St Vincent’s Hospital, Lismore
Screening and Vaccination (Occupational) Against
Infectious Diseases - Staff & Volunteers
CODE : 01 - 196
Author:
Infection Control
Coordinator
Purpose:
Authority:
Safe Practice &
Environment
Policy:
Applicable to:
Hospital Wide
All staff and volunteers shall be provided with adequate information,
education and, where appropriate, pre and post test counselling to make
informed decisions about screening and vaccination against infectious
diseases.
To prevent the spread of vaccine preventable diseases in the workplace,
whilst maintaining the staff members’ and volunteers’ rights and
responsibilities.
St Vincent’s Hospital management and staff have a duty of care to take all
reasonable steps to safeguard patients, staff members, other people and
visitors in the hospital from infectious diseases.
St Vincent’s Hospital shall comply with the Department of Health Circular
2003/91 Occupational Screening And Vaccination Against Infectious
Diseases.
Date Introduced:
12.2004
Procedure:
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Last Review Date:
00.00
Next Review Date:
12.2007
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Strict adherence to Standard and Transmission Based Precautions
remains the first line of protection for employees and patients against
exposure to infectious diseases.
All staff and volunteers shall complete the ‘Health Care Worker
Infectious Diseases Screening & Vaccination Assessment record
and attend immunity screening by the Infection Control Coordinator.
Valid consent shall be obtained from each staff member and
volunteer prior to screening and subsequent vaccination if required.
Evidence of immune status shall be obtained. This shall include
examination of documented evidence of vaccination obtained from
childhood vaccination records, adult vaccination record cards and
letter from General Practitioner confirming immune status, and/or
serological evidence of immunity.
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Medical Officers, registered nurses under medical direction, or registered nurses who are
authorised to immunise under the NSW Poisons & Therapeutic Goods Act 1966 Authorisation
to Supply Restricted Substances shall administer vaccines.
All vaccinations shall be administered in accordance with the recommendations of the current
NH&MRC Australian Immunisation Handbook.
Staff and volunteers who have patient contact (Risk Category A and B, refer Appendix A) shall
have an up-to-date record of immunity against hepatitis B, diphtheria, tetanus, measles,
mumps, rubella, chickenpox and tuberculosis. The staff member shall be responsible for
maintaining his/her own vaccination status.
The Infection Control Coordinator shall retain a secure and confidential record of each staff
members’ and volunteers’ pre-vaccination screening details, including date and results of all
serology, date, batch number, type/brand and results of all vaccines administered.
Written documentation of staff refusal to participate in screening and/or vaccination shall be
retained in each staff member’s personal screening record.
Each staff member shall be issued with a personal record card detailing results of all serology
and vaccinations administered.
Other personnel, including students, Visiting Medical Officers and contractors, must provide a
documented screening and vaccination history, which must be made available to the employer
prior to the commencement of their employment or clinical placement.
Staff and volunteers with any communicable diseases shall consult a doctor concerning the
required period of exclusion from work and notify the Infection Control Coordinator of same.
Staff who are performing exposure prone procedures (the potential for direct contact between
the skin and a sharp instrument in body cavities) are required to maintain a knowledge of their
HIV, HBV and HCV status annually.
Appendix A contains the NSW Department of Health employee risk categorisation, to guide
screening and specific vaccination requirements.
Related Legislation:
N.S.W. Department of Health Circular 2003/91 Occupational
Screening and Vaccination against Infectious Diseases
NH&MRC Australian Immunisation Handbook, 8th edition
NSW Department of Health Circular 2002/45 Infection Control
Policy
NSW Department of Health Circular 99/16 Patient Information
and Consent to Medical Treatment
References:
NH&MRC Infection Control in the Health Care Setting, 2004
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Appendix A
Risk Categorisation
The following categorization of employees and ‘other personnel’ may be used to guide screening and
vaccination policies. Work activities, rather than job title, should be considered on an individual basis
to ensure an appropriate level of protection is provided to each employee and ‘other personnel’.
Category A – direct patient contact or contact with blood or body substances
All employees and ‘other personnel’ who have physical contact with, or potential exposure, to blood or
body substances.
Category B – indirect patient contact or contact with blood or body substances
All employees and ‘other personnel’ who work in patient areas but who rarely have direct contact with
patients or with blood or body substances. These employees and ‘other personnel’ may be exposed to
infections spread by airborne routes, but are unlikely to be at risk from blood borne diseases.
Examples include catering staff and ward clerks.
Category C – laboratory personnel
Laboratories contain special risk factors because of the equipment used and the possible exposure to
high concentrations of microorganisms generated by culture procedures. The major risk to laboratory
personnel occurs in the handling of blood and blood products.
Category D – minimal patient contact
Clerical staff, gardening personnel and numerous other occupational groups have no greater exposure
to infectious diseases than the general public. These employees and ‘other personnel’ do not need to
be included in vaccination programs or other programs aimed at protecting Category A, B, and C
employees and ‘other personnel’. However, where there is public health benefit in facilitating
population recommendations against vaccine preventable diseases, it is best practice to ensure all staff
are appropriately immunised e.g. ADT and MMR vaccination.
Summary of Screening and Vaccination Policy
(Key: Y = yes, N = no, S = selected employees and ‘other personnel’)
Risk Cateories
Vaccine/screening
A
B
C
Adult Diphtheria and Tetanus
OR
Y
Y
Y
Adult Diphtheria, Tetanus & Pertussis (acellular)
S
S
N
Hepatitis A
S
N
N
D
Y
N
S
Hepatitis B
Y
Y
Y
N
Influenza
Y
Y
Y
N
Measles/Mumps/Rubella
Varicella (chickenpox)
Y
Y
Y
Y
Y
Y
Y
N
Tuberculosis
Y
Y
Y
N
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