Download Staff Immunisation Policy - Southern Health NHS Foundation Trust

SH HR 59
Staff Immunisation Policy
Version: 3
Summary:
This policy provides guidance on the immunisation
requirements with SHFT to ensure that employees,
patients and visitors to the organisation are protected
as far as is reasonably practical from vaccine
preventable disease
Keywords (minimum of 5):
(To assist policy search engine)
Immunisations, vaccinations, healthcare associated
infections, infectious diseases, Occupational Health
Service.
All staff employed by Southern Health NHS
Foundation Trust including volunteers and students
who may be at risk of vaccine-preventable diseases.
Target Audience:
Next Review Date:
November 2019
Approved and Ratified by:
Infection Prevention and
Control Group.
Date issued:
March 2017
Author:
Theresa Lewis
Lead Nurse Infection Prevention and Control
Sara Courtney Acting Chief Nurse
Director :
Date of meeting:
3 February 2017
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Immunisation Policy
Version 3
March 2017
Version Control
Change Record
Date
Author
Version
07.11.13
20.8.15
Theresa Lewis
Jacky Hunt
1
2
Feb 17
Theresa Lewis
3
Page
Reason for Change
This is a new policy
Includes risk assessment of actions if staff refuse
immunisation and lists the employees responsibilities
Transfer of Occupational Health provider in Jan 2017
Throughout
Reviewers/contributors
Name
Theresa Lewis
Angela Roberts/Louise Piper
Sara Courtney
Toni Scammell
Taylor, Liz
Position
Version Reviewed &
Date
28.8.15
28.8.15
15.9.15
15.9.15
15.9.15
John Stagg
Laura Rothery
IPC Lead Nurse
IPC Nurses
Associate Director of Nursing, AHP & Quality E ISD
Modern Matron
Associate Director of Nursing and Allied Health
Professionals Children's Services
Head of LD Services Bucks
Area Director
Paula Hull
Associate Director of Nursing, AHP & Quality SW ISD
15.9.15
Scott Jones
Tim Coupland
15.9.15
15.9.15
Kevin Page
Carol Cleary
Head of Facilities and Environment
Associate Director of Nursing, AHP & Quality Learning
Disability and Mental Health
Associate Director of Nursing
Interim Head of Services (Hampshire)
Shelly Mason
Louise Jones
Wendy Sharp
Modern Matron
Senior HR Manager Best Practice Development
Occupational Health Services (OH Assist)
15.9.15
28.8.15, 15.9.15
15.9.15
Ann Lesser
Darren Hedges
IPC Group
Occupational Health Services (OH Assist)
Health and Safety Officer Southern Health
IPC Group members
15.9.15
28.8.15,15.9.15
3.11.15
IPC Group
IPC Group Members
V3 03.02.17
IPC Team
IPC Nurses
V3 03.02.17
Louise Jones
Senior HR Manager
V3 03.02.17
Ross Taylor
Regional Business Manager PAM
V3 02.02.17
Janet O’Neil
Head of PAM Acadamy
V3 02.02.17
15.9.15
15.9.15
15.9.15
15.9.15
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Immunisation Policy
Version 3
March 2017
Quick Reference Guide
Southern Health NHS Foundation Trust (SHFT) values its staff and regards their health and
safety as paramount. In the context of this policy, SHFT recognises the risk from infectious
diseases that may be acquired in the course of work and in the importance of staff preventing
spread to patients and clients and will ensure that employees, patients and visitors to the
organisation are protected so far as is reasonably practicable from these diseases (COSHH
2002).
Workers have a duty to take care of their own health and safety and that of others who may be
affected by their actions at work (Health and safety at Work Act 1974). Immunisations are not
mandatory under Trust policy (except for those performing Exposure Prone Procedures)
however by declining vaccination you may be putting yourself and others at risk. Keep a record
of any vaccinations you receive.
See - Appendix 1 Immunisation Required per NHS Employee Category
Managers have a responsibility to ensure:
 All new staff must be referred to the Occupational Health Service (OHS) who will be
responsible for ensuring that appropriate pre-employment screening and immunisation
procedures are followed in line with national guidance
 That no healthcare worker is allowed to undertake any exposure prone procedure (EPP)
eg surgery unless they have received written clearance by OHS(see Appendix 2 for
more details)
 Staff are allowed reasonable time to attend the Occupational Health department for any
consultation.
 Providing appropriate personal protective equipment for any tasks staff are required to
undertake
 That their staff attend mandatory Infection Control and Health and Safety training
updates
 Ensuring that infection incidents reported in their areas are appropriately investigated
and remedial action taken to reduce future risk of transmission where necessary
The Occupational Health Service will:
 Vaccinate staff where immunisation is required as set out in ‘Immunisation Required per
NHS Employee Category’ (please see Appendix 1)..
 Provide regular updates on ‘Did Not Attend’ (DNA) rates in monthly Management
Information report
 Inform manager when a staff member is cleared to perform EPP.
 Maintain accurate and contemporaneous records of staff vaccinations and inform
Managers when staff are unprotected against vaccine preventable infections
 Provide clearance on new employees if fit to commence work, or advice regarding work
restrictions following pre-employment assessment.
Individuals
 Have a duty to take care of their own health and safety and that of others who might be
affected by their actions at work.
 Take responsibility for their own health and to keep a record of vaccinations they have
received and know when they are due to expire.
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Immunisation Policy
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March 2017
Contents
Section
Title
Page
1.
Introduction
5
2.
Who does this policy apply to?
6
3.
Definitions
6
4.
Duties and responsibilities
7
5.
Main policy content
9
6.
Training requirements
12
7.
Monitoring compliance
12
8.
Policy review
12
9.
Associated trust documents
12
10.
Supporting references
13
1
Appendices
Immunisations required per NHS employee category
14
2
What constitutes an exposure prone procedure (E.P.P)
16
3
Equality Impact Assessment Tool
19
4
Employee Immunisation Declaration Form (declined
vaccination)
Risk management- vaccine preventable infections in staff
20
5
22
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Immunisation Policy
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Staff Immunisation Policy
1.
Introduction
1.1
The overall purpose of this policy is to promote arrangements for preventing exposure to
vaccine-preventable diseases.
Southern Health NHS Foundation Trust (SHFT) values its staff and regards their health
and safety as paramount. In the context of this policy, SHFT recognises the risk from
infectious diseases that may be acquired in the course of work and in the importance of
staff preventing spread to patients and clients and will ensure that employees, patients
and visitors to the organisation are protected so far as is reasonably practicable from
these diseases.
1.2
1.3
The Health and Social Care Act 2008 Code of Practice on the prevention and control of
infections and related guidance (DH 2015) states that registered providers must ensure
that:

All staff can access occupational health services (OHS) or access appropriate
occupational health advice

Occupational health policies on the prevention and management of communicable
infections in care workers are in place.

Decisions on offering immunisations should be made on the basis of a local risk
assessment as described in ‘Immunisations against Infectious Disease’ (‘The Green
Book’). Employers should make vaccines available free of charge to employees if a
risk assessment indicated that it is needed (COSHH Regulations 2002)

There is a record of relevant immunisations

Occupational health service procedures should include risk-based screening for
communicable diseases and assessment of immunity after a conditional offer of
employment and on-going health surveillance including offer of relevant
immunisations (See Appendix 1 of this policy).

Occupational health service procedures should include having arrangements in
place for regularly reviewing the immunisation status of care workers and providing
vaccinations to staff as necessary in line with ‘Immunisations Against Infectious
Disease’ (‘The Green Book’) and other guidance from Public Health England.
Transmission of disease may occur in any healthcare, work or domestic setting if a
person acquires an infection from a patient, client or colleague.
The Sharps and Inoculation Management Procedure (IP&C Policy Appendix 10)
addresses infection risk from a puncture wound, bite, cut or abrasion to their skin, or
contamination of broken skin, eye or mucous membranes which exposes them to the
blood, secretions or excretions of an infected person.
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It is normally difficult to know whether another person is infected with a transmissible
disease or a blood-borne virus, and therefore not only should standard infection control
precautions be used by staff when dealing with any patient, but also if any inoculation
incident is suffered, the affected person should always follow the procedures set out in
the Sharps and Inoculations Management Procedure (Infection Prevention and Control
Policy: Appendix 10)
2.
Who does this policy apply to?
This policy is applicable to all existing and prospective employees of the Trust or any
individual who has a contract for services and whose work exposes them to direct
contact with service users. This includes:
Category 1
Staff involved in direct patient care eg doctors, nurses, healthcare support worker,
occupational therapists, physiotherapists, radiographers, chiropodists, pharmacists,
dieticians, plaster technicians, audiology staff, and psychology staff. Students and
trainees of these disciplines who are working directly with patients
Category 2
Laboratory and pathology staff (including mortuary staff) eg technical staff this may
include cleaners porters and secretaries and receptionists in labs
Category 3
Staff in healthcare settings whom only have social contact with patients but are not
directly involved in their care eg receptionists, volunteers directly employed by the Trust,
ward clerks, porters and housekeepers, Estates staff
3.
Definitions
3.1
Inoculation incident – Being pricked by a needle or cut by a sharp object that has been
exposed to the body / body fluids of another person; or contamination of broken skin,
eye or mucous membranes by the blood, secretions or excretions of another person
3.2
Vaccination - The administration of antigenic material (a vaccine) to stimulate an
individual's immune system to develop adaptive immunity to a pathogen. Vaccines can
prevent or reduce morbidity from infection.
3.3
Immunisation: The process of inducing immunity to an infectious organism or agent in
an individual or animal through vaccination
3.4
Exposure Prone Procedures (EPP): Are invasive procedures where there is a risk that
injury to the worker may result in exposure of the patients open tissues to the blood of
the worker. These procedures include those where the workers gloved hands may be in
contact with sharp instruments, needle tips or sharp tissues (eg spicules of bone or
teeth) inside a patients open body cavity, wound or confined anatomical space where the
hands or fingertips may not be completely visible. These procedures mainly occur in
surgery, A&E, dental and some podiatry settings. Some examples include suturing and
insertion of a chest drain. Please see Appendix 2 for more details of what constitutes an
EPP.
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4.
Duties and responsibilities
4.1
Chief Executive and Trust Board ensure:



4.2
Executive Director with responsibility for Infection Prevention and Control
(currently the Executive Director of Nursing and AHP)



4.3

Receiving and monitoring regular reports on the number and type of inoculation
incidents reported within SHFT through monthly Management Information – this will
come to IPCT via HR Contact Manager
Receiving information on Flu vaccinations and staff uptake
Infection Prevention and Control Team: Are responsible for:


4.6
Processing reports received from the OHS
Reporting numbers of staff appropriately vaccinated against target to Divisional
Managers and department heads
Infection Prevention and Control Group:
Reviews the effectiveness of the arrangements in place to manage the risks
associated with inoculation incidents by:

4.5
Has delegated responsibility from the Chief Executive for the operation of this policy
Ensures that the Trust Board is advised of the effectiveness of this policy and any
shortfalls in meeting the standards set
Chairs the Infection Prevention and Control Committee which will monitor
compliance with the effectiveness of this policy
Health and Safety Committee:
Reviews the effectiveness of the arrangements in place to manage the risks
associated with vaccine-preventable diseases by:


4.4
The overall implementation, monitoring and effectiveness of this policy
The allocation of resources to provide compliance with this policy
That managers are aware of their responsibilities and implement the policy
Providing some education on the need for appropriate immunisations required for
work in the Trust according to exposure/contact risks as part of the Trust’s Induction,
and mandatory training programme
Safe use and disposal of sharps as part of the Trust’s Induction and mandatory
training programme
Department Managers: Are responsible for:





Ensuring that all new staff must be referred to the Occupational Health Service
(OHS) who will be responsible for ensuring that appropriate pre-employment
screening and immunisation procedures are followed in line with national guidance
Providing appropriate personal protective equipment for any tasks staff are required
to undertake
Ensuring that no healthcare worker is allowed to undertake any EPP unless they
have received written clearance by OHS.
Ensuring that their staff attend mandatory Infection Prevention and Control and
Health and Safety training updates
Ensuring that infection incidents reported in their areas are appropriately
investigated and remedial action taken to reduce future risk of transmission where
necessary
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
4.7
Individual Responsibility: every member of staff is responsible for ensuring they:







4.8
Staff are allowed reasonable time to attend the Occupational Health department for
any consultation.
Familiarise themselves with this policy, and where additional screening and
vaccinations are required in order to comply with the policy, they should arrange for
these to be completed through the OHS.
Are up to date with the mandatory IP&C training
Disclose their pregnancy status to OHS prior to immunisation if female
Take responsibility for their own health and keep a record of any vaccinations they
receive and when they are due to expire.
Workers have a duty to take care of their own health and safety and that of others
who may be affected by their actions at work (Health and Safety at Work Act 1974)
Seek and follow confidential advice from OHS about whether to undergo testing if
exposed to a serious communicable disease. Affected staff members must notify
their line manager so that contact can be made with the OHS in a timely manner to
bring vaccination status up to date and in-line with Trust and departmental
guidelines
If you acquire a serious communicable disease you must promptly seek and follow
advice from the Occupational Health Service regarding whether and in what ways
you should modify your professional practice and whom to inform. You must not rely
on your own assessment of the risk you pose to patients If you know or have good
reason to believe that a colleague has a serious communicable disease and is
practising or has practised in a way which places patients at risk you must inform an
appropriate person eg Occupational Health Service. Wherever possible you should
inform the healthcare worker concerned before passing information to an employer
or regulatory body (General Medical Council, Nursing and Midwifery Council)
Occupational Health Service (OHS) Responsibilities
The Trust Occupational Health Service is responsible for vaccinating or assessing
immunity of Trust staff in line with the recommendations as outlined in ‘The Green Book’
where the need arises out of:


Work undertaken to fulfil job requirements or duties.
To meet the requirements of Southern Health NHS Trust to obtain health clearance
for staff
The Occupational Health Service will vaccinate staff where immunisation is required as
set out in the vaccination table (please see Appendix 1).
The Trust OHS does not provide vaccinations for: leisure or sporting activities, holiday
travel except for holiday taken as an extension of an overseas trip on Trust business or
personal health reasons incidental to work
The OHS will:
 Notify the line manager when staff fail to attend OH appointments
 Notify the line manager when an individual declines vaccination with a report stating
that OH clearance cannot be provided
 Provide regular updates on Did Not Attend (DNA) rates and compliance rates for
staff vaccination to the SHFT contract manager through monthly reports
 Inform manager when a staff member is cleared to perform EPP.
 Maintain accurate and contemporaneous records of staff vaccinations and inform
Managers when staff are unprotected against vaccine preventable infections
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Immunisation Policy
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
4.9
Provide clearance on new employees if fit to commence work, or advice regarding
work restrictions following pre-employment assessment.
Voluntary Workers
Volunteers directly employed by the Trust should be made aware of the Trust
Immunisation Policy (see Matrix in Appendix 1) . They should be advised that it will be a
requirement of their continued voluntary service that they undergo screening and
immunisation in line with this policy via the OHS.
5
Main policy content
5.1
This section outlines the OHS recommendations for staff working in the Trust.
Additional vaccinations may be required as a result of DH guidance or local prevalence
of disease. All staff are advised to comply with the immunisation schedule as outlined in
appendix 1 for their own health and the health of others.
5.2
Work where vaccination is strongly recommended:







Staff who have regular contact with patients/service users and who are directly
involved in patient care
Staff in healthcare settings whom only have social contact with patients but are not
directly involved in their care
Staff who are involved in culturing or handling of human pathogens or purified
biological toxins
Staff involved in the handling or processing of human blood, serum or tissue
specimens
Contact with human waste
Clinical duties or fieldwork outside of the Trust premises e.g. patients homes
It is expected that front line healthcare workers participate in the uptake of the
annual flu vaccine
NB All staff that carry out Exposure Prone Procedures (EPP) must be vaccinated and
proven to be immune to Hepatitis B before commencing EPP.
5.3
Notification of new work:
Departments must have in place arrangements to notify the Trust OHS of new areas of
work e.g. work with biological agents; or teaching activities where a risk assessment
identifies vaccination as a control measure. The OHS will require advance warning of
when the activity will commence and the numbers of individuals involved.
The person-in-charge of new work or treatment programmes for which specific
vaccination will be needed should inform the Trust OHS of the work.
The person in charge of the work should ensure staff & students are informed of the
need for vaccination & arrangements for getting vaccinated
5.4
Vaccinations for clinical work/ NHS clearance;

Staff who will be involved in patient care or who require NHS health clearance to
work in or visit Trust health care institutions should complete a Pre-Employment
Health Questionnaire and comply with arrangements to attend for assessment with
the Trust OHS as required. They should bring to the appointment any documentary
evidence of prior vaccinations or immunity. Clearance to commence work or advice
regarding work restrictions will be provided by Occupational Health once the
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Immunisation Policy
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



assessment is complete. Inclusion in the immunisation programme will be instigated
once the employee has commenced work. Immunisations, where required, should
be commenced during the induction period.
Undergraduate medical students are seen for vaccinations and health clearance
at the commencement of their course by direct arrangement with the Faculty of
Medicine Education Office of their institution. Their immunisation requirements
remain the responsibility of the institution and not the Trust.
Taught postgraduates who will have clinical contact with patients should complete
a health care work clearance questionnaire and arrange a health clearance
appointment with the Trust OHS.
Nursing students –the university will be responsible for ensuring that nursing
students receive the correct immunisations
All staff who carry out Exposure Prone Procedures must be vaccinated and
proven to be immune to Hepatitis B before commencing EPP. Offers of
employments will not be given where the primary function includes EPP unless
immunity to hepatitis B can be demonstrated. Staff already employed by Southern
Health must refrain from EPP unless immunity to hepatitis B can be
demonstrated.(See Flow Chart 1 and 2)
Flow chart 1 Prospective Employee
whose prime role will include EPP
Prospective
employee whose
role involves EPP
Flow chart 2 Existing employee whose role
includes EPP
Staff member already employed by
Southern Health NHS Foundation
Trust whose role includes EPP
es EPP
OHS will check hepatitis
B immunity during preemployment screening
of new employee
Prospective
employee
refuses
hepatitis B
immunisation
or fails to
respond to
hepatitis B
immunisation
Do not employ
staff member
to perform EPP
Written clearance
obtained by manger
from OHS, stating
staff member is
immune to
Hepatitis B
Written
clearance given
by OHS to
manager stating
staff member is
immune to
hepatitis B
If employing
staff member
authorised to
perform EPP
Staff member
authorised to
perform EPP
No written clearance
obtained by
manager from OHS
as immune to
Hepatitis B (either
staff member
refused vaccination
or didn’t respond
successfully to the
vaccine, or is
currently infected
Staff member can
still work but must
not perform EPP
until clearance has
been given by OHS
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Immunisation Policy
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5.5
Risk Assessment (restricting staff that are not immune to Hepatitis B from EPP):
Although Hepatitis B is not common amongst the general UK population 1.04 cases per
100,000 populations (PHE 2012) it can have severe consequences to health (even
causing death) and is readily transmitted via microscopic amounts of contaminated
blood/blood stained body fluid entering another’s body eg via a puncture wound, broken
skin, via mucous membranes. EPP is an invasive procedure where there is a risk that
injury to the worker may result in exposure of the patients open tissues to the blood of
the worker. These procedures include those where the workers gloved hands may be in
contact with sharp instruments, needle tips or sharp tissues (eg spicules of bone or
teeth) inside a patients open body cavity, wound or confined anatomical space where the
hands or fingertips may not be completely visible. It would therefore be quite possible
that cross infection could take place without the staff being aware. Once infected the
healthcare worker eg surgeon could transmit hepatitis B to other patient during EPP.
Likelihood score of cross infection with Hepatitis B: Possible (3)
Consequences of cross infection with Hepatitis B: Catastrophic (5)
Risk score: 3x5 =15
5.6
Completing schedules;




5.7
Notification of compliance;


5.8
OH will not routinely provide the employee with appropriate certification to confirm
that they have met all of the immunisation requirements. Individuals can request
this information via a subject access request
The OHS will inform managers of staff or students defaulting from a vaccination
programme.
Costs

5.9
Where a person will need to attend more than one appointment to complete a
vaccination schedule, the OHS will arrange a series of appointments and issue
reminders to the individual when their next appointment is due by text where mobile
numbers are known or email.
Individuals will receive a text or email 24hrs prior to the date / time of their
appointment
Where periodic re-vaccination is recommended to maintain protection for work the
OHS will actively recall individuals when a booster dose falls due.
Individuals who fail to attend a booked appointment, must be re-booked onto
another appointment by their manager
Vaccinations recommended as a control measure for work in the Trust will be
provided to staff without charge.
Non Immune staff
There are some staff members who decline/do not respond to vaccinations or for
some individual vaccination is contra-indicated on health grounds. Please see
Appendix 5 for risk management of these staff.
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5.10
Staff declining
Workers have a duty to take care of their own health and safety and that of others who
may be affected by their actions at work (Health and Safety at Work Act 1974).
Immunisations are not mandatory under Trust policy (except for those performing EPP)
however by declining vaccination you may be putting yourself and others at risk.
A staff member wishing to decline vaccination will be required to sign a
declaration confirming that they are aware of the risk from vaccine preventable
infection that may be acquired in the course of their work (see Appendix 4).

The Occupational Health Practitioner will hold copies of the ‘Declaration Form’ at the
clinic where the staff member is seen for the staff member to complete if declining
vaccination. The OHS will retain a copy and an electronic version will be emailed from
the OHS to the generic Human Resources email inbox. Human Resources will arrange
for this to be forwarded to the relevant manager so that the manager can file the form in
the staff member’s personal files on site.
6.
Training requirements
6.1
Immunisations requirements will be covered as part of the individuals induction
programme.
7.
Monitoring compliance
8.
Element to be
monitor
ed
DNA figures
Lead
Tool
Frequency Reporting arrangements
HR
Electronic
report
Monthly
Compliance
Figures with
Immunisation
HR
Electronic
report
Monthly
OHS will share with HR.
Reported to Infection Control
Committee but monitored by the
H&S Committee.
OHS will share with HR.
Reported to Infection Control
Committee but monitored by the
H&S Committee
Policy review
This policy will be reviewed by the OHS and IP&C team every 4 years or earlier to meet
with national guidance
9.
Associated trust documents







Occupational Health Pre Employment Guide
Management of Infected Healthcare Worker Policy – Hepatitis B, C or HIV and
advising on Fitness to Work
IP&C Policy, Appendix 5 Standard Precautions
IP&C Policy, Appendix 6 Hand Hygiene
IP&C Policy, Appendix 10 - Sharps and Inoculation Management
SFHT Waste Policy
SH CP 157 Exposure Prone Procedures (EPPs) and Blood Borne Viruses (BBVs) Management of the Infected Healthcare Worker
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10.
Supporting references











Salisbury, D., Ramsay, M., & Noakes, K. (2013) Immunisation against infectious
disease (The Green Book). Department of Health
Department of Health (rev 2015) The Health and Social Care Act 2008 Code of
Practice on the prevention and control of infections and related guidance
Department of Health (2007) Hepatitis B infected healthcare workers and antiviral
therapy.
Department of Health (2007) Health clearance for tuberculosis, hepatitis B,
hepatitis C and HIV: New healthcare workers
Department of Health (2005) HIV Infected Health Care Workers: Guidance on
Management and Patient Notification
Department of Health (2002) Hepatitis C Infected Health Care Workers
Immunization against infectious disease: the green book www.gov.uk
The Control of Substances Hazardous to Health Regulations 2002
www.legislation.gov.uk
The Management of HIV infected Healthcare Workers who perform exposure prone
procedures: updated guidance, January 2014 PHE www.gov.uk
Health and Safety at Work etc. Act 1974 (Commencement No.1) Order 1974,
1974/1439, art.2(a)/ Sch.1
Public Health England (2012) Hepatitis B Epidemiology in London 2012 data
available on www.gov.uk [accessed 22.10.15]
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Appendix 1: Immunisation Required per NHS Employee Category
Staff Group
Hep B
Immunity to
TB
MMR
Evidence
of
immunity
Category 1
Staff involved in direct patient care
eg doctors, nurses, healthcare
support workers, occupational
therapists, physiotherapists,
psychology staff, radiographers,
chiropodists, pharmacists,
dieticians, plaster technicians,
audiology staff. Students and
trainees of these disciplines with
patients
Category 2
Laboratory and Pathology staff
(including mortuary staff) eg
technical staff this may include
cleaners porters and secretaries
and receptionists in labs



Category 3
Non clinical staff in healthcare
settings whom only have social
contact with patients but not
directly involved in their care eg
receptionists, ward clerks, porters,
estates staff, housekeepers,
volunteers directly employed by the
Trust
History of
vaccination
Tetanus,
Polio,
Diphtheria

Hep A
×
Varicella
history born
and raised
UK
Non UK
varicella
screening
Influenza



Individuals with
a requirement
for tetanus,
polio and
diphtheria are
referred to their
GP
 for lab staff who may have
direct contact with patients’
blood or blood stained body
fluids.
 for workers at risk of
contact with blood and blood
stained body fluids including
those at risk injury from
blood contaminated sharp
instruments or of being
deliberately injured or bitten
by patients
 for
technical
staff in
microbiology
and
pathology
Offer


 (if handling
faeces specs
offer booster
polio) If may
be exposed to
diphtheria
may require
booster dose
of a diphtheria
containing
vaccine

The following vaccines are recommended for those who
work/handle these specific organisms:
Hepatitis A, Japanese encephalitis, Cholera
Meningococcal ACW 135 Small pox, tickborne encephalitis
typhoid, yellow fever, influenza, varicella
However this is N/A for SHFT as the Trust does not employ
staff who would routinely handle these specimens
×
Except
required for
Estates staff
working
with raw
sewage


Offer
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EPP Groups include:
Health Clearance for Exposure Prone Procedures
Hep B Screen (Surface
Hep B surface antibody
Hep C antibody
antigen and core antibody
titre (if previous
Screen
screening)
immunised for Hep B)
√
√
√
EPP Groups
TB Screening
HIV Screen
Surgeon performing open surgical
procedures
Anaesthetist if inserting chest drains
AE, placement of portocaths
Practitioner performing surgical
endoscopic procedures eg
laparoscopy, cystoscopy
Accident and Emergency (Dr or Nurse)
√
√
√
√
√
√
Urology
√
√
√
√
√
Ophthalmology – enucleation only
√
√
√
√
√
ENT - surgical procedures (except
simple ear or nasal procedures
performed using endoscope provided
fingers always visible)
Theatre staff who scrub for procedures
√
√
√
√
√
√
√
√
√
√
Podiatry (extended practice only) if
performing surgery on nails, bones and
soft tissue of the foot and lower leg
√
√
√
√
√
√
The above lists are based on the Green Book 2013 and are not exhaustive, and in the event of an outbreak vaccination may be offered more widely
NHS Trusts are obliged to undertake risk assessments to determine which roles are and are not EPP (see Appendix 2)
Please refer to refer to ‘Trust Policy SH CP 157 Exposure Prone Procedures (EPPs) and Blood Borne Viruses (BBVs) - Management of the Infected
Healthcare Worker’ for guidance on occupational health and EPP.
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Appendix 2: What constitutes an exposure prone procedure (E.P.P)
An Exposure Prone Procedure (EPP) is any invasive procedure where there is a risk that injury to the health care worker could result in the exposure
of the patient’s open tissue to the blood of the worker (called bleed back). EPPs are defined by the Department of Health as:
"Procedures where the health care worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissues inside the patient’s
open body cavity, wound or confined anatomical space where the fingertips may not be completely visible at all times" (Department of Health, 2005).
EPPs generally occur in surgery, obstetrics, and specialist nursing, such as operating theatre nursing. If routine infection control procedures are
followed meticulously, the following procedures are not considered as EPPS:


Procedures where the health care worker’s hands and fingertips are visible and outside of the patient’s body at all times.
Internal examinations or procedures that don’t involve possible injury to the health care worker’s gloved hands.
Table of Examples of what is Exposure Prone Procedure (EPP) and what is not
EPP
Not EPP
Anaesthetics
Resuscitation
The only procedures currently performed by anaesthetists which would Resuscitation performed wearing appropriate protective equipment does
constitute EPPs are:
not constitute an EPP. The Resuscitation Council (UK) recommends the
a) the placement of portacaths (very rarely done)
use of a pocket mask when delivering cardio-pulmonary resuscitation.
b) the insertion of chest drains in A&E trauma cases such as Pocket masks incorporate a filter and are single-use
patients with multiple rib fractures (probably go to acute A&E).
The insertion of a chest drain may or may not be considered to be
exposure- prone, depending on how it is performed. Where a larger
incision is made, and a finger is inserted into the chest cavity, as may be
necessary for example with a flail chest, and where the healthcare worker
could be injured by the broken ribs, the procedure should be considered
exposure-prone.
Gynaecology
Open surgical procedures are exposure-prone. Performing cone biopsies
with a scalpel (and with the necessary suturing of the cervix) would be
exposure-prone. Cone biopsies performed with a loop or laser would not
in themselves be classified as exposure-prone, but if local anaesthetic
Gynaecology
Many minor gynaecological procedures are not considered exposureprone, examples of which include dilatation and curettage, suction
termination of pregnancy, colposcopy, surgical insertion of depot
contraceptive implants/devices, fitting intrauterine contraceptive devices
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EPP
was administered to the cervix other than under direct vision (ie with
fingers concealed in the vagina), then the latter would be an EPP.
(See also Laparoscopy).
Not EPP
(coils) and vaginal egg collection, provided that fingers remain visible at
all times when sharp instruments are in use.
Routine vaginal or rectal examinations are not EPP
Orthopaedics
Orthopaedics:
EPPs include:
• manipulation of joints with the skin intact;
• open surgical procedures;
• arthroscopy, provided that if there is any
• procedures involving the cutting or fixation of
possibility that an open procedure might become
bones, including the use of K-wire fixation and
necessary, the procedure is undertaken by a
osteotomies;
colleague who is able to perform the appropriate
• procedures involving the distant transfer of
open surgical procedure;
tissues from a second site
• acute hand trauma;
• nail avulsion of the toes for in-growing toenails
and Zadek’s procedure(this advice may not apply to other situations such
as when nail avulsions are performed by podiatrists).
Endoscopy
EPP risk if surgical endoscopic procedures (eg cystoscopy, laparoscopy)
Endoscopy
Simple endoscopic procedures (eg gastroscopy, bronchoscopy) have not
been considered exposure-prone
Ear, nose and throat (ENT) surgery (otolaryngology)
ENT surgical procedures generally should be regarded as exposureprone, with the exception of simple ear or nasal procedures, and
procedures
performed using endoscopes (flexible and rigid), provided that fingertips
are always visible.
Ear, nose and throat (ENT) surgery (otolaryngology)
Non-exposure-prone
ear
procedures
include
stapedectomy/
stapedotomy, insertion of ventilation tubes and insertion of a titanium
screw for a bone-anchored hearing aid
Podiatrists
Podiatry undertaken by podiatric surgeons include surgery on nails,
Podiatrists
Routine procedures undertaken by podiatrists who are not trained in and
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EPP
Not EPP
bones and soft tissue of the foot and lower leg, and joint replacements. In do not perform surgical techniques are not exposure-prone
a proportion of these procedures, part of the operator’s fingers will be
inside the wound and
out of view, thereby making them EPPs.
Surgery
Open surgical procedures are exposure-prone
Surgery
 superficial surgery involving the soft tissues of the hand;
 work on tendons using purely instrumental tunnelling techniques that
do not involve fingers and sharp instruments together in the tunnel;
 procedures for secondary reconstruction of the hand, provided that
the operator’s fingers are in full view;
 carpal tunnel decompression, provided that fingers and sharp
instruments are not together in the wound;
 closed reductions of fractures and other percutaneous procedures
 minor surface suturing;
 the incision of external abscesses
None
Radiology
All percutaneous procedures, including imaging of the vascular tree,
biliary system and renal system, drainage procedures and biopsies as
appropriate, are not EPPs.
None
Other
 taking blood (venepuncture);
 setting up and maintaining IV lines or central lines (provided that any
skin-tunnelling procedure used for the latter is performed in a nonexposure-prone manner, ie without the operator’s fingers being at any
time concealed in the patient’s tissues in the presence of a sharp
instrument);
 Staff working in areas posing a significant risk of biting should not be
treated as performing EPPs
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Appendix 3: Equality Impact Assessment
The Equality Analysis is a written record that demonstrates that you have shown due regard to the need
to eliminate unlawful discrimination, advance equality of opportunity and foster good relations
with respect to the characteristics protected by the Equality Act 2010.
Stage 1: Screening
Date of assessment:
Name of person completing the assessment:
Job title:
Responsible department:
25.8.15
Jacky Hunt
Infection Control Nurse
Occupational Health, Infection Prevention and
Control and Human Resources
Intended equality outcomes:
Who was involved in the consultation of this
document?
OHS, HR, Legal Team, H&S Officer, IPC Group
Please describe the positive and any potential negative impact of the policy on service users or
staff.
In the case of negative impact, please indicate any measures planned to mitigate against this by
completing stage 2. Supporting Information can be found be following the link:
www.legislation.gov.uk/ukpga/2010/15/contents
Protected Characteristic
Age
Positive impact
Disability
Gender reassignment
Marriage & civil partnership
Pregnancy & maternity
Risk assessments will be carried
out by OHS
Race
Religion
Sex
Sexual orientation
Negative impact
No adverse impacts have been
identified at this stage of
screening
No adverse impacts have been
identified at this stage of
screening
No adverse impacts have been
identified at this stage of
screening
No adverse impacts have been
identified at this stage of
screening
No adverse impacts have been
identified at this stage of
screening
No adverse impacts have been
identified at this stage of
screening
No adverse impacts have been
identified at this stage of
screening
No adverse impacts have been
identified at this stage of
screening
No adverse impacts have been
identified at this stage of
screening
Stage 2: Full impact assessment – none required
What is the impact?
Mitigating actions
Monitoring of actions
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Appendix 4: Employee Immunisation Declaration
Employee Details
Employee Name:
Reference Number:
Staff Number:
Manager Name:
Directorate:
Appointment Date:
Appointment Location:
Immunisation(s) Declined
I confirm that I have declined the following immunisations (please tick as appropriate):
Hepatitis B (Primary Course)
Varicella
Hepatitis B (Immediate Booster)
Mantoux Test
Hepatitis B (5 Year Booster)
BCG
MMR 1
Other (please state below)
MMR2
…………………………………………………………
Reason Declined (Optional)
Please explain the reason for your decision to decline the immunisation(s) offered to you today:
……………………………………………………………………………………………
……………………………………………………………………………………………
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Employee Declaration
I am aware of the risk from vaccine preventable infections that may be acquired in the course of
my work and have had explained the potential benefits of vaccination.
I understand I must inform my Manager that I have declined a vaccination that is recommended
for my role, so that adjustments can be made to reduce my risk of contact with these vaccine
preventable infections where possible. I understand that I will not be able to perform exposure
prone procedures if I have declined vaccination to hepatitis B.
I understand that if at any point I wish to be given the above stated immunisation(s) that I can
discuss this with my Manager who will arrange for OH Assist to invite me for a further
appointment.
Signed:
Date:
A copy of this form to be retained on the OHS and Personnel File
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Appendix 5: Risk Management – Vaccine Preventable Injections in Staff
Identify the
hazard
Hepatitis B
Staff whom might be at risk
Risk mitigation
Staff at risk of contact with
blood and blood stained body
fluids including those at risk
injury from blood
contaminated sharp
instruments or of being
deliberately scratched or bitten
by patients
1) Occupational Health Service will assess
each staff member’s risk on preemployment screening based on their job
description, using matrix in Appendix 1.
2) Offer hepatitis B vaccination to staff who
may be at risk
3) Staff member to implement ‘standard
precautions’
 Appropriate use of personal protective
equipment (P.P.E)
 Good hand hygiene
 Prompt decontamination of a clinical
spillage
 Decontaminate equipment as per
Decontamination of Medical Devices
Procedure
 Safe handling of waste and linen
 Safe management of sharps
4) Contact OH Service for advice if :
a) accidental exposure to blood on
mucous membranes or broken skin or;
b) if injury from blood contaminated sharp
instruments or;
c) if scratched or bitten by patients
Risk Management if vaccination is
declined or unsuccessful
1) Implement ‘Standard Precautions’
2) Contact OH Service for advice
urgently if:
a) Accidental exposure to blood on
mucous membranes or broken
skin or;
b) If injury from blood contaminated
sharp instruments or;
c) If scratched or bitten by patient
Evidence of
protection
Documented course
of 3 vaccinations
vaccination, with a
level of antibody
100iu/l.
A booster is
recommended
Staff not immune to Hepatitis B must
be restricted from performing E.P.P
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Identify the
hazard
Tuberculosis
(TB)
Staff whom might be at risk
Risk mitigation
Staff that may have close
contact with infectious patients
or their lab specimens or staff
working in mortuaries.
1) Occupational Health Service will assess
each staff member’s risk on preemployment screening based on their job
description, using matrix in Appendix 1
2) Offer BCG vaccination to staff whom may
be at risk
3) Staff member to implement ‘Standard
Precautions’ as highlighted above.
4) Care for known or suspected TB cases in
their own room with the door shut in
communal settings for first 14 days of
treatment (assuming clinical improvement).
Staff members must wear a FFP3 mask as
well as single use gloves and aprons when
in isolation room, if patient can’t cover
mouth or drug resistant TB suspected.
5) Encourage patient to cover mouth when
coughing
Pulmonary TB is spread
through the airborne route.
Measles
Mumps and
Rubella
Staff with direct patient contact
Non clinical staff in healthcare
settings whom only have
social contact with patients but
are not directly involved in
their care
Lab/pathology staff who may
have direct contact with
specimens from infected
patients.
1) Occupational Health will assess each staff
member’s risk on pre-employment
screening based on their job description,
using matrix in Appendix 1
2) Offer MMR vaccination to staff whom may
be at risk
3) Staff member to implement ‘Standard
Precautions’ as highlighted above.
4) Care for patient in isolation room whilst
infectious if in a communal setting.
Risk Management if vaccination is
declined or unsuccessful
1) Non-immune individuals should be
informed of the symptoms of TB and
advised to report suspicious
symptoms to the Trust OH service.
2) Non-immune staff must avoid
known/suspected cases of TB and if
accidental exposure occurs, the staff
member must inform the
Occupational Health Service
3) Practice ‘Standard Precautions’
Evidence of
protection
Documented evidence
of previous BCG or
history of
immunisation plus
BCG scar or history of
immunisation no BCG
scar but documented
positive heaf/mantoux
test within the last 5
years
1)
Documented evidence
of 2 doses of MMR or
a positive antibody
test for measles and
rubella
2)
Avoid known/suspected cases of
measles /mumps / rubella and if
accidental exposure occurs, staff
member must inform the
Occupational Health Service.
Implement ‘Standard Precautions’
Mumps, measles and rubella
is spread through the droplet
route.
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Identify the
hazard
Varicella
(Chickenpox)
Staff whom might be at risk
Risk mitigation
Staff with direct patient contact
1) Occupational Health will assess each staff
member’s risk on pre-employment
screening based on their job description,
using matrix in Appendix 1
2) If no definite clinical history of chickenpox is
given, by staff identified to be at risk using
the matrix in Appendix 1, serologically test
a blood sample and vaccinate only those
without the varicella zoster antibody.
3) Staff member to implement ‘Standard
Precautions’ as highlighted above.
4) Care for patient in isolation room whilst
infectious if in a communal setting.
Non- clinical staff in healthcare
settings whom only have
social contact with patients but
are not directly involved in
their care
Lab/pathology staff who may
have direct contact with
specimens from infected
patients.
Risk Management if vaccination is
declined or unsuccessful
1) Avoid known/suspected cases of
chickenpox and if accidental exposure
occurs staff member must inform the
Occupational Health Service.
2) Implement ‘Standard Precautions’
Evidence of
protection
UK born –with a good
history of chickenpox
or shingles
1)
Annual Immunisation
Positive blood test for
antibodies to varicella
if not born in UK or
unsure of past history
of chickenpox
infection.
Varicella can be spread via
the droplet route or following
contact of a non-immune
individual with fluid from the
rash (vesicle)
Influenza
Staff with direct patient
contact.
Non clinical staff in healthcare
settings whom only have
social contact with patients but
are not directly involved in
their care.
Lab/pathology staff who may
have direct contact with
specimens from infected
patients.
1) Annual immunisation
2) Good hand hygiene with soap and water or
alcohol hand rubs.
3) Practice Catch it (in a tissue) Bin It (discard
the tissue into a bin, Kill It ( Clean your
hands)
4) Isolate symptomatic cases in a side room
(staff not to work till symptom free). Staff
must wear single use gloves, face mask
and aprons when within 1m of the infected
patient. If performing sputum inducing
procedures FF3 masks, single use gloves
and gowns are required.
5) Ensure good environmental cleaning with
soap and water of isolation room
6) Encourage infected individual to cover their
mouth when coughing
Avoid contact with known or
suspected cases of influenza where
possible.
2) Practice good hand hygiene with soap
and water or alcohol hand rubs.
3) Practice Catch it (in a tissue) Bin It
(discard the tissue into a bin, Kill It
(Clean your hands)
4) Ensure thorough environmental
cleaning with detergent and water
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Identify the
hazard
Tetanus/
Pertussis
Diphtheria/
Polio
Staff whom might be at risk
Risk mitigation
Staff with direct patient
contact.
1) Occupational Health Service will assess
each staff member’s risk on preemployment screening based on their job
description, using matrix in Appendix 1
2) Offer vaccination to staff whom may be at
risk if not already vaccinated
3) Staff member to implement ‘Standard
Precautions’ as highlighted above.
4) Transfer patients suffering from
Tetanus/Pertussis/Diphtheria/Polio
promptly to acute care, report accidental
exposure to OH Services for staff follow up.
5) Carry out isolation precautions until transfer
if it occurs in a communal area.
6) Always wash hands after changing nappy
or administering a polio vaccine
Non clinical staff in healthcare
settings whom only have
social contact with patients but
are not directly involved in
their care.
Lab/pathology staff who may
have direct contact with
specimens from infected
patients
Staff who have contact with
soil eg gardeners
Risk Management if vaccination is
declined or unsuccessful
1) Staff member to implement ‘Standard
Precautions’ as highlighted above.
2) Transfer patients suffering from
Tetanus/Pertussis/Diphtheria/Polio
promptly to acute care, report
accidental exposure to OH Services
for staff follow up.
3) Non immune staff to avoid contact
with patients suffering from
Tetanus/Pertussis/Diphtheria/Polio
4) Wear gloves when in contact with the
soil or rusty items if not immunised
against tetanus, if accidental puncture
of skin occurs with rusty/dirty object
seek medical advice.
5) Avoid administering polio vaccine if
not immunised (it is a live vaccine)
and avoid changing nappies of a polio
vaccinated person until 6 weeks after
vaccination.
Evidence of
protection
evidence of routine
vaccination checked
at pre-employment
screen
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