Protocol for vaccine preventable disease screening for contractors, students and volunteers

Protocol number: QH-HSD-047-1:2016

Effective date: 5 October 2022

Review date: 5 October 2025

Supersedes: Version 3

On this page:

1. Purpose
2. Scope
3. Process for vaccine preventable disease screening for contractors, students and volunteers
4. Monitoring VPD requirements
5. Supporting and related documents
6. Authorising health service directive
7. Definition of terms
8. Approval and implementation
9. Version control

1. Purpose

The purpose of this Protocol is to specify the mandatory vaccine preventable disease (VPD) pre-engagement/pre-commencement screening requirements for contractors, students and volunteers.

2. Scope

This protocol applies to all hospital and health services.

3. Process for vaccine preventable disease screening for contractors, students and volunteers

3.1 Vaccine preventable disease (VPD) role requirements and mandatory VPD requirements:

3.1.1 Evidence of vaccination against, OR proof that a contractor, student or volunteer (the prospective worker) is not susceptible to, the following VPDs:

1. measles
2. mumps
3. rubella (MMR)
4. varicella (chicken pox)

Is required to be provided by the prospective worker for roles where:

• face-to-face contact with patients occurs, or
• a normal work location is in a clinical area, or
• the prospective worker will frequently attend clinical areas.

3.1.2 For pertussis (whooping cough) evidence of vaccination within the last 10 years is required to be provided by the prospective worker for roles where:

• face-to-face contact with patients occurs, or
• a normal work location is in a clinical area, or
• the prospective worker will frequently attend clinical areas.

3.1.3 Evidence of vaccination against, OR proof that the prospective worker is not susceptible to, hepatitis B, is required to be provided by the prospective worker for roles where:

• there is direct physical contact with patients or the deceased, or
• where in the course of their work, there may be exposure to blood, body substances and/or equipment or surfaces contaminated with these.

This evidence may be provided by a third party on behalf of the prospective worker.

Hospital and health services must meet the following mandatory VPD screening requirements:

3.1.4 Unless otherwise contractually obligated or agreed by Queensland Health, ensure that for any prospective worker, whose contract, clinical placement or movement between Queensland Health entities was entered into/commenced on or after 1 July 2016 [1], and whose role requires VPD screening evidence provides:

1. evidence of vaccination against MMR, varicella, pertussis and/or hepatitis B as per their role requirements, or
2. proof that they are not susceptible to MMR, varicella and/or hepatitis B as per their role requirements, and
3. evidence of a future vaccination for pertussis (whooping cough) or any other VPD as per their role requirement in accordance with recommendations for healthcare workers in The Australian Immunisation Handbook (as updated from time to time), and
4. that the evidence described in (a) and (b) above is required to be provided by a specified date (or within a specified timeframe).

3.2 Evidence

A record of vaccination is the only acceptable evidence for pertussis.

Acceptable evidence for MMR, varicella and hepatitis B includes evidence of vaccination, or, where evidence of vaccination cannot be provided, that an individual is not susceptible to the VPDs specified for the role.

Refer to 3.2.1 and 3.2.2 for the forms that this evidence may take.

This evidence includes one or more of the following:

3.2.1 A vaccine preventable diseases evidence form (PDF 103 kB) completed by the prospective worker that is accompanied by copies of the evidence specified on the form. The acceptable forms of evidence to accompany the form are:

1. vaccine record book or vaccine record card with details of vaccine given and clinic attended
2. an Australian immunisation record (AIR) immunisation history statement
3. previous blood test results showing immunity where it is indicated as acceptable on the vaccine preventable diseases form (this is not acceptable evidence for pertussis)
4. letter or immunisation history statement from a medical practitioner, infection control practitioner, nurse practitioner or vaccine service provider with details of vaccine given.

3.2.2 Record of immunity/non-susceptibility (this is not acceptable evidence for pertussis):

1. pathology testing result
2. letter from a medical practitioner certifying non-susceptibility to MMR, varicella and/or hepatitis B
3. completion of vaccine preventable disease evidence certification form (PDF 83 kB) by a medical practitioner, infection control practitioner, registered nurse or vaccine service provider.

VPD specific recommendation information is contained in the Guideline for the vaccination of Healthcare Workers (PDF 7793 kB).

Statutory declarations from the prospective worker are not acceptable evidence of vaccination or non-susceptibility to the VPDs specified for the role.

3.3 Exemptions

3.3.1 Exemption: Verified supply shortage

Where a supply shortage of vaccine for a VPD has been verified by the Chief Health Officer to the chief executives of the hospital and health services (Health Service Chief Executives) (verified supply shortage), a hospital and health service is not required to comply with the relevant mandatory VPD screening requirements of the protocol for the period of the verified supply shortage (the exemption period), provided that the following requirements are met:

1. a risk assessment is completed by local experts, for example, an Infectious Diseases Physician, the Infection Control Unit or the Safety and Quality Unit, to determine the level of risk of the prospective worker contracting/transmitting the VPD, and
2. the Hospital and Health Service must manage staffing and other operational and clinical matters based on the completed risk assessment, and
3. the Hospital and Health Service must provide information to the prospective worker regarding:
   1. the risk of exposure to a VPD associated with the work proposed to be undertaken, and
   2. all policies and procedures relevant to avoiding the risk of exposure and/or injury from a VPD, and
   3. any lawful action the Hospital and Health Service wants to be taken by the Contractor, Student or Volunteer in the event of exposure and/or injury from the VPD.

In circumstances where a prospective contractor, student or volunteer is to be engaged following the completed risk assessment, approval for an exemption to the required vaccine that is in a verified supply shortage must be obtained from the Health Service Chief Executive.

The exemption period must not extend beyond the verified supply shortage.

The exemption period ends when the Chief Health Officer declares to Health Service Chief Executives that the vaccine is no longer in short supply.

The exemption applies only to the VPD vaccine that is affected by a verified supply shortage.

3.3.2 Exemption: Exceptional circumstances for a contractor only

An exceptional circumstance, for the purpose of this protocol, is an event, or combination of events, that requires the appointment of a contractor to meet a need of the hospital and health service or a facility where:

1. not appointing the contractor may create a risk that is unacceptable to the hospital and health service, that may lead to injury or death of a patient(s) or worker(s), and
2. this risk cannot be mitigated in any other practicable way.

Where an exceptional circumstance is identified, a health service chief executive may approve an exemption for a specified VPD vaccine for a specific contractor, provided that the following requirements are met:

1. a risk assessment is completed by local experts, for example, the Safety and Quality Unit, an infectious diseases physician or an infection control unit, to determine the level of risk of the prospective contractor contracting/transmitting the VPD, and
2. the Health Service Chief Executive is satisfied there is no other suitably qualified person who meets the VPD requirements that is able to perform the required duties under the contract,  and
3. the hospital and health service provides information to the prospective contractor regarding:
   1. the risk of exposure to a VPD associated with the work proposed to be undertaken, and
   2. all policies and procedures relevant to avoiding/reducing the risk of exposure and/or injury from a VPD, and
   3. any required modification of duties to be undertaken, and
   4. any action recommended to be taken by the contractor in the event of exposure and/or injury from the VPD.

The hospital and health service should request the contractor provide documentary evidence from a medical practitioner to support the decision to enter into the contract with the contractor.

The documentary evidence must include:

1. the reason for vaccine contraindication relevant to the contractor, and
2. the time period of the vaccine contraindication.

Hospital and health services may seek their own advice regarding managing any risks identified in exceptional circumstances, including epidemiological, medical, clinical or legal advice.

3.4 Record keeping

Hospital and health services must meet the following mandatory VPD recording requirements:

3.4.1 In circumstances where the contractor(s), student(s) and volunteer(s) vaccination history, or evidence that they are not susceptible to the specified VPDs, is provided directly to the hospital and health service, this documentation must be stored in a secure database that is accessible to authorised personnel only and maintained in accordance with the Information Privacy Act 2009 (Qld) and the Public Records Act 2002 (Qld). The HHS must ensure the management of these records is in accordance with the local HHS clinical records management policy and procedure. This should include the keeping and disposal of records at the appropriate times.

3.4.2 Where a contractor or volunteer is engaged by a contract provider, rather than directly by the hospital and health service, the contract provider is required as part of their contract, to provide only workers who meet the VPD requirements relevant to their role. In these circumstances the hospital and health service is not responsible for keeping a record of the vaccination history for individual contractors or volunteers.

3.4.3 Hospital and health services are not responsible for keeping a record of a student’s vaccination history. This is the responsibility of their education providers. Education providers are also responsible for monitoring the VPD and tuberculosis risk assessment status of students. However, hospital and health services may request this information from the education provider, and any information received must be stored in a secure database that is accessible to authorised personnel only and maintained in accordance with the Information Privacy Act 2009 and the Public Records Act 2002.

3.5 Additional VPDs

Hospital and health services should apply a risk-based approach to include pre-engagement/pre-commencement VPD screening for prospective workers for additional VPDs which are outlined in the Australian immunisation handbook (as updated from time to time), only where this pre-engagement/pre-commencement VPD screening has a legislative or lawful basis.

3.6 Tuberculosis

Mandatory requirements for assessment and screening for tuberculosis are described, and shall be undertaken, in accordance with the Tuberculosis control health service directive and Tuberculosis control protocol.

4. Monitoring VPD requirements

4.1 Hospital and health services must meet the following VPD monitoring requirements:

4.1.1 Monitor compliance by all relevant contractor(s) or volunteer(s) with the VPD screening conditions of their engagement.

4.1.2 Provide the Department of Health with a report about the reliance of an exemption period for a verified supply shortage, if requested.

4.1.3 Provide the Department of Health with a report regarding the number of, and the reason for, all exceptional circumstances exemptions, if requested.

4.1.4 Provide the Department of Health with a report regarding compliance by volunteer(s) or contractor(s) with the VPD screening conditions of engagement, if requested.

5. Supporting and related documents

Legislation

• Hospital and Health Boards Act 2011 (Qld)
• Work Health and Safety Act 2011 (Qld)
• Public Health Act 2005 (Qld)
• Information Privacy Act 2009 (Qld)
• Public Records Act 2002 (Qld)
• Right to Information Act 2009(Qld)

Guideline

• Guideline for the vaccination of healthcare workers (PDF 759 kB)—as updated from time to time

Related documents

• The Australian immunisation handbook—as updated from time to time
• Tuberculosis control health service directive
• Tuberculosis control health service directive protocol
• Student placement deed—group A education providers
• Student placement deed—group B education providers
• Staff vaccination guides: Healthcare workforce vaccination programs

For VPD screening and reporting requirements for health service employees refer to:

• Health employment directive No. 01/16: Vaccine preventable diseases (VPD) requirements (PDF 290 kB)
• Human resources policy B1: Recruitment and selection (PDF 3849 kB)
• Health employment directive No. 12/21: Employee COVID-19 vaccination requirements (PDF 1447 kB)
• Human resources policy B70: Employee COVID-19 vaccination requirements (PDF 1507 kB)

6. Authorising health service directive

• Vaccine preventable disease screening for contractors, students and volunteers QH-HSD-047:2016

7. Definition of terms

8. Approval and implementation

Protocol custodian

Dr Alun Richards

Acting Executive Director, Communicable Diseases Branch

Approving officer:

Shaun Drummond

Acting Director-General, Department of Health

Approval date: 5 October 2022

Effective from: 5 October 2025

9. Version control

1. For contracts drafted under a standing offer arrangement (SOA) tendered, or entered into, prior to 1 July 2016, please refer to the SOA terms and conditions for any scope to vary the contract.