Health Clearance for Tuberculosis, Hepatitis B, Hepatitis C and HIV for New Healthcare Workers with Direct Clinical Contact with Patient

STANDARD HEALTH CHECKS

Introduction

46. Employers will need to set up mechanisms in conjunction with their human resources and occupational health departments to identify new healthcare workers, returning healthcare workers and those moving to posts involving EPPs for the first time, to ensure that the necessary health checks are carried out. Standard health checks for non- EPP posts may be conducted on appointment; these should be completed before clinical duties commence. Students who have already undergone standard health checks at the commencement of their undergraduate qualification should not be required to undergo repeat standard health checks. It is the responsibility of the employer to satisfy themselves that such health checks have already been carried out.

Tuberculosis ( TB)

47. In accordance with guidelines from the National Institute for Health and Clinical Excellence ( NICE), (currently being adapted for Scotland by the TB Guidelines Group) and recent advice from the Joint Committee on Vaccination and Immunisation ( JCVI), health checks for TB should include the following:

• Employees new to the NHS who will be working with patients or clinical specimens should not start work until they have completed a TB screen or health check, or documentary evidence is provided of such screening having taken place within the preceding 12 months.
• Employees new to the NHS who will not have contact with patients or clinical specimens should not start work if they have signs or symptoms of TB.
• Health checks for employees new to the NHS who will have contact with patients or clinical materials should include:
  • assessment of personal or family history of TB;
  • symptom and signs enquiry, possibly by questionnaire;
  • documentary evidence of tuberculin skin testing (or interferon-gamma testing) and/or BCG scar check by an occupational health professional, not relying on the applicant's personal assessment;
  • tuberculin skin test (or interferon-gamma test) result within the last five years, if available.
• If an employee new to the NHS has no (or inconclusive) evidence of prior BCG vaccination, a Mantoux tuberculin skin test (or interferon-gamma test) should be performed.
• Employees new to the NHS who will be working with patients or clinical specimens and who are Mantoux tuberculin skin test (or interferon-gamma test) negative should have an individual risk assessment for HIV infection before BCG vaccination is considered.
• Employees new to the NHS should be offered BCG vaccination, if they will have contact with patients and/or clinical specimens, are Mantoux tuberculin skin test (or interferon-gamma test) negative and have not been previously vaccinated, according to recent advice from JCVI in the Green Book.
  • JCVI advice is that unvaccinated, tuberculin negative individuals aged under 35 are recommended to receive BCG. There are no data on the protection afforded by BCG vaccination when it is given to adults aged 35 years or over.
  • Not all healthcare workers are at an equal risk of TB. There are likely to be categories of healthcare workers who are at particular risk of TB, and this should be part of the clinical risk assessment when the use of BCG is being considered for a healthcare worker over 35 years of age. ( The "Green Book"- Immunisation against infectious disease, Chapter 32.)
• All new entrants to the UK from countries of high TB incidence are recommended by NICE to have a chest X-ray provided that they have not had one recently, are not younger than 11 years and are not possibly pregnant. Employees of any age who are new to the NHS and are from countries of high TB incidence, or who have had contact with patients in setting with a high TB prevalence, should have a Mantoux tuberculin skin test (or interferon-gamma test). If negative, recommendations in the two previous bullet points should be followed. If positive, they should be referred to a TB clinic for assessment and consideration of treatment for disease or latent infection.
• If a new employee from the UK or other low-incidence setting, without prior BCG vaccination, has a positive Mantoux tuberculin skin test (or interferon-gamma test), they should have a medical assessment and a chest X-ray. They should be referred to a TB clinic for consideration of TB treatment if the chest X-ray is abnormal, or for consideration of treatment of latent TB infection if the chest X-ray is normal.
• If a prospective or current healthcare worker who is Mantoux tuberculin skin test negative, declines BCG vaccination, the risks should be explained and the oral explanation supplemented by written advice. He or she should usually not work where there is a risk of exposure to TB. The employer will need to consider each case individually, taking account of employment and health and safety obligations.
• Clinical students, agency and locum staff and contract ancillary workers who have contact with patients or clinical materials should be screened for TB to the same standard as new employees in healthcare environments, according to the recommendations set out above. Documentary evidence of screening to this standard should be sought from locum agencies and contractors who carry out their own screening.
• NHS organisations arranging care for NHS patients in non- NHS settings should ensure that healthcare workers who have contact with patients or clinical materials in these settings have been screened for TB to the same standard as new employees in healthcare environments.

TB: Preventing infection in healthcare environments - occupational health

48. These recommendations set the standard for NHS organisations and therefore should apply in any setting in Scotland where NHS patients are treated.

• Reminders of the symptoms of TB, and the need for prompt reporting of such symptoms, should be included with annual reminders about occupational health for staff who:
  • are in regular contact with TB patients or clinical materials,
  • have worked in a high-risk clinical setting for four weeks or longer.
• One-off reminders should be given after a TB incident on a ward.
• There is a duty on staff to report symptoms as part of their responsibility to protect patients.
• If no documentary evidence of prior screening is available, staff in contact with patients or clinical material that are transferring jobs within the NHS should be screened as for new employees.
• The risk of TB for a new healthcare worker who knows he or she is HIV positive at the time of recruitment should be assessed as part of the occupational health checks.
• The employer, through the occupational health department, should be aware of the settings with increased risk of exposure to TB, and that these pose increased risks to HIV-positive healthcare workers.
• Healthcare workers who are found to be HIV positive during employment should have medical and occupational assessments of TB risk, and may need to modify their work to reduce exposure.

Hepatitis B

49. It is required that all healthcare workers, including students, who have direct contact with blood, blood stained body fluids or patients' tissues, are offered immunisation against hepatitis B and tests to check their response to immunisation, including investigation of non-response. To be clear, the only requirement is the offer of immunisation and testing; although health care workers should be encouraged to commence immunisation and testing there is no requirement for them to do so. Guidance on immunisation against hepatitis B, which includes information about dosage/protocols and supplies, is contained in chapter 18 of the UK Health Departments' Immunisation against Infectious Disease (the 'Green Book'). See also paragraph 57 - 61 on additional health clearance checks for Hepatitis B and suitability for performing EPPs.

Hepatitis C

50. All healthcare workers who are new to the NHS should be offered a pre-test discussion and hepatitis C antibody test (and, if positive, a hepatitis C RNA test) in the context of their professional responsibilities in relation to hepatitis C. Registrants of the General Medical Council, the General Dental Council, the Nursing Midwifery Council ( NMC) and the Health Professions Council ( HPC) have a professional duty to protect the health and safety of their patients. To be clear, the only requirement is the offer of discussion and testing; there is requirement for health care workers to agree.

51. It would be helpful to remind such workers of the ways in which they might have been exposed to hepatitis C. Risk factors for hepatitis C infection include:

• receiving unscreened blood or untreated plasma products (in the UK before September 1991 and 1987 respectively);
• sharing of injecting equipment whilst using drugs;
• having been occupationally exposed to the blood of patients known to be infected with hepatitis C, or deemed to be at high risk of infection.
• receiving medical or dental treatment in countries where hepatitis C is common and infection control precautions may be inadequate.

52. Other behaviours and activities associated with hepatitis C transmission, albeit uncommonly, include: engaging in unprotected sexual intercourse; being born to an infected mother; having a tattoo; undergoing body piercing; and sharing of toothbrushes and razors.

53. A positive test, or declining a test for hepatitis C, should not affect the employment or training of healthcare workers who will not perform EPPs. Healthcare workers new to the NHS have the right to decline testing, in which case they will not be cleared to perform exposure-prone procedures.

HIV

54. All healthcare workers new to the NHS should be offered an HIV antibody test with appropriate pre-test discussion, including reference to their professional responsibilities in relation to HIV. During this discussion, they should be given a copy of the guidance from their professional regulatory body, if relevant (see Annex C). It would be helpful to remind them of the ways in which they may have been exposed to HIV, which include:

• if male, engaging in unprotected sexual intercourse with another man;
• having unprotected intercourse in, or with a person who had been exposed in, a country where transmission of HIV through sexual intercourse between men and women is common;
• sharing injecting equipment whilst using drugs;
• having been occupationally exposed to the blood of patients known to be infected with HIV, or deemed to be at high risk of infection.
• receiving medical or dental treatment in countries where HIV is common and infection control precautions may be inadequate.
• engaging in unprotected sexual intercourse with someone belonging to any of the above categories.

55. A positive test, or declining a test for HIV, should not affect the employment or training of healthcare workers who will not perform EPPs. Nevertheless, HIV infected healthcare workers should remain under regular medical and occupational health supervision in accordance with good practice. Occupational health physicians should consider the impact of HIV on a positive individual's resistance to infections when advising on suitability for particular posts, especially if the duties may involve exposure to known or undiagnosed TB.