Offering Testing for Hepatitis B and C in Primary Care Presentation - - PowerPoint PPT Presentation

Quality Education for a Healthier Scotland 1 Quality Education for a Healthier Scotland 1

Offering Testing for Hepatitis B and C in Primary Care

Presentation 3

January 2016

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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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Raising the issue of Hepatitis B and C testing

• Normalise the request
• Avoid stigmatising and blaming language
• Emphasise the benefjts of testing for the individual

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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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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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Testing - benefjts 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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Testing - pre-test discussion

Remember – informed consent – not ‘counselling’! Three essentials:

• Explain what you are testing for and the benefjts 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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Testing - other issues

Window period – length of time after infection that it takes for a test to show a positive result

• Hepatitis C – 3 months
• Hepatitis B – 3 - 6 months
• (HIV – 4 weeks - 3 months)
• Test and repeat test after window period rather than

delay testing

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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 leafmet for Hepatitis C at http://www.healthscotland.com) or the British Liver Trust (http://www.britishlivertrust.org.uk)

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Testing - other issues (cont.)

• Patient anxiety whilst awaiting result

Ofger 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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Testing - how often to test for Hepatitis B and C?

• If a one-ofg 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 – ofger 6-12 monthly testing for

Hepatitis C (and HIV) - consider even if not disclosing injecting/sharing

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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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Testing - maximising uptake

• Perform test your self- don’t expect someone to come back for another

appointment

• Ofger the test again even if previously declined – emphasise the benefjts.
• Consider ofgering testing to all new registrants from areas of high prevalence
• Ofger to all drug users – even if no history of injecting
• Use Dried Blood Spot (DBS) testing if venous access hard

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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 fjnger prick capillary blood

• If using DBS all fjve target circles must be completely

covered in blood

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Dried Blood Spot (DBS) testing

• Dry blood spot testing
• Hepatitis C antibody testing
• Hepatitis C RNA detection

OR Antigen detection

• HIV antibody testing
• Hepatitis B surface antigen detection
• Hepatitis B core antibody testing

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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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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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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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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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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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Interpreting the results – Hepatitis C - PCR is the key!

• PCR test - viral load test
• Detects viral RNA by amplifjcation and a positive PCR

test indicates chronic infection

• Only Hepatitis C PCR +ve patients are chronically

infected

• Also used to determine effjcacy of treatment and

‘cure’

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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 confjrm 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)

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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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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 confjrm the negative result

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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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Diagram of Hepatitis B virus

DNA polymerase DNA Surface Protein HBs Core Protein HBc

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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
• ngoing Hepatitis B infection

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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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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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Test your previous knowledge

Working it out in practice – what does it mean if?

• Now please check your answers

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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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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 fmip chart for feedback at end

• f this session