Case 1
Roger has a blood test …
This
case illustrates many of the aspects related to the care of patients with
hepatitis C. As a result of completing this case you should now be confident to
diagnose and monitor patients with hepatitis C, be more aware of
epidemiology of hepatitis C, and have a better understanding of the confidentiality and
privacy issues relating to Hepatitis C care.
Learning Objectives
·
Understand pre-test and
post-test counselling guidelines
·
Be familiar with the
epidemiology of hepatitis C in
·
Be aware of the indications for
hepatitis C testing
·
Know how to follow up positive
hepatitis C tests
·
Be aware of issues relating to
hepatitis C treatment including indications for treatment and side-effects
Roger’s Clinical Summary
Past Medical
History:
Nil
Past
Surgical History:
Nil
Allergies:
Nil
Meds:
Nil
Case Notes:
Roger R is a 37-year-old male who is new to your practice. You are
taking a comprehensive medical history from him as you do for all patients who
visit you for the first time. When you get up to the social history and ask him
about recreational drug use, he tells you that he has injected drugs from time
to time in the past.
You counsel him to have blood tests for Hepatitis B, C and HIV. He is tested, and is positive for anti-HCV. The blood form the result comes back on says, “Hepatitis C is a notifiable disease. The results of this investigation have been forwarded to the Director of Public Health”.
Hepatitis C:
Since 1989, the hepatitis C public
health pandemic has been acknowledged and mapped. Hepatitis C has become the
major cause of primary liver cancer and the primary indication for liver
transplantation in the world. The human costs of hepatitis C, in terms of reduction in
quality of life and wellbeing and of occupational and social discrimination and
isolation, are hard to quantify. The financial cost of the virus, in terms of
medical and hospital care, lost productivity and social welfare, is immense.
Of all people with
hepatitis C in
Testing for
Hepatitis C:
Testing is
voluntary and needs to be accompanied by discussion about the test, the
implications of being tested, post-test counselling and specific informed
consent.
Test results
need to remain confidential at the clinical level, in data management and in the
notification process.
People with
hepatitis C should have access to ongoing monitoring of their health status
and, if needed, appropriate treatment. Testing and notification are critical to
determine the extent and location of hepatitis C in the community. Testing is
also of benefit to the individual. For people who think they may have hepatitis
C, knowing the result of a hepatitis C test may give them a sense of direction
over aspects of their health and encourage them to seek more information and make
informed decisions about their options. Being tested for hepatitis C may also
motivate people to change particular behaviours to prevent further transmission
of the virus. Some people who test positive choose to make important changes to
their lives, such as reducing alcohol intake, improving diet and considering
overall health maintenance.
Hepatitis C
testing should be routinely offered to people who:
It is a
legal requirement in most States and Territories (Western
Health
departments are bound by law to keep personal information (i.e. names and
addresses and other identifying details) confidential. Often the biggest issue
for people who have tested positive is whether or not to tell anyone, and who
to tell. This issue is often referred to as disclosure. This is distinct
from contact tracing, discussed
below.
There is no legal
requirement for an individual to disclose their hepatitis C status to anyone,
with the following exceptions:
Disclosure
may have an impact on personal and working relationships. It is up to the
individual with hepatitis C to decide who to tell, when, how and why. In order
to receive the best care and advice, it may be advisable for people with
hepatitis C to disclose their hepatitis C status to their health care worker
however it is not a legal requirement that they do so.
Many people
with hepatitis C have been discriminated against after disclosing their
hepatitis C status to others, so careful consideration about who to tell and
why is always advisable. If individuals require assistance on issues of
disclosure, or in dealing with any resultant discrimination, health care
workers can provide referral to a
Hepatitis C
Council or peer-based drug user organisation.
It is
important to raise the question of disclosure during pre- and post-test
counselling
with a person being tested for hepatitis C. This can help to assess their
psychosocial situation, their supports, and to inform them of their legal
rights.
Discussion
may include:
Health care workers
with hepatitis C who perform “exposure prone procedures” should be guided by
their State or Territory health department’s guidelines and by the policy of
their professional body and relevant board. For health care workers who do not
perform exposure prone procedures, the use of standard infection control
practices provides protection for both patients and health care workers. In all
other situations it is up to the individual health care worker to decide
whether to disclose, to whom, when, how and why.
Issues to Consider:
a) What points should you
specifically address in pre-test and post-test counselling (you may wish to
refer to the Hepatitis C Desktop Reference to answer this question)?
b) It is your role to perform contact
tracing where indicated. Is it indicated for Hepatitis C management? How would
this differ if the patient had HIV? (You may wish to refer to the Tasmanian
Notifiable Diseases Guidelines to answer this question)
Case Notes:
Roger is
really worried about this. He is married and has a young child. He is worried he
has passed the disease on to his family.
The role of contact tracing is to: -
(a)
Provide
education concerning notifiable
diseases and their prevention;
(b)
Ensure that individuals who may have
been at risk through past contacts are informed of that fact and are offered
testing, or treatment if appropriate;
(c)
Ensure that
individuals who may be at risk of infection through current or potential
contact are informed of that fact; and
(d)
Create
opportunities for counselling and support where necessary.
Who is responsible for contact
tracing?
Contact tracing responsibilities vary depending on the
disease. Examples of contact tracing include: -
(a)
For
tuberculosis, contact tracing will be undertaken in consultation with the
Department’s Regional Tuberculosis Physician;
(b)
For sexually transmissible infections
(STIs), contact tracing will be undertaken between the clinician and the
patient, with support from Sexual
Health Service staff as required; and
(c)
For other diseases, contact tracing will be
undertaken by staff from the Department’s PEHS, in consultation with the
clinician or other relevant health care workers.
(d)
Local
government may have a role in contact tracing, particularly for
gastrointestinal diseases.
Under the provisions of the Public Health Act,
1997, clinicians are responsible for contact tracing for sexually transmissible
infections that they identify in a patient. If assistance is required in
contact tracing for a sexually transmissible infection, Sexual Health Services
staff are able to provide assistance.
a) Cases of needle-stick injury where a
professional is aware of a positive test result for a blood-borne virus and the
health care worker has been exposed in circumstances where there is a real risk
of transmission and it is not possible to conceal the identity of the source
patient who has refused to consent to disclosure;
b) Where it is requested by the Director
of Public Health;
c) Alleged assault involving a real risk
of STI/HIV infection, where the survivor requests to know the infection status
of the person charged with the offence;
d)
Performance
of medical services where there is a scientifically based need to know the HIV
status for treatment purposes of benefit to the patient (e.g. not exposing
immune suppressed patients to live vaccines). This should not, however,
distract from the observance of universal infection control precautions; and
e)
Disclosure in
good faith to health authorities of the identity of an HIV-infected person
whose behaviour is unreasonably causing exposure of infection to others without
their knowledge or consent.
Confidentiality:
Section 147 of the Act
regulates the treatment and disclosure of any information obtained under the
Public Health Act including notifications and investigations. Section 61 of the
Act provides that a person must not disclose any information relating to a
notifiable disease unless authorised.
Sections 17, 18 and 19 of the HIV/AIDS
Preventative Measures Act 1993 contain
information regarding privacy issues,
confidentiality of records and disclosure of information relating to treatment,
counselling and care of persons infected with HIV/AIDS or at risk of HIV/AIDS
infection.
The
objectives of contact tracing are:
a) To
interrupt the transmission of infection;
b) To
identify people with an infection who may benefit from treatment and minimise
the complications of infection;
c) To
provide individual counselling to affect sustained behaviour change among
people with STI/HIV infection or at high risk of infection; and
d) More
generally, to identify and reach populations at particular risk of infection in
order to influence community norms.
When contact
tracing is performed the following principles are observed:
a) Health
care providers should respect the human rights and dignity of the index case
and contacts;
b) Contact
tracing should be a balanced part of any STI/HIV prevention, care and support
program and be co-coordinated in the context of primary health care with other
related services;
c) Contact
tracing should generally be voluntary and without coercion (except in the case
of HIV / AIDS where the HIV / AIDS Preventive Measures Act forces disclosure to
sexual partners. The index case and contacts should have equal and adequate
access to all available services regardless of their willingness to co-operate
with contact tracing. When an index case refuses to notify or permit
notification of a contact(s), the practitioner should seek expert assistance
from the Clinical Director, Sexual Health Services.
d) The
process should be confidential, including written and data base records. In
provider referral the anonymity of the index case must be protected unless
specific written permission has been given to release this information to the
contact(s).
e) Contact
tracing should be undertaken only when appropriate and culturally sensitive
support services are readily available to both the index case and contacts. The
quality of these services should be assured through monitoring.
For most
STIs and blood-borne infections the primary care provider bears the major
responsibility for ensuring that contacts are properly assessed and counselled
wherever possible. In addition to being a public health issue, contact tracing
is also a personal issue. For example, for many HIV patients personal issues
surrounding a positive diagnosis will not be resolved until they are satisfied
that their contacts have been managed adequately. Thus contact tracing is an
integral and essential part of the counselling process. If the patient needs to
be referred, the primary care provider should provide the patient with
explanation of the reason for the referral and the processes involved. Where
contacts are patients of the same practice, the primary carer may wish to
provide the initial assessment and counselling. Specialist services that
provide support include Sexual Health Services, Public and Environmental Health
Service, and appropriate hospital specialist clinics.
If the
health care provider feels inadequately trained to counsel STI/HIV patients or
to trace contacts, referral to or consultation with the Clinical Director,
Sexual Health Services should be considered. Contact tracing relies on the good
will of the index case, and (except in the case of TB) a person cannot be
compelled to attend for treatment or to divulge the names of contacts. The
health care provider should be seen as non-judgmental and supportive. His/her
role is also educational; to inform the index patient and contacts about the
implications of infection, modes of transmission and prevention, and treatment
options. The health care provider should have counselling skills and other
personal qualities such as tact, empathy and awareness of both the physical and
emotional condition of the patient. The health care provider also needs to have
current and accurate knowledge of treatment and support services and to be
familiar with legislation relevant to HIV/AIDS and other notifiable diseases.
Counselling
should be a largely non-directive process that facilitates patients to develop
an awareness of their own feelings and insight into their options for coping
with their diagnosis. Yet contact tracing is a somewhat directive process, with
specific objectives that need to be woven into the individual counselling plan
for each patient. The most appropriate time to embark on the contact tracing
process is therefore judged on a case-by-case basis. Factors that influence
this decision on timing include:
1. The
patient’s physical and emotional state. If the index patient is acutely
physically or emotionally distressed, it may be better to defer the issue until
a subsequent consultation.
2. The
patient’s own priority. For many index patients the issue of notifying contacts
is highest on their agenda and it may be helpful for them to deal with the
issue immediately.
3. The
nature of the condition. For easily treated conditions (e.g., chlamydia,
gonorrhoea and syphilis) that also tend to be very infectious, contact tracing
is usually dealt with during the same visit that the index patient is given
their diagnosis and treatment. Contact tracing is more often deferred to a
later consultation for chronic viral STIs, particularly HIV. This not only
avoids compounding the patient’s acute crisis, it also offers the counsellor
the chance to check that the information that the index case gives to his/her
contact(s) about their condition will be accurate.
4. Public
health factors. If it is considered that a contact is placing others at immediate
risk of infection, contact tracing should usually proceed with urgency.
Contact
tracing is sometimes discussed during pre-test counselling for HIV,
particularly if the patient voices concerns. This is usually linked to
addressing the patient’s concerns about confidentiality. After a positive
diagnosis, the patient’s sexual, IDU or other risk history should be
reassessed. Other potential risk factors or events frequently emerge at this
time. Asking open-ended questions non-judgmentally facilitates disclosure. For
example:
‘How do you think you might have picked up the
infection?’
‘Who do you think you need to tell about your
condition?’
‘How do you think your partner will react?’
Care should
be taken not to lock into the risk encounter that is the most recent or
apparent. Although the most recent encounter may have precipitated the
patient’s request for testing, infection often precedes this point. Accurate
determination of the patient’s risk history is also important for counselling
about future risk avoidance. When taking a social and sexual history for STIs
and blood-borne infections:
• Do not assume the gender of contact(s);
• Do not ask questions which imply a judgment;
• Ask open-ended questions;
• Ask explicit information about relationship with
contact(s), sexual practices, condom use and location e.g. brothel, gay sauna,
overseas;
• Ask about substance use that may have contributed to
risk – e.g., sharing drug injecting equipment and excessive alcohol use; and
• Ask about blood donation or receipt of blood
products.
For the
index case, contact tracing must be an enabling process and any interviews
relating to contact tracing should be guided by the following objectives:
a) Ensure
the education and empowerment of the index case and his/her contact(s). This
includes providing accurate information on modes of transmission, clinical
manifestations, treatment options and support/advocacy services;
b) Identify
and address the individual barriers to notification of the contact(s); and
impart communication skills that will enhance the outcome of the process for
both the index case, the contact(s) and the health care provider; and
c) Identify
the most appropriate method for notifying a contact and provide the index case
with support and instructions as required.
The method
of advising and counselling contacts about their exposure is chosen after
taking into account the risk history, condition, sexual or social milieu, and
motivation of the index case. The following strategies are available:
Patient (index case) referral
• Specific
instructions: The health care provider provides the index case with specific
advice on which contacts to advise and the information to be imparted including
appropriate agencies for assessment and counselling. The index case personally
notifies his/her contact(s). Many services provide ‘contact letters’, detailing
the index case’s diagnosis and treatment, which the contact can take to his/her
doctor.
• Skills
imparting: Patient referral requires a well-informed, motivated and
self-confident index patient. If relying on patient referral, it is important
to use follow-up consultations to confirm that the contacts have been advised
and assessed adequately.
Provider referral
Either at
the index patient’s request or at the suggestion of the health care provider,
the provider may advise the contact(s) directly or recruit another agency (e.g.
Sexual Health Services) to ensure that the contact(s) are assessed. To do so,
the health care provider should have the explicit approval of the index case.
Provider referral may have the advantage of offering the index case a higher
level of confidentiality. However provider referral is more time and resource
intensive. It is the contact tracing method of choice for certain situations
and conditions (e.g. infections involving sex workers, persons with
intellectual disability) and where patient referral has failed. A combination
of patient and provider referral is often used for the different contacts of
one index case.
Where provider referral
is the most appropriate strategy, several options are available to make initial
contact with the following advantages and disadvantages:
|
Method |
Advantages |
Disadvantages |
|
Phone |
Time-saving
and an appointment time can be organized |
Provides
verbal cues only |
|
|
Cost
effective, especially if the contact is rarely home |
Inappropriate
for disclosing full details as limited control over response |
|
|
Confidential
(if the source of the call is not revealed to others) |
Can be
intercepted by a third person |
|
|
Some
anxiety can be allayed |
Inappropriate
for the hearing impaired and people with limited English language skills |
|
Letter |
Allows the
person to phone when their confidentiality is assured |
Creates
anxiety especially if received after services are closed |
|
|
Letters
tend to be collected or redirected when a person is difficult to find at home
or has moved |
Can be
intercepted by a third person, problematic for people with literacy problems,
inappropriate for disclosing details |
|
Visit |
The health
care provider can give full details immediately, deal with the response and
link in with appropriate supports |
Visibility
can detract from confidentiality, can give impression of policing depending
on the training of the health care provider and the circumstances |
|
|
HIV
testing may be offered on the spot |
Expensive/time
consuming, testing on site can work against the individual’s willingness to
accept referrals |
|
Via
specialist agency (e.g. sexual health services) |
Time-saving
for general practitioner (agency contacted by phone), accesses greater
expertise / knowledge of social contexts, agencies may have other information
about contacts |
May reduce
continuity of care, resource intensive for other agency |
(From
Australasian Contact Tracing Manual, 2002)
The
information provided for each condition should be interpreted on a case-by-case
basis. For index cases detected by screening (rather than as a result of acute
symptoms) the duration of potential infectivity will usually have to be
assessed by sexual or IDU history in combination with the clinical picture. The
incubation period is only helpful to determine the infectious period for an
acutely symptomatic index case. Infected contacts are less likely to have
specific symptoms. Contacts who have not already sought medical attention are
more likely to be asymptomatic (or minimally symptomatic) than might usually be
expected for each condition. For many contacts, contact tracing may be their
only indication that they are at risk of infection.
As sexually
transmissible and blood borne infections frequently co -exist, in most cases
contacts should be screened for all common infections, not just the infection
diagnosed in the index case.
HIV infection
Causative
organism: Human
immunodeficiency virus.
Incubation
period: 1-6 weeks
for primary HIV (however many are asymptomatic and the illness may be poorly
recalled); usually several years to AIDS (median 8-10 years) without treatment.
How far
to trace back:
Partner notification is required. In the case of a confirmed primary HIV
illness, tracing 1-6 weeks prior to illness onset is required. For a late
HIV infection or an infection of unknown duration, tracing may need to be as
far back as possible (as early as 1980 depending on risk history).
Common
symptoms: The
primary illness consists of: acute fever, malaise, headaches, mouth ulcers,
rash and diarrhoea; and lasts a few days to a few weeks. After the primary
illness, patients are usually asymptomatic until they are immuno-compromised.
Likelihood
of transmission per act of unprotected intercourse: Usually <1 per cent but may be
higher with elevated viral load, e.g. during primary infection and late
infection or if other STIs are present.
Likelihood of transmission may be modified by HAART.
Likelihood
of long-term sexual partner being infected: >20 per cent.
Protective
effect of condoms:
High.
Transmission
by oral sex: Rare.
Duration
of potential infectivity: Lifetime.
Important
sequelae: AIDS;
death, congenital infection.
Direct
benefit of detection and treatment of contacts: Improved quality and duration of
life through antiviral drugs. Reduced vertical transmission. Reduced
transmission to others.
Usual
management of contacts: HIV-antibody testing and counselling; Antiviral therapy may be required
for post exposure prophylaxis if contact has been exposed in the last 72 hours
– appropriate specialist advice should be sought. If a contact is identified as
having HIV infection, referral to specialist services is indicated for
appropriate prophylactic therapies and antivirals.
Notification: Public health legislation requires
that people with HIV advise future sexual partners of their condition. Effective contact tracing does not depend on
disclosing information about the index case to their contacts. Where there has
been a number of sexual or needle sharing partners, the identity of the index
case may not be obvious. The purposes of contact tracing are to inform a person
or persons that they have been at risk of infection and to offer diagnosis,
counselling, education and treatment with the aim of minimising further
possible transmission or disease progression. It is recognised that where a
person has had few sexual or needle sharing partners, the identity of the index
case may be obvious to them.
Bacterial vaginosis
Contact
tracing priority:
Not appropriate – contacts are not traced for this infection.
Causative
organism: Associated
with Gardnerella vaginalis, anaerobes and other normal vaginal bacteria.
Incubation
period: Unknown.
Common
symptoms: Vaginal
discharge or odour.
Likelihood
of transmission per act of unprotected intercourse: Not sexually transmitted.
Likelihood
of long-term sexual partner being infected: Not applicable.
Protective
effect of condoms:
Not applicable.
Transmission
by oral sex: Not
applicable.
Duration
of potential infectivity: Not applicable.
Important
sequelae: Pre-term
delivery.
Direct
benefit of detection and treatment of contacts: Nil.
Usual
management of contacts: Assessment or treatment of partners not indicated.
Notification: Not notifiable.
Chlamydial infection (genital)
Causative
organism: Chlamydia
trachomatis, serovars D - K (a bacterium).
Incubation
period: > 2-60
days for male urethral infection. Most cervical infections in women and anal
infections in men and women remain asymptomatic.
How far
to trace back:
According to symptoms or sexual history; usually up to 6 months.
Common
Symptoms: Urethral
discharge/dysuria (in about 50% of infected men). Cervical and anal infections
are usually asymptomatic; Pelvic symptoms (see chapter 4.13 on PID);
Epididymitis (scrotal pain) in men <35 years.
Likelihood
of transmission per act of unprotected intercourse: High – 68% of male partners of
infected women are positive by PCR.
Likelihood
of long-term sexual partner being infected: 30 - 50 per cent.
Protective
effect of condoms:
High.
Transmission
by oral sex: Uncommon.
Duration
of potential infectivity: Months to years.
Important
sequelae: PID;
Neonatal pneumonitis; Preterm delivery; Ectopic pregnancy; Infertility;
Enhanced HIV transmission.
Direct
benefit of detection and treatment of contacts: Cure.
Usual management
of contacts:
Contacts of cases are treated routinely. Pathological confirmation of the
diagnosis is not required. Counselling, clinical examination, and testing of
appropriate sites (urine, cervix, and anus) are undertaken to exclude
co-existing infections. Contacts are treated with: doxycycline 100 mg bd for 7
days or azithromycin 1g orally statim (now acceptable in pregnancy); or for
pregnant or breast-feeding women: amoxycillin 500 mg orally four times a day
for 10 days.
Contact
tracing priority:
High.
Notification: Genital C. trachomatis infection
is a notifiable disease by doctors or laboratories.
Genital herpes
Notification: Not notifiable.
Causative
organism: Herpes
simplex viruses types 1 and 2.
Incubation
period: 2 days to
years; most are asymptomatic or have atypical symptoms.
How far
back to trace:
Usually current partner(s) only.
Common
symptoms: Recurrent
anogenital ulcers or blisters; Flu-like symptoms and bilateral lesions if
primary episode.
Likelihood
of transmission per act of unprotected intercourse: High if lesions present; low if no
lesions.
Likelihood
of long-term sexual partner being infected: >50 per cent.
Protective
effect of condoms:
Moderate to high; depends on site of lesions.
Transmission
by oral sex: Significant
for HSV type 1.
Duration
of potential infectivity: Lifelong, particularly during outbreaks.
Important
sequelae: Neonatal
infection; Psychosexual morbidity. Enhanced HIV transmission.
Direct
benefit of detection and treatment of contacts: Limited; frequent symptomatic
recurrences can be suppressed with treatment.
Usual
management of contacts: Counselling, particularly to help contacts recognise outbreaks;
contacts should be advised to present again within 36 hours if they develop
symptoms later. Any lesions should be swabbed for virus. Type-specific
serological tests have a role in assessing long-term partners – contact the
laboratory for information regarding available tests in your area. Initial
episodes or frequent recurrences of herpes may require antiviral treatment or
suppression.
Contact
tracing priority:
Low.
Genital warts
Notification: Not notifiable.
Causative
organisms: Human
papillomaviruses.
Incubation
period: 3 weeks to
> 12 months; many are sub-clinical.
How far
back to trace:
Concerned current partners only.
Common
symptoms: Anogenital
warts or ‘HPV’ on cervical cytology report.
Likelihood
of transmission per act of unprotected intercourse: High.
Likelihood
of long-term sexual partner being infected: >60 per cent.
Protective
effect of condoms:
Moderate.
Transmission
by oral sex: Rare.
Duration
of potential infectivity: Unknown (probably years).
Important
sequelae:
Association with genital cancer (particularly types 16, 18, 31). There is
little direct benefit of detection and treatment of contacts; treatment
objective is cosmetic only. Encourage compliance with Pap smears.
Usual
management of contacts: Counselling, clinical examination including Pap smears for women. If
lesions are present they may be treated by cryotherapy, diathermy, laser or
painting with podophyllotoxin, or imiquimod cream.
Contact
tracing priority:
Low (Pap smear program more important). The role of re-infection is probably
minimal. The majority of partners are probably already infected sub-clinically.
Gonorrhoea
Causative organism: Neisseria gonorrhoeae (a bacterium).
Incubation period: 2-10 days for male urethral
infection; occasionally weeks to months. Most women remain asymptomatic.
How far back to trace: According to sexual history, up to 6
months.
Common symptoms: Urethral discharge/dysuria; pelvic
symptoms in women; epididymitis in young men. The infection may occur in
atypical sites, especially in men who have sex with men.
Likelihood of transmission per act of
unprotected intercourse: Approximately 20 per cent to insertive partner; approximately 50 per
cent to receptive partner.
Likelihood of long-term sexual
partner being infected: >50 per cent.
Protective effect of condoms: High.
Transmission by oral sex: Significant.
Duration of potential infectivity: Up to 12 months.
Important sequelae: Pelvic inflammatory disease (PID);
epididymitis; disseminated infection; neonatal ophthalmia; enhanced HIV
transmission.
Direct benefit of detection and
treatment of contacts:
Cure.
Usual management of contacts: Counselling, clinical examination and
swabbing of appropriate sites (urethra, endocervix, pharynx, anal canal).
Contacts who test positive for gonococcal infection are treated with:
Ceftriaxone 250 mg IMI statim, azithromycin 1 gram orally or doxycycline 100 mg
bd for 10 days. Because of ciprofloxacin resistance the regimen of 500 mg p.o.
statim is used only if the organism is known to be sensitive.
Hepatitis A
Notification: the Public Health Unit will follow
up the contacts for this disease. The following is provided for your
information only. Acute viral hepatitis A is notifiable by all doctors and
laboratories by urgent means e.g. telephone.
Causative
organism: Hepatitis
A virus. Note: hepatitis A is transmitted by the faecal-oral route. Thus, in
every case transmission by contaminated food and water, as well as
interpersonal (social and sexual) contact must be considered.
Incubation
period: 15 - 50 days
(mean 28 days).
How far
back to trace: Up to
50 days from onset of symptoms.
Common
symptoms: Jaundice,
malaise, abdominal pain.
Likelihood
of transmission per act of unprotected intercourse: Unknown. Probably high if any faecal
contamination of mouth or fingers.
Likelihood
of long-term sexual partner being infected: High, if susceptible.
Protective
effect of condoms:
Nil (transmission is faeco-oral).
Transmission
by oral sex:
Possible if faecal contamination is present.
Duration
of potential infectivity: From time of infection until one week after jaundice appears.
Important
sequelae: Severe
hepatitis and acute liver failure.
Direct
benefit of detection and treatment of contacts: Passive immunisation reduces
symptoms (but not infectivity). Active vaccine provides long-term protection.
Usual
management of contacts: Passive vaccination with human immunoglobulin 2.0ml imi statim, if
contact within 2 weeks. Start active vaccination course immediately.
Contact
tracing priority:
High: including sexual contacts, domestic contacts, close social contacts, and
food handlers.
Hepatitis B
Causative
organism: Hepatitis
B virus.
Incubation
period: 30-180 days
(mean 60 days).
How far back to trace: Up to 180 days prior to the index case developing
symptoms; if asymptomatic, immediate contacts at risk are traced e.g. current
sexual partners, needle sharing contacts and institutional contacts.
Common
symptoms: Jaundice,
malaise, abdominal pain.
Likelihood
of transmission per act of unprotected intercourse: Unknown. (High if injecting
equipment is shared).
Likelihood
of long-term sexual partner being infected: 25-75 per cent (higher in the range if HbeAg
positive).
Protective
effect of condoms:
High.
Transmission
by oral sex:
Uncommon.
Duration
of potential infectivity: One to two months for acute infection; lifelong if chronic infection.
Important
sequelae: Severe
hepatitis, chronic liver disease, cirrhosis, and liver cancer.
Direct
benefit of detection and treatment of contacts: Infection or disease may be averted
by vaccination.
Usual
management of contacts: Counselling and testing (up to 12 weeks after exposure). Consider
active vaccination (3 injections over 6 months). If there is a high risk of
transmission (index case HbeAg positive, unprotected sex or needle stick
exposure) contact the Public Health Unit for advice regarding hepatitis B hyper
immune globulin.
Contact
tracing priority:
High for sexual contacts, needle sharing contacts and institutional contacts.
Notification: Acute viral hepatitis B is
notifiable by doctors and laboratories. For suspected transmission in an
institutional setting, telephone the Public Health Unit within 24 hours. Note:
Hepatitis D virus (HDV the delta agent) is a satellite virus that is entirely
dependent on concurrent hepatitis B infection. Measures to control hepatitis B
should control HDV. Effective contact tracing does not depend on disclosing
information about the index case to their contacts. Where there has been a
number of sexual or needle sharing partners, the identity of the index case may
not be obvious. The purposes of contact tracing are to inform a person or
persons that they have been at risk of infection and to offer diagnosis,
counselling, education and treatment with the aim of minimising further
possible transmission or disease progression. It is recognised that where a person
has had few sexual or needle sharing partners, the identity of the index case
may be obvious to them.
Hepatitis C
Causative
organism: Hepatitis
C virus.
Incubation
period: Up to
several months for acute infection.
How far
back to trace: Up to
180 days prior to index case developing acute symptoms; if asymptomatic
according to risk history.
Common
symptoms: Most
people experience no symptoms. Some people may have nausea, dark urine,
jaundice, abdominal discomfort, fatigue.
Likelihood
of transmission per act of unprotected intercourse: Rare. Transmission from HCV antibody
positive PCR negative people has not been documented.
Likelihood
of long-term sexual partner being infected: <5 per cent (if no other risk factors).
Protective
effect of condoms:
Unknown (probably high).
Transmission
by oral sex: Unknown
(probably rare).
Duration of potential
infectivity: Unknown, but
possibly lifelong; it may be highest before seroconversion. PCR negative people appear to be
noninfectious.
Important
sequelae: Severe
hepatitis, chronic liver disease, cirrhosis and liver cancer.
Direct
benefit of detection and treatment of contacts: Contacts with chronic active liver
disease may respond to treatment.
Usual
management of contacts: Counselling and testing (antibodies may take up to 6 months to
develop). Contacts with chronic active hepatitis C may benefit from interferon
/ribavirin therapy. Advised to minimise alcohol consumption. Vaccination
against hepatitis A and hepatitis B is necessary.
Contact
tracing priority:
High for needle sharing contacts, blood donors and recipients. Low for sexual
contacts. Zero if PCR negative.
Notification: Acute viral hepatitis C is
notifiable by all doctors in all States and Territories. If the index case has
received or donated blood within 6 months of developing symptoms, also advise
the relevant blood bank. Effective contact tracing does not depend on
disclosing information about the index case to their contacts. Where there has
been a number of sexual or needle sharing partners, the identity of the index
case may not be obvious. The purposes of contact tracing are to inform a person
or persons that they have been at risk of infection and to offer diagnosis,
counselling, education and treatment with the aim of minimising further
possible transmission or disease progression. It is recognised that where a
person has had few sexual or needle sharing partners, the identity of the index
case may be obvious to them.
Trichomoniasis
Notification: Not notifiable.
Causative
organism: Trichomonas
vaginalis (a protozoan).
Incubation
period: Days to
weeks. May remain asymptomatic indefinitely.
How far
back to trace:
Easily contactable recent partners only.
Common
symptoms: Vaginal
discharge, itch and odour. Men are usually asymptomatic but may have low-grade
urethritis.
Likelihood
of transmission per act of unprotected intercourse: Low–moderate.
Likelihood
of long-term sexual partner being infected: Unknown (probably moderate to high).
Protective
effect of condoms:
Unknown (probably high).
Transmission
by oral sex: Nil.
Duration
of potential infectivity: Indefinite.
Important
sequelae: Preterm
birth. Enhanced HIV transmission.
Direct
benefit of detection and treatment of contacts: Cure.
Usual
management of contacts: Counselling, clinical examination, and testing for other STIs. As T.
vaginalis cannot be excluded in male partners they are routinely treated
with metronidazole 2g p.o. statim; or tinidazole 2g p.o. statim.
Hepatitis C transmission:
To prevent
the transmission of hepatitis C, information about issues relating to blood
exposure needs to be targeted to each patient’s needs.
For patients
who continue to inject drugs, they must be made aware of ways to access new and
sterile injecting equipment and have access to information that creates a clear
awareness of the possibility of blood in any interaction, situation or
environment.
The safest
way to inject is:
It is not
essential to have sterile water in order to inject safely; ordinary tap water
is fine. All other equipment, the injecting space and hands need to be cleaned
with soap and water or with swabs.
The
Australian Intravenous League (AIVL) and State and Territory peer-based
drug user organisations produce booklets on safer using, cleaning fits and
handy hints for people who inject drugs. Needle and Syringe Programs (NSPs)
exist in all States and Territories, although the ranges of services differ.
Some of the services provided include access to needles and syringes (often
free), disposal options, information and education about safer using, safe sex,
blood-borne viruses, management and treatment programs (including methadone
maintenance), overdose prevention education and referrals to user-friendly
services.
All items of
injecting equipment should be disposed of appropriately to ensure that there is
no risk of transmission through accidental contact with used items.
Specifically, needles and syringes should be:
Some people
who inject drugs do not have access to disposal facilities located at NSPs, or
are unable to ensure safe disposal each time they inject. You should advise
individuals about appropriate domestic disposal that meets with local and
municipal requirements. If you are unsure, the Tasmanian Council of AIDS,
Hepatitis and Related Disorders will be able to advise you.
People with
hepatitis C may be concerned that they can transmit the virus to their
partners, their family, friends or other members of their household. People
should be aware that there are some personal care objects that, if shared, may
transmit hepatitis C from a person already infected to another person.
These may include toothbrushes, razors, tweezers, scissors and nail clippers.
To reduce the possibility of hepatitis C transmission, everybody in a household
should have, and exclusively use, their own personal care items, particularly
toothbrushes and razors.
Another
issue for the household relates to First Aid. Here are some basic infection
control and First Aid protocols:
Before
giving First Aid:
During
First Aid:
After
First Aid:
Case Notes:
Roger wants to know if
he needs any further tests to see ‘how bad’ his Hepatitis C is. He also wants to know what this
means for his health long-term, if there is anything he can do to improve his
health, and whether there is any appropriate treatment for him.
Investigations
and Management of Hepatitis C:
The
incubation period for hepatitis C is 2-16 weeks but can be up to 26 weeks.
Approximately 30% of those who become infected will actually clear the virus.
The remaining 70% will become chronically infected. Of these, 20 to 40% will
develop chronic hepatitis, and 10 to 20% will develop cirrhosis.
The investigations
required for someone with newly diagnosed hepatitis C are outlined on the
desktop reference below. There is currently no consensus regarding ongoing
testing for patients with hepatitis C. However, for someone with a recent
diagnosis of hepatitis C (such as Roger) hepatitis B serology and HIV serology
should be ordered if not ordered already. He also needs 3 liver function tests
over the next 6 months to see if his condition is stable. If he remains stable,
he will need regular liver function tests.
Hepatitis C
RNA is commonly ordered for newly diagnosed patients. Patients who are
hepatitis C antibody positive, but who clear the virus, will remain antibody
positive. However, their RNA will return to normal, demonstrating sustained
viral clearance. It can take up to 3 years to clear the virus. Therefore, if a
patient is antibody positive, it may be useful to order hepatitis C RNA. If the
RNA test is negative, they may be in a window period or may have cleared the
virus, therefore re-check the RNA in 6 months. If the RNA test is positive,
they still may clear the virus, therefore re-check RNA every 12 months for 3
years (Royal College of Pathologists
of
Roger needs
specific lifestyle advice:
-
Avoid alcohol
ingestion or, if not possible, minimize intake to < 20g / day
-
Maintain a
healthy diet and participate in regular physical activity
What would discourage you from referring this patient to a
specialist?
Treatment
may not be appropriate if Roger is:
What are the side-effects of treatment? What monitoring is required while he is on treatment?
The side-effects of
treatment include:
Regular monitoring is
required. Monitoring is usually weekly for the first month then monthly. FBE
and biochemistry is generally evaluated at each visit.
How long will treatment last and what are his chances of sustained viral response (SVR)?
This will depend on the
genotype of the virus:
Genotyping is used for pre-treatment evaluation of
patients being considered for antiviral therapy. Genotyping, together with
viral load, is used to determine the appropriate duration of therapy as
infection with genotypes 2 and 3 responds better to antivirals.
If he does clear
the virus, what advice does he need regarding his behaviour?
Yes. He has no immunity
therefore needs counseling regarding harm minimization or he may become
re-infected.
Issues to Consider:
Review
your knowledge of the clinical management of Hepatitis C by answering the
following questions:
Case Notes:
Roger and his wife Daria have discussed his hepatitis C. Daria is keen to also be tested for hepatitis C as she too has injected drugs in the past. Also, she has just discovered that she is pregnant and wants to know if there is any risk to her child. She is tested and found to be anti-HCV positive.
The risks to her infant:
Daria needs to know that the risk of transmitting
Hepatitis C to her infant is low (approximately 5%). Transmission may occur in
utero as well as at birth. A high level of maternal HCV RNA may be predictive
therefore she should be referred for further assessment and treatment. There is
no indication for elective caesarean section in this situation.
Issues
to Consider:
What if this woman had been found Hepatitis C positive prenatally? Would there have been any benefit to postponing pregnancy?
What should she be told regarding management and follow-up
for her child?
Should she breastfeed?
Summary:
This case illustrates many of the aspects
related to the care of patients with hepatitis C. As a result of completing
this case you should now be confident to diagnose and monitor patients with
hepatitis C, be more aware of epidemiology of hepatitis C, and have a better understanding of the confidentiality and
privacy issues relating to Hepatitis C care.
References and Further
American Public Health Association. Control of Communicable Diseases Manual. 18th Edition. 2005.
Tasmanian Department of Health and Human Services. Notifiable Diseases Manual. 2003.
Department of Health and Ageing. National Hepatitis C Resource Manual. www.health.gov.au