Hepatitis C - Are we doing enough to diagnose, test and refer for treatment in primary care? Lonsdale Medical Centre a case example

Transcription

1 Hepatitis C - Are we doing enough to diagnose, test and refer for treatment in primary care? Lonsdale Medical Centre a case example Chris Ford, Caitlin Chasser, Rita Alyward, Melanie McKay & Brian Whitehead LJWG for Substance Misuse and Hepatitis C Conference

2 Hepatitis C Potentially curable disease Important cause of morbidity and mortality Less than 50% infected are diagnosed Under 30% of diagnosed patients are currently receiving NICE recommended therapy Many patients may not realize that they have been at risk of HCV, have the disease or could get treatment for it

3 Hepatitis C Injecting drug use (needle sharing) is the single most important reported risk factor for acquiring HCV and accounts for 87.9% of new infections Prevalence of HCV in those starting to inject within 3 years is 22%, and 43% in current injectors 1 Health Protection Agency Surveillance Project , results presented in Hepatitis C in England, The Health Protection Agency Annual Report 2007

4 Hepatitis C HPA estimate that of HCV positive people: 44% will be in current injectors 43% in ex-injectors 5.6% South Asians 7.3% white/other ethnicity neverinjectors Hepatitis C in the UK London: Health Protection Agency, Colindale July 2011.

5 Injecting Drug Users (IDUs) There is regional variation Geographic variations in the prevalence of antibodies to hepatitis C among current and former injecting drug users in England (2007 and 2008 data combined) DataSource: Unlinked Anonymous survey of injectors in contact with drug agencies. Further regional data from this survey is available at:

6 There are 13,000 new cases of hepatitis C infection in the UK per year yet we are only treating around 5,000. In the dark. An audit of hospital hepatitis C services across England. London: The All Party Parliamentary Hepatology Group, August 2010.

7 87.9% of new infections Grebely J, Dore GJ. Enhancing treatment for hepatitis C among drug users. Nat. Rev. Gastroenterol. Hepatol. 2011; 8:11-13

8 Referral for treatment NICE recommend that injecting drug use should not constitute a barrier to treatment Reviews have suggested that HCV therapy in active drug users can be effective as in other HCV patients

9 Getting IDUs into treatment Overall, the sustained virological response (SVR) was 57% and was similar in active injectors and non-injectors The psychological profile of patients did not change on therapy. The adverse effects were comparable to non-opioid replacement patients Sasadeusz JJ, Dore G, Kronborg I, et al. Clinical experience with the treatment of hepatitis C infection in patients on opioid pharmacotherapy. Addiction 2011; 106:

10 15,000 patients Lonsdale Medical Centre Currently 140 patients in treatment for drug problems, 110 on OST Positive for Hepatitis C Predicted if average London population: Number identified: 105

11 Method Lonsdale Medical Centre In 2004 Realised lots of patients with HCV but many not getting referred and / or getting treatment First audit Reviewed known patients with HCV Reviewed all patients in drug treatment Invitation to all with history of drug use Re-audit October 2011 Review of Emis notes Reviewed known patients with HCV Reviewed all patients in drug treatment

12 Analysis of 2005 audit results 93 antibody positive 38 (40.8%) referred 34 referred and not treated 4 (8.3%) treated, 2 successful completions 1 no SVR, 1 stopped side-effects 55 people who are positive and declined referral Results in 2005 were shocking Nationally less than 10% of an estimated cases of hepatitis C infection had been diagnosed in 2005

13 Changed practice post 2005 audit 1. Negotiated with laboratory to do PCR s as standard 2. Changed our main referral hospital 3. Joined local clinical viral network 4. Searched for all patients who 1. Had known drug history 2. Were currently in treatment 3. Were known to be HCV antibody positive 5. Reoffered all above groups retesting with PCR & treatment update 6. Plus HIV and HBV testing and vaccinations 7. Screened all patients presenting for help with drug or alcohol problem 8. Agreed to offer all those with abnormal liver tests

14 Lonsdale Hepatitis C Audit 2011 Focused on 4 keys areas Patients diagnosed Proportion with active Chronic Hepatitis C Subsequent referral rate Treatment rate and outcome

15 Active Chronic Hepatitis C Our practice population 66% PCR positive 34% Cleared virus General Population 25% with Hepatitis C clear the virus

16 Audit patients positive for hepatitis C 68 PCR positive 68 (100%) offered referral 45 (66% cf 40.8%) referred for treatment 8 (17% cf 4.2%) completed successfully 6 (13%) no SVR 20 (29%) ongoing treatment 3 in treatment and 2 under 6 months post 11 not suitable 23 (33.8% cf 59%) declined referral

17 Comparison

18 Treatment Outcomes Tx not suitable 17% DNA 0% In treatment 20% Patient declined 42% Tx failed 9% Cured 12% 38 patient group study 68 patient group study

19 Outcomes of those in treatment

20 Referral to Secondary Care 100% PCR positive patients offered referral 66% accepted referral Potential reasons Low public awareness of hepatitis C Low but improving in general practice Patient attitude Location of treatment Opinions of secondary services, particularly about current people using drugs, leading to fear and patient drop out

21 Hepatitis C Of Lonsdale 105 HCV positive population: 62 (59%) patients in drug treatment 18 (17%) ex-drug user (16 ex-injector, 2 exsnort) 25 (24%) with other factor including alcohol (6), South Asians (2), born abroad (4) High rate of co-infected in both injectors and MSM (9 = 8.7%) HPA 2011 estimate that of HCV positive people: 44% will be in current injectors 43% in ex-injectors 5.6% South Asians 7.3% white/other ethnicity never-injectors

22 Current people in drug treatment Totals in drug treatment Tested for HBV Declined testing For HBV Tested immune for HBV Offered HBV vaccs of those needing Completed course (76%) 4(3%) 57 (41%) 60 (76%)? Current OST (95%) 3(2.7%) 37 (41%) 59 (92%) 52(83%)

23 Conclusions Our detection, diagnosis, referral rate have improved since 2005 But HCV is still under diagnosed, especially in the groups not in drug treatment We are good at offering treatment but there is ongoing resistance to acceptance Cure rates for those treated in line with published data

24 Lessons for the Future Think hepatitis! Target the less obvious population Treatment for all who want it Work on knowledge & attitudes Health professionals and patients New drugs on the way so cure rates may be even better Treatment in Primary Care with Specialist support shows increased uptake

25 Help for primary care Search for all known patients Regular review & treatment update Do an audit of key groups especially current and past patients with drug problems Check LFT in people with vague and non-specific patients If abnormal check HBV,HCV & HIV status Arnold DT, Bentham LM, Jacob RP, Lilford RJ, Girling AJ. Should patients with abnormal liver function tests in primary care be tested for chronic viral hepatitis: cost minimisation analysis based on a comprehensively tested cohort. BMC Family Practice. 2011;12:9.

26 Practical suggestions Emodule now available!! RCGP Certificate in the detection, diagnosis and management of hepatitis B and C in primary care Part 1: emodule uk And training day