State Laws on Measles, Mumps and Rubella Vaccination in Health Care Facilities

This summarizes a legal "menu" from CDC's Public Health Law Program. It covers state laws collected from June 6 to July 5, 2016.

Health care facilities increasingly require workers and patients to be vaccinated against preventable diseases, sometimes because state statutes or regulations tell them to. Such laws can contain three kinds of requirement:

• Assessment — the facility must check a worker's or patient's vaccination status.
• Offer — the facility must offer the vaccine.
• Ensure — the facility must require proof of vaccination or immunity.

Because measles, mumps and rubella behave differently in health care settings, many state laws name them separately rather than the combined MMR vaccine.

The vaccine and the diseases

The three vaccines were combined into MMR in 1971. The Advisory Committee on Immunization Practices recommends MMR for health care workers born in 1957 or later who have not had it or lack a current blood test showing immunity. Children get a first dose at 12–15 months and a second at 4–6 years (or at least 28 days after the first). Adults born in or after 1957 without evidence of immunity should get at least one dose. Women of childbearing age should be checked for rubella immunity and vaccinated if they lack it and are not pregnant; pregnant women without rubella immunity should be vaccinated right after giving birth. Vaccinated health care workers can keep working.

• Measles spreads through the air when an infected person coughs or sneezes. It begins with fever, then cough, runny nose and red eyes, then a rash of tiny red spots spreading from the head down. Before vaccination an estimated 3 to 4 million Americans caught it each year; about 500,000 cases were reported annually, with 400 to 500 deaths, 48,000 hospitalizations and 1,000 cases of encephalitis. It remains common abroad. In 2014 the United States had 667 cases from 27 states — the most since elimination was documented in 2000, mostly in unvaccinated people — and from January 1 to August 12, 2017, 118 people in 14 states.
• Mumps begins with a few days of fever, headache, muscle aches, tiredness and poor appetite, then swollen salivary glands. It spreads by coughing, sneezing or talking, shared cups and utensils, and contaminated hands and surfaces. Outbreaks still happen in well-vaccinated communities, especially schools, colleges and camps, though high coverage limits them.
• Rubella ("German measles") is caused by a different virus. It was eliminated from the United States in 2004 but can still be brought in. A woman infected while pregnant can pass it to her baby, causing birth defects.

How many states

• Health care workers: nineteen states have requirements — 8 covering measles, mumps and rubella, 7 rubella only, and 4 measles and rubella.
• Patients: 12 states — 5 covering all three, 6 rubella only, and 1 measles and rubella.

Hospitals

Patients. The three states' laws concern specific groups: two cover new mothers (Massachusetts has maternity services offer MMR before discharge to mothers who test negative for rubella antibodies); New York covers children under 18, whose immunizations hospitals must ask about and, if missing, make available; and South Carolina requires perinatal records to include the mother's rubella immunity and test results. No state's law covers all hospital patients, and none requires proof of vaccination. New York alone provides exemptions — medical, on a physician's certificate, and religious, for children of members of a recognized religion opposed to vaccination.

Workers. Ten states cover all hospital workers (Alaska's employee health programs must require evidence of rubella immunization); six cover workers with particular patient contact (Hawaii requires rubella antibody tests for staff in outpatient obstetric and family-planning clinics).

• Assessment: all 15 states — for example, Arizona bars a worker without evidence of immunity from caring directly for a mumps case, and Maine screens employees without documented rubella results.
• Offer: 2 states — New Jersey hospitals must offer rubella and measles vaccine to employees and medical staff; California employers must make CDPH-recommended vaccines available to exposed workers.
• Ensure: 13 states — Rhode Island requires evidence of immunity from all health care workers, following ACIP guidelines; Maine requires proof of immunization or immunity against all three diseases.
• Exemptions: medical in 6 states (a physician, physician assistant or nurse practitioner certifies, as in Rhode Island and Alaska); religious in 2 (Maine, Maryland); philosophical in 2 (Maine, and California, where workers who decline a vaccine sign a declination for each).

Long-term care facilities

Nursing homes and similar facilities give medical and personal care to people who cannot live independently.

Patients. Indiana requires written evidence of rubella and measles immunization on admission to facilities for children; Michigan requires children under 15 in child-care nursing units to be immunized as the physician orders; Illinois requires rubella antibody testing for every resident woman of childbearing age. Indiana allows medical exemptions, Michigan religious ones stated in writing by a parent or guardian; no state allows philosophical exemptions.

Workers. Five states cover all long-term care staff (Indiana requires records of current rubella immunization); three cover workers with particular patient contact (Nevada bars staff without proof of rubella immunity from contact with rubella cases or pregnant patients). All eight require assessment; California alone requires facilities to offer MMR; seven require proof (Rhode Island for all health care workers; New York makes rubella and measles immunization a condition of nursing home employment). Exemptions: medical in 5 states, religious only in Maine, philosophical in 2.

Ambulatory care facilities

Birth centers, dialysis centers, surgical centers and other outpatient facilities.

Patients. All seven states' laws concern pregnant women and mothers — Kentucky birthing centers must record immunization history and rubella antibody titer; Colorado birth centers must record a rubella titer. Two states require the vaccine to be offered (in New Jersey, a negative rubella titer calls for vaccination with counselling about future pregnancies). None requires proof, and none mentions exemptions.

Workers. Nine states cover all ambulatory care workers in specified settings, three those with particular patient contact (South Carolina ambulatory surgical facilities require proof of measles immunity from susceptible staff with direct patient contact). All 11 require assessment — Pennsylvania and the District of Columbia want rubella titers in pre-employment exams — and 9 require proof: Massachusetts birth-center staff must show rubella immunity or be vaccinated before starting; Arizona bars workers without immunity from caring for measles cases. None requires the vaccine to be offered. Exemptions: medical in 4 states, none religious, and philosophical only in South Carolina, where staff may decline a vaccine that is offered.

Even where the law makes no medical exemption, a worker or patient for whom vaccination is medically contraindicated is probably not required to be vaccinated.

Sources

• Centers for Disease Control and Prevention, Public Health Law Program, "State Healthcare Facility Measles, Mumps, and Rubella (MMR) Vaccination Laws," developed by Alexandra Bhatti, Lauren Tonti, Dawn Pepin and Aila Hoss with CDC's National Center for Immunization and Respiratory Diseases. https://www.cdc.gov/phlp/php/publications/mmr-vaccination-laws-healthcare-facilities.html
• Appendices by facility type: https://www.cdc.gov/phlp/php/publications/appendices-mmr-vaccination-laws-for-state-healthcare-facilities.html
• Words on this page from people and organisations outside the federal government — including state statutes — are paraphrased; rewritten in hubnx's own words.