National Guidelines on Blood-Borne Pathogens

1. National Guidelines on Blood-Borne Pathogens Dr Blánaid Hayes, FRCPI, FFOM, Occupational Health Department, Beaumont Hospital, Dublin.

2. DOHC Guidelines: 2005 • Launched DOHC website March 29th 2006 • HSE implementation group (multidisciplinary) to meet in early May National Needlestick Injury Conference

3. 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….. National Needlestick Injury Conference

4. 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 Key Questions National Needlestick Injury Conference

5. 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 Key Players National Needlestick Injury Conference

6. 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 National Needlestick Injury Conference

7. 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 National Needlestick Injury Conference

8. 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 National Needlestick Injury Conference

9. 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 National Needlestick Injury Conference

10. 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’ National Needlestick Injury Conference

11. 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 National Needlestick Injury Conference

12. 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 National Needlestick Injury Conference

13. 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 National Needlestick Injury Conference

14. 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 National Needlestick Injury Conference

15. 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 National Needlestick Injury Conference

16. 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 EPP: A procedure where there is a riskthat injury to the health-care worker may result in exposure of the patient’s open tissues to the blood of the worker” National Needlestick Injury Conference

17. 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 National Needlestick Injury Conference

18. 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 National Needlestick Injury Conference

19. 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. National Needlestick Injury Conference

20. 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 National Needlestick Injury Conference

21. 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 National Needlestick Injury Conference

22. 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) Testing National Needlestick Injury Conference

23. 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) National Needlestick Injury Conference

24. WORK RESTRICTIONS • All EPP workers to be screened for markers of HBV. If +, need viral load • testing 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 National Needlestick Injury Conference

25. 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 National Needlestick Injury Conference