Workers employed in Category A high risk positions

NSW Health has released a revised policy directive on health care worker screening and vaccination PD2018_009 Occupational Assessment Screening and Vaccination Against Specified Infectious Diseases which continues mandatory vaccination and screening for certain diseases for workers employed in Category A positions and introduces a mandatory requirement for annual influenza vaccination of workers employed in Category A High Risk positions. Annual influenza vaccination is highly recommended for all health care workers and staff employed in NSW Health facilities.

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General questions

Why do I need to be vaccinated?

Transmission of vaccine preventable diseases (VPDs) and tuberculosis (TB) in healthcare settings has the potential to cause serious illness and avoidable deaths in workers, patients and other users of NSW Health agencies as well as others in the community. Under the Work Health and Safety Act 2011, risks must be eliminated or minimised through controls. NSW Health therefore has a duty of care and a responsibility under work health and safety legislation to control and minimise risks.

How do vaccines work?

Vaccines work by triggering the immune system to fight certain infections. If a vaccinated person comes into contact with these infections, their immune system is able to respond more effectively, preventing the disease developing or greatly reducing its severity.

How safe are vaccines?

Vaccines used in Australia are safe and must pass strict safety testing before being approved by the Therapeutic Goods Administration (TGA). In addition, the TGA monitors the safety of vaccines once they are in use. More information about vaccine safety is available from the Australian Government Department of Health website.

What are the side effects of vaccination?

While there is a risk of adverse events following immunisation (AEFI) with any vaccine, most are mild and resolve quickly. The most common side effect is pain, swelling or redness at the injection site. Serious side effects are extremely rare. If you are concerned about any side effects after vaccination you should contact your local doctor who should also make a report to the local public health unit. Anaphylaxis is a severe allergic reaction that occurs very rarely after vaccination, however it is readily managed by trained nurses or doctors.

What evidence of my vaccinations do I need to provide?

Workers employed in Category A and Category A High Risk positions must provide the documentation evidence as specified in Attachment 4 Checklist: Evidence required from Category A Applicants.

What if I have a medical condition and cannot be vaccinated – what should I do?

Most people with medical conditions can be safely vaccinated. You should discuss your medical condition with the assessor in your local health district (LHD) who will provide advice on whether you have a medical contraindication to vaccination.

Not all vaccines are 100% effective – why do I have to have them?

The overwhelming evidence is that immunisation and the provision of population-wide vaccination programs remain one of the most effective public health measures to protect the community from preventable diseases. While no pharmacologic agent, including vaccines, is 100% effective, vaccination offers the best protection for individuals and for those they come into contact with.

I have already been assessed as compliant and have been given a card to keep in my purse/wallet. I am a locum/agency worker and when I move between local health districts I am repeatedly asked to provide all of my evidence of protection again –why is this?

An updated interim Certificate of Compliance (with a pop-out wallet card) has been developed that records the date of your last whooping cough vaccination (dTpa - pertussis), hepatitis B serology and TB assessment on the reverse of the card. If you do not have one of these cards completed (check for the additional details on the reverse of your card), you should make arrangements with your staff health department to have it completed. Once you have had this updated card completed you should not be asked to undergo another compliance assessment when you move between local health districts. This interim card will remain in place until a new state wide staff database is implemented in each local health district. These cards are available from the Better Health Centre. Please email requests to: You will need to include a contact name, delivery address and contact phone number.

Why can’t my hospital/facility access my vaccination history on the Australian Immunisation Register instead of me having to show my vaccination records?

The Australian Immunisation Register (AIR) was previously known as the Australian Childhood Immunisation Register (ACIR) and was expanded in October 2016 to record vaccinations given to individuals at all stages of life. There is no historical adult vaccination data held on the AIR so vaccination histories are unlikely to be complete at this stage. This will change over time as adult vaccinations are routinely reported to the AIR by immunisation providers. In addition to vaccination records, there are other requirements to demonstrate your compliance that are not available on the AIR, including serology results for hepatitis B protection and the TB checklist.

What if a health worker refuses to get vaccinated and screened?

Vaccine preventable diseases can cause serious illnesses, and so NSW Health staff have a responsibility to do everything they can to minimise the risk of disease spreading to their patients. Workers with a medical contraindication to vaccination will not be terminated on the basis of their medical contraindication but will be risk managed as specified in Attachment 2 Risk Management Framework (RMF) under CE Discretion.

In the absence of a medical contraindication to vaccination, other alternatives will be explored to minimise the risk of transmission, including re-deployment to low risk areas. Where these alternatives have been exhausted and the risk of transmission cannot be acceptably managed, the NSW Health agency reserves the right to terminate workers employed in any existing Category A and Category A High Risk positions who refuse to comply with the policy’s assessment, screening and vaccination requirements.

Do new recruits who were previously assessed as compliant as a student need to be reassessed?

Yes. Students who have been assessed as compliant for the purposes of attending clinical placements will be required to undergo assessment and screening in accordance with the policy prior to employment in a NSW Health facility.

What if a worker who was previously assessed as compliant applies for a new position in the LHD, do they need to be reassessed, especially for varicella as they were assessed as compliant under the previous policy by giving a verbal history of the disease?

No. Workers who have been previously assessed as compliant under the previous policy and apply for a new position in the LHD do not need to be reassessed, including for varicella. If the worker is transferring to a Category A High Risk position, they must be vaccinated against influenza annually (refer to Section 4 Annual Influenza Vaccination Program).

Do agency workers need to be compliant with the policy?

Yes. All agencies that provide workers to NSW Health facilities are obliged to comply with NSW Health policies including the requirements contained in the Occupational assessment, screening and vaccination against specified infectious diseases policy directive. Agencies must ensure that they only provide compliant workers to LHDs. Agency workers must ensure that they have evidence of their compliance available when presenting for shifts to assist with local compliance monitoring processes.

Which category are volunteers (Category A – High risk, Category A or Category B)?

Like all positions the role performed by volunteers varies depending on allocation of duties and the location of the work being performed. Therefore each volunteer position should be assessed against the risk categorisation guidelines in attachment 1 of PD2018_009 Occupational Assessment, Screening and Vaccination against specified infectious diseases. The cost of providing any required evidence of compliance should be met by the agency prior to appointment.

Do part time students need to undertake assessment in their first year of study?

Yes. This is to ensure that any issues with compliance are identified early in the students candidature as those who are non-compliant will not be able to attend their placement which may impact on their course completion. The TB assessment tool should be submitted within 4 months of their first placement.

Can overseas or interstate students be assessed beyond their first year of study?

Yes. Students who transfer from overseas or interstate to a NSW education provider beyond their first year of study should be assessed (as compliant or temporarily compliant) in the first year that they are a student in NSW. Students who have not been assessed in their first year that are studying with an interstate or overseas education provider and are attending clinical placement in NSW should be assessed on a case by case basis and prior to their placement.

If students enrolling in 2018 submitted their forms prior to the release of the new policy do they need to be resubmitted?

No. Compliance forms submitted prior to the policy release date (5 March 2018) may be accepted. All future assessments must be undertaken using attachments 6 and 7. This includes those students who are required to submit the TB assessment tool later in their course to comply with the requirement to submit their screening assessment within 4 months of placement.

Why are there only 5 high risk clinical areas, what about other areas?

The current list of Category A High Risk clinical areas were identified by an expert group as the highest priority areas to introduce the annual influenza vaccination program. This program will continue to be monitored and additional areas may be added in the future.

Does compliance evidence for new recruits have to be on a NSW Health record card prior to employment?

It is preferred that the health record card is used however there may be situations where other forms of evidence can be accepted. Alternate evidence should only be accepted if it is reviewed by a trained assessor and the assessor is satisfied that the record is accurate and meets the requirements of the PD.

Does evidence of vaccination require a batch number for it to be accepted?

No. The inclusion of a batch number is desirable where available but is not a requirement for the evidence to be accepted.​

Category A high risk position questions

How should compliance with the Category A High Risk requirements be recorded?

A state wide human resources information system (HRIS) is currently under development which will facilitate the recording of the requirements of the Occupational assessment, screening and vaccination against specified infectious diseases policy directive. The timeframe for availability of this system is currently unknown therefore LHDs should use local processes to record compliance in the interim.

Do the Category A High Risk areas include community workers?

Yes. If the nature of their work involves patients in the identified categories (refer to Attachment 1 Risk Categorisation Guidelines), the policy requirements apply. For example, this would include workers that provide post-natal home visits or workers in an antenatal/postnatal community clinic or outpatient oncology service.

Do students working in category A high risk clinical areas require the flu vaccine?

Students who are posted to a Category A high risk area must have evidence of annual influenza vaccination or wear a mask for the duration of their placement in that high risk clinical area.

How are workers that are involved in rotating positions/on call managed in relation to the Category A High Risk requirements?

Workers that are required to work in a variety of areas or change locations on a rotating basis may be required to work in Category A High Risk clinical areas and will therefore be categorised as Category A High Risk and required to have a seasonal influenza vaccination each year. Due to the variability of staff management systems used within each LHD, the process for managing these workers will need to be developed at the local level with consideration to LHD specific resources and processes.

If a patient from a Category A high risk unit is cared for (outlying) in another ward, are the workers in that ward required to comply with the Category A high risk requirement?

No. The category A high risk requirement be vaccinated against Influenza (or wear a mask for the influenza season) apply to workers posted to the specified units (including community services) and to workers who predominately work in those units.​

Does the Category A High Risk requirement apply to workers who work in the specified unit/s for part of their shift?

The requirement to be vaccinated against influenza (or wear a mask for the duration of the influenza season) applies if the worker is posted to or predominately works in a Category A high risk unit/s .

Do I still need to have the Southern Hemisphere influenza vaccine if I have already received this year’s Northern Hemisphere vaccine?

Yes. If you are attending a placement or working in a category A high risk position between 1 June and 30 September you will need to have received the current Southern Hemisphere influenza vaccine. Strains in the influenza vaccine are updated each year therefore the Southern Hemisphere vaccine will be more current. Additionally the Australian Technical Advisory Group on Immunisation (ATAGI) has advised that immunity from the influenza vaccine can start to reduce after a few months.

What type of mask do Category A high risk staff need to wear during the winter season if they have not had the annual influenza vaccination?

The worker must wear a level 2 fluid resistant mask that has either ear loops or ties. It must be applied in accordance with the manufacturer’s instructions and workers should ensure that it covers their mouth, nose and chin. Masks are for single use and should be discarded once removed. Masks should never be stored in pockets or be left hanging around the worker’s neck.

The mask must be worn when providing clinical care or when within 1 metre of a patient. The mask should be discarded and a new mask used if it becomes soiled or wet. Masks must be removed by untying the bottom tie and then the top tie and removed by holding the ties only or pulling the loops up and removing from ears ensuring that only the loops are touched. The worker should always avoid touching the front of the mask and must perform hand hygiene after discarding it.

Disease specific questions

Measles, Mumps, Rubella (MMR)

Is a low serology result for Rubella acceptable?

Rubella serology results are provided as a numerical value. Do not compare the numeric levels reported from different laboratories. The interpretation of the result given in the laboratory’s report must be followed i.e. the report may include additional clinical advice e.g. consideration of a booster vaccination for low levels of rubella IgG detected.

What if a worker has a birth date before 1966 and presents with a negative/equivocal/borderline serology for measles, mumps or rubella?

The worker must be advised to receive one dose of MMR vaccine, no further serology is required.


Is vaccination with Zostavax acceptable evidence to meet Varicella compliance?

Yes. Workers who are aged 50 years and over who have evidence of 1 dose of Zostavax should be considered compliant with the requirements of the policy directive.

Hepatitis B

Who can sign the Hepatitis B statutory declaration form? Can it be a Justice of the Peace?

No. The statutory declaration must be signed by an appropriately trained assessor. This is a health professional that has training on the interpretation of immunological test results, vaccination schedules, TB assessment and/or TB screening. (See Key definitions in the PD for further information).


Do workers and students that commenced TB compliance assessment against the previous policy need to be reassessed?

No. Workers and students who commenced assessment for compliance with the previous policy do not need to restart the assessment e.g. a student who is in the middle of a two-step TST can continue this process with the assessor that they commenced with.

Why do students need to have a TB screening within 4 months of commencing placement?

Students are required to have TB screening within 4 months of placement to ensure that they have not had a recent exposure to TB. All other requirements are assessed in the first year of study to ensure that any issues with compliance are identified early in the students candidature as those who are non-compliant will not be able to attend their placement which may impact on their course completion.

What evidence of a booked TB assessment is required?

Students and workers who require a TB assessment (and have no symptoms suggestive of TB disease) who commence work or clinical placement prior to this assessment must have a booked appointment for TB screening. A letter or email of the appointment details from a NSW Chest Clinic should be accepted as evidence of booking.

Who can sign off on an IGRA test result?

A laboratory report indicating a negative IGRA result can be signed off as compliant by an authorised immunisation assessor. If the result is positive the worker will need to be referred to a TB Service (Chest Clinic) for a chest x-ray and clinical review.

Do all students/new recruits who have a positive TST or IGRA need to be referred to a TB Service (Chest Clinic)?

All new recruits and students who have a positive TST or IGRA need to be referred for a chest x-ray and clinical review at a TB Service (Chest Clinic). This review is required to assess an individual’s risk of progressing from TB infection to disease, to provide education on disease progression, and consider the use of preventive therapy for each individual.

Who should pay for TB screening (TST and/or IGRA) and the chest x-ray?

All new recruits and students are required to meet the cost of initial TB screening (TST or IGRA test). Those that have a positive TST or IGRA should be referred for a chest x-ray and clinical review at a TB Service (Chest Clinic). A positive TST or IGRA indicates that follow up is required for active or latent TB, and as per the Principles for the Management of Tuberculosis in NSW (PD2014_050), all investigations for cases, or suspected cases, of TB (active or latent) carried out through admitted patient and non-admitted patient services (including ambulatory care services) in NSW public hospitals and health facilities must be provided free of charge to the patient. This includes chest x-ray following a positive TST or IGRA conducted under the Occupational Assessment, Screening and Vaccination Policy Directive (PD2018_009).


I work night shift and am not at work when they offer the annual flu vaccination during the day shift. What should I do?

Health services are required to make vaccinations available to all workers, including those on a rotating roster. Your staff health unit should provide information for all employees about arrangements to access influenza vaccine.

What do I do if I have a contraindication to the flu vaccine?

If you are a worker with specialist clinical skills (i.e. midwife, surgeon, anaesthetist), you will need to discuss your medical contraindication with your doctor as not all medical conditions are a medical contraindication to vaccination and vaccines may be administered under specialist supervision in some circumstances. You may also seek advice from the National Centre for Immunisation Research and Surveillance Specialist Immunisation Service (NSWISS) ​ regarding your medical condition as you may be able to be vaccinated under their clinical supervision. If you are a worker employed in a Category A High Risk position and cannot be vaccinated, you will be required to wear a mask or be redeployed to a low risk clinical area/care for low risk clients during the influenza season (1 June to 30 September annually).

Why do I have to have the flu vaccine when I have heard it doesn’t work?

Infected health care workers can pass the virus on to their patients before they even know they are sick. The most effective way to prevent the flu is by getting vaccinated and adopting additional preventative measures, such as proper hand hygiene and proper sneezing and coughing etiquette (more information is available). Immunisation helps health professionals reduce their risk of contracting influenza and spreading it to their patients. It also reduces the risk of you catching influenza at work and taking it home to your family.

While we know that influenza vaccines do not provide complete protection against influenza (vaccine effectiveness ranges from 30-70% depending on the match with circulating strains and the immune response of the recipient), they remain the best way to prevent influenza and are an important control measure in conjunction with regular hand cleaning and respiratory hygiene. In addition, there is evidence that vaccination also reduces the severity of illness among people who are vaccinated but still get sick. Although one of the vaccine strains in the 2017 vaccine did not protect as well for the circulating A virus, the three other vaccine strains provided good protection against influenza viruses for immunised staff.

Can the influenza vaccine give me the flu?

No. It is impossible for the influenza vaccine (the flu shot) to cause ‘the flu’. The vaccines used in Australia contain only part of the influenza virus and cannot cause infection. Common reactions to the flu shot may include soreness, redness and swelling where the vaccine was given. Occasionally other symptoms can include fever, headache and aching muscles that may last one to two days.

Why do unvaccinated workers have to wear a mask?

Wearing a mask, in conjunction with hand and respiratory hygiene, reduces the risk of influenza transmission. However, wearing a mask is still secondary to vaccination in terms of preventing the transmission of influenza.

During a season with pronounced vaccine mismatch, health care workers who have been vaccinated may voluntarily wear a mask to further reduce the risk of transmission. However, this not a requirement of this policy as there is no strong evidence to support universal wearing of masks as a preventive measure in the presence of pronounced vaccine mismatch and in the absence of an outbreak. In addition, influenza seasons with pronounced vaccine mismatch are, fortunately, uncommon.

To protect patients from influenza transmission, both vaccinated and unvaccinated staff members should consistently practice hand and respiratory hygiene and stay at home if they are experiencing influenza-like illness until symptom resolution.

When do I have to receive the influenza shot?

Influenza vaccine will be available through clinics in your workplace from April and staff in Category A High Risk positions should be vaccinated by 1 June annually.

What if I don’t receive it by 1 June?

Staff working in Category A High Risk positions who don’t receive the influenza shot by 1 June annually will be required to wear a surgical/procedural mask while providing patient care in high risk clinical areas to protect both yourself and those who work with you or will be deployed to a non-high risk clinical area during influenza season.

How will this requirement be monitored?

The Chief Executive of the local health district will be reporting annually to NSW Health on compliance with the policy directive.

What if I get vaccinated by my local doctor or nurse?

You should ensure that your doctor or authorised nurse immuniser signs, dates and stamps NSW Health’s Vaccination Record Card for Health Care Workers and Students as evidence of influenza vaccination so that a copy can be provided to your staff health clinic.​​​​

Can I have the influenza vaccine if I am pregnant or breastfeeding?

Yes. Vaccination remains is the best protection pregnant women and their newborn babies have against influenza. Influenza infection during pregnancy can lead to premature delivery and severe disease in the mother. Vaccination during pregnancy also reduces the risk of the baby becoming ill with influenza in the early months of life. Pregnant women can have the vaccine at any stage of pregnancy or while breastfeeding.

​​​​​​​​​​​​​​​​​​​​​​​Can NSW health staff who are aged 65 and over receive the higher immunogenicity vaccine through the staff health program?

Yes. Staff health programs can order this vaccine via the online ordering system. Facilities will need to ensure that it is clearly labelled to distinguish it from the quadrivalent​ influenza vaccine.

Page Updated: Wednesday 5 February 2020
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