Prevention opportunities arise all the time, brief interventions are useful. Written back up material should be used.
People may not be aware of the risk of sharing injecting equipment other than needles and syringes - all of this equipment will be available from IEP sites including water ampoules soon if not already. Know where your local IEP sites and sign post people to them.
Harm reduction is wider than needle exchange though - encouraging people away from injecting including by accessing opiate substitution therapy is very important. Hepatitis B immunisation should be widely promoted - give it when you see someone, don t ask them to come back to another appointment, they wont!
People in drug treatment services have better outcomes than those not in treatment. Stability in life helps access to BBV treatment. Detox is an ultimate aim but not necessary for access to Hepatitis C treatment. Don t forget safer sex - the drug using population is young and sexually active.
Where can your patients get free condoms?
Policy in UK is one of selective immunisation of those at risk but in very uncoordinated manner - comes down to local and personal policies. Specialist services may not give Hepatitis B immunisation. Give it when you think of it - in general practice have it in the fridge on stock order. Do not test serology before giving if you do not know about past infection or immunisation, you wont do any harm. There is NO immunisation against Hepatitis C (or HIV).
Especially in acute Hepatitis B the Health Protection Team will make contact with the patient. In both acute and chronic Hepatitis B contact tracing is important so that those at risk can be offered testing and immunisation. Close household contacts, sexual contacts and injecting contacts should be traced. For people with a single recent exposure to Hepatitis B there is the possibility of post exposure prophylaxis. Contact tracing for Hepatitis C is rarely carried out as it is rarely detected in the acute phase and there is no post exposure prophylaxis that can be offered to contacts, nor any immunisation.
Guidance to give both Hepatitis A and Hepatitis B immunisation or Twinrix (A and B) to ex or current IDU. Twinrix licensed for routine and super-accelerated schedules where as the single Hepatitis B vaccine can be given as the accelerated schedule which often fits well with appointments at drug clinics when immunising people who use drugs. Do not worry too much if the timing between doses is delayed - try to give 3 doses over a shorter period and remember the 4th dose after 12 months or more for longer term protection. Even a single dose will give some protection. Outbreaks amongst IDUs in Scotland have occurred in the past so although prevalence is thought to be low immunisation remains a priority for drug users.
Give Hepatitis B immunisation when you are testing for Hepatitis B and C. If the test shows existing immunity to Hepatitis B then you do not need to give further dose of immunisation. Delaying the immunisation until you have the BBV test result may mean that you have missed an important opportunity to give the immunisation. The current DH Green Book does not recommend post immunisation serology except in very particular cases (occupational immunisation and prior to renal dialysis). Unless the blood test is carried out at 2 months after the last dose of the course the result is hard to interpret. Even if antibody levels are not high it is likely that there is cellular immunity and that antibody levels can rise rapidly after exposure. Green Book Hepatitis B: the green book, chapter 18, updated December 2013 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/263311/green_ Book_Chapter_18_v2_0.pdf accessed September 2015
There is a policy of selective Hepatitis C testing of women at risk (for example people who use drugs) but this is not universally applied. There are no interventions to prevent mother to child transmission of Hepatitis C but children born to these mothers should be followed up to exclude chronic Hepatitis C infection as there is a 5% risk of transmission. Follow up doses of Hepatitis B immunisation at 1, 2, and 12 months may be done in general practice in some areas.