Offering Testing for Hepatitis B and C in Primary Care Presentation 3 January 2014
Quality Education for a Healthier Scotland
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Notes
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Testing for these viruses needs to be part of routine clinical practice if we are to reduce the number of people with undiagnosed infection. The request should be normalised. Be aware that the people who are at risk are in groups who are often stigmatised and excluded - injecting drug users, MSM, immigrants and we need to make sure that we are not seeming to blame them for their risk of infection. The benefits of having a test clearly outweigh any perceived risks and we need to be very clear what the benefits of knowing your diagnosis are when obtaining informed consent to test.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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’’
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Notes You need to find your own language and phrases that suit you.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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?”
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Notes NOT - drug users can catch all sorts of infections so I am going to test you for Hepatitis C and HIV. NOT - your country has lots of Hepatitis C infection so we had better test you for it.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes You are much more likely to do harm by not testing someone for a blood borne virus.You do need to get informed consent to taking the test.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes These essentials are based on the UK National Guidelines for HIV Testing 2008 published by BHIVA
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes People need to know whether the test will give them a definitive result - or it they will require a repeat test to ensure that they are not infected if the first test comes back negative. This situation arises if they test within the ‘window period’ that is the time during which antibody levels may not high enough in the blood stream for the current tests to detect. The length of time varies between the different BBV infection.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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 http://www.healthscotland.com) or the British Liver Trust (http://www.britishlivertrust.org.uk)
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Notes Risk of one BBV infection means that you have some risk for the others and it is often sensible to test for Hepatitis B, Hepatitis C and HIV on the same test, consenting the patient for all three tests. Good written materials are available to to back up the oral information that you are giving.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Waiting for the result is often the most anxious time for people, a test may take a week to come back in primary care. Offer support yourself and from other organisationsduring this time. Find out who your local voluntary organisation offering support to patients with BBV infections are. People often start to worry about who they need to tell that they are having a test. If they tell someone they are testing they are likely to have to tell them the result so they need to consider that.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes This is particularly an issue for Hepatitis C as there is no immunity from previous exposure and no vaccine to protect them. So all injecting drug users who continue to inject should be offered regular repeat testing - even if they are not disclosing sharing of equipment. Some people would recommend repeat testing of all drug users as they may not disclose injecting at all and there is a risk from snorting drugs.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Results ideally done in person, by person who did initial discussion, but to be done by any appropriately qualified professional at next contact, rather than risk missed opportunity. Harm reduction regardless of result is of prime importance.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes In view of the population that we are targetting it is best to take the opportunity to offer and carry out testing whilst they are with you. Bringing people back to appointments just for testing results in high non-attendance rates due to the other priorities in peoples lives. Non-attendance should not be taken as a refusal to test. Emphasise the benefits of testing.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Brown tube, single virology form.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Measuring the incidence, prevalence and genetic relatedness of Hepatitis C infections among a community recruited sample of injecting drug users, using dried blood spots. Hope VD, Hickman M, Ngui SL, Jones S, Telfer M, Bizzarri M, Ncube F, Parry JV. J Viral Hepat. 2011 Apr;18(4):262-70. doi: 10.1111/j.1365-2893.2010.01297.x.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Ask them to look at examples of results in their pack and write down what they think the result mean we will come back to these at the end of the talk.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Please see slide 30 for the answer.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Please see slide 30 for the answer.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Please see slide 30 for the answer.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Antigen testing in Lothian and starting in Glasgow and other areas.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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’
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Notes People are still telling patient who are Hepatitis C antibody positive but PCR negative that they have Hepatitis C infection. PLEASE DO NOT DO THIS - ONLY PATIENTS WHO ARE PCR OR ANTIGEN POSITIVE HAVE ONGOING INFECTION.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes In Lothian in 2013 the patient has an initial antibody test and if this is positive an ANTIGEN test is performed instead of the PCR test, if the antigen test is positive the patient has ongoing Hepatitis C infection. If the antigen test is negative the las=b requests that another blood sample is taken in a red EDTA tube on which PCR test is performed to confirm no active infection. This second test is required because the lab is concerned about false negative antigen tests. In Glasgow a more radical approach is being used and the initial blood test is for Hepatitis C antigen only. If this is positive an ongoing infection is diagnosed. If the antigen test is negative the patient does not have an ongoing Hepatitis C infection, it is not possible to tell from this test if they have been previously infected with Hepatitis C. The antigen test is cheaper and quicker than the PCR test. It may show an active infection earlier than the antibody test but has a higher false negative rate than the PCR test.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes These are the people who do NOT have evidence of Hepatitis C infection
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Antigen tests are not so straight forward in this situation and a negative antigen test associated with a positive Hepatitis C antibody test requires confirmation with a PCR test.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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)
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Notes Two questions - three tests to answer them. Hepatitis B surface antigen is a viral particle,the other two tests are for antibodies (i.e. the immune response) to viral elements.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
Diagram of Hepatitis B virus
Core Protein HBc
DNA
DNA polymerase Surface Protein HBs
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Notes Surface antigen on the outside of the virus is released into the blood stream during an infection and also evokes an immune response. Artificial surface antigen is uses in the Hepatitis B immunisation. Core antigen in the middle of the virus also evokes an immune response.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes Surface antigen is a bit of the virus so if it is detected in the blood stream there must be an active infection.If it is not present there is no active or ongoing infection.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes An immune response from a past infection or after immunisation. If it is not present the patient should not be considered immune.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes An immune reaction to the middle of the virus, only occurs after an infection NOT after immunisation.
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
Test your previous knowledge Working it out in practice – what does it mean if? • Now please check your answers
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Notes Slide 17 • Hepatitis C antibody test positive • Hepatitis C PCR test negative • Hepatitis B surface antigen positive
This shows previous exposure to Hepatitis C but no evidence of active infection, the patient is not immune to Hepatitis C. The patient has active Hepatitis B infection and requires urgent referral to Infectious Diseases or a Liver Unit.
• Hepatitis B core antibody negative Slide 18 • Hepatitis C antibody test negative • Hepatitis B surface antigen negative • Hepatitis B core antibody positive Slide 19 • Hepatitis C antibody test positive • Hepatitis C PCR test positive • Hepatitis B surface antigen negative
This shows no evidence of exposure to Hepatitis C infection. The patient does not have active Hepatitis B infection but has had previous infection and is immune to Hepatitis B infection now. They are not immune to Hepatitis C infection.
This shows active infection with Hepatitis C as the PCR is positive. There is no evidence of exposure to Hepatitis B infection and they are not immune, they require immunistation.
• Hepatitis B core antibody negative
--
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
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
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Notes
Offering Testing for Hepatitis B and C in Primary Care Presentation 3 © Health Protection Scotland/NHS Education Scotland
January 2014
