Bite in the playroom

Question 1

What is the incidence of bites at daycare?

Answer 1

If there are 60 kids at daycare, about one bite per day and one every 10 days that breaks the skin.

1.5 bites per 100 child-days of attendance

Question 2

What are some cited risk factors for transmitting blood born infections? (3)

Answer 2

Aggressive behaviour with frequent biting
Oozing skin lesion
Bleeding disorders

Question 3

How is HBV transmitted?

Answer 3

Contact with mucous membranes or open skin lesions with blood, saliva or genital secretions from actively infected individuals

Question 4

Can you get HBV from a bite that does not break the skin?

Answer 4

No

Te virus is not transmitted by simple contact of saliva or blood with intact skin

Question 5

Should daycares screen for HBV, HCV or HIV status?

Answer 5

Screening and exclusion is not acceptable

Parents should not be required to divulge the status of their child to the day care

Question 6

Have there been reports of HBV transmission with bites? HIV transmission?
HCV transmission?

Answer 6

HBV: yes, case reports
HIV: no - because infectivity of saliva is low (saliva is inhibitory to HIV)
HCV: there are reports in adults, but none in children

Question 7

Should kids get post-exposure prophylaxis for HIV after a bite?

Answer 7

It is only very exceptionally indicated and should be undertaken only in consultation with ID experts

Question 8

What is the order of the most to least risk for transmission after blood exposure: HIV, HBV, HCV

Answer 8

1st: HBV
2nd: HCV
3rd: HIV

Question 9

Can bites lead to bacterial infections?

Answer 9

Bites from young children very rarely lead to bacterial infection. They need to be fairly severe bites that break the skin significantly

Question 10

So overall what is the risk of transmitting a blood born infection with a bite?

Answer 10

Extremely low

Question 11

Do the parents need to divulge their child’s status if they bite another kid?

Answer 11

No. This is entirely up to the parents, because the risk is low

Question 12

What kind of recommendations can we give daycares re HBV? In general (2) and if there is a kid in the daycare who is HBV (1)

Answer 12

1. All staff should be immunised against HBV
2. Parents should be encouraged to have their child immunised against HBV
3. All kids and staff should be immunised, without revealing the identify of the infected child

Question 13

What do you do if a bite occurred and the skin is not broken?

Answer 13

You clean the wound with soap and water, and a cold compress should be applied while the child is gently soothed.

Question 14

What do you do if a bite occurred and the skin is broken? (6)

Answer 14

• The wound should be allowed to bleed gently without squeezing
• The wound should be carefully cleaned with soap and water, and a mild antiseptic should be applied
• An official report should be written and filed
• Both parents should be informed
• Report the bite to public health and refer both kids to a physician for assessment
• Advise given to parents to observe the wound for signs of infection.

Question 15

What does the medical evaluation entail?

Answer 15

• Tetanus status +/- vaccine
• Consider HBV exposure
• Consider HIV exposure
• Consider HCV exposures
• Consider antibiotic prophylaxis

Question 16

Which kids would you give antibiotics prophylactically?

Answer 16

1. Wounds that have caused moderate to severe tissue damage
2. Deep puncture wounds
3. Bites to the face, hand, foot or genitalia

Question 17

Which kids should get full HBV prophylaxis and what is the HBV prophylaxis

Answer 17

SITUATION 1:
The biter = known carrier
The bitten = nonimmune or incompletely immune
The wound = skin broken

SITUATION 2:
The biter = nonimmune or incompletely immune
The bitten = HBV carrier
The wound = skin broken

HBV x 3 doses (1, 2 and 6 months)
HBIG

Question 18

What do you do if the HBV status is unknown for one of the kids?

Answer 18

If one of the kids is unknown, and the other is non-immune, then you give the non-immune kid HBV vaccine. You do not have to test them, because the risk of infection is low.

Question 19

What do you do if the HBV status is unknown for both the kids?

Answer 19

Give HBV vaccine to both of them. You do not need to test them. The risk of infection is low.

Question 20

What do you do if a kid with HIV bites another kid?

Answer 20

If there is no break in the skin: do nothing. Disclose nothing.

If there is break in the skin and blood is exchanged (mucosa to skin blood): consult HIV specialist for advise. Usually you only give post-exposure prophylaxis if there is a deep bloody wound.

Question 21

If you want to start HIV prophylaxis after a bite, what is the appropriate time period for this?

Answer 21

Within 2 hours is idea, but up to 72 hours

Question 22

What do you do if the biter is HCV positive

Answer 22

If blood exposure was significant, arrange follow up and serology at six months for exposed kid.