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AIDS/HIV Infected Health Care Workers: Guidance on the Management of Infected Health Care Workers and Patient Notification

7. THE ROLE OF THE UK ADVISORY PANEL FOR HEALTH CARE WORKERS INFECTED WITH BLOOD-BORNE VIRUSES (UKAP)

7.1 Details of UKAP's general remit and contact details are provided in Annex C.

7.2 UKAP advises as a committee and is available to be consulted through its Secretariat:

• when the general guidelines in this document cannot be applied to individual cases;

• when assistance is required to help decide if a patient notification exercise is warranted;

• when health care workers or their professional advocates dispute local advice;

• if advice is needed about modification of working practices to avoid exposure prone procedures prospectively;

• where special circumstances exist.

7.3 The UKAP can also advise individual health care workers or their professional advocates on how to obtain guidance on working practices.

7.4 Those seeking the advice of the UKAP should ensure the anonymity of the referred health care worker and should avoid the use of personal identifiers.

8. WHEN A PATIENT NOTIFICATION EXERCISE SHOULD BE CONDUCTED

Purpose of patient notification

8.1 Notification of patients identified as having been exposed to a risk of HIV infection by an infected health care worker is considered necessary:

• to provide the patients with information about the nature of the risk to which they have been exposed;

• to detect any HIV infection, provide care to the infected person and advice on measures to prevent onward HIV transmission;

• to collect valid data to augment existing estimates of the risk of HIV transmission from an infected worker to patients during exposure prone procedures.

8.2 The overall objective of patient notification is to identify the patient population at a distinct risk of exposure to the infected health care worker's blood during exposure prone procedures. These patients should be contacted, offered counselling and encouraged to have an HIV antibody test. The decision on how far to look back should be taken by the DPH on a case-by-case basis after a criteria-based risk assessment has been carried out.

Risk assessment of need for patient notification

8.3 EAGA has advised that it is not necessary any longer to notify automatically every patient who has undergone any exposure prone procedure by an HIV infected health care worker because the overall risk of transmission is very low.

8.4 Instead, EAGA has recommended that the decision on whether a patient notification exercise should be undertaken should be made on a case-by-case basis using three risk assessment criteria. These are:

• evidence of possible HIV transmission; if found, a patient notification exercise should always be carried out and all exposed patients contacted;

• the nature and history of the clinical practice of the health care worker; this would take into account the clinical speciality and the level of risk of various exposure prone procedures performed ( see Paragraph 8.6);

• other relevant considerations, for example:

8.5 The definition of exposure prone procedures given in paragraph 3.4 embraces a wide range of procedures, in which there may be very different levels of risk of bleed-back (injury to the health care worker resulting in the worker's blood contaminating the patient's open tissues - see Paragraph 1.6). A risk-based categorisation of clinical procedures has been developed including procedures where there is negligible risk of bleed-back (non- exposure prone procedures) and three categories of exposure prone procedures with increasing risk of bleed-back.

8.6 The definitions and examples of categories 1, 2 and 3 are:

Category 1

Procedures where the hands and fingertips of the worker are usually visible and outside the body most of the time and the possibility of injury to the worker's gloved hands from sharp instruments and/or tissues is slight. This means that the risk of the health care worker bleeding into a patient's open tissues should be remote.

Examples: local anaesthetic injections in dentistry, removal of haemorrhoids.

Category 2

Procedures where the fingertips may not be visible at all times but injury to the worker's gloved hands from sharp instruments and/or tissues is unlikely. If injury occurs it is likely to be noticed and acted upon quickly to avoid the health care worker's blood contaminating a patients open tissues.

Examples: routine tooth extractions, appendicectomy.

Category 3

Procedures where the fingertips are out of sight for a significant part of the procedure, or during certain critical stages, and in which there is a distinct risk of injury to the workers gloved hands from sharp instruments and/or tissues. In such circumstances it is possible that exposure of the patient's open tissues to the health care workers blood may go unnoticed or would not be noticed immediately.

Examples: hysterectomies, caesarean sections, open cardiac surgical procedures.

8.7 A comprehensive categorisation of the most common clinical procedures depending upon the relative risk of bleed-back is being developed with the assistance of the Royal Colleges and their specialist associations. This will be available from the Department of Health in Autumn 2002.

8.8 In assessing the "other relevant considerations" criterion, the following information will be helpful:

• the health care worker's current or past health;

• any information to suggest that the infection could have affected his or her working practices, e.g. visual impairment, neurological deficit or dementia;

• whether the health care worker has a skin condition (e.g. weeping eczema);

• the employment history of the health care worker; any evidence of the health care worker not following recommended infection control practices;

• any direct evidence available that might suggest that the health care worker was at higher risk of transmitting HIV, e.g. reported episodes of needlestick injuries.

Additional information for risk assessment and deciding length of patient notification

8.9 In carrying out a risk assessment and deciding on how far back patient notification should go, the following information will also be needed. The co-operation of the health care worker will be needed, and should be sought in as sensitive a manner as possible, preferably by his or her own physician:

• confirmation of the date of diagnosis. Steps should be taken to ensure that there is no doubt that the worker is HIV infected, including repeat testing in a UK laboratory if appropriate;

• any information to suggest when the health care worker was infected. For example:

• whether there any stored sera that could be tested (with informed consent) to obtain further information;

• a carefully documented clinical history (including dates, places and results of tests for HIV antibody, HIV viral load, and CD4 cell counts) to assemble a record of the course of HIV infection;

• the interval between the health care worker being diagnosed as HIV positive and reporting this to an occupational health physician or to public health officials; what recommendations were made then and were they documented; did the health care worker continue to practise during this time;

• the nature of the duties performed while likely to have been HIV infected;

• whether the health care worker is willing for his or her medical adviser(s) to provide information on all/any of the above;

• after first seeking specialist virological advice on specimen collection and processing, specimens suitable for HIV isolation and gene sequencing should be obtained from the worker and securely stored in anticipation of a possible need for investigation at a later date.

8.10 Ideally, the bulk of the clinical history should be obtained from the health care worker. If for any reason this is not possible or appropriate, the history may require reconstruction or supplementation from other data sources after appropriate consent has been obtained. These may include hospital in-patient or out-patient notes, general practice records and the health care worker's partner and family.

8.11 Although it is unlikely that the date of the onset of the worker's infection with HIV will be known, in some cases the clinical history may indicate when this was likely to have occurred.

8.12 Where the duration of infection is unknown, where a clinical history cannot be obtained or if the health care worker has AIDS or has died, it is currently recommended that in the first instance patients who have undergone relevant exposure prone procedures during the preceding 10 years be notified, where records are still available. If there is evidence of transmission of HIV from the health care worker to a patient during this time then patient notification should be extended for as long as is possible.

Deciding whether patient notification should take place

8.13 Where there is evidence of HIV transmission from infected health care worker to patient, all patients who have undergone exposure prone procedures by that health care worker should be notified, counselled and offered an HIV test. In the absence of evidence of HIV transmission, all patients who have undergone category 3 procedures by an HIV infected healthcare worker should be notified, counselled and offered an HIV test. Notification of patients who have undergone procedures placed in categories 1 or 2 is not necessary unless information gathered under the other relevant considerations criterion suggests that it is.

8.14 If a DPH is informed by an HIV infected health care worker or their advocate that exposure prone procedures may have been performed, he or she should make a careful appraisal of the facts, seeking relevant specialist advice (e.g. occupational health, epidemiological and virological advice). It may be helpful to review some records of those treated by the infected health care worker to assess the range of procedures performed. As mentioned already, the need for patient notification will depend on the specific circumstances of each case and the perceived risk of bleed-back. Specialist epidemiological and virological advice can also be sought. This process should involve as few other people as possible, on a strictly confidential "need to know" basis.

8.15 The decision about the need for a patient notification exercise should rest with the DPH, supported as necessary by the Regional Epidemiologist and the Regional Director of Public Health, or in Scotland, SCIEH. The DPH is best placed to assess all the contributing factors and to guide PCTs, NHS trusts and others as to appropriate action needed. When a patient notification exercise is to be undertaken the DPH or delegated person (e.g. CCDC, or CPHM in Scotland) should inform the UKAP. If more than one PCT is involved, it will be appropriate for the Regional Epidemiologist(s) to become involved at this stage.

8.16 The UKAP should be consulted if there is doubt about the need for a patient notification exercise. This may arise if there is difficulty in reaching a conclusion locally about the categories of procedures performed by the health care worker or the application of the other criteria. UKAP should also be informed in writing of incidents where it is concluded that a patient notification is not warranted.

8.17 When it has been decided that a patient notification exercise is necessary, a small incident team should be set up locally. The DPH or delegated person (e.g. CCDC, or CPHM in Scotland) should promptly notify in confidence the DPH covering any other employing authority involved in the exercise. They should also inform the regional epidemiologist, who can assist in facilitating liaison and co-ordinating activities across boundaries, the PHLS Communicable Disease Surveillance Centre (for cases in England, Wales and N.Ireland) or the Scottish Centre for Infection and Environmental Health ( see Annex D). Consideration should be given also to the need for a multi-PCT incident team. The lead PCT should be identified, and the roles of members of local as well as multi-PCT teams should be clarified at the outset.

8.18 The number of individuals who know the identity of the infected worker should be kept to a minimum at all stages. It may not be necessary for all members of the team(s) to be aware of the identity of the infected worker. The consent of the infected worker to disclosure should be obtained where possible.

9. CARE OF THE HEALTH CARE WORKER

9.1 The interests of the health care worker and their family are very important. Where possible, the health care worker should be kept informed of decisions about the patient notification exercise. With their family, they may need immediate practical or psychological support including measures to protect privacy. If the health care worker has been only recently diagnosed as HIV infected, access to counselling and specialist medical advice will be needed, including a consideration of antiretroviral drug therapy.

9.2 It is important to make every effort to keep the health care worker's confidence during the assessment period and afterwards. Assurances should be given about measures to protect their identity, and that an injunction to prevent publication of their name will be sought on their behalf as necessary ( see Paragraphs 8.18, 10.2 and 11.40).

9.3 The worker or their family may wish to seek their own independent legal advice. If they do seek legal advice it will be helpful for the authority's legal advisers to keep in regular contact with those representing the health care worker.

9.4 Infected health care workers who normally perform exposure prone procedures as part of their duties will need to modify their practice or seek retraining or redeployment. Advice on the former can be obtained in the first instance from a specialist occupational health physician who may wish to take advice from the UKAP. The Trust's director of human resources and/or the regional postgraduate dean should be approached for advice on retraining and redeployment issues or alternative careers.

9.5 It is important that staff who are involved in managing the incident, particularly the DPH, do not act as personal advisers or advocates for the health care worker. A specialist occupational health physician may be the most appropriate person to represent the workers' interests ( see Section 6).

10. CONFIDENTIALITY CONCERNING THE INFECTED HEALTH CARE WORKER

10.1 There is a general duty to preserve the confidentiality of medical information and records. Breach of this duty is very damaging for the individuals concerned and it undermines the confidence of the public and of health care workers in the assurances about confidentiality which are given to those who come forward for examination or treatment. In dealing with the media, and in preparing press releases where necessary, it should be stressed that individuals who have been examined or treated in confidence are entitled to have their confidence respected.

10.2 Every effort should be made to avoid disclosure of the infected worker's identity, or information which would allow deductive disclosure. This should include the use of a media injunction as necessary to prevent disclosure of a health care worker's identity ( see Paragraph 11.40). The use of personal identifiers in correspondence and requests for laboratory tests should be avoided and care taken to ensure that the number of people who know the worker's identity is kept to a minimum ( see Paragraph 8.18). Any unauthorised disclosure about the HIV status of an employee or patient constitutes a breach of confidence and may lead to disciplinary action or legal proceedings. Employers should make this known to staff to deter open speculation about the identity of an infected health care worker.

10.3 The duty of confidentiality, however, is not absolute. Legally, the identity of infected individuals may be disclosed with their consent or without consent in exceptional circumstances where it is considered necessary for the purpose of treatment, or prevention of spread of infection. Any such disclosure may need to be justified.

10.4 In balancing duty to the infected health care worker and the wider duty to the public, complex ethical issues may arise. As in other areas of medical practice, a health care worker disclosing information about another health care worker may be required to justify their decision to do this. The need for disclosure must be carefully weighed and where there is any doubt the health care worker considering such disclosure may wish to seek advice from his or her professional body.

10.5 The duties of confidentiality still apply even if the infected health care worker has died or has already been identified publicly.

11. GUIDANCE ON NOTIFYING PATIENTS

Identification of exposed patients

11.1 Patient identification should be conducted as swiftly as practicable. However, there may be circumstances where it is considered advantageous to adopt a more measured approach to patient identification, and involve fewer personnel. This approach may help to reduce the risk of attracting attention of staff who are not involved, and possibly of the media to unusual activity. For example, if a major public holiday is imminent it may be prudent to postpone embarking on the patient identification process until immediately afterwards. A balance should be sought between conducting patient notification quickly and risking unnecessary public anxiety.

11.2 The patient identification process will require the assistance of the medical records officer and setting up a small team who, in some circumstances, may need to work out of hours and over weekends. There may be practical difficulties in tracking medical records, whether manual or computer based, as well as inaccuracies or omissions within the records themselves. If at all possible, patient identification should be complete before any public announcement is made to reduce unwarranted public anxiety. In practice, particularly when large numbers of patients are concerned and if the media have become aware, this may not be possible.

11.3 The number of people who need to know the identity of the worker should be kept as small as possible, even though a larger number of people may need to know that there is an incident. In some cases, for example, it may be possible for staff who do not know the worker's identity to perform a preliminary search of records for particular exposure prone procedures. These records may then be searched for procedures performed by the infected worker by those who know the worker's identity.

11.4 Depending on the particular circumstances, patient identification may include:

• checking operating theatre, delivery room, accident and emergency department records, dental records, and hospital or departmental computer records. It will often be necessary to use several sources, and data will require amalgamation and cross-checking;

• abstracting the following patient details: full name, date of birth, hospital number or other identifier, last known address/telephone number, date of death if known to have died, name, address and telephone/fax number of GP, date(s) and type and full name/description of procedure(s) performed by the health care worker, and the role played;

• further examination of records of patients known to have died, including review of death entry records.

11.5 When more than one PCT is involved, these activities should take place according to a timescale agreed by the multi-PCT incident team. The Regional Epidemiologist(s) or in Scotland, SCIEH, will play an important role in co-ordination and facilitation of liaison.

11.6 At the start of the patient notification exercise the procedures which the health care worker is known to have performed (or is likely to have performed) should be reviewed and categorised according to level of risk of bleed-back (categories 1 to 3). If category 1 or 2 procedures have been carried out, the need to notify patients should be assessed taking account of the other two risk assessment criteria.

11.7 It is important that procedures are described in sufficient detail to allow their categorisation by risk of bleed-back. Any abbreviations should be used with care to avoid misinterpretation.

11.8 Once patient identification is complete, a list of patients' names and procedures should be given in confidence to the incident team.

Contacting patients

11.9 In deciding how best to contact patients and the information to be given, the following factors should be borne in mind:

• the numbers likely to be involved;

• the profile of the patients who may require notification;

• the type of operation or procedures undertaken;

• whether children are involved.

11.10 As a general principle, it is preferable for patients to be personally contacted by a counsellor, health adviser or other relevant health professional before any press announcement is made and every effort should be made to do so.

11.11 However, in large-scale patient notification exercises it may be judged neither reasonable nor practicable to contact exposed patients personally, in which case they should be contacted by other means such as by letter.

11.12 For elderly or other more vulnerable patients, for example, those receiving psychiatric care (who may be disproportionately worried by receiving a letter), it may be preferable to write to the GP first, asking them to decide whether it is appropriate to inform the patient. However not all such cases are likely to be recognisable during the patient identification process.

Writing to patients

11.13 If possible, letters to patients should be sent so that they arrive before or on the day of any planned press statement. The addresses should be checked and letters sent by first class post marked strictly private and confidential. If letters are sent directly to patients, it is suggested that local GPs are written to at the same time to inform them that a patient notification exercise is underway, and to advise them which of their patients, if any, are involved.

11.14 It is helpful to enclose a pre-paid envelope and reply slip for the patient/GP to return, to confirm they have received the letter. This assists with the documentation and further handling of the incident.

11.15 The letters should give details of a dedicated confidential helpline number. Patients receiving a letter may be very anxious to discuss the situation or arrange to have an HIV test at the earliest opportunity. Details of the local general helpline number and the National AIDS Helpline number should also be included ( see Paragraphs 11.21-11.22).

11.16 Most patients' addresses should be available from the case notes, but more up to date addresses may be obtained from the PCT , NHS Board in Scotland or health and social services board, although identifying a new address when the patient has moved out of the area can take some time. Where the PCT or board has no record of a particular patient they may possibly be traced through the NHS Central Registry at Southport or Edinburgh, or the Central Services Agency in Northern Ireland.

Staff in the hospital(s) involved in the patient notification exercise

11.17 Staff in the hospital(s) involved may also be worried and concerned about the issues surrounding HIV or AIDS, the effect of the exercise on their relationships with patients, or because they know or worked with the health care worker. They may also be contacted by worried patients. It is recommended that appropriate staff are briefed by the incident team about the exercise, initially on a strictly need to know basis, or more widely if details have entered the public domain or are likely to do so. The identity of the infected worker should not be revealed or discussed.

General security and confidentiality of records

11.18 The general conditions applying to confidential information about patients are equally valid in patient notification exercises. This includes not only the names of patients being contacted, but also the names of those who have phoned the helplines. It therefore is important to restrict access to the local incident room or to any other place where confidential records may be held. In addition, general heightened security measures will be necessary as there may be unauthorised attempts to gain access to this information.

11.19 Documents which include details that can directly identify the health care worker or patients ideally should not be left on the hard disk of an unattended computer. If they are, they should be protected by passwords which should be changed regularly. All hard copy files and diskettes must be properly locked away in a secure place when not in use, and access to these should be limited to as few people as practicably possible.

11.20 If there is any doubt about security during electronic transmission, this route should not be used.

Telephone helplines

11.21 If details about an infected health care worker incident have entered or are likely to enter the public domain, PCTs/NHS Trusts should consider setting up a general helpline in addition to the specific helpline offered to patients contacted in the lookback. This will help avoid the hospital switchboard becoming jammed. It may be appropriate to contract existing local HIV helplines or NHS Direct to help provide such a service. The National AIDS Helpline can also provide more general help and advice. Any local helpline should also take account of the particular needs of people whose first language is not English.

11.22 If establishing a local helpline, it is useful to bear the following in mind:

• the telephone company should be contacted immediately the decision to set up a general helpline has been made;

• large numbers of telephone lines can take 24-48 hours to establish. If necessary, start with as many lines as can be made available at the time and then introduce more, once available. Lines can be decommissioned as demand subsides;

• the number of calls can be very large. At the start of larger incidents in the past, helplines often have had to deal with 300-400 calls an hour. This may, in part, have been due to the public alarm provoked by the widespread publicity given to their existence;

• the desirability of publicising a general helpline number should be balanced against the possibility that this may provoke needless alarm and that members of the public may feel they ought to contact it;

• lines should ideally operate from 8am to midnight in the first instance and over the weekend. An answerphone with a reassuring message, including the National AIDS helpline number, should be in operation overnight;

• helplines should not be routed through the main hospital switchboard, otherwise they will become jammed

• staff manning any helpline will need briefing and discussions with the incident team, so that they are able to reassure callers that any patient who is considered to have been placed at risk of HIV infection will be notified individually, counselled, and offered testing. Depending on the complexity of the case finding process, this may not be until after an evaluation phase has been completed;

• when patient identification is not complete callers should be told that they will be contacted, if appropriate, once their records have been checked;

• if patient identification is complete and a patient calls a helpline insisting that they have been treated by the worker whose identity is in the public domain but there is no record of this, their views must be respected;

• in the event that helplines are continually blocked, experience has shown some people telephone or come directly to the hospital. Switchboard and reception staff may require briefing and should know where to refer them. Such patients should be seen by a well briefed staff member on site as soon as possible.

Pre-test discussion and testing of patients

11.23 Patients who are contacted as part of a patient notification exercise should be informed that they may have been exposed to a low risk of HIV transmission from an infected health care worker and should be counselled and offered an HIV test.

11.24 People considering whether to have an HIV test may require reassurance concerning any effect this may have on their insurance. The Association of British Insurers has recommended to its members that for life insurance proposals and proposals for other types of insurance where health or lifestyle questions are asked, they no longer ask whether the applicant has had counselling or a negative test for HIV infection. Insurers continue to be entitled to ask about any positive HIV test result in connection with a life insurance application.

11.25 Arrangements should be in place for voluntary confidential HIV testing of patients who have undergone exposure prone procedures. Staff responsible for pre-test discussion will need to explain that occasionally a second specimen may be needed and that this does not necessarily indicate that HIV infection is present.

11.26 A large number of patients may decide to be tested for HIV infection. Such testing must be undertaken by an accredited laboratory with the facilities and experience to handle a heavy demand for testing, and which participates in a quality assurance scheme for HIV testing. The laboratory director should be consulted before any local arrangements are made. The laboratory director will also arrange for confirmatory testing and HIV gene sequence investigations where these are required.

11.27 If the patient's exposure prone procedure occurred less than three months earlier, the HIV test should be repeated at least three months following the procedure. This is because of the "window period" between infection with HIV and appearance of HIV antibody.

11.28 The results of the test must be made available to the patient as soon as possible, ideally by the person who provided pre-test discussion.

11.29 Depending on circumstances, it may be helpful if the laboratory forms accompanying patients' specimens are marked with an agreed code. This will allow any peripheral laboratories to recognise tests which relate to a particular incident and will facilitate the rapid reporting of results. Ideally these should all go through the same laboratory.

11.30 Any initially reactive test results should be discussed with a reference laboratory as a matter of urgency so that confirmatory HIV tests can be rapidly completed.

11.31 Laboratories should report relevant HIV test results to the incident team for incorporation into the patient notification database.

Further investigation of HIV positive results

11.32 In any exercise of this nature it is possible that unrelated positive test results may be obtained because of risk factors other than treatment by the infected health care worker. A repeat blood specimen should be collected from such patients and tested in a reference laboratory ( see Annex D).

11.33 If the presence of HIV infection is confirmed, the patient should promptly be referred to a specialist HIV physician for clinical management. The following investigations should also be undertaken:

• the senior investigator should personally undertake a detailed record review to document the exposure prone procedure and to confirm that the HIV infected patient was exposed to the HIV infected worker. Copies of the relevant records should be made and securely stored;

• if the patient received any blood or blood products, the National Blood Service should be asked to investigate the donors;

• the infected patient should be interviewed by an experienced clinician or counsellor in order to obtain a detailed history of risk factors for HIV infection;

• specimens suitable for HIV isolation and HIV gene sequencing should be obtained from the infected patient and securely stored;

• consideration should be given to offering HIV testing to the patient's sexual partner(s);

• specialist epidemiological and virological advice on further investigation should be sought.

Dealing with the media

11.34 A nominated press officer should be part of the incident team from the start of the exercise. If at all possible, he or she should have experience of working with the national media and should liaise with both the Directorate of Health and Social Care press officer and the Department of Health press officer, if appropriate ( see Annex D).

11.35 External pressure should be resisted and should not be permitted to prompt inappropriate action in haste, although it is accepted that public concern may influence the speed with which the case finding process is undertaken. Unnecessary or inappropriate notification (e.g. patients who have not undergone an exposure prone procedure) can cause unjustifiable distress, and detract from the value and acceptability of properly targeted patient notification exercises.

11.36 In the event of media interest or other external enquiries during the period of evaluation prior to a patient notification exercise, the DPH should acknowledge that a case is being investigated. If necessary the media should be told that when the evaluation is complete anyone who is considered to have been at risk will be notified individually, counselled and offered HIV testing. At the same time, an assurance should be given that the overall risk is considered very low.

11.37 A public announcement can give rise to unnecessary public alarm and may result in the loss of confidentiality for exposed patients and the infected health care worker. In some incidents involving small numbers of patients no such announcement has been made. An announcement may be necessary if, for instance, wide knowledge of the incident within a hospital or Trust means that it is likely to become known to the media and public. Although desirable, it is often not possible to complete patient identification or to contact patients before any public announcement is made. This needs to be decided on a case by case basis as local circumstances may vary.

11.38 A media statement should be held in readiness at all times, reviewed regularly, for use in the event of media enquiries.

11.39 An ideal scenario exists when all exposed patients have been identified and contacted, so that if necessary a press statement could be used to confirm, if the media enquire, that all patients exposed to risk have been informed and others need have no cause for concern.

11.40 If, however, a proactive public announcement is judged necessary, it will normally be made through a press release. This should be as informative as possible to avoid unnecessary public anxiety, whilst avoiding the inclusion of information which could lead to deductive disclosure of the health care worker's identity. The health care worker should not be named. It should:

• refer to "a health care worker" unless more explicit information about the worker's profession has already entered the public domain;

• include details of arrangements which are being or have been made to contact patients;

• reassure that all patients who may have been exposed to risk will be or have been contacted individually, and offered HIV testing as appropriate.

In addition, the "Notes for Editors" might state that a media injunction will be sought and invoked if necessary, to prevent any publication or other disclosure of the worker's identity. If a media injunction is sought, careful consideration should be given to how restrictive it needs be. A very restrictive media injunction may result in greater public alarm than one which allows a limited disclosure of information that would not lead to deductive disclosure of the health care worker's identity.

11.41 If details of an incident are in the public domain, NHS and other relevant authorities may consider that in order to deal effectively with the potentially large number of media enquiries, they should hold a press conference. A medically qualified person, usually the DPH or a deputy, should be present, along with senior managers and the incident team's nominated press officer. Public announcements should not be delayed if it proves difficult to assemble all relevant persons for a press conference. Press conferences may need to be held more than once if there is further media interest.

11.42 If it is known that an HIV infected worker has worked for a number of different authorities, any public announcements should ideally be made by all the authorities concerned at the same time. The multi-PCT incident team should issue a statement which covers all PCTs, or if separate communications are necessary, ensure that the content and timing of these are consistent.

Reviewing the outcome

11.43 Once the incident is over, the head of the incident team should correlate the master list of patients, appropriately coded, and details of the procedures undergone with the HIV antibody test results. The completed dataset should be archived at the PHLS CDSC or the Scottish Centre for Infection and Environmental Health ( see Annex D). This will be collated with data from all similar patient notification exercises to assist in further epidemiological assessment.

11.44 In all cases it is helpful, when the exercise is complete, to evaluate how it was managed, identify pressure points or problems and refine the local action plan accordingly.

11.45 The Department of Health would be grateful if the heads of incident team would consider sending summary datasets and/or final reports to the UKAP secretariat to assist in the further development of this guidance ( see Annex B).

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