To assure your department infection control policy actually works, your designated infection control officer (DICO) must have readily available medical records for department members who are at-risk for occupational exposure to communicable diseases. Childhood diseases such as measles and whooping cough are back nationwide. Health histories are needed to establish the potential risks members may pose to themselves, co-workers and patients. Many have questioned the need for DICO access to health histories; some believe these records are appropriately retained elsewhere. This article explains what information the DICO should collect and maintain and why the DICO should be the custodian of this information.
In order to establish a comprehensive infection control program, your department should request from each member their childhood disease history and the vaccinations/immunizations they have received. If this information has not yet been obtained, the department DICO should develop health history form and send it to each employee at risk for exposures with a memo explaining the need for this information and that it will be retained by the DICO in an individual, confidential medical record file. It should be made clear that this information is necessary for employees to receive appropriate medical treatment if they have an exposure to a communicable disease and to identify employees who are in need to vaccines and immunizations that can be offered before an exposure might occur. This information should also be obtained from all persons in the process of being hired. In addition, it should be noted that this information will be accessible only to the DICO and maintained under lock and key in a confidential medical records file.
- Evidence-Based Teaching Applied to Infection Control
- Protecting Confidentiality Following Communicable Disease Exposures
- Clarifying HIPAA & Disclosure of Disease Information
Providing health history and vaccines/immunizations received should be voluntary for members. If members choose to decline providing this information, they should be provided with a declination form to sign and date. The form should contain an acknowledgement that the member has been informed that information will be used solely for the purpose of assisting in the evaluation of whether the member should be offered a vaccine or immunization as a prevention measure or the evaluation and treatment of the member following an exposure. The form also should indicate that the member may change his or her mind and choose to complete the health history form at a later date. A declination form is required to be signed to document that the employers’ obligation was met to offer the vaccines. Declination forms do not remove any member rights. Declination forms document that the employer met his/her obligation to request this information.
The Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) have recommended that secure, preferably computerized, systems should be used to manage records for health-care personnel so records can be retrieved easily when needed. They state that each record should reflect the immunity status for vaccine-preventable diseases (i.e., documented disease, vaccination history or serology results), as well as vaccinations received during employment and any adverse events after vaccination. The CDC specifically included EMS in its definition of health-care personnel.1
The CDC has stated the following specifically regarding measles: “Health-care personnel place themselves and their patients at risk if they are not protected against measles. In accordance with current recommendations, health-care personnel should have documented evidence of measles immunity readily available at their work location. If this documentation is not available when measles is introduced, major costs and disruptions to health-care operations can result from the need to exclude potentially infected staff members and rapidly ensure the immunity for others.” CDC noted that documented evidence includes: documented receipt of two doses of live measles vaccine; laboratory evidence of immunity; documentation of physician-diagnosed measles; or birth before 1957.2
The following real-life scenario demonstrates the importance of having a trained DICO who has member health histories readily available. Department members transported a child to the hospital who was diagnosed with the measles by the emergency department. A team from the CDC investigated and determined that eight responders had been exposed to measles. An occupational medicine group contracted by the department to handle post-exposure follow up ordered titers costing $250 each for the eight exposed responders. Each responder needed to be off-duty for 36 hours pending their titer results, which meant that the department needed to pay overtime for other staff to their shifts.
If the health history of the eight responders had been obtained prior to the exposure, it is likely that most, if not all, would have had documented evidence of measles immunity. If the department had a trained DICO responsible for exposure management, he or she would have known that according to CDC, measles vaccine should have been administered instead of having titers ordered. This misunderstanding cost the department $14,400 for titers and replacement. The cost for administering eight doses of vaccine would have been approximately $560 and there would have been no need for the responders to be off of work. The reference for not having to do titers and just offering vaccine appears on page 16 of the CDC document (Immunization of Health-Care Personnel) referenced above. It clearly states that titers do not need to be performed if they are not cost effective. The vaccine cost is $700; the cost for a titer in this case was $250 each. Another example, although most new hires and current members have been vaccinated for protection against Hepatitis B (HBV), if an HBV exposure occurs, there are five different protocols for proper medical follow up depending on the member’s response to the vaccine series. If proper follow up is not rendered, the exposed care provider could be at risk for infection.
Let’s say the scenario involved mumps instead of measles. There would not be an option to administer mumps vaccine post-exposure because it has been shown to be ineffective. In the case of a mumps exposure, the responders involved would be required to be off-duty from day 12 through day 26 after the exposure, which is the incubation period for mumps. Overtime to replace exposed staff could be quite costly. This is a clear example showing that identification of unprotected members and administration of preventative vaccine would be far less costly than post exposure follow-up.
If improper care is rendered, who is responsible? This is a key factor in making the choice for who will provide post exposure medical follow up and counseling. The OSHA Bloodborne Pathogen Regulation states that” the employer is responsible to ensure that an exposed member receives proper care and counseling.” If not performed properly, the department is held responsible. Why not the physician? The physician is not held responsible because he/she is only acting as an agent on behalf of the employer – the department. OSHA enforces CDC post exposure and vaccination guidelines using the General Duty Clause from the OSH Act of 1970.3
If the DICO has access to the member medical record with their childhood disease and vaccination history, this can then be shared with the treating physician and post exposure follow up can be based on accurate information thus ensuring proper medical care and reducing potential liability.
Is it legal for departments to request member medical history? Such inquiries are subject to the Americans with Disability Act (ADA), which regulates employer disability-related inquiries and medical exams for applicants and members. In general, employers are prohibited from asking members questions that are likely to elicit information about a disability. They also cannot conduct medical exams seeking information about member physical or mental impairments. The Equal Employment Opportunity Commission (EEOC), which enforces its ADA regulations, has clearly stated in recent guidance that requesting proof of vaccination is not a disability-related inquiry; vaccinations are not medical exams under the ADA.4 In addition, such questions and exams are permissible if they are “job related and consistent with business necessity.” That standard clearly is met with the information contained in this article.
The ADA also permits an employer to require that a member disclose health information with respect to whether the member poses a “direct threat” to the health or safety of himself/herself or others. Factors in making this determination are: the duration of the risk; the nature and severity of potential harm; the likelihood potential harm will occur; and the imminence of potential harm. It certainly can be argued that emergency responders who have not been vaccinated for communicable diseases for which safe and effective vaccines are available pose a direct threat to themselves, co-workers and to patients.
The DICO plays an important role in managing the proper post-exposure medical follow-up and counseling, as well as risk and liability reduction for the department. It is essential that department administration fully support all aspects of the DICOs role and responsibilities.
1. CDC, General Recommendations on Immunization: Recommendations of the Advisory Committee on Immunization Practices (ACIP), MMWR 2011; 60 (No. RR-2) p.2-3.
2. CDC, Measles – United States, January 1 – April 25, 2008, MMWR 1998; 47 (No. RR-8).
3. Duties Part A, General Duty Clause from the OSHA Act of 1970.
4. EEOC – What you should know about COVID-19 and the ADA, the Rehabilitation Act, and other EEO laws, December 16, 2020.