SBAR for Medical Staff Immunity

By Bindu Kumar MD, System Director, Employee Health and Safety


 The MEC has approved the requirement that all members of the medical staff provide proof of immunity to Measles, Mumps, Varicella etc., in alignment with CDC guidance.  Having this information will help facilitate exposure management, minimize disruptions in service lines and patient care due to furlough and maximize the safety of the clinical care environment.


  • Currently MLH does not have the immunity status on record for existing medical staff as it relates to Measles, Mumps, Rubella, Varicella, Pertussis and Hepatitis B.
  • MLH has had to furlough providers in the past during times of exposures to Varicella, Mumps etc. based on CDC best practices and DOH recommendations.   This has caused disruptions in medical staff scheduling and service delivery.
  • Other large local health systems (i.e. Penn, Jefferson and Temple) have such requirements in place.


As part of MLH’s ongoing commitment to staff and patient safety, a policy has been approved by the MEC and Senior Leadership requiring existing medical staff and newly credentialing medical staff to comply with the immunity requirements as above.


  • By February 1, 2021 all members of the medical staff are expected to comply by demonstrating immunity to Measles, Mumps, Rubella, Varicella and MLH’s pertussis requirements.  Independent members of the medical staff are encouraged to know their Hepatitis B immunity status and comply with CDC guidelines in this regard. (see attached message map)
  • Medical staff who fail to meet this requirement by the deadline above will be subject to administrative suspension and referral to the Medical Executive Committee.
  • In the interim, administrative suspension can be recommended for non-immune medical staff by the Occupational Health Medical Director or System Medical Director of Infection Prevention in the case of significant exposure or clinical outbreak
  • New independent members of the medical staff seeking credentialing will also need to comply with the above.
  • The attached message map is informational and provides guidance regarding obtaining titers/vaccines and coverage options.

If you have any questions or concerns, please contact your Chair or email Dr. Kumar at

More information is attached here.

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