Chapter 6: hepatitis B
Where we are now
Scotland has historically been a country of very low prevalence of hepatitis B. The actual and potential burden of disease associated with HIV and hepatitis C were previously considered to be much greater. Consequently, systems and initiatives were established to generate comprehensive information on the burden of HIV and hepatitis C in Scotland while those for hepatitis B, until very recently, have been either absent or rudimentary.
In recent years, however, it has become evident that the number of people living in Scotland with chronic hepatitis B infection has increased considerably, as a consequence of a rise in the number of immigrants coming to Scotland from countries in the world where the prevalence of hepatitis B infection is high (particularly East Asia) (Hahne et al, 2004). In response, Health Protection Scotland, in association with laboratory and clinical colleagues, has embarked on a programme of information generating activity which will provide ongoing high quality information on the burden of hepatitis B infection and disease in Scotland.
The development of information systems and the use of statistical modelling techniques for hepatitis B, while well underway, are incomplete and will be unable to provide robust data until 2012. The following evidence cited in this chapter should, therefore, be considered in this context.
Where we want to be
Due to the historically low prevalence of hepatitis B, there has been no overarching national policy for hepatitis B in Scotland encompassing diagnosis, treatment and care as well as prevention. The inclusion of hepatitis B within the Sexual Health and Blood Borne Virus Framework demonstrates that hepatitis B has become a priority area for Scottish Government to progress two fundamental aims:
- to establish an understanding of the epidemiology and burden of hepatitis B-related disease in Scotland; and
- to ensure optimal prevention, treatment, care and support for hepatitis B across Scotland for those at risk or living with the infection.
Once our knowledge and understanding of hepatitis B in Scotland has developed, these aims will be translated into high level Framework Outcomes for hepatitis B to be progressed in future years:
Framework Outcomes: Hepatitis B
- Fewer newly acquired hepatitis B infections
- A reduction in health inequalities associated with hepatitis B
- People affected by hepatitis B lead longer, healthier lives
- A society whereby the attitudes of individuals, the public, professionals and the media in Scotland towards hepatitis B are positive, non-stigmatising and supportive.
The Multi-Agency Approach
If we are to be successful in our attempts to improve public and individual health in respect of hepatitis B, a more holistic, integrated and cross sector approach is required. The NHS, Local Authority, Scottish Prison Service and Third Sector are all essential to progress Framework Outcomes in relation to hepatitis B. The NHS has a critical role in preventing, diagnosing and treating infections, but it operates in a context where many other partners can influence service uptake and the behaviours, lifestyles and risk factors that put individuals at risk of infection. Consequently, the Framework also recognises the vital role of Local Authorities ( e.g. through education, social work, community services, addiction services) and the Third Sector for hepatitis B.
A range of infrastructure developments and new initiatives have been developed for hepatitis C during 2008-2011, through the Hepatitis C Action Plan for Scotland. Where feasible, these should be expanded to encompass hepatitis B but only where this is appropriate to local circumstance and need. Similarly, hepatitis B should be encompassed and/or linked with local sexual health infrastructures and initiatives where it is feasible and appropriate to do so.
Delivering the Outcomes
The following section details the recommendations and strategies multi-agency partners should adopt to contribute towards the delivery of each of the Framework Outcomes. Progress against Outcomes will be measured through the agreed set of national indicators (see Appendix 1).
Outcome 1: Fewer newly acquired blood borne virus infections.
The Scottish Government is committed to reducing the transmission of serious infections, including hepatitis B. While prevalence of hepatitis B in Scotland remains low, we cannot be complacent. During the 1990s, several hundred new transmissions of hepatitis B infection were diagnosed annually in Scotland, during a time when outbreaks of infection among injecting drug users were relatively frequent. The numbers of new transmissions started to decline in the early 2000s and in recent years between 50 and 100 new transmissions have been diagnosed annually. However, it is likely that the actual number of new transmissions occurring annually in Scotland lie within the 200-400 range (see Evidence Table 6.1).
The decline in new transmissions, particularly among injecting drug users, coincided with concerted efforts to vaccinate injecting drug users against hepatitis B. Of particular importance was the implementation of the offer of vaccination to prison inmates in Scotland in 1999.
A vaccine against hepatitis B has been available since 1982 and is 95% effective in preventing infection (Plotkin and Orenstein, 2004). Many countries provide universal hepatitis B immunisation, as part of either an infant or adolescent schedule. However, unlike most other western countries, Scotland, and the rest of the UK, does not provide universal vaccination against hepatitis B. This position is based on advice from the Joint Committee on Vaccination and Immunisation ( JCVI) who provide UK Health Departments with recommendations on all vaccination and immunisation issues. Currently, universal hepatitis B vaccination is not considered cost effective in the UK. Instead, a selective vaccination programme is in place which recommends that those at particular risk of infection are vaccinated.
- NHS Boards should continue delivery of the selective vaccination programme for hepatitis B in line with national immunisation policy, and specifically:
- NHS Board vaccination plans should be updated regularly in respect of local needs, population, epidemiology and national guidance to ensure the optimal uptake of hepatitis B vaccine by those most at risk of infection. These plans should reflect, promote and support the responsibilities of local community partners, including GPs, in offering hepatitis B vaccination for clinical reasons, to those at risk of infection in line with immunisation policy (Department of Health, 2006) and national and local best practice guidance;
- work should be done to increase the proportion of babies born to hepatitis B infected mothers, or to mothers who are otherwise identified as being at risk of infection, that receive a full course of vaccine in line with national immunisation policy (Department of Health, 2006) and national best practice guidance for neonatal immunisation (Department of Health, 2011); and
- hepatitis B vaccination should be incorporated into care plans for
those in harm reduction, drug treatment and rehabilitation services progressing through 'recovery orientated systems of care' (care pathways) for drug misuse in line with recommendations to encourage the uptake and availability of hepatitis B vaccination within the Scottish Government National Guidelines for Services Providing Injecting Equipment (Scottish Government, 2010b).
- Multi-agency partners should work together to:
- develop effective local strategies that support and promote early diagnosis and treatment of those already chronically infected with hepatitis B; and
- deliver regular training, education and continuing professional development to ensure the competence of the health and non-health hepatitis B related workforce in the context of blood borne virus prevention. Provision should be in line with existing NHS Education for Scotland national frameworks for workforce development, education and competency and Recommendation 9 of the Scottish Government National Guidelines for Services Providing Injecting Equipment (Scottish Government, 2010b). This should include the implementation of hepatitis B educational solutions (or blood borne virus/sexual health solutions encompassing hepatitis B) recommended by NHS Education for Scotland Advisory Group(s).
Outcome 2: A reduction in the health inequalities gap in sexual health and blood borne viruses.
Health inequality associated with hepatitis B infection in Scotland is currently unproven but there is potential for this to manifest in relation to affected migrant populations.
Strategies to reduce new transmissions of hepatitis B (see Outcome 1) and to improve the earlier diagnosis of those infected to enable access to specialist care and treatment (see Outcome 3) will help to reduce the pool and spread of infection within risk populations in Scotland to reduce inequality.
- Multi-agency partners should work together to ensure that prevention, treatment and care pathways for hepatitis B consider the language, literacy and/or cultural challenges to risk populations accessing these services in Scotland to optimise their uptake.
Outcome 3: People affected by blood borne viruses lead longer, healthier lives.
Hepatitis B is a condition where effective and timely intervention can minimise adverse health outcomes for the individual and the burden of resource on NHS and other services. Precise estimates on the number of people living in Scotland with chronic hepatitis B infection are unavailable but preliminary work indicates that the number lies within the 5000-15,000 range and the majority of infected individuals will be of Asian, African or East European ethnicity, areas with a high prevalence of hepatitis B infection.
A considerable proportion, possibly around 50%, of infected persons in Scotland remain undiagnosed (refer to Evidence Table 6.2). Undiagnosed infections present a transmission risk and can lead to further spread of disease. It is vital that undiagnosed infections are reduced to ensure the maximum individual and public health benefit.
Hepatitis B cannot currently be cured and is a complex condition, but it can be managed through appropriate treatment, care and support. Antiviral treatment can also contribute to efforts to prevent onward transmission. Unlike hepatitis C, there is no national guidance document or standards for the management of hepatitis B in Scotland. At present, only 1000-1500 chronically infected individuals are estimated to have attended a specialist for hepatitis B infection management and care during 2009/10 (refer to Evidence Table 6.2).
- National guidance, standards and/or recommendations on the diagnosis, treatment and care for hepatitis B should be developed. The potential for procurement of hepatitis B medicines ( e.g. home delivery/joint purchasing) to reduce costs to NHSScotland will be explored.Multi-agency partners should work together to reduce the pool of undiagnosed hepatitis B infection in Scotland and to optimise available treatment, care and support through effective local strategies to ensure:
- the use of innovative and targeted approaches to test, diagnose and case find for hepatitis B;
- establishment of care pathways for hepatitis B to ensure that those diagnosed are effectively signposted to services and referred to specialist care for assessment, even where clinical treatment is not immediately appropriate or necessary;
- delivery of diagnosis, treatment and care for hepatitis B in line with national guidance, standards and/or recommendations; and
- regular training, education and continuing professional development to ensure the competence of the health and non-health hepatitis B-related workforce, particularly those working with vulnerable groups. Provision should be in line with existing NHS Education for Scotland national frameworks for workforce development, education and competency and Recommendation 9 of the Scottish Government National Guidelines for Services Providing Injecting Equipment (Scottish Government, 2010b).
Outcome 5: A society whereby the attitudes of individuals, the public, professionals and the media in Scotland towards sexual health and blood borne viruses are positive, non-stigmatising and supportive.
Stigma and discrimination can be major determinants of health outcomes. Those infected or at risk of hepatitis B, may be disinclined to access services or be open about their infection and risk behaviours as a result of public perceptions of the infection or fear of discrimination.
If we are to successfully reduce the burden of disease associated with viral hepatitis we need to foster a culture in Scotland that is non-stigmatising and non-discriminatory to those infected or at risk. Education and awareness raising needs to be increased and misinformation in the media, if it exists, needs to be reduced. These are not easy issues to address and no single strategy or policy can successfully change beliefs or prejudices that may be common across the country, however we believe that there are things within our control that may contribute to the broader outcome.
Through this outcome we aim to progress understanding and attitudes towards hepatitis B in Scotland including how it is portrayed in the media through local and national strategies, encompassing:
- Efforts to promote a positive approach to hepatitis B in the media should continue nationally and locally through linking in with media groups such as the National Union of Journalists and national broadcasting regulators.
- Work to promote awareness and understanding of hepatitis B will continue locally, regionally and nationally.
The Scottish Government will monitor progress on delivery of the outcomes through the Framework Indicators detailed in Appendix 1.
The Scottish Government, including the national coordinators, Special Health Boards and other national organisations, will have key roles in progressing the achievement of the Framework Outcomes and supporting multi-agency partners. These roles are set out in Chapter 7.
Table 6.1 - Outcome 1: Fewer newly acquired blood borne virus infections
- In recent years between 50 and 100 new transmissions have been diagnosed annually.
- Since it is common for hepatitis B infection not to result in an acute symptomatic illness and, since not all individuals with acute symptomatic illness seek medical treatment and thus diagnosis, it is likely that the actual number of new transmissions occurring annually in Scotland lie within the 200-400 range.
- All pregnant women in Scotland are offered a hepatitis B test to allow babies of infected mothers to be vaccinated. In recent years, the numbers of hepatitis B infected pregnant women have increased considerably as a consequence of immigration; accordingly, the opportunity for hepatitis B transmission from mother-to-child has increased. Vaccination at the time of birth dramatically reduces the chances of such transmission.
Table 6.2 - Outcome 3: People affected by blood borne viruses lead longer, healthier lives
- While precise estimates of the number of people living in Scotland with chronic hepatitis B infection are unavailable, preliminary work indicates that the number lies within the 5000-15,000 range and the majority of infected individuals will be of Asian, African or East European ethnicity, areas with a high prevalence of hepatitis B infection.
- A considerable proportion - possibly around 50% - of infected persons in Scotland remain undiagnosed.
Treatment and Care
- During 2009-2010, it is estimated that between 1000 and 1500 chronically infected individuals attended a specialist for hepatitis B infection management/care.
- Antiviral therapy was being administered to between 10 and 20% of those attending for management and/or care. It should be noted, however, that only a proportion of chronically infected individuals in specialist care would be eligible for antiviral therapy.