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Occupational Medicine Advance Access originally published online on November 13, 2007
Occupational Medicine 2007 57(8):607-609; doi:10.1093/occmed/kqm127
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© The Author 2007. Published by Oxford University Press on behalf of the Society of Occupational Medicine. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Short Reports

Benchmarking self-reported practice regarding Scottish Executive guidance on hepatitis C-infected health care workers

Markus Steiner1, Elizabeth Murphy1,2, Kirsty M. Roy3 and Finlay Dick1,2

1 Department of Environmental and Occupational Medicine, University of Aberdeen, Aberdeen, UK
2 NHS Grampian Occupational Health Service, Foresterhill Lea, Foresterhill Site, Aberdeen, UK
3 Health Protection Scotland, Clifton House, Clifton Place, Glasgow, UK

Correspondence to: Markus Steiner, Department of Environmental and Occupational Medicine, University of Aberdeen, Aberdeen, UK. Tel: +44 1224 558188; fax: +44 1224 551826; e-mail: m.steiner{at}abdn.ac.uk


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Background The 2002 Scottish Executive guidance ‘hepatitis C-infected health care workers’ advised NHS Scotland occupational health departments regarding screening health care workers (HCW) who perform or who may perform exposure-prone procedures (EPPs) for hepatitis C virus (HCV) infection. In 2004, 2 years following the launch of the guidance, there was anecdotal evidence of challenges to implementation and clinical and ethical concerns regarding the screening process.

Aim To benchmark the implementation of the Executive guidance on hepatitis C-infected HCW in NHS Scotland.

Methods Lead occupational health practitioners in 15 Scottish NHS Boards completed a questionnaire and provided relevant local policies.

Results All 15 NHS Boards responded: 87% (n = 13) had implemented the guidance with partial implementation in the remaining boards. While 87% required identified and validated samples (IVS), no consistent method was reported for how results from an IVS were recorded. There was also no consensus as to the duration a result was considered valid or consistency in charging for tests required by other employers. Across Scotland, some employee groups were being screened over and above those recommended within the guidance. Overall, there was agreement on the value of a standardized NHS hepatitis C status certificate and the importance of explicit screening criteria and identifying EPP workers.

Conclusion The survey confirms the challenges in implementing the guidance on managing HCV-infected HCW within NHS Scotland. These include lack of clarity regarding who, when and how frequently a HCW should be screened and how the results of such tests should be recorded.

Keywords      Exposure prone procedures (EPP); healthcare workers; hepatitis C; identified validated samples (IVS); screening; surveillance


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 Conflicts of interest
 References
 
Health care workers (HCW) with direct clinical contact and specific duties are at risk of acquiring or transmitting infections as a consequence of their work. Hepatitis C virus (HCV) is one such infection and no immunization is currently available. Prevalence of HCV varies globally [1]; an estimated 1% (50 000) of Scotland's population has HCV; among HCW, prevalence is believed to be ~0.1 to 0.3% [2].

The Scottish Executive guidance ‘hepatitis C-infected health care workers’ [3] was launched in November 2002. It recommended all new HCW entering careers that relied upon performance of exposure-prone procedures (EPPs) be screened for HCV antibodies, and if positive for HCV RNA to refrain from such training unless responsive to treatment. Similarly, current HCW with known HCV infection and positive for HCV RNA were to be restricted from performing such procedures.

The Executive's guidance recommended HCV screening as a one-off test, undertaken when employees start their first training post for a career that relies upon EPPs, defined as ‘those invasive procedures where there is a risk that injury to the HCW may result in the exposure of the patient's open tissues to the blood of the worker ...’ [4]. Examples of such procedures are given in the Department of Health guidance on HIV-infected HCW [5], Annex A. The blood sample for this test has to be an identified and validated sample (IVS), obtained within the health care setting, by the HCW attending the occupational health service (OHS) and producing photographic identification (staff card, driver's licence, etc.) to confirm their identity [6]. The blood sample is taken by an OHS staff and sent by the OHS specimen transport service to the laboratory.

A number of clinical, financial and ethical concerns were raised regarding the hepatitis C screening process [7,8] including the potential for false-positive test results in a population with a low HCV prevalence leading to unnecessary anxiety in employees and their families. Also of concern was the justification for restricting the careers of highly trained HCW to reduce the risks of an adverse event (HCW-to-patient HCV infection) with a very low likelihood.

As there was neither an agreed implementation strategy nor additional funding provided to OHS, the authors investigated how NHS Boards across Scotland had implemented the guidance by undertaking a survey to benchmark current practice 2 years following its launch.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 Conflicts of interest
 References
 
The lead occupational health practitioner in each of the 15 NHS Board areas was asked to complete a short postal questionnaire in September 2004. Information on guidance implementation, the procedure for screening HCW and IVS was collected using closed questions, and responses were analysed descriptively. Copies of relevant health board policies, where available, were also requested.


   Results
Top
 Abstract
 Introduction
 Methods
 Results
Discussion
 Conflicts of interest
 References
 
The lead occupational health practitioner in each of the 15 NHS Boards responded to the survey questionnaire. Most NHS Boards (87%) had implemented the guidance in full as suggested. The same proportion required IVS for HCV antibody and HCV RNA testing but there was no consistent method for how the test result was recorded. Ninety-three per cent of the NHS Boards accepted IVS sample results from an OHS in another organization and almost half (47%) accepted these HCV test results from a non-IVS (Table 1). Of the six NHS Boards which did not accept a non-IVS test result, all indicated they would do so if a standard NHS certificate were available.


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  		Table 1. Summaries of reported practice regarding the implementation of the Scottish Executive guidance on hepatitis C-infected health care workers

 
Approximately half (53%, n = 8) of the OHS tested clients on behalf of other organizations, and of these, only two charged either the client or the other organization for this service.

The groups of staff screened for HCV as part of the pre-employment assessment varied widely across the country (Table 2). All NHS Boards screened those new to training posts which relied upon EPPs, and 80% screened staff moving into their first post involving such procedures. Half of the NHS Boards, however, also screened medical students when starting such placements.


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  		Table 2. Staff groups screened for HCV (multiple answers possible)

 
Only 67% of the NHS Boards reported having a redeployment policy to support any HCW working in an EPP post-testing positive for hepatitis C RNA. These workers would be restricted from performing such work.


   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
Conflicts of interest
 References
 
This survey confirms the challenges faced by OHS in implementing the Scottish Executive guidance on identifying HCV-infected HCW who perform or may perform EPPs. There is a lack of clarity among NHS Scotland OHS regarding which employee groups should be screened for HCV, how frequently and the criteria for recording test results of an IVS. Medical students and locums, in particular, are two groups treated inconsistently by NHS Boards.

If the purpose of the guidance is to protect patients from acquiring HCV from an infected HCW, then screening workers prior to commencing EPP posts would limit patient exposure and might prevent a few transmission events; it will not, however, prevent transmission of infection acquired thereafter unless the HCW is screened at regular intervals throughout their career. Also such limited HCV screening does not meet accepted criteria for a screening programme. However, given that the risk of a HCW acquiring HCV infection throughout occupational exposure in Scotland is low [9], encouraging staff to present for assessment after needlestick injuries would enable staff to protect themselves (through early detection and treatment of acute HCV infection) and their patients.

If HCV screening of HCW in NHS Scotland is to continue as at present, then harmonization of current practice is necessary. With the recent publication of the Department of Health guidance ‘Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New health care workers’ [10], many of these issues have been addressed by expanding screening to all HCW commencing any posts involving EPPs, thereby removing the confusion as to when you start a career dependent on EPPs. Unfortunately, the issues of recording IVS results for transfer between employers and the timescale for validity remain to be resolved. Furthermore, a number of issues have yet to be addressed with regards to medical and dental students, implications and practicalities of screening are still being discussed by the UK academic bodies.


   Conflicts of interest
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
References
 
None declared.


   Acknowledgements
 
Scottish Executive Health Department Human Resources Forum; Occupational Health & Safety Strategy Implementation Group, Peer Review Audit & Benchmarking Subgroup, Sue Blair, Dorothy Bell; David Goldberg; Julie Buchanan SpR SALUS; Sandra Chapman, Lead Administrator NHS Grampian OHS; Cathryn Travis, NHS Grampian Clinical Effectiveness Team.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 Conflicts of interest
 References
 

  1. WHO. Hepatitis C (2000) http://www.who.int/mediacentre/factsheets/fs164/en/ (10 October 2006, date last accessed).

  2. Hutchinson SJ, Roy KM, Wadd S, et al. Hepatitis C virus infection in Scotland: epidemiological review and public health challenges. Scott Med J (2006) 51:8–15.[Web of Science][Medline]

  3. Executive Scottish Health Department. Hepatitis C Infected Health Care Workers: NHS HDL(2002)75 [Letter] (2002) Edinburgh: Scottish Executive.

  4. Health UK Departments. Guidance for Clinical Health Care Workers: Protection against Infection with Blood-Borne Viruses [Circular] (1998) Wetherby: Department of Health, Crown Copyright. 1–29.

  5. Department of Health. HIV Infected Health Care Workers: Guidance on Management and Patient Notification (2005) London: Crown Copyright. 1–70. DH//HP/GHP3.

  6. Scottish Executive NHS Scotland. Hepatitis C Infected Health Care Workers—Advice to Health Professionals about Hep C and EPPs—HDL and Guidance Issued (2002) Edinburgh: Crown Copyright.

  7. Russell M. Screening in general health. Alcohol Res Health (2005) 28:17–22.[Medline]

  8. Ristinen E, Mamtani R. Ethics of transmission of hepatitis B virus by health-care workers. Lancet (1998) 352:1381–1383.[CrossRef][Web of Science][Medline]

  9. Thorburn D, Roy K, Cameron SO, et al. Risk of hepatitis C virus transmission from patients to surgeons: model based on an unlinked anonymous study of hepatitis C virus prevalence in hospital patients in Glasgow. Gut (2003) 52:1333–1338.[Abstract/Free Full Text]

  10. Department of Health. Health Clearance for Tuberculosis, Hepatitis B, Hepatitis C and HIV: New Healthcare Workers (2007) London: Crown Copyright. 1–68.


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This Article
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