Summary
In England, from the end of 2010 or early 2011 all medical practices and providers of healthcare, whether operating within the NHS or as independents, will be obliged under the Health and Social Care Act to register as a provider with the Care Quality Commission (CQC).
The Code of Practice on the Prevention and Control of Healthcare Associated Infections (HCAI) and related guidance outlines how NHS and independent dental providers can meet the registration requirements relating to HCAI set out in the regulations.
This information is made available to the general public via the CQC website and to commissioning agencies.
This topic explains the requirements for the management of occupational health service provision, staff immunisation and the management.
Employers’ Duties
Central to health and safety legislation and the Control of Substances Hazardous to Health (COSHH) Regulations 2002 in the UK and Northern Ireland is the duty for employers to assess work-related risks to staff, contractors, visitors and patients. This includes exposure to hazardous substances such as pathogens (called biological agents in COSHH). The employer must implement as far as is “reasonably practicable” measures to protect their staff and others who may be exposed to infectious pathogens in the workplace.
The law requires that employers engage the expertise of an occupational health services provider so as to ensure that employees are not a carrier or infected with a communicable disease. Employers have to be able to demonstrate that an appropriate employee immunisation programme is in place. They are obliged to pay for this service.
The occupational health provision should include the following services.
- Pre-employment health clearance of new staff.
- Ensure that existing staff receive all the recommended occupational immunisations and boosters.
- Immediate, 24-hour access to advice on post-exposure prophylaxis (PEP), to drugs and to appropriate support.
- All staff must be trained in the prevention and control of healthcare associated infections.
Employees’ Duties
The Health and Safety at Work, etc Act (1974) and the Health and Safety at Work (Northern Ireland) Order 1978 require employees to take reasonable precautions to ensure their own safety and the safety of others.
All GPs and Nurses have a professional duty to protect the health and safety of their patients in line with the GMC and NMC codes of conduct. . Registrants who believe that they may have been exposed to blood-borne viruses (BBV), such as HIV, hepatitis B (HBV) or hepatitis C (HCV), are under a legal and professional obligation to promptly seek and follow confidential advice on testing for BBVs. They are obliged to comply with expert recommendations and with national guidelines on practicing restrictions. A failure to do so would breach their duty of care to patients.
Medical personnel are advised not to rely on their own risk assessment. Instead, they should contact their occupational health service provider or local Director of Public Health in the Primary Care Trust for confidential advice on testing for BBVs.
Recommendations for Immunisation of Clinical Staff
Clinical staff should be immunised according to current guidance as recommended by the Care Quality Commission and the Green Book. The purpose of immunisation is two-fold.
- Immunisation helps to prevent transmission of communicable diseases to vulnerable and susceptible patients.
- Immunisation protects the healthcare worker, their colleagues, friends and families from occupational exposure to infectious disease.
Furthermore, staff immunisation can help to maintain the continued running of a clinical service during outbreaks of highly contagious infections, eg seasonal and pandemic flu.
Varicella, Hepatitis B and MMR vaccinations provide additional protection to women of childbearing age. These viral infections cross the placenta and can cause deformities in the unborn child. It should be noted that during pregnancy the woman has reduced immunity to infection. She becomes more susceptible to viral infections that often manifest with more severe and life-threatening symptoms than in the general public.
All new staff and existing clinical staff should have received vaccinations and be up to date with boosters against the following diseases.
- Hepatitis B.
- Tuberculosis (BCG vaccine if no natural immunity).
- MMR. Rubella is no longer available as a single vaccine and is a component of the Measles Mumps and Rubella (MMR) vaccine. Satisfactory evidence of immunity includes documentary evidence of receipt of two doses of MMR or having had positive antibody tests for measles, mumps and rubella.
- Diphtheria, tetanus and polio.
- Varicella (Chicken pox). This vaccination is recommended if the person is shown to be non-immune on antibody testing or there is no definite history of chicken pox or shingles.
- Seasonal influenza, as an annual vaccination in the autumn is recommended for front-line healthcare workers with direct patient contact.
- Covid- 19
Note:
Although immunisation provides protection against infection, it must never be regarded as a substitute for good infection control and prevention practice.
Recommendation for Immunisation of Non-clinical and Support Staff
Hepatitis B vaccination is recommended for non-clinical staff who are:
- at risk of injury from blood-contaminated sharp, eg cleaners who handle hazardous clinical waste
- at risk of being of bitten or deliberately injured by patients.
BCG vaccine is not routinely recommended for non-clinical staff in healthcare settings.
All non-clinical staff should be up to date with their routine immunisations and boosters, eg tetanus, diphtheria, polio and MMR.
All staff at the practice will be offered the Seasonal Influenza Vaccine as per Public Health Guidance.
Hepatitis B Immunisation and Interpretation of Post-vaccination Antibody Levels
A standard Hepatitis B vaccination (HBV) course consists of three immunisations but there are a range accelerated dosing schedules which includes an additional dose at 12 months. The vaccine stimulates the production of specific antibodies to hepatitis B surface antigen (HBsAg). Therefore, the vaccine is not required in personnel who have proven natural immunity to hepatitis B arising from previous infection.
Evidence shows that 10–15% of adults fail to respond (< 10 IU /mL) or respond poorly (10–100 IU/mL) to a course of HBV immunisation. An inadequate response is more common in those aged 40 years+ and is associated with obesity, alcoholism, smoking and underlying immunosuppression.
Importantly the vaccine is also ineffective in those people with a current acute hepatitis B infection or asymptomatic carriers.
The immune response to the vaccine (antibody titre) is maximal 1–2 months after completing a full course of immunisation. Vaccine immune response rates vary.
Hence, antibody responses should be measured 1–4 months after completing the full primary course of immunisation to ensure that the person has mounted an adequate antibody response (hepatitis B surface antibody titre (HBs Ab positive) 100 IU/ml).
The member of staff and occupational health service must keep a record of the immune response results. Such information allows appropriate decisions to be made concerning post-exposure prophylaxis following known or suspected exposure to the virus.
Declining a Test
All staff at the Uplands Medical Practice have the right to decline testing, in which case they will be refused clearance to take up a post that involves exposure prone procedures (EPPs).. However, a positive test, or declining a test for hepatitis C or HIV, should not affect the employment or training of healthcare workers that do not perform EPPs.
It is recommended that HIV infected healthcare workers should remain under regular medical and occupational healthcare in accordance with good practice.
The Uplands recognises that they have a greater duty of care to HIV infected healthcare workers. The Disability Discrimination Act 2005 protects such workers from discrimination in the workplace due to their chronic disability.
Clinical healthcare personnel and students for whom hepatitis B vaccination is contra-indicated, who decline vaccination or who are non-responders to vaccine should be restricted from performing EPPs unless shown to be non-infectious (ie negative for hepatitis B surface antigen). Periodic re-testing may need to be considered as advised by the lead GP Dr Ifat Hussain, personnel lead.
If a sharps injury involving a patient occurs during this time the patient should be assessed by local medical experts for the necessity of post-exposure prophylaxis and other supportive measures.
If non-immune medical personnel decline a BCG vaccination, the risks should be explained by the lead GP and supplemented by written advice. The person should usually not work where there is a risk of exposure to TB. The employer has employment and health and safety obligations with regard to their employee and should consider each case individually.
The risk assessment will be affected by the prevalence of TB locally and the practice’s case mix. Respiratory precautions such as the use of masks and respirators and appropriate surgery ventilation will help mediate the risk.
Hepatitis B Immunisation and Interpretation of Post-vaccination Antibody Levels
A standard Hepatitis B vaccination (HBV) course consists of three immunisations but there are a range accelerated dosing schedules which includes an additional dose at 12 months. The vaccine stimulates the production of specific antibodies to hepatitis B surface antigen (HBsAg). Therefore, the vaccine is not required in dental personnel who have proven natural immunity to hepatitis B arising from previous infection.
Evidence shows that 10–15% of adults fail to respond (< 10 IU /mL) or respond poorly (10–100 IU/mL) to a course of HBV immunisation. An inadequate response is more common in those aged 40 years+ and is associated with obesity, alcoholism, smoking and underlying immunosuppression.
Importantly the vaccine is also ineffective in those people with a current acute hepatitis B infection or asymptomatic carriers.
The immune response to the vaccine (antibody titre) is maximal 1–2 months after completing a full course of immunisation. Vaccine immune response rates vary.
Hence, antibody responses should be measured 1–4 months after completing the full primary course of immunisation to ensure that the person has mounted an adequate antibody response (hepatitis B surface antibody titre (HBs Ab positive) 100 IU/ml).
The member of staff and Practice Manager must keep a record of the immune response results. Such information allows appropriate decisions to be made concerning post-exposure prophylaxis following known or suspected exposure to the virus.