Proof of Immunity Requirements for Health Care Providers and Students: A Guide

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AUTHORS:
Kathy Pichel-McGovern, MSN, CRNP, and Theresa Smith, MSN, CRNP
Arcadia University, Glenside, Pennsylvania

CITATION:
Pitchel-McGovern K, Smith T. Proof of immunity requirements for health care providers and students: a guide [published online June 26, 2017]. Consultant360.

Although the Centers for Disease Control and Prevention (CDC) and the Advisory Committee on Immunization Practices (ACIP) vehemently state that serologic testing is not indicated for documented verification of childhood vaccinations, many health care organizations nevertheless are requiring “proof of immunity” from their health care providers, health professions students, and volunteers in their facility. So, which tests should be ordered, and how should the results be managed appropriately?

Over the past 9 years, the staff at our university student health center has witnessed a progression from a requirement to simply validate the immunization dates of individuals who will be entering the health care field (eg, medical, nursing, physical therapy, physician assistant, and genetic counseling students) or other profession that may include working with blood and body fluids (eg, forensic science students) to requiring serologic tests to confirm immunity, interpretation of the resulting data about therapeutic immunity responses, and follow-up with these individuals.

Verification of the usual childhood immunizations should include the following: 5 diphtheria, tetanus, and pertussis vaccinations; 4 oral or inactivated polio vaccinations; 2 doses of the measles, mumps, and rubella (MMR) vaccine; a positive history of chickenpox or 2 varicella vaccinations; and 3 doses of the hepatitis B virus (HBV) vaccine. Immunity titers must reflect a “therapeutic” response to qualify the individual as “immune,” and this is where confusion exists about how to manage nontherapeutic results. Health care organizations currently are not requiring serologic evidence of polio immunity, nor are hepatitis A and meningitis vaccination verification required. Annual influenza vaccinations are absolutely required of persons working, training, or volunteering in health care settings.

Hepatitis B Virus

• The CDC and ACIP recommend a 3-dose vaccination series for HBV. Health care providers can receive the vaccine at any time, with the first dose followed 1 month later by the second dose, and the third dose given at 6 months after the first dose. Serologic testing can be performed 1 month after the third and final dose. An accelerated series is available in which the first dose and the last dose can be 4 months apart, with 4 weeks required between the first and second dose and 8 weeks between the second dose and the third dose, with 16 weeks overall between the first and the third dose.¹ Additionally, incomplete vaccination series does not have to restart. Documentation of immunizations is considered acceptable, and the series can be completed from previous documented dates.²
• Testing: The hepatitis B surface antibody (anti-HBs) test determines immunity.
• If anti-HBs result is less than 10 mIU/mL (negative), the individual is not protected from HBV infection. He or she should receive 3 additional doses of the HBV vaccine on the routine schedule, followed by anti-HBs testing 1 to 2 months later. If the anti-HBs test results remain less than 10 mIU/mL after 6 doses, the patient is considered a nonresponder. Individuals who have measurable but low levels of anti-HBs after the initial series have a better response to revaccination than those who have no measurable anti-HBs.²
• Health care providers who are nonresponders could be susceptible to HBV infection and should be educated about precautions to prevent HBV infection and the need to obtain hepatitis B immune globulin prophylaxis for any known or probable parenteral exposure.² It is also possible that nonresponders are hepatitis B surface antigen (HBsAg) positive, and therefore HBsAg testing is recommended. Health care providers who are found to be HBsAg-positive should be counseled and medically evaluated. The ACIP does not recommend more than 2 vaccine series in nonresponders.³
• A person can be positive for total hepatitis B core antibody (anti-HBc) but HBsAG-negative.⁴ This implies that the person has chronic or ongoing HBV infection and thus must be counseled and advised about caring for patients in a health care setting.

Measles/Mumps/Rubella

• Per the CDC and ACIP, 2 documented doses of the MMR vaccine is considered an acceptable assumption of immunity.
• Testing: MMR enzyme immunoassay or enzyme-linked immunosorbent assay.
• Health care providers with 2 documented doses the MMR vaccine are not recommended to be serologically tested for immunity. Those who have had only 1 documented dose of the MMR vaccine should receive a second dose to complete the initial series. Serologic testing for immunity should be obtained at least 1 month after the second dose. Vaccination series need not be repeated if there is documentation. Those who do not have documentation of having received the MMR vaccine and whose serologic test results have been interpreted as indeterminate or equivocal should be considered not immune and should receive 2 doses of the MMR vaccine. The first and second dose should be separated by at least 4 weeks.⁵ Serologic testing should be repeated 1 month after the last dose. If the results remain subtherapeutic or negative, the person is considered a nonresponder. No further immunizations are required after the series has been repeated.

Varicella

• Per the CDC and ACIP, 2 documented doses of the varicella vaccine or a documented history of having had chickenpox is considered acceptable assumption of immunity.
• Testing: Varicella zoster virus immunoglobulin G antibodies.
• Health care providers with 2 documented doses the varicella vaccine or a documented history of illness are not recommended to be serologically tested for immunity. Those who have had only 1 documented varicella vaccination should receive a second dose to complete the initial series. The second dose should be given 4 to 8 weeks after the first dose. Serologic testing for immunity should be obtained at least 1 month after the second dose. Vaccination series need not be repeated if there is documentation. Those who do not have documentation of having received the varicella vaccine or having had chickenpox, or whose serologic test results have been interpreted as indeterminate or equivocal should be considered not immune and should receive 2 doses of the varicella vaccine.⁶ Serologic testing should be repeated 1 month after the last dose. If the results remain subtherapeutic or negative, the person is considered a nonresponder. No further immunizations are required after the series has been repeated.

Education Is Needed

Although the CDC and ACIP do not recommend serologic testing for documented vaccinations for HBV, MMR, or varicella, institutions are mandating documented evidence of immunity for the health care providers, students, and volunteers at their facility. The serologic testing for these individuals is relatively costly and may provide unclear results about these individuals’ immunity status. To avoid these pitfalls, we need to educate the decision-makers at institutions about the CDC and ACIP recommendations and the theories that correspond to them.

Kathy Pichel-McGovern, MSN, CRNP, is a certified nurse practitioner and the director of Student Health Services at Arcadia University in Glenside, Pennsylvania.

Theresa Smith, MSN, CRNP, is a certified nurse practitioner and is the assistant director of Student Health Services at Arcadia University in Glenside, Pennsylvania.

References:

1. Hepatitis A and hepatitis B vaccines: be sure your patients get the correct dose. Immunization Action Coalition. http://www.immunize.org/catg.d/p2081.pdf. Accessed April 12, 2017.
2. Schillie S, Murphy TV, Sawyer M, et al. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep. 2013;62(RR-10):1-19.
3. Shefer A, Atkinson W, Friedman C, et al. Immunization of health-care personnel: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2011;60(RR-7):1-45.
4. Mast EE, Weinbaum CM, Fiore AE, et al. 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) part II: immunization of adults. MMWR Recomm Rep. 2006;55(RR-16):1-33.
5. Standing orders for administering measles, mumps & rubella vaccine to adults. Immunization Action Coalition. http://www.immunize.org/catg.d/p3079.pdf. Accessed April 12, 2017.
6. Standing orders for administering varicella vaccine to adults. Immunization Action Coalition. http://www.immunize.org/catg.d/p3080.pdf. Accessed April 12, 2017.