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Bites - human and animal - Management
How should I manage someone who may be at risk of a blood-borne viral infection?
- Seek immediate advice from a consultant in infectious diseases for anyone considered to be at risk of HIV or hepatitis B. Consider all people to be at risk unless the current status of the biter is known (rare).
- If post-exposure prophylaxis (PEP) is needed:
- PEP for HIV should be started at soon as possible.
- Seek advice about the most appropriate PEP regimen for hepatitis B, see Table 1.
- Reassure the person that the risk of acquiring hepatitis or HIV from a bite is very small, even if the assailant is known to be infected.
- Arrange sequential testing to check for seroconversion (see Testing for seroconversion of virus).
Table 1. Hepatitis B vaccine prophylaxis for significant exposure (e.g. a bite from a high risk individual).
Hepatitis B vaccination status of person exposed | HBsAg positive source | HBsAg status unknown | HBsAg negative source |
|---|
Unvaccinated | Give an accelerated* or hyperaccelerated† course of hepatitis B vaccine and one dose of hepatitis B immunoglobulin | Give an accelerated or hyperaccelerated course of hepatitis B vaccine | Initiate course of hepatitis B vaccine |
Received one dose of hepatitis B vaccine pre-exposure | Give an accelerated* or hyperaccelerated† course of hepatitis B vaccine and hepatitis B immunoglobulin | Give an accelerated or hyperaccelerated course of hepatitis B vaccine | Finish course of hepatitis B vaccine |
Received two or more doses of hepatitis B vaccine | Give one dose of hepatitis B vaccine followed by one dose one month later | Give one dose of hepatitis B vaccine | Consider booster dose of hepatitis B vaccine |
Known responder to hepatitis B vaccine (anti HBs > 10 miU/mL) | Consider booster dose of hepatitis B vaccine | Consider booster dose of hepatitis B vaccine | Consider booster dose of hepatitis B vaccine |
Known non responder to hepatitis B vaccine (anti HBs < 10 miU/mL 2–4 months post immunization) | Give one dose of hepatitis B immunoglobulin and consider giving a booster dose of hepatitis B vaccine | Give one dose of hepatitis B immunoglobulin and consider giving a booster dose of hepatitis B vaccine | Consider giving a booster dose of hepatitis B vaccine. Do not give a course of hepatitis B immunoglobulin |
* An accelerated course of vaccine consists of doses spaced at 0, 1, and 2 months. A booster dose may be given at 12 months to those at continuing risk of exposure to HBV. † A hyper-accelerated course of vaccine may be offered by some Occupational Health Departments. This consists of doses at 0, 7, and 21 days with booster dose at 6 or 12 months. |
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Clarification / Additional information
- It is usually very difficult to assess whether or not a person is at risk of contracting HIV, or hepatitis B or C. For information on how to assess whether the person who has been bitten is at risk of acquiring a blood-borne virus, see Assessing someone with a human bite. Always err on the side of caution and seek immediate advice from a specialist if you consider there is any risk of infection.
- In people who are at high risk of a blood-borne virus infection, explain that it is important to take blood to store in the laboratory in case future follow-up tests are positive.
- When taking blood from a person who is at high risk of a blood-borne virus infection:
- Explicit valid consent from the person, or from their legal representative if appropriate, should be obtained before the test. Consent is needed both for taking and testing blood, and for checking results against archived samples.
- Obtain a 10 mL clotted sample from the person who has been bitten for archiving in the laboratory.
- Where practical, a sample should be obtained from the biter for testing for hepatitis B surface antigen (HBsAg), HIV, and hepatitis C.
Basis for recommendation
- These recommendations are based on expert opinion from the Health Protection Agency.
- The risk of transmission of HIV from a human bite is unknown but is likely to be small [HPA, 2005b]. In the rare cases when HIV transmission has occurred, bloody saliva has been present [Morgan, 2005]. Many reports are case studies [Vidmar et al, 1996; Khajotia and Lee, 1997; Pretty et al, 1999]. The risk is likely to be increased if [Pretty et al, 1999]:
- Blood is present in the oral cavity.
- The bite breaks the skin.
- The bite is associated with a previous injury.
- The biter had a deficiency in anti-HIV salivary elements.
- There are case reports that hepatitis B may be transmitted by a human bite [Stornello, 1991; Hui et al, 2005].
- There are case reports suggesting that hepatitis C may be transmitted by a human bite [Dusheiko et al, 1990; Figueiredo et al, 1994]. The Health Protection Agency states that hepatitis C appears to be transmitted more easily than HIV [HPA, 2005b].
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