Viral hepatitis is inflammation of the liver due to a viral infection. There are several types of hepatitis viruses including types A, B, C, D and E. Hepatitis B and C are known as blood borne viruses (BBVs) as they are spread via blood or other body fluids. They can both result in chronic disease which can lead to liver cirrhosis and failure. This can lead to considerable cost to the individual’s health and cost to health care services.

Hepatitis A and E are spread through consumption of food or water contaminated with faeces of an infected person. Hepatitis A and E usually resolve on their own, however outbreaks of the condition can lead to economic loss. A small number of people may develop more serious health complications. (NIDDK, 2012)

HDV is considered to be a sub viral satellite because it can propagate only in the presence of the hepatitis B virus (HBV).

Unmet need and gaps

• There is lack of awareness amongst health care professionals regarding hepatitis B and C and their risk factors.
• Chronic viral hepatitis remains strongly linked to social deprivation, hepatitis C because of its primary risk factor previous injecting drug use and hepatitis B because it is primarily a disease of migrant populations where it is spread by maternal transmission or poor health care. There is lack of targeted prevention activities amongst these groups.
• There is lack of knowledge amongst the public and vulnerable disadvantaged groups with regards to risk factors for hepatitis A, B, C and E.

• At present there are no targets for testing of hepatitis B and C or vaccination completion for hepatitis B.
• There are now new and highly effective oral medications for hepatitis C (cure rates of 97% or greater). The major challenges are under-diagnosis and lack of awareness in those who have a diagnosis which means they may not seek therapy.
• Prison services still require enhancement to every aspect of HCV care including increased testing rates and provision of therapy.
• Those living in Nottinghamshire County do not have access to treatment as readily as those in Nottingham City. There are no nurse led specialist viral hepatitis services at King’s Mill Hospital like there are at Nottingham University Hospitals. The distances that patient’s may need to travel act as a barrier to accessing treatment, particularly for vulnerable groups such as people who inject drugs or the homeless.

Recommendations for consideration by commissioners

• Promote harm reduction and awareness of viral hepatitis in different health settings.
• Promote hepatitis A and B vaccination for all at risk and eligible groups.
• Implement awareness programmes amongst the general population to help bring forward those people who are unaware that they may be at risk of viral hepatitis.
• Educate professionals and healthcare workers who come into contact with people who are at increased risk of viral hepatitis so that they are aware of testing opportunities.
• Support prison staff in continued opt-out testing of BBVs within prisons.
• Address the barriers to testing for hepatitis B and C within substance misuse services within Nottinghamshire County so that a more consistent routine approach is taken.
• Develop computer software for GPs to help identify patients at risk and provide prompting for testing.
• Continue to monitor and retest individual who further put them-selves at risk.
• Improve engagement in hepatitis treatment services through providing geographically appropriate services. This may include pharmacies, substance misuse services and hostels.
• Support for addiction services, sexual health services and GPs from commissioners to support people who need more active help in engaging with hepatitis treatment services.
• Consideration within viral hepatitis services and for discussion with CCGs for improved viral hepatitis services and access to services from those in Nottinghamshire County.
• Continued oversight from NUH Hepatology and ODN leadership with regards to progress made within this area.
• Close communication with neighbouring areas within the shared operational delivery network (ODN) to ensure fair and effective reaching of hepatitis C treatment targets.

Laura James, GP Fellow in Public Health, Public Health Nottingham City laura.james@nottinghamcity.gov.uk