National Guidelines on

Blood-Borne Pathogens

Dr Blánaid Hayes, FRCPI, FFOM,

Occupational Health Department,
Beaumont Hospital,
Dublin.

1
DOHC Guidelines: 2005

 Launched DOHC
website March 29th
2006
 HSE implementation
group (multidisciplinary)
to meet in early May

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Background to DOHC guidelines

 1995: Advisory Group on

Transmission of ID in
Health-care Setting
established to advise
Minister for Health
 1997: first report
published
 Standing Advisory
Committee established
 1999: The Prevention of
Transmission…..
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Key Questions
 Who?  All healthcare workers

 ‘Guideline’, ‘code of
 What? practice’, ‘policy’,
‘recommendations’,
‘protocols’
 When?  Now

 Any organisation in which

 Where? healthcare is practised e.g.
hospital, institution, clinic,
medical or dental practice
 How?..........
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Key Players
 Internal  External
 Individual HCWs  Minister for Health
 Clinical managers  DPH
 Employer / CEO  Local Expert Group
 ICNs / Consultant  Standing Advisory
Microbiology Committee
 OHAs and Specialist  Training Bodies
Physicians  Schools of medicine,
 ID consultant nursing and dentistry
 Risk manager  Specialist faculties
 Laboratory

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Key Solutions
 International guidelines
 Legislation
 Policies
 Standard operating procedures
 Good management
 Individual responsibility
 Up to date training / incorporating new
developments/ immunisation
 Data collection / incident management / surveillance
/audit

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DOHC Guidelines: contents
 Assume detailed knowledge of / familiarity with Standard
Precautions (1996)
 Risk management approach underpins guidelines
 Defines the risk
 Key recommendations
 Implications for employers
 Implications for OHS services
 Implications for employees
 Testing procedures
 Training
 Work restrictions
 Conclusion

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Recommendations: A
Risk Management and Infection Control
 ‘Develop and adopt risk
management and infection
control policies that are
monitored for effectiveness’
 Access for all to specialist
advice in ‘OH, microbiology, ID
and IC
 Education of all potentially at
risk HCWs in application of
SPs, on initial employment and
annually thereafter (by
competent individuals)
 IC education to be incorporated
into training of all medical,
nursing and dental students

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Recommendations: A
Risk Management and Infection Control
 Institutions to appraise new technology and invest in
appropriate / relevant devices
 Apply ‘protocols’ also to potential risk of
transmission between equipment and patients
 STANDARD PRECAUTIONS
 HCW responsibility to keep themselves informed on
developments and risks
 Haemodialysis units
 EPP workers to complete ‘risk assessment’
 Contact and SPs for patients positive for BBV with
uncontrolled bleeding

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Recommendations: B
Prevention of Transmission of Hepatitis B
 All at risk HCWs (and
students) to be immunised
or provide evidence of
immunity (natural or vaccine
induced)
 EPP workers (and those who
may in future perform EPPs)
to be tested for antiHBc and
HBsAg (professional
interpretation)
 No offer of employment
without compliance with
‘appropriate pre-
employment occupational
health assessment
programme’

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Recommendations: B
Prevention of Transmission of Hepatitis B
 Confidential maintenance of immunisation records
 Issue such records to individual HCWs
 EPP workers positive for HBsAg to be tested for HBeAg.
Exclude those positive from EPPs
 HBsAg+ and HBeAg- HCWs to have viral load determined
 Where risk of patient exposure has occurred, institutions
must have look back policy for implementation of look back
exercise if recommended by Local Expert Group. Standing
Advisory Committee to be informed

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Recommendations: C
Prevention of Transmission of HIV and Hepatitis C
 Incremental screening of
HCWs who perform EPPs to
be initiated and evaluated.
 Anti-HCV+ HCWs to have
PCR for HCV RNA. Exclude
those PCR+ from doing EPPs.
(No HIV screening pro tem)
 HCWs to be aware of ethical
obligation to seek diagnostic
testing if exposed to BBV
through work or other risk
behaviours
 Exclude HIV+ HCWs from
EPPs
 Look-back policy: as per HBV

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Recommendations: D
Dialysis and Renal Transplant Settings
 Implementation of SPs
and appropriate
segregation of infected
patients and their
equipment.
 Pre-treatment
screening and
vaccination of dialysis
patients and
surveillance while on
treatment

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 Recommendations: E
Identification of Infected Health-care Workers
 Employers to facilitate voluntary disclosure of
infection status. On commencing employment, all
employees should be made aware of risk factors for
acquiring BBD and of their ethical duty to disclose
such infection .
 Once notified, physician to inform DPH
anonymously who will dictate response depending
on previous or ongoing risk to patients. May require
LEG to be convened. Inform infected HCW and
CEO of any need for work restrictions

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Recommendations: F
Redeployment, retraining and/ or support
 Every effort should be made to retrain or re-deploy infected
HCWs where appropriate
 Training bodies to be aware of challenges and to take these into
account
 Provide appropriate support arrangements for infected
permanent employees unable to work
 Faculties should set up mentoring system to provide support and
information on financial, medical and career consequences of
infection
 Medical, dental and nursing schools should take account of
national guidance in developing policies

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EPP: A procedure where there is a risk that injury to the health-care worker may
result in exposure of the patient’s open tissues to the blood of the worker”

 Include  Don’t include

 “Surgical entry into tissues, cavities  Injections / taking blood/
or organs or repair of major traumatic
injuries, vaginal or Caesarean line set up
deliveries or other obstetric  Minor surface suturing
procedures during which sharp
instruments are used  Incision of abscesses
 The manipulation, cutting or removal  Routine vaginal or rectal
of any oral or perioral tissues
including tooth structure, during examination
which bleeding may occur  Uncomplicated endoscopies
 Where worker’s hands may be in
contact with sharp instruments,
needle tips or sharp tissues (spicules
of bone or teeth) inside patient’s
open body cavity, wound or confined
anatomical space…….

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Implications for Employers:
 Statutory duty to employees under H&S Act
2005: information, training, safe place of
work, safe systems of work, PPE, safer
devices etc.
 Resources for infection control
 ICNs, microbiologists
 Surveillance
 Policies
 Education (SPs, contact precautions where
appropriate)
 Resources for occupational health
 OHAs, specialist physicians
 Prevention, management and follow-up of OBEs
 PEHA assessment / vaccination
 Management of infected HCW
 Statutory duty to notify all cases of viral
hepatitis

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Implications for Employers : 2
 Prepare / update appropriate organisational policies on
prevention of exposure, management of infected HCW and
dealing with look-backs
 Arrange appropriate health assessment at recruitment
 Assess risk of work practices and modify those identified as
hazardous
 Observe specific arrangements for haemodialysis patients
(and staff)
 Educate staff on use of new devices, use of PPE, disposal of
sharps and health-care risk waste
 Promote a safety culture
 Record and audit incidents
 Maintain confidentiality
 Provide appropriate support arrangements for infected
permanent employees unable to work
RISK MANAGEMENT
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Implications for training bodies

 Medical, nursing, midwifery and dental

students must be immunised / and or tested
for evidence of hepatitis B infection
 Training bodies to be aware of
responsibilities in providing support for
infected HCWs / facilitating retraining/
mentoring system etc.

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Implications for OH Services
 At PEHA, do BBV risk assessment on all EPP workers (including
locums, temporary staff or supernumeraries).
 Ensure liaison with recruitment staff to ensure no offer of
employment until candidates comply with PEHA requirements
 Immunise those at risk against hepatitis B
 Test EPP workers for infection (HBV,HCV) in accordance with
accepted procedure
 Test renal unit staff for HBV . Restrict those with viral load >10 4
from ‘undertaking clinical procedures’ in the unit. Annual HBsAg
testing of those non-immune.
 Manage infected HCWs in supportive and professional manner
 Hepatitis B is prescribed disease: occupational injury benefit
available
 Remember statutory obligation to notify

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Implications for Employees
 Be aware of ethical obligations (primum non nocere)
 Be aware of legal responsibilities vis a vis H&S at work :
 Participate in training

 Take SPs at all times and in particular, use sharps safely

(planning, avoidance etc.)
 Report all incidents

 Avoid putting oneself at risk (personally and occupationally)

 Standard Precautions
 Infected HCW who is involved in clinical cases should remain
under medical / OH supervision
 Infected HCWs must abide by any restrictions imposed by LEG

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Testing
 General procedure:
 Ensure sample is verifiable: taken
in OHD, or confirm taken in OHD
elsewhere
 Repeat test if doubt integrity of
result
 HCWs must not provide their own
specimens
 Testing for EPP clearance
 Show proof of identity
 Take sample in OHD
 Transport sample to lab in normal
way and not by HCW
 OHD must confirm, on receipt of
results from lab, that sample was
taken in OHD
 OH professional should take
reasonable steps to ensure HCW is
not taking antivirals
 Approved laboratory is VRL Belfield
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 Specifics:
 HBV viral load on 3 sequential
samples using same testing kit
over 6 week period
 Annual testing for those with
viral load <104 (where eAg neg)
 Consider more frequent testing
where viral load >5,000
copies/ml or significant
increase in load.
 Hepatitis C antibody and if positive
do PCR.
 Test annually for PCR in those
who are antiHCV+
 Epidemiology if infectivity is
uncertain and decisions on
restrictions should be made on
case by case basis, particularly
for those on anti-virals (P 25)
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Training Programme Content:
(to be provided upon initial employment and at appropriate intervals thereafter)

 Epidemiology and mode of

transmission
 Use and location of PPE
 Understand SPs
 Be aware of role of OH
 Be aware of procedure for
blood exposures (1st aid and
PEP)
 Have access to relevant
policies to protect HCWs and
patients from BBVs
 Have access to policies for
infected HCWs
 Training should be interactive
 Training records must be
maintained (date, content,
names)

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 •WORK RESTRICTIONS

•All EPP workers to be screened for

markers of HBV. If +, need viral load
testing and exclude those with DNA >104
copies per ml 2005

•All EPP workers to be screened for HCV

(incremental i.e. starting with trainees)

•No routine testing for HIV but those who

believe they may have risk factors must be
tested. No HIV+ HCW should do EPPs

•All renal unit staff to be tested for HB

markers and restricted from clinical
procedures if DNA > 104

•Annual testing of renal unit workers who

are non-immune for HBsAg

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Conclusion
 Old guidelines have been enhanced but basics are
unchanged (infection control, risk management etc.)
 Additions summarised:
 Renal unit guidance
 Hepatitis C screening / work restrictions
 New threshold for HB screening
 Greater detail on testing procedures
 Sample OH form for EPPs (Appendix)
 Algorithm for managing infected HCWs (P 52)
 Retraining, redeployment and / or support: apply to those
who acquire infection in Irish public health sector
 Reference to risks from contaminated equipment

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