Integrated guidance on health clearance has been published by Public Health England and adopted for use in Scotland [1].
This includes
- evidence-based recommendations to reduce the risk of healthcare worker-to patient-transmission of bloodborne viruses (BBVs) in the clinical setting, and
- the management of healthcare workers living with BBVs.
The integrated guidance replaces BBV guidance in previous publications. Guidance on reducing the risk of transmission of Tuberculosis (TB) remains within the previous guidance.
According to the integrated guidance, a new healthcare worker (HCW) or student working in NHS Scotland who may be involved in Exposure Prone Procedures (EPPs),has to provide evidence that they are not infected with the BBVs (Hepatitis B (HBV), Hepatitis C (HCV) and Human immunodeficiency virus (HIV)) or, if they are living with BBVs, they meet certain criteria prior to commencing employment or being accepted onto a training course.
A new healthcare worker (HCW) is defined as:
- an individual who has direct clinical contact with patients in the NHS or independent sector for the first time whether as an employee or by agreement (e.g. student placement, visiting fellow).
- an existing HCW who is moving to a post/training that involves EPPs for the first time in their career.
- a HCW returning to work in the NHS, who may have been exposed to a BBV while away (based on a risk assessment carried out by the occupational health service).
In addition, a HCW moving between EPP posts should be able to provide evidence of their health clearance. If evidence of EPP clearance cannot be provided, the HCW should be treated as new and an additional health clearance is recommended. Note: HCWs who have been practicing EPPs prior to 1 August 2008 are not required to provide evidence of health clearance, if they move from one EEP post to another.
A HCW living with a BBV can carry out EPPs depending on their infective status. Health clearance guidance for these HCWs is separate to the routine occupational health checks and immunisations e.g. tetanus, diphtheria, polio and measles, mumps and rubella, and seasonal influenza.
Exposure Prone Procedures (EPPs)
Provided that appropriate infection prevention and control precautions are adhered to at all times, the majority of clinical procedures in the dental setting pose no risk of transmission from HCW to patient. However, there are occasions when an opportunity for staff to patient transmission does exist. These are described as exposure prone procedures (EPPs) where injury to the healthcare worker could result in the worker’s blood contaminating the patient’s open tissues. This is known as ‘bleed-back’.
EPPs include procedures where the healthcare worker’s gloved hands may be in contact with sharp instruments, needle tips or sharp tissues inside a patient’s open body cavity, wound or confined anatomical space, where the hands or fingertips may not be completely visible at all times.
A list of EPPs in dentistry is available in the UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses (UKAP) advice [2]. The UKAP advice categorises each procedure into the level of risk of bleed-back (EPP levels 0-3, where 0 is no risk/not exposure prone, and 3 is higher risk). For example, local anaesthetic injection is EPP Category Level 1 and routine tooth extraction is EPP Category Level 2. There are no Category Level 3 general dentistry procedures.
Cases of uncertainty about whether a procedure is classed as an EPP should be directed to the UKAP Secretariat.
Health screening
All clinical healthcare workers (NHS and non NHS) are required to complete a pre-employment occupational risk health screening questionnaire. This is provided by the local NHS Health Board and will inform if any further investigations are required. Health screening is divided into Standard Health Clearance and Additional Health Clearance. New HCWs who perform EPPs are required to have both standard and additional health clearance checks.
Standard Health Clearance checks apply to all new HCWs with clinical contact and should be completed before clinical duties commence. These include:
- checks for TB disease or TB immunity;
- offer of screening/immunisation for HBV;
- offer of testing for HCV;
- offer of testing for HIV.
Additional Health Clearance checks, (in addition to standard health clearance) apply to all new healthcare workers who will perform EPPs. These checks must be completed before confirmation of employment in an EPP post and include testing for BBVs (HBV, HCV and HIV). Staff will fulfil the requirements to carry out EPPs if the additional health clearance checks confirm that they do not have a BBV. Similarly, those with a BBV infection will also fulfil the requirements to carry out EPPs if their BBV status meets certain criteria as described in the integrated health clearance guidance.
The GDC scope of practice duties for dental nurses do not include EPPs (e.g. fingers are not placed in patients’ mouths) and therefore the Standard Health Clearance is sufficient. However, some dental nurses have additional training to perform procedures that may be exposure prone (e.g. suture removal) when fingers are not completely visible. Therefore, a risk assessment of each post is necessary to determine whether it entails EPPs and the necessity for an Additional Health Clearance.
New, or existing healthcare workers who apply for a post or training which involve EPPs for the first time in their career, who decline to be tested for HBV, HCV and HIV will not be cleared to perform EPPs. This does not apply to HCWs who are moving from an existing EPP post to a new EPP post if they started practising EPPs before 1 August 2008.
Healthcare workers who perform EPPs have a professional, ethical and legal duty to protect their patients and to take appropriate action (e.g. seek medical advice without delay and/or notify the practice owner) if they know (or suspect) that they become infected with a BBV. This includes meeting the requirements of health clearance.
A HCW who performs EPPs and has any reason to believe that they may have been exposed to a BBV infection, regardless of whether this was in an occupational or personal setting, has a responsibility to seek advice and/or a BBV test. This will be either through clinical services (most commonly via their GP or a sexual health clinic) or from an Occupational Health Service.
Healthcare workers living with bloodborne viruses
In recent years restrictions on HCWs with HIV or HBV who perform EPPs have been reduced. The integrated guidance provides detailed advice on occupational health monitoring and clearance for HCWs living with HBV, HCV and HIV. Monitoring relies on continuing care and regular viral load monitoring by their treating physicians and a Consultant Occupational Physician. Occupational health input should be sought as early as possible. Decisions about whether healthcare workers living with HBV can perform EPPs are made on a case-by-case basis. In additional to local monitoring, HCWs living with HBV or HIV who wish to perform EPPs and who meet the criteria for clearance must be registered on the UKAP-OHR, a central confidential register for the UK, overseen by UKAP.
Document the practice’s policy on health clearance and ensure that staff are aware of it (see Health Clearance and Immunisation Policy template).
Confirm with your local Health Board or Occupational Health Service (OHS) the health clearance and immunisation provision that is available to your staff.
Ensure staff with clinical contact are immunised for HBV, are free from active TB (with offer of immunisation as required) and are otherwise fit to work and that new staff have Standard Health Clearance per the Health Clearance guidance.
* Immunisation for HBV is recommended for all clinical staff and others who may have contact with patients’ blood and blood-stained body fluids.
Assess each post to determine whether duties include EPPs and the level of health clearance required.
Contact the UKAP Secretariat if you are unsure whether a dental procedure is classed as an EPP.
Ensure that new staff who will undertake EPPs have Additional Health Clearance prior to appointment.
Keep a confidential record of the fitness to work of relevant members of staff (e.g. an OHS notice of fitness to carry out clinical work and, as appropriate, EPPs).
Ensure all staff are aware that if they suspect they might be infected with a bloodborne virus (or other serious infection, such as TB), they have a duty to seek medical advice and testing and/or notify the practice owner without delay.
Seek advice from your local OHS or UKAP regarding registration of staff living with a bloodborne virus who perform EPPs.
Sources of information
- Practice of Exposure Prone Medical Procedures by Healthcare Workers Living with HIV or Hepatitis B. Scottish Government – Chief Medical Officer letter 24 Jan 2014
- UK Advisory Panel for Healthcare Workers Infected with Bloodborne Viruses (UKAP)
- Medical and Dental Students: Health Clearance for Hepatitis B, Hepatitis C, HIV and Tuberculosis. (PDF)Medical Schools Council, the Dental Schools Council, Public Health England, Health Protection Scotland, the Association of UK University Hospitals, and Higher Education Occupational Practitioners (2014).