New guidance published today (12 December) by healthcare guidance body NICE highlights the need to tackle ignorance about the risk factors and causes of hepatitis B and C, and misconceptions about its treatment if barriers to effective testing of those at increased risk of infection are to be overcome.

Hepatitis B and C are blood-borne viruses that predominantly infect the liver. Together they affect around half a million people in the UK, making them the second most common cause of liver disease in the UK, after alcohol misuse. Transmission is by contact with infected blood, primarily as a result of exposure through the skin to contaminated blood and through mother-to-child transmission. A hepatitis infection is manifested firstly as an acute infection (the first 6 months following initial infection). If the virus is not cleared from the body, either naturally or through the use of drugs to treat the infection, the infection can progress to a chronic state. Although often asymptomatic, particularly in the early stages, chronic hepatitis B or C infection increases the risk of chronic liver damage, cirrhosis and primary liver cancer.

A recent report from the Health Protection Agency (HPA)ⁱ has found that half of people who inject drugs are infected with hepatitis C. Out of a total of 12,642 hepatitis C infections diagnosed in the UK in 2011, around nine in ten of these infections were acquired through injecting drugs. The report also found that one in six people who inject drugs were found to have been infected with the hepatitis B virus at some point in their lives. Those at increased risk of infection with hepatitis B or C also include migrants from countries with high/medium prevalence of the disease, people who travel to countries where there is a high incidence of the disease, people who have heterosexual contact with someone who is infected, mother to child transmission and men who have sex with men. People from some minority ethnic groups in the UK may also be at higher risk, with estimates suggesting that the rate of acute infection within the South Asian population in England and Wales is twice the estimated average, largely as a result of mother-to-child transmission that occurs outside the UK. Statistics also suggest a higher than average prevalence of hepatitis C among people in prison.

The guidance sets out how services, organisations and practitioners can promote testing and reach people at increased risk. The recommendations cover:

• Awareness-raising among:
  - the general population
  - people at increased risk of hepatitis B and C infection.
• Developing the knowledge and skills of healthcare professionals and others providing services for people at increased risk of hepatitis B or C infection.
• Testing:
  - in primary care
  - in prisons and youth offender institutions
  - in immigration removal centres
  - in drugs services
  - in genitourinary medicine and sexual health clinics.
• Contact tracing.
• Providing and auditing neonatal hepatitis B vaccination.
• Commissioning hepatitis B and C testing and treatment services
• Laboratory services for hepatitis B and C testing.

Professor Mike Kelly, NICE Director of Public Health, said: “There are effective treatments for hepatitis B & C which can significantly reduce the risks of developing long-term complications, such as cirrhosis and liver cancer. However, what seems to be a general ignorance about the diseases and the potentially serious consequences of not being tested and treated is contributing to both a lack of offer of testing by services and the low uptake of testing among those at increased risk of infection. It is also contributing to the stigma surrounding hepatitis B and C.

Professor Kelly continued: “Recommendations in this guidance therefore encompass general awareness raising for the population as a whole, for those at increased risk of infection and for healthcare professionals and others providing services for those at increased risk of hepatitis B and C. This is aimed at addressing any misconceptions about the risk of hepatitis B and C that can act as barriers to testing, including the belief that treatments are not effective and that treatment is not needed until the illness is advanced. It is also aimed at demystifying the risks of transmission among families, friends and colleagues of people diagnosed with chronic hepatitis B or C, and in doing so reducing much of the stigma attached to the diseases.”

Matt Hickman, Professor in Public Health and Epidemiology at the University of Bristol and chair of the Programme Development Group said: “Liver disease caused by hepatitis B and C virus is preventable and curable. Not enough people, however, are being diagnosed and treated. The majority of chronic hepatitis B infections in the UK are among migrant populations, and over 85% of chronic hepatitis C is among people who have injected drugs (PWID). We show that testing or case-finding among migrant populations and among PWID that leads to referral and treatment is cost-effective in primary care and in specialist drug clinics. Case finding in prison also can be cost-effective if some continuity of care between prison and the community can be ensured. We have, therefore, made recommendations concerning “raising awareness” among people at risk of chronic hepatitis and improving training and the knowledge base among health care professionals, and recommend interventions that increase the uptake of hepatitis testing among populations at greater risk of infection. We highlight also other key ongoing interventions concerning hepatitis B vaccination, especially of children born to mothers with chronic hepatitis B.

Nat Wright, Clinical Director Vulnerable Groups, NHS Leeds and member of the Programme Development Group, said: "As both a general practitioner and clinical director of prison and community services for drug users and wider vulnerable groups, the key messages from this document are the critically important role that primary care can play in identifying those who may be hepatitis B or C positive, yet unaware of their status. The recommendation to offer testing to those entering prison is welcome as it is likely to lead to significant uptake. We know that treatment is effective for hepatitis B and C yet for too long there have been barriers to offering widespread testing in prison settings".

Deirdre Kelly, Professor of Paediatric Hepatology, Birmingham Children's Hospital NHS Foundation Trust and member of the Programme Development Group, said: “Hepatitis B and C carry a life time risk of serious liver damage. I welcome the guidance's recognition of the need to test children who are at risk from hepatitis B and C because we now have effective treatments for both diseases. Many children, particularly those with hepatitis C virus, clear infection more easily than adults and can be cured, so it is important to trace them before the infection becomes severe. It is also important that mothers at increased risk are offered appropriate information about hepatitis B during antenatal screening as this is more likely to ensure that they get their baby vaccinated against hepatitis B.”

Opal Greyson, Viral Hepatitis Specialist Nurse, NHS Bedford & Luton, and member of the Programme Development Group, said: “This important new guidance will help ensure that people at risk and those at increased risk are tested and those with hepatitis B and C are identified earlier. It means that more people will be offered effective treatment and, in the case of hepatitis C, the opportunity of a cure. We can save lives while helping to reduce health inequalities and deliver cost savings. That's surely something to be proud of!”

Will Irving, Professor and Honorary Consultant in Virology, University of Nottingham and Nottingham University Hospitals NHS Trust, and member of the Programme Development Group, said: “It is estimated that around half of the individuals living in the UK with chronic hepatitis B or C infection are unaware of their diagnosis, but they are at risk of developing serious complications of their infection. This timely and highly relevant NICE guidance is aimed at finding ways of identifying those individuals, and getting them to clinic for appropriate assessment, so they can be offered highly effective therapies before their disease is too advanced.”

Emily Kam-Yin Lam, Community Member on the Programme Development Group, said: “Hepatitis B and C, whilst commonly asymptomatic in the early stages, can be readily detected by simple tests. Early diagnosis will enable people who are infected to benefit from timely treatment which will markedly reduce premature deaths from liver failure and cancer, and also reduce the rates of transmission. Cultural barriers and stigma are known to discourage people from taking a test for hepatitis, so it is important to emphasise the efficacy and benefits of treatments now available in curing, ameliorating or even reversing disease progression. In offering testing facilities, consideration should be given in ensuring they are culturally and linguistically appropriate and acceptable. Engaging community and voluntary organisations and aligning with statutory agencies have also been found to be key factors in ensuring effective implementation.”

Ends

Notes to Editors

References

i. Shooting Up: Infections among people who inject drugs in the UK 2011. An update: November 2012. Health Protection Agency

About the draft guidance

• 1. The guidance will be available on the NICE website from 12 December 2012. Embargoed copies are available on request; please contact the press office.
• 2. In England and Wales between 1995 and 2000, an estimated 3780 people a year were infected with acute hepatitis B, about 7% of whom then went on to develop chronic hepatitis B.
• 3. According to the Chief Medical Officer, an estimated 180,000 people in the UK are now chronically infected with the hepatitis B virus although this figure may be closer to 360,000 when the estimated 6500-plus people with chronic hepatitis B who migrate to the UK each year are taken into account.
• 4. An estimated 216,000 people in the UK are chronically infected with the hepatitis C virus. However, only 85,565 diagnoses have been reported. By 2020 it is predicted that 15,840 people, in England alone, will be living with hepatitis C-related cirrhosis or hepatocellular carcinoma.

About NICE

5. The National Institute for Health and Care Excellence (NICE) is the independent organisation responsible for providing national guidance and standards on the promotion of good health and the prevention and treatment of ill health

6. NICE produces guidance in three areas of health:

• public health - guidance on the promotion of good health and the prevention of ill health for those working in the NHS, local authorities and the wider public and voluntary sector
• health technologies - guidance on the use of new and existing medicines, treatments, medical technologies (including devices and diagnostics) and procedures within the NHS
• clinical practice - guidance on the appropriate treatment and care of people with specific diseases and conditions within the NHS.

7. NICE produces standards for patient care:

• quality standards - these reflect the very best in high quality patient care, to help healthcare practitioners and commissioners of care deliver excellent services
• Quality and Outcomes Framework - NICE develops the clinical and health improvement indicators in the QOF, the Department of Health scheme which rewards GPs for how well they care for patients

8. NICE provides advice and support on putting NICE guidance and standards into practice through its implementation programme, and it collates and accredits high quality health guidance, research and information to help health professionals deliver the best patient care through NHS Evidence.