Prison Service Order

ORDER

NUMBER
3845
/ Blood Borne and Related Communicable Diseases
Date of Issue
/ Amendment / 30/04/1999
Issue No / 34
PSI Amendments should be read in conjunction with PSO
01/06/1999 / PSI 12/1999 – Communicable Diseases

Table of Contents

ForewordPage 1

Chapter One: Medical Background

HIV and AIDSPage 2

Pulmonary tuberculosisPage 6

Hepatitis B and CPage 9

Prophylactic treatmentPage 12

Chapter Two:The management of risk situations

Procedures to minimise riskPage 14

Searching ProceduresPage 14

Precautions to be used during a violent incidentPage 15

Dealing with needles and syringesPage 17

Guidelines for clearing up blood/fluid spillagesPage 19

ResuscitationPage 21

Testing for HIV antibodiesPage 21

Management of outbreaksPage 23

Chapter Three:Employment and job protection policies

Discrimination and Equal OpportunitiesPage 25

Responsibilities of Prison Service as employerPage 26

Procedures for dealing with impact of ill-healthPage 27

Responsibilities of the EmployeePage 28

Responsibilities of the Health Care WorkerPage 28

Responsibilities of the infected employeePage 29

Responsibilities of GP or Occup. Health PhysicianPage 30

ConfidentialityPage 28

Where to get further advicePage 31

PublicationsPage 32

FOREWORD

The upsurge in hepatitis B in the ‘70s followed at the end of the decade by the emergence of HIV and AIDS sharply focused on the dangers of blood borne viral infections. In 1989, the identification of hepatitis C virus revealed yet another serious infection that is transmitted by the same route. The spread of HIV and hepatitis is a matter of concern for the whole community, but the ease with which they are transmitted by needle sharing, and in the case of HIV and hepatitis B by unprotected sex, has made them of particular importance in the prison environment.

The Prison Service has given a great deal of thought to the ways in which the spread of blood borne infections between inmates can best be prevented and of ensuring that staff are protected as effectively as possible. Information and advice regarding HIV/AIDS and hepatitis B has been issued at intervals and from time to time earlier advice has been revised as strategy has changed in the light of increased knowledge.

The ‘Review of HIV and AIDS in Prison’ (1995) by the AIDS Advisory Committee recommended that there should be a clearly articulated HIV/AIDS policy for staff. This Prison Service Order gathers together in one place all current policies and recommendations regarding HIV/AIDS, hepatitis B and hepatitis C, and shows in clear and comprehensive terms how they apply to staff.

The first chapter of the Order is concerned with the medical background. It provides information on the different ways in which the blood borne viral infections are spread and identifies the rare circumstances in which staff could be infected as a result of contact with inmates. There is a brief mention also of pulmonary tuberculosis because this condition spreads easily among people who are infected with HIV.

The second chapter of the Order offers advice on the management of risk situations, how to keep the risk of infection to the minimum, and what procedures to follow in dealing with risk situations.

The third chapter of the Order details the personnel policies in force within the Prison Service regarding the employment of people and job protection for staff who may be carrying a potentially infectious condition such as HIV and hepatitis B or C, whether it was acquired in the course of their duties or in their private lives. The responsibilities of management, staff and medical professionals are addressed.

Prison Service Trade Unions have been fully consulted on the content of this Order

It is important that staff maintain a sense of perspective on the risks they run as result of their work. The chances of acquiring any serious infection are extremely small and adherence torecommended procedures will make them even smaller. It is however, in everybody’s interest - not only staff and inmates but also their families, relatives and friends - that everything possible should be done to prevent the spread of HIV, pulmonary tuberculosis and blood borne hepatitis within the prisons and young offender institutions of England and Wales.

Chapter 1 - Medical Background

HIV / AIDS

1.Key Points

  • HIV stands for Human Immunodeficiency Virus. Over a period of years, it causes a gradual destruction of the immune system. It is the virus that can cause AIDS.
  • AIDS stands for Acquired Immune Deficiency Syndrome. This describes the state in which people have repeated infections, and sometimes tumours, as a result of destruction of the immune system by HIV.
  • The HIV antibody test detects the antibodies to the virus which first appear in the blood some weeks after infection. The test is the only way of knowing if someone is infected.
  • HIV is spread in three ways:
  1. Blood spread. In the United Kingdom this is now almost entirely limited to injecting drug abusers sharing unclean works;
  2. Unprotected sexual intercourse. This may be vaginal, anal and possibly oral;
  3. From infected mother to baby. This may occur in the womb, during the birth process or through breast milk. The risk is about 1 in 6, but falling.
  • Spread among inmates can occur from unprotected sex or the sharing of unclean works by injecting drug abusers.
  • Spread from inmates to staff will not occur in any ordinary circumstances. There is a risk of infection from being stuck with a contaminated needle, but even if this occurs the chances of infection are very low. There is also a theoretical risk from blood getting into a wound during a fight, but infection by this route is extremely rare.
  • No vaccine is available which will protect against HIV and there is not likely to be one for many years.

Prisons in England and Wales have now been receiving inmates with HIV for more than ten years and over the whole of that time, no member of staff has been infected in the course of duty. There has been one documented case of a prisoner acquiring the virus while in custody.

2.The basic facts about HIV and AIDS

2.1HIV stands for Human Immunodeficiency Virus. If this virus gets into someone’s body, it infects a particular type of cell, called the CD4 cell, which is essential to the normal functioning of the immune system. When the virus has reduced the population of CD4 cells to about a third or less of their original number, which usually takes many years, the immune system is no longer able to fend off certain diseases. The HIV infected person then begins to get ill with a variety of infections, and sometimes tumours, most of which are rarely, if ever, seen in people with normal immune systems. They are then said to have the Acquired Immune Deficiency Syndrome or AIDS.

2.2Some people who catch HIV develop a mild illness a few weeks after infection consisting of fever, perhaps a few enlarged lymph nodes and a rash. This gets better without treatment and is followed by a long period during which the infected person looks and feels perfectly normal. All infected people produce antibodies to the virus, almost always within three months. It is the presence of these antibodies in the blood that is looked for when the HIV antibody test is done (see below).

2.3The length of time before the first serious illness that calls for a diagnosis of AIDS varies greatly. A small number of people fall ill as little as two years after infection, and after ten years about half of an HIV infected population will have progressed to AIDS. It is thought likely that most of those who remain well at ten years will eventually fall ill, but perhaps a few will hold the virus in check indefinitely. From the time AIDS is diagnosed, people used to live on average about 20 - 30 months, but recent improvements in the treatment available have extended this period. Quality of life for people with HIV is variable but with appropriate treatment and management it can be good.

3.The HIV antibody test

3.1The test is carried out on an ordinary blood sample and it shows whether or not the blood contains antibodies to the human immunodeficiency virus, HIV. If antibodies are present, it means that the virus is in the person’s body. When antibodies are found, we say that the person is ‘HIV antibody positive’, sometimes shortened to ‘HIV positive’ or ‘body positive’. It is important to note that the test does not detect the virus itself and it is not a test for AIDS.

3.2The HIV antibody test is the only generally available way of checking if someone is infected with the virus and is, in consequence, infectious to others. Most people who test positive will be looking and feeling completely normal. There is, however, one difficulty: antibodies are not produced for some time after infection; it sometimes takes as long as three months, and just occasionally even longer. During the time between infection and the appearance of antibodies, known as the ‘window period’, the test is negative, but the person is highly infectious.

3.3No-one who has run the risk of infection can be sure they are clear until they have had a negative test at least three months after the last occasion on which they could have contracted the virus. This has an important implication for staff. If anyone suffers a needle stick and there is a possibility that the needle was contaminated with HIV, it is going to be three months before they know whether or not they have been infected. During that time, even though the risk of having caught the virus may be very small, they will have to behave as if they were infected and protect their partner by practising safer sex even if they are in a stable relationship.

3.4Any member of staff who might be concerned about their own health should be aware that HIV testing is available through genito-urinary medicine (GUM) clinics where all proceedings are strictly confidential. GUM clinics are bound by law not to disclose information even to the patient’s general practitioner, without the express consent of the patient. General practitioners have to observe a professional standard of confidentiality, but they would be bound to disclose such information if, for example, the patient requested them to send a report for insurance purposes.

3.5HIV antibody testing is available in confidence, by consultation with the Medical Officer, to any inmate who is concerned that he or she might be infected; the arrangements will vary between establishments and must be checked out locally. It is a national requirement that everyone being tested for HIV should be counselled to ensure that they understand both how the virus is spread and the implications of a positive test. There should be at least one person in every prison who has been trained to counsel people who ask for HIV testing.

4.How HIV is spread

4.1HIV, the human immunodeficiency virus, is found in blood, semen and vaginal secretions. Infection occurs when a body fluid containing virus gets into the body of another person. There are only three known routes of infection:

  • Through blood. In the early part of the 1980’s, there was a risk of catching HIV from blood transfusions, but fortunately, few potential donors in the UK were infected at the time. However, approximately half of all haemophiliacs in the UK contracted the virus from contamination of an imported blood product used in their treatment. All blood donations are now tested for the virus and blood products are heat treated so this source of infection has been virtually eliminated.

Blood transmission now occurs only as a result of the sharing of unclean works by injecting drug abusers and, very rarely, as a result of needle sticks.

  • Through sexual intercourse. HIV is transmitted by unprotected vaginal intercourse and, in the world wide epidemic, this has been by far the most common way in which it has been spread. Unprotected anal intercourse is even more dangerous. Oral sex is thought to be less risky, but cannot be said to be entirely safe. Kissing, cuddling and any practices not involving exchange of blood, semen or vaginal secretions are safe.
  • From mother to baby. If a woman who is infected with HIV becomes pregnant, there is a chance she will pass the virus on to her baby. This may occur in the womb, during the birth process or, possibly, through breast milk. Until recently, about 1 in 6 babies born to infected mothers in the UK have themselves been infected. It is now known, however, that the risk can be reduced further by treating the mother with an antiviral drug during pregnancy.

4.2HIV cannot be spread by casual contact, shaking hands, sharing accommodation, sharing toilet facilities, sharing cups and plates or using someone else’s cutlery, even if they have not been washed. It is recommended, however, not to share razors or tooth brushes in view of the tiny risk that they will be contaminated with blood.

5.The risk of spread of HIV within a prison

5.1From inmates. In 1996/7 the total number of positive HIV tests was 123, in a total population in excess of 60,000. There will, however, almost certainly have been others who were infected, but were not known. There is a risk of HIV spreading from inmate to inmate as a result of sexual intercourse, particularly unprotected anal intercourse, and also as a result of injecting drug abusers sharing works. It is not known to what extent spread has occurred as a result of sexual activity, but there has been one documented case of HIV infection in a prison in England and Wales as a result of sex between men. Transmission between drug injectors has been demonstrated at Glenochil Prison in Scotland where 14 users were found to be HIV positive, some of whom had certainly not been infected on admission.

5.2The risk of a member of staff catching HIV from an inmate is very small. The only realistic hazard is from being stuck, accidentally or intentionally, by an infected needle; there has been one documented case in Australia of a prison officer being infected in this way. Even after a needle stick, the risk of transmission is quite low: in a large series of such accidents involving health workers, only 0.2% (2 in 1000) contracted the virus and infection was almost always associated with the more serious injuries. If, however, blood containing HIV was actually injected in the course of an assault, the risk of infection would be high. Blood spills as a result of fights and accidents carry hardly any risk of transmission of HIV. There is no risk from blood falling on the intact skin (though it is wise to wash it off promptly and thoroughly). A few cases have been reported in health care workers in which infection occurred as a result of blood getting into an open wound or an eye; infection is not known to have occurred in this way in any prison staff. Contamination by urine, faeces or saliva carries no risk of transmission of HIV.

5.3From staff. Members of staff who may have acquired the virus in the course of their private lives pose no threat at all either to colleagues or inmates as they carry out their duties.

6.Prevention of HIV infection

6.1There is no vaccine that can be used to immunise people against HIV. It is proving
very difficult to develop one and, even if a safe and effective vaccine is eventually produced, it will be many years before it has gone through the necessary tests and can be made generally available. For the foreseeable future, the prevention of HIV infection must depend entirely on the avoidance of those activities that are known to spread the virus.

7.Action that has been taken to minimise the risk of HIV transmission within prisons

7.1An extensive educational programme has been undertaken to ensure that staff and inmates are as fully informed as possible about HIV and AIDS and that they are aware of the dangers of unprotected sex and unclean works. Everything that anyone might need to know will be found in the revised video ‘AIDS INSIDE AND OUT’ (issued 1995) and its accompanying manual; this should be available in every establishment. Advice has been issued from time to time on the safest way of dealing with accidents such as needle sticks and blood spills; all that advice has now been updated as necessary and is gathered together in this Order (see The Management of Risk Situations, starting on page 14).

TUBERCULOSIS

Tuberculosis is caused not by a blood borne virus but a bacterium. It is referred to in this Order because people infected with HIV are very susceptible to the infection, and if they do develop the disease, it is likely to progress rapidly. It is therefore important that anyone with responsibilities in relation to HIV and AIDS is also well informed about tuberculosis.

8.Key Points:

  • Pulmonary tuberculosis is an infection of the lungs by tubercle bacilli. If not arrested, it causes progressive destruction of the lungs with serious ill health and eventual death. It is at present an uncommon disease in the UK and is rarely seen among inmates.
  • Transmission is by breathing in infected droplets that have got into the air as a result of someone with active disease coughing or sneezing. It can therefore be caught as a result of casual contact, particularly in confined and poorly ventilated places.
  • Treatment depends on drugs and is, in general, very successful.
  • HIV infection makes people much more vulnerable to tuberculosis as the immune system has a vital role in controlling the tubercle bacillus.
  • Tubercle bacilli resistant to one or more of the drugs used in treatment have appeared widely and bacilli resistant to most or even all of the available drugs now pose a serious threat in places such as New York. Infection with resistant organisms is a very serious matter as there may then be no way to stop the relentless progression of the disease.
  • In the USA, both prisoners and prison staff have contracted pulmonary tuberculosis, sometimes involving multiple drug resistant organisms, in outbreaks occurring where large numbers of HIV positive inmates provided the opportunity for it to spread easily.
  • In the UK, there is not, at present, cause for serious concern as the prevalence of HIV among inmates is much lower than in places such as New York, and multi drug resistant strains are much less common. Nevertheless, everyone should be aware of the possibility of an upsurge in pulmonary tuberculosis if conditions here should change.

9.Some basic facts about tuberculosis