No 11 - 2013

New guideline on HIV and hepatitis B and C virus

The Danish Health and Medicines Authority has recently published "Guideline on HIV (human immunodeficiency virus), hepatitis B and C virus. Prevention of blood-borne infection, diagnostics and handling in healthcare and at other places of work."

A single guideline, only available online

The new joint guideline is a consolidation and update of: "Guideline on human deficiency virus HIV and prevention of blood-borne infection, 1992", and "Guideline on prevention of viral hepatitis, 2002". The new guideline replaces both of these. Later this year, a brief, separate hepatitis A guideline will be published.

The new guideline reflects considerably improved treatment options for HIV, hepatitis B (HBV) and hepatitis C (HCV). HIV should no longer be considered an exceptional infection, but should be perceived in conjunction and in line with a range of other infectious diseases. Furthermore, the developments demand that the hepatitis diagnosis be considered in a wider range of situations than was previously the case.

The guideline will not be published on paper, but as from 13 March it is available for download (in Danish) from the homepage of the Danish Health and Medicines Authority, www.sst.dk, under the "HIV" and "Hepatitis" headings of the page on prevention/infectious diseases. The aim has been to create a dynamic, user-friendly and web-based overview and reference publication that links to more specific and updated knowledge and to the remaining provisions and guidelines aiming to avoid non-sexual infection.

The guideline will be updated continuously to reflect developments in the field, and relevant stakeholders are encouraged to contact the Danish Health and Medicines Authority at sst@sst.dk, to inform the authorities of any significant changes that may come to their knowledge.

Target group

The guideline's target group includes hospitals, the practice sector (GPs, specialist practices, podologists and dentists), medical officers of health, the municipal health service, employees and employers in professions at risk of infection, administrators and interest groups, including patient organisations.

Prevention of exposure at work and at home

The general infectious hygiene precautions remain the foundation of any prevention of contact infection. As previously, the principles governing general procedure-related guidelines are a pivotal element in the prevention of infection in healthcare and nursing. These principles are independent of (any knowledge of) the patients' diagnoses or infectious status.

The guideline provides specific hygiene recommendations including measures to avoid exposure to blood and secretions in patients homes and in day-care services. Furthermore, the guideline offers recommendations for the management of needle-prick incidents and accidents.

Who should receive hepatitis B vaccination?

During the preparation of the vaccination recommendations, the risk of infection was weighed against the socio-economic cost of vaccination. Note that the recommendations should be considered minimum recommendations, which may be extended by employers and by the Danish Working Environment Authority.

The range of professionals covered by the vaccination recommendation has been changed. Thus, the new guideline recommends vaccination of persons specifically assessed to be at risk, rather than persons belonging to specific professions. This delimitation should be made locally. The list comprises:

• Employees and students – healthcare professionals and others – who are at significant risk of infection transmission and sharps lesions, e.g. due to needle-prick or cutting accidents involving blood-contaminated syringes, knives, etc.
• Employees in residential units within institutions for mentally handicapped persons in which one or more of the residents are infected with hepatitis B.
• Employees in day-care institutions and private day-care services (dagpleje) who care for a pre-school child diagnosed with chronic hepatitis B.

Booster/post-vaccination testing

In otherwise healthy persons, routine antibody control after hepatitis B vaccination is not recommended; nor is booster vaccination after a number of years. However, selected persons should be tested for antibody response 1-2 months after concluding the vaccination series to test if the vaccine took and determine the need for re-vaccination.

This group includes children of mothers with chronic hepatitis B and immunosuppressed persons: Dialysis patients with HIV, IV drug users and Down syndrome patients. Furthermore, in patients who are at a persistent, high risk of infection, serological control for may be considered after concluding the vaccination series to determine if the vaccination took. Provisions on payment for vaccination remain unchanged.

Who should be offered which test, and which specimens are needed?

Neither HIV nor hepatitis are generally prevalent in Denmark. The Danish Health and Medicines Authority maintains that there is no basis for introduction of hepatitis B vaccination to the Childhood Vaccination Programme.

Instead, the preventive strategy targets persons and groups who are at increased risk of HIV and/or hepatitis B and C. Thus, specific measures are designed to target certain groups, including childbearing women, ethnic minorities, men who have sex with men (MSM), sex workers, IV drug users (IDU) and persons infected with HIV, HBV or HCV.

The guideline contains updated lists of groups of persons at increased risk of or particularly vulnerable to infection, who should therefore be offered testing.

All tests remain voluntary, but the Danish Health and Medicines Authority recommends that patients at special risk of HIV infection be routinely offered and actively encouraged to accept HIV testing whenever they come into contact with Danish healthcare, and not only when they themselves request testing, EPI-NEWS 46/09 and 11/10.

The objective of this measure is to identify as many HIV infectees as possible. Furthermore, the aim is to ensure that treatment offers reach patients timely, and to limit the infection pressure in the population through the preventive effect of counselling and antiretroviral management.

Contact tracing is recommended as an effective means of identifying unrecognised cases of HIV infection.
The guideline details the specimens needed to diagnose hepatitis B and C.

Anonymity remains an option in HIV testing, but HIV positives must be reported

If a patient so prefers, he or she may have HIV testing performed anonymously at screening clinics and hospital outpatient clinics. Furthermore, at a number of locations in major towns, patients can be HIV-tested anonymously at so-called "Checkpoints", which are not part of Danish public healthcare.

However, anonymity is not an option when positive test results are reported, nor (as is already the case) when a patient is referred for outpatient control or admission. Registration in these situations is based on the patient’s name and civil registration (CPR) number.

In the rare cases in which a patient holds back his or her identity, to avoid double registration, it is important that the form is not filled in using a dummy name or CPR number. Instead, the form should be marked "Anonymous", and it should provide details of sex and age, if possible.

Context-determined communication of HIV test results

The physician ensures that persons who are tested for HIV receive any test results in a suitable manner, depending on the assessed risk, the situation, and as agreed by the physician and patient.

HIV, hepatitis B and C are not handled any differently from other infectious diseases. Thus, the general provisions of the Danish Health Act apply to information and consent in the context of HIV, HBV and HCV. These provisions also apply to disclosure of health-related information, etc., for treatment purposes and to any collection of electronically stored health-related information, etc.
(Danish Health and Medicines Authority)

Hepatitis B vaccination of travellers

The recommendations stipulating which travellers should be offered hepatitis B vaccination are presented (in Danish) on the page "Rejser og smitsomme sygdomme" under the menu item ”Vaccination” on the Danish language version of www.ssi.dk, and in EPI-NEWS 27/12.

Antibody response control is not routinely recommended in otherwise healthy travellers advised to undergo hepatitis B vaccination. Furthermore, the booster vaccine is not recommended for this group. Where three hepatitis B vaccinations were given and the minimum intervals were observed, there is no need for any further vaccination, even if the recommended vaccination intervals were exceeded.
(Department of Infectious Disease Epidemiology) 

Link to previous issues of EPI-NEWS

13 March 2013