66. All healthcare workers from outside the UK who are applying for employment or a training place in the NHS (including those applying under international recruitment arrangements) will need to have standard clearance for serious communicable diseases (ie in relation to TB and hepatitis B). Where their employment involves, or may involve, the performance of EPPs, they will require additional health clearance for serious communicable diseases (ie in relation to hepatitis B, hepatitis C and HIV). It is recommended that both standard and additional health checks for serious communicable diseases be carried out in their own country before they apply for employment or training in the NHS. They should include the results of these health checks in their health declaration. This should assist in making them aware of the professional responsibilities in relation to serious communicable diseases in this country, and should avoid them making wasted applications. The prospective NHS employer or training institution should arrange for the necessary tests in this country to confirm the results of the tests already carried out before the post or training place is taken up. It should be made clear to applicants that all offers of employment or admission to training institutions will be conditional upon satisfactory health clearance.
Guidance on international recruitment of healthcare workers is available on the DH website at:
One-off Testing for Hepatitis C and HIV
67. The logic of one-off testing of new healthcare workers for Hepatitis C and HIV may be questioned, given that healthcare workers will be at ongoing risk of occupational (and potentially non-occupational) exposure. Professional codes of practice from regulatory bodies require healthcare workers who may have been exposed to risk of infection with a serious communicable disease, in whatever circumstances, to promptly seek and follow confidential professional advice about whether to undergo testing. Failure to do so may breach the duty of care to patients. Registrants of the General Medical Council ( GMC), the General Dental Council ( GDC), Nursing Midwifery Council ( NMC) and the Health Professions Council ( HPC) have a professional duty to protect the health and safety of their patients.
68. This means healthcare workers are under an ongoing obligation to seek professional advice about the need to be tested if they have been exposed to a serious communicable disease, obviating the need for repeat testing. This obligation applies equally to healthcare workers already in post.
Standard and Additional Health Clearance for all new healthcare workers
69. The vast majority of nursing and medical duties do not pose a risk of infection to patients, provided that normal infection-control precautions are observed. For this reason Additional Health Clearance is not recommended for all new healthcare workers. However, because there is a low risk of BBV transmission during EPPs, healthcare workers who are infected with BBVs must not be allowed to carry out EPPs, as injury to the worker could result in their blood contaminating their patient's open tissues. This means they must be non-infectious for HIV (antibody negative), hepatitis B (surface antigen negative or if positive, e-antigen negative with a viral load of 10 3 genome equivalents or less and hepatitis C (antibody negative or if positive, negative for hepatitis C RNA) (see paragraphs 56-65).
Identification and validation of samples submitted for testing
70. It is important that those commissioning laboratory tests for HIV, hepatitis B and hepatitis C ensure that samples tested are from the healthcare worker in question. Healthcare workers must not provide their own specimens.
71. The following standards of good practice for occupational health data recording have been agreed by the Association of NHS Occupational Physicians ( ANHOPS) and the Association of Senior Occupational Health Nurse Managers NHS Scotland Group as the two relevant professional bodies:
- Laboratory test results required for clearance for performing EPPs must be derived from an identified, validated sample ( IVS). Results should not be recorded in occupational health records if not derived from an IVS;
- An IVS is defined according to the following criteria:
- the healthcare worker should show a proof of identity with a photograph - NHS Board identity badge, new driver's licence, some credit cards, national identity card or passport - when the sample is taken.
- The sample of blood should be taken in the occupational health department.
- Samples should be delivered to the laboratory in the usual manner, not transported by the healthcare worker.
- When results are received from the laboratory, the occupational health record should be checked for a record that the sample was sent by the occupational health department at the relevant time.
72. Laboratory tests should be carried out in accredited laboratories within the UK, which are experienced in performing the necessary tests, and which participate in appropriate external quality assurance schemes. Two laboratories are currently designated in the UK for HBVDNA testing (see HDL (2000) 03).
Health clearance certificates
73. Following testing, health clearance certificates should be provided by occupational health to management to indicate if an individual is fit for employment, (and, if asked, whether or not the employee is cleared for exposure-prone procedures), and the time-scale for any further testing required (e.g. annual HBVDNA level for e-antigen negative healthcare workers - see paragraph 58). The certificate, which will not include clinical information, should be sent to appropriate managers or, in the case of students, to the Head of Course in accordance with local arrangements.
74. NHS Scotland is currently considering whether to introduce an electronic smart card and is gathering information to show whether it can be put forward as a spend to save project. In the interim NHS Boards should ensure that the existing OH records of healthcare workers who transfer are made available to the new employer.
Healthcare workers who are applying for posts or training involving EPPs and who decline to be tested
75. Healthcare workers who apply for a post or training which may involve EPPs and who decline to be tested for HIV, hepatitis B and hepatitis C must not be cleared to perform EPPs.
Occupational health advice
76. Arrangements should be made to provide healthcare workers who are new to the NHS with access to specialist occupational health advice during the pre-appointment health checks so that the processes can be explained and any questions about the health checks answered. Further, the occupational health department must be able to inform new healthcare workers of the results of their tests, including the implications for their own health and the need for referral for specialist assessment.
77. Occupational health departments and infection control teams will wish to take the opportunity to emphasise the importance of routine infection control procedures, including the importance of hand hygiene, appropriate use of protective clothing and compliance with local policies in the hospital or unit in which they will eventually work. Documentation detailing local infection control policies should be provided or sign-posted along with the contract of employment.
78. It would be appropriate to remind healthcare workers of the importance of avoiding needlestick injuries and other accidental exposures to blood and bloodstained body fluids. The local arrangements for reporting such accidents should be explained as should the range of interventions to protect healthcare workers (e.g. post-exposure prophylaxis after accidental exposure to HIV).
79. The importance of reporting symptoms suggestive of serious communicable disease such as TB or BBV infection to the occupational health department should be stressed. This is particularly important after the healthcare worker has been exposed to the risk of such infection, regardless of the route of exposure (occupational or not). If the new healthcare worker has not been provided with a copy of the written guidance on serious communicable diseases produced by the appropriate professional regulatory body, it should be provided during the pre-appointment health checks. The advice from each relevant regulatory body is reproduced in Annex C.
80. It is extremely important that healthcare workers receive the same right of confidentiality as any patient seeking or receiving medical care. Occupational health staff work within strict guidelines on confidentiality. They have a key role in revising local procedures for testing healthcare workers who are new to the NHS for serious communicable diseases. Occupational health notes are separate from other hospital notes. Occupational health staff are obliged, ethically and professionally, not to release information without the informed consent of the individual. There are occasions when an employer may need to be advised that a change of duties should take place, but infectious disease status itself will not normally be disclosed without the healthcare 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.
Publicising the new arrangements to prospective employees and students
81. It is recommended that employers publicise the new health clearance requirements in job advertisements, descriptions and application packs. Training institutions such as medical and dental schools and schools and colleges of nursing and midwifery should include such information in their prospectuses and application packs. Publicity material should make it clear that health clearance will be required in accordance with this guidance.
Audit and surveillance
82. Local clinical audit of the arrangements for health clearance of new NHS healthcare workers should take place.