Download Measles, Mumps, Rubella and Varicella Policy

Measles, Mumps & Rubella (MMR) and Varicella
(chickenpox): Occupational Health Screening and
Vaccination
Version
3
Name of responsible (ratifying) committee
Health & Safety Committee
Date ratified
24.09.14.
Document Manager (job title)
Consultant Occupational Health Physician
Date issued
07th October 2014
Review date
06th October 2017
Electronic location
Health and Safety policies
Related Procedural Documents
Trust
policies:
Hepatitis
Bprotecting
employees & patients; Control of TB in NHS
employees; Immunisation of Healthcare and
Laboratory Staff
Key Words (to aid with searching)
Measles;
Mumps;
Rubella;
Varicella;
Vaccination; MMR vaccine; Occupational health
and safety.
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
3
24.09.14.
No material change. Previous version review date
Dr S Harvey
Measles, Mumps and Rubella (MMR) and Varicella (chickenpox). Occupational
Health Screening and Vaccination. Issue Number 3 Issue Date
07/10/2014
(Review date: 06/10/17(unless requirements change)
1
expired.
CONTENTS
Quick Reference Guide……………………………………………………………page 3
Introduction………………………………………………………………………….page 4
Purpose………………………………………………………………………………page 4
Scope…………………………………………………………………………………page 4
Definitions……………………………………………………………………………page 4-6
Duties and responsibilities………………………………………………………….page 6
Process………………………………………………………………………………page 7,8
Training requirements……………………………………………………………….page 8
References and Associated Documentation……………………………………..page 8
Equality and Diversity Statement………………………………………………….page 8,9
Monitoring Compliance with and the effectiveness of procedural documents. Page 10
Measles, Mumps and Rubella (MMR) and Varicella (chickenpox). Occupational
Health Screening and Vaccination. Issue Number 3 Issue Date
07/10/2014
(Review date: 06/10/17(unless requirements change)
2
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust
procedural documents.
For quick reference the guide below is a summary of actions required. This does not
negate the need for the document author and others involved in the process to be
aware of and follow the detail of this policy. The quick reference can take the form of
a list or a flow chart, if the latter would more easily explain the key issues within the
body of the document
1. Under the Health and Safety at Work Act 1974 employers and employees
have specific duties to protect, as far as reasonably practicable, those at work
and others who may be affected by their work activity, e.g. patients.
2. The control of Substances Hazardous to Heath (COSHH) Regulations 2002
require employers to assess the risks from exposure to hazardous
substances, including pathogens (called biological agents in COSHH) and to
bring into effect measures necessary to protect workers and others from risk
as far as reasonably practicable.
3. Any vaccine-preventable disease that is transmissible from person to person
poses a risk to both healthcare professionals and their patients. Health Care
Workers (HCW) have a duty of care towards their patients. This includes
taking precautions, including vaccination, to protect then from communicable
diseases.
4. Staff involved in direct patient care should be up to date with the following
vaccinations: tetanus, diphtheria, polio, hepatitis B, Measles, Mumps and
Rubella (MMR), varicella and seasonal influenza. Separate Trust policies deal
with hepatitis B immunisation and TB screening/BCG vaccination.
5. The MMR vaccine is especially important in the context of the ability of staff to
transmit measles or rubella infections to vulnerable groups (e.g. the
immunosupressed).
Satisfactory
evidence
of
protection
includes
documentation of having received 2 doses of MMR or having had positive
antibody tests for measles and rubella.
6. Varicella (chickenpox) vaccine is recommended for susceptible HCW who
have direct patient contact. Susceptible HCW can pose a significant health
risk to high-risk patients and are themselves at risk of being infected by their
patients. Chickenpox infection in adults can be extremely serious with a 1030% mortality rate. Those with a definite history of chickenpox or herpes
zoster can be considered protected, although recent evidence showed that a
history of chickenpox is a less reliable predictor of immunity in individuals
born and raised overseas; therefore routine testing should be performed in
this group.
7. Occupational Health will assess new employees during the Work Health
Assessment process for measles, mumps, rubella and varicella immunity.
Non-immune staff will be offered vaccination. New staff born after the
introduction of MMR vaccine in 1988 who do not have evidence of 2 doses
MMR vaccine can proceed to vaccination without serological screening.
Written consent will be obtained before vaccination and a post vaccination
information sheet provided.
Measles, Mumps and Rubella (MMR) and Varicella (chickenpox). Occupational 3
Health Screening and Vaccination. Issue Number 3 Issue Date
(Review date: 06/10/17(unless requirements change)
07/10/2014
1. INTRODUCTION
From the introduction of measles vaccination in 1968 until the late 1980s
coverage was low and was insufficient to interrupt measles transmission.
Measles, Mumps and Rubella (MMR) vaccine was introduced in October 1988
and achieved coverage levels in excess of 90%. Because of the substantial
reduction in measles transmission in the UK, children were no longer exposed to
measles infection, and if they had not been immunised, they remained
susceptible at an older age. In order to prevent a predicted epidemic, a UK
vaccination campaign was started in November 1994 with measles-rubella (MR)
vaccine. In 1996 a 2 dose MMR schedule was introduced.
All children should have received 2 doses MMR before leaving school. MMR can
be given to individuals of any age and those who have not received MMR should
be offered immunisation. With regard to vaccination in adults, individuals born
between 1980 and 1990 may not be protected against mumps but are likely to
be vaccinated against measles and rubella, although may have only had one
dose of MMR. A second dose should be given in this case.
Those born between 1970 and 1979 may have been vaccinated against measles
and many will have been exposed to mumps and rubella during childhood.
Those born before 1970 are likely to have had all three natural infections and are
less likely to be susceptible. Serology should be checked in relevant staff groups
and immunisation offered where indicated.
2. PURPOSE
To inform the Trust’s employees about the risks and requirements pertaining to
measles, mumps, rubella and Varicella in health care staff in the health care
setting
3. SCOPE
The policy applies to all health care workers with direct patient contact
‘In the event of an infection outbreak, flu pandemic or major incident, the
Trust recognises that it may not be possible to adhere to all aspects of this
document. In such circumstances, staff should take advice from their
manager and all possible action must be taken to maintain ongoing patient
and staff safety’
4. DEFINITIONS
Measles
Measles is an acute viral illness transmitted via droplet infection. The incubation
period is about 10 days (but may be up to 18 days). The signs and symptoms
include runny nose, conjunctivitis, cough, Koplik spots (tiny white spots like
grains of salt on the inside of the mouth), rash and fever. Complications include
otitis media, pneumonia, convulsions and encephalitis. Measles infection in
pregnancy can result in miscarriage or premature delivery.
Measles is highly infectious from up to four days before the rash appears to four
days after the appearance of the rash. Until 1988 measles epidemics occurred
every two or three years in the UK and therefore most UK adults are immune as
a result of childhood infection or vaccination. Since 1988, exposure to natural
measles has declined dramatically and younger members of the UK population
who have not been fully vaccinated are likely to remain susceptible into adult life.
Measles, Mumps and Rubella (MMR) and Varicella (chickenpox). Occupational
Health Screening and Vaccination. Issue Number 3 Issue Date
07/10/2014
(Review date: 06/10/17(unless requirements change)
4
An increasing proportion of the UK health care workforce is therefore at risk from
measles infection. Between 1995 and 2000 a substantial number of cases of
measles infection have been reported. Many of these have involved health care
workers. Measles is highly infectious. Patients with immuno-suppressive
disorders who are not immune to measles are at very high risk of acquiring
infection from health care workers.
Mumps
Mumps is an acute viral illness caused by a paramyxovirus. It is usually
characterised by parotid swelling and may be preceded by several days of nonspecific symptoms such as fever, malaise and headache. Asymptomatic
infection is common in children. It is spread by airborne or droplet transmission
with an incubation period of around 17 days. Neurological complications
including meningitis and encephalitis can occur. Other complications include
pancreatitis and orchitis. Before the introduction of MMR vaccine in 1988,
mumps occurred commonly in school-age children and more than 85% adults
had evidence of previous mumps infection. Initially high coverage of MMR
vaccine resulted in a substantial reduction in mumps transmission in the UK, but
since 1999 there has been an increase in confirmed mumps cases. In 2004 a
further increase was seen with the majority of cases born between 1980 and
1987. Those most likely to lack immunity are adults born since 1980.
Rubella
Rubella is a mild infectious disease, most common among children aged 4 - 9
years. It causes a transient rash, swelling of glands at the back of the neck, and,
occasionally in adults, mild pain and swelling in joints. Clinical diagnosis is
unreliable since the symptoms can be caused by other viruses. A history of
rubella should not be accepted without serological evidence of previous
infection. The incubation period is 14-21 days and the period of infectivity is from
one week before until four days after the onset of the rash. Maternal rubella
infection in the first 8-10 weeks of pregnancy results in foetal damage in up to
90% of infants and multiple defects are common. The risk of damage declines to
about 10-20% by 16 weeks and after this stage of pregnancy foetal damage is
rare. Rubella is a notifiable disease. To avoid the risk of transmitting rubella to
pregnant and non-immune patients, all Health Care Workers (HCW), both male
and female, who have direct patient contact, should be screened for rubella
antibodies by blood testing. Non-immune HCW should be immunised with MMR.
Varicella (chickenpox)
Varicella (chickenpox) is an acute, highly infectious disease caused by the
Varicella zoster (VZ) virus. It usually starts with one or two days of fever and
malaise and then vesicles begin to appear on the face and scalp, spreading to
the trunk, abdomen and finally limbs. After 3 or 4 days the vesicles dry with a
granular scab and may be followed by further crops. The infectious period id
from 1 or 2 days before the rash appears until the vesicles are dry. Herpes
zoster (shingles) is caused by the reactivation of the patients Varicella virus.
Virus from lesions can be transmitted to susceptible individuals to cause
chickenpox.
Varicella is transmitted directly by personal contact or droplet spread with an
incubation period of one to three weeks. The infection is most common in
children less than 10 years age, in whom it usually causes mild infection. The
disease can be more serious in adults, particularly in pregnant women and in
smokers, as they are at greater risk of fulminating Varicella pneumonia.
Pregnant women appear to be at greatest risk late in second or early in the third
Measles, Mumps and Rubella (MMR) and Varicella (chickenpox). Occupational
Health Screening and Vaccination. Issue Number 3 Issue Date
07/10/2014
(Review date: 06/10/17(unless requirements change)
5
trimester. For neonates and immunosupressed individuals the risk of
disseminated or haemorrhagic Varicella is greatly increased. Susceptible HCW
can pose a significant health risk to high-risk patients. Susceptible HCW are at
risk of being infected by their patients. Since chickenpox is so common in
childhood, 90% of adults raised in the UK are immune.
Since 2003 it has been recommended that non-immune healthcare workers are
vaccinated against Varicella. This gives protection to the HCW form infected
patients but also protects non-immune patients.
Health Care Worker (HCW)
 Clinical and other staff, including those in primary care, who have regular,
clinical contact with patients. Includes doctors, dentists and nurses,
paramedical
professionals
such
as
occupational
therapists,
physiotherapists, radiographers, ambulance workers and porters, and
students in these disciplines
 Laboratory and other staff (e.g. mortuary staff) who have direct contact
with potentially infectious clinical specimens and may additionally be
exposed to pathogens in the laboratory.
 Non-clinical ancillary staff that may have social contact with patients, but
not usually of a prolonged or close nature. This group includes
receptionists, ward clerks and other administrative staff working in
hospitals and primary care settings and maintenance staff such as
engineers and cleaners.
Immunosupression
 Current treatment with chemotherapy or generalised radiotherapy, or
within 6 months of terminating such treatment
 Organ transplant recipient and currently on immunosuppressive
treatment
 Bone marrow transplant recipients who are still considered to be
immunosupressed, including those with graft versus host disease
 Adults who have received a dose of around 40mg prednisolone per day
for month than 1 week in the previous 3 months
 Patients on lower doses of steroids, given in combination with cytotoxic
drugs
 Some individuals on lower doses of steroids or other immunosuppressant
for prolonged periods, or who because of their underlying disease, may
be immunosuppressed and at increased risk of infection.
 Patients with evidence of impaired cell mediated immunity e.g.
immunodeficiency syndromes
HIV positive: HIV positive individuals with or without symptoms should receive
the following as appropriate: live vaccines (measles, mumps, rubella, polio) and
inactivated vaccines (pertussis, diphtheria, tetanus, polio, typhoid, Hepatitis B,
Hib). HIV positive individuals should NOT receive BCG or yellow
5. DUTIES AND RESPONSIBILITIES
Managers
All relevant managers in the health care setting should ensure that new and
existing staff (including agency and locum staff and visiting HCW) are aware of
the contents of this policy and that they have been cleared as fit for work
following Occupational Health assessment.
Measles, Mumps and Rubella (MMR) and Varicella (chickenpox). Occupational
Health Screening and Vaccination. Issue Number 3 Issue Date
07/10/2014
(Review date: 06/10/17(unless requirements change)
6
Occupational Health Department
Undertake screening and vaccination of employees as set out in process of this
policy.
Employee
Comply with screening and vaccinations as set out in this policy and with other
relevant Trust policies such as the Infection Control Policy
6. PROCESS
Measles, Mumps & Rubella
Occupational Health will undertake a Work Health Assessment for all new
employees and screen existing staff on an opportunistic basis wherever
possible. All HCW must have acceptable evidence of immunity to measles and
rubella. Neither self reported disease nor a history of vaccination is considered
adequate. Written documentation of vaccination with two doses of MMR vaccine
or serological evidence of positive antibody tests for measles and rubella are
required.
New staff born after the introduction of MMR vaccine in 1988 who do not have
evidence of having received 2 doses of MMR vaccine will be offered vaccination
without prior serological screening as set out in the Green Book (see
references).
Written consent will be obtained before vaccination is given and a post
vaccination information sheet provided.MMR vaccine provides protection for
around 90% of recipients for measles and mumps and over 95% for rubella.
MMR contains live attenuated measles, mumps and rubella viruses. Since the
vaccine viruses are not transmitted, there is no risk of infection from those
recently vaccinated.
Susceptible (no evidence of immunity) HCW who refuse vaccination, should be
advised on possible work restrictions and their duty of care towards colleagues
and patients. It remains the managers decision to employ HCW or not when
informed of such a refusal.
Staff case of, or contact with case of measles
If a staff member reports contact with a case of measles, or infection control
inform OH about a possible case in a patient, attempts will be made to confirm
the diagnosis in the case. If confirmation is not possible, but the diagnosis is still
suspected, the situation will be managed as if it was measles. Staff members
who are of unknown immune status should be blood tested for antibodies. Staff
members who are antibody negative should be considered for prophylactic
immunisation and managed as follows:
From the 7th day after contact to the 18th day after contact with the case, they
must take their temperature every morning and not come to work if they are
pyrexial (i.e. 37.2ºC or higher), feel unwell, or have any sign of a rash. Provided
they follow the above instructions, staff can continue to work during this period
but they must not work with immunocompromised patients or pregnant women.
Temporary redeployment for these staff may need to be considered.
Varicella
The Occupational Health Department screen all new clinical employees during
the Work Health Assessment process. Those with a definite history of
chickenpox or herpes zoster can be considered protected. HCW with a negative
or uncertain history of chickenpox or herpes zoster should be serologically tested
and vaccine offered only to those without VZ antibody. A recent survey showed
Measles, Mumps and Rubella (MMR) and Varicella (chickenpox). Occupational
Health Screening and Vaccination. Issue Number 3 Issue Date
07/10/2014
(Review date: 06/10/17(unless requirements change)
7
that a history of chickenpox is a less reliable predictor of immunity in individuals
born and raised overseas (MacMahon et al., 2004) and routine testing should be
considered.
Vaccination will be offered to non-immune staff. Varicella vaccine is a live
attenuated vaccine. Written consent will be obtained before vaccination and a
post vaccination information sheet given to the employee. Pregnancy must be
avoided between the doses and for 3 months following the second dose of
vaccine. HCW will be told at the time of vaccination that they may experience a
local rash around the site of the injection or a more generalised rash in the
month after vaccination. In either case, they should report to the Occupational
Health Department for assessment before commencing work. If the rash is
generalised and consistent with a vaccine-associated rash (papular or vesicular)
the HCW should avoid patient contact until all the lesions have crusted. HCW
with localised vaccine rashes that can be covered with a bandage and/or
clothing should be allowed to continue working unless in contact with
immunosupressed or pregnant patients. In the latter situation, an individual risk
assessment should be made.
If a HCW is exposed to Varicella or herpes zoster between the 1st and 2nd dose
of the vaccine, the second dose should be given immediately (after discussion
with Virology Consultant).Post vaccination serological testing is not routinely
recommended but is advisable for HCW in units dealing with highly vulnerable
patients e.g. transplant units.
Management of HCW exposed to VZ virus infection
Vaccinated HCW or those with a definite history of chickenpox or zoster should
be considered protected and be allowed to continue working. As there is a
remote risk that they may develop chickenpox, they should be advised to report
to OHD if they feel unwell and develop a rash or fever.
Unvaccinated HCW without a definite history of chickenpox or shingles and
having a significant exposure to VZ virus should be excluded from contact with
patients from eight to 21 days after exposure. There is some evidence that
Varicella vaccine administered within 3 days of exposure may be effective at
preventing chickenpox (Varivax is licensed for post-exposure prophylaxis). OHD
will liaise with Infection Control staff in these circumstances. In any case, vaccine
should be offered to reduce the risk of the HCW exposing patients to VZ virus in
the future.
HCW with localised herpes zoster on a part of the body that can be covered with
a bandage and/or clothing should be allowed to continue working unless they are
in contact with high risk patients, in which case an individual risk assessment
should be carried out.
7. TRAINING REQUIREMENTS
Information contained in this policy will be made available at general staff
inductions, Junior Doctor Inductions, sharps training and health promotion
activities and educational written material produced within the Trust
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1. Immunisation against infectious disease 2006. ‘The Green Book’. UK
Department of Health
Measles, Mumps and Rubella (MMR) and Varicella (chickenpox). Occupational
Health Screening and Vaccination. Issue Number 3 Issue Date
07/10/2014
(Review date: 06/10/17(unless requirements change)
8
9. EQULITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is
reasonably practicable, the way we provide services to the public and the way
we treat our staff reflects their individual needs and does not discriminate
against individuals or groups on any grounds. This policy has been assessed
accordingly.
Our values are the core of what Portsmouth Hospitals NHS Trust is and what
we cherish. They are beliefs that manifest in the behaviours our employees
display in the workplace. Our Values were developed after listening to our staff.
They bring the Trust closer to its vision to be the best hospital, providing the
best care by the best people and ensure that our patients are at the centre of
all we do. We are committed to promoting a culture founded on these values
which form the ‘heart’ of our Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all
times.
Measles, Mumps and Rubella (MMR) and Varicella (chickenpox). Occupational
Health Screening and Vaccination. Issue Number 3 Issue Date
07/10/2014
(Review date: 06/10/17(unless requirements change)
9
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
This document will be monitored to ensure it is effective and to assurance compliance.
Minimum requirement to
be monitored
Lead
Audit of Occupational Health
screening process- Work
Health Assessment of new
PHT employees
OH consultant
physician
Tool
audit
Frequency of Report
of Compliance
annual
Reporting arrangements
Lead(s) for acting on
Recommendations
Policy audit report to:

Health and Safety Committee
The effectiveness in practice of all procedural documents should be routinely monitored (audited) to ensure the document objectives are being
achieved. The process for how the monitoring will be performed should be included in the procedural document, using the template above.
The details of the monitoring to be considered include:






The aspects of the procedural document to be monitored: identify standards or key performance indicators (KPIs);
The lead for ensuring the audit is undertaken
The tool to be used for monitoring e.g. spot checks, observation audit, data collection;
Frequency of the monitoring e.g. quarterly, annually;
The reporting arrangements i.e. the committee or group who will be responsible for receiving the results and taking action as required.
In most circumstances this will be the committee which ratified the document. The template for the policy audit report can be found on
the Trust Intranet Trust Intranet -> Policies -> Policy Documentation
The lead(s) for acting on any recommendations necessary.
Measles, Mumps and Rubella (MMR) and Varicella (chickenpox). Occupational Health Screening and Vaccination. Issue Number 3 Issue Date 10
07/10/2014
(Review date: 06/10/17(unless requirements change)