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EXECUTIVE SUMMARY Introduction A working group was established in May 1999 to develop a strategy on bloodborne pathogens for the Grampian Health Board area. This strategy is designed to build on existing strategies/policies and takes account of advances in understanding of the viruses and available standards in prevention, diagnosis, management and care. In this instance the term Bloodborne Pathogens refers only to Human Immunodeficiency Virus, Hepatitis B and C. The strategy aims to: Improve awareness of bloodborne pathogens Reduce the spread of bloodborne pathogen infection through surveillance and prevention measures Ensure effective diagnosis, control and management of infection. Epidemiology of Bloodborne Pathogens Hepatitis B (HBV) Locally main routes of transmission are through blood contact, predominantly through sharing needles, syringes and other contaminated drug injecting equipment. There is an ongoing outbreak of acute hepatitis B within Grampian mainly focused in young adult injecting drug misusers in Aberdeen. Currently Grampian has the highest notification rate for HBV in Scotland. Hepatitis C (HCV) As with HBV the main transmission routes locally are through blood contact, the majority of infections occurring through sharing of contaminated drug-injecting equipment. However, in a small number of cases infection has occurred through administration of contaminated blood products. The latest available figures suggest that the rate of reporting of HCV antibody positive cases in Grampian is the third highest in Scotland. Human Immunodeficiency Virus (HIV) The main transmission route locally is through unprotected sexual intercourse – both heterosexual and between men who have sex with men. Transmission also occurs through sharing of needles, syringes and other contaminated drug injecting equipment. Prevalence of HIV infection in Grampian is lower than the Scottish average. However, data on high-risk behaviours in Grampian suggests higher levels of new injecting drug users in Aberdeen and higher levels of sharing injecting equipment in Grampian than the Scottish average. Evidence also indicates that sexually active young people in Grampian are more likely to have unprotected sex compared to 1995. There has also been an increase in sexually transmitted infections in Grampian. There is therefore no room for complacency. The Strategy Framework The strategy has been divided into seven priority areas to guide implementation; prevention, confidentiality, virological investigation, counselling, screening, management and monitoring and evaluation. 1. Prevention Health promotion efforts should be targeted at a number of priority groups including men who have sex with men, injecting drug misusers, prisoners, sex industry workers and the general public including young people and those infected or affected. Whilst the means by which key messages are communicated will vary according to the group, the information upon which they are based should be up-to-date and accurate. It was acknowledged that recently less emphasis had been placed on raising awareness of HIV and few initiatives have targeted HBV and HCV and this required immediate attention. A lack of information on current training available highlighted the need for an audit to be undertaken to enable development of a training strategy which builds on existing good practice and meets identified need. Needle exchange schemes have an essential role in the prevention of bloodborne infection amongst injecting drug misusers and their sexual partners. However information suggests that access to needle exchanges can be a problem. A vaccine is available for HBV but not HCV or HIV. Current national policy is to provide selective HBV immunisation to those judged to be at increased risk. In light of the ongoing HBV outbreak it is recommended that the appropriateness of selective HBV immunisation be reviewed. 2. Confidentiality It was noted that confidentiality might hinder seamless care for patients. It is therefore recommended that a policy statement on confidentiality is developed to support multiagency working. This would have to take account of the Data Protection Act (1998) and Caldicott Guidance. 3. Virological Investigation Early detection is key to control, management and treatment of bloodborne pathogens. Individuals in high-risk groups should be counselled and offered testing if they are considered to be at risk of infection. The main screening tests for HBV and HIV are undertaken locally with tests relating to infectivity and monitoring treatment carried out at the Regional Virus Laboratory at Gartnaval Hospital. Initial tests for HCV are carried out in Aberdeen with samples for confirmatory testing sent to the Regional Virus Laboratory. The current hepatitis B outbreak and increased HCV testing have placed increased burden on the laboratory locally. Potential policy changes for HBV infected health care workers may increase this burden further. 4. Counselling Counselling should be offered to all individuals requesting, or who have been offered testing, by an appropriately qualified member of staff or specialist service. 2 5. Screening New population screening programmes are introduced at the recommendation of the UK National Screening Committee. Currently pregnant women are the only group to whom routine screening for HBV should be offered. Screening is not available for other groups or diseases. 6. Management Clinical management embraces a range of needs, including the provision of an appropriate, high quality, timely and accessible service. It is important that all patients who fail to spontaneously clear their hepatitis B infection receive specialist clinical assessment and treatment to prevent long term liver damage. Patients with HIV and HCV infection will benefit from undergoing specialist clinical assessment and management. To date in Grampian, no specific allocation of funds has been made to meet the costs of providing diagnosis, counselling, treatment and support to people with hepatitis C infection. 7. Monitoring and evaluation Difficulties have been experienced in collating the information for the development of this strategy. Currently there are a number of strategic and operational groups whose remit includes bloodborne pathogens. The responsibility for co-ordination lies with the Consultant in Public Health Medicine (CPHM) with responsibility for communicable disease and environmental health. Following consultation and approval of the strategy it is recommended that the CPHM establish an implementation group to develop a detailed action plan. 3 RECOMMENDATIONS 1 EPIDEMIOLOGY Further research is required into risk taking behaviour and the reasons behind it in Grampian. 2 PREVENTION A high profile public awareness campaign should be undertaken, which highlights the potential risks of transmission of HIV and HBV & HCV, how transmission can be prevented and promotes a climate of understanding and tolerance of those affected. Ensure those infected and affected by bloodborne pathogens receive consistent and appropriate information. Provide a programme of training for teachers to support the implementation of the Health Promoting School – sexual health pack if supported by evaluation of the pilot scheme. Recommendations arising from the sexual health needs assessment of men who have sex with men should be considered. Recommendations arising from the sexual health needs assessment of sex industry workers should be considered. The provision of a variety of free condoms and lubricant for the general public should be expanded whilst ensuring ease of access for all groups Training An audit should be undertaken to establish what training is currently being provided and by whom. This information should provide the basis for a comprehensive training plan for those groups described in the report. This should include provision of appropriate information of risks of infection, prevention of transmission, risk assessment and appropriate controls. Needle exchange Further develop Needle Exchange services in Grampian. Assess the appropriateness of distributing other injecting equipment eg spoons or filters Immunisation Continue, for the foreseeable future, to promote opportunistic HBV immunisation of people in high-risk groups. Review the appropriateness of continuing the selective approach to HBV immunisation following assessment of the impact of current HBV outbreak control measures. 3 CONFIDENTIALITY Develop a policy statement on confidentiality to support multi-agency working through the Community Care Agenda taking into account the Data Protection Act and Caldicott Guidance. 4 4 5 6 VIROLOGY INVESTIGATION Make funding available to the laboratory to cover the costs of viral monitoring, resistance testing and drug levels in HIV patients, laboratory costs of testing for hepatitis C, and laboratory-associated costs with providing clinical assessment and treatment to people with chronic hepatitis B infection. MANAGEMENT Fund the drug costs associated with the management of people with chronic hepatitis B infection. Fund the establishment of a service for people suffering from hepatitis C, thereby allowing them to access appropriate specialist counselling, virological investigation, clinical assessment and drug treatment. Consideration should be given to ways in which Local Authority staff can support patients and their families. Through the community care planning process consideration should be given to the need for access to respite care. COMMUNICATION An Implementation Group to be established and led by the HIV Co-ordinator/ CPHM (CD&EH). The Implementation Group must take into consideration the action plans of the Joint Community Care Plan, Modernising Community Care Action Plan, the Health Improvement Plan and the Trust Implementation Plan. A communication mechanism is required to provide key personnel working in the area of bloodborne pathogens with relevant and up to date information to ensure that action taken by relevant groups is consistent with the bloodborne pathogens strategy. CONCLUSIONS The group considered the above list of recommendations and whilst supporting the implementation of all propose the following priorities should be addressed in year one. Prevention High profile public awareness campaign Needle exchange review and development Continue, for the foreseeable future, to promote opportunistic hepatitis B immunisation of people in high- risk groups. Diagnosis and management Ensure funding is available for laboratory costs. Establish a service for people suffering from hepatitis C Ensure available funding for associated drug costs. 5 Those who responded to the postal consultation were supportive of the content and recommendations of the strategy. Further consultation was undertaken as part of the ongoing development of the Health Improvement Programme, a seminar in October 2000 kick -started the process of developing a five year action plan for Bloodborne Pathogens (see appendix 7 for details). It is acknowledged that the recommendations within this strategy require to be fully costed to enable them to be prioritised against other competing demands for limited resources. This will be taken forward by the Implementation Group. 6 BLOODBORNE PATHOGENS STRATEGY 1 Introduction In May 1999, Grampian Health Board acknowledged the need to improve the coordination of the public health response to bloodborne pathogens and established a Bloodborne Pathogen Strategy Group. The role of the Group was to advise on an appropriate strategy to ensure a co-ordinated, consistent approach to the prevention, diagnosis, control and management of bloodborne pathogens throughout Grampian, maximising available resources. For the purposes of this document the term bloodborne pathogens refers only to Human Immunodeficiency Virus (HIV), hepatitis B (HBV) and hepatitis C (HCV). The strategy does not address other bloodborne pathogens. (For the remit and composition of the group see appendix 1). Information gathered for this report indicates that there is a range of activities currently underway. However, the group acknowledges gaps in provision and have discussed and deliberated the issues to produce a prioritised list of recommendations. This report is designed to build on the Grampian HIV/AIDS Strategy (1995) and takes account of advances in understanding of the viruses and in the standards of best practice that are available for treatment and care. During the course of this strategy there will be further advances: new treatments will become available, new guidance will detail best practice. This strategy is flexible enough to accommodate such changes. 2 The Strategy Framework The strategy’s goals and guiding principles that have been drawn from the previous HIV/AIDS strategy remain central to Grampian’s response to bloodborne pathogens. In adopting these goals it is recognised that the most effective response is dependent on; the risk behaviours within the population, the prevalence of bloodborne pathogens and other sexually transmitted infections existing service infrastructure and effectiveness of existing programmes. In addition consideration must be given to maximising health gain within an environment of limited resources. 2.1 Aims Improve awareness of bloodborne pathogens Reduce the spread of bloodborne pathogen infection through surveillance and prevention measures Ensure effective diagnosis, control and management of infection. 7 2.2 Objectives 1. Promote awareness and knowledge throughout Grampian about bloodborne pathogens, including transmission of the viruses, safer sexual practices and high risk behaviours including risks associated with substance misuse, taking account of ethnic, cultural and gender considerations. 2. Further develop and implement a co-ordinated training programme to support all groups and sectors involved in bloodborne pathogen prevention, responsive to identified needs. 3. Identify, prioritise and implement appropriate and effective bloodborne pathogen prevention initiatives e.g. within the penal system, targeting sex industry workers, drug misusers and men who have sex with men. 4. Promote quality infection control strategies e.g. universal precautions. 5. Further develop effective and efficient advice, counselling and testing services for individuals with bloodborne pathogens. 6. Provide up to date information on bloodborne pathogens and related services and where to find help and support for professionals and the general public. 7. Ensure an integrated pathway of care including investigation and management for those people infected by bloodborne pathogens throughout Grampian. 8. Ensure support for those affected by bloodborne pathogens. 9. Promote and facilitate collaboration and co-ordination between agencies and groups e.g. Drugs/Alcohol/HIV Forums, DATS (Drugs Action Teams), GHB Area Control of Infection Committee and Bloodborne Pathogens Strategy Group. 10. Prioritise, develop and implement where appropriate, research and clinical audit programmes in aspects of bloodborne pathogens, keeping abreast of national developments. 2.3 Priority Areas The strategy has various priority areas to guide implementation: prevention, immunisation, diagnosis, screening, control and management, training, monitoring and evaluation and communication structures. 8 3 The Epidemiology of Bloodborne Pathogens Bloodborne pathogens are transmitted through entry of blood or other body fluids containing the virus into the body of a susceptible person. These viruses are not transmitted through everyday social contact with an infected person. All infected individuals are potentially infectious and can transmit the virus to others. However the level of infectivity may be determined by various factors including treatment. Transmission may occur: During unprotected sexual intercourse By sharing contaminated injecting equipment Through skin puncture by blood-contaminated sharp objects, for example needles. From mother to child, infecting the child either before or during birth or depending on the virus through breast-feeding (see routes of transmission). By administering contaminated blood or blood products. However, all donations in the UK are now screened for HBV, HCV and HIV. Less common means of transmission are: Through contamination by blood or blood stained fluids of open wounds and skin lesions. Through splashing the mucous membranes of the eye, nose or mouth with blood or blood stained fluids. Through human bites when blood is drawn 1 3.1 Hepatitis B 3.1.1 Routes of transmission The predominant modes of transmission vary throughout the world. The main routes locally are through blood contact, predominantly through sharing needles, syringes and other contaminated drug-injecting equipment. Unprotected sexual intercourse is a very effective route of transmission but the local incidence is thought to be low. Transmission can also occur from mother to child at birth, however the risk of infection is very low if vaccination is given to the neonate. Mothers can safely breast-feed immunised babies (see section on immunisation in Section 4 Prevention). 9 Fig 1 Hepatitis B notified cases in 1999 by attributable risk category Grampian Health Board In 1999, of the 85 formally notified acute cases, 63 (74%) consented to be interviewed. From information gained at interview, the attributed risk categories for these acute cases were as follows: 2 Grampian Health Board Hepatitis B notified cases in 1999 by attributable risk category 22% IDU Sexual Other* 8% 70% Source: GHB CD Team Records * ‘Other’ includes where no information is available 3.1.2 Natural History Symptoms of acute infection vary according to age. Neonates usually show no symptoms while 50% of adults experience some illness e.g. lethargy, nausea, fever, jaundice. A small proportion of individuals (<1%) develop fulminant hepatitis, which has a high mortality rate. Most adults spontaneously clear their infection without treatment but the pattern of infection in children is very different. The likelihood of a patient developing chronic hepatitis is inversely related to age at the time of infection. Chronic infection (infection present for over 6 months) occurs in at least 90-95% of infected neonates and about 5-10% of adults.3 (See Figure 2) Individuals may progress to chronic active hepatitis with increasing liver damage, which is associated with progression to cirrhosis. Cirrhosis indicates permanent liver damage with the increased risk of primary liver cancer. 10 Fig 2 Disease progression in Hepatitis B infection Neonate Adult Fulminant hepatic necrosis (1%) 5-10% Recovery 90-95% 5-10% 90% 95% Recovery Chronic HBV Carrier Asymptomatic chronic Chronic hepatitis Chronic persistent hepatitis Primary liver cancer Cirrhosis 3.1.3. Amount of known Hepatitis B disease in the Grampian population Fig 3 Viral hepatitis B laboratory notifications Grampian Health Board 1992 - 1999 2 120 100 Acute Chronic Nos of cases 80 60 40 20 0 1992 1993 1994 1995 1996 1997 1998 1999 Year Source: GUHT Virology Laboratory & GHB CD Team Records 11 Analysis of the acute cases formally notified in 1999 shows that: 62% are male 82% are young adults in the age group 15-34 years 87% are Aberdeen residents. Only 7 cases gave addresses outside Aberdeen City. Fig 4 Hepatitis B cases in Scotland Rates of identification (acute and chronic) for first 10 months of 1999 Comparison of rates of identification of total new cases of acute and chronic hepatitis B in the first 10 months of 1999 for all Health Boards in Scotland. (based on data from laboratory reports plus formal notifications)4 20 No per 100,000 population 18 16 14 12 10 8 6 4 2 le s Is ys id e Ta es te rn W y la nd Sh et rk ne O ia n Lo th w gh la nd La na rk sh ire Hi la sg o an re at er G ra m pi y fe Va lle Fi rth Fo er s rd Bo w ay al lo G G G Health Board Du m fri es an d re rs hi Ay Ar gy ll & an d Cl Ar yd ra n e 0 Source: SCIEH Provisional Figures 3.1.4 Summary To date, hepatitis B has been mainly focused in young adult, injecting drug misusers in Aberdeen. There is an on-going outbreak of acute hepatitis B infection within Grampian. Grampian now has the highest notification rate for hepatitis B in Scotland and is 10 times the UK average. 12 Hepatitis C 3.2.1 Routes of Transmission Hepatitis C is mainly transmitted through blood, the majority of infections have occurred through sharing needles, syringes and other contaminated drug-injecting equipment. It is not spread efficiently by sexual contact (less than 5% risk) and the rate of transmission from mother to child is low (1 – 5%) with no identified risk through breastfeeding. In a small number of cases infection has occurred through administration of contaminated blood products. Since 1991 all blood and blood products have been screened for HCV. Fig 5 Persons reported to be hepatitis C antibody positive in Grampian by attributed risk factor (includes all persons reported, at any time, up to the end of 1999).5 No Information 25% Other* 4% IDU Blood Factor Other* No Information IDU 69% Blood Factor 2% Source: SCIEH Weekly Report 29/8/00 Vol 34 No 00/34 *For individuals placed in the “other” category, risk information such as “sexual intercourse” and “tattoo” were indicated. 3.2.2 Natural History The majority of individuals with acute infection do not experience any symptoms. A small proportion of patients develop an acute hepatitis with jaundice, malaise, weakness and anorexia. A high proportion (80-85%) of individuals infected fail to clear the virus and develop chronic hepatitis (infection present for more than 6 months). The disease progression is slow and variable but is faster in men, those who drink excessively, and those infected over the age of 406. Chronic hepatitis can lead to cirrhosis, liver failure and hepatocellular carcinoma (see figure 6). There is no vaccination for hepatitis C at present. 13 Fig 6 Disease progression in hepatitis C Hepatitis C infection Recover (15-20%) Chronic HCV infection (80-85%) Mild chronic hepatitis Moderate/severe chronic hepatitis Cirrhosis Primary liver cancer 3.2.3 Decompensated cirrhosis and liver failure i.e. ascites, encephalopathy and varices Amount of known Hepatitis C disease in the Grampian population The Hepatitis C virus was identified in 1989, with a test to detect antibodies becoming available in 1991. Since then the number of individuals being tested has increased steadily. The true prevalence of chronic hepatitis C is unknown. Estimated prevalence is 0.1- 1% of the population. Taking a midpoint of 0.5% gives an estimated prevalence of around 2,500 persons in Grampian. 60% of cases diagnosed as HCV antibody positive were aged between 15-29 years old and a further 31% were between 30-44 years old. 69% of the cases were attributed to intravenous drug misuse. (Appendix 2) Fig 7 Grampian Health Board notifications of hepatitis C2 1992 – 99 Total = 1112 250 Nos of cases 200 150 100 50 0 1992 1993 1994 1995 1996 1997 1998 1999 Year 14 Source: GUHT Virology Laboratory & GHB CD Team Records Fig 8 Persons in Scotland reported to be hepatitis C antibody-positive: rate/100,000 population by Health Board as at 31/12/99.5 Rate per 100,000 population 450 400 350 300 250 200 150 100 50 le G y ra re m at pi er an G la sg ow H ig hl an La d na rk sh ire Lo th ia n O rk ne y Sh et la nd Ta ys W es id e te rn Is le s G Fo rt h Va l Fi fe rr an B or ie s de & rs G al lo w ay fr D um an ire sh A yr A rg yl l& d C A ly d e 0 Health Board Source: SCIEH Weekly Report 29/8/00 Vol 34 No 00/34 3.2.4 Summary 3.3 People at greatest risk of developing the infection are young adult injecting drug misusers. Growth in numbers of people identified as hepatitis C antibody positive during the 1990s reflects improvements in access to testing as well as a true increase in the incidence of infection. In 1997, the rate of reporting of hepatitis C antibody positivity in Grampian was similar to that for Scotland as a whole. Human Immunodeficiency Virus 3.3.1 Routes of Transmission HIV is a virus which depletes the immune system and causes the Acquired Immune Deficiency Syndrome (AIDS). The predominant modes of transmission vary throughout the world. The main route locally is through unprotected sexual intercourse – both heterosexual and between men who have sex with men. There is a high-risk of mother to child transmission during normal delivery (15%) but this can be dramatically reduced by the use of drug treatments in the pregnant mother and infant, caesarian section and by avoiding breast-feeding. Transmission can also occur through sharing needles, syringes and other contaminated drug-injecting equipment. 15 Fig 9 HIV-1 infected persons: Grampian Health Board - How person probably acquired the virus.7 160 Others* 140 IDU Heterosexual Cumulative cases by risk factor 120 MSM 100 80 60 40 20 0 92/93 93/94 94/95 95/96 96/97 97/98 98/99 Year Source: GHB AIDS Control Act 1991/1992 – 1998/1999 * Other category represents risk factors such as blood/tissue transfer/mother to child and undetermined – see Appendix 3 3.3.2 Natural History The length of time from a person initially being infected with HIV to developing AIDS varies considerably with two thirds of untreated patients developing AIDS 10 years after HIV infection. Advances in treatments have resulted in significant improvements in patient survival but HIV disease remains incurable and no vaccine is available. 16 3.3.3 Amount of known HIV disease in the Grampian population Fig 10 New cases of HIV cases - diagnosed in Grampian 1990 to December 19998 20 18 Nos of cases diagnosed 16 14 12 10 8 6 4 2 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 Year Source: SCIEH Weekly Report 4/4/00 Vol 34 No 00/13 Fig 11 Cumulative number of HIV-1 infected persons, and cumulative number of AIDS cases reported to 31/12/999 HIV-1 infected persons AIDS cases Ratio Infected:AIDS Scotland 3027 1003 (745 deaths) 3:1 Grampian 160 37 (32 deaths) 4:3 Source: SCIEH Weekly Report 25/1/00 Vol 34 No 00/04 17 Fig 12 Numbers of people with known HIV infections in Scotland by Health Board as at 31/12/99 (number per 1000 population).8 1.2 No per 1000 population 1 0.8 0.6 0.4 0.2 A A r yr gyl sh l & ire C an lyd e d D um A r r fr ie B an o s & rd G ers al lo w ay Fo rt Fif h e Va l G G le re r y at am er pi G an la sg H ow ig La hl na an rk d sh i Lo re th ia O n rk ne S he y tla nd T W a es ys te ide rn Is le s 0 Health Board Source: SCIEH Weekly Report 4/4/00 Vol 34 No 00/13 3.3.4 Summary Prevalence of HIV infection in Grampian is lower than the Scottish average. The reduction in incidence of AIDS in recent years is probably due to the benefits of new drug treatments for HIV infection. Over recent years, heterosexual acquisition of infection appears to be more frequent. 3.4 High Risk Behaviours Two types of high-risk behaviour are particularly associated with an increased probability of acquiring hepatitis B and C, or HIV: Injecting drug misuse (where equipment – “works” – are shared) Frequent change of sexual partner (unprotected sexual intercourse) 3.4.1 Injecting drug misuse In 1999 the levels of new injecting drug misusers living in Aberdeen City, as recorded by the Scottish Drug Misuse Database (ISD), appears to indicate that there is a higher number of new Injecting Drug Users in Aberdeen as compared to the Scottish average10. The levels of sharing of injecting equipment in Aberdeenshire and Moray were higher than the Scottish average 10. 18 3.4.2 Frequency of change of sexual partners There is evidence that there has been increase in the number of sexually transmitted infections within Grampian. Fig 13 Genital Chlamydia Infections in females aged 15-24 years in Grampian reported by laboratories 1996-199811 12 9.8 10 No per 1000 population 8.8 8 8 6 4 2 0 1996 1997 1998 Year Source: SCIEH Weekly Report 3/8/99 Vol 33 No 99/31 3.5 High Risk Groups Local and national epidemiological information identify the following groups as being at significantly higher risk of bloodborne infection than the general population: Injecting drug misusers Men Who have Sex With Men (MSM) Sex industry workers Prisoners Household and sexual contacts of positive cases At Risk Individuals dealing with blood and body fluids. Staff and residents of institutions for those with severe learning difficulties 19 3.6 3.7 Information Gaps There is a lack of detailed information about variation of incidence and prevalence of HIV, and HBV and HCV within Grampian. The true overall prevalence and trends in injecting drug misuse, and variation within Grampian, is unknown. There is a major lack of detailed, accurate information on risk taking behaviour (and the reasons behind it) both in Grampian as a whole, and within more local areas. Recommendations Further research is required into risk taking behaviour and the reasons behind it in Grampian. 4 Prevention 4.1 Guiding Principles Whilst seeking to bring about behaviour change, account should be taken of the following guiding principles: Key stakeholders including target groups and relevant service providers should be active participants in the planning and implementation of health promotion initiatives. Health services should be aware of and be sensitive to the diversity of needs that exist amongst their service users. Initiatives should not only provide access to information and services but should seek to provide opportunities for skills development in order to allow communities and individuals to exercise more control over their own health and over their environments, and to make choices conducive to health. Where possible support should be provided to strengthen existing self-help and other formal and informal support networks. The provision of support to those that are infected or affected is of particular importance when considered in relation to potentially stigmatising illness such as HBV, HCV and HIV. 4.2 Key messages Key messages should be identified which aim to raise awareness of the need to prevent the spread of HIV and hepatitis B & C. Whilst the means by which these messages are communicated may vary according to the groups which are being targeted, the information upon which they are based is appropriate to all groups. The following information provides the basis for the formulation of key messages: Basic facts about HIV, hepatitis B and C How each virus is, and is not transmitted The importance of safer sex, including the appropriate use of protection. The importance of not sharing any injecting equipment, including water, spoons and filters, if drugs are injected The availability of testing 20 4.3 Health Promotion 4.3.1. General Public Since the early eighties efforts have been made to raise awareness of HIV via mass media campaigns, though there has been less emphasis in recent years. However, there have been few initiatives to raise the profile of HBV and HCV amongst the general public. Given the current trends it is important that the risk of transmission routes and associated risks of HBV and HCV are integrated into future campaigns. In order to do this effectively, there should be a shift of focus from specific disease prevention messages to more general sexual health promotion and drug education campaigns. This would include raising awareness of potentially elevated risks associated with travel abroad. 4.3.2 Young People It is important that education in relation to the prevention of the spread of bloodborne pathogens is integrated into the existing health education component of the formal and informal curriculum within schools12. National guidance on the 5 to 14 curriculum is currently in place in relation to sex and drug education, while locally the Health Promoting School Project provides a framework for a whole school approach to drug education and sexual health promotion. The provision of age appropriate information on these topics should be accessible to young people via the statutory and voluntary services with whom they have contact. 4.3.3. Men who have sex with Men The term ‘men who have sex with men’ (MSM) includes all men who participate in homosexual activity whether or not they identify as gay. A range of approaches developed in partnership with the gay community, including condom distribution, targeted campaigns and peer education are recognised ways of providing an appropriate response to HBV, HCV and HIV prevention. In particular initiatives should promote safer sex including the use of extra strong condoms and water-based lubricants for penetrative sex. 4.3.4 Injecting Drug Misusers The practice of sharing drug-injecting equipment is the most common route of transmission of hepatitis B and C in the Grampian area. It is therefore necessary to promote the avoidance of injecting where possible and safer injecting practice when this has not been achieved. The evidence from Grampian Primary Care Trust (Substance Misuse Service) is that the current practice of substitute prescribing treatment programs is reducing the levels of injecting behaviour13. (See Section 4.5) 4.3.5 Prisoners In Grampian there are two prisons, Peterhead and Craiginches. There is thought to be high levels of sharing injecting equipment among prisoners. There is a need for appropriate prevention activities that target this particular group. Such activities however must take into account the particular constraints which exist as a result of the prison environment i.e. lack of access to injecting equipment and condoms. Health promotion programmes therefore should be planned and implemented in partnership with prison staff. 21 4.3.6 Sex industry Workers There is evidence that a substantial proportion of those working in the industry in Grampian are injecting drug misusers.14 They are therefore at risk through more than one route of transmission. The findings of the sexual health needs assessment of sex industry workers suggest a need for an accessible “safe space” in the Aberdeen City harbour area. This could be used to promote information about bloodborne pathogens including routes of transmission and immunisation, Sexually Transmitted Infections (STI’s) and treatment options and harm minimisation that are sex worker focused. 4.3.7 Those who are infected or affected Health promotion activities which target those people who have tested positive for any of the bloodborne pathogens, their household and sexual contacts, should aim to assist in the process of coming to terms with a positive diagnosis, assist in maintenance of good health and avoid further transmission. 4.3.7 Other marginalised groups e.g. homeless, travelling people There is a need to raise awareness within these groups. Due to the nature of their transient lifestyle and / or cultural differences these groups need particular consideration. Mainstream services need to be flexible enough to meet their needs. 4.4 Training At present the statutory and voluntary sectors are involved in the provision of training to a wide variety of audiences. This training covers such topics as sexual health promotion, drug education, infection control and patient management. Such training not only seeks to provide accurate information on the nature of each of the viruses and routes of transmission but also aims to tackle prejudice and discrimination through the exploration of attitudes and values. The following professional groups have been identified as priorities in relation to the provision of training: Health care workers including doctors and nurses, in both primary and acute care, dentists and other workers e.g. domestic staff, porters, and laundry staff. Those likely to be in contact with blood and body fluids for example: Social care workers, including those who work in community and residential settings, workers within the criminal justice system including police and prison staff and staff working with the homeless. Teachers, youth and community workers and others who have a role in the provision of education 4.5 Needle Exchange Education and prevention programmes for people who inject drugs will continue to be a high priority. A range of strategies appropriate to particular environments and target groups will be continued including abstinence, reduction in injecting frequency, harm reduction/safer injecting practices, substitute prescribing treatment programmes and needle exchanges. These are promoted in the context of communicable disease prevention and drug and alcohol programmes and therefore are integral to the work of the three Drug Action Teams in Grampian. 22 Needle Exchange Schemes have an essential role in the prevention of bloodborne infection amongst injecting drug misusers and their sexual partners15. Currently the service provides a free supply of sterile injecting needles and syringes to reduce the risk of sharing together with the safe disposal of used equipment. Needle exchanges also provide harm minimisation information, skills and advice for injecting drug misusers. The Group noted that access to needle exchanges can be a problem (for current provision see appendix 4). Scottish Office regulations incorporating the Lord Advocate’s advice were updated in 1998 and Grampian Health Board is currently able to approve and develop the establishment of new Needle Exchange Schemes which adhere to national and local guidelines. 4.6 Immunisation A vaccine is available for HBV but not HCV or HIV. A full course of hepatitis B immunisation involves three injections over a period of six months. Where there is a need to provide more rapid immunisation, for example following exposure to the virus, the course of three doses may be given over a two-month period, with a booster dose at twelve months. The vaccine is effective and safe, with few side effects. In certain cases an injection of HBV immunoglobulin may be given as well to provide immediate protection whilst waiting for the immunisation course to work. In the UK, the current Department of Health policy is to provide selective HBV immunisation to those individuals judged to be at increased risk because of their lifestyle, occupation or other factors such as close contact with a case or carrier. In addition, antenatal screening for hepatitis B is undertaken, and immunisation offered to all babies born to infected mothers16. A number of actions are currently being implemented to control the spread of infection within Grampian. These include encouragement of opportunistic immunisation of people in high-risk groups within primary care and through services in contact with drug misusers. Hepatitis B immunisation is offered to pregnant women who misuse drugs. 4.7 Recommendations A high profile public awareness campaign should be undertaken, which highlights the potential risks of transmission of HIV and HBV & HCV, how transmission can be prevented and promotes a climate of understanding and tolerance of those affected. Ensure those infected and affected by bloodborne pathogens receive necessary information. Provide a programme of training for teachers to support the implementation of the Health Promoting School – sexual health pack if supported by evaluation of the pilot scheme Recommendations arising from the sexual health needs assessment of men who have sex with men should be considered. Recommendations arising from the sexual health needs assessment of sex industry workers should be considered. The provision of a variety of free condoms and lubricant for the general public should be expanded whilst ensuring ease of access for all groups 23 Training An audit should be undertaken to establish what training is currently being provided and by whom. This information should provide the basis for a comprehensive training plan for those groups described in the report. This should include provision of appropriate information of risks of infection, prevention of transmission, risk assessment and appropriate controls. Needle exchange Further develop Needle Exchange services in Grampian. Assess the appropriateness of distributing other injecting equipment eg spoons or filters Immunisation Continue, for the foreseeable future, to promote opportunistic hepatitis B immunisation of people in high-risk groups. Review the appropriateness of continuing the selective approach to HBV immunisation following assessment of the impact of current HBV outbreak control measures. 5 Confidentiality It is every individual’s right to expect their medical information to remain confidential and explicit permission must be obtained from patients prior to any disclosure. Because of the broad range of health, social and voluntary services involved in the treatment and care of people living with bloodborne pathogens, a continuum of care is particularly important to ensure that all elements of the system work together for the patient’s benefit. It has been noted that confidentiality is an issue both within and between organisations. Information may be restricted because of personalities/policies impacting on ability to perform duties. A statement on confidentiality should be developed through the Community Care Agenda. However, the importance of confidentiality when trying to attract hard to reach at risk groups into services must be recognised. Recommendation Develop a policy statement on confidentiality to support multi-agency working through the Community Care Agenda taking into account the Data Protection Act and Caldicott Guidance. 6 Virological Investigation The overall aim of early detection is the identification of those infected with bloodborne viruses to allow assessment of their disease, appropriate management, consideration for anti-viral therapy, advice on how to prevent further liver damage (if HBV or HCV) and minimise transmission to others. 24 6.1 Hepatitis B Hepatitis B surface antigen (HBsAg) is the main screening test used for possible current (acute or chronic) infection and is a marker of infectivity. IgM anti-core antibodies are positive in recent infection and this test is done when either HBsAg or total anti-core antibody are positive. Hepatitis B e antigen (HBeAg) when positive, is a marker of definite high infectivity. However, antibody to e (anti-HBe) positive test does not mean that someone is of low infectivity. Statistically this is likely but it is not possible to say for an individual person. All these tests, together with total anti-core, and anti surface antibody are done locally. Apart from confirmation of e status in an exposure-prone procedure worker, confirmation of positive tests is usually done locally, but where required, samples are sent to the Regional Virus Laboratory at Gartnavel Hospital, Glasgow. Hepatitis B DNA (HBV DNA) can be measured by different test methods of varying sensitivity. These tests are used in relation to assessing infectivity and monitoring treatment. In general, samples for these tests are sent to the Regional Virus Laboratory at Gartnaval General Hospital. There are no plans to do HBV DNA tests locally. 6.2 Hepatitis C Diagnostic antibody tests for HCV first became available in 1991. The diagnosis of HCV infection is made on the basis of a blood test that detects antibody to HCV virus in an enzyme linked immunosorbent assay (ELISA). Reactive specimens are retested in a supplemental assay such as the recombinant immunoblot assay (RIBA). Molecular assays can be used to detect, quantify and determine genotype of the HCV ribonucleic acid (RNA) in infected patients. Qualitative polymerase chain reaction (PCR) detects viral RNA/viraemia and is used to select patients for treatment and to monitor their response. Viral load is determined by quantitative PCR or by branched chain DNA tests. Genotyping, and to a lesser extent HCV viral load, is used to predict response to treatment and to select treatment regimens. The initial screening test with ELISA is undertaken in Aberdeen but samples for confirmatory testing are sent to the Regional Virus Laboratory at Gartnavel Hospital in Glasgow for RIBA and qualitative PCR and to the Regional Virus Laboratory at the City Hospital in Edinburgh for quantitative PCR and Genotyping. Samples are sent to specialist testing laboratories because facilities for RIBA and PCR are not available locally but these tests are not funded under a nationally agreed contract. 6.3 HIV Antibody to HIV 1 & 2 is the main screening test. Negatives are reported but reactive samples are sent to the HIV Reference Laboratory, Regional Virus Laboratory at Gartnavel Hospital for confirmation. HIV viral load is used to monitor HIV positive patients to assess when treatment should start and to monitor treatment. Selected patients who appear not to be responding to treatment sometimes require HIV resistance testing or measurement of anti HIV drug levels. Samples for viral load and resistance testing are sent to the Department of Retrovirology, Royal Free Hospital, London and for Saquinavir and Nelfinavir levels to the Department of Pharmacology and 25 Therapeutics, University of Liverpool. There are no plans to do HIV confirmation, viral load, resistance testing or drug levels locally. 6.4 Funding Issues Since HIV and hepatitis C testing began there has been no specific laboratory allocation of additional funding to meet the increased burden placed on the laboratory. The current outbreak of hepatitis B is causing a large increase in laboratory testing further stretching limited resources. Laboratory testing may also increase when the DOH changes their policy on hepatitis B positive healthcare workers and exposure-prone procedures. 6.5 Recommendation Make funding available to the laboratory to cover the costs of viral monitoring, resistance testing and drug levels in HIV patients, laboratory costs of testing for hepatitis C, and laboratory-associated costs with providing clinical assessment and treatment to people with chronic hepatitis B infection. 7. Who should be tested? Individuals in high-risk groups should be counselled and offered testing if they are considered to be at risk of infection. 7.1 7.2 7.3 General testing Those identified to be in high risk groups see Section 3.5 People with a history of multiple sex partners or sexually transmitted diseases People who specifically request a test – some people may not admit to any risk factors for infection but may have hidden risk factors. People with tattoos or other body piercing where standard infection control procedures may not have been followed Individuals that have sustained needlestick, bite injury or accidental exposure of mucous membranes to blood or body fluids. Visa requirement HBV testing As per general testing and Exposure prone workers including medical and nursing staff Patients presenting with clinical illness compatible with acute or chronic HBV All pregnant women as part of the ante natal screening programme (see section 9.1) HCV testing As per general testing and Recipients of blood clotting factors prior to 1987 Recipients of other blood products before 1991 Patients on chronic haemodialysis Patients with unexplained, abnormal liver enzymes. 26 7.4 Children of HCV positive mother – antibody testing after one year of age i.e. after maternal antibodies have declined. HIV testing As per general testing and Pregnant women from high prevalence areas Patients presenting with clinical illness compatible with HIV Anonymous testing is carried out to estimate the prevalence of HIV in a community. Anonymous positive HIV tests from the GUM clinic is a cause for concern, as these individuals may be unaware that they are positive. 8 Counselling Confidential counselling should be provided for all those individuals requesting or being offered testing (see section 7.2). Professionals providing testing should have the knowledge, skills and time to counsel their patients or should refer them to a specialist counselling service e.g. Department of Genito-Urinary Medicine. Training may be required for these professionals. Consent for testing must be obtained prior to testing for any serious communicable disease (including HIV, HBV and HCV) except in certain specified and rare circumstances17, 18, 19. The testing should also be linked with the opportunity for referral for specialist assessment. The pre-test discussion/ counselling should include: discussion about the nature of infection transmission and risk reduction identifying risk activities and the need for the test discussion on the advantages and disadvantages of testing implications of the positive or negative result for the individual the test procedure, giving of results and follow up support The patient must have time to consider and discuss the implications prior to giving consent. Post-test discussion should be available for those diagnosed both negative and positive this should include: 9 providing support and advice opportunity for referral for specialist assessment and management advice on risk reduction and prevention of transmission Screening Screening is a form of secondary prevention and seeks to identify an unsuspected disease or pre-disease condition for which an effective intervention is available and the benefits outweigh any physical or psychological harm. No new population screening programmes should be introduced unless recommended by the UK National Screening Committee (NSC). 27 9.1 Hepatitis B Pregnant women are the only group to whom routine screening should be offered because HBV infection can be transmitted from infected mothers to their babies at or around the time of birth. These babies have a high risk of becoming chronic carriers of the virus and will be at risk of developing liver disease including cirrhosis and hepatocellular carcinoma. The development of carrier status after perinatal transmission can be prevented in around 90-95% of cases by immunisation. Antenatal screening allows the babies of women with hepatitis B to be offered immunoglobulin and immunisation commencing at birth. Routine antenatal screening for HBV and immunisation of affected babies has been in place in Grampian for many years and the programme has recently been reviewed following a recommendation by the NSC that it should be available throughout the UK. 9.2 Hepatitis C It has been suggested that targeted population screening should be introduced for the asymptomatic population at high risk of acquiring HCV. The purpose of screening this group would be to offer anti-viral treatment on the assumption that earlier treatment was beneficial. It has not yet been demonstrated that the benefit of screening outweighs the harms and costs in either intravenous drug misusers or genito urinary medicine (GUM) attendees20. 9.3 HIV The NSC has recently approved a recommendation that universal antenatal screening should be introduced in England because anti-viral treatment of the mother and neonate plus caesarian section and not breastfeeding can reduce the risk of vertical transmission to about 1-2%. No decision has been made yet in Scotland. 10 Management Clinical management embraces a range of needs, including the provision of appropriate, high quality, timely and accessible service. 10.1 Hepatitis B Adults and children who develop chronic hepatitis B infection are at increased risk of long term liver damage including cirrhosis, and in a small number of cases, liver cancer. For adults who become chronically infected, about 25% will proceed to liver cirrhosis. It is important that all patients who fail to spontaneously clear their hepatitis B infection receive specialist clinical assessment to identify the most appropriate treatment, with the overall aim of eradicating the virus from the body, thereby preventing the long term damage to the liver associated with chronic infection. It should be noted that the current outbreak of acute hepatitis B infection within Grampian could be expected to lead to a growing pool of patients in whom chronic infection will develop. 28 10.2 Hepatitis C In patients who become infected with hepatitis C, approximately 80-85% will fail to spontaneously clear the infection. If left untreated, about 20% of these patients will proceed to gradually develop cirrhosis of the liver, and a smaller number liver cancer. For the patient these are very serious clinical conditions associated with significant mortality. All patients with chronic hepatitis C infection will benefit from undergoing specialist clinical assessment to identify the most appropriate treatment, with the overall aim of eradicating the virus from the body, thereby preventing the long term damage to the liver associated with chronic infection. Clinical management is focused on counselling and complex drug therapy, in combination with on-going monitoring of viral activity within the body. In hepatitis C, combination drug therapy has been shown to be much more effective than monotherapy and should now be the standard treatment. 21,22, 23 On cost effectiveness grounds alone the priority for funding would be to treat the Interferon relapsers first, then those suitable for six months combination therapy and lastly those needing 12 months combination therapy.24 10.3 HIV All patients with HIV require specialist clinical assessment of their condition. The purpose of assessment is to determine the most appropriate treatment in order to delay progression of infection to AIDS. Assessment and treatment revolves around counselling and the use of complex drug therapy. An essential component of treatment is the on-going monitoring of the level of viral activity within the body, in order to assess the effectiveness of the drug treatment and guide future therapy. In HIV, the benefits of combination anti-retroviral therapy are well known. However, there are still uncertainties about prediction of response, length of treatment and frequency of monitoring. The complexity of treatment, and the need for more research, means that treatment is most appropriately provided through a hospital clinic associated with supporting laboratory services and systems for collecting the necessary data. This provides the infrastructure for trials of new treatments. A recent survey within Aberdeen City by the Community Care Planning Group for People with HIV/AIDS indicated a need for access to respite care. However, more information is required for Grampian as a whole. 10.4 Funding Issues There will be significant resource implications in providing a comprehensive service for patients with hepatitis C. To date, in Grampian, no specific allocation of funds has been made to meet the costs of providing diagnosis, counselling, treatment and support to people with hepatitis C infection. Access to necessary treatment is therefore limited. As combination treatment is now regarded as the optimal choice of treatment and is not yet funded, people assessed as needing treatment do not get it. 29 Major health and health service consequences will result if the current situation continues. In addition, there will be significant pressures on local authorities and others to support patients and their carers. Additional funding is required to meet the cost of provision of combination drug therapy, counselling, clinical assessment, enhanced nursing input, and rising laboratory activity. In December 1997, a business case identified the funding required to allow treatment of patients with hepatitis C as being in the region of £250,000 per year (see Appendix 5). These costs are anticipated to have risen substantially over the last two years, and revised estimates are currently under preparation within the Grampian University Hospitals Trust. The drugs used to treat HIV infection are already funded within Grampian. However, there has been no additional allocation of funds to meet the increasing laboratory costs of monitoring HIV viral load, or the costs of HIV resistance testing and anti-HIV drug levels. Local Authority staff provide a range of services within community care, criminal justice, and children and families. Some people who receive services will also be undergoing treatment. Consideration should be given to ways in which Local Authority staff can support patients and their families. 10.5 Recommendations Fund the drug costs associated with providing management of people with chronic hepatitis B infection. Fund the establishment of a service for people suffering from hepatitis C, thereby allowing them to access appropriate specialist counselling, virological investigation, clinical assessment and drug treatment. Consideration should be given to ways in which Local Authority staff can support patients and their families. Through the community care planning process consideration should be given to the need for access to respite care. 11 Monitoring and Evaluation Monitoring and evaluation mechanisms are needed to ensure that current policy is based on best available evidence and information. At present some information on HIV related activity is collated by Grampian Health Board in order to complete the annual AIDS Control Act Report. Difficulties have been experienced in the collection of bloodborne pathogen data. It is essential that all agencies involved in any aspect of blood- borne pathogens use an identified reporting mechanism. 11.1 Recommendation An enhanced reporting mechanism is required to ensure comprehensive collation of relevant information by Grampian Health Board. 30 12 Communication Structures Strategies and policies that have relevance to the management of bloodborne pathogens need to be developed and implemented in a co-ordinated way. Currently there are a number of strategic and operational groups whose remit includes bloodborne pathogens e.g. Area Infection Control Committee, Community Care Planning Group, Drug Action Teams, etc. The role of the HIV Co-ordinator is the key to the ongoing communication between these groups. The responsibility for co-ordination lies with the Consultant Public Health Medicine (CD&EH). Once the bloodborne pathogen strategy has been agreed, it would be appropriate to establish an Implementation Group led by the HIV Co-ordinator to develop a detailed implementation plan within available resources. 12.1 Recommendations Implementation Group to be established and led by the HIV Coordinator/CPHM (CD&EH). The Implementation Group must take into consideration the action plans of the Joint Community Care Plan, Modernising Community Care Action Plans and the Health Improvement Plan and the Trust Implementation Plan. A communication mechanism is required to provide key personnel working in the area of blood borne pathogens with relevant and up to date information to ensure that action taken by relevant groups is consistent with the bloodborne pathogens strategy. 31 Appendix 1 Bloodborne Pathogens Strategy Group Remit The Bloodborne Pathogens Strategy Group will advise GHB Directors on an appropriate strategy to ensure a coordinated, consistent approach to the prevention and treatment of bloodborne pathogens throughout Grampian, maximising available resources. In carrying out this task the group will: Taking account of national and local policy guidance and research, review existing policies, which may impact on the prevention and treatment of bloodborne pathogens. In accordance with the guidance/strategies, agree aims and objectives for the prevention, treatment and management of bloodborne pathogens in Grampian. Summarise existing activities/initiatives and identify issues/gaps in current strategies/policies. Develop a prioritised 3 year action plan to address gaps/issues in the prevention and treatment of bloodborne pathogens in Grampian Review the communication mechanisms to ensure bloodborne pathogens are addressed in a consistent, appropriate manner across interested groups/organisations and make recommendations to GHB for ongoing effective communication. Recommend a monitoring and evaluation system. Membership The membership of the group varied during the course of the strategy development with the following individuals contributing to this document: Fiona Aitken Gillian Anderson Fiona Browning Roy Browning Prof. Peter Brunt Deborah Bunn Grahame Cronkshaw Alison Davidson Dr Aileen Downie Dr Helen Howie Susan Jappy Dr Rob Laing Jayne Leith Dr Pamela Molyneaux Nurse Specialist, HIV Clinical Training Coordinator, GHB Health Promotions Communicable Disease Control Nurse, GHB Infection Control Nurse, GPCT Consultant Gastroenterologist, GUHT Substance Misuse, GPCT Drugs Misuse Policy Manager, GHB Social Work Department, Aberdeenshire Council Consultant Physician, GUM Senior Registrar, Public Health Medicine, GHB Chairman, Health Promotions Commissioning Manager, Grampian Health Board Consultant Physician, Infection Unit, GUHT Communicable Disease Control Nurse, GHB Consultant Virologist, GUHT 32 Senga McDonald Dr Bill Reith Jean Sinclair Ian Smillie Dave Spalding Dr Henry Watson Dr Diana Webster Sue Williams Coordinator, Drugs Action GP Sub Committee Social Work Department, The Moray Council Drugs Worker, Craiginches Prison Social Work Department, Aberdeen City Council Consultant Haematologist, GUHT Consultant Public Health Medicine, GHB Consultant Nurse, Substance Misuse Service, GPCT Secretariat Diane McGregor GHB 33 Appendix 2 Fig 14 Persons reported to be hepatitis C antibody-positive in Grampian by age group cumulative to December 1999 45-59 6% 30-44 31% 60+ 2% NK 1% <14 0% <14 15-29 30-44 45-59 60+ NK 15-29 60% Source: SCIEH Weekly Report 29/8/00 Vol 34 No 00/34 34 Appendix 3 HIV Prevalence Fig 15 HIV infections: how the person probably acquired the virus during the period 1996 –1998 (SCIEH Weekly Report 26.1.99 Vol 33 No 99/04 Injecting drug misuse Homo/bisexual Heterosexual Other/undetermined Total 1996 1997 1998 1996 1997 1998 1996 1997 1998 1996 1997 1998 1996 1997 1998 Grampian 1 5 0 6 6 4 6 7 7 2 0 5 15 18 16 Scotland 36 33 17 76 74 61 48 53 43 6 9 18 166 169 139 Untraceable anonymous testing of Genito-urinary medicine clinic attenders: % of tests positive Grampian % Scotland % Homo/Bisexual Males 1995 0 3.64 (excl. IDU) 1996 1.2 4.09 1997 6 2.87 Heterosexual Males 1995 0.21 0.3 (excl. IDU) 1996 0 0.21 1997 0.4 0.19 Heterosexual Females 1995 0 0.17 (excl. IDU) 1996 0 0.21 1997 0.71 0.15 Injecting drug misusers 1995 0 2.83 1996 0 3.7 1997 0 3.37 Untraceable anonymous testing of neonates (including neonates of IDUs): % of tests positive. (The HIV status of a neonate is a surrogate marker of the infection status of its mother.) Grampian Scotland 1996 1997 1998 1996 1997 1998 0 0.02% 0.02% 0.02% 0.03% 0.02% APPENDIX 6.3.2 Total Number of Needles Exchanged in 1999/2000 a) Drugs Action 145,000 needles per year (approx) b) Community Pharmacies 150,000 needles per year (approx) 35 Appendix 4 Current Provision (April 2000) NEEDLE EXCHANGES in GRAMPIAN OPENING TIMES Community Pharmacies, Grampian Douglas Dickie, 96 Victoria Road, Torry, Aberdeen Monday Tuesday Wednesday Thursday Friday Saturday 0900 - 1730 0900 - 1730 0900 - 1300 0900 - 1730 0900 - 1730 0900 - 1730 Tillydrone Pharmacy, Unit 6, Tillydrone Shopping Centre, Hayton Road, Tillydrone, Aberdeen Monday Tuesday Wednesday Thursday Friday Saturday 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1245 closed 1300 - 1400 closed 1300 - 1400 closed 1300 - 1400 closed 1300 - 1400 closed 1300 - 1400 Holburn Pharmacy, 560 Holburn Street, Aberdeen Monday Tuesday Wednesday Thursday Friday Saturday 0900 - 1800 0900 - 1800 0900 - 1800 0900 - 1900 0900 - 1730 0900 - 1700 Alan Johnson, 68 Gardner Drive, Kincorth, Aberdeen Monday Tuesday Wednesday Thursday Friday Saturday 0900 - 1800 0900 - 1800 0900 - 1300 0900 - 1800 0900 - 1800 0900 - 1745 Boots the Chemist Ltd, 21-23 Marischal Street, Peterhead Monday Tuesday Wednesday Thursday Friday Saturday 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1730 Lloyds Chemist, 48 High Street, Elgin Monday Tuesday Wednesday Thursday Friday Saturday 0845 - 1730 0845 - 1730 0845 - 1730 0845 - 1730 0845 - 1730 0845 - 1730 H D McIntosh, 39 Main Street, New Elgin Monday Tuesday Wednesday Thursday Friday Saturday 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1300 Bishopsmill Pharmacy, 20 North Street, Bishopsmill, Elgin Monday Tuesday Wednesday Thursday Friday Saturday 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1630 West End Pharmacy, 166 High Street, Forres Monday Tuesday Wednesday Thursday Friday Saturday 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1730 0900 - 1300 37 Drugs Action, 48a Union Street Aberdeen Monday Tuesday Wednesday Thursday Friday 1100 - 1300 1100 - 1300 1200 - 1300 closed am 1100 - 1300 1400 1400 1400 1400 1400 - 1700 1700 1700 1800 1700 Drugs Action, Outreach Sessions Woodside Community Centre (Marquis Road entrance) Monday 1800 - 2000 Mastrick Young Unemployed Project (Lang Stracht) Tuesday 1400 - 1600 Middlefield Parish Church (Manor Avenue) Tuesday 1630 - 1800 Northfield Community Education Centre (Byron Square) Wednesday 1430 - 1730 Torry Advice Centre (Menzies Road) Thursday 1600 - 1800 Substance Misuse Service, Grampian Primary Care NHS Trust, Fraserburgh Monday Tuesday Wednesday Thursday Friday 1000 - 1700 closed 1400 - 1700 1400 - 1700 1400 - 1600 1800 - 2000 Drug & Alcohol Team, Grampian Primary Care NHS Trust 252 High Street, Elgin Monday – Friday 0900 - 1700 38 Map illustrating sites of Needle Exchanges in Aberdeenshire & Moray T = Grampian Primary Care Trust CP = Community Pharmacist 39 Map illlustrating sites of Needle Exchanges in Aberdeen City CP = Community Pharmacist DA = Drugs Action 40 Appendix 5 Hepatitis C Virus Infection: December 1997 Summary of Business Case Presented by GUHT Hepatitis C (HCV) is a virus spread predominantly by blood. The two main groups of people know to be affected are recipients of blood and blood products and injecting drug users (IDU), but at least 20% of infected people have no known risk factor. HCV is a chronic progressive infection in over 80% of infected people. Progression is normally very slow, taking more than 20 years, to the end points of liver failure and hepatocellular carcinoma. Prevention of spread is limited to universal precautions. Patients require assessment before treatment is offered. At the time of writing, alphainterferon is the only licensed drug for HCV. Reversible non-life-threatening side effects are common in the early stages of treatment. Not everyone is suitable for treatment, nor does everyone respond. Response should be determined after three months treatment by virological criteria. Responders should have alpha-interferon therapy for 12 months. 20% have no evidence of active HCV infection in the blood six months after cessation of therapy. Non-responders and relapsers require on-going surveillance to ensure appropriate management of end-stage complications of infection. People who have acquired HCV as a result of medical treatment should be traced and offered treatment if appropriate. While IDU and ex-IDU should not be actively recruited, they should be offered testing (after counselling) opportunistically and those found to be HCV-infected advised about prevention of spread. Ideally all HCV-positive people should be offered a consultant appointment for assessment. The decision to prescribe alpha-interferon rests with the Consultant and the patient who should be suitable, willing and prepared to comply with a trial of three months of treatment. Careful monitoring is necessary. Care may be undertaken jointly by the GP and the hospital. No new resources have been provided to ARHT for diagnosis, investigation or management of HCV since it was discovered. Tests for HCV became available in 1991 and were introduced. Over the last six years there has been a large increase in workload assessing HCV-infected patients and in investigations, especially for the Virus laboratory. Glasgow is not yet charging ARHT for HCV laboratory tests, but this is expected to change soon. £201,728 is sought per year for the management of HCV for: Medical evaluation and treatment of HCV Medical follow-up of HCV Drug costs of HCV Half-time Grade F staff nurse Part-time medical secretary £54,151 is sought (£53,215 recurring) to provide a comprehensive on-site virology service. 41 Appendix 6 References (1) Protection against Bloodborne infections in the workplace: HIV and hepatitis Advisory Committee on Dangerous Pathogens 1996 (2) GUHT Virology Laboratory data and GHB Communicable Disease Team records (3) Prevention and Control of Hepatitis B in the community Communicable Diseases Series, No1 1996 2nd Edition (4) SCIEH provisional figures – personal communication 1999 (5) SCIEH Weekly Report 29/8/00 Vol 34 No 00/34 (6) Poynard T, Bedossa P, Opolon P. Natural history of liver fibrosis progression in patients with chronic hepatitis C. Lancet 1997; 349:825-832 (7) HIV Risk Groups – AIDS Control Act – Grampian Health Board 1992 – 98/99 (8) SCIEH Weekly Report – 4/4/00 Vol 34 No 00/13 (9) SCIEH Weekly Report – 25/1/00 Vol 34 No 00/04 (10) Information Services Division Drug Misuse Statistics Scotland, December 1999 (11) SCIEH Weekly Report 3/8/99 Vol 33 No 99/31 (12) Grampian Health Board, Adult and Youth Lifestyle Surveys 1998 (13) Grampian Primary Care Trust Substance Misuse Service, March 1999 (14) Grampian Health Board, Sex Industry Workers – an assessment of sexual health needs in the Grampian area March 2000 (15) Stimson G Drug Injecting & the spread of AIDS. Transactions of the Medical Society of London 113 1998 (16) Immunisation Against Infectious Disease 1996 HMSO (17) General Medical Council Serious Communicable Diseases 1999 (18) UKCC Code of Professional Conduct for Nursing, Midwifery and Health Visiting No 10 June 1992 (19) Guidelines for pre-test discussion on HIV testing, The Scottish Office, October 1996 42 (20) Screening for Hepatitis C in intravenous drug users and genito-urinary clinic attendees. The Wessex Institute Development and Evaluation Committee Report No 81 March 1998 (21) Poynard T, Marcellin P, Lee SS et al. Randomised trial of interferon alfa/2b plus ribavirin for 48 weeks or for 24 weeks versus interferon alfa/2b plus placebo for 48 weeks for treatment of chronic infection with hepatitis C virus. Lancet 1998; 352: 1426-1432 (22) McHutchison JG, Gordon SC, Schiff ER et al. Interferon alfa-2b alone or in combination with ribavirin as initial treatment for chronic hepatitis C. N Engl J Med 1998: 339: 1485-1492 (23) Howie H. Scottish Health Purchasing Information Centre Report on Ribavirin and Interferon Alfa in Chronic Hepatitis C: an update. 1999. http/www.nhsconfed.net/shpic/doc11.htm (24) Personal communication Dr Helen Howie, Grampian Health Board . 43 Appendix 7 Feedback from the Bloodborne Pathogens Seminar, 4th October 2000. As part of the ongoing planning of the Grampian Health Improvement Programme and Trust Implementation Plans a Blood Borne Pathogen Seminar was held on October 4th 2000. The seminar aimed to build on the Grampian Bloodborne Pathogen Strategy which had been previously subject to wide consultation. Sixty- eight people attended the seminar from a range of disciplines. The objectives of this seminar were to: To increase awareness and understanding of bloodborne pathogens in terms of: Prevention, diagnosis, control, management of infection To identify, and prioritise, 5 year actions in line with the bloodborne pathogens strategy. These will be included in the health improvement programme planning process. Views were invited on: What service areas need improvement What are the priorities over the next five years Peoples information and training needs to support daily practice How can people work more effectively together The programme was chaired by Professor David Goldberg, introduced by David Sullivan GHB and Professor Peter Brunt (GUHT) who gave an overview of the story in Grampian. Thereafter a panel question and answer session included representatives from GUHT, GPCT, GHB, Health Promotions and Drugs Action. A series of workshops on prevention, management and social aspects enabled a sharing of ideas and experiences across a range of disciplines. Feedback from the workshops: 1. PREVENTION Current guidelines limit the number of needles that can be exchanged. Educate public/teachers etc as to what a needle exchange is and what it involves High profile media campaign – cards/beer mats: screen savers in pubs: video for youth groups, awareness cards for the population re BBP already in pipeline, a Grampian Helpline would be needed to support campaign. National Workshop November re HepC (HEBs, SCIEH, SNAP) may be national programme of awareness. Campaign needs to be backed up with education and help. Awareness essential to help alienate potential problems in future Immunisation policy change would require funding. Education given most discussion – in the broadest sense and specific groups e.g. needle exchange Immunisation – widen the immunisation policy – children of IDU’s 44 Encourage immunisation – Drugs Action, Outreach, Community pharmacists to advertise Lobby to change from selective immunisation as opposed to universal – Children of drug users not positive should still be immunised Expansion of needle exchange sites 2. MANAGEMENT What is happening now? Drug Therapy Fully funded for HIV treatment No specific funding for Hep B, C No named Bloodborne Pathogens Nurse HIV patients can get drugs they need as numbers are small Hep B chronic infection is small Management of HCV Combination of Drugs Years treatment £10,000 - £12,000 without lab monitoring Principle: ensure flexibility to respond to advances in technology and treatment regimes. Influence national debate on education and awareness of general public. Develop concept of ‘one-stop’ clinics in primary and secondary care to avoid patients waiting to see several people. Has implications for physical aspects (clinic space), human resources, time (possibly have particular clinic times). Improve communication and information links within BBP and beyond, while being aware of issues of confidentiality and human rights law. Drugs approved for use should be made available appropriately. Implement the shared care protocols which have been developed for Ribaviron and being developed for Interferon. Linked to availability of drugs: invest in laboratory services to maximise tests available locally and enable the implementation of protocols. 3. SOCIAL ASPECTS Looking at the wider needs of HBV, HCV and HIV victims. Facilitate a network of workers providing services and care. What social support is available for families who have contracted HIV,HBV& HCV Regular ‘getting together’ of individuals providing the services i.e. those individuals working on the shop floor with HBV, HCV, HIV carriers and potential carriers. This is along with and running parallel to a Bloodborne Pathogens monitoring/steering group, so that the Bloodborne Pathogens Group is a focused working strategy. Priorities High profile awareness campaign Extend immunisation Extend Needle Exchange Audit of Training Research – Risk taking behaviour 45 Evaluation of the seminar indicated that participants had a raised understanding of BBP and relative issues especially in the Grampian context and felt the seminar was an excellent opportunity to speak to very different professionals. The facilitated workshops created an environment for good conversations,people felt their contributions were valued and the bringing together of different agencies was very successful. The groups were enthusiastic, proved very valuable and were well facilitated. With regard to prioritising 5 - year actions in line with the strategy people commented that‘we’re getting there’. As an opportunity to participate in HIP it was commented as ‘yes’ but still a lot of work to be done. 46