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SCREENING AND IMMUNISATION OF HEALTHCARE AND LABORATORY STAFF POLICY

Version 1

Name of responsible (ratifying) committee Health and Safety Committee

Date ratified 23 March 2018

Document Manager (job title) Consultant Occupational Physician

Date issued 30 April 2018

Review date 22 March 2021

Electronic location Health and Safety Policies

Related Procedural DocumentsHepatitis B Virus (HBV): Protecting employees and patients.Control of TB in NHS employees.

Key Words (to aid with searching)

Work Health Assessment; Blood borne virus; tuberculosis; BCG; hepatitis B; Measles; Mumps; Rubella; Varicella; Vaccination; MMR vaccine; Occupational health and safety. Influenza

Version TrackingVersion Date Ratified Brief Summary of Changes Author

1 28.03.2018 Merger of two related policies:Immunisation of Healthcare and Laboratory Staff

and Measles, Mumps & Rubella (MMR) and Varicella

(chickenpox) Policy: Occupational Health Screening and Vaccination

Dr M Glover

Screening and Immunisation of Healthcare and Laboratory StaffVersion: 1Issue Date: 30 April 2018Review Date: 22 March 2021 (unless requirements change) of 14

CONTENTS

QUICK REFERENCE GUIDE................................................................................................................3

1. INTRODUCTION............................................................................................................................4

2. PURPOSE......................................................................................................................................4

3. SCOPE...........................................................................................................................................4

4. DEFINITIONS.................................................................................................................................5

5. DUTIES AND RESPONSIBILITIES................................................................................................6

6. PROCESS......................................................................................................................................7

7. TRAINING REQUIREMENTS.......................................................................................................11

8. REFERENCES AND ASSOCIATED DOCUMENTATION...........................................................11

9. EQUALITY IMPACT STATEMENT...............................................................................................11

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS.....................................12

EQUALITY IMPACT SCREENING TOOL...........................................................................................13


QUICK REFERENCE GUIDE

For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy.

1. The Health and Safety at Work Act 1974 requires employers and employees to protect, as far as reasonably practicable, those at work and others who may be affected by their work, e.g. patients. The Control of Substances Hazardous to Heath (COSHH) Regulations 2002 require employers to assess the risks from exposure to hazardous substances, including pathogens (called biological agents in COSHH) and to implement measures necessary to protect workers and others from risk as far as reasonably practicable. This includes appropriate immunization.

2. Any vaccine-preventable disease that is transmissible from person to person poses a risk to healthcare workers and their patients. Health Care Workers (HCWs) have a duty of care towards their patients to protect them from communicable diseases which includes taking precautions, such as vaccination.

3. The four main staff groups for vaccination are: ‘staff involved in direct patient care’; ‘non-clinical staff in healthcare settings’; ‘laboratory and pathology staff’ and ‘staff handling specific organisms’. Occupational Health identifies the vaccinations required by different groups of staff and arranges for these to be provided. Line managers are to ensure their staff attend for vaccinations where required and are informed whether their staff attend for vaccination and if workplace restrictions are required.

4. Staff involved in direct patient care should be immunised against tetanus, diphtheria, polio (provided by their general practitioner), hepatitis B, Measles, Mumps and Rubella (MMR), varicella and seasonal influenza. Satisfactory evidence of protection includes documentation of having received 2 doses of MMR or having positive antibody tests for measles and rubella.

5. HCWs susceptible to Varicella (chickenpox) pose a significant risk to immunocompromised and seriously ill patients with whom they have direct contact. They are also at risk of infection from their patients. A definite history of chickenpox or herpes zoster in UK is a reasonable predictor of naturally-acquired immunity, but a survey reported in 2004 shows that a history of chickenpox is a less reliable predictor of immunity in individuals born or raised in tropical climates in whom routine testing should be considered.

6. Occupational Health will assess new employees during the Work Health Assessment process for measles, rubella and varicella immunity by history and / or testing as appropriate. Non-immune staff will be offered vaccination. New staff born after the introduction of MMR vaccine in 1988 who do not have evidence of 2 doses MMR vaccine can proceed to vaccination without serological screening. Written consent will be obtained before vaccination and a post vaccination information sheet will be provided.

7. Influenza immunisation helps prevent influenza in staff and can reduce the transmission of influenza to vulnerable patients. At Portsmouth Hospitals NHS Trust, for future influenza seasons, the quadrivalent seasonal influenza vaccine will be offered on an annual basis to healthcare workers directly involved in patient care, as well as non- clinical staff in healthcare settings, laboratory and pathology staff and staff handling specific organisms

8. Further specific details about other vaccinations can be obtained from the individual Trust policies: ‘Hepatitis B Virus (HBV): Protecting employees and patients’; ‘Control of TB in NHS employees’.


1. INTRODUCTION

The Control of Substances Hazardous to health (COSHH) Regulations 2002 require employers to assess the risks from exposure to hazardous substances, including pathogens (biological agents in COSHH), and to introduce measures necessary to protect workers and others who may be exposed from those risks, as far as is reasonably practicable. Any vaccine preventable disease that is transmissible from person to person is a hazard to both health care professionals and their patients. Health care workers have a duty of care towards their patients to take reasonable precautions, including immunisation, to protect themselves from communicable diseases. Immunisation of healthcare and laboratory workers may therefore be indicated to:

Protect the individual and their family from an occupationally-acquired infection Protect patients and service users, including vulnerable patients who may not respond

well to their own immunisation Protect other healthcare and laboratory staff Allow for the efficient running of services without disruption.

The most effective method for preventing laboratory-acquired infections is the adoption of safe working practices. Immunisation should not be regarded as a substitute for good laboratory practice, although it does provide additional protection. Staff who work mainly with clinical specimens or have patient contact may be exposed to a variety of infections, while staff who mainly work with specific pathogens are only likely to be exposed to those pathogens handled in their laboratory. The health assessment for laboratory staff should take into account the local epidemiology of disease, the nature of material handled, the frequency of contact with infected or potentially infected material, the laboratory facilities and the nature and frequency of any patient contact. Staff considered to be at risk of exposure to pathogens should be offered pre-exposure immunisation as appropriate.

Measles, Mumps and Rubella (MMR) vaccine can be given to individuals of any age and those who have not received MMR should be offered immunisation. Individuals born between 1980 and 1990 may not be protected against mumps but are likely to be vaccinated against measles and rubella, although may have only had one dose of MMR. A second dose should be given in this case. Those born between 1970 and 1979 may have been vaccinated against measles and many will have been exposed to mumps and rubella during childhood. Those born before 1970 are likely to have had all three natural infections and are less likely to be susceptible. Serology should be checked in relevant staff groups and immunisation offered where indicated.

2. PURPOSE

To inform Portsmouth Hospitals NHS Trust employees of the hazards from common vaccine-preventable communicable diseases in the health care setting and the requirements and duties for workplace vaccinations. Staff are divided into four main groups: ‘staff involved in direct patient care’; ‘non-clinical staff in healthcare settings’; laboratory and pathology staff’ and ‘staff handling specific organisms’.

3. SCOPE

The policy applies to all employees of Portsmouth Hospitals NHS Trust, including staff employed on temporary or honorary contracts.

‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances,


staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’

4. DEFINITIONS

Healthcare and Laboratory Staff

Employees who fall into the following four broad groups:

Staff involved in direct patient care Non-clinical staff in healthcare settings Laboratory and pathology staff Staff handling specific organisms

Measles

Measles is a highly infectious acute viral illness transmitted via droplet infection. Complications include otitis media, pneumonia, convulsions and encephalitis. Measles infection in pregnancy can result in miscarriage or premature delivery. Since 1988, exposure to natural measles has declined dramatically so younger members of the UK population who have not been fully vaccinated are likely to remain susceptible into adult life and outbreaks in adults and children still occur, typically in those who have not received a full course of MMR.

Mumps

Mumps is an acute viral illness spread by airborne or droplet transmission. Asymptomatic infection is common in children. Complications include meningitis, encephalitis, pancreatitis and orchitis. Initially high coverage of MMR vaccine resulted in a substantial reduction in mumps transmission in the UK and those most likely to lack immunity are adults born since 1980 who have not been vaccinated.

Rubella

Rubella is a mild infectious disease. Clinical diagnosis is unreliable and so serological evidence is required to prove a history of infection. Maternal rubella infection in the first 8-10 weeks of pregnancy results in fetal damage in up to 90% of infants and multiple defects are common. The risk of damage declines to about 10-20% by 16 weeks and after this stage of pregnancy fetal damage is rare. Rubella is a notifiable disease. All Health Care Workers (HCWs) who have direct patient contact should be screened for rubella antibodies by blood testing. Non-immune HCWs should be immunised with MMR.

Varicella (chickenpox)

Varicella (chickenpox) is an acute, highly infectious disease caused by the Varicella zoster (VZ) virus and transmitted directly by personal contact or droplet spread. Herpes zoster (shingles) is caused by the reactivation of the Varicella virus. Virus from lesions can be transmitted to susceptible individuals to cause chickenpox. Varicella is most common in children less than 10 years age, in whom it usually causes mild infection. The disease can be more serious in adults, particularly in pregnant women and in smokers, as they are at greater risk of fulminating Varicella pneumonia. Pregnant women appear to be at greatest risk late in second or early in the third trimester. For neonates and immunosuppressed individuals the risk of disseminated or haemorrhagic Varicella is greatly increased. Susceptible HCW can pose a significant health risk to high-risk patients. Susceptible HCW are at risk of being infected by their patients. Since chickenpox is so common in childhood, 90% of adults raised in the UK are immune. Since 2003 it has been recommended that non-immune healthcare workers are vaccinated against


Varicella. This gives protection to the HCW from infected patients but also protects non-immune patients.

Immunosuppression

Current treatment with chemotherapy or generalised radiotherapy, or within 6 months of terminating such treatment

Organ transplant recipient and currently on immunosuppressive treatment Bone marrow transplant recipients who are still considered to be immunosuppressed,

including those with graft versus host disease Adults who have received a dose of around 40mg prednisolone per day for more than 1

week in the previous 3 months Patients on lower doses of steroids, given in combination with cytotoxic drugs Some individuals on lower doses of steroids or other immunosuppressant for prolonged

periods, or who because of their underlying disease, may be immunosuppressed and at increased risk of infection.

Patients with evidence of impaired cell mediated immunity e.g. immunodeficiency syndromes

5. DUTIES AND RESPONSIBILITIES

Directors

Employers need to be able to demonstrate that an effective employee immunisation programme is in place.

Occupational Health Department

The Occupational Health and Safety Service is responsible for the management of the immunisation programme and will undertake screening and vaccination of employees as set out in this policy. Occupational Health will inform employees of the risks to their health and others if they refuse, or are a poor or non-responder to an immunisation programme. Occupational Health will inform managers when employees do not attend for appointments, refuse vaccinations or if they are contraindicated.

Managers

Managers must complete Risk Identification Forms for new employees and ensure that these are available to Occupational Health. Managers must ensure that any employees for whom they have line management responsibility have had all relevant workplace vaccinations. All managers responsible for staff in a health care setting should ensure that new and existing staff (including agency and locum staff and visiting HCWs) are aware of the contents of this policy and that they have been cleared as fit for work following Occupational Health assessment.

Employees

Employees must comply with screening and vaccinations as set out in this policy and with other relevant Trust policies such as the Infection Control Policy. Health Care Workers have an additional duty of care towards their patients which includes taking reasonable precautions to protect themselves from communicable diseases, including by appropriate immunisations. Immunisation must not be used as a substitute for good practice in relation to the prevention of infection and general measures to prevent occupational transmission of blood-borne viruses must be followed.


6. PROCESS

Work Health Assessment

All new employees must undergo a Work Health Assessment which will include a review of immunisation needs. The job risk assessment form will indicate which pathogens staff are likely to be exposed to in their workplace. Staff considered to be at risk of exposure to pathogens will be offered routine pre –exposure immunisation as appropriate. Staff not considered to be at risk will not routinely be offered immunisation, although post-exposure prophylaxis may occasionally be indicated.

Staff involved in direct patient care

This includes staff, including those in primary care, who have regular clinical contact with patients and who are directly involved in patient care. This includes doctors, dentists, midwives, nurses, paramedics and ambulance workers, occupational therapists, physiotherapists, radiographers and porters. Students and trainees in these disciplines and volunteers who are working with patients must also be included.

All staff involved in direct patient care must be up to date with their routine immunisations, e.g. tetanus, diphtheria, polio and MMR (Measles, Mumps and Rubella). Any missed immunisations or required updates for tetanus, diphtheria and polio must be obtained from the employee’s General Practitioner.

The MMR vaccine is especially important in the context of the ability of staff to transmit measles or rubella infections to vulnerable groups. While healthcare workers may need MMR vaccination for their own benefit, they should also be immune to measles and rubella in order to protect patients.

BCG vaccine is recommended for healthcare workers who may have close contact with infectious patients. It is particularly important to test and immunize staff working in maternity and paediatric departments, and departments in which the patients are likely to be immunocompromised, e.g. transplant, oncology and HIV units. For more details on BCG vaccine and tuberculosis (TB) screening in employees please refer to the separate Trust policy “Control of tuberculosis (TB) in NHS employees” There is currently a shortage of BCG vaccine and, while this situation continues, it will impact on vaccination activity.

Hepatitis B vaccination is recommended for health care workers who may have direct contact with patients’ blood or blood-stained body fluids. This includes any staff who are at risk of injury from blood-contaminated sharp instruments, sustain a splash of blood stained body fluid to broken skin or mucous membranes or of being deliberately injured or bitten by patients. For more details please refer to separate Trust policy “Hepatitis B Virus (HBV): Protecting Employees and Patients”. There is currently a shortage of Hepatitis B vaccine and, while this situation continues, it will impact on vaccination activity.

Varicella vaccine is recommended for susceptible healthcare workers who have direct patient contact. Those with a definite history of chickenpox or herpes zoster (shingles) can be considered protected. Health care workers with a negative or uncertain history of chickenpox or herpes zoster should be serologically tested and vaccine offered to those without immunity.

Influenza immunisation helps prevent influenza in staff and may also reduce the transmission of influenza to vulnerable patients. Influenza vaccination is therefore recommended for healthcare workers directly involved in patient care, who should be offered influenza immunisation on an annual basis.


Non-clinical staff in healthcare settings

These individuals are not directly involved in patient care but may have social contact with patients which is not usually of a prolonged or close nature. This group includes receptionists, ward clerks, cleaners and other administrative staff working in hospitals and primary care settings and maintenance staff such as engineers and cleaners.

These staff should be up to date with their routine immunisations, e.g. tetanus, diphtheria, polio and MMR (Measles, Mumps and Rubella). With regards to tetanus, diphtheria and polio, any missed immunisations or required updates must be obtained from the employee’s General Practitioner.

The MMR vaccine is especially important in the context of the ability of staff to transmit measles or rubella infections to vulnerable groups.

At Portsmouth Hospitals NHS Trust, BCG vaccine is recommended for non-clinical staff in healthcare settings. For more details on BCG vaccine and tuberculosis (TB) screening in employees please refer to the separate Trust policy “Control of tuberculosis (TB) in NHS employees” There is currently a shortage of BCG vaccine and, while this situation continues, it will impact on vaccination activity.

Hepatitis B vaccination is recommended for workers who are at risk of injury from blood-contaminated sharp instruments, splashes of blood stained body fluid to broken skin or mucous membranes or of being deliberately injured or bitten by patients. For more details please refer to separate Trust policy “Hepatitis B Virus (HBV): Protecting Employees and Patients”.

Varicella vaccine is recommended for susceptible healthcare workers who have regular patient contact but are not necessarily involved in direct patient care. Those with a definite history of chickenpox or herpes zoster can be considered protected. Those with a negative or uncertain history should be serologically tested and vaccine offered to those without antibody. For more details refer to separate trust policy “Measles, Mumps & Rubella (MMR) and varicella (chickenpox): Occupational Health Screening and Management”.

Influenza vaccine is offered to non-clinical staff at Portsmouth Hospitals NHS Trust on an annual basis.

Laboratory and Pathology Staff

This includes laboratory and other staff (including mortuary staff) who regularly handle pathogens or potentially infected specimens. In addition to technical staff, this may include cleaners, porters, secretaries and receptionists in laboratories.

All staff should be up to date with their routine immunisations, e.g. tetanus, diphtheria, polio and MMR (Measles, Mumps and Rubella). The MMR vaccine is especially important for those who have contact with patients.

Staff regularly handling faecal specimens who are likely to be exposed to polio viruses should be offered a booster with a polio-containing vaccine every ten years.

Individuals who may be exposed to diphtheria in microbiology laboratories and clinical infectious disease units should be tested and, if necessary, given a booster dose of a diphtheria-containing vaccine. An antibody test should be performed at least three months after immunisation to confirm protective immunity and the individual should be given a booster dose at ten-year intervals thereafter. The cut-off level is 0.01IU/ml for those in routine diagnostic laboratories. For those handling or regularly exposed to toxigenic strains, a level of 0.1IU/ml should be achieved. Where a history of full diphtheria immunisation is not available, the primary course should be completed and an antibody test should be performed at least three months


later to confirm protective immunity. Boosters should be given five years later and subsequently at ten-yearly intervals.

BCG is recommended for technical staff in microbiology and pathology departments, attendants in autopsy rooms and any others considered being at high risk. For more details on BCG vaccine and tuberculosis (TB) screening in employees please refer to the separate Trust policy “Control of tuberculosis (TB) in NHS employees” There is currently a shortage of BCG vaccine and, while this situation continues, it will impact on vaccination activity.

Hepatitis B vaccination is recommended for laboratory staff who may have direct contact with patients’ blood or blood-stained body fluids or with patients’ tissues. See separate Trust policy “Hepatitis B Virus (HBV): Protecting Employees and Patients”. There is currently a shortage of Hepatitis B vaccine and, while this situation continues, it will impact on vaccination activity.

Staff handling specific organisms

For some infections, the probability that clinical specimens and environmental samples of UK origin contain the implicated organism, and therefore present any risk to staff, is extremely low. For these infections, routine immunisation of laboratory workers is not indicated. Those working in higher risk settings, however, such as reference laboratories or infectious disease hospitals may have a level of exposure sufficient to justify additional vaccinations in addition to those routinely required for all ‘laboratory and pathology staff’. For example, staff who regularly handle specimens and samples infected with Hepatitis A, Japanese encephalitis, meningococcal ACW135Y, typhoid, yellow fever etc. These staff will be identified through risk assessment by their line managers and referred to the Occupational Health Department where the required vaccine will prescribed and administered or the employee will be directed to an appropriate source of immunisation such as a designated Yellow Fever Vaccination Centre.

Measles, Mumps & Rubella

Occupational Health will undertake a Work Health Assessment for all new employees and screen existing staff on an opportunistic basis wherever possible. All HCWS must have acceptable evidence of immunity to measles and rubella. Neither self-reported disease nor a history of vaccination is considered adequate. Written documentation of vaccination with two doses of MMR vaccine or serological evidence of positive antibody tests for measles and rubella are required.

New staff born after the introduction of MMR vaccine in 1988 who do not have evidence of having received 2 doses of MMR vaccine will be offered vaccination without prior serological screening as set out in the Green Book (see references).

Written consent will be obtained before vaccination is given and a post vaccination information sheet provided. MMR vaccine provides protection for around 90% of recipients for measles and mumps and over 95% for rubella. MMR contains live attenuated measles, mumps and rubella viruses. Since the vaccine viruses are not transmitted, there is no risk of infection from those recently vaccinated.

HCWs who have no evidence of immunity and refuse vaccination should be advised on possible work restrictions and their duty of care towards colleagues and patients. It remains the manager’s decision to employ a HCW or not when informed of such a refusal.

Staff case of, or contact with, a case of measles

If a staff member reports contact with a case of measles, or Infection Prevention inform OH about a possible case in a patient, attempts will be made to confirm the diagnosis. If confirmation is not possible, but measles remains the most likely diagnosis, the situation will be managed as if it was measles. Staff members who are of unknown immune status should have


their blood tested for antibodies. Staff members who are antibody negative should be considered for prophylactic immunisation and managed as follows:

From the 7th day to the 18th day after contact with the case, they must take their temperature every morning and not come to work if they are pyrexial (i.e. 37.2ºC or higher), feel unwell, or have any sign of a rash.

Provided they follow the above instructions, staff can continue to work during this period but they must not work with immunocompromised patients or pregnant women.

Temporary redeployment for these staff may need to be considered.

Varicella

The Occupational Health Department screens all new clinical employees during the Work Health Assessment process. Those with a definite history of chickenpox or herpes zoster can be considered protected. A HCW with a negative or uncertain history of chickenpox or herpes zoster should be serologically tested and vaccine offered to those without VZ antibody. A survey reported in 2004 showed that a history of chickenpox is a less reliable predictor of immunity in individuals born or raised in tropical climates (MacMahon et al., 2004) and routine testing should be considered.

Vaccination will be offered to non-immune staff. Varicella vaccine is a live attenuated vaccine. Written consent will be obtained before vaccination and a post vaccination information sheet given to the employee. Pregnancy must be avoided between the doses and for 3 months following the second dose of vaccine. HCWs will be told at the time of vaccination that they may experience a local rash around the site of the injection or a more generalised rash in the month after vaccination. In either case, they should report to the Occupational Health Department for assessment before commencing work. If the rash is generalised and consistent with a vaccine-associated rash (papular or vesicular) the HCW should avoid patient contact until all the lesions have crusted. HCWs with localised vaccine rashes that can be covered with a bandage and/or clothing should be allowed to continue working unless in contact with immunosuppressed or pregnant patients. In the latter situation, an individual risk assessment should be made.

If a HCW is exposed to Varicella or herpes zoster between the 1st and 2nd dose of the vaccine, the second dose should be given immediately (after discussion with a Virology Consultant). Post vaccination serological testing is not routinely recommended but is advisable for HCWs in units dealing with highly vulnerable patients e.g. transplant units.

Management of HCWs exposed to VZ virus infection

Vaccinated HCWs or those with a definite history of chickenpox or zoster should be considered protected and be allowed to continue working. As there is a remote risk that they may develop chickenpox, they should be advised to report to OHD if they feel unwell and develop a rash or fever.

Unvaccinated HCWs without a definite history of chickenpox or shingles and having a significant exposure to VZ virus should be excluded from contact with patients from 8 to 21 days after exposure. There is some evidence that Varicella vaccine administered within 3 days of exposure may be effective at preventing chickenpox (Varivax is licensed for post-exposure prophylaxis). OHD will liaise with Infection Control staff in these circumstances. In any case, vaccine should be offered to reduce the risk of the HCW exposing patients to VZ virus in the future.

HCWs with localised herpes zoster on a part of the body that can be covered with a bandage and/or clothing should be allowed to continue working unless they are in contact with high risk patients, in which case an individual risk assessment should be carried out.


HIV positive individuals

HIV positive individuals with or without symptoms should receive the following as appropriate: live vaccines (measles, mumps, rubella, polio) and inactivated vaccines (pertussis, diphtheria, tetanus, polio, typhoid, Hepatitis B, Hib). HIV positive individuals should NOT receive BCG or yellow fever vaccines.

7. TRAINING REQUIREMENTS

There are no specific training requirements. Staff requiring workplace vaccinations will be identified by Occupational Health as part of the Work Health Assessment process, and will be invited for vaccination. Where employees do not attend for vaccination, line managers will be informed by Occupational Health if workplace restrictions are required for specific employees.

Information contained in this policy will be made available at general staff inductions, Junior Doctor Inductions, sharps training and health promotion activities and educational written material produced within the Trust

8. REFERENCES AND ASSOCIATED DOCUMENTATION

Immunisation against infectious disease. The Green Book. Department of Health. 2006. https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

9. EQUALITY IMPACT STATEMENT

Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.

This policy has been assessed accordingly

Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviours our employees display in the workplace.

Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.

We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:

Respect and dignityQuality of careWorking togetherEfficiency

This policy should be read and implemented with the Trust Values in mind at all times.


https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book

10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS

Minimum requirement to be

monitored

Lead Tool Frequency of Report of Compliance

Reporting arrangements Lead(s) for acting on Recommendations

Audit of Occupational Health screening process- Work Health Assessment of new PHT employees

Consultant occupational physician

audit annual Policy audit report to:

Health and Safety Committee

Consultant occupational physician

This document will be monitored to ensure it is effective and to assure compliance.


EQUALITY IMPACT SCREENING TOOL

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval for service and policy

changes/amendments.

Stage 1 - Screening

Title of Procedural Document: Screening and Immunisation of Healthcare and Laboratory Staff

Date of Assessment 6 March 2018 Responsible Department

Health Safety and Wellbeing

Name of person completing assessment

Mark Glover Job Title Consultant Occupational Physician

Does the policy/function affect one group less or more favourably than another on the basis of :

Yes/No Comments

Age No

Disability No

Gender reassignment No

Pregnancy or Maternity No

Race No

Sex No

Religion and Belief No

Sexual Orientation No

Marriage and Civil Partnership No

If the answer to all of the above questions is NO, the EIA is complete. If YES, a full impact assessment is required: go on to stage 2, page 2

More Information can be found be following the link below

www.legislation.gov.uk/ukpga/2010/15/contents

Stage 2 – Full Impact AssessmentScreening and Immunisation of Healthcare and Laboratory StaffVersion: 1Issue Date: 30 April 2018Review Date: 22 March 2021 (unless requirements change) of 14

http://www.legislation.gov.uk/ukpga/2010/15/contents

What is the impact Level of Impact

Mitigating Actions

(what needs to be done to minimise / remove the impact)

Responsible Officer

Monitoring of Actions

The monitoring of actions to mitigate any impact will be undertaken at the appropriate level

Specialty Procedural Document: Specialty Governance CommitteeClinical Service Centre Procedural Document: Clinical Service Centre Governance CommitteeCorporate Procedural Document: Relevant Corporate Committee

All actions will be further monitored as part of reporting schedule to the Equality and Diversity Committee
