Staff immunisation policy and procedures

Infection prevention and control guidelines

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Infection prevention and control guidelines

Last revised: 17 Jun 2024

Staff immunisation policy and procedures

All staff require immunisation/immunity to ensure they are protected from vaccine-preventable infectious diseases, as appropriate to their duties. Specific requirements may vary according to risk assessment based on the type of practice and the duties performed by the staff member. For example, document immunity to hepatitis B virus for any staff member who might be given the task of cleaning a spill of blood or other body substances.

The practice’s vaccination policy could incorporate individual assessments for staff members. Special consideration needs to be given to the vaccination status of staff born overseas and those who are pregnant or could become pregnant.

Practices must provide new employees with a list of recommended vaccinations, and give them the option of either receiving required vaccinations at work, or obtaining them from their own GP or immunisation service. Staff should obtain a copy of their immunisation history statements from Medicare or their regular GP and provide it to the practice manager.

If a staff member’s immunity to any vaccine-preventable infectious disease is in doubt, serological testing is generally indicated. Otherwise, the vaccination should be repeated.

If a staff member cannot receive live vaccines, this must be documented in staff records. If an alternative is not available, special arrangements such as redeployment may be required during an infectious disease outbreak.

New staff should receive the vaccines they require before starting or within the first few weeks of employment, and as recommended by health departments (eg influenza vaccine annually in April–June, COVID-19 vaccination as advised by the Australian Government Department of Health and Aged Care).

Documentation of vaccination or immunity must be included in staff records.

Refer to the current edition of the Australian immunisation handbook² for comprehensive information on vaccination, and for information on steps and checklists for health worker vaccination requirements.

Employer responsibilities

Where staff are at significant occupational risk of acquiring a vaccine-preventable disease (eg during an outbreak), employers should implement a comprehensive vaccination program, which may include:

a vaccine policy
reviewing and updating staff vaccination records
provision of information about the infectious disease
protocols to manage vaccine refusal.

Employers are not required to perform staff vaccination, but are responsible for advising of risks at work, recommending appropriate vaccination, maintaining records on staff vaccination/immunity status, and ensuring that unvaccinated staff comply with relevant exclusions and precautions (see Staff records).

During an infectious disease outbreak, state and territory public health regulations may mandate exclusion of unvaccinated staff.

If a non-immune staff member is exposed to a vaccine-preventable disease, employers must ensure that the person receives assessment and is offered postexposure prophylaxis, if indicated.

Staff records

Employers must keep an up-to-date record of the immunisation status of their employees (Table 6.1. Sample staff immunisation record). These can assist in identifying nonimmune staff. Such records must be stored in accordance with confidentiality and privacy requirements.

The following could be recorded for each staff member:

advice given about the need for appropriate vaccination suitable for the type of practice and their duties
status of vaccinations, natural infection and serological results before present employment
details of the vaccinations received and relevant infections since joining the practice (date given, type and brand, batch number, and antibody response if appropriate)
agreement or refusal to be appropriately vaccinated or have antibody levels assessed, and any further discussion/information provided.

Staff must be informed that lack of immunity may exclude them from some duties, for example:

those with lack of immunity to hepatitis B may not perform venipuncture
those inadequately immunised against pertussis may not work with babies
those with lack of immunity to measles should wear a mask during measles outbreaks and must be advised to do so.

Table 6.1. Sample staff immunisation record Download the staff immunisation record

Name: Date of birth: Address: Vaccinations required:
Vaccine	Up to date?	Pre-vaccination antibody status	Status	Post-vaccination antibody status (if relevant)
COVID-19	Y/N Date last checked:		Number of doses received: Date of last dose received:
Hepatitis A	Y/N Date last checked:		Number of doses received: Date of last dose received:
Hepatitis B	Y/N Date last checked:		Number of doses received: Date of last dose received:
Influenza	Y/N (within last 12 months)		Date last dose received:
Measles-mumps-rubella	Y/N Date last checked:		Number of doses received: Date of last dose received:
Diphtheria-tetanus-acellular pertussis	Y/N (within last 10 years) Date last checked:		Date last dose received:
Varicella	Y/N Date last checked:		Number of doses received: Date of last dose received:
Polio	Y/N (within last 10 years) Date last checked:		Date last dose received:
Risk of infection and benefits of vaccination explained Date: Signature of person providing advice: Signature of staff member acknowledging vaccination advice offered: Consent for vaccination obtained from staff member: Y/N Further counselling and/or education provided:

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