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Key issues in diagnosing and treating hepatitis C infection

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VOL: 102, ISSUE: 24, PAGE NO: 23

Terry Hainsworth, BSc, RGN, is clinical editor, Nursing Times

Hepatitis C remains a major public health concern, despite awareness campaigns (British Liver Trust, 2006; Department of Health, 2006) and strategies for management (DH, 2004; 2002). There is a large pool of infected individuals and, unless action is taken, this has the potential to result in a significant problem for the health service as untreated patients develop serious liver disease (All-Party Parliamentary Hepatology Group, 2006).

Hepatitis C remains a major public health concern, despite awareness campaigns (British Liver Trust, 2006; Department of Health, 2006) and strategies for management (DH, 2004; 2002). There is a large pool of infected individuals and, unless action is taken, this has the potential to result in a significant problem for the health service as untreated patients develop serious liver disease (All-Party Parliamentary Hepatology Group, 2006).

Epidemiology
Hepatitis C is a bloodborne, viral liver condition that can cause chronic infection and liver disease (HPA, 2006). Symptoms include fatigue, weight loss, nausea, flu-like symptoms, abdominal pain and jaundice but many people do not experience these. In about 15-20% of infected people the condition will clear without medical intervention within about six months but for the remaining 80-85% the outcome is extremely variable. Many will never develop any symptoms of liver disease and may not even know they have been infected, while others will go on to develop serious liver disease (HPA, 2006).

On a global scale, the UK is considered to have a relatively low prevalence of hepatitis C (HPA, 2006). Estimates for England and Wales vary between 200,000 and 500,000 infected people (Rosenberg et al, 2006). Chronic hepatitis C infection in England is estimated to be around 0.4% (HPA, 2006).

The most common way that hepatitis C is acquired is through injecting drug use, where contaminated injecting equipment is shared. Sexual transmission is relatively rare, as is transmission from a mother to a newborn baby. Hepatitis C is also a risk for any healthcare workers who sustain a sharps injury.

Prevention and treatment
There is no vaccine for protection against hepatitis C infection, so the mainstay of prevention is stopping blood from infected individuals coming into contact with others. One key issue is the transmission of hepatitis C among injecting drug users (DH, 2004).

The Hepatitis C Action Plan for England (DH, 2004) outlines ongoing action including:

- Provision of needle, syringe and other injecting equipment exchange services;

- Safe disposal of used needles and syringes;

- Provision of outreach and peer education services;

- Provision of specialist drug treatment services;

- Provision of advice about hepatitis C and other bloodborne viruses and the risks of injecting drugs;

- Provision of disinfecting tablets in prisons.

The importance of minimising the risk of hepatitis C transmission in healthcare settings, by adopting rigorous standard infection control and effective management of occupational blood exposure through sharps injuries, is also highlighted.

The action plan also includes an undertaking that the Department of Health would:

- Develop health promotion information on the risks of injecting drugs for young people entering juvenile and young offenders' establishments;

- Provide information about avoiding hepatitis C infection while travelling abroad.

The treatment for chronic hepatitis C infection is a combination of two drugs: interferon and ribavirin. This therapy is successful in clearing the virus in about 40% of individuals. Factors such as age, sex, duration of infection, the strain of the virus and the degree of liver damage determine its effectiveness. However, new and more effective treatments are likely to become available in the near future (All-Party Parliamentary Hepatology Group, 2006).

The problems
Although estimates suggest that around 200,000 people in England are chronically infected with hepatitis C, only 38,000 diagnoses have been reported. Therefore, it must be concluded that the majority of infected people are undiagnosed and have not received appropriate treatment (DH, 2004). The implications are that some will develop serious liver disease, including cirrhosis and liver cancer. This places an enormous pressure on the healthcare system (Rosenberg et al, 2006).

The UK has been criticised for not responding to the threat of the disease in the same way as its European neighbours. Management of hepatitis C in the UK has been described as both unstructured and underfunded (Rosenberg et al, 2006).

Following anecdotal evidence suggesting that the implementation of the hepatitis C strategy in England was at the very least patchy, the All-Party Parliamentary Hepatology Group undertook an audit. It used questionnaires to investigate the extent that the action plan's requirement that 'Chief Executives of Primary Care Trusts and NHS Hospital Trusts should be able to demonstrate that there are adequate services and partnerships at local level to enable models of best clinical practice to be followed, as set out in the Hepatitis C Strategy for England' was being implemented.

The audit surveyed 305 PCTs and results from the 191 (63%) respondents confirm that implementation of the plan is patchy (Fig 1). Of the 191 PCTs:

- Only 63 (33%) have made a realistic attempt to estimate the number of people with hepatitis C in their area;

- Only 64 (34%) have a protocol in place for testing and/or screening;

- Only 49 (26%) have a process in place in order to monitor treatment.

Data collected from 107 of the 165 NHS hospital trusts surveyed shows significant delays for patients wanting treatment in 46% of trusts; the time from recommendation for treatment to starting it varies from one week to one year.

This data led the group to conclude that the plan is not working because it is not being implemented. There is no concerted nationwide effort to identify people who are undiagnosed and this will become a burden the health service could have prevented (All-Party Parliamentary Hepatology Group, 2006).

Recommendations
The Hepatitis C Trust has published recommendations for action (Rosenberg et al, 2006). These are:

- The development of a detailed strategy for the management of hepatitis C, including detailed targets for both detection and treatment;

- That an individual is appointed to lead strategy development within the Department of Health;

- Implementation of an awareness campaign;

- The improvement of diagnostic services;

- The building of an appropriate infrastructure for diagnosis and treatment;

- The establishment of a 'diagnosis to treatment highway' for rapid referral and initiation of treatment;

- Linking clinical activity to a research programme, targeting epidemiology, and evaluating these programmes as well as clinical and basic science research into diagnosis and more effective treatment.

The trust suggests targets of 50% of those infected to be diagnosed in the next three years and 25% of them treated in the next eight years. It highlights the importance of awareness campaigns. Delivering this will require investment. The trust suggests that the UK will require about 30 major centres for hepatitis C management, with networks linked into each, and at least one new hepatologist and nurse specialist for each as well as funding for diagnostic testing and treatment (Rosenberg et al, 2006).

Without this kind of action many people infected with hepatitis C will remain undiagnosed. They have the potential to develop serious liver disease and be a significant burden to the healthcare system.

- This article has been double-blind peer-reviewed.

For related articles on this subject and links to relevant websites see www.nursingtimes.net

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