550-21: UCSF Campus Communicable Disease Exposure Follow-up

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Assigns actions and responsibilities required for confirming a UCSF campus exposure to a communicable disease.


The purpose of this policy is to assign actions and responsibilities required for confirming a UCSF campus exposure to a communicable disease, identifying those individuals likely exposed, and determining the risk of transmission and the appropriate follow-up activities. This policy applies only to UCSF faculty, residents, postdoctoral scholars, staff, and students only for exposures occurring on campus. It is not intended for outside production or publication without permission. Likewise, no representations or warranties made within the policy are intended for outside enforcement. For direct inquiries contact the Office of Environmental Health and Safety at (415) 514-3531.

An Infection Control Exposure Follow-Up Policy applying to exposures that occur within the Medical Center is located in section 7.1 of the UCSF Infection Control Manual, available at: http://infectioncontrol.ucsfmedicalcenter.org/html/ICManual.html.


A defined group of UCSF personnel who determine the severity of the exposure and recommend procedures for follow-up. Included in this group are: Occupational Health Services (OHS)—Medical Director, Office of Environmental Health & Safety (EH&S)—Public Health Officer (PHO), Adult & Pediatric Infectious Disease Physicians, Student Health Services (SHS)*, Hospital Epidemiology and Infection Control (HEIC) Director*
* as appropriate


As required by California Labor Code 6401.7—Injury and Illness Prevention Program, the campus PHO and OHS will coordinate any necessary follow-up and implement the action plan when a communicable disease exposure is reported. A technical advisory meeting shall be convened within twenty-four (24) hours or on the first business day following the initial report. The PHO and OHS are responsible for activities related to students, staff, faculty, house staff, clinical fellows, all other trainees, volunteers, and contractors. Student Health Services (SHS) is responsible for prophylaxis, treatment, and follow-up related to exposures affecting students.

A debriefing shall be scheduled at the close of the exposure follow-up activities.


A. A possible exposure shall be reported to the campus PHO, who shall be responsible for initiating by email, phone or pager an initial investigation. In the event that the PHO is unavailable, the assistant Biosafety Officer shall be responsible for initiating the investigation.

Contact information is available at: http://www.occupationalhealthprogram.ucsf.edu/ohpStaff.asp

B. Exposure investigation, screenings, communications, and coordination

The detailed UCSF Campus Exposure Plan is available at http://www.occupationalhealthprogram.ucsf.edu/ohpEE.asp#ID and provides specific procedural details on the exposure investigation, screening, testing, communication, education, and coordination with UCSF Medical Center Infection Control and Occupational Health Services.


The PHO and OHS shall notify the San Francisco Department of Public Health (SFDPH) and/or the California State Department of Public Health Communicable Diseases Branch as required by Title 17—Reportable Diseases.

The PHO and OHS shall provide summary reports of the exposure activities to the Medical Center Infection Control Committee, Institutional Biosafety Committee (for exposures involving research) and the Occupational Health Steering Committee as appropriate.

D.Work Restrictions

1. All UCSF students, staff, faculty, house staff, clinical fellows, other trainees, volunteers, and contracted employees who are infected with potential pathogens may be restricted from work to prevent transmission to other personnel. The campus will follow all work restriction guidelines outlined by the UCSF Medical Center Infection Control Manual http://infectioncontrol.ucsfmedicalcenter.org/html/ICManual.html or as designated by the Public Health Officer for the SFDPH.

2. Work restrictions for any transmissible infections not referred to in Section 3.2a Table of Illnesses/Infections and Related Work Restriction within the UCSF Medical Center Infection Control Manual (see link provided in #1 above) shall be determined by the Technical Advisors Group.

3. The EH&S PHO or OHS shall provide information to Human Resources regarding work restrictions for employees.

4. UCSF personnel returning from international assignment with symptoms of infectious disease, such as fever, must be cleared for return-to-work status by OHS.