dr blanaid hayes
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National Guidelines on
Blood-Borne Pathogens
Dr Blnaid 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 adviseMinister for Health
1997: first report
published
Standing AdvisoryCommittee established
1999: The Prevention
of Transmission..
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Key Questions
Who?
What?
When?
Where?
How?..........
All healthcare workers
Guideline, code ofpractice, policy,
recommendations,protocols
Now
Any organisation in whichhealthcare 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 StandardPrecautions (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 riskmanagement and infectioncontrol policies that aremonitored for effectiveness
Access for all to specialistadvice in OH, microbiology, IDand IC
Education of all potentially atrisk HCWs in application ofSPs, on initial employment andannually thereafter (bycompetent individuals)
IC education to beincorporated into training of allmedical, nursing and dentalstudents
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Recommendations: ARisk Management and Infection Control
Institutions to appraise new technology and invest inappropriate / relevant devices
Apply protocols also to potential risk oftransmission 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 (andstudents) to be immunisedor provide evidence ofimmunity (natural or vaccineinduced)
EPP workers (and those whomay in future perform EPPs)to be tested for antiHBc andHBsAg (professionalinterpretation)
No offer of employmentwithout compliance with
appropriate pre-employmentoccupational healthassessment 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 backexercise if recommended by Local Expert Group. StandingAdvisory Committee to be informed
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Recommendations: CPrevention of Transmission of HIV and Hepatitis C
Incremental screening ofHCWs who perform EPPs tobe initiated and evaluated.
Anti-HCV+ HCWs to havePCR for HCV RNA. Excludethose PCR+ from doing EPPs.(No HIV screening pro tem)
HCWs to be aware of ethicalobligation to seek diagnostictesting if exposed to BBVthrough work or other riskbehaviours
Exclude HIV+ HCWs fromEPPs
Look-back policy: as per HBV
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Recommendations: DDialysis and Renal Transplant Settings
Implementation of SPsand appropriatesegregation of infectedpatients and theirequipment.
Pre-treatmentscreening andvaccination of dialysis
patients andsurveillance while ontreatment
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Recommendations: EIdentification of Infected Health-care Workers
Employers to facilitate voluntary disclosure ofinfection status. On commencing employment, allemployees should be made aware of risk factors foracquiring BBD and of their ethical duty to disclosesuch infection .
Once notified, physician to inform DPHanonymously who will dictate response dependingon previous or ongoing risk to patients. May require
LEG to be convened. Inform infected HCW andCEO 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 infectedHCWs where appropriate
Training bodies to be aware of challenges and to take these intoaccount
Provide appropriate support arrangements for infectedpermanent employees unable to work
Faculties should set up mentoring system to provide support andinformation on financial, medical and career consequences ofinfection
Medical, dental and nursing schools should take account ofnational 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 patients open tissues to the blood of the worker
Include Surgical entry into tissues, cavities
or organs or repair of major traumatic
injuries, vaginal or Caesareandeliveries or other obstetric
procedures during which sharpinstruments are used
The manipulation, cutting or removal
of any oral or perioral tissues
including tooth structure, during
which bleeding may occur
Where workers hands may be in
contact with sharp instruments,needle tips or sharp tissues (spiculesof bone or teeth) inside patients
open body cavity, wound or confined
anatomical space.
Dont 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 Act2005: information, training, safe place ofwork, safe systems of work, PPE, saferdevices etc.
Resources forinfection control
ICNs, microbiologists Surveillance
Policies
Education (SPs, contact precautions whereappropriate)
Resources foroccupational 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 viralhepatitis
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Implications for Employers : 2 Prepare / update appropriate organisational policies on
prevention of exposure, management of infected HCW anddealing with look-backs
Arrange appropriate health assessment at recruitment
Assess risk of work practices and modify those identified ashazardous
Observe specific arrangements for haemodialysis patients(and staff)
Educate staff on use of new devices, use of PPE, disposal ofsharps and health-care risk waste
Promote a safety culture
Record and audit incidents
Maintain confidentiality
Provide appropriate support arrangements for infectedpermanent 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 (includinglocums, temporary staff or supernumeraries).
Ensure liaison with recruitment staff to ensure no offer ofemployment until candidates comply with PEHA requirements
Immunise those at risk against hepatitis B
Test EPP workers for infection (HBV,HCV) in accordance withaccepted procedure
Test renal unit staff for HBV . Restrict those with viral load >104
from undertaking clinical procedures in the unit. Annual HBsAgtesting of those non-immune.
Manage infected HCWs in supportive and professional manner
Hepatitis B is prescribed disease: occupational injury benefitavailable
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 remainunder medical / OH supervision
Infected HCWs must abide by any restrictions imposed by LEG
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Testing
General procedure:
Ensure sample is verifiable: takenin OHD, or confirm taken in OHDelsewhere
Repeat test if doubt integrity ofresult
HCWs must not provide their ownspecimens
Testing for EPP clearance
Show proof of identity
Take sample in OHD
Transport sample to lab in normalway and not by HCW
OHD must confirm, on receipt of
results from lab, that sample wastaken in OHD
OH professional should takereasonable steps to ensure HCW isnot taking antivirals
Approved laboratory is VRL Belfield
Specifics:
HBV viral load on 3 sequentialsamples using same testing kitover 6 week period
Annual testing for those withviral load 5,000copies/ml or significantincrease in load.
Hepatitis C antibody and if positivedo PCR.
Test annually for PCR in thosewho are antiHCV+
Epidemiology if infectivity isuncertain and decisions onrestrictions should be made oncase by case basis, particularlyfor 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 oftransmission
Use and location of PPE
Understand SPs
Be aware of role of OH
Be aware of procedure forblood exposures (1st aid andPEP)
Have access to relevantpolicies to protect HCWs andpatients from BBVs
Have access to policies forinfected HCWs
Training should be interactive
Training records must bemaintained (date, content,names)
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WORK RESTRICTIONS
All EPP workers to be screened formarkers 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 whobelieve they may have risk factors must betested. No HIV+ HCW should do EPPs
All renal unit staff to be tested for HB
markers and restricted from clinicalprocedures if DNA > 104
Annual testing of renal unit workers whoare non-immune for HBsAg
2005
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Conclusion
Old guidelines have been enhanced but basics areunchanged (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
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