Ask Matt - April 2011 – Vaccinations and Physicals

1. Ask Matt - April 2011 – Vaccinations and Physicals Matt Carver, J.D., Director of Legal Services tel - 515.267.1115 fax - 515.267.1066

2. Vaccinations & Physicals • Resource for health related issues at the DE: • Charlotte Burt, DE School Nurse and Health Services Consultant • Telephone - 515-281-5327 • email – charlotte.burt@iowa.gov.

3. Vaccinations & Physicals • The Iowa Association of School Board’s model policy includes the following language: “It shall be the responsibility of the superintendent to write an exposure control plan to eliminate or minimize district occupational exposure to bloodborne pathogens. • Check to ensure your district has an exposure control plan.

4. Vaccinations & Physicals • The Occupational Safety and Health Administration (OSHA) promulgated the Occupational Exposure to Bloodborne Pathogens Standard in 1991 (hereinafter the “Standard”), to protect employees from exposure to bloodborne pathogens, such as Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV), as well as many more pathogens that have no vaccination requirement and/or availability. • The Standard applies to all employees who have “occupational exposure” to blood or other potentially infectious materials (OPIM).

5. Vaccinations & Physicals • “Occupational exposure” is defined as “reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or OPIM that may result from the performance of the employee’s duties.” • “Parenteral” means piercing mucous membranes or the skin barrier through such events as needlesticks, human bites, cuts, and abrasions.” (29 CFR 1910.1030) • Every biting incident does not result in parenteral contact. The key is whether the skin barrier may have been pierced. • Think of OPIM as any body fluid that is visibly contaminated with blood, and all body fluid in situations where it is difficult or impossible to differentiate between body fluids. An employee’s contact with a student’s saliva or tears does not equate to an occupational exposure incident. A student spitting in the eye of a staff member may be gross, but is not an example of occupational exposure, nor is a student crying on a staff member’s shoulder.

6. Vaccinations & Physicals • Who has “occupational exposure” to blood or other OPIM in your school buildings? • It is important to know that an employee just having a chance of blood to blood exposure, or even occasionally providing first aid on site, does not meet the OSHA definition of a position having “occupational exposure.” • While the mere possibility of each employee encountering such an incident may not result in an “occupational exposure” determination for the position, it does highlight how recommended training may assist all staff with prevention on this topic.

7. Vaccinations & Physicals • What is the significance of a position not being classified as having “occupational exposure” to blood or OPIM? • While your district policy may require a Hepatitis B vaccination for all employees, OSHA will consider it a de minimis violation (carrying no penalties), and not issue a citation, if the vaccination is not provided to employees who provide first aid as a collateral duty to their routine work assignment. • This generally relates to first aid provided at the location of an incident.

8. Vaccinations & Physicals • Let’s say Tanner trips during class and knocks his head on a desk, resulting in a cut on his forehead. Mrs. Carver, Tanner’s teacher, grabs the first aid kit, puts on gloves, uses a protective barrier (e.g., an absorbent pad, towels, or some other barrier to prevent seepage of blood or OPIM), applies some gauze to his head, and walks Tanner to the nurse. In this example, Mrs. Carver is providing the first aid as a collateral duty, while the nurse provides first aid as a required duty under her job description. In addition to nurses, also consider other employees who may have additional duties to provide first aid. As a rule of thumb, consider whether individuals with injuries are brought to that employee for assistance, or if the employee is contacted to go to the site of a medical incident to provide assistance. If this is an expectation of the employee’s job duties, then s/he likely has occupational exposure to blood and OPIM, and the school district is required to provide hepatitis B vaccinations, free of charge to the employee.

9. Vaccinations & Physicals • Are kitchen staff or bus drivers considered to have occupational exposure? • There is no federal expectation that kitchen staff or bus drivers have occupational exposure to blood and OPIM, so district personnel will have to make an assessment of whether the duties expected in your district do include occupational exposure. While it is not mandated, your district may make a determination that kitchen staff and/or bus drivers do have occupational exposure.

10. Vaccinations & Physicals • Janitorial staff??? • Outside of health care facilities, OSHA does not generally consider janitorial staff to have an occupational exposure. OSHA expects products such as used sanitary napkins to be discarded into waste containers that are lined in such a way as to prevent contact with the contents. NO BAGLESS GARBAGE CANS OR CONTAINERS. • The employer must determine if employees can come into contact with blood during the normal handling of such products from initial pick-up through disposal in the outgoing trash. If OSHA determines, on a case-by-case basis, that sufficient evidence of reasonably anticipated exposure exists, the employer will be held responsible for providing protections of 29 CFR 1910.1030 (the applicable federal regulations on this topic) to the employees with occupational exposure.

11. Vaccinations & Physicals • Districts are not off the hook if employees provide first aid as a collateral duty, and the de minimis classification might protect the district from a citation. OSHA will expect a school district to meet the following conditions for the de minimis classification to apply: 1) Reporting procedures must be in place under the exposure control plan to ensure that all first aid incidents involving exposure are reported to the employer before the end of the work shift during which the incident occurs. 2) Reports of first aid incidents must include the names of all first aid providers and a description of the circumstances of the accident, including date and time, as well as a determination of whether an exposure incident, as defined in the standard, has occurred.

12. Vaccinations & Physicals 3) Exposure reports must be included on a list of such first aid incidents that is readily available to all employees and provided to OSHA upon request. 4) First aid providers must receive training under the Bloodborne Pathogens Standard that covers the specifics of the reporting procedures. 5) All first aid providers who render assistance in any situation involving the presence of blood or other potentially infectious materials, regardless of whether or not a specific exposure occurs, must have the vaccine made available to them as soon as possible but in no event later than 24 hours after the exposure incident. If an exposure incident as defined in the standard has taken place, other post-exposure follow-up procedures must be initiated immediately, per the requirements of the standard.

13. Vaccinations & Physicals • Back to the example of Mrs. Carver walking Tanner down to the nurse, with gauze applied to the cut on his head. (Remember, she should be wearing gloves and using a protective barrier as she assists Tanner.) While OSHA may not require the school district to give a hepatitis B vaccination to Mrs. Carver up front, since first aid is a collateral part of her duties, the district is required to make a hepatitis B vaccination available to Mrs. Carver within 24 hours of the incident, in order for the de minimis classification to apply, if there was potential blood to blood exposure during the incident. • Such blood to blood exposure may have occurred if Tanner’s blood potentially came into contact with non-intact skin on Mrs. Carver (such as a cut or a sore).

14. Vaccinations & Physicals • For positions with an occupational exposure to blood and OPIM, when does OSHA require the school district to offer hepatitis B vaccinations? • Vaccinations must be offered within ten (10) working days of initial assignment. Your school district must bear those expenses relating to provision of the hepatitis B vaccination, as well as post-exposure evaluations and follow-up [e.g., the school district would cover costs related to Mrs. Carver’s potential blood to blood exposure with Tanner’s blood (via a cut or sore on Mrs. Carver’s skin)]. • In some instances, these expenses may be covered under district provided health care insurance, but the employee should not have to bear related out of pocket expenses, such as a co-pay.

15. Vaccinations & Physicals • Other than what we have already discussed above, when are hepatitis B vaccinations not required? • Even for those with occupational exposure, OSHA does not require school districts to provide the hepatitis B vaccination to employees: 1) who have previously received the vaccination series; 2) who are already immune as their antibody tests reveal [as a side note – most times this test is the same cost as hepatitis B vaccination, so the hepatitis B vaccination is just administered]; or, 3) who are prohibited from receiving the vaccine for medical reasons.

16. Vaccinations & Physicals • May employees decline vaccination? • Yes, after the school district has informed an employee of the benefits of the hepatitis B vaccination, the employee may decline the vaccination, as long as s/he signs a hepatitis B vaccine declination. If your administration feels there is a reason to require vaccination for a particular job, I would run such a requirement by your school district’s legal counsel.

17. Vaccinations & Physicals • Key portions of Iowa law. • 281 Iowa Administrative Code • 12.4(14) Physical examination. Except as otherwise provided in 281—43.15(285), the local board shall require each employee to file with the local board, after an offer of employment is made and before or within six weeks of the beginning of service, certification of fitness to perform the tasks assigned which shall be in the form of a written report of a physical examination by a licensed physician and surgeon, osteopathic physician and surgeon, osteopath, or qualified doctor of chiropractic, licensed physician assistant, or advanced registered nurse practitioner. • Each doctor of chiropractic licensed as of July 1, 1974, shall affirm on each certificate of physical examination that the affidavit required by Iowa Code section 151.8 is on file with the Iowa board of chiropractic examiners.

18. Vaccinations & Physicals • Work with your school district’s legal counsel to develop job descriptions for each position. This will not only assist on determining essential functions for disability related purposes, but may allow your district to refine what medical certification is necessary for each employee.

19. Physicals (Bus Drivers) • 281—43.15(285) Physical fitness. Except for insulin-dependent diabetics, an applicant for a school bus driver’s authorization must undergo a biennial [every 2 years] physical examination by a licensed physician or surgeon, osteopathic physician or surgeon, osteopath, qualified doctor of chiropractic, licensed physician assistant, or advanced registered nurse practitioner. The applicant must submit annually to the applicant’s employer the signed medical examiner’s certificate (pursuant to Federal Motor Carrier Safety Administration regulations 49 CFR Sections 391.41 to 391.49), indicating, among other requirements, sufficient physical capacity to operate the bus effectively and to render assistance to the passengers in case of illness or injury, and freedom from any communicable disease. At the discretion of the chief administrator or designee of the employer or prospective employer, the chief administrator or designee shall evaluate the applicant’s ability in operating a school bus, including all safety equipment, in providing assistance to passengers in evacuation of the school bus, and in performing other duties required of a school bus driver.

20. Physicals (Bus Drivers) • 281—43.17(285) Insulin-dependent diabetics. A person who is an insulin-dependent diabetic may qualify to be a school bus driver if the person meets all qualifications of Iowa Code subsection 321.375(3). Such driver is subject to an annual physical examinationby a qualified medical examiner as listed in rule 281—43.15(285).

21. Physicals (Bus Drivers) • Iowa Code §321.375(3) 3. a. Notwithstanding any provision to the contrary, an insulin-dependent diabetic may qualify under subsection 1, paragraph “d”, for purposes of operating a school bus under this section if a person identified by federal or state law as authorized to perform physical examinations annually provides a signed statement indicating that based upon an annual physical examination the individual is physically able to perform the required functions despite insulin dependency. The insulin-dependent diabetic shall not qualify to operate a school bus if, at minimum, the individual results of a glycosylated hemoglobin test indicate values less than 6.0 percent or greater than 9.5 percent on other than an incidental basis and not as a result of failure to control glucose levels. The statement shall also indicate that within the past three years the insulin-dependent diabetic has completed instruction to address diabetes management and driving safety, signs and symptoms of hypoglycemia and hyperglycemia, and what procedures must be followed if complications arise.

22. Physicals (Bus Drivers) • b. A school district or authorities in charge of the nonpublic school that employs or otherwise secures the services of an individual with an authorization who is an insulin-dependent diabetic shall monitor the insulin-dependent diabetic to determine that they are in compliance with all of the following: (1) Self-monitoring blood glucose and demonstrating conformance with requirements, more than one hundred milligrams per deciliter and less than three hundred milligrams per deciliter, within one hour before driving a school bus and approximately every four hours while on duty using a United States food and drug administration approved device. (2) Reporting immediately to the school district or school any failure to comply with specific glucose level requirements as listed in subparagraph (1) or loss of consciousness or control.

23. Physicals (Bus Drivers) (3) Carrying a source of readily absorbable, fast-acting glucose while on duty. (4) Maintaining a daily log of all glucose test results for the previous six-month period and providing copies to the school district or school, the examining physician, and the department of education upon request. (5) Submitting all required department of education forms within the prescribed timelines.

24. Physicals - Iowa Quality Preschool Program Standards (IQPPS) • Preschool 4 year old program 3 choices-National Association for Young Children (NAEYC) and Iowa Quality Preschool Program, or Department of Human Services Licensure [DHS license for child care center]. IQPPS and NAEYC must meet 85% of the standards, so if the program does not meet teacher health requirement it could be in the 15% of the standards evaluators decide not to meet. • If you have questions about IQPPS check with your AEA contact.

25. Physicals - Iowa Quality Preschool Program Standards (IQPPS) • Iowa Quality Preschool Program Standards (IQPPS) - 4 year old state grant program (bold added)-Same for NAEYC Program • 281 IAC 16.2 Definitions • “Preschool program” means the statewide voluntary preschool program for four-year-old children created in Iowa Code chapter 256C. • “Program standards” means the expectations for the characteristics or quality of early childhood settings, centers, and schools approved by the department. Approved program standards include National Association for the Education of Young Children (NAEYC) Program Standards and Accreditation Criteria, Head Start Program Performance Standards, the Iowa Quality Preschool Program Standards (QPPS) and Criteria, or other approved program standards as determined by the department [DHS license for child care center].

26. Physicals - Iowa Quality Preschool Program Standards (IQPPS) • 281 IAC 16.3 • 281—16.3(256C) Preschool program standards. Approved program standards include Head Start Program Performance Standards, Iowa Quality Preschool Program Standards and Criteria, or the National Association for the Education of Young Children Program Standards and Accreditation Criteria. All approved local preschool programs shall adopt preschool program standards and, in addition, shall meet the following requirements: … location IQPPS-and NAEYC requirements • http://www.iowa.gov/educate/index.php?option=com_content&task=view&id=681&Itemid=1571 • Go to bottom of page to IQPPS Implementation Guide (pdf) • Standard 10.17

27. Physicals - Iowa Quality Preschool Program Standards (IQPPS) • Standard 10.17 - Programs maintain current health information from documented health assessments for all paid staff and for all volunteers who work more than 40 hours per month and have contact with children. A current health assessment (not more than one-year-old) is received by the program before an employee starts work or before a volunteer has contact with children. The health assessment is updated every two years. Documented health assessments include: • Immunization status; • Capacities and limitations that may affect job performance; and

28. Physicals - Iowa Quality Preschool Program Standards (IQPPS) • Standard 10.17 - (cont.) • Documentation by a licensed health professional of TB skin testing using the Mantoux method and showing the employee to be free from active TB disease. For those who have positive TB skin tests and who develop a persistent cough or unexplained fever, immediate assessment by a licensed physician is required. For those who have increased risk of TB according to the Centers for Disease Control (CDC), documentation is required annually by a licensed health professional showing that the employee is free from active TB disease. • The Mantoux method is named after a French physician, Charles Mantoux, who developed the test in 1907.

29. Physicals - Iowa Quality Preschool Program Standards (IQPPS) • Summary IQPP Standard Requirements: • IQPP staff report additional requirements list immunization dates/status, TB test annually, capacities and limitations, health assessment every 2 years, fingerprint search documentation, professional development plan and evaluation annually

30. Physicals - Iowa Quality Preschool Program Standards (IQPPS) • Department of Human Services (DHS) License requirements Child Care Centers            • 441—109.9(237A) Records. • 109.9(1) Personnel records. The center shall maintain personnel information sufficient to ensure that persons employed in the center meet minimum staff and training requirements and do not pose any threat to the health, safety, or well-being of the children. Each employee’s file shall contain, at a minimum, the following: . . . • d. A physical examination report. Personnel shall have good health as evidenced by a preemployment examination, including testing for communicable diseases which shall include testing for tuberculosis, performed within six months prior to beginning employment by a licensed medical doctor, doctor of osteopathy, physician’s assistant or advanced registered nurse practitioner and repeated at least every three years after initial employment.

31. Vaccinations & Physicals - Questions ???????