Transcript Report squats

INFECTIOUS DISEASES
March 2016
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To identify of signs and symptoms of infectious diseases
through screening and assessment
To understand the rationale for regular screening for
infectious diseases
To describe appropriate care plans which include prevention
and treatment for both substance misuse and infection
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Substance misuse is associated with infectious diseases
Levels of infection in injecting substance misusers is high ie ~
50%
Life style and mode of use of substances are the main ‘causes’
Substances can predispose to infection by lowering immunity
or specific local effects
Infectious disease risk is related to the mode of use rather
than specific substances
Assessment of drug users for risk behaviour and infectious
diseases
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Hepatitis B and C are major causes of liver disease and liver
cancer
20-25% of people with chronic hepatitis B have progressive
liver disease which leads to cirrhosis in some cases
Over 90% people with hepatitis C have a history of injecting
15-20% people with hepatitis C will develop liver cirrhosis
after 20 years and 5% of those will develop liver cancer
Hepatitis C is the commonest indication for transplantation
214000 are chronically infected with hepatitis C
2.2% of all people being seen for care in the UK have HIV
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Individuals put themselves at risk due to chaotic lifestyle and
effect of substances
Drug users who are having sex without protection and sharing
injecting equipment or paraphenalia are at risk of contracting
BBV (blood borne viruses eg hepatitis B and C, and HIV)
Patients who misuse substances are likely to be susceptible to
tuberculosis (TB)
Drinking alcohol – especially binge drinking – and ‘club drugs’
alter judgement and impair decisions about sex and other
drug use, leading to unprotected sex and sharing of injecting
equipment
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Substance misusers may view BBV as ‘occupational’ hazards
of drug use
Drug users may not recognise or differentiate the symptoms
of BBV from intoxication, withdrawal or poor self care
Drug users may think the symptoms derive from impurities in
street drugs
Patients may present late to services and be less compliant
with the medication prescribed
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Infections may be viral, acute bacterial and sexually
transmitted
History taking should elicit information about behaviours that
may have put the patient at risk
Injecting, unprotected sex and receiving a blood transfusion
in other countries
Information about those with whom the patients has had
intimate or prolonged contact
Contact tracing may need to take place
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Common where water supplies and sewage disposal are poor
Personal and food hygiene are poor
Living in poor conditions, in crowded accommodation where
this is no running water or adequate sewage eg hostels,
squats
Blood to blood spread through needle sharing
Transmission is by fecal and oral routes
Symptoms may last for a week or more and include: flu type
symptoms, nausea, stomach ache and diarrhoea, jaundice
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Hepatitis B causes liver inflammation and fibrosis
Untreated can lead to cirrhosis and liver failure or
hepatocellular cancer
2% cause chronic hepatitis
Information about initiation of injecting, sharing of injecting
equipment, frequency of sharing, number and type of
contacts who may have been injecting
Hepatitis B is notifiable to Public health England
Transmission is by injecting, sexual contact and mother to
baby
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A mild flu like fever
Tiredness
Aching limbs or joints
Loss of appetite
Feeling sick or vomiting
Reluctance to drink alcohol or smoke
Jaundice, itchy skin and dark urine
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Many individuals with hepatitis C are abusing alcohol
50% lead to cirrhosis, chronic hepatitis and hepatocellular cancer
Transmission is via injecting, sexual contact, mother to child at
birth
In 40% cases infected individuals cannot identify a source for their
infection
Cocaine can damage the inside of the noe leading to bleeding
Inhalation of contaminated blood may lead to infection
Sharing items eg toothbrushes, razors, scissors and blood
products may spread infection
No vaccine is available
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Flu like symptoms
Mild to severe fatigue
Anxiety
Weight loss
Loss if appetite
Inability to tolerate alcohol
Discomfort over liver area
Problems with concentration
Nausea
Jaundice
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Antibody test – proteins made by the body to respond to the
virus
Polymerase chain reaction (PCR) or viral RNA tests – identify
the presence of the virus
Liver function test to identify the impact on the liver
Liver biopsy to assess severity of damage from chronic
hepatitis C
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Flu like illness a few weeks after infection with HIV – 80% cases
Symptoms indicate that the body is responding to the infection
Symptoms are non-specific
History should try to establish risks associated with unprotected
sex, sex with bisexual men, sharing injecting equipment or
paraphernalia
Transmission is via injecting, sexual contact, blood including
menstrual blood, mother to baby before during or after birth
during breast feeding
HIV cannot be transmitted through saliva, sweat, tears, feces and
urine
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Fever
Sore throat
Body rash
Tiredness
Joint pain
Muscle pain
Swollen glands
Tests on blood are very reliable and provide a result from 4
weeks after possible infection
Treatment is very successful with anti retroviral treatment
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Transmission is via injection
Staphylococcus and streptococcus are the agents
Endocarditis – fever, heart murmur, peripheral stigmata
Necrotising fasciitis – pain out of proportion with clinical
findings
Botulism: scratchy throat, cranial nerve palsies and paralysis
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Risk factors include:
Smoking cigarettes, other serious illnesses (hear disease, liver
cirrhosis), immune system problems (cancer treatment,
HIV/AIDS, organ transplant)
Symptoms: Fever
Cough with yellow, green or blood tinged mucous
Chest pain the worsens when coughing or breathing
Sudden onset of chills
Headache and muscle pains
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Food, saliva, liquids or vomit is breathed into the lungs or
airways after alcohol consumption or overdose
Symptoms include: bluish skin discolouration
Chest pain
Coughing up foul smelling sputum
Fatigue
Fever
Shortness of breath
Wheezing
Excessive sweting
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Listen for abnormal chest sounds
Take blood sample to get a white cell count. A high count
usually indicates infection
Take blood or mucous samples to identify infection causing
pathogen
Order chest x rays to confirm the presence and extent of
infection
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Early detection makes it easier to treat with antibiotic
combination therapy for 6 months: drug users might find
compliance a problem
Signs and symptoms include: persistent fever
Heavy sweating at night
Loss of appetite
Unexplained weight loss
General and unusual sense of tiredness
Haemoptysis
Recent contact with someone who has TB
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Frequently asymptomatic
Need regular screening for detection
All associated with morbidity if left untreated
Syphylis
Chlamydia
Gonorrhoea
HPV – human papilloma virus
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Vaccine is available
Consider single dose or combined vaccine – depends on
whether the patient is likely to return for a subsequent dose
One dose of single vaccine confers greater protection against
Hep A than one dose of the combined Hep A Hep B vaccine
Vaccinate all injecting drug users against Hep A
Single component preferable to combined Hep A and Hep B
vaccine
For single vaccine give 2 doses with second dose after 6-12
months
Second dose may be delayed for up to 3 years
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Most people with acute hepatitis recover without treatment
within 4-12 weeks
2% cause chronic hepatitis which can lead to cirrhosis and
hepatocellular cancer
Can be treated with antiretroviral drugs
A vaccine is available
Vaccinate all drug users against Hepatitis B – non-injectors
may become injectors
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No need to carry out pre vaccination testing
Use accelerated 0, 7 and 21 day schedule to aim to complete
the course quickly.
Incomplete vaccination offers some protection but completing
the course is recommended
Offer vaccination to partners and children
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Treatment can eradicate infection in 40-80% of infected individuals
Antiviral treatment consists of self administered weekly
subcutaneous injections of pegylated interferon and twice daily
oral ribavirin for 24-48 weeks
No vaccine is available
Substance misusers will need to persevere as treatment is intensive
They need to be detoxified or stable on substitute medication and
abstinent from other drugs
Injecting the antiviral medication may lead to relapse to (injecting)
drug use
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If patients continue to drink while taking medication there is a
high risk of liver damage
Regular blood tests required to check on liver function
Patients with HIV or hepatitis will need regular liver function tests
Antiretroviral medication taken together with TB treatment may
have side effects and interactions requiring careful monitoring
Treatment can last for 6-12 months so some patients may drop
out and need assertive outreach approaches to re-engage
A vaccine is available
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HIV: Antiretroviral treatment is successful; no vaccine is
available
Acute bacterial infections: Staphylococcus and streptococcus
can be treated with identification of source and antibiotics
Sexually transmitted infections all associated with long term
morbidity if left untreated
Chlamydia and gonorrhoea: antibiotics but some strains are
resistant
Syphylis: penicillin is preferred treatment; early treatment is
crucial
Genital herpes: antiviral medication; no cure; can flare up
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Specialist advice should be sought from e.g. sexually
transmitted disease clinic (STD), specialist chest clinic
The GP and services should liaise regularly to ensure
screening and effective treatment
Specialists working in primary care, chest clinics and STD
services should contact specialist addiction services to
arrange access and management of substance problems
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If patients are reluctant to stop or reduce their drug use,
preventative measures should be discussed and implemented
to contain infection risks and spread
Advice on safer injecting, use of sterile equipment , and risks
of diseases should be given
If patients continue to inject, clean needles and syringes
should be obtained
Prevention of BBV has many benefits including reducing
health harms by those who use substances
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Needle and syringe programmes
Comprehensive protocols to raise awareness of risks of BBV:
promotion of testing, deliver vaccination and access pathways into
treatment
Provision of advice and materials to reduce harm from injecting
drug use
Offers of testing and vaccination to all those at risk
Prevention of uptake of injecting drug use and promote switching
from injecting to other routes
Implementation of workforce and occupational health interventions
for people working with those at risk of contracting BBV
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Findings (2014) Drug Matrix cell D1: Organisational functioning; Reducing harm
http://findings.org.uk/count/downloads/download.php?file=Matrix%2FDrugs%2FD1.htm
Health Protection Agency (2015) Hepatitis C in the UK.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448710/NEW_FINAL_HCV_2015_IN_THE_UK_RE
PORT_28072015_v2.pdf
Health Protection Agency (2014) Shooting Up Infections among injecting drug users in the UK 2013. An update: November 2014
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/370707/Shooting_Up_2014.pdf
Health Protection Agency (2013) Substance misuse and TB: Information for key workers (care workers, social workers, project
workers and health professionals)
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/466947/NKS_Substance_misuse_and_TB_Infor
mation_for_key_workers_.pdf
Jones D. R. et al, (2004) Prevalence, severity, and co-occurrence of chronic physical health problems of persons with serious
mental illness. Psychiatric Services, 55 pp1250-1257
National Knowledge Service - TB:
http://www.neli.org.uk/IntegratedCRD.nsf/e67b3914fbe8da658025755c0062cd62/45aa03ceba2bc98080257145003ace45?Ope
nDocument&Highlight=0,TB
NICE (2004) Hepatitis C - pegylated interferons, ribavirin and alfa interferon (NICE technology appraisal,TA75)
http://guidance.nice.org.uk/TA75 This guidance replaces Hepatitis C - alpha interferon and ribavirin (TA14). This guidance is
extended by Hepatitis C - peginterferon alfa and ribavirin (TA106). http://guidance.nice.org.uk/TA75
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NICE (2014) Needle and syringe programmes: NICE public health guidance 52 guidance. http://www.nice.org.uk/guidance/ph52
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NICE (2006) Hepatitis B (chronic) - adefovir dipivoxil and pegylated interferon alpha-2a (NICE technology appraisal,TA96)
http://guidance.nice.org.uk/TA96
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NICE (2010) Hepatitis C - peginterferon alfa and ribavirin (NICE technology appraisal,TA200) http://guidance.nice.org.uk/TA200
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Public Health England (2015) Hepatitis C in the UK: 2015 report.
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/448710/NEW_FINAL_HCV_2015_IN_THE_UK_REPORT_28072015_v2.pd
f
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Public Health England: https://www.gov.uk/topic/health-protection/infectious-diseases
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Raoult D., Foucalt, C., Brouqui P.(2001) Infections in the homeless. The Lancet Infectious Diseases Vol 1(2) September pp77-84
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Tetrault, J M, Fiellin, D A, and Sullivan L E (2010) Substance Abuse and HIV: Treatment Challenges Substance Abuse and HIV: Treatment. The AIDS
Reader. August 13, pp1-8
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Wiessing, L., Ferri, M., Grady, B., Kantzanou, M., Sperle, I., Cullen, K., Hatzakis, A., Prins, M., Vickerman, P., Lazarus, J.V., Hope, V., Matheï, C. (2014)
‘Hepatitis C virus infection epidemiology among people who inject drugs in Europe – A systematic review of data for scaling up treatment and
prevention’, PLoS ONE 9(7): e103345. doi:10.1371/journal.pone.0103345
World Hepatitis Alliance http://www.worldhepatitisalliance.org/