Hepatitis C Virus (HCV): Protecting Employees and Patients

Version 4

Name of responsible (ratifying) committee Health and Safety Committee

Date ratified 25 February 2015

Document Manager (job title) Consultant Occupational Health Physician

Date issued 09 March 2015

Review date 28 February 2018

Electronic location Health and Safety policies Hepatitis B Virus: Protecting Employees & Patients; HIV infected health care workers. Guidance on Related Procedural Documents management & patient notification; Prevention and Management of Needlestick Injuries & Contamination Incidents Occupational health; exposure prone procedure; pre- Key Words (to aid with searching) employment health assessment; hepatitis C virus

Version Tracking Version Date Ratified Brief Summary of Changes Author 4 25.02.2015 No material changes to policy. Dr S Harvey.

Hepatitis C Virus (HCV): Protecting Employees and Patients Version: 4 Issue Date: 09 March 2015 Review date: 28 February 2018 (unless requirements change) Page 1 of 8 CONTENTS

Quick Reference Guide…………………………………………………………….page 3

1. Introduction…………………………………………………………………………..page 4

2. Purpose……………………………………………………………………………….page 4

3. Scope………………………………………………………………………………....page 4

4. Definitions…………………………………………………………………………….page 4

5. Duties and responsibilities……………………………………………………………page 5

6. Process………………………………………………………………………………..page 6

7. Training requirements………………………………………………………………..page 6

8. References and associated documents…………………………………………….page 7

9. Equality Impact Statement………………………………………………….………page 7

10. Monitoring Compliance………………………………………………………….. page 8

Hepatitis C Virus (HCV): Protecting Employees and Patients Version: 4 Issue Date: 09 March 2015 Review date: 28 February 2018 (unless requirements change) Page 2 of 8 QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1. Hepatitis C virus (HCV) is a blood borne virus which causes inflammation of the liver. Many people who are infected have no symptoms and are unaware that they are carrying the virus.

2. Following Department Health recommendations in 2007 and as part of the Work Health Assessment process carried out by Occupational Health, HCV is screened for in Healthcare Workers (HCW) who are new to the NHS and who will be performing Exposure Prone Procedures (EPP) or new to (EPP).

3. For HCW who commenced their post prior to 2007 the requirements are that those who know that they are carriers of HCV must refrain from EPP; those with hepatitis C antibodies must be tested for HCV RNA; those intending to undertake professional training for a career that relies upon the performance of EPP must be tested for HCV, and those who perform EPP and who believe they could have been exposed to HCV must seek professional advice on whether they should be tested.

4. Employment restrictions are required for HCW who are carriers of HCV and who wish to perform EPP. HCW who are treated for HCV with appropriate anti-viral medication and who remain hepatitis C virus RNA negative 6 months after cessation of treatment will be allowed to return to performing EPP at that time. As a further check, they must be shown still to be RNA negative 6 months later.

5. Transmission of HCV can occur in the occupational setting e.g. after Needlestick injury from an infected source patient. It is therefore essential that all Needlestick injuries and contamination incidents are managed as per the Trust policy on the correct management of Needlestick injuries and contamination incidents.

6. In the occupational setting, general measures to prevent infection from HCV, as well as other blood borne viruses such as hepatitis B and HIV, include: use of personal protective equipment (gloves, face visors etc.) to minimise exposure to blood or body fluids; safe handling and disposal of sharps and good adherence to appropriate hand hygiene policies.

7. With regard to Patient Notification exercises: whenever a transmission of HCV from an infected HCW to a patient is detected, notification of other patients of that HCW who have undergone EPP, with the offer of serological testing, should normally follow. The UK Advisory Panel for Healthcare Workers Infected with Blood-borne Viruses (UKAP) should be approached for advice whenever patient notification is being considered, and before preparations for such an exercise are put in place.

Hepatitis C Virus (HCV): Protecting Employees and Patients Version: 4 Issue Date: 09 March 2015 Review date: 28 February 2018 (unless requirements change) Page 3 of 8 1. INTRODUCTION Hepatitis C virus is a blood borne virus which causes inflammation of the liver. Many people who are infected have no symptoms and are unaware that they are carrying the virus. The World Health Organization estimates that there are 170 million carriers of HCV worldwide. The United Kingdom is considered to be a relatively low prevalence country with a prevalence of chronic hepatitis C infection in England of around 0.4%. Today, injecting drug use is the most common way to acquire HCV. Individuals who inject drugs acquire their infections when they share contaminated injecting equipment. In the UK blood donations have been screened for HCV since September 1999, but prior to this, and in countries that do not screen donor blood, it was possible to acquire the virus through contaminated blood transfusions. HCV can also be acquired during body piercing, tattooing, and acupuncture if sterile needles are not used. The risk of sexual transmission is relatively rare. Transmission can occur in the occupational setting e.g. after Needlestick injury from a contaminated source patient. There is no vaccine available to prevent HCV infection. Treatment can be undertaken with a combination of interferon and ribavirin. Employment restrictions are required for HCW who are carriers of HCV and who wish to EPP. In the occupational setting, general measures to prevent infection from HCV, as well as other blood borne viruses such as hepatitis B and HIV, include: use of personal protective equipment (gloves, face visors etc) to minimise exposure to blood or body fluids; safe handling and disposal of sharps and good adherence to appropriate hand hygiene policies.

2. PURPOSE This policy has been developed to inform the Trust’s employees of the background and risks of hepatitis C virus infection in the workplace and the requirements needed in terms of safe working and the protection of staff and patients.

3. SCOPE This policy applies to all staff of Portsmouth Hospitals NHS Trust, the MDHU (Portsmouth) and Carillion, including bank, agency and locum, whilst acknowledging for staff other than those of the Trust the appropriate line management or chain of command will be followed. Whilst the policy outlines how the Trust will manage hepatitis C in employees, implementation does not replace the personal accountability of all staff in this regard.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4. DEFINITIONS HCV: hepatitis C virus HIV: Human Immunodeficiency virus Health Care Worker (HCW): Includes all staff working in hospitals and primary care who have direct patient contact, e.g. domestics on wards, some catering staff, ambulance staff, some reception and clerical staff, as well as medical and nursing staff. Exposure Prone Procedures (EPP): invasive procedures where there is a risk that injury to the worker may result in the exposure of the patient’s open tissues to the blood of the worker (bleed-back). These include procedures where the worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (e.g. spiccules of bone or teeth) inside a patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times. Other situations, such as pre-hospital trauma care should be avoided by health care workers restricted from performing exposure prone Hepatitis C Virus (HCV): Protecting Employees and Patients Version: 4 Issue Date: 09 March 2015 Review date: 28 February 2018 (unless requirements change) Page 4 of 8 procedures, as they could also result in the exposure of the patient’s open tissue to the blood of the worker. Non-exposure Prone Procedures: where the hands and finger tips of the worker are visible and outside the patient’s body at all times, and internal examinations or procedures that do not involve possible injury to the worker’s gloved hands from sharp instruments and/or tissues, are considered not to be exposure prone provided routine infection control procedures are adhered to at all times. Examples of non-EPP:  Taking blood  Setting up and maintaining intravenous lines or central lines (provided any skin tunneling procedure used for the latter is performed in a non-exposure prone manner)  Minor surface suturing  Incision of external abscesses  Routine vaginal or rectal examinations  Simple endoscopic procedures

Obstetric/ intrapartum care: Normal vaginal delivery in itself is not an Exposure Prone Procedure but an infected health care worker must not perform procedures involving the use of sharp instruments such as infiltrating local anaesthetic or suturing of a tear or episiotomy, since the fingertips may not be visible at all times. Neither can they perform an instrumental delivery requiring forceps or suction if infiltration of local anaesthetic or internal suturing is required. Renal Dialysis/ Transplantation Units Activities undertaken on renal units are not regarded as EPP. However the possibility of transmission of Hepatitis B virus cannot be entirely ruled out. Therefore HCW who are HBeAg positive or HBeAg negative with a hepatitis B virus DNA level exceeding 10³ genome equivalents per ml should not undertake clinical duties on renal units. HIV and HCV infected HCWs may continue to perform clinical duties on renal units.

5. DUTIES AND RESPONSIBILITIES Trust Board and Executive Directors The Trust Board and Executive Directors are responsible for effective risk management within the Trust and recognise the need for appropriate prevention and management of hepatitis C in employees in the organisation.

Line Managers Line Managers are responsible for ensuring that hepatitis C infected staff are managed appropriately as set out in this policy and that staff attend Occupational Health as required after the pre—placement work health assessment process.

Occupational Health Department: responsible for:  Ensuring HCV risks to employees and patients are managed appropriately as set out in the Process section of this policy  Giving health clearance for EPP work after the pre-placement Work health Assessment process and for the administration of all relevant and required immunisations or other processes

Healthcare Workers: have ethical and legal obligations to take all proper steps to safeguard the interests of their patients and this includes ensuring all appropriate steps are taken to protect patients from transmission of infection; HCW must ensure that they are safe to practice and must inform Occupational Health in confidence if they believe they may be carriers of any blood borne virus, including HCV. Blood exposure incidents to both HCW and patients must be

Hepatitis C Virus (HCV): Protecting Employees and Patients Version: 4 Issue Date: 09 March 2015 Review date: 28 February 2018 (unless requirements change) Page 5 of 8 managed appropriately as set out in the relevant Trust policy (Prevention and Management of Needlestick (‘sharps’) Injuries and Contamination Incidents).

6. PROCESS In March 2007, it became a requirement of the Department of Health that HCW who are new to the NHS and who will perform EPP, and existing HCW who are new to EPP, are required to have HIV and HCV screening blood tests in addition to the standard pre-employment health checks.

For HCW who commenced their post prior to 2007 the requirements are that those who know that they are carriers of HCV must refrain from EPP; those with hepatitis c antibodies must be tested for HCV RNA; those intending to undertake professional training for a career that relies upon the performance of EPP must be tested for HCV, and those who perform EPP and who believe they could have been exposed to HCV must seek professional advice on whether they should be tested.

The blood tests will be carried out by Occupational Health with appropriate pre test discussion and consent. Employees with positive HCV antibody tests will be further tested for ongoing HCV carrier status in the blood. HCW with confirmed on-going carrier status (hepatitis C virus RNA positive) will be restricted from performing EPP.

HCW who are treated for HCV with appropriate anti-viral medication and who remain hepatitis C virus RNA negative 6 months after cessation of treatment will be allowed to return to performing EPP at that time. As a further check, they must be shown still to be RNA negative 6 months later.

Blood tests for hepatitis B, HCV and HIV must be Identified Validated Samples (IVS) i.e. the HCW must show proof of identity with a photograph (e.g. Trust ID card, new drivers license, passport) when the sample is taken; blood should be taken in the occupational health department and be delivered to the lab in usual way (i.e. not carried by the HCW).

Managers and recruitment personnel will be informed of employees who are not cleared to perform EPP, although the specific reason may not be given, if requested by the employee. HCW who apply for a post or training which may involve EPP and who decline to be tested for HIV, hepatitis B and HCV will not be cleared to perform these procedures.

Occupational Health will refer HCV infected HCW to their General Practitioners for onward referral to a liver specialist for clinical assessment and treatment where indicated, since there is evidence to suggest that early treatment of acute hepatitis C infection may prevent chronic hepatitis C infection.

With regard to Patient Notification exercises: whenever a transmission of HCV from an infected HCW to a patient is detected, notification of other patients of that HCW who have undergone EPP, with the offer of serological testing, should normally follow. Most new infections with HCV are asymptomatic. It has yet to be determined whether there is a need for patient notification exercises when a HCV carrier HCW is identified in the absence of evidence of transmission. Until more precise indications for patient notification in this situation can be defined, the UK Advisory Panel for Healthcare Workers Infected with Blood-borne Viruses (UKAP) should be approached for advice whenever patient notification is being considered, and before preparations for such an exercise are put in place.

7. TRAINING REQUIREMENTS The Occupational Health Department provides relevant training on prevention and management of blood borne viruses, including hepatitis C infection, at staff and junior doctor Hepatitis C Virus (HCV): Protecting Employees and Patients Version: 4 Issue Date: 09 March 2015 Review date: 28 February 2018 (unless requirements change) Page 6 of 8 inductions and by provision of leaflets and written information during pre-placement work health assessments. Training in hand hygiene, use of personal protective equipment, safe handling and disposal of sharps and reporting of Needlestick injuries is provided in Health and Safety and Infection Control regular training packages and updates.

8. REFERENCES AND ASSOCIATED DOCUMENTATION Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers. London: Department of Health, March 2007.

Hepatitis C Infected Care Workers: Health Service Circular; HSC 2002/010. London: Department of Health, 14 August 2002.

Hepatitis C Infected Health Care Workers. Department of Health, August 2002.

Guidance for Clinical Healthcare Workers: Protection against Infection with Blood-born Viruses. London: UK Health Departments, 1998.

9. EQUALITY IMPACT STATEMENT Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace. Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do. We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignity Quality of care Working together No waste

This policy should be read and implemented with the Trust Values in mind at all times.

Hepatitis C Virus (HCV): Protecting Employees and Patients Version: 4 Issue Date: 09 March 2015 Review date: 28 February 2018 (unless requirements change) Page 7 of 8 10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Minimum Lead Tool Frequency of Report Reporting Lead(s) for acting on requirement of Compliance arrangements Recommendations to be monitored Compliance Consultant Audit of Annually Occupational Health Consultant OH physician. with pre- OH Occupational Team placement physician Health notes health assessment Compliance Consultant Audit of Annually Occupational Health Consultant OH physician. with correct OH Occupational Team management of physician Health notes Needlestick injuries

This document will be monitored to ensure it is effective and to assurance compliance.

Hepatitis C Virus (HCV): Protecting Employees and Patients Version: 4 Issue Date: 09 March 2015 Review date: 28 February 2018 (unless requirements change) Page 8 of 8