Operating Policy and Procedure
HSC OP: 40.01 , Health Surveillance Program for TTUHSC
PURPOSE: It is the policy of the Texas Tech University Health Sciences Center (TTUHSC) to maintain a Health Program that conforms to the guidelines established by the Centers for Disease Control and Prevention (CDC), recommendations of the Texas Department of State Health Services (DSHS), Texas Administrative Code (TAC) §96 – Bloodborne Pathogen Control, §97 – Communicable Diseases, and §99 – Occupational Diseases. This Program is directed toward primary prevention, early detection, and diagnosis of exposure related illnesses. The Program targets those who have contact with patients and/or human body fluids/tissues or those that (3) work with animals or infectious materials in any laboratory through the laboratory animal resource center. (LARC)
SCOPE: This Program applies to TTUHSC (all campuses). Attachments to this policy delineate processes by population (students, volunteers, and lab animal handlers addressing the management of Tuberculosis (TB), Immunizations, and Exposure Management.
IMPLEMENTATION: The President appoints an Institutional Health Managing Director to work with the Dean or Dean’s designee of each School, the Director of LARC, and the Director of Volunteer Services to implement the Program.
REVIEW: This HSC OP and attachments will be reviewed on June 1 of each odd-numbered year (ONY) by the Managing Director of the Office of Institutional Health, with recommendations for revision forwarded to the Chief Academic Officer/Provost by July 1.
POLICY/PROCEDURE:
1. Definitions:
a. Covered Individuals: Each Attachment to this policy designates categories of individuals covered by TTUHSC’s Institutional Health Program.
b. Exposure(s): An event (i.e., needlesticks, splash, cut, and puncture) where blood, body fluid, or infectious material/aerosol comes in contact with eyes, mouth, mucous membranes, or non-intact skin, during performance of assigned duties either as an employee or student.
c. Institutional Health Program: Immunizations, TB testing, pre/post exposure testing and monitoring, and education are arranged, coordinated, or provided by designated Institutional Health Resource at each campus under the direction of the Institutional Health Managing Director.
d. Designated Health Surveillance Unit: The office entity or individual designated by the Dean of each School to provide and administer the Institutional Health Program to covered individuals, in collaboration with the Institutional Health Managing Director. Please see Attachment F.
e. Laboratory Animal Resources Centers (LARCs): The campus facilities in which research animals are housed.
f. Post-Exposure Management: Treatment and monitoring initiated upon report of a TTUHSC related known or possible exposure to infectious diseases.
g. Pre-Exposure Management: Covered Individuals are (1) identified, (2) provided training for primary prevention of disease transmission and exposure to infectious materials, and (3) monitored for immunization compliance.
h. Medical Service Fee: Student Health fees paid by all TTUHSC students for basic health services.
i. Volunteer Services/Volunteer Representative: The office or designee responsible for orienting and tracking all volunteers working on a campus and associated off campus clinics.
j. Bacillus Calmette-Guérin (or Bacille Calmette-Guérin, BCG): is a vaccine against tuberculosis that is prepared from a strain of the attenuated (weakened) live bovine tuberculosis bacillus.
k. Screening and Immunization Fee: Fees paid by all TTUHSC students covering the cost of TB screening, annual Flu vaccine administration, blood borne pathogen exposure, immunization validation and record maintenance, and various other related costs.
l. APIC: Association for Professionals in Infection Control
m. SHEA: Society for Healthcare Epidemiology of America
n. IDSA: Infectious Disease Society of America
o. CDC: Centers for Disease Control and Prevention
p. TB Blood Test (IGRA): Interferon-Gamma Release Assay testing including both T-SPOT and Quantiferon.
q. Antibody Titers: Blood work proving immunity against vaccine preventable diseases.
2. Institutional Health Program
a. Program Components:
(1) Tuberculosis Surveillance: Tuberculosis surveillance for Covered Individuals is based on current U.S. Department of Health and Human Services, Centers for Disease Control and Prevention (CDC) Recommendations and Reports (2019) Tuberculosis Screening, Testing, and Treatment of US Health Care Personnel.
(2) Immunizations: Covered individuals should be in compliance with Healthcare Worker Vaccination Recommendations (attached, CDC, 2017) and Texas Administrative Code (TAC) § 97.64, “Required Vaccinations for Students Enrolled in Health-Related and Veterinary Courses in Institutions of Higher Education.” In accordance with section (a) this applies to all “students enrolled in health-related courses which involve direct patient contact in medical or dental care facilities. This includes all medical students, interns, residents, fellows, nursing students and others who are being trained in medical schools, hospitals, and health science centers listed in the Texas Higher Education Coordination Board's list of higher education in Texas…, regardless of: number of courses taken, number of hours taken, and classification of student.”
(3) Exposure Management: Institutional management of exposure to: (1) blood-borne pathogens, (2) body fluids (3) other miscellaneous exposures is based on regulations, guidelines and recommendations available as of June, 2012 from the Texas Administrative Code (TAC), Texas Department of State Health Services (DSHS), the U.S. Centers for Disease Control and Prevention (CDC).
(4) LARC Animal Occupational Health program: Health surveillance guidelines are designed to protect both people and the laboratory animals, and are based on the Guide for the Care and Use of Laboratory Animals (NRC 2008) Biosafety in Microbiological and Biomedical Laboratories, 5th Edition (2007), and other relevant published information.
(5) COVID-19 Vaccination: The Office of Institutional Health will provide, upon request, TTUHSC employees and students working or learning at a health care setting with direct patient care education and information on obtaining a COVID-19 vaccination. Education may include the benefits, risks, and potential side effects associated with the vaccine. Additionally, information will be provided regarding vaccine dosage as well as where to acquire the COVID-19 vaccine. Such requests for education and information on COVID-19 vaccinations will be voluntary.
In the event a non-TTUHSC facility requires COVID-19 vaccination, TTUHSC employees and students may be subject to those requirements as further provided in attachment G to this operating policy.
b. Identification of Covered Individuals:
(1) All TTUHSC students with direct patient care: covered under the Screening and Immunization Fee
(2) TTUHSC employees and volunteers (who have patient contact or work directly with animals): Updated lists of covered individuals will be provided to the Office of Institutional Health as requested and in a timely manner.
(3) Individuals working with animals through the Laboratory Animal Research Centers
c. Health Records:
(1) Employees: Each designated office shall maintain a separate health record including immunization, TB testing records, and exposure investigation documentation on SOM employees with direct patient care. All employees outside the SOM with direct patient care will be maintained through the Office of Institutional Health.
(2) Students: The Office of Institutional Health shall receive, validate, and maintain required pre-matriculation immunization documentation. Annual TB testing, influenza, and exposure management documentation will be coordinated and maintained through the Office of Institutional Health.
(3) Volunteers: Each campus that has a volunteer program will determine where the records will be maintained
d. Education/Training Program:
(1) Education towards primary prevention, early detection, and management of exposure will be coordinated through the Office of Institutional Health and the designated health surveillance units.
3. Responsibilities:
a. Covered Individuals: Responsible for reporting any exposure incidents to their immediate supervisor, or as otherwise designated per campus protocol, and for obtaining all immunizations/tests as required under the program.
b. Deans or Dean’s Designee of each School:
(1) Responsible for designating the school’s Institutional Health Resource office, entity, or individual and communicating with the Office of Institutional Health to ensure that the program operates in accordance with this policy.
(2) Require personnel under their supervision attend scheduled training sessions and keep follow up appointments as necessary with the Office of Institutional Health.
(3) Responsible for implementing disciplinary action, if necessary, in matters of non-compliance involving covered individuals under their supervision.
c. Director of Volunteer Services: Responsible for informing all volunteers regarding the Office of Institutional Health and ensuring compliance.
Attachment A - Health Surveillance Program for Students
Attachment B - Health Surveillance Program for Employees
Attachment C - Health Surveillance Program for Volunteers
Attachment D - Health Surveillance Program for LARC Employees and Animal Handlers
Attachment E - Healthcare Personnel Vaccination Recommendations
Attachment F - Delineation of Designated Health Surveillance Units
Attachment G - COVID-19 Vaccination Requirements of Non-TTUHSC Sites
Attachment H - Medical Exemption to COVID-19 Vaccination Request Form
Attachment I - Religious Exemption to COVID-19 Vaccination Request Form