Hepatitis C: migrant health guide
Advice and guidance on the health needs of migrant patients for healthcare practitioners.
Main messages
Healthcare professionals should:
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in line with NICE Guidance offer hepatitis C screening for people born or brought up in a country with an intermediate or high prevalence (2% or greater) of chronic hepatitis C
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consider screening close contacts of someone known to be living with hepatitis C
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refer individuals identified as living with hepatitis C for specialist assessment and provide appropriate support if needed to help the person attend (this may include peer support)
Background
The hepatitis C virus (HCV) can cause both acute and chronic hepatitis, ranging in severity from a mild illness to a serious, lifelong illness including cirrhosis and cancer.
The World Health Organization estimates that 50 million people are living with chronic hepatitis C globally, with around 1 million new infections occurring per year.
The highest burden of disease is found in the Eastern Mediterranean Region with 12 million people estimated to be living with chronic infection. In the South-East Asia Region (9 million), European Region (9 million) and the Western Pacific Region (7 million) people are estimated to be living with chronic hepatitis C. 8 million people are estimated to be living with chronic hepatitis C in the African Region and 5 million in the Region of the Americas.
On a global scale, the UK is a relatively low prevalence country. Between 2015 and 2023, the number of people living with chronic hepatitis C in England has fallen in the general population by 56.7%. Approximately 55,900 people in England were estimated to be living with chronic hepatitis C infection in 2023.
Symptoms
During acute infection many people have no symptoms, and when symptoms do occur, they can be mistaken for another condition. Symptoms can include:
- fatigue
- sweats (especially at night)
- aches and pains
- decreased appetite
- nausea
- vomiting
- right upper quadrant discomfort and abdominal pain
- jaundice – which may be less noticeable on brown or black skin – may also occur with dark urine and/or pale stools if cholestasis
Transmission and infection
Transmission of HCV is usually through blood-to-blood contact.
In the UK:
- the most important risk factor for acquiring hepatitis C virus infection is injecting drug use (past or current) through sharing of injecting equipment.
- Other people 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 transfusion prior to 1 September 1991 or NHS blood products prior to 1986
For migrants, depending on countries previously lived in, there may be additional factors that increase risk of transmission through:
- the reuse or inadequate sterilization of medical equipment, especially syringes and needles in healthcare settings
- the transfusion of unscreened blood and blood products
HCV can be passed from an infected mother to their baby (vertical transmission), and via sexual practices that lead to exposure to blood (sexual transmission). However, these modes of transmission are less common.
Most people that are exposed to hepatitis C do not have symptoms. Of those that do develop symptoms, the average period from exposure to symptom onset is 2 to 12 weeks.
Approximately 30% (15% to 45%) of 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 HCV infection, which means they:
- require treatment
- can develop chronic liver disease including cirrhosis, end-stage liver disease and liver cancer
Testing
Healthcare professionals should offer testing, including 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.
GP surgeries, sexual health clinics, genito-urinary medicine (GUM) clinics or drug treatment services all offer testing for hepatitis C. A finger-prick test at home can also be used.
A blood test is done to test for HCV infection. This is usually a test for antibodies, and then a reflex ribonucleic acid (RNA) or antigen test on positive antibody test results. In some circumstances only an RNA test is done but this is not common.
Detection of antibodies (the antibody test) indicates current or resolved infection and can be detected 5 to 12 weeks after infection. However, antibodies may not be generated, especially if the person is immunosuppressed.
Detection of HCV RNA (the RNA test) indicates current infection and can be detected as early as 1 to 3 weeks after infection.
See Hepatitis C: information for GPs and NICE: Testing for hepatitis B and C in primary care
Positive antibody result and positive HCV RNA result
Refer patients to a specialist for further assessment and treatment.
Positive antibody result, negative HCV RNA result
Repeat the test after 4 to 6 weeks to confirm negative status.
A positive antibody result and negative HCV RNA test indicates a previously resolved infection but does not provide immunity to further infection. Give information and advice on measures to prevent re-infection.
Negative antibody result
Further testing is required if the last exposure risk occurred in the preceding 3 month ‘window period’. The antibody test determines whether a person has ever been exposed to the hepatitis C virus. However, the window period (time between infection and when the test can reliably detect the infection) for HCV can be months, with an average of 60 days.
Reassure the person and give information and advice on measures to reduce the risk of hepatitis C.
Consider repeating the test (especially if the person is at high risk of infection) at an appropriate time, based on when the last risk exposure occurred. Seek specialist advice if there is uncertainty about the optimal time to repeat the test.
If the person remains at increased risk of infection, offer annual testing for hepatitis C.
For immunocompromised people ensure an HCV RNA test has also been conducted.
Further guidance on testing and management
NICE guidance: Hepatitis B and C testing: people at risk of infection
Hepatitis C: guidance, data and analysis
Hepatitis C: information for GPs
Treatment
In the UK, anyone who is living with hepatitis C and has given informed consent can receive treatment. Hepatitis C can be successfully treated by taking a short course of well-tolerated and effective orally administered medicines with fewer side effects than previous treatment regimens for several weeks, usually resulting in a loss of viraemia, which means the person is cured.
Overview:
- hepatitis C is treated using direct-acting antiviral (DAA) tablets
- DAA tablets are the safest and most effective medicines for treating hepatitis
- treatment can successfully clear the virus in more than 90% of people.
- the tablets are taken for 8 to 12 weeks – the length of treatment will depend on which type of hepatitis C they have
- some types of hepatitis C can be treated using more than one type of DAA
People who are currently injecting drugs and people who drink excess alcohol are not usually precluded from treatment.
Prevention and control
Currently there is no vaccine available to prevent hepatitis C 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 may be at increased risk of acquiring infection.
Some patients may choose or require medical treatment during their trip (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.
Resources
Video: 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 Hepatitis C Terrence Higgins Trust.
Updates to this page
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Updated links.
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Rebranded page to UKHSA. No change to content.
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Updated prevalence statistics, guidance on testing and resources.
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Made editorial changes to meet GOV.UK style.
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First published.