Immunization Requirement for Medical Staff
DATE: February 16, 2009 TO: Medical and Allied Health Staff FROM: James Breitenbucher, MD
Vice President of Medical Affairs, UMMC RE: New Immunization Requirements for Membership on Medical or Allied Health Staff Fairview Health Services has recently approved an immunization policy for credentialed practitioners to ensure vulnerable patients in our entities are protected from preventable diseases while in our care. The new membership threshold criteria requires all medical and allied health staff credentialed at a Fairview hospital or clinic meet immunization requirements as established by the System Credentialing Policy Committee. Practitioners submitting initial applications received by the Fairview System Credentialing Office after February 1, 2009 must meet the requirements. Practitioners currently on staff prior to February 1, 2009 will be required to comply over a two year time period as they are reappointed according to Fairview’s reappointment schedule. | REQUIRED IMMUNIZATIONS | | | Initial Appointment or
First Reappointment
After Feb. 1, 2009 | Reappointment | | Tuberculin Skin Test (TST) | - Two step Mantoux test
-If positive, CXR required or documentation of CXR in past 12 months
| - One step Mantoux test
-If previously positive, symptom questionnaire
-CXR required if new positive at reappointment
| | Measles, Mumps, Rubella (MMR) & Varicella | - Documentation of 2 live virus vaccines; or
- Documentation of disease by a healthcare provider; or
- Documentation of positive titers
| | | Hepatitis B | - Documentation of completed series; or
- Declination signed; or
- Positive titer
| | Recommended Immunizations (not required): - Influenza Vaccine - annually
- T-dap (Pertussis) Vaccine- once
| Fairview’s requirements are based on recommendations from the Centers for Disease Control and Prevention (CDC), Morbidity and Mortality Weekly Report (MMWR), and Advisory Committee on Immunization Practices (ACIP), as well as best practices at other leading hospitals. Immunization recommendations are more rigorous for health care workers than the general public due to close proximity with vulnerable patients. The immunization requirements for credentialed practitioners are the same as the standards already in place for the Fairview employees who you work with in our hospitals and clinics. Answers to several frequently asked questions you and your colleagues may have about this new policy are attached. Please feel free to contact me at 612-273-6086 if you have comments or questions. Thank you.
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