In 2003, the Department of Health publication Taking a public health approach in the workplace1 stated that OH nurses needed to become more actively involved in enhancing the health of the employees within the organisation for which they worked.
Although much of OH adviser clinical activity is now focused on surveillance and associated biological monitoring, there is still one area of OH practice that is almost exclusively the domain of nurse practitioners – immunisations. The type of immunisations that need to be acquired, stored, and given will vary considerably dependant on the type of industry, or the employment sector that they relate to.
The recent journal article ‘A safe pair of hands’ (Occupational Health, November 2008)2 dealt with the training of OH practitioners. This article continues the immunisation theme and deals with the operational factors involved with the process, especially where the OH department is responsible for academic research or clinical staff. These people will be working closely with, or embedded within, the NHS, and delivering care in a non-NHS setting – a situation that is particularly true in those OH departments embedded within academia and working for universities.
There are several key areas of OH practice that need to be addressed, regardless of the type of vaccine or the reason for giving it, before including the practice within the operational remit of an OH department.
Policy
Immunisation may or may not have been a part of the skill grouping of the department and there may be a need to write a policy specific to the provision of vaccines. Within the organisation, such a policy, from a business perspective, has to be not only based on sound clinical evidence – it also has to ensure that it will clearly identify the appropriate target group(s), provide an evidence-based reason for asking those groups to comply with immunisation, and be cost effective, both in its execution and proposed outcomes.
Dependent on the employers’ organisational structure, it is possible that such a policy may also need to go through several ‘committee’ stages for discussion before acceptance by either the employer and/or employee representative bodies such as trade unions.
The development of an immunisation policy needs to take into account a number of issues such as the individual areas of OH practice, which tend to fall into identifiable groups:
Employment groups where vaccines are essential to protect the employee from work-related infections and/or are also needed to comply with statutory guidance or legislation
Once a policy has been accepted then thought can be given to a protocol that will address the issues of delivery of the focus of that policy: the what, when, where, by whom, and how often, and whether any post-immunisation biological monitoring or special surveillance processes are needed (serology). For example, in March 2007, the Department of Health published a document1 making it compulsory for NHS employers’ to screen all new healthcare workers for Tuberculosis (TB) and the blood-borne viruses hepatitis B, hepatitis C, and HIV. It also provided guidance on the requirement for screening for measles, varicella and rubella, and where it is identified that immunity is not present, the necessary provision of immunisation for those diseases for which there is a vaccine available.
Although focused primarily on employees either newly entering the NHS or employees taking up a new contract, these requirements were made retrospective for medical students already in training, and also include the need for both the immunisations, and any post-immunisation biological monitoring.
There is a further requirement for all immunisations and biological monitoring to be identity validated by photographic means (eg, passport, driving license, university card) by the nurse or physician at the time of the clinical procedure.
Vaccines that are essential for personal safety or health and safety reasons such as travel vaccines for business travellers
There are also those vaccines which are desirable for social or business continuity reasons, such as an annual corporate influenza immunisation programme for all staff.
Vaccines that are desirable from a public health perspective such as meningitis immunisation for university students
This last group is not usually an OH responsibility, and it is generally accepted throughout academia that all first-year students from the UK should have been to their family doctor before coming to university for the conjugate meningitis vaccine, if not already given at school. Students from overseas should have tried to obtain the A+C vaccine from their own doctor before travelling to the UK. All students should be encouraged to register with a local GP as soon as they arrive at university.
Employment immunisations
Which vaccine?
Although there is often only one type of vaccine available against a particular disease, there can sometimes be several of a similar type available from different manufacturers. The choice then needs to be based on other factors such as documented clinical response, vaccine availability, or even cost.
Which employment groups should the vaccines be given to?
The administration of vaccines needs to be controlled and offers of immunisation made only to those employee groups where an up-to-date risk assessment shows them to be at risk from exposure to the disease.
Where will the vaccines be administered?
In the academic or industrial occupational health setting, it is not always possible to provide a clinical environment in which to administer vaccines. This is particularly true if the organisation is spread across many different satellite locations, or where it would disrupt the manufacturing process, or where the employees are peripatetic (for example, utility workers).
In these instances, thought has to be given to where within each separate satellite location would provide the best opportunity to safely administer vaccines. Usually this is a clean, private office, with facilities for hand-washing close by, which would also allow for the eventuality of a patient fainting.
Who will administer the vaccines?
As a minimum requirement, this will need to be a registered nurse (not necessarily holding a qualification in occupational health) who has received training in giving immunisations,4 knows the contra-indications and side effects of each vaccine they are to administer, and is competent to recognise and treat anaphylaxis.5 Although there is not a need for a physician to be present, for safety in case of fainting or anaphylaxis, wherever possible, it is desirable that the nurse does not administer vaccines alone. The second person needs to be another nurse, a first-aider, or an administrative support person.
How often will the vaccines be administered?
Some vaccines (such as influenza) only require a single dose of vaccine per course, making the logistics of administration relatively easy. However, if there is a requirement to provide a course that consists of multiple immunisations (for example, hepatitis B), then in the process of planning the session, the availability and compliance of the employee must be taken into account to ensure that the employee will be able to return to receive successive doses at the appropriate times.
Also to be considered is the requirement to implement a robust recall for booster vaccinations if these will be needed in the future.
Will pre- or post-biological monitoring related to the immunisation be required?
There may be a requirement for either pre- or post-immunisation biological monitoring. This is particularly important with vaccines such as those given for hepatitis B, as the only way to ensure that the immunisation has been effective is by serology – a blood test to assess the antibody level and response. The location and requirements for conducting such tests may need to mirror the arrangements that were made to administer the vaccine.
Any nurse practitioner involved in the collection of biological monitoring samples must be aware of, and if necessary be reminded of, the need for ‘universal (standard) precautions’9 when collecting samples or handling vaccines, especially live vaccines – for example, Yellow Fever.
Recently, the recommendations for screening for TB have changed from using the Heaf test to using the Mantoux test.3 However, the Mantoux test in the OH setting is very time consuming as it requires the employee to attend two appointments – one for the administration of the test, and one for the reading of the skin reaction 48 to 72 hours later,6 and there is a very real issue of patient non-compliance in attending the second appointment.
To address this, several employers and universities are now using either the T-spot7 or the Quantiferon TB Gold8 blood tests. These new blood tests are relatively expensive in comparison to the Mantoux test. However, apart from being able to identify latent as well as active TB, they save money by reducing the overall number of OH appointments needed, and by reducing the amount of time employees are out of the workplace.
These tests also have the added advantage that, by virtue of being a blood test, once the blood is taken you have ensured 100% compliance. Furthermore, they do not rely on the subjective reading of a skin reaction.
Other considerations
Employee consent
Even if the employee has volunteered to have an immunisation, they will still need to give consent for the actual administration of the vaccine. To do this (which can either be an informed, verbal consent or a more formal written consent), they have to be aware of the reasons for the immunisation and any possible side effects. This can be managed during a one-to-one consultation or by using a comprehensive information sheet. In any event, there is a need to check with each and every patient for any contra-indications to the vaccine, and also that they understand the potential risks of immunisation.
Vaccine stability
Apart from the choice of vaccine and the location in which to administer it, there are several other factors to take into account, especially if using a location that is remote from a clinical base.
One of the principle factors, if not the main one, is the storage and transport of the vaccine stock. Vaccines are relatively susceptible to damage caused by temperature fluctuation, and need to be kept within defined storage parameters that, on average, tend to be between +2°C and +8°C, although each vaccine will have guidance on its specific storage temperatures printed on its packaging.
Within a clinical environment, vaccines should be stored in a refrigerator designed for that purpose, and the temperature checked and recorded regularly.3 If visiting satellite or remote locations, a cool-bag designed for vaccine transportation (domestic cool- bags available from camping shops are not suitable) will be required, and must be cooled adequately prior to use. Ideally a maximum-minimum thermometer should be supplied to constantly record the temperature inside the bag.
If using a cool-bag, only the minimum necessary number of vaccines should be transported, and the bag should be opened as few times as possible during the session. After the immunisation session, unused vaccines should not be returned to stock. If the storage temperature in the bag has been allowed to rise above the maximum permissible, the vaccines should be destroyed.
Clinical waste
Disposal of clinical waste is another major consideration. Yellow clinical waste bags and burn-bins are an absolute priority, and care should be taken to ensure these are collected and removed for appropriate disposal at the end of each immunisation session. A bio-hazard disposal pack is also useful for dealing with the possibility of spillage of either vaccine or blood. Again, any nurse practitioner involved in the immunisation session must follow universal precautions and ensure that any clinical waste is not left for office cleaners to dispose of.
Travel immunisations
Employers usually restrict travel immunisation to employees (and sometimes their families) travelling abroad on company business. The employer provides this type of immunisation to discharge its duty of care to ensure ‘as far as reasonably practicable the health and safety of the employee’.
The vaccine(s) that are offered should be based on a risk assessment that is founded on knowledge of the diseases that the traveller may encounter in the part of the world to which they are travelling, how long they are going to be in the particular geographical area, and whether or not they are staying in a city, or visiting and working in rural areas.
As the requirements of travel immunisation and prophylaxis change almost daily, it is necessary to have access to specialist advice before embarking on offering vaccines for travel purposes. If the organisation doesn’t have access to an in-house specialist in infectious diseases, then it is possible to subscribe to an organisation such as Masta,10 which will make the necessary information available for a reasonable fee.
If the organisation wishes to provide Yellow Fever immunisations, it must first register with the National Travel Health Network and Centre (NaTHaC)11 to become a UK authorised Yellow Fever centre.
Conclusion
The procedures for administering immunisations as part of an OH service and for the protection of the workforce needs careful evidence based consideration following a thorough risk assessment.
Robert Dunn TD is operations manager, Oxford University Occupational Health Service
References
1 Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers. Department of Health, March 2007
2 Training and competency assessment for Occupational Health Nurses administering vaccinations’, Occupational Health, November 2008
3 Immunisation against infectious disease – ‘The Green Book’. Department of Health, 2006
4 National Minimum Standards for Immunisation Training. Health Protection Agency, June 2005
5 Emergency treatment of anaphylactic reactions. Guidelines for healthcare providers Working Group of the Resuscitation Council (UK), January 2008
6 The Mantoux test – Administration, reading and interpretation, NHS Department of Health Publications
9 Standard precautions
10 Medical Advisory Services for Travellers Abroad (Masta)
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11 National Travel Health Network and Centre (NaTHNaC)
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