Prevention of and Immunisation against Hepatitis B and C Presentation 5 October 2018 0
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 and C 1
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 patients registrations Waiting room information Brief interventions and written materials are effective. Prevention opportunities arise all the time, brief interventions are useful. Written back up material should be used. 2
Hepatitis B and C prevention Harm reduction may include advice on safer injecting:- Not to share needles, syringes, water, filters, spoons and tourniquets How to access injecting equipment exchange IEP sites supply needles and syringes and other equipment used to inject or inhale drugs filters, foil, cookers, tourniquets, water for injections Do not assume PWID are aware of this. 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 is not already. Know where your local IEP sites are sign post people to them. 3
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 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 won t! 4
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 People in drug treatment services have better outcomes then 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. 5
Hepatitis B and C prevention (cont.) Safer sex:- Use condoms protective against HIV and Hepatitis C, may not always be protective against Hepatitis B (but Hepatitis B immunisation is!) Access to free condoms Where can your patients get free condoms? 6
Hepatitis B immunisation The objective is to provide a minimum of three doses of hepatitis B vaccine for: Infants, as part of the routine childhood immunisation programme, to protect against future exposure (pre-exposure immunisation) - total of three doses of vaccine at 8, 12 and 16 weeks of age using hexavalent vaccine Individuals at high risk of exposure or complications of the disease (pre-exposure) Individuals who have already been exposed (post exposure immunisation) including infants born to hepatitis B infected mothers NHS education for Scotland has produced a number of resources to support registered practitioners these can be found at the following link: https://www.nes.scot.nhs.uk/education-and-training/by-theme-initiative/publichealth/health-protection/immunisation/the-hexavalent-dtapipvhibhepbcombination-vaccine.aspx 7
Hepatitis B prevention (cont.) Selective immunisation of those at high risk of exposure or the complications of disease 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 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 won t do any harm. There is NO immunisation against Hepatitis C (or HIV). 8
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 Close family contacts of individuals with chronic hepatitis B 9
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 10
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 post exposure hepatitis B immunisation at birth, 4 weeks, 8 weeks, 12 weeks, 16 weeks and 12 months of age. Birth, 4 week and 12 month doses will be monovalent hepatitis B vaccine. Doses at 8, 12 and 16 weeks, are part of the routine childhood programme, using the infant hexavalent combination vaccine. If the mother is highly infectious or baby in pre-term they will also get Hepatitis B immunoglobulin at birth If any further information is required, hexavalent resources are available at http://www.nes.scot.nhs.uk/education-and-training/bytheme-initiative/public-health/health-protection/immunisation/thehexavalent-dtapipvhibhepb-combination-vaccine.aspx 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. 11
Prevention of vertical transmission of Hepatitis B (cont.) Post exposure 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 the risk of transmission 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 does at 5 years is recommended. There are many different immunisation schedules for hepatitis B vaccine which depend on the vaccine product used and how quickly protection is needed for pre or post exposure. Guidance to give both Hepatitis A and Hepatitis B immunisation or Twinrix (A and B) to ex or current IDU. Twinrix licenced 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 to much of the timing between doses is delayed try to give 3 doses over a shorter period and remember the 4 th 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. Guidance on booster doses now indicates that On the advice of the Joint Committee on Vaccination and Immunisation (JCVI), boosters (priority group 5) will no longer be routinely required in healthy, immunocompetent adults who have completed a primary course of vaccine, including healthcare workers who are known responders https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/683 13
830/Plan_for_phased_reintroduction_of_hepatitis_B_vaccine_for_lower_priority_groups_2018_.pdf. 13
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 non-immune contact after a SINGLE unprotected sexual exposure or parental exposure/needlestick injury This works best with 48 hours and is often of no use after more than seven days 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. 14
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) 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 Hepatitis B: the green book, chapter 18, updated December 2013. https://www.gov.uk/government/uploads/system/uploads/attactment_data/file/263 311/Green_Book_Chapter_18_v2_0.pdf accessed September 2015 15
Group work improving uptake of Hepatitis B immunisation It is important to share learning from this day with practice colleagues and to see 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 16
Group work improving uptake of Hepatitis B immunisation (cont.) This could be a strategy successfully implemented in own area which could be shared with a 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 17
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