Medical Screening, Surveillance and Vaccination
Christopher Brown of OSHA discussed the medical screening, surveillance and vaccination elements of the potential program standard OSHA is considering. Under the potential standard, employers would be required to make the following vaccinations available: seasonal influenza and other vaccines and booster doses recommended by the CDC Advisory Committee on Immunization Practices (ACIP). Employers would also be required to provide vaccine-related training (e.g., on the benefits of vaccinations) prior to making vaccinations available to workers. Employers would not be required to make vaccinations available to workers who have already been vaccinated, have documented immunity (e.g., antibody titer), have a medical contraindication, or have chosen to sign a declination form. Employers would be required to perform post-exposure follow-up with workers, to provide information about a worker's exposure to the worker's physician or other licensed healthcare professional (PLCHP), to ensure confidentiality, and to follow PLCHP recommendations for restrictions and modifications to job duties.
Employers would also be required to provide medical removal protection benefits for workers removed from their jobs or medically limited as a result of occupational exposure to an infectious disease. Although OSHA is considering including influenza in a potential standard's vaccination requirements, influenza or the common cold would not be included in the requirements for post-exposure reporting or medical removal protection.
Stakeholders expressed concern over how a new standard would affect employer-mandated vaccinations as a condition of employment. Focusing on how OSHA should not include language that would keep employers from requiring vaccinations as a condition of employment, they discussed the following points:
- In hospitals, public health concerns are the priority. Hospitals do have vaccination requirements as a condition of employment. Employees are also protected by measuring titers that indicate waning immunity. Variations in this requirement are community-specific.
-OSHA should refer to the BBP standard's language on hepatitis B for guidance. Although the BBP standard does not make a hepatitis B vaccination a condition of employment, it includes careful wording about properly informing employees of the benefits of the vaccination and post-exposure evaluation through training.
- OSHA should consider the legal and labor implications of mandatory vaccines. For example, one stakeholder stated that employer may not terminate workers for refusing vaccinations, but may restrict access to certain facility locations and require the worker to change jobs.
Edens clarified that employers may make vaccinations a condition of employment; however, while the potential standard OSHA is considering would require that employers make vaccinations available, that potential standard would not require employees to get them. The potential standard OSHA is considering would require that employers record which employees declined the vaccination, and implement means to train employees on the benefits of vaccinations and the risks associated with declining them.
Regarding declination of vaccinations, stakeholders made the following points:
- A new standard should require an educational program similar to the practices found in the hepatitis B section of the BBP standard. The commenter's BBP practices include an initial information sheet about the vaccination as well as further vaccination education if the worker refuses to get vaccinated. This approach allows the worker to make an informed and positive decision to get vaccinated.
- Most hospitals tend to require mandatory vaccinations. However, some hospitals do not do so. In this latter scenario, a worker who signs a declination form must meet with an epidemiologist to further discuss the implications of refusing the vaccine. This approach has proven to be effective.
- Employees may decline a vaccination if they have been previously vaccinated. OSHA needs to address scenarios where new employees do not have records of past vaccinations.
Stakeholders also expressed thoughts on vaccine-related issues:
- OSHA should not assume that vaccines will be 100 percent effective, and should rigorously pursue other alternative preventive practices. Although vaccination is the preferred method of prevention, OSHA should also consider PPE requirements.
- OSHA should consider vaccine availability issues that occurred during the H1N1 pandemic when supply of the vaccine could not meet the demand. If OSHA develops a new standard, OSHA should address situations where workers are required to be vaccinated but are not on the priority list.
- OSHA should address emerging pathogens in a new standard. Vaccinations will not be possible for all infectious agents.
- OSHA should address the use of investigational vaccines in a new standard. OSHA should consider availability and expense incurred with investigational vaccines.
- OSHA should address the extent of employer responsibility when providing vaccinations. For example, OSHA should consider whether employers are responsible for ensuring that workers receive all subsequent shots in a vaccination series.
Levinson said that OSHA is considering including the CDC's Advisory Committee on Immunization Practices' (AClP) recommendations for healthcare workers and laboratory workers in the potential standard.
There were a number of concerns related to exposure considerations that stakeholders shared:
- OSHA should address how employers determine whether there is occupational exposure to an infectious disease.
- Employers cannot always be aware of exposures. OSHA should emphasize that workers need to be adequately trained and provided with resources and PPE no matter what the exposure scenario.
- Some facilities have an internal risk assessment group that evaluates exposure situations and determines whether a significant exposure has occurred. OSHA should consider this approach if it develops a new standard to prevent unnecessary concern at the workplace.
- OSHA should emphasize the importance of screening, vaccinating and training new workers in a new standard. Employers should be required to immediately screen, vaccinate and train new employees when they first start the job to avoid exposure to infectious agents.
Stakeholders noted that the medical screening, surveillance and vaccination elements of the potential standard OSHA is considering are
already in place in most healthcare facilities.