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Public Health Wales
Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Screening, Testing and
Immunisation for Blood
Borne Viral Hepatitis in
Primary Care
Quality Improvement Toolkit
Author: Primary Care Quality and Information Service
Date: November 2009
Version: Final Version
1
Status: Final
Intended Audience: Public (internet) / NHS Wales (Intranet) / NPHS (Intranet)
This document is for use by general practices who are engaged in screening, testing and
immunisation for Blood Borne Viral Hepatitis in Primary Care. The purpose of this quality
improvement toolkit is to support practices to review and improve where necessary, the
recording of information available when providing this service to their patients.
The audit toolkit will provide the user with a summary of the evidence associated with
screening, testing and immunisation for Blood Borne Viral Hepatitis in Primary Care.
Also included is a practice review section designed to encourage a whole practice
response to the audit findings and an evaluation of the quality and usefulness of the audit
itself.
Publication / distribution:
 Publication in NPHS document database (Primary Care Quality and Information)
 Link from NPHS e-bulletin
Author
Primary Care Quality & Information Service
Blood Borne Viral Hepatitis Version 1
Date
October 2009
1
Status; Final Version 1
Intended audience: Public (Internet)/
NHS (intranet PHW (Intranet) / PCQIS
Public Health Wales
Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Preface
Quality Improvement Toolkits
The Primary Care Quality and Information Service (PCQIS) has developed quality improvement
toolkits to assist practices in collating and auditing information.
These are produced with reference to evidence based practice and Welsh priorities. They should
be seen as good practice. They cover areas that some or even all practices may not be recording
at this stage. It is not expected that all the criteria within the audits will be achieved in year one.
The PCQIS suggests that the toolkits be used to improve data quality and aid development within
the practice.
Improvements in practice will be optimised by multidisciplinary involvement in the audit and team
discussion of the results. We recommend that action plans following audits are reviewed within 6
months and re-audit undertaken if possible in 6-12 months.
You can access other quality improvement toolkits that support Enhanced Services and National
Service Frameworks from the Public Health Wales (PHW) website:
Intranet http://nww2.nphs.wales.nhs.uk/page.cfm?pid=33294
Internet http://www.wales.nhs.uk/sites3/page.cfm?orgid=719&pid=25575
Approved READ Codes (in Version 2 and Clinical Terms Version 3) have been developed to
support practices wishing to build searches and extract the data from their clinical system.
If you have any queries regarding this document please contact:
Laura Beer, Team Lead – PCQIS
Tel: 01792 607311
Email: [email protected]
Author
Primary Care Quality & Information Service
Blood Borne Viral Hepatitis Version 1
Date
October 2009
2
Status; Final Version 1
Intended audience: Public (Internet)/
NHS (intranet PHW (Intranet) / PCQIS
Public Health Wales
Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Contents
Page
Introduction
4
Aims
5
Background
5
Method
7
Data Collection
8
Evidence
9
References
13
Practice review
15
Evaluation form
16
Appendix A – Recommended tests
17
Appendix B – READ codes
18
Appendix C – Patient leaflets
21
Abbreviations
Anti-HCV
Anti-HBc
Anti-HBS
ICDS
BBV
HBV
HCV
IDUs
MSM
PHLS
PHCT
LFTs
NICE
Antibodies to hepatitis C virus
Antibody hepatitis B core antigen
Hepatitis B antibodies
Infection and Communicable Disease Service
Blood borne virus (e.g. HBV, HCV and HIV)
Hepatitis B virus
Hepatitis C virus
Injecting drug users
Men who have sex with men
Public Health Laboratory Service
Primary Health Care Team
Liver Function Tests
National Institute of Health and Clinical Excellence
Author
Primary Care Quality & Information Service
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Public Health Wales
Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Definition of a user of drugs of dependence
For the purpose of this toolkit, a user of any drugs of dependence is defined as a person who
misuses substances such as heroin, crack cocaine, amphetamines, marijuana, opiates and
benzodiazepines.
Definitions of Screening and Testing
For the purpose of this toolkit screening is the process of assessing the risk factors associated with
the acquiring of a blood borne virus.
Testing is the undertaking of a blood test or dry spot test to detect the presence or absence of a
blood borne virus. However, it should be noted that many documents and clinical guidance use
the terms interchangeably.
Introduction
In January 2008, the Welsh Assembly Government published ‘Working Together to Reduce Harm’,
a 10 year strategy which aims to set out a clear national agenda to tackle and reduce the harms
associated with substance misuse in Wales.1 The strategy describes the requirement of primary
care in applying best practice, to prevent and control the hepatitis B virus (HBV) in injecting drug
users (IDUs).
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Key Performance Indicator 18 states that “all clients who are IDUs to be offered
information, counselling, screening, and where appropriate, immunisation against hepatitis
B”.1
Published in March 2009, the Welsh Assembly Government Blood Borne Viral Hepatitis Action
Plan for Wales consultation document 2 states that:
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Transmission of blood borne viruses (BBV) can be prevented, yet in Wales transmission is
common amongst high risk groups.
HBV infection is preventable with an effective vaccine
With modern therapy, depending on the genotype of hepatitis C virus (HCV) infection,
between 40% - 85% of patients with chronic HCV can be cleared of the virus. The
treatment is cost effective and has been recommended by the National Institute of Health
and Clinical Excellence (NICE) in a technology appraisal. 3
Treatment for chronic HBV infection has been recommended by NICE in a technology
appraisal.4
Less than 2000 people are currently being monitored or treated for hepatitis C by specialist
services across Wales. Failure to improve uptake of treatment will lead to an increase in
liver disease and the number of untimely deaths in Wales.
The action plan states that an effective response must
 prevent transmission
 diagnose infection in people who have the virus in their blood
 treat disease in those with chronic infection
and recommends that within Primary Care,
Author
Primary Care Quality & Information Service
Blood Borne Viral Hepatitis Version 1
Date
October 2009
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Status; Final Version 1
Intended audience: Public (Internet)/
NHS (intranet PHW (Intranet) / PCQIS
Public Health Wales
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Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
high quality shared care provision of substitute drug treatment is provided
uptake of testing for blood borne viruses is improved - targeting those on their patient lists
who are most at risk
delivery of the antenatal screening programme for hepatitis B is supported
hepatitis B vaccination is provided to all high risk groups in primary care
contribution to the care pathway providing community based support to those affected is
increased
Currently within Wales and England only acute hepatitis B infection (HBV) is recorded so no
estimates exist for chronic infection of HBV within Wales.2
The number of people infected with HBV and HCV increases each year because of continued high
risk behaviour. 2
Aims
The aim of this toolkit and audit is to address some of the issues for primary care raised in the
above publications and help to increase the number of all high risk groups receiving screening,
testing, and immunisation for blood borne viral hepatitis by:
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identifying all high risk groups in General Practice.
raising awareness through offering information and counselling.
offering testing and immunisation against hepatitis B, and offering referral for
screening/testing for hepatitis C, to those in the relevant high risk groups.
providing recommended READ codes to enable information relating to patients who are at
high risk to be consistently recorded on GP practice systems.
Background
Hepatitis B
Hepatitis B is a viral infection that is spread through the blood, and semen, saliva and vaginal fluid
of an infected person and by perinatal transmission from mother to child. The incubation period
ranges from 40-160 days and causes inflammation of the liver (hepatitis) which may lead to long
term liver damage.5,20,7
In the UK, hepatitis B infection is usually acquired in adulthood, with sexual activity or injecting
drug use being the most commonly reported routes of infection. Infection with hepatitis B, is
however preventable using a widely available, safe and effective vaccine.6
Hepatitis B vaccine is a killed preparation of the purified major surface antigen of the virus
manufactured by recombinant DNA technology, adsorbed onto aluminium hydroxide. It is highly
effective and has an excellent safety record.20
The Immunisation Against Infectious Disease: The Green Book, states that HBV immunisation is
recommended for the following individuals and groups:-7
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All IDUs as a high priority (including those who inject intermittently)
Those who are likely to “progress” to injecting, for example those who are currently
smoking heroin and/or crack cocaine, and heavily dependent amphetamine users
Non-injecting drug users who are living with current injectors
Author
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Status; Final Version 1
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NHS (intranet PHW (Intranet) / PCQIS
Public Health Wales
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Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Sexual partners of injecting users
Children of injectors
Men who have sex with men (MSM)
Sex workers
Those who change sexual partner frequently
Close family contacts of a case or individuals with chronic HBV infection
Families adopting children from countries with high or intermediate HBV prevalence
Foster carers
Individuals receiving regular blood or blood products and their carers
Patients with chronic renal failure or chronic liver disease
Individuals in residential accommodation for those with learning difficulties
Travellers to areas of high or intermediate prevalence,
Individuals at occupational risk.7
In 2005, the NPHS carried out a survey on General Practitioners who provided hepatitis B
immunisation. It was found that 66.4% of GPs across Wales provided hepatitis B immunisation for
IDUs.8
Hepatitis C
Hepatitis C is transmitted through blood-to-blood contact. In the UK, sharing of needles and
paraphernalia when injecting drugs is the most common way to acquire hepatitis C (only rarely is it
passed on through other body fluids e.g. during sex). The HCV causes inflammation of the liver
(hepatitis) and may also cause long term liver damage.
In relation to other areas in the UK, Wales currently has lower levels of hepatitis B, hepatitis C and
HIV in IDU populations. However, in the larger cities in Wales and particularly amongst homeless
drug misusers, hepatitis C is common.1
Higher risk injecting practices e.g. multiple drug injecting, injecting heroin with crack/cocaine
(speedballing) increase the risk of infection and associated harms.1
Evidence from NPHS is that in Wales there are an estimated 12,000 individuals, (0.4% of the
population) with chronic hepatitis C.9 If left untreated, hepatitis C can cause serious liver disease
in some patients, including cirrhosis and liver cancer. 92% of reports of hepatitis C infection to the
PHLS, in which risk factors were reported, related to either current or previous drug use.10
Contaminated blood or blood products accounted for a further 2.5% of reported infections. Other
people may have become infected with hepatitis C through non-sterile medical or dental
procedures; non-sterile tattooing, body-piercing or other skin-incision procedures; other forms of
blood-to-blood contact. There is around a 6% risk of transmission from mother to child before or
during birth if the mother has chronic hepatitis C and detectable viraemia.9
There is no vaccine to protect against hepatitis C.
The NPHS, state that as the virus may be transmitted by contact with blood from an infected
person, certain people may be at a higher risk of acquiring hepatitis C. These include people who:
10,21,22
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Have unexplained abnormal liver function tests (e.g. elevated ALT), or unexplained
jaundice
Have ever injected drugs, even if it was only once or twice, or many years ago
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Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Have had a blood transfusion (before September 1991) or blood products (before 1986 in
the UK)
Are children of a mother with hepatitis C. (The test result may be difficult to interpret in
children under 18 months, due to the presence of material antibodies and specialist
virological advice will be needed)
Are regular sexual partners of someone with hepatitis C.
Have had medical or dental procedures abroad, in countries where infection control may be
poor
Have been accidentally exposed to blood where there is risk of hepatitis C infection
Have had an ear piercing, a body piercing, tattoo, acupuncture or electrolysis with unsterile equipment (although not stated in the website those with prison tattoos).
Have previously been diagnosed with non-A, non-B hepatitis and not subsequently tested
for hepatitis C.
Are drug users, whether smoking or injecting drugs, who have ever shared any drug
paraphernalia.
Have received medical treatment or blood products in a country where hepatitis is common
Were born in a country where hepatitis c is common.
Come into contact with blood products i.e. healthcare workers, prison officers
Method
It is recommended that Practices complete the Data Collection Sheet provided. This sets out the
criteria taken from evidence based sources.
Practices should agree a data collection period prospectively and members of the Primary
Healthcare Team (PHCT) should be involved in the identification of patients.
Practices should use the audit results as the basis of a discussion by the PHCT. The Practice
review form can be used to reflect on findings and changes needed to ensure quality improvement.
It is suggested that Practices re-audit annually to ensure that any changes implemented are having
a positive effect on patient care.
Author
Primary Care Quality & Information Service
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Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Data Collection Sheet
Screening, Testing, Immunisation for blood borne viral hepatitis amongst
high risk groups in primary care
Number
A Number of patients in at risk groups for hepatitis B
Some READ Codes for patients in the “Risk Groups” can be found in Appendix B (page 18), however,
NHS Connecting for Health have been contacted to request new READ Codes on the italic bulleted
lists on pages 5,6,7. New READ codes are released quarterly, updates are available on the
Connecting For Health website
http://www.connectingforhealth.nhs.uk/systemsandservices/data/readcodes/changestocurrentrelease
B Number of patients in A offered a test for hepatitis B
(Please note the evidence on page 9 – opportunistic immunisation of those unlikely to re-attend is
recommended and lack of certainty of immunisation status should not act as a barrier to
immunisation)
READ V2
65W5. Requires a course of hepatitis B
65WC. Hepatitis B immunisation recommended
CTV3
65W5. Requires a course of hepatitis B
XaMe9 Hepatitis B immunisation recommended
C Number of patients in at risk groups for hepatitis C.
Some READ Codes for patients in the “Risk Groups” can be found in Appendix B (page 18), however,
NHS Connecting for Health have been contacted to request new READ Codes on the italic bulleted
lists on pages 5,6,7. New READ codes are released quarterly, updates are available on the
Connecting For Health website
http://www.connectingforhealth.nhs.uk/systemsandservices/data/readcodes/changestocurrentrelease
D Number of patients in C offered a test for hepatitis C
(Please see note under B above)
E Of those in A - Number who have received 1 dose of hepatitis B immunisation
READ V2
14b0. History of one hepatitis B immunisation
65F1. 1st hepatitis B immunisation
65MD. First combined hepatitis A & B vacc.
CTV3
XaN0g History of one hepatitis B immunisation.
65F1. 1 st hepatitis B immunisation
65MD. First combined hepatitis A & B vacc.
F Of those in A - Number who have received 2 doses of hepatitis B immunisation
READ V2
65F2. 2nd hepatitis B immunisation
65ME. Second combined hepatitis A & B vacc.
CTV3
65F2. 2nd hepatitis B immunisation
65ME. Second combined hepatitis A & B vacc
G Of those in A - Number who have received 3 doses of hepatitis B immunisation
READ V2
65F3. 3rd hepatitis B immunisation
65MF. Third combined hepatitis A & B vacc.
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Primary Care Quality & Information Service
Blood Borne Viral Hepatitis Version 1
CTV3
65F3. 3rd hepatitis B immunisation
65MF. Third combined hepatitis A & B vacc.
Date
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Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Evidence to support the screening, testing immunisation for blood
borne viral hepatitis amongst high risk groups within primary care
Hepatitis B
Promoting immunisation uptake
A pragmatic approach to an immunisation schedule is recommended. This involves providing
current users of any drugs of dependence with both the means and opportunity to significantly
reduce the risks associated with injecting. Drug misusers whether injecting or not, should be
encouraged to access relevant advice and information or counselling which includes strategies for
avoiding exposure to blood-borne virus infection and contamination.11
Strategies to help identify other groups at risk of hepatitis B should also be taken. This would
include highlighting the risks for those travelling to high risk areas, occupational risk etc.
Prominent display of posters and use of leaflets promoting hepatitis B immunisation may be
helpful. Promotion of immunisation is dependent on motivated knowledgeable staff.12
Testing for hepatitis B
Testing for HBV serves the dual purpose of identifying those who are currently infected, and those
who are immune by natural infection (and by eliminating those who are still susceptible and should
be immunised).15 Diagnostic tests for HBV are recommended in anyone presenting with suspected
acute hepatitis and in those with symptoms or signs of chronic liver disease, or abnormal LFTs
consistent with acute or chronic hepatitis. 13
However, poor patient attendance for testing is often reported as a major barrier to immunisation.
To address this, current expert advice is to focus on protection through immunisation rather than
testing.12 Immunisation should be offered and administered opportunistically perhaps at the time
when the 'at risk' individual makes initial contact with the practice. Delaying immunisation can do
harm because a drug misuser may become infected before the next visit or may not return.21 Lack
of certainty of immunisation status should not act as a barrier to immunisation and reliance on
recall of history of immunisation is not advised. 12
Keeping records
Information on hepatitis B vaccine uptake and completion is however useful and may assist in
assessing the quality of a service and help teams to plan achievable improvements. A full record of
immunisations given should be kept on the GP practice system, using recommended READ
codes. Evidence recommends that recording systems between GPs and specialist clinics including
those in prisons are developed and strengthened to ensure that where possible the full course of
hepatitis B vaccine is administered to all relevant patients. 11, 12, 14
Sexual and Other Contacts
The partners and children of drug misusers are also at risk of hepatitis B infection, but their need
for immunisation is often overlooked. Hepatitis B can be transmitted through sexual contact and
non-sexual intimate contact.12
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Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Sexual partners, close household contacts, and children of users of any drugs of dependence are
at risk of hepatitis B infection and it is recommended that these should be immunised. Children
infected with hepatitis B have a higher risk of chronic infection than adults.7, 12
Organising immunisation for families may not be straightforward. Families may not be registered
in the same practice as the drug misuser. Some drug misusers may be reluctant to disclose the
risk to their partners. Health care workers need to work with drug misusers to advise them of the
risks and promote the routine offering of immunisation to partners and children.12
Testing to identify those with current or past infection should be undertaken at the same time as
immunisation and should not delay immunisation.12
Hepatitis B Immunisation Schedule
There are 3 recommended schedules for hepatitis B immunisation.
Conventional – immunisation given at zero, one and six months can be used for pre-exposure
prophylaxis where rapid protection is not required and there is a high likelihood of compliance.7
Accelerated - An accelerated schedule is recommended for pre-exposure prophylaxis for adults
and children in at risk groups. Immunisation is given at zero, one and two months with a fourth
dose after 12 months. This schedule is recognised as the most appropriate for users of any drugs
of dependence.7
Higher completion rates for three doses at zero, one and two months have been reported.
Improved compliance is likely to offset the slightly reduced immunogenicity when compared with
the zero, one and six months schedule, and similar response rates can be achieved by
opportunistic use of a fourth dose after 12 months.7
Rapid - A primary immunisation schedule is also licensed for adults (Engerix B only), three doses
given at zero, seven and twenty one days with a fourth dose 12 months after the first. This
schedule is licensed for use in circumstances where adults over 18 years of age are at immediate
risk and where a more rapid induction of protection is required. In teenagers under 18 years of
age, response to vaccine is as good as or better than in older adults. Although not licensed for this
group, this schedule can be used in those aged 16 – 18 where it is important to provide rapid
protection and to maximise compliance.7
Even incomplete immunisation schedules offer some protection.
ensure that there is a robust system for re-call.12
In addition services need to
Immunisation Schedules for hepatitis B using monovalent vaccine or combined A+B vaccine. 15
Immunisation Schedule
0, 7, 21 days,
12 months
Advantages
- Rapid immunity,
- Short duration,
- High antibody titres at 12
and 13 months
- Better uptake
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Disadvantages
- Less information on HIV or other
immune-compromised patients
- Low antibody titres in 1st year
(but current evidence suggests
that protection is still adequate in
the immune-competent)
- Not licensed for under 18s
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0, 1, 2, 12 months
0, 1, 6 months
Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
- Shorter time to early
immunity than the 0, 1, 6
course
- High antibody titres at 12
and 13 months
- Higher antibody titres at 7
months than the other two
regimens although this may
not be clinically important
- Long established regimen
- Most researched in HIV
- Antibody titres lower than the 0,
1, 6 regimen in the first year
- Poor uptake of the 6 month dose
in the clinical setting
Pre and /or post-immunisation testing for hepatitis B antibodies (anti-HBs), is not generally
recommended (please see ‘Testing for hepatitis B’ on page 9 of this toolkit). It is however essential
in certain occupational groups, and babies who are born to hepatitis B positive mothers
would require both anti-HBs and HBsAg. Practices should follow the guidance issued by Public
Health Wales23 and the Green Book 7 for advice on scheduling for babies and children and the use
of combined HAV/HBV vaccines. When previous history is not available, individuals should be
assumed to be unimmunised and a full course of immunisation planned.7, 16
For those babies and children (up to the age of 18 years) who are administered hepatitis B
immunisation, notification must be sent to the Child Health Department via an unscheduled form
as soon after the vaccine is given as possible so the central recording system has a full, accurate
record of the vaccines given. 23
Hepatitis C
Screening for hepatitis C
Screening for HCV infection is the offer of a test in people not complaining of symptoms
associated with HCV or requesting a test of HCV status. Screening for HCV is currently
undertaken in a range of groups and settings, and supported by several consensus statements
internationally and NHS Policy with respect to screening in IDUs.17
Health Technology Assessment 2002; Vol 6: No 31 states that “while selective screening may be
more cost-effective and affordable than universal screening, we believe that it remains open to
question whether seeking people other than IDUs for screening represents a cost effective use of
NHS resources”.17
Health Technology Assessment 2006; Vol 10: No 32 concluded that case-finding for hepatitis C is
likely to be considered cost-effective by NHS commissioners. Improvements in the effectiveness
of treatments to slow or halt disease progression are likely to improve the cost-effectiveness of
case finding. Case finding is likely to be most cost-effective if targeted at people whose HCV
disease is more advanced. 3
Drug Misuse
There are estimated to be around 8,000 current IDUs in Wales – around 0.4% of the adult
population in Wales.1 The health service cost in Wales of problem drug use has been estimated at
£17.6 million per year.18
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The prevalence of blood borne virus infection amongst drug injectors
To address the epidemiology of blood borne viral transmission in Wales, a large multi-centre
incidence study was carried out between 2004 and 2006. This study, the largest of its kind in
Wales, has produced up to date evidence of the prevalence and incidence of HCV, HBV amongst
IDUs in Wales. The study found prevalence rates of antibodies to hepatitis C virus (anti-HCV) 26%
and antibody hepatitis B core antigen (anti-HBc) - 9%. 7% had markers of exposure to both HCV
and HBV. There were marked regional differences in prevalence for example, in Cardiff anti-HCV
prevalence was 35% and anti-HBc was 18%, whilst in Merthyr Tydfil respective prevalences were
10% and 0%.14
Incidence rates of 6 per “100 person years” 14 for hepatitis C were found. This means that in a
year, between 3 and 9 in every 100 injectors will become infected with hepatitis C. Incidence
rates of 2 per “100 person years” for hepatitis B were found. This means that within the injecting
drug user population, in a year between 1 and 4 will become infected with hepatitis B. These
figures are not static and may rise due to the year on year increase in those infected and
potentially passing on the virus to others.14
Initial analysis of incidence data suggests that the incidence of HCV is at least as great amongst
recent initiates to injecting as amongst long term injectors.14
The prevalence of infection was greatest among those who had long injecting careers, however,
an anti-HCV prevalence of 5% was found in those, usually young people, who had been injecting
for one year or less.14
Only one quarter of those individuals who tested anti-HCV positive were already aware of their
status, the remaining three quarters (over 135 individuals) were unaware of their status.14
Of serious concern was the lack of awareness of hepatitis C and hepatitis B transmission routes
and the implications for health among this population despite contact with substance misuse
services.14
Needle Exchange Services
Needle exchange provision is fundamental in the prevention of blood borne viral transmission in
Wales. Work undertaken by the Infection and Communicable Disease Service (ICDS) states that
the provision of clean needles and syringes across Wales is varied and at times problematic.
Furthermore, barriers exist in the ability of individual injectors to access services. A greater
understanding of both these barriers and of current provision is needed.14
The services provided must include needle exchange, harm minimisation advice, blood-borne virus
testing and immunisation for hepatitis B. Access to these must be easy and convenient and
include better provision via outreach services.19
Working Together to Reduce Harm states that commissioners should engage with providers to
ensure additional venues are available for the provision of sterile injecting equipment, such as
mobile facilities, and the need to expand outreach teams, including those aimed at rough
sleepers.1
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Viral hepatitis in Primary Care
References
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
WAG. Working Together to Reduce Harm. The Substance Misuse Strategy for Wales
2008-2018. WAG January 2008.
WAG. Proposed Blood Borne Viral hepatitis Action Plan for Wales 2009-2014. WAG
March 2009.
Castelnuovo E, Thompson-Coon J, Pitt M et al. The cost-effectiveness of testing for
hepatitis C in former injecting drug users. Health Technology Assessment 2006; Volume
10: No. 32. Accessed 05/03/2009.
National Institute for Health and Clinical Excellence. Adefovir dipivoxil and peginterferon
alfa-2a for the treatment of chronic hepatitis B. London: NIHCE; (2006b)
http://www.nice.org.uk/nicemedia/pdf/TA096guidance.pdf. Accessed 29/03/2009.
NPHS. Hepatitis B. Available from Health Protection web page.
http://howis.wales.nhs.uk/sites3/home.cfm?orgid=457 . Accessed 29/03/2009 (intranet
only)
Health Protection Agency, Health Protection Scotland, National Public Health Service for
Wales, CDSC Northern Ireland and CRDHB. Shooting Up: Infections among injecting
drug users in the United Kingdom 2006. London: Health Protection Agency, 2007
Salisbury D, Ramsay M, Noakes K. Immunisation against infectious disease. The Green
Book. Chapter 18 Hepatitis B. London: The Stationery Office; 2006.
NPHS. Report 9 – Primary Care Services for blood borne viral hepatitis prevention,
treatment and care. October 2006.
NPHS. Secondary and Tertiary Service Provision for Chronic Hepatitis C across Wales.
October 2006.
NPHS. Hepatitis C web pages. (intranet only)
http://howis.wales.nhs.uk/sites3/page.cfm?orgId=719&pid=20099 Accessed 21/04/2009.
National Treatment Agency for Substance Misuse. Drug Misuse and dependence UK
guidelines on clinical management. 2007.
http://www.nta.nhs.uk/areas/Clinical_guidance/clinical_guidelines/docs/clinical_guidelines_
2007.pdf. Accessed 20/11/2008.
Substance Misuse Management in General Practice (SMMGP) and the Royal College of
General Practitioners (RCGP). Guidance for hepatitis A and B immunisation of drug users
in primary care and criteria for audit. 1st Edition 2005.
Screening Guidelines Steering Committee commissioned by Clinical Effectiveness Group.
Sexually Transmitted Infections: UK National Screening and Testing Guidelines. August
2006
NPHS. Report A - Blood Borne Viral Hepatitis Action for Wales Research Programme –
Developing the evidence base. Findings, Implications and Recommendations. October
2006.
British Association of Sexual Health and HIV. United Kingdom National Guideline on the
Management of the Viral Hepatitides A, B, C 2008. http://www.bashh.org.uk Accessed
13/02/2009
World Health Organisation (WHO) web site.
http://www.who.int/csr/disease/hepatitis/en/index.htm Accessed 05/03/2009.
Health Technology Assessment 2002; Volume 6: No. 31. Screening for hepatitis C among
injecting drug users and in genitourinary medicine clinics: systematic reviews of
effectiveness, modelling study and national survey of current practice.
Coles E and Pates R for Welsh Assembly Government. The Economic and Social Costs of
Class A drug and alcohol abuse in Wales. Cardiff: Welsh Assembly Government
(unpublished).
National Treatment Agency for Substance Misuse. Treating Drug Misuse Problems:
Evidence of Effectiveness. London: National Treatment Agency for Substance Misuse,
2006
Author
Primary Care Quality & Information Service
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20
21
22
23
Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
NPHS for Wales. Immunisation and Vaccination web pages.
http://howis.wales.nhs.uk/sites3/home.cfm?orgid=474 Accessed March 2009.
Heptonstall J. Strategies to ensure delivery of hepatitis B vaccine to injecting drug users.
Communicable Disease and Public Health, 1999. 2(3): p.154-6.
http://www.nhs.uk/hepatitisc/hcp/testing-for-hepatitis-c/Pages/who-to-test.aspx
The British Liver Trust http://www.britishlivertrust.org.uk/home/the-liver/liverdisease/hepatitis-c-updated.aspx Accessed 16th June 2009
Public Health Wales formerly NPHS for Wales. Childhood Immunisation (COVER) data
April-June 2009
http://howis.wales.nhs.uk/sites3/page.cfm?orgid=474&pid=21302 Accessed Sept 2009
Author
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Practice Review
A. What lessons did the practice discover from carrying out this audit?
B. What changes, if any have the practice agreed to implement as a result of this audit?
C. What support would enable the practice to enhance the service it provides to patients?
This audit was compiled by;
Name(s)
___________________________________________________________
Signature(s)
___________________________________________________________
Practice (name and address)
________________________________________________________________________
Date ___________________________________________________________________
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Quality improvement toolkit – evaluation form
The Primary Care Quality and Information Service would like to ensure that the information
and suggested tools help practices to monitor and audit their practice data, therefore please
could you take a moment and provide your comments on the blood borne viral hepatitis
quality improvement toolkit.
1)
Did you find the introduction, aims and methodology to be clear and easy to understand?
YES
NO
If No, please comment _____________________________________________
2)
Did you find the organisational checklist to be clear and easy to understand?
YES
NO
If No, please comment _____________________________________________
3)
Did you find the patient audit data proforma easy to use?
YES
NO
If No, please comment _____________________________________________
4)
Did you find the practice review template helpful?
YES
NO
N/A
If No, please comment _____________________________________________
5)
Did you find the hints and tips section useful?
YES
NO
N/A
If No, please comment _____________________________________________
6)
Did you find the information within the appendices helpful?
YES
NO
If No, please comment _____________________________________________
7)
Do you have any suggestions on how we should improve our quality improvement Toolkits?
Please send to: Laura Beer, PCQIT
NPHS 36 Orchard Street Swansea SA1 5AQ / or email
[email protected]
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Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Appendix A
Recommended Tests
This figure is based on a flow chart produced by DoH and adapted by WAG1, and outlines the key
stages in diagnosis and referral to specialist hepatitis treatment services and is relevant to all
those responsible for diagnosis and referral.
Diagnosis and referral pathways for blood borne viral hepatitis
Client / Patient with identified risk factors
behavioural or clinical
Pre test discussion
Sample 1 – Dried blood spot or venepuncture blood test
Negative antibody test
result
Positive antibody test
result
Retest within 12 weeks
(window period)
Sample 2 – Further
confirmatory venepuncture
antibody tests
Negative result – viral
load not detected
Positive result and
viral load detected
Further antibody tests
Post test discussion. No
treatment required. May
need further tests in future
Post test discussion.
Genotype testing and liver
function tests. Referral to
specialist hepatitis services
If outside window period
– post test discussion
In the case of chronic
--------------- infection, notification to
local Health Protection
Team
1. Welsh Assembly Government. Proposed Blood Borne Viral Hepatitis Action Plan for Wales
2009-2014.
http://new.wales.gov.uk/consultations/healthsocialcare/blood/?lang=en&status=closed
Accessed November 2009.
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Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Appendix B
READ Codes
Note: “Risk Groups” - NHS Connecting for Health have been contacted to request new READ Codes on the italic
bulleted lists on pages 5,6,7. New READ codes are released quarterly, updates are available on the Connecting For
Health website http://www.connectingforhealth.nhs.uk/systemsandservices/data/readcodes/changestocurrentrelease
Read V2
Code
CTV3
Code
Read V2 Description
CTV3 Description
RISK GROUPS
65PL.
Hepatitis B contact
65PM.
Hepatitis C contact
13N5.
Multiple sexual partners
13N9.
Sexual contact with high risk partner
1P70.
Number of sexual partners in past year
Xa1pO
XaLGb
Ua1ZB
XaLHk
Ub0oP
133N.
Approved foster parent
XaF0D
L1765
L1765
13c..
Viral hepatitis complicating pregnancy,
childbirth and the puerperium
Drug user
Ub0mt
Hepatitis B contact
Hepatitis C contact
Multiple sexual partners
Sexual contact with high risk partner
Number of sexual partners in past
year – requested new term
Approved foster parent – new term
requested
Viral hepatitis complicating pregnancy,
childbirth and the puerperium
Drug user
13c0.
13c1.
13c2.
13c3.
Injecting drug user
Intravenous drug user
Never injecting drug user
Intramuscular drug user
Ub00U
Ub0nA
XaJgi
Ub0n9
Injecting drug user
Intravenous drug user
Never injecting drug user
Intramuscular drug user
Ub0n4
XaKSC
XaKcY
Intranasal drug user
Current drug user
Previously injecting drug user
Ua1O4
XaLTv
6828.
XaLND
XaKuU
XaIyP
8CE..
XaLoH
XaBib
677Q.
XaLTu
XaJh4
XaLDh
XaLNE
XaNPZ
Pre-screening counselling
Hepatitis B screening counselling
Hepatitis B screening
Hepatitis B screening declined
Health education - safe sex
Health education - sexual health
Self-help advice leaflet given
Safer sex leaflet given
Drugs – health education
Hepatitis C screening counselling
Hepatitis C screening counselling
Hepatitis C screening
Hepatitis C screening offered
Hepatitis C screening declined
Hepatitis C screening not offered
XaLIH
XaKiz
XaKiz
Hepatitis B immunisation declined
Hepatitis B immunisation refused
No consent for hepatitis B
13c4.
Intranasal drug user
13c7.
Current drug user
13cJ.
Previously injecting drug user
PRE SCREENING COUNSELLING
677J.
Pre-screening counselling
677R.
Hepatitis B screening counselling
6828.
Hepatitis B screening
8I3u.
Hepatitis B screening declined
679S.
Health education. - safe sex
679K.
Health education - sexual health
8CE..
Self-help advice leaflet given
8CEC.
Safer sex leaflet given
679A.
Health ed. – drugs of addiction
677Q.
Hepatitis C screening counselling
6829.
9Op1.
8I3v.
682A.
Hepatitis C screening
Hepatitis C screening offered
Hepatitis C screening declined
Hepatitis C screening not offered
IMMUNISATIONS
8I3r.
Hepatitis B immunisation declined
68Nm.
Hepatitis B immunisation refused
68Nm.
No consent for hepatitis B immunisation
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Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
immunisation
Requires a course of hepatitis B
Hepatitis B immunisation
recommended
History of one hepatitis B
immunisation
History of two hepatitis B
immunisations
History of three hepatitis B
immunisations
1st hepatitis B immunisation
2nd hepatitis B immunisation
3rd hepatitis B immunisation
Booster hepatitis B immunisation
4th hepatitis B immunisation
5th hepatitis B immunisation
Sixth hepatitis B immunisation
Third combined hepatitis A and B
vaccination
First combined hepatitis A and B
vaccination
Second combined hepatitis A and B
vaccination
Booster combined hepatitis A and B
vaccination
65W5.
65WC.
Requires a course of hepatitis B
Hepatitis B immunisation recommended
65W5.
XaMe9
14b0.
History of one hepatitis B immunisation
XaN0g
14b1.
History of two hepatitis B immunisations
XaN0h
14b2.
History of three hepatitis B immunisations
XaN20
65F1.
65F2.
65F3.
65F4.
65F6.
5F7.
665FM
65MF.
1st hepatitis B immunisation
2nd hepatitis B immunisation
3rd hepatitis B immunisation
Boost hepatitis B immunisation
4th hepatitis B immunisation
5th hepatitis B immunisation
Sixth hepatitis B immunisation
Third combined hepatitis A and B
vaccination
First combined hepatitis A and B vaccination
65F1.
65F2.
65F3.
65F4.
65F6.
65F7.
XaKXg
65MF.
Second combined hepatitis A and B
vaccination
Booster combined hepatitis A and B
vaccination
65ME.
RESULTS
43X6.
43dC.
43dB.
43d8.
43B..
43dA.
43d9.
43B8.
43d8.
43dB.
A703.
Hepatitis C antibody level
Hepatitis B e antibody level
Hepatitis B core antibody level
Hepatitis B surface antibody level
Hepatitis B immunity test
Hepatitis B core IgM level
Hepatitis B surface antigen level
Hepatitis B core antigen test
Hepatitis B surface antibody level
Hepatitis B core antibody level
Viral (serum) hepatitis B
XaIM5
XaFuV
XaFuU
XaFuR
XE2ww
Hepatitis C antibody level
Hepatitis B e antibody level
Hepatitis B core antibody level
Hepatitis B surface antibody level
Hepatitis B immune
XaFuS
XaEOm
XaFuR
XaFuU
A703.%
Hepatitis B surface antigen level
Hepatitis B core antigen test
Hepatitis B surface antibody level
Hepatitis B core antibody level
Viral serum hepatitis B
A707.%
Chronic viral hepatitis
43B6.
6773.
6772.
677B.
65X..
Hepatitis B non-immune
Investigation result counselling
Disease counselling
Advice about treatment given
Contact tracing
44D6.
43X2.
43dD.
Liver function test
Hepatitis C antibody test
Hepatitis C recombinant immunoblot assay
43B6.
6773.
6772.
677B.
Ua1RW
XaAgt
X77WP
XaEOG
XaFuX
Hepatitis C viral load not detected
Hepatitis C viral load detected
Hepatitis B non-immune
Investigation result counselling
Disease counselling
Advice about treatment given
Contact tracing
Referral to contact tracing nurse
Liver function tests
Hepatitis C antibody test
Hepatitis C recombinant immunoblot
assay
New term requested
New term requested
Hepatitis C sustained negative viral load
New term requested
65MD.
65ME.
65MG.
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65MD.
65MG.
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Viral hepatitis in Primary Care
Acute Hepatitis C
Active Hepatitis C (up to 12 months)
Chronic Hepatitis C (after 12 months)
Past history of HCV successfully eradicated
HCV spontaneous clearance
Hepatitis re-infection
REFERRAL
8H15.
Referral to drugs therapist
8Hk5.
Referred to hepatology service
8HA5.
Follow-up refused
8H48.
Gastroenterological referral
8HVN.
Private referral to Gastroenterologist
8Hk5.
Referred to hepatology service
TREATMENT FOR HBV/HCV
9N42.
Did not attend - no reason
9N41.
Did not attend - reason given
9kX..
Hepatitis status 6 months post treatment enhanced services administration
FOLLOW UP
9G1..
Infectious disease notification
65V..
Notification of disease
9kT..
Hepatitis C screening negative - enhanced
services administration
9kV..
Hepatitis C screening positive - enhanced
services administration
9kR..
Chronic hepatitis annual review - enhanced
services administration
Author
Primary Care Quality & Information Service
Blood Borne Viral Hepatitis Version 1
New term requested
New term requested
New term requested
New term requested
New term requested
New term requested
XaMzM
XaLrh
8HA5.
8H48.
8HVN.
XaLrh
Referral to drugs worker
Referred to hepatology service
Follow-up refused
Referral to gastroenterology service
Private referral to gastroenterologist
Referred to hepatology service
XE2NM
9N41.
XaPE9
Did not attend - no reason
Did not attend - reason given
Hepatitis status 6 months post
treatment - enhanced services
administration
XE2Mn
65V..
XaPLZ
Infectious disease notification
Notification of disease
Hepatitis C screening negative enhanced services administration
Hepatitis C screening positive enhanced services administration
Chronic hepatitis annual review enhanced services administration
XaPLl
XaPLW
Date
October 2009
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Screening, Testing & Immunisation for Blood Borne
Viral hepatitis in Primary Care
Appendix C
Patient Leaflets
Patient information leaflets on Hepatitis are available from the following:
National Public Health Service for Wales has Information for pregnant women who are hepatitis B positive
available at: http://howis.wales.nhs.uk/sites3/page.cfm?orgid=474&pid=21234
The British Liver Trust have a variety of booklets on Hepatitis A,B,C, available on request from the British
Liver Trust, 2 Southampton Road, Ringwood, BH24 1HY. Tel 0800 652 7330 or web
www.britishlivertrust.org.uk
Patient UK have information leaflets on Hepatitis A,B,C, and Immunisation for Hepatitis A, B available from
http://www.patient.co.uk
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