UCSF Communicable Disease Surveilance and Vaccination Policy

550-20
This policy identifies requirements for enterprise-wide communicable disease surveillance and vaccinations to reduce the risk of exposure and the transmission of communicable diseases at its many campus sites and describes necessary actions to be compliant with applicable regulations. This policy applies to all students, staff, housestaff, fellows, post-doctoral scholars, trainees, faculty, visiting students and scholars, volunteers, contractors and affiliates who have occupational-based risk due to contact with patients, human subjects, animals, or cell lines, potential for blood-borne pathogen exposure, or other regulatory requirement.

Risk Category 1

Applies to individuals performing activities with the greatest risk of transmission of an infectious agent and individuals performing activities that have regulatory requirements for specific surveillance and immunity. These activities usually involve staff who have direct, prolonged contact with the infectious agent; experience face-to-face contact with an individual capable of spreading the infection; and pose a risk of transmission to a human research subject or laboratory animal.

Risk Category 2

Applies to individuals performing activities with a probable risk of transmission of an infectious agent as a result of their work being geographically located on the clinical unit or in the laboratory.

Risk Category 3

Applies to individuals performing activities with a possible risk of transmission of an infectious agent. These activities usually involve staff who have indirect contact with the source of the infectious agent through airborne transmission, the use of vehicles, accidental face-to-face contact such as in the cafeteria, or occupy an academic or administrative office in the Medical Center building.

Risk Category 4

Applies to individuals performing activities with minimal risk of transmission of an infectious agent. These staff work off-site from the source of an infectious agent and do not travel to any medical center, dental clinic, or laboratory site of the source with the infectious agent, or are researchers whose methodologies do not require face-to-face contact with high risk subjects.

  1. Responsibility for monitoring and enforcing compliance with this policy is decentralized and resides with the following
    a. Medical Center program managers for Medical Center staff
    b. Medical Staff Affairs office for individuals with clinical privileges
    c. Managers in the Schools of Dentistry, Medicine, Nursing, and Pharmacy for faculty and staff with patient contact in clinical
    programs falling outside the Medical Center license
    d. Principal Investigators for research programs with human subjects regardless of setting, or travel programs
    e. Graduate Medical Education for housestaff and clinical fellows
    f. Graduate Division for Postdoctoral Affairs
    g. Institutional Bio-safety Committee for research laboratories
    h. Institutional Animal Care and Use Committee for animal protection
    i. Environmental Health and Safety Public Health Officer for other campus staff
    j. Managers for any programs hosting visiting students, faculty, or other visitors, vendors, or contract staff

  2. OHS makes surveillance and vaccination compliance information (not clinical results) available to responsible enforcement programs

  3. The Chancellor’s Occupational Health and Safety Steering Committee receives periodic reports of compliance with TB skin testing and vaccination requirements.