Adams School of Dentistry: Infection Control Manual - Chapter 04: Immunizations, Trainings, and Infectious/Communicable Disease Requirements

Introduction

Dental procedures are performed in a septic environment, posing significant hazards to both dental personnel and patients. Refer to the Infection Control Manual - Chapter 01: Introduction for an outline of risks and specific definitions. To safeguard the health and safety of ASOD personnel and the public, ASOD has established specific requirements, which includes immunizations, trainings, compliance monitoring, and post-exposure procedures.

Requirements and oversight detailed in this chapter are a collaborative effort with UNC Health Systems, as ASOD is a Community Connect partner, UNC Environment, Health, and Safety (EHS), UNC Student Campus Health, UNC Information Technology Services (ITS), UNC Institutional Privacy Office (IPO), and the ASOD Infection Control Committee.

ASOD Student vaccination requirements are reviewed biennially by the UNC Campus Health Immunization Committee, with ASOD representative(s) present. Any changes to vaccination, immunization, or communicable disease policies require review from the ASOD Infection Control Committee and/or a designated epidemiological faculty member.

Employee Training and Immunization Requirements

ASOD employees include faculty, staff, residents, affiliates, and temporary/intermittent employees. Maintenance and responsibility of collecting all relevant records belong to UNC EHS, with responsibility delegated to UNC Information Technology Services (ITS), UNC Institutional Privacy Office (IPO), and ASOD. Upon start/hire, all employees of ASOD become subject to the following enforcement of training and medical surveillance policies:

  1. EHS - Chapter 01.11: EHS Management System - Enforcement of Training and Medical Surveillance
  2. EHS - Chapter 06.01: Clinical Safety - Occupational Health Requirements for University Employees Located in Healthcare Facilities
  3. EHS - Chapter 06 Appendix A: Required Immunization Guidelines for Certain Positions Within UNC-Chapel Hill
  4. HIPAA Training Policy and Procedure
  5. Information Security Controls Standard

ASOD Employee Required Trainings

Within ten (10) days of official start date, and depending on the classification of the employee, ASOD employees are required to complete the following trainings:

  1. Office / Laboratory / Clinic / Environment Orientation or Student Support Services Orientation
  2. ASOD Basic Life Support (course sign up is separate)
  3. Bloodborne Pathogens Training
  4. Tuberculosis Awareness and Infection Control
  5. HIPAA Training at UNC-Chapel Hill
  6. ITS Security Awareness Training
  7. ASOD Medical Emergency Training
  8. Respiratory Protection
  9. Respiratory Protection: N-95
  10. Respiratory Protection for Tuberculosis and Infectious Diseases
  11. Radiation Safety for UNC School of Dentistry X-Ray Equipment Operators
  12. HazCom 2012 Global Harmonization System
  13. Vendor Relations for Adams School of Dentistry
  14. Joint Commission and Emergency Preparedness Refresher for the Clinic Environment

ASOD Employee Required Immunizations

The University Employee Occupational Health Clinic (UEOHC) provides pre-employment screening, annual immunization reviews, and medical surveillance for all UNC healthcare employees. While dependent upon the role, all ASOD employees are required to have annual immunization reviews. If a new clinical employee is not automatically enrolled in the Immunization Review process, or an employee has transferred to a clinical role, contact ASOD HR at sod_hr@unc.edu and request the employee be added to the Immunization Review program via the ePar system.

  1. Hepatitis B
    • Offered for free by UEOHC, unless contraindications;
    • Immunity to hepatitis B virus is strongly encouraged for all employees;
    • Laboratory evidence of immunity;
    • Prior receipt of 2 or 3 doses of vaccine, with appropriate schedule;
    • Signed OSHA declination.
  2. Tuberculosis (TST/PPD)
    • 2-Step TST or Serological Titer;
    • Annual TB Immunity Questionnaire.
  3. Influenza Vaccine
  4. COVID-19

Student Training and Immunization Requirements

Immunization requirement for all students enrolled in ASOD are outlined in the New Learner Compliance Checklist, found in Connect Carolina, and available during matriculation. Checklist models Campus Health's Immunization for Health Science Students webpage, with additional trainings. All students are required to complete and provide documentation before the completion of their respective orientation course. Definitions of mandatory health, safety, and legal requirements of all Doctor of Dental Surgery (DDS) and Dental Hygiene (DH) are listed within the ASOD: Policy on DDS and DH Student Programs Compliance.

ASOD Student Required Trainings

Within the orientation period of each respective program (30 days maximum), the following trainings are required, with documenting proof of completion via the ASOD Compliance Portal:

  1.  HIPAA Training at UNC-Chapel Hill
  2. ITS Security Awareness Training
  3. ASOD Medical Emergency Training
  4. ASOD Basic Life Support (course sign up is separate)
  5. Tuberculosis training (integrated into the curriculum)

ASOD Student Required Immunizations

Prior to entry into any ASOD program, the following immunizations must be completed or scheduled for completion. All documentation is entered into both Connect Carolina and ASOD Compliance Portal:

  1. Hepatitis B
    • 2 or 3 dose series required;
    • AND quantitative titer required.
  2. Tetanus, Diphtheria, Pertussis (Tdap/TD)
    • 3 dose series required;
    • AND minimum 1 Tdap booster within past 10 years.
  3. Varicella
    • 2 dose series;
    • OR serological titer demonstrating immunity.
  4. Measles, Mumps, Rubella (MMR)
    • 2 dose series.
  5. Tuberculin Screening
    • Serologic test preferred (recommended T-SPOT.TB or QuantiFERON Gold Plus);
    • OR 2-Step TST.
  6. Influenza Vaccination
  7. COVID-19
    • Strongly recommended CDC "up-to-date" vaccinations;
    • AND EITHER:
      •  Documentation of previous vaccination;
      • Intent to request exemption

Infectious Agent Transmission - HBV, HCV, and/or HIV-Infected Healthcare Professionals

Applicable to all ASOD personnel and students, Chapter 06.07: Clinical Safety - Healthcare Personnel Who Are Infected With Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus from UNC EHS outlines the policy and procedure, related to reporting if a healthcare professional is currently or becomes aware that they are infected with HBV, HCV, and/or HIV. Summarizing, any clinician who pose a risk of transmitting an infectious agent must consult with the appropriate healthcare professionals, to determine whether continuing to provide professional services represents a material risk to patients or other healthcare workers. Per UNC Health Infection Prevention and Screening Program: Occupational Health Service (requires Epic login to access), the appropriate reporting facility for ASOD employees is UNC University Employee Occupational Health Clinic (UEOHC), with ASOD students reporting to UNC Campus Health. If either UEOHC or UNC Campus Health decide that continuing to provide professional services represents a material risk to patients or co-workers, the ASOD personnel member or student must inform the Dean of Adams School of Dentistry. Once informed, the Dean will take such action as necessary to protect against the transmission of infection to others. ASOD will protect the privacy and confidentiality of any and all associated test results.

Additional reporting procedures may be required, depending on the situation. Review Chapter 06.07: Clinical Safety - Healthcare Personnel Who Are Infected With Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus for full details.

Bloodborne Pathogens Policy Statement and Summary

The safety and health of our healthcare personnel and students are of utmost importance. UNC ASOD is committed to providing a safe educational and working environment, which is why UNC ASOD recognizes the potential hazards posed by exposure to bloodborne pathogens (BBP) and other potentially infectious materials (OPIM), as outlined in the Infection Control Manual - Chapter 01: Introduction.

  1. Education and Training
    • All ASOD personnel and students will receive training on BBP standards, risks of exposure, and preventative strategies. Full outline of provided trainings is listed earlier in this policy (Infection Control Manual - Chapter 04: Immunizations, Trainings, and Infectious/Communicable Disease Requirements).
  2. Prevention
  3. Personal Protective Equipment (PPE)
  4. Exposure to BBP or OPIM
  5. Post Exposure Evaluation and Follow Up
    • Following the reporting of the exposure incident, Campus Health, UEOHC, or the external clinical site will provide an evaluation and follow up care, as outlined in the Exposure Control Plan for Bloodborne Pathogens (requires Epic login to access).

Relevant Policies

  1. UNC-Chapel Hill Health: Exposure Control Plan for Bloodborne Pathogens
  2. UNC-Chapel Hill Health: Exposure to Communicable Disease
  3. UNC-Chapel Hill Health: Infection Prevention and Screening Program: Occupational Health Service
  4. UNC-Chapel Hill Health: COVID-19 Control Plan
  5. UNC EHS: Chapter 01.11: EHS Management System - Enforcement of Training and Medical Surveillance
  6. UNC EHS: Chapter 06.01: Clinical Safety - Occupational Health Requirements for University Employees Located in Healthcare Facilities
  7. UNC EHS: Chapter 06 Appendix A: Required Immunization Guidelines for Certain Positions Within UNC-Chapel Hill
  8. UNC EHS: Chapter 06.07: Clinical Safety - Healthcare Personnel Who Are Infected With Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus
  9. Privacy Office: HIPAA Training Policy and Procedure
  10. UNC ITS: Information Security Controls Standard
  11. ASOD: Policy on DDS and DH Student Programs Compliance
  12. ASOD: Basic Life Support (BLS) Certification Policy
  13. ASOD: Policy for Management of Medical Emergencies
  14. ASOD: Procedure Following Bloodborne Pathogens Exposure
  15. ASOD: Infection Control Manual - Chapter 03: Incident Reporting
  16. ASOD: Incident Report, Documentation, & Corrections

 

Back to Chapter 03

Proceed to Chapter 05

Details

Article ID: 139920
Created
Sun 6/5/22 3:29 PM
Modified
Tue 4/16/24 9:45 AM
Effective Date
If the date on which this document became/becomes enforceable differs from the Origination or Last Revision, this attribute reflects the date on which it is/was enforcable.
06/07/2022 12:00 AM
Issuing Officer
Name of the document Issuing Officer. This is the individual whose organizational authority covers the policy scope and who is primarily responsible for the policy.
Issuing Officer Title
Title of the person who is primarily responsible for issuing this policy.
Director of Clinical Compliance
Last Review
Date on which the most recent document review was completed.
04/11/2024 7:44 AM
Last Revised
Date on which the most recent changes to this document were approved.
04/11/2024 7:44 AM
Next Review
Date on which the next document review is due.
06/07/2025 12:00 AM
Origination
Date on which the original version of this document was first made official.
05/18/2020 12:10 PM
Responsible Unit
School, Department, or other organizational unit issuing this document.
Adams School of Dentistry

Related Articles (12)

Adams School of Dentistry: Basic Life Support (BLS) Certification Policy
Policy provides guidance and requirements for maintaining a BLS/CPR certification. UNC Adams School of Dentistry (ASOD) personnel that are involved in professional contact with patients, clients, families, and/or human subjects are required to present prior to their start date and bi-annually thereafter, documentation of completion of an approved Basic Life Support (BLS) certification.
Adams School of Dentistry: Incident Report, Documentation, & Corrections
Procedure for Adams School of Dentistry on reporting incidents.
Adams School of Dentistry: Infection Control Manual - Chapter 03: Incident Reporting
Chapter 3 of the Adams School of Dentistry's Infection Control Manual explains how to document and report various incidents.
Adams School of Dentistry: Policy on DDS and DH Student Programs Compliance
Adams School of Dentistry policy and procedure related to DDS and DH student compliance requirements, expectations, and consequences for Non-Compliance.
Adams School of Dentistry: Procedure Following Bloodborne Pathogens Exposure
The purpose of this Procedure is to provide detailed, step-by-step guidance for UNC Adams School of Dentistry (ASOD) personnel to follow in the event of a potential bloodborne pathogens exposure. For a visual aid, see Attachment C ("Procedure Infographic").
Adams School of Dentistry: Procedure for Policy Management
To provide specific steps to create, review, revise, publish, and decommission official Adams School of Dentistry Policies, Standards, or Procedures. This Procedure applies to all Policies, Standards, and Procedures developed to support the internal operations of the Adams School of Dentistry, including the Dental Faculty Practice.
Environment, Health and Safety Manual - Chapter 01.11: EHS Management System - Enforcement of Training and Medical Surveillance
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Environment, Health and Safety Manual - Chapter 06.01: Clinical Safety - Occupational Health Requirements for University Employees Located in Healthcare Facilities
Working in a health care environment poses a risk for acquiring certain infectious diseases greater than that for the general public. To reduce the potential risk, employers are required to establish a medical surveillance program which documents immunity for some diseases, monitoring for others such as Tuberculosis, along with safety training on methods to prevent exposure and disease.
Environment, Health and Safety Manual - Chapter 06.07: Clinical Safety - Healthcare Personnel Who Are Infected With Hepatitis B Virus, Hepatitis C Virus, and/or Human Immunodeficiency Virus
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This standard defines the minimum security controls for Information Technology systems in use at UNC-Chapel Hill including personal and University-owned devices. Units within the University may apply stricter controls to protect information and systems in their areas of responsibility. The standard applies to each UNC-Chapel Hill Constituent, student, employee, or other for any covered system under their control.