Abstract
Summary
Household contacts of hepatitis B (HBV) are at risk of infection, and guidelines advise vaccination of these contacts in addition to sexual partners (along with traditional high-risk groups). We present a case of intrafamilial transmission of acute hepatitis B virus (HBV) following failure to self-disclose status to family members. Complex confidentiality issues can arise following a diagnosis of HBV infection.
A 65-year-old man presented to our genitourinary (GU) medicine clinic with symptoms of a recently infected sebaceous cyst at the base of his penis, mild penile itch and dysuria over the preceding two months. His last sexual contact was unprotected insertive oral sex with a casual female partner approximately three months earlier but had no vaginal or anal sex at that time. His last other sexual contact was approximately 18 months earlier with his wife aged 60 years. His total lifetime number of partners was around 40, all female and none from areas with high HIV or viral hepatitis endemicity. He denied any male sexual contacts, never used intravenous drugs nor had any partners who he believed used intravenous drugs. There was no history of blood transfusion or tattoos. His medical history was unremarkable apart from a possible transient ischaemic attack one year earlier. He lived with his wife and the couple would child mind their grandson (aged 6 years) on a regular basis. They holidayed regularly in southern Europe, often bringing this grandson along. General and genital examinations were normal aside from two perianal warts; urethral smear was also normal.
The results of his GU screen subsequently indicated evidence of acute hepatitis B virus (HBV) infection (HBsAg positive, HBeAg reactive, HBc IgG reactive, anti-HBe negative, anti-HBc IgM reactive, anti-HBs 1 mU/L). Plasma HBV DNA quantitation was 110,000,000 copies/mL. Other results of his GU screen (including HIV, syphilis and bacterial sexually transmitted infections) were negative. He was recalled to clinic where the results were discussed; he was given written information and risks of transmission to household and sexual contacts were explained. Further history did not reveal any more information about risks for acquisition and there was no history of acute seroconversion illness for HBV. He expressed severe anxiety at disclosure to his family, in particular to his daughter, the mother of his grandson, whose consent would be required to offer screening and vaccination to the grandson. He requested if his grandson could be offered screening and vaccination without involving the child's mother. He explained that he was due to go on holiday with his wife and grandson later in the month. He was counselled against holidaying with the family and that rapid vaccination should be undertaken of all household and sexual contacts to prevent transmission and that parental consent for testing of his grandson must be obtained. He left clinic agreeable to inform family contacts and advise them to attend immediately at the clinic for testing and vaccination purposes. He was also advised that the public health team would be notified.
In the following week, the patient failed to reattend clinic and nor had any family members attended. The circumstances were discussed with the public health team. Repeated attempts to contact him by phone were unsuccessful and written correspondence was also undertaken. There was insufficient information to trace his grandson. He eventually made contact approximately eight weeks later. He admitted to having gone abroad on holidays with his wife and grandson and stated that they had sought a second medical opinion while away; however, no vaccinations were undertaken of any family members.
Eventually, he was contacted by letter to advise that his confidentiality would be overruled in view of there being a potential child health protection issue should he not self-disclose. He was persuaded to bring his wife, daughter and grandson (with parental consent) to clinic for screening and vaccination. His wife's screening investigations were normal; however, his grandson also showed evidence of (likely) acute infectious HBV (HBsAg positive, HBeAg reactive, HBc IgG reactive, anti-HBe negative, anti-HBc IgM reactive, anti-HBs 0 mU/L). Remaining contacts were thereafter screened and rapidly vaccinated successfully. Six months later however, neither the patient nor his grandson had spontaneously cleared their infections.
In discussion with child protection services about potential concerns of sexual abuse, they sought to take guidance from the physicians involved in care as to whether transmission was possible through routes other than sexual acquisition or overt blood exposure. It was subsequently explored with the child's mother during follow-up as to whether there were concerns about potential sexual abuse; the child was also referred to a paediatric infectious disease consultant who saw the family and explored the same issues. No concerns were raised and it was felt that the case was one of household transmission and that raising this to child protection authorities on such grounds would be harmful to the family dynamic. The child now lives full-time with his mother.
Discussion
Within the UK, GU medicine clinics play a prominent role in the diagnosis of viral hepatitides in high-risk groups and subsequent tracing and vaccination of contacts. HBV is one of the viral hepatitides against which effective vaccination is available and also postexposure prophylaxis in the form of human immunoglobulin. Household spread of HBV infection has been reported and current vaccination guidelines from both North America and Europe have been adapted to acknowledge the risk of transmission to household contacts. 1 Within the UK, the prevalence of chronic infection with HBV is in the region of 0.2-0.3% of the population. 2 Previously, in studies from countries with high HBV endemicity (defined as >8% population prevalence), prevalence of markers for either past or current HBV infection among first- and second-degree relatives and sexual contacts of those who are HBsAg positive/HBeAg positive have reached 48.5%, whereas in similar contacts of those who are HBsAg positive/HBeAg negative the prevalence was 34%; thus transmission, although more common in HBsAg/HBeAg-positive patients, also occurs with high frequency in those who are HBsAg positive/HBeAg negative. 3 Household transmission is well documented and while it is an important issue to explore, it was equally important not to assume sexual abuse or falsely accuse in such cases. A recent study from New Zealand, a country with a similar prevalence of HBV endemicity to the UK, showed that among 931 children identified through a school screening programme as HBsAg positive, 24.3% of household contacts were also HBsAg positive. 4 At follow-up six months later, only 907 children had shown evidence of spontaneous clearance and underlines the concern with HBV exposure/infection in children as the rate clearance of virus is inversely related to age. Furthermore, these studies show clearly that household contacts are at high risk of HBV infection, which has not been demonstrated in other blood-borne viral infections such as HIV or hepatitis C, and reflects the need for screening and moreover vaccination of these contacts, especially given the preventable nature of transmission.
The complexity of our case was founded in the avoidance of the index case in disclosing his HBV status. In terms of disclosure of HIV to family members, qualitative research has shown that disclosure represents a major source of anxiety for patients; common barriers cited are fear of rejection, loss of respect, negative emotions and concern that the disclosure will expose infidelity; it is assumed that similar barriers exist for HBV 5 So at what point is it acceptable to break confidentiality of the patient and disclose on his/her behalf? Apart from HIV, reporting serious communicable blood-borne viral infections is supported under the UK Public Health Act and similarly guidance from the UK General Medical Council (GMQ regarding breaching confidentiality supports disclosure if public interest outweighs that of the patients.2,6 It is generally accepted that good medical practice is to minimize distress to patients by allowing them first opportunity to inform other individuals who might be at risk of a communicable disease in order to limit damage to interpersonal relationships that may be caused by certain diagnoses which have an associated stigma. Thereafter, where there is a failure to disclose, the GMC advises informing the patient of any plan to break confidentiality and to explain the reasons for this. 6 There are, however, no clear or predetermined timescales that dictate a reasonable length of time to afford the patient before healthcare professionals undertake disclosure, and this remains largely at the discretion of the physician and guided by the perceived urgency of threat to others. The Department of Health in the UK has also issued guidance on safeguarding children potentially exposed or already infected by blood-borne viruses and advises that wherever possible, every effort should be made to work in partnership with parents and carers to explain the available options and the possible consequences for their child's health of avoiding disclosure. 2 However, if a parent were to refuse testing or treatment for a child and this was likely to result in the child suffering significant harm, there are grounds for using child protection processes and legal action. This has been tested in relation to other medical conditions and the need for treatment, but not yet in relation to blood-borne viruses. 2
In our case, the issue of confidentiality was not directly tested as the patient had misled us into believing he was going to inform the relevant parties immediately. He subsequently defaulted and there was insufficient information to allow us to trace his grandson. Retrospectively, one could ask the question if the intrafamilial transmission could have been prevented if the clinician was to offer the vaccine to the grandson in the absence of parental consent, based on the best interest is to first protect the child – most clinicians would undoubtedly be reluctant to take this decision. Our case tested many ethical dilemmas and demonstrates the lack of clarity in relation to how much time should be afforded to an index case of a communicable disease to disclose their diagnosis so that all contacts can be afforded treatment to prevent contracting an infection. HBV is a preventable communicable disease but with a high likelihood of transmission to household contacts without intervention. Spontaneous clearance of infection is least likely in children, which added to the concern in our case. 1 Transmission risk is likely to increase with time and this increases the urgency with which contacts need to be informed so that primary prevention can be undertaken. Social stigma may act as a barrier to disclosure of infection and given the seriousness of associated morbidity and mortality, GU and infectious disease physicians need to be prepared to break confidentiality, especially where there is a risk to children.