Better safe than sorry

Recent
global events have highlighted the potential risks of infectious diseases such
as smallpox and SARS1. However, every day in the UK, many people are put at
risk of infection through their occupation. What role can vaccination play to
minimise risk and where does the duty of care lie? By Dr Charlie Easmon

Rabies
vaccine

Bats
are known to carry viruses such as rabies or the equally fatal rabies-like
European bat lyssavirus. However, the rabies vaccine protects 100 per cent
against the rabies virus and rabies-like viruses.

With
this basic knowledge, it would seem an obvious duty of care to ensure that all
bat handlers, be they professional or casual, were vaccinated against the
rabies virus and rabies-like viruses.

David
MacRae was a licensed bat-handler who died an unfortunate, but media-intensive,
death on 24 November 2002. Despite his line of work and a previous history of
being bitten by bats, he had never received rabies immunisation.

No
blame should specifically be apportioned in the MacRae case, however, as
difficulties may have arisen because he was not a full-time employee.

This
raises very interesting questions about who should intervene to ensure casual
staff have the same level of protection as full-time workers.

A
personal view would be that the liability would still remain with the person
who gave them the final employment.

Yellow
fever vaccine

The
MacRae case raises similar parallels to other situations where people may have
thought the personal risk was low and did not warrant a vaccination.

For
example, a German cameraman acquired yellow fever infection while in Africa and
died.2 He had travelled to areas in which recent human yellow fever infection
had not been recorded. However, his employer should have advised him to have an
up-to-date yellow fever vaccine for his work in Africa.

The
fallacy of the risk assessment may have been to forget that monkeys, as well as
humans, carry yellow fever. A lack of reported human infection does not mean an
animal reservoir does not exist and, in fact, no reported human infections may
be because of high levels of immunisation among the local population.

Yellow
fever is covered by the International Quarantine Regulations, which are taken
very seriously by authorities.3

The
yellow fever vaccine must be administered by a specially authorised doctor (see
box, page 17) and lasts up to 10 years. It is the only vaccination that
requires certification and is a legal requirement for entry into certain
countries.

Hepatitis
vaccines

Healthcare
workers in the UK are protected from a predictable risk by routine vaccination
against hepatitis B.4 However, there have been cases where the follow-up of
hepatitis B vaccination has been so inadequate that it has led to infection of
patients.5

Another
example of a problem area in OH terms has been public sector workers outside of
the NHS, such as refuse collectors and police staff.

Both
of these groups can be exposed to needle stick injuries in the course of their
work. They may visit a drug addict’s home or clear bins where potentiality
infected needles have been thrown away. Given the very high levels of hepatitis
B infection among drug addicts, this is a clear risk, in addition to the risk
of hepatitis C and HIV.

Most
local authorities in the UK have come to accept they should vaccinate all their
staff who are at risk from hepatitis B, but then are unclear as to whether they
can get this vaccine free from GPs.

A
recent debate on the internet raised several concerns on this issue.

GP
and vaccine specialist Dr George Kassianos’ interpretation is that GPs are not
actually paid by the Government to give hepatitis B vaccination to anyone
outside recommendations provided in the The Green Book (healthcare
professionals, staff and residents of residential accommodation for those with
severe learning disabilities, occupational risk groups, inmates and those
travelling to areas of high prevalence), and that it should be paid for by the
agency, such as a local authority.

Travel
vaccines

Business
travellers represent another group being exposed to diseases they would not
normally encounter in their home country.

There
is a duty of care by the employer to ensure they are properly vaccinated, given
the right advice and encouraged to use correct protective measures. There are
now some case-law examples where people have been sued for this level of
negligence in terms of duty of care.6

Summary

Making
sure the right advice and, where necessary, the right vaccination is given to
the right people at the right time is the key to efficient travel health and
the health of those working in specific occupations. Currently, the infectious
agents suffer somewhat from a lack of visibility, sparse research and less
expertise.

Dr
Charlie Easmon, has a special interest in travel medicine and occupational
health, and is the medical director of Travel Screening Services based at 1
Harley St, London

References

1.
Chan-Yeung M, Yu WC, Outbreak of severe acute respiratory syndrome in Hong King
Special Administrative Region: case report, BMJ, 2003; 326:850-2

2.
www.eurosurveillance.org/ew/2000/000810.asp

3.
www.who.int/ith

4.
NHS Executive Addendum to HSG(93)40: protecting healthcare workers and patients
from hepatitis B, Leeds, NHSE, 1996

5.
The Incident Control Team and Others, Lessons from two linked clusters of acute
hepatitis B in cardiothoracic surgery patients, Communicable Dis Rep CDR Rev
1996, 6: R119-125

6.
Easmon C, Health and safety aspects of business travel, J R Soc Health, 2002
Mar;122(1):7-8

Table
1: Suggested vaccines for those at risk

The
Department of Health recommends that healthcare professionals be vaccinated
against hepatitis B, influenza and have any other vaccine that will prevent
them from contracting a vaccine-preventable disease.

These
are the additional occupations that may also be at risk of other
vaccine-preventable diseases:

Hepatitis
A


Staff in institutions for those with learning disabilities


Sewage workers

Hepatitis
B


Mortician and embalmers


Police


Ambulance workers


Firefighters


Rescue services


Dentists and dental assistants


Sex workers


Staff in institutions for those with learning disabilities

Influenza


Office workers


Healthcare professionals

Rabies


Zoo staff


Customs and excise officers


Government vet or technician


Animal quarantine staff

For
those whose jobs involve travelling to at-risk destinations, yellow fever, hepatitis
A, typhoid and tetanus vaccinations are recommended. Refer to the vaccine
recommendations for each country.

Yellow
fever vaccination centres in the UK

England

Sue
Doran, Department of Health, Room 601a, Skipton House, 80 London Road, London,
SE1 6LH
020 7972 5047
Sue.doran@doh.gsi.gov.uk

Northern
Ireland

Michael
Kelly, Public Health Branch, Department of Health and Social Services and
Public Safety, Room C4.15, Castle Buildings, Stormont, Belfast BT4 3PP
02890 522118
michael.kelly2@dhsspsni.gov.uk

Scotland

Charles
Hodgson, Public Health Policy Unit Branch 1, Scottish Executive Health
Department, 3E (South), St Andrews House, Regent Road, Edinburgh, EH1 3DG
0131 244 2501
charles.hodgson@scotland.gov.uk

Wales

Catherine
Cody, Public Health Division, National Assembly for Wales, Cathays Park,
Cardiff, CF10 3NQ
02920 823395
Catherine.cody@wales.gsi.gov.uk

Further
information


Aventis Pasteur MSD, www.apmsd.co.uk


VIS (Vaccination Information Service), 01628 773737. A vaccination helpline run
by highly-trained vaccine advisers


Department of Health guidance and support services for OH professionals,
www.doh.gov.uk/healthandsafety


Public Health Laboratory Service, www.phls.co.uk


British Travel Health Association, www.btha.org


Royal Society of Tropical Medicine and Hygiene, www.rstmh.org


International Society of Travel Medicine, www.istm.org


The A-Z of healthy travel, www.travax.scot.nhs.uk


NHS Chief Medical Officer, Memorandum on rabies, February 2000, www.doh.gov.uk
/rabies/memorandumonrabies/rabies.pdf


Department of Health, Welsh Office, Scottish Office Department of Health, DHSS
(Northern Ireland), Immunisation against Infectious Disease (The Green Book),
1996, London, The Stationery Office


Public Health Laboratory (Centre for Communicable Disease Control),
www.phls.co.uk


Medical Advisory Service for Travellers Abroad, www.masta.org


Updated Immunisation against Infectious Disease (The Green Book),
www.doh.gov.uk/greenbook


George C Kassianos, Immunization: Childhood and Travel Health (4th Edition),
2001, Oxford, Blackwell Science Ltd

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