode of infection with
w w w. c d c . g o v / m m w r / p r e v i e w / m m w r h t m l /
hepatitis B: penetrating bone fragments due to the explosion of a
mm5649a4.htm.
suicide bomber. Isr Med Assoc J 2002;4:528–9.
4. Wong J M-l, Marsh D, Abu-Sitta G, et al. Biological foreign body PEPline, available 24-hours/day at telephone 888­
implantation in victims of the London July 7th suicide bombings. J 448-4911 (preferred) or at http://www.ucsf.edu/
Trauma 2006;60:402–4. hivcntr/Hotlines/PEPline.html.
5. Israel Ministry of Health. Hepatitis B vaccination protocol in survi­ HIV/AIDS Treatment Information Service, available
vors of mass casualty bombings. Israel Ministry of Health Medical at http://aidsinfo.nih.gov.
Guidelines 2001(35)/1/13(Communique 57/2001).
6 Israel Ministry of Health. Hepatitis B vaccination protocol in survi­ Postexposure Prophylaxis (PEP) Against HBV and
vors of mass casualty bombings–revision. Israel Ministry of Health HCV in Occupational Settings
Medical Guidelines 2001(35)/2/13(Communique 72/2001).
7. Health Protection Agency. Post exposure prophylaxis against hepatitis
CDC. Updated U.S. Public Health Service guide­
B for bomb victims and immediate care providers. Consideration of
lines for the management of occupational exposures
other blood borne viruses (hepatitis C and HIV). London, United
to HBV, HCV, and HIV and recommendations for
Kingdom: Health Protection Agency; 2005.
postexposure prophylaxis. MMWR 2001;50(No. RR­
11). Available at http://www.cdc.gov/mmwr/preview/
mmwrhtml/rr5011a1.htm.
Vol. 57 / RR-6 Recommendations and Reports 15

TABLE 2. Summary of recommendations for immediate prophylactic intervention

Type of injury or
blood exposure HBV* HCV † HIV§ Tetanus
Category 1. Penetrating For persons for whom No prophylaxis Generally, no PEP** is Clean and debride
injury/nonintact skin¶ no reliable history of recommended.Consider warranted; consider wound as
hepatitis B vaccination testing (immediately or only if exposure is to a appropriate.Give age-
exists and for whom no during a follow-up known or highly likely appropriate tetanus
contraindication to referral) if exposure is HIV-infected source. toxoid vaccine if date of
vaccine is known, to a known or likely receipt of last dose is
initiate hepatitis B HCV-infected source or unknown and no known
vaccine series, multiple sources. If history of vaccine
preferably within 24 testing is performed, contraindication exists.
hours and not later than obtain baseline (within
7 days. 7-14 days) and follow- May consider adminis­
up (4–6 months) anti- tering TIG (in addition to
HCV and ALT. tetanus toxoid) if no
reliable history of
tetanus primary series
exists (always use
separate syringes and
separate administration
sites). If TIG is in short
supply, persons aged
>60 yrs and immigrants
from regions other than
Europe or North
America are most likely
to derive benefit.

Category 2. Mucous For persons for whom Generally no action. Generally, no PEP** is No action
membranes†† no reliable history of Testing for early warranted. Consider
hepatitis B vaccination identification of HCV only if exposure is to a
exists and for whom no infection following known or highly likely
contraindication to mucous membrane HIV-infected source.
vaccine is known, exposure should be
initiate hepatitis B considered only in
vaccine series, settings in which
preferably within 24 exposure to an HCV-
hours and not later than infected source is
7 days. known or thought to be
highly likely.

Category 3. Superficial No action No action No action No action

exposure of intact
skin††
* Hepatitis B vaccine.
† Hepatitis C vaccine.

§ Human immunodeficiency virus.

¶ Penetration of skin by a sharp object that was in contact with blood, tissue, or other potential infectious body fluid (i.e., semen, vaginal fluid,

cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid or any other visibly bloody body fluid or tissue) before
penetration. Nonintact skin exposure is defined as contact of nonintact skin with any of these potentially infectious tissues or fluids
** Postexposure prophylaxis. HIV PEP rarely is indicated. If PEP is indicated, the following procedures should be undertaken: 1) PEP should be started
as soon as possible after exposure, without waiting for HIV test results; 2) PEP should be continued for 4 weeks; 3) Specimens should be collected
for baseline testing, including HIV, complete blood count, liver function, creatinine, and pregnancy tests; 4) testing should be conducted in accordance
with applicable state and local laws; 5) expert consultation should be obtained; sources of expert consultation include local persons with infectious
diseases, hospital epidemiology, or occupational health expertise; local, stage, or federal public health authorities; PEPline (available 24 hours/day via
telephone 1-888-448-4911 [preferred] or online at http://www.nccc.ucsf.edu/Hotlines/PEPline.html; or the HIV/AIDS Rx information service at http://
aidsinfo.nih.gov; 6) PEP should be continued for 4 weeks; 7) the patient should be discharged with written information, a 5–7 day supply of medication,
and a follow-up appointment; and. 8) an HIV specialist should reassess the patient’s condition within 72 hours.
†† Contact of mucous membranes (i.e., eyes, nose, mouth, or inner surfaces of the gut or genital areas) with blood, tissue, or other potential infectious
body fluid (i.e., semen, vaginal fluid, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid or any other visibly
bloody body fluid or tissue).
†† Superficial exposure of intact skin (but not of mucous membranes) with blood, tissue, or other potential infectious body fluid (i.e., semen, vaginal fluid,
cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid or any other visibly bloody body fluid or tissue).
16 MMWR August 1, 2008

TABLE 3. Summary of recommendations for issues in special situations potentially associated with immediate prophylactic
intervention
Issue/Situation HBV* HCV† HIV§ Tetanus
Vaccine supply Local public health NA¶ NA Age-appropriate
shortage departments, mutual aid vaccines are preferred.
agreements, or
commercial vendors If age-appropriate
should be relied on.If vaccine supply is
local capacity is expended, any tetanus
exceeded, local public vaccine formulation
health authorities should may be used, as the
work through estab­ tetanus toxoid content
lished communication is adequate for tetanus
channels with CDC and prophylaxis in any age
others. group. In this setting,
the benefit of supplying
tetanus prophylaxis
outweighs the potential
for adverse reactions
from formulations from
a different age indica­
tion.

Local public health

departments, mutual aid
agreements, or
commercial vendors
should be relied on. If
local capacity is
exceeded, local public
health authorities should
work through estab­
lished communication
channels with CDC and
others.

Counseling Exposed persons Exposed persons Exposed persons NA

should refrain from should refrain from should refrain from
donating blood, plasma, donating blood, plasma, donating blood, plasma,
organs, tissue, or organs, tissue, or organs, tissue, or
semen. semen. semen. In addition,
persons known to be
exposed to HIV should
avoid breastfeeding and
organ/tissue donation
and take precautions to
avoid sexual transmis­
sion until HIV infection
has been ruled out.

HIV PEP** is initiated NA NA HIV PEP rarely is

indicated. If it is,
recommended
procedures should be
followed.††
* Hepatitis B vaccine.
† Hepatitis C vaccine.

§ Human immunodeficiency virus.

¶ Not applicable.

** Postexposure prophylaxis.
†† If PEP is indicated, the following procedures should be undertaken: 1) PEP should be started as soon as possible after exposure, without waiting for
HIV test results; 2) PEP should be continued for 4 weeks; 3) specimens should be collected for baseline testing, including HIV, complete blood count,
liver function, creatinine, and pregnancy tests; 4) testing should be conducted in accordance with applicable state and local laws; 5) expert
consultation should be obtained; sources of expert consultation include local persons with infectious diseases, hospital epidemiology, or occupational
health expertise; local, stage, or federal public health authorities; PEPline (available 24 hours/day at telephone 1-888-448-4911 [preferred] or at http://
www.nccc.ucsf.edu/Hotlines/PEPline.html; or the HIV/AIDS Rx information service, available at http://aidsinfo.nih.gov; 6) PEP should be continued for
4 weeks; 7) the patient should be discharged with written information, a 5–7 day supply of medication, and a follow-up appointment; and 8) an HIV
specialist should reassess the patient’s condition within 72 hours.
Vol. 57 / RR-6 Recommendations and Reports 17

TABLE 3. (Continued) Summary of recommendations for issues in special situations potentially associated with immediate
prophylactic intervention
Issue/Situation HBV HCV HIV Tetanus
Simultaneous adminis­ HBV vaccine and NA NA Separate syringes and
tration tetanus toxoid can be anatomic sites should
administered concur­ be used for concurrent
rently; use separate administration of TIG§§
syringes and anatomic and tetanus toxoid.
sites.
NA Receipt of blood
Administration of blood Receipt of blood NA products does not
products products does not require deferral of
require deferral of vaccination.
vaccination.
Pregnancy is not a Td is preferred to Tdap
Pregnancy Pregnancy is not a NA contraindication to HIV for pregnant adoles­
contraindication to HBV PEP. Efavirenz should cents and adults who
vaccination. be avoided if pregnancy received their most
is suspected. recent tetanus toxoid
product >5 yrs
previously.

Workers should be Tetanus toxoid

Responders and other Workers should be Workers should be managed according to vaccination should be
personnel managed according to managed according to existing guidelines for offered proactively if no
existing guidelines for existing guidelines for management of reliable history exists of
management of management of occupational expo­ a booster within the
occupational expo­ occupational expo­ sures. past 10 years;
sures. sures. unwounded workers
remain at risk for
wounds throughout
response.

Nevirapine should not Contraindicated if

Contraindications and Vaccine is contraindi­ NA be used for HIV PEP history of neurologic or
precautions cated if history of because of liver toxicity. severe allergic reaction
anaphylactic allergy to to a previous dose. If
yeast or to any vaccine Efavirenz should not be wound is at risk and
component or of used if pregnancy is vaccine is contraindi­
serious adverse event known or suspected. cated, TIG should be
after prior receipt of used.
HBV vaccine. Persons with HIV PEP
expertise should be
consulted if possible.

MEDWATCH http:// VAERS, telephone

www.fda.gov/medwatch 1-800-822-7967 or
Reporting adverse Vaccine Adverse NA or telephone 1-800-332­ http://vaers.hhs.gov.
events Events Reporting 1088.
System (VAERS), MEDWATCH http://
telephone, 1-800-822­ www.fda.gov/medwatch
7967 or http:// or telephone 1-800-332­
vaers.hhs.gov. 1088..

NA Health Resources and

National Vaccine Injury Health Resources and NA Services Administration
Compensation Program Services Administration (HRSA), telephone
(HRSA), telephone 1-800-338-2382 or
1-800-338-2382 or http://www.hrsa.gov/
http://www.hrsa.gov/ vaccinecompensation.
vaccinecompensation.
§§ Tetanus immune globulin.
18 MMWR August 1, 2008

8. Jagger J, De Carli G, Perry J, Puro V, Ippolito G. Occupational expo­ 26. CDC. Preventing tetanus, diphtheria and pertussis among adults: use
sure to bloodborne pathogens: epidemiology and prevention. In: of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis
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ed. Baltimore, MD: Lippincott, Williams and Wilkins; 2003. tion Practices (ACIP) and Recommendation of ACIP, supported by
9. Alter HJ, Stramer SL, Dodd RY. Emerging infectious diseases that the Heatlhcare Infection Control Practices Advisory Committee
threaten the blood supply. 1. Semin Hematol 2007;44:32–41. (HICPAC), for use of Tdap among health-care personnel. MMWR
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sion of hepatitis B virus infection in the United States: recommenda­ 28. Srivastava P, Brown K, Chen J, Kretsinger K, Roper M. Trends in
tions of the Advisory Committee on Immunization Practices (ACIP). tetanus epidemiology in the United States, 1972–2001 [Presenta­
Part II: Immunization of adults. MMWR 2006;55(No. RR-16). tion]. Presented at the 39th National Immunization Conference,
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RR-11). immunity to diphtheria and tetanus in the United States. Ann Intern
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2007:56:880–5. vaccination as a risk factor for tetanus among children younger than
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years—United States, 2006. MMWR 2007;56:885–8. 31. Talan DA, Abrahamian FM, Moran GJ, et al. Tetanus immunity and
15. CDC. Hepatitis B vaccination among adults—United States, 2004. physician compliance with tetanus prophylaxis practices among emer­
MMWR 2006;55:509–11. gency department patients presenting with wounds. Ann Emerg Med
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Am J Infect Control 2003;31:168–75. 1991:40(No. RR-10).
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sion studies. JAMA 2006;296:2005–11. cents, and pregnant women in health-care settings. MMWR
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in the United States and dependent areas, 2005. Vol 17. Revised June 36. CDC. Interim immunization recommendations for disaster respond­
2007. Atlanta, GA: US Department of Health and Human Services, ers: Hurricane Katrina. Atlanta, GA: US Department of Health and
Public Health Service, CDC; 2007. Human Services, CDC; 2005. Available at http://www.bt.cdc.gov/
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ment of occupational exposures to HIV and recommendations for 37. CDC. Emergency wound care after a natural disaster. Atlanta, GA: US
postexposure prophylaxis. MMWR 2005;54(No. RR-9). Department of Health and Human Services, CDC; 2005. Available at
23. CDC. Notice to readers: updated information regarding antiretroviral http://www.bt.cdc.gov/disasters/woundcare.asp.
agents used as HIV postexposure prophylaxis for occupational HIV 38. CDC. Update: NIOSH warns of hazards of flood cleanup work. Atlanta,
exposures. MMWR 2007;56;1291–2. GA: US Department of Health and Human Services, CDC; 1997.
24. CDC. Antiretroviral postexposure prophylaxis after sexual, injection- NIOSH publication no. 94-123. Available at http://www.cdc.gov/
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States. MMWR 2005;54(No. RR-2). 39. Occupational Safety and Health Administration. Fact sheets on natu­
25. Bell DM. Occupational risk of human immunodeficiency virus infec­ ral disaster recovery: flood cleanup. Washington, DC: US Department
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able at http://www.osha.gov/OshDoc/floodCleanup.html.
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Vol. 57 / RR-6 Recommendations and Reports 19

41. CDC. Prevention of pertussis, tetanus, and diphtheria among preg- 42. Bloodborne Pathogens Standard, 29 C.F.R. Sect. 1910.1030 [56 FR
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2008;57(No. RR-4). 18, 2001; 71 FR 16672 and 16673, April 3, 2006].
20 MMWR August 1, 2008

Appendix 1
Sample Information to Be Provided to Patients at Discharge,

With a Copy Retained on the Patient Chart

Discharge instructions for the health-care provider of: ____________________________

Patient Name
This patient was discharged from ____ Outpatient Clinic of _______________________
____ Emergency Department Institution
____ Hospital
On Date: _______/_____/_____
Month / Day / Year
This patient received pre-discharge administration of:
_____ Tetanus toxoid–containing vaccine
____ DTaP Manufacturer____________ Lot # _____________

____ Tdap Manufacturer____________ Lot # _____________

____ Td Manufacturer____________ Lot # _____________

____ TT Manufacturer____________ Lot # _____________

_____ Tetanus Immune Globulin (TIG)

____ Dose Manufacturer____________ Lot # _____________
_____ Hepatitis B vaccine
Manufacturer____________ Lot # _____________
Product: _____________________ Dose: ________________________
This patient will need further evaluation regarding whether administration of a vaccine or completion of an immunization
series is needed.
Evaluate need for immunization series completion:
_____Tetanus

_____Hepatitis B

_____Other:___________________________

Assess need for evaluation of seroconversion to:

_____Hepatitis C infection
• Baseline testing for anti-HCV and alanine aminotransferase (ALT) within 7–14 days of the exposure
• Follow-up testing for anti-HCV and ALT 4–6 months after exposure to assess seroconversion
• HCV RNA test at 4–6 weeks if earlier diagnosis of HCV infection is desired
• Confirm positive anti-HCV with low signal-to-cutoff results using a more specific supplemental assay before
communicating results to patient

_____HIV infection

Follow up on the following tests collected during the acute care visit:
_______AST/ALT

_______Hepatitis C virus serology

_______HIV serology

Antibiotic or other antimicrobial given:

Specific discharge instructions that need further medical evaluation:

Wound care instructions:

Other:
Vol. 57 / RR-6 Recommendations and Reports 21

Appendix 2

Abbreviations Used in This Report

AAP American Academy of Pediatrics IM Intramuscularly

ACIP Advisory Committee on Immunization LFT Liver function test
Practices NACCHO National Association of County and City
AIDS Acquired immunodeficiency syndrome Health Officials
ALT Alanine aminotransferase NVICP National Vaccine Injury Compensation Program
BID Twice daily PEP Postexposure prophylaxis
CBC Complete blood count RNA Ribonucleic acid
CI Confidence interval SNS Strategic National Stockpile
CSTE Council of State and Territorial Epidemiologists Td Adult and adolescent tetanus and diphtheria
DTaP Pediatric diphtheria and tetanus toxoids and toxoids vaccine
acellular pertussis vaccine Tdap Adult and adolescent tetanus and diphtheria
FDA U.S. Food and Drug Administration toxoids and acellular pertussis vaccine
HAV Hepatitis A virus TIG Tetanus immune globulin
HBV Hepatitis B virus TIIDE Terrorism Injuries: Information, Dissemination,
HBIG Hepatitis B immune globulin and Exchange
HBsAg Hepatitis B surface antigen TT Tetanus toxoid vaccine
HCV Hepatitis C virus VAERS Vaccine Adverse Events Reporting System
HIV Human immunodeficiency virus
 Recommendations and Reports
August 1, 2008 / Vol. 57 / RR-6
Morbidity and Mortality Weekly Report
www.cdc.gov/mmwr

Continuing Education Activity Sponsored by CDC

Recommendations for Postexposure Interventions to Prevent Infection with Hepatitis B Virus,

Hepatitis C Virus, or Human Immunodeficiency Virus, and Tetanus in Persons Wounded During

Bombings and Similar Mass-Casualty Events — United States, 2008

Recommendations of the Centers for Disease Control and Prevention (CDC)

EXPIRATION — August 1, 2010

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depar tment of health and human ser

department vices
services
vices

Centers for Disease Control and Prevention

Prevention

CE-2 MMWR August 1, 2008

Goal and Objectives

The goal of this report is to provide uniform guidance on prophylactic interventions appropriate for persons injured in bombings and similar events resulting in mass
casualties. Upon completion of this educational activity, the reader should be able to 1) describe the indications for hepatitis B vaccine during response to a bombing
or a similar mass-casualty event, 2) describe the indications for tetanus toxoid–containing vaccines during response to a bombing or a similar mass-casualty event,
3) describe the issues that should influence a decision to initiate postexposure prophylaxis against human immunodeficiency virus infection during response to a
bombing or a similar mass-casualty event, 4) describe the issues that should influence a decision to initiate testing to evaluate for infection with hepatitis C virus
during response to a bombing or a similar mass-casualty event, and 5) list the mechanisms for accessing assistance in the United States if adherence to these guidelines
results in an acute shortage of vaccines during response to a bombing or a similar mass casualty event.
To receive continuing education credit, please answer all of the following questions.
1. Individual state medical consent laws define the nature of informed 8. Tetanus is a potentially fatal disease that …
consent that might be required before certain medical interventions, A. has been associated with injuries to otherwise healthy persons.
provide for exemptions in emergency circumstances, and should guide B. rarely occurs among persons known to be adequately vaccinated.
response when circumstances preclude adherence to standard C. in the United States, might be more likely among older adults,
informed consent processes. foreign-born immigrants from regions other than North America or
A. True. B. False. Europe, or children whose parents object to vaccination.
D. all of the above.
2. The bloodborne pathogens that merit consideration in the setting of
response to a bombing or similar mass casualty include hepatitis B 9. Which of the following statements is true?
virus, hepatitis C virus (HCV), West Nile Virus, and human A. Failure to provide a tetanus vaccination when needed could result in
immunodeficiency virus (HIV). preventable illness, while unnecessary vaccination is unlikely to cause
A. True. B. False. harm.
B. Failure to provide a hepatitis B virus vaccination when needed could
3. Persons with penetrating injuries or nonintact skin exposed to blood result in preventable illness, while unnecessary vaccination is unlikely
from others are candidates for… to cause harm.
A. the first dose of the hepatitis B vaccine. C. Postexposure prophylaxis against HIV infection usually should be
B. consideration of testing for hepatitis C virus transmission. given to all victims of bombings and similar mass casualty events.
C. HIV postexposure prophylaxis (PEP) D. A. and B.
D. vaccination against tetanus.
E. A, B, and D. 10. Which statement about administration of TIG is true?
A. The currently recommended TIG prophylactic dose is 250 units
4. Persons who have intact mucous membranes exposed to blood from intramuscularly (IM) for adult and pediatric patients.
others are candidates for… B. When tetanus toxoid and TIG are given concurrently, separate
A. the first dose of the hepatitis B vaccine. syringes and separate sites should be used.
B. testing for hepatitis C virus infection. C. If passive protection is clearly indicated, but TIG is unavailable,
C. HIV PEP. intravenous immune globulin (IVIG) may be substituted for TIG.
D. vaccination against tetanus. D. If TIG is in short supply, use should be reserved for patients least likely
E. all of the above. to have received adequate primary vaccination (persons aged 60 years
or older, immigrants from regions other than North America or
5. Persons who have superficial exposure of intact skin but not mucous Europe, and children of parents who object to vaccination.
membranes to blood from others are candidates for… E. All of the above.
A. the first dose of the hepatitis B vaccine.
B. consideration of testing for hepatitis C virus transmission. 11. Persons who received or are identified as candidates for any vaccine,
C. HIV PEP. testing related to hepatitis C virus transmission, or HIV PEP should be
D. vaccination against tetanus. discharged with a referral for follow-up, with written information on
E. none of the above. pre-discharge treatment to facilitate a primary health-care provider’s
ability to evaluate and, if appropriate, initiate or complete age-
6. To determine appropriate actions in response to evaluation of victims, appropriate treatment.
assume that exposure to blood of other injured persons has occurred, A. True. B. False.
HIV PEP is not indicated, the patient has no history of either
vaccination with tetanus toxoid or hepatitis B vaccine, and no 12. Which statement(s) are true about persons who are responders to and
contraindication exists to receipt of either of these vaccines unless therefore may be evaluated in association with mass casualty events?
reliable available information contradicts these assumptions. A. Persons who are responders or engaged in debris clean up and
A. True. B. False. construction are candidates for tetanus toxoid vaccine even if no
wound is sustained.
7. If adherence to these recommendations increases the acute demand for B. Health-care personnel and other emergency response and public
tetanus toxoid, tetanus immune globulin (TIG), and hepatitis vaccine safety workers (e.g., police, firefighters) who are injured and exposed
beyond the available local or national supply, which of the following to blood while providing assistance in a mass casualty event should be
statements is true? managed according to existing guidelines for the management of
A. Local authorities should rely on local and state health departments, occupational exposures.
mutual aid agreements, or commercial vendors to supply needed C. Persons who are not health-care responders (e.g., construction
pharmaceuticals. workers or equipment operators) and who are injured and exposed to
B. If local or regional resources are inadequate, local and state public blood or body fluids during the course of response work should receive
health jurisdictions can, through their established communication follow-up care consistent with existing guidelines for the management
channels for health emergencies, work with CDC and others as of occupational exposures of health-care and public safety personnel
appropriate to assist with product shortages. to blood and body fluids.
C. Both A and B. D. All of the above.
 Vol. 57 / No. RR-6 Recommendations and Reports CE-3

13. Which best describes your professional activities? 18. After reading this report, I am confident I can describe the issues that
A. Physician. D. Office staff. should influence a decision to initiate postexposure prophylaxis
B. Nurse. E. Other. against human immunodeficiency virus infection during response to a
C. Health educator. bombing or a similar mass-casualty event.
A. Strongly agree. D. Disagree.
14. I plan to use these recommendations as the basis for …(Indicate all B. Agree. E. Strongly disagree.
that apply.) C. Undecided.
A. health education materials.
B. insurance reimbursement policies. 19. After reading this report, I am confident I can describe the issues that
C. local practice guidelines. should influence a decision to initiate testing to evaluate for infection
D. public policy. with hepatitis C virus during response to a bombing or a similar mass-
casualty event.
E. other.
A. Strongly agree. D. Disagree.
15. Overall, the length of the journal report was… B. Agree. E. Strongly disagree.
A. much too long. D. a little too short. C. Undecided.
B. a little too long. E. much too short.
20. After reading this report, I am confident I can list the mechanisms for
C. just right. accessing assistance in the United States if adherence to these
16. After reading this report, I am confident I can describe the indications guidelines results in an acute shortage of vaccines during response to a
for hepatitis B vaccine during response to a bombing or a similar mass- bombing or a similar mass-casualty event.
casualty event. A. Strongly agree. D. Disagree.
A. Strongly agree. D. Disagree. B. Agree. E. Strongly disagree.
B. Agree. E. Strongly disagree. C. Undecided.
C. Undecided. 21. The learning outcomes (objectives) were relevant to the goals of this
17. After reading this report, I am confident I can describe the indications report.
for tetanus toxoid–containing vaccines during response to a bombing A. Strongly agree. D. Disagree.
or a similar mass-casualty event. B. Agree. E. Strongly disagree.
A. Strongly agree. D. Disagree. C. Undecided.
B. Agree. E. Strongly disagree.
C. Undecided.
(Continued on pg CE-4)

Detach or photocopy.
nonphysicians
Hepatitis B Virus, Hepatitis C Virus, or Human Immunodeficiency

Bombings and Similar Mass Casualty Events — United States, 2008

MMWR Response Form for Continuing Education Credit

Date I Completed Exam

[ ]F
CHES Credit
Recommendations for Postexposure Interventions to Prevent

CME Credit

CEU Credit
CNE Credit
Virus Infection, and Tetanus for Persons Wounded During

Check One

CME for

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Credit
Failure to complete these items can result in a delay or rejection of your application for

Fill in the appropriate blocks to indicate your answers. Remember, you must answer all
2. indicate your choice of CME, CME for nonphysicians, CEU, CNE, or CHES credit;

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of the questions to receive continuing education credit!
Fax Number
First Name
5. submit your answer form by August 1, 2010.

To receive continuing education credit, you must

State
4. sign and date this form or a photocopy;

or

[ ]C [ ]D [ ]E
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continuing education credit.

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Last Name (print or type)

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CE-4 MMWR August 1, 2008

22. The instructional strategies used in this report (text, tables, figures, 28. The MMWR format was conducive to learning this content.
boxes, and appendix) helped me learn the material. A. Strongly agree.
A. Strongly agree. D. Disagree. B. Agree.
B. Agree. E. Strongly disagree. C. Undecided.
C. Undecided. D. Disagree.
E. Strongly disagree.
23. The content was appropriate given the stated objectives of the report.
A. Strongly agree. D. Disagree. 29. Do you feel this course was commercially biased? (Indicate yes or no; if
B. Agree. E. Strongly disagree. yes, please explain in the space provided.)
C. Undecided. A. Yes.
B. No.
24. The content expert(s) demonstrated expertise in the subject matter.
A. Strongly agree. D. Disagree. 30. How did you learn about the continuing education activity?
B. Agree. E. Strongly disagree. A. Internet.
C. Undecided. B. Advertisement (e.g., fact sheet, MMWR cover, newsletter, or journal).
C. Coworker/supervisor.
25. Overall, the quality of the journal report was excellent. D. Conference presentation.
A. Strongly agree. D. Disagree. E. MMWR subscription.
B. Agree. E. Strongly disagree. F. Other.
C. Undecided.
26. These recommendations will improve the quality of my practice.
A. Strongly agree. D. Disagree.
B. Agree. E. Strongly disagree.
C. Undecided.
27. The availability of continuing education credit influenced my decision
to read this report. 1. A; 2.B ; 3. E; 4. A; 5. E; 6. A; 7. C; 8. D; 9. D; 10. E; 11. A; 12. D.
A. Strongly agree. D. Disagree. Correct answers for questions 1–12:
B. Agree. E. Strongly disagree.
C. Undecided.
 MMWR

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