[MCOH-EH] Varicella Vaccine refusal due to religious beliefs

Swift, Melanie D., M.D. Swift.Melanie at mayo.edu
Thu Jan 31 05:52:37 PST 2019

The issue of MMRV serology continues to be an area of diverse practice which can be confusing.

From a purely scientific standpoint, if you have documentation of adequate MMR vaccination (2 doses for measles and mumps; 1 dose for rubella) then the person can be considered immune. Postvaccination serology is not recommended by ACIP/CDC, who explicitly states that if postvaccination serology is obtained and is negative, additional MMR vaccination is actually NOT recommended. The reason for this is that serologic markers of vaccine-medicated immunity are far from perfect. You can have negative results with preserved cell-mediated immunity. (Some of you may have heard my anecdote about the resident who held a measles baby in a small room for 30 minutes before we knew it was measles – she had a negative IgG at the time of exposure, but never got measles. While she was on furlough she found records of her three prior MMRs!)

You can also have positive serology in the absence of vaccine-mediated immunity. There are documented cases of people contracting mumps or measles or chickenpox despite a positive IgG prior to the exposure. People can have a low-avidity antibody to the wild type virus, or they can have a great antibody against the vaccine strain without any effective antibody for wild type virus.

So in fact documentation of vaccination provides better assurance of immunity than documentation of postvaccination serology for MMR. In the absence of vaccination records, institutions can vaccinate (mandatory or voluntary per state/institutional requirements) or they may opt to  obtain or accept serologies (paid by institution or employee, per policy). From a practical standpoint, despite its imperfections a positive IgG is an acceptable and reasonable evidence of immunity, and it’s appropriate to accept that in lieu of vaccination – but whether you want to pay for three serologies vs insist on the more reliable MMR vaccination is up to your facility.

Varicella is a different case and evolving as younger, previously vaccinated individuals enter the workforce. For people without a history of vaccination, serology is probably the best first step, because you are assessing disease-mediated rather than vaccine-mediated immunity.

A good rule of thumb is to try and document vaccination first. If you know or suspect they were vaccinated, ensure they are fully vaccinated and don’t check postvaccination serology. If they were never vaccinated then serology is more reliable.

That said, institutions will vary in their practice based upon logistics, practical considerations,  employee preference, and resources.


Melanie Swift, MD
Senior Associate Consultant
Assistant Professor of Medicine
Division of Preventive, Occupational, and Aerospace Medicine
Phone 507.284.2560
Mayo Clinic
200 First Street SW
Rochester, MN 55905

From: MCOH-EH [mailto:mcoh-eh-bounces+budnicla=njms.rutgers.edu at mylist.net] On Behalf Of Cockrum, MD David S
Sent: Wednesday, January 30, 2019 5:21 PM
To: MCOH/EH <mcoh-eh at mylist.net>
Subject: Re: [MCOH-EH] Varicella Vaccine refusal due to religious beliefs

Similarly, we don’t mandate vaccines, and they can also refuse the titer. But if we have no proof of immunity, they sign a statement of understanding that they could be removed from work without pay should there be an outbreak for which they are not protected – or if they are diagnosed with one of the diseases.







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From: MCOH-EH [mailto:mcoh-eh-bounces at mylist.net] On Behalf Of Tim Crump
Sent: Wednesday, January 30, 2019 3:28 PM
To: MCOH/EH <mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>>
Subject: Re: [MCOH-EH] Varicella Vaccine refusal due to religious beliefs

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In Oregon, we are not able to require that staff get vaccinations.  However, we are now implementing a program of requiring those who decline vaccinations to get a titer.  At least then we have a better sense of their immune status.  Best, Tim

From: MCOH-EH [mailto:mcoh-eh-bounces+crumpt=ohsu.edu at mylist.net] On Behalf Of Lisa Dyrdahl
Sent: Wednesday, January 30, 2019 12:56 PM
To: MCOH/EH <mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>>
Subject: Re: [MCOH-EH] Varicella Vaccine refusal due to religious beliefs

We would allow a religious exemption for any vaccine.  These are approved through HR only if based on religion, not on a philosophical belief.  They must submit the objection in writing about why their religion opposes vaccination.  There are tons of these on the web, we get mostly the same script.

Philosophical beliefs are so easily refuted, i.e., “I don’t put anything foreign in my body”…while eating a donut covered in sprinkles with food dye.

Lisa Dyrdahl, RN, BSN
Manager Employee Health
UWMC Valley Medical Center
Ph 425-228-3440 x5720
Fax 425-656-5066

From: MCOH-EH <mcoh-eh-bounces at mylist.net<mailto:mcoh-eh-bounces at mylist.net>> On Behalf Of Marilyn Byrd
Sent: Wednesday, January 30, 2019 12:44 PM
To: MCOH/EH <mcoh-eh at mylist.net<mailto:mcoh-eh at mylist.net>>
Subject: [MCOH-EH] Varicella Vaccine refusal due to religious beliefs

Good afternoon,
I have recently had a new hire request to refuse the varicella vaccine due to her own religious beliefs. No specific doctrine, just her own beliefs.
We have not had this request before now which thinking about it now I can’t believe we have not.

I am curious if any of you allow healthcare workers to refuse the varicella vaccine based on their religious beliefs?

Thank you

Marilyn Byrd, RN MSN
System Director
Employee Health
Office: 812-238-7163
Fax: 812-238-7287

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