Blood Borne Viruses - Guidance for the Protection of Looked After Children
This should be read in conjunction with CoramBAAF Practice Note 53 - Guidelines for the Testing of Looked After Children Who are at Risk of a Blood Borne Infection.
AMENDMENTIn March 2017, a link to the NCB Practice Guidance: Supporting Young People with HIV Testing and Prevention was added to this chapter.
Blood borne infections occur where infected blood or other bodily fluids are transferred into the body.
The Hepatitis Viruses (Hepatitis B, C and D) which cause liver disease, and HIV that causes AIDS, can sometimes be found in certain groups of population. A person may be a carrier of a virus without realising as they have not shown any of the symptoms. They can however still pass the virus on through accidental exposure to another person's blood or other infected blood fluids.
Most people recover from Hepatitis B after a period of 6 months. About 10% of people who get the infection develop a chronic condition where there is more risk of damage to the liver. They may also become long-term carriers of the infection.
Hepatitis A and E viruses are normally transmitted by faecal or oral route. They do not present a significant risk of blood-borne infection.
1. Confidentiality and the Disclosure of Children's Status
- Confidentiality is extremely important in relation to blood-borne viruses, both legally and ethically. The decision to disclose a persons HIV status must always be guided by the best interests of the child. Generally disclosure should only take place with the consent of the person concerned, unless there is a risk of significant harm to the child and this has a direct bearing on the assessment of the risk, or where there is a legal requirement to disclose;
- Where a child is Looked After, the child's social worker must ensure the immediate carers of the child are informed if it is known that the child is infected with HIV. Wherever possible, the parent's consent to this will be obtained before the placement;
- Foster carers are asked to consider carefully whether their own children should be told as well, depending on their age and level of maturity to hold the information in confidence;
- Where a child is placed in residential care, only those members of staff who have a special involvement with the child and where their knowledge would enhance their work with the child need be informed of the child's HIV status;
- In exceptional circumstances, when a child is deliberately trying to infect others, specific training and advice should be obtained and additional staff in a residential placement should be made aware of the child's HIV status;
- The fear of prejudice, discrimination and victimisation that may result from a positive diagnosis makes it essential that all staff members know Herts Aid's arrangements for observing confidentiality and the procedures in the event of a breach of confidence.
2. Hepatitis B
- What is Hepatitis B? Hepatitis B is an infectious disease of the liver caused by a virus. It can lead to an acute and serious illness after an incubation period of between one and six months. People generally recover completely within two to three months, but the illness is often unpleasant, can be serious, very occasionally life threatening, and can result in liver damage in the longer term. Ninety per cent of adults who are infected make a full recovery and do not go on to become carriers. Ten per cent of infected adults completely recovered remain infectious carriers for months or years. However, the majority of children, who will have acquired the disease from their mothers, will go on to become carriers. These children are at risk of developing serious long-term liver disease, and contribute a reservoir of virus for infection to others;
- Hepatitis B is much more common in certain parts of the world than others; for example, in some countries of Eastern Europe, south East Asia and South America. The possibility of Hepatitis B infection must be borne in mind in inter-country adoption particularly from these countries. It has to be remembered that testing in the country of origin may be sub-optimal. In the UK, studies have shown that 0.1% to 0.6% of the population (1-6 per 1000) carry the virus;
- How is Hepatitis B spread? The Hepatitis B virus is present in the blood and body fluids (such as semen, saliva, urine and faeces) of infected persons. It is spread most readily by:
- Intimate personal or sexual contact with an infected person;
- Transfer of infected blood or other body fluids into the bloodstream e.g. by sharing needles whilst injecting drugs, needle stick injuries, puncture wounds from other sharp objects contaminated with infected body fluids, or from human bites;
- Extensive or prolonged contact with blood or body fluids on bare skin (especially broken skin), and the eyes or mouth;
- Sometimes, new-born babies become infected from their mother around the time of delivery. This is known as vertical transmission. These children can then pass on the virus to other people. Women who are infected can be identified at antenatal clinics, and their infants can be immunised successfully.
- Will I know if a child or parent has Hepatitis B? No. An adult or child with Hepatitis B can be completely well, so it is important to take precautions at all times to minimise the risk of infection. Only a blood test can establish if a person is infected.
3. Prevention of Hepatitis B
- There is a safe and effective vaccine available against Hepatitis B, given in a course of three, and in the case of infants born to infected mothers, four, injections. After the last injection, a blood test is recommended to confirm that vaccination has been successful. It is recommended that the following should be offered immunisation against Hepatitis B:
- Permanent carers and their immediate family (those in close contact with the child) caring for a Hepatitis B carrier child;
- Babies born to mothers with Hepatitis B infection including chronic carriers;
- Residential care staff;
- Adopters involved in inter-country adoption;
- In some areas it is recommended that anyone sustaining a needle stick injury is immunised;
- All short-term carers should be counseled about the risks of transmission of undiagnosed infection.
Note:- All individuals in a home with a child with Hep B should be immunised.
4. Hepatitis C
- What is Hepatitis C? Hepatitis C is an infectious disease of the liver caused by a virus. It was formerly known as non A non B hepatitis. It was only recognised in 1989. Therefore there is less information about the spread and the long-term outcome for children infected with the virus than is the case for Hepatitis B. Hepatitis C can lead to an acute illness after an incubation period of two weeks to six months. After this acute illness, which can occasionally be life-threatening, long-term liver damage is common in adults. High risk areas for Hepatitis C include North America, Southern Europe, Egypt and Japan;
- How is Hepatitis C spread? Hepatitis C is spread in the same way as Hepatitis B, by contact with blood and other body fluids. It has been found most commonly amongst injecting drug users, where estimates of infection rates vary from 60% to 90%. Sexual transmission can also occur. It can also be passed from an infected mother to her baby, probably around the time of delivery. Transmission during pregnancy is relatively uncommon; the risk is less than 5%. However, if the mother is also infected with HIV infections, risks are greatly increased;
- Will I know if a child or parent has Hepatitis C? No. An adult or child with Hepatitis C may be completely well, so it is important to take precautions to minimise the risk of infection. Only a blood test can establish if the person is infected;
- Testing children for Hepatitis C It is likely to be in a child's best interests to know their Hepatitis C status because of future developments. Monitoring of liver function is important and early treatment may improve the outlook for the health of those infected.
Testing is carried out by a simple blood test, looking for Hepatitis C antibodies. If positive, this means that the person has been exposed to the virus at some time in the past. This test alone is not reliable as an indicator of Hepatitis C in children under the age of 18 months. At this age a positive test may reflect the infection in the mother rather than the child. A further test, called the PCR, detects viral genetic material and, if positive, indicates an active infection regardless of the child's age;
- It is recommended that testing should be offered to the following children:
- Those from families vulnerable to infection who are being placed in long-term accommodation;
- Those arriving from areas of the world with a high prevalence of Hepatitis C;
- Children whose mothers are infected, or who are carriers of the virus;
- Children who may have been exposed to the virus (e.g. sexual abuse, needle stick injury);
- Children with clinical symptoms such as jaundice.
- Prevention of Hepatitis C. There is, at present, no vaccination against Hepatitis C.
5. Hepatitis A
- Hepatitis A should not be confused with Hepatitis B or C, as it is usually acquired in a completely different way. It is an infectious disease which is initially spread by contact with food or water contaminated by faeces, and may subsequently be spread by person to person contact, especially between young children. People do not become carriers of Hepatitis A, and there are no issues specifically relevant to child care.
6. HIV Infection
- What is HIV? HIV stands for the Human Immunodeficiency Virus. It infects the immune system and leads to damage of the body's ability to resist infection. The infected person becomes prone to recurrent infection. When the immune system is seriously compromised, HIV infection can progress to AIDS (Acquired Immune Deficiency Syndrome);
- Risk factors for HIV infection:
- Adults with a history of needle sharing;
- Adults with a history of unprotected sexual activity;
- Adults from high risk areas of the world (two areas - sub-Saharan Africa and South and South-East Asia account for 85% of the HIV infection on the world);
- Adults having unprotected sexual activity with a partner who is vulnerable to infection through any of the above risk factors;
- Children can acquire the infection from their mothers around the time of birth and through breastfeeding.
- How is HIV spread? HIV is much less infectious that other blood-borne virus infections such as Hepatitis B and C, although it is spread in exactly the same manner;
- Will I know if a child has HIV infection? No. HIV infection in children can present in ways which mimic common childhood conditions, such as swollen glands, recurrent infections, diarrhoea, slow growth and delayed development. The only way to find out if a child has HIV infection is by a blood test;
- Most children with HIV infection remain relatively well provided they receive appropriate medical supervision and treatment, which typically allows them to lead full and active lives in their local communities and schools;
- Prevention of HIV infection. At present, there is no cure for HIV infection, but combination therapy with anti-retro viral drugs is radically altering the outlook for infected adults and children. A safe vaccine against HUV infection has not yet been developed. It is now known that HIV transmission from mother to child can be reduced from 20-25% to less than 5% if the mother's HIV status is known during pregnancy and the pregnancy is appropriately managed by a specialist centre. For this reason the Intercollegiate Working Party has recommended universal testing of pregnant women for HIV as a routine and integral part of antenatal care throughout the UK;
- Testing for HIV infection.
Consent to HIV testing - All Children
- The informed consent of a child aged 16 or over must be given before testing;
- If a child under 16 has sufficient age and understanding, his or her permission must be given before testing;
- There should be no attempt to test a child under 16 without seeking the consent of the parents. Where the consent of the parents is not forthcoming, legal advice should be sought;
- Where parental consent is not forthcoming but there is a clear medical recommendation that testing is in the child's best interests, legal advice should be obtained as to whether and in what circumstances the test can proceed.
In order for children and parents to be able to participate in decision-making in an informed way, they must be provided with adequate information and given appropriate support including access to specialist counselling from trained counselors both before the test and in the event of a positive diagnosis.
Consent to HIV testing of Looked After Children
It is not the policy to test children routinely prior to placement in the Looked After Children service, including with prospective adoptive parents. The HIV status of every child placed cannot be guaranteed, and foster carers and adoptive parents should be made aware of this.
Any decision to test a Looked After Child before a placement must be as a result of this being in the child's interests, for example that they are from a high risk background and early diagnosis would ensure appropriate preventative treatment.
As well as the consents of the child and the parent, all requests for HIV testing of Looked After Children should be referred for discussion with the LAC Nurse who will discuss the case with the HIV/AIDS Lead Officer to the Social Services Department.
Testing can only proceed on a Looked After Child if the written consent of the Designated Manager is given.
If a child is suspected to be HIV infected, they must be referred to the Paediatricians and a specialist centre will be involved if they test positive.
7. Emergency Treatment
- Emergency advice may occasionally be required, for example, for teenagers involved in risk taking behaviour, or for younger children following an episode of sexual abuse, or following a needle stick injury. If a child is seen immediately after an episode of exposure to possible HIV infection, health professionals may consider that emergency preventative treatment should be offered, without waiting for blood results. This will depend upon the circumstances of the incident;
- The risk of transmission following exposure to HIV infected blood is very small (around 0.3%). There is no risk unless the skin is broken, or mucous membranes breached, when blood or infected body fluids from the infected person could pass into the bloodstream of the injured person. Simple first aid measures such as encouraging more bleeding and thorough washing of the wound with plenty of soap and water will minimise the risk. Combination anti-retro viral therapy may, in certain circumstances, be considered to reduce this risk further, but must be started as soon as possible (ideally within an hour of the injury). There are toxicity problems with these drugs, so the local casualty department, infectious diseases department or HIV specialist will balance up the degree of risk of infection with the potential risks of treatment.
8. Social Considerations
- A diagnosis of HIV infection or AIDS carries considerable social stigma. This leads to families withholding the diagnosis from professionals, and professionals withholding information from one another. Children with HIV infection are entitled to the same degree of confidentiality as all other children. Information about the child's illness should only be divulged in the best interest of the child, with the consent of parents (and child, if appropriate), and only shared with those who need to know;
- Testing a child may leave professionals in the difficult position of having to tell a birth mother with no symptoms that she has a life-threatening disease. For this reason, the informed consent of the child's birth parents must be actively sought in all cases;
- It must be borne in mind that many children who are not infected with HIV, could live in families where parents or siblings are infected. These children may have experienced multiple bereavement, and will require sensitive expert support and counselling.
9. Placement of Children with HIV Infection
- Families who wish to adopt or foster a child with HIV infection need to be assessed in exactly the same way as any family who is prepared to look after a child with a long-term life-limiting condition. The child's health needs will have to be discussed, together with the implications of deteriorating health, possible developmental regression, and end of life care. Possible reactions from family members, friends, schools and the community should be addressed before placement;
- It may be possible to place another child in a family which is already looking after a child with HIV infection. Stringent hygiene measures must be emphasised. Each case must be considered individually, taking into account the age, health and needs of both children.
10. Hygiene Precautions and Universal Settings
- Hygiene precautions
The following precautions apply equally to the prevention and spread of Hepatitis B, Hepatitis C, and HIV infection. The risk of being exposed to infection can be minimised through good hygiene practice. The precautions must be applied when there is a possibility of direct contact with blood or any body fluids from another person. These practices include;
- Washing of the skin with soap and water following any contact with blood or bodily fluids;
- Appropriate care of cuts and abrasions by covering them with waterproof dressings;
- Avoid sharing items which might be contaminated with blood e.g. toothbrushes and razors;
- Use of rubber gloves as appropriate, if there is a risk of mixing body fluids between carer and child e.g. presence of cuts, eczema;
- Prompt clearing up of spillages of blood or other body fluids with freshly diluted bleach and disposable tissues;
- Careful disposal of nappies, or any disposable items soiled with blood or bodily fluids - these should be burned or put out in sealed polythene bags;
- Washing of soiled clothing in hot water and detergent in a hot wash cycle;
- Cleaning of dishes and cutlery in the usual way with hot water and detergent.
- Universal Precautions
- It is not always possible to identify people who may spread infection to others. Therefore, precautions to prevent the spread of infection must be followed at all times. These routine procedures are called Universal Precautions. They apply to all of the viruses mentioned above;
- Universal Precautions is the term used to describe practices taken to reduce the spread of blood borne viruses relating to the handling of contaminated equipment and material in such a manner as to prevent the transmission of infection to patients and healthcare workers;
- Universal Precautions are in accordance with the principles expressed in the Health and Safety at Work Act 1974 and the Control of Substances Hazardous to Health (COSHH) regulations. All employees have a responsibility to follow Hertfordshire County Council Guidelines on Protection Against Blood Borne Viruses and safe working practices at all times;
- Universal Precautions mean assessing the task to be undertaken in terms of the likely risk of blood or body fluid splash and wearing protective clothing accordingly, e.g. gloves for taking blood, gloves and aprons for cleaning up blood, vomit and urine. Latex/vinyl gloves and disposable apron should always be worn when dealing with excreta, blood and body fluids;
- Risk analysis - HIV and Hepatitis B and C viruses can be transmitted by the following contaminated body fluids:
- Vaginal secretions;
- Any other body fluid or excrement containing visible blood, i.e. saliva in connection with dentistry.
The components of Universal Precautions are:
- Hand washing;
- Skin care, which includes protection of cuts and abrasions;
- Protective clothing;
- Action taken after accidental sharps and splash injury;
- Waste management.
11. Hand Washing
- Hand washing is recognised as the single most effective method of controlling infection. Hands should be washed between each client activity. The wearing of gloves is not a substitute for hand washing. Where possible a designated sink should be used for hand hygiene only, i.e. not for washing contaminated instruments.
- Types of hand washing methods:
|Social||Social Liquid soap (anti-bacterial are necessary for social hand hygiene)||For all routine tasks|
|Hygienic hand disinfection||Antiseptics, e.g. chlorohexidine or alcohol hand rub after social clean||In high risk areas and during outbreaks|
- How to wash your hands:
The areas of the hands that are often missed are the wrist creases, thumbs, fingertips, under the fingernails and under jewellery, which should for this reason be kept to an absolute minimum. A plain band only, no wristwatches and no nail varnish. Artificial fingernails also present several problems and must be avoided in accordance with Infection Control Guidance:
- They harbour fungi and bacteria that can not be effectively removed, even with nailbrushes;
- Micro-organisms can dwell and even thrive between the natural and artificial nail;
- Artificial nails can cause tears to gloves as they cling to the glove surface and do not give adequate protection to employees performing a procedure.
Hands must be dried using disposable paper towels, as wet hands can be a source of infection. The mechanical action of drying the hands also helps to remove any dead skin cells and bacteria. Other methods of hand drying may increase the number of bacteria on the hands, i.e. shared towels and dirty and incorrectly maintained hot-air dryers.
- Hand washing should be performed as follows:
- Wet your hands up to the wrists before applying hand cleanser or liquid soap;
- Apply the cleanser/liquid soap;
- Smooth it evenly all over your hands, including the thumbs, and in between the fingers and lather well, rubbing vigorously;
- Rinse off every trace of lather;
- Dry really thoroughly, taking special care between the fingers. More than one paper towel may be used;
- Alcohol hand rub should be used at this stage if working in a high risk area, or involved in an outbreak of infection.
In the absence of adequate/suitable hand washing facilities, i.e. in an individuals home, an alcohol hand rub or wet wipe may be used but only if the hands are visibly clean (free from dirt or grime). However, the hands should be washed thoroughly before attending another client. Manufacturers of alcohol hand rub recommend that it should only be used a maximum of seven consecutive times, by which time the hands need to be washed with soap and water.
- Hands should be washed at least:
- Before and after each work shift or work break. Remove jewellery (rings) and wristwatches as they can harbour germs;
- Before and after physical contact with a client;
- After handling contaminated items such as dressings or personal care;
- Before and after use of protective clothing, i.e. gloves and aprons;
- After using the toilet, blowing your nose, covering a sneeze or cough;
- Whenever hands become visibly soiled;
- Before eating, drinking or handling food and before and after smoking.
12. Skin Care
- All cuts and abrasions should be covered with a waterproof dressing. Blue dressings must be used if contact with food is likely. If suffering from chronic skin lesions on hands, e.g. weeping dermatitis/eczema, this must be reported to the appropriate manager and if necessary the advice of the Occupational Health Unit should be sought.
13. Protective Clothing
- The selection of protective clothing depends on the anticipated risk of exposure to the blood or body fluid during the particular activity;
- In short, think about what the task involves and wear the appropriate protective clothing to protect against exposure to any body fluid you will come in contact with;
- Always dispose of protective clothing as clinical waste;
- Gloves - un powdered latex (or vinyl) gloves should be worn for any activity where blood or body fluid may contaminate the hands. Hands should be washed immediately after removal of gloves as the gloves may be punctured and because hands are easily contaminated when gloves are taken off. To prevent transmission of infection, gloves must be discarded after each procedure/client contact. Gloves should not be washed between clients as they are for single use only, the integrity of the glove will be compromised by washing it and if punctured unknowingly, may cause body fluid to remain in direct contact with the skin for prolonged periods;
- Water-repellent aprons and gloves. Water-repellent protection should be worn for procedures anticipated to cause contamination of the skin and clothing with blood or body fluid and should be changed between each client. This will protect the skin and clothing of the health care worker from contamination by potentially infected body fluid and reduce the risk of cross infection to other clients via clothing. These should be readily available in all areas and are single use only, to be discarded after the task is completed - they are not to be re-used.
14. Safe Disposal of Sharps
- All sharps must be correctly and safely disposed of in a leak-proof, puncture resistant, lockable container. The container should not be filled by more than two-thirds, and then sealed and disposed with as per departmental procedures. All health care workers should take precautions to prevent needle stick injuries and other sharp instruments or devises during procedures;
- Do not re-sheath, bend or break used needles;
- Do dispose of used needles and syringes as one unit.
Managing spills - spillage must be cleaned up immediately. A body of fluid spillage kit should be available for spillages of blood and other body fluids.