PAINFUL GUIDELINES (BBV healthcare worker, BBV in dialysis, HAV)

Question 1

A healthcare worker with hep B is on antiviral therapy. How often should they have viral load checked?

Answer 1

Every 6 months

If they stop antivirals:

2 tests 6 months apart
( the first being no less than 6 months after ceasing
treatment)

Therefore if someone stops antivirals
or after a minimum of 12 months after stopping a course is when they could resume EPP (Is that correct?)

Question 1

With regards to a BBV exposure what is a patient notification exercise?
When should it be performed?

Answer 1

A look back exercise discussed in UKAP guidance.

If a HCW is diagnosed with a BBV, need to do a risk assessment of risk of transmission (based on incubation periods, level of viraemia, EPP). Patients potentially exposed may then be contacted and offered testing

Done on a case by case assessment by UKAP, but you can voluntarily do one locally
(this is a change from earlier guidance when it used to be that large scale PNE were performed)

Question 2

What is the name of the assessment tool for herpes B risk exposure and its key features?
5 key points

Answer 2

McGill protocol
-was there adequate first aid
-what sort of exposure (ie mucosal splash/break in skin integrety)
-how deep was the bite
-where was the bite (head and face higher risk than limbs)
-monkey has to be a macaque (a healthy one low estrisk)

Question 3

Surgeon with HbSAg positive v/l 100
What do you do

Answer 3

Case by case which may result in no action
Recheck 10 days later
If it goes above 200 then would stop

Ensure UKAP-OHR registrered
All bloods under IVS
Monitor 6 monthly if DNA

Question 4

If HBsAg postive how often to check viral loads

Answer 4

4 weeks apart for initital clearance, <200
Then 6 monthly

Question 5

HCV exposed healthcare worker

Answer 5

6, 12, 24 weeks

PCR at each- Abs at 12 and 24

Question 6

BBV assessment required pre dialysis

Answer 6

HBsAg anti-HBc anti-HBs
HCV IgG (if high risk recent consider HCV RNA)
HIV Ab / Ag combined

Question 7

Frequency of monitoring of hep B immunity for dialysis patients

Answer 7

Ant- Hbs anually

Hep B surface antibody >100 mIU/ml, Hep surface Ag 6 monthly

If Hep B surface < 100mIU/ml: 3 monthly

If under 100 in last 6 months then give booster

Question 8

Methods for reduction of BBV transmission in renal units

Answer 8

Vaccination
Regular testing
Segration of HBV positive-with HBV
Dialyisis away from base

Question 9

Stratify high, intermed and low risk countried for dialysis away from base

Answer 9

Low risk countries:
UK, Europe, US, Canada, Australia, New Zealand and Japan
High risk countries:
Indian subcontinent, parts of Africa
Intermediate risk countries:
Rest of the world including South East Asia, South America, Middle East

Question 10

Protocol for enhanced surveillance

Answer 10

Protocol for enhanced surveillance following a new case of BBV infection
HBV The exposed cohort should be tested for HBsAg and those who have not
demonstrated anti-HBs levels ≥ 100 mIU/ml in the preceding 12 months should
be re-tested every 2 weeks for at least 3 months after the last exposure to the index case.
For patients who have previously been immunised and shown to have responded,
a booster dose of vaccine should be considered.
In non-responders, or where status is unknown, HBIG and an accelerated course
of vaccine should be considered.
HCV The exposed cohort should be tested for HCV RNA by PCR at 2-weekly intervals
until 3 months after the last exposure to the index case, particularly if the index case
seroconverted whilst receiving dialysis on the unit (i.e. when (s)he would have had a
high viral load during the acute phase of infection).
HIV Undertake a risk analysis. If the index case seroconverted whilst receiving dialysis on
the unit (i.e. when (s)he would have had a high viral load during the acute phase of
infection) consider HIV RNA testing of the exposed cohort by PCR at 2-weekly
intervals until 3 months after the last exposure.

Question 11

Procedure for individual returning after dialysis away from base in risk countries: 4 marks

Answer 11

Assess
Segregated dialysis
Test for BBV
Should have been vaccinated prior

Depending on the risk of BBV exposure we recommend the following level of surveillance:
Low risk
 Continue with HCV Ab and HBsAg screening as per routine practice.
 Segregation not required

Intermediate Risk
 HCV Ab (or HCV RNA) every 2 weeks for 3 months
 HBsAg every 2 weeks for 3 months
 HIV Ag/Ab if indicated by risk assessment
 High risk
 HCV Ab (or HCV RNA) every 2 weeks for 3 months
 HBsAg every 2 weeks for 3 months
 HIV Ag/Ab if indicated by risk assessment

Our previous guidelines have suggested that enhanced surveillance for HBV is not required if immune with
HBsAb level >100 mIU/mL in the last 12 months. However, antibody titres can fall over time, leading some
patients to become unprotected. In view of this and in an attempt to reduce the level of complexity in the
guidelines, which can lead to errors if misinterpreted, we have recommended same level of surveillance
irrespective of HBsAb levels.

Regarding segregation:
Medium risk: If initial screening is negative,
machine and patient
segregation not required

High risk: segregate for 3 months

Question 12

For dialysis: Defintion of a non-responder to vaccine- <100 (?units), 8 weeks following primary vaccinations

Answer 12

And strategy to overcome this
If between 10-100: give booster
If <10 repeat whole course

Question 13

Exposed to HBV on dialysis unit, HB surface antibody level of 70. What do you do?

Answer 13

Give dose of vaccine only

(if Hbs antibody within 6 months of exposure is between 10-100 vaccinate, if less than 10 and exposure is within last 7 days give HBig)

Question 14

Dose if HBIG for adults (people over 10 years of age)

Question 15

How long after exposure to HAV do you have to offer HNIG in following situations

Other name for HNIG (subgam)

1) Person with HIV and CD4 count of 50

2) Patient 62 years old who got a one dose of hep a vaccine 3 years ago

3) Patient with chronic hep B

Answer 15

1) 14 days from exposure
(plus vaccine)

2) TRICK QUESTION- this person would be considered “susceptible but primed), gets vaccine only.

But 60 is cut off for giving vaccine + HNIG (within two weeks of exposure if susceptible)

3) 28 days
-applies to any chronic liver disease

(note 28 days in the average incuabtion period for HAV)

Question 16

Who should not receive HNIG post HAV exposure and why

Answer 16

Those who have known vaccination or known previous Hep A

• subgam is likely to contain a fairly small amount of Hep A IgG, the magnitude of protection is much greater for active immunisation, and therefore not waranted if already immune
• test Hep A IgG if unsure, but only if time

This is also why should not give more than 7 days post vaccine

Question 17

Indications for Hep A vaccine (pre-exposire)

Answer 17

Travel
Occupational risk
Haemophilia
High risk sex
PWIDs
Chronic hep B and C

Question 18

You have 8 weeks to offer HAV vaccine as PEP in what situation

Answer 18

Non-immune person, if more than one close contact in household

(also only if aged over 12 months, don’t give HAV vaccine to those under 12 months)

Question 19

Indications for HNIG post HAV exposure

Answer 19

Have to be suscpetible
Within 14 days of exposure, always give with vaccine
- over 60
-HIV with CD4< 200
-immunosupressed
- chronic liver disease

Question 20

My mum and dad have been exposed to HAV, (they are 67 and not vaccinated), what would their PEP

Answer 20

HNIG and HAV vaccine (within 2 weeks of exposure)