Document Title: IMMUNE STATUS PROGRAM Date of Origin: 05/2010 ASANTE WIDE Document Number 400-EH-0312 Rev 1 Document Type Policy Procedure Department of Origin: Health Effective Date: 09/2011 Owner (Department): Health Review Due Date: 09/2014 Regulations: OAR 333-018 Key Words: vaccines, infectious diseases, CDC guidelines, immunizations Approved: Signature: /s/gregg K. Edwards Title: Chief People Officer Date: 09/01/2011 PURPOSE (Summary): Asante Health System requires that healthcare personnel (HCP) be aware of their immune status to infectious diseases; they are strongly advised to be vaccinated according to the current Centers for Disease Control and Prevention (CDC) recommendations. The Health Services (EHS) is responsible for assessing and maintaining records for HCP. In addition, Healthcare personnel (HCP) as defined by the current Centers for Disease Control and Prevention includes all paid and unpaid persons working in healthcare settings who have the potential for exposure to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces or contaminated air. These personnel may include but are not limited to emergency medical service personnel, dental personnel, laboratory personnel, autopsy personnel, nurses, nursing assistants, physicians, technicians, therapists, pharmacists, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care but potentially exposed to infectious agents (e.g. clerical, dietary, housekeeping, maintenance, and volunteer personnel). See Addendum A. Immunity status of HCP is important in helping to prevent the spread of disease to patients, coworkers and the community. According to CDC healthcare personnel vaccination recommendations, the following diseases are identified as worthy of efforts taken for preventing their spread:, measles (rubeola), mumps, rubella (German measles), varicella (chicken pox), hepatitis B, tetanus, diphtheria, pertussis (whooping cough), influenza and meningococcal. POLICY DETAIL: 1. Documentation of immune status: a.) Accepted documentation of immunity consists of one or more of the following: i.) Written documentation of the following diseases from a medical provider: mumps, measles, rubella, varicella, hepatitis B. ii.) Laboratory evidence of immunity or confirmation of disease. iii.) Original vaccination record of recommended vaccines. 10/11/2011 400-EH-0312 Immune Status Program Page 1 of 6
2. Recommended vaccine/immunity for all HCP: a.) Measles, mumps, rubella (MMR): i.) HCP with no documentation of immunity are given two (2) doses of MMR four weeks apart. b.) Varicella: i.) HCP with no documentation of immunity are given two (2) doses of varicella four weeks apart. c.) Influenza: i.) Annual influenza vaccinations are provided by the organization for all HCPs. If HCP declines the influenza vaccine, a signed declination is requested by EHS. 3. Recommended vaccine for select group(s) of HCP: a.) Meningococcal: All microbiologists who are routinely exposed to isolates of N. meningitides. i.) Meningococcal conjugate vaccine (MCV4) is preferred for employees up to 55 years of age (given IM). ii.) Meningococcal polysaccharide vaccine (MPSV4) is recommended for employees over 55 years of age (given SC). b.) Hepatitis B: HCP who perform tasks that may involve exposure to blood or body fluids shall: i.) Receive a three (3) dose series given at 0, 1-month and 6-month intervals. Lab: Obtain anti-hbs serology testing one month after dose number three. If lab shows no immunity recommend revaccination as follows: Three (3) dose series given 0, 1-month and 2-month intervals. Obtain anti-hbs one month after dose number three. ii.) If lab shows no immunity, the employee is considered a non-responder to hepatitis B. iii.) If HCP declines vaccine, a signed OSHA waiver (declination) is required by law (29 CFR Part 1910.1030). c.) Tetanus, Diphtheria, Pertussis (Tdap): i.) HCP younger than 65 years with direct patient contact are given a one time dose of Tdap if their last Td was administered at least two years previously. 4. Other recommended adult vaccines: Asante promotes employees receive additional CDC recommended adult vaccines based on age and risk factors. These include: hepatitis A, human papillomavirus, pneumococcal polysaccharide, tetanus and diphtheria, and zoster (shingles). 5. Fitness for duty/exclusion from work: s and volunteers who do not have evidence of immunity and are exposed to the following communicable diseases will be excluded from work or duties as follows: 10/11/2011 400-EH-0312 Immune Status Program Page 2 of 6
Infectious disease Stage Fitness for Duty Length of restrictions Rubeola (Measles) Mumps Pertussis (Whooping Cough) Rubella (German Measles) Varicella-Zoster (Chickenpox ) Varicella-Zoster (Shingles) Active Until 7 days after the rash appears From 5th day after 1st exposure through 21st day after last exposure. Active Until 5 days after onset of parotitis From 12th day after 1st exposure through 26th day after last exposure. Active From beginning of catarrhal stage through 3rd week after onset of paroxysms or until 5 days after start of effective antimicrobial therapy (asymptomatic No restrictions, prophylaxis personnel) (symptomatic personnel) Until 5 days after start of effective antimicrobial therapy Active Until 7 days after rash appears From 5th day after 1st exposure through 21st day after last exposure Active Until all lesions dry and crusted From 10th day after first exposure through 21 st day after last exposure. Localized, in healthy person Cover lesions, restrict from care of high risk patients Until all lesions dry and crusted 10/11/2011 400-EH-0312 Immune Status Program Page 3 of 6
Infectious disease Stage Fitness for Duty Length of restrictions Generalized or Restrict from patient contact Until all lesions dry and localized in crusted immunosuppressed person Influenza From the 10th day after 1st exposure through 21 st day after last exposure or if varicella occurs, until all lesions dry and crust. Active Exclude until resolution of malaise and fever for at least 24 hours without fever reducing medication. In a community-wide outbreak, all non-vaccinated HCP may be required to wear a mask for recommended duration or be evaluated for antiviral medications according to Asante s guidelines for administering antiviral medications. During an outbreak situation, the facility s Infection Prevention and Control Department policies should be followed and any additional recommendations will be issued by that department. In a community -wide outbreak: as directed by the Infection Prevention and Control Department. 6. Responsibilities: a.) Maintenance of records, data management, and administration of immunizations is managed by the Health Services according to federal, state, and local standards. b.) Compliance of HCP with approved policies will be the responsibility of the HCP s manager. c.) The Infection Preventionist will be involved in the surveillance for infection in personnel and assisting with exposure investigation and implementation of preventive measures in the healthcare setting. d.) The Infection Prevention and Control Committee shall have oversight to review and recommend changes in procedures, policies and programs that include employee immunization recommendations, as per policy 100-IC-092, Authority Statement for the Infection Prevention & Control Program, RVMC and TRCH Policy# 110-IC-032. 10/11/2011 400-EH-0312 Immune Status Program Page 4 of 6
Addendum A Health Policy 400-EH-0312 Immune Status Program Screening of Healthcare Personnel* for Immunity/Exposure per CDC, CMS, OR-OSHA Category of Personnel with/without Patient Contact** Screening 1, 2, 3**, 4 Volunteer 1, 2,3**, 4 Who Administers Health Health Students 1, 2, 3**, 4 School Nursing Other Contract 1, 2, 3**, 4 1, 2, 3**, 4 Nursing Providing Who at AHS Monitors for Compliance Health Provider Volunteer Services Director Education Department Initializing Contract Nursing Service Initializing Contract Services Dept Initializing Contract or Human Resources In Contract Language Health Policy #400-EH- 312 Health Policy #400-EH- 312 Yes Yes Yes In the Event of an Exposure, Who Notifies the Exposed Health Director of Volunteer Services School 1. Tuberculosis Screening. 2. Measles, mumps and rubella (MMR) and chickenpox (varicella). 3. Hepatitis B vaccine/immunity, meningococcal, tetanus, diphtheria and acellular pertussis (Tdap, age limit 65 and older exempt). 4. Influenza during flu season. ** Job dependent/job location. *Definitions Asante Health System requires that healthcare personnel (HCP) be aware of their immune status to infectious diseases and are strongly advised to be vaccinated according to the current Centers for Disease Control and Prevention (CDC) recommendations. Healthcare personnel as defined by the Centers for Disease Control and Prevention includes all paid and unpaid persons working in healthcare settings who have the potential for exposure to infectious materials, including body substances, contaminated medical supplies and equipment, contaminated environmental surfaces or contaminated air. These personnel may include but are not limited to emergency medical service personnel, dental personnel, laboratory personnel, autopsy personnel, nurses, nursing assistants, physicians, technicians, therapists, pharmacists, students and trainees, contractual staff not employed by the health care facility, and persons not directly involved in patient care but potentially exposed to infectious agents (e.g. clerical, dietary, housekeeping, maintenance, and volunteer personnel). 10/11/2011 400-EH-0312 Immune Status Program Page 5 of 6
CDC: Centers for Disease Control and Prevention. CMS: Centers for Medicare and Medicaid Services. LITERATURE CITATIONS: Healthcare Personnel Vaccination Recommendations, Immunization Action Coalition October 2009. Immunization of Healthcare Workers; Recommendations of the Advisory Committee on Immunization Practices (ACIP), Morbidity & Mortality Weekly Report, December 1997. Infection Control Guidelines for the Prevention and Control of Influenza in Acute Care Facilities, CDC 12/19/08. Using Antiviral Medicines to Control Influenza Outbreaks in Institutions, CDC 12/19/2008. Recommended adult immunization schedule by vaccine and age group United States, 2009, MMWR Quick Guide, January 9, 2009/Vol. 57/No. 53. Seasonal Influenza in Adults and Children Diagnosis, Treatment, Chemoprophylaxis, and Institutional Outbreak Management: Clinical Practice Guidelines of the Infectious Diseases Society of America. Harper, Scott A., Bradley, John S. Englund, Janet A., et.al., IDSA Guidelines for Seasonal Influenza in Adults and Children, DID 2009:48 (15 April) pg. 1003-1032. Control of Communicable Diseases Manual, Heymann, David L. M.D. 19th Edition 2008. Oregon Health Services Disease Investigation Guidelines. Retrieved 1/18/2010 from http://www.oregon.gov/dhs/ph/acd/reporting/guideln/guideln.shtml. Updated Recommendations for Isolation of Persons with Mumps, CDC MMWR October 10, 2008v/57(40);1103-1105. Policy Revisions: Rev Revision date: Revision Description: Responsible Department 1 09/2011 Updated; title changed; added original Health vaccination record to Section 1, a, iii. Policy Submitted By: Policy Reviewed By: Shirley Frigaard, ANP Health RVMC Nancy Malone, FNP Health TRCH Debra Hurst RN, BSN, CIC Infection Preventionist RVMC Toni Kristensen, RN Infection Preventionist TRCH 09/2011 HR Policy Committee Debbie McQueen, Manager Work Health Infection Prevention and Control Committee RVMC Infection Prevention and Control Committee TRCH 09/2011 Title Date Title Date 10/11/2011 400-EH-0312 Immune Status Program Page 6 of 6