Minimising the risk

The
dangers of exposure to the SARS virus may be hitting the headlines, but for
most healthcare workers, the threat of blood-borne viruses are a daily risk,
by Linda Goldman & Joan Lewis

Ever
since the days of Typhoid Mary, the ‘powers-that-be’ have concentrated on
minimising the transmission of infection.

Recently,
the impact of the inhalation route has become of great importance as the
epidemic of severe acute respiratory syndrome (SARS) threatens to become a
pandemic.

It
has highlighted the importance of the standard use of masks and gloves when
dealing with at-risk contacts. However, non-fatal SARS is an illness of limited
duration, likely to be prevented by avoidance of droplet inhalation.

This
is and remains one aspect of preventive medicine in an OH generation that is
also concerned with the on-going problems of blood-borne viral disease. Whereas
infection may be transferred through interpersonal abrasion or mucosal
contacts, the common risks for the medical profession are needlestick injuries.

In
a nutshell, these are best avoided. It is not where the offending needle or
knife is going that counts – it is where it has been. And the sad fact is that
where it has been could be somewhere laden with a form of infection for which
there is little or no prospect of cure.

The
basic problem

Certain
diseases have serious professional as well as general health effects on members
of the healthcare professions.

Human
immunodeficiency virus (HIV) and the related autoimmune deficiency syndrome
(AIDS) have achieved notoriety. Dealing with their preventive aspects has
brought the problems of blood-borne viruses, including hepatitis B (HBV) and C
(HCV), into a practical focus. These have consequences for personnel involved
in any form of invasive procedure or mucosal contact.

Setting
aside the issue of inadequately sterilised instruments, there is also a
significantly greater risk of transmission from patient to doctor than
vice-versa.

OH
practitioners are involved both with prevention and the rehabilitation of
infected workers who are fit enough to continue work, but who should not be
permitted to put co-workers or patients at risk.

Although
needlestick injury is a known route of infection, the term should be
interpreted to include injury from any sharp (or relatively so) instrument. It
appears that the chances of becoming infected can be 30 per cent for HBV if the
source is a high-risk carrier, to 0.3 per cent for transmission of HIV.1
Infection depends on the level and virulence of the source patient’s infection,
and the type of injury sustained.

The
risk arises where exposure prone procedures (EPP) are performed, defined by the
Department of Health as:


invasive procedures where there is a risk that injury to the worker may result
in 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 with
sharp instruments, needle tips or sharp tissues inside a patient’s open body
cavity, wound or confined anatomical spaceÉ"

Although
it is unlikely that OH practitioners will undertake an EPP, there is an
increasing probability that they will have to deal with people who do, whether
or not they have actually sustained an injury.

In
some professions, such as dentistry, almost all procedures fit within the
‘exposure-prone’ category.

It
appears that a needlestick injury occurring while treating an HCV positive
patient carries a 1.8 per cent probability of transmitting the virus. This is a
substantially lower risk than HBV, but there are catastrophic professional
consequences of infection.

Occupational
health support can play a large part in career-change counselling and access to
training – essential factors for the employer to consider avoiding a Disability
Discrimination Act claim.

Information

Although
SARS has been hitting the headlines of late, it is important not to lose sight
of the continuing efforts by the Department of Health to deal with  the specific risks of transmission of
blood-borne infection to the medical profession.

Health
Service Circular HSC 2002/010 was issued on 14 August 2002 throughout the NHS,
together with guidance, to provide information on the management of
HCV-infected healthcare workers.

Healthcare
workers who know they are carrying HCV, or who have tested positive for it,
should not perform EPPs.

A
person will be fit to resume clinical duties, described as ‘exposure-prone’, if
they have had six months of negative tests following relevant antiviral therapy.

Testing
for HCV is mandatory where healthcare workers are known to have been exposed to
the virus.

People
who are found to be HCV positive should not be permitted to take up or resume
healthcare work that involves invasive contact, such as dentistry, surgery or
midwifery.

Occupational
health input

EPPs
occur mainly in surgery and related examinations. Some EPPs will have been
performed in parts of the world or in restricted populations – such as
drug-users – where there is a high prevalence of HCV.

OH
personnel dealing with infected workers have the usual ethical quandary of the
requirement of confidentiality against the need to protect the public. They
should discuss the full implications of viral status with the affected worker
so as to arrange appropriate tests, many of which will be carried out with a
view to a resumption of duties.

The
guidance points out that a trust may not necessarily be contractually bound to
carry out on-going status tests, so a private source of funding may have to be
located.

Further
advice on recommending resumption of duties is available from the medical
secretary to the UK Advisory Panel for Health Care Workers Infected with Blood
Borne Viruses (UKAP).2

The
guidance states that HCV positive healthcare workers should see a consultant OH
physician, who may refer the patient on to other levels of the department for
practical advice and personal counselling.

Career
change, for whatever reason, may be a painful process but people who have
acquired an illness while carrying out their professional duties are very
likely to have to deal with anger as well as sorrow at a time when their physical
resources are low.

Duty
of care

The
employer is under a duty of care to ensure that healthcare workers do not
perform EPPs while they present any risk of transmission to patients.

A
patient infected by a healthcare worker can sue for damages for the injury
suffered, whereas the healthcare worker will most likely have only their
contract of employment and the Disability Discrimination Act to rely on.

If
illness is contracted because the employer provided faulty equipment, the
employee may have some chance of redress, but it is an uphill road.

These
days, by treating all patients as if they are infected, the risks are
minimised. A needlestick injury is usually dealt with as an unfortunate
accident for which compensation is either not available or difficult to get.

Linda
Goldman is a barrister at 7 New Square, Lincoln’s Inn. She is head of training
and education for ACT Associates & Virtual Personnel. Joan Lewis is the
senior consultant and director at  ACT
Associates & Virtual Personnel, employment law and advisory
service consultancies, and licensed by the General Council of the
Bar in employment matters under BarDirect

References:

1.
Keynote speech at British Dental Association Workshop, 19 – 20 February 2002:
Professor Jeremy Bagg (professor of clinical microbiology, Glasgow Dental
Hospital)

2.
UKAP, Room 635B, Skipton House, 80 London Road, London SE1 6LH

Case
round up

Disability discrimination

According
to the Disability Discrimination Act 1995, an employer must not discriminate against
a disabled employee by refusing to offer him training, or by dismissal or
subjecting him to any other detriment. Thus, all retraining avenues must be
explored. In Fu v London Borough of Camden, 2001, IRLR 186, the employer
discriminated against Fu by dismissing her without considering all available
options, including retraining for a completely different form of work than that
which she had performed as a care worker prior to injuring her back.

Work-related
transmission of HCV

Five
incidents have been reported since 1994 of the transmission of hepatitis C
virus (HCV) from healthcare workers to patients during exposure prone
procedures. The Communicable Disease Centre reports that 15 patients have been
infected, one of whom was infected by a surgeon.

Although
small numbers of patients have been involved, the risk should not be
trivialised. Any employer who knows or ought to have known that a member of
staff is HCV positive owes a duty of care to patients to prevent infection. It
is therefore essential to follow the guidance and remove the healthcare worker
from clinical duties.

The
guidance recommends occupational health involvement in redeployment, retraining
and access to benefits for the healthcare worker, whose infective status puts
an effective bar on work that they have hitherto been trained and employed to
do. It states: "Employers should make every effort to arrange suitable
alternative work and retraining opportunities in accordance with good general
principles of occupational health and management practice".

Notification
for at-risk patients may not necessarily be within the OH department’s remit,
but if in doubt, advice should be sought from UKAP.

Transmission
from patient to doctor

Doctors
required to treat patients with communicable blood-borne disease should be
provided with proper training and equipment, including suitable contaminated
disposal facilities, needle-guards and heavy-duty gloves.

If
required to treat nervous patients, whose involuntary movements could cause
injury, sedation should be considered. The court deems the employer to know
that the employee is at risk.

Stokes
v GKN, 1968, 1WLR 1776, highlights the level of the duty of care. The employer
negligently failed to warn Stokes of the risk of contracting scrotal cancer
through exposure to mineral oils. The company doctor had failed to alert the
employer 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".

This
case was quoted in Mughal v Reuters, 1993, IRLR 571. Mughal lost his claim for
damages for contracting repetitive strain injury (RSI), which the court refused
to recognise, by reason of excessive computer use. The judge said: "É if
the employer is found to have fallen below the standard to be properly expected
of a reasonable and prudent employer in [respect of training and equipping the
employee], he is negligent."

There
is also a duty on the employee to take care of himself. In Lane v Shire Roofing
Co, 1995, IRLR 493, Lane’s damages were cut by 50 per cent because using his
own equipment (an unsuitable ladder) in a dangerous way was attributable to the
accident in which he fell and injured his back.

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