Cynulliad Cenedlaethol Cymru

National Assembly for Wales

Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Health, Social Care and Sport Committee

Ymchwiliad i Hepatitis C

Inquiry into Hepatitis C

HSCS(5) H03

Ymateb gan Iechyd Cyhoeddus Cymru

Evidence from Public Health Wales

Section 1: The action being taken to meet the requirements of the Welsh Health Circular (WHC/2017/048) published in October 2017 and subsequently meet the World Health Organization target to eliminate Hepatitis B and Hepatitis C as significant public health threats by 2030.

1.         The World Health Organization (WHO) has announced a global health sector strategy on viral hepatitis which sets out to eliminate hepatitis B (HBV) and hepatitis C (HCV) as significant public health threats by 2030. The WHO target is a 90% reduction in occurrence of new cases (incidence) and 65% reduction in death (mortality) due to hepatitis B and C by 2030. Wales is signed up to this strategy. This goal has been incorporated into Public Health Wales’ new long-term strategy to 2030 published in 2018.

2.       The Welsh Health Circular (WHC/2017/048, issued in October 2017) highlights the three key areas where action is needed in Wales to progress toward the 2030 elimination target. Those three areas are:-

a.      Reduce and ultimately prevent ongoing transmission of HCV within Wales;

b.     Identify individuals who are currently infected with HCV including those who have acquired HCV outside the UK and are now resident in Wales; and

c.      Test and treat individuals currently infected with HCV who are actively engaged in behaviours likely to lead to further transmission.

3.       In Wales the Together for Health Liver Disease Delivery Plan 2015-2020’  has built on the good work facilitated by the Blood Borne Viral (BBV) Hepatitis Action Plan for Wales 2010-2015. The implementation of this plan is supported by the Liver Disease Implementation Group (LDIG), which is chaired by the Executive Director of Public Health Services at Public Health Wales and includes representation from each health board in Wales, the British Liver Trust (BLT) and the Children’s Liver Disease Foundation. The LDIG identified blood borne viral hepatitis as one of the key priority areas.

4.       To support taking this agenda forward the Viral Hepatitis Subgroup was established. This subgroup, chaired by the national lead for hepatitis, provides both strategic leadership and support to health boards in progressing this area of work. This subgroup includes multidisciplinary representation including representation from the Hepatitis C Trust. Epidemiological and administrative support to this group is provided by Public Health Wales.

5.       This Viral Hepatitis Subgroup reports regularly to the LDIG and updates on the work of this subgroup are included in the annual statement of progress submitted by the LDIG to Welsh Government. This group has facilitated a number of developments working with other agencies as appropriate to develop and support increased testing and treatment in a variety of settings including prisons, drug and alcohol services, third sector services and community pharmacies.

6.      The Viral Hepatitis Subgroup also helped to obtain funding and administration for a variety of projects on testing and treatment strategies for hepatitis C, e.g. funding to develop reflex Polymerase Chain Reaction (PCR) testing from dried blood spot tests that will facilitate and increase speed of access to a confirmed diagnosis which in turn can speed up access to treatment in some settings (e.g. community pharmacy); and the appointment of a point of care testing lead for the Wales Specialist Virology Centre to  develop these services in various settings across Wales.

7.       The Viral Hepatitis Subgroup also co-ordinates the collection of data to ensure appropriate governance of the national plan and feeding relevant information back to Welsh Government, health boards and other relevant stakeholders. In addition, the subgroup has been working with NHS Wales Informatics Service (NWIS) to develop a hepatitis C electronic form that will facilitate live collection of national treatment data in the future. The subgroup has also been involved in the development of an elimination model using an independent company funded through a non-restricted grant from pharmaceutical industry.

8.      The Viral Hepatitis Subgroup supports the regular review of the national plan with expert advice and recommendations for development as and when appropriate. The subgroup has also been instrumental in administration of the virtual panel that enables discussion of complicated patients to ensure most appropriate treatment options are given to these individuals.

Reduce and ultimately prevent ongoing transmission of HCV within Wales

9.       Over 90 per cent of ongoing transmission of hepatitis C is via injecting drug use.  As such, the most effective way of reducing transmission is through a reduction in the number of individuals injecting and through provision of effective Needle and Syringe Programmes (NSPs).  Public Health Wales provides support to all 270 NSPs in Wales, through (as at 2017/18) the development of guidance, policy and monitoring.   Statutory, voluntary and community pharmacy based NSPs all record individual activity on the Harm Reduction Database module, which provides a means of evidencing the nature and scale of injecting drug use as well as coverage of needle and syringe provision.  An annual report is published by Public Health Wales to monitor progress, (available on the Public Health Wales website at http://www.wales.nhs.uk/sitesplus/documents/888/HRD%20Report%202017-18%20-%20Final%20.pdf).

10.   In 2017/18 there were a total of 14,000 regular users of needle syringe services, and over the last five years there has been a decrease in the proportion of young people injecting drugs and accessing services, from 5.5% in 2013/14 to 2.7% in 2017/18.

11.      Public Health Wales, with Welsh Government, led on a national commissioning process in 2016-17. The new NSP framework was initiated in July 2017 and has led to the introduction of ‘single injection kits’ in all NSPs. 

Identify individuals who are currently infected with HCV including those who have acquired HCV outside the UK and are now resident in Wales

12.    With the advent of new, highly effective and well-tolerated medicines to treat hepatitis C, Public Health Wales is leading the co-ordination and implementation of a national patient re-engagement exercise. This looks to identify individuals with a historical diagnosis of Hepatitis C who, for whatever reason(s), have not completely engaged with treatment services and seeks to bring them back into the service and offer them treatment with the new therapies now available (as appropriate).

13.    This work is being supported by an implementation group which includes representation from the Hepatitis C Trust, the British Liver Trust and the General Practitioners Committee (GPC) Wales in addition to every health board in Wales. 

14.    Using historical laboratory testing data as the starting point, work has been undertaken to identify these individuals. From Spring 2019, they will be contacted and offered the opportunity to re-engage with services and be assessed for treatment.

15.    The Viral Hepatitis Subgroup has also supported a number of initiatives/pilot projects to support the identification and treatment of individuals with hepatitis C infection. This includes an evaluation of an outpatient service in one health board, and case finding in primary care in another health board. In addition, a national project and research lead for hepatitis has been appointed to help develop approaches and share learning across health boards.

Test and treat individuals currently infected with HCV who are actively engaged in behaviours likely to lead to further transmission

16.    Public Health Wales has developed a Harm Reduction Database (HRD) Blood Borne Virus Module, which has been implemented in all specialist substance misuse services across Wales and in a number of pilot community pharmacy sites. It is envisaged that a national roll-out across all relevant community pharmacies will commence over the next few years.  Given that the prevalence and incidence of HCV infection is highest among individuals with current or historic substance misuse, it is vital that these populations are routinely tested and referred for treatment as soon as identified.  The HRD blood borne virus module provides a system for recording routine testing, in line with the implementation of routine opt-out testing in all substance misuse services in Wales (https://gov.wales/docs/dhss/publications/160906substance-missuse-2016-2018en.pdf ).  In addition, the database enables the testing and outcome history to follow the patient wherever they are in Wales, and over time.  The database provides a mechanism for screening, diagnosis, referral and treatment milestones including commencement, Sustained Virological Response (SVR) and reinfection.  Public Health Wales provides an annual report on progress (available Public Health Wales website at: http://www.wales.nhs.uk/sitesplus/documents/888/BBV%20Annual%20report%202017-18%20FOR%20PUBLICATION.pdf ).

17.    Over 1600 individuals in contact with substance misuse services were tested in 2017 and this has increased by over one third to date in 2018.  However, a significant proportion of individuals remain untested and it is important that services are appropriately resourced to enable all ‘at risk’ clients to be tested on an annual basis.

18.    In addition, Public Health Wales has supported Welsh Government in the reintroduction of a Key Performance Indicator (KPI) for all substance misuse services.  This will facilitate the testing of all individuals in contact with services on at least an annual basis until no longer at risk of HCV infection.  The KPI will be monitored for each site via the HRD, which ensures an individual patient record of testing, diagnosis and treatment.  The system also reduces the likelihood of an individual testing reactive for HCV from being lost to services, or ‘falling through the net’ which has been an issue in the past.

19.    Since 2010, BBV testing has become a routine part of prison health provision.  In November 2016, Welsh Government issued a formal policy move to opt-out testing for blood borne viruses for all those on admission to prison. All prisons in Wales offer BBV screening although levels of delivery remain varied.  Table 1 shows the number of individuals attending BBV services in each prison in Wales 2015-2017.  The table demonstrates an increase in the number of men tested since November 2016 when opt-out screening was introduced. Mean prevalence of hepatitis C antibody was 10% in 2015, 7% in 2016 and 10% in 2017.

Table 1 Numbers of individuals attending Blood Borne Virus services in each prison in Wales 2015-2017

Requesting site

Individuals attending, per year

2015

2016

2017

Total

H. M. PRISON BERWYN

0

0

264

264

H. M. PRISON CARDIFF

238

885

1290

2413

                 H. M. PARC BRIDGEND

398

857

1463

2718

H. M. PRISON PRESCOED

98

114

196

408

H. M. PRISON SWANSEA

0

4

162

166

H. M. PRISON USK

70

255

71

397

Total

804

2115

3446

6366

1.

20. All prisons in Wales offer treatment for blood borne viruses.  Specialist nurses run clinics within each prison to see those testing hepatitis C antibody positive.  Portable scanners used within prisons mean that in the majority of cases, individuals can transition from testing to treatment without the need to leave the prison.

21.    An increase in the numbers of men screened for BBVs was evident following the introduction of the opt-out screening policy.  Despite this, implementation of opt-out testing across prisons remains variable and many men appear to be untested.  The setting of a staggered target for BBV screening in prisons is being considered.  As yet, prisons in Wales have increased testing rates without any additional direct resource.  Adequate resourcing of prisons to support continued increases in prison testing needs to be considered. 

Section 2: How the knowledge and awareness of the public and health professionals of the Hepatitis C virus can be increased.

22.  The British Liver Trust (BLT) (as part of their work with the Liver Disease Implementation Group) is working in Wales to raise public awareness of liver health,  highlight the main causes of liver disease and what lifestyle choices and prevention is needed to maintain good liver health. The BLT is also delivering ‘Love Your Liver’ screening and scanning events throughout Wales and undertook a ‘Love Your Liver’ roadshow in November 2018, which saw the Mobile Scanning Unit visiting Bangor, Wrexham, Cardiff, Bridgend and Swansea. 

23.  As part of the BLT-funded Royal College of General Practitioners (RCGP) liver disease clinical priority programme, in July 2018, Wales hosted one of four UK regional BLT/RCGP  primary care education events.

24.  In December 2017, a good practice hepatitis C roadshow was held in Cardiff. This event was organised by HCV Action and Public Health Wales, and aimed to bring together professionals working with hepatitis C in a variety of contexts, identify challenges and solutions for tackling hepatitis C locally, and showcase and share examples of good practice in prevention, testing, and treatment. The summary report from the roadshow is available on the HCV action website at http://www.hcvaction.org.uk/resource/summary-report-hepatitis-c-good-practice-roadshow-cardiff-december-2017 [accessed 27/12/2018].

25.  In addition, the national lead for hepatitis has led two national network meetings per year, to help share learning between teams and health boards. These were made possible through unrestricted educational grants provided by the pharmaceutical industry.

26.  The BBV teams provide support to initiatives to raise awareness. These include examples such as education of primary care teams, awareness raising on World Hepatitis Day, engagement with media around awareness raising events, and a project to test and raise awareness in a mosque. However, the impact of these initiatives to date is uncertain.

27.  Increasing awareness of the public and health professionals is one of the challenging areas of the elimination plan. Support for a focussed awareness-raising campaign would be welcomed.  This is particularly important in finding those patients who are not easily identified (e.g. individuals from high prevalence countries, people who used to inject drugs or dabbled in early life, and those at risk through blood transfusion).

Section 3: The scope to increase community-based activity e.g. the role of community pharmacies.

28.  The Viral Hepatitis Subgroup of LDIG has developed a national protocol for the delivery of testing for hepatitis C in the community, which has been approved by National Pharmacy Wales.

29.  With funding from the LDIG, a national pharmacy lead for hepatitis has been appointed and is now working on rolling out testing in community pharmacies. A map of all pharmacies that carry out needle exchange and opiate substitution therapy has been constructed from data extracted from the HRD and this will be used to facilitate roll-out. Funding for a pilot project to test the protocol in the live environment has been secured and will run in January 2019. 

30. BBV teams from across Wales are aware of the protocol and are in position to support the roll out of testing in this environment.

31.    The national pharmacist lead is now starting work on a nationally agreed treatment pathway in community pharmacy for development and roll-out in 2020.

Section 4: The long-term viability of treatment programmes.

32.  The Viral Hepatitis Subgroup, through the national lead for hepatitis, has provided support for the national tendering process and the delivery of equitable and transparent access to treatment. This has resulted in the delivery of significant savings to the NHS in Wales through national procurement, adherence to the principles of prudent healthcare, the use of cheapest possible treatment options when appropriate, and taking senior decisions to delay treatment in patients who could afford to wait for newer cheaper options in the early days of management of hepatitis C.

33.  The National Hepatitis C treatment pathway and treatment recommendation protocol has been developed through the coordination of the BBV network and clinical leadership.

34.  Treatment programmes are currently supported by a combination of health board level BBV teams and national roles (pharmacist lead, project and research lead, point of care testing lead). The Liver Disease Implementation Group supports these national roles.  Funding for those roles is uncertain beyond 2020.  At the current trajectory elimination will not be achieved until after 2030.  If testing and treating is to be up scaled to the point that elimination by 2030 is to be achieved, then it is imperative that these roles are sustained beyond 2020.

35.  There are many developments designed to increase the testing of at risk individuals and link them to care (e.g. increased testing in prisons, drug and alcohol services, third sector agencies, community pharmacies).  It is imperative that these initiatives are appropriately resourced so that an increase in testing in these environments is sustainable.

36.  The developments to increase testing and treatment of at risk individuals needs to be appropriately matched with investment to promote harm reduction messages to reduce the risk of re-infection and make the delivery of elimination as cost effective as possible.