NICE public health guidance
Issued: December 2012 (last modified: March 2013)
PH43

Hepatitis B and C: ways to promote and offer testing to people at increased risk of infection

This is an extract from the guidance. The complete guidance is available at guidance.nice.org.uk/ph43

1 Recommendations

Introduction

There has been a change in recommendation 7. See Changes after publication for details.

The evidence statements underpinning the recommendations are listed in appendix C.

The Programme Development Group (PDG) considers that the recommended measures and approaches are cost effective.

For the research recommendations and gaps in research, see section 5 and appendix D respectively.

Pre-requisites

The recommendations are based on the assumption that hepatitis B and C tests are provided according to current best practice and are offered as part of a care pathway covering diagnosis, treatment and immunisation.

Testing

The recommendations assume that:

  • Testing facilities are equipped with sharps bins and follow advice on infection control and appropriate testing methods, particularly if testing is done outside healthcare settings.

  • People being tested for hepatitis B and C are offered pre- and post-test discussions (see Box 1).

  • Testing is undertaken with the person's consent.

  • Standards for local surveillance are followed, including laboratory reporting to Public Health England centres and follow-up of hepatitis B and C.

Box 1. Areas to consider when offering a test for hepatitis B or C

Have issues of confidentiality and anxiety been addressed?

Has the offer been accompanied by an agreed mechanism for providing the result to the person being tested?

Has the offer been phrased in a way that suits the person's age, culture and literacy level and is respectful and non-judgemental?

Has the offer taken into account potential barriers to testing such as the stigma associated with hepatitis B and C or lack of access to services?

Has the offer included information to enable people to make informed choices about their care should they test positive, and to reduce their risk of hepatitis B and C infection should they test negative?

Has the offer been accompanied by details of support available for clinical and non-clinical needs, both while waiting for test results and following diagnosis?

Treatment

NICE has recommended a number of drugs to treat hepatitis B and C and also has clinical guidelines in development on the diagnosis and management of hepatitis B and C (see section 7 for details). Guidance on managing co-infection with HIV-1 and hepatitis B or C is available from the British HIV Association[1]. The European Association for the Study of the Liver (EASL)[2] has published best practice guidelines on managing hepatitis B and hepatitis C.

Immunisation

Whose health will benefit?

In the UK, the majority (95%) of new chronic hepatitis B infections occur in migrant populations, having been acquired perinatally in the country of birth. In contrast, approximately 90% of chronic hepatitis C infections are seen in people who inject drugs or have done so in the past.

Groups at increased risk of hepatitis B compared with the general UK population include:

  • People born or brought up in a country with an intermediate or high prevalence (2% or greater) of chronic hepatitis B. This includes all countries in Africa, Asia, the Caribbean, Central and South America, Eastern and Southern Europe, the Middle East and the Pacific islands.

  • Babies born to mothers infected with hepatitis B.

  • People who have ever injected drugs.

  • Men who have sex with men.

  • Anyone who has had unprotected sex, particularly:

    • people who have had multiple sexual partners

    • people reporting unprotected sexual contact in areas of intermediate and high prevalence)

    • people presenting at sexual health and genitourinary medicine clinics

    • people diagnosed with a sexually transmitted disease

    • commercial sex workers.

  • Looked-after children and young people, including those living in care homes.

  • Prisoners, including young offenders.

  • Immigration detainees.

  • Close contacts of someone known to be chronically infected with hepatitis B.

For hepatitis C, groups at increased risk include:

  • People who have ever injected drugs.

  • People who received a blood transfusion before 1991 or blood products before 1986, when screening of blood donors for hepatitis C infection, or heat treatment for inactivation of viruses were introduced.

  • People born or brought up in a country with an intermediate or high prevalence (2% or greater) of chronic hepatitis C. Although data are not available for all countries, for practical purposes this includes all countries in Africa, Asia, the Caribbean, Central and South America, Eastern and Southern Europe, the Middle East and the Pacific islands.

  • Babies born to mothers infected with hepatitis C.

  • Prisoners, including young offenders.

  • Looked-after children and young people, including those living in care homes.

  • People living in hostels for the homeless or sleeping on the streets.

  • HIV-positive men who have sex with men.

  • Close contacts of someone known to be chronically infected with hepatitis C.

Recommendation 1 Awareness-raising about hepatitis B and C among the general population

Who should take action?

Commissioners and providers of national public health services, for example Public Health England, working in partnership with:

  • other government departments allied to health

  • local commissioners and providers of public health services, including local authorities and health and wellbeing boards

  • primary and secondary care including genitourinary medicine and sexual health clinics

  • the commercial sector, national and local voluntary sector, not-for-profit and non-governmental organisations.

What action should they take?

  • 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

Who should take action?

  • Commissioners and providers of national public health services, for example Public Health England and the NHS Commissioning Board.

  • Local authorities, in particular directors of public health.

  • Local organisations providing services for children and adults at increased risk of hepatitis B or C infection.

  • Other local and national organisations that raise awareness of hepatitis, promote testing or provide treatment.

What action should they take?

  • 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

Who should take action?

  • Health Education England.

  • Public Health England.

  • Royal medical and nursing colleges.

  • Local authorities, in particular directors of public health.

  • Clinical commissioning groups.

  • Local education and training boards.

What action should they take?

  • 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

Who should take action?

  • GPs and practice nurses.

  • Antenatal services.

  • Local community services serving migrant populations.

What action should they take?

  • 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 (see Whose health will benefit?).

  • 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 (see Whose health will benefit?).

  • 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 5 Testing for hepatitis B and C in prisons and immigration removal centres

Who should take action?

  • Prison healthcare services, including services for young offenders.

  • Immigration removal centre healthcare services.

  • Secondary care services that provide treatment for hepatitis B and C.

  • Public Health England centres.

What action should they take?

  • Prison and immigration removal centre healthcare services should develop a policy on testing for hepatitis B and C with local partners, including secondary care services that provide treatment, the Public Health England centre, and commissioners of prison and immigration removal centre healthcare services.

  • Prison and immigration removal centre healthcare services should designate a member of staff as the hepatitis lead in every prison, young offender service and immigration removal centre. The lead should have the knowledge and skills to promote hepatitis B and C testing and treatment and hepatitis B vaccination. Consideration should be given to training peer mentors and health champions from the prison and immigration removal centre populations to support this work.

  • The NHS lead for hepatitis treatment (for example, a community hepatitis nurse) should develop a care pathway for prisoners and immigration detainees with diagnosed hepatitis B or C. This should be developed in conjunction with prison or immigration removal centre healthcare services (including commissioners), local drugs services and the Public Health England centre. The care pathway should ensure:

    • people with diagnosed hepatitis B and C should be referred to, and managed by, the local hepatitis treatment services, in liaison with prison or immigration removal centre healthcare services

    • investigations and follow-up should be undertaken in the prison or immigration removal centre, if possible

    • prisoners and immigration detainees with hepatitis B and C should be treated in the prison or immigration removal centre, using in-reach services involving local specialist secondary care providers or the prison or immigration removal centre healthcare team. The prison or immigration removal centre should support this, for example, by giving security clearance to healthcare staff.

  • Prison and immigration removal centre healthcare services (coordinated with and supported by the NHS lead for hepatitis) should ensure that:

    • all prisoners and immigration detainees are offered hepatitis B vaccination when entering prison or an immigration removal centre (for the vaccination schedule, refer to the Green book)

    • all prisoners and immigration detainees are offered access to confidential testing for hepatitis B and C when entering prison or an immigration removal centre and during their detention

    • prisoners and immigration detainees who test for hepatitis B or C receive the results of the test, regardless of their location when the test results become available

    • results from hepatitis B and C testing are provided to the prisoner's community-based GP, if consent is given

    • all prison and immigration removal centre staff are trained to promote hepatitis B and C testing and treatment and hepatitis B vaccination (see recommendation 3).

  • Prison services should have access to dried blood spot testing for hepatitis B and C for people for whom venous access is difficult.

  • The NHS lead for hepatitis treatment in prisons should ensure continuity of hepatitis treatment through contingency, liaison and handover arrangements before the prisoner release date, or before any prisoner or immigration detainee receiving hepatitis treatment is transferred between prisons or removal centres. Once a prisoner has started treatment, it may be helpful to put them on medical hold to ensure continuity of care (which might be compromised by transfer between prisons). Planning should involve NHS, prison and immigration removal centre healthcare services and other agencies working with prisoners or detainees.

Recommendation 6 Testing for hepatitis B and C in drugs services

Who should take action?

  • Drugs services, including drug and alcohol action teams.

  • Commissioners of hepatitis testing and treatment services, including local authorities and clinical commissioning groups.

  • Secondary care services that provide treatment for hepatitis B and C.

  • Public Health England centres.

What action should they take?

  • Commissioners of hepatitis testing and treatment services should agree local care pathways for people with hepatitis B and C who use drugs services. If possible, the pathway should include provision of hepatitis C treatment services in the community.

  • Drugs services should designate a hepatitis lead for the service. The lead should have the knowledge and skills to promote hepatitis B and C testing and treatment and hepatitis B vaccination. Consideration should be given to training peer mentors and health champions from the drugs service to support this work (for further information see NICE guidance on Community engagement).

  • Drugs services should have access to:

    • dried blood spot testing for hepatitis B and C for people for whom venous access is difficult

    • specialist phlebotomy services in order to encourage hepatitis C treatment in the community, particularly for people who inject drugs.

  • Drugs services 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

    • offer annual testing for hepatitis C to people who test negative for hepatitis C but remain at risk of infection

    • ensure people diagnosed with hepatitis B and C are referred for specialist care; for hepatitis C this may involve offering hepatitis C treatment in the community for people who are unwilling or unlikely to attend hospital appointments, and whose hepatitis C treatment could be integrated with ongoing drug treatment (such as opiate substitution treatment)

    • 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 and dried blood spot testing are trained and competent to do so

    • provide information to women with hepatitis C about the importance of testing in babies and children born after the woman acquired infection

    • provide information to injecting drug users about the importance of hepatitis B vaccination for sexual partners and children (see the Green book).

Recommendation 7 Testing for hepatitis B and C in sexual health and genitourinary medicine clinics

Who should take action?

  • Commissioners of hepatitis testing and treatment services, including local authorities and clinical commissioning groups.

  • Sexual health and genitourinary medicine clinics.

What action should they take?

  • 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

Who should take action?

  • Public Health England centres.

  • Primary care practitioners.

What action should they take?

  • Public Health England centres should:

  • 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 9 Effective delivery and auditing of neonatal hepatitis B vaccination

Who should take action?

  • Directors of public health.

  • Public Health England.

What action should they take?

  • Directors of public health should ensure existing recommendations on hepatitis B prophylaxis for babies born to mothers with chronic hepatitis B infection are implemented locally by general practitioners, as described in the Green book.

  • Public Health England should audit the hepatitis B vaccination programme for babies. The audit should note how many children received vaccines, whether vaccinated children were given all doses and if not how many doses they received, whether doses were given on schedule, whether babies were tested after completing the vaccination course and the rate of vaccination failure. This audit should be carried out annually and deficiencies addressed.

Recommendation 10 Commissioning locally appropriate integrated services for hepatitis B and C testing and treatment

Who should take action?

  • Local authorities, in particular directors of public health and clinical commissioning groups

  • Commissioners of hepatitis testing and treatment services.

What action should they take?

  • 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

Who should take action?

  • Commissioners of laboratory services for hepatitis B and C testing.

What action should they take?

  • 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.



[1] NICE has accredited the process used by the British HIV Association to produce UK national guidelines. Accreditation is valid for 5 years from 12 July 2012 and is applicable to guidance produced since 2011. The NICE Accreditation Scheme recognises organisations that demonstrate high standards in producing health or social care guidance. Users of the accredited guidance can therefore have high confidence in the quality of the information.

[2] Guidance produced by EASL has not been reviewed by the NICE Accreditation Scheme. EASL guidelines may assist healthcare providers in the clinical decision-making process by describing a range of generally accepted approaches for diagnosing, treating and preventing hepatitis B and C. However, it should be ensured that action taken is in line with NICE guidance.