Management of Hepatitis B Procedure

1. Purpose

1.1 Oxford Brookes University has a legal duty to ensure that where there is a potential exposure to hazardous substances that risk assessments are undertaken to ensure the risk is controlled and prevented where reasonably practicable. Immunisation as a preventative measure against workplace infection, is the last line of defence in the hierarchy of control measures as outlined in the Control of Substances Hazardous to Health Regs (2002). Meaning that additional controls should be available. However, vaccination is a suitable extra precaution for workers who may be exposed to blood-borne viruses.

1.2 Hepatitis B is a serious viral infection causing inflammation of the liver. The virus is spread by contact with blood or body fluids (through vaginal/anal intercourse, blood-to-blood contact including needle sharing, ‘needle-stick injury) from an infected person. The virus can infect without causing symptoms but some suffer an acute disease with flu-like symptoms.

1.3 The procedure is designed to set out how the University manages its responsibilities in terms of those staff and students exposed to blood borne viruses particularly Hepatitis B.

2. Scope

2.1 This procedure applies to staff and students of Oxford Brookes University involved in exposure prone procedures which could reasonably be expected to expose them to Hepatitis B. This could include:

staff and students carrying out research, e.g. human sciences
maintenance / refuse disposal / estates and accommodation site services
laboratory researchers / technicians / forensic work, etc
medical / dental / health care.

2.2 This procedure does not apply to health care students where alternative provision exists in relation to current fitness to practise arrangements.

3. Definitions

Exposure Prone Procedure (EPP) are those procedures where the worker's gloved hands may be in contact with sharp instruments, needle tips or sharp tissues (e.g. bone or teeth) inside a patient's open body cavity or wound, where the hands or fingertips may not be completely visible at all times. A sharps injury to the healthcare worker undertaking an EPP may result in the patient being contaminated with the blood of the healthcare worker, with risk of infection.

4. Responsibilities

4.1 Pro-Vice-Chancellor and Directors of Service are responsible for:

ensuring processes are in place for the assessment of risk associated with activities where Hepatitis B may be a hazard.

4.2 Heads of Department are responsible for:

ensuring appropriate risk assessments are in place for activities that present a risk from exposure to Hepatitis B
ensuring processes are in in place to notify staff/students of the option for Hepatitis B vaccination (where required) if they are not already protected.

4.3 Laboratory Managers/Line Managers/Team Supervisors are responsible for:

completing suitable risk assessments are in place for activities that may expose staff/students to Hepatitis B
ensuring Standard Operating Procedures are in place as appropriate
ensuring staff/students receive the appropriate training as identified through the risk assessment and that this is appropriately recorded
ensuring staff and students receive appropriate induction to include advising them of the risks associated with Hepatitis B and advising them of how to obtain a Hepatitis vaccination
notifying the Health and Safety Department of staff and students who wish to undertake a course of Hepatitis vaccinations.

4.4 Health and Safety Department are responsible for:

coordinating the arrangements for Hepatitis B vaccinations for staff and students and maintaining appropriate records.

4.5 Staff and Students are responsible for:

cooperating with the University in all matters relating to health and safety including following all safety controls relating to exposure to Hepatitis B
complying with the arrangements of the Hepatitis vaccination program and contacting the Health and Safety Department when a blood test is required
notifying their line manager/laboratory manager of any reasons why they have not been able to complete the course of vaccinations.

5. Procedure

5.1 The risk of contracting Hep B due to a work or study activity must be suitably risk assessed. Other than health care staff and students, the University does not engage in any activities that would be considered an exposure prone procedure (EPP) beyond a Category 1. As such, activities that bring employees and students into contact with bodily fluids and contracting Hepatitis B is remote.

5.2 Immunisation must not be considered the only control measure and appropriate mitigations must be adopted to minimise the risk staff and students coming into contact with bodily fluids. The following general principles are to be applied:

General principles

5.3 The risk of exposure to blood borne viruses can be significantly reduced by:

implementing good hand washing techniques
using protective clothing that is supplied; proportionate to the anticipated level of risk
covering broken skin with plasters and suitable gloves
not consuming food or drink in areas where there may be a risk of exposure to blood borne viruses.

5.4 Gloves and skin protection

Gloves of a suitable kind for the activity should be worn when handling bodily fluids. Latex and powdered gloves should be avoided.
An alcohol-based hand rub may be used where the ands are not visibly contaminated and no wash facilities are available.
Laboratory clothing should be washed at high temperature (ideally over 60 degrees).

5.5 Waste disposal and sharps

All sharps (metal and glass, needles, blades, pipette tips able to puncture bags must be placed in the designated yellow sharps containers.
Wastes contaminated with cytotoxic or cytostatic substances may require further segregation.

Risk assessment

5.6 All activities that involve exposure prone procedures must be suitably risk assessed in line with the University’s Risk Assessment Procedure

5.7 The risk assessment should determine the level of risk faced by those undertaking the activity..

For example, the following may be considered as a guide to risk levels:

Higher risk

Includes those who, as part of their normal duties, would be expected to experience frequent direct exposure to blood or other potentially contaminated human tissue or fluids; and where an acute contamination incident may not be immediately noticed.

Moderate risk

Includes those where there is a risk of contamination on a regular basis, but safe systems of work should normally provide adequate protection against blood borne virus contamination. Contamination incidents are isolated and recognisable e.g. academic medical staff not carrying out invasive or exposure prone procedures; laboratory technicians in pathology, haematology etc.

Low risk

Includes those where there is occasional risk of exposure, but this is not a regular feature of the role. Potential contamination incidents are isolated and recognisable. This includes security staff, porters, safety officers and domestic staff in areas where Hepatitis B is not a significant hazard.

5.8 Where higher risk activities are identified, this must be discussed with the H&S office to determine if Hep B vaccination should be considered a requirement for the role/activity. The advice of the OH service will be sought as appropriate.

5.9 Where Moderate Risk activities are identified, those undertaking them must be made aware and be offered a full course of Hep B vaccination if they do not already have immunity against Hepatitis B. Taking part in the vaccination is considered good practice but is not mandatory. Where staff have been advised of the program but do not want to take part, the laboratory/line manager should record and retain this information locally.

5.10 The University will make arrangements (through the H&S team) for those involved in Higher and Moderate risk activities to receive a course of Hep B vaccinations and associated serology.

5.11 The cost of the vaccination course, subsequent serology and booster doses will be met by the H&S Department.

5.12 The schedule of vaccinations and subsequent serology will be in line with the requirements of the UK Health Security Agencies ‘Green Book’

5.13 Where activities are assessed as low risk, yet the Faculty/Directorate wishes to offer Hepatitis B vaccination, staff and students will be able to access the voucher scheme through the H&S department. Costs for the vouchers will be recharged to the Faculty/Directorate.

6. Training and competency

6.1 Staff and students involved in activities that may expose them to Hepatitis B should receive the training that has been identified as a control in the risk assessment. Laboratory/line managers are responsible for maintaining a record of this training.

6.2 Laboratory/Line managers are to ensure only those deemed competent undertake tasks that could expose them to a risk of Hepatitis B.

10. Document control

Document title: Management of Hepatitis B procedure.

Document number: OB-HAS-PROC-16.00

Version number: V1

Originator name/document owner; Paul Bradley

Directorate: Health and Safety department

Implementation date: 01-Feb-2025

Date of this version: 01-Feb-2025

Date of next review: Feb-2028

Approved at: VCG-Ops Group

Date: 09-Jan-2025