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5.5.5 Blood Borne Viruses

Contents

  1. Introduction
  2. Which Children are at Risk of HIV and Hepatitis Infections
  3. Hepatitis C Infection
  4. Hepatitis B
  5. Referral
  6. Looked After Children
  7. Counselling
  8. Consent
  9. Tests Results

    Appendix 1: About HIV And Hepatitis

    Appendix 2: Consent - Children and Young People


1. Introduction

This guide outlines the procedures for the investigation and management of children who may be at risk of blood borne viruses.

Advances in the treatment of Hepatitis and HIV infection means that early identification can improve the outcome for children. It is therefore important that carers and professionals involved with children at risk of infection have access to up to date information about the infections and there are clear arrangements for counselling, testing and communication of results.

Please also refer to the HIV Procedure.


2. Which Children are at Risk of HIV and Hepatitis Infections

Testing should be considered for children who may be at risk of infection. The categories below should be used as a guide and the need for testing should be fully evaluated for each individual child. There may be a different level of risk for siblings within the same family. Any testing should always be in the best interest of the child

  • Children with clinical symptoms of HIV infection or Hepatitis;
  • Children whose mothers are known to be infected with Hepatitis B, C or HIV virus;
  • Children who live in the same house as someone who has Hepatitis B;
  • Children who may have been exposed to infection (Sexual Abuse or any unprotected sexual activity, needle sharing, needle stick injury);
  • Children whose parents come from a high risk area of the world, (Sub Saharan Africa, South Africa);
  • South East Asia - HIV), (Eastern Europe, South East Asia and South America - Hepatitis B);
  • Children whose parents have a history of injecting drug use;
  • Children whose parents have a history of sexually transmitted infection;
  • Children whose parents have a history of multiple sexual partners.


3. Hepatitis C Infection

Transmission during pregnancy is relatively uncommon. However, if the mother is also HIV positive the risk of transmission of the virus during pregnancy is greatly increased.

The need for testing should be carefully evaluated on a case by case situation.


4. Hepatitis B

There is a safe, effective vaccine available against Hepatitis B. Health Visitors, midwives, school nurses and general practitioners can administer this vaccine.

The following individuals should be offered immunisations:-

  • All carers should be counselled about the risks of transmission of undiagnosed infection in children placed with them and offered immunisation;
  • Carers and their immediate family who are caring for a child who is a carrier of the Hepatitis B virus;
  • A child placed with a carer who is known to have a history of Hepatitis B infection will need to be tested and offered immunisation as appropriate;
  • Babies born to mothers with Hepatitis B infection including chronic carriers;
  • Close contacts of someone who is Hepatitis B positive (living in same household);
  • Following a risk assessment by their employers organisation, anyone working with children and adults who has been identified at increased risk of being infected with Hepatitis B;
  • Anyone sustaining a needle stick injury;
  • Injecting drug users.


5. Referral

If the social worker considers or is informed that a child could be at risk of HIV and Hepatitis B they should, in the first instance, contact Community Paediatrician (Dr Poynor based at Halliwell Health Centre, Bolton) to discuss and decide whether the child needs further assessment and testing.

If the child is deemed to need testing Dr Poynor will arrange for the child to be tested.

Parents can if they chose discuss the risks to their child with their general practitioner who will then, if appropriate, refer the child for testing.


6. Looked After Children

If a Looked After child is deemed to be at risk of HIV and Hepatitis B the social worker should contact the Community Paediatrician (Dr Poynor) to decide whether the child should be tested.

Parents should be included in any discussions (where possible) about the need for testing and given the opportunity to meet with Dr Poynor.

Dr Poynor will then make the arrangements for testing if appropriate.


7. Counselling

It is the responsibility of the medical practitioner who assesses the level of risk of infection and makes the decision to test to provide information and an opportunity to answer questions.

If the parents do not wish to meet with the community Paediatrician, Dr Poynor, the social worker can provide the information to the parents after full briefing from the Community Paediatrician.

The following should be discussed:-

  • The purpose of the test;
  • Details of the tests and uncertainties about the ability of the tests to diagnose infection;
  • Likely benefits from testing;
  • Likely disadvantages from testing;
  • Options for treatment in the event of any positive test;
  • Immunisation against Hepatitis B.

Additional advice and information about the infections can be obtained from the Specialist Nurse Communicable Diseases (Jane Gill, Pikes Lane Health Centre).

For clinical features of HIV and Hepatitis infections please refer toAppendix 1: About HIV And Hepatitis.


8. Consent

The legal position concerning consent and refusal of treatment by those under the age of 18 is different from the position of adults, in particular where treatment is being refused.

Please refer to 'Consent - Children and Young People' in Appendix 2: Consent - Children and Young People.

The use of consent forms is good practice and should always be obtained by the parent/carer wherever possible.

If a child is Looked After and consent is not achievable by the parent, the consent form should be signed by a Head of Service.


9. Tests Results

Test results should be in the first instance sent to the referring medical practitioner (Community Paediatrician, GP, etc).

Persons holding Parental Responsibility should also be informed of the results of the test.

If a competent young person does not wish their parents to know the results, their wishes should be respected.

In the event of any positive test, there may be health implications for the child, child's mother and possibly other family members.

The medical practitioner should communicate these results so that any advice about testing or treating family members can be given.

If the parent is unable to attend a meeting with the medical practitioner, a decision should be made as to who is the most appropriate person to communicate the test results, for example GP or social worker.

Further dissemination of the results to other parties should be considered on a need to know basis.


Appendix 1: About HIV And Hepatitis

HEPATITIS B

Hepatitis B is a viral infection of the liver. In infected persons it is present in blood and body fluids (semen, saliva, urine, faeces). In the UK studies have shown that 0.1% - 0.6% of the population carry the virus. In parts of Africa and South East Asia up to 20% of the population are carriers of the virus.

Mode of Infection with Hepatitis B

The virus is spread in the following ways:-

  • Intimate personal or sexual contact with an infected individual;
  • Transfer of infected blood or other body fluids into the bloodstream (e.g. needle sharing, needle stick injuries, human bites from an infected person);
  • Extensive or prolonged contact with blood or body fluids from an infected person on bare skin (e.g. broken skin, eyes and mouth);
  • Vertical transmission of the virus from infected mothers to their newborn child around the time of delivery.

Clinical Features of Hepatitis B Infection

After the Hepatitis B virus enters the body, there is an incubation period of between one and six months before the infected person shows signs of the illness. In many instances, the disease is asymptomatic. Only 5% of infections in infancy show symptoms. The first symptoms of infection are - nausea, loss of appetite, tiredness, and abdominal pain. About 5 - 10 days later, these symptoms are followed by jaundice, which usually lasts about two weeks, but may persist for months. Rarely, the liver disease may progress to liver failure during the acute phase.

Treatment

If there is a good reason to suspect that there may have been recent exposure to Hepatitis B virus, treatment with hyerimmune gammaglobin, which contains antibodies to Hepatitis B infection should be given. If Hepatitis B infection is confirmed, treatment is now available with a drug called Interferon. This can benefit 30-40% of children who are infected.

Recovery from Hepatitis B infection and the Carrier State

90% of adults who are infected make a full recovery and do not go on to become carriers of the infection. 10% of infected adults, although completely recovered from their clinical symptoms, remain infectious carriers for months or years.

The majority of children (80%) who have acquired the infection from their mothers around the time of birth, will go on to become carriers of infection. However, less than 20% of children infected between the ages of two to three years become carriers. Carriers of Hepatitis B infection are at risk of infecting others and developing long-term liver disease themselves (e.g. cirrhosis, liver cancer).

OTHER FORMS OF HEPATITIS

Hepatitis A

Hepatitis A is a viral infection of the liver. It is spread by contact with food and water contaminated by infected faeces. It may also be spread from person to person. The incubation period varies from 15 - 40 days (considerably shorter than Hepatitis B). The clinical symptoms are similar to Hepatitis B, but there are few long-term complications and the carrier state does not occur.

Hepatitis C

Hepatitis C is a viral infection of the liver. High risk areas for Hepatitis C infection include North America, Southern Europe, Egypt and Japan. Infection rates of between 60 - 90 % of drug users have been found.

Mode of Infection with Hepatitis C

The Hepatitis C virus is present in blood and body fluids of an infected person. The virus is spread in the same ways as Hepatitis B infection and HIV infection.

Vertical transmission of the virus from infected mothers to their newborn child around the time of delivery is relatively uncommon. Less than 5% of babies become infected. If a mother is also infected with HIV infection, the risk of infection in the baby is greatly increased.

Clinical Features of Hepatitis C

Hepatitis C infection can lead to an acute illness similar to Hepatitis A and Hepatitis B infection after an incubation period of between 2 weeks and 6 months. The symptoms are often milder. A significant number of infected individuals do not have symptoms of the disease.

Treatment of Hepatitis C

The liver function of Hepatitis C carriers should be monitored. Treatment with Interferon and Ribavarin is available. Not all patients are suitable for this treatment (specific guidelines available).

Recovery and Carrier State

Recovery from the acute disease occurs without complications. Between 60% and 70% of infected individuals do not clear the virus and become carriers of the Hepatitis C virus. The majority of carriers continue to have mild liver disease. About half of this group will have progressive liver disease leading to cirrhosis within the next 30 years. Between 1 - 5% of carriers will develop liver cancer.

Immunisation

At present, no immunisation is available against the Hepatitis C virus.

HIV INFECTION

The human immunodeficiency virus (HIV) infects the immune system and damages the body's ability to resist infection. HIV can progress to AIDS (Acquired Immune Deficiency Syndrome). No immunisation is available.

Mode of Infection

HIV is less infectious than Hepatitis B and C but is spread in the same way. The use of antiviral treatment, caesarean section and the discouragement of breastfeeding in known HIV positive mothers, can reduce vertical transmission from 20 - 25% to 5%.

Clinical Features of HIV Infection

After the HIV virus enters the body, there follows an incubation period of 2 - 6 weeks. The virus then spreads around the body and the individual may experience glandular

fever like symptoms, such as fever, rash and gland enlargement. Many individuals do not have symptoms during this viraemic phase. It may then be many years before the infected individual experiences any problem with their immunity. All HIV positive individuals have the potential to infect others.

Treatment

There is no specific cure for HIV infection. Antiviral therapy can control the disease and prolong life.


Appendix 2: Consent - Children and Young People

1. The legal position concerning consent and refusal of treatment by those under the age of 18 is different from the position for adults, in particular where treatment is being refused. In the following paragraphs the terms 'child' and 'young person' are used interchangeably;
YOUNG PEOPLE AGED 16 - 17
2. By virtue of section 8 of the Family Law Reform Act 1969, people aged 16 or 17 are entitled to consent to their own medical treatment, and any ancillary procedures involved in that treatment, such as an anaesthetic. As for adults, consent will be valid only if it is given voluntarily by an appropriately informed patient capable of consenting to the particular intervention. However, unlike adults, the refusal of a competent person aged 16 - 17 may in certain circumstances be over-ridden by either a person with Parental Responsibility or a court (see below paragraphs 8-8.5);
2.1 Section 8 of the Family Law Reform Act applies only to the young person's own treatment. It does not apply to an intervention which is not potentially of direct health benefit to the young person, such as blood donation or non-therapeutic research on the causes of a disorder. However, a young person may be able to consent to such an intervention under the standard of Gillick competence, considered below;
3. In order to establish whether a young person aged 16 or 17 has the requisite capacity to consent to the proposed intervention, the same criteria as for adults should be used (see paragraph 2 of chapter 1);
4. If the requirements for valid consent are met, it is not legally necessary to obtain consent from a person with Parental Responsibility for the young person in addition to that of the young person. It is, however, good practice to involve the young person's family in the decision making process, unless the young person specifically wishes to exclude them.
CHILDREN UNDER 16 - THE CONCEPT OF 'GILLICK COMPETENCE'
5.

Following the case of Gillick, the courts have held that children who have sufficient understanding and intelligence to enable them to understand fully what is involved in a proposed intervention will also have the capacity to consent to that intervention. This is sometimes described as being 'Gillick competent' and may apply to consent for treatment, research or tissue donation.

As the understanding required for different interventions will very considerably, a child under 16 may therefore have the capacity to consent to some interventions but not others. As with adults, assumptions that a child with a learning disability may not be able to understand the issues should never be made automatically ( see chapter 1, paragraph 2.6).

5.1 The concept of Gillick competence is said to reflect the child's increasing development to maturity. In some cases, for example because of a mental disorder, a child's mental state may fluctuate significantly so that on some occasions the child appears Gillick competent in respect of a particular decision and on other occasions does not. In cases such as these, careful consideration should be given to whether the child is truly Gillick competent at any time to take this decision.
6. If the child is Gillick competent and is able to give voluntary consent after receiving appropriate information, that consent will be valid and additional consent by a person with parental responsibility will not be required. However, where the decision will have on-going implications, such as long term use of contraception, it is good practice to encourage the child to inform his or her parents unless it would clearly not be in the child's best interests to do so.

THE REQUIREMENT OF VOLUNTARINESS

7. Although a child or young person may have the capacity to give consent, valid consent must be given voluntarily. This requirement must be considered carefully. Children and young people may be subject to undue influence by their parents, other carers, or a potential sexual partner, and it is important to establish that the decision is that of the individual him or herself.

CHILD OR YOUNG PERSON WITH CAPACITY REFUSING TREATMENT

8. Where a young person of 16 or 17 who could consent to treatment in accordance with section 8 of the Family Law Reform Act, or a child under 16 but Gillick competent, refuses treatment, such a refusal can be over-ruled either by a person with Parental Responsibility for the child or by the court. If more than one person has Parental Responsibility for the young person, consent by any one such person is sufficient, irrespective of the refusal of any other individual.
8.1 This power to over-rule must be exercised on the basis that the welfare of the child/young person is paramount. As with the concept of best interests, 'welfare' does not just mean physical health. The psychological effect of having the decision over-ruled must also be considered. While no definitive guidance has been given as to when it is appropriate to over-rule a competent young person's refusal, it has been suggested that it should be restricted to occasions where the child is at risk of suffering 'grave and irreversible mental or physical harm'.
8.2 The outcome of such decisions may have a serious impact on the individual concerned. Examples might include a young person with capacity refusing an abortion or further chemotherapy for cancer in the knowledge of poor prognosis. When a person with Parental Responsibility wishes to over-rule such decisions, consideration should be given to applying to the court for a ruling prior to undertaking the intervention. Such applications can be made at short notice if necessary.
8.3 For parents to be in a position to over-rule a competent child's refusal, they must inevitably be provided with sufficient information about their child's condition, which the child may not be willing for them to receive. While this will constitute a breach of confidence on the part of the clinician treating the child, this may be justifiable where it is in the child's best interests. Such a justification may only apply where the child is at serious risk as a result of their refusal of treatment.
8.4 Refusal by a competent child and all persons with responsibility for the child can be over-ruled by the court if the welfare of the child so requires.
8.5 A life-threatening emergency may arise when consultation with either a person with Parental Responsibility or the court is impossible, or the persons with Parental Responsibility refuse consent despite such emergency treatment appearing to be in the best interests of the child. In such cases, the courts have stated that doubt should be resolved in favour of the preservation of life and it will be acceptable to undertake treatment to preserve life or prevent damage to health.

CHILD OR YOUNG PERSON WITHOUT CAPACITY

9. Where a child lacks capacity to consent, consent can be given on their behalf by any one person with Parental Responsibility or by the court. As is the case where patients are giving consent for themselves, those giving consent on behalf of child patients must have the capacity to consent to the intervention in question, by acting voluntarily, and be appropriately informed. The power to consent must be exercised according to the 'welfare principle': that the child's 'welfare' or 'best interests' must be paramount. Even where a child lacks capacity to consent on their own behalf, it is good practice to involve the child as much as possible in the decision-making process.
9.1 Where necessary, the courts can, as with competent children, over-rule a refusal by a person with Parental Responsibility. It is recommended that certain important decisions, such as sterilisation for contraceptive purposes, should be referred to the courts for guidance, even if those with Parental Responsibility consent to the operation going ahead.
10.

The Children Act 1989 sets out persons who may have Parental Responsibility. These include:-

  • The child's parents if married to each other at the time of conception of birth;
  • The child's mother, but not father if they were not so married unless the father has acquired Parental Responsibility via a court order or a Parental Responsibility agreement or the couple subsequently marry;
  • The child's legally appointed guardian;
  • A person in whose favour the court has made a Residence Order / Child Arrangement Order concerning the child;
  • A Local Authority designated in a Care Order in respect of the child;
  • A Local Authority or other authorised person who holds an Emergency Protection Order in respect of the child.

Section 2 (9) of the Children Act 1989 states that a person who has Parental Responsibility for a child 'may arrange for some or all of it to be met by one or more persons acting on his behalf'. Such a person might choose to do this, for example, if a childminder or the staff of a boarding school have regular care of their child. As only a person exercising Parental Responsibility can give valid consent, in the event of any doubt specific enquiry should be made. Foster parents do not automatically have Parental Responsibility.

11. Consent given by one person with Parental Responsibility is valid, even if another person with Parental Responsibility withholds consent. However, the courts have stated that a 'small group of important decisions' should not be taken by one person with Parental Responsibility against the wishes of another, citing in particular non-therapeutic male circumcision. Where persons with Parental Responsibility disagree as to whether non-therapeutic procedures are in the child's best interest, it is advisable to refer the decision to the courts. It is possible that major experimental treatment, where opinion is divided as to the benefits it may bring the child, might also fall into this category of important decisions, although such a case has not yet been considered in the English courts.
12. In order to consent on behalf of a child, the person with Parental Responsibility must themselves have capacity. Where the mother of a child is herself under 16, she will only be able to give valid consent for her child's treatment if she herself is Gillick competent (see paragraphs 5-6 above). Whether or not she has capacity may vary, depending on the seriousness of the decision to be taken.
13.

Where a child is a ward of court, no important step may be taken in the life of the ward without the prior consent of the court. This is likely to include more significant medical interventions but not treatment for minor injuries or common diseases of childhood.

14. In an emergency, it is justifiable to treat a child who lacks capacity without the consent of a person with Parental Responsibility, if it is impossible to obtain consent in time and if the treatment is vital to the survival or health of the child. The Department of Health Reference guide to consent for examination or treatment, second edition 2009 includes coverage of situations where parents refuse consent to examination, and abuse or Neglect is suspected.

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