Occupational Health Vaccination Policy

Transcription

1 Occupational Health Vaccination Policy Please be advised that the Trust discourages the retention of hard copies of policies and procedures and can only guarantee that the policy on the Trust Intranet is the most up to date version (The most recent version of this template is available electronically on the Trust intranet/frequently Used Forms/Integrated Governance. Please use this template in conjunction with the Trust SOP for Approval of MCHFT Guideline / Policy) Document Type: Policy -Clinical Version: 3 Date of Issue: February 2016 Review Date: February 2019 Lead Director: Post Responsible for Update: Approving Committee: Approved by them in the minutes of: Distribution to: Director of Nursing & Quality & Director of Infection Prevention & Control Lead Nurse Occupational Health Executive Infection Prevention & Control Group 10 th February 2016 All Trust staff via the Trust Intranet Occupational Vaccination Policy, Version 3, February 2016 Page 1 of 29

2 Contents: Heading Page Vaccination Policy Number Number Contents / Risk rating 2 1 Introduction / Purpose 3 2 General Document - Process 3 3 Definitions 15 4 Associated Documents 16 5 Duties 16 6 Consultation and Communication with 17 Stakeholders 7 Implementation 18 8 Education and training 19 9 Monitoring and review References / Bibliography Appendices 21 Risk Rating Who will be affected Trust Employees Patients Contractors by this procedure? Is there an existing no risk assessment related to this procedure? If is one required? Yes./ Yes Date completed If Yes does it require updating? Yes / Yes Date completed Raw Risk Rating (no control measures in place) Final Risk Rating (control measures in place) A Consequence (1-5) B Likelihood of Occurrence (1-5) C Risk rating (A x B = C) Name: Keith Williamson Date: January 2016 Occupational Vaccination Policy, Version 3, February 2016 Page 2 of 29

3 1 Introduction / Purpose It is the policy of Cheshire Occupational Health Service as agents of Mid Cheshire Hospitals NHS Foundation Trust and East Cheshire NHS Trust, to ascertain the immunity status of all employees at pre-employment and to offer a comprehensive immunisation programme according to type of employment. Immunisation recommended for employment is free of charge to all Trust employees and volunteers. Adherence to this policy by employer and employees both permanent and temporary is governed by The Health and Safety at Work etc. Act 1974 and the Control of Substances Hazardous to Health 2002 (COSHH) It is the policy of the Trust that employees will not be discriminated against on grounds of age, disability, gender, gender re-assignment, marital status, race (including colour, nationality and ethnic or national origins), religion or belief or sexual orientation. The Trust will provide interpretation services or documentation in other mediums as requested and necessary to ensure natural justice and equality of access. Purpose The purpose of the Occupational Vaccination Policy is to protect employees and patients from illness associated with communicable disease. To prevent employee absence associated with vaccine preventable disease. 2 Process Who is recommended for Immunisation? Any employee (including contractors and locums) of the previously mentioned Trusts who has patient contact or contact with clinical waste or blood and body fluids is eligible for immunisation. The association of Occupational Health Physicians define employee groups requiring vaccination as: Clinically based (doctors, dentists, nurses, paramedics, professions allied to medicine and students of these professions) Laboratory based employees n-clinical/ ancillary (i.e. secretarial, catering) Estates and ancillary staff exposed to patients or body fluids. (porters, domestics, plumbers) Clinically based administration staff. (Ward Clerks) All employees regardless of occupation should be offered immunisation if routine vaccination courses are incomplete or employee is not immune as a measure to reduce occupational sickness. All employees will be offered immunisation appropriate to their occupation/employment and exposure risk, providing they have no demonstrated Occupational Vaccination Policy, Version 3, February 2016 Page 3 of 29

4 immunity. For some employment certain vaccinations are mandatory to protect patients, in accordance with Nursing and Midwifery Council guidelines and the General Medical Council Doctors Handbook. Recommended Occupational Vaccinations are: Hepatitis B Hepatitis A Hepatitis A & B combined vaccine Varicella (Chicken pox) Tuberculosis/ BCG vaccination Rubella and measles (MMR) Poliomyelitis, Diphtheria, and Tetanus Meningococcal C Meningitis ACW135&Y Typhoid If any immunisation programme is interrupted, it should be resumed and completed as soon as possible; there is no reason to restart any immunisation course from the beginning (Ref: Department of Health Immunisation Against Infectious Disease 2006 the Green Book (update: September 2014) available online at: programme is interrupted, it should be resumed and completed 2.1. Informed Consent.partment of Health Green Book 2006) Adults and those over 18 years of age must consent to their own treatment. Those capable of giving consent may give so by written, verbal or co-operation. It is recognised that the mere signing of a consent form does not necessarily deem consent unless the individual has been offered both written and verbal Information pertaining to the proposed treatment and have consented with full knowledge of the procedure, schedule, contra-indications and side effects. Written consent is not a legal requirement but evidences good practice and documents that consent was informed and therefore valid. Full information sheets are available to patients prior to immunisation and the opportunity will be available for the patient to ask questions. It is the practitioner s responsibility to ensure that all consent is informed. It is good practice to ensure that the individual consents to each vaccine in a vaccination programme. Verbal plus co-operative consent are satisfactory in this circumstance Administration & Storage. All nurses administering vaccines within the Occupational Health Department are professionally accountable for their own actions and will adhere to the Nursing and Midwifery Council guidelines on accountability and administration of medicines. All nurses will receive specific training regarding vaccine administration and be trained and competent in anaphylaxis management. Anaphylaxis boxes containing adrenaline must be available and no vaccine can be administered if the nurse is alone in the building. Individual prescription is not necessary for each vaccination but the nurse must be signed off as competent on the departmental group directive stored in pharmacy. (Exception being Tuberculin for Mantoux testing which requires a patient specific Occupational Vaccination Policy, Version 3, February 2016 Page 4 of 29

5 directive) Nurses administering medication under patient group directive should re-read the directive frequently to contemporise their knowledge and understanding. Prior to administration informed consent will be sought and lack of contra-indications to vaccine administration confirmed, the pregnancy status of pre-menopausal women will be established and the recipient must be made aware of any adverse reactions. The preferred mode of administration is by intra-muscular injection unless contraindicated and the deltoid region of the upper arm is the preferred site. Alternatively the anterolateral aspect of the thigh can be used. Different vaccines must never be mixed in one syringe; any 2 vaccines administered on the same visit should ideally be given in each arm or at least 2.5 cm apart. Correct vaccine, dose, expiry date and compatibility must be checked prior to all administrations. Whilst injecting observation should be maintained to ensure no adverse reactions are evident. All vaccines must be stored in the original packaging in the designated drug fridge at between 2C and 8C. A daily record of fridge temperature (including maximum and minimum temperatures) will be maintained for audit purposes. All vaccines must be stored protected from light. Adverse changes of temperature and UV light can affect the efficiency of the vaccine and potency cannot be guaranteed. Vaccines must never be frozen Pre-employment Health Assessment. All healthcare workers and clinically based administration staff and existing employees of these groups changing jobs will undergo a pre-employment health assessment by qualified nurses. Questionnaires are either solely paper screening or may require attendance at the OH department. Vaccination status is an integral part of the assessment in accordance with the immunisations required for proposed employment. All clinical employees transferring within the Trust will be required to complete a health declaration. OH will review vaccination histories in every case and will schedule appointment with all employees with an unfinished course, or no serological evidence of immunity status as appropriate. Confirmation of routine immunisations will be established for all employees and consensually administered if outstanding; specific immunisations will be offered to healthcare employees who will be exposed to specific pathogens as a pre-exposure prophylaxis measure. (As per risk assessment) Health care professionals have a duty of care (as stipulated by the various professional governing bodies), towards patients in their care, which includes taking every reasonable precaution to protect them from communicable diseases. Additionally they must follow stipulations within local and national guidelines/policies and ensure their immunisations regimes are completed and that they are aware of their immunity status Immunisation of Laboratory and Healthcare Staff. The Green Book recommends vaccination of all healthcare and, laboratory employees that during execution of their work may have contact with vaccine preventable diseases. Staff involved in direct patient care: Occupational Vaccination Policy, Version 3, February 2016 Page 5 of 29

6 All staff should be up to date with their routine immunisations e.g. tetanus, diphtheria, polio and MMR (measles mumps and rubella). MMR is particularly important in the context of healthcare workers being able to pass the disease on to vulnerable persons (children, maternity, and oncology). Also some healthcare workers may need MMR for their own protection against the diseases of rubella and measles, non-immunised workers could act as carriers for these diseases if they became infected. Vaccination, previous infection (documented) or serological evidence is required for this group of workers. This group also need evidence of BCG vaccination presentation of scar / documented evidence, or immunity to tuberculosis if neither of these is evident then BCG vaccination will be offered. Hepatitis B inoculation is recommended for all healthcare workers who come into contact with blood and body fluids during the execution of their duties. Varicella vaccination is recommended for all healthcare workers who have direct patient contact. (Especially children s and maternity) Any HCW who has no previous history of Varicella Zoster or shingles infection should be serologically tested, and if non-immune offered 2 Varicella vaccinations. Influenza: This group should be directly targeted during influenza campaigns to prevent infection to themselves, their relatives and their patients. n-healthcare staff in clinical settings: Should be treated as above but it is not the department of health s current guideline to target these staff during influenza campaigns although it is local policy to promote vaccination to these staff as part of the co-ordinated influenza vaccination campaign. Laboratory and Pathology staff: Routine vaccination as stipulated above plus Hepatitis B vaccination and specific vaccinations according to the COSHH risk assessment for potential pathogens that maybe present in any samples routinely dealt with. For example: laboratory staff likely to be handling faecal matter on a regular basis may be exposed to poliovirus, therefore should be offered polio vaccination with booster vaccination every 10 years. For recommended vaccinations of all workers see Table in Section 5.7 of this document Contraindications to Vaccination. Almost all individuals can be safely vaccinated with all vaccines. All vaccinations are contraindicated in all individuals who have a confirmed anaphylaxis reaction to previous vaccination containing the same antigen, or a confirmed anaphylaxis to any component of the vaccine i.e. neomycin, streptomycin or Polymyxin B which may be present in small traces in vaccines. Live vaccines may be temporarily contra-indicated in individuals who are pregnant or immunosuppressed. Occupational Vaccination Policy, Version 3, February 2016 Page 6 of 29

7 The Occupational Health Nurse will establish that there are no contraindications to vaccination prior to administration of vaccine; including specific contraindications for each vaccine group Specific Contraindications to Live-Vaccines: Pregnancy. Live vaccines should be delayed until after delivery. Immunosuppression. Staff currently being treated for malignant disease with immunosuppressive chemo/radiotherapy or terminated treatment within 6- months. HIV infection. Patients who have received an organ transplant. On immunosuppressive drugs. Patients who have received a bone marrow transplant within 12-months. Patients on high dose steroids. Until at least 3 months after completion of the course, adults on 40mg Prednisolone per day for more than one week should be considered immunosuppressed Refer to latest Green Book Chapter 6: Contraindications and Special Consideration and OH consultant regarding administration of vaccines in these circumstances Management of Outbreaks Involving Healthcare Workers (Pandemic Response) During infectious outbreaks of vaccine preventable/ notifiable disease within the healthcare setting the Occupational Health Department will be responsible for the coordination of the vaccination programme of all affected staff members and/or the administration of prescribed prophylactic treatments to those identified by Infection Prevention and Control Services via contact tracing. The Occupational Health Nurses will liaise closely with colleagues in Infection Prevention and Control and the Consultant Microbiologist and additionally follow guidance recommended by experts from the Health Protection England (HPE). The Clinical lead Nurse for Occupational Health will attend any outbreak meetings and report back to the OH team on agreed strategies. It is the responsibility of the Occupational Health Nurses to ensure that all necessary history and stipulated laboratory investigations are completed for identified contacts as required. The Occupational Health Department will be responsible for liaising with General Practitioners and ensuring that staff is aware of specific signs and symptoms of infection and the appropriate action. They will maintain scrupulous record keeping and ensure reporting of cases of notifiable diseases to the HPE The Clinical Lead Nurse for Occupational Health will take responsibility for liaising with the Pharmacy Department to ensure that sufficient supply of medications is maintained. If large-scale vaccination is necessary then the Clinical Lead Nurse for Occupational Health will be responsible for the logistical organisation with the involvement of other disciplines as appropriate. Occupational Vaccination Policy, Version 3, February 2016 Page 7 of 29

8 BCG. Hepatitis B & C. Hepatitis A 2.7 Recommended Vaccination According to Employee Groups Healthcare Workers. Vaccination or Scar/ documented evidence. Estates & Facilities. Vaccination or Scar/ documented evidence. Laboratory. Food Handlers. HCW that perform Exposure Prone Procedures Vaccination or Scar/ documented evidence. Vaccination or Scar/ documented evidence. Vaccination or scar/ documented evidence. Volunteers/ Work experience Vaccination or scar/ documented evidence. Vaccination, Evidence of Hep B antibody response >100units/ml. Vaccination for staff that have contact with patient/body fluids. Evidence of antibody response. Vaccination, evidence of Hep B antibody response >100 units/ml. t recommended For occupational Purposes. Vaccination & evidence of antibody response>100 units/ml Hep B surface antigen Negative Hepatitis C antibody negative. t a requirement for placement t a requirement for employment Recommended for estate workers who have repeated exposure to raw sewage Recommended for individuals who may be exposed to Hepatitis A in their work t a requirement for employment t a requirement for employment t a requirement for placement Occupational Vaccination Policy, Version 3, February 2016 Page 8 of 29

9 Varicella. Polio. Healthcare Workers. Estates & Facilities. Laboratory. Food Handlers. HCW that perform Exposure Prone Procedures Volunteers/ Work experience History of Varicella Zoster or Shingles infection. High risk areas i.e. Children s, maternity, oncology: serological evidence of varicella zoster IgG or documented evidence of varicella vaccination X2. If no evidence then serological testing and vaccination as appropriate History of vaccination required, booster dose not necessary. Primary course offered to any not immunised. History of Varicella Zoster or Shingles infection, or documentary evidence of immunity/ Vaccination for clinical based with staff/contact with body fluids. History of vaccination required, booster dosing not necessary. Primary course offer to anyone not immunised. History of Varicella Zoster or Shingles infection, or documentary evidence of immunity Serological evidence of immunity/ Vaccination. 2 doses History of vaccination required. 10-year boosters offered to anyone handling faecal samples. t a usual requirement for employmentdependent on individual risk assessment Recommended if not already immunised. History of Varicella Zoster or Shingles infection. High risk areas i.e. Children s, maternity, oncology: serological evidence of varicella zoster IgG or documented evidence of varicella vaccination X2. If no evidence then serological testing and vaccination as appropriate History of vaccination, booster dosing not necessary. Primary course offered to anyone not immunised. Recommended for those in high risk clinical areas (Maternity, Children s and ITU) with incomplete courses/ n-immune providing direct care. Recommended for those in clinical areas with no evidence of vaccination. Occupational Vaccination Policy, Version 3, February 2016 Page 9 of 29

10 Rubella. Healthcare Workers. Estates/ Facilities/ Ancillary. Laboratory. Food Handlers. Healthcare workers who perform EPP s Volunteers/ Work Experience Previous serological evidence of immunity or documented evidence of vaccination with 2 doses MMR. If NO Vaccinate 2 doses MMR Completion of all incomplete courses Previous serological evidence of immunity or documented evidence of vaccination with 2 doses MMR. If NO Vaccinate 2 doses MMR Completion of all incomplete courses. Patient and body fluid contact only Previous serological evidence of immunity or documented evidence of vaccination with 2 doses MMR. If NO Vaccinate 2 doses MMR Completion of all incomplete courses t a usual requirement for employmentdependent on individual risk assessment Previous serological evidence of immunity or documented evidence of vaccination with 2 doses MMR. If NO Vaccinate 2 doses MMR Completion of all incomplete courses Recommended for those in high risk clinical areas (Maternity, Children s and ITU) with incomplete courses/ n-immune providing direct care. Occupational Vaccination Policy, Version 3, February 2016 Page 10 of 29

11 Measles. Meningococcal C Healthcare Workers. Estates/ Facilities/ Ancillary. Laboratory. Food Handlers. Healthcare workers who perform exposure prone procedures Volunteers/ Work Experience Previous serological evidence of immunity or documented evidence of vaccination with 2 doses MMR. If NO Vaccinate 2 doses MMR Completion of all incomplete courses HCW with no history of vaccination and who are under 25 years of age. HCW s who work with children Previous serological evidence of immunity or documented evidence of vaccination with 2 doses MMR. If NO Vaccinate 2 doses MMR Completion of all incomplete courses. t a usual requirement for employmentdependent on individual risk assessment Previous serological evidence of immunity or documented evidence of vaccination with 2 doses MMR. If NO Vaccinate 2 doses MMR Completion of all incomplete courses Laboratory staff who may be exposed to Meningococcal C in the course of their work t a usual requirement for employmentdependent on individual risk assessment. t a usual requirement for employmentdependent on individual risk assessment Previous serological evidence of immunity or documented evidence of vaccination with 2 doses MMR. If NO Vaccinate 2 doses MMR Completion of all incomplete courses HCW with no history of vaccination and who are under 25 years of age. HCW s who work with children Recommended for those in high risk clinical areas (Maternity, Children s and ITU) with incomplete courses/ n-immune providing direct care. Recommended for individuals under 25 years of age in high risk clinical areas (Maternity, Children s and ITU) with incomplete courses/ n-immune providing direct care. Occupational Vaccination Policy, Version 3, February 2016 Page 11 of 29

12 Meningitis ACW135&Y Typhoid Healthcare Workers. Estates/ Facilities/ Ancillary. Laboratory. Food Handlers. Healthcare workers who perform exposure prone procedures Volunteers/ Work Experience All individuals over 16 years of age who have no history of ACWY vaccination who may come/may have come into contact with meningococcal A, W or Y strains during the course of their employment Healthcare workers where employment requires them to travel overseas to Typhoid high incidence areas. t a usual requirement for employmentdependent on individual risk assessment t a requirement for employment All individuals over 16 years of age who have no history of ACWY vaccination who may come into contact with meningococcal A, W or Y strains All individuals who may be exposed to typhoid during the course of their employmentaccording to risk assessment t a usual requirement dependent on individual risk assessment t a requirement for employment All individuals over 16 years of age who have no history of ACWY vaccination who may come/may have come into contact with meningococcal A, W or Y strains during the course of their employment Healthcare workers where employment requires them to travel overseas to Typhoid high incidence areas. t a usual requirement dependent on individual risk assessment t a requirement Occupational Vaccination Policy, Version 3, February 2016 Page 12 of 29

13 Mumps. Diphtheria Tetanus. Healthcare Workers. Evidence of immunity 2 MMR. If non-immune then Vaccination 2 doses MMR or complete course. t a requirement for employment. Estates/ Facilities/ Ancillary. Evidence of immunity/ Vaccination 2 dose MMR for those with clinical contact. Completion of incomplete all courses, t a requirement for employment. Laboratory. Food Handlers. Healthcare workers who perform exposure prone procedures Serological evidence of immunity/ Complete vaccination 2 doses MMR, t a requirement for employment. t a usual requirement dependent on individual risk assessment Serological evidence of immunity/ complete vaccination 2 dose MMR. t a requirement for employment. Volunteers/ Work Experience t a usual requirement dependent on individual risk assessment. t a usual requirement dependent on individual risk assessment. t a requirement for employment All individuals who may be exposed to diphtheria during the course of their employmentaccording to risk assessment t a requirement for employment t a requirement for employment t a usual requirement dependent on individual risk assessment. History of vaccination required, vaccinate anyone not immune. Booster not required for adults who have received 5 / more vaccines. History of vaccination required, adults who have received 5 or more vaccines do not need booster. History of vaccination required, vaccinate those not immune. Booster not required for adults who have received 5 / more vaccines. Recommended if not already immunised. Up to 5 vaccines in a lifetime. History of vaccination required, vaccinate those not immune, Booster not required for adults who have received 5 /more vaccines. Recommended if not already immunised and working in clinical areas. Occupational Vaccination Policy, Version 3, February 2016 Page 13 of 29

14 2.8. Employees that refuse vaccination/ fail to seroconvert following vaccination. In the first instance information will be given to vaccine refusers regarding the importance of vaccination for healthcare employees. The wider public health issues will be stressed i.e. ensuring the protection of the employee themselves but also the patients, colleagues and the wider health economy. Under COSHH 2002 regulations staff that refuse recommended vaccination/ fail to seroconvert following vaccination will require OH to discuss with line managers the consequences regarding employment. Continued offer of employment will be based on acceptable risk following assessment. Under specific circumstances it maybe necessary to either temporarily or permanently redeploy employees without immunity to certain disease; this would be following comprehensive risk assessment and discussion with the employee, line manager and Human Resources. 2.9 Administration of Vaccine All vaccinations must be administered in accordance with MCHFT Medicines Management Procedures and Cheshire Occupational Health Service Human Medicines Exemptions Monographs. Occupational Health Nurse must adherence to best practice as stipulated in the Green Book, NICE guidelines and Department of Health national guidelines and policies. Practice must be modified according to relevant Health Service Circular recommendations when issued. All nurses that administer vaccination in the Occupational Health Department must have attended certified vaccination training. They are required to attend annual update regarding vaccination. Nurse must attend biennial basic life support training including anaphylaxis management Adverse Events Following Immunisation (AEFI). Vaccines induce protection by eliciting active immune response to specific antigens. There are predictable adverse reactions (side-effects) however most are mild and resolve quickly. The process of vaccine safety monitoring and reporting of suspected vaccineinduced adverse reactions will be reported the Medicines and Healthcare Products Regulatory Agency (MHRA) via the Yellow Card scheme. The World Health Organisation (WHO) classifies adverse events following immunisation according to four main categories: Programme-related: Wrong vaccine, wrong dose, wrong diluents, out-of-date drugs, wrong time interval, incorrect storage (not an exhaustive list) in these circumstances it is inappropriate to report to MHRA. Reporting via local incident reporting is sufficient. Vaccine-induced: Localised pain, swelling at injection site. These occur commonly after immunisation and should be anticipated. This does not contraindicate further doses of immunisation with the same vaccine or vaccines containing the same antigens. Systemic adverse reactions including fever, malaise, myalgia, irritability, headache and loss of appetite. Systemic reaction may start within a few hours or be up to seven to ten days after certain vaccine. (e.g. measles) This does not contraindicate further doses of immunisation with the same vaccine or vaccines containing the same antigens. Page 14 of 29

15 Idiosyncratic responses include idiopathic thrombocytopenic purpura (ITP) and anaphylaxis immediately after vaccination. When there has been a confirmed anaphylactic reaction to a dose of vaccine this contraindicates further vaccination with the same vaccine or a component of that vaccine. Coincidental: These are not true adverse reactions to immunisation or vaccines but are only linked because of the timing of their occurrence. This does not contraindicate further doses of immunisation with the same vaccine or vaccines containing the same antigens. Unknown: insufficient evidence to classify as one of the above. Managing Vaccine-Induced Adverse Effects Following Immunisation Employees should be given advice about AEFI that they can expect and how to manage events. Leaflets available from the Department of Health will be available from the Occupational Health Department. Fevers over 37 o C are not uncommon and are usually mild. Employees will be advised regarding appropriate Paracetamol or ibuprofen administration. Local reaction at the immunisation site are usually self-limiting and do not require treatment. Anaphylaxis All Occupational Health clinical staff that administers vaccines will be trained in anaphylaxis diagnosis and management. All occupational medical and nursing staff involved in immunisation should be able to distinguish an anaphylactic reaction from fainting and panic attack. All Occupational Health clinical staff responsible for immunisation must be familiar with, (having received recent training or update within 2-years) in adult resuscitation. A protocol for anaphylaxis management and an anaphylaxis pack must always be available whenever vaccines are delivered. 3 Definitions Healthcare workers are o Doctors o Nurses o Healthcare Assistants o Physiotherapists o Occupational Therapists o Phlebotomists who have contact with patients or body fluids. Healthcare workers who perform exposure prone procedures are Surgeons, Midwives, Theatre Scrub Staff, Dentists and Dental Assistants, General Practitioners, A&E doctors and nurses regularly involved in trauma cases, and renal dialysis staff. Estates/Facilities/Ancillary who requires higher protection includes porters, clinically based administration staff, domestics, sewage workers, and any other staff group who has patient contact and/or contact with body fluids. Exposure Prone Procedures: (EPP) is one in which the worker's gloved hand may be in contact with sharp instruments inside a patient's open body cavity, wound, or confined anatomical space, where the fingertips may not be visible at all times. The possibility of performing such procedures must be explicit in the job descriptions of relevant posts (surgeons, emergency department medical staff, critical care anaesthetists, certain nursing staff (scrub nurses), midwives, Page 15 of 29

16 dentists, dental nurses, and certain General Practitioners) and clearly indicated on the pre-employment job risk assessment. Vaccine: a suspension of attenuated or killed microorganisms (viruses, bacteria, or rickettsiae), or of antigenic proteins derived from them, administered for prevention, amelioration, or treatment of infectious diseases. 3.1 Policy A policy is a statement of Trust intent for a given issue and gives a clear position statement for the Trust s customers and employees on its values and beliefs (Parsley & Corrigan 1999). A policy is a must do ; there should be no deviation from the actions as defined in the policy. Any deviation must be discussed and approved by the Strategic Integrated Governance Committee. 3.2 Guideline A guideline is an overview of processes either clinical or non-clinical, to be undertaken in certain conditions. A guideline gives practical guidance as to how to deliver best practice but allows for professional initiative and informed decision making. Any deviation from a Trust guidance document, along with the reasons why, must be documented in the Health Records. 3.3 Clinical Pathway / Standard Operating Procedure (SOP) A Clinical Pathway / SOP is a working document detailing the current agreed working practice that takes account of all the areas that are applicable to the management of a process in an individual setting 4 Associated Documents Policies: Hepatitis B and C Occupational Health Employment Procedure AIDS and HIV Clinical Employment Procedure Measles, Mumps, Rubella and Varicella Zoster Policy Occupational Health Operational Policy Occupational Health Pandemic Plan Redeployment of Staff Procedure Sharps, Needlestick Injury and Body Fluid Exposure Management Policy Occupational Health Consent Procedure Occupational Health Control of Measles, Mumps, Rubella and Varicella Procedure Occupational Health Vaccination Medicines Ordering, Storage and Cold Chain Procedure Documents: Health and Safety at Work etc. Act 1974 Control of Substance Hazardous to Health 2002 Reporting of Incidents and Dangerous Occurrences 2013 Department of Health, Immunisation Against Infectious Disease 2006 (Green Book) updated: September 2014 The Human Medicines Regulations Duties The Trust and its employees have a statutory obligation under the Health and Safety at Work etc. Act l974 to be mindful of the safety of others. All policies and procedures are laid down to protect employees and patients must be adhered to at all times. Page 16 of 29

17 As required by the COSHH Regulations 2002, the Trust will review every procedure carried out by health care workers that involves contact with a substance hazardous to health, including pathogenic micro-organisms. Patient safety is dependent on the voluntary self-declaration of the health care worker. Consequently the Trust, through its policies and procedures, will promote a climate to encourage disclosure. A deliberate breach of confidentiality, in whatever context could result in disciplinary action being taken. 5.1 Duties within the Organisation Chief Executive: Is ultimately responsible for Health and Safety and should ensure that this policy is robustly implemented. Line Managers: Will ensure that employees, for whom they have managerial responsibility, adhere to this policy. Will cooperate with the Occupational Health Service by enabling employees to attend for occupational vaccination. Will undertake individual risk assessment should an employee be identified as having low or no immunity following vaccination to ensure that both the employee and patient s health are not potentially compromised. Will understand their responsibilities under the Health and Safety at Work Act 1974 and the relevance and importance of this policy under the terms of the Act. Occupational Health: Will provide a comprehensive occupational vaccination programme with recall appropriate to risk. Will be responsible for the implementation, audit and update of this policy. Will provide assurance to the respective Trust Boards that the health and safety of all employees is maintained with regard to protection from vaccine preventable disease. Human Resources: Will identify redeployment opportunities for individuals in high-risk roles with no immune response whose health or the health of patients could be compromised. Will investigate any wilful breaches of this policy. Infection Prevention and Control Service: Will inform Occupational Health of any potential exposure incidents regarding Trust employees or volunteers. Strategic Infection Prevention and Control Committee has responsibility for approval of this document and is involved in providing expect input in to its development. Employees: It is the responsibility all employees to be aware of this policy and their duties under it. It is the employee s responsibility to ensure their immune status is contemporary Page 17 of 29

18 and to retain documented evidence of such. Professional employees are also reminded of their obligations as stipulated by the various governing bodies i.e. Nursing and Midwifery Council (NMC), General Dental Council (GDC) General Medical Council (GMC) 6 Consultation and Communication with Stakeholders The Clinical Lead Nurse for Cheshire Occupational Health Service developed this policy in consultation with the Consultant in Occupational Medicine and the Clinical Director for Cheshire Pathology Service/Consultant Microbiologist. This policy is a development of East Cheshire NHS Trust s 2007 ratified Occupational Vaccination Policy. It was distributed for communication and consultation to the following individuals and committees: Consultant Microbiologist-Mid Cheshire Hospitals Foundation Trust Consultant Microbiologist- East Cheshire NHS Trust Head of Human Resources-MCHFT Deputy Director of HR and Workforce-ECT Deputy Director of HR Strategy-Central and Eastern Cheshire PCT HR Business Partners-Cheshire HR Services HR Managers-MCHFT Service Manager Infection Prevention and Control-ECT Service Manager Infection Prevention and Control-MCHFT Chief Pharmacist-ECT Deputy Director of Governance-ECT Director of Governance-MCHFT Director of Governance-Western Cheshire PCT Deputy Director of Nursing and Quality-ECT Deputy Director of Nursing and Quality-MCHFT Health and Safety Committee-ECT Health and Safety Committee-MCHFT Joint Negotiating and Communication Committee-MCHFT (Informal/Formal) Governance.policies@mcht.nhs.uk must be included in the consultation process for all policies Version 1: Feedback was received and incorporated into the final document presented to JCNC for initial approval March It was discussed and approved at the Joint Negotiating and Communication Committee MCHFT on the 17 th March 2010 and approved without need for further amendment. Version 2: Feedback was received from membership of the Strategic Infection Control Committee MCHFT and incorporated in to this policy. Version 2 of this policy was approved by SICC in February Version 3: The policy was reviewed and distributed for consultation to the membership of the Executive Infection Prevention and Control Group in February 2016 it was reissued with only minor grammatical changes and changes in line with Medicines regulations monographs and updated version of the Department of Health Immunisation against Infectious Disease 2016 (Updated 2014) 7 Implementation Page 18 of 29

19 Implementation of this policy is a mandatory requirement of all Cheshire Occupational Health Service staff. (Clinical and nonclinical as appropriate) Directors, managers and employees of the Trust and partner organisations must cooperate with Cheshire Occupational Health Service in the implementation of this policy, in-order to maintain a safe working environment for employees, patients and visitors by protecting staff and visitor against healthcare associated viruses. Implementation of this policy is required to ensure that the Occupational Health Service and the Trust meet their collective obligations under Health and Safety legislation, COSHH and applicable domestic and European law therefore reducing the chances of tribunal or legal proceedings. Implementation of this policy and associated Occupational Health policies and procedures should ensure essential functions of the Occupational Health Service are achieved. Therefore successfully meeting NHS Employers, NHS Heath at Work, and CQC requirements. This policy will be available on each Trust s intranet and senior staff and managers will be alerted by the Trust s communication processes when new policies are issued or existing polices are update and reissued. Due to the advisory and supportive function of the Cheshire Occupational Health Service the implementation of this policy is an on-going and consistent process. 8 Education and Training All Occupational Health nurses are to adhere to this policy and carry out their responsibilities under it in order to achieve the objectives outlined in section 5 of this document. All OH nursing staff will undertake mandatory and specialised vaccination training for on-going personal development. Training needs will be identified through Knowledge Skills Framework assessment. The Clinical Lead for Cheshire Occupational Health Service will communicate changes in practice to all Occupational Health clinical staff through monthly clinical meetings or more frequently if urgency dictates. Training for Trust staff in the application of this policy will be delivered in the following ways: o o Ad-hoc Clinical Updates: covering strategic and clinical aspects of occupational vaccination, including national initiatives, National Institute for Clinical Excellence standards, Care Quality Commission requirements Health Protection Agency guidance and Department of Health changes to the Green Book. On Request: specific topics can be covered for both specialist and general areas. E.g. vaccination training for influenza campaigns and virus outbreaks. Specific training to assist the Occupational Health staff in the execution of this policy is delivered in the following ways: o o Accredited Courses: All Cheshire Occupational Health Service medical and nursing staff requires current registration with their respective governing bodies (NMC/GMC). The consultant and senior nursing staff also hold additional specialist qualifications in the speciality. Practical Updates: covering the practical application this policy. Including immunisation training/update; resuscitation and anaphylaxis management, Mantoux training and delivery, management of sharps injury etc. Training will be both structured at recognised time intervals and ad-hoc when required. Page 19 of 29

20 o o Yearly Training Needs Analysis: A yearly training plan is completed according to training needs identified via appraisal for the entire OH Service staff. All nursing staff who undertakes vaccination must have attended a certified vaccination course and attend a minimum two-yearly vaccination updates and annual anaphylaxis training. Continuing Professional Development: Occupational Health Nursing staff will keep their training/development up-to-date as appropriate to satisfy the Nursing and Midwifery Council s requirements for revalidation in order to: Support clients and colleagues Enhance care Develop clinical practice Reduce risk Develop personally through education. This document will form part of the Occupational Health local induction pack for new starters. It forms one of the Occupational Health Service s core policies and as such Occupational Health nursing staff will be assessed for understanding and appropriate application during appraisal. Occupational Health Nurse will be permitted to undertake vaccination under Occupational Health Medicines Exceptions Proformas without demonstrable knowledge and understanding of this policy. Reference to the document will form part of the OH section of the Trust s induction and its importance highlighted. It will be available for reference and download via MCHFT and ECT intranet sites. Employees will be informed of changes to this policy via Intranet update. 9 Monitoring and Review Standard/process/issue required to be monitored Staff are immunised appropriate to their employment Process for monitoring e.g. audit audit Monitoring and Audit Responsible individual /group Lead Nurse Occupational Health Frequency of monitoring Ad-hoc following policy breaches Responsible committee Workforce Governance 9.1 Action Plan The MCHFT Trust Gap Analysis/Action Plan must be used to demonstrate effective monitoring of all documents. This can be found on the intranet in frequently used forms. 9.2 Audit Proforma The MCHFT Audit proforma must be used to demonstrate effective monitoring and implementation of planned actions. This can be found on the intranet in frequently used forms. Page 20 of 29

21 The Occupational Health Lead Nurse will be responsible for the audit of this policy. Audit will be undertaken on an ad-hoc following any significant incidents or breach of policy. The quality and audit of the Occupational Health Department Vaccination Policy will be measured against this document. Audit will be a retrospective analysis of a random cross-section of employee OH records from the previous 24-month period to determine compliance with best practice as detailed in this policy document. Audit findings will be reported to each collaborative Trust s, Health and Safety Committee and Infection Prevention and Control Committee. Any necessary amendments to the policy will be made after audit and following consultation with the above committees. The MCHFT Audit proforma must be used to demonstrate effective monitoring and implementation of planned actions. This can be found on the intranet in frequently used forms/clinical audit. 10 References / Bibliography Department of Health, Vaccination Against Infectious Disease, 2006 (Updated September 2014 ) (Green Book) Health and Safety Executive, Control of Substances Hazardous to Health Department of Health, The Health Act 2006 Health Service Circular 2001/023: Good Practice in Consent: Achieving the NHS Plan Commitment to Patient-Centred Consent Practice. World Health Organisation (2006) Temperature Sensitivity of Vaccines. Resuscitation Council UK. Management of Anaphylaxis. 11 Appendices All Appendices must be in numerical order 1, 2, 3 etc and positioned before the mandatory appendices below. A B C Version Control Document Communication / Training plan Equality Impact and Assessment Tool Page 21 of 29

22 APPENIDX A - Control Sheet This must be completed and form part of the document appendices each time the document is updated and approved. VERSION CONTROL SHEET Date dd/mm/yy Version Author Reason for changes 10/08/09 1 Clinical Lead for New Policy OH Lead Nurse for OH 3 year renewal, inclusion of typhoid, diphtheria and Meningitis ACWY. Minor formatting changes. 22/01/ Lead Nurse for OH 3-year review minor grammatical and format changes Changes in training and education in accordance with introduction of nurse revalidation Reference change to September 2014 update Immunisation against infectious disease Reference to OH Medicines Regulations Exemption Monographs Page 22 of 29

23 APPENDIX B - Training needs analysis Communication/Training Plan (for all new / reviewed documents) Goal/purpose of the To ensure awareness and understanding communication/training plan of importance of occupational vaccination Target groups for the COHS vaccinating staff. communication/training plan All employees Target numbers Trust wide Methodology how will the Trust induction presentation. communication or training be carried Intranet out? Communication/training delivery PowerPoint Funding N/A Measurement of success. Learning Staff will comply with occupational outcomes and/or objectives vaccination Review effectiveness learning Numbers of overdue and outstanding outputs vaccination programmes, vaccine update Issue date of Document March 2016 Start and completion date of On-going communication/training plan Support from Learning & N/A Development Services For assistance in completing the Communication / Training Plan please contact the MCHT Learning and Development Services Page 23 of 29

24 APPENDIX C - Form 1 Equality Impact Screening Assessment Please read the Guide to Equality Impact Assessment before completing this form. To be completed and form part of the policy or other document appendices when submitted to governance-policies@mcht.nhs.uk for consideration and approval or to be completed and form part of the appendices for proposals/business cases to amend, introduce or discontinue services. POLICY/DOCUMENT/SERVICE Yes/ Justification and Data Sources A Does the document, proposal or service affect one group less or more favourably than another on the basis of: 1 Race, ethnic origins (including gypsies and travellers) or nationality The policy treats all employees fairly and equitably with regard to race. Employees with laboratory results not from a UK Certified laboratory will be required to undergo fresh serological testing. 2 Sex 3 Transgender 4 Pregnancy or maternity The policy treats all employees fairly and equitably with regard to gender, the policy is applied equally to both The policy treats all employees fairly and equitably with regard to trans Pregnant or breast feeding employees are contraindicated regarding administration of live vaccines. 5 Marriage or civil partnership impact identified 6 Sexual orientation including lesbian, gay and bisexual people 7 Religion or belief 8 Age 9 Disability - learning disabilities, physical disability, sensory impairment and mental health problems 10 Economic/social background B Human Rights are there any issues which may affect human rights 1 Right to Life The policy treats all employees fairly and equitably with regard to sexuality The policy treats all employees fairly and equitably with regard to religion and belief. Some vaccines are grown in egg or animal protein. Around 10 to 15% of adults fail to respond to three doses of Hep B vaccine or respond poorly. Poor responses are mostly associated with age over 40 years The policy treats all employees fairly and equitably with regard to disability, this document and any associated literature is available in other formats The policy treats all employees fairly and equitably with regard to socioeconomic status. Vaccination for occupational purposes is free of charge. impact identified Page 24 of 29

25 2 Freedom from Degrading Treatment 3 Right to Privacy or Family Life 4 Other Human Rights (see guidance note) impact identified impact identified impact identified NOTES If you have identified a potential discriminatory impact of this document, proposal or service, please complete form 2 or 3 as appropriate. Date: Name: Keith Williamson Job Title: Lead Nurse Date: Name: Gail Ford-Rowley Job Title: OH Nurse Page 25 of 29

26 Form 2 Equality Impact Assessment Please read the Guide to Equality Impact Assessment before completing this form. To be completed when potential impact has been identified, but necessary steps to address that impact have been identified, agreed and included in the document or proposal. If you have identified a potential discriminatory impact of the document or proposal for which actions need to be identified or for which actions are complex in nature, please complete form 3 instead. To form part of the policy or other document appendices when submitted to governancepolicies@mcht.nhs.uk for consideration and approval or to form part of the appendices for proposals/business cases to amend, introduce or discontinue services. Any actions listed in this form should be highlighted in red, with timescales for action and lead responsibility noted. POLICY/DOCUMENT/SERVICE Yes/ Justification & data sources. Include nature of impact for which action has been agreed and details of that action. Also record provisions already in place to mitigate impact. A Does the document, proposal or service affect one group less or more favourably than another on the basis of: 1 Race, ethnic origins (including gypsies and travellers) or nationality 2 Sex 3 Transgender 4 Pregnancy or maternity 5 Marriage or civil partnership 6 Sexual orientation including lesbian, gay and bisexual people 7 Religion or belief 8 Age 9 Disability - learning disabilities, physical disability, sensory impairment and mental health problems 10 Economic/social background B Human Rights are there any issues which may affect human rights 1 Right to Life 2 Freedom from Degrading Treatment 3 Right to Privacy or Family Life 4 Other Human Rights (see guidance note) NOTES: Date.. Name.. Signature Date.. Job Title.... Name.. Signature Job Title..... Page 26 of 29