Action stations against the ‘silent epidemic’
SUMMARY
Around a decade ago, hepatitis C in Scotland was a growing problem. With a prevalence around twice that of England, many people undiagnosed, and a tiny minority receiving treatment, it was a gloomy picture. Fast forward to 2014. Scotland is now recognised internationally as a model of good practice. The Hepatitis C Action Plan launched in 2006 led to concerted action, putting nurse specialists at the centre of care. Scottish Government senior medical officer Nicola Steedman lists the action plan’s successes: ‘More than half of the 38,000 Scots estimated to have been chronically infected have now been diagnosed, compared with 39 per cent in 2007. ‘Furthermore, the number of people chronically infected has fallen from 38,000 to 37,100. Of those, about 1,100 new patients
ALAMY
Nurses have been pivotal to Scotland’s success in tackling hepatitis C, says Jennifer Trueland
Hepatitis C has been a major public health issue in Scotland. However, thanks to a nurse-led action plan launched in 2006, the country is now a globally recognised model of good practice where diagnosis and treatment levels are improved and spread of infection is falling. Author Jennifer Trueland is a freelance journalist
a year are receiving treatment, nearly triple the number from 2007. The aim is to reach 2,000 new patients a year, which should help prevent up to 5,200 cases of liver cirrhosis by 2030.’ So how has this been achieved – and what has been the role of nurses? The action plan aimed to prevent the spread of infection – particularly in those who inject drugs – diagnose those infected, and ensure they received optimal treatment, care and support.
The first stage involved raising awareness of hepatitis C as a major public health issue, increasing the evidence base on the disease, and collecting information on the services available in Scotland. Phase two involved a commitment to test, diagnose and treat that started in 2008, backed by an unprecedented Scottish Government investment of £43 million over three years. The funding has continued through the National Sexual Health and
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Care network
This is certainly the case in NHS Tayside, one of Scotland’s larger health board areas, which includes Dundee, Perthshire and Angus. Jan Tait, lead clinical nurse specialist in gastroenterology at Dundee’s Ninewells Hospital, says setting up a nurse-led service has made a real difference to patients. A managed care network was set up in Tayside in 2004 – each health board area in Scotland has such a network as a result of the action plan – and involved primary and secondary care and beyond. ‘It was decided right from the start that it would be a nurseled service,’ Ms Tait explains. ‘It was also unusual in that rather than getting referrals only from GPs, anyone could refer people, including drug workers and prison officers.’ Importantly, the nurses run outreach clinics across the health board area, meaning that patients do not have to travel to Dundee. They also run clinics in prisons, an area of high hepatitis C prevalence. In Tayside, as in the rest of Scotland, there has been an impressive increase in numbers of people being tested and treated. Health Protection Scotland consultant epidemiologist David
Risk factors for hepatitis C Anyone who has ever injected or snorted drugs, including anabolic steroids, using shared equipment at any time in the past, even if it was years ago and only once or twice. Anyone who had a blood transfusion in the UK before 1991. Anyone who received blood products before 1986 in England or 1987 in Scotland. Anyone who has had tattoos, acupuncture, or electrolysis where infection control procedures were poor. Anyone who has received medical or dental treatment in countries where infection control procedures are poor. Anyone who is a migrant from a country with a medium or high prevalence of hepatitis C. A fuller list can be found on the Hepatitis Scotland website www.hepatitisscotlandc.org.uk/ what-is-hepatitis-c/how-do-you-get-it.aspx
SPL
Blood-Borne Virus framework (see www.scotland.gov.uk/ publications/2011/08/ 24085708/0). Leon Wylie, lead officer with the national voluntary sector organisation Hepatitis Scotland, believes that the Scottish approach has been successful because of commitment at a national level and cross-party support. ‘Although there are pockets of good practice in England, there hasn’t been the national approach that we have seen in Scotland,’ he says. It is widely agreed that nurses have been at the heart of the strategy. ‘Nurses are absolutely pivotal,’ says Dr Steedman. ‘They are the lynchpins of hepatitis C management and central at every step in the process – from diagnosis to cure.’
Goldberg says nurses will continue to play a crucial role. ‘What we have done is had specialist nurses at the heart of clinical care. It is a model that is relatively unique – we have an army of specialist nurses delivering clinical care. In a few years, with the new all-oral treatments coming in, clinical care will mostly be provided in primary care, but there will still be a role for the specialist
nurses in case finding, assessment and organisation.’ Some fear that the expense of the new drugs could be an obstacle to further progress, but Professor Goldberg says the ‘real challenge’ will be case finding. ‘The new therapies themselves are free of side effects and easy to administer, but it is a question of finding the people who would benefit,’ he says. The other big challenge for nurses is essentially a public health or health promotion role. ‘It is supporting people so that they do not go back to injecting, or drink excessively so that they develop liver cirrhosis,’ he adds. ‘Nurses can get engaged in making sure the impact of therapy is not lost.’ Professor Goldberg believes that Scotland is exceptionally placed to benefit from the new oral treatments coming on stream for hepatitis C. ‘What we have is a well-developed and well-trained workforce, with good communication at a local and national structure. We have real, fit-for-purpose infrastructure, and great information,’ he says. ‘I think in the future we will look back at 2014 as the year we saw a real breakthrough in tackling hepatitis C. Indeed, I don’t think any other country is better positioned’ NS
What nurses can do to improve detection of hepatitis C Hepatitis C is often called the ‘silent epidemic’ because it can be symptomless for several years. Former and current injecting drug users are by far the biggest at-risk group, but they can be hard to reach and hard to identify. Nurse specialist Jan Tait says there is a big group of people who still need to be found: ‘There are people living with hepatitis C who just do not know they have it.’ People may present in a variety of settings, she says, from obvious places like addiction services, to midwifery, general practice and other health services.
For nurses, it is a matter of looking for the signs and signals that someone might be at risk – a history of injecting, for example, or ‘prison’ or amateur tattoos – and suggesting a test. ‘Universal testing is not cost-effective,’ says Ms Tait. ‘We cannot screen everyone, so it is about knowing the risk factors and asking people about it in the right way. ‘The important message to put out there is that there are treatments for hepatitis C, and they are getting better all the time. It is worth getting tested.’
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SUMMARY
Around a decade ago, hepatitis C in Scotland was a growing problem. With a prevalence around twice that of England, many people undiagnosed, and a tiny minority receiving treatment, it was a gloomy picture. Fast forward to 2014. Scotland is now recognised internationally as a model of good practice. The Hepatitis C Action Plan launched in 2006 led to concerted action, putting nurse specialists at the centre of care. Scottish Government senior medical officer Nicola Steedman lists the action plan’s successes: ‘More than half of the 38,000 Scots estimated to have been chronically infected have now been diagnosed, compared with 39 per cent in 2007. ‘Furthermore, the number of people chronically infected has fallen from 38,000 to 37,100. Of those, about 1,100 new patients
ALAMY
Nurses have been pivotal to Scotland’s success in tackling hepatitis C, says Jennifer Trueland
Hepatitis C has been a major public health issue in Scotland. However, thanks to a nurse-led action plan launched in 2006, the country is now a globally recognised model of good practice where diagnosis and treatment levels are improved and spread of infection is falling. Author Jennifer Trueland is a freelance journalist
a year are receiving treatment, nearly triple the number from 2007. The aim is to reach 2,000 new patients a year, which should help prevent up to 5,200 cases of liver cirrhosis by 2030.’ So how has this been achieved – and what has been the role of nurses? The action plan aimed to prevent the spread of infection – particularly in those who inject drugs – diagnose those infected, and ensure they received optimal treatment, care and support.
The first stage involved raising awareness of hepatitis C as a major public health issue, increasing the evidence base on the disease, and collecting information on the services available in Scotland. Phase two involved a commitment to test, diagnose and treat that started in 2008, backed by an unprecedented Scottish Government investment of £43 million over three years. The funding has continued through the National Sexual Health and
22 october 8 :: vol no 6 :: 2014 STANDARD Downloaded from29 RCNi.com by ${individualUser.displayName} on Nov 24, 2015. For personal use only. NoNURSING other uses without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
Care network
This is certainly the case in NHS Tayside, one of Scotland’s larger health board areas, which includes Dundee, Perthshire and Angus. Jan Tait, lead clinical nurse specialist in gastroenterology at Dundee’s Ninewells Hospital, says setting up a nurse-led service has made a real difference to patients. A managed care network was set up in Tayside in 2004 – each health board area in Scotland has such a network as a result of the action plan – and involved primary and secondary care and beyond. ‘It was decided right from the start that it would be a nurseled service,’ Ms Tait explains. ‘It was also unusual in that rather than getting referrals only from GPs, anyone could refer people, including drug workers and prison officers.’ Importantly, the nurses run outreach clinics across the health board area, meaning that patients do not have to travel to Dundee. They also run clinics in prisons, an area of high hepatitis C prevalence. In Tayside, as in the rest of Scotland, there has been an impressive increase in numbers of people being tested and treated. Health Protection Scotland consultant epidemiologist David
Risk factors for hepatitis C Anyone who has ever injected or snorted drugs, including anabolic steroids, using shared equipment at any time in the past, even if it was years ago and only once or twice. Anyone who had a blood transfusion in the UK before 1991. Anyone who received blood products before 1986 in England or 1987 in Scotland. Anyone who has had tattoos, acupuncture, or electrolysis where infection control procedures were poor. Anyone who has received medical or dental treatment in countries where infection control procedures are poor. Anyone who is a migrant from a country with a medium or high prevalence of hepatitis C. A fuller list can be found on the Hepatitis Scotland website www.hepatitisscotlandc.org.uk/ what-is-hepatitis-c/how-do-you-get-it.aspx
SPL
Blood-Borne Virus framework (see www.scotland.gov.uk/ publications/2011/08/ 24085708/0). Leon Wylie, lead officer with the national voluntary sector organisation Hepatitis Scotland, believes that the Scottish approach has been successful because of commitment at a national level and cross-party support. ‘Although there are pockets of good practice in England, there hasn’t been the national approach that we have seen in Scotland,’ he says. It is widely agreed that nurses have been at the heart of the strategy. ‘Nurses are absolutely pivotal,’ says Dr Steedman. ‘They are the lynchpins of hepatitis C management and central at every step in the process – from diagnosis to cure.’
Goldberg says nurses will continue to play a crucial role. ‘What we have done is had specialist nurses at the heart of clinical care. It is a model that is relatively unique – we have an army of specialist nurses delivering clinical care. In a few years, with the new all-oral treatments coming in, clinical care will mostly be provided in primary care, but there will still be a role for the specialist
nurses in case finding, assessment and organisation.’ Some fear that the expense of the new drugs could be an obstacle to further progress, but Professor Goldberg says the ‘real challenge’ will be case finding. ‘The new therapies themselves are free of side effects and easy to administer, but it is a question of finding the people who would benefit,’ he says. The other big challenge for nurses is essentially a public health or health promotion role. ‘It is supporting people so that they do not go back to injecting, or drink excessively so that they develop liver cirrhosis,’ he adds. ‘Nurses can get engaged in making sure the impact of therapy is not lost.’ Professor Goldberg believes that Scotland is exceptionally placed to benefit from the new oral treatments coming on stream for hepatitis C. ‘What we have is a well-developed and well-trained workforce, with good communication at a local and national structure. We have real, fit-for-purpose infrastructure, and great information,’ he says. ‘I think in the future we will look back at 2014 as the year we saw a real breakthrough in tackling hepatitis C. Indeed, I don’t think any other country is better positioned’ NS
What nurses can do to improve detection of hepatitis C Hepatitis C is often called the ‘silent epidemic’ because it can be symptomless for several years. Former and current injecting drug users are by far the biggest at-risk group, but they can be hard to reach and hard to identify. Nurse specialist Jan Tait says there is a big group of people who still need to be found: ‘There are people living with hepatitis C who just do not know they have it.’ People may present in a variety of settings, she says, from obvious places like addiction services, to midwifery, general practice and other health services.
For nurses, it is a matter of looking for the signs and signals that someone might be at risk – a history of injecting, for example, or ‘prison’ or amateur tattoos – and suggesting a test. ‘Universal testing is not cost-effective,’ says Ms Tait. ‘We cannot screen everyone, so it is about knowing the risk factors and asking people about it in the right way. ‘The important message to put out there is that there are treatments for hepatitis C, and they are getting better all the time. It is worth getting tested.’
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