Healthcare Student Electives: Some Communicable Disease Issues and Occupational Health

1. Healthcare Student Electives:Some Communicable DiseaseIssues and Occupational Health Pam Mellors, Consultant in Occupational Medicine Tai Bakare, ST in Occupational Medicine

2. Aims of discussion • Introduction to • Implications of spending elective in countries with higher incidence of certain serious communicable disease • What diseases, where, how exposed • DoH guidance relevant to this • Signpost to further information to assess and reduce risks of exposure and consequences • (NB world prevalence charts shown here are not the most recent available).

3. Serious Communicable diseases for discussion • Tb • HIV • Hepatitis B • Hepatitis C

4. Estimated TB incidence rate, 2005(High risk country definition 40/100,000) Estimated new TB cases (all forms) per 100 000 population No estimate 0-24 25-49 50-99 100-299 300 or more The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2006. All rights reserved

5. Tuberculosis-Your immune status • Should have had immune status update on entry to medical school • Either BCG scar check or tuberculin/Quantiferon testing and appropriate follow up • Vaccination only partially protective • If in doubt, contact Occupational Health Service (OHS)

6. TB: key points about exposure and follow up • About 1/10 risk of TB illness after high risk contact • Takes months to years to present itself • Pulmonary, Non pulmonary, Latent • Classical symptoms: Cough>3 weeks, fever, night sweats, weight loss.

7. Exposure and infectious TB: Situations deemed higher risk IN UK • cough inducing procedures, eg physiotherapy • performed /assisted at bronchoscopy • mouth to mouth resuscitation • close constant high dependency care • aerosolised TB in a mortuary or pathology department. • stay in the home of/or more than eight hours contact in a room with someone with infectious tuberculosis. • you have immune suppression and have had contact with a person/patient with TB. • In high risk countries, work exposure more likely

8. Action if concern have had significant TB contact • For those who have been to high risk countries will be further presentation by OHS on your return • Contact OH Service on your return • Risk assessment –exposure and individual factors • Know the symptoms, early reporting

9. Blood borne viruses • HIV, Hepatitis B, Hepatitis C • Personal consequences of infection • Occupational consequences of Infection (EPP role) • Must consider these risks in choice of elective • Brief introduction, websites suggested for more details and up to date epidemiology • If have had risk of exposure, must seek advice and testing • Personal benefit of earlier treatment if required

10. BBV exposure risk • Occupational sharps injury, splash mucous membranes contamination of open wound, cut, abrasion (higher risk of exposure - certain specialities eg surgery, obstetrics and in certain countries) • Social sex with infected person needle sharing • Healthcare contaminated needles blood products

11. BBV infection -Prevention • The most effective approach is not to put yourself at risk at all!! • Use good infection control procedures at all times • Wear gloves if you are likely to be contaminated with body fluids (take gloves with you) • Think about what you will do in the event of an injury before it happens

13. HIV • Quoted risk after injury approx 3/1000 • In some high risk countries, Post Exposure prophylaxis (PEP) will be available to you • If not available can take supply with you (so must find out in advance) • I month course of antiviral therapy • OHS will prescribe one week supply to allow time for repatriation if high risk injury • BUT

14. HIV PEP • Evidence limited (- is good enough to recommend consider using after high exposure risk) • Not a substitute for safe behaviour • Expensive • Side effects and interactions • Take ASAP after accidental exposure

15. HIV PEP Risk assessment Will take into account • Source case factors re infectivity • Background population incidence if source unknown • Factors about the injury

16. HIV PEP If going to high HIV incidence countries, OH Service can provide • Further presentation and advice on website as to how to assess risk after occupational exposure • Prescription for 1 week supply (You pay) • Centre for Sexual health 24 hr contact details for emergency advice when away

17. Costs for 7 days HIV PEP in 2009 • Combivir 1 bd + Kaletra 2 tablets bd • 7 days = £185.98 • Recommend 7 day pack • Legal and GMC Issue: Prescribed medicines only for person named in prescription.

18. Hepatitis B • Quoted risk for needle stick injury from infectious source is 3/10 • Good protection from vaccination • Should know your immune status • If not, contact OHS for advice

19. Prevalence of chronic infection with hepatitis B virus, 2006

20. Prevalence of hepatitis B in various areas

21. Hepatitis C • Quoted risk after needle stick from infectious source is 3/100 • No vaccine available • No PEP • But strong evidence that early intervention improves prognosis +++ • Therefore if injury sustained attend local OHService for advice and follow up when return to UK

22. Prevalence of hepatitis C infection WHO 2004

23. Department of Health Guidance Health clearance for tuberculosis,hepatitis B, hepatitis C and HIV: (New healthcare workers) • http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_073132 • Applies not only to new hcws/students • Requires risk assessment for those returning from countries with high prevalence communicable disease • Will be a reminder presentation when you return

24. Report injuries, attend OH follow up • Take care to avoid injury • Ensure you know local procedure before you start work there • If occurs report it immediately • Usually source case tested urgently for BBV • Contact OH Service when you return for advice and follow up

25. OH Service • Medically Confidential • Provide support and advice • Anyone found to have infection- medically confidential • If alteration to working arrangement required because of infection, support to individual and advice to Medical school

26. Useful website/telephone numbers • OHS nurse advisors: SJUH 2067071 and 2064473 LGI 3923267 http:www.hpa.org.uk search WHO country data TB http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_088185 Chapter 4 http:www.dh.gov.uk/Policyandguidance/Healthandsocialcaretopics --key documents on HIV, Hep B, Hep C, Health clearance http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf http:www.nice.org.uk Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control • Emergency Advice on PEP available from GUM Consultant/SpR 24/7 (Office hours 0113 3926762, out of hours LGI switchboard 0113 2432799)