Jumping through the Hoops:

Immunization and Other Pre-Matriculation Mandates for EMS and Allied Health Students

Daryl Boucher, MS, RN, CCEMT-P, Allied Health Coordinator, Northern Maine Community College

At the start of every clinical course, EMS instructors and clinical coordinators are faced with the arduous task of ensuring that all students entering the clinical environment meet many admission requirements. Students and instructors alike may become frustrated with the growing list of regulatory prerequisites for clinical, and the hours that are needed to document compliance. For some students, the mandatory admission requirements present another barrier to pursuing their education. However, with proper preplanning and early application, the burden of completing these tasks is lessened. More importantly, both clinical instructors and students can feel confident that students will be as safe as possible as they begin caring for high risk patients. The purpose of this article is to guide students and instructors through the maze of state, federal and facility immunization requirements before every student’s clinical experience, and to provide tips to clinical coordinators on how to better track and monitor students.

There are two critical points on which this article is based: first, it is important to recognize that colleges, schools, clinical organizations, and ambulance services have different and varying requirements, and with emerging research, these requirements seem to change annually. Additionally, programs may change their requirements for students based on risk. For example, the risk of needle stick for an EMT-Basic student is significantly lower than that for an ALS provider, and the time spent doing clinical work is far less, therefore, the overall risk for the EMT-Basic is less. Consequently, it may be reasonable for some programs to adjust the clinical requirements slightly based on level of licensure course or on assessment of risk of exposure to the student. However, there are some constants that every EMS student must meet, and this article will provide general CDC guidelines. When in doubt, though, it is important to contact the experts.

The second critical point on which this article is based is that government mandated immunization is not only for the protection of the provider, but also for the protection of the immunocompromised patients we come in contact with during every clinical experience. I frequently remind frustrated applicants that above all, our charge is to first “do no harm,” and failing to be fully immunized could potentially place high risk patients at even greater risk.

Who makes the rules

Immunization guidelines and prerequisite lists are established by various organizations, including the Centers for Disease Control (CDC), CDC Maine (formerly the Bureau of Health), OSHA, and by various accrediting bodies. Additionally, hospitals, ambulance services and healthcare organizations may add additional requirements. Colleges and sponsoring organizations may also have slightly different rules. For example, at Northern Maine Community College, we require all EMS students not only to have a complete immunization record, but also to have a respirator fit test and a complete physical prior to entry into the program. This assures that, should a student need to care for a high risk patient, he or she has already been properly fitted and is knowledgeable about accurate use of a respirator. While not all programs have this obligation, the risk of exposure is considerable, and the cost for such a requirement is minimal. Many places contract with an advanced practice nurse to perform this function.

Furthermore, most clinical facility contracts specify student and faculty requisites for clinical. Failure to comply places the clinical contract between the clinical site and the training entity in jeopardy, so leaders painstakingly assure all students meet the clinical requirements.

Table 1

Sample Clinical Contract Student and
Faculty Requirement List

All students completing clinical rotations at this facility must have on record:

Immunizations including DPT, hepatitis B, polio, MMR and titer, varicella or titer, and PPD annually

CPR healthcare provider

Liability insurance of $1 million per occurrence/$3 million aggregate

Signed HIPAA and confidentiality agreements

Rules for hospital-based and municipal-based services also vary considerably. Hospital-based service employees and students are generally required to follow all hospital personnel mandates which, in some cases, are more stringent than municipal or private service requirements. It is incumbent upon program leaders to get a list of requirements from each clinical agency and to assure that current program immunizations meet each clinical agency’s rules. If possible, course coordinators should work with clinical sites to standardize the requirements as much as possible. With that being said, even if a certain clinical agency does not mandate some immunizations, the program must still assure students and faculty members meet CDC, state, OSHA and other applicable standards.

Immunization requirements

Information regarding immunizations can easily be retrieved from both the Maine CDC web site (www.maine.gov/dhhs/boh) and from the federal CDC web site (www.cdc.gov). For the purposes of the immunization program, students in any healthcare career educational program are defined as “Healthcare workers;” therefore, all requirements placed on facilities for healthcare employees also apply to students completing clinical rotations in those facilities. Fortunately, the immunization success at the grade school level in Maine has been exceptional; therefore many students who come to us for EMS education already have many of the requirements. All students entering college are required by the State of Maine to have a current tetanus/diphtheria and a current MMR (as evidenced by titer results) (Maine Immunization Program, 2007). Additionally, clinical facilities, based on OSHA standards, require three doses of Hepatitis B, and, more recently, have added the need to have a positive titer or additional booster if needed. Annually, healthcare workers must have an annual TB skin test. For healthcare workers assigned to maternal newborn units, serologic evidence of rubella (German measles) conversion is needed (a blood titer is drawn to confirm immunity). Finally, varicella (chicken pox) immunity is required. Healthcare workers must have documented a reliable history by a physician, or have serologic evidence (again, a blood titer) that they are immune. In 2006, influenza vaccination was added as a core measure, and most facilities now require healthcare workers to be vaccinated. These requirements are summarized in Table 2.

In addition, many colleges are now suggesting three additional vaccinations, especially for those students living on campus. Administration of meningitis vaccine should be considered for college students residing in dorms (CDC Advisory Committee on Immunization Practices; Academy of Pediatrics; American College Health Association). The groups also urge education for college students about the risks and modes of transmission of all diseases. For female college-age students, the HPV (human papilloma virus) vaccine is strongly recommended to prevent the development of cervical cancer. Finally, many places are advocating immunizing high risk populations with the Hepatitis A vaccine. Although none of the above is currently state or federally mandated, high risk persons should consider the vaccines, as clearly the consequences of each of these diseases could be catastrophic. [For more information, see the CDC and American Academy of Pediatrics (www.aap.org) Web sites.]

Table 2

Immunization Requirements for Clinical Rotations

PPD annually

MMR (two doses and a serologic titer demonstrating immunity)

Hepatitis B (three doses and a serologic titer demonstrating immunity)

Tetanus booster (within 10 years)

Varicella (two doses and/or a serologic test demonstrating immunity)

Complete childhood vaccination record, including five DTP/DTaP (diphtheria, tetanus, pertussis), and four polio doses

Consider pneumococcal vaccine, meningococcal vaccine, HPV, and Hepatitis A

Waivers and Barriers

Obviously, for the adult student returning to college, the above list is enough to scare them away. Cost, fear of injections or adverse reactions, and personal or religious beliefs have all been cited as common reasons for vaccination refusal. However, given the high risk nature of EMS work, most ambulance services now require employees to maintain these immunizations as well, and those who refuse should be counseled regarding the risk that they will incur and their selected career choice. Additionally, there continue to be programs to assist students to obtain these immunizations at little or no cost (CDC Maine, 2007). Adverse reaction information is easily available on the CDC immunization web site, and prospective students should be educated about the benefits of the vaccines as well as the risks of contracting or spreading these diseases.

Occasionally, students will request a waiver of the immunization requirements, and education leaders must develop policies to address this. In some cases, the refusal by the student is temporary (i.e. during pregnancy). It is appropriate in these cases to delay vaccination, but to assure the student understands the risks of exposure (that is, if the student is even allowed to participate in the clinical experience.) However, it sometimes occurs that the student, for whatever reason, refuses the immunization. In these situations, students would typically be prohibited from participating in the clinical experience, and would therefore be unsuccessful in the class. Policies which include the counseling process, appeals mechanism, and person responsible for the review should be in place. Many higher education institutions have avoided this by making the immunization process part of the application process. A student’s application will not be considered unless all admission requirements have been met, including the required immunizations.

Recently, there has been some controversy surrounding the varicella titer (chicken pox) requirement. In the past, most healthcare organizations required that a “reliable history of chicken pox” could be recalled as sufficient to document immunity. Reliable history was defined as “a recollection or record of disease from the person, parent, or physician as sufficient evidence” that the disease had occurred. This was based on longitudinal studies that 97%-99% of the time the recalled history was accurate (CDC, 2004). However, since there is virtually no risk with administering the varicella vaccine to those healthcare workers assigned to high risk areas, many organizations have chosen simply to require the administration of the vaccine as an effective way to protect high risk patients (especially in OB, oncology, and hospice units).

Finally, students who have a positive PPD are typically required to have a chest x-ray to assure there is no latent TB infection. A positive PPD skin test indicates that there is either a latent or active TB infection occurring, and a chest X-ray is used to make this determination. Students who have had a negative chest x-ray are permitted to resume their clinical experience, and no longer need to provide annual TB tests.

Recommendations for clinical coordinators

News reports about disease outbreaks occur regularly, and EMS students are part of the highest risk category, as they frequently care for infected patients. Last year, there was an alarming mumps outbreak in Nova Scotia, Canada (CBC, 2007). Additionally, up to 75 New Brunswick residents contracted the disease. Many of those infected were young college age students. There is a significant Maine-Nova Scotia connection, as many students from Nova Scotia come to Maine colleges to complete their education, and the tourist exchange between Maine and Nova Scotia is growing. As we watched the spread of the disease, it reinforced the importance of these vaccinations, as we had students who were definitely in harm’s way. I had a lot of comfort knowing that our local EMS students had been appropriately vaccinated and had very low risk of contracting this debilitating disease, and virtually no risk of spreading it to the patients they were caring for in their clinical settings.

For program leaders, it is crucial that a uniform list of requirements be published and enforced. Contracting with or hiring a health officer with this responsibility is ideal, as this individual can help assure that all students meet the requirements. The health officer at many colleges is also a nurse practitioner or physician, and therefore can assist in immunizing those students who are non-compliant.

I have found it to be preferable to decline admission of students who don’t meet the immunization requirements rather than “chasing” them after admission. Students who are motivated to get into competitive programs are active in assuring a complete medical file. If a student is admitted without the immunizations, he or she has to be prohibited from clinical, and not only does this take up a valuable “seat” in the classroom, it also places the student in jeopardy of failing and not being able to successfully pass the course.

It is also important to recognize that immunizations are contractually or federally mandated, and as such, appropriate and comprehensive documentation of these is required. The health officer should maintain copies of immunization records, potential exposures and correspondence with clinical sites. I also maintain a simple Excel spreadsheet that includes all program requirements with expiration and due dates, and we include some of the information on the students’ portal and college web site. Appropriate marketing of the requirements has helped reduce the number of students who are non-compliant at time of admission.

It is equally important to have policies in place that deal with potential student exposures. Though it is beyond the scope of this article, contractual agreements should specify what happens if a student might have been exposed to an infectious disease, like who is responsible for testing, etc. Legal guidance for development of policies is suggested, as some students could potentially be disqualified from some clinical settings or experiences.

Finally, an important role that we have assumed has been that of educator. Program leaders and the health officer have worked diligently with clinical facilities to assist in standardizing their requirements, and making them more consistent with CDC mandates. This is significant because students who rotate between facilities now meet the requirements of all the facilities, making clinical scheduling less time-consuming. The health officer now produces a letter to the facilities listing all of the students who practice/perform clinical duties in that facility, identifying the immunizations that they hold, and providing contact and reference information. During site visits by JCAHO or other accrediting or licensing agencies, individual student files with proof of immunization are made available for review by the site visitors.

A large amount of the clinical coordinator’s time can be taken up with tracking and maintaining the immunization record of students. By addressing the immunization issue up front, clinical experiences are preserved, and students and patients are protected.

References:

American Academy of Pediatrics (2007). Immunization initiatives. http://www.cispimmunize.org.

CBC News (2007). http://www.cbc.ca/health/story/2007/06/08/mumps-ns.html).

CDC (2007). Immunization requirements and fact sheets. www.CDC.gov.

CDC Maine (2007). Immunization requirements. Retrieved July 28, 2007. www.gov/dhhs/boh/ddc/_immunizations/school_requirements.html.

Centers for Disease Control and Prevention (CDC) (2004). Varicella Vaccine- FAQ about healthcare workers. www.cdc.gov.

Kuenzi, L. (2007). Meningococcal Education: More than just a vaccine. Journal of American Health, 53 (2), 93-96.

Northern Maine Community College (2007) Admission requirements. Retrieved July 24, 2007, www.nmcc.edu.