GENERAL ADMINISTRATIVE POLICY EMPLOYEE SERVICES Date Written: 06/77 Date Reviewed/Revised: 07/10 Page No. 1 of 12

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1 OCCUPATIONAL HEALTH: GENERAL ADMINISTRATIVE POLICY EMPLOYEE SERVICES Date Written: 06/77 Date Reviewed/Revised: 07/10 Page No. 1 of 12 I. PURPOSE To provide Services to UC, Irvine Medical Center that is consistent with current medical practice guidelines, as well as the Requirements of state and federal regulations. II. BACKGROUND Title 22, Section OCCUPATIONAL HEALTH EXAMINATIONS AND HEALTH RECORDS require that personnel working in the clinics and/or hospital shall have a health examination performed upon employment to assure applicant is physically able to perform assigned duties. III. POLICY A. DESCRIPTION OF PROGRAMS AND SERVICES Services program will include the following: 1. PRE-PLACEMENT PHYSICAL All UC Irvine Medical Center applicants must be physically/emotionally capable of performing their job duties as defined in Job Description/Physical Demands. 2. ANNUAL HEALTH ASSESSMENT All UC, Irvine Medical Center employees are required to complete an annual health questionnaire, skin test or chest x-ray as defined by Center for Disease Control (CDC) or the Orange County Health Care Agency TB Policy. Each employee will be screened in his/her anniversary month via the TB assessment/screening questionnaire. 3. WELLNESS THROUGH PREVENTION PROGRAM Each UC, Irvine Medical Center employee is required to be fit for duty. 4. WORK-RELATED INJURIES AND ILLNESSES The Program provides assessment and treatment for employees' work-related injuries and illnesses under the scope of its practice. 5. EMPLOYEE ILLNESS - FIRST VISIT (NON-WORK RELATED) To provide assistance and direction for the ill or concerned employee as needed. 6. HAZARDOUS EXPOSURES - MEDICAL SURVEILLANCE All UC Irvine Medical Center employees working with hazardous or toxic substances 1

2 IV. PROCEDURES Page 2 of 12 will receive proper education, training and medical surveillance, as mandated by CAL-OSHA and University guidelines. UC, Irvine Medical Center Environmental Safety and Health Department and/or Departmental Managers will be responsible for notifying of existing or potential exposure of employees to non-infectious health hazards. will contact the Employee, Departmental Manager, Environmental Health and Safety and others as indicated. 7. RESIDENT PROGRAM Residents are subject to the same health and safety standards set for UC Irvine Medical Center employees (except urine drug screen). 8. MEDICAL STUDENTS Medical students with rotations at any UC Irvine Medical Center facility, hospital, or program are subject to the same health and safety standards set for UC, Irvine Medical Center employees (except urine drug screen). 9. VOLUNTEERS All Volunteers will be referred to by the Volunteer office and complete Health Screening before starting volunteering services and annually thereafter. All volunteers are subject to the same health and safety standards set for UC Irvine Medical Center employees (except urine drug screen). 10. ATTENDING PHYSICIANS/FACULTY Attending physicians and faculty will follow the Medical Staff Policy. EP30i. Occupatoinal Health Employee Services.pdf PERSON(S)/DEPT RESPONSIBLE DESCRIPTION/PROCEDURE A. PRE-PLACEMENT PHYSICAL ASSESSMENT Physical assessment and examination will be completed prior to employment start date/orientation. This will include the following: 1. Health questionnaire 2. Skin test or chest x-ray as indicated per Department Protocol (See Attachment I TB Screening Algorithm: New Hire Applicants). A history of previous BCG is not a contraindication for skin testing.2-step testing will be done when indicated 3. N-95 Mask fit test will be done on applicants with potential exposure to airborne pathogen (as defined by Epidemiology and Infection Prevention (EIP). 4. Lab tests: The following labs will be included: 2

3 Page 3 of 12 a. Hepatitis B Antibody: This will be provided if applicant has been previously immunized but has no record of titer. If titer indicates no immunity, immunization is indicated. For all health care workers with exposure to blood and body fluids who have not been immunized, or are documented to have no immunity, the immunization series will be offered. If declined, document and have employee sign Hepatitis B Declination form, to be kept in file. Hepatitis B Antibody titer will be drawn two months after immunizations are completed. b. Hepatitis C Antibody: All applicants with occupational exposure to blood will be tested for Hepatitis C Antibody. c. Measles, Mumps, and Rubella (MMR): Rubella, Mumps, and Measles immunity is mandatory. Titers will be drawn unless applicant provides written documentation of two previous immunizations after the age of one year, or documented serologic immunity. d. Urine drug screening is done on all pre- placement exams with the exception of UC, Irvine School of Medicine transfers without a break in service. e. Varicella: Varicella immunity is mandatory. Titers will be drawn unless serologic proof of immunity is provided, or documentation of two previous vaccination. 5. Additional Lab tests required: If further lab testing is indicated in order to ensure applicant is free of infectious disease, applicant will be referred to his/her own physician to provide Occupational Health with written documentation, prior to being cleared for hire. 6. Vaccines: a. MMR is given to all staff with no written documentation of immunity or no history of immunization. (Two doses of MMR four weeks apart if no contraindications). If documentation of one MMR after age one, only one MMR booster will be given. Employee will be provided with Vaccine information sheet (VIS) and will sign a consent form* b. Varicella (Chickenpox) immunization will be offered, after hire, to susceptible residents, and employees. (Two doses four weeks apart if no contraindications). Employee will be given VIS and will sign a consent form.* c. Hepatitis B Immunization: All health care workers (HCW) with exposure to blood and body fluids are eligible. Hepatitis B immunization is provided, within ten days of hire, to employees who have potential occupational exposure to blood/body fluids, and who have not received the immunization series, or do not demonstrate immunity through titer results. Employee will be 3

4 given VIS and will sign a consent form* EP30i. Occupatoinal Health Employee Services.pdf Page 4 of 12 Hepatitis B titers will be drawn on employees two months after completion of the series by.* Declination: If a susceptible employee declines Hepatitis B immunization, he/she will be required to complete a Hepatitis B Declination Form, which will be maintained in the employee s record. The employee will remain eligible for Hepatitis B immunization, free of charge, at any time in the future while still an employee. d. Pertussis: Tdap vaccine will be required for all employees with direct patient contact if they have not received Tdap previously. Employees will be given VIS and will sign a consent form. If they have had a previous documented Tdap vaccination, they will not need the vaccine. e. Influenza: Influenza vaccine will be given to all new employees October through March at time of pre-placement evaluation (subject to vaccine availability). Employees will be given a VIS and sign a consent form*. If the employee declines an influenza vaccine, he/she will be required to sign an influenza vaccine declination form and follow masking policy. * In all cases, noted contraindications will be reviewed by nurses and/or physician prior to immunization. (Contraindications for MMR and Varicella include pregnancy, current or planned, within 3 months, immunocompromised, anaphylaxis after eating eggs or receiving Neomycin. If recent administration of immune globulin, delay vaccine administration). 7. Tuberculosis: For Algorithm for New Hire Applicants, see Attachment I: TB SCREENING ALGORITHM: NEW HIRE APPLICANTS. Refer to Tuberculosis Exposure Control Plan in Epidemiology and Infection Prevention Policy and Procedure Manual. New employees with history of positive PPD and negative chest x-ray (CXR) who have not received treatment for latent TB will be referred to their Primary Care Physician for consideration of prophylactic treatment. 8. Audiometry: Only as indicated by physician if necessary to assess applicant's ability to perform job functions 9. Vision screening: Snellen testing will be completed. Titmus testing and/or further evaluation will be included as indicated by physician if necessary to assess applicant s ability to perform job functions. 10. Physical Exam: will be done by physician and it will include physical assessment, range of motion and testing as indicated by physician. 11. Clearing Applicant: If additional medical information is needed to determine the status of new-hire, the following steps will be 4

5 Page 5 of 12 taken: a. Put a "hold" on internal processing by notifying Human Resources of the hold. b. Give the job description and a cover letter to applicant for completion by applicant's personal physician. c. When letter is received from applicant's physician, it will be reviewed by the physician and a recommendation made to Human Resources, by phone or in writing by the Occupational Physician, or as delegated, to clinical staff. d. Final hiring decision will be made by Human Resources. UC, Irvine Medical Center will not cover any expense incurred in this process. Employee * If new employees do not comply with second TB test, immunization or declination with one month of start date, a letter will be sent to their manager stating that Occupational Health physician has requested to take the employee off the schedule until the requirements are met. B. ANNUAL HEALTH AND WELLNESS ASSESSMENT DESCRIPTION/ PROCEDURE All employees who have direct or close indirect patient contact are required to complete an annual health assessment through the. Screening will include history of symptoms, as an adjunct to a Skin Test. If history of previous positive PPD skin test and negative CXR only completion of online TB assessment is required annually. (See Attachment IV for Departments that are exempt from Annual TB screening). Employees are given one month grace period from the annual due date in which to complete the annual health assessment. Medical center employees must schedule their annual health assessment appointment using the web based scheduling system. Manager/Supervisor Once the employee s assessment has been successfully completed, staff document completion in the web based scheduling system. This automatically updates the employee s record in IHRS and sets a new assessment date for the next year. Documentation also results in an automated to the employee s supervisor indicating that the annual assessment has been completed. Management is responsible for tracking employee compliance by using the action pending reports in IHRS. An employee who does not complete the annual health assessment and TB testing by the end of the identified grace period, the 5

6 Page 6 of 12 employee will be designated "delinquent". The manager/supervisor will take the employee off pay status on the first day of the month following the completion of the grace period. Volunteers who have not complied with the annual health assessment screening requirement will be taken off the work schedule immediately. C. WELLNESS THROUGH PREVENTION PROGRAM Immunizations 1. Pertussis: Tdap is required for all HCW assigned to direct inpatient contact in the departments of Peri-natal services, the Pediatric Resource Team, and the NICU who do not have medical contraindications to the vaccine. If they have had a previous documented Tdap vaccination, they will not need the vaccine. Employees will be given VIS and will sign a consent form. 2. Tdap vaccination is provided for work-related injuries ONLY if prescribed by the Physician. Td is given if Tdap has been previously given. 3. Influenza vaccine is required for HCW and is offered October to March to all eligible staff based upon supply available. A declination must be signed if HCW declines to receive vaccination. The HCW must follow the masking policy if they decline the vaccine. 4. Effective September 1, 2010, per the Cal/OSHA Aerosol Transmissible Disease Standard, all individuals working in hospitals and outpatient medical facilities who may be exposed to pertussis will be offered the Tdap immunization. Employees who decline to be vaccinated must sign a declination form. D. EXPOSURES TO INFECTIOUS DISEASE In the event of employee exposure to infectious disease, Epidemiology and Infection Prevention will notify Occupational Health and coordinate the treatment and /or referral of actual exposures. Varicella Exposure: a. Varicella titer will be drawn on all exposed staff members after an exposure if there is no documented immunity or proof of Varicella vaccine (Two doses). b. Immunization will be offered to all identified susceptible staff members if there are no contraindications. Staff will be required to complete an informed consent for Varicella vaccine series or sign a declination form. c. Exposed susceptible staff will be placed on administrative leave if alternative work cannot be arranged. Pertussis Exposure: 6

7 Page 7 of 12 a. provides the Pertussis Exposure questionnaire for each exposed HCW to confirm and document exposure (See Attachment: Pertussis Exposure Questionnaire) b. For non-immune HCW confirmed as exposed but asymptomatic the following regimen will be given: I. Administer Erythromycin 500 mg. four times per day for 14 days, OR II. Azithromycin 500 mg Day 1 followed by 250 mg Daily for 4 days, OR III. Trimethoprim/sulfamethoxazole (Bactrim) Two regular strength tablet twice per day or 1 double strength tablet twice per day for 14 days, OR IV. Clarithromycin mg/kg per day in 2 divided doses (maximum 1g/day) for 7 days. c. Provide Tdap booster to health care worker. d. Chemoprophylaxis initiated > 3 weeks after exposure has limited value for contacts and therefore is not offered. e. Instruct exposed HCW to report any symptoms consistent with Pertussis that develop within 42 days of the exposure to. f. For HCW confirmed as exposed and onset of symptoms greater than 4 days from date of exposure (runny nose, sneezing, low-grade fever, or cough). Exclude from work for the first 5 days of a full course of antimicrobial therapy. g.. HCW with symptoms of Pertussis who cannot or refuse to take antimicrobial therapy should be excluded from work for 21 days from onset of cough. i. Obtain posterior nasopharyngeal specimens from each symptomatic HCW. Specimens are sent to the laboratory for culture identification of B. Pertussis. Additionally, in select circumstances, the Chief of EIP may advise specimens to be sent for PCR testing. 3. TB exposure: EP30i. Occupatoinal Health Employee Services.pdf a. When an exposure incident occurs, the employees with unprotected exposure will be identified and referred to for follow-up and medical evaluation. b. EIP, and Nursing Administration assist in identifying all exposed employees and immediately provide a TST (unless the annual TST was done within the prior 2 months) as well as perform followup TST testing 3 months after exposure, to detect conversion. If the TB skin test converts to positive, a CXR will be done. For an employee whose skin test converts to positive, the employee will be referred to the Occupational Health Physician; employee should complete workers compensation paperwork to document the conversion is Work-related. c. will coordinate the exposure follow-up. 7

8 Page 8 of 12 d. Any employee suspecting he/she has been involved in an unprotected exposure must report to his/her supervisor and to. will interact with EIP to evaluate the incident. 4. Scabies/lice or exposure a. is notified of exposure or symptoms and employee is seen by. b. Document specific exposure signs or symptoms c. Evaluation by physician, and if exposure occurred as a result of an exposure at work, treat as work-related illness per current medical guidelines. If exposure is work related, a prescription is phoned to Pharmacy as indicated by physician. d. If exposure is not work related and treatment is needed, employee is referred to personal physician for further evaluation e. In all cases of diagnosed scabies, employee is returned to work after clearance through f. If exposure is work related, document as workers Compensation. Responsible Entity/Person Employee E. RESPONSIBILITIES: INFECTIOUS CONDITIONS OR SIGNS/SYMPTOMS Signs and Symptoms of Communicable Disease a. Any employee with drainage, undiagnosed rash, diarrhea over 24 hr. duration, productive cough, Herpes-Zoster, or any communicable diseases signs or symptoms should be evaluated by or remain off work until cleared by. Managers/Supervisors b. Individual health concerns and all non-work related illness or injuries will be referred to private provider. F. Fitness for Duty: Referral for Fitness for Duty Exam (Refer to Fitness For Duty policy) G. BLOOD OR BODY FLUID EXPOSURE All employees with work-related blood or body fluid exposure will be evaluated and treated per current medical practice and state and federal regulation. Refer to policy, Exposure to Blood borne Pathogens. These are considered work-related exposures for the purposes of workers' compensation. Employee Supervisor H. EMPLOYEE ILLNESS OR INJURY- WORK RELATED a. The injury is to be reported immediately to the employee s supervisor (or available supervisor) if absent. b. If an obvious emergency exists, the employee is to be transported or escorted to Emergency Department, regardless of whether condition is work-related or not. Employees with 8

9 Page 9 of 12 Supervisor / Employee/ Employee/Occupational Health all other injuries should report to 7:30-5:00 p.m., Monday-Friday. For injuries after 5:00 p.m., weekends and holidays, please contact the house supervisor at pager (714) c. Contact Workers Compensation Department by phone (714) and notify of injury. If necessary, then accompany or send the employee to. d. All employees with work related injuries or illness must clear through prior to returning to work. e. will provide the supervisor with employee s work status prior to returning employee to work. I. EMPLOYEE ILLNESS-FIRST VISIT / NON-WORK RELATED a. Call to have employee seen in, if possible. b. A history of current complaints and assessment are conducted by the Nurse if indicated. c. First aid is administered as indicated. d. Employee with non-work related illness will be referred to his/her Primary Care physician. e. A note may be required from provider as indicated by policy, upon return to work. f. Supervisor is notified of employee's work status (including restrictions) prior to returning employee to work. A return to work clearance note is issued to employee and is taken to supervisor by employee, or communicated to supervisor by. g. Consults by Occupational Physician may be made with Infectious Disease Fellow, Chief of EIP, Orange County Health Department and/or other medical personnel as indicated to assess employee's fitness for work. J. Hazardous Exposures - Medical Surveillance Occupational Health Department Manager/ Environmental Health and Safety Department Manager Departmental Supervisor, Manager, House Supervisor or Employee a. will be notified of all anticipated contacts with hazardous substances. b. Employee will be referred to for preplacement assessment with job description when surveillance baseline/routine requirements exist as part of an employee's job duties. c. Employee is referred to for initial, routine, or ongoing medical surveillance as indicated d. Acute exposures to hazardous materials are referred to Emergency Department if an emergency or if event occurs after hour, or, otherwise to 7:30-5:00 Monday through Friday. K. RESIDENT PROGRAM 9

10 Page 10 of 12 Resident a. Obtain forms from School of Medicine b. Obtain a physical examination from your medical provider of choice. c.. Return all completed forms to prior to start of Residency Program. d.. Ensure that immunization records are complete and included in mailing/delivery to Resident Resident e. Current TB skin test or chest x-ray results (see attachment I) f. Documented Measles, Mumps and Rubella immunity. Titers will be drawn unless applicant provides written documentation of o previous immunization after the age of 1 year (Two doses) o or proof of immunity g. Varicella (Chickenpox) titers, or documentation of two Varicella vaccines h. Documentation of Hepatitis B vaccine series and a Hepatitis B Surface Antibody titer. i. Hepatitis C Antibody Titer within two months j. Tdap if they have not received Tdap previously. They will be given VIS and will sign a consent form. Tdap is mandatory for all employees with patient contact unless medically contraindicated. k. Review completed forms. l. Identify deficiencies in physical assessment, health history, labs, immunization, and TB skin testing/cxr. m. Complete laboratory tests, chest x-ray and immunizations as indicated. n. Residents are notified through their resident coordinator to report to for testing or immunizations as indicated. o. Upon completion of records, health clearance will be documented in the computer website. Report all work-incurred injuries/illnesses immediately to Resident Coordinator; report to immediately for evaluation/treatment unless treatment in Emergency Department is indicated. Health records and reports obtained by and created by are to remain confidentially in Occupational Health. L. MEDICAL STUDENTS and CLINICAL LABORATORY SCIENTIST TRAINEES. Medical Student Clinical Laboratory Scientist Program Trainees. Upon start of the program, medical students are required to provide the Student Affairs Office a current TB skin test and chest x-ray performed within one year with documented positive TB skin test results. will provide the TB skin test and CXR as necessary. Student Affairs Office is responsible for maintaining the medical student s records. Clinical Laboratory Scientist trainees will provide the following to : 10

11 Page 11 of 12 Current TB skin test or chest x-ray results Documented Measles, Mumps and Rubella immunity. Titers will be drawn unless applicant provides written documentation of previous immunization after the age of one year (2 doses) or immunity Varicella (Chickenpox) titers, or documentation of two vaccine Documentation of Hepatitis B vaccine series and titers. Tdap is required if they have not received Tdap previously. A one-time administration of 1-dose Tdap is mandatory unless medically contraindicated. They will be given VIS and will sign a consent form. Volunteer Director/Volunteer M. VOLUNTEER PROGRAM Refer applicant volunteer to with the referral form. Complete pre-placement TB assessment per Occupational Health Departmental Protocol prior to clearing applicant. Applicant volunteers do not need to have first PPD read. Second PPD will be applied one week after first and be read hours later prior to clearance. If the TB test result is positive, the volunteer will have a chest x-ray done at UC, Irvine Medical Center If past history of positive TB test, the volunteer will have a chest x-ray done at UC, Irvine Medical Center if a chest x-ray done within one year is not provided. Assess MMR immunity status (require written documentation of immunity or immunization). Absent these, draw titer. If negative, give MMR vaccine per UC, Irvine Medical Center protocol. Varicella (Chickenpox): If no proof of immunity, a titer is drawn. If negative, give Varicella vaccine per UC, Irvine Medical Center protocol. Tdap. A one-time administration of 1-dose Tdap is mandatory for all individuals with patient contact if not medically contraindicated. Once completed, the volunteer applicant is given the signed referral form verifying completion, to return to the Director of Volunteer Services. The volunteer program is covered by the UC, Irvine Medical Center Worker's Compensation program. Work-related injuries should be reported and referred in the same manner as employees. Attending Physician/ Faculty N. ATTENDING PHYSICIANS/FACULTY Attending physicians and faculty will follow the Medical Staff policy. REFERENCES: 11

12 Page 12 of Center for Disease Control (CDC) U.S. Department of Health and Human Services Public Health Service. 2. Barclays California Code of Regulations Title 22, Section CDC: Guideline for Infection Control in Health Care Personnel, MMWR-Recommended adult Immunization Schedule-United States, October 2004-September Apic Position Paper: Immunization, Department of Health and Human Services, Center for Disease Control and Prevention. Guideline for Preventing the Transmission of Mycobacterium tuberculosis in Health Care Settings, County of Orange Health Care Agency recommended expanded use of the Tdap vaccine due to the pertussis epidemic, July 19 th, Barclays California Code of Regulations Title 8, Section 5199 Aerosol Transmissible Diseases ATTACHMENT I: TB Screening Algorithm: New Hire Applicants ATTACHMENT II: TB Screening Algorithm: Annual Assessment ATTACHMENT III: TB Screening Algorithm: Pregnancy Author: Approvals: EIP Committee September 01, 2010 Policy & Communication Committee September 15, 2010 Med Exec Committee September 20, 2010 Governing Body September 27,

13 Attachment I TB SCREENING ALGORITHM NEW HIRE APPLICANTS Applicant Is Not Pregnant Prior BCG or no documentation of previous PPD Proof of neg. PPD within 12 months Proof of >2 neg PPD in the past, History of documented positive PPD History of positive PPD without documentation PPD is negative Do 2 nd. Step TB test PPD is positive PPD (x1), symptom assessment PPD is positive *** Get chest x-ray*, Occupational M.D to clear for hire if CXR neg. refer to PMD for Assess/Treatment PPD is negative PPD x1 Annual assessment in 1 year PPD is positive*** Get chest x-ray. OH MD to clear for hire if CXR neg. Refer to PMD for assess/treatment. If CXR positive * X-rays will be provided in accordance with current medical practice and TB assessment guidelines from CDC. See algorithm for instructions for pregnant applicants/employees. Chest x-ray*,if none in last year. Occupational M.D. assessment Chest x-ray is positive or more assessment is needed. Refer to personal M.D. for assessment/ clearance, and do not clear without written documentation. Occupational M.D. to clear for hire after personal M.D. clearance PPD is negative Do 2 nd. Step TB test PPD is negative Annual assessment in 1 year PPD (x1) and symptom assessment PPD is positive Get chest x-ray. OH MD to clear for hire if CXR neg. If CXR positive ** Annual assessment includes a written review of symptoms. *** In selected cases occupational health MD may refer for Quantiferon test If applicant is on immunosuppressive medication do chest x-ray if not pregnant. 13

14 ATTACHMENT II TB SCREENING ALGORITHM: ANNUAL ASSESSMENT EP30i. Occupatoinal Health Employee Services.pdf Prior PPD = negative Prior PPD = positive On line symptom assessment & PPD Annual on line symptom assessment: (If asymptomatic symptom assessment in one year) Employee is pregnant Annual symptom assessment PPD = positive PPD = negative and has no symptoms PPD = negative but has symptoms If assessment positive Asymptomatic Symptomatic If not pregnant, get Chest x-ray Annual PPD and on line symptom assessment in one year Occupational Health MD assesses or refers for diagnosis and/or Treatment if indicated Chest x-ray = negative Cheat x-ray = positive On line symptom assessment in one year No chest x-ray. Occ. Health MD assesses and/or refers to PMD. If work related refer to UC Irvine ID attending Chest x-ray = negative Chest x-ray= positive Occ. Health MD assesses. Determine if work related. If not refer to PMD for Latent TB treatment Occ. Health MD assesses/refers for diagnosis and /or treatment, assesses exposure incident, and notifies Infection Prevention On line symptom assessment in one year Occ. Health MD assesses or refers for diagnosis and/ treatment If indicated On line TB assessment in one year On line TB assessment in one year If pregnant, No CXR Occ. Health MD to assess and clear. CXR after delivery 14

15 Attachment III TB SCREENING ALGORITHM-NEW HIRE PREGNANT APPLICANT New Hire Pregnant Applicant Documented positive PPD and has no document of CXR within 1 yr Prior PPD neg, prior BCG, no doc. of previous PPD, or history of positive PPD without documentation Proof of neg PPD within 12 months PPD x 1* Proof of > 2 neg PPD in the past Symptom assessment If neg. CXR after delivery 2 step TB test* PPD is negative PPD is positive Annual assessment & TB test in 1 yr. No CXR Refer to PMD for assessment and treatment. * TB skin tests are not contraindicated in pregnancy 15