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Health and Safety - Staff Immunisation Procedure

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Section 1 - Summary

(1) This Procedure:

  1. ensures that Victoria University (VU) meets the immunisation requirements enacted by legislation, and its duty of care under the Victoria University (VU) Health & Safety and Biosafety Policies; and,
  2. outlines the process for identifying immunisation requirements, accessing vaccinations and the responsibilities associated with immunisations.
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Section 2 - Scope

(2) This Procedure applies to staff who, as part of their work: may be at risk of exposure to vaccine-preventable diseases; work in biological containment laboratories; work with biohazards; or have a duty of care to ensure a safe environment for clients using VU’s clinical services. For this Procedure staff will include HDR students.

(3) This Procedure does not provide medical advice – please consult with your Medical Practitioner.

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Section 3 - Definitions

(4) High Risk Activity: include:

  1. handling human blood and blood products
  2. handling human faeces, urine or intestinal contents
  3. handling infectious organisms associated with vaccine-preventable diseases
  4. exposure to mammalian foetuses, placentae or uterine contents
  5. exposure to zoonotic pathogens when working with animals
  6. exposure to wild caught or infected biting arthropods
  7. exposure to wildlife
  8. working overseas especially developing countries
  9. exposure to contaminated sharps
  10. exposure to waste water or sewage facilities
  11. contact with high risk populations that maybe carriers of infectious organisms e.g. hospital patients, elderly & children, animals
  12. exposure to soil or dust.

(5) High Risk Groups: High-risk groups at VU include individuals:

  1. participating in practicals, field work and professional practice placements that include high risk activities as part of University courses (e.g. Nursing, Midwifery, Dermal Therapies, Osteopathy, Biological sciences, Teacher Education, Sports and Exercise Science)
  2. undertaking high-risk activity as part of a research project
  3. working in a Physical Containment Laboratory, Clinic or Hospital setting where they are exposed to high-risk activity
  4. travelling overseas on University business to developing countries and locations where there is a high risk of infection
  5. working in remote locations
  6. that come in contact with waste, sharps and spills
  7. that are First Aid Officers
  8. with compromised immune systems (e.g. pregnant, diabetic, elderly etc.).

(6) Infectious disease: Infectious diseases are disorders caused by organisms — such as bacteria, viruses, fungi or parasites.

(7) Zoonotic disease: A disease that can be transmitted from animals to people or, more specifically, a disease that normally exists in animals but that can infect humans.

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Section 4 - Policy Statement/Regulation

(8)  Health and Safety Policy

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Section 5 - Procedures

Part A - Summary of Roles and Responsibilities

Roles Responsibilities
Biosafety & Institutional Biosafety Committee (IBC) Responsible for providing advice regarding safe work practices and procedures involving biohazards.
Reviews high risk projects that fall within the scope of this Procedure.
Can mandate vaccinations.
Audits and reviews the University's vaccination programs in laboratories under their care.
HSW Team Responsible for the administration of the VU incident management process.
Provide support and assistance in the development of risk assessments.
Ensures VU procedures reflect Legislation requirements regarding immunisation.
Executive Deans and Directors Have a strategic responsibility to ensure that the requirements of this Procedure are developed, implemented, monitored and reviewed in their organisational units. Ensure regular auditing to monitor compliance to procedure.
Have final approval of the course of action for individuals who decline vaccinations.
Managers, Course Coordinators, Supervisors, Unit Coordinators, Clinic Coordinators & Academic staff Responsible for recognising situations where this Procedure may apply.
Ensure the operational requirements of this Procedure, and any College level processes, are implemented.
Advise persons who have disclosed that they have not been immunised and are at potential risk of exposure to infectious disease to be vaccinated.
Ensure the relevant documentation is completed by all who decline vaccination and conduct risk assessments to reduce potential risk of exposure to infectious diseases and determine if there is any alteration required (or possible) to their work duties.
Advise the Executive Dean/Director of any difficulties in implementing local immunisation procedures.
Where organisational units have specific immunisation recommendations (Health care setting) they are responsible for ensuring that local level documentation is developed to meet the requirements of this Procedure.
Ensure that all the necessary safety equipment to protect personnel is supplied.
Comply with this Procedure and seek guidance from their Supervisor in the event of uncertainty as to its application.
Have a responsibility to:
a. "First do no harm."
b. Ensure that they are protected from infection by being vaccinated.
c. Throughout their work must learn and practice infection control precautions.
d. Take measures to prevent transmission of infectious diseases from themselves to others and vice a versa.
e. Take measures to prevent exposure to others if the research being performed involves a high risk activity.
Where applicable,  provide their organisational unit with a signed declaration and undertaking that they:
f. have been immunised for all vaccinations required for their work as documented in position descriptions and pre-employment documentation.
g. if not immunised, undertake to complete any outstanding immunisations and testing by the relevant date prescribed by their organisational unit or contract of employment.

Part B - Principles

(9) VU seeks to minimise the risk of exposure to infectious diseases in the workplace by ensuring, to the best of its ability, individuals potentially exposed to occupationally-acquired vaccine-preventable diseases are vaccinated.

(10) VU is committed to ensuring a safe environment for clients using its clinical services. 

Part C - Hazards and Risk Assessment

(11) A risk assessment must be completed for all high risk activities where the requirement for immunisation is assessed, including associated quality control processes. The Senior Manager, Research Infrastructure and Biosafety is available to review risk assessments.

(12) Staff must be vaccinated if a risk assessment of the work to be conducted at VU has identified that they are at risk of a disease where a vaccine exists.

(13) Managers and Supervisors have a responsibility to ensure the risks of exposure to infectious disease are minimised as far as is reasonably practicable.

(14) Work activities rather than a job title should be considered on an individual basis to ensure an appropriate level of protection is afforded to each person.

(15) Each person who may be exposed to a high risk activity or is part of a high risk group should be individually assessed by their Medical Practitioner for specific vaccines, to ensure all possible contraindications are also taken into account. This is particularly important if the individual is immunocompromised, as this may change their immunisation requirements; see Australian Immunisation Handbook, Section 3.3.

(16) Immunisation is not a substitute for good infection control practices. As outlined in Australian Procedures for the Prevention and Control of Infection in Healthcare and AS 2243.3 - standard precaution, sharps precautions, sterile technique, personal protective equipment and the relevant administrative and engineering controls must be implemented at all times to reduce the chance of exposure. The organisational unit must put in place adequate controls/measures to appropriately limit exposure and reduce the risk as far as reasonably practicable.

(17) For a list of vaccine preventable diseases see Appendix A - Vaccine Preventable Diseases. This is not an exhaustive list; the Department of Health and Aged Care Website 'Vaccine Preventable Diseases' must be consulted to ensure that when new vaccinations are available all relevant Risk Assessments are reviewed.  The Department of Health and Aged Care Website - Immunisation for Travel has advice for immunisation for travel.

(18) The Australian Immunisation Handbook provides detailed information on the recommended vaccinations for persons at increased risk of occupationally acquired vaccine-preventable diseases. The vaccine recommendations in the Handbook must be used in conjunction with workplace risk assessments to determine the immunisation requirements of staff and students.

Part D - Informed Consent

(19) The provision of information about the relevant vaccine-preventable diseases should be provided as part of the process of consent and declaration of immunisation.

Part E - Communicating Immunisation Requirements

(20) It is the responsibility of the organisational unit to communicate immunisation requirements specific to work conducted in their area in a timely manner.

(21) The recommendation for immunisation must be documented and communicated to staff. Employee immunisation requirements must be incorporated in pre-employment medical assessment documentation and position descriptions.  

(22) Where possible, Managers should plan well in advance. Consideration needs to be given to the length of:

  1. appointments: research staffs who are at VU for a short period may not have sufficient time to receive the identified vaccinations and develop sufficient immunity.
  2. a treatment course: It can take six months to a year to successfully complete all courses of some vaccinations.

Part F - Record Keeping

(23) Staff are to complete a HSW-F-076 Declaration of Immunisation prior to any work being commenced. To avoid the need to maintain medical records, it is recommended that the individual maintain their own immunisation record and that the Manager sights the records before the commencement of work.

(24) All documentation, including vaccination declaration, notice of declined vaccinations and associated Risk Assessments, shall be maintained as a record and be stored in accordance with the Records Management Policy and Procedures regarding access, storage and security.

(25) Immunisation records must include;

  1. staff number
  2. given name and surname
  3. department, laboratory, clinic and/or travel details
  4. a declaration that the individual understands that they may be exposed to infectious materials and may be at risk of acquiring infectious diseases and that it has been recommended that they are vaccinated
  5. a declaration that the individual has been immunised against, and has current immunity to, diseases where vaccines exist specific to their appointment, or a declaration stating why they are not immunised. 

Part G - Arranging Vaccinations

(26) Staff are responsible for sourcing vaccinations as required and detailed by VU as part of their employment.

Accessing vaccination records

(27) Staff may access their own vaccination records through: Australian Childhood Immunisation Register; Services Australia, or their medical practitioner (including requesting a check of serology). 

(28) The Vaccine Acronyms government site should be consulted when reviewing records to confirm old, non-standard and international immunisation records.

After Vaccination

(29) After some vaccinations a doctor confirms seroconversion has taken place, as some people are non-responders and/or may require booster shoots.

(30) For some high risk projects, baseline antibody levels and diagnostic blood tests may be required as part of the project approval process, as reviewed by the IBC and required by the relevant government department (e.g. work with Mycobaterium tuberculosis).

Part H - Cost of Vaccination

(31) For all new staff appointments, the University requires appropriate vaccinations as a pre-condition of employment for high risk activities. Contracts of Employment may require the staff member to maintain vaccinations at their own expense.  For current staff whose roles have been identified as requiring additional hazard controls (e.g. medical monitoring/further vaccines etc.) the organisational unit will pay for these measures. The College and Institutes will pay for the vaccination of staff if they are required to be vaccinated due to workplace exposure or work-related travel, which is part of the University’s obligations under the Occupational Health and Safety Act 2004 (Vic).

(32) Unless there is a contract of employment in place, Higher Degree Research students are not 'employees' of the University. While they may undertake research as part of their studies, this does not, on its own, create an employment relationship. Organisational units may of course decide that they will pay for, or contribute to, such expenses, and this is essentially a policy decision that should be made at the local level based on a risk assessment.

(33) Researchers are encouraged to incorporate the cost of vaccinations as part of project budget.

Part I - Failure to Comply

(34) Staff have the right to decline vaccinations.

(35) There may be medical reasons why individuals may not be protected, including; failure to respond to a vaccine, or the presence of an underlying medical condition preventing vaccination.

(36) Staff who decline vaccination or are not protected should be advised on the resultant health risks related to their work. VU will take all reasonable steps to encourage staff that have disclosed that they have not been immunised, to be vaccinated.

(37) In instances where staff are not protected, the College/ organisational unit must formalise this in writing including how the staff member will be protected i.e risk assessment. 

(38) The College/Institute is responsible for ensuring that risk assessments are conducted for persons who decline vaccination to determine if there is any alteration required to their work duties to reduce the potential risk of exposure to infectious diseases.

(39) Where the risk assessment identifies that alterations to work duties are required, further assessment of the University’s ability to make reasonable accommodation of these alterations should be undertaken, in consultation with a P&C Business Partner.

(40) In some cases, staff not complying with the immunisation requirements:

  1. will be unable to teach and/or practice. E.g. VU Clinics, Healthcare setting;
  2. will not be able to be employed as a Nurse or Midwifery educator;
  3. may not be able to undertake work that places them at risk of the infection;
  4. may be stopped from doing certain work or entering certain laboratories;
  5. may put other staff and students, and in a clinical setting patients, at risk by:
    1. transferring infectious microorganisms from patient to patient.
    2. becoming infected with infectious microorganisms acquired from patients.
    3. by acting as a carrier and infecting patients or family and other colleagues.

(41) Colleges/Institutes must ensure that staff who have been vaccinated but are non-responders, but still wish to undertake activities where they may be exposed declare in writing using the HSW-F-075 Decline of Vaccination for Staff.  This Clause does not apply to Nursing and Midwifery Staff due to the Department of Health requirements.

Part J - Audit/Inspection

(42) Compliance to this procedure will be monitored and audited on a regular basis.

(43) The IBC will randomly audit the laboratories under their care for immunisation associated documentation and immunisation records to ensure the Colleges and Institutes are compliant with this Procedure.