A bird’s eye view: Sexual health adviser coordination of contact tracing for hepatitis B

Introduction

Despite an effective vaccine, an estimated 257 million people live globally with hepatitis B infection. This has resulted in 887,000 deaths, mostly from complications including acute hepatitis, cirrhosis and hepatocellular carcinoma. ¹ Identifying individuals with hepatitis B is a key outcome of the Scottish Government’s Sexual Health and Blood Borne Virus Framework, in order to offer appropriate management and to vaccinate others at risk. ² Similar to evidence from England, effective hepatitis B contact tracing is suboptimal in Scotland, where just under half of the 9000 estimated cases remain undiagnosed.^3,4 In 2012, a National Health Service (NHS) sexual health adviser led service, comprising mostly nurses, who trace contacts for sexually transmitted infections (STIs), extended their coordinating role in managing community diagnosed gonorrhoea and chlamydia to include hepatitis B. This work took place exclusively within the local health board (an organisation in Scotland responsible for the population’s health within a regional area) and for which a funded post had been created. This audit sought to determine contact tracing outcomes for acute and chronic hepatitis B cases following introduction of this service.

Methods

In receiving a copy of each new positive hepatitis B surface antigen result, the sexual health adviser team contacted testing clinicians by telephone to facilitate giving timely results to patients and referral to appropriate specialist services. The sexual health advisers coordinated contact tracing activities for each case. To achieve this, they established working partnerships with community-based colleagues, mainly doctors, practice nurses and health visitors.

Sexual health adviser activity relating to hepatitis B cases between 1 September 2012 and 31 December 2019 was reviewed. The total number of cases, date and location of testing, country of birth, ethnicity and sexual orientation of each index case was extracted from a Microsoft Access database. Outcomes, including identified contacts, tests undertaken, test results and vaccination history were recorded for sexual partners, family and household contacts.

Results

A total of 1344 (1279 chronic and 65 acute) cases were reported to the sexual health advisers between September 2012 and December 2019 (see Table 1). Most tests came from general practice (n = 425, 32%), antenatal clinic (n = 282, 21%) or outpatient departments (n = 180, 13%), mainly gastroenterology or infectious diseases. The remaining 457 (34%) cases came from prisons, NHS sexual health clinics, and local refugee services. Concurrent with the global distribution of endemic hepatitis B, but in contrast to Scotland’s background ethnic population, most individuals diagnosed were Chinese (n = 389, 29%), thereafter white Scottish and non-Scottish (n = 295, 22%) and Black African (n = 273, 20%).^1–3

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Table 1.

Main characteristics of index cases.

Index case characteristic (n = 1344)	Number of cases (%) or median (range)
Age, years	41 (1–88)
Sexual orientation
Heterosexual	979 (73)
Other	26 (2)
Not known	339 (25)
Ethnicity
Chinese	389 (29)
Black (African and other)	278 (21)
White Scottish	116 (9)
White other	179 (13)
Arab	89 (7)
Asian	56 (4)
Pakistani	75 (5)
Indian	16 (1)
Other	14 (1)
Not known	132 (10)
Acute or chronic hepatitis B infection
Chronic	1279 (95)
Acute	65 (5)
Where tested for hepatitis B
GP surgery	425 (32)
Antenatal	282 (21)
Outpatient department	180 (13)
Acute	144 (11)
Other	313 (23)

Most cases were heterosexual (n = 979, 73%). In many cases, the sexuality of the index case was unknown (n = 339, 25%). This included lone, sexually inactive asylum-seeking individuals with unrecorded sexual orientation, and the small number of child index cases. Ages ranged from 1–88 (median = 41) years and less than 1% injected drugs. A total of 2248 sexual partners, children and other social contacts were identified (see Figure 1). A documented outcome was established for 1741 (78%: 1.3 per index case). 1222 (54%) contacts were vaccinated either prior to or following identification through contact tracing. A positive hepatitis B surface antigen was recorded for 257 (11%) contacts. A further 162 (7%) contacts had natural immunity. 1509/1741 (87%) of these outcomes were confirmed with another healthcare professional (67% of total contacts). 28 (1%) of identified contacts were untraceable or did not attend services.OPEN IN VIEWER

Discussion

This audit demonstrates that sexual health advisers are well placed to coordinate contact tracing for hepatitis B infection, as this work aligns with their responsibilities for managing STIs in specialist sexual health care. With direct contact tracing mostly carried out by colleagues in local healthcare settings, the team utilised their ‘bird’s eye’ view of the patient journey from diagnosis to specialist care, identifying gaps in this complex care pathway. The multi-agency approach traced considerably more contacts than those located elsewhere through primary care services alone, suggesting that individual services diagnosing a few cases of hepatitis B annually benefit from this central coordinating facility. ⁵ The partnership approach had several key advantages: (1) sharing the workload across the health board, (2) avoidance of unnecessary sexual health service attendances and (3) enabling local clinicians to utilise existing relationships with index patients to trace contacts. Although most contacts were identifiable in electronic medical records, GP practice data and other NHS databases, challenges existed in tracing mobile patients with high rates of clinic non-attendance. This review highlights previously documented low rates of testing among ethnic minority subpopulations in Scotland who bear the greatest burden of hepatitis B. ³ Notably, over one third of those with hepatitis B live in Scotland’s most deprived areas. ³ The introduction in 2017 of a UK-wide universal infant vaccination programme will eventually achieve widespread coverage across the indigenous population. ⁶ Migrants into the United Kingdom, however, remain at risk, similar to those in other high-income countries. ⁷ Barriers to testing include reduced awareness, misunderstandings around severity and language barriers. ⁸ While linkage to care remains a global challenge, low technology interventions have improved access to testing. ⁹ The sexual health adviser service should contribute to a programme of interventions improving access to care pathways for individuals with hepatitis B and their contacts.