Clinical Tools

Clinical Tools

Name Description

Guidelines for Hepatitis B and C Virus

UGANDA GUIDELINES FOR PREVENTION, TESTING, CARE AND TREATMENT OF HEPATITIS B AND C VIRUS INFECTION

 

 

 

 

 

NOVEMBER 2019

 

 

 

 

 

 

 

 

Uganda Guidelines for Prevention,Testing,Care And Treatment of Hepatitis B and C Virus Infection   May 2019

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Table of Contents

 

FOREWARD......................................................................................................................... 5

 

ACKNOWLEDGMENTS.................................................................................................... 7

 

Contributors:..................................................................................................................... 7

 

ABBREVIATIONS............................................................................................................... 8

 

DEFINITIONS.................................................................................................................... 10

 

CHAPTER ONE............................................................................................................ 11

 

1 INTRODUCTION.......................................................................................................... 11

 

1.1 CONTEXT.................................................................................................................... 11

 

1.2OBJECTIVES................................................................................................................ 12

 

1.3 TARGET AUDIENCE................................................................................................ 13

 

1.4 GUIDELINES DEVELOPMENT.............................................................................. 13

 

1.5 STRUCTURE OF THE GUIDELINES...................................................................... 13

 

CHAPTER TWO.......................................................................................................... 15

 

1  HEPATITIS B VIRUS TRANSMISSION.................................................................. 15

 

2.2 NATURAL HISTORY AND CONSEQUENCES OF HEPATITIS B INFECTION.15

 

2.3 PREVENTION OF HEPATITIS B INFECTION..................................................... 16

 

2.4 HEPATITIS B TESTING............................................................................................ 17

 

2.4.1 HBV testing service approaches................................................................... 17

 

2.4.2 HBV diagnosis....................................................................................................... 18

 

2.4.3 Laboratory Strategy for Hepatitis B Testing.............................................. 18

 

2.5 MANAGEMENT OF HEPATITIS B INFECTION................................................ 29

 

2.5.1  Approach to a patient with a positive Hbsag test result..................... 29

 

2.5.2  Who to treat........................................................................................................ 30

 

2.5.3 Who should not be treated but monitored............................................. 31

 

2.5.4  Monitoring patients with Chronic Hepatitis B Infection..................... 31

 

2.5.5 Drugs Available for Hepatitis B treatment In Uganda........................... 33

 

2.5.6 Discontinuation of Treatment.................................. ,................................... 33

 

2.5.7 Hepatitis B and special populations............................................................. 34

 

CHAPTERTHREE....................................................................................................... 40

 

3.1 HEPATITIS C VIRUS TRANSMISSION................................................................ 40

 

3.2 NATURAL HISTORY AND CONSEQUENCES OF HEPATITIS C INFECTION               40

 

3.4 HCV Testing.............................................................................................................. 41

 

3.4.1 Initial screening for hepatitis B virus infection........................................ 41

 

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Uganda Guidelines for Prevention,Testing,Care and Treatment of Hepatitis B and C Virus Infection  May 2019

 

 

3.4.2 Where to test from;.......................................................................................... 42

 

3.4.3 Samples for initial HBsAg testing.................................................................. 43

 

3.4.4 Who to screen?................................................................................................... 43

 

3.5 MANAGEMENT OF HEPATITIS C....................................................................... 43

 

3.5.1 Introduction.......................................................................................................... 43

 

3.5.2 Types of response.............................................................................................. 44

 

3.5.3 Drugs available for Hepatitis C treatment................................................. 44

 

3.5.4 Where should patients be treated and by whom?............................... 45

 

3.5.4 Who to treat?....................................................................................................... 45

 

CHAPTER FOUR........................................................................................................ 47

 

4.1SURVEILLANCE......................................................................................................... 47

 

Definition.......................................................................................................................... 47

 

4.1.1 Surveillance goals:.............................................................................................. 47

 

4.1.2 Standard case definition.................................................................................. 47

 

4.1.3 Types of surveillance for HBV and HCV...................................................... 48

 

4.2 ADHERENCE MONITORING................................................................................ 49

 

4.2.1 Introduction......................................................................................................... 49

 

4.2.2 Adherence preparation................................................................................... 49

 

4.2.3 Assessment of adherence.............................................................................. 50

 

4.2.4 How to assess adherence............................................................................... 50

 

4.2.5 Strategies for improving adherence........................................................... 50

 

4.2.6 How to help patients who have failed to adhere to their medication     51

 

4.3 CARE AND SUPPORT............................................................................................. 51

 

4.3.1 Introduction.......................................................................................................... 51

 

4.3.2 Nutritional support............................................................................................ 51

 

4.3.3 Life style and behavioral change.................................................................. 51

 

4.3.4 Ongoing psychosocial care and support.................................................... 52

 

4.4 MONITORING AND EVALUATION.................................................................... 52

 

4.4.1 Introduction.......................................................................................................... 52

 

4.4.2 Reporting............................................................................................................... 52

 

4.4.3 Routine supervision and data auditing....................................................... 53

 

4.4.4 Data use................................................................................................................. 53

 

4.5 RESEARCH.................................................................................................................. 54

 

4.6 Capacity building..................................................................................................... 54

 

 

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Uganda Guidelines for Prevention,Testing,Care And Treatment of Hepatitis B and C Virus Infection           May 2019

 

 

List of Tables

 

Table 1: Steps into linkage into care for a patient with positive HBsAg tes               23

 

Table 2:Tests for monitoring patients on treatment....................................... 26

 

Table 3: Tests available at different facility levels............................................. 28

 

Table 4: Routine reports and their frequency................................................... 53

 

List of figures

 

Figure 1: The distribution of chronic hepatitis B infection in the country

 

as is shown below (UPHIA, 2016)............................................................................ 12

 

Figure 2: shows the different elements of the guidelines

 

along each continuum of care.................................................................................. 14

 

Figure 3: Extracts from WHO Hepatitis B Guidelines 2015

 

illustrating HBV disease progression by age....................................................... 16

 

Figure 4: Interpretation of the HBsAg test results........................................... 20

 

Figure 5: Algorithm for Chronic Hepatitis B testing.......................................... 27

 

Figure 6: Algorithm for management of HBsAg positive in

 

pregnancy with the aim of (PMTCT)...................................................................... 39

 

Figure 7: Diagram showing the natural history of HCV................................... 41

 

Figure 8: Summary algorithm of approach to a patient who is HCV

 

antibody positive.......................................................................................................... 46

 

List of Annexes

 

ANNEX 1: HBV LABORATORY REQUEST FORM................................................... 55

 

ANNEX 2: INTERPRETATION OF HEPATITIS B MARKERS................................. 56

 

ANNEX 3: INTERPRETATION OF TEST RESULTS FOR HCV I

 

NFECTION AND FURTHER ACTION.......................................................................... 57

 

ANNEX 4: KEY HBV AND HCV INDICATORS.......................................................... 58

 

ANNEX 5: SAMPLE KEY MESSAGES TO THE GENERAL PUBLIC...................... 59

 

 

 

 

 

 

 

 

 

 

 

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Uganda Guidelines for Prevention,Testing,Care and Treatment of Hepatitis B and C Virus Infection

May 2019

 

 

 

FOREWARD

 

Uganda currently has strategies for prevention of transmission of hepatitis B and C virus infection. These include early childhood vaccination against hepatitis B which was incorporated into the national expanded program on Immunization in the year 2002, safe injection practices, screening donor transfusions for Transfusion Transmitted Infections (TTIs) and Hepatitis B vaccination for health workers, adults and adolescents. In spite of these interventions, there is still a large cohort of people who are infected with Hepatitis B and C viruses.

 

Increasing the number of people accessing clinical management is imperative in reducing the burden of Chronic Hepatitis B and Hepatitis C. While the goal of hepatitis B treatment is to suppress viral replication, reduce the risk of progression to advanced liver disease and reduce the development of complications such as liver failure or liver cancer, that of Hepatitis C is to achieve cure. An increased understanding of hepatitis B and Cinfection and support for those who are infected, at personal and community level will help reduce the burden associated with chronic infection therefore improving health outcomes

 

A first step to reducing the burden of hepatitis and C infection is to improve the level of awareness among primary healthcare workers. People requiring management often experience complex social and psychological challenges. A patient with a good understanding of the impact of chronic infection, the purpose of treatment and the clinical process of treatment is more likely to adhere to treatment and respond effectively to the advice of their treating doctor.

 

The burden of Chronic Hepatitis B and Hepatitis C on specialist liver services is increasing and existing services have lengthy waiting periods for new referrals. This situation necessitates the development of a model of care for delivering hepatitis B and C care through a range of services (including the primary health care level) and identifying mechanisms for appropriate resourceand service delivery.

 

 

Uganda Guidelines for Prevention,Testing,Care And Treatment of Hepatitis B and C Virus Infection

 

May 2019

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These guidelines provide simplified framework for all actors including health care workers, district health teams, implementing partners, training institutions, researchers, civil society organizations and the community for providing the requisite service to the clients with Hepatitis B and C.

I therefore, call upon all stakeholders from Government, Civil Society organizations, Private sector and Development Partners to combine efforts in supporting the implementation of the guidelines.

 

 

 

 

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Dr. Henry G. Mwebesa

AG. DIRECTOR GENERAL HEALTH SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Uganda Guidelines for Prevention,Testing,Care and Treatment of Hepatitis B and C Virus Infection

May 2019

 

 

 

ACKNOWLEDGMENTS

 

The Ministry of Health would like to thank all the stakeholders who participated in the development of these guidelines. In a special way we thank the following chairpersons who led the guidelines subcommittee meetings of the Hepatitis technical working group committee: Prof. Ocama Ponsiano (Uganda Gastroenterology society and Makerere University), Dr. Bwanga Freddie (Laboratory subcommittee, Microbiology department Makerere University) and we also thank the organizations and individuals listed below who participated in the guidelines development process:

 

Ministry of Health: Dr. Henry G. Mwebesa, Dr. Amandua Jacinto, Dr. Amone Jackson, Dr Beyagira Racheal, Dr. Upenytho George, Dr. Obonyo John, Dr. Driwale Alfred, Dr. Namuwenge Proscovia, Dr. Atugonza Rita, Ms Kembabazi Harriet, Ms Baku Emily Atria, Mr. Okwi Richard.

 

WHO: Dr. Kaggwa Mugaga, Dr. Easterbrook Phillipa and Prof. Lesi Olufunmilayo (WHOAFRO)Uganda Gastrenterology Society/Maker