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Home Topics Emergency Response Explosions and fires Health effects of Explosions Post exposure prophylaxis against hepatitis B for bomb victims and immediate care providers. Consideration of other blood borne viruses (hepatitis C and HIV)

Post exposure prophylaxis against hepatitis B for bomb victims and immediate care providers. Consideration of other blood borne viruses (hepatitis C and HIV)

Risk Assessment by Expert Group Convened by the Health Protection Agency 8 July 2005

The background prevalence of infectious hepatitis B infection in the UK population is generally low, but higher in London where there are people from many different areas of birth, some of which are endemic areas. Hepatitis B can be transmitted by blood contact via a wound or, more rarely, via skin abrasions or through mucous membranes. We therefore propose a precautionary policy in relation to possible exposure to hepatitis B infected blood following the bomb blasts in London on 7 July 2005.

Categories of individuals

  1. Directly injured in explosion with major penetrating injuries leading to non-intact skin and admitted to hospital
  2. Directly injured in explosion with penetrating injuries leading to non-intact skin and discharged after receiving treatment at A&E
  3. Directly injured in explosion with penetrating injuries leading to non-intact skin and did not attend A&E
  4. Indirectly injured (leading to non-intact skin) as a result of providing assistance to victims of the explosion (for example cut from fragments of glass or metal on bodies of victims)
  5. Superficial exposure of skin or mucous membranes to blood of victims

Concerning Hepatitis B for categories 1 to 3 the risk of exposure was considered sufficient to justify evaluation and immunisation as described below because of the probable magnitude of the blood exposure through their injuries. Although overall the risk is low, it is likely that it will be related to the extent of injury, so that most priority should be given to ensuring post exposure prophylaxis to those in category 1. The risk of exposure in category 2 is likely to be lower, and lower still in category 3. All of these exposures come into the category of an "unknown source".

For categories 4 to 5 the risks are presumed to be similar to other significant exposures in the community to blood of unknown infectivity.

This guidance follows advice in Immunisation Against Infectious Disease 1996 Chapter 18 (Table HBV Prophylaxis for reported exposure incidents - page 106) [external link]

Recommended post exposure management for risk categories 1 to 4

Individual assessment of risk and then if considered appropriate

  1. Accelerated course of hepatitis B vaccination i.e. 0, 1, 2, and 12 months
  2. Blood specimen at 0 to be stored, and at 3 and 6 months to be tested for hepatitis B and hepatitis C

(first dose should be offered as soon as possible, ideally within 7 days, but people should continue to be called for up to 14 days after exposure)

Feasibility

Category 1

Post exposure management as above is feasible for in-patients and
recommended as routine for Category 1 with the expectation that most patients will receive vaccination.

Category 2

Where there are adequate A & E records the patient's GP should be contacted and advised to offer post exposure management as above. Information about GPs has not been retained in a number of casualties. In this case the recommended standard of care is that where individuals contact their GP or other medical care provider or helpline (eg NHS Direct), and that they should be offered post exposure management as above.

Categories 3 and 4

As for category 2.

Recommended post exposure management for risk category 5

As for the other categories persons are recommended to be assessed by a health care professional. If following an assessment it is judged that blood was in contact with non-intact skin or splashes to the eyes or mouth, then post-exposure prophylaxis is recommended as for 1 to 4.

Practical implementation by category of risk

Category 1

Hospital trusts receiving bomb-blast victims should ensure post-exposure management for in-patients.

Category 2

Where records are kept of GPs by hospital trusts receiving bomb-blast victims a list of all victims who attended A&E should be drawn up and attempts made to contact them if possible via their GP.

Categories 2, 3 and 4

Our assessment is that it is not possible to systematically contact all people with these categories of risk, but where they present to services (emergency or health care) they should be offered post exposure management. NHS Direct and GPs should be informed of this policy to be able to respond in the event of victims contacting them directly. Where public messages and statements are made about the health outcomes for victims, reference should be made to the need to contact GPs for advice on a number of health matters including post traumatic stress, hearing loss as well as BBV risk. This to be distributed locally by HPU to care givers and NHS Direct alerted.

Category 5

People in this category who contact health care providers should have appropriate risk assessment and post exposure management only if blood exposure to non-intact skin or mucous membranes occurred.

The above assessment and testing will also cover risk of hepatitis C. The group considered the risk of HIV to be so low as not to require action though patients may require counselling and if indicated testing at the discretion of their medical carers.

Finally the group observed that while standing guidance in Immunisation Against Infectious Disease covered this eventuality, practical policy for implementing this guidance after explosions or other trauma did not seem to exist in the UK. The group strongly recommended that such guidance should be developed as a matter of urgency.