UAMS ADMINISTRATIVE GUIDE
|SUBJECT:||EMPLOYMENT MEDICAL SCREENING|
The purpose of this policy is to minimize potential exposure to infectious disease for all UAMS employees, students, volunteers, patients, and visitors. UAMS strives to ensure all employees can perform the essential functions of their jobs with reasonable accommodation, and without undue risk of injury to themselves, their co-workers, or UAMS patients. To accomplish these goals, all UAMS employees are required to complete an initial medical screening and an annual, limited, screening which will be conducted twelve months following the date of their previous screening.
The employee medical screening is performed within thirty-one calendar days of the date of hire for all new employees. Annual (limited) medical screenings are required for employees during the duration of their employment with UAMS. The new employee medical screening and annual medical screenings are a condition of employment with UAMS. Supervisors are required to allow “released, paid time” from work for an employee to fulfill this requirement.
All newly hired employees who attend new employee orientation will be scheduled for their medical screening at that time. Those not attending orientation should be scheduled within the first thirty-one calendar days of employment. It is the responsibility of the department head to notify the employee if they are required to attend orientation and complete their Employment Medical Screening.
The initial new employee medical screening will minimally consist of a medical assessment (i.e., blood pressure, listing of known allergies, special job accommodations, and tobacco cessation assistance), review of immunizations (MMR, Hepatitis B, and Tetanus,) history of chicken pox (Varicella,) and the placement and reading of a Tuberculin Skin Test (TST.)
If the new employee has not completed the Employment Medical Screening within thirty-one calendar days from their hire date, the employee’s department head will be notified by Student and Employee Health Services (SEHS.) Adherence to the above mentioned policies and procedures for new employees is a condition for employment at UAMS.
Employment Medical Screenings will be conducted for those employees stationed in Pulaski County at either of the two SEHS locations; 1) Student & Employee Health Services clinic located in back of the Family Medical Center (ground level,) or 2) the Satellite Clinic located on the 8th floor, Rm8035, of the main hospital. Employees working outside of Pulaski County must be screened, either at one of the two SEHS locations or, with the consent of their supervisor, by making their own arrangements with an AHEC unit or with their private physician. All required documentation must be provided to SEHS within thirty-one calendar days from their date of hire.
Annual medical screenings will minimally consist of a Tuberculin Skin Test (TST.) The employee may supply documented proof of a Tuberculin skin test, (or health card,) obtained within twelve months of their previous annual medical screening date. Employees who have a documented past positive TST reading will complete the Tuberculosis Screening for Reactors which can be conducted over the phone by calling the SEHS office at 686-6565. Completed forms may also be returned by mail to SEHS, Mail Slot #530-8.
The nature of an employee’s job, location, and patient contact, may dictate the need for additional TB testing. Employees working in high risk areas will be identified by Occupational Health & Safety and their Departmental Manager. The employee will be notified, by their Manager, of their “TB team” status and instructed to receive bi-annual TB screenings.
SEHS will report the results of the new employee and annual medical screening, on an exception basis only. The employee and the employee’s Departmental Manager will be notified if the employee fails to meet essential physical requirements or poses a threat to themselves or others.
If an employee disagrees with the medical screening report, they may elect to secure a second opinion at their own expense. Results must be presented to SEHS within two weeks of notification to SEHS of the employee’s request for the second opinion.
If the two medical opinions disagree, UAMS Medical Center’s Medical Director will make the final determination on the medical status of the employee. The determination of the Medical Director will be reported to the employee and SEHS, in writing, within two weeks following receipt of the second opinion.
If it is determined that special job accommodations are required for an employee to perform their job functions, SEHS will work with Occupational Health and Safety and Human Resources to determine if reasonable accommodations, or performance of job without undue risk of injury to self and others, can be achieved.
Employment may be terminated if the employee cannot perform the essential functions of the job with reasonable accommodation, or if they present an undue risk of injury to themselves or others. The Office of Human Resources will notify the employee and the department in writing of the decision to terminate employment.
All medical records, including the results of all medical screenings, will be maintained by Student and Employee Health Services (SEHS). All employee medical records will be maintained confidentially. A copy of the medical record may be requested by the employee by contacting the SEHS office.
All physicians, students, and faculty seeking privileges at UAMS must comply with TB testing policies in place for UAMS employees.
PROCEDURE (New Employee Medical Screening)
I. REQUIRED SCREENING:
TUBERCULIN SKIN TEST (TST):
All new employees will require a baseline Tuberculin Skin Test (TST.) The new employee may provide documented proof of a TB skin test as long as it has been no longer than twelve months prior to UAMS hire date. This documented TST will count toward one of the two required readings of the baseline TST.
The baseline TST will include a two-step process if the new employee has; 1) never had a TST or has no documentation of TST, or 2) if it has been greater than twelve months since the new employee had a documented, negative, TST reading result. The first TST will be placed at orientation or at the employee’s New Employment Medical Screening. The two-step process will require the employee to return within 10 – 21 calendar days for the 2nd placement and reading which will then be recorded as the baseline Tuberculin Skin Test.
The baseline TST includes employees with a prior Bacille Calmette-Guerin vaccination (BCG). At the employee’s request, a half dose, (two and one-half (2.5) tuberculin units, or 0.05 ml,) may be applied during skin tests for employees with a history of BCG or previous (undocumented) positive reactions. However, the employee must understand that, if the half dose test results in a negative TST, a second placement of the full dose of 0.10 ml will be required. The results of the 2nd placement and reading will be recorded as the baseline TST.
For persons vaccinated with BCG, the probability that a TST with a positive reaction is a result of infection with TB increases; 1) as the size of the reaction increases, 2) as the person encounters persons with active TB, 3) if the employee’s country of origin has a high prevalence of TB, and, 4) the length of time between vaccination with BCG and the placement of a TST increases. A positive TST, with a reaction of greater than or equal to 10mm, probably can be attributed to TB infection in an adult who was vaccinated with BCG as a child and who is from a country with a high prevalence of TB.
For new employees, all reported, prior positive Tuberculin Skin Tests must provide documented proof which must include the name and address of provider, date applied, size (in millimeters) of induration, date read, and signature of provider.
Documentation of chest radiography must include the name and address of provider, date performed, interpretation, interpreter’s signature, printed or typed name of interpreter, and identification of interpreter’s medical specialty (which must be radiology, pulmonology, or infectious disease.)
If no documented proof of a past positive is available, a TST will be placed and read with 48-72 hours. The employee may request the TST be done with one-half dose (2.5 tuberculin units or 0.05ml). If the TST is positive, the reading will then be recorded in millimeters of induration for UAMS baseline records. However, the employee must understand that, if the half dose test results in a negative TST, a second placement of the full dose 0.10 ml, will be required with the results of the 2nd placement and reading being recorded as the baseline TST.
Employees with existing medical conditions, which prohibit them from participating in the TST process, should contact SEHS. Arrangements will be made in a confidential manner (with the Department of Health) to complete the annual medical screening requirements.
Employees with an induration of 0 - 4mm will be recorded as negative.
(A negative test does not rule out the presence of TB.)
Employees with a TST induration of 5-9mm will be considered intermediate. Intermediate skin tests will be repeated on the day of 1st reading with the 2nd placement and reading (recorded within 48-72) as the TST result.
An induration of >5mm may be considered “positive” in the following groups:
1) Contact with an active case of TB
2) HIV positive persons
3) Chest x-rays consistent with old, healed TB
4) Recipients of organ transplants, and other immunosuppressed conditions (receiving the equivalent of > 15mg/day of prednisone for > 1 month)
Employees with a TST induration of 10 millimeters or greater will be referred to the Arkansas Department of Health (ADH) for further evaluation and preventive therapy if indicated. The chest radiography will be performed at the Pulaski County Health Unit and reviewed by a Radiologist at the unit.
The specialist at the ADH will determine whether the employee does/does not have an active case of TB. If no signs of active TB are found, a temporary health card will be issued by the Health Department to the employee. The employee must then provide a copy of the Health Card to SEHS before they are cleared for the workplace.
The Epidemiologist at ADH maintains TB surveillance of UAMS for several situations. They are; a) the occurrence of true TB skin test “conversions” or “active” TB in employees, b) the occurrence of possible person-to-person transmission of TB and, c) situations in which patients or employees with active TB are not promptly identified and isolated, thus exposing others to TB.
Conversions are defined as “an increase in induration of greater than or equal to 10mm over a two-year period.” Positive TB skin tests are defined as an induration of greater than, or equal to, 10mm as the Tuberculin Skin Test reading.
Employees with a positive TB skin test reaction are required to have a radiograph which meets with the requirements of the TB Control Officer for the State of Arkansas. The employee can provide documentation that they have completed an adequate course of treatment for latent TB infection along with a negative initial radiograph. This information will be forwarded to the TB Control Officer. Only the TB Control Officer for the State of Arkansas, or his designee, may determine the adequacy of a course of treatment, or documentation of treatment, resulting from a positive TST.
Employees who have been determined by the TB Control Officer for the State of Arkansas to have latent TB infection and are receiving preventive treatment, or are unable to, or choose not to accept or complete their preventive treatment, should not be excluded from the workplace.
Employees with radiographic findings consistent with active TB disease will be required to seek additional evaluation and/or treatment to ensure the employee does not pose a risk of TB infection to others. The employee will be notified and instructed to remove themselves from the workplace until, a) a diagnosis of TB is ruled out OR, b) a diagnosis of TB is established, the employee receives treatment, and a determination has been made that the employee is non-infectious. Only the Tuberculosis Control Officer for the State of Arkansas, or his designee, may determine the adequacy of a course of treatment or documentation of treatment for an active case of TB disease.
Employees with TB at sites other than the lung or larynx usually do not need to be excluded from workplace if a diagnosis of concurrent pulmonary TB has been ruled out.
The nature of the employee’s job, location, and patient contact may dictate the need for more frequent TB testing. Employees who are exposed to patients with active TB, areas where diagnostic or treatment procedures that stimulate coughing are performed, clinic waiting areas, and emergency departments, are some examples of high risk areas.
Employees who refuse to comply with the required TST will be referred to the Arkansas Department of Health and their supervisor will be notified.
II. STRONGLY RECOMMENDED IMMUNIZATIONS:
MEASLES, MUMPS, AND RUBELLA (MMR)
Medical personnel are at higher risk for acquiring measles than the general population. The following Measles, Mumps, and Rubella (MMR) vaccine is strongly recommended for employees at UAMS: new employees born in, or after, 1957 will be asked to provide documented proof of the following:
1. Two doses of live measles vaccine on or after their first birthday (at least one month apart)
2. Documentation of physician-diagnosed measles
3. Laboratory evidence of measles immunity (reactive titer)
Persons born in or after 1957,
who do not have documentation of vaccination or other evidence of measles
immunity, will be asked to receive the MMR vaccination at the time of
employment. In addition, birth before 1957 does not guarantee mumps immunity.
Therefore, during mumps outbreaks, MMR vaccination will be considered for
persons born before 1957 who may be exposed to mumps and who may be
Susceptible personnel who have been exposed should be relieved from direct patient contact from the fifth to the 21st day after exposure regardless of whether they received vaccine or IG after the exposure. Personnel who become ill should be relieved from patient contact for seven days after they develop rash.
Exceptions: Pregnancy or anticipated pregnancy within three months following vaccine, previous allergic reaction to the vaccine, persons who have experienced anaphylactic reactions to neomycin, and persons with immune-deficiency diseases and persons with immunosuppression (i.e., leukemia, lymphoma, generalized malignancy, or therapy with alkylating agents, antimetabolites, radiation, or large doses or corticosteroids. Measles vaccine should not be given for at least six weeks to three months, after a person has been given IG, whole blood, or anti-body-containing blood products. Minor illnesses, such as a mild upper-respiratory infection, with or without low-grade fever, are not considered a contraindication for the vaccine.
REMINDER: Some employees require a 2-step TST. The MMR vaccine should not be given until the day of placement, or following the reading of, the 2nd placement of a 2-stepTST. If this is not possible, the TST should be postponed for 4-6 weeks due to the fact that measles vaccination may temporarily suppress tuberculin reactivity.
(CDC. Measles Prevention: Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1989; 38(S-9); 1-18. http://www.cdc.gov/mmwr/preview/mmwrhtml/00053391.htm
VARICELLA (CHICKEN POX):
All employees who have close contact with persons at high risk for serious complications resulting from Varicella must provide a positive history of disease (reliable predictor), documentation of vaccination for Varicella, or laboratory evidence (reactive titer) confirming the presence of Varicella antibodies. Persons at “high risk” include; a) premature infants born to susceptible mothers, b) infants who are born at < 28 weeks of gestation or who weigh < 1,000 grams at birth (regardless of maternal immune status), c) pregnant women and d) immunocompromised persons.
Employees and students in high risk areas, who are unable to provide any of the above mentioned requirements, will be asked to comply with serological testing to determine their immune status. Serologic results will be reported to the employee or student. Those employees/students with a "non-reactive" test result will be vaccinated. The vaccination consists of two doses given 4-8 weeks apart.
Exceptions: Pregnancy, allergic reaction to neomycin or gelatin, reaction to previous chickenpox vaccine, immunocompromised, steroid treatment, or recipient of blood products during the past five months
(CDC. Varicella Vaccine: FAQs about Health Care Workers, National Immunization Program.)
ANIMAL CARE EMPLOYEES:
All employees in the Department - Lab Animal Medicine (DLAM), are required to have documentation of a current TB skin test, MMR, and Tetanus vaccine. This is a condition of employment in this specific workplace at UAMS.
Exceptions: Please refer to contraindications for MMR and Tetanus vaccines.
All employees whose duties involve the risk of directly contracting and spreading the Hepatitis A virus, specifically employees who prepare food for consumption, are required to receive the Hepatitis A vaccine. The Hepatitis A vaccine requires a booster which is recommended six to twelve months from initial immunization.
Exceptions: Persons who have reported an allergic reaction to previous Hepatitis A vaccine. Persons who are moderately or severely ill should wait until they recover. Hepatitis A is an inactivated virus and any risk to pregnant women, or the fetus, is thought to be very low.
All employees will be offered the Hepatitis B vaccine. Generally, employees who are at increased risk for Hepatitis B infection are in locations or occupations where contact with blood from infected patients is frequent. The locations and occupations are as follows:
Blood bank Dentists and dental surgeons
Clinical laboratories Dialysis technicians
Dental clinics Laboratory technicians
Dialysis wards Nurses
Emergency Room Physicians (especially surgeons
Hematology/Oncology wards and pathologists)
Hospital personnel who do not have physical exposure to blood are at no greater risk than
the general population. Patient contact without physical exposure to blood has not been documented to be a risk factor.
Employees in locations or occupations listed above must have documented proof of completing the vaccine series, laboratory evidence of the presence of antibodies (reactive titer), or they will be required to obtain the three-shot series. Any employee who declines the vaccine must sign a waiver stating that they have been offered the vaccine, but choose not to receive it.
Exceptions: Allergic reaction to baker’s yeast or a previous Hepatitis B vaccine. Employees who are moderately or severely ill should postpone their vaccine until they recover.
Adapted from Maynard, JE. Nosocomial viral hepatitis. Am J Med 1981;70:440. http://www.phppo.cdc.gov/cdcRecommends/
III. ADDITIONAL RECOMMENDED IMMUNIZATIONS:
TETANUS AND DIPTHERIA
Employees who have not had a primary series of tetanus and diphtheria toxoids or a booster within the past ten (10) years will be offered this immunization.
Exceptions: Allergic reaction to previous Tetanus or any other tetanus and diphtheria vaccine, moderate or severe illness, or pregnancy.
Influenza vaccine will be offered annually to all employees. An influenza vaccine log will be signed by employees receiving the immunization.
Exceptions: Allergic reaction to eggs or to a previous dose of influenza vaccine, or have a history of Guillain-Barre Syndrome.