We need to know who is at risk of Hepatitis B and C infections so that we can identify them and offer them testing. Primary care has important roles

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2 We need to know who is at risk of Hepatitis B and C infections so that we can identify them and offer them testing. Primary care has important roles in diagnosing patients but also after diagnosis, helping people to minimise damage to their liver and supporting them into and through treatment. 1

3 Treatment reduces morbidity and mortality in those infected with Hepatitis B and C - both infections are also underdiagnosed meaning that many people develop significant liver disease before they know they are infected. 2

4 Hepatitis C in the UK: 2017 report. Authors: PHE, Publication date: July

5 In the UK Hepatitis C is largely an infection of People who inject drugs. The prevalence of infection in people who inject drugs in Scotland ranges from 51 to 65 % in different NHS board areas. Hepatitis C in the UK: 2017 report Authors: PHE, Publication date: July

6 Some groups of people other than drug users also have a higher prevalence of Hepatitis C infection - this includes prisoners (19% prevalence across all prisons in Scotland) but that may be due to high levels of injecting drug use in that population (up to 58% and usually between a quarter and a third of prisoners are PWID). Hepatitis C Prevalence and Incidence among Scottish Prisoners and Staff Views of its Management, Final Report. Authors: University of the West of Scotland et al. Published: May 2012 Hepatitis C prevalence also varies across the world varies and immigrants from higher prevalence countries are an important target for testing. Areas of the world with a higher prevalence are South Asia including Pakistan and India, Eastern Europe and certain parts of Africa (e.g. Nigeria and Ghana). These areas of the world often have poorly developed health services where infection control can be poor increasing risk of infection to residents and travellers who receive medical or dental care. Prior to screening of blood and blood products Hepatitis C could be transmitted in this way, it would have come under the heading of non-a, non-b Hepatitis at that time. A look back exercise was carried out to attempt to diagnose these people but a small number may not have been diagnosed. The report of the Penrose Enquiry published in March 2015 recommended Hepatitis C testing for all people who received a blood transfusion prior to Sexual transmission of Hepatitis C is not common other than in one group, HIV+ve 5

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8 So what are the consequences of being infected with Hepatitis C? Acute HCV infection is asymptomatic in 50-90% of cases. Failure to spontaneously eradicate infection occurs in 50-90% of cases according to the route of transmission, the presence of symptomatic Hepatitis, and to the age at which infection occurred. Santantonio T, Wiegand J, Gerlach JT. Acute Hepatitis C: current status and remaining challenges. J Hepatol 2008;49: Emphasis that Hepatitis C is a serious disease. Liver disease progression takes place over several decades, and is accelerated in the presence of co-factors such as alcohol consumption, diabetes mellitus (to which HCV itself appears to predispose), older age of acquisition, human immunodeficiency virus (HIV) co-infection, or co-infection with other hepatotropic viruses. HCV infection has become the leading cause of primary liver cancers in Europe. Extra hepatic manifestations including cryoglobulinaemia, lichen planus, porphyria cutanea tarda, lymphocytic sialoadenitis, and membranous glomerulonephritis may occur. EASL Recommendations on Treatment of Hepatitis C J Hepatol (2016), jhep

9 This graph shows the annual number of deaths related to liver disease in patients with Hepatitis C infection. The blue bars show patients with any mention of liver disease on the death certificate and the orange bars show patients with end stage liver disease as the cause of death. In both cases you can see that the number of deaths is growing annually. 8

10 Hepatitis B across the world is a huge problem, it is largely due to endemic vertical transmission but can also be due to injecting drug use, unsterile medical care, transmission to close family contacts and sexual transmission. Two billion people worldwide have been infected with the virus and about people die every year due to the consequences of Hepatitis B. Hepatitis B is endemic in China and other parts of Asia % of the adult population is chronically infected. Liver cancer caused by Hepatitis B is among the first three causes of death from cancer in men, and a major cause of cancer in women in this region. High rates of chronic infections are also found in the Amazon and the southern parts of eastern and central Europe. In the Middle East and Indian subcontinent, an estimated 2 5% of the general population is chronically infected. Less than 1% of the population in western Europe and North America is chronically infected. World Health Organisation Hepatitis B Fact sheet, July 2017, - accessed October

11 S America Brazil/Peru and the Amazon Basin Africa China/SE Asia regions 10

12 It is largely an imported infection and immigrants are at the highest risk. For infections acquired within the UK, patterns of transmission are different from those in developing countries. The majority of infections in developed countries are transmitted during young adulthood by sexual activity and injecting drug use. MSM have a higher risk of infection due to the higher risk of anal sex. World Health Organisation Hepatitis B Fact sheet, July 2017, - accessed October

13 Hepatitis B virus is transmitted between people by direct blood-to-blood contact or semen and vaginal fluid of an infected person but also potentially through other bodily fluids such as saliva. Hepatitis B virus is 50 to 100 times more infectious than HIV. Unlike HIV, the Hepatitis B virus can survive outside the body for at least seven days. During this time, the virus can still cause infection if it enters the body of a person who is not protected by the vaccine. This means that people living in close, non-sexual contact, may also be at risk of infection and occupational risk is high in unimmunised people. World Health Organisation Hepatitis B Fact sheet, July 2017, - accessed October

14 Most people do not experience any symptoms during the acute infection phase. However, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain. 13

15 The likelihood that infection with the Hepatitis B virus becomes chronic depends upon the age at which a person becomes infected. Young children who become infected with the Hepatitis B virus are the most likely to develop chronic infections: 90% of infants infected during the first year of life develop chronic infections 30-50% of children infected between one to four years of age develop chronic infections. In adults: 25% of adults who become chronically infected during childhood die from Hepatitis B-related liver cancer or cirrhosis; 95% of healthy adults who are infected with the Hepatitis B virus will recover and be completely rid of the virus within six months. World Health Organisation Hepatitis B Fact sheet, July 2017, - accessed October

16 Advice about weight reduction, alcohol reduction, smoking, diabetes control and other co-factors in liver damage are an important role for primary care. 15

17 Minimising liver damage through diagnosis and treatment of the viruses but also through management of other factors which cause liver damage 16