3.02 - Guidelines for Staff With Blood Borne Virus Infection

8/2/2019 3.02 - Guidelines for Staff With Blood Borne Virus Infection

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Guidelines for Staff with BloodBorne Virus Infection

Printed copies must not be considered the definitive version

DOCUMENT CONTROL POLICY NO. 3.02

Policy Group Corporate

Author H Borland Version no. 1.0

ReviewerAndrea Crossan,Heather Aitchison &Dr David Breen

Implementationdate

November2010

Scope(Applicability)

Board wide

Status Final and approved Next review date November2012

Approved by

Board ManagementGroup

Last review date:


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Title: Guidelines for Staff with Bloodborne Virus InfectionDate: November 2010Version: 1.0

Author: Andrea Crossan, Heather Aitchison & Dr David Breen

The only current version of this policy is on the internet 2

CONTENTS Page

1: Introduction. 3

2: General measures to prevent occupational transmission

of Blood Borne Viruses. 3

3: Exposure Prone Procedures (EPPs) 4

4: Non Exposure Prone Procedures. 5

5: Staff groups who perform EPPs. 6

6: Pre employment notification. 7

7: Management of Healthcare workers (HCWs) in relation

to Hepatitis B infection. 7

8: Pre employment screening for exposure prone procedureposts in relation to Hepatitis B 9

9: Management of HCWs in relation to HIV infection. 11

10: Management of HCWs in relation to Hepatitis C virus 14

11: Healthcare workers who refuse to be tested. 16

12: Occupational health advice to BBV infected healthcare workers. 16

13: Confidentiality 16

14: Duties of other Healthcare workers. 16

15: Patient notification and Lookback exercises. 17

16: Implementation of the policy responsibilities. 17

17: Regulatory bodies statements on Professional Responsibilities 19

Appendix 1: Investigation of Hepatitis B infected HCWs who perform 20exposure prone procedures

Appendix 2: Hepatitis B infected Healthcare worker algorithm 21

Appendix 3: Useful contacts 22


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1. INTRODUCTION

Documented cases of Hepatitis B and Hepatitis C infections have occurred inpatients operated on by Hepatitis B or Hepatitis C infected health care workers. It is

plausible that HIV could be transmitted under similar circumstances, although therisk of HIV transmission has been shown to be considerably less than for Hepatitis Bor Hepatitis C following needlestick injuries.

Worldwide, there have been three reports of possible transmissions of HIV frominfected health care workers performing exposure prone procedures.

These guidelines are based on authoritative guidance from the UK Department ofHealth and Scottish Executive Health Department.

All health care workers are under ethical and legal duties to protect the health and

safety of their patients. They also have a right to expect that their confidentiality willbe respected and protected.

The blood borne viruses addressed by this policy are Human ImmunodeficiencyVirus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV).

2. GENERAL MEASURES TO PREVENT OCCUPATIONAL TRANSMISSIONOF BLOOD BORNE VIRUSES

2.1 Apply good basic hygiene practices with regular hand washing, before andafter contact with each patient, and before putting on and after removing gloves.Change gloves between patients. Refer to local Hand Hygiene policy, D&Gintranet, Policy No: 2.02

2.1.1 For all clinical procedures, cover existing wounds, skin lesions and all breaksin exposed skin with waterproof dressings, or, with gloves if hands extensivelyaffected.

2.1.2 HCWs with chronic skin diseases such as eczema should avoid thoseinvasive procedures which involve sharp instruments or needles when their skinlesions are active, of if there are extensive breaks in the skin surface. A non-intact

skin surface provides a potential route for blood borne virus transmission, andblood-skin contact is common through glove puncture, which may go unnoticed.

2.1.3 Use protective clothing as appropriate, including protection of mucousmembrane of eyes, mouth and nose from blood and body fluid splashes. Avoidwearing open footwear in situations where blood may be spilt, or where sharpsinstruments or needles are handled.

2.1.4 Prevent puncture wounds, cuts and abrasions and if present, ensure that theyare not exposed.


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2.1.5 Avoid sharps usage wherever possible and consider the use of alternativeinstruments, cutting diathermy and laser.

2.1.6 Where sharps usage is essential, exercise particular care in handling, useand disposal, following approved procedures and using approved sharps disposal

containers. Explore the provision and use of sharps safety devices. Refer to localSharps policy on D&G internet, policy No: 2.12.

2.8 Clear up spillages of blood and other body fluids promptly and disinfectsurfaces. Refer to local policy Management of blood and other body fluidspillages on NHS D&G intranet, policy No: 2.04.

2.9 Follow approved procedures for sterilisation and decontamination ofinstruments and equipment, refer to local decontamination policy on NHS D&Ginternet, policy No: 2.03

2.10 Follow approved procedures for safe disposal of contaminated waste, refer tolocal clinical waste policy, on NHS D&G Intranet, policy No: 2.06.

3. EXPOSURE PRONE PROCEDURES (EPPs)

The majority of procedures in the health care setting pose no risk of transmission ofblood borne viruses from an infected health care worker to a patient, providedappropriate health care measures are adhered to scrupulously, the circumstances inwhich a blood borne virus could be transmitted from an infected health care workerto a patient are limited to Exposure Prone Procedures (EPPS).

Exposure prone procedures are those invasive procedures where there is a risk thatinjury to the worker may result in the exposure of the patients open tissues to theblood of the worker (bleed-back).

These include procedures where the workers gloved hands may be in contact withsharp instruments, needle tips or sharp tissues (e.g. spinacles of bone or teeth)inside a patients open body cavity, or confined anatomical space where the handsor fingertips may not be completely visible at all times. However, other situations,such as pre-hospital trauma care and care of patients where the risk of biting ispredictable (e.g. such as with a disturbed and violent patient or a patient having anepileptic fit) should be avoided by health care workers restricted from performingexposure prone procedures.

Examples of such procedures include:

Surgical entry into tissues, cavities or organs

Repair of major traumatic injuries.

Vascular access where cut down technique may be used.


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Manipulation, cutting or removal of any oral or perioral tissues including toothstructure during which bleeding may occur.

Vaginal or caesarean deliveries or other obstetric procedures during which

bleeding from an HCW may occur as sharp instruments are used. Normalvaginal delivery in itself is not an exposure prone procedure. Whenundertaking a vaginal delivery an infected HCW must not performprocedures involving the use of sharp instruments, such as infiltrating localanaesthetic or suturing of a tear or episiotomy. Neither can they perform aninstrumental delivery requiring forceps or suction if infiltration of localanaesthetic or internal suturing is required.

In practice, a HCW who is restricted from performing Exposure Prone Proceduresshould only undertake a vaginal delivery, if it is certain that a second midwife ordoctor will also be present who is able to undertake all such operative interventions

as might arise during the course of delivery.

The risk of an injury to the HCW that may cause him or her to bleed and pose a riskto a patient depends on a variety of factors including:

The type of procedure;

The skill of the operator;

The circumstances of the operation;

The physical condition of the patient.

4 NON EXPOSURE-PRONE PROCEDURES

Procedures where the hands and fingertips of the worker are visible and outside thepatients body at all times, and internal examinations or procedures that do notrequire the use of sharp instruments, are not considered to be exposure-proneprovided routine infection control measures are adhered to at all times including thewearing of gloves as appropriate and the covering of cuts or open skin lesions onthe workers hands. Examples of non-exposure-prone procedures are;

Taking blood.

Setting up and monitoring IV lines.

Minor surface suturing. Simple endoscopic procedures.

Staff working in areas posing a significant risk of biting should not betreated as performing EPP`s.

The final decision about the type of work that may be undertaken by a blood bornevirus infected healthcare worker should be made on an individual basis, by theOccupational Health and Safety Service (OHS), taking into account the specificworking practices of the worker concerned.


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5. STAFF GROUPS WHO PERFORM EXPOSURE PRONE PROCEDURES

The following categories of directly employed staff have been identified asperforming or likely to perform EPPs. This includes staff employed temporarily or aslocums.

Medical staff in:

Surgical/medicalAnaestheticsGPs who perform minor surgical proceduresAll dentists/ orthodontists

Nursing staff in:

Theatres including reception and recoveryDental nurses/hygienistsAll Midwives.A /E

PAMsPodiatric surgeryParamedicsAmbulance technicians

StudentsDentalMidwifery

Exposure Prone Procedures can only be performed by those who are:

Hepatitis C negative

HIV negative

Hepatitis B ( Refer to Appendix 2)

Managers have a responsibility to assess all clinical posts whether or not theyinvolve Exposure Prone Procedures. Advice can be sought from the OHS.

Independent Contractors or staff employed by Independent Contractors who arelikely to be classed as performing Exposure Prone Procedures are:

Dentists Dental Hygienists Dental Nurses Medical staff working in A&E Departments

GPs who perform minor surgery may perform EPPs depending on the procedureand the technique. All such procedures must be assessed in line with the currentdefinition of EPP. Expert advice should be sought where there is doubt.

All Independent Contractors have a legal and ethical duty to assess theirduties and those of their employees to ascertain whether they undertake EPPsin NHS Dumfries and Galloway.


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6. -EMPLOYMENT NOTIFICATION.

All candidates for employment in an EPP post must be made aware of this policy atthe application stage.

The OHS will maintain a database of all staff notified as working in EPP posts.Managers must notify the OHS of all new employees to EPP posts prior to pre-employment health screening. Staff who are to be employed in posts which involveEPP must not be allowed to commence employment until they have been assessedas fit to perform EPPs by the OHS. If a candidate is rejected by the OHS as notbeing suitable for an EPP post the exact clinical reason for this will not normally benotified to management. This is in line with current guidance on OHS confidentiality.

7. MANAGEMENT OF HEALTH CARE WORKERS IN RELATION TOHEPATITIS B INFECTION

Provided appropriate infection control procedures are adhered to scrupulously, thecircumstances in which HBV could be transmitted from an infected healthcareworker to a patient are limited to Exposure Prone Procedures (EPPs). Refer toSections 3 & 5 of this Policy for further information on EPPs.

7.1 Hepatitis B Virus Markers

The infectivity of those infected with HBV will vary depending on circulating antigensand antibodies. There are 3 markers that are important in determining whethersomeone who is infected with HBV can perform EPPs. These are:

Hepatitis B e Antigen (HBeAg)HBeAg is associated with the presence of infectious virus. While carriers of HBV areHBeAg positive their blood contains a high concentration of virus and is likely totransmit infection. Some carriers may have persistent HBeAg whilst others maydevelop antibodies to it after a variable period. This usually leads to a reduction inthe level of infectivity.

Hepatitis B Surface Antigen (HBsAg)HBsAg is found during the latter part of the incubation period and acute phase ofHepatitis B Infection. Its persistence is associated with failure to clear virus from thebody.

Hepatitis B Viral LoadSome individuals infected with Hepatitis B may carry a genetic variant, which doesnot produce Hepatitis B e-antigen, but is still capable of assembling infectious viralparticles. In such cases the person will be Hepatitis B surface antigen positive buthave no e antigen markers. Viral load testing should take place for individuals in thiscategory to determine their infectivity.


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Hepatitis B Virus Immunisation.

The NHS Dumfries and Galloway policy on HBV immunisation is contained in theGuidelines for Health Clearance and Prevention of Blood Borne Viruses in NHSStaff.

All HCWs who perform EPPs must be immunised against HBV unless immunity toHBV as a result of natural infection or previous immunisation has been documented.Response to vaccine must subsequently be checked. Staff who have previouslybeen infected with HBV and are HBsAg positive will have their viral load checked.

It should be borne in mind that HCWs are at greater risk of acquiring HBV in thehealth care setting than patients. Therefore, all staff whose duties may bring theminto contact with blood or blood stained fluid or tissues are strongly advised to beimmunised against infection.

Exposure Prone Procedure Staff

Staff groups who have been identified as performing EPPs are detailed in Section 5of this policy.

All HCWs undertaking Exposure Prone Procedures must:

Show evidence of immunity to Hepatitis B either from immunisation orprevious infection

or

Be HBsAg negative HBeAg negative if non-responders to the vaccine(Annual testing of the HBV immune status of non-responders in EPP postswill be carried out by the OHS)

or

Be HBsAg positive HBeAg negative with a viral load less than 103 genomeequivalents per ml

Recent guidance from the Department of Health (March 2007) permits e-antigennegative hepatitis B infected health care workers with pre-antiviral HBV DNA levels

between 10 and 105

genome equivalents to perform EPPs while on oral antiviraltherapy if their viral load level is maintained below 10 genome equivalents. It isrecommended that these healthcare workers should have their HBV DNA levelschecked every 3 months, and should cease to perform EPPs if the level rises above10 on or after treatment, or if treatment stops for any reason. Due to patient safety

concerns, healthcare workers with a baseline viral load of above 105 will not beallowed to perform EPPs while taking oral antiviral therapy.


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HBV-carrying HCWs who have been treated with interferon or antivirals must have aviral load less than 10 12 months after cessation of treatment before a return tounrestricted working practices can be considered. Annual testing then applies as forother e-antigen negative workers.

An algorithm detailing the screening andinvestigation of Hepatitis B infected healthcare workers who perform EPPs is contained in Appendix 1, and also Appendix 2.

The virological criteria for fitness to undertake EPPs are kept under review by theExpert Advisory Groups and these may change in the future. The policy of NHSDumfries and Galloway will be amended to incorporate any change.

8. PRE EMPLOYMENT SCREENING FOR EXPOSURE PRONE PROCEDUREPOSTS IN RELATION TO HEPATITIS B

8.1 All candidates for employment must be notified to the OHS giving adequatenotice for pre-employment screening. The person undertaking the recruitment, i.e.the Service Manager or other senior person must liase with the OHS to ensure thatappropriate evidence of Hepatitis B immunisation is provided. Under normalcircumstances an individual/personal record of immunity to Hepatitis B is issued toall staff who have been screened.

i It is important to remember that for new HCWs the immunisation programmecan take up to 10 months to complete. Where the risk of contractingHepatitis B is determined as high an accelerated course of hepatitis B

immunisation will be given.

i The pre-employment screening mustbe completed prior to any job offer beingmade and will include the following:

Prospective employees who fail to mount an immunologic response to vaccinationwill be offered a second course of Hep B vaccine and post course testing. If theemployee fails to respond following the second course, they will be able to continueto perform EPPs subject to annual Hep B surface antigen testingProspective employees who are HBsAg carriers will require to be furtherinvestigated to determine HBeAg and viral load status.

If restriction from performing EPPs is not considered practicable the followingmay not be considered for employment to anEPP post:

Individuals who are HBeAg carriers of the virus.

Individuals who are HBsAg positive HBeAg negative with a viral load greaterthan 103 genome equivalents per ml.


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Individuals who are infected with Hepatitis B Virus and are currently receivingoral viral medication whos viral load exceeds 103 geq/ml.

8.2 HBeAg Positive HCWs in EPP Posts

HCWs in post who are found to be HBeAg positive must not perform ExposureProne Procedures.

All health care workers who are HBsAg positive must cease EPPs until theirHBeAg status has been established.

HBeAg positivity need not necessarily be life-long; spontaneous loss ofHBeAg with the development of antibody, anti-HBe, occurs each year inabout 5-15% of those infected as adults. HBeAg carriers infected as adultsmay respond well to treatment with interferon and carrier state may bereversed in up to 40% of those treated.

Advice regarding the duties that HBeAg positive HCWs may continue toperform must be sought from the Occupational Health Medical Officer.

8.3 HBsAg Positive HBeAg Negative HCWs in EPP Posts

Please refer to algorithm in Appendix 2.

8.4 Staff Rights

Hepatitis B-infected HCWs will receive the same rights of confidentiality as anypatient seeking or receiving medical care. Occupational Health notes are keptseparately from other hospital notes. The OH staff are ethically and professionallyobliged not to release notes or information without the consent of the individual.There are occasions when NHS Dumfries and Galloway may need to be advisedthat a change in duties should take place but HBV status itself will not normally bedisclosed without the HCWs consent. However, in exceptional circumstances,where patients are, or have been at risk, it may be necessary in the public interestfor the Occupational Health Medical Director to disclose confidential informationwithout permission, e.g. if an HBeAg infected HCW has performed EPPs.

NHS Dumfries and Galloway will make every effort to arrange suitable alternativework or retraining as required, should this be necessary.

The OHS will act as the adviser to the HCW and NHS Dumfries and Galloway on allemployment related matters in conjunction with the Human Resources Department.

Hepatitis B is a Prescribed Industrial Disease for HCWs. Benefits are also availableunder the NHS Injury Benefits Scheme for NHS staff who become infected in thecourse of their work.


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Physicians who are aware that HBeAg positive HCWs under their care have notfollowed advice to modify their practice must inform the employing authority and, asappropriate, the General Medical Council, General Dental Council or the Nursingand Midwifery Council.

8.5 Non-Responders To Hepatitis B Vaccine

Staff in post who are vaccine non-responders and who have no markers of previousHBV infection are at risk of acquiring infection. They may continue withoutrestriction of practice, provided those inoculation incidents are reported, treated andfollowed-up in accordance with the Dumfries and Galloway Control of InfectionManual Needle stick Policy for NHS Staff.

Non-responders who perform EPPs will be checked annually, by the OccupationalHealth Service, for Hepatitis B surface antigen.

9. MANAGEMENT OT HEALTH CARE WORKERS IN RELATION TO HIVINFECTION.

Provided appropriate infection control precautions are adhered to scrupulously, themajority of procedures in the healthcare setting pose no risk of transmission of theHuman Immunodeficiency Virus (HIV) from an infected health care worker to apatient.

The circumstances in which HIV could be transmitted from an infected health careworker to a patient are limited to exposure prone procedures in which injury to thehealth care worker could result in the workers blood contaminating the patients

open tissues. This is described as bleed-back in this guidance. HIV infectedhealthcare workers must not perform any exposure prone procedures. The majorityof health care workers do not perform exposure prone procedures.

Exposure Prone Procedures must not be performed by an HIV infected HCW.

9.1 Health care workers who already perform exposure prone procedures shallbe provided with information outlining current guidance on HIV transmission andreminding them of their professional responsibility to report any instance where theymay have been exposed.

9.2 All doctors, dentists, nurses, midwives, health visitors and other professionalswho have direct clinical care of patients, have a duty to keep themselves informedand updated on the codes of professional conduct and guidelines on HIV infectionlaid down by the regulatory bodies and any relevant guidance issued by the HealthDepartments.

9.3 Infected HCWs who continue to work in non EPP posts must remain underclose medical supervision and receive appropriate medical and occupational adviceas their circumstances change.


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9.4 HIV infected health care workers applying for new posts should completehealth questionnaires honestly. HIV infection is a medical condition about which anoccupational physician should be informed, verbally if preferred. Details will remainconfidential to the Occupational Health and Safety Service, as for other medical

conditions disclosed in confidence to occupational health practitioners.

9.5 Health care workers who know or have good reason to believe (having takensteps to confirm the facts as far as practicable) that an HIV infected worker ispractising in a way which places patients at risk, or has done so in the past, mustinform an appropriate person in the health care workers employing authority (e.g.an Occupational Health Physician) or, where appropriate, the relevant regulatorybody. The Director of Public health should also be informed in confidence. TheUnited Kingdom Advisory Panel (UKAP) (see page 21 for contact details)can beasked to advise when the need for such notification is unclear. Such cases arelikely to arise very rarely. Wherever possible, the health care worker should be

informed before information is passed to an employer or regulatory body.

9.6 Responsibility of HCW

All health care workers are under ethical and legal duties to protect the healthand safety of their patients. They also have a right to expect that their confidentialitywill be respected and protected.

HCWs have an ethical duty to protect patients. Those who believe they may havebeen exposed to infection with HIV in their personal life or during the courseof their work must seek medical advice, and, if appropriate, diagnostic HIV

testing. HCWs found to be infected must seek appropriate expert medical andoccupational health advice. Those who perform or assist in EPPs must obtainfurther advice on their work practice, as it may need to be modified or restricted toprotect their patients.

If exposure prone procedures are currently being performed these activitiesmust cease whilst expert advice is sought.

The Director of Public Health (DPH) of NHS Dumfries & Galloway must be notifiedby all HIV infected HCWs who have performed exposure prone procedures. TheHCW may, however, request that a physician acting on his/her behalf inform theDPH.

9.7 Responsibility of Caring Physician

Physicians who are aware that HIV positive HCWs under their care have notfollowed advice to modify their practice must inform the employing authority, theDPH and, as appropriate, the General Medical Council, General Dental Council orthe Nursing and Midwifery Council.


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HIV infected HCWs who do not perform EPPs but who are involved in the clinicalcare of patients must remain under regular medical and occupational healthsupervision and receive appropriate occupational health advice if theircircumstances change.

9.8 Responsibilities of NHS Dumfries and Galloway and Rights of HCWs

NHS Dumfries and Galloway will bring to the attention of current and newemployees, including agency staff and independent contractors, the professionalregulatory bodies notices of ethical responsibilities and occupational guidance forHIV infected HCWs and ensure that students in training are apprised of the relevantprofessional bodies statements. The NHS Dumfries and Galloways policy withrespect to HIV infected HCWs will be made known to its employees.

Strict confidentiality must be guaranteed for HIV infected HCWs seeking advice from

their attending the Occupational Health and Safety Service. Occupational HealthService notes are kept separately from other hospital notes and OH staff areethically and professionally obliged not to release notes or information without theconsent of the individual concerned.

There are occasions when NHS Dumfries and Galloway may need to be advisedthat a change in duties should take place, but HIV status itself will not normally bedisclosed without the HCWs consent. However, in exceptional circumstances,where patients are, or have been, at risk it may be necessary in the public interestfor the Director of occupational health (and safety) to disclose confidentialinformation without consent.

NHS Dumfries and Galloway will make every effort to arrange suitable alternativework and re-training, or where appropriate, early retirement, for HIV infected HCWs.

The Director of Occupational Health and Safety service will act as the adviser to theHCW and NHS Dumfries and Galloway on all employment related matters inconjunction with the Human Resources Department.

NHS Dumfries and Galloway has a duty to keep information on the health, includingHIV status, of employees confidential and are not entitled to disclose an employeeas HIV infected. This duty does not end with the death of the worker.

Occupationally-acquired HIV infection is covered under the terms of the NHS InjuryBenefits Scheme.


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10. MANAGEMENT OF HEPATITIS C VIRUS (HCV) INFECTED HEALTHCAREWORKERS

This advice is based upon NHS HDL (2002) 75 Hepatitis C Infected Health Care

Workers

Health care workers who are infected with the virus (i.e. who are Hepatitis CRNA positive) shall be restricted from performing exposure prone procedures

10.1 Health care workers who perform exposure prone procedures and whomay have been exposed to Hepatitis C infection;

Health care workers who perform exposure prone procedures, and who believe, thatthey may have been at risk of acquiring hepatitis C, should promptly seek and

follow, confidential advice on whether they should be tested for hepatitis C. Testingshould be for antibodies to hepatitis C virus, and if positive, for hepatitis C virusRNA. Health care workers should take account of their regulatory bodiesstatements on professional responsibilities in relation to communicable disease.The major risk factors for hepatitis C in the general population are:

Receipt of a blood transfusion prior to the introduction of Screening of all donationsin September 1991.

Use of blood clotting factors, prior to the introduction of heat treatment process toprotect against hepatitis C and other viruses. In Scotland heat treated Factor VIIIand IX were available in 1987 and 1985 respectively.

The sharing of injecting equipment whilst misusing drugs

Additionally the following risk factors also apply to health care workers:

Having been occupationally exposed to the blood of patients known to be infected,or deemed to be at high risk of infection, with hepatitis C by sharps or other injuries.Involvement as a health care worker or patient in invasive medical, surgical, dentalor midwifery procedures in parts of the world where infection control precautions

may have been inadequate.

10.2 Health care workers who already know themselves to have been infectedwith Hepatitis C (i.e. who have antibodies to Hepatitis C virus) and who carry outexposure prone procedures should be tested for Hepatitis virus RNA. Health careworkers in this position should take account of their professional bodys statementson professional responsibilities in relation to communicable disease. This testing isnot necessary for health care workers who are already known to be Hepatitis C virusRNA positive. Those found to be carrying the virus (i.e. who are Hepatitis C RNApositive) should not be allowed to perform exposure prone procedures in futureunless they have responded successfully to treatment.


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10.3 Health care workers who are intending to undertake professional training fora career that relies upon the performance of exposure prone procedures should betested for antibodies to hepatitis C virus and, if positive, for Hepatitis C virus RNA.Those found to be Hepatitis C virus RNA positive should be restricted from starting

such training whilst they are carrying the virus unless they have sustained avirological response to treatment. It will obviously be to the advantage of health careworkers to establish their hepatitis C status early as they make their career choices.

10.4 Hepatitis C infected healthcare workers who have responded successfully totreatment with antiviral therapy should be allowed to resume exposure proneprocedures, or to start professional training for a career that relies upon theperformance of exposure prone procedures. Successful response to treatment isdefined as remaining Hepatitis C virus RNA negative 6 months after cessation oftreatment. Successfully treated health care workers will be allowed to return to

performing exposure prone procedures at that time. As a further check, they shouldbe shown still to be Hepatitis C virus RNA negative 6 months later. Provided thecriteria above are met, a return to exposure prone procedure would be a localdecision and would not need to be referred to the UK advisory panel for HCWinfected with blood borne viruses (UKAP). However UKAP is available to provideadvice if needed.

10.5 Staff are provided with information and training about measures to reduce therisk of occupational exposure to Hepatitis C infection (e.g.; safe handling anddisposal of sharps and measures to reduce risks during surgical procedures)..10.6 The Advisory Group on Hepatitis has assessed that the risk of transmissionof Hepatitis C from a health care worker of unknown Hepatitis C status duringexposure prone procedures is low. It does not, therefore, advise that all health careworkers doing exposure prone procedures should be routinely tested for Hepatitis C.However, it has recommended the following precautionary measures to reduce therisk of infection to patients:

11. HEALTH CARE WORKERS WHO REFUSE TO BE TESTED

Health care workers, who already know that they have been infected with a BBV, or

who are intending to undertake professional training for a career that relies upon theperformance of exposure prone procedures, and who refuse to be tested, will not beallowed to carry out exposure prone procedures in future or commence theirtraining.

12. OCCUPATIONAL HEALTH ADVICE TO BBV INFECTED HEALTHCAREWORKERS

Arrangements should be made to provide individual health care workers with accessto a consultant Occupational Health Physician. Occupational Health Departmentsshould explain to health care workers the purpose of the new testing arrangements


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and how they might affect continued performance of exposure prone procedures.After testing, Occupational Health departments should inform health care workers ofthe results of their tests and the implications for their working practice. OccupationalHealth departments should refer BBV infected health care workers for specialistclinical assessment by an infectious diseases physician, if this has not already taken

place. All BBV infected health care workers should be given accurate and detailedadvice on ways of minimising the risks of transmission in the health care setting andto close contacts.

13. CONFIDENTIALITY

It is extremely important that BBV infected health care workers receive the sameright of confidentiality as any patient seeking or receiving medical care.Occupational Health staff, who work within strict guidelines on confidentiality, have akey role in this process. It is recommended that Occupational Health and SafetyService are closely involved in revising local procedures for managing BBV infected

health care workers. Occupational Health notes are separate from other hospitalnotes. Occupational Health staff are ethically and professionally obliged not torelease information without the consent of the individual. There are occasions whenan employer may need to be advised that a change of duties should take place, butBBV status itself will not normally be disclosed without the health care workersconsent. Where patients are, or have been, at risk, however, it may be necessary inthe public interest for the employer to have access to confidential information.Employers should ensure that data are collected and stored in accordance with theData Protection Act.

14. DUTIES OF OTHER HEALTH CARE WORKERS

Health care workers who know or have good reason to believe (having taken stepsto confirm the facts as far as practicable), that a BBV infected health care workerhas not complied with this guidance or followed advice to modify their practice,should inform an appropriate person in the health care workers employing orcontracting authority (e.g. a Consultant Occupational Health Physician, MedicalDirector or Director of Public Health), or where appropriate, the relevant regulatorybody. Health care workers may wish to seek advice from their regulatory andprofessional bodies before passing such information on. Such cases are likely toarise very rarely. Wherever possible, the health care worker should be informed

before information is passed to an employer or regulatory body.

15. PATIENT NOTIFICATION AND LOOKBACK EXERCISES

The responsibility for instituting and co-ordinating a look-back exercise rests with theDirector of Public Health who will normally consult the UK Advisory Panel for HealthCare Workers infected with Blood borne Viruses before embarking upon such anexercise. It is strongly recommended that the procedures recommended in thereport HIV Infected Health Care Worker Incident Highland 2002.


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16. IMPLEMENTATION OF THE POLICY RESPONSIBILITIES

16.1 NHS Dumfries and Galloways Medical Director

The Medical Directors responsibility is to ensure that:

Service Managers/Heads of Departments undertake their responsibility withregard to the policy.

HCWs involved in exposure prone procedures that decline HBV/HCV/HIVtesting are excluded from performing EPPs.

16.2 Service Managers & Heads of Departments

Service Managers and Heads of Departments are responsible for:

Defining which posts/staff undertake EPPs even if this is only on anoccasional basis, e.g. during cross cover;

Ensuring, in liaison with the OHS, those HCWs in EPP posts havedocumentary evidence of their BBV status. If such documentation is notavailable, it is the responsibility of the Service Manager/Head of Departmentto ensure the new HCW obtains evidence in accordance with the procedure,before being allowed to take up appointment and that existing staff fulfil theobligation to attend Occupational Health for the required tests.

Passing the names of non-compliers to the Medical Director for further actionas required timorously.

Notifying OHS of any staff changes in relation to EPPs workers.

Notifying OHS in strict confidence of any member of staff who are knowninternally to have acquired blood borne virus (BBV) infection.

Ensure that all new members of staff employed by NHS Dumfries andGalloway have health clearance completed by Occupational Health andSafety Service, as per recruitment and selection policy.

16.3 All HCWs Who Perform Exposure Prone Procedures

All HCWs who perform EPPs have a responsibility to ensure that they have theappropriate and up-to-date HBV status and attend Occupational Health for boosterdoses and/or testing as required.


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16.4 Occupational Health and Safety Service

The responsibilities of the Occupational Health and safety Service are:

To ensure that this policy is rigorously applied.

To maintain a confidential index and up-to-date record of the Hepatitis Bstatus of all notified medical, nursing and midwifery staff as well as otherHCWs who perform exposure prone procedures. In addition the OHS willmaintain a record of all other staff who have received Hepatitis Bimmunisation.

To provide a HBV immunisation and screening programme that complies withnational guidelines and NHS Dumfries and Galloway procedures.

To maintain a record of all other staff who have received Hep Bimmunisation.

To record serological test results from an accredited laboratory within thedepartment database and to issue a record of status to all HCWs who requireit.

To maintain a computerised recall system for booster immunisation andserological testing.

To liase with the Human Resources Department, Service Managers andHeads of Department with regard to staff screening procedures.

To undertake regular audit of records of staff employed within exposureprone procedures and non-exposure prone procedures areas.

To advise and counsel HCWs who are/have been chronically infected with aBlood borne Virus, relating to their own health and implications for currentemployment, and including the onward referral to a consultant wherenecessary.

To follow up all staff who have had a significant exposure to blood or otherbody fluids.

16.5 Human Resources

Human resources department will support Occupational Health in ensuringthat this policy is rigorously applied.

Human resources will ensure that all new employees are made aware of thispolicy at the application stage.


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17. REGULATORY BODIES STATEMENTS ON PROFESSIONALRESPONSIBILITIES.

Staff should be aware of the relevant Regulatory Bodies Statements on Professional

Responsibilities

General Medical Council Serious Communicable Diseases 1998

General Dental Council Maintaining Standards: Guidance To Dentists onProfessional and Personal Conduct Nov 1997

UKCC Acquired Immune Deficiency Syndrome And HumanImmunodeficiency Virus Infection (AIDS And HIV Infection) The CouncilsPosition Statement Registrars Letter 4/1994

UKAP Department of HealthRoom 635BSkipton House80 London RoadLondonSE1 6HL

Telephone: 020 7972 1533 (medical Secretary)020 7972 56849 (administrative Secretary)


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APPENDIX 1

Investigation of Hepatitis B Infected Health Care Workers (Hepatitis B SurfaceAntigen [HBsAg] Positive) who perform Exposure Prone Procedures

Any hepatitis B infected health care worker associated with transmission of infectionto a patient should cease performing exposure prone procedures

Test for HBsAg

HBeAg positivePRACTICE

RESTRICTED

HBsAg Negative

Test for e -

markers.

NoRestrictions.

HBsAg Positive

Anti HBepositive

No e-markers

Test for HBV DNA

HBV DNA not exceeding 10 3

genome equivalents per ml.Practice NOT restricted, BUT

subject to annual testing.

HBV DNA exceeding 103

genome equivalents per ml.See HepB infected HCWalgorithm (Appendix 2).


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The only current version of this policy is on the internet

APPENDIX 2. Hep B Infected Healthcare Worker

HepB eAg+ve or HepB eAg ve withviral load =/> 10

5geq/ml

Ineligible to perform EPPs

HepB eAg-ve with viral load =/< 10

geq/ml on no antiviral therapy

May perform EPPs subject toannual viral load testing

They mcontinu

load is sutwo cons

The Hepthe contiDisea

me

Viral load

intervals

If individviral load

On discobe chec

remain 10geq/ml the HCW will not

perform EPPs until they havebeen on different antiviral

treatment and two HB viral loadlevels of less than 10

3geq/ml

have been obtained no lessthan 1 month apart

In the event of the Hep B infected HCW failing

to attend appointments or refusing HBV DNAtesting they will be referred to the OHP

The Hep B infected HCW will be reminded bythe OHP of their professional and ethical dutyto report to Occupational Health if theydiscontinue medicine or have accidentallyexposed a patient to their blood

The infected HCW will be prevented fromperforming EPPs

This restriction will be notified to the employerby the OHP


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A th A d C H th Ait hi & D D id B

APPENDIX 3

CONTACTS FOR FURTHER INFORMATION

Dr Colin Jamieson Tel: 01387 244451Director Fax: 01387 244653Occupational Health DepartmentNithbank

Mrs Ros Kelly Tel: 01387 244626Senior Nurse Fax: 01387 244653Occupational Health DepartmentNithbank

Dr David Hamilton Tel: 01387 241532Consultant Bacteriologist Fax: 01387 241639DGRI

Dr Martin Connor Tel: 01387 241560Consultant Bacteriologist Fax: 01387 241560DGRI

Dr Derek CoxDirectorate of Public Health Medicine Tel: 01387 272725

Crichton Hall Fax: 01387 272759

Dr David Breen Tel: 01387 272724Consultant in Public Health Medicine Fax: 01387 272759Crichton Hall

Dr Angus Cameron Tel: 01387 244001Medical DirectorCrichton Hall

Caroline Sharp

Director of Human Resources Tel: 01387 241755DGRI

3.02 - Guidelines for Staff With Blood Borne Virus Infection

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Transcript of 3.02 - Guidelines for Staff With Blood Borne Virus Infection