2.2.6 Blood Borne Viruses |
Contents
1. Recognition of Risk
All Professionals involved with Children at Risk of Blood Borne Virus should Refer to Children in Need HIV and Hepatitis and Bloodborne Viruses, DH 2004
The main child protection issues likely to arise with the blood borne viruses are when a:
- Mother known to be HIV+ refuses to accept testing and treatment for herself in pregnancy and / or for the baby following delivery;
- Mother known to be HIV+ positive insists on breast feeding her baby against medical advice (breast feeding currently nearly doubles the risk of transmission from mother to child in the UK);
- Child is thought to have a blood borne disease and his/her parents refuse to agree to medical testing and / or treatment;
- Child is on the appropriate treatment, but medication is given inconsistently or stopped altogether and there is a danger of resistance developing;
- Child has been sexually abused and the abuser is thought to be/known to be infected with a blood borne disease HIV testing should be considered;
- Child has been exposed to contaminated needles and syringes;
- Child is a young carer for a parent known to be infected with any blood borne virus and repeatedly protective measures are not used / encouraged when cleaning / dressing open wounds.
It is in the best interest of any infant/child/young person thought to be at risk of exposure to HIV infection to be tested. Testing is only deemed urgent in children who are at risk of rapid disease progression or who are symptomatic. A significant number of young people who have acquired HIV through vertical transmission are surviving childhood thus resulting in late diagnosis or even death.
A significant number of children born to HIV positive parents and living in the UK and Ireland remain untested. Many of these children could potentially be infected with HIV and survive through childhood to adolescence without any symptoms. Many HIV infected parents are reluctant to test their child despite the increasing knowledge about HIV and improved prognosis with highly active antiretroviral therapy (HAART). Some of the main reasons for refusing testing are:
- The child being well;
- Fear around disclosure of parent HIV diagnosis to the child;
- Stigma/isolation/guilt;
- Inability to cope with a positive result.
The Medical Foundation of AIDS and Sexual health (Medfash) and the British HIV Association (BHIVA) reinforce that: “it is within the competencies of all clinicians and appropriately trained healthcare workers to obtain consent and perform an HIV test. There is no need for special counselling skills beyond those required for routine clinical practice”.
HIV testing in children may be seen as a process, the urgency of the process depends on the age and health of the child.
In the case of infants and symptomatic children a test must occur immediately. Where the child is too young for consent a guide of 6 months is felt to be acceptable. In the case of asymptomatic non – sexually active young people it is felt that up to a year is acceptable. For sexually active young people, the possibility of onward transmission makes testing urgent.
The decision for a parent to agree to HIV testing for a child may take a period of time. Professionals must always keep the timescales for the child in focus and seek advice from health specialists in the field to ensure that risks to the child are not increased by this delay.
2. Confidentiality and Consent
Both parents and the child have rights, which are protected by UK law. Disclosure of medical information about a child may indirectly provide information about the parent. Informing the child of the parent’s HIV status without parental permission will infringe the parents right to medical confidentiality and must be justified. Similarly, informing other professionals about the child’s HIV status may indirectly provide information about the parent. Never the less, such a disclosure may be justified to protect the rights of the child. Decisions to share information without parental, or in some cases, the child’s consent, are complex and should be explored carefully. When necessary, legal advice should be sought.
In some cases a professional who works exclusively with patients who have blood borne conditions such as HIV may have cause to refer the family to social services for other reasons. This increases the possibility of breaching confidentiality unintentionally. When knowledge of a blood borne virus is not essential to assessing risks and providing support to the family, social services may need to ensure that other professionals involved with the family do not know about the involvement of specialist health staff.
Local Education Authorities and Proprietors Providing Services in Schools and in Early Years and Childcare Settings
In schools, early years and childcare settings there may be reasons why the proprietor/person in charge should be informed. These reasons include if the child is frequently absent due to ill health or to attend hospital appointments and may need additional educational support. If the child is on medication, arrangements may be needed to manage the medication safely.
Where the education setting is informed every effort should be made to safeguard the child’s confidentiality and right to privacy. Those who are made aware should be strictly confined to those who need to know in order to ensure the proper care of the child and for any additional pastoral and educational support that may be required. Local advice on blood borne viruses may be sought from the Consultant in Communicable Disease Control, who may be contacted via the local Integrated Care Board or Health Protection Agency, where appropriate, advice can be sought from a microbiologist, virologist or a genitourinary medicine (GUM) or infectious diseases physician.
Information should not be disclosed to carers or in schools solely on the basis that it might help protect those involved in the care or treatment of a child with bloodborne virus infection. Standard hygiene precautions should be in use to protect against infection and it is a requirement under COSHH for risk assessments to be done in all settings to assess the risk and to control and minimise the risk of infection.
Under the Equality Act 2010, schools have duties not to discriminate against students on grounds relating to a disability in admissions, education and associated services, and exclusions from school for discussion of HIV and disability). In exceptional circumstances, where a child’s behaviour is thought to pose a serious risk of infection to others, disclosure of the child’s bloodborne virus status may be warranted (e.g. if a child is deliberately trying to harm other children by activities involving the direct exchange of fresh blood).
3. Response to Identified Risks
Concerns about blood borne viruses such as hepatitis and HIV should be sensitively explored. If a child’s concerns arise because they have suffered abuse, s/he may need time to make a full disclosure. It is in the best interest of any infant/child/young person thought to be at significant risk of exposure to a blood borne virus to be tested.
The risk of community acquired HIV is extremely low, however children and adolescents are potentially at risk of contracting HIV from a variety of exposures including needlestick injury, sexual abuse, consensual sexual activity in adolescence, biting or being bitten by another child. There have been no school-related transmissions. Counselling should be considered as appropriate for anyone deciding whether or not to be tested for blood borne viruses such as HIV.
If a professional is concerned that a child may have been placed at risk of HIV or hepatitis B an informed decision must be made about whether to raise this with the child or parent/s.
Post exposure prophylactic treatment (PEP) may be available to children who have been exposed to HIV or hepatitis B e.g. through a needle-stick injury or sexual assault. This treatment minimises the risk of infection. HIV prophylaxis should be started ideally within an hour of exposure. PEP is now generally not recommended after 72 hours post – exposure. HIV PEP is most effective if started within 1 hour of exposure but may be beneficial up to 72 hours after the risk of exposure. Following exposure to blood borne viruses, it should be remembered that the risk of transmission is highest for Hepatitis B, then Hepatitis C and lastly HIV. Professionals should seek urgent specialist advice about treatment. (See Inoculation injuries and children in schools and similar settings: Risk Assessment Guidelines for Health Protection Unit November 2009, HPA)
4. Advice and Guidance
Professionals in all agencies should contact, the genitourinary clinic or lead officers within their own agencies for specialist advice and support.
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