Employers have a duty of care to ensure that employees work in a safe environment, where infection and injury risks are minimised as far as is reasonably practicable. Similarly, employees have a duty of care to maintain a safe environment for all individuals attending the dental practice.
Employee Health Records
Employers have a duty of care to ensure that employees work in a safe environment, where infection and injury risks are minimised as far as is reasonably practicable. Similarly, employees have a duty of care to maintain a safe environment for all individuals attending the dental practice.
From an infection prevention and control (IPC) perspective, immunisation is a key strategy in reducing the risk of vaccine-preventable diseases (VPDs). Immunisation not only protects employees from acquiring VPDs but also reduces the potential for onward transmission to patients and others within the healthcare environment.
Employees with certain allergies, including dermatological conditions, may require different IPC strategies to ensure that they can either wear suitable personal protective equipment (PPE), be able to use hand hygiene or cleaning products, and maintain skin health to reduce infection risks. Allergies can also pose a general health risk in the workplace for the employee (i.e. anaphylaxis).
It is important for dental practices to implement an assessment process to identify employees’ immunisation status and any significant allergies. This ensures employees are:
- adequately protected against VPDs
- health risks from identified allergens are minimised as much as practicable
- managed appropriately if exposed to an identified pathogen or allergen.
Implementation of an Employee Health Record Program
All employees should be assessed for their immunisation status for identified vaccine preventable diseases and any significant allergies. This assessment is best performed during the recruiting process for new employees, but should also be conducted for existing employees, if not done previously.
Section 47 of the Work, Health and Safety Act 2011 (Cth) (WHS Act) (and corresponding State and Territory legislation) requires employers to consult, so far as reasonably practicable, with employees who are, or are likely to be, affected by a matter relating to their health or safety.
Where a practice does not have existing policies and procedures to identify employees who may be vulnerable or susceptible to pathogens or allergens due to their immunisation status in the course of their work, it is strongly recommended employers consult with employees before introducing a policy/procedure of this nature.
As part of the consultation process, employers are required to:
- provide workers with relevant information about the matter;
- provide workers an opportunity to express their views and to raise issues in relation to the matter;
- provide workers an opportunity to contribute to the decision-making process relating to the matter;
- take the views of workers into account; and
- advise workers on the outcome of the consultation in a timely manner.
The ADA Staff Member Health Assessment and Records FAQs can assist in providing further information to current and new staff regarding Employee Health assessment and records. If concerns are raised by employees regarding the policy and/or process, further support can be sought from the ADA HR advisory service, or from ADA Infection Control Committee (if relating to immunisations/vaccination queries).
Employee Health Record Management and Maintenance
The collection and documentation of an employee’s health status, including the reasons for why an employee elects not to be immunised or share their immunity status, falls within the scope of health information for the purpose of the Privacy Act 1998 (Cth) (Privacy Act). Under the Privacy Act, employers must ensure that:
- active measures are taken to ensure the security of collected employee health information, and reasonable steps to protect the information from misuse, interference, loss, modification, disclosure or unauthorised access.
- the use or disclosure of collected employee health information for a secondary purpose is restricted to situations where the individual would reasonably expect the employer to use or disclose the information for that purpose and the secondary purpose is directly related to the primary purpose of collection
- reasonable steps are taken to ensure the employee health information is accurate and up to date.
Employers are also encouraged to check for specific obligations that may be applicable under State and Territory legislation that also applies with respect to health information, for example:
- Health Records Act 2001 (Vic);
- Health Records and Information Privacy Act 2002 (NSW);
- Health Records (Privacy and Access) Act 1997 (ACT); and
- Personal Information Protection Act 2004 (Tas).
Employee Health Records must be kept securely and confidentially, only accessible by designated responsible person(s) in the dental practice who may be either involved in the review/assessment of collected employee health information and/or the direct management of any employee health work related incidences.
Where an employer needs to disclose health information of an employee to another individual or entity (i.e.
in the event of a potential or actual exposure to a pathogen, or other work-related employee health issue), an employer should confirm whether the employee has previously consented to the employer disclosing this information, and where practicable reconfirm an employee’s consent in writing or via conversation.
Reconfirming an employee’s consent may be in the form of writing or via a conversation and should then be recorded in their Staff Health Record.
Despite the above, where it is unreasonable or impracticable to obtain an employee’s consent an employer is permitted to disclose the information where the disclosure is required to lessen or prevent a serious threat to the life, health or safety of any individual or to public safety. However, caution should be exercised when relying upon this exception.
As Employee Health Records must be accurate and up to date, it is recommended that employers regularly review staff health records with their employees and update their records as required, for example:
- current vaccination information for seasonal (i.e. influenza) or other time limited (i.e. diphtheria tetanus-acellular pertussis) vaccinations
- identification of an allergy or change to an allergy management plan
- management of a potential or actual exposure to a pathogen (i.e. BBFE event)
- management of a non-pathogen related staff health issue (i.e. dermatitis)
- disclosure of any other new relevant health information
Records for VPD immunity/vaccination that are not seasonal or time limited, such as Hepatitis, Measles, Mumps, Rubella and Varicella, do not need to be re-visited after the initial assessment and confirmation of immunity has been established.
Employers may choose to utilise the ADA Immunisation Summary (Staff Immunisation Register) as a summary document to assist in the regular review of Employee Health Records, and to identify when records may need updating. This Register would also be considered as health information and must be managed as per individual Employee Health Records.
Immunisation
Health care workers are at risk of exposure to a range of VPDs through patient contact as well as through community or travel-related exposure. Immunisation recommendations must take into account the risk of exposure for all VPDs for the individual. Immunisation recommendations should therefore take into account both occupational and non-occupational risk factors, along with the individual’s medical history.
While most dental health care workers may already be immune to the typical childhood VPDs from routine immunisation or prior infection, serological testing can be helpful to confirm immunity. VPD infections in adults often carry a greater burden of illness than in childhood, therefore if serology indicates a lack of immunity, appropriate vaccination should be undertaken.
The Australian Immunisation Handbook recommends all health care workers be immunised against:
- hepatitis B
- influenza
- measles mumps rubella (MMR) (if non-immune)
- pertussis (dTpa [diphtheria-tetanus-acellular pertussis]) (every 10 years)
- varicella (if non-immune)
- hepatitis A (if working in remote Aboriginal and Torres Strait Islander communities or with Aboriginal and Torres Strait Islander children in NT, QLD, SA, WA, or as specified by state or territories).
In addition, depending on personal health, occupational setting, and travel risk, the following vaccinations should also be considered:
- poliomyelitis
- pneumococcal disease
- meningococcal disease
- typhoid
Regular surveillance for tuberculosis infection may also be appropriate in some circumstances, using immunological tests for responsive lymphocytes (e.g. Quantiferon Gold test) rather than repeat skin testing (Mantoux test), since the latter causes false positive results when repeated often.
Dental practices must also remain informed of any jurisdictional mandates regarding vaccination. Those employed in the public health sector should consult their relevant state or territory health department for requirements relating to specific vaccines.
Assessing employee immunisation status
Assessment of immunisation status involves reviewing documented vaccination records and/or serological results for the Australian Immunisation Handbook recommended VPDs for health care workers. This should be conducted by a qualified health professional with expertise in interpreting immunisation and serological records - such as a general practitioner, immunisation provider, or infection prevention and control practitioner.
Results of the assessment must be reviewed by a designated responsible person in the dental practice, and appropriate actions enacted if an employee is:
- not immunised,
- immunisation fails in producing a sufficient immunological response (non-responder), or
- if an employee declines to provide immunisation documentation or be immunised.
To assist practices in this process, the ADA has developed an Employee Health Record - Record of Immunisation form. This form facilitates the collection and review of vaccination records and supports appropriate follow-up. Page 1 should be completed by a qualified assessor, and Page 2 should be completed by the practice’s responsible person following review of the evidence provided.
If there is no evidence of immunisation or serology (depending on the disease), the employee should be referred to their general medical practitioner or immunisation provider for immunisation, and their record subsequently updated.
For staff who have been vaccinated for hepatitis B, but serology shows insufficient levels of antibody to hepatitis B surface antigen (Anti-HBs), the employee should be referred to their general medical practitioner or immunisation specialist to consider further vaccination strategies available to stimulate an immunological change.
Management of non-immunised or non-responder employees
Employees who choose not to be immunised (or to provide immunisation information), or are a confirmed non-responder to immunisation, must be counselled and managed appropriately. They should be informed of:
- Their increased risk of acquiring VPDs in the workplace
- The risk of transmission to patients, colleagues, and their own household contacts
- Possible restrictions on their scope of work depending on exposure risks.
Employees should then formally acknowledge and that they understand and accept the implications of their vaccination status. Dental practices may choose to utilise the ADA Declination to participate in Immunisation Screening for those that decline to be vaccinated/provide vaccination information, and those that are vaccine non-responders.
Employers must also undertake a risk assessment considering the employee’s role and responsibilities. Where necessary, reasonable adjustments to their duties and or workspace should be made to reduce potential exposure risks. For example:
- A dental assistant who is not immunised against a VPD may be excluded from providing care to a patient with a suspected or confirmed infection with that pathogen
- A non-responder to hepatitis B vaccination may be reassigned from tasks such as reprocessing reusable medical devices (RMDs) due to the risk of BBFE injury.
In such cases, practices must balance their duty of care to the employee with the overarching requirement to provide a safe environment for patients and the broader healthcare team.
Hepatitis B
Hepatitis B vaccination usually follows a 3-dose schedule (0, 1 and 6 months) and induces protective levels of neutralising antibody against hepatitis B virus in more than 90% of healthy adults. Seroconversion occurs in approximately 30–55% of people after the first dose, increasing to approximately 75% after the second dose. The third dose is needed to increase the percentage of people who respond and to provide long-term protection. More compressed 3-dose schedules, such as 0, 1, 3 months, are not recommended as they are associated with lower peak levels of antibody to hepatitis B surface antigen (anti-HBs), and likely shorter duration of antibody persistence at protective levels.
Levels of antibody to hepatitis B surface antigen should be checked at least 4 weeks after the full 3-dose vaccination course to check for adequate seroconversion (anti-HBs level of ≥10 mIU per mL). Hepatitis B vaccines are prepared using recombinant technology.
Following purification, the hepatitis B surface antigen (HBsAg) protein is adsorbed onto elemental aluminium (as hydroxide and/or phosphate). These vaccines may contain up to 1% yeast proteins (but no yeast DNA). Notably the Engerix-B and H-B Vax II vaccines are manufactured by different processes, and the HBsAg content of ‘equivalent’ doses of these 2 vaccines is different, and therefore switching of ‘brands’ should not occur during the vaccination schedule.
Dental staff who have been successfully immunised against hepatitis B (i.e. have documented evidence of anti-HBs level of ≥10 mIU per mL at any time 4+ weeks post vaccination) do not need post-exposure prophylaxis after a blood and body fluid exposure (such as a sharps injury) from a hepatitis B source (e.g. a chronic carrier).
Dental staff who have not been vaccinated for hepatitis B, not adequately or have an unknown seroconversion from prior hepatitis B vaccination, will be, or considered, at risk of contracting hepatitis B after a blood and body fluid exposure. It is critical that these staff who experience a blood and body fluid exposure are managed in a timely and appropriate manner as prompt post exposure prophylaxis (hepatitis B immunoglobulin) is crucial in reducing the risk of hepatitis B infection.
Blood Borne Virus (BBV) Status
In general, there is a minimal risk of transmission of a BBV from an infected employee to a patient provided that appropriate routine infection prevention and control precautions are practised. However, performing exposure prone procedures (EPPs) presents an increased risk of an injury occurring to a health care worker (HCW) that could result in the patient tissues being exposed to the HCWs blood. EPPs are procedures where the HCW’s hands (whether gloved or not) may be in contact with sharp instruments, needle tips or sharp tissues (spicules of bone or teeth) inside a patient’s open body cavity, wound or confined anatomical space where the hands or fingertips may not be completely visible at all times. Appendix 1 of the The Australian National Guidelines for the Management of Healthcare Workers Living With Blood Borne Viruses and Healthcare Workers Who Perform Exposure Prone Procedures at Risk of Exposure to Blood Borne Viruses provides examples of dental procedures which are considered EPPs.
While the BBV status of employees is not considered a requirement of the employee health assessment, dental practitioners who perform exposure prone procedures should be reminded of their obligations as part of their AHPRA registration to be compliant with The Australian National Guidelines for the Management of Healthcare Workers Living With Blood Borne Viruses and Healthcare Workers Who Perform Exposure Prone Procedures at Risk of Exposure to Blood Borne Viruses, specifically:
- a HCW performing EPP’s must be tested at least once every three years and also after the occurrence of any potential occupational exposure incident.
- that if a HCW has a blood borne virus, they: o under appropriate and ongoing medical care o only perform EPPs if they meet the clinical criteria in the Guideline for that blood borne virus.
Employees are not required to disclose to employers their blood borne virus (BBV) status, but they may wish to do so, and if so, the information should be recorded in their Employee Health Record.
Pathogen (including Blood and Body Fluid (BBFE)) Exposure Management
Non-BBFE exposure
In the event that employees are exposed to a VPD, the immune status of the exposed employee must be considered. If they do not have recorded immunity to the VPD, the dental practice must ensure that appropriate medical follow up and care is provided. For all employee who may have been exposed (excluding BBFE exposure) to other pathogens that are not considered VPDs, medical advice should be sought to determine if medical follow up and care is required.
BBFE exposure
Employees should be reminded of their obligation to report all BBFE injuries to the appropriate manager as they occur so timely and appropriate follow up can be arranged. Information on managing blood and body fluid exposures can be found in the Appendix: Blood and body fluid exposure (BBFE) protocol of the ADA Guidelines for Infection Prevention and Control (5th edition).
Employee Health Record - Incident Notes
If exposed to a pathogen, the Employee’s Health Record must be updated to record:
- details of the exposure
- details of the follow up care/advice that was sought, or deemed not required
- any other relevant information associated with the exposure.
Dental practices may choose to utilise the ADA template for recording such detail. This form can also be used to record other employee health information and/or incidences, such as cases of dermatitis or other staff health incidences.
Allergies
An allergy occurs when a person has an abnormal or excessive immune system response to a particular stimuli (allergen). Allergens may be encountered through inhalation, ingestion, injection, skin contact, or as a result of an autoimmune condition.
There are 4 types of allergic reactions:
Type 1/immediate:
An IgE mediated reaction that usually develops within a few minutes of exposure. Reactions may be mild but can progress to anaphylaxis. Examples include allergic rhinitis, some forms of asthma, acute urticaria, and food, drug or latex allergies.
Signs of anaphylaxis include:
- Difficulty or noisy breathing
- Swelling of tongue
- Swelling or tightness in throat
- Wheeze or persistent cough
- Difficulty talking/hoarse voice
- Persistent dizziness/collapse
Signs of mild to moderate reactions include:
- Swelling of lips, face, eyes
- Hives or welts
- Tingling mouth
Signs of mild to moderate allergic reactions may occur before progressing to anaphylaxis.
Type 2:
An IgG/IgM mediated cellular cytotoxic reaction that is usually a drug-induced reaction, but also present in some auto-immune diseases, and results in cell destruction (cytopenia or cytolysis) of affected cell types.
Type 3:
An IgG/IgM immune complex mediated reaction where antibody-antigen complexes are deposited in tissues throughout the body and causes inflammation. Examples include systemic lupus erythematosus and rheumatoid arthritis.
Type 4/delayed allergy/contact dermatitis:
T cell mediated with symptoms appearing 12 to 72 hours after exposure to the allergen. Examples include contact dermatitis, celiac disease and some forms of asthma. Clinical presentation will depend on the allergen and the tissue type affected.
From an IPC perspective, allergies may impact on a staff member being able to wear certain PPE or use other IPC products (such as hand hygiene products or cleaning products). For example, if a staff member has a proven or suspected allergy to natural latex, or other chemicals present in gloves, a suitable alternative will allow the employee to be able to wear gloves without affecting their health.
As intact skin is a first-line defence mechanism against infection, it is also important that dermatological conditions that affect the integrity of the skin barrier in hands is managed well.
Assessing employee allergy
Allergy assessment is achieved by having the staff member advise the dental practice of any suspected or confirmed allergies, and the type of reaction they have to the allergen. Any reported allergies must be reviewed by a designated responsible person in the dental practice, and an appropriate management plan (of required) documented and implemented.
The ADA Employee Health Record - Record of Allergies form can be used to assist dental practices in document allergy information and agreed allergy management plan(s) for staff. Page 1 is to be completed jointly between the staff member and the responsible person in the practice. It is recommended that the advice of a suitable medical practitioner is sought if clarification is regarding allergen identification, reaction types, or management strategies.
Management of employees with an allergy
The allergy management plan for a staff member will depend on:
- the type of allergy
- the likelihood of allergen exposure in the workplace
- the clinical presentation of the allergic reaction.
Type 1/immediate allergy that results in anaphylaxis:
The dental practice must ensure, as far as reasonably practical, that the workplace is free of that allergen. For example,
- if the allergen is latex, the clinic must be latex-free.
- if anaphylaxis is triggered by a particular food, the dental team must avoid bringing that allergen into the workplace.
- In the event that there is an exposure to the allergen, the management plan should include:
- immediate treatment with adrenaline (epinephrine), usually delivered in the form of an Epi pen/Anapen
- follow up with further medical attention.
Mild Type 1 and some Type 4 allergies:
Employees may need access to alternative IPC products, such as:
- hand hygiene products that are free from the allergen
- different environmental cleaning products that are free from the allergen
- alternative gloves or masks that are from the allergen.
Other workplace management plan strategies may include:
- separation of food storage, preparation, or eating utensils and crockery
- labelling/identification of potential allergies in foods/drinks, especially if shared
- adjustment of work duties and/or workplace environment
Active dermatitis:
A management plan may include:
- access to skin-friendly paper towels and specific topical treatments
- ensuring proper hand hygiene practices, including thoroughly drying hands before donning gloves
- covering any cuts, cracked skin and opened wounds with a flexible, fluid-proof/water-proof dressing when being involved with the provision of health care services
- excluding staff excluded from duties involved in the provision of health care service during periods of severe dermatitis, and seeking the advice of a suitable medical practitioner.