Detection of Hepatitis B and C in Primary Care Presentation 2 October 2017 0
Learning Outcomes Participants will be able to: Identify groups of people who have a higher prevalence of Hepatitis B and C Recognise clinical presentations of these infections Discuss how we can detect Hepatitis B and C in primary care case finding Page 1 1
Hepatitis C Page 2 2
Hepatitis C routes of transmission Sharing of any injecting equipment filters, spoons, water Use of crack pipes and snorting cocaine All drug users should be offered testing as some may not disclose their injecting drug use Page 3 Injecting drug use is the commonest route of transmission in Scotland and the UK. Sharing of any of the equipment used to inject drugs can result in transmission of Hepatitis C not just needles and syringes. Some people who inject drugs may not be aware of the risk from sharing other paraphernalia. Other routes of using drug may also result in transmission exposure to microscopic amounts of blood can occur when snorting drugs or using crack pipes. Injecting drug use is highly stigmatised and some people may not wish to disclose this. Some people may not remember injecting on a single occasion. For this reason and due to the risk from snorting it is advised that all drug users are offered BBV testing even if they say they have never injected. 3
Hepatitis C routes of transmission (cont.) Sharing injecting equipment is the main risk Needle Exchange Surveillance Initiative (NESI) 2015 16 Report to measure and monitor the prevalence of the Hepatitis C virus (Hepatitis C) and injecting risk behaviours among injecting drug users (IDUs) in Scotland 21% of PWID (current), interviewed during 2015 16, reported having in last six months used filters, spoons or water that had previously been used by someone else This figure is lower than that reported in 2010 when the figure was 39% During June 2008 to June 2009 this had been 48% Page 4 One HPA estimate in England suggested approximately 31% of those with chronic Hepatitis C are current injectors, 57% are ex injectors and 12% had never injected. NESI is a survey of injecting drug users attending needle exchange sites across Scotland to determine injecting behaviour and also carries out anonymous Hepatitis C testing to determine prevalence of infection. The proportion of PWID (current) reporting having shared a previously used needle/syringe (i.e. injecting with a needle/syringe that had previously been used by someone else) within the six months prior to interview was 7% in 2015/2016 compared with 15% in 2008/2009. Needle Exchange Surveillance Initiative (NESI), Prevalence of Hepatitis C and injecting risk behaviours among people who inject drugs attending injecting provision services in Scotland 2008/2009 and 2015 16. Author: University of the West of Scotland, Publication date: March 2017 Sweeting MJ, De Angelis D, Brant LJ, Harris HE, Mann AG, Ramsay ME. The burden of Hepatitis C in England. J Viral Hepat 2007;14:570 6 4
Hepatitis C prevalence in Scotland Significant regional variation across Scotland with overall prevalence of 58% Prevalence in current PwlD in Scotland (2015/2016) 48% Lothian (41% in 2103/14), 65% Glasgow, 59% Tayside Uptake of opiate substitution therapy and high levels of needle/syringe provision can achieve substantial reductions in the risk of Hepatitis C transmission among PwlD but prevalence has risen in the last 2 year especially in new injectors Page 5 Information on the prevalence of Hepatitis C infection was available from two data sources, on IDUs who have: (i) had a named HIV test, from an unlinked anonymous testing survey; and (ii) attended services providing injection equipment, from the Needle Exchange Surveillance Initiative. Analysis of pooled data from across the UK, involving almost 1,000 IDUs surveyed in Greater Glasgow and Clyde NHS Board during 2008 2009, demonstrated that both the uptake of opiate substitution therapy and high levels of needle/syringe provision (i.e. a sterile needle/syringe for each injection) can achieve substantial reductions in the risk of Hepatitis C transmission among IDUs. However prevalence of Hep C in PWID has increased over the last 2 years for unknown reasons. Rapid Decline in HCV Incidence among People Who Inject Drugs Associated with National Scale Up in Coverage of a Combination of Harm Reduction Interventions. Norah E. Palmateer mail, Avril Taylor, David J. Goldberg, Alison Munro, Celia Aitken, Samantha J. Shepherd,Georgina McAllister, Rory Gunson, Sharon J. Hutchinson Published: August 11, 2014 DOI: 10.1371/journal.pone.010451. http://www.plosone.org/article/info%3adoi%2f10.1371%2fjournal.pone.0104515 5
Hepatitis C people who use drugs other issues Anabolic steroid users and Novel Psychoactive Substance users may not present to traditional drug services or IEP sites Due to the natural history of Hepatitis C infection, drug use that resulted in infection may have been many years ago they may no longer identify themselves as a drug user How can we identify these groups in primary care? Page 6 Primary care should be involved in testing current drug users but we also need to think about reaching other groups who will not be attending drug misuse services. In particular people who may have used drugs many years ago and no longer identify themselves as a drug user, they may have used drugs very infrequently or even on a single occasion. 6
Hepatitis C cases in Scotland other routes of transmission Piercings, tattoos and shaving where infection control is sub optimal Vertical transmission estimated to be a 5% risk with no interventions known to reduce this (breast feeding is not contra indicated) Needlestick injuries with hollow bore needles (1 in 50 risk of transmission from known Hepatitis C source) Page 7 Although drug use is the commonest route of transmission, it is not the only one and we need to be mindful of other risks where blood to blood exposure could have resulted in transmission. 7
Hepatitis C cases in Scotland other routes of transmission (cont.) Transmission rarely occurs through the sharing of personal items such as razors, nail clippers and toothbrushes that are contaminated with blood Partners/children therefore have a very low risk from household transmission Page 8 Transmission through this route is theoretically possible, so we advise against sharing of these items when a person is diagnosed with Hepatitis C. In reality this is a very low risk for transmission. 8
Hepatitis C cases in Scotland other routes of transmission (cont.) Sexual transmission: Heterosexual transmission of Hepatitis C is possible but uncommon. The risk of transmission is greater if the person is co infected with HIV or other STIs HIV co infection, particularly in gay men, may make it more likely to transmit Hepatitis C to sexual partners More likely if blood or trauma in sex e.g. anal sex Page 9 Cohort studies on heterosexual monogamous couples showed low incidence of lifetime transmission 0 2 per 1,000 years of sexual contact. Terrault NA. Sexual activity as a risk factor for Hepatitis C. Hepatology. 2002 Nov; 36(5 Suppl 1):S99 105 (M Klevens, D Daniels, K Iqbal, and others. Is Heterosexual Transmission an Important Risk Factor for Hepatitis C in the United States? 50th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC 2010). Boston, September 12 15, 2010. (Abstract V 1787). http://www.hivandhepatitis.com/2010_conference/icaac/ docs/0921_b.html accessed December 2012) However there is increasing evidence of transmission sexually in MSM, especially if they are HIV positive. van de Laar TJW, Matthews GV, Prins M, Danta M. Acute Hepatitis C in HIV infected men who have sex with men: an emerging sexually transmitted infection. AIDS 2010;24:1799 1812 Turner J, Bansi L, Gilson R, et al. for the UK Collaborative HIV Cohort (UK CHIC) Study. The prevalence of hepatitis C virus (HCV) infection in HIV positive individuals in the UK trends in HCV testing and the impact of HCV on HIV treatment outcomes. Journal of Viral Hepatitis 2010; 17: 569 577. 9
Danta M, Brown D, Bhagani S et al, Recent epidemic of acute hepatitis C virus in HIVpositive men who have sex with men linked to high risk sexual behaviours. AIDS 2007; 21 (8): 983 91. Hagan H1, Jordan AE, Neurer J, Cleland CM. Incidence of sexually transmitted hepatitis C virus infection in HIV positive men who have sex with men. AIDS. 2015 Nov;29(17):2335 45. doi: 10.1097/QAD.0000000000000834. 9
Hepatitis C cases in Scotland other routes of transmission (cont.) Receiving blood clotting factor concentrates prior to 1987 in UK Receiving blood and blood components before September 1991 and organ/tissue transplants before 1992 in UK Medical or dental treatment in countries where Hepatitis C is common and infection control may be poor e.g. Africa countries, South Asia (Pakistan, India) and Eastern Europe Page 10 10
Hepatitis C cases in Scotland other groups who should be considered for testing? MSM men who have sex with men (especially if HIV+ve) People who have lived in South Asia, Africa, Eastern Europe Anyone who has had a tattoo (from a unregistered practitioner) Sexual partner/child/household contact of Hepatitis C patient OR drug user Anyone who received blood before screening Page 11 All blood is now screened in the UK and Western countries but as we have said before people may have been at risk from blood or blood products prior to screening and from this or other unsterile medical treatment abroad. 11
Prevalence of chronic infection with Hepatitis C Source: CDC Yellow Book (https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious diseases related totravel/hepatitis c) Page 12 This map shows the prevalence of Hepatitis C infection across the world. Higher prevalence in parts of South America, Africa, South Asia and Eastern Europe. 12
Hepatitis C cases in Scotland other groups who should be considered for testing? Anyone diagnosed with HIV or Hepatitis B Anyone who has been in prison Hepatitis C prevalence studies in Scotland s prisons in 2012 all adult prisons were surveyed. Overall, Hepatitis C antibody prevalence was 19%. Page 13 If you have been at risk of one BBV, you may have been at risk of the others and should be tested for them. Do not assume that someone will have been tested at the specialist service if they are being treated for a BBV. Prisoners have a higher risk of Hepatitis C infection likely to be due to higher incidence of injecting drug use. 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 13
Clinical reasons for Hepatitis C testing Investigation of icteric Hepatitis Investigation of abnormal liver function tests (LFT) studies suggest it is more effective to screen everyone with abnormal LFT NB: Normal LFT do NOT exclude Hepatitis C infection Investigation of chronic fatigue? Page 14 We should also think about Hepatitis C infection when attempting to diagnoses some clinical syndromes. Although acute Hepatitis is uncommon in Hepatitis C infection it can occur and jaundice may also occur due to chronic liver damage. Hepatitis C is common enough that is should be part of a routine liver screen investigating abnormal LFTs. 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. Arnold DT, Bentham LM, Jacob RP, Lilford RJ, Girling AJ. BMC Fam Pract. 2011;12:9 Follow up of mild alanine aminotransferase elevation identifies hidden hepatitis C in primary care Charles Helsper et al Br J Gen Pract. 2012 Mar; 62(596): e212 e216. Published online 2012 Feb 27. doi: 10.3399/bjgp12X630115 14
Hepatitis B Page 15 15
Hepatitis B prevalence in Scotland Scotland has historically been a country of very low prevalence of Hepatitis B the number of people... with chronic Hepatitis B infection has increased considerably, (due to) a rise in the number of immigrants coming from countries in the world where the prevalence of Hepatitis B infection is high (particularly East Asia) Page 16 Hepatitis B is largely an imported infection. Prevalence is increasing in Scotland due to immigration. Hahne, S. Ramsay, M. Balogun, k. Edmunds, WJ. Mortimer, P. Incidence and routes of transmission of Hepatitis B virus in England and Wales, 1995 2000: implications for immunisation policy, Journal of Clinical Virology, Volume 29, Issue 4, April 2004, Pages 211 220. 16
Prevalence of chronic infection with Hepatitis B virus, 2006 Source: https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious diseases related to travel/hepatitis b Page 17 This map shows the areas of the world with a higher prevalence of Hepatitis B infection South Asia, including China and Africa are where most of the imported infection in the UK derives from. 17
Hepatitis B prevalence in Scotland (cont.) 4966 the number of people diagnosed and living in Scotland with chronic Hepatitis B infection by the end of December 2015 Majority of infected individuals will be of Asian, African or Eastern European ethnicity (73%) A considerable proportion, estimated 46%, of infected persons in Scotland remain undiagnosed Page 18 Surveillance systems for Hepatitis B in Scotland have until recently been rudimentary or non existent. New systems are being developed and implemented. Health Protection Scotland Surveillance Reports. Hepatitis B in Scotland 2015, published 17 January 2017, accessed October 2017. http://www.hps.scot.nhs.uk/bbvsti/wrdetail.aspx?id=71817&wrtype=6 18
Hepatitis B routes of transmission Hepatitis B is the most infectious BBV 100 times more infectious than HIV Page 19 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. World Health Organisation Hepatitis B Fact sheet No. 204, July 2016, http://www.who.int/mediacentre/factsheets/fs204/en accessed October 2016 http://www.who.int/mediacentre/factsheets/fs204/en/ 19
Hepatitis B routes of transmission (cont.) In endemic countries the majority of infections are VERTICAL, that is passed from mother to child in utero, in childbirth or through breast feeding In the UK the most common route of transmission is by unprotected penetrative vaginal, anal or oral sex without using a condom Page 20 In developing countries, common modes of transmission are: perinatal (from mother to baby at birth) early childhood infections (inapparent infection through close interpersonal contact with infected household contacts) unsafe injection practices unsafe blood transfusions unprotected sexual contact. In many developed countries (e.g. those in western Europe and North America), 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. Hepatitis B is a major infectious occupational hazard of health workers. The Hepatitis B virus is not spread by contaminated food or water, and cannot be spread casually in the workplace. World Health Organisation Hepatitis B Fact sheet No. 204, July 2016, http://www.who.int/mediacentre/factsheets/fs204/en accessed October 2016 http://www.who.int/mediacentre/factsheets/fs204/en/ 20
Hepatitis B routes of transmission (cont.) Sharing any equipment used to inject, snort or smoke drugs i.e. needles, syringes, spoons, water, filters, straws, notes, crack pipes Using unsterile equipment and poor infection control procedures for tattooing, body piercing, ear piercing and acupuncture Page 21 21
Hepatitis B routes of transmission (cont.) Undergoing medical or dental treatment in some countries where Hepatitis B is common and where infection control is inadequate Sustaining an occupational injury involving transmission of blood e.g. needlestick injuries Bites that break the skin Transmission may rarely occur through the sharing of personal items such as razors, and toothbrushes Page 22 Other, much rarer risks. 22
Who should be considered for testing? Page 23 Audience should be asked to suggest risk groups e.g.: Immigrants and family members of immigrants from higher prevalence countries MSM People with frequent change of sexual partners, sex industry workers 23
Who should be considered for Hepatitis B testing? Immigrants and family members of immigrants from higher prevalence countries MSM People who have used drugs People with frequent change of sexual partners, sex industry workers People who have had medical or dental treatment in countries where sterilisation of equipment may not have been satisfactory People who have undergoing piercing or tattooing in circumstances where sterilisation of equipment may not have been satisfactory Household contacts of Hepatitis B infected patients Page 24 MSM and IDU important but low prevalence in UK MSM: The prevalence of Hepatitis B infection in MSM is higher than in the general population. During the 1980s, the prevalence of Hepatitis B infection among MSM ranged from 34.0% to 81.7%, while HBsAg prevalence was 3.0% to 8.7%. IDU: During the 1990s, several hundred new transmissions of Hepatitis B infection were diagnosed annually in Scotland, during a time when outbreaks of infection among injecting drug users were relatively frequent. Acute hepatitis B (England): annual report for 2015 Infection reports / Immunisation Volume 10 Number 28 Published on: 26 August 2016 24
Clinical reasons for Hepatitis B testing Investigation of acute icteric Hepatitis Investigation of abnormal LFTs People about to undergo immunosuppressive therapy or renal dialysis All pregnant women to prevent vertical transmission Investigation of sexually transmitted disease Co existent Hepatitis C or HIV infection Page 25 25