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Chapter 12 - IHS Employee Immunization Program

Part 1 - General

Title Section
Employee Immunization 1-12.1
    Purpose 1-12.1A
    Background 1-12.1B
        Introduction 1-12.1B1
        General Principles 1-12.1B2
        Definitions 1-12.1B3
    Policy 1-12.1C
    Procedures 1-12.1D
        Immunity Required for Patient and Employee Protection 1-12.1D1
        Additional Important Protection for Employees 1-12.1D2
        Generally Recommended Protection 1-12.1D3
        Special Considerations 1-12.1D4
        Vaccine Administration 1-12.1D5
        Records 1-12.1D6
    Responsibilities 1-12.1E
        Headquarters Offices 1-12.1E1
        Area Offices 1-12.1E2
        Service Units 1-12.1E3
        Employees 1-12.1E4
    References 1-12.1F
    Appendixes 1-12.1G

Appendixes Description
Appendix I Diphtheria, tetanus and Td vaccines
Appendix II Measles, mumps, and rubella and measles mumps and rubella vaccines
Appendix III Influenza and influenza vaccine
Appendix IV Hepatitis B and Hepatitis B vaccine
Appendix V Pneumococcal disease and pneumococcal vaccine
Appendix VI Polio and Polio vaccine
Appendix VII Rabies and Rabies vaccine
Appendix VIII Consent Form
Appendix IX Refusal Form
Appendix X Immunization Form



    The Indian Health Service (IHS) employee immunization Policy provides for the development of IHS employee immunization programs and addresses two employee health, work related concerns:

    • The Protection of patients from certain infectious diseases that may be transmitted from infected employees and for which there are recommended vaccines.
    • The protection of employees from adult infectious diseases for which there are recommended vaccines.
    1. Introduction

      The goal of the IHS is to elevate the health of American Indians/Alaska Natives (AI/AN) to the highest possible level.  All IHS program activities, curative and preventive, focus on this important goal.

      Employee health is also of concern to the IHS.  Thus, the IHS adopted an employee health objective:  "The IHS will place major emphasis on promoting health and well-being of all its employees through the development of effective activities that will encourage changes in employee life styles and behaviors and in the work environment."  Healthy employees more efficiently and effectively perform their job responsibilities, and health workers who demonstrate healthy practices are valued role models.  Employees who are well informed about the value of immunization and who are fully immunized will experience better health, will be more effective employees and will enhance the health care given to IHS beneficiaries.

    2. General Principles

      All adults should consider their need to be immunized against the following eight diseases:

      Hepatitis B
      Pneumococcal disease

      The need for immunization against some or all these diseases is based on the individual's current immune status, age and exposure risks.  Special considerations may be necessary in certain circumstances of high exposure (examples: polio and rabies).

      In the hospital and clinic setting, unprotected employees, because of contact with patients, are at increased risk for some infectious diseases.  Also patients are vulnerable and must be protected as much as possible from infectious diseases that may be spread by infected employees.  In the best interests of patients, employees who are in contact with patients must be immune to the following diseases:


    3. Definitions
      1. Employee

        For the purposes of this policy, "employee" includes salaried IHS personnel, consultants, contractors, temporary employees and volunteer workers who work within an IHS health care facility.

      2. Patient Contact

        Employee-patient contact varies widely, depending on the type of work and the work assignment.  Measles, rubella and influenza are spread from person to person through airborne nasopharyngeal droplets.  All employees at IHS Service Unit facilities are therefore in contact with patients.

      3. Immune

        Immunity to an infectious disease for which there is a vaccine can be assumed if:

        1. the employee is appropriately vaccinated, or
        2. the employee shows serologic evidence of immunity.
    1. Every IHS employee shall be Informed about current immunization recommendations for adults in the USA (Appendixes I-VII).
    2. Every IHS employee at a health care facility shall be informed about the risks of job related exposure to and the dangers to patients of exposure to vaccine-preventable disease.
    3. Every employee at a health care facility who gives Informed written consent (Appendix VIII) shall be provided, at no charge, vaccines for any or all of the following diseases:


    4. All employees whose duties require contact with patients must comply with the requirements of this immunization program as a condition of employment and be immune to the following diseases:


    5. Employees or potential employees who are allergic to a component of a vaccine and/or have a history of a severe reaction to a vaccine wi11 not be required to receive that vaccine.
    6. When indicated and requested, employees who are required to demonstrate immunity shall be assisted, at no charge, in obtaining serologic tests to evaluate their immune status with regard to the following diseases:


    7. Employees who receive vaccines or have their immune status evaluated with serologic testing shall be provided with appropriate signed documentation of the vaccinations and testing.
    8. Female employees of child bearing age should have a pregnancy test before administration of a live virus vaccine.  Although measles, mumps, and rubella vaccines are not known to cause special problems for pregnant women and their unborn babies doctors usually avoid giving any drugs or vaccines to pregnant women unless there is a specific need.  To be safe, pregnant women should not get these vaccines.
    9. Employees subject to this policy who are not Immune to rubella and measles and refuse the recommended vaccine(s) are subject to be reassigned or removed from the Service.
    10. After the Implementation of this policy, current employees who are affected by this policy will come Into compliance as soon as possible, but no later than 10/l/91.  All applicants to positions located at an IHS health care facility shall provide documentation of immunity to measles and rubella prior to or at the time of their entrance on duty.  Contract medical staff members shall be required to furnish this Information at the time of application for medical staff membership and/or clinical privileges.  Volunteers shall furnish this information prior to working in an IHS health care facility.
    1. Immunity Required for Patient and Employee Protection
      1. Measles

        All employees susceptible by history or serology who are In contact with patients must be protected.

        Persons born before 1957 have probably been infected naturally and generally need not be considered susceptible; measles vaccine or proof of immunity is therefore not required for anyone born before 1957.  Persons born in 1957 or more recently can be considered immune only if they have documentation of physician-diagnosed measles, laboratory evidence of measles immunity, or adequate immunization with two doses of live measles vaccine on or after the first birthday.

        Consideration should be given to administering measles vaccine in combination with rubella and mumps vaccines (measles-mumps-rubella trivalent vaccine) (MMR), especially if there Is doubt regarding the immunity to rubella or mumps.

      2. Rubella

        All personnel (male or female) who have contact with patients, especially with pregnant patients, must be immune to rubella.

        Before immunizing, serologic screening for rubella need not be done unless the health facility considers it cost-effective or if the employee requests it.

        Persons can be considered susceptible unless they have laboratory evidence of immunity or documented Immunization with live virus vaccine on or after their first birthday.

        Consideration should be given to giving-rubella vaccine in combination with measles or mumps or MMR vaccines.

    2. Additional Important Protection for Employees
      1. Influenza

        Employees are encouraged to be vaccinated to reduce their chance of acquiring influenza infection and to reduce staff absenteeism during the influenza season.  Physicians, nurses, and other personnel having contact with patients with high risk medical conditions are encouraged to be immunized in the fall of each year to prevent the spread of Influenza to patients.

        Persons for whom influenza vaccine is recommended include:

        All health workers in contact with patients; those with chronic disorders of the cardiovascular or pulmonary system requiring medical followup or hospitalization within the preceding year; those with chronic metabolic disease (including diabetes), renal dysfunction, anemia, immunosupression, or asthma severe enough to have required follow-up or hospitalization during the preceding year; and otherwise healthy individuals 65 years of age and over.

      2. Hepatitis B

        Health-care personnel who have frequent contact with blood or blood products are at Increased risk and should be actively immunized.  These groups include, but are not limited to, physicians, nursing staff, dental professionals, and laboratory technicians.

        Before immunizing serologic screening for Hepatitis B need not be done unless considered cost-effective or the employee requests it.

        Prophylaxis with an Hepatitis B immune globulin (HBIG) vaccine should be used to protect susceptible employees when indicated, such as following needle-stick or percutaneous exposure to blood that is at high risk of being Hepatitis B, e antigen (HBeAg) positive, or Hepatitis B, surface antigen (HBsAg) positive.  Active vaccination should be started at the same time.

        HBIG should not be used as a substitute when active immunization is indicated.

    3. Generally Recommended Protection

      Employees in contact with patients are not at substantially higher risk than the general population of acquiring tetanus, diphtheria, or mumps, but should seek these additional immunizations.

      1. Tetanus and Diphtheria

        All adults lacking a complete primary series of tetanus and diphtheria toxoids should complete the series with adult tetanus and diphtheria toxoid (Td) vaccine.  A primary series for adults is three doses of preparations containing tetanus and diphtheria toxoids, with the first two doses given at least 4 weeks apart and the third dose given 6 to 12 months after the second dose.  All adults for whom 10 years or more have elapsed since completion of their primary series or since their last booster dose should receive a booster dose of Td.  Thereafter, a booster dose of Td should be administered every 10 years.  There is no need to repeat doses if the primary schedule for the series or booster doses is delayed.

        Complete and appropriately timed immunization is nearly 100 percent effective in preventing tetanus and at least 95 percent effective in prevention of diphtheria.  The combined preparation, Td, is the preferred preparation for active tetanus immunization of adults since a large proportion of adults lack protective levels of circulating antitoxin against diphtheria.  Furthermore, Td contains much less diphtheria toxoid than other diphtheria toxoid-containing products, and as a result, reactions to the diphtheria component are less likely.  Immunization with toxoid does not, however, prevent or eliminate carriage of Corynebacterium diphtheriae.

      2. Mumps

        Mumps vaccine is indicated for all adults, particularly males, believed to be susceptible.  Most adults are likely to have been infected naturally and generally can be considered immune, even if they did not have clinically recognizable mumps disease.  Killed mumps virus vaccine was available from 1950 until 1978.  Persons who received killed mumps virus vaccine might benefit from vaccination with live mumps virus vaccine.

    4. Special Considerations
      1. Pneumococcal Disease

        Routine administration of pneumococcal vaccine is not recommended.  However, personnel for whom pneumococcal vaccine is recommended include:

        • Those with chronic illness, especially cardiovascular and pulmonary disease.
        • Those with slenic dysfunction or anatomic asplenia, Hodgkin's disease, multiple myeloma, cirrhosis, alcoholism, renal failure, cerebral spinal fluid leaks, and conditions associated with immunodeficiency, and
        • All others healthy adults 65 years of age and older.
      2. Poliomyelitis

        Routine primary immunization for adults in the United States is not recommended.  Personnel who may have direct contact with patients who may be excreting polioviruses should complete a primary series.  Primary immunization with inactivated polio vaccine (IPV) instead of oral polio vaccine (OPV) is recommended for these persons whenever feasible.

        IPV is preferred because the risk of vaccine associated paralysis following OPV is slightly higher in adults than in children and because personnel may shed virus after OPV administration.  Primary immunization with IPV consists of three doses at intervals of 1 to 2 months between doses, with a fourth dose 6 to 12 months after the third dose.

        In an outbreak, OPV should be provided to anyone who has not been completely immunized or whose immunization status is unknown.

      3. Rabies

        Although rabies rarely affects humans in the United States, thousands of persons receive rabies vaccine every year, principally for postexposure prophylaxis.  The likelihood of human exposure to rabies from domestic animals has decreased greatly in recent years.  In every year since 1976, more than 85 percent of all reported cases of animal rabies have been among wild animals.  They are the most important source of possible infection for humans in the United States.  However, for persons traveling overseas to developing countries with endemic rabies, the dog remains the animal most likely to transmit rabies.

        Pre-exposure Immunization should be considered for high-risk groups such as animal handlers and persons planning to be in countries or areas of countries for more than 1 month where rabies is a constant threat.  Persons whose jobs bring them in contact with potentially rabid animals should also be considered for pre-exposure immunization.

    5. Vaccine Administration

      Specific vaccine dosage, schedule of administration, route of administration, indications, contraindications, side effects and adverse reactions are outlined in a variety of generally accepted sources.  For the purposes of the policies and procedures established in this Chapter the primary reference is:

      Adult Immunization
      Recommendations of the Immunization
      Practices Advisory Committee (ACIP)
      U.S. Department of Health and Human Services
      Public Health Service
      Centers for Disease Control (CDC)
      Atlanta, Georgia 30333

      Revisions to statements in this reference are made from time to time by the ACIP and are published in the Morbidity Mortality Weekly Review (MMWR).  The published revisions supersede the primary document referenced above.

    6. Records

      All employees who are given vaccine(s) or who have serologic testing to evaluate their immune status must be provided an individual record of the immunization(s) and test(s).  The record must include the following information:

      Employees Name
      Name of Vaccine
      Date Vaccine Administered
      Vaccine Lot Number
      Who gave or Where the Vaccine was Administered
      Date Next Dose or Booster is Due
      Serologic Test
      Date of Test
      Results of Serologic Test

      Appendix X shows a suggested record format.

      Similar immunization data must be entered in the employee's hospital or clinic record or in the employee's file.

    1. Headquarters Offices

      The Division of Personnel Management, Office of Administration and Management is responsible to inform Headquarters Office employees of the content and rationale of the IHS policy on employee immunizations.  Some Headquarters employees have occasional contact with patients and therefore should comply with the requirements established in this policy.  Although many Headquarters employees never are in contact with patients, they should be encouraged to update and maintain their immunization status for their own well being.

    2. Area Offices

      The Area Director is responsible for the implementation of the policies and procedures outlined in this Chapter.  Periodically, the Area Director may need to assess employee immunization levels to ensure that patients and employees are protected against vaccine preventable diseases.

    3. Service Units

      The Service Unit Director is responsible for establishing procedures that will ensure that all Service Unit employees are informed about the IHS employee immunization policy.  Procedures are to be set-up to provide employees the necessary vaccines or serologic tests.  Documentation of the immunizations and tests must follow the intent of the procedures outlined in this Chapter.

    4. Employees

      All IHS employees are expected to review their immune status and seek appropriate immunizations for the protection of patients with whom they are in contact and for their personal protection.


    Immunization Practices Advisory Committee, Adult immunization, MMWR 1984;33(Suppl l):lS-68s.

    Immunization Practices Advisory Committee, Measles prevention, MMWR 1989;38;No.S-9.

    Immunization Practice Advisory Committee, Protection against viral hepatitis, MMWR 1990;39;(No.RR-2):5-22.

    Immunization Practices Advisory Committee, Rubella prevention, MMWR 1990;39;(No.RR-15):1-18.

    Immunization Practices Advisory Committee, Diphtheria, tetanus, and pertussis:  guidelines for vaccine prophylaxis and other preventive measures, MMWR 1985;34:405-14,419-26.

    Immunization Practices Advisory Committee, Update: pneumococcal polysaccharide vaccine usage - United States. MMWR 1984;33:273-6,281.

    Immunization Practices Advisory Committee, Poliomyelitis prevention, MMWR 1982;31:22-6,31-4.

    Williams WW. CDC Guidelines for infection control in hospital personnel, Infect Control 1983;4(Suppl):245-325.

    1. Diphtheria, tetanus and Td vaccines
    2. Measles, mumps and rubella and measles, mumps and rubella vaccines
    3. Influenza and influenza vaccine
    4. Hepatitis B and Hepatitis B vaccine
    5. Pneumoccal disease and pneumococcal vaccine
    6. Polio and Polio vaccine
    7. Rabies and Rabies vaccine
    8. Consent Form
    9. Refusal Form
    10. Immunization Form