Infectious/Communicable Disease Policy Infectious/communicable diseases are common and may be a threat to students and faculty of the School of Nursing. During the performance of clinical practice/research activities, students may have contact with patients/subjects with various infections such as bloodborne transmitted disease (e.g., Hepatitis B [HBV], Hepatitis C [HCV], Human immuno-deficiency virus [HIV; AIDS]), airborne transmitted disease (e.g., tuberculosis[TB], measles, varicella), droplet transmitted disease (e.g., influenza, pertussis, mumps) and contract transmitted disease (e.g., methicillin-resistant Staphylococcus aureus). This contact may expose the student to infectious agents, and may result in the student transmitting an infectious disease to other students, faculty, patients, family members, and subjects. During pregnancy, the fetus may also be at risk depending on the infection (e.g., Varicella).
To help protect the health and safety of its students, as well as that of patients and subjects, the School of Nursing requires:
A. Initial infectious disease screening
B. Pre-exposure prophylactic immunization against specified infectious/communicable diseases
C. Post-exposure prophylactic follow-up/treatment following exposure to specified infectious diseases such as HBV, HIV, and tuberculosis
Clinical Agency Infectious/Communicable Disease Policies/Protocols
Students must comply with the communicable/infectious disease policy and protocols of the agency or facility with which they are assigned for clinical practice or research activity, as well as with the policies of the UNC-Chapel Hill School of Nursing, the University, state and Federal statues, regulations, and the contractual mandates of clinical affiliates.
Enrollment and Health Screening
A. All students enrolled in the University, are required by North Carolina statute to present to the University on or before the first day of enrollment a certificate of immunization that indicates that the student has received the vaccinations required. Student failure to submit documentation as described shall constitute significant non-compliance. In accordance with University policy, the student shall have 30 calendar days from the first day of classes to obtain the required immunizations. Students who fail to comply with the immunization requirements by the end of the specified 30 calendar days will be administratively withdrawn from the University by the University’s Registrar.
B. Student failure to submit documentation specific to School of Nursing required immunizations, health data and safety elements prior matriculation in the School of Nursing, shall result in the rescission of the student’s offer of admission to the School. Non-compliance that occurs after matriculation shall result in the student being withdrawn from lab/clinical practice/research assignments, loss of privileges in applicable Learning Management Systems, incurring an account hold and may impact enrollment.
C. Students have the right to petition for an exemption from statutorily required or School required immunizations. Appeals must be based on a student’s health condition, medical disorder or religious beliefs. Documentation supporting the exemption should be submitted to OASS and include: (1) a written justification from the student’s personal medical provider explaining why the vaccination is contraindicated; OR (2) a notarized copy of the “Request for Exemption from Immunization Requirements: Religious Reasons” form.
Health Costs and Coverage
Students may become ill, injured or exposed to infectious/communicable diseases while engaging in clinical practice/research activities. Illness, injury, or exposure to disease may require, but may not be limited to, counseling, prophylactic intervention, diagnostic procedures and/or follow-up treatment.
A. The School of Nursing is not liable for health care costs associated with a student’s illness or injury resulting from clinical practice/research activities.
B. For any student who experiences a blood or body fluid exposure incident, the School of Nursing is responsible for medical costs incurred for counseling and both initial and serial diagnostic testing. The student is responsible for all follow-up care and treatment and/or any diagnostic tests/procedures conducted subsequent to the evaluation phase. Should such post-exposure testing become necessary, all results will be held in the strictest confidence by CHS. Designated CHS staff will document exposures they manage in charts maintained only for such exposures and available only for review by CHS designees and, when necessary, the legal counsel for the University. All specimens will be sent to the Roche Biomed Reference Laboratory using a code. For each “exposure” the following will be documented: the route(s) of exposure, the circumstances, and the name of the source and HIV and Hepatitis B status of the source.
C. Any student who exposes another to his/her blood/body fluids and/or an infectious disease during clinical practice/research activities may be responsible for all costs incurred as a result of that exposure.
All School of Nursing students (undergraduate, graduate, and post-graduate) who engage in clinical practice/research activities are also required to submit documentation to OASS of current enrollment in a health insurance plan. Students may carry any health and accident insurance plan that provides coverage for blood/body fluid exposure. Students without current health insurance coverage are strongly encouraged to enroll in the UNC System-wide Student Health Plan. Enrollment in this Plan provides coverage for blood/body fluid exposures as well as other health related problems. For information related to specific coverage and coverage costs of the Plan, students are to contact:
Pearce & Pearce, Inc.
P.O. Box 2270, Florence, S.C. 29503
Students who fail to provide documentation of health insurance prior to the first day of enrollment in the School of Nursing will not be permitted to matriculate. Students failing to maintain on-going coverage while enrolled in the School, may not engage in any course related activities, and may be dis-enrolled until coverage has been re-established.
Safety Education and Training
As required by the Occupational Health and Safety Administration (OSHA) students must undergo annual training in the use of universal precautions and transmission-based precautions applicable to individuals with infectious communicable diseases, including HBV, HCV, HIV and tuberculosis. Safety training will be undertaken utilizing the University’s training modules or those required by the UNC Health Care System. The specific communicable disease policies of the agency to which a student is assigned for clinical experience will be reviewed by faculty and students prior to conducting clinical practice/research activities in that facility. Evidence of certification is required by the School upon initial matriculation and annually thereafter, and for each clinical agency assigned. A copy of the certifying document must be maintained in the student’s permanent file in OASS.
Student Refusal to Care for Patients with HBV, HCV, HIV, and Tuberculosis
Refusal to provide care to persons with HBV, HCV, HIV, Tuberculosis, and/or other infectious diseases is inconsistent with performance expectations for students at the School of Nursing and is antithetical with the ethics of the nursing profession. It is expected that students will provide care to persons with HBV, HCV, HIV, and Tuberculosis. In cases when continuing clinical practice/research activities present more than a minimal risk, such as when a student is immunosuppressed, the student may be temporarily reassigned.
Nursing’s mandate to provide care is exquisitely expressed in an ANA publication:
“Nursing is a caring profession, oriented toward patient advocacy. Because of nursing’s long history of standing ready to assist the ill and vulnerable in society, society has come to rely on nursing and to expect that it will rise to the health demands of virtually any occasion. In a sense, this reciprocity is crucial to the profession. All must know that care will be given when needed and that it will not be arbitrarily, prejudicially or capriciously denied.” (American Nurses Association Position Statement on Risk Versus Responsibility in Providing Nursing Care, December 8, 1994.)
Required Immunizations for Students
A. Diphtheria, Tetanus, Pertussis (childhood DTP) or Tetanus-Diphtheria (Adult TD) – 3 dose series.
B. Tetanus-Diphtheria (Td) Booster – every 10 years, or if no Td Booster obtained in this time period, a Tetanua-Diptheria-acellular Pertusis (TDaP) vaccination is required
C. Polio – 3 doses only if under 18 years of age.
D. Mumps – (1) documented administration of two doses of live mumps virus vaccine, or (2) laboratory evidence of immunity
E. Measles (Rubeola) – (1) documented administration of 2 doses of live measles virus vaccine, or (2) laboratory evidence of immunity
F. Rubella (German measles) – (1) documented administration of two doses of live rubella virus vaccine, or (2) laboratory evidence of immunity,
NOTE: Immunizations A through F are stipulations of the North Carolina immunization statutes and upheld by the University of North Carolina at Chapel Hill: http://www.immunizenc.com/ncrulesandlaws.htm
G. TDaP – documented administration of one dose of Tetanua-Diptheria-acellular Pertusis since 2005
H. Varicella (Chicken Pox) – (1) Documentation of completed two-dose series vaccination, or (2) Laboratory evidence of a positive serologic titer
I. Hepatitis B Virus (HBV) Vaccination
1. Documented administration of three dose vaccination series, completed no later than 6 months from program matriculation for all students engaged in clinical practice/research activities
2. Effective May 2001, laboratory evidence of immunity in the form of a post-vaccination serum antibody titer obtained 4-6 weeks following completion of the vaccination series. The titer many be obtained from CHS or primary care provider of choice.
J. Seasonal influenza: documentary evidence of seasonal influenza vaccine submitted prior to admission and annually.
K. Tuberculosis Screening
1. Tuberculosis Skin Test ( TST: purified protein derivative of Mycobacterium tuberculosis) and results within the past 12 months , unless the test is contraindicated upon a health care provider’s written advice. Written verification of the test results and/or contraindication must be submitted to OASS and CHS. Effective May 2001, the University’s Campus Health Services is requiring a two-step initial TST. All matriculating students shall undergo the primary test as described above, then within no less than 7 days and no more than 12 weeks report to CHS or preferred primary provider for a second test. This approach establishes a baseline test reaction in each student. Annual testing is required thereafter.
2. A student with a positive TST shall:
a. If reaction is >5mm induration, adhere to the follow-up/therapeutic regimen of CHS or his/her health care provider
b. If reaction is >10 mm induration, present documentation of: TST results, follow-up therapeutic regimen, treatment received (if any), and chest film results (if any). If treatment is initiated, a negative chest x-ray must be submitted one year post-diagnosis. An Annual TB Symptoms Questionnaire completed by CHS or the student’s health care provider is required annually thereafter
3. A student who has diagnosed pulmonary symptoms suggestive of TB shall refrain from contact with patients/subjects until his/her health care provider submits written documentation that the health of patients/subjects is no longer jeopardized. Neither faculty, staff nor students of the School of Nursing may “read” a student’s TST.
4. Persons allergic to the preservative in the TST, have been vaccinated with BCG or prefer an alternative to the TST, may instead undergo QuantiFERON-TB Gold testing initially and on an annual basis to diagnose current and latent cases of TB.
5. All students travelling outside the US must obtain a TST 6-8 weeks subsequent to their return to the US L. Other vaccinations: Students participating in international travel which is funded by the University or for which course credit is awarded must adhere to the University’s policies related to international travel, including adherence to all health and security requirements established by the Centers for Disease Control and Prevention and/or the US Department of State.
Immunization and Infectious Disease Record
An immunization record shall be established and maintained in OASS and in CHS.
A. OASS shall maintain records of the following:
1. TST results and associated documents, if any
2. Documentary evidence of immunizations (DPT, TDaP, MMR, Varicella, Influenza, HBV and seasonal influenza)
3. Signed vaccination contraindication and religious exemption forms
4. Documentation of vaccinations required for international travel
5. OSHA training and test results
6. Anecdotal documentation of exposure incidents involving students
7. Documentation of physician’s recommendation of return to clinical setting following exposure or positive test results.
B. Campus Health Services maintains official records of 1-4 above, plus:
1. Polio vaccination
2. Official records of exposure incidents involving students
School of Nursing Responsibilities and Resources
Infectious Disease Coordinator
A faculty member designated by the Dean serves as the Infectious Disease Coordinator to facilitate communication and dissemination of information about infectious disease control. The Coordinator apprises academic administrators and faculty of CDC recommendations, University, School, and/or agency requirements and other applicable information. The Infectious Disease Coordinator may serve as a resource to students who are exposed to an infectious disease. The University’s CHS will maintain official records of students’ exposure incidents that may occur during clinical practice/research activities. CHS will serve as an available consultant for local providers when a needlestick exposure occurs off-site. In the consultant capacity, CHS will provide local providers with a student’s health record information and information related to the CHS blood and body fluid exposure protocol. CHS will not serve as infectious disease consultants in the case of off-site exposures, however, they will manage care of the student upon the student’s return to the UNC-Chapel Hill campus. It is the responsibility of the clinical faculty to notify the Infectious Disease Coordinator or designee when exposure incidents occur. Anecdotal records of exposure incidents will be submitted to OASS to be filed with the student’s record. The following documents addressing University policy and North Carolina law are available for students’ review/copy in the Office of the Infectious Disease Coordinator, Dr. Margaret Miller, Assistant Dean, Suite 1400, Carrington Hall:
A. North Carolina Immunization Law General Statutes of North Carolina
B. General Statutes of North Carolina
a. Control Measures for Communicable Diseases
b. Control Measures – HIV
c. Control Measures – Hepatitis B
d. Control Measures – Tuberculosis
C. OSHA Occupational Safety and Health Standards, Bloodborne Pathogens
E. CDC Infection Prevention Guideline for Outpatient Settings
An “exposure incident” refers to a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from the performance of an employee’s duties [a student’s clinical practice/research activities] (OSHA). Students who follow the recommendations developed by the Centers for Disease Control (CDC Universal Blood and Body Fluid Precautions) have minimal danger of contracting any infection in the course of their clinical practice/research activities. When an incident occurs, students must follow the Exposure Protocol for Students at UNC-Chapel Hill as established by CHS.
Follow-Up to Exposure to Blood/Body Fluids
Initial and subsequent care and follow-up activities including recommendations related to counseling, prophylactic/treatment regimens, and continued or restricted practice activities following a student’s exposure incident will be determined by the student’s health care provider (in collaboration with the student) and other appropriate health care professionals. In the absence of a primary health care provider, the student should utilize CHS for health care.
All determinations regarding source of exposure including contact with source, notification of the source’s health care provider, testing of the source, and applicable laws/regulations regarding confidentiality will be made by the student’s health care provider.
1. In the case where source and student testing has been performed and evaluated, CHS will provide the student with information regarding the health care professional’s opinion.
2. “Exposure” incidents are reported to the appropriate sources by CHS. Documentation maintained by the School of Nursing is strictly anecdotal.
Student As Source of Blood or Body Fluid to Another Individual
The following steps are recommended when a student has exposed another individual (to his/her own blood/body fluids during practice, research or other care activities:
1. The exposed individual should immediately call the Campus Health Services Needlestick Hotline, (919) 966-6561 during week-day hours (8am – 5pm). After hours call 966-6561 and have the Health Link nurse page the on-call CHS physician. Students on-site should report to CHS immediately after the call. Off-site students should report to CHS immediately upon return to the UNC-Chapel Hill campus. Health care providers at CHS determine any needed follow-up for the exposed individual in accordance with their Bloodborne Pathogen Exposure Protocol.
2. In any instance where students practicing at UNC Hospitals are the source of a blood or body fluid occupational exposure to a patient, that exposure must be reported to Hospital Epidemiology (919) 966-1638. The information must also be reported to the appropriate unit of the non-UNC Hospitals agency(ies) to which the student is assigned.
American Nurses Association (1992). American Nurses Association position statement on HIV infection and nursing students. In: Compendium of American Nurses Association position statements. Washington, DC.
American Nurses Association (1996). American Nurses Association position statement on risk versus responsibility in providing nursing care. In: Compendium of American Nurses Association position statements. Washington, DC.
Campus Health Services, University of North Carolina at Chapel Hill (2010). Information about tuberculosis (TB) screening tests, Retrieved from http://campushealth.unc.edu/index.php?option=com_content&task=view&id=787&Itemid=65
Campus Health Services, University of North Carolina at Chapel Hill (2011). Bloodborne pathogen exposures – students (policy number: INF-N-03).
Campus Health Services, University of North Carolina at Chapel Hill (2011). Protocol for students of UNC-Chapel Hill, Retrieved from http://campushealth.unc.edu/index.php?option=com_content&task=view&id=121&Itemid=84
Centers for Disease Control and Prevention (1997). Immunization of health-care workers: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC), Morbidity and Mortality Weekly Report, 46(RR-18)
Centers for Disease Control and Prevention (1998). Measles, mumps, and rubella – Vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: Recommendations of the Advisory Committee on Immunization Practices (ACIP), Morbidity and Mortality Weekly Report, 47(RR-8)
Centers for Disease Control and Prevention (2000). Poliomyelitis prevention in the United States: Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 49(RR-5).
Centers for Disease Control and Prevention (2006). A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Hospital Infection Control Practices Advisory Committee (HICPAC) Part п: Immunization on Adults, Morbidity and Mortality Weekly Report, 55(RR-16)
Centers for Disease Control and Prevention (2007). Prevention of varicella: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report, 56(RR-4).
Centers for Disease Control and Prevention (2011). Guide to infection prevention for outpatient settings: Minimum expectations for safe care. Retrieved from http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html
General Assembly of North Carolina (2010). North Carolina Immunization Law General Statutes of North Carolina. Chapter 130A, Article 6, Part 2 Immunization. Retrieved from: http://www.immunizenc.com/NCRulesandLaws.htm
Jagger, J. De Carli, G., Perry, J. L., Puro, V., & Ippolito, G. (2003). Occupational exposure to blood-borne pathogens: Epidemiology and prevention. In R. P. Wenzel (Ed.), Prevention and control of nosocomial infections (4th ed, pp. 430-466). Philadelphia, PA: Lippincott Williams & Wilkins
North Carolina Office of Administrative Hearings (2003). Control measures for Hepatitis B (10A NCAC 41A .0203). Retrieved from http://ncrules.state.nc.us/ncac/title%2010a%20-%20health%20and%20human%20services/chapter%2041%20-%20epidemiology%20health/subchapter%20a/10a%20ncac%2041a%20.0203.html
North Carolina Office of Administrative Hearings (2005). Control measures- General(10A NCAC 41A .0201). Retrieved from http://ncrules.state.nc.us/ncac/title%2010a%20-%20health%20and%20human%20services/chapter%2041%20-%20epidemiology%20health/subchapter%20a/10a%20ncac%2041a%20.0201.html
North Carolina Office of Administrative Hearings (2007). Control measures – HIV (10A NCAC 41A .0202). Retrieved from http://ncrules.state.nc.us/ncac/title%2010a%20-%20health%20and%20human%20services/chapter%2041%20-%20epidemiology%20health/subchapter%20a/10a%20ncac%2041a%20.0202.html
North Carolina Office of Administrative Hearings (2011). Control measures – Tuberculosis (10A NCAC 41A .0203). Retrieved from http://ncrules.state.nc.us/ncac/title%2010a%20-%20health%20and%20human%20services/chapter%2041%20-%20epidemiology%20health/subchapter%20a/10a%20ncac%2041a%20.0203.html
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