Offering Testing for Hepatitis B and C in Primary Care

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1 Offering Testing for Hepatitis B and C in Primary Care Presentation 3 January 2014 Quality Education for a Healthier Scotland 1

2 Learning Outcomes Participants will be able to:- Undertake a pre-test discussion for Hepatitis C and Hepatitis B testing to ensure informed consent is obtained Implement strategies in practice to maximise uptake amongst those at risk Interpret Hepatitis C and Hepatitis B serology results Quality Education for a Healthier Scotland 2

3 Raising the issue of Hepatitis B and C testing Normalise the request Avoid stigmatising and blaming language Emphasise the benefits of testing for the individual Quality Education for a Healthier Scotland 3

4 Testing - normalising testing suggested approaches Your tests have shown some damage to your liver and it is important that we work out why this is happening. There are many causes of this damage, including viral infections called Hepatitis B and Hepatitis C. These are treatable infections and I recommend we test for them in these circumstances Quality Education for a Healthier Scotland 4

5 Testing - avoiding stigmatising and blaming language People who have used drugs, even if it was a long time ago, are at higher risk of certain viral infections including Hepatitis C, Hepatitis B and HIV. All of these are now treatable infections and we recommend routine testing for them. Would you agree to us taking these tests? Quality Education for a Healthier Scotland 5

6 Testing - benefits of Testing Emphasise the following: Allows access to treatment which can control or cure infection Helps you to avoid future risk to yourself or others close to you Can allay anxiety if you are worried you June be infected Allows you to take measures to help protect liver if infected with Hepatitis B or C Quality Education for a Healthier Scotland 6

7 Testing - pre-test discussion Remember informed consent not counselling! Three essentials: Explain what you are testing for and the benefits of testing to that individual Allow opportunity to ask questions (and be able to answer them) Explain how and when they will get the results Quality Education for a Healthier Scotland 7

8 Testing - other issues Window period length of time after infection that it takes for test to show a positive result Hepatitis C up to 6 months Hepatitis B 3 to 6 months (HIV 6 to12 weeks) Test and then repeat after window period rather than delay testing Quality Education for a Healthier Scotland 8

9 Testing - other issues (cont.) What to test for? As the risks overlap it is sensible to test for Hepatitis C, Hepatitis B and HIV at the same time Use published material at pre-test discussion Available from Health Scotland (Take Control leaflet for Hepatitis C at or the British Liver Trust (http://www.britishlivertrust.org.uk) Quality Education for a Healthier Scotland 9

10 Testing - other issues (cont.) Patient anxiety whilst awaiting result Offer support and signpost to organisations such as the Hepatitis C Trust and Hepatitis Scotland Informing others Discuss who they should tell about having the test and who they do not have to tell at this stage Quality Education for a Healthier Scotland 10

11 Testing - how often to test for Hepatitis B and C? If a one-off exposure to infection, check about window period and if tested after that then no more testing is required If recent exposure, test after the window period (6 months) Immunise against Hepatitis B no further testing required for Hepatitis B All active drug users offer 6-12 monthly testing for Hepatitis C (and HIV) - consider even if not disclosing injecting/sharing Quality Education for a Healthier Scotland 11

12 Testing - getting the result Arrange appointment at pre-test discussion stage. Ideally done by the person who undertook pre-test discussion (and took blood samples) Invite patient to have someone with them when they get the result. Use as a harm reduction opportunity Quality Education for a Healthier Scotland 12

13 Testing - maximising uptake Perform test your self- don t expect someone to come back for another appointment Offer the test again even if previously declined emphasise the benefits. Consider offering testing to all new registrants from areas of high prevalence Offer to all drug users even if no history of injecting Use Dried Blood Spot (DBS) testing if venous access hard Quality Education for a Healthier Scotland 13

14 Testing - taking the test Single venous blood test can be used to test for Hepatitis B, Hepatitis C and HIV Clearly state clinical history and risk factors on request from including estimated date of last possible exposure DBS testing available in Scotland for diagnosis of all BBV using finger prick capillary blood If using DBS all five target circles must be completely covered in blood Quality Education for a Healthier Scotland 14

15 Dried Blood Spot (DBS) testing Dry blood spot testing -- Hepatitis C antibody testing -- Hepatitis C RNA detection -- HIV antibody testing -- HB surface antigen -- Hepatitis B core antibody Quality Education for a Healthier Scotland 15

16 Interpreting the results Make sure you give the person the correct result! Test your previous knowledge gained from elearning module now! Write down answers to the questions on the following 3 slides and check your knowledge at end of this section Quality Education for a Healthier Scotland 16

17 Test your previous knowledge Working it out in practice what does it mean if? Hepatitis C antibody test positive Hepatitis C PCR test negative Hepatitis B surface antigen positive Hepatitis B core antibody negative Quality Education for a Healthier Scotland 17

18 Test your previous knowledge Working it out in practice what does it mean if? Hepatitis C antibody test negative Hepatitis B surface antigen negative Hepatitis B core antibody positive Quality Education for a Healthier Scotland 18

19 Test your previous knowledge Working it out in practice what does it mean if? Hepatitis C antibody test positive Hepatitis C PCR test positive Hepatitis B surface antigen negative Hepatitis B core antibody negative Quality Education for a Healthier Scotland 19

20 Interpreting the results - Hepatitis C Initial test is serology for antibodies to Hepatitis C Hepatitis C antibody positive it shows exposure to the virus but not whether infection is ongoing A positive result will automatically be sent for PCR (or in some areas an ANTIGEN) test Quality Education for a Healthier Scotland 20

21 Interpreting the results Hepatitis C - PCR is the key! PCR test - viral load test Detects viral RNA by amplification and a positive PCR test indicates chronic infection Only Hepatitis C PCR +ve patients are chronically infected Also used to determine efficacy of treatment and cure Quality Education for a Healthier Scotland 21

22 Interpreting the results Hepatitis C antigen test In some areas an ANTIGEN test is carried out to diagnose Hepatitis C In some areas it replaces the PCR test to confirm ongoing infection- If the antigen test is positive it shows chronic infection with Hepatitis C If the antigen test is negative the patient needs a PCR test to double check result (another sample) In Glasgow the ANTIGEN test replaces both the antibody and PCR test only patients with ongoing infection are diagnosed Quality Education for a Healthier Scotland 22

23 Interpreting the results Hepatitis C negative tests If the test comes back Hepatitis C antibody negative the patient has not been infected with Hepatitis C (however remember the window period!) Should be advised that they have not been infected but if they put themselves at risk again they could become infected Quality Education for a Healthier Scotland 23

24 Interpreting the results Hepatitis C negative tests (cont.) If the test shows Hepatitis C antibody positive but the PCR test is negative: They have been infected with Hepatitis C, but have cleared the virus They are not immune to Hepatitis C and could become infected again and it may become a chronic infection next time If the test shows Hepatitis C antibody positive but the antigen test is negative: Lab may request EDTA (red) tube for PCR testing to confirm the negative result If the antigen test is the only test and is negative: There is no evidence of active infection, you cannot tell if the have had previous infection, they are NOT immune to future infection Quality Education for a Healthier Scotland 24

25 Interpreting the results Hepatitis B Must establish two key factors:- Is the person infected currently? If not currently infected, is the person immune? Three tests can answer these questions:- Hepatitis B surface antigen (HBsAg) Antibody to HBSsAg (anti-hbsag) Antibody to HB core antigen (anti-hbcag) Quality Education for a Healthier Scotland 25

26 Diagram of Hepatitis B virus Core Protein HBc DNA DNA polymerase Surface Protein HBs Quality Education for a Healthier Scotland 26

27 Interpreting the results Hepatitis B surface antigen: a viral component Hepatitis B surface antigen (HBsAg) is detected in current infection. (>6 months = chronic infection) If this is positive the patient has an ongoing Hepatitis B infection If this is negative the patient does not have an ongoing Hepatitis B infection Quality Education for a Healthier Scotland 27

28 Interpreting the results antibody to Hepatitis B surface: an immune response Hepatitis B surface antibody (anti-hbs) If this is positive it means that the patient has had a past infection or been immunised and is now immune to Hepatitis B If this is negative it means that they have not had a past infection, and if the antigen test is also negative, they need immunised Quality Education for a Healthier Scotland 28

29 Interpreting the results antibody to Hepatitis B core: an immune response Hepatitis B core antibody (anti-hbc) If this is positive it means that the patient has had a past infection and may now be immune to Hepatitis B If this is negative it means that they have not had a past infection, if the antigen and surface antibody tests are also negative, they need immunised Quality Education for a Healthier Scotland 29

30 Test your previous knowledge Working it out in practice what does it mean if? Now please check your answers Quality Education for a Healthier Scotland 30

31 Interpreting Hepatitis B antibody results - summary Anti-HBc Anti-HBs Interpretation and action - - Never had Hepatitis B and no immunity - immunise + + Past infection - no action as now immune + - Past infection - no action as now immune - + Past immunisation complete the course or re-immunise unless certain fully immunised Quality Education for a Healthier Scotland 31

32 Group work - testing The group facilitator will present you with three case studies on Testing Each case study has a number of questions to be addressed For each case please discuss and capture main points of responses on flip chart for feedback at end of this session Quality Education for a Healthier Scotland 32

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