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INFECTIOUS DISEASES March 2016 To identify of signs and symptoms of infectious diseases through screening and assessment To understand the rationale for regular screening for infectious diseases To describe appropriate care plans which include prevention and treatment for both substance misuse and infection Substance misuse is associated with infectious diseases Levels of infection in injecting substance misusers is high ie ~ 50% Life style and mode of use of substances are the main ‘causes’ Substances can predispose to infection by lowering immunity or specific local effects Infectious disease risk is related to the mode of use rather than specific substances Assessment of drug users for risk behaviour and infectious diseases Hepatitis B and C are major causes of liver disease and liver cancer 20-25% of people with chronic hepatitis B have progressive liver disease which leads to cirrhosis in some cases Over 90% people with hepatitis C have a history of injecting 15-20% people with hepatitis C will develop liver cirrhosis after 20 years and 5% of those will develop liver cancer Hepatitis C is the commonest indication for transplantation 214000 are chronically infected with hepatitis C 2.2% of all people being seen for care in the UK have HIV Individuals put themselves at risk due to chaotic lifestyle and effect of substances Drug users who are having sex without protection and sharing injecting equipment or paraphenalia are at risk of contracting BBV (blood borne viruses eg hepatitis B and C, and HIV) Patients who misuse substances are likely to be susceptible to tuberculosis (TB) Drinking alcohol – especially binge drinking – and ‘club drugs’ alter judgement and impair decisions about sex and other drug use, leading to unprotected sex and sharing of injecting equipment Substance misusers may view BBV as ‘occupational’ hazards of drug use Drug users may not recognise or differentiate the symptoms of BBV from intoxication, withdrawal or poor self care Drug users may think the symptoms derive from impurities in street drugs Patients may present late to services and be less compliant with the medication prescribed Infections may be viral, acute bacterial and sexually transmitted History taking should elicit information about behaviours that may have put the patient at risk Injecting, unprotected sex and receiving a blood transfusion in other countries Information about those with whom the patients has had intimate or prolonged contact Contact tracing may need to take place Common where water supplies and sewage disposal are poor Personal and food hygiene are poor Living in poor conditions, in crowded accommodation where this is no running water or adequate sewage eg hostels, squats Blood to blood spread through needle sharing Transmission is by fecal and oral routes Symptoms may last for a week or more and include: flu type symptoms, nausea, stomach ache and diarrhoea, jaundice Hepatitis B causes liver inflammation and fibrosis Untreated can lead to cirrhosis and liver failure or hepatocellular cancer 2% cause chronic hepatitis Information about initiation of injecting, sharing of injecting equipment, frequency of sharing, number and type of contacts who may have been injecting Hepatitis B is notifiable to Public health England Transmission is by injecting, sexual contact and mother to baby A mild flu like fever Tiredness Aching limbs or joints Loss of appetite Feeling sick or vomiting Reluctance to drink alcohol or smoke Jaundice, itchy skin and dark urine Many individuals with hepatitis C are abusing alcohol 50% lead to cirrhosis, chronic hepatitis and hepatocellular cancer Transmission is via injecting, sexual contact, mother to child at birth In 40% cases infected individuals cannot identify a source for their infection Cocaine can damage the inside of the noe leading to bleeding Inhalation of contaminated blood may lead to infection Sharing items eg toothbrushes, razors, scissors and blood products may spread infection No vaccine is available Flu like symptoms Mild to severe fatigue Anxiety Weight loss Loss if appetite Inability to tolerate alcohol Discomfort over liver area Problems with concentration Nausea Jaundice Antibody test – proteins made by the body to respond to the virus Polymerase chain reaction (PCR) or viral RNA tests – identify the presence of the virus Liver function test to identify the impact on the liver Liver biopsy to assess severity of damage from chronic hepatitis C Flu like illness a few weeks after infection with HIV – 80% cases Symptoms indicate that the body is responding to the infection Symptoms are non-specific History should try to establish risks associated with unprotected sex, sex with bisexual men, sharing injecting equipment or paraphernalia Transmission is via injecting, sexual contact, blood including menstrual blood, mother to baby before during or after birth during breast feeding HIV cannot be transmitted through saliva, sweat, tears, feces and urine Fever Sore throat Body rash Tiredness Joint pain Muscle pain Swollen glands Tests on blood are very reliable and provide a result from 4 weeks after possible infection Treatment is very successful with anti retroviral treatment Transmission is via injection Staphylococcus and streptococcus are the agents Endocarditis – fever, heart murmur, peripheral stigmata Necrotising fasciitis – pain out of proportion with clinical findings Botulism: scratchy throat, cranial nerve palsies and paralysis Risk factors include: Smoking cigarettes, other serious illnesses (hear disease, liver cirrhosis), immune system problems (cancer treatment, HIV/AIDS, organ transplant) Symptoms: Fever Cough with yellow, green or blood tinged mucous Chest pain the worsens when coughing or breathing Sudden onset of chills Headache and muscle pains Food, saliva, liquids or vomit is breathed into the lungs or airways after alcohol consumption or overdose Symptoms include: bluish skin discolouration Chest pain Coughing up foul smelling sputum Fatigue Fever Shortness of breath Wheezing Excessive sweting Listen for abnormal chest sounds Take blood sample to get a white cell count. A high count usually indicates infection Take blood or mucous samples to identify infection causing pathogen Order chest x rays to confirm the presence and extent of infection Early detection makes it easier to treat with antibiotic combination therapy for 6 months: drug users might find compliance a problem Signs and symptoms include: persistent fever Heavy sweating at night Loss of appetite Unexplained weight loss General and unusual sense of tiredness Haemoptysis Recent contact with someone who has TB Frequently asymptomatic Need regular screening for detection All associated with morbidity if left untreated Syphylis Chlamydia Gonorrhoea HPV – human papilloma virus Vaccine is available Consider single dose or combined vaccine – depends on whether the patient is likely to return for a subsequent dose One dose of single vaccine confers greater protection against Hep A than one dose of the combined Hep A Hep B vaccine Vaccinate all injecting drug users against Hep A Single component preferable to combined Hep A and Hep B vaccine For single vaccine give 2 doses with second dose after 6-12 months Second dose may be delayed for up to 3 years Most people with acute hepatitis recover without treatment within 4-12 weeks 2% cause chronic hepatitis which can lead to cirrhosis and hepatocellular cancer Can be treated with antiretroviral drugs A vaccine is available Vaccinate all drug users against Hepatitis B – non-injectors may become injectors No need to carry out pre vaccination testing Use accelerated 0, 7 and 21 day schedule to aim to complete the course quickly. Incomplete vaccination offers some protection but completing the course is recommended Offer vaccination to partners and children Treatment can eradicate infection in 40-80% of infected individuals Antiviral treatment consists of self administered weekly subcutaneous injections of pegylated interferon and twice daily oral ribavirin for 24-48 weeks No vaccine is available Substance misusers will need to persevere as treatment is intensive They need to be detoxified or stable on substitute medication and abstinent from other drugs Injecting the antiviral medication may lead to relapse to (injecting) drug use If patients continue to drink while taking medication there is a high risk of liver damage Regular blood tests required to check on liver function Patients with HIV or hepatitis will need regular liver function tests Antiretroviral medication taken together with TB treatment may have side effects and interactions requiring careful monitoring Treatment can last for 6-12 months so some patients may drop out and need assertive outreach approaches to re-engage A vaccine is available HIV: Antiretroviral treatment is successful; no vaccine is available Acute bacterial infections: Staphylococcus and streptococcus can be treated with identification of source and antibiotics Sexually transmitted infections all associated with long term morbidity if left untreated Chlamydia and gonorrhoea: antibiotics but some strains are resistant Syphylis: penicillin is preferred treatment; early treatment is crucial Genital herpes: antiviral medication; no cure; can flare up Specialist advice should be sought from e.g. sexually transmitted disease clinic (STD), specialist chest clinic The GP and services should liaise regularly to ensure screening and effective treatment Specialists working in primary care, chest clinics and STD services should contact specialist addiction services to arrange access and management of substance problems If patients are reluctant to stop or reduce their drug use, preventative measures should be discussed and implemented to contain infection risks and spread Advice on safer injecting, use of sterile equipment , and risks of diseases should be given If patients continue to inject, clean needles and syringes should be obtained Prevention of BBV has many benefits including reducing health harms by those who use substances Needle and syringe programmes Comprehensive protocols to raise awareness of risks of BBV: promotion of testing, deliver vaccination and access pathways into treatment Provision of advice and materials to reduce harm from injecting drug use Offers of testing and vaccination to all those at risk Prevention of uptake of injecting drug use and promote switching from injecting to other routes Implementation of workforce and occupational health interventions for people working with those at risk of contracting BBV Findings (2014) Drug Matrix cell D1: Organisational functioning; Reducing harm http://findings.org.uk/count/downloads/download.php?file=Matrix%2FDrugs%2FD1.htm Health Protection Agency (2015) Hepatitis C in the UK. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448710/NEW_FINAL_HCV_2015_IN_THE_UK_RE PORT_28072015_v2.pdf Health Protection Agency (2014) Shooting Up Infections among injecting drug users in the UK 2013. An update: November 2014 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/370707/Shooting_Up_2014.pdf Health Protection Agency (2013) Substance misuse and TB: Information for key workers (care workers, social workers, project workers and health professionals) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/466947/NKS_Substance_misuse_and_TB_Infor mation_for_key_workers_.pdf Jones D. R. et al, (2004) Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious mental illness. Psychiatric Services, 55 pp1250-1257 National Knowledge Service - TB: http://www.neli.org.uk/IntegratedCRD.nsf/e67b3914fbe8da658025755c0062cd62/45aa03ceba2bc98080257145003ace45?Ope nDocument&Highlight=0,TB NICE (2004) Hepatitis C - pegylated interferons, ribavirin and alfa interferon (NICE technology appraisal,TA75) http://guidance.nice.org.uk/TA75 This guidance replaces Hepatitis C - alpha interferon and ribavirin (TA14). This guidance is extended by Hepatitis C - peginterferon alfa and ribavirin (TA106). http://guidance.nice.org.uk/TA75 NICE (2014) Needle and syringe programmes: NICE public health guidance 52 guidance. http://www.nice.org.uk/guidance/ph52 NICE (2006) Hepatitis B (chronic) - adefovir dipivoxil and pegylated interferon alpha-2a (NICE technology appraisal,TA96) http://guidance.nice.org.uk/TA96 NICE (2010) Hepatitis C - peginterferon alfa and ribavirin (NICE technology appraisal,TA200) http://guidance.nice.org.uk/TA200 Public Health England (2015) Hepatitis C in the UK: 2015 report. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448710/NEW_FINAL_HCV_2015_IN_THE_UK_REPORT_28072015_v2.pd f Public Health England: https://www.gov.uk/topic/health-protection/infectious-diseases Raoult D., Foucalt, C., Brouqui P.(2001) Infections in the homeless. The Lancet Infectious Diseases Vol 1(2) September pp77-84 Tetrault, J M, Fiellin, D A, and Sullivan L E (2010) Substance Abuse and HIV: Treatment Challenges Substance Abuse and HIV: Treatment. The AIDS Reader. August 13, pp1-8 Wiessing, L., Ferri, M., Grady, B., Kantzanou, M., Sperle, I., Cullen, K., Hatzakis, A., Prins, M., Vickerman, P., Lazarus, J.V., Hope, V., Matheï, C. (2014) ‘Hepatitis C virus infection epidemiology among people who inject drugs in Europe – A systematic review of data for scaling up treatment and prevention’, PLoS ONE 9(7): e103345. doi:10.1371/journal.pone.0103345 World Hepatitis Alliance http://www.worldhepatitisalliance.org/