Last month, we focused on how to create a written Exposure Control Plan as part of the practice's OSHA compliance program. In this issue, we are focusing attention on OSHA's requirement for keeping employee medical records and the availability of the hepatitis B vaccine as well as the guidelines for other important immunizations. Next month we will discuss how to build a Postexposure Management Plan.
The discussion of immunizations may remind you of your childhood vaccines and school requirements. Perhaps your hepatitis B vaccine comes to mind. Every dental office must carefully gather the necessary documentation for the employees' medical records to comply with Occupational Safety and Health Administration (OSHA) record keeping requirements that promote safety and health among those employees who have occupational exposure to bloodborne pathogens, such as HIV and the hepatitis B and C viruses.1 Currently, there are no immunizations for hepatitis C (HCV) or HIV.
Employee Medical Record The employee medical record is separate from the personnel record, which contains payroll information, the W-4 tax form, proof of identification, and copies of cardiopulmonary resuscitation (CPR) certification and a dental license. Rather, OSHA requires employee medical records on Class I and II employees with specific content:
• Name and Social Security number of employee • Copy of employee's hepatitis B vaccination (HBV) status, including all dates of series or copy of hepatitis B declination • Copy of results of examinations, medical testing, and follow-up of postexposure management
To simplify this task and to preserve confidentiality of personnel payroll data, the Safety Coordinator may want to assemble employee medical information in a separate file folder from the personnel record or in a file folder that can be inserted into the personnel record as an individual component. In this manner, the Safety Coordinator can request an individual medical record without having access to payroll information. Medical records remain on file for the duration of an employee's employment plus 30 years after the final employment date, according to OSHA's Bloodborne Pathogens Standard2 as well as its Access to Employee Exposure and Medical Records Standard.3
Hepatitis B Vaccine OSHA requires employers to make available, within 10 days of employment, the HBV at no cost to employees who have potential exposure. When gathering data for the employee medical record regarding the HBV, a mere, "Yes, I already had that done," is not sufficient. This type of comment is commonly heard when assembling documentation.
Note OSHA's requirement: "A copy of the eployee's hepatitis B vaccination status including the dates of all the hepatitis B vaccinations and any medical records relative to the employee's ability to receive vaccination."4A copy of the titer is acceptable.
The HBV is administered in 3 intramuscular ijections, with the second dose 30 days after the initial dose and the third dose 6 months later, which confers optimal protection.
Should employees have an HBV booster? According to the Centers for Disease Control and Prevention (CDC), further studies are necessary to assess the long-term protection of the vaccine and whether boosters should be recommended.5 Thus, at this time, boosters are not recommended providing there is evidence of successful seroconversion after having completed the series. Successful conversion is confirmed with a titer. A titer is a test that measures the presence and amount of hepatitis B antibodies in the blood. It indicates the body's exposure to the antigen, which causes the immune system to produce antibodies. Postvaccination testing is recommended for health care workers.6
Declination If the employee refuses the vaccine for personal reasons, such as religious views, medical history, or simply not wanting the vaccine, it is very important for the Safety Coordinator to obtain a Declination Statement, which must be retained in the employee's medical record. Statement language is dictated by OSHA7:
I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with hepatitis B vaccine, I can receive the vaccination series at no charge to me.
Other Recommended Vaccines According the CDC, dental workers are considered to be at substantial risk for acquiring or transmitting hepatitis B virus, influenza, measles, mumps, rubella, and varicella—all of which are vaccine-preventable. Therefore, the CDC recommends health care workers to show documented immunity to these diseases.8
Although these guidelines were published in the Guideline for Infection Control in Health Care Personnel, 1998, the recommendations were specifically adapted for dental personnel in December 2003. How complete are your practice's records?
Mumps The 2006 mumps epidemic in Iowa has made many individuals question their level of immunity. Mumps is caused by a virus and affects the parotid salivary glands. Severe complications include inflammation of the brain, ovaries, testicles, spontaneous abortion, and permanent deafness. The mumps virus is spread by direct contact with respiratory secretions, saliva, and fomites. Individuals born before 1957 were likely infected and are considered immune.9
Health care workers are at increased risk for acquiring and transmitting mumps. Therefore, 2 doses of measles, mumps, and rubella (MMR) vaccine are recommended unless an employee can provide proof of immunity.10
Varicella/Chicken Pox The Advisory Committee on Immunization Practices advises that all health care personnel verify their immunity to varicella because of the risk of acquiring and transmitting the virus. If a worker has had the disease, he or she is considered to be immune. If disease history is not certain, serologic screening is recommended. After the 2-dose adult vaccine, testing to determine seroconversion is not necessary because of the 99% response rate.11
Influenza Plain and simple, the CDC states: "All health care workers should be vaccinated against influenza annually. Facilities that employ health care workers are strongly encouraged to provide vaccine to workers by using approaches that maximize vaccination rates. This will protect health care workers, their patients, and communities, and will improve prevention of influenza-associated disease, patient safety, and will reduce disease burden."12
According to the CDC, removing administrative barriers, such as costs, inaccessible locations, and inconvenient times, can substantially improve the number of employees who get vaccinated. One survey indicated that 33% of health care workers would reject the influenza vaccine if they were required to pay for it.13
Summary According to the National Institute for Occupational Safety and Health, health care is the second fastest growing sector of our nation's economy, consisting of 12 million workers, 80% of which are women.14 Dental workers are exposed to a wide range of hazards. Although there are no current vaccines yet available for HCV and HIV, compliance with OSHA's regulation regarding the HBV and the CDC's vaccine recommendations for influenza, measles, mumps, rubella, and varicella promotes health and safety among dental workers by promoting prevention of vaccine-preventable diseases.
Next month, Compliance in Practice will review employee training on what constitutes an exposure incident and setting up a management plan that includes record keeping.
5. Mast EE, Margolis HS, 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 1: immunization of infants, children, and adolescents [published erratum appears in MMWR Morb Mortal Wkly Rep. 2006;55: 158-159]. MMWR Recomm Rep [serial online]. 2005;54(RR-16): 1-23. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/rr5416a1.htm?s_ci=rr5416a1_e. Accessed May 22, 2006.
6. National Center for HIV, STD, & TB Prevention. Hepatitis B vaccine fact sheet. Centers for Disease Control and Prevention Web site. Available at: www.cdc.gov/ncidod/diseases/hepatitis/b/factvax.htm. Accessed May 19, 2006.
8. Centers for Disease Control and Prevention. Guidelines for infection control in dental health care settings—2003. MMWR Recomm Rep. 2003;52(RR-17):7.
9. Bolyard EA, Tablan OC, Williams WW, et al. Guideline for infection control in health care personnel, 1998. Centers for Disease Control and Prevention Web site. Available at: http: //www.cdc.gov/ncidod/dhqp/pdf/guidelines/InfectControl98.pdf. Accessed May 22, 2006.
12. Recommendations for vaccination of health care workers. Centers for Disease Control and Prevention Web site. Available at: www.cdc.gov/flu/professionals/vaccination/hcw.htm. Accessed May 18, 2006.
13. Pearson ML, Bridges CB, Harper SA, et al. Influenza vaccination of health-care personnel: recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP) [published erratum appears in MMWR Recomm Rep. 2006;55(9):252]. MMWR Recomm Rep [serial online]. 2006;55(RR-02):1-16. Available at: http: //www.cdc.gov/mmwr/preview/mmwrhtml/rr5502a1.htm. Accessed May 18, 2006.
14. National Institute for Occupational Safety and Health. Health care workers. Centers for Disease Control and Prevention Web site. Available at: http: //www.cdc.gov/niosh/topics/healthcare. Accessed May 18, 2006.
Olivia Wann, RDA Olivia, owner of Modern Practice Solutions, specializes in compliance issues of dental practices. She is authorized by the Department of Labor as an OSHA Outreach Trainer and has developed user-friendly compliance materials. Olivia graduates this year from St. Joseph's College of Maine with a Bachelor's of Science Degree in Health Care Management and she plans to continue writing, consulting, and presenting seminars on compliance issues such as OSHA, HIPAA, coding, and human resource management.
Last month, we focused on how to create a written Exposure Control Plan as part of the practice's OSHA compliance program. In this issue, we are focusing attention on OSHA's requirement for keeping employee medical records and the availability of the hepatitis B vaccine as well as the guidelines for other important immunizations. Next month we will discuss how to build a Postexposure Management Plan. 
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