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

2. 22/04/2006 National Needlestick Injury Conference 2 DOHC Guidelines: 2005 Launched DOHC website March 29 th 2006 HSE implementation group (multidisciplinary) to meet in early May

3. 22/04/2006 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…..

4. 22/04/2006 National Needlestick Injury Conference 4 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

5. 22/04/2006 National Needlestick Injury Conference 5 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

6. 22/04/2006 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

7. 22/04/2006 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

8. 22/04/2006 National Needlestick Injury Conference 8 Recommendations: A Risk 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

9. 22/04/2006 National Needlestick Injury Conference 9 Recommendations: A Risk 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

10. 22/04/2006 National Needlestick Injury Conference 10 Recommendations: B Prevention 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’

11. 22/04/2006 National Needlestick Injury Conference 11 Recommendations: B Prevention 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

12. 22/04/2006 National Needlestick Injury Conference 12 Recommendations: C Prevention 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

13. 22/04/2006 National Needlestick Injury Conference 13 Recommendations: D Dialysis 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

14. 22/04/2006 National Needlestick Injury Conference 14 Recommendations: E Identification 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

15. 22/04/2006 National Needlestick Injury Conference 15 Recommendations: F Redeployment, 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

16. 22/04/2006 National Needlestick Injury Conference 16 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

17. 22/04/2006 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

18. 22/04/2006 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

19. 22/04/2006 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.

20. 22/04/2006 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 >10 4 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

21. 22/04/2006 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

22. 22/04/2006 National Needlestick Injury Conference 22 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 <10 4 (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)

23. 22/04/2006 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 (1 st 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)

24. 22/04/2006 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 >10 4 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 > 10 4 Annual testing of renal unit workers who are non-immune for HBsAg 2005

25. 22/04/2006 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