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Immunisations for under 19s

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What is covered

This interactive flowchart covers recommendations on how to increase immunisation uptake among the under 19s in groups and settings where immunisation coverage is low. It also covers improving uptake of the hepatitis B immunisation for babies and young children born to mothers who are chronically infected with the virus, or who have had acute hepatitis B infection during pregnancy.

Updates

Updates to this interactive flowchart

15 March 2017 Flowchart restructured and summarised recommendations replaced with full recommendations.
1 March 2017 Vaccine uptake in under 19s (NICE quality standard 145) added.
28 July 2014 Hepatitis B (NICE quality standard 65) added.

Short Text

Everything NICE has said on immunisation in under 19s in an interactive flowchart

What is covered

This interactive flowchart covers recommendations on how to increase immunisation uptake among the under 19s in groups and settings where immunisation coverage is low. It also covers improving uptake of the hepatitis B immunisation for babies and young children born to mothers who are chronically infected with the virus, or who have had acute hepatitis B infection during pregnancy.

Updates

Updates to this interactive flowchart

15 March 2017 Flowchart restructured and summarised recommendations replaced with full recommendations.
1 March 2017 Vaccine uptake in under 19s (NICE quality standard 145) added.
28 July 2014 Hepatitis B (NICE quality standard 65) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Vaccine uptake in under 19s (2017) NICE quality standard 145
Hepatitis B (2014) NICE quality standard 65

Quality standards

Vaccine uptake in under 19s

These quality statements are taken from the vaccine uptake in under 19s quality standard. The quality standard defines clinical best practice for vaccine uptake in under 19s and should be read in full.

Quality statements

Recall invitations

This quality statement is taken from the vaccine uptake in under 19s quality standard. The quality standard defines best practice for vaccine uptake in under 19s and should be read in full.

Quality statement

Children and young people who do not attend their immunisation appointment are followed up with a written recall invitation and a phone call or text message.

Rationale

Children and young people who are due to have a vaccination should receive an invitation to an appointment. If they do not attend the appointment, a written recall invitation and phone call or text message increase the likelihood that the appointment will be rebooked, and that the child or young person will be immunised.

Quality measures

Structure
a) Evidence of local arrangements to ensure that children and young people who do not attend their immunisation appointment are followed up with a written recall invitation.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that children and young people who do not attend their immunisation appointment are followed up with a phone call or text message.
Data source: Local data collection.
Process
a) Proportion of children and young people who do not attend their immunisation appointment who are followed up with a written recall invitation.
Numerator – the number in the denominator who are followed up with a written recall invitation.
Denominator – the number of children and young people who do not attend an immunisation appointment.
Data source: Local data collection.
b) Proportion of children and young people who do not attend their immunisation appointment who are followed up with a phone call or text message.
Numerator – the number in the denominator who are followed up with a phone call or text message.
Denominator – the number of children and young people who do not attend an immunisation appointment.
Data source: Local data collection.
Outcome
Immunisation after a recall invitation in under 19s.
Data source: Local data collection and COVER programme.

What the quality statement means for different audiences

Service providers (for example, GP practices and school health services) ensure that systems are in place for children and young people to be followed up with a written recall invitation and a phone call or text message after a missed immunisation appointment.
Healthcare professionals (for example, health visitors, school nurses, GPs and practice nurses) ensure that they follow up children and young people who have missed an immunisation appointment with a written recall invitation and a phone call or text message. Healthcare professionals should record if parents or carers have decided not to immunise their child and the reasons for this decision.
Commissioners (for example, clinical commissioning groups and NHS England) ensure that they include in contracts and service specifications the requirement for services to make sure children and young people are followed up with a written recall invitation and a phone call or text message after a missed immunisation appointment. The child health information system (CHIS) can be used for tracking non-attendances and generating recall invitations.
Children and young people who have missed an appointment for an immunisation and, if appropriate, their parents or carers, are contacted by their health visitor, nurse or doctor to arrange another appointment.

Source guidance

Immunisations: reducing differences in uptake in under 19s (2009) NICE guideline PH21, recommendation 1

Equality and diversity considerations

Healthcare professionals should consider the literacy levels and the first language of children and young people and their families or carers when issuing recall invitations. In some cases, a telephone call may be preferable to a letter or text message.
Consideration should also be given to the best method for communicating with transient communities, such as travellers and the homeless, who do not have a permanent address and contact details.

Offering outstanding vaccinations

This quality statement is taken from the vaccine uptake in under 19s quality standard. The quality standard defines best practice for vaccine uptake in under 19s and should be read in full.

Quality statement

Children and young people identified as having missed a childhood vaccination are offered the outstanding vaccination.

Rationale

When a child or young person is found to have missed a vaccination, it is important that healthcare professionals discuss the importance of, and any concerns about, the outstanding vaccination with the child or young person and, if appropriate, their parents or carers. Doing this can increase immunisation coverage in the population and provide protection against disease for the child or young person.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people identified as having missed a childhood vaccination are offered the outstanding vaccination.
Data source: Local data collection.
Process
a) Proportion of children and young people identified as having missed a childhood vaccination who are offered the outstanding vaccination.
Numerator – the number in the denominator who are offered the outstanding vaccination.
Denominator – the number of children and young people identified as having missed a childhood vaccination.
Data source: Local data collection.
b) Proportion of children and young people identified as having missed a childhood vaccination who are offered a referral to a service where they can receive an outstanding vaccination.
Numerator – the number in the denominator who are offered a referral to a service where they can receive an outstanding vaccination.
Denominator – the number of children and young people identified as having missed a childhood vaccination.
Data source: Local data collection.
Outcome
Immunisation after identification of missed immunisation appointments in under 19s.
Data source: Local data collection and COVER programme.

What the quality statement means for different audiences

Service providers (for example, hospitals, GP practices and walk-in centres) ensure that systems are in place for children and young people who are identified as having missed a childhood vaccination to be offered the outstanding vaccination or referral to a service that can give the vaccination.
Healthcare professionals ensure that when they identify children and young people who have missed a childhood vaccination, they offer the vaccination or refer the child or young person to a service that can give the vaccination.
Commissioners (for example, clinical commissioning groups and NHS England) ensure that services are available to identify children and young people who have missed a childhood vaccination, and offer the vaccination or refer the child or young person to a service that can give the vaccination.
Children and young people who are found to have missed a vaccination are offered the vaccination straight away, or referred to a service that can give them the vaccination.

Source guidance

Immunisations: reducing differences in uptake in under 19s (2009) NICE guideline PH21, recommendation 1

Equality and diversity considerations

Healthcare professionals need to be aware that some children may arrive in the UK without vaccination records, and vaccination schedules in other countries may be different from the current UK programme. Healthcare professionals should ensure they get as much information as possible from the child or young person and/or parent or carer about their immunisation history and offer outstanding vaccinations. They should also identify differences in the UK programme with the country of origin of the child or young person.
Healthcare professionals should also be aware that children and young people from vulnerable groups, such as homeless, travellers, young offenders, refugees and those who are HIV positive, are at increased likelihood of having missed previous vaccinations. Healthcare professionals should ensure they get as much information as possible from the child or young person and/or parent or carer about their immunisation history and offer outstanding vaccinations.

Recording vaccinations

This quality statement is taken from the vaccine uptake in under 19s quality standard. The quality standard defines best practice for vaccine uptake in under 19s and should be read in full.

Quality statement

Children and young people receiving a vaccination have it recorded in their GP record, the child health information system (CHIS) and in their personal child health record.

Rationale

Accurate recording of vaccinations allows services to monitor uptake rates in their area. This can help when planning for future population immunisation programmes and appointment requirements. It aids the timely administration of vaccinations to children and young people and supports the use of call–recall systems.

Quality measures

Structure
a) Evidence of local arrangements to ensure that children and young people receiving a vaccination have it recorded electronically in their GP record.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that children and young people receiving a vaccination have it recorded on the CHIS.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that children and young people receiving a vaccination have it recorded in their personal child health record.
Data source: Local data collection.
Process
Proportion of children and young people receiving a vaccination who have it recorded on their GP record and personal child health record.
Numerator – the number in the denominator who have their vaccination recorded on their GP record and personal child health record.
Denominator – the number of children and young people receiving a vaccination identified as receiving one by CHIS.
Data source: Local data collection and NHS public health functions agreement 2016–17, requirement 3.19.
Outcome
a) Accurate planning for future population immunisation programmes and appointment requirements.
Data source: Local data collection.
b) Timely administration of vaccines to children and young people.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (for example, GP practices) ensure that systems are in place to record vaccinations of children and young people in their GP record, the CHIS and their personal child health record when the vaccination is given. The recording should be done electronically on the GP record and the CHIS.
Healthcare professionals (for example, GPs, health visitors, practice nurses and school nurses) ensure that the vaccinations of children and young people are recorded in the GP records, the CHIS and the personal child health record when the vaccination is given. The recording should be done electronically on the GP record and the CHIS.
Commissioners (for example, clinical commissioning groups and NHS England) ensure that they commission services that have systems for recording vaccinations when they are given. The recording should be done electronically on the GP record and the CHIS.
Children and young people have every vaccination recorded in their GP’s record, their personal child health record (often shortened to ‘PCHR’ or ‘the red book’) and the child health information system. The child health information system is a record of the healthcare received by every child in England (often shortened to CHIS).

Source guidance

Immunisations: reducing differences in uptake in under 19s (2009) NICE guideline PH21, recommendation 2

Definitions of terms used in this quality statement

GP record
Every time a person visits an NHS service in England, a record is created or updated. This record is held in their GP practice and contains all the clinical information about the care the person has received. It enables every healthcare professional involved at different stages of the person’s care to have access to their medical history, including allergies, operations or tests, medicines and immunisations. Based on this information, healthcare professionals can make judgements about the person’s care.
[Adapted from NHS Choices and expert opinion]
Child health information system (CHIS)
CHIS is a patient administration system that provides a clinical record for individual children and supports a variety of activities related to child health, including universal services for population health and support for statutory functions. It identifies registered eligible children, sends out lists to GP practices and sends appointments directly to patients. The childhood seasonal influenza vaccination is not required to be recorded on CHIS.
[Public health functions to be exercised by NHS England (2013) NHS England and expert opinion]
Personal child health record (PCHR)
The PCHR, also known as the ‘red book’, is a record of the health history of children aged under 5 years. It is held by the child’s parents or carers. The PCHR also provides information on the UK childhood vaccination schedule.
[NICE guideline on immunisations, and expert opinion]

Checking immunisation status at specific educational stages

This quality statement is taken from the vaccine uptake in under 19s quality standard. The quality standard defines best practice for vaccine uptake in under 19s and should be read in full.

Quality statement

Children and young people have their immunisation status checked at specific educational stages.

Rationale

Checking the immunisation status of children and young people at specific educational stages can identify gaps in vaccination. For children aged under 5 years, a healthcare professional, usually the health visitor, can check the child’s immunisation status through the personal child health record or the ‘red book’. This can be done together with childcare or education staff at key stages such as when a child joins a preschool children’s centre or starts primary school. For children and young people aged 5 to 19 years, immunisation checks can be done by school nursing teams or GP practices when the child or young person transfers to a new school or further educational setting.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people have their immunisation status checked at specific educational stages.
Data source: Local data collection.
Process
a) Proportion of children aged under 5 years who have their immunisation status checked at preschool entry by a health visitor.
Numerator – the number in the denominator who have their immunisation status checked at preschool entry by the Healthy Child Programme team.
Denominator – the number of children aged under 5 years.
Data source: Local data collection and the Healthy Child Programme.
b) Proportion of children aged 4 to 5 years who have their immunisation status checked at school entry.
Numerator – the number in the denominator who have their immunisation status checked at school entry.
Denominator – the number of children aged 4 to 5 years entering school.
Data source: Local data collection.
c) Proportion of children and young people aged 4 to 19 years who have their immunisation status checked when they transfer to a new school.
Numerator – the number in the denominator who have their immunisation status checked when they transfer to a new school.
Denominator – the number of children and young people aged 5 to 19 years transferring to a new school.
Data source: Local data collection.
d) Proportion of young people aged under 19 years who have their immunisation status checked at further educational setting entry.
Numerator – the number in the denominator who have their immunisation status checked at further educational setting entry.
Denominator – the number of young people aged under 19 years entering a further educational setting.
Data source: Local data collection.
Outcome
a) Identified children and young people in education with gaps in vaccination history.
Data source: Local data collection.
b) Vaccine uptake in children and young people.
Data source: Local data collection and COVER programme.

What the quality statement means for different audiences

Service providers (for example, school nursing teams and child health teams) work with preschools, primary schools, secondary schools and further educational settings to ensure that children and young people have their immunisation status checked at specific educational stages.
Healthcare professionals (for example, nurses, health visitors and school nurses) ensure that they check the immunisation status of children and young people at specific educational stages.
Commissioners (for example, local authorities, clinical commissioning groups and NHS England) ensure that they have school nursing services and child health teams who have specifications that require children and young people’s immunisation status to be checked at specific educational stages.
Children and young people have their vaccination records checked by a health visitor or nurse at specific stages of their education, such as when they join a new preschool, start at a primary or secondary school, or start further education.

Source guidance

Immunisations: reducing differences in uptake in under 19s (2009) NICE guideline PH21, recommendation 4

Definitions of terms used in this quality statement

Specific educational stages
These include entry to preschool, primary school, secondary school and further educational settings as well as when changing schools.
[Adapted from NICE’s guideline on immunisations, recommendation 4]

Checking immunisation status of young offenders and offering outstanding vaccinations

This quality statement is taken from the vaccine uptake in under 19s quality standard. The quality standard defines best practice for vaccine uptake in under 19s and should be read in full.

Quality statement

Young offenders have their immunisation status checked on entry into a secure setting and are offered any outstanding vaccinations.

Rationale

Young offenders are less likely to be fully immunised against infectious diseases than the general population. Having their immunisation status checked when they enter a secure setting can identify any gaps in their immunisation history. By identifying missed vaccinations and offering the outstanding vaccinations, coverage in secure settings can be increased.

Quality measures

Structure
a) Evidence of local arrangements to ensure that young offenders have their immunisation status checked on entry into a secure setting.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that young offenders in secure settings are offered outstanding vaccinations.
Data source: Local data collection.
Process
a) Proportion of young offenders in secure settings who have their immunisation status checked on entry.
Numerator – the number in the denominator who have their immunisation status checked on entry.
Denominator – the number of young people entering secure settings.
Data source: Local data collection.
b) Proportion of young offenders in secure settings identified as having gaps in their immunisation history who are offered outstanding vaccinations.
Numerator – the number in the denominator who are offered outstanding vaccinations.
Denominator – the number of young people entering secure settings identified as having gaps in their immunisation history.
Data source: Local data collection.
Outcome
Immunisation coverage in young offenders.
Data source: Local data collection.

What the quality statement means for different audiences

Service providers (for example, prison medical services, GP practices and community trusts) ensure that systems are in place for healthcare professionals to check the immunisation status of young offenders at the time of entry to a secure setting and offer them any outstanding vaccinations.
Healthcare professionals (for example, nurses) ensure that they check the immunisation status of young offenders at the time of entry to a secure setting and offer them any outstanding vaccinations. The immunisation status can be checked by asking the young offender and liaising with their GP practice.
Commissioners (for example, NHS England and Public Health England) ensure that they commission services that check the immunisation status of young offenders at the time of entry to a secure setting and offer them any outstanding vaccinations.
Young people moving into a secure setting (such as a secure children’s home or a young offender institution) have their vaccination records checked and are offered any outstanding vaccinations.

Source guidance

Immunisations: reducing differences in uptake in under 19s (2009) NICE guideline PH21, recommendation 5

Testing and vaccination for hepatitis B

This quality statement is taken from the hepatitis B quality standard. The quality standard defines clinical best practice for hepatitis B and should be read in full.

Quality statement

People who are at increased risk of hepatitis B infection are offered testing and vaccination.

Rationale

Children, young people and adults who are at increased risk of hepatitis B infection should be offered testing in a range of settings (for example, in GP practices including new registrations, prisons or immigration removal centres, drug services, sexual health and genitourinary medicine clinics) alongside appropriate vaccination. This is essential for ensuring early diagnosis, prompt treatment and prevention of infection.

Quality measures

Structure
Evidence of local arrangements to ensure that people who are at increased risk of hepatitis B infection are offered testing and vaccination.
Data source: Local data collection.
Process
a) Proportion of new GP registrants who belong to a group at increased risk of infection who are offered testing for hepatitis B.
Numerator – the number in the denominator offered testing for hepatitis B.
Denominator – the number of new GP registrants who belong to a group at increased risk of infection.
Data source: Local data collection.
b) Proportion of new GP registrants who test negative for hepatitis B but remain at increased risk of infection who are offered vaccination for hepatitis B.
Numerator – the number in the denominator offered vaccination for hepatitis B.
Denominator – the number of new GP registrants who test negative for hepatitis B but remain at increased risk of infection.
Data source: Local data collection.
c) Proportion of prisoners/immigration detainees who are offered vaccination for hepatitis B when entering prison or an immigration removal centre.
Numerator – the number in the denominator offered vaccination for hepatitis B.
Denominator – the number of prisoners/immigration detainees entering prison or an immigration removal centre.
Data source: Local data collection.
d) Proportion of prisoners/immigration detainees who are offered testing for hepatitis B when entering prison or an immigration removal centre.
Numerator – the number in the denominator offered testing for hepatitis B.
Denominator – the number of prisoners/immigration detainees entering a prison or an immigration removal centre.
Data source: Local data collection.
e) Proportion of prisoners/immigration detainees who are offered testing for hepatitis B during their detention in prison or an immigration removal centre.
Numerator – the number in the denominator offered testing for hepatitis B.
Denominator – the number of prisoners/immigration detainees detained in a prison or an immigration removal centre.
Data source: Local data collection.
f) Proportion of people using drug services who are offered vaccination for hepatitis B.
Numerator – the number in the denominator offered vaccination for hepatitis B.
Denominator – the number of people using drug services.
Data source: Local data collection.
g) Proportion of people using drug services who are offered testing for hepatitis B.
Numerator – the number in the denominator offered testing for hepatitis B.
Denominator – the number of people using drug services.
Data source: Local data collection.
h) Proportion of people at increased risk of infection using sexual health and genitourinary medicine clinics who are offered vaccination for hepatitis B.
Numerator – the number in the denominator offered vaccination for hepatitis B.
Denominator – the number of people at increased risk of infection using sexual health and genitourinary medicine clinics.
Data source: Local data collection.
i) Proportion of people at increased risk of infection using sexual health and genitourinary medicine clinics who are offered testing for hepatitis B.
Numerator – the number in the denominator offered testing for hepatitis B.
Denominator – the number of people at increased risk of infection using sexual health and genitourinary medicine clinics.
Data source: Local data collection.

What the quality statement means for service providers, health and public health practitioners, and commissioners

Service providers (GP practices, prisons and immigration removal centres, drugs services and secondary care providers of sexual health and genitourinary medicine clinics) ensure that testing and vaccination for hepatitis B are offered to people who are at increased risk of infection. This includes dried blood spot testing for hepatitis B in appropriate service settings for people in whom venous access is difficult.
Health and public health practitioners offer hepatitis B testing and vaccination to people at increased risk of infection and ensure pre- and post-test discussions with appropriate information about their risk of infection. Assurance about confidentiality and privacy should also be given. Healthcare professionals ensure that they have received appropriate training and have been assessed as competent for delivering vaccinations, in line with the recommendations in Public Health England’s Immunisation against infectious disease: the green book, chapter 18: Hepatitis B.
Commissioners (local authority commissioners, NHS England area teams and clinical commissioning groups) work with service provider partners to ensure that testing (including dried blood spot testing) and vaccination for hepatitis B are offered to people who are at increased risk of infection.

What the quality statement means for patients, service users and carers

People at increased risk of hepatitis B infection are offered a blood test to check if they have the infection and a vaccination to help prevent infection.

Source guidance

Definitions of terms used in this quality statement

People at increased risk of hepatitis B infection
People at increased risk of hepatitis B infection compared with the general UK population include:
  • People born or brought up in a country with an intermediate or high prevalence (2% or greater) of chronic hepatitis B. This includes all countries in Africa, Asia, the Caribbean, Central and South America, Eastern and Southern Europe, the Middle East and the Pacific islands.
  • Babies born to mothers infected with hepatitis B.
  • People who have ever injected drugs.
  • Men who have sex with men.
  • People who may have been exposed to sexually acquired infection, particularly:
    • people who have had unprotected sex with multiple sexual partners
    • people reporting unprotected sexual contact in areas of intermediate and high prevalence
    • people presenting at sexual health and genitourinary medicine clinics
    • people diagnosed with a sexually transmitted disease
    • commercial sex workers.
  • Looked-after children and young people, including those living in care homes.
  • Prisoners, including young offenders.
  • Immigration detainees.
  • Close contacts (these could include sexual, close friends, family and household) of someone known to be chronically infected with hepatitis B. [Adapted from NICE public health guidance 43, section on Whose health will benefit?]
Testing and vaccination
Testing strategies for hepatitis B should be implemented alongside hepatitis B vaccination in line with Public Health England’s Immunisation against infectious disease: the green book, chapter 18: Hepatitis B in the following settings:
  • GP practices including new registrations.
  • Prison or an immigration removal centre.
  • Drug services.
  • Sexual health and genitourinary medicine clinics. [NICE public health guidance 43, recommendations 4 to 7]

Equality and diversity considerations

The offer of hepatitis B testing in a range of settings should take into account the age and culture of groups at increased risk, and their needs in relation to the format of the information and the language used. Services should be responsive to social and cultural barriers to testing, vaccination and treatment (for example, stigma). Good communication between healthcare professionals, public health practitioners and the people at increased risk of hepatitis B infection is essential.

Referral for specialist care

This quality statement is taken from the hepatitis B quality standard. The quality standard defines clinical best practice for hepatitis B and should be read in full.

Quality statement

People who test positive for hepatitis B surface antigen (HBsAg) are referred to specialist care for further assessment.

Rationale

Chronic hepatitis B infection affects the liver and can cause serious health problems if left untreated. It is important that people who test positive for HBsAg are referred for specialist care so that they can be assessed for the stage of hepatitis B and for other infections (such as HIV, hepatitis C and hepatitis D). Further assessment in specialist care is essential in determining whether and when to start pharmacological treatment. This statement does not apply to pregnant women who test HBsAg-positive at antenatal screening, which is the focus of quality statement 3.

Quality measures

Structure
Evidence of local arrangements to ensure that people who test positive for HBsAg are referred to specialist care for further assessment.
Data source: Local data collection.

Process

a) Proportion of adults (aged 18 years and over) who test HBsAg positive who are referred to specialist care for further assessment.
Numerator – the number in the denominator who are referred to specialist care for further assessment.
Denominator – the number of adults (aged 18 years and over) who test HBsAg positive.
Data source: Local data collection. NICE Hepatitis B: clinical audit tool – primary care, audit standard 2.
b) Proportion of children and young people (under 18 years) who test HBsAg positive who are referred to specialist care for further assessment.
Numerator – the number in the denominator who are referred to specialist care for further assessment.
Denominator – the number of children and young people (under 18 years) who test HBsAg positive.
Data source: Local data collection. NICE Hepatitis B: clinical audit tool – primary care, audit standard 3.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (GP practices, prisons and immigration removal centres, drug services and secondary care providers of sexual health and genitourinary medicine clinics) ensure that local referral pathways are in place and that people who test positive for HBsAg are referred to specialist care for further assessment.
Healthcare professionals refer people who test HBsAg-positive to specialist care for further assessment.
Commissioners (local authority commissioners, NHS England area teams and clinical commissioning groups) work with providers of testing and vaccination services to ensure that people who test HBsAg-positive are referred to specialist care for further assessment.
Clinical commissioning groups work with partners in secondary care to ensure that specialist services provide further assessment for people who test HBsAg-positive.

What the quality statement means for patients, service users and carers

People who are found to have hepatitis B infection are referred to a specialist for further assessment.

Source guidance

Definitions of terms used in this quality statement

Specialist care
  • Adults who test HBsAg-positive are referred to a hepatologist, or to a gastroenterologist or infectious disease specialist with an interest in hepatology.
  • Children and young people who test HBsAg-positive are referred to a paediatric hepatologist, or to a gastroenterologist or infectious disease specialist with an interest in hepatology. [NICE clinical guideline 165, recommendations 1.2.2 and 1.2.7]

Referral to and assessment by specialist care for pregnant women who are identified as hepatitis B surface antigen-positive at antenatal screening

This quality statement is taken from the hepatitis B quality standard. The quality standard defines clinical best practice for hepatitis B and should be read in full.

Quality statement

Pregnant women who are identified as hepatitis B surface antigen (HBsAg)-positive at antenatal screening are assessed by a specialist within 6 weeks of receiving the screening test result.

Rationale

Specialist assessment within 6 weeks of receiving the screening test result is important to allow antiviral treatment (tenofovir) in the third trimester if needed to reduce the risk of the baby becoming infected with hepatitis B.

Quality measures

Structure
Evidence of local arrangements to ensure that pregnant women who are identified as being HBsAg-positive at antenatal screening are assessed by a specialist within 6 weeks of receiving the screening test result.
Data source: Local data collection.
Process
Proportion of pregnant women who are identified as being HBsAg-positive at antenatal screening who are assessed by a specialist within 6 weeks of receiving the screening test result.
Numerator – the number in the denominator who are assessed by a specialist within 6 weeks of receiving the antenatal screening test result.
Denominator – the number of pregnant women who are identified as being HBsAg-positive at antenatal screening.
Data source: UK National Screening Committee Key performance indicators – KPI ID2 (Antenatal infectious disease screening – timely referral of hepatitis B-positive women for specialist assessment).
Outcome
Vertical transmission rates from mother to child.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (antenatal care) ensure that healthcare professionals refer all pregnant women who are identified as being HBsAg-positive at antenatal screening to specialist care.
Hospital-based specialist care demonstrates that pregnant women who are referred for specialist care assessment are assessed by a specialist within 6 weeks of receiving the screening test result.
Healthcare professionals refer pregnant women who are identified as being HBsAg-positive at antenatal screening to a specialist within 6 weeks of receiving the screening test result.
Commissioners (clinical commissioning groups) work with partners in secondary care to ensure that specialist services are available to provide pregnant women who are identified as being HBsAg-positive at antenatal screening with specialist assessment within 6 weeks of receiving the test result.
Clinical commissioning groups and NHS England area teams (screening and immunisation teams) work together to ensure that providers of antenatal care refer pregnant women who are identified as being HBsAg-positive at antenatal screening to a specialist.

What the quality statement means for patients, service users and carers

Pregnant women who are found to have hepatitis B infection during antenatal testing are assessed by a specialist within 6 weeks of receiving the screening test result.

Source guidance

Definitions of terms used in this quality statement

Specialist care assessment
Pregnant women who are identified as HBsAg-positive are seen by a hepatologist, or a gastroenterologist or infectious disease specialist with an interest in hepatology. [NICE clinical guideline 165, recommendation 1.2.4]
Equality and diversity considerations
Pregnant women with complex social needs may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol and/or drugs)
  • ave recently arrived as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20 years
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that special consideration is given to these groups of women.

Complete course of neonatal hepatitis B vaccination and blood testing at 12 months

This quality statement is taken from the hepatitis B quality standard. The quality standard defines clinical best practice for hepatitis B and should be read in full.

Quality statement

Babies born to hepatitis B surface antigen (HBsAg)-positive mothers receive a complete course of hepatitis B vaccination and, at age 12 months, receive a blood test for hepatitis B infection.

Rationale

Hepatitis B infection can be transmitted from mothers with hepatitis B to their babies. Babies who acquire the infection have a very high risk of developing chronic hepatitis B. Vaccination of babies is highly effective in preventing transmission. It is important that the babies of mothers with hepatitis B (whether they are delivered in hospital or at home) are given the first vaccine dose promptly and that the recommended vaccination course is completed at the right time, including, when appropriate, hepatitis B immunoglobulin, in line with Public Health England’s Immunisation against infectious disease: the green book, chapter 18: Hepatitis B.
If vaccinations are delayed or missed, it is more likely that the child will become infected.

Quality measures

Structure
a) Evidence of local commissioning arrangements to ensure that babies born to HBsAg positive mothers are given a complete course of hepatitis B vaccination.
b) Evidence of local arrangements to ensure that there is an identified person responsible for coordinating the local hepatitis B vaccination programme for babies at risk of infection. This person should also be responsible for scheduling vaccinations and follow-up to ensure that babies at risk are vaccinated at the right time.
Data source: Local data collection.
Process
a) Proportion of babies born to HBsAg-positive mothers who receive the complete course of hepatitis B vaccination.
Numerator – the number in the denominator who receive a complete course of hepatitis B vaccination.
Denominator – the number of babies born to HBsAg-positive mothers.
b) Proportion of babies born to HBsAg-positive mothers who receive a blood test for hepatitis B infection at age 12 months.
Numerator – the number in the denominator who receive a blood test for hepatitis B infection.
Denominator – the number of babies at age 12 months born to HBsAg-positive mothers.
Data source: Local data collection. NICE Reducing the differences in the uptake of immunisations: audit support, criterion 3.
Outcome
Vertical transmission rates from mother to child.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (maternity, paediatric, primary care and community support teams) ensure that babies born to HBsAg-positive mothers are given a complete course of hepatitis B vaccination through a coordinated programme that includes an identified person who is responsible for scheduling vaccinations and follow-up to ensure that babies at risk are vaccinated at the right time.
Healthcare professionals give babies born to HBsAg-positive mothers a complete course of hepatitis B vaccination and then, at age 12 months, a blood test for hepatitis B infection.
Commissioners (clinical commissioning groups and NHS England area teams for screening and immunisation) work together to ensure that a coordinated hepatitis B neonatal vaccination programme is in place to vaccinate babies born to HBsAg-positive mothers, which includes scheduling of vaccinations and follow-up to ensure that babies at risk are vaccinated at the right time.

What the quality statement means for patients, service users and carers

Babies born to mothers with hepatitis B infection are given a complete course of hepatitis B vaccinations, and when they are aged 12 months they are given a blood test to check whether they have the infection.

Source guidance

Definitions of terms used in this quality statement

Complete course of hepatitis B vaccination and a blood test for hepatitis B
A complete course consists of an initial dose of vaccine and of hepatitis B immunoglobulin where indicated within 24 hours of birth, with further doses at 1 month, 2 months and 12 months and an additional booster at preschool age. A blood test for HBsAg should be performed at 12 months (at the time of the fourth dose) to check for vaccine failure.
The blood test at age 12 months should be performed regardless of the uptake of the vaccination course. [Public Health England’s Immunisation against infectious disease: the green book, chapter 18: Hepatitis B. Public Health England’s Public health functions to be exercised by NHS England: Neonatal hepatitis B immunisation programme (service specification 1)]
The transfer of care between maternity services and primary care can be a key issue and it is important that there is effective coordination and communication between services.

Equality and diversity considerations

The implications of hepatitis B neonatal vaccination should be understood by all women to enable them to make informed decisions. Information should be provided in an accessible format (particularly for women with physical, sensory or learning disabilities and women who do not speak or read English).
Pregnant women with complex social needs may be less likely to access or maintain contact with antenatal care services. Examples of women with complex social needs include, but are not limited to, women who:
  • have a history of substance misuse (alcohol and/or drugs)
  • have recently arrived as a migrant, asylum seeker or refugee
  • have difficulty speaking or understanding English
  • are aged under 20 years
  • have experienced domestic abuse
  • are living in poverty
  • are homeless.
It is therefore appropriate that special consideration is given to these groups of women.

Personalised care plan

This quality statement is taken from the hepatitis B quality standard. The quality standard defines clinical best practice for hepatitis B and should be read in full.

Quality statement

People with chronic hepatitis B infection, and their family members or carers (if appropriate), are offered a personalised care plan outlining the proposed treatment and long-term management of their infection.

Rationale

Personalised care plans are important to promote regular discussion and involvement in decision-making about proposed treatment and long-term management between the healthcare professional and the person with chronic hepatitis B infection (and their family members or carers if appropriate).
It is important that people are actively involved in decisions about their care, and that they fully understand their treatment plan. People with hepatitis B should be encouraged to follow their care plan and take an active role in ensuring that any necessary monitoring, treatment and/or screening tests happen in a timely way. Engaging patients in their care planning and management helps to ensure that they adhere to long-term treatment, and minimises non attendance, inadequate monitoring and poor patient outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that people with chronic hepatitis B infection, and their family members or carers (if appropriate), are given a personalised care plan outlining the proposed treatment and long-term management of their infection.
Data source: Local data collection.
Process
Proportion of people with chronic hepatitis B infection, and their family members or carers (if appropriate), who are given a personalised care plan outlining the proposed treatment and long-term management of their infection.
Numerator – the number in the denominator who receive (or whose family members or carers receive) a personalised care plan outlining the proposed treatment and long-term management of their infection.
Denominator – the number of people with chronic hepatitis B infection.
Data source: Local data collection.
Outcome
People with chronic hepatitis B infection, and their family members and carers (if appropriate) feel informed about their proposed treatment and long-term management plan of their infection.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (within secondary care) ensure that personalised care plans outlining the proposed treatment and long-term management of their infection are given to people with chronic hepatitis B infection, and their family members or carers (if appropriate).
Healthcare professionals offer people with chronic hepatitis B infection, and their family members and carers (if appropriate), a personalised care plan outlining the proposed treatment and long-term management of their infection.
Commissioners (clinical commissioning groups) ensure that secondary care service providers have protocols in place for healthcare professionals to offer personalised care plans to people with chronic hepatitis B infection, and their family members and carers (if appropriate), outlining the proposed treatment and long-term management of their infection.

What the quality statement means for patients, service users and carers

People with chronic hepatitis B infection (infection that has lasted for 6 months or more), and their family members or carers (if appropriate), are offered a personalised care plan that outlines their treatment and long-term care.

Source guidance

Definitions of terms used in this quality statement

Chronic hepatitis B
Chronic hepatitis B infection is defined as persistence of hepatitis B surface antigen (HBsAg) for 6 months or more after acute infection with hepatitis B virus. Chronic hepatitis B infection can be divided into e antigen (HBeAg)-positive or HBeAg-negative disease based on the presence or absence of e antigen. The presence of HBeAg is typically associated with higher rates of viral replication and therefore increased infectivity. [NICE clinical guideline 165]
Personalised care plan
A personalised care plan should outline the proposed treatment and long-term management specific to the patient’s chronic hepatitis B condition (for example, it should include a copy of the hospital consultation summary) to help promote regular discussions between the patient, and their family members or carers (if appropriate), and the healthcare professional. [Adapted from Hepatitis B (chronic) (full guideline)]

Equality and diversity considerations

A personalised care plan should be tailored to the person with chronic hepatitis B infection. For some people with hepatitis B (for example, children, older people and people with learning disabilities), it may be appropriate for a family member or carer to be involved in the review of the personalised care plan.

Monitoring people with chronic hepatitis B infection who do not meet the criteria for antiviral treatment

This quality statement is taken from the hepatitis B quality standard. The quality standard defines clinical best practice for hepatitis B and should be read in full.

Quality statement

People with chronic hepatitis B infection who do not meet the criteria for antiviral treatment are monitored regularly at intervals determined by their infection status and age.

Rationale

Monitoring starts shortly after a person is diagnosed with chronic hepatitis B infection. For people who do not need antiviral treatment, continuous follow-up is needed to determine the stage of infection, whether treatment needs to be started and if they are at risk of developing fibrosis.

Quality measures

Structure
Evidence of local arrangements to ensure that people with chronic hepatitis B infection who do not meet the criteria for antiviral treatment are monitored regularly at intervals determined by their infection status and age.
Data source: Local data collection.
Process
Proportion of people with chronic hepatitis B infection who do not meet the criteria for antiviral treatment who are monitored regularly at intervals determined by their infection status and age.
Numerator – the number of people in the denominator who are monitored regularly at intervals determined by their infection status and age.
Denominator – the number of people with chronic hepatitis B infection who do not meet the criteria for antiviral treatment.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (hospital-based specialist care) ensure that competent healthcare professionals are in place to meet the commissioned levels of activity through outpatient clinics.
Healthcare professionals ensure that people with chronic hepatitis B infection who do not meet the criteria for antiviral treatment are monitored regularly at intervals determined by their infection status and age.
Commissioners (clinical commissioning groups and hospital-based specialist care providers) ensure that systems and facilities are in place for monitoring and follow-up of people with chronic hepatitis B who do not meet the criteria for antiviral treatment.

What the quality statement means for patients, service users and carers

People with chronic hepatitis B infection (infection that has lasted for 6 months or more) who do not meet the criteria for antiviral treatment are monitored regularly to check the stage of the infection, whether they need to start treatment and if they are at risk of developing fibrosis (scarring of the liver).

Source guidance

Definitions of terms used in this quality statement

Chronic hepatitis B infection
Chronic hepatitis B infection is defined as persistence of hepatitis B surface antigen (HBsAg) for 6 months or more after acute infection with hepatitis B virus. Chronic hepatitis B infection can be divided into e antigen (HBeAg)-positive or HBeAg-negative disease based on the presence or absence of e antigen. The presence of HBeAg is typically associated with higher rates of viral replication and therefore increased infectivity. [NICE clinical guideline 165]
Recommended intervals for monitoring
Monitoring intervals for people who do not meet the criteria for antiviral treatment are outlined in NICE clinical guideline 165. These vary with infection status and age, and include:
  • Adults with HBeAg-positive disease in the immune-tolerant and immune-clearance phases (recommendations 1.6.1 and 1.6.2).
  • Adults with inactive chronic hepatitis B (immune-control phase) (recommendation 1.6.3).
  • Children and young people (recommendations 1.6.4, 1.6.5 and 1.6.6).
  • Children, young people and adults with HBeAg or HBsAg seroconversion after antiviral treatment (recommendations 1.6.7 and 1.6.8).
Monitoring people with chronic hepatitis B infection who meet the criteria for antiviral treatment
Monitoring intervals for people who meet the criteria for antiviral treatment are outlined in NICE clinical guideline 165. These vary with infection status, age and clinical status. [NICE clinical guideline 165, recommendations 1.5.1 to 1.5.53]

Equality and diversity considerations

The information on monitoring people (including children, young people and adults) with chronic hepatitis B infection who do not meet the criteria for antiviral treatment should be accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English. Adults receiving information should have access to an interpreter or advocate if needed. The information should be tailored to the age of the person.

Six-monthly surveillance testing for hepatocellular carcinoma in adults with chronic hepatitis B infection who have significant liver fibrosis or cirrhosis

This quality statement is taken from the hepatitis B quality standard. The quality standard defines clinical best practice for hepatitis B and should be read in full.

Quality statement

Adults with chronic hepatitis B infection who have significant liver fibrosis or cirrhosis are offered 6 monthly surveillance testing for hepatocellular carcinoma.

Rationale

Significant liver fibrosis or cirrhosis is a substantial risk factor for hepatocellular carcinoma, and people with chronic hepatitis B infection who develop liver damage are at increased risk. This form of cancer develops quickly and may be asymptomatic until it is advanced. Regular surveillance testing at 6-month intervals helps to ensure that hepatocellular carcinoma is detected early, which can lead to earlier treatment and may improve the person’s chances of survival.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with chronic hepatitis B infection with significant liver fibrosis or cirrhosis are offered 6 monthly surveillance testing for hepatocellular carcinoma.
Data source: Local data collection.
Process
Proportion of adults with chronic hepatitis B infection with significant liver fibrosis or cirrhosis who receive 6 monthly surveillance testing for hepatocellular carcinoma.
Numerator – the number in the denominator who received their most recent hepatocellular carcinoma surveillance testing within 6 months of their previous test or within 6 months of having significant liver fibrosis or cirrhosis identified.
Denominator – the number of adults with chronic hepatitis B infection with significant liver fibrosis or cirrhosis.
Data source: Local data collection.
Outcome
Stage of hepatocellular carcinoma at diagnosis for adults with chronic hepatitis B infection.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (hospital-based specialist care providers) ensure that competent healthcare professionals are in place to meet the commissioned levels of activity through outpatient clinics and may demonstrate outcomes to commissioners by monitoring the stage of hepatocellular carcinoma at diagnosis for adults with chronic hepatitis B infection.
Healthcare professionals offer adults with chronic hepatitis B infection and significant liver fibrosis or cirrhosis 6-monthly surveillance testing for hepatocellular carcinoma.
Commissioners (clinical commissioning groups) ensure that hospital-based specialist care providers have systems and facilities in place to provide 6 monthly surveillance testing for hepatocellular carcinoma for adults with chronic hepatitis B and significant liver fibrosis or cirrhosis. For more information on surveillance testing see Hepatitis B (chronic): diagnosis and management of chronic hepatitis B in children, young people and adults (NICE clinical guideline 165) section 1.7.

What the quality statement means for patients, service users and carers

Adults with chronic hepatitis B infection (infection that has lasted for 6 months or more) and severe scarring of the liver (called fibrosis or cirrhosis) are offered an ultrasound scan and a blood test every 6 months to check for liver cancer.

Source guidance

Definitions of terms used in this quality statement

Chronic hepatitis B
Chronic hepatitis B infection is defined as persistence of hepatitis B surface antigen (HBsAg) for 6 months or more after acute infection with hepatitis B virus. Chronic hepatitis B infection can be divided into e antigen (HBeAg)-positive or HBeAg-negative disease based on the presence or absence of e antigen. The presence of HBeAg is typically associated with higher rates of viral replication and therefore increased infectivity. [NICE clinical guideline 165]
Significant liver fibrosis or cirrhosis
Fibrosis is a progressive form of liver disease that can be caused by hepatitis B infection. Damage to liver cells results in scarring that prevents the liver from working normally. Significant fibrosis is determined by histological assessment and semi-quantitative scoring systems (METAVIR and Ishak score). Significant fibrosis is METAVIR stage F2 or higher, or Ishak stage 3 or higher.
Cirrhosis occurs when liver inflammation and fibrosis spread to disrupt the shape and function of the liver. Even with no signs or symptoms of liver disease, the working capacity of liver cells has been badly impaired and they are unable to repair the liver. This is permanent cell damage and can lead to liver failure or liver cancer. [Adapted from Hepatitis B (chronic) (full guideline)]
Hepatocellular carcinoma
People with cirrhosis of the liver are at a small but significantly increased risk of developing a type of liver cancer called hepatocellular carcinoma.
[NHS choices, accessed June 2014]
Surveillance testing
The 6 monthly surveillance testing for hepatocellular carcinoma is carried out by hepatic ultrasound and alpha-fetoprotein testing. [NICE clinical guideline 165, recommendation 1.7.1]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Pathway information

Supporting information

Glossary

under the family nurse partnership programme, specially trained nurses visit some of the most vulnerable young mothers and their families at home, working with them from early pregnancy until the child is aged 2 years
personal child health record
anyone with parental responsibility
A person with parental responsibility may be a parent, step-parent or the parent's civil partner. In the case of looked-after children, this responsibility may have been acquired by another adult or the local authority under the Children Act.
Those with parental responsibility do not necessarily need to be present when a vaccination is given, provided they have received information about it and then arranged for another person (for example, a grandparent or childminder) to attend with the child. For further information see chapter 2 of the Green book.

Paths in this pathway

Pathway created: October 2011 Last updated: March 2017

© NICE 2017

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