HEPATITIS C INFECTED HEALTH CARE WORKERS
Health care workers who have had antiviral therapy
12 Hepatitis C infected health care workers who have been treated with antiviral therapy, and who remain hepatitis C virus RNA negative for at least 6 months after cessation of treatment, should be permitted to return to performing exposure prone procedures at that time. As a further check, they should be shown to be Hepatitis C virus RNA negative 6 months later. Provided that the criteria above are met, a return to exposure prone procedures would be a local decision and would not need to be referred to the UK Advisory Panel for Health Care Workers Infected with Blood-borne Viruses (UKAP). However, UKAP is available to provide advice if required. 11
Health care workers who refuse to be tested
13 Health care workers, who already know that they have been infected with hepatitis C, or who are intending to undertake professional training for a career that relies upon the performance of exposure prone procedures, and who refuse to be tested, should not be allowed to carry out exposure prone procedures in future or start their training.
Occupational health advice to hepatitis C infected health care workers
14 Arrangements should be made to provide individual health care workers with access to a consultant occupational health physician. Occupational health departments should explain to health care workers the purpose of the new testing arrangements and how they might affect continued performance of exposure prone procedures. After testing, occupational health departments should inform health care workers of the results of their tests and the implications for their working practice. Occupational health departments should refer hepatitis C infected health care workers for specialist clinical assessment, if this has not already taken place. All hepatitis C infected health care workers should be given accurate and detailed advice on ways of minimising the risks of transmission in the health care setting and to close contacts. 12
15 It is extremely important that hepatitis C infected health care workers receive the same right of confidentiality as any patient seeking or receiving medical care. Occupational health staff, who work within strict guidelines on confidentiality, have a key role in this process. It is recommended that occupational health departments are closely involved in revising local procedures for managing hepatitis C infected health care workers. Occupational health notes are separate from other hospital notes. Occupational health staff are ethically and professionally obliged not to release information without the consent of the individual. There are occasions when an employer may need to be advised that a change of duties should take place, but hepatitis C status itself will not normally be disclosed without the health care worker's consent. Where patients are, or have been, at risk, however, it may be necessary in the public interest for the employer to have access to confidential information. Employers should ensure that data are collected and stored in accordance with the Data Protection Act.
Duties of other health care workers
16 Health care workers who know or have good reason to believe (having taken steps to confirm the facts as far as practicable), that a hepatitis C infected health care worker has not complied with this guidance or followed advice to modify their practice, should inform an appropriate person in the health care worker's employing or contracting authority (e.g. a consultant occupational health physician, Trust Medical Director or Director of Public Health), or where appropriate, the relevant regulatory body. Health care workers may wish to seek advice from their regulatory and professional bodies before passing such information on. Such cases are likely to arise very rarely. Wherever possible, the health care worker should be informed before information is passed to an employer or regulatory body.
Management of blood exposure incidents
17 As recommended in SODH/CMO(98)12: Guidance for clinical health care workers: protection against infection with blood-borne viruses, each employer should draw up a policy on the management of blood exposure incidents for both staff and patients. Each NHS Trust/Island NHS board should designate one or more doctors to whom health care staff or any other person present in the health care setting may be referred immediately for advice if they have been exposed, or have exposed others, to potentially infected blood. Local policies should also specify who will be responsible for the follow-up of any staff or patients who have been exposed. Dental and medical practitioners in primary care should also ensure that similar procedures are in place for themselves and their staff.
18 Guidance on the investigation and appropriate management of occupational exposure to blood has been published by UK Health Departments and the Public Health Laboratory Service. 13 A summary of the Public Health Laboratory Service's recommendations about the investigation of and follow-up of health care workers in relation to hepatitis C when they have been occupationally exposed to blood is shown below.
Known hepatitis C infected source
obtain baseline serum for storage from health care worker
obtain serum/EDTA for HCV RNA testing at 6 and 12 weeks
obtain serum for anti-HCV testing at 12 and 24 weeks
Source known not to be infected with hepatitis C
Hepatitis C status of source unknown
Health care workers found to have acquired hepatitis C infection following occupational exposure should be referred as soon as possible for specialist assessment.
19 There is currently no post-exposure prophylaxis for hepatitis C. However, a recent study suggests that early treatment of acute hepatitis C infection may prevent chronic hepatitis C infection. 14 This underlines the need for careful management and follow-up of occupational exposures and early referral for specialist occupational medicine and gastroenterology/hepatology/ infectious diseases assessment if infection has been transmitted.
20 This guidance is directed mainly at health care workers, but patients who are exposed to blood should be managed in the same way as exposed health careworkers. There may be occasions when a patient is accidentally exposed to the blood of a health care worker who may be infected with hepatitis C in circumstances that may or may not involve exposure prone procedures. Health care workers are under ethical and legal obligations to take all proper steps to safeguard the interests of their patients. This would include ensuring that in the event of a patient being exposed to the infected health care worker's blood, information about the latter's status was reported to the appropriate person to consider what action might be necessary for the wellbeing of the patient. The General Medical Council's guidance Good Medical Practice and Serious Communicable Diseases state that doctors who have a serious communicable disease and continue in professional practice must have appropriate medical supervision and should not rely upon their own assessment of the risks they pose to patients. Statements from the General Dental Council and the Nursing and Midwifery Council also emphasise the duties of health care workers to safeguard the wellbeing of their patients.
21 The Scottish Centre for Infection and Environmental Health carries out national surveillance of health care workers who have been occupationally exposed to blood-borne viruses. Occupational exposures to hepatitis C should be reported through this surveillance scheme (for enquiries, please contact the research nurse at SCIEH on telephone number 0141-300 1100 extension 1133).
Patient notification exercises
22 Whenever a transmission of hepatitis C from an infected health care worker to a patient is detected, notification of other patients of that health care worker who have undergone exposure prone procedures, with the offer of serological testing, should normally follow. Most new infections with hepatitis C are asymptomatic. It has yet to be determined whether there is a need for automatic patient notification exercises when a hepatitis C virus RNA positive health care worker is identified in the absence of evidence of transmission. Until more precise indications for patient notification in this situation can be defined, the UK Advisory Panel for Healthcare Workers Infected with Blood-borne Viruses (UKAP) should be approached for advice whenever a patient notification exercise is being considered, and before preparations for such an exercise are put in train. 15
Redeployment, retraining and benefits
23 It is expected that relatively small numbers of health care workers will be affected by the new restrictions and their retraining/redeployment needs will vary. Employers should make every effort to arrange suitable alternative work and retraining opportunities in accordance with good general principles of occupational health and management practice.
24 NHS employers already assist and support cases where staff retraining or redeployment is necessary for a variety of reasons. Postgraduate medical and dental deans also play an important role in retraining or redeployment programmes for doctors and dentists, not only within the training grades, but often within the career grades too. Professional bodies may also be able to provide advice. Local employers are best placed to support staff displaced because of the new restrictions, and to ensure that the process is handled sympathetically and sensitively. Medical Directors will have an important contribution to make. NHS Trusts will want to consider the training and development needs of the non-medical workforce (e.g. midwives) using training and development opportunities available within the Trust and facilitated through NHS Education for Scotland. In particularly difficult cases which cannot be resolved locally, employers will be able to draw on advice from the Scottish Executive Health Department's Human Resources Directorate (contact: Bill Welsh, Directorate of Human Resources, Ground Floor Rear, St Andrew's House, Edinburgh EH1 3DG; telephone: 0131-244 2492).
25 The NHS Injury Benefits Scheme and the Industrial Injuries Disablement Benefit Scheme provide benefits where hepatitis C has been occupationally acquired. Occupational health services locally should provide health care workers with advice in cases where entitlement to benefits for occupationally acquired infection is under consideration. Details of the benefits available under the Injury Benefit Regulations for NHS employees in Scotland can be obtained from the Scottish Public Pension Agency, Injury Benefit Section, 7 Tweedside Park, Galashiels TD1 3TE (Telephone 01896 893111).
26 The NHS Injury Benefits Scheme and the Industrial Injuries Disablement Benefit Scheme provide benefits where hepatitis C has been occupationally acquired. The NHS Injury Benefits Scheme provides temporary or permanent benefits for all NHS employees who lose NHS remuneration because of an injury or disease attributable to their NHS employment. The scheme is also available to general medical and dental practitioners working in the NHS. Under the terms of the scheme, it must be established whether, on the balance of probabilities, the injury or disease was wholly or mainly attributable to the duties of the NHS employment. The Industrial Injuries Disablement Benefit Scheme provides benefits where viral hepatitis (including hepatitis C) has been acquired as a result of an accident arising out of, and in the course of, employment, e.g. a needlestick injury.
27 Ill-health retirement benefits under the NHS Pension Scheme may be payable when health care workers are permanently incapable of performing their duties because of their hepatitis C infection. Information on ill-health retirement is available from Scottish Public Pension Agency, Injury Benefit Section, 7 Tweedside Park, Galashiels TD1 3TE (telephone 01896 893111).
SODH/CMO (98) 12: Guidance for clinical health care workers: protection against infection with blood-borne viruses
NHS MEL (1999) 29: Guidance on the management of AIDS/HIV infected health care workers and patient notification
Ramsay M E. Guidance on the investigation and management of occupational exposure to hepatitis C. Commun Dis Public Health 1999; 2: 258-262. http://www.phls.co.uk/publications/CDPHvol2/no4/guidelines.pdf
The provision of occupational health and safety services for general medical and dental practitioners and their staff. (Department of Health 2001) ( http://www.show.nhs.uk/publicationsindex.htm ).