There are several vaccinations on offer that can protect UK workers from diseases posing severe health risks. Occupational health practitioners involved in the immunisation process should ensure that relevant policies and procedures are up to date, says Diane Romano-Woodward, director of Sunny Blue Sky.
Occupational health is a speciality within the domain of public health, and many practitioners are listed on the third part of the Nursing and Midwifery Council (NMC) register as specialist community public health nurses. One definition of public health is: “The science and art of promoting health, preventing disease and prolonging life through the organised efforts of society” (Acheson, 1988). As such, OH practitioners will be involved in the prevention of disease in working populations, and immunisation is one obvious and practical aspect of disease prevention.
In the UK, The Green Book, published by the Department of Health (DH), is the standard against which practice in immunisation is judged. It was last published as hard copy in 2006 and is also available to consult online.
The book presents information on vaccines and vaccination procedures for all of the vaccine-preventable infectious diseases that may occur in the UK. It is important that an occupational health service’s policies and procedures reflect the advice in The Green Book. If a policy deviates from this advice, a clear explanation of the justification needs to be recorded.
There have been numerous amendments since 2006 and each update is published in order that hard copies can be updated. However, many practitioners rely solely upon consulting it online in its updated form.
Health practitioners should encourage all employees to ensure that they have had the basic vaccinations covered by the UK immunisation programme (The Green Book, chapter 11) (see box 1).
The programme commences from childhood and continues until five doses of a tetanus-containing vaccine have been issued, usually around school-leaving age (The Green Book, chapter 30).
However, many individuals may not have completed the full schedule of all vaccines when they start work. While vaccinations in the UK immunisation programme are free to the patient up to the age of 15, there may be a charge for them after this age. For example, although the policy is to ensure that the individual has received two doses of the measles, mumps and rubella (MMR) vaccine, GPs are only remunerated for giving one dose of MMR and the payment system for GPs under their contract does not oblige them to implement this in full (although they may choose to do so). A guide to payment for a second dose of MMR has recently been published in the free monthly email bulletin “Vaccine update” (issue 179, May 2011).
Under the Health and Safety at Work Act 1974, employers, employees and the self-employed have specific duties to protect, so far as reasonably practicable, those at work and others who may be affected by their work activity, such as contractors, visitors and patients. Central to health and safety legislation is the need for employers to assess the risks to staff and others (The Green Book, chapter 12).
The Control of Substances Hazardous to Health Regulations 2002 (COSHH) require employers to assess the risks from exposure to hazardous substances, including pathogens (called biological agents in COSHH), and to bring into effect the measures necessary to protect workers and others from those risks as far as is reasonably practicable. Control measures such as universal precautions and the use of personal protective equipment contribute to reducing risk, and the use of immunisation for those diseases that are vaccine preventable is another.
If a vaccine is required because of occupational risk, it is the responsibility of the employer to arrange and pay for vaccination, even if it is part of the UK immunisation programme. GPs cannot charge their own patient for such vaccinations but can charge a person who is not their registered patient (for example, a person registered with a different general practice) for occupational health immunisations (“Vaccine update”, issue 179, May 2011).
Probably the biggest group of workers who require immunisation for work are those based in the NHS. This will include not only healthcare workers and laboratory staff, but also others working in healthcare settings. Their requirements are covered in chapter 12 of The Green Book.
The purpose of immunising these groups is not only to protect the worker and their family from acquiring occupational infections, but also to protect patients and service users. Some of these individuals have compromised immune systems and may not respond well to their own immunisations, so cannot be protected.
Additionally, by protecting those working in the NHS from infectious diseases, it is hoped that there will be less absence due to ill health, thus allowing services to run efficiently without disruption.
The latter is the premise of the annual flu vaccination campaign in the NHS. In spite of offering the vaccine to a group that might understand the benefits, voluntary uptake remains low. In the 2010/11 season, overall vaccine uptake among healthcare workers was 34.7% compared with 26.4% for the 2009/10 season (seasonal flu vaccine only). Strategies to increase the uptake of this vaccination have been a topic of interest in UK occupational health email groups such as JISCMail.
The MMR vaccine is also important in the context of the ability of staff to transmit these infections to vulnerable groups, and for this reason may be offered by healthcare OH departments, as may vaccination against varicella (chickenpox).
Since 1999, there has been a considerable increase in confirmed mumps cases. Most of these cases have occurred in adolescents or young adults who were too old to have been offered MMR when it was introduced in 1988, or to have had a second dose when this was introduced in 1996. They had not previously been exposed to natural mumps infection as children and so remained susceptible. In late 2004, a further increase in clinically diagnosed and confirmed mumps infections was observed. The vast majority of confirmed cases were in those born between 1980 and 1987 (The Green Book, chapter 23).
From 1953 to 2005, TB (BCG) vaccinations were part of the UK immunisation programme at age 14. It is now a risk-based programme; therefore, younger healthcare workers may not have had the vaccination and require it, although there is little evidence of its effectiveness in those over the age of 16 (The Green Book, chapter 32).
Hepatitis B is the only major blood-borne virus that can be prevented by vaccination, according to the Guidance for clinical health care workers: protection against infection with blood-borne viruses.
Other occupational groups
There is some evidence that workers who may come into contact with sewage should be vaccinated against hepatitis A and hepatitis B. However, those working with solid waste do not appear to be at the same risk (Rajnarayan et al, 2008).
The standards and system of voluntary accreditation for occupational health services aim to:
(i) enable services to identify the standards of practice to which they should aspire;
(ii) credit good work being done by high-quality occupational health services, providing independent validation that they satisfy standards of quality;
(iii) raise standards where they need to be raised; and
(iv) help purchasers to differentiate occupational health services that attain the desired standards from those that do not.
A report from the Institute of Occupational Medicine suggests that embalmers should receive immunisation against polio, tetanus, TB and hepatitis B (Creely, 2004). Workers who handle specific pathogens in their job may also have specific requirements.
In 2007, the DH introduced a programme of free seasonal flu vaccinations for poultry workers. This was a public health measure because people who work closely with poultry were perceived to be at most risk of catching bird flu from infected birds.
By protecting poultry workers against the human flu virus, seasonal flu vaccination was being used to prevent these workers from having human and bird flu viruses at the same time, a situation that might lead to a flu pandemic.
However, the DH has decided, based on advice from the Joint Committee on Vaccination and Immunisation (JCVI), to stop the poultry workers seasonal flu immunisation programme as there is currently no benefit. The seasonal influenza immunisation programme for poultry workers will not be implemented in the 2011/12 flu season.
Anyone who has to travel for work purposes should ensure that they are up to date with the UK immunisation programme vaccines, as other countries may have particular problems that are not usually seen in the UK. At the time of writing, for example, there is a measles outbreak in Europe – France has had more than 5,000 cases, and problems are also reported in Germany and Denmark.
Giving advice on immunisation requirements for specific countries is a specialist subject. It is important to discuss diseases and health issues not amenable to protection by immunisation, for example, malaria. Many business travellers stay in hotels and have access to reasonably hygienic facilities. However, the facilities in business accommodation in less-developed countries may be of a lower standard. Others may work in parts of the world in remote locations, for example, university researchers in life sciences, archaeology and geology. If it is thought that there will be difficulty or delay in obtaining medical assistance in case of an accident, a tetanus booster may be administered. As healthcare workers and blood products may not be as carefully screened as they are in the UK, hepatitis B vaccination may be indicated. Some vaccine-preventable diseases that may be relevant for travellers are listed in vaccination box 2.
Training and guidance
In 2010, the Faculty of Occupational Medicine published standards for occupational health services (see box 3). Along with the individual standards, guidance on suitable evidence of meeting the standards was provided. Several sections relate to the provision of immunisations.
1. The aims of immunisation: national policy and schedules.
2. The immune system and how vaccines work.
3. Vaccine-preventable diseases.
4. The different types of vaccines used and their composition.
5. Current issues and controversies regarding immunisation.
6. Communicating with patients and parents.
7. Legal aspects of vaccination.
8. Storage and handling of vaccines.
9. Correct administration of vaccines.
10. Anaphylaxis and other adverse events.
11. Documentation, record keeping and reporting.
12. Strategies for improving immunisation rates.
“Standard C: People” relates to competency to undertake the duties for which they have been employed. Section C1.2 addresses the minimum standard of ensuring that staff have the “knowledge, skills, qualifications, experience and training for the tasks they perform”. In s.D3.2 it requires that “an [occupational health service] must ensure that staff who advise or give immunisation are clinically competent according to national minimum standards for immunisation training”. Someone working in OH may not be familiar with the National Minimum Standards for Immunisation Training, produced by the Health Protection Agency (HPA).
The aims of these standards are to ensure that all health professionals engaged in vaccination are trained to be able to provide accurate and up-to-date information about the diseases and vaccines to their patients, to ensure that their practice is safe and effective and to give a high standard of care. The objectives are to enable health professionals to promote and administer vaccinations confidently, competently and effectively.
This training should be undertaken, not only by those who administer vaccines, but also by those whose only role is to advise. The suggested minimum duration of basic training is a two-day course, and annual updates must be provided for and attended by those who have completed basic training. A core curriculum has been suggested by the HPA (see box 4).
It would be prudent for OH physicians to check a nurse’s competencies to administer vaccines, using the HPA guidance annually when signing written instructions to administer prescription-only medicines. There is no specific training requirement for doctors other than they should maintain competencies appropriate to the scope of their practice through continuing professional development.
There is clear guidance in The Green Book on all practical matters regarding the use of vaccines. Each practice, clinic or pharmacy should have at least one trained individual, with at least one trained deputy, responsible for the receipt and storage of vaccines and the recording of refrigerator temperatures.
Regular audit, carried out at least once a year, should be undertaken. Any other staff who may be involved with vaccines must be trained appropriately.
The importance of the cold chain cannot be over-emphasised, this includes checking the vaccine on receipt for supplier, routine storage and also if the vaccine is taken to an outlying clinic. The vaccine refrigerator must be a special refrigerator for the storing of pharmaceutical products and not a domestic refrigerator. Nothing else should be stored in it and it must be lockable or situated in a locked room. The temperature within the vaccine refrigerator must be continuously monitored with a maximum/minimum thermometer. If vaccines are being transported off site to outlying clinics, validated cool boxes with maximum/minimum thermometers should be used. Domestic cool boxes should not be used.
If you are involved in giving advice on vaccines or administrating vaccines, consider the following actions:
- Review The Green Book (general chapters) to ensure that your practice is in line with national standards.
- Assess your knowledge of UK immunisation policy and practice on the HPA website online testing facility.
- Perform an audit of one aspect of the guidance to ensure consistency throughout the organisation. This may highlight deficiencies in training.
- Benchmark your processes and forms (consent, temperature recording, stock control) with another similar OH service.
- Identify the training requirements of your staff including nurses, physicians and administrators who may receive vaccines when nurses are not available.
Diane Romano-Woodward is an occupational health adviser and director of Sunny Blue Sky.
“Independent inquiry into inequalities in health”. Sir Donald Acheson, London, 1988.
Immunisation against infectious disease – The Green Book. 2006 updated edition.
“Vaccine update”, issue 179, May 2011, special issue.
Influenza vaccine uptake monitoring of behalf of the Department of Health.
Guidance for clinical health care workers: protection against infection with blood-borne viruses”.
Rajnarayan R, Tiwari (2008). “Occupational health hazards in sewage and sanitary workers”. Indian Journal of Occupational and Environmental Medicine. December 2008; 12(3): 112-115. Doi: 10.4103/0019-5278.44691.
Waste Manage Res 2005: 23: 79-86. “Vaccinations for waste-handling workers: a review of the literature”.
Creely KS (2004). “Infection risks and embalming”. Institute of Occupational Medicine research report TM/04/01P 34.
HSC, Advisory Committee on Dangerous Pathogens and Advisory Committee on Genetic Modification (1990).”Vaccination of laboratory workers handling vaccinia and related poxviruses infectious for humans”.
“Vaccine update”, issue 180, June 2011. Poultry workers influenza immunisation programme – JCVI advises against implementation of programme in 2011/12.
Royal College of Nursing. “Measles outbreak in Europe”.
“Occupational health service standards for accreditation”. London, Faculty of Occupational Medicine 2010.
HPA (2009). “National minimum standards for immunisation training”.
HPA (2005). “Core curriculum for immunisation training”.
“Vaccine update”, issue 178, May 2011.
HPA UK immunisation policy and practice online testing facility.