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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
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ne
O
ia
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gh
la
nd
La
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sh
ire
Hi
la
sg
o
an
re
at
er
G
ra
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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
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nd
Ta
ys
W
es
id
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te
rn
Is
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s
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Fo
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Va
l
Fi
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an
B
or
ie
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de
&
rs
G
al
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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
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d
D
um
A
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ie
B an
o
s
& rd
G ers
al
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ay
Fo
rt Fif
h
e
Va
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G
le
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r
y
at am
er
pi
G an
la
sg
H ow
ig
La hl
na an
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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