Managing hepatitis B in general practice

Sammi: Good evening everybody and welcome to this evening’s Managing Hepatitis B in General Practice webinar. My name is Samantha and I am your host for this evening. Before we jump in I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to Elders past and present.

I would like to introduce our presenter for this evening, Dr Vicky Sheppeard and our facilitator, Dr Tim Senior. Vicky is a public health physician who has been working for New South Wales Health since 1999. Vicky’s current role is Medical Advisor for Viral Hepatitis and she is working with local health districts and primary care to achieve the targets of the hepatitis B and C strategies. So thank you for joining us, Vicky.

Vicky: Thank you, Sammi.

Sammi: And also our facilitator, Tim. So Tim is a GP at Thurawal Aboriginal Corporation in South Western Sydney. Tim is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, and a Senior Lecturer in General Practice and Indigenous Health at UWS. So welcome, Tim.

Tim: Good evening everyone.

Sammi: Wonderful. I will hand over to you now Tim to take us through our learning outcomes before we jump over to Vicky.

Tim: Thank you very much. So these are the learning outcomes, which is the educational speak for what we are hoping to achieve over the next hour or so. So by the end of this online activity, we all should be able to prescribe methods to identify our patients with hepatitis B, understand the essential role of general practice in managing chronic hepatitis B, describe contact management for people with hepatitis B, recount the triggers for specialist referral and access available hepatitis B resources and education tools. So I shall hand on to Vicky to start us off. Thank you very much, Vicky.

Vicky: Thanks Tim and yes, good evening everyone again. It is great to be here with you and really pleasing that we have got so much interest in this webinar tonight. So first off, why is hepatitis B a health priority? You are online, so you must understand that it is. Now, with our younger people born in Australia, hepatitis B is almost no issue because since we have had universal vaccination in the past 20 years, people under 20 rarely get hepatitis B in Australia and usually those that do were born overseas and missed out on vaccination and we have got a slide about that in a minute. But nevertheless, despite that success of our vaccination, hepatitis B is the most common blood borne virus in Australia. And it is estimated there is around a quarter of a million people living with chronic hepatitis B. Now, a decade ago, many of these people were thought to be healthy carriers and given that label. But we are now very well aware of the complications of hepatitis B which is cirrhosis leading to liver failure and hepatocellular carcinoma, and those conditions are increasing in Australia, and particularly in parts of New South Wales were there are high immigrant populations. And we will look at where those countries are and which areas of New South Wales are effected. But the really good news is that, effective long term management of hepatitis B in primary care can reduce the burden for hepatitis B, so in some ways this is another cancer prevention activity and you know, I think that is a useful lens to look at it with. So, between one in four and one in five people with chronic hepatitis B will die from cirrhosis or hepatocellular carcinoma.

So, what are we trying to do with hepatitis B? So one of our national strategy’s aims is to diagnose 80% of people living with hepatitis B and have at least half people with chronic hepatitis B engaged in care and increase the proportion of people on antiviral treatment to 20%. So there are obviously some caveats that go into these objectives. There is no, I guess in an ideal world we would diagnose 100% of people but that is probably not possible, and we would like to have everyone with hepatitis B engaged in care. That is desirable but the current target for Australia by 2022 is to have half the people engaged in care. Now hepatitis B is definitely very different to hepatitis C where we want to treat everyone with hepatitis C with antivirals. For hepatitis B it is recognised that only about between 15% to 20% of people will need antivirals at any one time, so that is the target, to get 20%. That is thought to be the desirable level of antiviral treatment.

But how are we doing? So the data I present now is at the end of 2016, only 62% of people in Australia were diagnosed. Only 17% were engaged in care so that is very low, and only 7% were receiving antiviral treatment. And there has not been a lot of change since the end of 2016, very marginal increase in those figures in New South Wales.

So before we get into the meat of it, just a recap about hepatitis B. So, it is a blood borne virus transmitted by blood and other body fluids. The most common time of transmission is mother to infant but it can also be transmitted sexually to other household members, through needles and sharps and in healthcare. So acute hepatitis B will manifest somewhere between one and six months after someone is exposed to the virus. It is often asymptomatic especially in young children and infants, but it can still cause severe liver injury and rarely it can cause liver failure in adults. But we do rarely encounter acute hepatitis B. But certainly in chronic hepatitis B it is the condition we are talking about tonight. Now the most really interesting thing about this is that the likelihood of getting chronic hepatitis B is very much dependent on the age at which someone catches the infection. So because of immature immune systems in infants and children under five, 90% of infants are unable to clear the infection so it becomes a chronic infection in the liver. And that compares to someone who catches the infection as an adult where 90% of adults will clear the infection and only 10% become chronically infected. So this is all very much tied up in the pattern of hepatitis B we now see in Australia.

Also really crucial to understanding it is the distribution of hepatitis B internationally. So, the darkest colour are countries where the prevalence of chronic hepatitis B is more than 8%. The medium green countries are between 2% and 7% and the low prevalence countries are in the grey where less than 2% of the population have chronic hepatitis B. And so once again we see that countries where many of our patients are drawn from have either high or intermediate prevalence of hepatitis B, and so the migrants from those countries bring that risk of hepatitis B with them when they come to Australia. I guess the thing that this graph does not show with Australia having a low prevalence is that the Aboriginal population does have a high prevalence of hepatitis B, certainly for Aboriginal people older than 20 years of age, and they have a prevalence similar to that in high prevalence countries. And that is something that is found around the world with indigenous populations which is I think why in Canada areas where it is mainly inhabited by indigenous Alaskans, north Americans, is why there is a green band up there affecting Greenland and Northern Canada.

So this is the notifications in New South Wales. Fairly stable and what I was speaking about before, the pink and the dotted orange line, those are children under five and children five to 14, almost zero and pretty much all those cases there are children born overseas or children, very rarely, children born to women with chronic hepatitis B whose preventive treatment at birth was unsuccessful. Interestingly, the kind of magenta dotted line is dropping, so that is 15 to 24 years of age. So as the vaccinated cohorts come through, the prevalence in that age group is also decreasing. And we are seeing an increase in the 45 to 64 year olds, which might be due to increased recognition and better testing, or it might be also related to migration patterns. And then the final thing as far as our epidemiology is where the cases are in New South Wales. So here there is a very big distinction between metropolitan and non-metropolitan parts of New South Wales, so Sydney, Western Sydney, South-Western Sydney, Northern Sydney and sorry I missed one there, the five main metropolitan local health districts, South-Eastern Sydney, have a relatively high notification rate compared to the non-metropolitan local health districts. And once again, that is about where migrants have come from and the highest proportion of migrants.

So, I think this then leads us to say who should be tested for hepatitis B? So, New South Wales Health would recommend that all patients born in Asia, the Pacific Islands, Africa, the Middle East, Eastern and Southern Europe, South and Central America and the Caribbean, are tested for hepatitis B. And then other patient groups that are important to test are Aboriginal and Torres Strait Islander people, people who have ever injected drugs, men who have sex with men, anyone who has ever been in a prison, people who are hepatitis C or HIV positive, and then patients who are on renal dialysis, people with abnormal liver function tests with unknown cause, or pregnant women, and anyone who requests to be tested. And just highlighted here with the green asterisks, are people who also should have a hepatitis C test as well because of shared risk factors for those infections. And then the final recommendation is that any patients that are planning chemotherapy or immunosuppressive therapy should also be tested for hepatitis B because they are at risk of severe flare of their infection if they are immunosuppressed.

We just wanted you to know that in the New Year, we will be starting a new campaign that is targeting Chinese, Vietnamese, Arabic, Korean and sub-Saharan African communities. The sub-Saharan one is in English, the others are in the community language of those groups, and the tag line of this is to increase awareness amongst people born in those high risks countries that we have already been discussing that hepatitis B may be asymptomatic, so they should be tested and to talk to your doctor. So we are hoping that this prompts many people at high risk of hepatitis B to come and ask you for a hepatitis B test.

So I will just pause there. Are there any questions we should get to at the moment, Tim? Or I will push on.

Tim: No. There is one question that I think we are going to be covering later on in the presentation anyway. So unless people type quickly now, we are all good to go.

Vicky: Okay. Alright. So, here is where you know, I think Tim’s general practice experience is really, I really want to draw on that, because it is how do you identify your hepatitis B patients? So I have already said we know at least 80% of people with hepatitis B know who they are and have half of them engaged in treatment. And obviously they have to be diagnosed before they can be engaged in your care. So obviously anyone who asks for a test and they are in one of those risk groups that we discussed, should be tested. But the next thing, and I will ask Tim to comment about this, is about how you can use your practice and quality improvement in your practice to find your patients who should be tested and get them in for testing. So, Tim, can I ask?

Tim: Yes, absolutely. So, a really important question. So we will have some people come in and we recognise that they may be in one of those risk groups but not particularly requesting a test, and we can raise this with them. With many of those risks groups it can be a little bit difficult because they are not easily coded in our medical records, so some of it may depend on our tacit knowledge about patients, about their country of birth or about their history and who they are living with and whether they have ever used intravenous drugs. So some of that may be searchable in the patient record for us to do active recalls for people saying we would like you to come in for a hepatitis B test, and some of it will just be good history taking, so knowing our communities and that there are communities where for example IV drug use may have been prevalent and sort of being able to ask that. The next thing would be the way that we actually use our patient record to be able to code say, country of birth or IV drug use so we can actually do active recalls of people who are at risk, and I think there are probably examples of some practices who are able to do that, but it is not easily coded in the records. So some of those things are things that you could take back to your practices and have a discussion about well who do we know and how can we identify patients who we should be testing for hepatitis B.

We have had a couple of questions come in as well Vicky about people with tattoos, whether we should be testing them routinely?

Vicky: Yes, certainly if they are tattoos that are done in the home or overseas, cultural settings so in the Pacific Islands and parts of Asia they will done without any sterile conditions. Tattoos done in prisons. So those are risky tattoos. If people have had tattoos in a tattoo parlour, their standards are usually very good and it is very rare that people who have gone to a tattoo parlour in Australia, or in New South Wales, will pick up hepatitis, so I would not routinely test people with tattoo art.

Tim: And so again, that comes down to our good history taking, about, oh I like your tattoo, where did you get that done? And sort of just a conversation to check whether people are at risk. Oh, I got it done on a beach in Thailand as a teenager. You might need testing.

Vicky: Yes, and the tattoo in prison is definitely a risk.

Tim: Absolutely. And people do do self-tattoos in prison and tattoo each other, that is a thing.

The other thing we have got there about management of hepatitis B positive pregnant women. I think we will come on to cover some of that later on.

Vicky: We will come on to that, yes. And the other question about managing people with chronic hep B and normal liver function tests, we will cover all that in a minute.

Alright, so the next thing is once you have identified the patient that you should be testing, is how to test. So there are three tests that should be requested. And here we need to understand a little bit about hepatitis B infection. So we should be requesting for surface antigen, which is obviously the outside of the hepatitis B virus. We should ask for hepatitis B core antibody and hepatitis B surface antibody. So, these are looking at different parts of the hepatitis B virus and these help us interpret whether the patient has infection and whether they are immune and we will go through that in a minute. Now on the form you write query hepatitis B and that means that the testing is covered by Medicare if it is done in the context of someone with those risk factors that we have been describing.

There was a question about e antigen. That comes later. So the first step, the cheapest step, is determining whether someone has chronic hepatitis B so these are the three tests to request. We will talk in a minute what to do if they come back positive.

So, this is the first case study we have which is about Mahmoud and he is a 40-year-old, one of your regular patients. And he comes to see you prompted by a campaign in Arabic about needing to get tested for hepatitis. So you review your file notes. Mahmoud was born in Libya and migrated to Australia at 10 years of age and he has been your patient for 15 years. You do not have any records of ever testing him for hepatitis and he has not had any abnormal liver function tests during this period. Your records indicate that both his parents are deceased but you do not have a cause of death recorded. And to your knowledge, Mahmoud is a devoted family man and a devout Muslim. So, what should you do? So, explain to Mahmoud that yes, Libya is in a region where hepatitis B is endemic and due to the risk of him having being born there and him having an early childhood infection, it is important that he gets tested. And also recommend that he is tested for hepatitis C and HIV also because of coming from the Middle East. So what you do is order hepatitis B surface antigen, core antibody and surface antibody and write query chronic hepatitis B on the order form.

Now interpreting test results. So here is where by ordering these three serology tests in combination, they can tell us about the patient’s hepatitis B status. So if all three tests are negative, they are susceptible to hepatitis B. They have never been exposed and if they are at ongoing risk of hepatitis B infection they should be vaccinated.

The next column is someone who is surface antigen negative, but they have their core antibody and their surface antibody. So that tells you that they have had a past infection because they have got a core antibody, but because they have got a surface antibody and their surface antigen is negative, it means that they have cleared their infection. So they are immune to hepatitis B. But there is a risk that they could get a relapse of disease with severe immunosuppression, so that is something to note for the future, that if for example they are having to have a transplant or monoclonal antibodies, that you might need to consult a hepatologist about the risk of hepatitis B flare at that time.

The next column is immune due to vaccination. So, because this person if they have never experienced the full hepatitis B virus, they have only experienced the vaccine which is just the surface antigen part of the virus, they are not going to have core antibody. They have just got surface antibody. And of course they do not have surface antigens. So that person can be reassured that they are immune and that they are immune due to vaccination.

So the one we want to focus on tonight is the fourth column, so chronic infection. So these are people with surface antigen and core antibody and because it is a chronic infection, they have not yet developed surface antibody. So these are the people we are going to be focussing on tonight and talk about disease staging and monitoring.

And then the fifth column is a bit confusing where there is just a core antibody but no surface antigen or surface antibody. That might be a recent infection, it might be a false positive, it could be an occult infection, and that one is a bit more complicated and we will not have time to discuss that tonight, but there may be some clinical context that helps you interpret it or you may need to seek specialist advice about those patients.

So Mahmoud’s tests come back. So he is surface antigen positive and he is core antibody positive. So he has chronic hepatitis B. He has a long-standing infection that has not been cleared. He still has surface antigen. So you take your further history. Has he ever had a hepatitis test before? Did he have any surgery in Libya? Has he ever injected drugs? And what did his parents die from? So importantly you find out that his mother died of liver cancer. His father unrelated. He has not injected drugs nor had surgery overseas and to his knowledge he has not previously been tested. So this starts to add up now. His mother probably had chronic hepatitis B as well, passed it on to him in infancy, probably at birth, and unfortunately she died from the complications of that chronic hepatitis B. So, what do you need to do now?

So, here we are going to talk about the staging of his chronic hepatitis B. So, the first thing to do is to assess his disease phase, and to do that you need to look at his hepatitis e antigen which is another part of the hepatitis virus that we do not need to test for, only if we know someone has chronic hepatitis B. We need to order a DNA level, so quantitative, how much virus he has circulating. We need to look at his liver function tests, his blood count, his clotting, his alpha fetoprotein. You need to do a physical examination to look for stigmata of liver failure. A liver ultrasound is indicated and assess whether he has liver fibrosis using an APRI score which is using the ALT and platelet count. And there is an online calculator that you can use to calculate that.

So that is assessing his disease phase. The next thing you need to check is if he has any co-infections, so it is really important to check for hepatitis A, C, D and HIV. Now, hepatitis C, D and HIV may have been acquired by the same route, but it is also important to know if he has a coinfection with any of these hepatitis viruses because that can lead to more severe outcomes and if he is not immune to hepatitis A, then it is really important to vaccinate him, because if he has chronic hepatitis B and catches hepatitis A, that can lead to full hepatic failure. So an important preventative measure to do right up front.

And the third thing to do is assess his contacts. So it is important to arrange for his household and sexual contacts to be screened for hepatitis B. And if they are not immune, to vaccinate them because they could be at ongoing risk of hepatitis B.

So this is covering some of the earlier questions we had Tim, about assessing disease phase and what to do. So out of those tests that you have just ordered, a virus level or a DNA, the liver function test, ALT and the e antigen, these are used together to classify chronic hepatitis B into one of four immune phases. So the first phase is immune tolerance where early in the infection there are high levels of circulating virus but the liver is not impaired and the person still has the e antigen as well. Then the disease at some stage and it will vary by individual, will move on to an immune clearance phase when in fact the DNA is coming down but there is active response in the liver, so the ALT is raised, and during this period the e antigen starts to disappear and the antibody starts to rise. So this immune clearance phase is at a time where patients are at high risk of cirrhosis and hepatocellular carcinoma. So people in this phase should be referred for consideration of treatment. Then, after patients move through that phase, they move to the immune control phase where the DNA is low, the liver is fine and they have got the e antibody. And those patients can be monitored in general practice. And then the final phase is the immune escape phase where once again, the virus becomes active, the liver inflammation starts up and this phase again needs to be considered for treatment to prevent cirrhosis and hepatocellular carcinoma. So, you know general practice is crucial to be monitoring the DNA and the liver function tests and the e antigen and antibody. If patients are in the immune tolerant phase or the immune control phase, they can just continue to be monitored every 6-12 months in general practice. They do not need specialist intervention. But once they enter the immune clearance or immune escape phase, then it is really crucial for a specialist consultation to happen and the patients are considered for treatment.

Tim: We have got a few questions. One about the hepatitis B DNA, the viral load. Is that Medicare rebatable in someone who you has done the initial serology testing?

Vicky: That is right. So for patients that are not on treatment, it is rebatable every 12 months and for patients who are on treatment, every quarter, four times a year it can be done.

Tim: And do people move between groups? So for example if someone is in the immune clearance group and moves to the immune control, then they can shift just to the monitoring phase. Does that happen? That is one of the questions.

Vicky: Yes. Usually once someone starts on treatment it is then life-long. They risk a flare of infection if they do stop. But you know, that is where the hepatologist will give you the best advice about what to expect. Once they start on antivirals, that is ongoing treatment.

Tim: Yes, even it is just a mildly abnormal LFT, that justifies a referral?

Vicky: Yes, well it is usually more than double the cut off and we have got the cut offs in some upcoming slides for men and women. Yes and you know if it is just mildly raised you might want to get them back in three months to see what is happening because as the graph indicates, it can fluctuate a bit in those immune clearance phases.

Tim: Yes. And do the different phases change the nature of risk to contacts of the patient? Or are we just doing contact tracing on everyone anyway.

Vicky: Yes. Well clearly if the DNA is low then they are going to be at lower risk of transmission, but if you have for example diagnosed someone in immune control phase, they might be at very low risk of transmission then, but if it has been their sexual partner for the past five years, may be they have had a higher DNA level earlier, so yes, we do not really use the current DNA level or immune phase to look at what kind of contact tracing is necessary, but interestingly for health care workers, so there has been a recent change to the national guidelines and now even health care workers with chronic hepatitis B, provided their viral load is suppressed, they can do surgery or exposure-prone procedures, as long as their viral load is fully suppressed. So that is a new thing that came in earlier this year.

Tim: Yes. And we will talk about the cut off points for viral loads as well. We will see some examples and some figures shortly. Someone was asking about fertility considerations for patients undergoing treatment, and whether they might need to consider having eggs or sperm stored prior to treatment?

Vicky: Well we will talk about pregnancy a little bit later on. So in fact we do use antivirals during pregnancy to prevent the risk of transmission, so you know, in consultation with a hepatologist and obstetrician, antiviral treatment is not a barrier to pregnancy.

Tim: Excellent. I think that is all the questions for now.

Vicky: Okay. Alright, so what we have done so far is assess the phase and look at infection. The other thing we need to think about with patient monitoring and once again this is very much something that can occur in general practice, is looking at the patient’s risk of hepatocellular carcinoma. So the things that dictate risk of hepatocellular carcinoma are the presence of cirrhosis which you have assessed initially by your APRI score and if your APRI score is abnormal then you would refer for a proper assessment of if there is cirrhosis present. Age and race. So, in particular, Africans from the age of 20 years, Asian males and females from 40 and 50 years and Aboriginal people from 50 years are at increased risk of hepatocellular carcinoma irrespective of other contributing factors. And then people with a family history of liver cancer are also at risk. So, if your patient has any of these risk factors, on top of monitoring their hepatitis B they need hepatocellular carcinoma surveillance as well.

So we need to develop a monitoring plan. So it is depending on the disease phase. Patients in phases 1 and 3 can be monitored in general practice with six to 12 monthly viral load and liver function tests. Of course the viral load can only be funded 12 monthly. And then on top of that, the patients at risk of hepatocellular carcinoma need six monthly alpha fetoprotein and an ultrasound.

And then the final and really important thing to be happening in general practice is education of the patients. Their understanding that this is a life-long condition and the importance of them coming to see you every six to 12 months to have their condition monitored. What their transition risk is, because I understand there is a lot of misunderstanding. Some cultural groups think it can be transmitted by sharing food for example. So explaining to your patient how it is transmitted and what they need to do to protect others. And then also their liver health, so their weight, their alcohol intake, smoking et cetera to minimise the other strains on their liver. And this also includes things like not taking traditional remedies and botanical extracts et cetera because many of those can have liver hepatotoxins in them. Okay.

Alright, and the triggers for specialist referrals. So just to summarise, we have really talked about all these things but patients in the immune clearance or immune escape phase, so if the ALT is elevated, and that is more than 30 units per litre in men and more than 19 units per litre in women. If the DNA is also above 2,000, so it recognises that you might get some small fluctuations from alcohol or something. They do not all need referral just because their ALT is up a bit. So in conjunction with a high DNA. Any abnormalities in the ultrasound. High alpha fetoprotein. If your patient who has got chronic hepatitis B has a need for chemotherapy or immunosuppression, if you find they have a co-infection with hepatitis C or hepatitis D and for pregnant women, if their viral load is above two hundred thousand international units per mil irrespective of what immune phase they are in.

So I will just touch very briefly on the basics of antiviral treatment because that is not the purpose of tonight’s webinar to learn about antiviral treatment because it is an S100 prescription authority so you need to do a course to be able to prescribe hepatitis B antivirals. But both entecavir and tenofovir are the first line treatments in Australia. They are oral, one tablet a day, and as we said before once a patient starts on hepatitis B antivirals it is usually indefinite and the exception is when the antivirals are used during pregnancy to stop transmission then women will usually be weaned off them postnatally. It is important to emphasise to your patients that once they start on treatment they should not stop and if they do they risk a flare of acute hepatic failure. And the good thing to know is it is very unusual to develop antiviral resistance but it is crucial that they do comply with their daily pills once they start on it. And while interferon is no longer the treatment of choice, you know hepatologists may consider it in a select group of patients. But we will not delve into that any more tonight.

Tim: We have got a few questions coming through just before we move back onto the case. If patients prefer to be initiated on treatment in phase 1 and 3 in that previous diagram, is that worth doing?

Vicky: Well I think certainly they could be referred for a consultation but I believe that unless they were pregnant, most hepatologists would not be recommending treatment in those phases because once it starts it is ongoing. But you know, that would have to be discussed with the specialist.

Tim: Yes. If there is no evidence of HCC but chronic hep B would patients still need half yearly AFP and ultrasound?

Vicky: Yes. Because it could develop at any stage, so it is important to monitor that every six months.

Tim: Absolutely. And someone is asking about the management plan for babies born to mothers with chronic hepatitis B. There is a whole set of prophylaxis during deliveries, isn’t there?

Vicky: Yes. So, I will just briefly touch on that then. So, women with chronic hepatitis B as you said need a viral load measured and their ALT monitored. If their level is above two hundred thousand units they should be referred for treatment. But all women, whether they have got a high viral load or not, their infants should be given hepatitis B immunoglobulin within 12 hours of birth. They should be given hepatitis B vaccine within 12 hours of birth. And then they should receive the full course of hepatitis B vaccine at six weeks, four months and six months of age, and they should be tested with those three tests that we mentioned, surface antibodies, surface antigen and core antibody. Three months after they finish their course, their primary course, and hopefully you demonstrate that they have got immunity to hepatitis B. If they do not have immunity at that age, nine months plus, then they should be referred to a paediatric hepatologist and there is a service at the Children’s Hospital Westmead. So that is the basics of infants born to mothers with hepatitis B.

Okay, we had better move on. Is that right, Tim?

Tim: Yes, that is good. Let’s move on.

Vicky: Alright. So, back to Mahmoud. He got his results back. So he is e-antibody positive. His DNA is low, less than 2,000 and his ALT is within the normal range for his age for men. So he is in the immune control phase. So he has developed e-antibody. So his other tests, his full blood count is normal. His clotting is fine. His ultrasound is fine, his alpha fetoprotein is low. You pick up that he is not immune to hepatitis A but fortunately he does not have any coinfection with hepatitis C or hepatitis D. So, on that basis you recommend a course of hepatitis A vaccine, two doses six months apart. So you have assessed he is in immune control phase. You have got a plan there. The next thing is his hepatocellular carcinoma risk. So we have already established that he has got a family history of liver cancer. He is not in one of the racial groups that have a higher risk. His AFP and ultrasound are normal and his APRI score is less than 1, so we do not think he has cirrhosis, it is a pretty sensitive test for picking up cirrhosis. But because of he has chronic hepatitis B and he has got a family history of hepatocellular carcinoma or liver cancer, he needs to be monitored every six months for hepatocellular carcinoma. So you need to educate him that it is crucial to see you every six months for his AFP ultrasound and liver function tests and then get his DNA done every 12 months. He should avoid alcohol, smoking and herbal medications, maintain a healthy diet, healthy weight and explain to him how hepatitis B is transmitted. So the main risk for him is sexual partners.

So, his family comes in. His wife Salima. She is 38 years old, born in Oman, two children, otherwise well, does not recall being vaccinated for hepatitis B. Her parents are both well and alive and she has a normal physical examination. Their two children are born in Australia, and you check the Australian Immunisation Register and they are fully vaccinated against hepatitis B. So, for Salima you need to find out if she has chronic hepatitis B, so you write query chronic hepatitis B on the form, ask for surface antigen, core antibody and surface antibody. So, Salima also has chronic hepatitis B. So she is surface antigen positive and core antibody positive. So she also needs a work up for disease phase and co-infection just as you have just done for Mahmoud.

The children are born in Australia. As we have said they are fully vaccinated. So their mum has chronic hepatitis infection and she does not have any record of being screened during pregnancy and the children were born in another state, so you cannot access those records. So, you need to also see if they have chronic hepatitis B, so the same three tests are ordered. And here, very fortunately they come back as immune to hepatitis B so they have got no core antibodies so they have never been exposed to the virus. But they have got surface antibody above 10 international units per mil, so they are immune through vaccination. So, the preventative interventions for those children have been successful so they do not need any further action. They are protected against hepatitis B.

Okay, so assessing Salima. Same tests that we ordered for Mahmoud. So she is e antigen positive. Her DNA is high, two million international units per mil and her ALT is elevated. So, Salima is in immune clearance phase, the second phase. So, she needs to be referred. Her other assessment is fine, so full blood count fine, clotting, alpha fetoprotein. She is also susceptible to hepatitis A, so you recommend that she is vaccinated and that can be started straight away. Explain to her about hepatitis B transmission and the natural history. Discuss the importance chronic hepatitis B infection for any future pregnancies. Explain she is in immune clearance phase, so different to her husband, it is important that she does see a specialist and be assessed for hepatitis B treatment and let her know that she might be started on oral anti-virals. But it is also important for her to hear the other liver health messages that you are giving, and check if there is any other contacts that may need screening, because clearly in this family there is a risk of hepatitis B. So maybe siblings, other sexual partners. So it is important to explore all that.

Okay. So, in New South Wales we fund adult hepatitis B vaccine for high risk groups, so any Aboriginal people, household and sexual contacts of any acute and chronic hepatitis B cases, immunosuppressed people, people with HIV or hepatitis C, men who have sex with men, injecting drug users, sex workers and clients of sexual health clinics are all eligible for a free hepatitis B vaccine course. There was a restriction earlier this year and last year because of international shortage but the supplies are now replenished, so you can now order it via the online system just with all the other vaccine orders that you put in. But please just use it for eligible patients, it is not to be used for travel vaccine and we have got Engerix B at the moment. And the routine schedule is three doses at zero, one and six months apart. If there are longer intervals there is no need to repeat a dose and please report all doses to the Immunisation Register so that others that see your patients can know that they are vaccinated.

I saw a question there about the hepatitis A vaccine and eligibility, so it is not offered free, but it might be rebatable on health insurance. The children do not need to have hepatitis A vaccine because we are only giving hepatitis A vaccine to their parents because of the risk of co-infection of hepatitis B and hepatitis A, and because the children are protected against hepatitis B that coinfection risk does not exist for them.

Any other questions at this stage, Tim?

Tim: Yes, there are quite a few come through. Someone was asking about detailed information about herbal medicines to avoid if there is any source of information for that?

Vicky: Oh, yes and I am having a mental block. Maybe you can help me Tim, there are some real classics there. Sorry.

Tim: Not off the top of my head, but I can do some quick googling and we can get some information. And I think that you are right that there is a whole range of different medications. Quite a lot of them do have interactions and quite a lot of them can be up for regulators of the cytochrome enzymes in the liver and have particular liver effects I think. Often it is good to be cautious. So we have got some people answering St. John’s wort and gingko biloba as being particular examples and they are widely used by people. So certainly the common ones we have to be careful of.

We have got, oh questions about FibroScans and Hepascores about the value of those. A FibroScan gives a measure of the stiffness of liver tissue and is an indication of cirrhosis as I understand it.

Vicky: That is right. So that would be something that we would probably progress to if the APRI score is above 1. By having a low cut off for the APRI score, it is actually quite a sensitive test, so while a FibroScan could be becoming more accessible, really if patients have an APRI score of less than 1, there is no need to progress to a FibroScan. But if your patients do get referred to the liver clinic because of other factors, it will undoubtedly be done there.

Tim: Yes. And someone is asking does the APRI score need to be repeated and monitored? I suspect yes, because the ALT and AST and platelet score can all change.

Vicky: That is right. So those tests should be ordered at the routine at least 12 monthly, monitoring.

Tim: Yes. We have answered that one. Does antiviral treatment need to be ceased in a future pregnancy? I think from what you were saying earlier that that may not be the case.

Vicky: Yes, usually not. It would usually be continued but once again, you know the obstetrician and the hepatologist would need to work together to look at the individual circumstances.

Tim: Yes. We have had a few questions about the booster vaccines for the hepatitis B vaccine. The immunisation handbook is pretty good on the decision making about immunity after the vaccines and whether to give boosters and how many to give.

Vicky: It is important, yes. So if you are testing some time after the course and it is less than 10, then you give the one booster test again, and if it is still below, then complete that second course and if it is still negative after that then it is important to exclude chronic hepatitis B infection that can be a cause of non-response. But two courses if they are still not immune by that stage and they do not have chronic infection, they are a non-responder and need to take precautions if they are exposed.

Tim: And there is a question there, after childhood vaccination, if an adult can be treated with hep B vaccine during childhood, and the hepatitis B surface antigen is negative, core antibody negative and anti HB surface antigen is between 10 and 100 does he need a hepatitis B booster? I think if it is over 10, then they are immune, aren’t they?

Vicky: Yes, they are immune.

Tim: So they would not need a booster. How long is hepatitis B positive blood infective outside the body?

Vicky: Yes, a long time. It is very persistent and that is one reason it is a real risk for dialysis patients for example. So, probably about a week. Yes. So it can live on tourniquets and all kinds of things which is a real risk in a health setting.

Tim: And quite a few questions coming through there. There is a question about resources in other languages. You showed the posters initially for the campaign. Are there also patient information leaflets in other languages as well?

Vicky: Yes, yes there are. And I am happy to send the link through to that later.

Tim: Lovely. Thank you very much. Someone commenting about the vaccines being free for hepatitis C. I think you went through the New South Wales free vaccination schedule where it is hepatitis B for those groups on the screen at the moment, but not hepatitis A.

Vicky: That is right. And there is a question there about Twinrix in the past was two doses. I mean that is only giving two doses of Twinrix will just give immunity to hepatitis A. To complete the hepatitis B dose, you do need to have a third dose. And if that patient has surface antibodies of 44, well for prolonged immunity a third dose of hepatitis B vaccine is recommended.

Tim: Someone is asking about the Victorian schedule for hepatitis B. I do not know that off the top of my head. I do not know if you do. That is worth consulting the Victorian Department of Health website, I think they will have the information.

Vicky: Yes, I do not know what they offer free there.

Alright, I will just move on to this last slide which is resources. Now, I have looked at all the health pathways for hepatitis B, and by and large they are excellent. And in fact they really take you through step by step what we have talked about like who is at risk, assessing disease phase, monitoring. So I think I would really recommend that you all use your health pathways to guide you through this. And the other thing there is, there is usually a link to your local liver clinic referral so I think they are very handy.

The other thing, and this is a resource that is in the handout tonight, so there is a link there to it, you can download it, is from ASHM, the Australian Society pf HIV, Viral Hepatitis and Sexual Health Medicine. It is just a two pager that is probably useful to print out, and really just summarises exactly what we have talked about tonight, how to interpret tests, what tests to do for monitoring et cetera. I think it is an excellent summary. ASHM also have other useful things. So, if you have a lot of patients with hepatitis B or wanted to become a prescriber, they offer the S100 prescriber courses and there are other useful things there. They often have face to face training, online training and the National Testing Policies and so forth. So I think that is a really good website to have a look at.

Okay. Well, Tim.

Tim: Yes. So these are our learning outcomes. So we have reached the end. It is half past eight. So by now we should be able to describe methods to identify patients with hepatitis B, and those are all in the ASHM decision making guide as well, so do download that. Understand the essential role of general practice in managing chronic hepatitis B, describe the way we do contact management, recount the triggers for specialist referral and access the available hepatitis B resources and education tools.

Thank you very much for your participation and all the questions that you sent in as well, that is fantastic. And thank you very much Vicky for taking us through all that. And thank you very much Sammi for hosting us tonight.

Sammi: That is great, thanks Tim and thanks Vicky again. And also thank you to everyone online for joining us, we really hope you enjoyed it, and enjoy the rest of your evening.