guidelines for the management of human bites in schools ... · private. parents should be made...

Acknowledgements: South East London Health Protection Unit

North East and North Central London Guidance for the Management of Human Bites in

Schools and other Child Care Settings

April 2013 Published: October 2010 For review: February 2014

Acknowledgements: South East London Health Protection Unit 2

Contents Page number

Introduction 3

Part 1 3

Background 3

Strategies to prevent adverse outcomes of human bites 3

Part 2 4

Risk 4

Confidentiality 4

Part 3 5

Management in the school or other childcare setting 5

Initial wound care 5

Initial assessment 5

Further assessment 6

Additional actions where a member of staff is involved 6

Further management by healthcare professionals 6

Appendices 7

Appendix A – School action card Hospital A&E departments 8

Appendix B – Procedure to follow in the event of a human bite that breaks the skin

9

Appendix C – Algorithm for the management of a human bite that does not break the skin

10

Appendix D – Supporting information 11

Appendix E – Glossary 13

Appendix F - Clinical Care of Severe Bites that Break the Skin

14

Appendix G – Letter to be taken to A&E or GP – BBV status not known

16

Appendix H - Letter to be taken to A&E or GP – BBV status known

17

Appendix I - Suggested Form for recording incident

18

References 21

Useful contacts/information 22


Introduction The document is intended as a resource for staff in schools in North East and North Central London to provide practical guidance for the assessment and management of infection risks due to human bites in schools and other childcare settings. Part 1: Background It is widely accepted that it is possible, (although extremely rare), for a bite from an infected individual to transmit hepatitis B, HIV or hepatitis C. In addition, bacterial infections may occur following human bites and can be serious if not managed appropriately. Therefore it is essential that bites are managed promptly. Fortunately, incidents of this nature are extremely rare in most educational establishments, but as the risk to health can be significant, it is essential that staff are aware of them and know how to respond. Unlike occupational exposure in adult healthcare workers, the infection status of the source is usually unknown and difficult to establish. Biting that occurs in schools and other child care setting is often an expression of aggression or frustration in young children. Most human bites in this situation occur on the fingers or hands. Most do not break the skin. Strategies to prevent adverse outcomes of human bites Bites may occur quickly and without an obvious warning to the adults present. A child may bite when he/she is crowded or cornered and is unable to use words to get the other child or children to move away. The incidence of biting tends to increase at times that children find stressful, for example, starting a new school. Predicting stressful situations and acting to support children accordingly can decrease the incidence of biting. The following actions to reduce the infection risk associated with biting may include the following:

Take a history from parents to assess the BBV risks in children who bite repeatedly

Consider offering testing and possible immunisation against hepatitis B in children who bite repeatedly

Consider individual plans for children who repeatedly bite, involving parents and the child’s GP

Agree a policy for immunising teachers at risk of hepatitis B

Consider immunity of classmates at school entry

Ensure staff wear long sleeved clothing if caring for a child who bites regularly


Part 2: Risk

Bites that do not break the skin do not normally pose an infection risk, unless there is a pre-existing skin break or skin condition. If there is severe bruising without a skin break however, medical advice should be sought. Any break in the skin caused by a biting incident is a potential source of bacterial infection and of bloodborne viruses (BBVs), as it may not be known whether the biter is infected. However, the risk of transmission from a bite is extremely low. To reduce the risk of infection, treatment may be needed for the biter and the recipient, such as antibiotics, tetanus or hepatitis B immunisation. Following a biting incident, medical attention and advice must be sought immediately and risk assessment performed, for both the person bitten and the biter. Infection risk is from:

Bacteria including Staphylococcus aureus, Haemophilus spp Bacteroides spp and other anaerobes

Viruses such as hepatitis B, hepatitis C and HIV The risk of a BBV being transmitted is higher if there is blood in the biter’s saliva. The risk may be reduced if the bite is through fabric. Hepatitis B virus (HBV) infection has the greatest potential for transmission via this route. HIV transmission has rarely been reported following a bite injury. Between 1987 and 2006 worldwide there were only four reported cases of HIV transmission from a bite. In all cases the bite broke the skin and there was a history of bleeding from the biter’s mouth. Worldwide, there has been at least two reports of Hepatitis C virus infection being transmitted via a bite; however there have been no reports of transmission via this route in the UK. Confidentiality Staff should be aware that medical information about individual children is private. Parents should be made aware that there may be circumstances that personal sensitive information will be shared between the school and health care professionals. It is important to keep the number of people who are aware of the person’s medical conditions to a minimum and divulging such information should be on a strictly ‘need to know’ basis. The decision as to the extent of any disclosure within the school will need careful consideration and be minimised in each case.


Part 3 Management in the school or other child care setting Initial Wound Care If the bite is particularly severe, the biter may require urgent first aid treatment (e.g. to control the bleeding). In all cases where the bite has broken the skin the management of the wound should include the following: Apply first aid:

Wash and dry your own hands

Cover any cuts on your own hands and put on disposable gloves

Encourage the wound to bleed, unless it is bleeding freely. Do not suck

Wash the wound thoroughly with soap and warm, running water for 1-2 minutes. Do not scrub

Dry and cover the wound with a waterproof dressing

Seek medical advice

If the bite is on the hand the arm should be elevated

If the biter has blood in the mouth they should swill it out with tap water Even if the bite has not broken the skin, the area should still be washed thoroughly with water and soap.

Initial Assessment All assessments should include the possibility that the person bitten and the biter both may have been exposed to a BBV or bacterial infection. All bites should be examined to ascertain whether the skin has been broken and the following information recorded for all incidents where this is the case:

An accident/incident report should be completed

Who was bitten

Who was the biter

When and where did the incident take place

Who was also present

Factors that may have contributed to the occurrence of the incident

Examine the mouth of the biter to assess the likelihood that the bitten person was exposed to the biter’s blood

Examine and describe the wound of the person bitten to include whether there is a possibility of soil contamination

Any known immunosupression (problems with the immune system) in the biter or person bitten

Any known allergies to medicines

Any known infections or other medical conditions in both parties

Whether the person bitten is up to date with their tetanus vaccinations

Has the biter or recipient been immunised against Hepatitis B


Further assessment If the biter or the person bitten is known to have or is considered likely to have a BBV infection then refer immediately to the local A&E department, telephoning the department beforehand to alert them. Telephone the parents and inform them of the incident and ask them to accompany the child to A&E. Ideally arrangements should be made for the biter to have a blood test for BBVs as this will help to inform management of the person bitten. If the biter or bitten person is not thought likely to be infected with BBV, but the wound is severe it may be appropriate to refer to the local accident and emergency department. Otherwise local primary care facilities may be used. If a part of the body has been torn off, for example part of an ear, it should be surrounded by ice, stored in a plastic bag for transport to hospital. Additional optional questions which should be asked if the school lead/first aider feels it appropriate include:

Are any of the parents of the biter or bitten person known to be infected with hepatitis B, hepatitis C or HIV?

Are any of the parents of the biter or bitten person known to be intravenous drug users?

Has the biter or bitten person or anyone in their families been ill with jaundice?

Were the biter or bitten person, or their parents born in an area where BBVs are endemic (Africa, Asia, South America)

Additional actions where a member of staff is involved The organisation should ensure that:

o An accident/incident report is completed o The appropriate line manager is informed o If the bite breaks the skin the occupational health department should

be informed Those whose work puts them at increased risk of biting should be offered hepatitis B vaccination where appropriate. They should be made aware of the immediate action to take following a bite. Further Management by Health Professionals This will include:

An assessment of the need for antibiotics to prevent bacterial infection

Assessment of the need for immunisation against tetanus and hepatitis B

Assessment of the need for HIV PEP (drugs to prevent HIV infection in situations where the biter is HIV positive or highly likely to be HIV positive)

Taking a sample of blood from the bitten person to store and possibly test later.

Taking a sample of blood from the biter to test for existing infection


APPENDICES


Appendix A School action card

Date:

Hospital A&E departments

Hospital Telephone number

Queen’s Hospital 0845 130 4204 or 01708 435 0000

King George Hospital 020 8983 8000

Whipps Cross Hospital 020 8539 5522

The Royal London Hospital 020 7377 7000

St. Bartholomew’s Hospital 020 7377 7000

Newham General Hospital 020 7476 4000

Homerton University Hospital 020 8510 5555

Barnet Hospital 0845 111 4000

Chase Farm Hospital 0845 111 4000

Edgware Community Hospital 020 8952 2381

North Middlesex University Hospital 020 8887 2000

Royal Free Hospital 020 7794 0500

University College Hospitals 0845 155 5000

Whittington Hospital 020 7272 3070

North East & North Central London Health Protection Team, 2nd Floor. 151 Buckingham Palace Road. London. SW1W 9SZ

020 7811 7100

Information required following a human bite The following information should be recorded:

Who was bitten

Who was the biter

When and where did the incident take place

Who was also present

Factors that may have contributed to the occurrence of the incident

Examine the mouth of the biter to assess the likelihood that the bitten person was exposed to the biter’s blood

Examine and describe the wound of the person bitten to determine the possibility of soil contamination

Any known immunosupression (problems with the immune system)

Any known allergies to medicines

Any known infections or other medical conditions in both parties

Whether the child who is bitten is up to date with their tetanus vaccinations

Has either child been immunised against hepatitis B


Appendix B Procedure to follow in the event of a human bite wound that breaks the skin. Use normal first aid procedure plus use of disposable gloves

o

At school Phone nearest A&E department and explain incident and action taken so far and seek advice on next steps. Depending on risk assessment getting to A&E within 1 hour may be needed. Ensure ongoing support for the bitten person and biter as appropriate

At school Notify

H&S and Occupational health teams

Complete accident/incident report

RIDDOR (Reporting of injuries, diseases and dangerous occurrences regulations 1995)

At school Cover the wound (Plaster or dressing)

At the Hospital Clinical assessment of risk of infection and tissue damage

At the Hospital Antibiotics may be prescribed to prevent bacterial infections Possible actions for viral infections:

If Consultant decides there is a risk of HIV infection, they will begin anti-HIV-therapy for 1 month (this is very rare)

Vaccination history will be taken for Hepatitis B. Either an accelerated course or a booster may be given

If there are concerns around hepatitis C, regular testing will take place and treatment against hepatitis C will begin if infected

Follow up – GP and Occupational health

At school Encourage bleeding from skin wound, do not suck wound

At school If there is blood in the mouth of the biter swill it out with water

At school Wash the wound with soap and running water

Hospital A&E departments Barking & Dagenham, Redbridge, Havering, Waltham Forest, Newham, Tower Hamlets, Hackney: Queen’s Hospital – 0845 130 4204 King George Hospital – 020 8983 8000 Whipps Cross Hospital – 020 8539 5522 The Royal London Hospital – 020 7377 7000 St. Bartholomew’s Hospital – 020 7377 7000 Newham General Hospital – 020 7476 4000 Homerton University Hospital – 020 8510 5555

Hospital A&E departments Barnet, Camden, Enfield, Haringey, Islington: Barnet Hospital – 0845 111 4000 Chase Farm Hospital – 0845 111 4000 Edgware Community Hospital – 020 8952 2381 North Middlesex University Hospital –020 8887 2000 Royal Free Hospital – 020 7794 0500 University College Hospitals – 0845 155 5000 Whittington Hospital – 020 7272 3070


Appendix C Algorithm for the Management of a human bite that does not break the skin

Has the bite made an opening in the skin?

No Yes – see Appendix B

Clean the area and reassure the child

Letter to parents of biter and/or recipient


Appendix D

Supporting Information Bacterial infection from human bites A multi-centre study of bites in adults and children in the United States reported that 54% of the patients were hospitalised (Talan et al, 2003). The median number of isolates per wound culture was four (three aerobes and one anaerobe); aerobes and anaerobes were isolated from 54% of wounds, aerobes alone were isolated from 44%, and anaerobes alone were isolated from 2%. Isolates included Streptococcus anginosus (52%), Staphylococcus aureus (30%), Eikenella corrodens (30%), Fusobacterium nucleatum (32%), and Prevotella melaninogenica (22%). Candida species were found in 8%.

HIV Transmission from Human Bites The risk of HIV transmission through biting is thought to be very low but is more likely if there is extensive tissue damage and if there is bleeding in the mouth of the biter. Although there have been some case reports of HIV transmission as a result of human bites (Rickman and Rickman, 1993; Andrea et al, 2004; Quava-Jones et al, 2005; Didmar et al, 2006), this is extremely rare. HIV is present in saliva at low concentrations but the presence of blood in the mouth of the biter is likely to increase the risk of transmission. The risks of HIV seroconversion from needlestick injury are 0.3-0.5%. Since needlestick injuries transmit 20 times more HIV-infected cells than a human bite from a HIV positive individual the HIV transmission risk from biting is likely to much lower (Rickman and Rickman, 1993). Of the documented cases of HIV transmission from a human bite two involve HIV positive patients who inadvertently bit during a grand mal seizure, in both cases, blood was noticed in the mouth of the patients at the time of the bite (Barra et al, 2004; Vidmar et al, 1996). Another case report documents HIV transmission by an HIV positive parent with dental caries and bleeding gums who bit his daughter (Quava-Jones et al, 2005). The Centers for Disease Control in the United States report no cases of occupational transmission of HIV by a human bite (CDC, 2005) Hepatitis Transmission from Human Bites The Centers for Disease Control, Atlanta (1989) report that saliva of some persons infected with HBV contains HBV-DNA at concentrations 1/1,000 to 1/10,000 of that found in the infected person's serum. HbsAg-positive saliva has been shown to be infectious when injected into experimental animals and in human bite exposures. However, HBsAg-positive saliva has not been shown to be infectious when applied to oral mucous membranes in experimental primate studies or through contamination of musical instruments or cardiopulmonary resuscitation dummies used by HBV carriers.


Hepatitis C appears to be more easily transmitted than HIV but there is currently no PEP or vaccine. Hepatitis C RNA has been found in saliva and there are at least two case reports of transmission via human bites (Henderson, 2003).


Appendix E Glossary Allergy An inappropriate and harmful response of the immune system to a normally harmless substance Bacteria Small single-celled organisms that cause disease Bloodborne virus (BBV) This refers to viruses which can be spread through blood: hepatitis B, hepatitis C and HIV (Human Immunodeficiency Virus). Infection The multiplication of an infectious agent in the body of an infected person or animal Immunoglobulin Antibodies which can be used to temporarily increase person’s immunity to an infection. Immunisation The use of a vaccine to produce an immune response to a particular disease in an individual Immunosuppression A weakened immune system (caused by various means), making a person more susceptible to infections. Immunity/immune Protection against infection achieved either by vaccination, or by natural infection Intact skin If the bite has not punctured the skin, there is no risk of infection either from bacteria or blood borne viruses. The incident should be managed by cleaning the area and reassuring the patient. Post Exposure Prophylaxis (PEP) Treatment for example drugs, to reduce risk of infection following possible exposure Punctured skin If the bite has punctured the skin then there is a theoretical risk of transmission of infection. Transmission The way in which an infectious agent is spread Vaccine A preparation administered as a precaution against contracting a disease. Usually the vaccine stimulates the body to produce antibodies to the disease, making the person immune.


Appendix F

Clinical Care of Severe Bites that Break the Skin The hospital doctor or GP assessment will include the following (this is to serve as a guide only. Local policies to be followed): Full clinical assessment to examine for signs of infection, foreign bodies, damage to blood vessels, nerves, tendons, joints, bones and lymphadenopathy (e.g. swelling at site). Antibiotic prophylaxis Bacterial infection of severe human bite wounds is common. A seven day course of Co-amoxiclav is recommended as first line treatment. In persons allergic to penicillin, metronidazole plus either erythromycin or doxycylcine are alternatives. Tetanus prophylaxis For those whose immunisation schedule is not up to date or whose status is unknown then the risk of tetanus infection associated with the bite should be assessed. Tetanus is only a risk if the bite is deep and there is possible contamination with soil. In this case manage according to the Department of Health Green Book recommendations. (See references) Bloodborne viruses A risk assessment should be made and where appropriate hepatitis B vaccine/immunoglobulin and or HIV post exposure prophylaxis (PEP) should be offered. HIV PEP is unlikely to be required unless the biter or victim is known to be HIV positive or is considered highly likely to be HIV positive. Even then it should only be provided with specialist support. There are no current guidelines on the use of PEP in children. Hepatitis B prevention must be considered according to previous immunisation history and hepatitis B status or risk factors Hepatitis C appears to be more easily transmitted than HIV but there is currently no PEP or vaccine. However, if the child who bites or is bitten is known to be hepatitis C positive then the other child, (or member of staff), will require serial testing and appropriate referral. The Children’s HIV association (CHIVA) has developed PEP Guidelines for children and adolescents exposed to blood-borne viruses. (See references)


If the risk is considered significant then the person exposed should be tested as follows (From HPA Inoculation Injuries and Children in schools and similar settings: Risk

assessment guidelines for Health Protection Units, November 2009)

Time after exposure

Hepatitis B Hepatitis C HIV

RNA testing Antibody testing

Baseline Storage

6 weeks Yes Yes

12 weeks Yes Yes Yes Yes

24 weeks Yes Yes (Yes)

*If HIV PEP was taken the follow up tests should be 12 weeks after stopping PEP


Appendix G Letter to be taken to A&E or GP – BBV status not known This person has sustained a human bite which has broken the skin. The bloodborne virus status of the biter and bitten person is not known. Please manage according to your own local policy and in line with recommendations on management of human bites and involving potential exposure to blood borne viruses please consider the following

Need for antibiotic prophylaxis or treatment

Need for tetanus immunisation

Need for hepatitis B immunisation

Need for HIV PEP

Serum for storage

Ensure clear arrangements are in place for follow up, including repeat blood samples at appropriate intervals and completion of hepatitis B vaccine course if required.

Yours sincerely, Health Protection Team


Appendix H Letter to be taken to A&E or GP – BBV status known This person has sustained a human bite which has broken the skin. The <<biter / bitten person>> is known to be << HIV / Hepatitis B / Hepatitis C>> positive. (Delete as appropriate) Please manage according to your own local policy and in line with recommendations on management of human bites and involving potential exposure to blood borne viruses please consider the following

Need for antibiotic prophylaxis or treatment

Need for tetanus immunisation

Need for hepatitis B immunisation

Need for HIV PEP

Serum for storage

Ensure clear arrangements are in place for follow up, including repeat blood samples at appropriate intervals and completion of hepatitis B vaccine course if required.

Yours sincerely, Health Protection Team


Appendix I Suggested Form for recording incident

Section A: Details of the Recipient

First Name:

Surname:

Date of Birth:

Job title / Post

Home address:

Home telephone number:

GP:

GP address and telephone number:

Hepatitis B Status

Has recipient been immunised against Hepatitis B virus? Yes No N/K

If Yes:

Date of completion of course?

Date of last vaccination booster?

Was antibody test done?

Result: Immune / Partially immune / Non responder

Section B: details of Source

Is the source patient known? Yes No

If Yes:

First Name:

Surname:

Date of Birth:

Address:

Home telephone number:

Mobile telephone number:

GP:

GP address and telephone number:


Section C: Assessment of exposure risk

1 Nature of the incident:

Date of incident:

Time of incident:

Place of incident:

Name and contact details of witness:

Nature of material: Significant: Yes No

Nature of injury: Significant: Yes No

Overall, is the exposure significant? Yes No

2. Assessment of source infectivity (tick appropriate section)

Virus type Known Positive or known high

risk

Known negative or known low risk

Unknown risk

Hepatitis B

Hepatitis C

HIV

Section D: Investigations checklist

Done

Has first aid treatment been given?

Blood taken from recipient, test requested for antiHBs (if appropriate) and serum storage?

Request for bloods to be taken from source patient (with informed consent) and tests requested as necessary?


Section E: Post exposure prophylaxis treatment record

Has HBIG been given? Yes / No

Has hepatitis B vaccination been given? Yes / No

Has HIV PEP been offered? Yes / No

Has HIV PEP been accepted? Yes / No

Has written consent been obtained? Yes / No

Has HIV PEP been given? Yes / No

Time between exposure and receiving PEP:

Drugs prescribed for PEP:

Section F: details of follow-up arrangements To include: Follow up arrangements for receiving test results and continuing vaccinations; Precautions advised during follow up period; Any precautions who have given advice and the advice given; The action taken to prevent recurrence; Compliance with medication prescribed; Potential adverse effects of drugs; Results of any follow-up testing.


References Andrea S., Barra L., Costta L., Sucupira M., Souza I and Diaz R. HIV Type1 Transmission by Human Bite. AIDS Research and Human Retrovirus, 2004; 20: 349-350

CDC, 2005 www.cdc.gov/mmwr/PDF/rr/rr5409.pdf (Accessed 20 October 2010)

CHIVA, 2009 (Accessed 20 October 2010)

Department of Health. (2006) Immunisation against infectious disease. Department of Health. London (Green Book) (Accessed 20 October 2010)

Hamilton J. Larke B., Qizilbash A. Transmission of hepatitis B by a human bite: an occupational hazard. Canadian Medical Association Journal, 1976; 115: 439-440

Health Protection Agency, (2009) Inoculation Injuries and Children in Schools and similar settings: Risk assessment Guidelines for Health Protection Units http://www.hpa.org.uk

Henderson D. Managing occupational risks for Hepatitis C in the Health Care Setting. Clinical Microbiology Reviews, 2003, 16:543-568

Pretty I., Anderson G., Sweet D. American Journal of Forensic Pathology, 1999; 20: 232-9

Quava-Jones A., Bartholomew M, Bartholomew C. Human Bites. A risk factor for HIV transmission. IAS Conf HIV Pathology Treat 2005 July 24-27; 3rd: Abstract No MePo10.1P10

Rickman K., Rickman L. The potential for transmission of human immunodeficiency virus through human bites. Journal of Acquired Immune Deficiency Syndrome 1993; 6:402-6

Stockheim, J., Wilkinson N., Ramos-Bonoan, C., Human Bites and Blood Exposures in New York City Schools. Clinical Pediatrics, 2005; 44:699-703

Talan DA; Abrahamian FM; Moran GJ; Citron DM; Tan JO; Goldstein EJ; Clin Infect Dis. 2003; 37(11):1481-9

Vidmar L., Tomazic J., Poljak M., Seme K., Kristancic L., Klavs I., Maticic M. A human bite: possible mode of HIV-1 transmission Int Conf AIDS 1996 July 7-12; 11: 362 (abstract no Tu.C.2563)

http://www.cdc.gov/mmwr/PDF/rr/rr5409.pdf

http://www.hpa.org.uk/

http://www.medscape.com/medline/publicationbrowser/123?pmid=14614671


Useful contact/information North East and North Central London Health Protection Team

2nd Floor

151 Buckingham Palace Road

London SW1W 9SZ

020 7811 7100

[email protected]

Health Protection Agency http://www.hpa.org.uk

mailto:[email protected]

http://www.hpa.org.uk/

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