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

ADDITIONAL HEALTH CHECKS

Introduction

56. Additional health checks for hepatitis B, hepatitis C, and HIV are required for all healthcare workers who are new to the NHS and who will perform EPPs, and for existing healthcare workers who will be performing EPPs for the first time.

Hepatitis B

57. All HCWs who are new to the NHS and who will perform EPPs and existing workers who are performing EPPs for the first time in their careers (see paras 17 and 39 above) should be tested for hepatitis B as described in this section. Healthcare workers for whom hepatitis B vaccination is contra-indicated, who decline vaccination or who are non-responders to vaccine should be restricted from performing EPPs unless shown to be non-infectious. Periodic re-testing may need to be considered.

58. Previous guidelines assumed that a hepatitis B antibody (anti- HBs) response measured after a course of vaccine could be taken as indicating non-infectivity. However, it is now recognised that, on occasion, this response may occur in individuals who have current infection (unpublished reports from a number of UK occupational health and virology departments). Where anti- HBs is present in such circumstances, it is usually in low titre, but levels of >100 mIU/ml have been documented in hepatitis B-infected healthcare workers, some of whom would be restricted from performing EPPs under current guidelines. Relying on an anti- HBs response to vaccine to indicate non-infectivity may not be secure, since some infectious carriers of the virus could be missed. Therefore, it is now recommended that healthcare workers who will perform EPPs should:

• be tested for hepatitis B surface antigen (HBsAg), which indicates current hepatitis B infection;
• if negative for HBsAg, be immunised (unless they have already received a course of vaccine) and have their response checked (anti- HBs). Where there is evidence that a healthcare worker, who is known to have had previous hepatitis B infection which has cleared, now has natural immunity, immunisation is not necessary, but the advice of a local virologist or clinical microbiologist should be sought;
• if positive for HBsAg, be tested for hepatitis B e-markers. If they are e-antigen (HBeAg) positive, they must not be allowed to perform EPPs. If they are e-antigen negative, they should have their hepatitis B viral load ( HBVDNA) tested. If the viral load is greater than 10 ³ genome equivalents per ml, they should not be allowed to perform EPPs. Hepatitis B viral load testing should be carried out in designated laboratories (see paragraph 72).

59. There are no restrictions on the working practices of hepatitis B-infected healthcare workers who have HBVDNA below 10 ³ genome equivalents/ml, subject to annual measurement of their HBVDNA (see Scottish Executive Health Department letter HDL (2000) 03 Hepatitis B Infected Healthcare Workers.
http://www.show.scot.nhs.uk/sehd/mels/HDL2000_03.html).

60. In March 2007 the Department of Health published new guidance on hepatitis B infected health care workers. The guidance allows such workers who are e-antigen negative and have relatively low HBVDNA to perform EPPs, whilst taking continuous antiviral therapy that suppresses their HBVDNA to 10 ³ genome equivalents/ml or below (subject to regular monitoring by a consultant occupational physician). It is felt that this guidance will have limited application in Scotland but a Scottish version is being considered. Meantime the Department of Health guidance is available at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073164

61. Guidance on hepatitis B infected healthcare workers is contained in the following documents:

• Scottish Executive Guidelines: Protecting healthcare workers and patients from Hepatitis B (August 1993) and its addendum issued under cover of MEL (1996) 93 (November 1996)
• Scottish Executive Health Department Letter NHSHDL (2000) 03: Hepatitis B Infected Healthcare Workers (18 August 2000).
  http://www.show.scot.nhs.uk/sehd/mels/HDL2000_03.html

Hepatitis C

62. All HCWs who are new to the NHS and who will perform EPPs and existing workers who are performing EPPs for the first time in their careers (see paras 17 and 39 above) should be tested for hepatitis C antibody. Those who are positive should be tested for hepatitis C RNA to detect the presence of current infection. Qualitative testing for hepatitis C virus RNA should be carried out in accredited laboratories that are experienced in performing such tests, and which participate in external quality assurance schemes. The assays used should have a minimum sensitivity of 50 IU/ml. Those who are hepatitis C RNA positive must not be allowed to perform EPPs. This extends existing guidance on hepatitis C testing (see NHSHDL (2002) 75, reference below) to cover all staff new to the NHS who will perform EPPs as defined in paras 17 and 39 above, regardless of career stage.

63. Healthcare workers should be asked about antiviral treatment when submitting a blood sample because special arrangements exist for healthcare workers who are receiving or have recently received interferon and/or antiviral therapy for hepatitis C (see NHSHDL (2002) 75, reference below).

64. Guidance on hepatitis C infected healthcare workers is contained in the following document: Scottish Executive Health Department Letter: NHSHDL (2002) 75: Hepatitis C infected healthcare workers (22 November 2002).
http://www.show.scot.nhs.uk/sehd/mels/HDL2002_75.pdf

HIV

65. All HCWs who are new to the NHS and who will perform EPPs and existing workers who are performing EPPs for the first time in their careers (see paras 17 and 39 above) should be tested for HIV antibody. Those who are HIV antibody positive should not be allowed to perform EPPs. Guidance on HIV infected healthcare workers is contained in the following document: Guidance on the management of AIDS/ HIV infected healthcare workers and patient notification, HDL (2005) 33.
http://www.scotland.gov.uk/Resource/Doc/55971/0016200.pdf.