Cmo Hepatitis C

27 October 2008
Improving the detection and diagnosis of hepatitis C in primary care

Dear Colleague, We are writing to ask for your help in improving the detection and diagnosis of hepatitis C in primary care. This would do much to reduce the level of undiagnosed infection and enable referral of those infected for specialist assessment and treatment with antiviral drugs recommended by the National Institute for Health and Clinical Excellence (NICE). The Departments guidance, Hepatitis C: Quick reference guide for primary care provides a single sheet of concise information and good practice advice about hepatitis C testing and diagnosis for use by doctors and nurses in primary care, including a testing and diagnosis flowchart (copy attached).1 Although diagnoses of hepatitis C have been increasing since the Departments Hepatitis C Action Plan for England was published in 2004,2 it is estimated that there could be about 100,000 people with undiagnosed chronic hepatitis Cd. Therefore, efforts need to be sustained and improved, as was highlighted in CMO Update 47 in May 2008,3 because hepatitis C can lead over time to cirrhosis and primary liver cancer. As mentioned, there is effective drug therapy recommended by NICE, which can prevent this.4 Treatment for chronic hepatitis C should be provided by a hepatitis C specialist - usually a consultant hepatologist, gastroenterologist or infectious disease physician. Most people who have hepatitis C infection experience no symptoms for many years, which means it is unlikely that people will actively seek a test. Therefore, unless a patient has unexplained abnormal liver function tests or unexplained jaundice, the only indications for offering testing will be risk factors for hepatitis C infection. As a blood-borne virus, hepatitis C is mainly spread through direct bloodto-blood contact. In this country, patients who may have injected drugs (even if only once, a long time ago) are most at risk. Other transmission routes include through a blood transfusion (before September 1991), or through blood products (before 1986) in the United Kingdom. Hepatitis C can also be transmitted through tattooing or piercing with unsterile equipment or by sharing razors or toothbrushes with someone infected with the virus. There is a small risk of contamination from mother to child during pregnancy or childbirth and through unprotected sex with someone who has the virus.
From the Chief Medical Officer and the Chief Nursing Officer
Sir Liam Donaldson MSc, MD, FRCS(Ed), FRCP, FFPHM Professor Dame Christine Beasley CBE RN
Richmond House 79 Whitehall London, SW1A 2NS PL/CMO/2008/7, PL/CNO/2008/7

For action Chief Executives of Primary Care Trusts Chief Executives of Strategic Health Authorities in England For information PCT Directors of Public Health PCT Medical Directors Lead Nurses at PCTs Chief Executives of NHS Trusts Medical Directors of NHS Trusts Consultants in Communicable Disease Control NHS Foundation Trusts
Hepatitis C: Quick reference guide for primary care. Available from www.nhs.uk/Livewell/hepatitisc/Documents/hep_c_quick_ref_guide_for_primary_care.pdf and from the DH Orderline in hard copy quoting publication number 280160 (www.orderline.dh.gov.uk; telephone 0300 123 1002; e-mail: [email protected]) 2 www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4084 521 3 www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/CMOupdate/DH_084715 4 www.nice.org.uk/Guidance/TA75 and www.nice.org.uk/Guidance/TA106
Medical or dental treatment abroad in countries where hepatitis C is common (e.g. parts of the Middle East, Asia and Africa), and where infection control may be poor, is also a risk. There is emerging evidence that Pakistani communities in this country may be at increased risk of infection. We are continuing our national hepatitis C awareness campaign for healthcare professionals, the general public and groups at increased risk of infection. The campaign is supported by a website for healthcare professionals and the public at www.nhs.uk/hepc and a Hepatitis C information Line (0800 451451). The National Treatment Agency for Substance Misuse has commissioned a harm reduction campaign for current injecting drug users. This should help in contributing to increased testing, diagnosis and treatment of those at risk. Patients who remain undiagnosed are at risk of serious liver disease. Please ensure that GPs, practice nurses and appropriate community nurses are made aware and that every effort is made to offer patients a hepatitis C test in primary care if they may have been exposed to hepatitis C infection and recommend to them that they should accept testing, as there is effective treatment available.
Improving detection and diagnosis of hepatitis C in primary care
Date: 27 October 2008
Further information Gerry Robb Department of Health, Room 531 Wellington House, 133-155 Waterloo Road, London SE1 8UG [email protected] Authorised by the Department of Health: Gateway no: 10544
Sir Liam Donaldson Chief Medical Officer
Professor Dame Christine Beasley Chief Nursing Officer
Hepatitis C
Quick reference guide for primary care
What is hepatitis C (HCV)?
A blood-borne virus, spread mainly through blood-toblood contact Can damage the liver, potentially causing cirrhosis and primary liver cancer Symptoms can take years or decades to occur An estimated 200,000 people are chronically infected in England HCV has been associated with injecting drug use, but there are a variety of ways in which it can be transmitted (see below)
Pre-test discussion
Pre-test discussion should include: Hepatitis C, its natural history and the benefits offered by treatment What the test involves, testing timescale and confidentiality of results Assessment of exposure risks and establishing when the last risk activity took place Implications of a positive result for the individual and his/her family or close contacts What personal support network the individual may have; information about national/local organisations that provide support It may also offer the opportunity to advise injecting drug users about harm minimisation and to offer them the hepatitis A and hepatitis B vaccine.
Why should I be proactive in diagnosing HCV?

The majority of those infected in England are probably unaware of it Treatment can successfully clear the virus in more than half of patients treated overall
Who is at risk of HCV?

Hepatitis C testing should also be offered to anyone who: Has unexplained abnormal liver function tests (e.g. elevated ALT), or unexplained jaundice Has ever injected drugs in the past (including anabolic steroids) using shared equipment, however long ago, even if this was only once or twice Has had a blood transfusion in the UK before September 1991 or received any blood products before 1986 Has received medical or dental treatment in countries where infection control may be poor Is the child of a mother with HCV Is a regular sexual partner of someone with HCV Has been accidentally exposed to blood where there is a risk of transmission of HCV Has had tattoos, piercings, acupuncture or electrolysis where infection control procedures are poor
Post-test discussion
Post-test discussion should also include: Negative antibody result Further testing will be required if the last exposure risk occurred in the preceding three month window period Ways of avoiding infection in the future Positive antibody result Positive antibody results should be confirmed on a second blood sample, when tests for HCV RNA can also be performed if the positive antibody results are confirmed Advise not to donate blood or carry an organ donor card Positive HCV RNA result Patients should be referred to a specialist for further assessment Stop or reduce alcohol consumption (associated with more rapid progression of liver disease) Ways of avoiding infecting others Consider the need to test other family members or close contacts Negative HCV RNA result A positive antibody and negative HCV RNA test indicates a previously resolved infection, but not immunity to further infection Patients who are antibody positive but HCV RNA negative should have a second HCV RNA test after 46 weeks to confirm their negative status
How do I test for HCV?

The primary screening test is a blood test for antibodies to the virus (anti-HCV), which indicates if a person has ever been infected with HCV. A positive test should be confirmed by testing a second sample. It can take three months for antibodies to become detectable. A negative test should be repeated if the exposure was within three months of the test. About 2040% of people will clear the virus naturally, so a test to detect HCV RNA is required to establish if the patient is still infected.
Hepatitis C
What you need to know
Treatment for HCV
The National Institute for Health and Clinical Excellence (NICE) recommends treatment of chronic hepatitis C with combined pegylated interferon and ribavirin, which can successfully clear the virus in up to 55% of patients overall. Current injecting drug users and people who drink excess alcohol are not precluded from treatment. Since the recent NICE recommendations, liver biopsy need no longer be routine in assessing patients for treatment, though it may be advised for some patients. Treatment may have side effects but these can be satisfactorily managed in most cases. Treatment may be contraindicated for some medical and psychiatric conditions.
From diagnosis to treatment flow chart

Unexplained abnormal liver function tests or unexplained jaundice Pre-test discussion HCV antibody test Test positive Repeat antibody test on second sample for confirmation Test positive HCV RNA test Test positive Referral to a hepatitis C specialist Post-test discussion Test positive Further tests Treatment (subject to no contraindications) Test negative Post-test discussion Test negative Repeat antibody test, if in window period Post-test discussion, if not in window period
Identify risk factor(s)
Test negative
Repeat HCV RNA test on a second sample for confirmation
Further information
NHS hepatitis C awareness website: www.hepc.nhs.uk Hepatitis C Information Line: 0800 451 451 To obtain further copies of this guide call the Department of Health publications line 08701 555 455 or email [email protected] quoting publication number 280160.
Test negative Post-test discussion

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27 October 2008

Improving the detection and diagnosis of hepatitis C in primary care

Richmond House 79 Whitehall London, SW1A 2NS PL/CMO/2008/7, PL/CNO/2008/7

Improving detection and diagnosis of hepatitis C in primary care

Date: 27 October 2008

Sir Liam Donaldson Chief Medical Officer

Professor Dame Christine Beasley Chief Nursing Officer

Why should I be proactive in diagnosing HCV?

Who is at risk of HCV?

How do I test for HCV?

From diagnosis to treatment flow chart

Identify risk factor(s)

Repeat HCV RNA test on a second sample for confirmation

Test negative Post-test discussion

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