HD-IC-005 · Staff Health, Immunization & Illness Exclusion (UPDATED)

Staff Health, Immunization, and Illness Exclusion for Hemodialysis Personnel

Policy HD-IC-005 · Hemodialysis Unit

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To prevent transmission of vaccine-preventable diseases and other infections from staff to immunocompromised hemodialysis patients, and to protect staff from occupational exposure per CDC 2019, OSHA, and MOH-Jordan 2023 requirements.

2 Scope

Applies to all employees, physicians, agency staff, students, volunteers, biomedical engineers, and housekeeping with any patient contact or entry into the Hemodialysis Unit. No exceptions.

3 Definitions

Immune Documented serologic evidence or vaccination series complete Non-responder Anti-HBs <10 mIU/mL after 2 complete Hep B series Exclusion Staff prohibited from patient care or unit entry Furlough Paid/unpaid leave for infectious illness

4 Policy Statement UPDATED

Update 1.1 Mandatory vaccination & HBV immunity

Mandatory vaccination: Hepatitis B, MMR, Varicella, annual Influenza. HBV immunity required.

Enhanced: • HBV Immunity required – Anti-HBs ≥10 for ALL staff. • Non-responders cannot care for HBsAg+ patients or perform CVC care. Must double-glove for all patient care. • Ill staff exclusion – fever, diarrhea, vomiting, draining lesions, respiratory symptoms = excluded. • Pre-employment clearance – no new hire starts until Employee Health clears file. Agency staff must provide same documentation.

Rationale: MOH audits staff HBV titers as #1 priority. Immunocompromised HD patients are at high risk for vaccine-preventable diseases.

Update 1.2 Annual requirements & agency staff

Annual: TB screen, flu vaccine, HBV titer for non-responders.

Added: • Agency/Float/Students – cannot enter unit without Temporary Staff Health Clearance showing HBV ≥10, MMR, Varicella, Tdap, Flu, TB. No exceptions for "1 day float." • Annual competencies – PPE, hand hygiene, exposure protocol quiz due yearly.

Rationale: Agency staff are the #1 source of immunization gaps. MOH audits agency files during surveys.

5 Procedure UPDATED

A. Pre-Employment/Pre-Placement Requirements – Must Complete Before 1st Day UPDATED

Test/Vaccine	Requirement	Documentation Required	If Non-Immune
Hepatitis B	3-dose series + Anti-HBs titer ≥10	Vaccination dates + lab report	Repeat series x1. If still <10 = Non-responder. Cannot work HBV room or CVC
MMR	2 doses OR positive IgG titers for all 3	Vaccination record OR lab	Give 2 doses 28 days apart. No patient care until 1st dose
Varicella	2 doses OR positive IgG titer OR MD diagnosis	Vaccination record OR lab OR MD note	Give 2 doses 4 weeks apart. No patient care until 1st dose
Tdap	1 dose as adult, then Td/Tdap q10yr	Vaccination record	Give 1 dose. May work same day
Influenza	Annual, Sept-Dec each year	Vaccination record	Must wear mask in unit Oct-May if declined + sign declination
TB Screening	IGRA blood test OR 2-step TST	Lab report or TST read	If positive, CXR + MD clearance. Latent TB tx encouraged
COVID-19	Per current MOH policy	Vaccination record	Follow MOH-Jordan current rules

B. Hepatitis B Protocol – MOH #1 Audit Item UPDATED

Update 2.1 Non-responder restrictions

All staff must have Anti-HBs titer. Non-responders rechecked annually.

Enhanced: • All Staff: Must have Anti-HBs titer on file. Do not accept "I was vaccinated as a child." • Titer <10: Repeat full 3-dose series 0, 1, 6 months, 40mcg dose. Recheck 1-2 months after. • Non-Responder Work Restrictions: Cannot be assigned to HBsAg+ isolation room. Cannot perform CVC dressing changes or access. Must double-glove for all patient care. • Post-exposure: HBIG x2 doses + start 3rd vaccine series if needlestick. • Annual Check: Non-responders rechecked annually.

Rationale: MOH inspectors will ask for every staff member's titer. Non-responders are a high-risk group that must be restricted.

⚠️ Non-Responder Work Restrictions:

Cannot be assigned to HBsAg+ isolation room
Cannot perform CVC dressing changes or access
Must double-glove for all patient care
Post-exposure: HBIG x2 doses + start 3rd vaccine series
Annual titer check required

C. Illness Exclusion – Staff Cannot Work With These UPDATED

Fever ≥38°C + respiratoryExclude until afebrile 24h without meds · Return: MD note/Employee Health clear · Notify in-charge RN immediately

Vomiting/DiarrheaExclude until 48h after last episode · Return: 48h symptom-free + formed stool · If norovirus suspected: 72h

Purulent conjunctivitisExclude until discharge stops · Return: MD clearance · Notify in-charge RN

Draining skin lesionExclude until drainage stops + covered · Return: Lesion dry, covered, MD note · Notify Employee Health

Scabies, Lice, BedbugsExclude until treated x24h · Return: Treatment complete · Notify Employee Health

Herpes Zoster ShinglesExclude until lesions crusted · Return: All lesions crusted, MD note · Cannot care for immunosuppressed

COVID-19/FluPer MOH current isolation · Return: Negative test + symptom-free per policy · Notify Employee Health + Infection Control

Hep AExclude until 7 days after jaundice onset · Return: MD clearance · MOH reportable

Exposure to Measles/VaricellaIf non-immune: exclude 21 days from exposure · Return: Immunity documented or 21 days pass · Notify Employee Health

Staff Responsibility: Must call in-charge RN before shift if any symptoms. Cannot "tough it out." Working ill = disciplinary action.

D. Post-Exposure Protocol – Needlestick/Body Fluid

Immediate: Wash wound with soap/water. Flush mucous membranes. Do NOT squeeze wound.

Report: Notify in-charge RN + Employee Health within 1 hour. Complete incident report.

Source Testing: Test source patient for HBsAg, Anti-HCV, HIV stat with consent.

Staff Testing: Baseline HBsAg, Anti-HBs, Anti-HCV, HIV at time of exposure.

Prophylaxis: HBV: If staff Anti-HBs <10, give HBIG + start vaccine within 24h. HIV: Start PEP within 2h if source HIV+. Contact ID. HCV: No PEP. Follow-up HCV RNA at 4-6 weeks.

Follow-up: Repeat labs at 6 weeks, 3 months, 6 months. Counseling provided.

E. Annual Requirements – Due by October 31 Each Year

Influenza Vaccine: Mandatory. Declination requires mask Oct 1 – May 31 + signed form HD-IC-005-F1.

TB Screen: IGRA or TST. If prior positive, annual symptom review + CXR if symptoms.

HBV Titer: For non-responders only. If <10, offer 3rd series.

Competency: Donning/doffing PPE, hand hygiene, exposure protocol quiz.

F. Agency/Float/Student Requirements UPDATED

Update 2.2 Temporary staff clearance

Agency staff must provide documentation.

Enhanced: Cannot enter unit without HD-IC-005-F2 Temporary Staff Health Clearance showing: HBV titer ≥10, MMR, Varicella, Tdap, Flu, TB all documented. If missing any item, cannot work. No exceptions for "1 day float."

Rationale: Agency staff are the #1 source of immunization gaps. MOH audits agency files during surveys.

8 Disciplinary Action UPDATED

Update 4.1 Working ill & falsification

Working while ill: warning → suspension → termination. Missing vaccines: cannot work. Falsifying: immediate termination.

Enhanced: • Working While Ill: 1st offense = written warning. 2nd = suspension. 3rd = termination. • Missing Vaccines: Cannot work until complete. Unpaid leave after 30 days. • Falsifying Health Record: Immediate termination + report to MOH licensing.

Rationale: Working ill is a patient safety risk. Falsification is a licensing board offense.

9 References UPDATED

Update 5.1 Updated reference list

CDC. Immunization of Health-Care Personnel: Recommendations. MMWR 2011;60(RR07). Updated 2019.
CDC. Guidelines for Infection Control in Health-Care Personnel, 1998. Updated 2019.
MOH-Jordan. National Guidelines for Healthcare Worker Vaccination, 2023.
OSHA. Bloodborne Pathogens Standard 29 CFR 1910.1030.
JCI Accreditation Standards, 8th Ed. Staff Qualifications SQE.8 Vaccination.
MOH-Jordan Staff Health Audit Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	HBV immunity mandatory for ALL staff; non-responders restricted from HBV room and CVC care; agency staff must have complete file before shift	MOH audits staff HBV titers as #1 priority. Agency staff are #1 source of immunization gaps.
5. Procedure (B)	Non-responder restrictions: cannot work HBV room or CVC, must double-glove, HBIG post-exposure	Non-responders are high-risk. MOH requires documented restrictions.
5. Procedure (C)	Expanded illness exclusion table with specific return criteria and notification requirements	Prevents staff from working while infectious. MOH audits exclusion logs.
5. Procedure (F)	Agency/float/student: must have all immunizations documented before entering. No exceptions for "1 day float"	Agency staff are #1 source of immunization gaps. MOH audits agency files.
8. Disciplinary	Working ill: warning → suspension → termination. Falsifying health records: immediate termination + MOH report	Working ill is patient safety risk. Falsification is licensing offense.

Policy HD‑IC‑005 · Proposed updates June 26, 2026 All changes reviewed against CDC 2019, MOH‑Jordan 2023, OSHA 1910.1030, JCI 8th Edition.
⚠️ This policy is audit-proof for MOH 2023 + JCI SQE.8. MOH will ask for every staff member's Anti-HBs titer – if missing or <10, you fail.

Staff Health And Vaccination Policy · Version 2026-06-27 · Hemodialysis Unit

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Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.