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National Guidelines on Blood-Borne Pathogens

Dr Blánaid Hayes, FRCPI, FFOM, Occupational Health Department,Beaumont Hospital,Dublin.

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DOHC Guidelines: 2005

Launched DOHC website March 29th 2006

HSE implementation group (multidisciplinary) to meet in early May

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Background to DOHC guidelines

1995: Advisory Group on Transmission of ID in Health-care Setting established to advise Minister for Health

1997: first report published

Standing Advisory Committee established

1999: The Prevention of Transmission…..

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Key Questions

Who?

What?

When?

Where?

How?..........

All healthcare workers

‘Guideline’, ‘code of practice’, ‘policy’, ‘recommendations’, ‘protocols’

Now

Any organisation in which healthcare is practised e.g. hospital, institution, clinic, medical or dental practice

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Key Players

Internal Individual HCWs Clinical managers Employer / CEO ICNs / Consultant

Microbiology OHAs and Specialist

Physicians ID consultant Risk manager

Laboratory

External Minister for Health DPH Local Expert Group Standing Advisory

Committee Training Bodies

Schools of medicine, nursing and dentistry

Specialist faculties

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Key Solutions

International guidelines Legislation Policies Standard operating procedures Good management Individual responsibility Up to date training / incorporating new

developments/ immunisation Data collection / incident management / surveillance

/audit

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DOHC Guidelines: contents

Assume detailed knowledge of / familiarity with Standard Precautions (1996)

Risk management approach underpins guidelines Defines the risk Key recommendations Implications for employers Implications for OHS services Implications for employees Testing procedures Training Work restrictions Conclusion

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Recommendations: ARisk Management and Infection Control

‘Develop and adopt risk management and infection control policies that are monitored for effectiveness’

Access for all to specialist advice in ‘OH, microbiology, ID and IC

Education of all potentially at risk HCWs in application of SPs, on initial employment and annually thereafter (by competent individuals)

IC education to be incorporated into training of all medical, nursing and dental students

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Recommendations: ARisk Management and Infection Control

Institutions to appraise new technology and invest in appropriate / relevant devices

Apply ‘protocols’ also to potential risk of transmission between equipment and patients

STANDARD PRECAUTIONS HCW responsibility to keep themselves informed on

developments and risks Haemodialysis units EPP workers to complete ‘risk assessment’ Contact and SPs for patients positive for BBV with

uncontrolled bleeding

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Recommendations: BPrevention of Transmission of Hepatitis B

All at risk HCWs (and students) to be immunised or provide evidence of immunity (natural or vaccine induced)

EPP workers (and those who may in future perform EPPs) to be tested for antiHBc and HBsAg (professional interpretation)

No offer of employment without compliance with ‘appropriate pre-employment occupational health assessment programme’

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Recommendations: BPrevention of Transmission of Hepatitis B

Confidential maintenance of immunisation records Issue such records to individual HCWs EPP workers positive for HBsAg to be tested for HBeAg.

Exclude those positive from EPPs HBsAg+ and HBeAg- HCWs to have viral load determined Where risk of patient exposure has occurred, institutions

must have look back policy for implementation of look back exercise if recommended by Local Expert Group. Standing Advisory Committee to be informed

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Recommendations: CPrevention of Transmission of HIV and Hepatitis C Incremental screening of

HCWs who perform EPPs to be initiated and evaluated.

Anti-HCV+ HCWs to have PCR for HCV RNA. Exclude those PCR+ from doing EPPs. (No HIV screening pro tem)

HCWs to be aware of ethical obligation to seek diagnostic testing if exposed to BBV through work or other risk behaviours

Exclude HIV+ HCWs from EPPs

Look-back policy: as per HBV

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Recommendations: DDialysis and Renal Transplant Settings

Implementation of SPs and appropriate segregation of infected patients and their equipment.

Pre-treatment screening and vaccination of dialysis patients and surveillance while on treatment

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Recommendations: EIdentification of Infected Health-care Workers

Employers to facilitate voluntary disclosure of infection status. On commencing employment, all employees should be made aware of risk factors for acquiring BBD and of their ethical duty to disclose such infection .

Once notified, physician to inform DPH anonymously who will dictate response depending on previous or ongoing risk to patients. May require LEG to be convened. Inform infected HCW and CEO of any need for work restrictions

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Recommendations: FRedeployment, retraining and/ or support

Every effort should be made to retrain or re-deploy infected HCWs where appropriate

Training bodies to be aware of challenges and to take these into account

Provide appropriate support arrangements for infected permanent employees unable to work

Faculties should set up mentoring system to provide support and information on financial, medical and career consequences of infection

Medical, dental and nursing schools should take account of national guidance in developing policies

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EPP: A procedure where there is a risk that injury to the health-care worker may result in exposure of the patient’s open tissues to the blood of the worker”

Include “Surgical entry into tissues, cavities

or organs or repair of major traumatic injuries, vaginal or Caesarean deliveries or other obstetric procedures during which sharp instruments are used

The manipulation, cutting or removal of any oral or perioral tissues including tooth structure, during which bleeding may occur

Where worker’s hands may be in contact with sharp instruments, needle tips or sharp tissues (spicules of bone or teeth) inside patient’s open body cavity, wound or confined anatomical space…….

Don’t include Injections / taking blood/

line set up Minor surface suturing Incision of abscesses Routine vaginal or rectal

examination Uncomplicated endoscopies

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Implications for Employers:

Statutory duty to employees under H&S Act 2005: information, training, safe place of work, safe systems of work, PPE, safer devices etc. Resources for infection control

ICNs, microbiologists Surveillance Policies Education (SPs, contact precautions where

appropriate) Resources for occupational health

OHAs, specialist physicians Prevention, management and follow-up of OBEs PEHA assessment / vaccination Management of infected HCW

Statutory duty to notify all cases of viral hepatitis

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Implications for Employers : 2 Prepare / update appropriate organisational policies on

prevention of exposure, management of infected HCW and dealing with look-backs

Arrange appropriate health assessment at recruitment Assess risk of work practices and modify those identified as

hazardous Observe specific arrangements for haemodialysis patients

(and staff) Educate staff on use of new devices, use of PPE, disposal of

sharps and health-care risk waste Promote a safety culture Record and audit incidents Maintain confidentiality Provide appropriate support arrangements for infected

permanent employees unable to work

RISK MANAGEMENT

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Implications for training bodies Medical, nursing, midwifery and dental

students must be immunised / and or tested for evidence of hepatitis B infection

Training bodies to be aware of responsibilities in providing support for infected HCWs / facilitating retraining/ mentoring system etc.

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Implications for OH Services At PEHA, do BBV risk assessment on all EPP workers (including

locums, temporary staff or supernumeraries). Ensure liaison with recruitment staff to ensure no offer of

employment until candidates comply with PEHA requirements Immunise those at risk against hepatitis B Test EPP workers for infection (HBV,HCV) in accordance with

accepted procedure Test renal unit staff for HBV . Restrict those with viral load >104

from ‘undertaking clinical procedures’ in the unit. Annual HBsAg testing of those non-immune.

Manage infected HCWs in supportive and professional manner Hepatitis B is prescribed disease: occupational injury benefit

available Remember statutory obligation to notify

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Implications for Employees

Be aware of ethical obligations (primum non nocere) Be aware of legal responsibilities vis a vis H&S at work :

Participate in training Take SPs at all times and in particular, use sharps safely

(planning, avoidance etc.) Report all incidents

Avoid putting oneself at risk (personally and occupationally) Standard Precautions Infected HCW who is involved in clinical cases should remain

under medical / OH supervision Infected HCWs must abide by any restrictions imposed by LEG

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Testing

General procedure: Ensure sample is verifiable: taken

in OHD, or confirm taken in OHD elsewhere

Repeat test if doubt integrity of result

HCWs must not provide their own specimens

Testing for EPP clearance Show proof of identity Take sample in OHD Transport sample to lab in normal

way and not by HCW OHD must confirm, on receipt of

results from lab, that sample was taken in OHD

OH professional should take reasonable steps to ensure HCW is not taking antivirals

Approved laboratory is VRL Belfield

Specifics: HBV viral load on 3 sequential

samples using same testing kit over 6 week period Annual testing for those with

viral load <104 (where eAg neg) Consider more frequent testing

where viral load >5,000 copies/ml or significant increase in load.

Hepatitis C antibody and if positive do PCR. Test annually for PCR in those

who are antiHCV+ Epidemiology if infectivity is

uncertain and decisions on restrictions should be made on case by case basis, particularly for those on anti-virals (P 25)

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Training Programme Content:(to be provided upon initial employment and at appropriate intervals thereafter)

Epidemiology and mode of transmission

Use and location of PPE Understand SPs Be aware of role of OH Be aware of procedure for

blood exposures (1st aid and PEP)

Have access to relevant policies to protect HCWs and patients from BBVs

Have access to policies for infected HCWs

Training should be interactive Training records must be

maintained (date, content, names)

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•WORK RESTRICTIONS

•All EPP workers to be screened for markers of HBV. If +, need viral loadtesting and exclude those with DNA >104 copies per ml

•All EPP workers to be screened for HCV (incremental i.e. starting with trainees)

•No routine testing for HIV but those who believe they may have risk factors must be tested. No HIV+ HCW should do EPPs

•All renal unit staff to be tested for HB markers and restricted from clinical procedures if DNA > 104

•Annual testing of renal unit workers who are non-immune for HBsAg

2005

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Conclusion

Old guidelines have been enhanced but basics are unchanged (infection control, risk management etc.)

Additions summarised: Renal unit guidance Hepatitis C screening / work restrictions New threshold for HB screening Greater detail on testing procedures Sample OH form for EPPs (Appendix) Algorithm for managing infected HCWs (P 52) Retraining, redeployment and / or support: apply to those

who acquire infection in Irish public health sector Reference to risks from contaminated equipment