VIRAL HEPATITIS (A, B AND C)

Transcription

1 VIRAL HEPATITIS (A, B AND C) Reference should also be made to the NHSGGC policy on BBV testing (April 2013). This can be downloaded from Hepatitis A,B and C are not notifiable diseases for the purposes of The Public Health Etc(Scotland)Act 2008 Hepatitis A Usually presents to sexual health in as either prodromal or icteric phases. 50% are asymptomatic or have mild non-specific symptoms with little or no jaundice. Most cases diagnosed in sexual health are in MSM with jaundice. Main Transmission Routes Faeco-oral (via food, water, close personal contact). Outbreaks have been reported in gay men, possibly linked to oro-anal or digital-rectal contact, multiple sexual partners, anonymous partners, sex in public places and group sex (saunas have been point sources including a recent outbreak in Bristol, 2010). However, several seroprevalence studies have shown a similar rate of hepatitis A (IgG) antibodies in homosexual and heterosexual men. Management Of Acute Hepatitis A 1. If suspected, confirm by a positive serum Hepatitis A virus-specific IgM (HAV-IgM) which remains positive for six months or more. HAV-IgG does not distinguish between current or past infection and may remain positive for life. Also perform serology for other hepatitis viruses, HIV and syphilis if non-specific illness. 2. Check LFTs and clotting. If Prothrombin time (PT) prolonged by more than 5 seconds suggests developing hepatic decompensation: consider admission to the local acute medical Unit. Admit if severe vomiting, dehydration, or if conscious level or personality changes. 3. Patients should be advised to avoid food handling and unprotected sexual intercourse until they have become non-infectious. This should be reinforced by giving them clear and accurate written information (see 5 below). 4. Screen for other sexually transmitted infections in cases of sexually-acquired hepatitis. 5. Refer to Sexual Health Advisor for partner notification and support. Partner notification should be performed for at-risk contacts within the period two weeks before to one week after the onset of jaundice. Passive immunisation should be considered for close household and sexual contacts who are not known to be immune. Pregnant women should be advised of the increased risk of miscarriage/premature labour and the need to seek medical advice if this happens. 6. Review at two weekly intervals until amino-transferase levels are normal (usually 4-12 weeks). HEPATITIS CEG JULY 2015 Page 1 of 11

2 Partner Notification The infectious period is two weeks before and up to one week after onset of jaundice: for potential sexual transmission in MSM PN by SHA all other household, social or food handling contacts to be dealt with by Health Protection Unit.. At-risk sexual contacts (oro-anal, digital/anal, penetrative anal) can be given Hep A vaccine up to 7 days after exposure. HNIG mg im can be given if outside this window but offers no protection more than two weeks after exposure Hepatitis A vaccination within Sandyford Routine vaccination for MSM attending Sandyford is Twinrix so Hep A is covered but to achieve optimal response to hepatitis A component doses must include the 4 th at one year. Single agent vaccine is two doses six months apart, giving 95% protection for over 10 years. There is thus no need to check total anti-hep A antibody See protocol on MSM. Hepatitis B UPDATE No routine titre checks post vaccination. Complete rather than restart schedules See administration procedures for 12 month recall. In the UK, prevalence varies from % in blood donors to up to 25% in injecting drug users. It is mainly imported by new entrants to the UK. (see table 1 appendix for list of high endemic areas). In Glasgow, 16% of men who have sex with men have had hepatitis B. Hepatitis B can be prevented by vaccination. Main Transmission Routes Parenteral (blood, blood products, drug-users sharing needles and syringes, needlestick, acupuncture) and vertical (infected mother to infant). Sexual transmission occurs in unvaccinated MSM and correlates with multiple partners, unprotected anal sex and also with oro-anal sex ("rimming"). Transmission also occurs after heterosexual contact e.g. 18% infection rates for regular partners of patients with acute hepatitis B. Sex workers are also at higher risk of acquiring and transmitting the infection. HEPATITIS CEG JULY 2015 Page 2 of 11

3 Screening and Primary Prevention of Hepatitis B in Glasgow The following populations should be screened for hepatitis B immunity at the Sandyford and offered vaccination if no previous exposure and ongoing risk: men who have sex with men people who have been sexually assaulted male/female prostitutes sexual partners of clients at risk injecting drug users HIV positive individuals Those having sex with people resident in areas with high prevalence of Hepatitis B In exceptional circumstances, healthcare and other staff (eg police) who may be at risk of needlestick injuries can be screened in GUM, however this should usually be done through the appropriate Occupational Health department. Anti-HBc ( Anti-core ) Initial screening test in someone who is unvaccinated or is of unknown infection status. If found to be anti-hbc positive, the lab will check carrier status by testing for HepBsAg and (if HBsAg positive) HepBeAg. If anti-hbc negative please recall client for vaccination if in a risk group Vaccination schedules Vaccination outcomes have been poor in Glasgow and other GUM services. We now use a rapid vaccination schedule over 3 weeks which has improved completion rates in the SRP to 89% of those starting compared to 59% before. Selected nurses in Sandyford can administer Twinrix, combined Hep A and Hep B vaccine under a PGD directive or as nonmedical prescribers. Vaccination should ideally be offered and started at first visit. There is no requirement to wait for the anti-hbcab result. Ensure client is issued with a vaccination schedule card (Blue Card). Use Twinrix for clients with no past history of hepatitis vaccination or infection. Specific single-agent vaccines for Hep A and Hep B are also available where there is a clear history of prior infection or prior vaccination with single-agent vaccine. Adult doses are licensed for use in clients over 16 years of age: however, if adolescents under age 16 have an adult physical form, then use the adult dosing schedule. If adolescent clients clearly have less mature physical form then use appropriate dose for age. A two-dose regime for adolescents using adult doses is available but potentially gives less good cover for hepatitis B than it dose for hepatitis A. If in doubt about appropriate dosing then seek advice. Preferred regimen is 0, 1 and 3 weeks with final FOURTH dose at 12 months. Alternative schedules include 0, 1, 2 and 12 months or 0, 1 and 6 months. Although these are the licensed intervals it is clear that any gap of more than a week between 1 st and 2 nd injections and more than 2 weeks between 2 nd and 3 rd injections would be acceptable. Offer an appointment clinic (includes Steve Retson Project - SHA list) or rapid access through the generic urgent care booked return or an SC20 slot. After rapid schedules remind clients about the 4th dose at one year. See appendix for 1yr diary (this acts as a reminder for the fourth dose and a single recall opportunity if missed doses although default rate is low on rapid schedules) Current DH advice: no requirement to check post-immunisation titres. sset/dh_ HEPATITIS CEG JULY 2015 Page 3 of 11

4 Missed Vaccine Doses This is common. One or two doses of vaccine may provide immunity in 40% and over 90% of immunocompetent patients respectively. There is no routine recall for clients who may have missed vaccine doses. If a course of immunisation is interrupted: simply resume so that it is completed rather than restart the entire programme. (DH green book) Within a five-year time period, if two doses have already been administered, give the third. If only one dose has been administered, give the remaining two at least 4 weeks apart. If delayed representation following missed doses allows resumption of a slower recognised-conventional regime, then follow this plan. Summary of Hepatitis tests Situation Test Interpretation New client with history of THINK!!!! Hep B vaccination If incomplete course then COMPLETE course first New client with Hep B risk if complete, document detail in Hep B section of BBV form on NASH Anti-Hep B core Ab Negative: no infection offer vaccination Positive Further tests done by lab Positive Hep B cab Anti Hep A total Ab HBsAg neg HBsAg+ HBeAg+ Not needed as TWINRIX used Naturally immune previously infected requires no action chronic hepatitis B carrier requires referral High-infectivity carrier-refer Brownlee Management Of Acute Hepatitis B 1. Confirm diagnosis by HBsAg and IgM anti-core. The most important thing to do is to write the appropriate information on the form to the Regional Virus Lab and say that acute hepatitis B is suspected. 2. Further investigations as for hepatitis A (LFTs, PT, test for other viruses, STIs and HIV). 3. Refer to Health Advisor for partner notification and general advice. Patients should be advised to avoid unprotected sexual intercourse, including oro-anal and oro-genital contact until they have become non-infectious or their partners have been successfully vaccinated. Patients should also be given a detailed explanation of their condition with particular emphasis on the long-term implications for the health of themselves and their partner(s), routes of transmission of infection and advised not to donate blood. 4. Review at two weekly intervals until amino-transferase levels are normal (usually 4-12 weeks). In view of the possibility of chronic infection, serology should be repeated after six months even if the LFT is normal. Immunity after recovery from infection (surface antigen negative) is lifelong in over 90%. HEPATITIS CEG JULY 2015 Page 4 of 11

5 Partner Notification Should include any sexual contact (penetrative vaginal or anal sex or oro-anal sex) or needle sharing partners during the period in which the index case is thought to have been infectious. The infectious period is from two weeks before the onset of jaundice until the patient becomes surface antigen negative. In cases of chronic infection trace contacts as far back as any episode of jaundice or to the time when the infection is thought to have been acquired although this may be impractical for periods of longer than two or three years. Specific hepatitis B immunoglobulin 500 i.u. intramuscularly (HBIG) may be administered to a non-immune contact after a single unprotected sexual exposure or parenteral exposure/needle-stick injury if the donor is known to be infectious. This works best within 48 hours and is of no use after more than seven days. An accelerated course of recombinant vaccine should be offered to those given HBIG plus all sexual and household contacts (at 0, 1, 2 and 12 months). Avoid sexual contact, especially unprotected penetrative sex, until vaccination has been successful. Management Of Chronic Hepatitis B Infection In Glasgow & Clyde All follow up is arranged through the sexual health advisor team based at Sandyford Central. Patients are referred to Gartnavel Hepatitis Centre, level 7, Gartnavel General Hospital. Check with the patient for consent to inform GP or other services and document this in the notes. Patients in Clyde should be referred to Dr S Hislop or Dr J McPeak at the RAH or Dr J Dilawari at the IRH. Patients will be fully assessed (which may require liver imaging and biopsy) and considered for therapy which may include interferon and anti-viral therapies.. Hepatitis D (Delta virus infection, HDV) This is an incomplete RNA virus that requires the hepatitis B virus outer coat. It is only found in patients with hepatitis B. It is largely an infection of IDUs and their sexual partners but also in female prostitutes, and sporadically in other groups. Suspect HDV in hepatitis B particularly if the acute hepatitis is severe, if chronic hepatitis B carriers get a further episode of acute hepatitis or if the liver disease in chronic HBV is rapidly progressive. Response to anti-viral therapy is poor Diagnosis is confirmed by a positive anti-hdv antibody or HDV-RNA test. Hepatitis C See 1. (the website for the NHSGG Managed Care Network) Scottish prevalence varies from 0.02% in blood donors to over 60% in IDUs. Sexual transmission occurs at a low rate (approximately 0.2 2% per year of relationship, or 2-11% of spouses in long-term relationships) but these rates increase if the index patient is also HIV infected. HEPATITIS CEG JULY 2015 Page 5 of 11

6 Natural History The majority of patients (>80%) undergo asymptomatic acute infection. Approximately 50-85% of infected patients become chronic carriers - a state which is normally asymptomatic but may cause non-specific ill health. Of 100 people infected with Hep C, 16 will get cirrhosis over 20 years and 1-2 of these will eventually develop liver cancer. Who Should Be Offered A Test For Hepatitis C? Ideally, a client should be offered pre-test discussion with a sexual health advisor. In the hubs, this is the nurse with sexual health advising competencies. People who have ever injected drugs People who received blood products or organ transplant before Sept 1991 Following a needlestick injury if the donor HCV status is positive or unknown Those with known HIV infection Children born to HCV positive women (deferred until aged 12 months) Sexual partners of those at risk of or living with Hepatitis C People who may have had ear piercing, body piercing, tattooing or acupuncture with unsterile equipment People who may have had unsterile medical or dental procedures abroad In Sandyford patients should not be routinely tested for hepatitis C at the same time as taking blood for hepatitis B pre vaccination unless there is a likely increased risk of HCV exposure. Hepatitis C Testing at Sandyford Services The screening test from 9 May 2013 for all Sandyford patients is an HCV Antigen test (9 ml plasma, purple bottle).. Hepatitis C Antigen testing detects active hepatitis C that requires intervention. It will not determine if someone has been cleared previous infection (as this is not clinically important). Patients who have been treated successfully for Hep C will have a negative HCV Ag result. HCV Antigen positive: This is evidence of ongoing infection that may require treatment. The lab will do a Hep C antibody test if the patient is not known to have Hepatitis C. If this is unexpectedly negative they will do a Hep C PCR test as well. Refer patients to a health adviser for a detailed explanation of their condition and partner notification to include any sexual contact or needle sharing partners during the period in which the index case is thought to have been infectious. The infectious period is from two weeks before the onset of jaundice in acute infection. If there was no acute infection trace back to the likely time of infection (e.g. blood transfusion, first needle sharing) although this may be impractical for periods longer than two or three years. Sexual transmission should be discussed. It seems likely that if condoms are used consistently then sexual transmission will be avoided, but given the very low rate of transmission outside of HIV co-infection, monogamous partners may choose not to use them. Sex likely to result in blood exposure (eg fisting, S&M) should be avoided. Patients should also be advised not to donate blood, semen or organs, not to consume alcohol & never to share injecting equipment or razors or toothbrushes. Hep C antigen negative there is no evidence of acute or chronic HCV infection. HCV antigen is usually positive (90%) within two weeks of infection so there is much less concern about window periods (see diagram). If there are concerns about very early acute infection discuss with the specialist virology lab or repeat the test after 1-2 weeks. HEPATITIS CEG JULY 2015 Page 6 of 11

7 The agreed window period for HCV Antigen testing is ONE MONTH. The test is usually positive within days of infection. Offer testing for syphilis and other bloodborne viruses including HIV. Flow diagram for HCV diagnoses with antigen testing HCV core Ag HCV core Ag Equivocal (3-20 fmol/l) HCV core Ag POSITIVE HCV core Ag Negative HCV Antibody Negative HCV PCR (HCV PCR result reported as currently) If NEW diagnosis: HCV antibody HCV antibody test POSITIVE Report: HCV antigen (Ag) negative: there is no evidence of acute or chronic HCV infection. If EARLY ACUTE infection is suspected or HCV Ab is required please call the WoSSVC on ( ) with clinical details, date of onset and maximum ALT. Report: HCV antigen (Ag) POSITIVE: Evidence of ongoing HCV infection. Patient should be referred to a specialist HCV unit. A HCV PCR should be carried out as part of the specialist assessment. Known HCV positive (by antigen or PCR) Report: HCV antigen (Ag) POSITIVE: Patient is a known to have an ongoing HCV infection HEPATITIS CEG JULY 2015 Page 7 of 11

8 HCV antibody assays are positive on average days (up to 180 days) Antibody negative while patients are highly infectious in the window period HCV RNA is PCR positive 7-14 days post infection Architect HCV Ag assay is positive days post infection Management of Hepatitis C Infection in Greater Glasgow & Clyde Further investigations should not be routinely undertaken. Tertiary referral will be facilitated by the health advising team or senior clinician. Check with the patient for consent to inform GP or other services and document this in the notes. All patients with hepatitis C, if not immune, should be vaccinated against hepatitis A and B. Hepatitis and Women All women who are either partners of individuals who have Hepatitis B or C, or who test positive themselves and who are considering pregnancy should be referred to the Women s Health Unit at Princess Royal Maternity for further support and advice about reproductive health issues. This may include issues relating to pregnancy, breast feeding and reducing the risk of vertical transmission, as well as dealing with social issues and contraceptive needs. Further info: HEPATITIS CEG JULY 2015 Page 8 of 11

9 Table1: Prevalence of hepatitis B in various areas % of population positive for infection Area HBsAg anti-hbs neonatal childhood Northern, Western, and Central Europe, North America, Australia rare infrequent Eastern Europe, the Mediterranean, Russia and the Russian Federation, Southwest Asia, Central and South America frequent frequent Parts of China, Southeast Asia, tropical Africa very frequent very frequent HEPATITIS CEG JULY 2015 Page 9 of 11

10 HEPATITIS CEG JULY 2015 Page 10 of 11

11 Recalling clients for their 4 th dose Engerix B or Twinrix vaccine HEPATITIS CEG JULY 2015 Page 11 of 11