Comments are closed. Related posts:No related photos. Previous Article Next Article Minimising the riskOn 1 Jun 2003 in Personnel Today Thedangers of exposure to the SARS virus may be hitting the headlines, but formost healthcare workers, the threat of blood-borne viruses are a daily risk,by Linda Goldman & Joan LewisEversince the days of Typhoid Mary, the ‘powers-that-be’ have concentrated onminimising the transmission of infection.Recently,the impact of the inhalation route has become of great importance as theepidemic of severe acute respiratory syndrome (SARS) threatens to become apandemic.Ithas highlighted the importance of the standard use of masks and gloves whendealing with at-risk contacts. However, non-fatal SARS is an illness of limitedduration, likely to be prevented by avoidance of droplet inhalation.Thisis and remains one aspect of preventive medicine in an OH generation that isalso concerned with the on-going problems of blood-borne viral disease. Whereasinfection may be transferred through interpersonal abrasion or mucosalcontacts, the common risks for the medical profession are needlestick injuries.Ina nutshell, these are best avoided. It is not where the offending needle orknife is going that counts – it is where it has been. And the sad fact is thatwhere it has been could be somewhere laden with a form of infection for whichthere is little or no prospect of cure.Thebasic problemCertaindiseases have serious professional as well as general health effects on membersof the healthcare professions.Humanimmunodeficiency virus (HIV) and the related autoimmune deficiency syndrome(AIDS) have achieved notoriety. Dealing with their preventive aspects hasbrought the problems of blood-borne viruses, including hepatitis B (HBV) and C(HCV), into a practical focus. These have consequences for personnel involvedin any form of invasive procedure or mucosal contact.Settingaside the issue of inadequately sterilised instruments, there is also asignificantly greater risk of transmission from patient to doctor thanvice-versa.OHpractitioners are involved both with prevention and the rehabilitation ofinfected workers who are fit enough to continue work, but who should not bepermitted to put co-workers or patients at risk.Althoughneedlestick injury is a known route of infection, the term should beinterpreted to include injury from any sharp (or relatively so) instrument. Itappears that the chances of becoming infected can be 30 per cent for HBV if thesource is a high-risk carrier, to 0.3 per cent for transmission of HIV.1Infection depends on the level and virulence of the source patient’s infection,and the type of injury sustained.Therisk arises where exposure prone procedures (EPP) are performed, defined by theDepartment of Health as:”Éinvasive procedures where there is a risk that injury to the worker may resultin the exposure of the patient’s open tissues to the blood of the worker[including] procedures where the worker’s gloved hand may be in contact withsharp instruments, needle tips or sharp tissues inside a patient’s open bodycavity, wound or confined anatomical spaceÉ”Althoughit is unlikely that OH practitioners will undertake an EPP, there is anincreasing probability that they will have to deal with people who do, whetheror not they have actually sustained an injury.Insome professions, such as dentistry, almost all procedures fit within the‘exposure-prone’ category.Itappears that a needlestick injury occurring while treating an HCV positivepatient carries a 1.8 per cent probability of transmitting the virus. This is asubstantially lower risk than HBV, but there are catastrophic professionalconsequences of infection.Occupationalhealth support can play a large part in career-change counselling and access totraining – essential factors for the employer to consider avoiding a DisabilityDiscrimination Act claim.InformationAlthoughSARS has been hitting the headlines of late, it is important not to lose sightof the continuing efforts by the Department of Health to deal with the specific risks of transmission ofblood-borne infection to the medical profession.HealthService Circular HSC 2002/010 was issued on 14 August 2002 throughout the NHS,together with guidance, to provide information on the management ofHCV-infected healthcare workers.Healthcareworkers who know they are carrying HCV, or who have tested positive for it,should not perform EPPs.Aperson will be fit to resume clinical duties, described as ‘exposure-prone’, ifthey have had six months of negative tests following relevant antiviral therapy.Testingfor HCV is mandatory where healthcare workers are known to have been exposed tothe virus.Peoplewho are found to be HCV positive should not be permitted to take up or resumehealthcare work that involves invasive contact, such as dentistry, surgery ormidwifery.Occupationalhealth inputEPPsoccur mainly in surgery and related examinations. Some EPPs will have beenperformed in parts of the world or in restricted populations – such asdrug-users – where there is a high prevalence of HCV.OHpersonnel dealing with infected workers have the usual ethical quandary of therequirement of confidentiality against the need to protect the public. Theyshould discuss the full implications of viral status with the affected workerso as to arrange appropriate tests, many of which will be carried out with aview to a resumption of duties.Theguidance points out that a trust may not necessarily be contractually bound tocarry out on-going status tests, so a private source of funding may have to belocated.Furtheradvice on recommending resumption of duties is available from the medicalsecretary to the UK Advisory Panel for Health Care Workers Infected with BloodBorne Viruses (UKAP).2Theguidance states that HCV positive healthcare workers should see a consultant OHphysician, who may refer the patient on to other levels of the department forpractical advice and personal counselling.Careerchange, for whatever reason, may be a painful process but people who haveacquired an illness while carrying out their professional duties are verylikely to have to deal with anger as well as sorrow at a time when their physicalresources are low.Dutyof careTheemployer is under a duty of care to ensure that healthcare workers do notperform EPPs while they present any risk of transmission to patients.Apatient infected by a healthcare worker can sue for damages for the injurysuffered, whereas the healthcare worker will most likely have only theircontract of employment and the Disability Discrimination Act to rely on.Ifillness is contracted because the employer provided faulty equipment, theemployee may have some chance of redress, but it is an uphill road.Thesedays, by treating all patients as if they are infected, the risks areminimised. A needlestick injury is usually dealt with as an unfortunateaccident for which compensation is either not available or difficult to get.LindaGoldman is a barrister at 7 New Square, Lincoln’s Inn. She is head of trainingand education for ACT Associates & Virtual Personnel. Joan Lewis is thesenior consultant and director at ACTAssociates & Virtual Personnel, employment law and advisoryservice consultancies, and licensed by the General Council of theBar in employment matters under BarDirectReferences:1.Keynote speech at British Dental Association Workshop, 19 – 20 February 2002:Professor Jeremy Bagg (professor of clinical microbiology, Glasgow DentalHospital)2.UKAP, Room 635B, Skipton House, 80 London Road, London SE1 6LHCaseround upDisability discriminationAccordingto the Disability Discrimination Act 1995, an employer must not discriminate againsta disabled employee by refusing to offer him training, or by dismissal orsubjecting him to any other detriment. Thus, all retraining avenues must beexplored. In Fu v London Borough of Camden, 2001, IRLR 186, the employerdiscriminated against Fu by dismissing her without considering all availableoptions, including retraining for a completely different form of work than thatwhich she had performed as a care worker prior to injuring her back.Work-relatedtransmission of HCVFiveincidents have been reported since 1994 of the transmission of hepatitis Cvirus (HCV) from healthcare workers to patients during exposure proneprocedures. The Communicable Disease Centre reports that 15 patients have beeninfected, one of whom was infected by a surgeon.Althoughsmall numbers of patients have been involved, the risk should not betrivialised. Any employer who knows or ought to have known that a member ofstaff is HCV positive owes a duty of care to patients to prevent infection. Itis therefore essential to follow the guidance and remove the healthcare workerfrom clinical duties.Theguidance recommends occupational health involvement in redeployment, retrainingand access to benefits for the healthcare worker, whose infective status putsan effective bar on work that they have hitherto been trained and employed todo. It states: “Employers should make every effort to arrange suitablealternative work and retraining opportunities in accordance with good generalprinciples of occupational health and management practice”.Notificationfor at-risk patients may not necessarily be within the OH department’s remit,but if in doubt, advice should be sought from UKAP.Transmissionfrom patient to doctorDoctorsrequired to treat patients with communicable blood-borne disease should beprovided with proper training and equipment, including suitable contaminateddisposal facilities, needle-guards and heavy-duty gloves.Ifrequired to treat nervous patients, whose involuntary movements could causeinjury, sedation should be considered. The court deems the employer to knowthat the employee is at risk.Stokesv GKN, 1968, 1WLR 1776, highlights the level of the duty of care. The employernegligently failed to warn Stokes of the risk of contracting scrotal cancerthrough exposure to mineral oils. The company doctor had failed to alert theemployer to the risk, as he did not want to cause alarm to the staff. However,the court found that the doctor’s knowledge was imputed to the employer who”knew or ought to have known”.Thiscase was quoted in Mughal v Reuters, 1993, IRLR 571. Mughal lost his claim fordamages for contracting repetitive strain injury (RSI), which the court refusedto recognise, by reason of excessive computer use. The judge said: “É ifthe employer is found to have fallen below the standard to be properly expectedof a reasonable and prudent employer in [respect of training and equipping theemployee], he is negligent.”Thereis also a duty on the employee to take care of himself. In Lane v Shire RoofingCo, 1995, IRLR 493, Lane’s damages were cut by 50 per cent because using hisown equipment (an unsuitable ladder) in a dangerous way was attributable to theaccident in which he fell and injured his back.