Purpose

All NHS trusts are required to carry out health assessment screening on their staff to determine suitability and fitness to undertake their roles. Similarly, healthcare workers have a duty to protect patients from communicable diseases, including taking reasonable precautions to protect them.

This framework has been developed to standardise and streamline occupational health screening requirements of NHS employees by establishing a baseline standard for all NHS trusts. It will:

• ensure a consistent approach to recording screening and vaccination data
• facilitate use and trust in screening and vaccination data
• minimise unnecessary variation and repetition of health screening and potential delays in new staff starting work
• provide an updated core list of screening and vaccination requirements for all new NHS employees as part of the pre-employment health assessment (see annex 1)

The framework aligns with the Immunisation of healthcare and laboratory staff green book (chapter 12) and the Health and Safety at Work Act 1974. It clearly defines the standards required, recognising different needs and risks for different job roles.

Outlined within the framework are the minimum pre-employment health assessment checks for enabling staff movement within the NHS.

While immunisation and vaccination records can be accepted from trusted platforms, NHS trusts are responsible for determining occupational health clearance based on available information and potential local risks. Managers and employees at risk of occupational exposure must have clear information about immunisation outcomes to make informed decisions about work restrictions and post-exposure (or suspected exposure) prophylaxis. Local risk assessments are required if a vaccine is contraindicated or declined.

This work was led by subject matter experts from NHS England, UK Health Security Agency (UKHSA) and NHS Health at Work network, and it extends to include the work done with the Professional Record Standards Body (PRSB) to define a recommended information model for screening and vaccination records.

The reference guides were developed in collaboration between NHS England, UKHSA and NHS Health at Work network and are endorsed by the Safe Effective Quality Occupational Health Service (SEQOHS).

Recommended screening and vaccinations by staff groups

1. Staff involved in direct patient care

For staff who are directly involved in patient care and staff who have regular clinical contact with patients, the following should be considered based on job role and exposure:

• MMR (measles, mumps and rubella)
• BCG vaccination for tuberculosis
• hepatitis B (if in contact with blood or blood-stained body fluids or tissues, as well as staff who are at risk of injury from blood-contaminated sharp instruments or of being deliberately injured or bitten by patients)
• varicella
• pertussis
• influenza

There should also be a check for:

• up-to-date routine immunisations, for example, tetanus, diphtheria and polio

This group includes roles such as doctors, dentists, midwives, nurses, paramedics, ambulance drivers, occupational therapists, physiotherapists, radiographers and pharmacy professionals. Students and trainees in these disciplines and volunteers who are working with patients must also be included.

2. Non-clinical staff involved in healthcare setting

For non-clinical ancillary staff who may have social contact with patients but are not directly involved in patient care, the following should be considered based on job role and exposure:

• MMR (measles, mumps and rubella)
• hepatitis B (if in contact with blood or blood-stained body fluids or tissues, as well as staff who are at risk of injury from blood-contaminated sharp instruments or of being deliberately injured or bitten by patients)
• varicella
• influenza

There should also be a check for:

• up-to-date routine immunisations, for example, tetanus, diphtheria and polio

This group includes (but not limited to) receptionists, café staff and estate workers etc.

3. Laboratory and pathology staff

For laboratory and other staff (including mortuary staff) who regularly handle pathogens or potentially infected specimens, the following should be considered based on job role and exposure:

• MMR (measles, mumps and rubella)
• tetanus, diphtheria and polio
• hepatitis B
• varicella
• pertussis
• influenza

In addition to technical staff, this may include cleaners, porters, secretaries and receptionists in laboratories. Staff working in academic or commercial research laboratories who handle clinical specimens or pathogens should also be included.

Consider the vaccination of laboratory workers where the following microorganisms are handled or cultured, and others who work in highly specialist laboratories undertaking procedures with a significantly higher risk of exposure (in line with Advisory Committee on Dangerous Pathogens and the Advisory Committee on Genetic Modification, 1990):

• hepatitis A
• Japanese encephalitis
• cholera
• meningococcal ACW135Y
• smallpox, mpox
• tick-borne encephalitis
• typhoid
• yellow fever

Individuals working in diagnostic laboratories, including those undertaking polymerase chain reaction (PCR) or serology testing for these diseases, should be using standard protective equipment and safety cabinets and therefore the risk of exposure, even in high incidence areas, should be minimal.

Flu vaccination is one of the best tools we have to protect the health of our patients and staff, easing winter pressures and reducing the risk of avoidable disruption to our services. For this reason, yearly influenza vaccination is recommended for eligible cohorts of staff.

Exposure prone procedures screenings

Identification of healthcare workers requiring additional screening

Additional exposure prone procedures (EPP) clearance will be required for any staff who:

• carry out EPP activity
• or practice in an EPP environment
• or carry out clinical duties in renal units (hepatitis B clearance only)

and

• this is their first post within the NHS or healthcare sector
• or they are existing staff but moving to a post that involves EPP for the first time
• or they have had a break in NHS service and are returning

Health clearance requirements

Serology must be identified and validated samples (IVS) and undertaken in an accredited laboratory. Testing should include:

• hepatitis B surface antigen (HBsAg)
• hepatitis B surface antibody
• hepatitis C antibody
• HIV (human immunodeficiency virus) antibody

Identified and validated sample requirements

• Proof of identity with a photograph (for example, a trust identity badge, photocard driver’s licence, passport or national identity card) at the time the sample is taken.
• The sample of blood should be taken in the occupational health service. Exceptions are where this would result in duplication of testing, and in these cases, local arrangements should be made between the treating physician and the occupational health service. In circumstances where the individual is difficult to bleed, they can be referred to the phlebotomy service (providing the phlebotomist has been instructed on how to take IVS bloods).
• Samples should be delivered to the laboratory in the usual manner; they must not be taken to the laboratory by the individual.
• When results are received from the laboratory, the clinical notes should be checked to confirm that the sample was sent by the occupational health service or under local arrangements, at the correct date and time, and the name and date of birth match.  

Blood results

Blood results used for EPP clearance (including those submitted at pre-placement) and ongoing monitoring must be from:

• a UK accredited laboratory and use identified and validated samples (IVS)

Results should not be recorded in occupational health records if not derived from an IVS.

Identified and validated samples (IVS) hepatitis B surface antibody

If an individual has received a course of hepatitis B vaccinations in childhood, a “challenge dose” can be administered to confirm if they have vaccine-induced immunologic memory before serology is taken (see the hepatitis B guide for further information).

If an individual has evidence of an incomplete course of hepatitis B vaccine, the course should be completed before serology is taken.

If an individual has not previously had any hepatitis B vaccinations, the course should be started and completed before serology is taken.

If an individual has evidence of 2 complete courses of hepatitis B vaccination but has not achieved immunity (with an anti-HBs taken at the correct time, that is, 1 to 2 months after vaccination), they are recorded as a non-responder and will require annual HBsAg testing.

Results and actions

• Anti-HBs >100 and HBsAG negative – no further serology.
• Anti-HBs >10 <100 and HBsAG negative – booster dose of hepatitis B vaccine and no further serology required.
• Anti-HBs <10 and HBsAG negative – annual monitoring of HBsAg.
• Anti-HBs <10 and HBsAG negative and HBcAb (core) positive:
  • if the anti-HBs is <10iu/mL, additional testing for HBcAb is required
  • if an individual is HBcAb positive (and HBsAg negative), they are deemed to have natural immunity and would not require any further vaccination, further serology or annual recalls for HBsAg. However, they must be advised of the risk of reactivation if they start immunosuppressive treatment or have any illness that may compromise their immune system. They will need to inform occupational health of any decision to start immunosuppressive treatment or of any illness that may compromise their immune system
• If an individual starts immunosuppressive treatment or becomes immunosuppressed, then monitoring schedules should be agreed locally on a case-by-case basis with input from an accredited occupational health specialist or treating physician and a hepatologist using clinical judgement and local risk assessment. HBcAb positive HBsAg negative healthcare workers, not starting antiviral prophylaxis, may require more regular monitoring. The more detailed UKAP integrated guidance (see page 34) should be followed.

Identified and validated samples (IVS) hepatitis b surface antigen (HBsAg)

• HBsAg negative – no restrictions from EPP or clinical work in renal units
• HBsAg positive – restrict from EPP or clinical work in renal units and establish current viral load (hepatitis B DNA):
  • >200 IU/mL – must not be cleared for EPP or clinical work in renal units
  • < 200IU/mL – initial clearance to perform EPP or clinical work in renal units requires 2 IVS samples taken no less than 4 weeks apart, with both showing a viral load result <200 IU/mL

Ongoing UKAP monitoring of healthcare workers living with hepatitis B

• 6 monthly regardless of treatment status.
• If a healthcare worker stops treatment – restrict from EPPs for 12 months. Demonstrate viral load <200 IU/mL on 2 consecutive tests 6 months apart.

Reactivation of hepatitis B virus (rHBV)

There is a risk of reactivation of hepatitis B virus when a person becomes immunosuppressed.

Reactivation may occur in 2 settings:

• those who have current infection (HBsAg positive) but a low or negative HBV DNA level (viral load)
• in those with past, cleared, infection (HBsAg negative, hepatitis B core antibody [HBcAb] positive)

The following actions will be taken to manage the risk of hepatitis B virus reactivation:

• all EPP workers under 6 monthly monitoring and not on antiviral therapy for hepatitis B virus should be advised to inform the occupational health department of any decision to start immunosuppressive treatment or of any illness that may compromise their immune system
• all new EPP workers who are HBsAG negative and HBcAb positive must be advised of the risk of reactivation and must inform occupational health of a decision to start immunosuppressive treatment or of any illness that may compromise their immune system. There is no requirement for a “look back” exercise. However where any opportunity arises existing EPP workers who are HBcAb positive should be advised of the risk of reactivation

In any case where the virus does reactivate and viral load is >200 IU/mL, the healthcare worker should cease conducting EPPs immediately.  A second test must be done on a new blood sample 10 days later to verify the viral load:

• if viral load still > 200 IU/mL, the healthcare worker should remain unable to perform EPPs until their viral load returns to being stably below 200 IU/mL in 2 consecutive tests no less than 4 weeks apart
• if viral load is < 200 IU/mL, then further action should be informed by the test result as above – if test results are unexpected, seek further advice from a local virologist or UKAP secretariat

Hepatitis B UKAP monitoring

See UKHSA quick reference guide for flow charts of management.

Hepatitis B – monitoring actions

Hepatitis B virus DNA level: <60 IU/mL

No action. Retest in 6 months.

Hepatitis B virus DNA level: >60 but <200 IU/mL

A case-by-case approach based on clinical judgement should be taken, which may result in no action (as above) or recommending that a second test should be done 10 days later to verify the viral load remains below the threshold. Further action will be informed by the test result.

Hepatitis B virus DNA level: 200 IU/mL or above

The healthcare worker should cease conducting EPPs immediately. A second test must be done on a new blood sample 10 days later to verify the viral load remains above 200 IU/mL.

If the viral load is still in excess of 200 IU/mL, the healthcare worker should cease conducting EPPs until their viral load, in 2 consecutive tests no less than 4 weeks apart, is reduced to <200 IU/mL.

If the viral load is below 200 IU/mL then further action should be informed by the test result as above.

If test results are unexpected (for example, from very high viral load to low viral load) then seek further advice from a local virologist or UKAP secretariat.

A full risk assessment (see chapter 9 of UKHSA guidance) should be triggered to determine the risk of healthcare worker to patient transmission. At a minimum, this will include discussion between the accredited specialist in occupational medicine and the treating physician on the significance of the result in relation to the risk of transmission.

The need for public health investigation or action (for example, patient notification) will be determined by a risk assessment on a case-by-case basis in discussion with UKAP.

Identified and validated samples (IVS) hepatitis C (HCV)

• Anti-HCV negative – no restrictions from EPP
• Anti-HCV positive – restrict from EPP and establish whether current or previous infection (hepatitis C RNA):
  • hepatitis C RNA negative – no restrictions from EPP
  • hepatitis C RNA positive – restrict from EPP – refer for consideration of antiviral treatment as appropriate

• if hepatitis C RNA negative – can be cleared for EPP (3 month expiry) – repeat hepatitis C RNA test 3 months after initial negative test
• if the second test is negative – no further monitoring required

Hepatitis C RNA positive

See UKHSA quick reference guide for flow charts of management.

Identified and validated sample HIV

• HIV negative – no restrictions from EPP
• HIV positive – restrict from EPP and establish if elite controller or on combination anti-retroviral therapy (cART)
  • if elite controller – refer to OH for monitoring in line with UKAP guidance
  • If not on cART – restrict from EPP
  • if on cART – undertake HIV plasma viral load – 2 initial tests taken no less than 12 weeks apart:
    • HIV viral load >200 copies/mL – restrict from EPP
    • HIV viral load <200 copies/mL on the 2 tests taken no less than 12 weeks apart – no restrictions on EPP but must have ongoing monitoring
    • UKAP monitoring – 12 weekly HIV plasma viral load

HIV positive UKAP monitoring

See UKHSA quick reference guide for flow charts of management.

Hepatitis B vaccination

Hepatitis B vaccination is recommended for the following groups who are considered at increased risk:

• healthcare workers in the UK and overseas (including students and trainees): all healthcare workers who may have direct contact with patients’ blood, blood-stained body fluids or tissues, require vaccination. This includes any staff who are at risk of injury from blood-contaminated sharp instruments, or of being deliberately injured or bitten by patients. Advice should be obtained from the appropriate occupational health department
• laboratory staff: any laboratory staff who handle material that may contain the virus
• depending on local risk assessment this may include workers such as cleaners and estate workers
• for EPP workers, please also refer to the EPP section

A flowchart describing the hepatitis b screening and immunisation requirements is available.

Previously vaccinated healthcare workers with no immunity response status for hepatitis B

• Healthcare workers who have been previously immunised but have no record of immunity status can have an anti-HBs titre undertaken. Levels of vaccine-induced antibody to hepatitis B decline over time, but there is evidence that immune memory can persist in those successfully immunised. Therefore, a challenge dose of hepatitis B vaccine can be used to determine the presence of vaccine-induced immunologic memory. The individual can be given the choice to have the challenge dose before serology being taken or be advised of the potential that their serology may come back as non-immune, which would then lead to further vaccines and serology.
• Please note there is a risk of a false positive surface antigen (HBsAg) test result if blood for an antigen test is taken shortly after a hepatitis B vaccination. Therefore, blood for HBsAg should either be taken before a vaccination, or at least 2 weeks later. If the individual is due EPP serology this must be undertaken before the vaccination to avoid the risk of a “false positive” result.

Measles, mumps and rubella (MMR)

While healthcare workers may need the MMR vaccination for their own benefit, they should also be immune to measles and rubella for the protection of their patients.

Satisfactory evidence of protection would include documentation of either:

• having received 2 doses of MMR
• positive antibody tests for measles and rubella

A flowchart describing the MMR screening and immunisation requirements is available. 

Pertussis

Priority group 1 workers

• When a healthcare worker is in regular and close clinical contact with vulnerable patients, such as:
  • clinical staff working with women in the last month of pregnancy (for example, in midwifery, obstetrics and maternity settings)
  • neonatal and paediatric intensive care staff who are likely to have close or prolonged clinical contact with severely ill young infants up to 3 months old

Healthcare workers in priority group 1 have been eligible for vaccination since July 2019. Staff in priority group 1 who have received a dose of vaccine since 2019 are eligible for a booster, once an interval of 5 years has elapsed since their previous dose.

Priority group 2 workers

• When a health care worker is in regular clinical contact with young unimmunised infants in hospital or community settings – including those who are:
  • general paediatric staff
  • paediatric cardiology staff
  • paediatric surgery staff
  • health visitor staff
  • and they have not had pertussis vaccination in last 5 years

Please note vaccine demand will be closely monitored and extension of vaccination to priority group 3 will occur once stocks allow.

Health care workers in priority group 2 became eligible in June 2024.

Vaccination and screening according to priority group

Efforts should remain directed towards maximising uptake among priority group 1: 

• those who are as yet unvaccinated since 2019
• those where 5 years has passed since receiving their last pertussis-containing vaccine will be offered a further booster

Following the above, a 1-time vaccine eligibility can be extended to priority group 2.

Pregnancy

Healthcare workers who are pregnant should be vaccinated as recommended under the maternal pertussis programme. This will normally occur between 20 and 32 weeks, although pertussis-containing vaccine can be given from as early as 16 weeks’ gestation. The individual should be signposted to their GP or midwife to confirm they have had the vaccine and provide evidence of such if they have reached week 20 of their pregnant and not yet been offered a vaccination.

A flowchart describing the pertussis screening and immunisation requirements is available.

Tuberculosis

Recommendation

The 2007 health clearance for tuberculosis (TB), hepatitis B, hepatitis C and HIV guidance states the following regarding TB:

• employees new to the NHS who will be working with patients or clinical specimens should not start work until they have completed a TB screen or health check or until documentary evidence is provided of such screening having taken place within the preceding 12 months
• employees new to the NHS who will not have contact with patients or clinical specimens should not start work if they have signs or symptoms of TB
• health checks for employees new to the NHS who will have contact with patients or clinical materials should include:
  • assessment of personal or family history of TB
  • symptom and signs enquiry, possibly by questionnaire

Please note that it is important to assess the risk of TB for a new healthcare worker who knows they are HIV positive at the time of recruitment for immunocompromise risk. Please refer to the following detailed guidance:

• National Institute for Health and Care Excellence (NICE) tuberculosis guidance
• Chapter 32 of the green book

The current recommendation in the TB chapter of the green book gives guidance on the use of BCG vaccination.

• Individuals at occupational risk – people in the following occupational groups, with direct TB patient contact or contact with infectious materials, should be vaccinated with BCG:
  • healthcare worker or laboratory worker, who has either direct contact with TB patients or with potentially infectious clinical materials or derived isolates

BCG is recommended for unvaccinated, tuberculin-negative individuals in these occupations. It should be noted that the risk of exposure of healthcare workers other than those listed in the category above is unlikely to exceed the background risk of TB the general population and therefore vaccination is not routinely required.

What is accepted as evidence of TB screening? 

Staff new to NHS from UK or countries at low risk for TB

Confirmation of no signs or symptoms of TB plus any of the following:

• documented evidence of Mantoux test result (or IGRA negative) within the past 5 years (see NICE guidance)
• documented evidence of BCG vaccination or BCG scar by an occupational health professional
• documented evidence of IGRA (T-spot/Quantiferon) blood test result

Please note that the individual must not have visited a country with a high incidence of TB for more than 12 weeks (continuous time period) since the IGRA or Mantoux was carried out. Find more information about countries at low risk of TB.

Staff from country with high incidence of TB and new entrant to UK

Confirmation of no signs or symptoms of TB plus any of the following:

• UK visa and immigration TB certificate (must be within valid range date) confirming chest x-ray undertaken and result negative for TB
• documented evidence of IGRA (T-spot/Quantiferon) blood test result – individual must not have visited a country with a high incidence of TB for more than 12 weeks since their IGRA or Mantoux was carried out.

A flowchart describing the tuberculosis pre-placement assessment is available.

Varicella

The green book, which contains the latest guidance, states the following:

• Those with a definite history of chickenpox or herpes zoster can be considered protected.
• Healthcare workers with a negative or uncertain history of chickenpox or herpes zoster should be serologically tested and vaccine offered only to those without VZ antibody.
• A recent survey showed that a history of chickenpox is a less reliable predictor of immunity in individuals born and raised overseas (MacMahon et al., 2004) and routine testing should be considered.

The Royal College of Physicians in their Varicella Zoster Virus guidance supported the above approach. 

Occupational health professionals should ensure that on employment, health care workers born or raised in tropical  or subtropical climates have serological screening regardless of a positive history of past VZV infection (see Appendix 6 of the Varicella zoster virus: Occupational aspects of management for a map of tropical and subtropical zones).

A flowchart describing the varicella zoster virus requirement is available.

Diphtheria, polio and tetanus

Laboratory and pathology staff

Consider vaccination of workers in laboratories where diphtheria organisms are handled or cultured, and others who work in highly specialist laboratories undertaking procedures with a significantly higher risk of exposure (Advisory Committee on Dangerous Pathogens and the Advisory Committee on Genetic Modification, 1990).

Individuals working in diagnostic laboratories, including those undertaking PCR or serology testing for these diseases, should be using standard protective equipment and safety cabinets and therefore the risk of exposure, even in high incidence areas, should be minimal.

A flowchart describing the diphtheria, polio and tetanus screening and immunisation requirements is available.

Data sharing

A workforce screening and vaccination information model has been developed with support from the Professional Record Standards Body (PRSB)  and subject matter experts. It aims to standardise storage of screening and vaccination records.

The model will facilitate accurate storage, easier transfer and effective interpretation of records across occupational health professionals using diverse workflow management systems across various NHS trusts. The model will also drive the interoperability of the different occupational health workflow systems across the NHS.

Work is ongoing between NHS England and some occupational health workflow systems used in NHS trusts to implement multilateral integrations. Such integrations will ensure that staff screening and vaccination records are no longer held in siloed systems, giving staff the opportunity to carry their data with them as they move from 1 employer to another.