A Clinical Guideline For Use in: By: For: Division responsible for document: Key words: Name and job title of document author: Name and job title of document author s Line Manager: Supported by: Assessed and approved by the: Date of approval: 25/03/2016 Ratified by or reported as approved to (if applicable): To be reviewed before: This document remains current after this date but will be under review To be reviewed by: Workplace Health & Wellbeing Occupational Health Nursing and Medical Staff All Health Care staff, contracted workers, agency workers and students on placement Corporate Tuberculosis (TB), screening staff for TB, occupational health Dr Mark Ferris, Specialty Doctor, Workplace Health & Wellbeing Hilary Winch, Occupational Health Nurse Manager Dr Phillips, Consultant Respiratory Medicine Dr N Elumogo, Consultant Microbiologist Clinical Guidelines Assessment Panel (CGAP) If approved by committee or Governance Lead Chair s Action; tick here Clinical Standards Group and Effectiveness Sub-Board 25/03/2019 Occupational Health Team Reference and / or Trust Docs ID No: CA4010 id 1265 Version No: 4 Description of changes: Compliance links: (is there any NICE related to guidance) If Yes - does the strategy/policy deviate from the recommendations of NICE? If so why? Updated following publication of new NICE guideline January 2016 NICE guidelines [NG33] No This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance should be documented in the patient's case notes. The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document. Review date: 18/11/2018 Available via Trust Docs Page 1 of 12
1. Quick reference guideline/s 1.1 New Starter screening for all Health Care Workers (HCW) who are new to the NHS / transferring to the Norfolk and Norwich University Hospital from another NHS organisation. This screening process will be undertaken by Workplace Health & Wellbeing, (See Quick Reference Guide 1.1) 1.2 Contact trace guidance to follow should a HCW be exposed to a case of pulmonary or laryngeal tuberculosis (TB). This will be initiated and managed by Workplace Health & Wellbeing with the assistance of line managers (See Quick Reference Guide 1.2) Quick Reference Guide 1.1 Review date: 18/11/2018 Available via Trust Docs Page 2 of 12
TB Screening New Starter Review date: 18/11/2018 Available via Trust Docs Page 3 of 12
Quick Reference Guide 1.2 Testing and treating Health Care workers who have had close contact with an individual diagnosed with pulmonary or laryngeal TB Review date: 18/11/2018 Available via Trust Docs Page 4 of 12
2.0 Objective of Guideline 2.1 To prevent and manage the risk of a Health Care Worker (HCW) developing tuberculosis (TB) from patient contact. 2.2 To prevent and manage the exposure of TB in HCWs 2.3 To outline the health surveillance and reporting mechanisms for those staff who are regularly exposed to patients with TB or who work in high risk clinical environments for exposure to TB. 3.0 Rationale 3.1 Around 8000 cases of TB are currently reported each year in the United Kingdom. Most cases occur in major cities, particularly in London (HPA 2014) 3.2 The basis for the prevention and control of tuberculosis amongst health care workers (HCWs) is taken from the NICE (2016) Guidance Tuberculosis, which stresses the importance of new starter screening in HCWs, new entrant screening, administration of Bacillus Calmette-Guerin (BCG) vaccination and infection control measures associated with cases of tuberculosis. 4.0 Broad recommendations 4.1 All staff who have contact with patients or clinical specimens must adhere to the Trust Guidelines on the Prevention and Management of Tuberculosis (TB) in the following circumstances: Prior to commencement of employment with the Trust During employment, with safe working practices. If they have had contact with a patient diagnosed with tuberculosis. 4.2 Locum agencies, training organisations and sub-contractors are responsible for ensuring suitable screening and appropriate immunisation have been carried out and that the staff and students concerned can provide evidence of this. 5.0 Responsibility of the Trust 5.1 To ensure the health & safety of patients is not compromised by their exposure to HCWs who are infected with tuberculosis 5.2 To ensure the health & safety of staff members are not compromised by their exposure to patients who are infected with tuberculosis 6.0 Responsibility of Employee 6.1 To attend Workplace Health & Wellbeing (WHWB) for new starter screening / new entrant screening as requested 6.2 To adopt safe practices for patient care in accordance with the Trust Infection Prevention and Control Policy (C10). Review date: 18/11/2018 Available via Trust Docs Page 5 of 12
6.3 To promptly report any symptoms suspicious of tuberculosis to Workplace Health & Wellbeing 6.4 To complete an annual health surveillance questionnaire identifying any symptoms associated with tuberculosis, if working in areas identified with an increased risk of exposure to tuberculosis (see12.2). This will also include information on reporting any symptoms promptly to Workplace Health & Wellbeing. 6.5 To inform Workplace Health & Wellbeing if contact with known cases of tuberculosis. 6.6 To attend appropriate screening if requested by Workplace Health & Wellbeing in the event of being in contact with a tuberculosis case. 7.0 Responsibility of HIV infected health care workers 7.1 All HCWs who have been diagnosed as being infected with HIV must seek and follow advice from Workplace Health & Wellbeing regarding tuberculosis. HCWs must not rely on their own assessment of the risk they pose to patients or staff. 8.0 Responsibility of Managers 8.1 To ensure all staff within their departments have had the appropriate new starter TB screening undertaken prior to the commencement of work in their area 8.2 To ensure that all staff have attended immunisation updates / blood tests as indicated on the New Starter Fitness certificate provided by Workplace Health & Wellbeing. 8.3 To undertake an individual risk assessment if a member of staff is identified to them by Workplace Health & Wellbeing as not having evidence of immunity from or vaccination for tuberculosis. 8.4 To inform Infection Prevention and Control and Workplace Health & Wellbeing if a member of staff or patient is diagnosed with or exposed to tuberculosis. 8.5 To provide information to Workplace Health & Wellbeing and Infection Prevention and Control when contact tracing programmes are required. 8.6 To ensure that staff have received training and fit testing for personal protective equipment (PPE) that may be required when there is potential contact with patients known to have tuberculosis Review date: 18/11/2018 Available via Trust Docs Page 6 of 12
9.0 Role of Workplace Health & Wellbeing 9.1 New Starter Screening 9.1.1 To undertake the appropriate new starter screening for TB when employees commence employment with the Trust, as per quick reference guide 1.1. 9.1.2 HCWs who are new to the NHS / transferring to the Norfolk and Norwich University Hospital from another NHS organisation who will be working with patients or clinical specimens should not start work in a high risk area (see 12.2) until they have completed a TB health check (or they can provide evidence that the TB health check has been completed in the preceding 12 months). The TB health check is defined as an assessment of personal and family history, symptom questionnaire and either reliable evidence of TB skin testing in the last 5 years (or IGRA) or a BCG scar check by Occupational Health). Staff can start work in other clinical areas if they have completed a symptom check questionnaire and on condition that the TB health check is undertaken after commencement of employment. 9.1.3 Staff who are new to the NHS / transferring from another NHS organisation who will not have patient contact or contact with clinical specimens should not start work if they have signs or symptoms of TB. 9.1.4 HCWs and other NHS employees who have contact with patients or clinical specimens who are previously unvaccinated (that is, without adequate documentation or a BCG scar) and have a Mantoux (tuberculin) test result of less than 5mm or negative interferon-gamma release assay (IGRA), who are not immuno-compromised, should be offered the BCG vaccination irrespective of their age. If the BCG vaccination is contra-indicated or refused, the risks should be explained to the individual and supplemented with written advice, the outcome recorded in their occupational health record and their line manager informed that they are not protected against infection with tuberculosis. The importance of reporting possible symptoms of tuberculosis promptly will be re-emphasised. If the person still declines BCG vaccination, he or she should not work where there is a risk of exposure to TB. The employer will need to consider each case individually, taking account of employment and health and safety obligations. 9.1.5 Routine screening tests for HIV infection before BCG vaccination of HCWs are not appropriate but enquiries should include questions to determine whether the individual is at risk of HIV infection. If they are at significant risk, HIV testing (with counselling) will be offered; this will be undertaken when the tuberculin test / interferon gamma test is undertaken. 9.1.6 A Mantoux test of 5 mm or larger (regardless of BCG history) should prompt an IGRA, as NICE guidance, to confirm latent TB regardless of previous exposure or symptoms. If the IGRA is positive, a chest x-ray will be arranged. The HCW will subsequently be seen by a doctor at Workplace Health and Wellbeing to consider appropriate management. Review date: 18/11/2018 Available via Trust Docs Page 7 of 12
9.1.7 New entrants arriving from a country where the annual incidence of tuberculosis is greater than 40/100,000, or new NHS employees who have had contact with patients in settings where tuberculosis is highly prevalent, should be screened with an IGRA. If the test is positive, then the individual will have a chest x-ray and be seen by an occupational health physician to discuss referral to a TB clinic. If a new employee has lived or worked in a country with a high annual incidence of tuberculosis (or travelled there for a period of 3 months or more within the last 12 months) then they will be considered and treated as a New Entrant. A list of such countries is published by the World Health Organization (WHO). Estimates of tuberculosis incidence by country, 2014 (sorted by country) is found via the following link: http://www.hpa.org.uk/web/hpaweb&hpawebstandard/hpaweb_c/1195733758290 If the IGRA is negative and there is not reliable evidence of previous BCG, then the individual should be offered BCG vaccination, in line with the Green Book, after undertaking a HIV risk assessment. 9.2 HIV infected health care workers 9.2.1 Provide guidance on restrictions for HIV infected HCWs. Guidance from the Expert Advisory Group on AIDS (EAGA) is that HIV infected HCWs who are well on antiretroviral treatment (viral load undetectable and CD4>500 cells/mµ), who have been screened for tuberculosis by occupational health and have taken chemoprophylaxis if indicated, no longer need to be restricted from working with patients who have tuberculosis. Workplace Health & Wellbeing will liaise with their treating consultant to receive regular updates regarding viral load and CD4 count, in order to review the requirement for restrictions. 9.2.2 If an HIV infected HCW does not meet this criteria, then their exposure to patients with tuberculosis may need to be restricted. Workplace Health & Wellbeing will inform their line manager of the requirement for the restriction, but not the reason for it. 9.2.3 To stress to this group of staff the importance of, and the responsibility to, report symptoms which may be suggestive of tuberculosis. 9.2.4 To ensure that HIV infected HCWs do not receive the BCG vaccination. Workplace Health & Wellbeing will undertake an HIV risk assessment and, if appropriate, offer HIV counselling and testing at the time of undertaking a Mantoux test / IGRA. 9.3 HCWs who have contact with Tuberculosis 9.3.1 Contact tracing will be implemented by Workplace Health & Wellbeing if the index (source) case has pulmonary or laryngeal tuberculosis. Workplace Health & Wellbeing will be alerted about the commencement of a HCW contact trace by the following staff: For exposure to inpatients with suspected tuberculosis - the Infection Prevention and Control Team will inform Workplace Health & Wellbeing once confirmed diagnosis. Review date: 18/11/2018 Available via Trust Docs Page 8 of 12
For exposure to outpatients with suspected tuberculosis - the TB Liaison Nurse Specialist will inform Workplace Health & Wellbeing of the confirmed diagnosis. Mortuary staff wear appropriate respiratory protection for known tuberculosis post mortems. If they are exposed to an unexpected tuberculosis case, the Senior Mortuary Technician (in charge) will advise Workplace Health & Wellbeing both at the time of the exposure and when verification of the pathology has been received 9.3.2 The HCW contact will be categorised as either a 'casual contact' or 'close contact'. Casual contact includes staff members attending tuberculosis patients in a routine manner. Close contact is defined as staff who have undertaken any of the following procedures: mouth to mouth resuscitation without appropriate protection, prolonged care of a patient who requires a high level of dependant nursing care, repeated chest physiotherapy, involved in a tuberculosis infected case at post mortem or bronchoalveolar lavage without use of correct protective procedures. Prolonged care will not generally be considered to have occurred until a cumulative total exceeding 8 hours of high dependency nursing has occurred. If the source patient has had two weeks or more of anti-tuberculosis treatment the risk is significantly reduced. 9.3.3 Close contacts of tuberculosis cases will be screened as advised in the NICE (2016) guidance (see Quick reference guide 1.2). Contact tracing should be undertaken for the period that the case had respiratory symptoms, including cough. If this is unknown, contacts should be traced from 3 months preceding the first positive sputum smear. Tracing is extended backwards, a month at a time, if clinical indications in contacts suggest that transmission has occurred. 9.3.4 Possible close contacts will be identified by the ward / department and Workplace Health & Wellbeing will make contact with them to determine whether contact screening is required. 9.3.5 HCWs with HIV who are close contacts require active disease excluded and to then be given treatment for latent TB infection. They will be seen in Workplace Health and Wellbeing to assess whether they have symptoms of tuberculosis, arrange an IGRA and CXR and onward referral to a respiratory physician (in consultation with their treating HIV physician). 9.3.4 HCWs in casual contact with a case of tuberculosis will (unless immunocompromised) only need to be reassured and reminded of the possible symptoms (over the next twelve month period). 9.3.5 Those staff who work in areas of increased risk of tuberculosis (see 12.2) will receive annual health surveillance questionnaires to complete and return to Workplace Health & Wellbeing. Review date: 18/11/2018 Available via Trust Docs Page 9 of 12
9.4 HCWs who have a confirmed diagnosis of Tuberculosis 9.4.1 If a HCW is diagnosed with tuberculosis, whether occupationally acquired or not, liaison will occur between Workplace Health & Wellbeing, the treating Respiratory Physician, the TB Community Nurse and the Infection Prevention and Control Team. Tuberculosis contact tracing procedures will be initiated by the Infection Prevention and Control Team/TB Community Nurse for patient contacts and by Workplace Health & Wellbeing for staff contacts. If identified as a work acquired disease, then a RIDDOR report will be submitted anonymously to the Health & Safety Executive by Workplace Health & Wellbeing. The Consultant in Communicable Disease Control will be informed by the respiratory team and will initiate any wider screening (family members etc.) that may be required. 10.0 Role of Infection Prevention and Control 10.1 To inform Workplace Health & Wellbeing of any suspected or confirmed cases of pulmonary or laryngeal tuberculosis. 10.2 To initiate contact tracing of any patient contacts from an inpatient case. 11.0 Education and training 11.1 Staff education will occur both during the pre-employment screening process and on the Trust Risk Management Induction and Mandatory training sessions. 11.2 Individual training / updates will be given on an opportunistic basis, when undertaking immunisation updates. Staff will be reminded that BCG does not offer complete protection and so the requirement to be aware of and to report relevant symptoms remains after immunisation. 12.0 Clinical Audit Standards derived from guideline (audit will be undertaken as part of Workplace Health & Wellbeing s rolling audit programme) 12.1 Workplace Health & Wellbeing Audit statements: All HCWs working in the higher risk areas for tuberculosis will have had their immunity to tuberculosis assessed prior to commencement of work in the Trust. All HCWs who do not have a BCG scar or reliable history of having had BCG vaccination will have a Mantoux test and a BCG vaccination administered, if nonimmune and not contraindicated. All New Entrants will have an IGRA prior to commencing work within the Trust. An annual surveillance questionnaire will be completed by staff working in higher risk areas. Review date: 18/11/2018 Available via Trust Docs Page 10 of 12
12.2 Staff at higher risk of exposure to tuberculosis are those who have: Regular contact with TB patients or clinical specimens. Worked in a high risk clinical setting for 4 weeks or longer. Higher risk areas for TB are as follows: Mortuary Histopathology Respiratory Medicine Thoracic Surgery GUM Clinic EAU (Medical) Oncology/Haematology Renal Dialysis Unit 13.0 Summary of development and consultation process undertaken before registration and dissemination This guideline has been developed by Workplace Health & Wellbeing in consultation with Respiratory Medicine, Microbiology and the TB Group within the Norfolk and Norwich University Hospital NHS Trust. 14.0 References and related documents: 1. Norfolk & Norwich University Hospital NHS Trust, Trust Guideline for the management of patients with confirmed or suspected tuberculosis C10 Trust Doc ID 627 v3, NNUH Trust Intranet. 2. Norfolk & Norwich University Hospital NHS Trust, Personal Protective Equipment Procedure. Document 040 V1.5, NNUH Trust Intranet. 3. National Institute for Health and Clinical Excellence, Tuberculosis (NG33). January 2016. Available at http://www.nice.org.uk/guidance/ng33 (accessed 16/02/16) 4. Department of Health 2007, Health Clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers. Available at http://webarchive.nationalarchives.gov.uk/20130107105354/http:/www.dh.gov.uk/en/p ublicationsandstatistics/publications/publicationspolicyandguidance/dh_073132 Accessed 26/09/15) 5. Public Health England Tuberculosis: the green book, chapter 32https://www.gov.uk/government/publications/tuberculosis-the-green-book-chapter- 32 6. Joint Tuberculosis Committee of the British Thoracic Society. Control and prevention of tuberculosis in the United Kingdom: Code of Practice, 2000. Thorax 55.11 (2000): 887-901. Review date: 18/11/2018 Available via Trust Docs Page 11 of 12
7. Meredith S, Watson J, Citron K, Cockcroft A, Darbyshire J. Are healthcare workers in England and Wales at increased risk of tuberculosis? BMJ 1996; 313:522-5 8. Public Health England. (2014) Tuberculosis in the UK: 2014 report. Public Health England: London. Available at https://www.gov.uk/government/publications/tuberculosis-tb-in-the-uk (accessed 13/09/15) 9. Public Health England. (2013)Tuberculosis (TB) by country: rates per 100,000 people. Available at https://www.gov.uk/government/publications/tuberculosis-tb-by-countryrates-per-100000-people (accessed 13/09/15) 10. NHS Plus. Policy for Occupational Health Management of Tuberculosis Review date: 18/11/2018 Available via Trust Docs Page 12 of 12