Hepatitis C: migrant health guide

Main messages

ConsiderHealthcare screeningprofessionals patientsshould:

• in fromline countries with aNICE higherGuidance prevalenceoffer of hepatitis C virusscreening (HCV)for thanpeople theborn UK,or particularlybrought thoseup wherein thea prevalencecountry ofwith HCVan isintermediate considerablyor higherhigh prevalence (2% or ifgreater) otherof riskchronic factorshepatitis apply.C

• Considerconsider screening close contacts of HCV-infectedsomeone patients.known to be living with hepatitis C

• Referrefer individuals identified as positiveliving with hepatitis C for specialist assessment.assessment and provide appropriate support if needed to help the person attend (this may include peer support)

Background

The hepatitis C virus (HCV) causescan cause both acute and chronic hepatitis, (inflammationranging ofin theseverity liver)from anda canmild leadillness to chronica liverserious, disease.lifelong illness including cirrhosis and cancer.

The World Health Organization estimates that globally50 58 million people haveare living with chronic hepatitis C,C globally, with aboutaround 1.51 million new infections occurring per year.

RegionsThe with the highest prevalenceburden of hepatitisdisease Cis includefound in the Eastern Mediterranean regionRegion andwith 12 million people estimated to be living with chronic infection. In the South-East Asia Region (9 million), European region.

OnRegion a(9 globalmillion) scale,and the UKWestern isPacific consideredRegion (7 million) people are estimated to be aliving relativelywith lowchronic prevalencehepatitis country.C. Approximately8 89,000million people inare England were estimated to be living with chronic hepatitis C infectionin the African Region and 5 million in 2019.the Region of the Americas.

SurveillanceOn a global scale, the UK is a relatively low prevalence country. Between 2015 and research2023, studiesthe number of people living with chronic hepatitis C in England havehas foundfallen thatin individualsthe ofgeneral Southpopulation Asianby origin56.7%. Approximately 55,900 people in England arewere amongestimated thoseto atbe increasedliving riskwith ofchronic hepatitis C infection.infection in 2023.  

Symptoms

During acute infection many people have no symptoms, whileand otherswhen symptoms do occur, they can experiencebe mistaken for another condition. Symptoms: can include:

• feverfatigue
• fatiguesweats (especially at night)
• aches and pains
• decreased appetite
• nausea
• vomiting
• abdominalright pain
• darkupper urine
• grey-colouredquadrant faeces
• jointdiscomfort and abdominal pain
• jaundice (yellowing– ofwhich themay be less noticeable on brown or black skin and– themay whitesalso ofoccur thewith eyes)
• ‘flu-like’dark symptomsurine and/or pale stools if cholestasis

Transmission and infection

Transmission of HCV is transmittedusually bythrough contactblood-to-blood withcontact.

In infectedthe blood, and is spread by:UK:

• sharingthe ormost useimportant ofrisk contaminatedfactor equipmentfor duringacquiring hepatitis C virus infection is injecting drug use (past or intranasalcurrent) drugthrough usesharing of injecting equipment.
• receivingOther infectiouspeople who may have been exposed to hepatitis C include:
  • people who are from a country with a higher prevalence of hepatitis C
  • received a blood (viatransfusion transfusion)prior to 1 September 1991 or infectiousNHS blood products (forprior exampleto clotting factors)1986

For migrants, depending on countries previously lived in, there may be additional factors that increase risk of transmission through:

• the reuse or inadequate sterilisationsterilization of medical equipment
• needlestickequipment, orespecially othersyringes sharpsand injuriesneedles in healthcare settings
• tattooingthe transfusion of unscreened blood and bodyblood piercingproducts

MinorHCV transmissioncan routesbe include:

• verticalpassed transmissionfrom (motheran infected mother to baby)
• their baby (vertical transmission), and via sexual practices that lead to exposure to blood (sexual transmission). However, these modes of transmission

are less common.

TheMost averagepeople incubationthat are exposed to hepatitis C do not have symptoms. Of those that do develop symptoms, the average period isfrom betweenexposure 2to weekssymptom onset is 2 to 612 months.weeks.

Approximately 15%30% (15% to 45%45%) of infected people living with hepatitis C clear their infections naturally (spontaneously or without treatment) within the first 6 months of infection, but they do not become immune to future HCV infection.

The remainder will develop chronic hepatitisHCV C infection, which means they:

• require treatment
• will be infectious to others
• can develop chronic liver disease including cirrhosiscirrhosis, end-stage liver disease and carcinomaliver cancer

Testing

SeeHealthcare ‘Hepatitisprofessionals C:should guidance,offer datatesting, andincluding analysis’a pre-test discussion, to anyone at increased risk of hepatitis C virus infection. This includes migrants from intermediate or high prevalence countries, and people who currently inject or have previously injected drugs.

Testing

Sample

GP requiredsurgeries, sexual health clinics, genito-urinary medicine (GUM) clinics or drug treatment services all offer testing for diagnosis

hepatitis C. A finger-prick test at home can also be used.

SendA ablood clottedtest bloodis (2mldone to 6ml)test samplefor toHCV yourinfection. localThis laboratoryis usually a test for antibodyantibodies, testing.and Ifthen positive,a thereflex laboratoryribonucleic willacid (RNA) or antigen test toon detectpositive viralantibody test results. In some circumstances only an RNA, andtest willis requiredone abut secondthis sampleis fornot confirmation.common.

SeeDetection PHE’sof Hepatitisantibodies C:(the informationantibody fortest) GPs.

Offerindicates testingcurrent or resolved infection and can be detected 5 to anyone12 atweeks riskafter ofinfection. hepatitisHowever, Cantibodies infection,may including:not be generated, especially if the person is immunosuppressed.

• Detection of HCV RNA (the RNA test) indicates current infection and pastcan injectingbe drugdetected users

• recipientsas ofearly bloodas transfusions1 beforeto September3 1991weeks andafter orinfection.

  See thoseHepatitis whoC: haveinformation receivedfor treatmentGPs withand anNICE: NHSTesting bloodfor producthepatitis beforeB 1986and C in England

• peopleprimary borncare

  Positive orantibody raisedresult inand positive HCV RNA result

  Refer patients to a highspecialist prevalencefor country

• babiesfurther whoseassessment mothersand havetreatment.

  Positive antibody result, negative HCV infection

• prisonersRNA andresult

  Repeat youngthe offenders

• lookedtest after children
• those4 livingto in6 hostelsweeks orto whoconfirm arenegative homeless
• HIV-positivestatus.

  A menpositive whoantibody haveresult sexand withnegative men

• closeHCV contactsRNA oftest someoneindicates witha HCVpreviously resolved infection
• people withbut abnormaldoes livernot functionprovide testsimmunity (LFT)

Post-testto discussion

Referfurther toinfection. theGive information followingand guidanceadvice on formeasures post-testto discussion.prevent re-infection. 

Negative antibody result

Further testing is required if the last exposure risk occurred in the preceding 3 month ‘window period’.

Discussperiod’.  waysThe ofantibody avoidingtest infectiondetermines inwhether thea future.

Positiveperson antibodyhas result

Confirmever positivebeen antibodyexposed resultsto onthe ahepatitis secondC bloodvirus. sample,However, andthe arrangewindow testsperiod for(time HCVbetween RNA.

Adviseinfection notand towhen donatethe bloodtest orcan carryreliably andetect organthe donorinfection) card.

Positivefor HCV RNAcan result

Referbe patientsmonths, towith aan specialistaverage forof further60 assessment.days.

StopReassure orthe reduceperson alcoholand consumptiongive information (associatedand withadvice on moremeasures rapidto progressionreduce the risk of liverhepatitis disease)C.

DiscussConsider waysrepeating ofthe avoidingtest infecting(especially others.

Considerif the needperson tois testat otherhigh familyrisk membersof orinfection) closeat contacts.

Negativean HCVappropriate RNAtime, result

Abased positiveon antibodywhen andthe negativelast HCVrisk RNAexposure testoccurred. indicatesSeek aspecialist previouslyadvice resolvedif infection,there butis notuncertainty immunityabout the optimal time to furtherrepeat infection.the test.

PatientsIf whothe areperson antibodyremains positiveat butincreased HCVrisk of RNAinfection, negativeoffer shouldannual havetesting afor secondhepatitis C.

For immunocompromised people ensure an HCV RNA test afterhas 4also tobeen 6 weeks to confirm their negative status.conducted.

Further guidance on testing and management

Hepatitis C: informationNHS for GPsinformation, Public Health England, 2020.

HepatitisNICE C:guidance: guidance,Hepatitis dataB and analysis,C Publictesting: Healthpeople England,at 2021.risk of infection

HepatitisHome C,test NICE,for 2020.Hep C

TheHep prevention,B&C: testing,RCGP treatmentonline andlearning

Hepatitis managementC: ofguidance, hepatitisdata Cand inanalysis

Primary primaryCare careToolkit,

Hepatitis RoyalC: Collegeinformation offor General Practioners, 2007GPs

Treatment

In the UK, anyone who is living with hepatitis C positive and has given informed consent can receive  treatment.

Hepatitis C iscan generallybe managedsuccessfully accordingtreated toby NICEtaking guidelines,a whichshort recommendcourse treatment of chronicwell-tolerated hepatitisand Ceffective withorally combinedadministered pegylatedmedicines interferonwith andfewer ribavirinside –effects see:

• Peginterferonthan alfaprevious andtreatment ribavirinregimens for theseveral treatmentweeks, usually resulting in a loss of mildviraemia, chronicwhich means the person is cured.

  Overview:

  • hepatitis C is treated using direct-acting antiviral (DAA) tablets
  • InterferonDAA alfatablets (pegylatedare andthe non-pegylated)safest and ribavirinmost effective medicines for thetreating hepatitis
  • treatment ofcan chronicsuccessfully hepatitisclear C

  Referthe allvirus patientsin withmore athan positive90% HCVof RNApeople.

• the resulttablets toare ataken physicianfor with8 specialistto knowledge12 ofweeks – the treatmentlength of chronictreatment will depend on which type of hepatitis C.

  TreatmentC canthey successfullyhave

• some cleartypes theof virushepatitis inC can be treated using more than 90%one type of patients.DAA

People Currentwho injectingare drugcurrently usersinjecting drugs and people who drink excess alcohol are not usually precluded from treatment.

There is separate guidance for peginterferon alfa and ribavirin treatment for children and young people.

Prevention and control

Currently,Currently there is no vaccine available to prevent hepatitis C infection.infection. Prevention therefore depends on avoiding exposure. For people that have previously been exposed to HCV and have cleared the infection, there can be a risk of reinfection. Therefore, it is important to offer advice on prevention even if there has been a previous exposure, negative test results or treatment.

Ask about future travel plans as patients who visit friends and relatives in countries where hepatitis C is endemic aremay be at increased risk of acquiring infection.

Some patients may choose or require medical treatment during their trip,trip like(such as kidney dialysis, or blood transfusions) which can put them at increased risk of infection with blood borne viruses. Advise patients about this potential risk.

For country specific travel advice, consult the National Travel Health Network and Centre (NaTHNaC).

Hepatitis C is a notifiable disease in the UK. If a case is diagnosed it should be notified to your local health protection team (HPT) who will ensure that information is provided to prevent onward transmission.

The primary care practitioner has a role in advising those chronically infected on how to prevent transmission to others.

Resources

Video: chronic viral hepatitis in migrants

Chronic viral hepatitis in migrants.

NHS guidance about hepatitis C.

The National Travel Health Network and Centre (NaTHNaC) publishes information sheets.

Patient.info has a leaflet for patients about hepatitis C.

The British Liver Trust is a charity which provides resources including a helpline and publications for people with liver disease.

The Hepatitis C Trust is a charity for hepatitis C which aims to increase awareness, provide information, support and representation for people with hepatitis C.

The ‘Hep C, Ki?’ programme is designed to support South Asian people living in Britain to understand risk factors, symptoms and testing for hepatitis C.

Information on hepatitis C and sexual transmission is available from Avert.

TheHepatitis CDAC FoundationTerrence andHiggins Polaris Observatory has a dashboardTrust of country-specific data and global data about hepatitis B and C..