Infection Control Procedures
Approving authority
University Council
Approval date
4 June 2012 (2/2012 meeting)
Advisor
For advice on this policy, contact your Group Health & Safety Staff
Next scheduled review
2014
Document URL
http://policies.griffith.edu.au/pdf/Infection Control Procedures.pdf
TRIM document
2012/0007782
Description
These procedures describe the University's obligations and commitment, and
the obligations of staff and students, to managing the risk of contracting or
spreading an infectious disease.
Related documents
Health and Safety Policy
Student Misconduct Policy
Code of Conduct
First Aid Guidelines
Reporting & Recording Procedures for Incidents, Injuries, Dangerous Incidents, Hazards and Near Misses
Inability to Complete Required Components of Professional Qualification Policy
Workplace Harassment, Bullying and Discrimination Policy
Resolution of Complaints of Workplace Harassment, Bullying and Discrimination Procedures
Individual Grievance Resolution Procedure
Student Review and Appeals Policy
Student Review and Appeals Procedures
Exposure Prone Procedure Declaration Form
Non-Responder to Hepatitis B Vaccination – Acknowledgement Form
External Documents
Work Health and Safety Act 2011
Work Health and Safety Regulation 2011
Public Health Act (Qld) 2005
Health Regulation 1996 (Queensland)
Privacy Act 1998 (Commonwealth)
National Health and Medical Research Council Australian Guidelines for the Prevention and Control of
Infection in Healthcare (2010) (National Guidelines)
Australian Immunisation Handbook
Australian National Guidelines for the Management of Health Care Workers known to be infected with
Blood-Borne Virus
Prevention and Control of Healthcare Associated Infection (HAI) in Queensland Health
Management of Human Immunodeficiency Virus (HIV), Hepatitis B Virus, and Hepatitis C Virus Infected
Healthcare Workers (Queensland Health)
NSW Health Infection Control Policy Amendment
Revision of NSW Health Occupational Assessment, Screening and Vaccination Policy Directive – Interim
Advice
[Definitions] [Introduction] [Scope] [Requirements for Infection Control] [Management Strategies Infectious Disease Exposure] [Compliance] [Appeals]
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Infection Control Procedures
1.
DEFINITIONS
Exposure-prone procedures are a limited subset of invasive procedures characterised by the
potential for contact between the skin (usually finger or thumb) of a person and sharp surgical
instruments, needles or sharp tissues (splinters/pieces of bone/tooth) in body cavities or in poorly
visualised or confined body sites including the mouth.
Infectious Diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites
or fungi; the diseases can be spread, directly or indirectly, from one person to another.
Invasive Procedure is any procedure that pierces the skin or mucous membrane or enters a body
cavity or organ. This includes surgical entry into tissues, cavities or organs or repair of traumatic
injuries.
2.
INTRODUCTION
Griffith University is committed to providing staff and students with a healthy and safe environment in
which to work and study. The University acknowledges that some staff and students as a part of their
work or study at the University may be at increased risk of exposure to infectious diseases as a result
of involvement in areas including but not limited to:

Work with infectious organisms;

Work with human blood or body fluids;

Clinical work with humans (including work undertaken by students on work-integrated placement
in either University-run clinics or in facilities, including healthcare facilities, run by external
organisations);

Work with animals;

First aid;

Cleaning and maintenance;

Overseas travel on University business.
Griffith University staff and students have an obligation to care for the safety of others (including but
not limited to fellow staff members and students of the University, patients/clients and members of
the public with whom they are in contact through the course of their University activities) under both
common law and the Workplace Health and Safety Act 1995. This duty of care includes a duty to
minimise the risk of spreading or contracting infectious diseases.
The University is required to comply with the Public Health Act (Qld) 2005, the Work Health and
Safety Act 2011 and other legislation to ensure the health and safety of the University community
and the wider community with respect to infectious diseases. The University must also comply with
other State and Commonwealth legislation that enables it to provide an environment free from
unlawful discrimination, harassment and vilification, which includes persons in the University
community who have an infectious disease.
The purpose of these procedures is to outline the precautions that should be taken with respect to
infectious diseases to protect the health of staff, students and the community during the course of
staff employment and students' studies with the University (including during the course of any
fieldwork, placements, practicum or the like that occurs at sites other than on University campuses).
3.
SCOPE
These procedures apply to all staff and students of the University who are or may be required to
undertake activities as part of their work, research or study (eg. course / program / research project),
which may cause them to come into contact, either on-campus or on sites external to the University,
with potentially infectious/hazardous (biological) material, or may potentially make them an agent of
transmission of infection. These procedures also cover those staff members or students who are
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aware that they have a notifiable disease or acquire such a disease during their study or employment
at the University.
4.
REQUIREMENTS FOR INFECTION CONTROL
Staff and students must understand their responsibilities to protect themselves and others from the
hazards of blood-borne and other infectious diseases. Pregnant or immuno-compromised staff and
students are encouraged to declare their status to their supervisor or course convenor in order that
risks to their health and the health of others can be appropriately assessed and managed.
4.1
Risk Assessment
Each Element (e.g., academic school or department, administrative department and / or
research Element) is responsible for assessing the infection control risks related to the
activities for which they are responsible. The University promotes ongoing risk assessment
and management of exposure to infectious diseases according to the National Guidelines
(www.nhmrc.gov.au/node/30290). The risk assessment by academic Elements must include
courses and programs for which the Element is the host, student placements, and research
projects or consultancy activities in which staff members and/or students are engaged.
4.2
Documentation of Procedures
Where risk is identified, the Element is responsible for documenting infection control
procedures and requirements applicable to the activities of the Element. Infection control
procedures and requirements may include but are not limited to:
4.3

Cleaning, disinfection and sterilisation;

Hand hygiene and hand washing protocols;

Handling and disposal of potential infectious / hazardous material (biological);

Handling and disposal of sharps;

Provision and use of protective clothing and equipment;

Requirements for immunisation of staff and students;

Processes to be followed in the event of occupational exposures via percutaneous and
non-percutaneous injury (e.g. needlestick injury or body fluid exposure), including followup procedures;

Standard precautions and additional precautions.
Communication, Education and Management
Where risk is identified, the Element is responsible to ensure that the documented infection
control requirements are supported by an appropriate education and management program.
The education and management program shall include, but not be limited to:
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
Provision of, or reference to, material, informed by the National Guidelines, covering topics
including infection control requirements related to the work and study areas of staff and
students, prior to them undertaking any activity that may expose them, or anyone they
come into direct contact with, to an infectious disease. Where possible, the information
should be located on the Griffith University website and be publicly accessible. Elements
must also advise their staff and students of any subsequent changes to requirements
throughout the duration of their employment or studies.

Staff and students are required to read and comply with infection control guidelines
provided to them, either by the University or, in the event that they are to undertake work
or study (including work integrated placement) within external organisations, by the
relevant external organisation;

Provision of appropriate training in infection control requirements in which staff and
students are required to participate;

Ensuring staff and students have access to appropriate protective clothing and equipment
and that this is used appropriately;
Infection Control Procedures
4.4

Ensuring all accidents / incidents which may place staff, students or others at risk of
infection are recorded and actioned in accordance with the infection control requirements
determined by the University or other relevant authority (e.g., Queensland Health
Communicable Diseases Unit);

In the case of exposure, provision of advice about appropriate counselling/support where
required.

Immuno-compromised persons and pregnant staff and students (where this is known) are
provided with relevant information from the University Health Service and/or Queensland
Health to assist them to avoid infectious circumstances;

Steps are taken to ensure that the risk of possible transmission of infection among clients
accessing University facilities and services is minimised, and that where appropriate
clients are advised of risks of transmission of infection.
Requirements for Immunisation and/or Health Certification
Where, as a part of the Element's infection control requirements, students undertaking a
particular course or program are required to provide evidence of immunisation or to provide
any other form of health certification, these specific requirements must be conveyed to
students via the Program Catalogue. Requirements set down by Elements may include, but
are not limited to:

documentary evidence signed by a medical practitioner that staff/students have received
required immunisations and/or achieved required levels of immunity against infectious
diseases within the timelines specified on the Program Catalogue;

requiring staff/students to take responsibility for maintaining ongoing awareness of their
own infectious disease status and taking appropriate action to ensure their own safety and
the safety of others in the event that they contract an infectious disease.
The relevant Element in which staff or students are employed or enrolled is responsible for
recording required evidence of immunisations and immunity against infectious diseases and
for maintaining confidentially the records relating to each staff or student's compliance with the
requirements. The Element is responsible for ensuring that no information gathered through
the operation of these procedures is disclosed to any person outside of the provision of these
procedures without the express consent of the staff or student to whom the information relates.
Where a staff member or student has failed to comply with an Element's infection control
(including immunisation and/or health certification) requirements, the Element may prevent the
staff member or student from undertaking certain activities. In the case of a student, the
Element may progress the matter through the Inability to Complete Required Components of a
Professional Program Policy through which the University may impose a range of measures
including, but not limited to, preventing a student from enrolling in a course in which risk of
them contracting or transmitting an infectious disease as a result of their failure to comply with
the Element's infection control requirements has been identified.
Students are responsible for all costs associated with meeting the immunisation/vaccination
requirements specified for their program.
Where staff require screening or administration of vaccines, due to the nature of their work, the
Element is responsible for the associated costs.
4.5
Practicum and Placements
Staff and students who undertake practical educational experiences and/or work-integrated
placements either on a University campus or at an organisation external to the University are
required to comply with the relevant infection control and immunisation requirements of the
organisation in which they are undertaking the practicum or placement, (and where required
provide evidence of subsequent levels of immunity achieved).
Staff and students who undertake, or could reasonably be expected to undertake invasive or
exposure-prone procedures as a part of their work or study with the University, including work
or study undertaken on work-integrated placement must:

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undergo testing to determine their infectious disease status prior to commencing their
studies and prior to their first clinical placement;
Infection Control Procedures

undergo further testing to detect changes in their infective status at least every 12 months
while enrolled in their program, or as recommended by current medical guidelines;

in the event they have been at risk of acquiring a blood borne virus (e.g., through
occupational exposure or through unprotected sexual activity or unsafe injecting practice
with a partner whose infection status is not definitely known) arrange further blood borne
virus testing at an appropriate interval after any exposure, and must refrain from
participating in exposure prone procedures until they have been definitely determined not
to be infected;

complete documentation relevant to their work or studies. Students must complete all
documentation specified on the Program Catalogue as required for their program including
where required but not limited to the Exposure Prone Declaration Form relating to
infectious disease management; and

take all reasonable steps to protect other staff, students, patients/clients and members of
the community with whom they interact from adverse outcomes including the acquisition of
avoidable infectious diseases.
Staff and students undertaking invasive or exposure-prone procedures should employ
precautions against infectious diseases including adopting safe work practices to all persons
with whom they are interacting in the work environment regardless of those persons' known or
presumed infectious status. Standard precautions constitute the frontline approach to infection
control and include hand washing, use of appropriate personal protective equipment,
management of sharps and immunisation.
A staff member or student who is aware that he or she is infected with a blood-borne virus
must not undertake exposure-prone procedures and should seek urgent confidential advice
from an appropriate staff member in their School, or from the Queensland Health
Communicable Diseases Unit. If exposure-prone procedures are a required component of a
student's program, a student who is infected with an infectious disease may not be able to
complete practical aspects of their program. In this instance the matter will be dealt with under
the Inability to Complete Required Components of a Professional Qualification policy.
4.6
Notification of Communicable Disease
There are certain infectious diseases that legislation such as the Public Health Act (Qld) 2005
(and other comparable laws that exist in all Australian states and territories and the
Commonwealth) mandates as notifiable to State, Territory or Commonwealth health
departments. Infectious diseases that are notifiable are generally highly communicable and/or
are associated with a high severity of illness. They may be spread by contact, droplet or
airborne transmission, and include (but are not limited to): Acquired Immune Deficiency
Syndrome (AIDS)/Human Immunodeficiency Virus (HIV) infection, Hepatitis B virus (HBV)
infection, Hepatitis C virus (HCV) infection, Neisseria Meningitis infection, Whooping Cough,
Measles, Rubella, Legionellosis and Tuberculosis.
In accordance with State legislation, staff and students of the University do not have to
disclose notifiable diseases they may have to the University, however they are required to
disclose to the appropriate State Health Department. Disclosure to the University is
encouraged so that the University can take steps to support infected staff and students and
minimise the risk of harm to others.
Staff and students who are involved in programs in which Hepatitis B immunization is
mandatory are required to disclose to their School if they have a Hepatitis B infection.
Disclosure is necessary as many clinical institutions in which students attend placements have
a mandatory requirement for Hepatitis B immunity and confidential negotiation may be
required between the School and placement provider for an appropriate placement to be
arranged. This information will be held in the strictest confidence.
5.
MANAGEMENT STRATEGIES - INFECTIOUS DISEASE EXPOSURE
5.1
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Known use of biological infectious agents
Infection Control Procedures
Where a known biological infectious agent is being used by staff or students (e.g., in research
activities), there must be a standard protocol developed and located within the facility in which
the agent is being used which can be referenced by all staff, students, cleaners and/or
external clients or visitors for the management of that agent including:
5.2

the procedural steps for containment (including where relevant PC2 or PC3 laboratory
containment of infectious agents);

management protocol for exposure; and

procedures for reporting.
Incidence of infectious disease
In the event of an occurrence of an infectious disease involving a University staff member or
student, of which the University is made aware, the University (via the head of Element or
nominee) will immediately contact the relevant state or territory health department within the
jurisdiction in which the occurrence took place (or health department of the country in which
the occurrence took place in the event of international incidents) and will comply with advice
received from this organisation.
In the event of an occurrence of an infectious disease involving a University staff member or
student of which the University is not made aware, it is the responsibility of the infected
person(s) to immediately contact the Queensland Health Communicable Diseases Unit or
other relevant state, territory or international health department and comply with advice
received from this organisation.
5.3
Incident involving occupational exposure
Elements must have procedures in place for dealing with occupational exposures, which are
relevant to their staff and students.
Examples of exposure-prone activities include activities undertaken in:

the clinical context (e.g. needlestick/sharps injury, body fluid exposure, splashes, aerosols,
contact transmission); and

the laboratory and practical class context (e.g. use of equipment, splashes, aerosols from
body fluids, sharps injury).
An exposed person should follow the required protocol and procedures and report the incident
immediately to their supervisor, who is responsible for ensuring the safety of the area. The
designated supervisor must follow the appropriate procedures as determined by the Element
for such an injury or incident, and complete the appropriate documentation at the time. The
exposed person should have a medical evaluation at an appropriate health care facility, e.g.,
the nearest Griffith University Health Service, Emergency Department at the nearest local
hospital, or their own medical practitioner.
If an injury occurs outside of normal working hours, the staff member or student at risk should
contact the Emergency Department at their nearest local hospital.
An Incident / Injury Report Form must be completed detailing the incident and forwarded to the
Office of Human Resource Management.
6.
COMPLIANCE
All staff and students are expected to follow instructions of safe practice in work/study activities and
to act in a manner that does not place themselves or others at risk of contracting an infectious
disease. It is the responsibility of staff and students to ensure that they comply with the instructions
given for workplace health and safety in regard to infection control. Deliberate disregard for
workplace health and safety instructions may be the subject of action under the University's Student
Misconduct Policy or Staff Misconduct Procedures and may result in a report being made by the
University to the relevant professional registration board.
Failure by a staff member or student to comply with relevant infection control protocols and
requirements, including conscientious objection to immunisation, may lead to an increased risk of
serious illness for that person or other persons with whom a staff member or student comes into
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Infection Control Procedures
contact in the course of their work or studies. Failure to comply may also mean that staff and
students may be prevented from engaging in activities (e.g., work-integrated learning placements)
that place themselves and those persons with whom they may come into contact with at risk of
infection.
7.
APPEALS
Where a member of staff or a student has a grievance concerning a decision made under these
procedures, they are entitled to raise the grievance under the provisions of the Grievance Resolution
Procedure (for staff) or the Policy on Student Reviews and Appeals (for students).
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