Some tips and suggestions for contact tracing and family notification for chronic hepatitis B

What is contact tracing?
Contact tracing is the process of identifying the relevant contacts of a person (called the ‘index patient’) with an infectious disease and ensuring that those contacts are aware that they may have been exposed. The Victorian Department of Health only provides support in contact tracing for the sexual contacts of people with hepatitis B. Of course, hepatitis B transmission is not that simple! It makes more sense to talk about partner and family notification for hepatitis B.

Transmission and talking about hepatitis B
The majority of people with chronic hepatitis B acquired it at birth or in early childhood. This means it is possible that their parents, siblings and children also have chronic hepatitis B.

The hepatitis B virus is also transmitted sexually and through blood to blood contact. 95% of adults will recover and develop immunity. If babies, children or pregnant women come into contact with hepatitis B, however, the outcome could be much more serious. A safe effective vaccine against hepatitis B exists which makes prevention much more straightforward! Click here for more information.

A person newly diagnosed with chronic hepatitis B will most likely have acquired it during early childhood, but may have transmitted it to others as an adult.

A person newly diagnosed with acute hepatitis B has most likely acquired it through unprotected sex or unsterile injecting. They may have also passed it on to other contacts.

Tips for success

DO

  • Have family and partner notification permanently on your checklist for following up hepatitis B diagnoses.
  • Gain the goodwill and cooperation of the patient. Well-informed patients are more likely to be involved in the family notification process.
  • Work sensitively with the patient and show empathy. Families can be complex and sensitivity is of the utmost importance
  • Educate the patient about hepatitis B. Inform them about asymptomatic infections, potential complications of untreated infection and the availability of vaccine.
  • Form a clear picture of who the patient’s contacts may be. They may be family members, but there also may be sexual and drug related contacts.
  • Understand the patient’s particular situation and identify individual barriers to notifying contacts.
  • Identify the most appropriate method for notifying family and other contacts and provide the patient with support.

DON’T

  • Appeal to the ‘wider public good’ when discussing why it is necessary to notify contacts – try to personalise the discussion.
  • Assume the gender of contacts.
  • Ask questions that imply a judgement.
  • Involve interpreters in these discussions without seeking the permission of the patient.
  • Assume that the index patient will be able to notify family without some support.

Timing the discussion
The most appropriate time to discuss contact tracing with the patient will depend on the situation. Factors to consider include:

The patient’s physical and emotional state
If the patient is physically unwell or emotionally distressed, it may be better to defer the discussion to a subsequent consultation.

The patient’s own priority
For many patients the issue of notifying contacts is high on their agenda and it may suit them to deal with the issue immediately.

The nature of the condition
A diagnosis of chronic hepatitis B can be a significant event for a person, and many people are shocked and confused. Deferring this discussion may be appropriate. A diagnosis of acute hepatitis B, on the other hand, is less serious and distressing. Therefore a discussion about contact tracing is appropriate at diagnosis and important in limiting further transmission or re-infection of the index patient.

Patient versus provider referral
Broadly, there are two different methods used to advise contacts: patient referral and provider referral.

Patient referral

  • The index patient personally notifies his or her contact.
  • The health care provider provides the information to be imparted by the index patient to the partner.

    Advantages

    • Individuals usually prefer to notify contacts personally.
    • Quicker and easier.

    Disadvantages

    • Less confidentiality.
    • Patients may not actually follow thorough with contacting partners and family.

    Provider referral

    • The health care provider directly advises the contact or uses another agency (for health department contact tracer or supporting community agency) to ensure that contacts are notified.
    • The health care provider must have the explicit approval of the index patient.

    Advantages

    • Higher level of confidentiality for the index patient.
    • Method of choice when an individual is worried about a bad reaction from their contact.

    Disadvantages

    • More time and resource intensive.

    Supporting patients concerned about notifying contacts

    • Take the time to get a sense of any real or perceived concerns the index patient may have in notifying contacts.
    • Discuss a variety of notification methods with the index patient and let them decide.
    • Be aware that people may differ in their ability to successfully notify partners and family, or in their preferences for raising the issue with partners and family.

    Specific populations
    All contact tracing should be undertaken whilst respecting the individual patient’s sensitivities and needs, and should not result in harm. The approach to contact tracing may vary depending on the population involved. Some of these are discussed below.

    Working with people from culturally and linguistically diverse backgrounds
    Cultural taboos, shame, guilt, gender inequality, language barriers and limited knowledge about STIs can compound the difficulties of gaining trust and cooperation. Furthermore, individuals may feel their confidentiality is threatened by use of an interpreter from the patient’s own ethnic group. Confidentiality can be a particular concern for small communities. Interpreters who are experienced in sexual health can be helpful.

    Working with Aboriginal and Torres Strait Islander People
    A flexible approach that respects the rights and dignity of clients through cultural sensitivity is recommended. It is recommended that contact tracing be conducted in partnership with a local Indigenous health care worker and that contact tracing is part of an overall prevention and care package. Of particular importance will be the question of who does the actual contact tracing. As well as the issue of gender concordance, there are other issues such as kinship relationships, use of multiple identifiers (nicknames), multiple itinerant addresses and the consequences of diagnosis to the client that need to be taken into account. Care should be taken in all circumstances to establish and maintain a rigorous approach to confidentiality.