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APPENDIX 8 D:\582727889.doc Cornwall Drug & Alcohol Services Integrated Care Pathway Blood Borne Virus (BBV) Testing and HAV/HBV Immunisation 1. Description This service is provided by the Primary Care Viral Hepatitis Nurse Specialists (2), based within specialist substance misuse services or accessed via the GU Clinic or any GP. This ICP describes those interventions that are provided for Cornwall and the Isles of Scilly residents and includes: Pre and Post test discussion Testing for BBV – HCV, HBV and HIV Appropriate information leaflets Harm reduction advice Appropriate immunisation for HAV /HBV Referral for HCV/HBV treatment if required Testing to be offered annually or more frequently if indicated Referral To GU for HIV assessment and treatment If indicated Advice for carers, partners and wider community 2. Access & referral Clients accessing Cornwall Substance Misuse Services may access this service via any local alcohol and drug services or via the Primary Care Viral Hepatitis Nurse Specialists directly. This includes All Tier 2 or 3 services. Drug and alcohol services in Cornwall are available through GP surgeries or team bases in Liskeard, Bodmin, Truro, St Austell, Redruth, Newquay and Penzance. Referrals can be made by telephone, email or in person Waiting time Appointments will be offered within 21 days of referral being received. 3. Treatment aims and objectives To offer advice and information about the transmission and risks of Hepatitis A, B and C To offer Pre and post test discussion where appropriate To take blood for testing To offer the full course of HAV / HBV vaccinations / boosters / blood tests where appropriate To ensure that anybody undertaking this service is fully aware of any testing implications To offer a seamless link into Hepatitis C treatment services where appropriate To facilitate treatment completion by care co-ordinating drug treatment clients through hepatitis C treatment and through delivery of treatment through primary care. To offer annual testing and more frequent testing where indicated for all clients in structured drug treatment. Target: 95% of all those eligible complete vaccination programme for Hepatitis B and receive testing for hepatitis C. 4. Who is the service for? (client group served) Substance misusers who report current or historic risk of contracting hepatitis A, B or C, HIV Advice and signposting for carers, partners, family members Eligibility CIOS residents who report current or historic risk of contracting hepatitis A, B or C, HIV Priority Groups Pregnant substance misusers. Advice From Twinrix manufacturer and DoH differs slightly in emphasis: 1 APPENDIX 8 D:\582727889.doc Pregnancy Data on outcomes of a limited number of pregnancies in vaccinated women do not indicate any adverse effects of Twinrix Adult on pregnancy or on the health of the fetus/newborn child. While it is not expected that recombinant hepatitis B virus surface antigen would have adverse effects on pregnancies or the fetus it is recommended that vaccination should be delayed until after delivery unless there is an urgent need to protect the mother against hepatitis B infection. (Summary of Product Characteristics – GlaxoSmithKline UK – 24.3.2010) Lactation It is unknown whether Twinrix Adult is excreted in human breast milk. The excretion of Twinrix Adult in milk has not been studied in animals. A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with Twinrix Adult should be made taking into account the benefit of breast-feeding to the child and the benefit of Twinrix Adult therapy to the woman. (Summary of Product Characteristics – GlaxoSmithKline UK – 24.3.2010) Pregnancy and Breast Feeding ‘Immunisation should not be withheld from a pregnant woman if she is in a high risk category. There is no evidence of risk from vaccinating pregnant women or those who are breast-feeding with inactivated viral or bacterial vaccines or toxoids. Since hepatitis B is an inactivated vaccine, the risks to the foetus are likely to be negligible, and it should be given where there is a definite risk of infection’ (DOH 2007, ‘The Green Book’ p179) Exclusions/Contraindications Hypersensitivity to the active substances or to any of the excipients or neomycin. Hypersensitivity after previous administration of hepatitis A and/or hepatitis B vaccines. The administration of Twinrix Adult should be postponed in subjects suffering from acute severe febrile illness. (Summary of Product Characteristics – GlaxoSmithKline UK – 24.3.2010) 5. Duration This service is offered for the duration of the testing and where appropriate immunisation period Immunisation is offered as follows: Combined HAV/HBV vaccine (Twinrix) Accelerated schedule: 0, 7, 21 days with booster ideally at 12 months ( DOH, 2007 ‘The Green Book’) Routine Schedule: 0, 1 month, 6 months with or without booster dose (DOH, 2007 ‘The Green Book’) Alternative accelerated schedule: 0, 1 month, 2 months with booster at 12 months ( DOH, 2007 ‘The Green Book’) 6. Cost This service is free to service users. £100,000 of the contract price is dedicated to this service area. 7. Referral pathways and relevant pathways of care Immunisations, test dates and results will be shared with the Care Coordinator and should be recorded within case notes and NDTMS. 8. Description of the treatment process/phases The Testing process will be offered to clients as indicated by their reported level of risk behaviour. 9. Aftercare & Case Closure Refer back to care of GP and Substance Misuse Service as appropriate. 2