ROWAN UNIVERSITY POLICY

Title: Housestaff Immunizations and Health Requirements
Subject: Health Services
Policy No: SOM: 2013:03
Applies: School of Osteopathic Medicine
Issuing Authority: Dean, School of Osteopathic Medicine
Responsible Officer: Dean, School of Osteopathic Medicine 
Adopted: 07/12/2012
Last Revision: 01/29/2015

I. PURPOSE

To prevent or reduce the risk of transmission of vaccine-preventable and other communicable diseases between RowanSOM medical interns and residents (housestaff) and their patients and other persons at RowanSOM and RowanSOM-affiliated health care units.

II. ACCOUNTABILITY

The Dean shall ensure compliance with this policy. The Associate Deans or other administrators responsible for graduate medical education, and the individual Program Directors shall implement this policy in conjunction with the campus Occupational Medicine Service.

III. APPLICABILITY

This policy shall apply to all interns and residents (including clinical fellows), hereinafter called "house officers" or "housestaff," enrolled in any RowanSOM-sponsored graduate medical education program conducted in any health-care facility participating in the program, and all visiting, exchange or special-program housestaff from other institutions. New housestaff will preferably be in full compliance with this policy prior to beginning their programs, but must be in full compliance within six months of beginning their duties.

IV. DEFINITIONS

RowanSOM - sponsored graduate education program is one for which RowanSOM maintains academic responsibility.

V. REFERENCES

1. Rowan University School of Osteopathic Medicine Policy: Tuberculosis Surveillance
2. Rowan University School of Osteopathic Medicine Policy: HIV, HBV and HCV
3. Centers for Disease Control and Prevention, Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-care Settings, 2005, MMWR 2005; 54 (RR-17), i-141.
4. National Research Council, Occupational Health and Safety in the Care and Use of Research Animals, National Academy Press, Washington, D.C., 1997.
5. Immunization of Health-Care Personnel: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR 2011;60(No. RR-7).
6. Centers for Disease Control and Prevention, Guidelines for Infection Control in Dental Health- Care Settings – 2003. MMWR 2003;52(No. RR-17).
7. Occupational Safety and Health Administration, "Occupational Exposure to Bloodborne Pathogens," 29 CFR Part 1910.1030. 

VI. POLICY

A. Immunization and Health Requirements

1. History and physical exam:
   Each house officer shall undergo a complete medical history review within thirty (30) days of beginning the program and, if needed, an appropriate physical examination based upon the history.
2. Hepatitis B:
   New housestaff shall undergo testing for HBV infection and immunity pre-placement (post-offer of employment), and prior to patient contact. These tests should ordinarily consist of hepatitis B surface antigen (HBsAg), antibody to HBsAg (HBsAb) and antibody to hepatitis B core antigen (HBcAb), followed by additional tests as deemed appropriate by the campus Occupational Medicine Service.
   1. If house officers test negative for HBV infection and immunity, and they have not been previously immunized, they shall begin immunization against HBV or sign a UMDNJ-approved waiver declining immunization prior to patient contact or contact with blood or other potentially infectious body fluids or laboratory material. If house officers test negative for HBV infection and have been previously immunized but have inadequate levels of antibodies despite such previous immunization, they shall receive a booster dose of the vaccine or sign a UMDNJ-approved waiver declining immunization prior to patient contact or contact with other potentially infectious body fluids or laboratory material. Testing for antibody titers (HBsAb) 1-2 months post-immunization should be performed; non-responders to a primary series of immunizations or booster dose should complete a second three-dose immunization series and be tested again for serologic response. Individuals who still do not respond with antibody production following a second series of immunizations are considered susceptible to HBV infection, and shall be counseled regarding precautions to prevent HBV infection and the need to obtain hepatitis B immune globulin (HBIG) prophylaxis for any known or probable significant exposure to HbsAg-positive blood.
   2. In all instances, current CDC recommendations should be followed regarding initial HBV immunization, post-immunization antibody titers, re-immunization or booster doses for inadequate antibody titers, and post-exposure immunoglobulin prophylaxis for non-responders. If the initial HBV tests are positive and indicate a significant potential for transmission of the virus, an evaluation shall be made prior to patient contact of the need for monitoring of clinical performance and/or of the scope of assigned or permitted clinical activities consistent with patient protection, especially the performance of exposure-prone procedures. This evaluation shall be made by designated personnel as per the University policy on HIV, HBV and HCV, 00-01-45-52:00. If hired under these circumstances, house officers may be restricted in their clinical activities.
   3. Currently employed housestaff shall comply with all HBV requirements of the University policy on HIV, HBV and HCV, 00-01-45-52:00.
3. Tuberculosis:
   1. All housestaff must meet the requirements of the Rowan University School of Osteopathic Medicine policy on Tuberculosis Surveillance.
   2. Each house officer shall undergo TB skin testing (TST) using the Mantoux method (5 tuberculin units of intradermal TST), or an FDA-approved blood assay for TB, prior to employment. All TST must be administered, read and interpreted in accordance with Centers for Disease Control and Prevention (CDC) guidelines (see Reference B). All FDA-approved blood assays for TB must be administered, read and interpreted according to guidelines issued by the CDC, FDA and the manufacturer. Positive reactions shall be appropriately followed up. The two-step method shall be used if the pre-employment TST is negative and there is not another documented negative TST within the preceding 12 months.
   3. Thereafter, annually or more frequently if indicated, house officers with negative reactions shall be re-tested. Housestaff with non-human primate contact shall receive periodic testing every six months in accordance with the National Research Council's Occupational Health and Safety in the Care and Use of Research Animals. Those with positive reactions shall be followed and treated as appropriate.
   4. House officers with a history of BCG (bacille Calmette-Guerin) vaccination are not exempt from the TB testing requirement because there are no data to indicate that these individuals experience an excessively severe reaction to TST, and because anyone with a history of BCG with a positive TST result is considered infected with TB and is treated accordingly.
   5. House officers who have initial positive TB test results, subsequent TB test conversions, or symptoms suggestive of TB must be evaluated promptly for active TB. This evaluation must include a history, clinical examination and a chest X-ray. If the history, clinical examination or chest X-ray is compatible with active TB, additional tests, such as sputum microscopy and culture, must be performed. If symptoms compatible with active TB are present, the house officer should be excluded from clinical activities until either (a) a diagnosis of active TB is ruled out or (b) a diagnosis of active TB is established, treatment is begun and a determination is made by the director of a RowanSOM Occupational Medicine/Employee Health Service that the house officer is noninfectious. Those house officers who do not have active TB should be evaluated for preventive therapy according to published CDC guidelines. However preventive therapy for latent infection in the absence of active disease is not required. If the evaluation for active TB, treatment for active TB and/or preventive therapy for latent infection is carried out at a facility other than a RowanSOM site or RowanSOM-approved site, all test results and documentation of care provided must be shared with the director of the appropriate RowanSOM Occupational Medicine Service. House officers receiving preventive treatment for latent TB infection need not be restricted from usual clinical activities.
4. Measles-mumps-rubella:
   1. Each house officer must submit documented proof of immunity to measles, mumps and rubella prior to or within thirty (30) days of beginning the program. (People born before 1957 may be immune from childhood exposure to the naturally occurring diseases, but this evidence has proved unreliable.) Immunity can be proved by serologic (laboratory) evidence of immunity to each disease.
   2. Housestaff lacking serologic immunity must receive at least one dose of MMR vaccination prior to or within thirty (30) days of beginning the program.
5. Influenza:
   Housestaff should be immunized each year of their employment with RowanSOM during the fall season with seasonal and any other current influenza vaccines available.
6. Varicella:
   Housestaff must receive two doses of varicella vaccine 4 to 8 weeks apart or prove immunity to varicella-zoster virus via serology prior to beginning the program or prior to patient contact. If the titer is negative, the housestaff member will be offered varicella vaccine to complete a vaccination series. If the housestaff member has a negative varicella titer and has not previously had varicella vaccine, the housestaff member will be required to complete a series of varicella vaccination within the first three months of patient contact. Because of potential transmission of the vaccine virus to susceptible high-risk patients, such as immunocompromised patients, newborns and pregnant women, contact with high-risk susceptible patients should be avoided if a vaccine-related rash develops within three weeks of receipt of either the first or second dose of the vaccine.
7. Tetanus-diphtheria-pertussis:
   Each house officer prior to beginning the program should have completed a primary series of tetanus, diphtheria and pertussis immunizations (DPT), and received a booster dose of Td (tetanus-diphtheria) every ten years since. Effective for house officers hired in 2007 or later, with the availability of Tdap (tetanus-diphtheria-acellular pertussis) immunization, house officers must, prior to employment, receive one dose of Tdap.

B. Exemptions/Exceptions

1. A house officer may be exempted from any required immunization if he/she has a medical contraindication for that immunization and if failure to receive this immunization does not prevent fulfillment of the requirements of the training program. Conditions comprising valid medical contraindications to vaccine administration are those set forth by the Centers for Disease Control and Prevention. Such housestaff must present a written statement from a physician licensed to practice medicine in the United States or a foreign country stating that a specific immunization is medically contraindicated, and giving the reasons for and duration of this contraindication. These written physician's statements shall become part of the individual's immunization record and shall be reviewed annually by the Program Director in conjunction with the Director of Graduate Medical Education or infectious disease expert from the health-care unit where the house officer works to determine whether this exemption shall remain in effect for the next year. When a medical contraindication no longer exists, the house officer must then comply with the immunization requirements. The University shall provide reasonable accommodations to those housestaff whose medical conditions contraindicate immunizations so long as the failure to be vaccinated will not prevent the individuals from fulfilling the requirements of the training program. Housestaff should be informed of the immunization and testing requirements prior to employment.
2. A house officer may be exempted from any required immunization if he/she submits a bona fide written signed statement explaining how immunization conflicts with his or her religious beliefs and if failure to receive this immunization does not prevent fulfillment of the requirements of the training program. The individual may be required to acknowledge in writing that he or she was informed of the value of immunizations and has knowingly declined to have such immunizations for religious reasons. RowanSOM shall provide reasonable accommodations to those housestaff whose religious beliefs bar immunizations so long as the failure to be immunized will not prevent the individuals from fulfilling the requirements of the training program. Housestaff should be informed of the immunization and testing requirements prior to employment.
3. Housestaff who are not able to complete immunizations and tests by the start of the program may be employed on a provisional basis if temporary exemption is granted by the Program Director. However, depending upon which documentation, immunization or test is lacking, these housestaff may be excluded from certain activities such as patient contact or laboratory work. For example, housestaff may be restricted from contact with patients or with blood or other potentially infectious body or laboratory fluids if they have not received at least one dose of hepatitis B vaccine or cannot provide serologic evidence of current immunity to hepatitis B or have not signed a waiver. Housestaff shall not be permitted to have contact with patients unless they have received tuberculin testing and any required follow up. Provisional employment on this basis may be limited by the Program Director, at his or her discretion. If a house officer is restricted from patient contact or laboratory work and is unable to fulfill the academic requirements of the program, the house officer may be subject to dismissal.

C. Record-Keeping Requirements

1. There must be acceptable evidence of required immunizations, immune status or health status listed in Section VI.A for each house officer prior to beginning the training program.
2. Acceptable documents serving as evidence of previous immunization and/or immunity may include:
   1. an official school immunization record or copy thereof from any primary, secondary, undergraduate, graduate, health professions or other school;
   2. a record from any public health department;
   3. a medical record or form summarizing a medical record and prior immunizations signed by a physician licensed to practice medicine in any jurisdiction of the United States or foreign country or other licensed health professional approved by the New Jersey Department of Health and Senior Services;
   4. a report of serology from a licensed laboratory.
3. Records shall be maintained of the documented histories, physical exams, immunizations, immune status and any exemptions of all housestaff. These records shall be updated upon additional immunization, immunity testing or occurrence of a relevant infectious disease. Immunization records shall be kept for thirty (30) years following completion of the program, termination, transfer or other departure of a house officer from RowanSOM.
4. Summaries of measles-mumps-rubella housestaff immunization/immune status shall be available for inspection by authorized representatives of the New Jersey Department of Health and Senior Services, and as part of the Annual Hospital Rubella and Measles Immunity Report required under hospital licensing standards.