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Hepatitis B and C testing: people at risk of infection

This Guidelines for Nurses summary is deliberately concise—covering recommendations 1–4, and 7–11. For the complete list of recommendations, please refer to the full guideline

Recommendation 1

Awareness-raising about hepatitis B and C among the general population

  • Conduct awareness-raising campaigns, using campaign material and resources on hepatitis B and C. These should include up-to-date information on:
    • the main routes of infection and transmission
    • hepatitis B vaccination
    • the benefits of early testing and treatment, including the role of earlier treatment in preventing serious illness such as chronic liver disease and liver cancer
    • the potential for chronic infection to be asymptomatic, particularly in the early stages
  • Ensure national and local awareness-raising campaigns address common misconceptions about the risk of hepatitis B and C that can act as a barrier to testing. This includes the belief that treatments are not effective, or that treatment is not needed until the illness is advanced. Campaigns should also make it clear that testing and treatment is confidential and address the stigma surrounding these infections
  • Ensure messages to raise awareness of hepatitis B and C are coordinated and integrated within other health promotion campaigns, where possible or appropriate
  • Ensure national and local awareness-raising activities take into account age, culture, and religious beliefs of groups at increased risk, and their needs in relation to format and the language used. For example, the needs of people with low literacy level and learning disabilities, and people with little interaction with statutory services should be considered

Recommendation 2

Awareness-raising for people at increased risk of hepatitis B or C infection

  • Public Health England, the NHS Commissioning Board, and directors of public health should facilitate partnership working to ensure there is a coordinated national and local programme of awareness-raising about hepatitis B and C among groups at increased risk
  • Directors of public health should promote local testing and hepatitis B vaccination services
  • Local and national organisations should provide awareness-raising material tailored to the needs of groups at increased risk. In addition to the information outlined in recommendation 1, this should:
    • inform people how and where to access local testing and hepatitis B vaccination services
    • describe what testing for hepatitis B and C involves
    • explain how a positive diagnosis can affect lifestyle
  • Material should:
    • address the needs of non-English-speaking groups at increased risk, for example, by providing translated information or information in audio or visual formats
    • be culturally and age appropriate
    • address the needs of people with low literacy levels or learning disabilities
  • Local organisations should encourage and support people from groups at increased risk who have been diagnosed with hepatitis B or C to contribute to awareness-raising activities (for further information see NICE guidance on Community engagement )
  • Local organisations should run awareness-raising sessions to promote hepatitis B and C testing in venues and at events popular among groups at increased risk. Examples of possible venues include: faith and cultural centres, NHS and non-NHS drugs services, GP surgeries, sexual health and genitourinary medicine services, immigration centres, hostels for the homeless, prisons and youth offender institutions
  • Local and national organisations should consider offering testing for hepatitis B and C at awareness-raising sessions. If this is not possible, information on where and how to access testing locally should be provided

Recommendation 3

Developing the knowledge and skills of healthcare professionals and others providing services for people at increased risk of hepatitis B or C infection

  • Ensure there is an ongoing education programme for professionals providing health and social care services for people at increased risk of hepatitis B or C infection. This includes:
    • clinical and non-clinical staff in primary and secondary care including nurses, health visitors, midwives, healthcare assistants and support workers as well as staff in sexual health, genitourinary medicine and HIV clinics
    • people working in drugs services
    • staff in community-based criminal justice services
    • social workers working with people at increased risk of hepatitis B or C infection
    • statutory and non-statutory staff working with looked-after children
    • prison, youth offender, and immigration removal centre staff
    • staff in voluntary and community organisations that care for or support migrant populations, people who inject drugs, people with HIV, or men who have sex with men
    • people working in hostels for the homeless and providing outreach services to homeless people
  • Ensure education programmes address the following core topics and are designed to meet the needs of the target group:
    • incorporating the recommendations in national guidance to improve identification and testing of people at increased risk of hepatitis B and C infection
    • overcoming social and cultural barriers, and improving access to testing and treatment for people at increased risk of hepatitis B and C infection
    • reducing morbidity and mortality associated with hepatitis B and C through early detection and diagnosis
    • improving clinical management and quality of life for people diagnosed with hepatitis B and C infection, and reducing the number of people admitted to secondary and tertiary care with hepatitis B- and C-related morbidity, for example, liver disease
  • Ensure training programme content is accurate and up-to-date, reflecting advances in testing, diagnosis, and treatment of hepatitis B and C
  • Think about linking awareness-raising activities with existing education for health and social care professionals. This could take a variety of forms, for example, it could be offered as a taught or an electronic learning module
  • Local education and training boards in each region should ensure that people involved in testing for hepatitis B and C take part in a programme of continuing professional development
  • Directors of public health should ensure all healthcare and public health managers, in collaboration with the local education and training board, use staff annual appraisals and personal development plans to reinforce training and education on hepatitis B and C

Recommendation 4

Testing for hepatitis B and C in primary care

  • GPs and practice nurses should offer testing for hepatitis B and C to adults and children at increased risk of infection, particularly migrants from medium- or high-prevalence countries and people who inject or have injected drugs
  • GPs and practice nurses should offer testing for hepatitis B and C to people who are newly registered with the practice and belong to a group at increased risk of infection
  • GPs and practice nurses should ask newly registered adults if they have ever injected drugs, including image and performance enhancement substances, at their first consultation
  • GPs and practice nurses should offer hepatitis B testing and vaccination to men who have sex with men who are offered a test for HIV and have not previously tested positive for hepatitis B antibodies (see NICE guidance on Increasing the uptake of HIV testing among men who have sex with men )
  • GPs and practice nurses should offer hepatitis B vaccination to people who test negative for hepatitis B but remain at increased risk of infection (see the Green book )
  • GPs and practice nurses should offer annual testing for hepatitis C to people who test negative for hepatitis C but remain at increased risk of infection
  • GPs and practice nurses should ensure people diagnosed with hepatitis B or C are referred to specialist care
  • Local community services serving migrant populations should work in partnership with primary care practitioners to promote testing of adults and children at increased risk of infection. This should include raising awareness of hepatitis B and C, promoting the availability of primary care testing facilities, and providing support to access these services
  • Staff providing antenatal services, including midwives, obstetricians, practice nurses, and GPs, should ask about risk factors for hepatitis C during pregnancy and offer testing for hepatitis C to women at increased risk. Women who are diagnosed with hepatitis C should be offered hepatitis A and B vaccination in line with the Green book

Recommendation 7

Testing for hepatitis B and C in sexual health and genitourinary medicine clinics

  • Commissioners of hepatitis testing and treatment services should agree local care pathways for people with hepatitis B and C who use sexual health and genitourinary medicine clinics
  • Sexual health and genitourinary medicine clinics should:
    • offer hepatitis B vaccination to all service users in line with the Green book
    • offer and promote hepatitis B and C testing to all service users at increased risk of infection, including people younger than 18
    • ensure people diagnosed with hepatitis B or C are referred for specialist care
    • ensure staff have the knowledge and skills to promote hepatitis B and C testing and treatment (see recommendation 3)
    • ensure staff who undertake pre- and post-test discussions are trained and competent to do so

Recommendation 8

Contact tracing

  • Public Health England centres should:
    • take overall responsibility for tracing the close contacts of people with confirmed acute and chronic hepatitis B infection
    • advise and oversee the activities of other local organisations undertaking contact tracing, such as GP surgeries and genitourinary medicine clinics, to ensure the national standards for local surveillance and follow-up of hepatitis B and C are met. For example, GPs may need to offer close contacts hepatitis B vaccination and refer for treatment
  • Primary care practitioners should promote the importance of hepatitis C testing for children who may have been exposed to hepatitis C at birth or during childhood

Recommendation 10

Commissioning locally appropriate integrated services for hepatitis B and C testing and treatment

  • Local authorities, in particular directors of public health and clinical commissioning groups, should ensure the inclusion of hepatitis B and C in the health and wellbeing board's joint strategic needs assessment. This should provide information on local prevalence of chronic hepatitis B and C and groups at increased risk, including by country of origin or risk behaviour
  • Commissioners should encourage the development of locally enhanced services for hepatitis B and C in areas where there is a higher than average number of people at increased risk (especially areas with a large migrant population or high prevalence of people who inject drugs)
  • Commissioners should regularly undertake a health needs assessment, health equity audit, and an audit of hepatitis B and C services as part of the agreed local care pathway and commission testing and treatment services accordingly
  • Commissioners should ensure mechanisms are in place for following up patients who defer treatment
  • Commissioners should audit the uptake of testing and outcomes, including:
    • the number of people tested for hepatitis B and C
    • the number of people diagnosed with hepatitis B and C
    • the number of people with chronic infection who:
      • are referred to a treatment service
      • attend a treatment service
      • are receiving treatment in accordance with treatment guidelines
    • the number of people with hepatitis C who obtain a sustained virological response on antiviral therapy
  • Commissioners should develop and commission a fully integrated care pathway, working with services that provide hepatitis B and C testing and treatment in primary and secondary care (in the community or specialist services in hospital). This should:
    • take into account the needs of people who test positive for hepatitis B or C infection and are assessed for treatment, including their broader health and psychosocial needs
    • consider all venues where testing and treatment services are, or could be offered that can also ensure continuity of care and onward referral to specialist treatment for people who test positive (such as pharmacy testing and outreach testing and treatment)
    • ensure primary and secondary care staff are educated and trained in hepatitis B and C testing and treatment (see recommendation 3)

Recommendation 11

Laboratory services for hepatitis B and C testing

  • Ensure that samples are transported from patients to laboratories within 24 hours (adjusted for weekends and bank holidays as necessary)
  • Ensure service specifications specify that laboratory services providing hepatitis B and C testing:
    • have Clinical Pathology Accreditation (UK)
    • can support the range of samples used for hepatitis B and C testing (for example, dried blood-spot or venepuncture samples) or can refer the sample to a laboratory which can perform these tests
    • automatically test samples that are positive for hepatitis C antibody for the presence of hepatitis C virus (for example, using a polymerase chain reaction [PCR] assay), or refer the sample to a laboratory which can perform this test
    • can deliver results within 2 weeks of the sample being received
    • ensure local Public Health England centres are notified of cases of hepatitis B and C infection, in line with national public health legislation
    • provide the organisation or professional requesting a test with an accurate interpretation of the laboratory results and guidance on future management of confirmed cases, such as onward referral to specialist care
  • Ensure laboratory services provide accurate data on the following:
    • the number of people tested and the type of test performed
    • the referral source of samples (for example, primary care, secondary care, drug and alcohol services, prisons)
    • exposure category, if provided
    • the number of people testing positive:
      • for hepatitis B, this should include acute, chronic, and past infection
      • for hepatitis C, this should include PCR positive/current and PCR negative/resolved

 

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© NICE 2016. Hepatitis B and C testing: people at risk of infection. Available from: www.nice.org.uk/guidance/PH43. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication. 

First included: May 2016.