Good evening everyone and welcome to tonight’s webinar on hepatitis B and primary care. This is the second of five webinars in this series sponsored by ASHM. May name is Natalia Rode and I will be your host this evening. I would like to start by acknowledging country, acknowledging traditional owners of the land and sea _____ but I know that we have got people from around the country here so welcome and I would like to pay respects to elders past, present and emerging. So, little bit of housekeeping. This webinar is being recorded and will be made available for your in the coming week. To interact with us today, you will need to use the Zoom control panel which is at the bottom of your screen. If you cannot see it try hovering your cursor over the bottom of the shared presentation screen and the panel should appear. This control panel allows you to select your preferred audio settings and it is where you can ask questions by the Q&A mode, that is what we will be using this evening, not the chat but the Q&A, so we have put everybody onto mute this evening to ensure that we are not going to be disrupted by any background noise [software background noise] as participants because it is a webinar. If you do need assistance, please use the Q&A feature to raise any technical issues and just submit your questions throughout the presentation. Please do not enter any personal information outside your name and the question as other attendees are able to see your questions. We will be addressing questions throughout at the presentation. We really encourage you to all ask questions. We love this to be as interactive as possible that we will make sure that we have got some dedicated answer to the question answer time at the end. If you see questions that you are also interested in asking, please avoid the questions by selecting the tick icon next to the question and this will mean that we will answer the questions that are of most interest to you first and we will reduce the same or similar questions that are being asked. Tonight’s webinar is proudly supported ASHM and our presenter this evening is Nicole Allard. Nicole is a postdoctoral researcher and medical epidemiologist at VIDRL Victorian Infectious Disease Reference Laboratory. He is also a GP with a special interest in refugee health and hepatitis B treatment in primary care. Nicole is an honouring lecturer at the department of medicine at the University of Melbourne and is supervising master’s and PhD students. We will get started now and I will handover to Nicole to commence the presentation.
Hi everyone and welcome to the webinar. I am just getting the dreaded slightly unstable internet connection so I hope there is no problem with everyone seeing me and I am sure the team will let me know if there are any issues. I am just going to share my screen and we will start the presentation. So, as Natalia said, it is planned to be interactive so please ask any questions as we go along in the chat. I just wanted to confirm from my fellow team that I am coming through okay and that my internet instability is not affecting my presentations, is that right Natalia.
All good, thank you, we can hear you and see your presentation.
Great, okay, it is always that point in the presentation when you think I am going to kick every adolescent off Netflix and maybe they will actually do some schoolwork, so I would also like to echo the acknowledgement of country, I am on Wurundjeri country of the Kulin Nation. It is freezing here in Melbourne tonight and quite a few of us Melburnians wish we were somewhere else, but here we go, so we are talking about hepatitis B tonight and hopefully by the end of this activity, you should be able to identify priority populations for testing for hepatitis B, interprets serology which I think is a very important thing as a part of general practice and also understand the role of primary care in the testing diagnosis and management of people with hepatitis B. The overview of our talk this evening, we are going to talk briefly about the epidemiology public as I cannot help myself because I am an epidemiologist. Also, why worry about transmission prevention, a brief commitment on the effective 2020, the COVID pandemic and the testing and interpreting results, what to do when someone is hepatitis B positive and monitoring and treatment and a little bit of a plug at the end about how you can become a GP prescriber. So we are going open with a polling question and the question is how many people, oh actually Natalia is going to do the questions.
True, you can ask me questions and I do not mind Nicole ask me questions.
Okay, how many people in the world are living with chronic hepatitis B and you got an option from 1 to 50 to 150 to 250 million.
Just waiting for people to vote. We have already had one very interesting question come through, but I think we might leave this one till the end if that is okay, it comes from peer hood and it is about a specific patient of theirs who is wanting to be a phlebotomist. It is an interesting question and we might just leave it until a little bit later and see if there are some other questions that is similar. We have got answers that come through.
Okay so we have got a bit of a spread across the answers which you know it is fine, this is a talk, so from 1 to 150 million but yes the majority of your answers, although the red bar is actually the correct answer, so it is an estimate that 250 million people worldwide living with chronic hepatitis B and that this equates to about nearly three quarter of a million deaths per year worldwide and most of both the burden of disease and the burden of mortality and morbidity is actually in average in the Asia-Pacific. Clearly China in there with such a large population makes a big difference but a lot of our smaller especially all our neighbours have very high prevalence of hepatitis B. So this is the geographic distribution of hepatitis B with countries in yellow being low prevalence which is defined by WHO as less than 2% and countries with intermediate and high prevalence in the other colours orange and then the countries in white are basically countries where we do not have enough data, but what I think it is really important to understand is that over half the people in the world live in an area with intermediate or high prevalence and also there are pockets of high prevalence in certain areas, so certainly indigenous people across the world have a high prevalence of hepatitis B and there is actually a conference specifically around viral hepatitis and indigenous population so whether that is indigenous populations in the Amazon or in the America is more broadly they do have much higher rates. We cannot also say as I alluded to you before, we cannot really see the Pacific Islands but nearly most specific islands certainly Solomon, Vanuatu, Kiribati parts of Micronesia, they are all in the high category, so they do not really appear on the map, due to their size and why is it important to know this because one of the main risk factors that we assess when we think about screening for hepatitis B is actually around where someone was born, so this is a second polling question, so hepatitis B in our backyard, so how many people are notified with hepatitis B each year and we will just imagine, by the way there is a typo it should be 7000 not 70000 that last category is 6000 to 7000, sorry about that. We will not include 2020 because that was just a year when nothing went quite as planned.
I suppose this is an important point to make that hepatitis B is a notifiable disease and I am not sure Nicole whether [software background noise] territory, because I believe in Victoria the notification occurs from both the laboratory, but also should be done by the doctor, is that correct.
Yeah, that is right, so hepatitis B, we have several automatic lab notifications in Victoria, but hepatitis B should also be notified by the practitioner. However, that does not actually always happen, so it only probably happens in 30% to 40% of cases, so actually the right answer is we have 6000 to 7000, unfortunately the right answer also had a typo but 6000 to 7000 knew hepatitis B infections are notified every year and that has basically been stable for well and truly over a decade. Now last year, the 2020 effect was obviously probably a little bit of a drop off in notifications and that is partly to do with a drop-off in migration and we will talk about that a little bit further. Okay, so at the moment there is about 230,000 people estimated to be living with hepatitis B in Australia, which equates to 1% prevalence overall. In Aboriginal and Torres Strait Islander people the prevalence is higher, so this is a population that is disproportionately affected by hepatitis B. We estimate that about 22% of the total number are engaged in care and nearly approaching 10% receiving treatment and currently we have around nearly 400 accredited GPs who are prescribing treatment across Australia and when we look at the breakdown of who is living with hepatitis B in Australia by priority population again, it is people born in Asia and Pacific and Aboriginal and Torres Strait Islander people who make up a majority of people living with hepatitis B in Australia. Hepatitis B has been in Australia for a really long-time millennia, in fact, it was an infection that predated the colonial overtake or invasion of Australia. So we have also got smaller populations, people born in North Africa in Middle East, people in Sahara and Africa and as I mentioned before the Pacific, then we have got other populations at risk, and they are the ones that we would associate with other blood-borne virus, especially people who inject drugs and men who have sex with men. So key points for epidemiology is hepatitis B is a worldwide issue. The majority of people living with chronic hepatitis B are migrants from high prevalence areas, particularly Asia and the Pacific and Aboriginal and Torres Strait Islander people are a priority population with a higher prevalence of chronic hepatitis B and therefore should know their status. I will just pause there for a minute, are there any questions regarding the background or epidemiology of hepatitis B, we are going to then now move on to talk about who should be tested which will reflect _____ epidemiology, but also cover up on other groups as well. Okay any questions there Natalia.
Karen Hong Tong has made a comment about this being surprised Australians without risk factors make up 14.5% was that correct and can you comment on that.
Yes, I guess when we actually look at this next bit about actually sort of area five the testing and interpreting results especially, there are whole lot of other categories of risk including you know tattooing, travel overseas, also transmission during infancy, a whole lot of things like that, so it is surprising and it is actually interesting you mentioned that because we recently looked at women giving birth in Victoria and looked at notification data and hepatitis B and yet it was actually about that of the percentage that was nearly 4000 people who had given birth who had a notification of hepatitis B and it was about 10% or 12% did not have an obvious risk factors so I think that is consistent and there is some sort of background risk that we do not necessarily know about. Okay so why worry, so worldwide hepatitis B is the most common cause of HCC or hepatocellular carcinoma, which is primary liver cancer and the risk of developing HCC is 20 to 100 times high in people living with hepatitis B relative to those without infection. When we look at liver cancer broadly in Australia about 60% of liver cancers are caused by hepatitis B and C, and at the moment hepatitis C contribute a little bit more to attributable fraction of liver cancer, but hepatitis B is certainly following closely behind. So liver cancer is the fastest increasing cause of cancer death in Australia so we have seen it go up the league tables since I have been working on hepatitis B it has come from 12 to 9 to I think now 7 in terms of the cancers that are causing death in Australia and there has been a 200% increase in the cancer mortality between 1982 and 2017 and I think it is really important sometimes people work in hepatitis B, the hepatitis B vaccine is actually the first anticancer vaccine. We often talk about the HPV vaccine being the first cancer prevention vaccine, but the hepatitis B vaccine that was developed in the late 1980s is actually the first anticancer vaccine because if you prevent primary prevention of liver cancer includes preventing hepatitis B infection and therefore preventing any of the sequelae of hepatitis B infection. So, if we look at hepatitis B we see like diagnoses still in up to 30% of people diagnosed with cirrhosis or liver cancer, we say like diagnoses we mean that they have been diagnosed with hepatitis B in the two years or even after they have had a cancer diagnosis, so there has been really no opportunity to prevent that cancer. So at the moment, surveillance or screening for HCC is recommended in certain groups with hepatitis B including men from the Asian region over 40, women from the Asian region over 50 and people from the African region really sub-Saharan Africa we are talking about here over 20 years any patient with cirrhosis with a family history or Aboriginal and Torres Strait Islander people over 50 years with hepatitis B and this is because hepatitis B unlike hepatitis C can cause cancer without there being cirrhosis. So in hepatitis C we only really worry about cancer diagnosis once someone has cirrhosis but hepatitis B is itself a carcinogen and can cause cancer.
Okay _____ has asked a great question about HCC surveillance that if somebody has managed to naturally clear the hepatitis B virus and developed surface antibody and an undetectable hepatitis B viral load, do they still require ongoing surveillance in somebody who has had a 20 to 30 year history of chronic hepatitis B but managed to clear themselves.
So if they do not have cirrhosis and if they have cleared S antigen, then no they do not need ongoing surveillance. If they have cirrhosis regardless of their S antigen loss and developing surface antibody, they would still need surveillance. I think it is slightly more complicated, even in someone who has lost S antigen and gained surface antibody if they have a very strong family history of liver cancer and I would advise those people that that decision is made by specialist, we are all specialists, that is a really bad term, you should seek advice from a physician, gastroenterologist or ID specialist regarding an individual.
Okay so now we are just briefly going to talk about transmission and prevention. Okay, so really, this is certainly the most common forms of transmission so vertical or perinatal transmission is by far the most common worldwide followed by skin and _____ in school children, which we call horizontal transmission so this is usually women who have had very high viral loads passing the infection to the baby at birth It is very rare to get into uterine transmission of hepatitis B so it is a phenomenon of birth really, then there are other forms of transmission including you know sexual acquisition, percutaneous including injecting drug use, acupuncture, tooth brushes, well I do not think that is a common tattooing and then blood transfusion only prior to when we started screening, I mean that is really not in issue but a lot of people with coming from overseas, they might have actually been exposed to transfusions overseas you know therefore have an on sight transfusion. Dialysis in Australia there is still cases of dialysis related hepatitis B transmission most people who are reaching the end-stage renal failure should actually be tested first, obviously, but then vaccinated against hepatitis B but there is a small group of people like in any vaccine that do not respond to vaccine, so we still do see transmission in that setting. We think a vertical and prenatal transmission were predominantly a problem of countries overseas but people do not have access to active vaccination and passive vaccination so this is birth dose of hepatitis B and immunoglobulin. However, we have seen transmission in Australia and certainly looking at the Victorian data. I talked about earlier we are in small numbers but we have seen episodes of transmission in Australia in the last 5 to 7 years. So this is an important concept in hepatitis B so if we look at a child, what is the likelihood that a child when I say child here it is really talking about an infant or neonate infected with hepatitis B will go on to develop chronic infection so the answers are 10%, 25%, 50% and 95%. It is one of those moments I cannot see the polling numbers but we just wait a certain amount of time so everyone gets a chance to choose.
Just while everybody is doing that, a reminder that if you got any questions, please put them in the Q&A box that you should be able to find at the bottom of your screen. We love to be able to answer your questions throughout the presentation.
Okay, so the bottom one the 95% is in fact the correct answer. So, when we look at transmission in adults it is only about 10% of people who get chronic hepatitis B as an adult go on to develop chronic infection but when we look at children and neonates at birth, it is more like 90% to 95% and that is due to their immature immune system. Basically, allowing to host the virus whereas an older person is much more likely to amount an immune response and clear the infection. So this is just summarised on this slide, most transmission is occurring in this early time and this is when you are discussing with people, and a lot of people will say from where did I get this, you can confidently say that they got it perinatally or in early childhood. You have to be sensitive about delivering that information. For sometimes it can be seen as blaming their mother and so I would normally deliver that bit of information with the sort of qualifier, you know, at the time when you were born you probably did not have access to hepatitis B vaccination which would have prevented it like we do now so to put it in context for people and also to say that very early childhood contact can also cause it. So, in Australia when we look at transmission in Australia it is primarily adults in risk groups, but there is a much lower progression to chronic infection, so we think of Australia as overall a low prevalence country. However, people who were born overseas in high prevalence countries are much more likely to have hepatitis B and that is part of how we look at screening.
Nicole, Anuka has asked how effective immunoglobulin is in preventing vertical transmission, I guess the question is immunoglobulin plus vaccination may be.
Yes, so vaccination in the most effective. In terms of risk reduction, we go from someone getting hepatitis B or a baby having high likelihood of getting it with very high maternal viral load. If we just give them birth dose which is timely birth dose under 24 hours there is a risk reduction around 70% and immunoglobulin further reduces by about another 10% and in certain women who have viral loads, we also give them, during pregnancy, antiviral therapy to further reduce that down so you can get it right down to less than 5% chances of transmission if all those things are implemented, but really birth dose is number one and we look overseas at implementing programs in the Pacific, which were done recently is really all about getting that birth dose as I think a lot of countries do not have access to immunoglobulin, obviously in Australia immunoglobulin is really important, but interestingly again in this prenatal study we had information that some hospitals did not have it at the time of birth and so immunoglobulin has to really be delivered within 12 hours postdelivery and is probably best delivered within four. So then if we look at risk of hepatitis B infection from exposure to body fluids, we think of high risk so that is blood serum, wound exudates, semen and vaginal fluid and we think of what does not cause transmission, so urine, faeces, sweat, tears and breast milk is very important that breastmilk is emphasised especially to women who are diagnosed during pregnancy. Breastmilk is considered safe. Salivary transmission is very rare, it can be through human bites so if there is a breaking in the mucosal skin and there is you know blood or something, that is in theory possible. Sharing food and drink is really not a risk and it is important because when you start talking to people about hepatitis sometimes they have had those kind health promotion messages around hepatitis A and we have seen a lot of self-stigmatisation of people who have after they diagnosed decided that they would not eat with their family they are very worried about communal eating because they are worried about what might happen and they might transmit it to their family. So it is important when we go through and counsel someone that we emphasise the importance of testing and vaccination of other family members, what is high risk situations, but really we do have an effective vaccine and this is what we should be emphasising. We are not going to spend a lot of time talking about vaccination, there is relative, I said new, but it is relatively old, in the last couple of years the immunisation handbook was updated in terms of hepatitis B section. I think it is also very important to say if that is free immunisation for certain groups but unfortunately it is different in each jurisdiction, so I am not going to it now but you can go on to hep B health if you want and click through to your jurisdiction and find out about free hepatitis vaccine and we do not check the immunity status of most people who have been vaccinated; however, we do check in certain situations. So, if someone has contacted someone with hepatitis B and certainly healthcare workers and other groups like people on dialysis and so forth, we will have them checked and there is a non-responder schedule and I do not want to go into that tonight because it is quite involved. I do not mind asking questions at the end but there is the section on what to do if someone is a non-responder and that includes repeating the cause, doubling the dose, subcutaneous injections, etc, and some people just do not respond.
We have got one question about vaccination. Ben has asked how effective hepatitis B vaccination is and has asked if for example some who was vaccinated could they have unprotected intercourse with hepatitis B carrier or is protection still recommended.
So, if they have been vaccinated and you have evidence of adequate service antibody response after the primary course of vaccine then yes, they do not need further protection, they are protected and sometimes you see antibody [software background noise] overtime but there will be an amnestic response if they get exposed to hepatitis B again and their antibodies should boost up.
Okay so just a few points on transmission, most people with hepatitis B in Australia acquired the infection at birth, acute hepatitis B infections in Australia are due to sexual transmission or unsafe injecting drug use and certainly anyone who injects drugs should be offered hepatitis B vaccination to protect them as well as other tests including other blood-borne viruses, hepatitis C. People from certain groups can access free immunization and I think it is important you know hepatitis B is not a particularly expensive vaccine, so if they do not fall into one of those free groups, you can also suggest to people that they pay for it. The GPs play a critical role in prevention, vaccination and high minimisation.
Anoop is just wanting to clarify, someone who has acquired hepatitis B vertically, whether they can spontaneously clear the virus.
Yeah it is about 1% per year in adults, so about 1% per year do spontaneously clear so you can see that in both people on treatment and people off treatment, you will occasionally see spontaneous clearance. One group that does clear is women who have gone through multiple pregnancies and that is because pregnancy is an immune tolerance state and what happens is just after delivery the immune system reconstitutes and sometimes that is the time when there is a flare and it chooses to kind of the immune system fights off the virus a little bit so sometimes we do see both E antigen seroconversion and S antigen loss postpartum as well.
And Irene has got a question about vaccination which I think you have sort of already answered but what she asks is if patient has seroconverted to hepatitis B vaccination do they still need to have their antibody checked every few years and if there is no antibody do we need to give them a booster dose.
No, so you do not need to give booster dose as if you have that documented that they have had an S antibody response, like I said we are not routinely checking that, I think in general practice the most common like if you do for example a sexual health screen and you might then check hepatitis B service antibody and then you might be stuck in that situation where you think should I boost if you do not have any and then you have to assess the risk of that person and If there is an ongoing risk of transmission, and presumably if you have done a sexual health screen they probably are then you can choose to give them a booster and retest them in 6 to 8 weeks later just to see if actually they do have sufficient service antibody. If you already know their immunisation status. If you do not know their immunisation status and they have less than 10 and they do not report ever having hepatitis B vaccine, then it is reasonable to give them a primary course.
In regards to screening, Sophie has asked how often to check hepatitis B in patients who are on dialysis
So for example if someone had had repeated vaccinations and hence seroconverted so really we are aiming for everyone on dialysis to be immune to hepatitis B before they go on dialysis, it is a part of end-stage renal failure workup. If for some reason they do not seroconversion you know, despite the double dose and despite best efforts they do not manage to, then I probably advise buy the renal unit that I imagine screening for S antigen probably at least yearly would be reasonable but yeah again what you are aiming for is immunity through vaccination in that group. Okay so now we are on to testing and interpreting results. This is a cascade of care for hepatitis B so the estimated 230,000 people living with hepatitis B diagnosed is only about two thirds and when I say diagnosed that is cases notified to health departments across Australia and I think we got to understand that that is how that is calculated and it is calculated using notification data and living with chronic hepatitis B is from modelling, so diagnosed you know is that they have ever been diagnosed but it does not necessarily mean they are aware of their status, they are engaged in care, they understand their diagnosis, and so forth so, at least a third remain undiagnosed and when we actually look at this group, this is obviously a critical part of general practice is to try and find these undiagnosed people living with hepatitis B, but I think there is a number of people in that diagnosed section who are essentially undiagnosed so the health department might know about them, but either you is the current GP or the person themselves do not really understand their status and so because of that you are not aware and you do not have them in care and just briefly there are some diagnosis targets for 2022 and the diagnosis targets set by our third national hepatitis B strategy was to have 80% of people diagnosed by 2022 though the graph they are really just shows you the dotted line and shows you where we are up to, sort of we first developed a cascade up here in 2012 and watching the proportion diagnosed there has basically been almost no change. It has sort of gone from 56% to 64% over nearly a 10-year period. So, we are not going to reach that 80% diagnosed target and we are not going to reach the 90% diagnosed target, which is world health organisation target by 2030 and the modular at our unit did some calculations we are actually not going to hit it until I think it was 2046 at the rate we are going, so we really need to do something new. We need to shake it up a bit and we need to get people diagnosing more people with hepatitis B in the practices. So the bottom line is opportunistically test people at risk, particularly people born in most intermediate high prevalence countries and aboriginal and Torres Strait Islander people should also be offered the opportunity to know their status. There is another sort of a longer list of people who are priority populations for testing including we do test all pregnant women at _____ universal screening we have got and we also test people about to undergo immunosuppression because hepatitis B can reactivate in those circumstances, and we also test unvaccinated adults who we see are at risk either sex or household contacts or people with hepatitis B, men who have sex with men, people who inject drugs, people with multiple sexual partners, haemodialysis, people living with hepatitis C or HIV because of the implications that an additional infection with hepatitis B has on their disease course and I think the people presenting with liver disease, so an elevated ALT particularly is important and then health professionals involved with exposure prone procedures and also members of the armed force. We have recently done a paper actually which is published in the MJA this week, where we have actually prosecuted that because we have had such poor diagnosis rates and because this is a very easy test to do that we should apply more broadly and so we put actually a sort of this this is what we have got in front of you, it is the national testing policy but we have actually said that we should be thinking about universal hepatitis B testing in Australian adults. I guess that is just something we are sort of prosecuting at the moment [software background noise] with WHO Centre for viral hepatitis.
Around screening and testing _____ stated that usually when people apply for immigration hepatitis B is one of the blood tests and she said I think that if it is positive notification is already made and they are usually chronic hepatitis B, is that correct.
So it is actually not a predeparture test so if people are applying for permanent residency when in Australia, yes they will get tested for hepatitis B. If people coming from overseas they would not be tested for hepatitis B prior to departure unless they are applying to be a health worker in Australia. So if they are applying to be any form of health worker then yes they are tested. So if we look at our kind of migration humanitarian entrants have traditionally been disproportionately better screened than other migrant groups. People coming on family reunion or business visas are not necessarily screened. When there is an application for permanent residency from someone inside Australia, then yes they do tend to be screened so it is by no means complete across the board for people coming from other countries to be screened.
Lune has asked that if you are screaming someone as a potential part of STI screening and they have a positive surface antibody do you continue to need to scream them for hepatitis B in the future as part of STI screening.
No you do not, if they have got positive surface antibody actually need to continue to screen and so a lot of people actually get an unnecessary hepatitis B test while there is a whole heap of people who do not get tested at all, so we have sort of try and balance that up and think if we have got like for example the other one I particularly like is pregnancy. If you got a hepatitis B surface antigen positive and you have been monitoring the person for years you do not need to do the S antigen again although everyone tends to do it again. What you really want to do is make sure that woman has a viral load during pregnancy. Anyway because of procedures in hospitals and health pathways almost inevitably, these women get rescreened and women have often been rescreened in a multiple times in pregnancies and then never linked to care throughout that process so it is kind of balancing those two things, but no you do not have to keep repeatedly screening someone if you have got evidence that there are immune to hepatitis B and I do not have hepatitis B and that is why actually one of the cost effective and arguments about a sort of more universal approach to screening and if you are sitting in your practice and you look at your practice and you think well actually there is a lot of people in my practice who need hepatitis B testing, then by all means, you know start making a routine part it is really cancer prevention. Okay so having said all that there are some clinical indicators for testing but you actually never see the clinical signs okay you might get the odd person come back from overseas post tattoo who has abdominal pain, fever, joint pain, loss of appetite, nausea, vomiting, weakness and fatigue and maybe some symptoms suggestive of high bilirubin. However, the vast majority of people do not have any symptoms, so it is not an acute illness, it is a chronic illness and you would not see any clinical signs. This is just some data I put in thanks to the amazing Jennifer McGaughlin in my unit. So we have looked at our 1.6 million patient records across three PHNs in Melbourne and this is actually people who qualify for hepatitis B or hepatitis C testing across that group and then looking at by category who is actually being screened okay, so of those 1.6 million patients, a quarter of a million of them met a screening criteria for viral hepatitis either B or C and one of the biggest gaps I do not know if you can see the pointer was the ethnicity hepatitis B so people with a priority ethnicity including an aboriginal or Torres Strait Islander status only about a third of them had been screened for viral hepatitis in the last seven years. I think the other interesting bit is to mention down this end, so in some ways the pointy end of liver disease, so people who had symptoms suggestive of cirrhosis or even cirrhosis specified they still did not have a complete screening history for hepatitis B and C. Fatty liver is another one you cannot make the diagnosis of NASH without doing hepatitis B and C tests because NASH is basically a diagnosis of exclusion and so you have to have a negative hepatitis B and C test to then say this person has NASH or fatty liver. So this is just sort of interesting, in some ways I put it in as a call to action, there is a lot of people out there who need both hepatitis B and hepatitis C screening. This is a hepatitis B talk, but as a generalist I am trying a bit of hepatitis C along the way. Okay and this is just what happened last year so this is the 2020 effect so we basically had a fairly stable number of hepatitis serology tests by month and we cannot pick this out a B versus C because it just gets coded in Medicare and this is Medicaid data we are looking at as hepatitis serology. It is actually coded and that can include hepatitis B, hepatitis C and even hepatitis A testing. However, we saw a big drop-off at the beginning of 2020 and this is obviously national data, but if we actually looked at Victorian data, we would have seen you know a continuing drop-off especially through our prolonged lockdown. So this has had an effect in terms of lack of diagnoses and we will see that in the coming years and we will see probably a slight uptick in the what we call late diagnoses of hepatitis B when people present with liver cancer or cirrhosis and they were diagnosed within two years of that presentation. Okay, we are going to move to a case study, James, and for this I think everyone should have received and also it has been posted in the chat or the Q&A in the chat which is the decision-making and hepatitis B guide which is produced by ASHM, so this is a wonderful resource. It is two pages which nearly fits my rule. I always think all good information should fit on one page and really the one page is who to test, what to test and serology interpretation and basically all the decision-making hepatitis B is contained in this resource. I used to print it out and have it beside me, but I think I know now, so I do not, but it is very very useful when if you want just a one stop resource to look and think about hepatitis B. So, we are going to talk about James, he is a 48-year-old Chinese Australian businessman and he presents for a checkup and he let you know that his brother has died of a liver tumour and he is attending your practice as he had a bit of intermittent nausea for a year and just to make it 2021 relevant. He did not come in last year because of the lockdowns so he must live in Melbourne because we got lockdowns _____ okay so should you opportunistically test James, and it is a yes no answer bit of a drum roll around should be able to really do this quickly. Okay and the results of the poll are yes, okay, three people do not want to test James alright so why do we want to opportunistically test James well, he is Chinese Australian so he is at risk, he fits into one of the many countries, China now has an intermediate prevalence because it is about 7% of people living in China have hepatitis B but for James' age group actually it would be higher, it would be closer to 10% would have hepatitis B, but he has also got the added risk factor which is his brother died from a liver tumour so he has got both family history and he is from a high prevalence country, so both of those things should trigger a desire to test him. Okay this is the next point which is to do the right tests. Okay, so we have made the decision to test but now we got to make sure that that person is tested correctly, the correct tests for hepatitis B are to do all three surface antigens which tells us yes no, does this person have hepatitis B. Core antibody is a way to look at whether the person has been exposed to hepatitis B and surface antibody is whether or not someone is immune to hepatitis B and you miss the story if you do not test all three. So, the recommendation in our national testing policy is not just order hepatitis B serology because the pathology service might not test for all three markers but is actually to request all three and if you got a pathology favourites you can set up in your pathology favourites, so you do not have to sort of you know remember and write it out every time. Are there any questions coming in about that Natalia.
Not about that question specifically, we do have some questions by interpreting serology and what to do. I think you are moving on to.
We are moving on to that. So maybe we will cover off on that and then we will come back and have a look at those questions.
Actually we do have two questions, Melissa has asked can you clarify what they each represent so surface antigen core antibody and surface antibody and Cho has asked, can we skip doing the core antibody, so two questions around testing all three serology.
So surface antigen is the presence of the virus really, is there surface antigen so if they have got surface antigen they have got hepatitis B. Core antibody is exposure and it is actually important to know whether someone has been exposed because it partly gives you an idea of their risk and then the surface antibody is important in terms of understanding their immunity. For example core antibody is useful if you are seeing a family and you do someone is core antibody and surface antibody positive you want to make sure everyone in that family had been tested because you think well this is somewhere where family you know hepatitis B is within this family, so I would always order all three and all three are recommended except in the Northern Territory, which is a complication which with territorians can have a chat about, I am very happy to chat about that later if we have got anyone from the Northern Territory. Okay, so testing for at-risk people is covered by Medicare and if you write all three tests there are rebateable, if you just write ?chronic hepatitis B and you do not have to worry some people in the past worried because it is screening. I call it testing. It is really testing [software background noise] hepatitis B positive and especially you know if you have got a pre-test probability of that person coming from a very high prevalence country, I mean I think there is no argument that you should test. Okay so this is James’ serology and we are going to talk further about interpreting serology so his surface antigen is positive, his core antibody is positive and his surface antibody is negative. So what does this mean, so this is the polling question number five.
We have a got a number of questions around interpreting serology so we will let people answer this question first and I think if everyone wants to bring out they should hopefully have that link to the decision-making tool because I think that on that decision-making tool there is some information around interpreting serology as well but Nicole will go into that in more detail.
Alright so, again 88/405, I am not sure how many people we have got on this webinar, but there is always interesting you know floating patterns of up-and-down, so yes James has chronic hepatitis B infection so I always look at it and I have taught this a lot in the past too to various groups, always look at the surface antigen first, that is, your yes now, okay, so if someone has surface antigen they have hepatitis B and that is the first point I always look at and I always think of it as do they have the virus, have they been exposed to the virus in the past and do they have immunity with surface antigen, core antibody and surface antibody. Okay so interpreting serology and if you do look at the decision-making guide they have got boxes where they have got every single serological patter, but if you are surface antigen positive core antibody positive you have hepatitis B you cannot have surface antibody being positive.
Nicole, I do no know whether there are anybody else _____ and your screen has frozen, _____ anyone having this problem.
It is same for me all the time.
Nicole may be you could turn your video off. Well apologies everyone, looks like we have just lost Nicole, we have got lots of great questions coming through and apologies to those people who might feel that I am ignoring their question, I am not, I know that we will address all of them before the end of the presentation, it just might be a more appropriate place to address those and Nicole is back with us and you are mute.
Okay I am back, sorry about that everyone. I have just asked my whole family to get off the internet and hopefully that will improve the situation, yes, you can imagine how popular that is. Okay, so I was just saying acute hepatitis B infection that is really you only have to add core IgM which indicates acute infection. If you got a really recent illness story, someone said Ah yeah I was jaundiced and tired and etc. Then you might add IgM but for the vast majority people you are just going to do those three tests and really we are talking about chronic hepatitis B tonight it is very rare that you acute hepatitis B in Australia.
This is a question around how long to wait for seroconversion, for example with STI screening when you should repeat the test.
I mean in STI screening with acute infection in an adult we do not call it chronic infection until it being surface antigen positive for six months. In James' case, he is most likely to have acquired it at birth and you do not need to wait six months to call this chronic hepatitis B, you make the call that he is most likely to have been exposed at birth in China and if we remember that 95% of children born to have hepatitis B and only 10% of adults while it is possible that he has been exposed if you have no history of acute illness, you call that chronic hep B. Does that answer that question do you think Natalia.
I think so and if they need any clarification, I can ask again, somebody else asked whether we needed to wait six months.
Yeah so absolutely not and people from high prevalence countries, the only thing would be if you had a previous negative surface antigen and then you got a positive and you knew that actually recently been infected, may be through sexual contact with their partner, then yes you would want to wait for six months but other than that no, you are basically saying that someone with chronic hepatitis B has chronic hepatitis B from that moment and diagnosed.
We will just come to that question around I guess if someone has a potential exposure to hepatitis B, and it may be through sexual contact or some other reason, how long after exposure do you need to wait before you may seek seroconversion. Okay, so in that setting it can take up to three months to see seroconversion, but what you are doing for that immediately, is you are vaccinating. Okay, so these two sides, this is really chronic hep B and acute hep B and then this is also included on that guy that we post around so again here, hepatitis B surface antigen is negative so they do not have hepatitis B, they have never been exposed to hepatitis B because the core is negative and they do not have immunity to hepatitis B okay so this is someone who should consider vaccination. When the surface antigen is negative, but they are core positive and surface antibody positive, they are immune but this has resolved infection so this is passed exposure immunity, but there do not have chronic hepatitis B. If they have no surface antigen, no core antibody and they have got positive surface antibody this is immunity due to hepatitis B vaccination, and then the last option, we always mentioned with a bit of kind of trepidation because it always brings up the most comments, but the most common thing you see if you just have one of core antibody positive is the most common reason is it has resolved infection with just a low surface antibody okay and occasionally it could be occult hep B. This is less than 1% of cases with this serological pattern.
We had a question about that, do they need vaccination.
So they usually do not need vaccination, in fact, you know the question here is if they had liver disease of some description or very abnormal liver function tests, then you might want to send them along to your local hospital liver clinic querying whether they should be further investigated for occult hepatitis B. If you do the hepatitis B viral load in the community when someone is surface antigen negative your patient is going to get a bill of about $100, if you are willing to do that that is fine but that is worth nine. You can give them hepatitis B vaccine and occasionally you will see them boost anti-HBs but we do not really want people doing this for everyone, it is not actually important to establish there is usually not occult hep B and the vast majority of people they might have a surface antigen of say nine, if you have got a quantitated surface antigen on qualitative results and then you are pretty confident this is resolved infection, so 10 is the cut-off for positivity for surface antibody but you will often see a quantitative value in various reports and certainly _____ does report them quantitatively and that would just vary according to your pathology provider.
Well that brings us to one of the questions actually which was around if surface antibody was a low level and they have said 10 to 20, do you need to retest or booster vaccinate.
____ so you do not have to revaccinate, so you know, when we look at like obviously most children now get the dose and a primary course of vaccination in the first year of life and if you test all adolescents you will see that a certain number of them have waning surface antibody and the majority of those will actually if for some reason you do need to boost them like they are living in the household with someone with hepatitis B or you are worried about their exposure then you can boost them but most of them will actually mount an excellent response with just a single booster.
That brings us to another question around hepatitis B surface antibody negativity _____ has asked do you need to check surface antigen before you vaccinate them.
So if you have got someone who is not mounting surface antibody you want to be pretty sure that they do not have surface antigen because someone with chronic hepatitis B will not seroconvert using immunisation so that is why we always suggest doing the three tests because then you get a complete picture of infection, exposure and immunity.
Edmund has asked if someone had surface antigen positive and if it became negative; however, the surface antibody remain negative, have they cleared hepatitis B.
So usually yes they have but you actually look for persistence of S antigen loss over a year and you should see over that time like you might do this surface antibody in a little while, like 3 to 6 months to see the surface antibody come up and most cases you will see that happen occasionally you do not.
Richard has asked a good question around Medicare, will Medicare allow us to call a patient chronic hepatitis and start ordering relevant tests unless we have two surface antibody positive result over a six-month period.
Two surface antigen, yeah they will, basically all you have to do to order the viral load is have a positive surface antigen. So you do not have to fit that definition in the nation testing guidelines, it is very clear that people who you know suspected of having chronic hepatitis B, we should call a chronic hepatitis B at that point, so the six months is really only for someone who we have a negative test for and then they become positive and then we would wait another six months or you know someone has just come back from overseas and they had an acute illness and then you find out they are hepatitis B positive and you might do see their idea still up and then you will wait again six months for them to call back chronic hepatitis B, knowing that most people will actually clear the infection. Okay so James is hepatitis B positive. Have we got anymore.
We do have more, would like to move on and come back to serology questions later.
Yes, let us move on because I just want to get through the next section then we can always store those serology questions. Okay so there is a range of illness with hepatitis B and the vast majority of people, especially children who have hepatitis B infection, it is an asymptomatic infection and no one ever notices, so an infant when they get hepatitis B not much of an illness response and/or it is a very acute self-limited hepatitis which is basically subclinical. Rarely in adults we do see severe or formal hepatitis B and that is especially with superinfection. So for example, if someone already has seen _____ on top, then sometimes that can trigger a fulminant hepatitis so chronic hepatitis B most likely is asymptomatic and I think it is really worth talking about how cirrhosis in its early stages can be asymptomatic as well. It is a big organ in the liver and you can lose quite a lot of it before you start to show symptoms. In about 20% of people with hepatitis B if they are not monitored and the appropriate group treated, about 20% to 25% of people will die because of liver related complications, which is either end-stage cirrhosis or liver cancer. Okay so this is the initial assessment of someone who is surface antigen positive like James in our case. We wanted to do a history, do a physical examination. We want to assess E antigen status. So this is where hepatitis B serology starts to get a little bit more complicated as well as doing the initial tests we want to add E antigen status which is hepatitis B, E antigen and E antibody. We want everyone to have a viral load and assessment of liver function, full blood count, clotting and an alpha-fetoprotein and people should have a liver ultrasound and if you have access, you can consider a FibroScan. We can talk about that a little bit more in this case so I would not cover up too much on FibroScan and additional assessment includes looking for coinfection so it is standard of care to test for hepatitis A is not really coinfection, it is just if people are not immune they should be vaccinated against hepatitis A, hepatitis C, hepatitis D which is the virus that piggybacks on to _____. You cannot have D if you do not have B and HIV and these things both alter, obviously if someone has HIV. They need to be on HIV treatment and then if they have hepatitis C just alters your treatment and triage decisions and they are all associated with worse outcomes, untreated of course, if they are treated that is not worse outcomes and you also need to evaluate comorbidities, so think of other things that affect the liver including alcohol, drug use, diabetes, fatty liver, smoking also has importance cigarettes will is also a cause of liver cancer _____ and obviously most importantly, and maybe this should be at the top, it is actually to adequately deliver the diagnosis and give people good discussion about what having hepatitis B means and to offer screening to their contacts, sexual partners for hepatitis B. I think it is really important to talk about diagnosis and the trauma of diagnosis that people who have had an awful experience from insufficient information at the term of diagnosis and poor support at the time of diagnosis. So being diagnosed with any infectious disease can cause someone to become depressed, it might cause them to lose a relationship, sometimes it brings up questions of fidelity within a long-term relationship arm and sometimes they can be stigmatised by their family but then there is also the added pressure of cell stigmatisation so worrying about transmission to your loved ones and preventing yourself eating with them and sitting together, hugging your grandchildren and these are all stories we have heard from people that experience. Okay on the back of our guide for hepatitis B two pages, the decision-making guide from ASHM is the _____ top and bottom and this is really just to understand the four phases of hepatitis B and you do not have to remember this, what you have to remember is that there is no such thing as a healthy carrier and that hepatitis B is a dynamic disease that moves during different stages and your job as a GP is to assess where that person is and if you are not sure how to do that to refer to the decision-making guide because it is all written down there basically. So early on in life or early in infection, hepatitis B DNA tends to be very high, but the immune system has not actually reacting to the virus and there is no liver inflammation. So the ALT which is a very specific enzyme for liver inflammation is essentially normal. In this early stage, we call immune tolerance, hepatitis B, E antigen is positive. When we move into the next stage immune clearance, the immune system starts to react against the virus and it is that raise in ALT which is indicating cell death and cell turnover within the liver and that is actually the immune response to the virus rather from the virus itself and during that time the viral load actually might decrease so initially it might be very high above 170 million IU/ml and then it might sort of drop to 3 million or in the hundred thousands during this stage. Active liver damage is taking place during this immune clearance stage. E antigen is still positive. We transit to the next stage which is what we used to call a healthy carrier but we now know that that is a poor label because it meant a lot of people were not followed up where the viral load is low there is no activity in the liver and we have had what we call the antigen seroconversion so we have got E antibody and then 10% to 20% of people will go into the immune escape where later in life, you might have been monitoring them for a decade, their viral load starts to rise and their ALT starts to rise and there is something to do with the immune system actually sort of you know letting go off the _____ hepatitis B infection, there is ongoing replication. Why is all this important, all this is important because any immune tolerance you do not need to treat someone. An immune clearance and immune escape you do need to treat and when you are in immune control you do not need to treat unless the person has cirrhosis. Okay so let us look at James and if you look at this tool if there is any way you can have it open at the same time, the other thing is to consider an immune clearance. We say someone is immune clearance when their hepatitis B DNA is over 20,000IU/ml and for immune escape we say someone is in immune escape when there hepatitis B DNA is greater than 2000IU/ml units and ALT is elevated in both of those states. It is really important that I point out here that elevation of ALT is not necessarily what the pathology company says is a normal ALT, so for men it is over 30IU/ml and for women it is over 19IU/ml. Okay, so let us look at James and at the same time, we can look at where he is on this _____ so he is E antigen negative, he is E antibody positive. His viral load is 3500 and his ALT is 35 bearing in mind that a normal ALT is greater than 30. Three months later or three months earlier whichever way you do it his is 45 so the question is what stage is James in. So again you do not have to remember it you have to look at the chart using immune tolerance, immune clearance, immune control or immune escape.
While people are answering that, _____ cirrhosis and whether you can use an _____ score instead of a FibroScan and how good the score is outside hepatitis C.
It has actually been really well validated in hepatitis B the _______ you just need someone's platelet count, the normal AST level and you can do that on something called MedicCalc or various websites that you can access, maybe I will try and show that at the end if I get time, that I am bit worried I am running out of time. Let us see what the polling questions have come in as. Okay, so James is in fact an immune escape. So if we look at his E antigen it is negative, his A antibody is positive, so he is in either immune control or immune escape and his viral load is greater than 2000 and his ALT is elevated so that is an exchange in immune escape, now if you did not get it quite right you do not need to remember, you need to remember where the resource is and that is the thing that I want you to take away, you got this two-page resources, you can actually place patients by just looking at that resource until you have had enough of them that you remember of by heart. Okay so this is where he is, he is a hepatitis B DNA type, whether 2000, his ALT is elevated, his E antigen and A antigen positive so he is someone we consider for treatment. So he is an immune clearance and immune escape
_____ just asked whether you can go backwards in the phase _____
Yes look you can have this is why when someone is A antigen seroconverted we follow them for a while because you cannot see a little bit of backwards and forwards. It is pretty unusual and as you are doing a lot of hepatitis B test you will virtually never see it, but it does not sort of happen from the end of immune control to here but if they are kind of in that zone it can happen. Okay so key points, there is no such thing as a healthy carrier everyone with hepatitis B needs to be monitored to find. So even if they are in immune control when you first meet them, or first diagnose them what you are watching for is that moment when they go into immune escape and I saw a woman yesterday, who my colleague has been you know doing hepatitis B DNAs for a decade and she has finally gone into immune escape. She is in her mid-40s. Her husband is on treatment arm. She has had seven pregnancies. Her viral load has always been low and then bingo one year it comes back and it was 150,000 and her ALT had crept up to 30 so she was a woman in immune escape, so it is about that consistency and that is why the rebate is for monitoring so we are going to move on to talk about monitoring a little bit about treatment so using that decision-making guide I have really given you the answers to this which phases are indicated, phases that means there is more than one are indicated for consideration of treatment, so immune tolerance clearance, immune control and immune escape and the names kind of give it away as well. We might go quickly through this because I feel like we are running out of time and I want to get to the end where we talk about treatment. So again it is both immune clearance, and immune escape is what we are looking at in terms of when we consider treatment. Now what does treatment mean, what can we do, so let us talk about monitoring first, so the recommendation currently is that everyone living with hepatitis B who is not on treatment should have liver function tests every six months and a hepatitis B DNA test every 12 months and this helps us to determine if this is a new disease activity like in a woman who I mentioned we had been monitoring for years, okay, and it is important that you understand the hepatitis B DNA test is only rebatable every 12 months and in the past I used to say do not worry no one every checks but actually they do now somehow, so like for example I would put you know I saw someone today with hepatitis B and I noticed their DNA had been done for nearly a year and then I actually write on the pat slip hepatitis B DNA do not do before such and such a date because the patient will get a bill. Okay who do we treat, we treat people in immune clearance and immune escape and anyone with cirrhosis which is why the question about _____ are relevant. The key messages in a first-line treatment is single oral anti-viral therapy, one pill a day and it is usually considered to be indefinite. There are a few stopping exclusions, but they are unusual. It is really well-tolerated and it reduces the risk of liver cancer by up to 75% so very effective and there is almost no resistance with both of these. There is a tiny bit of resistance of entecavir at five years about 1%. There has never been documentation of a tenofovir resistance. And unlike HIV where we have to have multiple drugs involved it is really just single oral therapy and treatment is usually lifelong.
And John has asked if there are any long-term side effects for entecavir.
No it really has the safety profile of Panadol basically, in fact, some people argue it has a better safety profile than Panadol but sometimes people take too much paracetamol. Okay, what are we really aiming, so we are aiming for normalisation of that ALT which sort of makes us think that we are limiting the liver damage, sustain suppression of viral replication, which reduces the risk of progression to cirrhosis and liver cancer. You do occasionally see S antigen seroconversion while on treatment and occasionally in about 20% of people you might see E antigen seroconversion. The last of these is actually one of the things where you do consider treatment cessation. However, it is best to understand that for most people it is it is lifelong. Okay so what about hepatitis B treatments, they are currently it is an S100 medication and GPs cannot prescribe hepatitis B treatment unless they have done the S100 prescribed course. There are nearly 400 accredited prescribers in Australia and if you are interested in becoming a prescriber, please contact ___86:06__ they are running a course so we will get to that. So we have established that James is an immune escape, so should he be considered for treatment, we are going to close the vote quickly to gather all the content, oh you see look 89 people were pretty quick on the buzzer which is great say yes, he should definitely be considered for treatment so he is in the immune escape phase, so he gets to treatment straight away. He is at risk of progression to cirrhosis and cancer and he has also got a family history so definitely this is a guy who you want to treat. Okay so should James be screened regularly for HCC and there are two questions, no because he is starting on treatment and yes because he has got a family history and he is over 40 years old and an Asian now, and again you got to be quick on your buzzer, so yes he should definitely be screened for HCC and the screening is six monthly surveillance with an ultrasound and alpha-fetoprotein. Six monthly ultrasound is sometimes hard, especially in young people and someone like James, would be pretty motivated because his brother died of a liver tumour and probably pretty anxious to get his screening in regularly and it is important that it is six monthly, there was no benefit for more screening so they did a RCT six vs three months. There was no increased benefit but if you have longer screening intervals, then it is more likely that that person will present with a tumour if it is not treatable and certainly not curable. Okay, this is an interesting question gets back to the person who asked about _____ FibroScan before he is eligible for treatmen and again we are going to close that off really quickly because of time, so no you do not have to. Probably the aim would be to get a FibroScan done in James, but you do not actually have to do it before you start treatment. He qualifies for treatments and because he is in immune escape, so it would be balanced, if you are locally able to get a FibroScan fairly quickly you probably do it any how while you are having the treatment discussion. If James was living in Longreach and you are unlikely to have a FibroScan available you would start him on treatment and arrange it at some point in the future for him to have a FibroScan. APRI scores for the person who asked that question, they are validated and hepatitis B APRI score of less than 1 makes cirrhosis of fibrosis very unlikely and APRI score over 2 makes fibrosis or cirrhosis very likely and an APRI score between 1 and 2 is the kind of person you think of, let us get a further evaluation may be get a FibroScan so if you are living remotely or somewhere where there are not FibroScans you can APRI and certainly WHO has had a standard practice across the world where are no availability of FibroScan. So, key points all patients with hepatitis B need to be monitored every 6 to 12 months so 6 months is the liver function test 12 months is hepatitis B DNA. Not all patients require antiviral therapy, but it is targeted at people in immune clearance and immune escape or people with cirrhosis. First-line treatments are entecavir, tenofovir and accredited GPs can prescribe, and GPs are essential in ensuring that people with hepatitis B undergo liver cancer surveillance. So take home messages on our role in general practice, opportunistically test people at risk, vaccination is obviously a core business. There is no such thing as a healthy carrier but there is treatment and treatment can prevent liver cancer and can be provided by accredited GPs and we have got a growing hepatitis B S100 community, and we certainly Victoria we meet regularly for case studies and it is something you know I have got a number of hepatitis B positive patients in my practice and it is something that it is something that I enjoy as part of my special interests. The case recap is hopefully you have learned how to identify priority populations and interpret serology and I hope this has picked your interest and maybe in the future being a prescriber. We got some other arm webinars in this series. There are two hep Cs and sexual and reductive health webinar, and there are also hepatitis B prescriber courses coming up one in Queensland and there is one in Victoria as well. The one in Victoria I think again it is going be delivered online so sometimes we sneak people in from interstate, but do not tell vital I said that. Anyway, so hopefully that is interesting for everyone there are various resources for clinicians, the testing portal was where you can go if you want a longer description of testing, however, really, the quick is great, be positive all you wanted to know a guide for primary care which was updated in 2018, will probably be superseded by these consensus guidelines that will be out later this year, but it actually does not say anything different, particularly hepatitis B helps an independent website which is quite useful and the decision-making guide we have already talked about and there is some other online modules and resources that you can consider. I think also this talk we have not had a lived experience speaker, but it is really important that people understand the lived experience of hepatitis B can be quite traumatic and we do as much as we can _____ to reduce stigma and discrimination towards people with hepatitis B. I would like to make a shout out for consumer organisation, so a lot of you will have this this Hepatitis Australia but you also have hepatitis _____ within your state. There are places where people can be connected _____ and my favourite hepatitis B resource is the hep B story, which is a low literacy resource. It is also translated into various languages, but it is really great going through someone with a new diagnosis or someone who has been diagnosed. Okay questions.
Well Nicole, thank you so much that was an excellent presentation and we had a wonderfully engaged audience who have asked many, many questions and unfortunately there is still in number that we have not managed to answer within our timeframe _____ to organise to get a list of the unanswered questions sent through to you, Nicole if you are happy to. There are some great questions there and I think it would be a shame if we were not able to provide answers for our participants, so that would be wonderful. Some of them double up so we might be able to sort of summarise and send them out to all participants _____ this evening. So thank you to you, thank you to all the people who have asked questions that has made us all think, that is unfortunately all we have time for this evening so we would hope to see you any of you who are interested at the next upcoming ASHM Webinar, it is on the 22 June 2021 to innovate hepatitis C models of care and as Nicole said there are two hepatitis B prescribing courses coming up and this is a really great decision I think to our GP toolkit being able to prescriber for our patients and manage hepatitis B patients in general practice. If you are not already a prescriber consider becoming one. That is fantastic so I think we still got a 18 questions remaining and we will get answers to you regarding those. So thanks again everyone and have a good night.
Thank you, thanks all for attending.