Immunisation of healthcare and laboratory staff

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1 12 of heathcare and aboratory staff Heath and safety at work Under the Heath and Safety at Work Act (HSWA) 1974, empoyers, empoyees and the sef-empoyed have specific duties to protect, so far as reasonaby practicabe, those at work and others who may be affected by their work activity, such as contractors, visitors and patients. Centra to heath and safety egisation is the need for empoyers to assess the risks to staff and others. The Contro of Substances Hazardous to Heath (COSHH) Reguations 2002 require empoyers to assess the risks from exposure to hazardous substances, incuding pathogens (caed bioogica agents in COSHH), and to bring into effect the measures necessary to protect workers and others from those risks as far as is reasonaby practicabe. Pre-empoyment heath assessment A new empoyees shoud undergo a pre-empoyment heath assessment, which shoud incude a review of immunisation needs. The COSHH risk assessment wi indicate which pathogens staff are exposed to in their workpace, and staff considered to be at risk of exposure to pathogens shoud be offered routine pre-exposure immunisation as appropriate. This decision shoud aso take into account the safety and efficacy of avaiabe vaccines. Staff not considered to be at risk need not routiney be offered immunisation, athough post-exposure prophyaxis may occasionay be indicated. Provision of occupationa heath immunisations Empoyers need to be abe to demonstrate that an effective empoyee immunisation programme is in pace, and they have an obigation to arrange and pay for this service. It is recommended that immunisation programmes are managed by occupationa heath services with appropriatey quaified speciaists. This chapter deas primariy with the immunisation of heathcare and aboratory staff; other occupations are covered in the reevant chapters. of heathcare and aboratory staff 83

2 of heathcare and aboratory staff of heathcare and aboratory staff Any vaccine-preventabe disease that is transmissibe from person to person poses a risk to both heathcare professionas and their patients. Heathcare workers have a duty of care towards their patients which incudes taking reasonabe precautions to protect them from communicabe diseases. of heathcare and aboratory workers may therefore: protect the individua and their famiy from an occupationay-acquired infection protect patients and service users, incuding vunerabe patients who may not respond we to their own immunisation protect other heathcare and aboratory staff aow for the efficient running of services without disruption. The most effective method for preventing aboratory-acquired infections is the adoption of safe working practices. shoud never be regarded as a substitute for good aboratory practice, athough it does provide additiona protection. Staff who work mainy with cinica specimens or have patient contact may be exposed to a variety of infections, whie staff who mainy work with specific pathogens are ony ikey to be exposed to those pathogens handed in their aboratory. Many empoyers are directy or indirecty invoved in the provision of heathcare and other patient services. Empoyees may be working in genera practice, in the NHS, nursing homes or private hospitas and cinics. Fu- or part-time permanent and agency staff shoud aso have a heath assessment. of heathcare and aboratory staff Further information on pre-empoyment heath assessments for heathcare staff, record-keeping and the exchange of empoyee records between hospitas can be found in the Association of Nationa Heath Occupationa Physicians (ANHOPS) guideines (ANHOPS, 2004). The heath assessment for aboratory staff shoud take into account the oca epidemioogy of the disease, the nature of materia handed (cinica specimens or cutures of pathogens or both), the frequency of contact with infected or potentiay infected materia, the aboratory faciities (incuding containment measures), and the nature and frequency of any patient contact. Staff considered to be at risk of exposure to pathogens shoud be offered pre-exposure immunisation as appropriate. Foowing immunisation, the managers of those at risk of occupationa exposure to certain infections, as we as the workers themseves, need to have 84

3 of heathcare and aboratory staff sufficient information about the outcome of the immunisation to aow appropriate decisions to be made about potentia work restrictions and about post-exposure prophyaxis foowing known or suspected exposure. Recommendations by staff groups The objective of occupationa immunisation of heathcare and aboratory staff is to protect workers at high risk of exposure and their famiies, to protect patients and other staff from exposure to infected workers, and to sustain the workforce. Potentia exposure to pathogens, and therefore the type of immunisation required, may vary from workpace to workpace. Guidance on the types of immunisation that may be appropriate foows. Staff invoved in direct patient care This incudes staff who have reguar cinica contact with patients and who are directy invoved in patient care. This incudes doctors, dentists, midwives and nurses, paramedics and ambuance drivers, occupationa therapists, physiotherapists and radiographers. Students and trainees in these discipines and vounteers who are working with patients must aso be incuded. Routine vaccination A staff shoud be up to date with their routine immunisations, e.g. tetanus, diphtheria, poio and MMR. The MMR vaccine is especiay important in the context of the abiity of staff to transmit meases or rubea infections to vunerabe groups. Whie heathcare workers may need MMR vaccination for their own benefit, they shoud aso be immune to meases and rubea in order to assist in protecting patients. Satisfactory evidence of protection woud incude documentation of having received two doses of MMR or having had positive antibody tests for meases and rubea. Seected vaccines BCG BCG vaccine is recommended for heathcare workers who may have cose contact with infectious patients. It is particuary important to test and immunise staff working in maternity and paediatric departments and departments in which the patients are ikey to be immunocompromised, e.g. transpant, oncoogy and HIV units (see Chapter 32 on TB). Hepatitis B Hepatitis B vaccination is recommended for heathcare workers who may have direct contact with patients bood or bood-stained body fuids. This incudes of heathcare and aboratory staff 85

4 of heathcare and aboratory staff any staff who are at risk of injury from bood-contaminated sharp instruments, or of being deiberatey injured or bitten by patients. Antibody titres for hepatitis B shoud be checked one to four months after the competion of a primary course of vaccine. Such information aows appropriate decisions to be made concerning post-exposure prophyaxis foowing known or suspected exposure to the virus. Infuenza Infuenza immunisation heps to prevent infuenza in staff and may aso reduce the transmission of infuenza to vunerabe patients. Infuenza vaccination is therefore recommended for heathcare workers directy invoved in patient care, who shoud be offered infuenza immunisation on an annua basis. Varicea Varicea vaccine is recommended for susceptibe heathcare workers who have direct patient contact. Those with a definite history of chickenpox or herpes zoster can be considered protected. Heathcare workers with a negative or uncertain history of chickenpox or herpes zoster shoud be seroogicay tested and vaccine ony offered to those without the varicea zoster antibody. Non-cinica staff in heathcare settings This incudes non-cinica anciary staff who may have socia contact with patients but are not directy invoved in patient care. This group incudes receptionists, ward cerks, porters and ceaners. Routine vaccination A staff shoud be up to date with their routine immunisations, e.g. tetanus, diphtheria, poio and MMR. The MMR vaccine is especiay important in the context of the abiity of staff to transmit meases or rubea infections to vunerabe groups. Whie heathcare workers may need MMR vaccination for their own benefit, they shoud aso be immune to meases and rubea in order to assist in protecting patients. Satisfactory evidence of protection woud incude documentation of having received two doses of MMR or having had positive antibody tests for meases and rubea. of heathcare and aboratory staff Seected vaccines BCG BCG vaccine is not routiney recommended for non-cinica staff in heathcare settings. 86

5 of heathcare and aboratory staff Hepatitis B Hepatitis B vaccination is recommended for workers who are at risk of injury from bood-contaminated sharp instruments, or of being deiberatey injured or bitten by patients. Antibody titres for hepatitis B shoud be checked one to four months after the competion of a primary course of vaccine. Such information aows appropriate decisions to be made concerning post-exposure prophyaxis foowing known or suspected exposure to the virus. Varicea Varicea vaccine is recommended for susceptibe heathcare workers who have reguar patient contact but are not necessariy invoved in direct patient care. Those with a definite history of chickenpox or herpes zoster can be considered protected. Heathcare workers with a negative or uncertain history of chickenpox or herpes zoster shoud be seroogicay tested and vaccine ony offered to those without varicea zoster antibody. Infuenza Infuenza vaccination is not routiney recommended in this group. Laboratory and pathoogy staff This incudes aboratory and other staff (incuding mortuary staff) who reguary hande pathogens or potentiay infected specimens. In addition to technica staff, this may incude ceaners, porters, secretaries and receptionists in aboratories. Staff working in academic or commercia research aboratories who hande cinica specimens or pathogens shoud aso be incuded. Routine vaccination A staff shoud be up to date with their routine immunisations, e.g. tetanus, diphtheria, poio and MMR. The MMR vaccine is especiay important for those who have contact with patients. Satisfactory evidence of protection woud incude documentation of having received two doses of MMR or having had positive antibody tests for meases and rubea. In addition to routine vaccination, staff reguary handing faeca specimens who are ikey to be exposed to poio viruses shoud be offered a booster with a poio-containing vaccine every ten years. Individuas who may be exposed to diphtheria in microbioogy aboratories and cinica infectious disease units shoud be tested and, if necessary, given a booster dose of a diphtheria-containing vaccine. An antibody test shoud be of heathcare and aboratory staff 87

6 of heathcare and aboratory staff performed at east three months after immunisation to confirm protective immunity and the individua shoud be given a booster dose at ten-year intervas thereafter. The cut-off eve is 0.01IU/m for those in routine diagnostic aboratories. For those handing or reguary exposed to toxigenic strains, a eve of 0.1IU/m shoud be achieved. Where a history of fu diphtheria immunisation is not avaiabe, the primary course shoud be competed and an antibody test shoud be performed at east three months ater to confirm protective immunity. Boosters shoud be given five years ater and subsequenty at ten-yeary intervas. Seected vaccines BCG BCG is recommended for technica staff in microbioogy and pathoogy departments, attendants in autopsy rooms and any others considered to be at high risk. Hepatitis B Hepatitis B vaccination is recommended for aboratory staff who may have direct contact with patients bood or bood-stained body fuids or with patients tissues. Antibody titres for hepatitis B shoud be checked one to four months after the competion of a primary course of vaccine. Such information aows appropriate decisions to be made concerning post-exposure prophyaxis foowing known or suspected exposure to the virus. of heathcare and aboratory staff Staff handing specific organisms For some infections, the probabiity that cinica specimens and environmenta sampes of UK origin contain the impicated organism, and therefore present any risk to staff, is extremey ow. For these infections, routine immunisation of aboratory workers is not indicated. Staff handing or conducting research on specific organisms and those working in higher risk settings, such as reference aboratories or infectious disease hospitas, may have a eve of exposure sufficient to justify vaccination. The foowing vaccines are recommended for those who work with the reevant organism and shoud be considered for those working with reated organisms, as we as those in reference aboratories or speciaist centres: hepatitis A Japanese encephaitis choera meningococca ACW135Y smapox 88

7 of heathcare and aboratory staff tick-borne encephaitis typhoid yeow fever infuenza varicea. Anthrax vaccine is aso recommended for those who work with the organism, or those who hande specimens from potentiay infected animas. Rabies vaccination is recommended for those who work with the virus, or hande specimens from imported primates or other animas that may be infected. Post-exposure management Specific additiona measures may sometimes be required foowing an incident where exposure to an infected individua, pathogen or contaminated instrument occurs. Advice shoud be sought from an occupationa heath department or from the oca microbioogist or other appropriate consutant. Some advice on post-exposure management is contained in the reevant chapters or may be found in reevant guideines (beow). Reference Association of Nationa Heath Occupationa Physicians (2004) of Heathcare Workers (ANHOPS guideines). Further reading Advisory Committee on Dangerous Pathogens (2005) Bioogica agents: managing the risks in aboratories and heathcare premises. Sunbury: HSE Books Department of Heath and Socia Security, Wesh Office (1984) Vaccination and immunisation poicy for NHS staff. London: HMSO. Department of Heath (1993) Protecting heathcare workers and patients from hepatitis B: HSG(93)40. London: Department of Heath. Department of Heath (1996) Addendum to HSG(93)40: Protecting heathcare workers and patients from hepatitis B. London: Department of Heath. Department of Heath (2004) Guideines on post-exposure prophyaxis for heathcare workers occupationay exposed to HIV. enter HIV post-exposure prophyaxis in search box. of heathcare and aboratory staff 89

8 of heathcare and aboratory staff Heath and Safety Commission/Advisory Committee on Dangerous Pathogens (1997) Infection risks to new and expectant mothers in the workpace: A guide for empoyers. Sunbury: HSE Books. Heath and Safety Commission s Heath Service Advisory Committee (1993) The management of occupationa heath services for heathcare staff. Sunbury: HSE Books. Heath and Safety Executive (2005) Contro of Substances Hazardous to Heath (fifth edition). The Contro of Substances Hazardous to Heath Reguations 2002 (as amended). Approved Code of Practice and Guidance. Sunbury: HSE Books Heath and Safety Executive (1998) The reporting of injuries, diseases and dangerous occurrences reguations 1995: Guidance for empoyers in the heathcare sector. Heath Services Information Sheet 1. Sunbury: HSE Books. Joint Tubercuosis Committee of the British Thoracic Society (1994) Contro and prevention of tubercuosis in the United Kingdom: Code of Practice. Thorax 49: NHS Executive HSC 2000/020 Hepatitis B infected heathcare workers. London: Department of Heath. NHS Executive HSC 2000/020 Guidance on impementation of HSC 2000/020. London: Department of Heath. NHS Executive HSC 2000/020 Further background information for occupationa heath departments. London: Department of Heath. UK Heath Departments (1998) Guidance for cinica heath care workers: protection against infection with bood-borne viruses. Recommendations of the Expert Advisory Group on AIDS and the Advisory Group on Hepatitis. London: Department of Heath. of heathcare and aboratory staff 90

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