Occupational Health Guidelines for the Immunisation and

Vaccination of Staff

1. Introduction

 These guidelines should be used in conjunction with all other

relevant Trust policy’s and procedures.

 It must be noted that the immunisation given to protect staff and

patients/clients acts as an adjunct to good infection control
procedures.

 All new employees will be offered an immunisation update, via the

Occupational Health Service (OHS) as dictated by the post, when
taking up employment.

 Only vaccinations relating to job risk will be available.

 Other vaccinations, which may be due, but are not needed for the
job, should be updated via the GP Practice.

 All advice / vaccinations required for (non-work) travel purposes

should be sought via the GP surgery or at an appropriate travel
centre

2. Purpose

 To ensure that all staff identified as being at risk of acquiring an

infection from their work are protected by immunisation and, if
necessary, serologically tested to show adequate protection
 To protect patients against exposure to infection from Health Care
Workers (HCW’s)
 To comply with Department of Health (DOH) and Public Health
Guidance and best practice.
 To allow for the efficient running of services without disruption.

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3. Background Information – Risk Management

 Health and Safety At Work

The employer has a responsibility under the Health and Safety at Work
etc Act 1974 and the Control of Substances Hazardous to Health
Regulations 2002 to ensure as far as reasonably practical to protect
employees and contractors from work activity which could adversely
affect their health.

 New Employee Health Assessment

All new employees should undergo a health assessment which should

include a review of immunisation needs.

 Provision of Occupational Health Immunisations

Employers need to be able to demonstrate that an effective

immunisation programme is in place. This will be provided by the OHS.

4. DUTIES AND RESPONSIBILITIES

4.1 Trust:

The Trust recognises its responsibility to ensure the protection of staff

and patients and will ensure that adequate resources are available via
the OHS for the delivery of an agreed immunisation and vaccination
programme.

4.2 Managers:

 Managers will conduct risk assessments to determine what infectious

agents staff are potentially exposed to, and keep relevant records.

 Managers will ensure that the risk identification section on pre-

placement health questionnaires provided to prospective employees is
completed, identifying any specific risks to the post.

 Managers will encourage staff to comply with recommended

immunisation and vaccination programmes.

 Managers will ensure staff are allowed reasonable time to attend the
OHS for vaccination.

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  In exceptional circumstances satisfactory immunity may not be
achievable. This may require redeployment or job restriction as advised
with joint discussion with OHS and Infection Control.

4.3 Employees:

 Employees must co-operate with their manager so far as is necessary

to ensure that all safety measures are in place to protect themselves
and others in the work place.

 Employees must use all the equipment and procedures in place as

necessary for protection.

 Employees should attend the OHS prior to employment and at regular

intervals as recalled by the OHS to undertake programmes of
immunisation or screening relevant to their occupation.

 All HCW’s are under an ethical and legal duty to protect the health and
safety of their patients. Any HCW’s suffering from an infection MUST
NOT rely on their own assessment of the risk they pose to patients.

 Under the Health and Safety at work etc Act 1974, HCW’s have a legal
duty to take reasonable care for the health and safety of themselves
and others, such as colleagues and patients and co-operate with their
employer in health and safety matters.

 Employees must, in line with their professional code of conduct, inform

the OHS in confidence if they have been in contact with any infectious
disease that may pose a risk to patients

 Seek advice from Occupational Health if you become unusually

vulnerable to infection or are immunocompromised e.g. by steroids,
chemotherapy / radiotherapy or human immune deficiency (HIV) etc. It
may be unsafe for you to have live vaccines, work in certain areas or
perform some surgical procedures.

4.4 Occupational Health Service

 The OHS will ensure that the immunisation status of all employees will
be assessed at pre-placement stage and updated as required by
national and local guidance.

 The OHS will ensure all employees at risk of infectious diseases will be
offered vaccination against this disease where a vaccine is available.

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  The OHS will advise employees what vaccines are indicated for their
post, the reasons why vaccination is advisable and explain the
implications in addition to the associated risks of refusing vaccinations.

 The OHS will ensure an effective recall of staff for appropriate

immunisations or screening in line with the agreed Trust immunisation
and vaccination programme.

 The OHS will inform staff of any results of immunity assessments and
provide advice of future actions if indicated.

 The OHS will advise managers where any restrictions to practice are
required due to immunity or vaccination reasons.

 The OHS will advise regarding staff that are unable to comply with or
refuse to comply with standard immunisation programmes and provide
any appropriate recommendations to managers to assist in the
management of infection(s).

 The OHS will provide initial and ongoing advice & support for staff
regarding infectious diseases. Where appropriate, make links with
infection control specialists and make onward referral to appropriate
agencies for treatment when indicated.

 The OHS will preserve the confidentiality of employees by keeping

records and the results of testing secure. Copies of immunisation
records will only be released upon the receipt of a written, signed
request from the employee indicating their name, date of birth and
address to which the information is to be forwarded, or on receipt of a
request from another Occupational Health Department or interested
party which bears the signed consent of the individual concerned.

5. Definitions

 Health Care Worker – Persons, including students and trainees,

locums and agency staff and independent contractors, whose activities
involve direct clinical contact with patients or with blood or other body
fluids in a health care setting.

 Non-clinical staff employed in health care settings – Staff who have

social contact with patients only, and are not involved in direct patient
care. This group includes receptionists, ward clerks, porters and
cleaners.

 Exposure Prone Procedures – (EPP’s)

Exposure Prone Procedures are defined as “Procedures where there is
a risk that the injury to the worker may result in the open tissue of the
patient being exposed to the blood of the worker. These procedures
include those where the worker’s gloved hands may be in contact with
sharp instruments, needle tips and sharp tissues (spicules of bone or

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 teeth) inside a patients open body cavity, wound or confined
anatomical space, where the hands or finger tips may not be
completely visible at all times. (British Medical Association 1995 and
UKAP)

6. VACCINE REFUSAL

 In the event of a member of staff refusing either immunisation or

immunity assessment when advised by Occupational Health Service,
they may be excluded from employment within an area or modifications
recommended to their practice.

 Refusal to be immunised should be documented within the OH notes

along with the reasons why and any action taken.

7. IMMUNISATION SCHEDULE FOR OCCUPATIONAL HEALTH

SERVICE

All staff should be offered vaccination in line with Table 1.

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 TABLE 1
Staff Group
Category 1.
1 A) Clinical and other
staff, including those in
primary care, who have
regular clinical contact
with patients.
1 B All clinical staff
performing Exposure
Prone Procedures
(EPP)
Category 2
(Laboratory and other
staff (including
mortuary staff) who
have direct contact with
potentially infectious
clinical specimens and
may be additionally
exposed to pathogens
in the laboratory
(May vary according to lab activity)
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Consider Routine
 Diphtheria/Tetanus/Polio (for those  Hepatitis B
identified through risk assessment)  MMR (or documentary evidence)
 BCG (or documentary evidence)
 Hepatitis A ((For staff working with  Varicella (In the absence of proof of immunity through disease history or
persons with learning difficulties identified serological blood test)
at risk assessment).  Influenza (Seasonal)
 As above  Hepatitis B (EPP workers must also demonstrate an absence of acute or
chronic Hepatitis B infection through relevant tests before being permitted to
undertake such duties )
 MMR
 BCG
 Varicella (In the absence of proof of immunity through disease history or
serological blood test)
 Influenza (Seasonal)
 Hepatitis A (Where handling faeces)  Diphtheria/Tetanus/Polio
 Other vaccines where handling relevant  MMR (or documentary evidence)
organism e.g.  Hepatitis B (Subject to risk assessment where direct exposure to blood, blood
Typhoid stained fluids and tissues.)
Cholera  BCG
Meningitis C  Influenza (Seasonal)
Anthrax
Yellow Fever
Japanese encephalitis
Tick-borne encephalitis
Varicella
Rabies
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Category 3
Non-clinical staff who
may have social
contact with patients in
clinical settings
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 For staff working in certain non-clinical  Diphtheria/Tetanus/Polio
settings e.g. prisons, care homes, (For gardening staff and maintenance
homeless and refugee facilities. Varicella staff subject to risk assessment in relation to tetanus)
(if having regular patient contact and in  MMR (or documentary evidence)
the absence of proof of immunity through  Influenza
disease history or serological blood test)
 Hepatitis B (For staff working with
persons with severe learning difficulties
and staff who work with
prisoners, the homeless or
refugees)
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 Additional Information

i. Hepatitis B vaccination

A standard immunisation course will be one dose of vaccine at 0, 1 & 6

months with antibodies checked 1- 4 months after completion of course.
Satisfactory immunity will be confirmed by antibody levels of 100miu/ml, or
antibody levels of >10miu/ml and an immediate booster dose of vaccine. A
further single dose of vaccine after 5 years should be given, and booster
doses offered following high risk injuries.

An accelerated immunisation course will be one dose of vaccine at 0, 1 & 2

months with a reinforcing dose at 12 months, with antibodies checked 1-4
months after completion of course. Immunity will be assessed as for the
standard immunisation course. This regime should be used for post exposure
prophylaxis and can be considered for unimmunised occupational groups at
high risk.

Post Vaccination testing

Antibody titres should be checked one to four months after the completion of a
primary course of vaccine.

 Antibody levels greater than or equal to 100mIU/ml do not require any

further primary doses.
A booster dose should be given after 5 years.
Further assessment of antibody levels is not required

 Antibody levels of 10 to 100mIU/ml should receive one additional dose

of vaccine
Further assessment of antibody levels is not required
A booster dose should be given after 5 years

 Antibody levels below 10mIU/ml are classified as a non-response to

vaccine
Testing for markers of hepatitis B infection should be carried out.
If no evidence of infection a repeat course of vaccine should be
administered followed by retesting after one to four months.

 Non-responders to two courses of vaccine will be advised they are not

immune to hepatitis B and that they should report any exposures to
blood or body fluid immediately so that Hepatitis B immunoglobulin
may be given.

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 Relying on an anti-HBs response to vaccine to indicate non-infectivity may not
be secure, since some infectious carriers of the virus could be missed.
Therefore, it is now recommended that healthcare workers who will perform
EPPs should:
 be tested for hepatitis B surface antigen (HBsAg), which indicates
current hepatitis B infection;
 if negative for HBsAg, be immunised (unless they have already
received a course of vaccine) and have their response checked (anti-
HBs).

Where there is evidence that a healthcare worker, who is known to have

had previous hepatitis B infection which has cleared, now has natural
immunity, immunisation is not necessary, but the advice of a local
virologist or clinical microbiologist should be sought.

ii. MMR vaccination

 If there is no evidence of previous vaccination, rubella and measles

serology should be undertaken. If negative, and there are no
contraindications, vaccination should be offered in line with the local
protocol (2 doses of MMR vaccine, 4 weeks apart)

 If there is evidence of previous vaccination in the form of two

documented doses of MMR vaccine or laboratory evidence of immunity
to measles and rubella, this should be documented in the notes and no
further action taken

 If there is evidence of only one MMR vaccine having been administered

previously, offer a further vaccine dose (without serology) in line with
the local protocol.

 Post vaccination serology is not required.

Note:
Protection of healthcare workers, particularly those in contact with
immunosupressed patients, is an essential part of infection control in
hospital and other healthcare settings. Under the Health Act 2006, specific
duties are required of NHS bodies in England to control respiratory viruses
including an alert system for suspect cases, isolation criteria and infection
control measures, and Occupational Health Services should include
relevant immunisations.

It is strongly recommend that all staff in contact with immunosupressed

patients or paediatric patients are given MMR vaccine. If a staff member is
unable to have the vaccine for any reason, employers will need to consider
the potential risk to patients.

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iii. BCG vaccination

Employees new to the NHS should be offered BCG vaccination, following

a risk assessment for HIV infection, whatever their age, if they will have
contact with patients and/or clinical specimens, are Mantoux tuberculin
skin test (or interferon gamma test) negative and have not been previously
vaccinated.

iv. Varicella vaccination

In December 2003, following advice from the Joint Committee on

Vaccination and Immunisation (JCVI), the Chief Medical Officer (4th
December 2003, PL/CMO/2003/8) recommended vaccination with
Varicella vaccine of all non-immune health care workers who have direct
patient contact in primary care and in hospitals (NHS and private). This
has been recommended for two reasons:

 To protect susceptible healthcare workers

 To protect vulnerable patients from acquiring chickenpox from an

infected member of staff

A policy of selective vaccination is recommended – healthcare workers

with no previous history of chickenpox or shingles should be screened for
varicella antibodies and only those who are seronegative should be offered
vaccination. It is recommended that:

 All staff in primary care and hospitals should have any past history of
chickenpox or shingles ascertained

 Staff who are unsure if they have had chickenpox or shingles or who
have never had chickenpox or shingles should be offered varicella
serology

 Staff who are negative for varicella antibodies should be offered two
doses of Varicella vaccine six to eight weeks apart, providing there are
no contraindications; routine post-vaccination serological testing is not
advised

 The priority groups of staff are:

o those working with immunocompromised patients (e.g.
oncology, haematology and transplant patients);
o those working in neonatal, maternity and paediatric patients;
o those working in infectious disease units.
o New entrants to the health service
o All other relevant staff

 Ascertainment of a past history of chickenpox or shingles should

become part of the routine pre-employment screening of staff by
occupational health services, and acted on as required

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EXPOSURE PRONE PROCEDURES GUIDANCE:

EPPs do NOT include:

 Taking Blood
 Setting up and maintaining I.V.Infusions
 Minor surface suturing
 Incisions of abscesses or uncomplicated endoscopies
 Normal delivery of neonates e.g. by a midwife (UK Health Department)

Within the NHS setting the following categories of health care workers
are considered to perform EPPs:

 Surgeons, some anaesthetists and some cardiologists

 Midwives performing repairs following episiotomies and perineal tears
 Some operating Theatre Nurses
 Dentists
 Dental Surgery Assistants, Hygienists and therapist (as determined by
risk assessment)
 Podiatrists (as determined by risk assessment)
 Accident and Emergency staff (as determined by risk assessment)

Non EPP Workers include:

 Nurses
 Health Visitors
 Health Care Assistants
 Laboratory Workers
 Mortuary Workers
 Radiographers
 Phlebotomists
 Physiotherapist
 Occupational Therapists

Karen Brayley
Head of Health Work and Well Being
December 2011
Review date 2014

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References:

Department of Health (DH) - Immunisation against Infectious Disease

(2006). The Green Book. An electronic version of the 2006 edition of the
Green Book can be accessed on the following DH website and revised
chapters are added as when available.
(http://www.dh.gov.uk/en/Publichealth/Healthprotection/Immunisation/Greenbook/
DH_4097254).

Department of Health (DH) - Health clearance for tuberculosis,

hepatitis B, hepatitis C and HIV: New healthcare workers (Published
16th March 2007).
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy
AndGuidance/DH_073132

The Health Act 2006 - Code of Practice for the Prevention and Control
of Healthcare Associated Infections (Revised January 2008).
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/docu
ments/digitalasset/dh081928.pdf

Department of Health (DH) - Dear Colleague Letter (Measles): Letter to

medical directors, recommending that, unless the relevant staff can
provide written evidenceof having received two doses of MMR or
laboratory evidence of immunity to measles, all staff in contact with
immunosupressed patients or paediatric patients are given MMR vaccine
(Issued 19th May 2008).
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Dearcolleaguel
etters/DH_085628

NICE (2006) Clinical diagnosis and management of tuberculosis, and

measures for its prevention and control.
www.nice.org.uk/page.aspx?o=CG033&c=infections

PL CMO (2003)8: Chickenpox (Varicella) Immunisation for health care

workers (Issued 4th December 2003).
http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Professiona
lletters/Chiefmedicalofficerletters/DH_4065215

Control of Substances Hazardous to Health. Health and Safety

Executive, 2002 HMSO London.

The Health and Safety at Work etc.Act 1974. Health and Safety
Executive 1974. HMSO London

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