Page updated 9 October 2006
Staff Health and Immunisation
Immunisation
On employment, checks should be made to ensure that staff are immunised according to current national guidelines. All clinical staff (including Dentists, Dental Nurses (DCPs), Therapists and Hygienists) should have received vaccinations against hepatitis B, rubella, tetanus, polio, tuberculosis (and varicella, if non-immune). Annual vaccination in the autumn against seasonal influenza is strongly recommended.
Guidance on immunisation against tuberculosis with the BCG vaccine has recently been revised and is now based on targeted immunisation of neonates living in areas where the incidence of TB >40 cases per 100,000 population/ annum and other groups at high risk. There is however, no change in the recommendation for vaccination for those people at risk of occupational exposure e.g. in dentistry. Tuberculin skin testing has changed from the Heaf test to the Mantoux test.
The dentist must keep written documentary evidence that they and their employees have been immunised against hepatitis B.
Record the following:
- Completion date of the hepatitis B vaccination course
- Post vaccination antibody levels (with date of blood test)
- Record immune response (categories -non-responder <10 iu/ml; poor responder 10-100iu/ml, good responder >100iu/ml)
- Date for booster vaccination
Nominate a person within the practice to co-ordinate staff health and keep a written confidential record of immunisation schedules and antibody test results.
Permission (written consent) must be first gained from the team members before requesting any confidential information from their GP. A letter can then be written to the GP requesting the appropriate information. Put in place markers or an alerting system to help the practice keep their records contemporary and ensure that all members of the dental team are up to date with booster vaccinations.
In many PCTs, occupational health department are funded to work with dental practices to ensure that their staff receive the necessary vaccinations, advice and follow-up.
For further advice and information on staff health and immunisation contact your local Infection Control Nurse or Dental Advisor
Who should be immunised against hepatitis B?
All staff (dentists, DCPs, therapists and hygienists and others) who are likely to have contact with blood/body fluids, clinical waste and sharps in the course of their duties should have received and completed a hepatitis B immunisation course.
Their antibody response should be measured 1-2 months after the completing the course of immunisation to ensure that they have mounted an adequate antibody response (hepatitis B surface antibody titre (HBs Ab) ³ 100 iu/ml) and the details recorded. The highest antibody titres are usually found one month after completing the course with a rapid decline over the next 12 months and thereafter more slowly. An anti-HBs titre ³ 100 iu/ml is considered sufficient to provide protection against hepatitis B infection. Poor-responders with an antibody response of between 10-100 iu/ml may be offered an additional booster injection. Immunological memory ensures that protection against infection is sustained even though the circulating concentration of antibodies declines with time.
Non-vaccine responders (anti-HBs titre < 10 iu/ml) should be referred to their GP for hepatitis B surface and HBe antigen testing and a repeat course of immunisation if appropriate. A small percentage of people do not respond to the vaccine and will require prompt referral to the local Accident and Emergency Department/Occupational Health department following a needle stick injury for assessment and if required hepatitis B immunoglobulin. Other non-responders to the vaccine may have natural immunity due to past infection or be asymptomatic carriers of hepatitis B.
A single booster vaccine is recommended at 5 years. People who produced an adequate immune response after the initial course of immunisation and who have a needle stick injury within 1-5 years of completing the course of vaccine may be offered a booster vaccine. If this occurs there is no requirement for a second booster dose at 5 years.
Further information and a fact sheet for staff can be obtained from www.dh.gov.uk
Health Clearance
It is current policy in the NHS to screen all new entrants to the Health Service including dental students for:
- Evidence of tuberculosis disease/immunity.
- To offer hepatitis B (HBV) immunisation, with post-immunisation testing of response.
- The offer of testing for hepatitis C (HCV) and HIV, within the context of reminding them of their professional responsibilities in relation to serious communicable diseases.
HCV testing is recommended for those embarking on careers or training involving exposure prone procedures (EPP) See section add hyperlink . Most routine dental and minor oral surgical (MOS) procedures are classified as EPP.
Healthcare workers who are known to be infectious carriers of HCV, HBV (HBe Ag positive) or HIV seropositive or are found to be so following testing are not allowed to perform EPPs. Hepatitis C infected healthcare workers who have a sustained virological response to antiviral therapy will be allowed to perform EPPs six months after cessation of antiviral therapy.
Dentists, DCPs or hygienists/therapists who are HBeAg positive and those HBsAg positive carriers who are HBe Ag negative but who have a significant viral load (>1000 genome equivalents /ml) will not be allowed to perform exposure-prone dental procedures. HBe Ag negative infected health care workers whose viral load is < 1000 genome equivalents /ml may continue to perform EPPs but should receive appropriate occupational health advice. Such persons will require re-testing every 12 months and if the viral load rises above the specified level or there is evidence of transmission from the dental healthcare worker to a patient then they must cease performing EPPs.
Dental Nurses (DCPs) do not routinely perform exposure prone procedures but the dentist should undertake a risk assessment to determine whether the DCP's specific duties pose a risk to patients or other members of staff and whether they would need to be redeployed within the practice.
(See Maintaining Standards)
Legal obligations on blood borne virus (BBV) infected healthcare workers
Dentists currently registered with the GDC who believe that they may have been exposed to blood borne viruses such as HIV, Hepatitis B (HBV) or Hepatitis C (HCV) e.g. via unprotected sexual activity, occupational exposure, blood transfusions etc. ( see risk factors for HIV transmission ) are under a legal, professional and ethical obligation to promptly seek and follow confidential advice on testing for BBV (blood borne viruses) and national guidelines on practising restrictions.
Healthcare workers must not rely on their own assessment of the risk they may pose to patients. Confidential advice on testing for BBV can be obtained from your local Director of Public Health of Primary Care Trusts. Failure to do so may breach your duty of care to patients under the Health and Safety at Work Act and the COSHH regulations (see HIV infected healthcare workers: Guidance on management and patient notification July 2005. Department of Health paragraph 4.7).
This guidance applies to all those working in the NHS and the independent sector. All medical information and records held on staff must be kept strictly confidential and the confidentially must be protected and respected at every stage.
For further information on your obligations and the correct procedures to follow see the Department of Health website for guidance relating to HIV and for information relating to HBV.
Guidance on testing HCW joining or rejoining the NHS
The Department of Health has proposed a series of health clearance checks for all healthcare workers joining (including dental students) or re-joining the NHS in HSC 2002/008.
Under the proposals all healthcare workers would require "specified standard health checks" for TB and HBV and the offer of testing for HCV and HIV as under current guidance. "Additional health checks" are proposed for all healthcare workers who perform exposure prone procedures (such as dentist /therapists / hygienists/ dental students ) who would be required to demonstrate that they are free of infection with HBV, HCV and HIV:
- Hepatitis B surface Antigen. Those who test negative should be immunised and have their response checked. Those who test positive should be tested for HB e-markers and if negative for HBV viral load.
- Be tested for Hepatitis C infection i.e. tested for hepatitis C antibody. Those who test positive should be tested for hepatitis C RNA.
- Be tested for HIV infection i.e. testing for HIV antibody
Implementation of the guidance on health checks is currently under review by the General Dental Council. A pre-registration medical history form to evaluate an individual's risk of past exposure or risk behaviours for blood borne viruses is due for publication on the GDC website and is designed to be completed by the dental healthcare worker and their GP (for further information see www.gdc-uk.org , registration).
Health Clearance for Serious Communicable Diseases: New Health care workers (January 2003; )
Varicella immunisation
Chickenpox is caused by the virus Varicella zoster (VZV) and is highly infectious. VZV is spread via respiratory droplets or direct contact with the blisters and contaminated clothing. The infection can occur at any age but is more common in children. However, disease in adults tends to be more severe.
The primary infection presents initially with itchy blisters on the skin that later scab and may cause scarring. The virus eventually becomes latent in the sensory ganglion (nerve cells) but can reactivate later in life as Shingles (Herpes Zoster) resulting in a painful, vesicular (blistering) skin rash. Vesicles whether in the primary or the reactivation secondary form of the disease contain virus and are infectious. Shingles is normally occurs unilaterally; affecting the area of skin supplied by the sensory nerves to the trunk or the face via the sensory Trigeminal nerve.
The ophthalmic branch of the Trigeminal Nerve is 20times more commonly affected than the other branches. Patients with ocular infection should be sent for an urgent ophthalmic consultation, as ulceration and scarring of the cornea can result in loss of sight. A proportion of people later develop a chronic and dehabilitating pain condition (post-herpetic neuralgia).
In pregnant women chickenpox infection during the first 20 weeks of pregnancy can occasionally cause damage to the foetus, fortunately this is an uncommon occurrence. The newborn baby may also be infected if the mother develops chicken pox during the perinatal period. Perinatal chickenpox in the newborn is associated with a high death rate if the mother is infected 5 days before the baby is born or 2 days after delivery. This is thought to be due to the newborn baby not receiving transplacental antibodies from the mother and the immaturity of the baby's immune system.
New recommendations for varicella vaccination
Following advice from the Committee on Vaccination and Immunisation, varicella immunisation is now recommended for non-immune members of the dental team who have direct patient contact. Approximately 10 % of the population have no immunity to chickenpox. Vaccination is recommended to protect both susceptible healthcare workers and to protect vulnerable patients from acquiring chickenpox from an infected member of staff. Members of the dental team with direct patient contact who have no previous history of chickenpox or shingles should have a blood test to check their immunity. Staff with a definite history of chickenpox or shingles can be considered to be immune. Those who are seronegative (with no antibody evidence of immunity) will be recommended the vaccine.
Non-immune staff should receive 2 doses of the live attenuated vaccine 4-8 weeks apart. Routine post-serological testing is not advised. Varicella vaccine is contraindicated in pregnancy. Furthermore, pregnancy should be avoided for 3 months post vaccination. Surveillance of inadvertent vaccination of pregnant women in the USA has not however identified any special risk to the foetus. Additional information and a fact sheet for staff can be obtained from www.dh.gov.uk/cmo
Sharp safe working
Handling sharps safely
Key points:
- Most routine dental treatment and minor oral surgery procedures are classified as EPP.
- Safe disposal of needles (and scalpels) used in dental treatment is the responsibility of the clinician (dentist, therapist or hygienist).
- Never re-sheath needles manually use a resheathing device
Background
When do sharps injuries occur
Sharps and needle stick injuries are relatively uncommon and often only result in minor injury to the skin, but they are significant due to the risk of transmission of blood borne viruses infections e.g. hepatitis B, hepatitis C or HIV. Transmission can occur either from the infected patient to the clinician or from the infected clinician to the patient.
Clinical members of the dental team report between 1 to 4 sharps injuries in a year. Although, we know that many staff are reluctant to report sharps injuries, so these figures may be an underestimate of the true number of incidents. Intraorally, needle stick and sharps injuries may occur accidentally during treatment if the patient moves or closes their mouth unexpectedly or as a consequence of poor visibility. But the majority of needle stick injuries are sustained outside the mouth during resheathing, dismantling or disposal of the needle. Such needle stick injuries are considered "avoidable" with good practice and the use of preventive measures such as safety syringes with retractable sheaves, needle guards, or single-handed resheathing techniques.
The other high risk procedures are clearing instruments away between patients and manual instrument cleaning. It is here that DCPs are most at risk. You can reduce the number of accidents by not leaving unsheathed needles on the bracket table. Forty percent of injuries involve dental burs and probe tips. Fortunately, these instruments are usually less heavily contaminated with blood than hollow-bore needles and so pose less of a risk for transmission of infection.
Exposure prone procedures (EPPs)
Assessment of the risk to a patient following a sharps injury involving a clinician who is a carrier of a blood borne virus depends on whether there is a possibility of unrecognised bleed back into the patient's open tissues. Such an occurrence is referred to as an exposure prone procedure (EPPs). The term is applied to all peri-oral clinical procedures where the hands or finger tips that come into contact with sharps (e.g. needle tips, sharp instruments, or sharp tissues such as teeth or bone speckles) may not be completely visible at all times.
EPPS are classified into 3 broad categories based on the degree of visibility of the hands and the risk of significant sharps injury occurring during the procedure.
Category 1: Lowest risk of bleed back as the worker's hands are usually visible outside the mouth, for example giving a local anaesthetic.
Category 2: Intermediate risk of bleed back, hands are partially visible but if bleed back occurs it would be recognized and acted on quickly e.g. dental extraction.
Category 3: Greatest risk of significant injury and unrecognised bleed back e.g. Osteotomy.
Most routine dental treatment performed in primary care falls within categories 1 and 2, but certain maxillo-facial surgery procedures are defined as Category 3. Taking an extra-oral radiograph, examination of the mouth with a mouth mirror, taking impressions and fitting full dentures in a totally edentulous patient are not considered to be exposure prone.
Sharp safe working in the dental surgery:
- Use an instrument (mirror/cheek retractor) rather than fingers to retract tongue and cheeks when using sharp implements. This has the added advantage of enhancing visibility
- Do not bend the needle (as this makes resheathing difficult and is more likely to lead to injury)
- If giving multiple injections with the same needle, recap between use. To recap employ a single handed technique or a needle guard or alternatively a safety needles with a retractable sheaf
- Avoid passing of sharp instruments from hand to hand during dental treatment
- The same sharp instrument should not be touched by more than one person at the same time. Place the sharp in a neutral zone in the tray or bracket table where it can safely be picked up by the second person. Alert the other person that you are putting a sharp instrument into the neutral zone
- Disposal of used needles (and scalpels) is the responsibility of the clinician (dentist, therapist or hygienist).
- Don't leave syringe needles, suture needles or scalpel blades on the bracket table at the end of use, dispose of them immediately. Use disposal scalpels, which avoids the need to release the blade
- Don't leave burs in the handpiece at the end of treatment as they can catch on skin and clothing. Remove them immediately after finishing use, then the handpiece can be dismantled from the connector and cleaned without risk of injury
- To protect hands when cleaning instruments wear heavy-duty gloves and goggles or visors to protect the eyes from splashes
For Further information see Clinical Guidelines 2. Infection control. Prevention of healthcare -associated infections in primary and community care. National Institute for Health and Clinical Excellence (NICE) 2003 http://www.nice.org.uk
Safe methods for resheathing syringe needles:
There are a variety of different designs of commercially available safety devices for resheathing syringe needles:
- Needle guards and resheathing blocks - help to protect the hand that is used to recap the needle.
- Safety needles with integrated retractable sheath - the sheath can be retracted whenever the needle is required to give an injection and is then slid down over the needle protecting the operator between use and during dismantling and disposal. S ome manufacturer's syringe and needle devices are fully disposable as a single unit, which minimizes the degree of handling. Safety needles have been shown to reduce the number of avoidable needle stick injuries to zero. The cost of safety needles is comparable to conventional disposable syringe needles.
How to avoid sharps injuries - safe resheathing and disposal
Resheathing:
- Never re-sheath needles manually use a resheathing device (e.g. single handed resheathing block, needle guard or safety needle with integrated retractable sheath)
- If a device is not readily accessible use the "single handed scoop method", whereby the barrel of the syringe is held in one hand and the needle cap is scooped from a smooth hard surface onto the needle. Once covered the needle cap can be secured in place
- Sharps should be disposed of immediately after use
- Disposable sharps should be placed directly into an approved waste container (BS 7320) by the user. Never leave sharps to be disposed of by someone else
Disposal:
- When using a disposable syringe then dispose of syringe and needle as one unit directly into a sharps container wherever possible
- Ensure that the sharps bin is correctly assembled and that the lid is securely fastened before commencing use
- Containers should be conveniently placed close to the point of use. Wall and trolley brackets can be used to ensure that bins are conveniently located, especially in areas where space is limited.
- Sharps containers should not be placed on the floor, on an unstable surface or above shoulder height. They should be inaccessible to children and unauthorised persons.
- Keep the aperture closed when the sharps container is not in use
- Containers should be sealed and disposed of when three-quarters full (do not attempt to press down on container to make more room!)
- Never try to retrieve any items from a sharps container
- Containers must not be placed into yellow bags prior to disposal.
- If a sharps container is damaged, place into larger container, lock and label prior to disposal
- The container should be labelled with practice name, address and date before disposal
- Ensure that sealed bins awaiting collection are housed in a locked area, which is inaccessible to unauthorised persons
- Contact your local PCT if you require further information on disposal of sharps containers.
Managing sharps injuries
Immediate action following needle stick /sharps injuries or significant contamination of eyes or mucous membranes
Sharps injuries are defined as any percutaneous injury or skin puncture involving sharp instruments e.g. dental bur, syringe needles or suture needles. You should have a written policy for the management of sharps and significant splashes into the eye or on broken skin. A formal arrangement should be established with a local occupational health department or, if not available , your local Accident and Emergency Department for 24-hour cover for the management of sharps injuries. Keep the contact number by the phone for easy access.
Immediate first aid; reporting procedures and further management
- Encourage puncture site to bleed by applying pressure ( do not suck )
- Wash site liberally with soap and running water for several minutes. Do not scrub as this may inoculate virus into the tissues. Cover with waterproof plaster
- Wash exposed eyes thoroughly with running water or eye wash solution. Remove contact lens prior to washing eyes.
- Exposed oral mucous membranes. Rinse vigorously with water and spit out.
- Remove offending item and dispose of it carefully into a hazardous waste sharps bin
- Report incident immediately , recheck medical history of patient and ask about risk behaviours for BBV . Assess the risk . Promptly contact ( local Occupational Health Department / Accident and Emergency Department) for urgent advice on requirement for post exposure prophylaxis, information and counselling
- Complete an Accident report form (BI 510).
Do not delay in contacting the local Accident and Emergency Department/Occupational Health service for advice on risk assessment, requirement prophylaxis against HIV and hepatitis B infection, plus guidance, psychological support and counselling. At the present time there is no effective prophylaxis or vaccine available against hepatitis C. If HIV post exposure prophylaxis (PEP) is required ideally it should be given within 1 hour to achieve maximum preventive benefits. Although it is valid to offer prophylaxis for up to 2 weeks after the injury.
HIV Post exposure prophylaxis (PEP)
HIV PEP consists of three antiretroviral drugs:
1. Nelfinavir 1250mg twice daily (or 750mg three times daily),
2. Zidovudine 250-300mg twice daily
3. Lamivudine 150mg twice daily
- The use of PEP is unlikely to be justified in the majority of exposures where the source patient is unknown. This decision to prescribe PEP is based on a case -by -case risk assessment undertaken by the on-call doctor in the Accident and Emergency Department or Occupational Health Department, in conjunction with the wishes of the staff member.
- PEP will not be offered if the source case is HIV negative, or following a risk assessment that indicates the risk of HIV infection is unlikely.
- Please note that blood from an HIV positive source coming into contact with intact skin does not pose a risk for transmission of infection.
(For a more detailed explanation of the guidance on HIV PEP please see http://www.advisorybodies.doh.gov.uk/eaga/PDFS/prophylaxisguidancefeb04.pdf ) on the Department of Health website.
When you are assessed by the Occupational Health Doctor/ Nurse you are likely to be asked for the following information that will aid the doctor in deciding if the exposure was significant (with the potential to transmit blood borne virus (BBV) e.g. HIV, hepatitis B or C).
Your immune status for Hepatitis B
- Post vaccination hepatitis B antibody level
- When was your last Hepatitis B vaccination or booster?
Assessment of significance of injury -Factors that increase risk of transmission of HIV
- Type of exposure? e.g. percutaneous (punctured the skin), exposure of broken skin or exposure of mucous membrane including the eye (splash)?
- Depth of the injury?
- Device contaminated with blood?
- Had the needle been in the patient's blood vessel?
- Terminal HIV -related illness in the source patient?
- Source patient has high viral load for any of the blood borne viruses?
The answers you give will aid the risk assessment of the injury and inform the decision on whether to administer HIV prophylaxis or if a booster immunization of hepatitis B or immunoglobulin is required. In order to be able to answer these questions you may need to recheck the patient's medical history or ask additional specific questions (see below).
Assessment of patient's risk factors
- Has the patient ever had HCV, HBV or HIV infection?
- Ever had unprotected sexual intercourse between men?
- Had unprotected heterosexual sex with a person who had been exposed in a country where transmission of HIV through sexual intercourse is common, e.g. Sub-Saharan Africa, India
- Shared injecting equipment when using recreational drugs?
- Received a blood transfusion in the UK before 1991 (blood screening started in 1991 for hepatitis C) or plasma products before 1985, or received a blood transfusion in a country were heterosexual transmission of HIV through sexual intercourse is common.
If the injury occurred on an instrument that was contaminated with blood from a known/identifiable patient, then a staff member (preferably not the exposed person) should explain about the incident and why the additional enquires and blood tests are being sought. In the majority of cases you will have to arrange for the patient's GP to take the blood sample. Organise for the patient to receive a pre-test discussion and to give informed consent for a blood sample to be taken for HIV, HBV, HCV testing. Strict confidentiality must be maintained throughout.
If on assessment the exposure was considered significant, a baseline and then a follow-up blood sample at 6 months will be taken from the health care worker to establish that transmission of infection has not occurred. Blood samples are retained for 2 years. There is no need to stop performing invasive dental procedures whilst waiting for the test results, as both the risk of occupational seroconversion and then subsequent transmission of infection to a patient during an EPP are both estimated to be very low.
If the dentist/therapist/hygienist does become infected with HIV, hepatitis B or C then they will be prohibited from providing EPP dental treatment in accordance with national guidelines.
Recording of sharps injuries
All sharps injuries and significant splashes however minor must be recorded in an "accident book". In order to comply with Data Protection Regulations 1998 accidents must be recorded on separate forms (B1 510) available from the Stationary Bookshop. These forms have an identification system, which allows for a chronological record keeping. Once completed they must be stored securely (e.g. in a lockable drawer) and in such a way that the confidentiality of the person concerned is protected. They must be kept for a minimum of three years.
In the event of a significant occupational exposure to HIV infection or hepatitis B/C you may have to report the incident to RIDDOR as a "dangerous occurrence" or if HIV infection occurs as a "disease ". (See www.riddor.gov.uk ).
DH Injury Benefit Scheme provides temporary or permanent benefit for those who lose remuneration because of an injury or disease attributable to NHS employment. But in order to be able to make a successful claim you will need to prove that the infection was due to an occupational exposure and a completed accident form may help support your claim .
Clinical governance and accident risk assessment
Reviewing your clinical procedures and undertaking risk assessments is an important component of clinical governance so don't waste accidents and near misses use them for staff training. It is important that the dentist creates an environment where his/her team members feel confident to inform them that something might or has gone wrong. The circumstances that lead up to the exposure should be identified and steps taken to prevent a recurrence.
References
Hepatitis B Key Documents. Department of Health.
Zakrzewska JM, Greenwood I, Jackson J. Introducing safety syringes into a UK dental school- a controlled study. Br Dent J 2001; 190 : 88-92.
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