Immunisation Tool - Instructions - TB Form - New Staff (2023)

Immunisation Screening - Action Required The National Safety & Quality Health Standards require St Andrew’s Hospital to ensure that we have a risk-based workforce immunisation program in place to protect our employees and patients.

As a health care worker, you have an increased level of risk of contracting an infectious disease due to the fact that you could be exposed to blood and bodily fluids in the course of your duties. You also have a responsibility to take reasonable steps to ensure that you are not transmitting vaccine preventable diseases to other staff or patients by getting vaccinated.

In light of the above and as a condition of your employment, you are asked to provide documented evidence of immunity (vaccination history and/or serological evidence of past infection/vaccination) to the following: • • • • • •

Hepatitis B (not required for Ward Clerks or Dietary staff) Measles/Mumps/Rubella (MMR) Varicella (Chickenpox) Diphtheria/Tetanus/Pertussis (Whooping Cough) Tuberculosis (if you provide direct patient care) COVID-19

Please make an appointment with your GP as soon as possible prior to commencing employment. The GP must complete and sign the attached Immunisation Screening Tool.

Please take any immunisation records you have with you (these can also be obtained from your local immunisation provider or via your myGov account). If you do not have immunisation records your GP will conduct a serology test.

The purpose of the GP visit is to ensure a Medical Officer has reviewed your immunisation history, undertaken any relevant blood testing (serology) and prescribed relevant vaccinations and/or boosters if required and then signed the form per the hospital policy.

Tuberculosis (TB) Screening If you are working in a clinical role, you must be screened in section 5 of this form (refer to last page of Immunisation Tool).

If you answer YES to any of the questions within section 5 your GP to conduct an IGRA test. If the result is positive your GP will need to complete the enclosed, “TB Clearance for Employment Healthcare Worker” form and refer you to the Royal Adelaide Hospital Chest Clinic by completed the enclosed, “Referral Request for TB Appointment” form.

You must then provide evidence of the visit to HR at St Andrew’s Hospital as soon as possible.

ST ANDREW’S HOSPTIAL IMMUNISATION TOOL – NEW EMPLOYEE – FEBRUARY 2022

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This information will be recorded and made accessible to your Clinical Manager and the Infection Control Coordinator to facilitate appropriate allocation of patient care based on immune status.

Please note, regardless of immune status, personal protective equipment (PPE) is a work, health and safety (WHS) requirement. It is essential that PPE is worn in accordance with the St Andrew’s Hospital WHS and infection control policies and procedures.

COVID-19 Vaccination against COVID-19 is now mandatory for all healthcare settings workers in South Australia. Please provide evidence that you have been vaccinated (at least three doses), against COVID-19 as soon as possible. Examples of acceptable evidence include your vaccination record from myGov, a letter from your GP or confirmation slip provided to you at the vaccination clinic.

Seasonal Influenza Seasonal influenza vaccination is offered annually at no cost to the employee and can be obtained via the SAH Emergency Services Department from late March annually.

All information collected will remain confidential and handled in accordance with current privacy legislation requirements.

Please return your completed Immunisation Tool (and proof of COVID-19 vaccination if you have not already done so) to Human Resources either via internal mail or via email to human.resources@stand.org.au.

Should you have any questions, you can contact HR by calling 8408 2002 or emailing the address above.

Thank you for your cooperation.

Human Resources

Please see next page for Immunisation Tool ST ANDREW’S HOSPTIAL IMMUNISATION TOOL – NEW EMPLOYEE – FEBRUARY 2022

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Staff Immunisation Screening Form Dear Doctor, St Andrew’s Hospital requires employees to provide documented evidence of immunity against vaccine preventable diseases. Some vaccines / serology may be needed dependent on their history.

The employee has been requested to bring with them any documented immunisation history to this appointment. This may include serology results and vaccination records.

Instructions This document is to be completed for the following healthcare workers who have direct or indirect contact with patients, or contact with blood or other body substances from patients, in a health care setting as a result of their workplace activities. This includes: • • • • • • • •

Medical Officers Nursing (including students) Allied Health Professionals Biomedical Engineering staff CSSD (sterilising) staff Clinical Orderlies & Personal Care Attendants (PCAs) Catering staff involved in the delivery of meals to patients (excl. Hep B) Ward clerks (excl. Hep A & B)

Reference documents: 1. SA Health Immunisation Guidelines for Health Care Workers in South Australia Policy (2021) 2. Australian Government Department of Health, Australian Immunisation Handbook, (2020).

For completion by Doctor Doctor’s Name: Doctor’s Signature: Practice Name: Contact number: Date of Assessment: St Andrew’s Hospital Employee Details: Name: Date of Birth: Position:

ST ANDREW’S HOSPTIAL IMMUNISATION TOOL – NEW EMPLOYEE – FEBRUARY 2022

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Section 1: HEPATITIS B (not required for Ward Clerks or Catering staff) A. Has a Hepatitis B vaccination course been completed?

 Yes - Go to B & Record dates & Serology  No - Arrange vaccination  Unsure - Arrange serology – Go to C

B. Record Dates of 3 doses below 1. …………………………………. 2. …………………………………. 3. ………………………………….

Has Serology been taken to confirm immunity via Hepatitis B surface antibody (HBsAb)?

 Yes – Go to C and document results  No – Go to C and arrange serology

C. Serology - Document results below:

*Hepatitis B surface antibody (HBsAb) level >10 IU/L indicates immunity to Hepatitis B Date: ………………………………………… Level: ………………………………………… IU/L Is result >10 IU/L?

 Yes – No further action required  No – Please consult the Australian Immunisation Handbook for advice on whether a Booster is required (Go to D)

D. Booster: Date: ……………………………

E

E. Serology result:

(4 weeks after booster)

Arrange further serology 4 weeks after booster - document in

Date:…………………………

Level: ………………………IU/L

If the Hepatitis B surface Antibody levels are still <10 IU/L, please consult the Australian Immunisation Handbook for advice.

Comments:

OFFICE USE ONLY: SECTION 1 COMPLETE

Evidence of current immunisation YES  NO  YES  NO  Date: ………………………………………………………………

ST ANDREW’S HOSPTIAL IMMUNISATION TOOL – NEW EMPLOYEE – FEBRUARY 2022

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Section 2: MEASLES/ MUMPS/ RUBELLA (MMR) Born before 1966 and immunocompetent?

Continue below

 Yes – Go to Section 3  No –

Have the 2 doses of MMR vaccination course been completed if born during/after 1966?  Yes - Go to A  No – Arrange immunisation course  Unsure - Go to B – Serology required

A. Dates of vaccination

Date 1: ……………………………

Date 2: ……………………………

If two dates are recorded no further action OR serology is required.

B. Serology Required – Document results below indicates immunity

Note: IgG detected “YES”

Measles:

Date: ……………………………

IgG detected YES 

Mumps:

Date: ……………………………

IgG detected YES 

Rubella:

Date: ……………………………

IgG detected YES 

Rubella Level (only if available): ………………………………………………………

IU/mL If there is no immunity on serology and 2 vaccination dates are not recorded – arrange vaccination and chart in A. Further serology is not required following vaccination.

Comments:

OFFICE USE ONLY: NO  SECTION 2 COMPLETE

Evidence of current immunisation YES  YES  NO  Date: ………………………………………………………………

ST ANDREW’S HOSPTIAL IMMUNISATION TOOL – NEW EMPLOYEE – FEBRUARY 2022

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Section 3: VARICELLA A. History of previous chickenpox infection  YES - no further action required

B. Serology required:

 No/Unsure – Go to B

Date taken: …………………………..

IgG detected:  YES - no further action required  No – Arrange vaccination - Go to C

C. Vaccination required.

Document dates for each dose

Dose 1 Date: ………………………………………………

Dose 2 Date: ………………………………………………

Once 2 dates recorded No further action required

Comments:

OFFICE USE ONLY: NO  SECTION 3 COMPLETE

Evidence of current immunisation YES  YES  NO  Date: ………………………………………………………………

Section 4: DIPTHERIA/TETANUS/PERTUSSIS A. Childhood vaccination course (DTPa) and one adult dose completed (dTpa)

 Yes - Date of last dose: …………………………………. If >10 years since last dose Booster required. Go to B.  No/Unsure - Booster required – Go to B

B. Booster Required. Record date below Date: …………………………………………

NOTE: Boosters are required every 10 years

Comments:

OFFICE USE ONLY: SECTION 4 COMPLETE

Evidence of current immunisation YES  NO  YES  NO  Date: ………………………………………………………………

Date of last dose recorded on PRECEDA YES  Booster required every 10 years

ST ANDREW’S HOSPTIAL IMMUNISATION TOOL – NEW EMPLOYEE – FEBRUARY 2022

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Section 5: TB SCREENING (Required for employees providing direct patient care i.e. nurses, doctors, orderlies).

1. Were you born in a high prevalence TB country*?

 YES

 NO

2. Did you train or work for 3 months or more in a high prevalence TB country*?

 YES

 NO

3. Do you have a history of TB disease?

 YES

 NO

4. Do you have evidence of TB infection as indicated by a history of a positive TB screening test result (e.g. TST or IGRA)

 YES

 NO

5. Have you had previous or current contact with an active TB disease case?

 YES

 NO

If “YES” to ANY of the above questions: Please conduct an IGRA test:• If the results are NEGATIVE – no further action is required (please provide evidence of this test ) • If the results are POSITIVE – please complete the below “TB Clearance for Employment Healthcare Worker” form and if required, the attached “Referral request for TB Appointment” form. Please inform the healthcare worker to provide evidence of clearance to work to St Andrew’s HR Division. (If the

healthcare worker is currently residing outside of South Australia, please contact HR for further information).

All “NO” above - no further Action is required

*High prevalence TB countries are those where TB is endemic (WHO estimated rate 100,000) WHO global lists of high burden countries for TB 2021 – 2025 Comments:

OFFICE USE ONLY:

Evidence of current immunisation YES  NO 

SECTION 5 COMPLETE

YES  NO  Date: ………………………………………………………………

ST ANDREW’S HOSPTIAL IMMUNISATION TOOL – NEW EMPLOYEE – FEBRUARY 2022

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SA Tuberculosis Services

Healthcare Worker Pre-Employment Screening Dear Doctor, This individual has been identified through a risk assessment performed by Worker Health as requiring further TB screening prior to the commencement of their employment.

A recent IGRA blood test was positive.

Please arrange a chest x-ray and complete a TB symptom check. If there are no signs of active TB, you as their GP can clear the individual, but must also refer them to SATB Services for follow-up.

Please contact SA TB Services if you have any urgent concerns or if the patient is exhibiting any symptoms. SYMPTOM CHECK: 3-4 weeks cough, fever, or unexplained weight loss.

Screening Instructions Assessment Clearing the worker for placement  

If the chest x-ray is normal, clearance for employment can be given, provided there is no evidence of active TB disease. Please use the attached clearance certificate.

Refer all positive IGRAs to SATB Services using the provided request for referral, attached.

For more information Royal Adelaide Hospital, SA TB Services, Clinic 3E Telephone: (08) 7117 2967 Fax: (08) 7117 2998 Monday-Friday, 8:45am-4:30pm © Department of Health, Government of South Australia. All rights reserved. Updated Jan 202

Central Adelaide Local Health Network

ROYAL ADELAIDE HOSPITAL SA Tuberculosis Services Thoracic Medicine, Clinic 3E 1 Port Rd Adelaide, SA 5000

TB Clearance for Employment Healthcare Worker This document, signed by a GP or authorised healthcare worker, may be accepted as TB clearance for Healthcare Workers beginning employment..

Patient Details First Name

Last name

DOB

/

/

Address Phone

Symptom Check

□3-4 week cough

□Fever

□Unexplained weight loss

*If any of the above, please refer immediately to SATB Services*

□NONE of the above This certifies that the individual named above has completed the requirements for tuberculosis screening prior to beginning employment, as recommended by SA Tuberculosis Services.

Follow up with SATB Services: (circle one) Is required

Is not required

Clearance Date

GP Details Name Practice Address Phone Signature

Fax Referral to: SATB Services 7117 2998 /

/

Central Adelaide Local Health Network

ROYAL ADELAIDE HOSPITAL SA Tuberculosis Services Thoracic Medicine, Clinic 3E 1 Port Rd Adelaide, SA 5000

REFERRAL REQUEST FOR TB APPOINTMENT Pre-employment HCW assessment IGRA blood test AND chest x-ray MUST be completed before referral Referral to SA TB Services

Hospital RAH

FAX 7117 2998

Phone 7117 2900

Patient Details First Name DOB

Last name /

/

/

/

Address Phone

Date of Referral

1. POSITIVE IGRA + chest x-ray completed Reason for Referral (please circle)

2. IMMUNESUPPRESSED + chest x-ray completed IGRA:

Positive / Negative

3. SYMPTOMS that may indicate Active TB Radiology Notes

Referrer Details Name Practice Address Phone Signature

Bensons / Jones

/

Radiology SA / Other: _____________