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8.1. INTRODUCTION
8.1.1 The steps necessary to maintain the occupational health and safety of NHS employees must be effectively integrated into infection control strategies. These will not only protect the health of health care workers themselves but must also protect patients from nosocomial infection and maintain the integrity of sterile products produced within the health service.
8.1.2 The Health and Safety at Work Act (see Appendix 2) places legal responsibilities on employers to ensure the health, safety and welfare of all employees and other persons who use their premises. It also imposes a duty on all employees, while at work, to take responsibility for their own personal health and that of others with whom they are in contact.
8.1.3 COSHH Regulations make reference to the requirements for risk assessment and control of processes involving biological agents. The Biological Agents Approved Code of Practice 71 specifies the need to consider immunisation, where appropriate, as a further means of personal protection, e.g. against Hepatitis B.
8.1.4 Health Boards and other employing authorities, if applicable, should therefore ensure that Trusts and other health service deliverers are aware of their legal obligations and the current guidance on OHS for the NHS in Scotland32 . Service level agreements with health service deliverers should refer specifically to the need for both protection of patients from infected health care workers and the protection of workers from occupationally acquired infection. General Medical and Dental practitioners also have similar responsibilities for those whom they employ. Further guidance has recently been published providing detailed advice for employers on protecting the health and safety of workers who are new or expectant mothers against the risk of infection in the workplace76 .
8.2. RISK ASSESSMENT AND CONTROL
8.2.1 Current legislation requires formal risk assessments to be carried out in the workplace so that the degree of risk can be evaluated and effective control measures implemented. The principles involved are discussed in detail in Risk Management in the NHS77. Consideration ought also to be given to the HSC/HSAC publication "Management of health and safety in the health services"78. These principles apply equally to processes involving biological agents. The Health & Safety Commission's Approved Code of Practice: Control of Biological Agents75 gives guidance on the standards to be achieved.
8.3. THE ROLE OF OCCUPATIONAL HEALTH SERVICES
8.3. OHS advise managers and employees about both the effect of work on health - and health on work - and devise risk management programmes which should ensure that the hazards which staff face during their work are minimised.
8.3.2 The roles of the OHS and Infection Control Staff will overlap and it is essential that close co-operation and liaison exists in order to ensure that Control of Infection policies are effectively implemented and regularly monitored.
8.4. HEALTH SURVEILLANCE DURING EMPLOYMENT
8.4.1 Employees should be encouraged to attend their OHS for assessment in circumstances where ill health due to infection may have implications for infection control in the work environment. Similarly referral to the OHS should be made if it is suspected that ill health due to infection has arisen while at work. Food handlers (including nursing staff who serve pre-prepared foods and prepare enteric feeds) should be regularly reminded of their obligation to report ill health of an infectious nature e.g. diarrhoea, skin infection, at the earliest opportunity.
8.5. IMMUNISATION PROGRAMMES FOR EMPLOYEES
8.5.1 It is the responsibility of the OHS to advise managers and employees on a suitable immunisation policy drawn up in conjunction with the ICT as advisers/co-ordinators. Where differing protocols exist the CPHM(CI)/EH) can be consulted for advice in cooperation with the ICT.
8.5.2 All employees should be contractually required to comply with this policy which should apply also to agency staff, locums, students and certain voluntary workers. It is important that managers ensure that all employees, at the onset of employment, should have their immunisation status assessed and recorded. The OHS should confirm with the employee's manager when the immunisation programme has been satisfactorily completed and should also maintain a confidential clinical record and a recall system. In the event of a move to a new health authority, these immunisation records should be transferable (with the employee's agreement), to the new health authority's OHS.
8.5.3 The immunisation protocol for an individual employee will depend on the work undertaken and the degree of clinical exposure to patients or biological specimens. The most commonly considered vaccines are:
8.5.4 A more extended protocol to include hepatitis A, typhoid, diphtheria or meningococcal disease may have to be considered for health care workers in infectious diseases units or certain laboratories. Laboratory staff who undertake specific work with anthrax, diphtheria, rabies, tetanus and other organisms may require to be covered by the specific vaccine if a risk assessment of working practices indicates that this is necessary.
8.5.5 Vaccines against varicella zoster virus (VZV) are not currently licensed in the UK. There is concern, however, about the potential for employees who have had contact with VZV to transmit the infection to high risk groups such as immunosuppressed or pregnant patients. Consequently it is recommended that before working with these patients, hospital staff without a definite history of chickenpox, should be screened for VZ antibodies so that susceptible employees are already identified79l.
8.5.6 Many NHS employees travel overseas in the course of employment. It is therefore important that travel health advice is sought, and that appropriate travel vaccines are made available. If hepatitis A vaccine is advised, they should have their hepatitis A immune status checked and offered active vaccination if susceptible. After returning from overseas travel they should be advised to report any persistent ill health or flu-like illness in case there is a need to arrange specialist assistance from an Infectious Diseases Consultant.
8.6. DEALING WITH NEEDLESTICK INJURIES
8.6.1 Needlestick injuries deserve special mention because of their frequency and the potential for transmission of bloodborne infection e.g. HIV, Hepatitis B and C. In addition to injuries with needles or sharp objects in contact with blood10, splashing of blood on broken skin or mucous membranes is also of concern. The risk of infection from a contaminated needlestick injury is approximately 30% if the source is hepatitis B e antigen (HBeAg) positive, 3% for hepatitis C virus (HCV) and 0.3% for HIV.
8.6.2 Trusts require to develop clear policies in order to reduce the frequency of needlestick injuries by defining safe systems of work, providing appropriate training and education for staff and monitoring the frequency and causes of the incidents. (See template in Appendix 3). Systems for dealing with injuries when they do occur must also be clearly defined within the policy so that all injured staff know what action they must take. Accident and emergency staff or OHS staff providing immediate treatment and follow up must also have clear guidelines so that they are able to give consistent advice.
8.6.3 Recent studies on the effectiveness of prophylactic treatment following known HIV +ve needlestick injuries indicate that there is merit in giving a combination of antiretroviral drugs within 1-2 hours after an incident. Local policies should ensure the availability of starter packs of such drugs (with information leaflets) and access to advice on a 24 hour basis from an appropriate specialist such as a consultant in infectious diseases, virology or genito-urinary medicine. National guidance is now available10.
8.6.4 Needlestick injuries can cause considerable anxiety and worry to health care workers and their families. Confirmation that the source blood is free from infection is the most effective form of reassurance. If the source blood can be identified, reasonable steps should be taken by the clinical staff involved in the care of the source patient, to seek the individual's informed consent to have appropriate testing undertaken. Injured employees should be given the opportunity to attend the occupational health service to have their baseline blood stored and, if necessary, tested with their consent. Appropriate counselling should also be offered.
An example of Guidelines for dealing with significant blood or body fluid exposure are set out in Appendix 3.
8.7. EMPLOYEES INFECTED WITH BLOODBORNE VIRUSES
8.7.1 A number of outbreaks of hepatitis B, and sporadic cases of hepatitis C and HIV infection have been attributed to the transfer of infection from health care workers who are infective to patients during the course of surgical procedures.
8.7.2 The term "exposure prone procedures" has been used to describe those procedures where there is a risk of injury to the worker which may result in the exposure of the patient's open tissue to the blood of the worker. As a result, there would be a risk to the patient if the health care worker were a carrier of a bloodborne virus, e.g. Hepatitis B.
8.7.3 All prospective candidates for posts involving exposure prone procedures must be subject to an individual risk assessment undertaken by the OHS. Any applicant who has any reason to believe that he/she may be infected with HIV, H13V, HCV or other bloodborne infection, has an ethical duty to seek specialist medical advice in relation to their work and to follow that advice. Recruitment procedures can require applicants to sign that they accept this duty and will continue to do so. The same duty also applies to all existing employees.
8.7.4 It is also essential that all applicants for exposure prone posts demonstrate that they have adequate evidence of immunity to hepatitis B or evidence of freedom from such infection. Those who are hepatitis B e antigen positive (HBeAg +ve) or HIV +ve must not perform exposure prone procedures and cannot be employed in posts where such procedures are necessary. The OHS can provide counselling and occupational advice in these circumstances.
8.8. REPORTING REQUIREMENTS UNDER HEALTH & SAFETY LEGISLATION
8.8.1 The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (see Appendix 2) came into force on 1 April 1996. These place a responsibility on employers to report cases of work related disease to the HSE. The stimulus for management to report a case of disease may arise from a diagnosis confirmed in writing by a doctor and this may include a recommendation from the OHS. The person affected by the disease must be currently employed in an associated work activity. The list of reportable diseases includes a number of infections which could be related to work within the health services. These include anthrax, brucellosis, avian and ovine chlamydiosis, hepatitis, legionellosis, leptospirosis, lyme disease, Q-fever, rabies, Streptococcus suis infection, tetanus, tuberculosis and any infection reliably attributable to the performance of work in the health service.
8.8.2 These arrangements are primarily employers' responsibilities and are separate from the legal responsibilities of medical practitioners to notify certain communicable diseases to Directors of Public Health and in some circumstances to SCIEH.
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