Prevention of and Immunisation against Hepatitis B and C

Transcription

1 Prevention of and Immunisation against Hepatitis B and C January 2014 Quality Education for a Healthier Scotland 1

2 Learning Outcomes Participants will be able to:- Demonstrate an increased knowledge and understanding of opportunities for prevention of Hepatitis B and C Demonstrate an awareness of the importance of contact tracing for Hepatitis B infection Quality Education for a Healthier Scotland 2

3 Hepatitis B and C - opportunities for prevention At time of testing for BBV and when giving results Any consultation about drug use, sexual health, travel, pregnancy planning New patient registrations Waiting room information Brief interventions and written materials are effective. Quality Education for a Healthier Scotland 3 Prevention opportunities arise all the time, brief interventions are useful. Written back up material should be used.

4 Hepatitis B and C - prevention Harm reduction may includes advice on safer injecting:- Not to share needles, syringes, water, filters, spoons and tourniquets How to access to injecting equipment exchange IEP sites supply needles and syringes and other equipment used to inject drugs filters, foil cookers, tourniquets, water for injections Do not assume PWID are aware of this Quality Education for a Healthier Scotland 4 People may not be aware of the risk of sharing injecting equipment other than needles and syringes - all of this equipment will be available from IEP sites including water ampoules soon if not already. Know where your local IEP sites and sign post people to them.

5 Hepatitis B and C - prevention (cont.) Harm reduction may also include:- Alternatives to injecting (smoking, UYB) Opiate substitution therapy (methadone) Safer sex information and access to condoms Referral for benefits and housing advice Detox and recovery Hepatitis B immunisation Quality Education for a Healthier Scotland 5 Harm reduction is wider than needle exchange though - encouraging people away from injecting including by accessing opiate substitution therapy is very important. Hepatitis B immunisation should be widely promoted - give it when you see someone, don t ask them to come back to another appointment, they wont!

6 Hepatitis B and C - prevention (cont.) Treatment for drug dependence:- Opiate substitution therapy has a good evidence base that it reduces harm including BBV transmission Treatment increases stability and ability to deal with issues such as treatment for BBV infections Recovery is not always abstinence especially early on Quality Education for a Healthier Scotland 6 People in drug treatment services have better outcomes than those not in treatment. Stability in life helps access to BBV treatment. Detox is an ultimate aim but not necessary for access to Hepatitis C treatment. Don t forget safer sex - the drug using population is young and sexually active.

7 Hepatitis B and C - prevention (cont.) Safer sex:- Use of condoms protective against HIV and Hepatitis C, may not always be protective against Hepatitis B (but Hepatitis B immunisation is!) Access to free condoms Quality Education for a Healthier Scotland 7 Where can your patients get free condoms?

8 Hepatitis B and C - prevention (cont.) Hepatitis B immunisation:- Selective immunisation of those at risk Opportunistic intervention don t rely on someone coming back for it Don t assume will be done elsewhere Even one dose will confer some protection If unsure give immunisation. Do not wait for serology Quality Education for a Healthier Scotland 8 Policy in UK is one of selective immunisation of those at risk but in very uncoordinated manner - comes down to local and personal policies. Specialist services may not give Hepatitis B immunisation. Give it when you think of it - in general practice have it in the fridge on stock order. Do not test serology before giving if you do not know about past infection or immunisation, you wont do any harm. There is NO immunisation against Hepatitis C (or HIV).

9 Prevention - Hepatitis B immunisation The following groups should be offered immunisation:- All drug users, whether or not injecting, should be offered Hepatitis B immunisation Partners and children of current or past injectors and consider BBV testing MSM People with multiple sexual partners Sex workers People with HIV or Hepatitis C Quality Education for a Healthier Scotland 9

10 Prevention - Hepatitis B immunisation (cont.) Other groups offered immunisation:- Foster carers Individuals receiving regular blood or blood products and their carers Patients with chronic renal failure/chronic liver disease Inmates of custodial institutions Travellers/occupational risk Quality Education for a Healthier Scotland 10

11 Prevention - Hepatitis B contact tracing Notifiable disease health protection team will be informed Household and sexual contacts should be traced and offered testing and immunisation Specific Hepatitis B immunoglobulin 500 i.u. intramuscularly (HBIG) may be administered to a nonimmune contact after a SINGLE unprotected sexual exposure or parenteral exposure/needlestick injury. This works best within 48 hours and is of no use after more than seven days Quality Education for a Healthier Scotland 11 Especially in acute Hepatitis B the Health Protection Team will make contact with the patient. In both acute and chronic Hepatitis B contact tracing is important so that those at risk can be offered testing and immunisation. Close household contacts, sexual contacts and injecting contacts should be traced. For people with a single recent exposure to Hepatitis B there is the possibility of post exposure prophylaxis. Contact tracing for Hepatitis C is rarely carried out as it is rarely detected in the acute phase and there is no post exposure prophylaxis that can be offered to contacts, nor any immunisation.

12 Vaccination schedules Hepatitis B - Routine - 0,1 and 6 months - Accelerated - 0,1,2 and 12 months - Super accelerated - 0,7,21 days and 12 months Hepatitis A and B (Twinrix) - Routine - Super accelerated For those at ongoing risk a single booster dose at 5 years is recommended Quality Education for a Healthier Scotland 12 Guidance to give both Hepatitis A and Hepatitis B immunisation or Twinrix (A and B) to ex or current IDU. Twinrix licensed for routine and super-accelerated schedules where as the single Hepatitis B vaccine can be given as the accelerated schedule which often fits well with appointments at drug clinics when immunising people who use drugs. Do not worry too much if the timing between doses is delayed - try to give 3 doses over a shorter period and remember the 4th dose after 12 months or more for longer term protection. Even a single dose will give some protection. Outbreaks amongst IDUs in Scotland have occurred in the past so although prevalence is thought to be low immunisation remains a priority for drug users.

13 Blood tests and Hepatitis B immunisation Do BBV testing at time of first immunisation to exclude infection Checking serology after Hepatitis B immunisation course is not recommended (except for occupational reasons or renal dialysis) Quality Education for a Healthier Scotland 13 Give Hepatitis B immunisation when you are testing for Hepatitis B and C. If the test shows existing immunity to Hepatitis B then you do not need to give further dose of immunisation. Delaying the immunisation until you have the BBV test result may mean that you have missed an important opportunity to give the immunisation. The current DH Green Book does not recommend post immunisation serology except in very particular cases (occupational immunisation and prior to renal dialysis). Unless the blood test is carried out at 2 months after the last dose of the course the result is hard to interpret. Even if antibody levels are not high it is likely that there is cellular immunity and that antibody levels can rise rapidly after exposure. Green Book the complete current edition, 28 November, accessed December 2012

14 Prevention of vertical transmission of Hepatitis B Routine opt-out testing for Hepatitis B (and HIV but NOT Hepatitis C) in pregnancy If Hepatitis B infection is detected in the mother the baby will receive Hepatitis B immunisation at birth, 1 month, 2 months and 12 months of age If the mother is highly infectious or baby is pre-term they will also get Hepatitis B immunoglobulin at birth Quality Education for a Healthier Scotland 14 There is a policy of selective Hepatitis C testing of women at risk (for example people who use drugs) but this is not universally applied. There are no interventions to prevent mother to child transmission of Hepatitis C but children born to these mothers should be followed up to exclude chronic Hepatitis C infection as there is a 5% risk of transmission. Follow up doses of Hepatitis B immunisation at 1, 2, and 12 months may be done in general practice in some areas.

15 Prevention of vertical transmission of Hepatitis B (cont.) Immunisation starting at birth is 90-95% effective in reducing transmission Breast feeding is allowed for immunised babies All babies of infected mothers required testing for HBsAG at 12 months of age to exclude chronic infection Some highly infectious mothers may be offered anti-viral treatment with tenofovir in the third trimester to reduce risk of transmission Quality Education for a Healthier Scotland 15

16 Group work - improving uptake of Hepatitis B immunisation It is important to share learning from this day with practice colleagues and to use it to improve clinical practice in your work setting Discuss with your group the most effective ways to improve uptake of Hepatitis B immunisation in General Practice, especially for drug users, MSM or ethnic minorities. Quality Education for a Healthier Scotland 16

17 Group Work - improving uptake of Hepatitis B immunisation (cont.) This could be a strategy already successfully implemented in own area which could be shared with the group The group is to produce an outline of a practice guideline or a patient information leaflet that could be taken back to their own practice area for discussion/ further development Quality Education for a Healthier Scotland 17