CHAPTER ONE INTRODUCTION
Background
1.1 Certain occupations are associated with an increased risk of accidents and injuries involving blood or body fluids that may be infected with blood borne viruses ( BBVs) such as HIV, hepatitis B ( HBV) and hepatitis C ( HCV). Since these infections can be transmitted to a varying degree via mucous membranes, or broken or punctured skin, injured workers are potentially at risk of acquiring a BBV, although the risk of infection is considered to be low (Health and Safety Executive ( HSE), 2008).
1.2 Health care workers are most at risk, but public safety workers such as police and prison staff are also at risk of exposure to BBVs by the nature of their work, i.e. they deal with groups of people ( e.g. drug injectors) who are at relatively high risk of being infected with a BBV (Rischitelli et al, 2001; Greater Glasgow and Clyde NHS Board, 2007). For example, the prevalence of HCV in the Scottish prison population has been estimated at 20% (Scottish Prison Service, 2008).
1.3 Studies in the United States have shown that the incidence of occupational exposure to blood or body fluids among public safety workers is higher than among the general public (Pagane et al, 1996; Lorentz et al, 2000; Averhoff et al, 2002; Gershon et al, 2007). These studies have suggested that occupational exposure is often under-reported in the police, though a recent review of the literature from several countries has indicated that this may no longer be the case (Sonder et al, 2005b). Police service staff experience different types of occupational exposure from health care workers, with bites, spits, splashes and cuts the most common, rather than needle-stick injuries ( NSIs) (Sonder et al, 2005b). Although some studies have found that the prevalence of BBV infections in the police is similar to that in the general population, indicating that transmission may be uncommon (Rischitelli et al, 2001; Sonder et al, 2005b), the fear of BBV infection following an injury may be a cause of work-related anxiety in police service staff (Flavin, 1998). Less is known about the incidence of occupational exposure among prison service staff, the most common types of incidents or the incidence of resulting BBV infection. However, a recent Australian study found that 7% (17/246) of prison officers reported having experienced an NSI, most often while carrying out searches, but that fewer than half the injured officers had accessed support services (Larney and Dolan, 2008).
1.4 Published guidance exists on protection against infection and the appropriate management of incidents of exposure in the occupational setting (DoH, 1998; 2006; 2008; Ramsay, 1999; Fisher et al, 2006; HSE, 2008). Most existing guidance has focused on health care settings and staff, and all NHS bodies or health settings have been advised to develop a post-exposure policy and protocol (DoH, 2006).
1.5 The risk of BBV infection can be reduced by i) safe working practices, ii) first aid measures immediately after an exposure (washing, encouraging bleeding), and iii) reporting the incident and seeking medical attention as quickly as possible. If the source person is identifiable, he/she might be asked to consent to their blood being tested for BBV infectivity.
1.6 If the source person is not infected with a BBV then the exposed person has incurred no risk of BBV infection from contact with his/her blood or body fluids. Blood tests can establish the presence or absence of a BBV, although viruses cannot be detected in the blood for some time after the acquisition of an infection and false negative test results are possible. Nevertheless, knowledge of negative source blood test results, if available, can offer reassurance to an exposed person. Source blood test results generally can aid post-incident management (Manavi et al, 2004).
1.7 Incidents of exposure to blood or body fluids which occur in the community, as opposed to health care settings, may be more difficult to assess in terms of the risk of BBV infection, since less may be known about the circumstances, and source testing may be problematic (Sonder et al, 2005a). Also, the exposed person may be less well informed than health care workers about the risk of infection, and there may be no specified channels for management. There has been little research investigating the prophylactic treatment and follow-up that is offered or available for incidents in the community (Sonder et al, 2005a).
1.8 In 2002 the Scottish Police Federation ( SPF) submitted a petition to the Scottish Parliament. The petition requested "legislation to make it compulsory for assailants and others who caused police officers to be exposed, or potentially exposed, to the risk of BBV infection, and for whom no conclusive and up-to-date information on their BBV infection status was available, to submit to a blood test so that the officer concerned can be informed as soon as possible of whether there was a real possibility of infection" (Scottish Executive, 2005a:3). The petition highlighted examples of assaults on police officers by those suspected or claiming to be infected with a BBV.
1.9 At the time this petition was submitted, no published guidance existed in the UK for the specific management of police or prison service staff occupationally exposed to blood and/or body fluids. Although sector-specific guidelines do not exist, the principles of follow-up management embedded within national guidance for NHS settings are applicable. It had been recommended that police service staff at risk of exposure be vaccinated against HBV (DoH, 1998). To date, in Scotland, the guidance of Greater Glasgow and Clyde NHS Board (2007) has recognised the increased prevalence of BBVs among certain high-risk groups, and makes recommendations applicable to public safety workers. Also, the Health and Safety Executive ( HSE, 2008) consultation document on protection against BBV infections in the workplace has included sector-specific guidance for the police and prison services.
1.10 The SPF proposal was included in a Scottish Executive consultation document, 'Blood testing following criminal incidents where there is a risk of infection: Proposals for legislation' (2005). Following the consultation period, a Short Life Working Group was established to review this document, advise whether legislative change would be appropriate, and address the needs of all those potentially exposed to a BBV. On the basis of the consultation responses and their own discussions, the Working Group rejected the SPF request for mandatory testing. However, they made a number of recommendations, including standardising procedures, keeping records and ensuring that police, prison and fire rescue service staff had access to information and training about BBVs (Scottish Executive, 2007).
1.11 The evidence gathered by the group indicated that little was known about either the incidence or the management of occupational exposure in the Scottish police and prison services (Scottish Executive, 2006). They recommended that a service evaluation be undertaken of the post-incident management of police and prison service staff who were occupationally exposed to blood and body fluids (Scottish Executive, 2007).
The study
1.12 Funding was provided by the Scottish Government Directorate-General for Justice and Communities to undertake an evaluation of the post-incident management of police and prison service staff occupationally exposed to blood and/or body fluids. Initially a 6-month study was envisaged, but funding was extended so that data could be collected for 12 months.
1.13 The aim of the evaluation was to describe and evaluate post-incident management services for preventing psychological and physical harm in police and prison staff exposed to blood-borne viruses in the work context.
1.14 The objectives were:
- To ascertain how many police and prison staff notified their Occupational Health ( OH) and Health and Safety (H&S) departments about an exposure to blood and/or body fluids over the study period
- To collect data on each incident reported to OH departments in relation to the circumstances and care given by all those involved
- To evaluate current service provision in relation to post-incident advice and interventions to reduce psychological and physical harm and whether appropriate guidelines were followed.
1.15 It was hoped that the evaluation would identify any gaps and inequities in the current systems and inform the discussions around limiting psychological harm following exposure to blood and body fluids. The findings would also support the development of policies and procedures to ensure that the post-incident management of blood and/or body fluid exposures experienced by police and prison services staff is of a consistent and high standard across Scotland.
1.16 The study was carried out by researchers at the Institute for Applied Social and Health Research, University of the West of Scotland, and Health Protection Scotland, between March 2007 and December 2008.
Structure of the report
1.17 The study began by ascertaining the policies and procedures for the post-incident management of incidents of occupational exposure to blood or body fluids, in the Scottish police and prison services. These procedures are summarised in Chapter Two. Chapter Three outlines the methods of carrying out the evaluation. Chapter Four presents the findings on (i) the number of incidents of occupational exposure to blood or body fluids reported over the study period, (ii) the types of incident and the circumstances of all cases included in the evaluation, and the post-incidence care and management provided, (iii) the evaluations of expert panel members regarding the appropriateness and adequacy of post-incident management, and (iv) the views and experiences of exposed members of staff about the care they received. Chapter Five draws conclusions from the findings and offers recommendations.