Immunizing Health Care Workers

Shane Woods RN OHN Red River Community College

As the manager of both Health & Recreation Services at Red River College it is my responsibility to coordinate, implement, and deliver immunizations and tuberculosis testing for students in health related programs. I have been doing this for about 10 years and have seen numerous changes to our immunization policies during this time.

Since Red River College took over the Victoria Hospital nursing training program in the early 70's, the College has been providing immunizations and TB testing in one form or another to nursing students. In the early 80's the immunization program was expanded covering not just nursing students but students in Medical Radiology, Medical Lab Sciences, Health Care Aide, Dental Assisting, and the RN Refresher programs. At one time even students in child care programs like Early Childhood Education, and Child and Youth Care were required to have immunizations. The College has since discontinued immunization requirements for child and youth care programs considering immunizations are not an industry standard in child care related jobs.

The Health Centre at the College reviews and manages immunization records for over 1000 students in health related programs annually. As you can appreciate certain programs like HCA have more than one intake per year, so the 1000 number is conservative at best. Immunization records are a challenge for both the College and the students in programs requiring immunizations and tuberculosis testing.

When I started at the College the immunization program was vastly different than it appears today. At that time we would pick a mutually agreeable date with the program coordinator for the course, and have all the students in the program line up outside the Health Centre and bring into the Health Centre 5-6 students at a time. Students were informed to bring with them any documents indicating previous immunizations-which in most cases students did not have a record of previous immunizations which only complicated and slowed down the immunization process in the Health Centre. Each student would meet the first nurse to review any history with exposure to TB and any previous known immunizations and document them on that student's immunization record. The student would then proceed to the second nurse and receive their step one TB test and any other immunizations required. This process was the same for every student in any health related program. Then each class was scheduled for a second visit to read the results of their mantoux test. In the cases where a positive mantoux result appeared the student was sent to their own MD for a CXR to rule out active tuberculosis.

Remember most of these students were relatively fresh graduates from high school and lining them all up outside the Health Centre like livestock for branding seriously concerned me. As you can appreciate students were extremely nervous and as a result created undue stress amongst one another talking about how painful it is going to be, etc. It didn't help that those students who completed the process as they left the Health Centre stopped at those still in line and although jokingly made untrue comments about the process only added to the stress of those still in line. We had them fainting, shaking, and literally turning as white as a sheet with this process. Remember, most of these students had never visited any type of clinic without at least one parent accompanying them. This would even delay the whole process as we would have to stop the immunization process to deal with these fainters, etc. These faints were not the result of any allergy or sensitivity to the vaccines or tuberculin, but rather a simple stress reaction to receiving immunizations partly due to the fact the students knew very little if anything about immunizations. This immunization and TB testing process was not only extremely stressful for the students, it was very costly for the College in terms of staffing and supply costs. The immunization program was also interrupted whenever an emergency occurred on campus as it is the Health Centre's staff responsibility to respond to all emergencies on campus. Whenever this occurred the remaining students in line would be even more stressed considering the program would have to be postponed, and they would have to return another date and time and go through the whole process again.

Also during this time immunization and TB testing were not mandatory even though students in these programs are at risk for exposure to communicable diseases and in contact with patients and/or materials from infected patients. Numerous students signed waiver forms based on their own or their parent's beliefs about immunizations. Some even convinced their doctors to write letters to the College recommending no immunizations or TB testing without any rational explanation from the doctor. This really concerned me considering the College would be graduating health care professionals who did not seem to have much regard for their patients and risking transferring infections to their patients, or acquiring a vaccine-preventable disease from their patients who may not be diagnosed yet. As a result of these increasing number of waiver forms the College implemented a policy stating that immunization waiver forms would only be accepted with a written doctor's letter with a medical reason attached as to why they are not recommending immunizations or TB testing. In other words personal beliefs or religious beliefs were not acceptable reasons for refusing immunizations or testing. We certainly had our issues with this new policy but if nothing else we were immunizing more students and protecting the patient's whey would be coming in contact with.

The University of Manitoba who graduates degree nurses had similar policies for their student nurses. Immunization programs at both the college and university changed when a University student challenged the immunization policies in a court of law. The end result was that the student lost her case but recommendations were made through the court that the Winnipeg Regional Health Authority adopts immunization guidelines in respect to students practicing in their facilities.

On the screen in Red River College's Immunization record which is based on the WRHA guidelines. As you can see the immunizations are categorized as "Required" or "Recommended". Previous to these WRHA guideline the College followed the immunization recommendations for health care workers from the Canadian Immunization Guide. But after all these were recommendations only and the College had little rationale or back up in making immunizations mandatory considering these guidelines were recommendations only.

Of course this all changed in 2001 with the immunization policies put forth by the WRHA in response to the court recommendations. About this same time the cost of tuberculin testing solution increased over 100%, so the College decided to make immunizations a pre-entrance requirement.

What this means in that as soon as a prospective student applies for a health related course they are sent with their application package an immunization record which requires completion prior to being accepted into the program. Considering this enrolment activity is done by the Enrolment Services department of the College it remains the Health Centre's responsibility to receive and review the submitted records and keep Enrolment Services aware of submitted complete-to-date immunization records. Enrolment Services would then remove this restriction off the student's application and grant them a seat in the program. With the College making immunizations an entrance requirement our costs of immunizing and TB testing each health related course student dropped significantly. With the WRHA guidelines students could no longer sign a waiver form refusing immunizations unless they had a doctor's letter attached stating a medical reason for no immunizations. Even in these cases the College forwards these records and letters to the WRHA for their final review and approval prior to the student being accepted in their chosen program of study. Most importantly though, was the fact students did not have to experience he herd mentality of lining up outside the Health Centre for their immunizations and experience all the issues which I described earlier.

Although these changes were positive from both mine and the College's perspective, it does not come without its challenges;

CHALLENGES

•  Financial -Students would now have to pay of immunizations and TB testing. Many prospective students find the costs very high considering immunization providers can charge whatever they want for this process.

•  Time Management -Prospective students are given deadlines to submit their record and if deadline is not met students will loose their tentative reserved seat in the program.

•  Finding Immunization Providers -Some family physicians do not offer immunizations or TB testing leaving the prospective students to search out other immunization providers. With the formation of travel health clinics like Skylark Medical this situation has been somewhat resolved as family doctors will now refer their patients to these clinics for immunizations related to entering health related programs.

•  History of Previous Immunizations -this is not a new challenge but students continue to have difficulty tracking down previous immunizations mostly due to the fact their parents did not keep a record of their immunizations or the family physician are no longer practicing and it is virtually impossible to retrieve these old records.

•  Inconsistencies in Health Authorities Immunization Guidelines -not all Health Authorities in Manitoba have adopted the WRHA guidelines. Rural areas may require few if any immunizations to practice in their facilities. I understand this is changing in the very near future as all the health authorities in Manitoba are going to adopt the Winnipeg Health Authority guidelines in respect to immunizations and TB testing.

When the WRHA developed these guidelines they separated immunizations into "Required" or "Recommended" based on the effectiveness of the vaccine, probability to/transmission of the disease, and the consequences of the disease in vulnerable patients groups. All the WRHA immunization guidelines are in accordance with The National Advisory Committee on Immunizations developed by Health Canada. Although the College encourages health related course students to receive even the recommended immunizations (like the annual flu shot for example), we do not reject submitted immunization records if the recommended section on the record is not completed. Considering the number of records we review it is almost a full-time job for the nurse in the Health Centre.

Common Reasons for Rejecting Records,

As you can see the record has a significant amount of information to be completed and the College revises the record annually based on the previous year's questions from both the student and those providing the immunizations. I would like to highlight where mistakes are made on the record which would prompt a rejection. It is certainly not unusual to have records rejected 2-3 times based on incomplete information like no signatures or an improperly conducted mantoux test.

•  Personal Identifying Information -frequently the student fails to sign their record or include their assigned student number or program of study on the record. At the bottom of the form is a space for the immunization provider to sign and date the record reason being the immunization record is considered a legal document and can be called into evidence in a court of law and thus will be rejected without the required signatures

•  Varicella Vaccine -Current WRHA guidelines require either a physicians or patient/parent diagnosed history of chickenpox. If history of disease cannot be established the immunization is required. Frequently enough the immunization provider does not complete the antibody test after vaccination to determine immunity and in these cases the record is rejected until which time immunity is determined by the antibody test.

•  Hepatitis B -The Health Centre receives significant number of calls from prospective students about how they are going to complete their whole Hep B series (3 shots over 6 months) along with the antibody test by their submission deadline from Enrolment Services. We of course explain that as long as their Hepatitis B series are up-to-date and according to schedule the record would be accepted if all other information on the record is complete to date. We also experience a significant number of records where the antibody test being ordered to determine immunity after immunization is the wrong antibody test. Often we see the Hepatitis B Surface Antigen being ordered which only determines whether or not the student is a carrier of Hepatitis whereas the Antibody to Hepatitis B Surface Antigen is the test which determines an immune response to Hep B vaccination. Historically the Health Centre sees numerous records where the Hep B series is far off schedule and the College will accept such records with reasonable explanations such as sick when due for their second Hep B shot.

Mantoux testing -Now comes the one requirement on the record that causes everyone from the student to the immunization provider the most for the lack of a better word-GRIEF. Although the College no longer administers this test or reads the results, Mantoux testing continues to haunt us in some respects. Some family physicians do not provide mantoux testing leaving the student to seek alternate sources to complete this test. There is also significant controversy in the immunization community about mantoux testing itself and how and when it should be done, along with how often it should be done. Although the WRHA guidelines are in accordance with the "Guidelines for Preventing the Transmission of Tuberculosis in Canadian Health Care Facilities and Other Institutions" from Health Canada this remains an area with significant different interpretations. Most frequently we reject records when the window period of 7-21 days between step one and step two are not adhered to in the testing process. The intent is that the step 2 test boosts immunity memory best if done between 7-21 days from the first test, and although there is evidence to suggest the step 2 can illicit immunity memory response even after 21 days the College has adopted the Gold Standard of 7-21 days between step one and step two, otherwise we could simply be all over the map with mantoux testing, and risk the possibility of students infecting patients. Up until recently facilities under the direction of the WRHA had different policies in respect to mantoux testing. Recently I became aware that the Occupational Health departments in each facility are working toward the same standards and policies in respect to TB testing. Currently there is controversy indicating that a one-step mantoux test is all that may be necessary. It is anticipated that the WRHA revised guidelines ill address this controversy. Some immunization providers still accept that a current CXR replaces the need for mantoux testing, and occasionally records are rejected when mantoux testing is not performed and replaced with a CXR. Although the directions on both the front and back of the record are quite specific in respect to immunizations and TB testing immunization providers continue to make errors in mantoux testing and the record would be rejected in these cases.

As mentioned earlier these records being considered a legal document require the signatures of both the student and the immunization provider especially in the event of an exposure while the student is practicing in the facility. As an example, in the event of a needle stick injury a copy of this record would be forwarded to the Occupational Health department of that facility to assist in determining the need for certain post-exposure testing.

Immunizations initially carry with them many challenges. The goal of the College is not simply to produce academically prepared graduates but to graduate students who are prepared with the necessary vaccines to prevent vaccine-preventable diseases in both their patients and themselves. The vast majority of the funding for the College comes from provincial tax dollars. The College is graduating health care professionals who will be working in your communities caring for Manitobans and others, and the College has a responsibility to reduce the risk of infection from any graduate.