TESTING AND MANAGEMENT Dr Nicole Allard GP Cohealth, Joslin Clinic, West Footscray PhD student, Epidemiology Unit VIDRL
Disclosure and acknowledgments No conflicts of interest Board Member of Hepatitis Victoria Advisory capacity State Government and ASHM Acknowledgement: ASHM Advanced Management of Hepatitis B course for GPs A/Prof Ben Cowie Jennifer MacLachlan
TESTING AND DISCLOSURE
Who should we test? People born in intermediate and high prevalence countries Aboriginal and Torres Strait Islanders Family members of people with Chronic Hepatitis B(CHB) Individual or family members with history of liver cancer or cirrhosis All antenatal women Ref: ASHM: National testing policy http://testingportal.ashm.org.au/hbv/indications-forhbv-testing#hbv-section-3.1
Who should we test? People living with Hepatitis C or past infection Other indigenous populations, MSM, history of injecting drug use, Tattoos, liver disease, people in custodial settings or have been in custodial settings, health care workers, sex workers, dialysis patients, patients with a history of immunosuppression including HIV infection, prior to biologics or chemotherapy and pre transplantation Ref: ASHM: National testing policy http://testingportal.ashm.org.au/hbv/indications-forhbv-testing#hbv-section-3.1
Before the test: informed consent Pre test counseling: informing the patient of the reason for testing and the implication of the test result In certain groups where prevalence is higher and likelihood of the test being positive is higher then need to spend extra time and care to use appropriate language. Ref: ASHM: National testing policy http://testingportal.ashm.org.au/hbv/indications-for-hbv-testing#hbv
What tests should we order? If chronic infection HBsAg anti-hbc (= HBcAb) anti-hbs (= HBsAb) DON T order HEPATITIS B SEROLOGY In suspected acute infection IgM anti- HBc
Interpreting tests If HBsAg positive = Person has hepatitis B (If HBsAg negative does not have hepatitis B) Anti-HBc= exposure to HBV Anti-HBs= immunity If from high or intermediate prevalence country and HBsAg positive it is most likely to be chronic infection
HBsAg anti-hbc anti-hbs Interpretation of HBV Serology negative negative negative susceptible HBsAg anti-hbc anti-hbs negative positive positive resolved HBV infection HBsAg anti-hbc anti-hbs negative negative positive vaccinated HBsAg anti-hbc IgM anti-hbc * anti-hbs positive positive positive negative (high titre)* acute HBV infection* HBsAg anti-hbc IgM anti-hbc * anti-hbs positive positive negative negative chronic HBV infection* HBsAg anti-hbc anti-hbs negative positive negative various possibilities Mast 2006
Conveying positive results Use an interpreter where appropriate providing information about the legal considerations around disclosure of hepatitis B status and the provision of information about (and referral to) available to support services Deliver information in more than one form (resources HepB help, ASHM, Cancer council, hepatitis organisations) Arrange for follow up appointment to answer questions and to review further testing and check understanding ASHM website http://testingportal.ashm.org.au/hbv/indications-for-hbv-testing/164-50-conveying-hepatitis-b-testresults
Workplace Sexual partners Family and or household members Patient living with CHB Friends & Community Sporting club Childcare centre or school
Negative results If negative and not immune offer vaccination BUT NOT ALWAYS FREE Ref: The Australian Immunisation handbook 10 th edition 2013
Notification to health departments Notification by laboratories all states and territories Notification by clinicians The patient does not have to consent to notification (privacy act) Ref: ASHM 2014 B positive: All you need to know about hepatitis B a guide for primary providers
Contact tracing All family members and close household and sexual contacts should be offered testing screening and vaccination if susceptible. In the case of antenatal women need to think about post natal care and the child needs follow up at 12 months Primary care providers are not always well equipped to do contact tracing Keep working at it over time households change Conflict between privacy of the patient and duty to a third party a practitioner can refer case to health department.
ASSESSMENT, MONITORING AND TREATMENT
Clinical questions Tests How active is the virus? Is there evidence of liver disease? HBeAg, anti- HBe, Viral Load (HBV DNA) Prothrombin time (? Lengthened) Platelet count (?decreased) Albumin (?low) AST/ALT ratio (?reversed) Ultrasound (? Cirrhosis, portal HT) FibroScans (?Fibrosis) Is there any coinfection present? Should they be offered Hepatitis A vaccine? HIV, HCV,HDV HAV
FibroScan Clinics Clinics at Monash, Royal Melbourne, Alfred, St Vincent s, Boxhill with 4-12 week wait for appointments (all different forms) Portable machines to certain locations (Health Works, Joslin Clinic)
Cancer surveillance Cancer surveillance is part of routine monitoring for specific groups. 6 monthly ultrasound and AFP: African men and women from >20 Asian men for the age of >40 and Asian women from the age of >50 Patients with cirrhosis Patients with a family history of HCC ATSI from 50 years
But presents a challenge Community data Ref: Allard 2014 Viral Hepatitis conference 2015 Liver cancer surveillance in primary care: challenges in coordination and care for people from affected communities 2 0 12013 Kennedy et al: consecutive audits at Flinders Medical centre with system redesign 3 patient and clinician education P r US last 6 months 46% to 92% and over 24 months 0% to 64% e s
Treatment Antiviral treatment is cost effective as cancer prevention strategy Reduces the risk of cancer by 75% Halts progression of liver disease and reverses fibrosis 2 drugs (tenofovir and entecavir) oral once a day, well tolerated and low resistance profiles at 5 years BUT lifelong treatment Peg Interferon considered HBeAg positive patients Ref: Fattovich, Cohen 2010, Robotin 2010
Who needs consideration of treatment? Phase 2 and phase 4 patients ALT> 2 times normal over a prolonged period of time 3-6 months Phase 2 VL >20,000 IU/ml or Phase 4 VL >2,000 IU/ml Anyone with cirrhosis no matter what the viral load or phase Pregnant women HBV VL >= 10,000000 IU/ml (not PBS covered)
All patients All patients need yearly viral load and liver function tests done 6 monthly CHB is a dynamic disease changes over time Ideally all should be assessed for cirrhosis using transient elastography FibroScan THERE IS NO SUCH THING AS A HEALTHY CARRIER
Management children and pregnant Children women yearly DNA, HBeAg, LFTS paediatric assessment liver cancer and liver failure rare Antenatal women Support and assessment of their health in relation to CHB Viral load (HBV DNA) during pregnancy and referral to specialist service Follow up post pregnancy for management and testing of baby at 1 year
.antenatal women 2 Sydney Hospitals 14,857 Births 295 CHB antenatal patients 98% born overseas HBeAg 65% DNA 3.5% Specialist care 7% 3 Victorian hospitals 46,855 Births 398 CHB antenatal patients 87% born overseas HBeAg 33% DNA 20% Specialist care 18% Ref: Guirgis, M JGHF 2009 and Giles et al ANZJOG 2013
Minding the gaps Babies born to mothers with CHB not followed up and tested Contact tracing not done more than a third only third adult contacts vaccinated (Williams 2011) Children not always transited to adult care Length of care required challenges specialist and primary care services with lost to follow up in all settings (30% FTA rates)
KEY POINTS TESTING SHOULD BE OFFERED TO ALL AT RISK OF CHB ALL PATIENTS WITH CHB NEED REGULAR CARE LONG TERM MANAGEMENT PRESENTS CHALLENGES AND NEEDS WHOLE OF HEALTH SYSTEM APPROACH
References The Australian Immunisation handbook 10 th edition 2013 ASHM: National testing policy http://testingportal.ashm.org.au/hbv/indications-for-hbv-testing#hbvsection-3.1 ASHM 2014 B positive Antenatal guidelines (NSW focus) http://www.ashm.org.au/images/hepb_antenatal_tool_2.pdf
Resources Hepatitis Victoria Help line 1800 703 003 http://www.hepcvic.org.au HepB Help http://www.hepbhelp.org.au Cancer Council Help Line 131120 http://www.cancervic.org.au/for-healthprofessionals/community-health-professionals/hepatitis-band-liver-cancer The Australian Injecting and Illicit Drug Users League (AIVL) Telephone: 02 6279 1600 www.aivl.org.au The Multicultural Health and Support Service http://www.ceh.org.au/default.aspx