Policy for the Protection of Healthcare Workers from Exposure to Blood Borne Viruses

INSERT PRACTICE NAME HERE

OCCG IPC Core Policy 4; Protection of healthcare workers from occupational exposure to blood borne viruses, TB, childhood illnesses and other infectious diseases

Contents

1. Introduction 2. Definitions 3. Accountability and responsibility 4. Standard health checks and required vaccinations for health care workers 5. Protecting staff during the flu season 6. Exclusion from work 7. Risks from Body Fluid Exposure and Sharps and Inoculation injury 8. Skin and soft tissue infections 9. References

Date of policy: August 2016 Date for review: 3 yearly or earlier if new guidance published

1. Introduction The Health and Social Care Act 2008 (updated July 2015): Code of practice on the prevention and control of infection9.1 puts the onus on registered providers to ensure that policies and procedures are in place so that care workers are free of and are protected from exposure to infections that can be caught at work, and that all staff are suitably educated in the prevention and control of infection. This includes the expectation that all staff can access occupational health services or appropriate advice, have pre employment checks and screening, have vaccines available and that education and training is in place and recorded. The Health and Safety at Work Act (1974)9.2 states that employers, employees and the self employed have specific duties to protect, as far as reasonably practicable, those at work and others who may be affected by their work activity. Employers need to be able to demonstrate that an effective employee immunisation programme is in place and they have an obligation to arrange and pay for this service.

This policy is designed to prevent the spread of blood borne viruses (BBVs) Tuberculosis (TB) and childhood diseases in health care staff and prevent these infections being passed onto patients. Healthcare workers are prone to contracting and spreading infection as they have contact with infectious patients. Therefore they can potentially spread the infections to other patients and vulnerable groups.

The Control of Substances Hazardous to Health (COSHH) regulations 2002 (2013)9.5 require employers to assess the risks from exposure to hazardous substances, including pathogens (biological agents) and to bring into effect the measures necessary to protect workers and others from those risks as far as is reasonably practicable. Staff can also be exposed to infections caused by injuries associated with sharps including needles, blades and broken glass.

2. Definitions The definitions this policy relates to are:-  Blood Borne Viruses (BBVs) which include Hepatitis B, Hepatitis C and Human Immunodeficiency Virus (HIV)  Childhood illnesses include measles, rubella and varicella (chicken pox).  Tuberculosis  Healthcare workers. The Department of Health (the Green Book9.3 - chapter 12) define healthcare workers in to four groups Staff involved in direct patient care  Non clinical staff in health care settings, e.g. non clinical ancillary staff who have social contact with patients in the healthcare settings (receptionists, cleaners)  Laboratory and pathology staff  Staff handling specific organisms

 Exposure prone procedures (EPP): are those 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 or the workers blood to the exposed tissues of a patient. These include procedures where the gloved hands may be in contact with sharp instruments, needle tips or sharp tissues inside a patients open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times.

3. Accountability and responsibility (Name of practice) as the registered provider has the responsibility to ensure that there are effective procedures and training in place to ensure that staff are protected from occupational exposure to infection, there is the appropriate education and training for existing staff and that new staff are screened for communicable diseases and are trained in the principles of occupational exposure.

(Name of practice) should ensure that risk assessments are carried out for staff who may come into contact with blood and/or body fluids and that suitable occupational health support and advice is provided. The service chosen can be at the practice’s discretion.

Staff must follow policy and safe working practices and should understand their responsibility for preventing and controlling infection and the risks associated with non- compliance to this policy.

4. Standard health checks for healthcare workers

4.1 New Staff The purpose of performing health checks on new staff is to ensure patients are protected and that healthcare workers are offered treatment at the earliest opportunity if they are found to be infected with a BBV, TB or have no immunity to childhood illnesses. The Department of Health recommended in its publication Health Clearance for tuberculosis, hepatitis B, hepatitis C and HIV: 20079.4 that

“all new healthcare workers have checks for tuberculosis disease/immunity and are offered hepatitis B immunisation, with post-immunisation testing of response and the INSERT PRACTICE NAME HERE

offer of tests for hepatitis C and HIV. These standard health clearance checks should be completed on appointment.”

New staff will also need to demonstrate that they have been immunised against or have immunity to measles, chicken pox and rubella 9.2. The practice will risk assess the post to which staff are applying and if required will either require evidence of their immunisation status or agree to offer relevant immunisations.

4.2 Exposure prone procedures (EPP) For new healthcare workers who will perform exposure-prone procedures (EPPs), additional health clearance should also be undertaken 9.4, 9.6. Additional health clearance means being non-infectious for HIV, hepatitis B and hepatitis C. These checks should be completed before confirmation of an appointment to an EPP post, as the healthcare worker will be ineligible if found to be infectious. An alternative role in the NHS which does not involve EPP would need to be sought.

4.3 Existing staff The practice will have arrangements in place for regularly reviewing the immunisation status of health care workers and providing vaccinations to staff as necessary in line with Immunisation against infectious disease (The Green Book) and other Department of Health and Health Protection Agency guidance. 9.4

5. Protecting staff during the influenza season Influenza immunisation helps to prevent influenza in staff and may also reduce the transmission of influenza to vulnerable patients. Influenza vaccination is therefore recommended for healthcare workers directly involved in patient care, who should be offered influenza immunisation on an annual basis 9.2,9.3.

6. Exclusion from work

When necessary, care workers may need to be excluded from work until they have recovered or results of specimens are available. Staff with vomiting and or diarrhoea should be advised to remain off work until at least 48 hours have elapsed since their symptoms ceased 9.7.

7. Risks from Body Fluid Exposure

7.1 .1 Body fluids, which may pose a risk of Blood-borne Virus Infection if significant occupational exposure occurs, are: . Amniotic fluid Cerebrospinal fluid Human breast milk Pericardial fluid Peritoneal fluid Pleural fluid . Saliva in association with dentistry (likely to be contaminated with blood, even when not obviously so) . Synovial fluid . Unfixed human tissues and organs . Any other body fluid if visibly bloodstained  Exudate or other tissue fluid from burns and skin lesions  Semen . Vaginal Secretions 7.1.2.Risk of Infection to health care workers Hepatitis B & C The Hepatitis B and C virus is transmitted by blood and body fluids from an infected person and may enter through the eyes, mouth or breaks in the skin. It is recommended that care workers who have, or are likely to have, contact with blood and body fluids, secretions and excretions, are immunised against the Hepatitis B virus.

There is no vaccine available for protection against Hepatitis C

7.1.3.Human Immunodeficiency Virus (HIV) HIV is less transmissible than HBV/HCV but is transmitted in the same way. Acquired Immune Deficiency Syndrome (AIDS) is an alteration in the cellular immune system of a previously healthy person, causing the person with the disease to become susceptible to infection.

7.2 .Sharps and Inoculation Injury Inoculation injuries are the most likely route for the transmission of blood borne viruses and other infections in the health care setting. A sharps/inoculation injury is when someone’s blood or body fluid gains access to another person’s blood or tissue. This may be caused by:-

A cut or puncture of the skin by a contaminated sharp; Splashes to the eyes, nose and mouth from blood or body fluids; Contamination of a care worker’s broken skin e.g. scratches, cuts, eczema by a service user's blood or body fluid; Bites which break the skin and draw blood.

Most cases of occupationally acquired HIV have arisen following injury from hollow needles, and great care must be taken when handling ALL sharps. Body fluids splashed into the eye or mouth may also transmit infection. Remember – all sharps injuries are potentially preventable

Sharps include items such as needles, blood glucose lancets, ampoules, sharp surgical instruments, used razor blades and disposable razors that may be contaminated with blood or other body fluids.

7.2.1.Reducing the risk of sharps/inoculation injuries Use of personal protective equipment (refer to Standard Precautions Policy) will reduce contamination of skin and clothing with blood and body fluids. The greatest risk of a blood borne virus (BBV) being transmitted is as a result of a sharps injury, especially those resulting from injury with a hollow bore needle where blood may remain. Transmission of BBVs may also result from contamination of mucous membranes with splashes of blood/body fluids. There is no evidence that BBVs can be transmitted through intact skin.

7.2.2 Sharps containers Sharps containers must be of a type UN approved, correctly assembled and never be over-filled, i.e. above the manufacturer’s fill line, or ¾ full. The container must be puncture resistant and leak proof. It must be stable and provided with a handle and an aperture which will inhibit the removal of the contents, but will ensure that it is possible to dispose of items safely.

It is the responsibility of the person using the sharp to dispose of it correctly. INSERT PRACTICE NAME HERE

7.3 Safe use of sharps The safe handling and disposal of sharps is paramount in reducing the risk of exposure to blood borne viruses and extreme care must always be taken when using and disposing of sharps.

Avoid using sharps, including pen injecting devices when administrating medication to service users, wherever possible (e.g. use a system such as Vacutainer for venepuncture or Unistix for finger pricking). Wear disposable gloves when handling sharps. Always request assistance when using sharps with an uncooperative service user and use safe needle devices.

. Assemble containers following manufacturer’s instructions. Label sharps containers when assembling them. . Sharps containers must comply with UN3291 and BS7320: 1990. . Sharps containers must be kept off the floor, away from children, and inaccessible to unauthorised persons. Do not place them on the floor, window sills or above shoulder height. . Secure containers using brackets attached to the wall or a trolley. . Place sharps containers of a suitable size on a level surface in each location where sharps are used. . Discard all sharps into a sharps container at the point of use. Never leave needles or any other sharps lying around. Never walk about with unguarded sharps. . Do not pass an exposed sharp to another person. Clinical sharps should be single- use only. Needles must not be resheathed. . The user of sharps must discard them directly into a sharps container.

When carrying a sharps container, or whenever the container is left unattended, use the temporary closure to prevent spillage or tampering. Carry sharps containers by the handle or on a tray, do not hold them close to the body. Do not dispose of wrappers, cotton wool, etc in sharps boxes as this may prevent the sharps being dropped in directly, and may cause an injury if someone tries to force a sharp in. Do not attempt to retrieve items from a sharps container. Do not attempt to press down upon sharps to make more room.

For more information on the disposal of sharps containers see OCCG Core Policy 6, Waste Management.

7.4 Assessing the risk following an inoculation injury In a healthcare setting, the risk of acquiring a blood borne virus as the result of a sharps or inoculation injury from a source known to be infected has been estimated as follows:- Hepatitis B - around 1 in 3; Hepatitis C - around 1 in 30; HIV - around 1 in 300. The degree of risk should be assessed immediately after the incident has occurred and should be determined by the injured care worker and their immediate supervisor.

A Significant exposure is defined as: Percutaneous Injury – breaks in the skin e.g. from needles, instruments, bone fragments or a significant bite. Exposure of broken skin – e.g. due to eczema, cuts, abrasions or injury. Exposure of mucous membrane including the eye.

Injury with an unused/clean sharp No risk of infection, (except from the microorganisms on your own skin). Record incident, but no further action.

Injury with a used/dirty sharp – also human bite/scratch/mucous membrane splash from a source that is known or unknown. During normal working hours seek professional advice from the Occupational Health Service, or Accident and Emergency Department at the Oxford University Hospitals NHS Trust. This should be within one hour of the incident having taken place. Out of hours the injured care worker must attend the A and E Department.

Injury from a used/dirty sharp from a person known or strongly suspected to be HIV positive.

During working hours contact the Occupational Health Service on 01865 902904 If the incident occurs out of hours the injured care worker must attend the A and E Department at the local hospital immediately.

The risk of acquiring an HIV infection from a sharp or inoculation injury in a low risk population when the infection status of the source is unknown is very small.

7.5 Immediate action to take in the event of a sharps/inoculation injury:-  Bleeding from a small wound should be promoted for a few seconds by gently squeezing the surrounding skin. Do not suck or scrub.  Wash the wound with warm running water and liquid soap. Cover the wound with a waterproof dressing.  If the eyes are contaminated irrigate for 2 minutes with normal saline or running water. If contact lenses are worn, irrigate both before and after removal.  Contaminated mucus membrane (e.g. the nose or mouth) should be washed with plenty of water.  Report the injury to the person in charge who should carry out a risk assessment using the checklist in Appendix  Record the incident following the usual procedure. A poster and flow chart summarising the action to take in the event of a sharps or splash injury and the action to take following a sharps find can be found in the Appendix.

7.6 Management of needle stick/inoculation incidents and post exposure INSERT PRACTICE NAME HERE prophylaxis (PEP).

Human immuno deficiency virus (HIV) The Department of Health has issued guidelines on HIV post-exposure prophylaxis (PEP) for health care workers. Although HIV PEP is recommended for health care workers following „high risk‟ incidents, the risk of transmission is very small and requires the inoculation of a significant volume of infected body fluid. The side effects of the treatment may also outweigh any potential benefit.

Following incidents where the source of the injury is thought to be high risk for HIV the injured person should attend either of the A and E departments at the Oxford University Hospitals NHS Foundation Trust or the A and E department of Royal Berkshire NHS Foundation Trust, depending on location of the practice. The decision to administer PEP will be taken by the A and E consultant and microbiology.

If recommended, a course of PEP should be started as soon as possible after the incident. Ideally this would be within one hour if there were a high risk of exposure to HIV. However, PEP may be commenced up to 2 weeks after the injury if circumstances change, for example if the source of the injury is subsequently found to be HIV positive. The PEP specialist should advise pregnant women, who may have been exposed to HIV, regarding the risks and benefits of HIV PEP.

Hepatitis B If the source of the injury is known, or suspected to be, hepatitis B positive, occupational health or the care workers GP should check the hepatitis status of the injured care worker and if appropriate consider starting a course of hepatitis B vaccine and or giving immunoglobulin. This should be administered ideally within 48 hours of the injury, though it can be given up to 7 days after the incident if necessary.

Hepatitis C Where possible an attempt should be made to assess the HCV status of the source. An initial blood sample should be taken from the injured person and sent to the laboratory to be stored. If the source is found to be positive, the injured party should also be investigated for subsequent sero-conversion and appropriate referral made. There is currently no vaccine available for hepatitis C.

Following all exposure incidents a review of the event should be undertaken in order to identify if a similar injury could be avoided in future.

8. Skin and soft tissue infections

Care workers with recurrent skin and soft tissue infections should report this to their manager and be referred to the Occupational Health department.

9. References

9.1 Department of Health (2015) The Health Act 2008; Code of Practice for the Prevention and Control of Healthcare Associated Infections. Department of Health. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida nce/DH_122604

9.2 The Health and safety at work act (1974) http://www.hse.gov.uk/legislation/hswa.htm

9.3 Immunisation against infectious diseases (The Green Book) Department of health. Published by the Stationary office. 2006 Chapter 12 for Immunisation of healthcare staff https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the- green-book

9.4 Health Clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers. 2007. Department of Health http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuida nce/DH_073132

9.5 Health and safety Committee (2013) Control of substances hazardous to health regulations 2002, sixth edition: approved code of practice and guidance; http://www.hse.gov.uk/coshh/

9.6 NHS England (2014) Standard operating procedure (SOP) for primary care support services Standard operating procedure for occupational health clearance to join the medical, dental and ophthalmic performers list https://www.england.nhs.uk/wp- content/uploads/2014/08/sop-pl-occ-hlth-clr.pdf

9.7 PHE (2012) Guidance for managing norovirus outbreaks in health care settings https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/322943/Guid ance_for_managing_norovirus_outbreaks_in_healthcare_settings.pdf

9.8 HSE (2015) Preventing contact dermatitis and urticarial at work http://www.hse.gov.uk/pubns/indg233.pdf Oxfordshire Clinical Commissioning Group