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 and/or research activities, students may have contact with patients/subjects with AIDS(HIV), Tuberculosis (TB), Hepatitis B (Hep B), and other infections. This contact may expose the student to infectious agents that place the student at risk for contracting a communicable disease, or unknowingly transmitting an infectious disease to other students, faculty, patients, family members, and subjects. During pregnancy, the fetus may also be at risk.

To help protect the health and safety of its students, as well as that of patients and subjects, the School of Nursing requires:

1. Initial Infectious Disease Screening by the University's Student Health Service and the School's Office of Admissions and Student Services (OASS)

2. Pre-exposure prophylactic immunization against specified infectious/communicable diseases

3. Initial tuberculosis (TB) screening (two-step method) and annual follow-up

4. Post-exposure prophylactic follow-up/treatment of students following exposure to specified infectious diseases such as HIV/AIDS, tuberculosis and Hepatitis B.

5. Initial & annual training/self-study and testing in requisite clinical content for: bloodborne pathogens, tuberculosis &, infection control, and healthcare worker safety. (NOTE: the UNC Department of Environment, Health & Safety offers self-study online modules on these topics.)

Clinical Agency Infectious/Communicable Disease Policies/Protocols

Students must comply with the communicable/infectious disease policies 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-CH School of Nursing, the University, and state and Federal statues, regulations and mandates.

Enrollment and Health Screening

1. All students enrolled by the School of Nursing, are required by North Carolina statute to present to the University on or before the first day of enrollment a certificate of immunizations that indicates that the student has received the immunizations required. A deferral of the required immunizations for medical reasons may be granted provided written documentation is presented to Student Health Services and OASS.

2. If documentation of University required immunizations is not presented to Student Health Services on or before the first day of enrollment, 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 Registrar.

3. If documentation of the School of Nursing required immunizations is not presented to OASS (excluding the last injection of the Hepatitis B series [due no later than 7 months following the initial injection]), prior to the first day of enrollment in the School of Nursing, or as specified by OASS, the student shall be withdrawn from clinical practice/research assignments including Skills Lab Practice, and may be disenrolled from courses.

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.

1. 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.

2. For any student who experiences a blood or body fluid exposure incident, the School of Nursing is responsible for any and all medical costs incurred for the student's 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 the Student Health Service. Designated staff of SHS will document exposures managed by the SHS in charts maintained only for such exposures and available only for review by SHS designees and, when necessary, the legal counsel for the University. All specimens will be sent to the laboratory using a special code. For each "exposure" the following will be documented: the route(s) of exposure, the circumstances, the name of the source and HIV and Hepatitis B status of the source.

3. Any student who exposes another to his/her blood/body fluids and/or an infectious disease during clinical practice/research activities is responsible for all costs that may be incurred as a result of that exposure.

All School of Nursing students (undergraduate, graduate, post-graduate) who engage in clinical practice/research activities are required to submit documentation to OASS of current enrollment in a health insurance plan. Students may carry any health insurance plan that provides coverage for blood/body fluid exposure. Students without current health insurance coverage are strongly encouraged to enroll in the UNC Student Preferred Care Medical Insurance 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:

Students who fail to provide documentation of health insurance prior to the first day of enrollment in the School of Nursing, and on-going coverage while enrolled in the School, will not be allowed to engage in clinical practice/research activities, and may be disenrolled from courses.

Safety Education and Training

As required by the Occupational Health and Safety Administration (OSHA) students must receive annual instruction in the use of universal precautions and the care precautions applicable to individuals with infectious communicable diseases, including AIDS, tuberculosis, and Hepatitis B. Faculty and students will review the specific communicable disease policies of the facility or agency providing the clinical experience prior to clinical practice/research activities in that facility. Safety training may be undertaken with OASS in the School, or, if the student is employed by the University or UNC Health Care System, the education department of the employing facility. Evidence of certification, including date of instruction and post-test completion are required annually. Annual training and testing using self-study tutorials for these modules is required: Tuberculosis and Infection Control, Bloodborne Pathogens, and Healthcare Worker Safety. A copy of the certifying document must be maintained in the student's permanent file in OASS.

Student Refusal to Care for Patients with HIV-1 Disease, HBV, and Tuberculosis

Refusal to provide care to persons with HIV-1, HBV, Tuberculosis, and/or other infectious diseases is not in keeping with performance expectations for students at the School of Nursing and is inconsistent with the ethics of the nursing profession. It is expected that students will provide care to persons with HIV infection, Hep B, and Tuberculosis. In cases when continuing clinical practice/research activities present more than a minimal risk to the student, such as when a student is immunosuppressed, the student may be temporarily reassigned.]

Nursing's mandate to provide care is exquisitely expressed in a recent 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, April 1992.)

Required Immunizations for Students

1. Diphtheria, Tetanus, Pertussis (childhood DTP) or Diphtheria-Tetanus (Adult DT) - 3 dose series.
2. Diphtheria-Tetanus Booster - within last 10 years (may be part of DT series).
3. Polio - 3 doses only if under 18 years of age.
4. Mumps - vaccine or physician certified history of disease.
5. Measles (Rubeola) - required if born after 1956. Physician certified history of the disease or live vaccine given on or after first birthday, and after 03/21/63. (Booster prior to entry to first grade strongly recommended.)
6. Rubella (German measles) - required if under age 50 years. Vaccine after 06/09/69 or proof of immunity by blood test (titer). History of disease not acceptable.
   NOTE: Immunizations A through F are stipulations of North Carolina immunizations statutes/laws and are upheld by the University of North Carolina at Chapel Hill.
7. Varicella (Chicken Pox) - Submit a signed Affidavit of Varicella Immunity form indicating one of the following:
   1. Reliable memory of having had the disease (date and description of experience)
   2. Documentation of completed two-dose series vaccination
   3. Positive serologic titer
8. Hepatitis B Virus (HBV) Vaccination
   1. Students engaged in clinical practice/research activities shall begin the HBV three- dose vaccination series prior enrollment in the School of Nursing. It is required that students complete the HBV vaccination series no later than seven (7) months from the date of the initial injection of the three injection series.
   2. Effective May 2001, students must provide documentation of a post-vaccination serum antibody titer 4-6 weeks following completion of the vaccination series. The titer many be obtained from SHS or primary care provider of choice.
   3. Hepatitis B immunization is required of all undergraduate and graduate students who participate in clinical practice/research activities unless contraindicated upon a health care provider's advice. Written verification of the Hepatitis B vaccination contraindication or official deferral must be submitted to OASS. Both the student and health care provider must sign the deferral forms.
   4. Documentation of all required vaccinations must be submitted to OASS and maintained in the student's permanent file.
9. Tuberculosis Screening
   1. Prior to the first day of enrollment in the School of Nursing, students are required to submit documentation of two PPD Tuberculosis Skin Tests (Mantoux) within the past 12 months and the results, unless the test is contraindicated upon a health care provider's written advice. Written verification of the contraindication must be submitted to OASS and SHS. Failure to submit written documentation of TB screening shall result in the student being withdrawn from clinical practice and/or research assignments (including Skills Lab Practice) by the designated academic administrator or clinical faculty, and may be disenrolled from courses.
   2. Effective May 2001, the University's Student Health Service is requiring a two-step initial TB screen. All matriculating students shall undergo the primary test as described above, then within 2-3 weeks report to SHS or preferred primary provider for a second test. The purpose of this new requirement is to establish a baseline test reaction in each student. Following the initial two-step screen, students are required to submit documentation of annual testing thereafter.
   3. A student with a positive (>5mm induration) TB Skin Test shall:
      1. Adhere to the follow-up/therapeutic regimen of SHS or his/her health care provider
      2. Submit written documentation of adherence to any prescribed follow-up therapeutic regimen from SHS or preferred health care provider to OASS
      3. If reaction is >10 mm induration, present evidence of negative chest X-ray at least one year following initiation of treatment.
      4. Submit an Annual Tuberculosis Screen Questionnaire completed by SHS or his/her health care provider to OASS.
   4. A student who has diagnosed pulmonary symptoms suggestive of TB shall refrainfrom contact with patients/subjects until his/her health care provider submits writtendocumentation that the health of patients/subjects is no longer jeopardized. This required documentation must be submitted to OASS who shall submit copies of the documentation to Student Health Services.
   5. Neither faculty nor staff of the School of Nursing may "read" a student's TB skin test.

An immunization record shall be established and maintained in OASS and in Student Health Services.

1. OASS shall maintain records of the following:
   1. TB skin test results and Annual Tuberculosis Screening Questionnaires
   2. Hepatitis immunization and titer results
   3. Affidavit of Varicella Immunity form
   4. Annual OSHA test results
   5. Signed vaccination contraindication and refusal forms
   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.
   8. For RN-BSN and PMSN students only, immunization records for DTP or DT booster and MMR
2. Student Health Services maintains records of:
   1. DTP (Childhood) or DT (Adult Diphtheria-Tetanus)
   2. Diphtheria-Tetanus Booster
   3. Polio
   4. Mumps
   5. Measles (Rubeola)
   6. Rubella (German measles)
   7. TB Skin Test and positive results follow-up (International students)
   8. Official records of exposure incidents involving students

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 Student Health Service will maintain official records of students' exposure incidents that may occur during clinical practice/research activities. SHS will serve as an available consultant for local providers when a needlestick exposure occurs off-site. In the consultant capacity, SHS will provide local providers with a student's health record information and information related to the SHS blood and body fluid exposure protocol. Student Health Service 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-CH 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, Margaret Miller, Assistant Dean, Suite 1400, Carrington Hall:

1. Infection Control - Health Care Settings
2. HIV Treatment for Students After Needlestick Exposure
3. HIV-Infected and HBV-Infected Employees and Students
4. State and Federal statutes/regulations

Exposure Incidents

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. [Should an incident occur, you must follow the Exposure Protocol for Students at UNC-CH as established by the Student Health Service]

Follow-Up to Exposure to Blood/Body Fluids

Initial and subsequent care, and follow-up activities including recommendations related to counseling, prophylactic/treatment regimes, continued or restricted practice activities after 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 Student Health Service.]

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, SHS will provide the student with information regarding the health care professional's opinion.
2. "Exposure" incidents are reported to the appropriate sources by Student Health Services. 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 Student Health Services Needlestick Hotline, (919) 966-6573 or 966-6551, extension 2, during week-day hours (8 am - 5 pm) and Health Link during off-hours (966-2181) Students on-site should report to SHS immediately after the call. Off-site students should report to Student Health Services immediately upon return to the UNC-CH campus. Student Health Services' health care provider determines what the follow-up shall be for the exposed individual per their Bloodborne Pathogen Exposure Protocol.
2. In any instance where students practicing at UNC Hospitals have been the source of a blood or body fluid occupational exposure to a patient, that exposure must be reported to Hospitals' Risk Management Department. The information must also be reported to the appropriate unit of the non-UNC Hospitals agency(ies) to which the student is assigned.

References