Some individuals are at increased risk of severe or complicated illness if they suffer from influenza. This guidance gives advice on protecting healthcare employees who are pregnant or in one of the other at risk groups identified for (H1N1) 2009 flu (swine flu).
- Employers have a legal duty to ensure, so far as is reasonably practicable, the health, safety and welfare of their employees in the course of their work;
- Where workers are at risk from infectious diseases, such as swine flu, as a result of their work then the employer has a duty to prevent that exposure or, where that is not reasonably practicable, to control exposure adequately;
- Employers must ensure that a proportionate risk assessment is conducted for all workers;
- Pregnant women are at increased risk of complications if they contract pandemic (H1N1) 2009 flu (swine flu). As a result measures should be taken to minimise the risk to pregnant workers, and staff in other at-risk groups, who might otherwise be working in close contact with people who have swine flu;
- The risk assessment should be carried out together with the worker who is pregnant, or who is in one of the at risk groups, taking advice from occupational health professionals as appropriate;
- Organisations should, where appropriate, ensure engagement with staff side representatives and health and safety representatives. Staff side representatives may also help to reassure staff;
- Vaccination is an important part of any risk minimising strategy. Employers and their Occupational Health teams should work with all pregnant workers and other at- risk staff to ensure they are offered the vaccine as soon as possible.
1. Health and safety advice on protecting employees from infection is based on the potentially increased likelihood of close exposure to infection in the workplace, compared with everyday exposure in the community, and the requirement for employers to protect workers from exposure to substances hazardous to health, like the swine flu virus. The current advice on actions needed to ensure the safety of at-risk employees in a pandemic is that -
- employers prevent exposure to the infection where possible or,
- where prevention is not possible, they use adequate control measures.
2. Health and Safety at Work legislation also requires employees to take steps to protect their own health and safety while at work.
3. Some individuals are at increased risk of severe or complicated illness if they suffer from influenza. In the current pandemic of swine flu this includes pregnant women where severe illness is more likely if it occurs in mid - to late pregnancy. A list of the current at-risk groups for the purpose of this paper is at Annex A.
4. As swine flu only emerged in April 2009 there is limited information to inform precise risk assessments. However, most people who catch the disease, including most pregnant women, have only a mild illness and make an uncomplicated recovery.
5. This guidance is based on information available from swine flu cases so far. It will be updated in the future as knowledge about the virus increases.
6. Advice on how to minimise the risk of getting swine flu is the same for pregnant women or staff in other risk groups as it is for the general population1. They should:
- observe good hand hygiene, with frequent use of soap and water or alcohol-containing gel;
- wherever possible, avoid contact with someone who is known or suspected to have swine ‘flu.
- in the case of people in at-risk groups, including pregnant women, make early contact with health services if they develop flu-like symptoms, when treatment with antiviral drugs may be advised.
7. It is important to realise that many infected individuals, with or without distinct symptoms, will be encountered in the community, in family life and during travel. Measures to minimise exposure at work will not influence the risk of exposure in the wider environment, and healthcare workers should not assume that such measures guarantee avoidance of exposure or infection.
8. General guidance about human resources for employers and staff is available in the joint NHS Employers and Department of Health Pandemic Influenza - Human Resources Guidance for the NHS2.
Actions for employers and occupational health advisors
9. Advice to ensure the safety of at-risk employees in a pandemic is based on employers -
- preventing exposure to the infection where possible, or, where prevention is not possible,
- using adequate control measures. General advice on the use of PPE is at Annex B.
10. In order to ensure that they comply with their duties under the legislation, employers should ensure that they complete an assessment of risks to their employees’ health and safety.
11. The risk assessment should be undertaken in consultation with the affected member of staff and include the potential increased risks to staff in at-risk groups as well as to any pregnant workers, arising from their normal work activity, and to keep this under review throughout the pandemic. Annex C contains further guidance on risk assessment.
12. Where appropriate, employers should seek advice from occupational health professionals who are able to access the most up to date information on risk. In the health care sector this may be best achieved by Occupational Health Departments working together on a regional basis.
13. The outcome of the risk assessment and the action proposed by the employer must be shared with the worker. Where appropriate employers should engage with staff side representatives and health and safety representatives to help ensure local issues are addressed.
Actions for employers and employees, including healthcare staff in at-risk groups
14. If a member of staff is pregnant or is in an at-risk group they should inform their employer in writing as soon as they can. This will allow the employer to take appropriate action to ensure that staff are not exposed to risks, which may include exposure to pandemic flu infection (see paras 16 & 17).
15. Staff who are pregnant, particularly in the 2nd and 3rd trimester and people in other at-risk groups, and their managers, should familiarise themselves with the Department of Health Guidance Infection Control in Hospitals and Primary Care Settings3 (see Annex D for extract). HSE guidance on employers’ responsibilities is available online in the document New & Expectant Mothers at Work - A Guide for Employers4 (INDG373).
In particular -
- employers should discuss with employees who are at-risk or are pregnant the need to be deployed away from areas used for the care of those who have, or are clinically suspected of having, pandemic flu; or in the primary care setting, from clinics set up to manage people with flu-like symptoms;
- when considering the risks, the likely closeness of the work to the patient (for example close personal care), including frequency and duration of contact, should be considered as part of a risk assessment;
- when, following the risk assessment, it is agreed that redeployment is required, employees who are at-risk or are pregnant should be deployed away from the direct care of suspected or known cases of pandemic flu until they have been vaccinated (where appropriate following a further risk assessment, given that vaccination does not always provide total protection), given birth or fully recovered from confirmed swine flu;
- employers should take into account any redeployment when considering resource requirements.
Staff members who develop flu
16. Those individuals who contract flu will normally develop immunity to the infecting flu virus. Immunity will usually develop even if they take antiviral medicines, because the immune response is already developing when symptoms appear.
17. However, staff who have recovered from flu or a flu-like illness should continue to apply infection control and other control measures to avoid exposure to flu viruses, given that more than one flu virus may be in circulation.
At-risk groups for the purpose of this paper5
1. People with the following underlying medical conditions:
- Chronic lung disease
- Chronic heart disease
- Chronic kidney disease
- Chronic liver disease
- Chronic neurological disease
- Immunosuppression (whether caused by disease or treatment)
- Diabetes mellitus
2. Patients who have had medical treatment for their asthma within the past three years.
3. Pregnant women
4. People aged 65 years and older
5. People who are morbidly obese
General advice on the use of Personal Protective Equipment
1. Personal protective equipment will not eliminate the risk of exposure, but will help minimise the possibility of such exposure.
2. In the healthcare setting, all staff should follow local and national guidelines on the use of masks in at-risk situations. Current guidance is to wear moisture-repellent surgical masks if working closer than one metre from patients who have or who may have swine flu (see extract from the DH guidance in Annex D below);
3. ONLY those staff carrying out aerosol-generating procedures should use FFP3 respirators, and must be trained in, and follow, correct fitting procedures.
Practical steps for assessing and managing the risks as applied to swine flu and high risk groups
A risk assessment is an important step in protecting workers and businesses as well as complying with the law. It helps employers to focus on the risks that really matter in the workplace - the ones with the potential to cause real harm. Workers, and others such as patients, have a right to be protected from harm caused by a failure to take reasonable control measures.
How to assess and manage the risks in the workplace
These five steps should be followed:
STEP 1: Identify the hazards - in this case exposure to the swine flu virus.
STEP 2: Decide who might be harmed and how - vulnerable groups of people such as pregnant women, or those with underlying medical conditions, such as asthma.
STEP 3: Evaluate the risks and decide on appropriate control measures - such as minimising exposure through redeployment, good personal hygiene, and frequent handwashing.
STEP 4: Record findings and implement them - for example written advice should have been received that a staff member is pregnant, and this should be recorded as well as the measures being taken to minimise the occupational risk of exposure to swine flu.
STEP 5: Review the assessment and update it if necessary - for example once a staff member has had a baby and returned to work.
Further information can be found at http://www.hse.gov.uk/risk/fivesteps.htm
The process should not be overcomplicated. In this instance, the risks are known and the necessary control measures are easy to apply. It helps if staff or their representatives are involved in the process. They will have useful information about how the work is done that will make the assessment of the risk more thorough and therefore more effective. But it must be remembered that the employer remains responsible for seeing that the assessment is carried out properly.
When undertaking the risk assessment, remember that a hazard is anything that may cause harm, such as swine flu. The risk is the chance, high or low, that somebody could be harmed by these and other hazards, together with an indication of how serious the harm could be. For example, evidence suggests that pregnant workers or those with chronic diseases such as respiratory problems are at more risk than others. The risk assessment, and control measures, should take account of these differences.
Example for an ‘at risk’ health care worker
A nurse states in writing that she is pregnant. A meeting is arranged to discuss her work and simple measures that can be taken to avoid exposure to the swine flu virus. She says that her normal duties include direct care of patients who may have swine flu. She confirms that she has been trained in and is familiar with infection control procedures and the precautions necessary for swine flu.
An assessment of the risks is conducted, and the need for redeployment to other duties is discussed with the nurse in order to avoid direct care or contact with patients with flu, until she has had the baby. An agreement is reached for immediate redeployment, and her attention is drawn to guidance on how to avoid exposure to the virus, including;
- observing good hand hygiene, with frequent use of soap and water or alcohol-containing gel;
- wherever possible, she should avoid contact with someone who is known or suspected to have swine ‘flu.
- the need for her to make early contact with health services if she develops flu-like symptoms, to discuss treatment with antiviral drugs;
- arrangements for vaccination to help to protect against the virus.
Options for redeployment include to roles such as;
i. the supervision of staff transferred into specialist units from other duties
ii. teaching and training of temporary staff
iii. performing temporary administrative duties.
A recommendation is made that she sees the occupational health physician if she wants further advice. The action plan is agreed with her and recorded, with an agreement to review the position at a further meeting.
Extract from 2007 DH guidance ‘infection control in hospitals and primary care settings6:
Para 4.4 Workers at risk of complications from pandemic influenza
Healthcare workers who are at high risk of complications of influenza (eg pregnant women and immunocompromised workers) should be considered for alternate work assignments, away from the direct care of patients, for the duration of the pandemic or until they have been vaccinated if it is clinically appropriate for them to be vaccinated. At the very least they should not provide care to patients who are known to have influenza, and neither should they enter parts of the facility segregated for the treatment of patients with influenza.
Para 5.3.5 Fluid repellent surgical masks
Surgical masks should be fluid repellent and should be worn by healthcare workers for any close contact with patients (ie within one metre). The mask will provide a physical barrier and minimise contamination of the nose and mouth by droplets.
Surgical masks should:
- cover both the nose and the mouth
- not be allowed to dangle around the neck after or between each use
- not be touched once put on
- be changed when they become moist
- be worn once only and then discarded in an appropriate receptacle as clinical waste - hand hygiene must be performed after disposal is complete.
When influenza patients are cohorted in one area and several patients must be visited over a short time or in rapid sequence (eg in cohorted areas of a hospital or nursing home, an ‘influenza clinic’ or a GP surgery session for influenza patients), it may be more practical for healthcare workers to wear a single surgical mask upon entry to the area and to keep it on for the duration of the activity or until the surgical mask requires replacement. This also minimises hand-to-face contact and reminds healthcare workers that they are working in a high-risk area.
However, other PPE (eg gloves and apron) must be changed between patients and hand hygiene performed.
1 Guidance from CMO to pregnant women 20 July 2009, DH http://www.dh.gov.uk/en/Publichealth/Flu/Swineflu/DH_103068
5 Apart from people who are morbidly obese, these groups are based on the at‐risk groups for symptomatic treatment using antivirals as at August 2009.
6 as at September 2009