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.
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.
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.
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 multi-agency working. This would have to take account of the Data Protection Act (1998) and Caldicott Guidance.
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.
Counselling should be offered to all individuals requesting, or who have been offered testing, by an appropriately qualified member of staff or specialist service.
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.
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.