Elimination of Hepatitis C infection is one of the WHO’s Sustainable Development Goals. An eight-week course of Direct-Acting Antiviral Drugs can cure what has previously been a debilitating and potentially fatal chronic disease.
Community pharmacies in Dundee and Tayside have been at the forefront of a programme to identify and treat local people living with the virus. Providing leadership for the pharmacy programme is Andrew Radley, Consultant in Public Health Pharmacy with NHS Tayside. Pharmacy teams are not just treating but also diagnosing the infection and assessing patients for treatment.
Scotland is in an excellent position to be one of the first countries in the world to eliminate Hepatitis C. In Tayside, we have been working for a number of years to cure people carrying the virus, the majority of whom are injecting drugs. This group generally stay away from hospitals but regularly attend community pharmacies, which are local to where they live. Pharmacy colleagues have built up good long-term relationships with the group and are likely to be trusted sufficiently for them to accept the offer of a test.
To show first that somebody has been exposed to the Hepatitis C virus, all you require is to get one good-sized drop of blood from a finger prick and dab it onto a piece of blotting paper, which is posted off to a local lab. The laboratory then assay the dried blood spot to look for the presence of Hepatitis C antibodies.
About a quarter of people will clear the virus spontaneously but the remaining three quarters will have an ongoing infection though, often, they’ll have no symptoms, or they’ll have had a short acute phase without realising. You can have Hepatitis C for years and have non-specific vague feelings of being unwell – you feel weak, fatigued and perhaps depressed. Eventually, you may become cirrhotic, and develop jaundice and other signs of liver disease.
When the initial dried blood spot test shows exposure to the virus, we arrange for a phlebotomist or a peripatetic nurse to meet the person in the pharmacy to take some blood samples which are then sent off for assessment. These include a polymerase chain reaction (PCR) test for viral RNA to confirm the presence of circulating virus and liver function tests.
Back in the day when I was a young pharmacist working on hospital wards, we used to assess kidney function using a Cockcroft-Gault equation. In a similar way, pharmacists in Tayside have been using the Fib-4 test to assess whether the patient has cirrhosis. The community pharmacist can use an app to do the Fib-4 calculation, and there is a website they can use to check for potential drug interactions with the direct-acting antiviral drugs before starting the treatment. If the patient’s laboratory tests are within normal ranges, the pharmacist can use the PGD or a prescribing pharmacist will write the prescription and the patient can start treatment, according to our local protocol.
Overall in Tayside, we think that we have diagnosed about 80% of those with Hepatitis C and we have probably treated about 70% of those we have diagnosed. Some of the Tayside community pharmacies have done particularly well and have treated all of the people with infection from the entire cohort of people attending their pharmacy. Progress in Tayside compares well with most other places in Scotland.
The programme in Tayside has, I think, succeeded in doing something really quite special with community pharmacy colleagues. We have linked them with the hospital team and delivered effective care to a vulnerable group.
My contribution has been to build the evidence base for pharmaceutical care, showing that the outputs and patient outcomes that can be achieved by using pharmacy services to improve the health of their local populations. Working with Dundee University, we have carried out a whole series of studies to understand the perspectives of the patient group and experiences of pharmacy staff so we could tweak the intervention and make it as good as possible. We used a method called a ‘discrete choice experiment’, a health economics approach to assess the value people placed on different choices for a service; and most recently, we’ve completed a cluster randomised trial with colleagues in Grampian and Glasgow, which should be the definitive study to quantify the clinical effectiveness of using pharmacy to clear Hepatitis C from this population.
It is important that the profession grasps the potential to grow the practice and how much patients value hands-on services. Our studies have shown that assessing and identifying patients for the right treatment, counselling them and prescribing drugs – were all things that were accomplished excellently by the pharmacists who took part in this work. Right across our programme of work, the patient feedback has been about how much they valued having a longitudinal, positive relationship with a pharmacist.
Throughout my career, I have always been proud to be a member of the pharmacy profession and valued the significant contribution we make to patient care. Right from the start, I have tried to innovate and extend the boundaries of what can be delivered through pharmacy and, at this stage in my career, I am particularly pleased with what we’ve been able to achieve for people with Hepatitis C.
But, with a new programme getting underway to deliver care to breast cancer patients from community pharmacies, I am not quite finished yet.
Andrew Radley will be leading a session on ‘Dot C -Community Pharmacy Hep C treatment’ at the Celtic Conference for Pharmacy in Scotland, Wales and Northern Ireland, being held in Edinburgh on Tuesday 26 March. Registration is free for healthcare professionals at www.pharman.co.uk/celtic-conference.