Alcoholics Liver

hello, i'm norman swan. welcome to this programon viral hepatitis. in australia, the number of people diagnosed each year with hepatitisis increasing. there are probably about 300,000 peopleliving with chronic hepatitis b or c, and in australians, it's 1 in 12 people. viral hepatitis isa major public-health issue. many thousands of australiansremain undiagnosed, yet early detection remainsthe best option

for treatment and secondary prevention. tonight, we'll look at recentdevelopments in hepatitis prevention, diagnosis and treatment,with a particular focus on people living in remote and rural areas. you'll find a number of useful resources at the rural education foundation'swebsite: let me introduce our panel. professor bob batey is currentlythe clinical director of the viral hepatitis program

with the australasian societyfor hiv medicine, ashm. he's also chair of the academic board ofthe sydney institute of health sciences and chair of the alcohol and drugresearch committee for nsw health. bob has worked in sydney and innewcastle in major teaching hospitals, as well as in regional nsw and indigenous communitiesin the northern territory. dr ben cowie is an infectious-diseasephysician and epidemiologist with the victorianinfectious diseases service at the royal melbourne hospital.

- welcome, ben.- thank you. ben is a senior lecturerin the department of medicine at the university of melbourne as well. he has a particular clinicaland research interest in viral hepatitis, focusing onthe epidemiological research to guide the developmentof public-health responses, particularly to hepatitis b. tracey jones is a hepatology nursepractitioner. - welcome, tracey.- thanks, norman.

are you one of a kind? - one of five.norman: one of five? it's a very special, elite group. tracy has worked in the fieldof hepatology for 16 years with a focus on hepatitis c. in fact, she was the first authorisedhepatology nurse practitioner in nsw. she's a founding memberand past president of the australasianhepatology association and member of numerous committees.

when do you do your day work? what are you allowed to doas a nurse practitioner that you weren'tas a common-or-garden nurse? i'm allowed to prescribefrom a set formulary. i can also manage patientsas a sole practitioner in a collaborative arrangement with gpsand/or specialists. i'm able to make dose reductions interms of the s100 therapies they're on without consulting with medicalspecialists if i feel it's appropriate because i have to be able to justifywhat i do.

you dole out pegylated interferonlike smarties? no, i'm not allowedto write the scripts for it because the s100 guidelines do not allownurse practitioners to write scripts, which is an issue we'll discuss later, but i can do the dose adjustmentsas appropriate. enaam oudih holds a degree in nursing and a post-graduate diplomain community health. - welcome, enaam.- thank you. for the last 27 years, enaam has workedin a range of government

and non-government settings,both in australia and israel. currently, she manages peacemulticultural services for relationships australiain south australia. peace provides services for people from culturally and linguisticallydiverse backgrounds who have viral hepatitisand/or hiv/aids. - welcome to you all.- thank you. it's an alphabet soup, bob,of hepatitis. in my notes, there's no g.when i was training, there was a g.

there was an f as wellfor a short period. well, let's not get rudeabout these things. g was there in patients who hadabnormal liver-function tests, but it was ultimately decided thatthis virus was not causing hepatitis. it actually has some benefits to peoplewith liver disease. people who have transplants who get hep g,or whatever it's now called, do better. we're left with a to eto discuss this evening. ben, what's the trend here?

the trend in hepatitis a diagnosis... we'll come back to hepatitis a in amoment, but the a to e, what's going on? i said in the intro they're increasing. what's increasing?incidence, prevalence? particularly the prevalenceof hepatitis b and hepatitis c, which are the viral hepatitides whichdevelop chronic infection. we know that the numbers of peopleliving with chronic hep b and hep c are increasing every year. it's probably approaching 400,000 peoplein australia now with b and c.

that's increasing by several thousandper year for each of those. for hepatitis a, for instance,the number of new diagnoses or incidence of infectionshas been falling. it will be interesting to see whatthe respondents have felt in terms of number of cases per year. we've got an early question here frommarissa pillar in northern queensland. 'do hepatitis a and b immunisationsdecrease in effectiveness over time? do we have to give boosters?' excellent question.

norman: marissa always asksexcellent questions. for people who have normal immunefunctions, they're not immunosuppressed, if you vaccinate someone againsthepatitis a and they develop a response, if you've given them two dosesspaced by at least six months, that creates prolonged immunity and there's no need for boostingdown the track if they mount an immune response.it's a very effective vaccine in the proportion of peoplewho develop an immune response. so, you've got a 17-year-olddoing their gap year

and they get hep a immunisation... if they have two shotsspaced by at least six months, you can anticipate thata very large proportion - 95%-plus of those 17-year-olds -will develop immunity, and that will be for the long term. they do not require further boostingdown the track. for hepatitis b, again, for someone whohas a complete course of vaccination, who doesn't have any otherchronic medical problems and has a normal immune function,

if they mounted immune responseto hepatitis b vaccine, there is no indication for boostingdown the track. - they're immune for life.norman: they are. ok. coming back to the growth in this,this is a combination of prevalences. why would hepatitis b be going upif we've got immunisation? again, that's a really good question. the infant-vaccination programhere in australia, which has been been universal since 2000 and has had coverage rates ofapproximately 93% - 95% of newborns

in australia, is really important. it's not only cost-effective,it's cost-saving. it's a preventive-health best buy. however, it won't have any impactwhatsoever on the proportion of peopleliving with chronic hep b in australia. probably more than 90% of new, chronicinfections entering the population enter through migration, and notthrough domestic-incident infections that progress to chronicity. is that an issue for the migrantpopulations that you deal with?

yes. we deal a lot with hepatitis b, by far a lot more than hepatitis a and more than hepatitis c. the issue for migrant communitiesis quite big, quite challengingfor the health-care system. let's acknowledge thatour health-care system is quite complex. it is built for a culture that relies onself-responsibility and self-management, as opposed to peoplefrom other cultures, who rely heavily oncollective responsibility -

collective responsibilities madeof doctors, nurses, family members, sometimes even community leaders. that poses a lot of challengesfor people from other cultures. also add to it the linguistic issues and the way people describetheir feelings, their experiences. people have different experiences and different waysof interpreting their diagnoses or relating to,or understanding diagnoses. they've presumably got a generic termlike jaundice...

totally. ..rather than 'i've got hepatitis b,thank you very much.' yeah.there is a fundamental difference... are they frightened of the impactit might have on citizenship? no, but there is a belief,especially for new arrivals, they believe thatscreening for hepatitis can be perceived as a test - if i get positive results,i might be deported. so you think they shrink from testing?

i think they're quite reluctantto do testing unless we engage with themmore effectively. we need to engage with themin a way that they understand, that relates to their context,their way of understanding the world, depending on where they come from,the reasons they arrive, their pre-migration history. people who live in refugee camps wouldhave a completely different experience than someone who comes as a businessor international student. there is no one way of engaging withpeople of other cultures.

which are notifiable? all these conditions are notifiable. there's different legislationsor regulations in states and territories regarding which are notifiable justby the lab or by the treating clinician. many of them, regulations specify thatthey need to be notified by both. how do you do it? there are contact numbersand website-based notifications and fax numbers in all the statesand territories for those where cliniciansare required to do it.

testing laboratories,they're required to do it, and usually they do it electronicallyto the health department. what do you think are the main clinicalchallenges with the viral hepatitides? the clinical challenges is one,educating the workforce across the country, and two is engaging that workforcewith the patient population. what are the biggest myths that consumers and patientscome to you with, or even other clinicians?

some people don't know thatthere's any treatment available for different viral-hepatitis diseases,and also the acronyms we use. the medical workforce,we're very good at shortening things because it makes it easy for usto manage it. acronyms like hiv, hbv, hcv,they all sound the same, particularly for peoplefrom the migrant communities that don't have a good graspon the language or a good understandingof what we're telling them. what about challengesin remote and rural australia, bob?

it's workforce numbers -having enough people in the situation to be able to do the assessmentand treatment. it's also, communities out there do havedifferent understandings of disease than those living in cities. our indigenous colleagues do notthink about health the same way we do. we've tried to impose a western modelon those and wonder why it doesn't work. to what extent are we still forcedinto major centres to start treatment? that's been an issue. you had to go to a place whereyou could get a liver biopsy

for hepatitis b and cfor a number of years. c was removed in 2006. the drugs themselves had to be dispensedfrom a major hospital setting, so a lot of people in some partsof the country just didn't bother, because they had to travelto get to a treatment centre. there's more share care now,isn't there? yeah, that's absolutely true. community-based care,including shared care, has been the norm for hivfor a long time.

most people living with hivare treated in the community now. for hepatitis c, shared-care programshave been around for a substantial period of time. many hepatitis services in hospitalshave been engaging more with shared care and also againgp-led care. for hepatitis b,the first pilot programs for gps to be able to be trainedto prescribe hepatitis b drugs is hopefully starting next yearin six jurisdictions in the country. - we move quickly, don't we?- well, yeah...

that's a question of perspective,i guess. can i make a comment about the termshared care? is it dumped care? no, no. i just think we use this titlelike it's a brand-new thing and it's just been inventedand it's what we're doing. the reality is that gps and nursesacross the country are looking after these patients. they're referring their patients to us

and inviting us to be part of theoverall care and management of people. you're the ones doing the sharing? i just thinkwe all need to work together. it's part of a triangle,or part of the continuum of care. gps, us and the patient.we all have to work together. you asked, norman,about the clinical challenges, and we were talking about shared care. there is a fundamental issue here when we're dealing with peoplefrom other cultures.

we have to look at adherenceto treatment and adherence to monitoring or adherence to a care plan. it's not enough to just have a care plan negotiated between a nurseand a doctor. we have to look at, how is that relevantto people from other cultures? what would prevent themfrom adhering to that particular plan? i don't think we are doing quite wellin this area. i can't comment on what's going onin country areas, but certainly that's not happening...

their community unit, where it's familyor extended family or extended group... especially if people are new arrivals and not familiarnot just with the health-care system but not familiar withusing public transport. sometimes they have a number of kidsthey have to look after, and that prevents them... i'm familiar with a casewhere an appointment was made to go to the hospitalearly in the morning

when the mother was really busygetting the kids ready to go to school. as simple as those things. what's the extent of underdiagnosisof all the hepatitis... hepatitides? (all laugh) you went the second time. look, that's a really important issue. it's perhaps most importantfor those viral hepatitides b and c that have chronic manifestations and that appropriate diagnosis earlycan lead to intervention

to either, in the case of hepatitis c,cure the infection... you're going as far these daysas saying cure? sustained biological response,so yes, a cure. which answers one question we've got -how effective are current treatments? hepatitis c, i probably should leaveuntil we talk about that. to get to the point of your question,which was underdiagnosis, it's estimated that approximately 20%of people living with hepatitis c have not been diagnosed. it's somewhat more for hepatitis b.

probably more than a third have no ideathey're infected. that means those people have no choicesabout engaging with treatment and care. hepatitis b isa vaccine-preventable disease. their households and sexual contactsaren't being protected from infection. if we talk about how hepatitis b mainlyaffects people from other cultures, we don't havestructured screening programs for people who come to the country, unless they comeunder the humanitarian program. then they're more likely to be tested.

other than that, we don't think of itunless there is a symptom. let's go to our first case study.this is riley. she's a 28-year-old childcare workerwho comes to see her gp complaining of nausea and vomiting,fever, aches and pains. when you look at her,she does look jaundiced. bob? this young lady clearly has some illnessupsetting her liver, giving rise to the jaundice. the symptoms are systemic,so one would think of a viral infection

or perhaps some liver reactionto medication she may have taken. i know she's a childcare worker,which puts her at risk of some virus exposure. has she travelled recently? i'd want to push the question,has she taken any medications or alternative medicines. which medications are there? some alternative medicationscan give rise to liver injury, probably fewer of themthan we'd like to think.

antibiotics can cause cholestasis, some of the hypertensivescan upset the liver. there's a range of drugs. norman: all reversible? most are reversibleif you stop the drug quickly, but many people have died from drug-related liver diseaseover the years. amoxiclav can be quite toxicto the liver, can't it? indeed. fluclox isone of the classical drugs doing that.

this lady's systemic symptoms drive youmore down the path of a viral infection,which you'd like to sort out. would it be hepatitis aif she's living in the middle of a city? you'd probably not think of thatas the first cause. - why not?- it's still a fairly uncommon disease. only 250 cases diagnosed a yearin australia. we do need to think about that and thinkthat other causes may be more common. is she in an at-risk group? she is at riskbecause she's exposed to children.

she may well have travelled,she may have eaten somewhere unusual and picked up the virus that way. what are the at-risk groups, ben? bob has touched on them. a lot of hepatitis a diagnoses made,reported to health departments are related to overseas travel. the other at-risk populationsinclude childcare workers. another occupation is sewerage workersor plumbers. other groups who are at riskbased on likelihood of exposure

include men who have sex with men. there have been outbreaks among menwho have sex with men in the past. another important group is aboriginaland torres strait islander people, particularly in some jurisdictionsin remote areas - wa, queensland, northern territoryand south australia have been identified as at-risk, and therefore are prioritisedfor vaccination. what investigationsare you doing on them? i agree with bob -it's important to take a full history.

she does need to be tested foracute viral hepatitis and hepatitis a. as we've mentioned,she's a childcare worker. often amongst young children,hepatitis a is asymptomatic or very non-specifically symptomatic. so you can have ongoing transmissionamong young children, particularly if childcare workers areinvolved in changing nappies et cetera, they're exposed throughthe faecal-oral route in that way. i'd discuss risk factors for herfor hepatitis b and hepatitis c and test accordingly.

you have co-infection - once you'vegot one, you think about another? yes. it depends, again,on the epidemiology. other viruses, like cmv and ebv can be transmitted from childrento workers. that would also be partof the testing panel. it's going to take a whileto get your viral tests back. presumably,it's the transaminases you'll look at? in part. if she's got jaundiceand has the other systemic features,

if this is a viral hepatitis, we can anticipate transaminaseswell above 1,000 or 2,000. is there any correlation between severityand the level of transaminases? not essentially. you can have a very high transaminase and still have complete resolutionof the infection. some of the factors that areassociated would include if the level of bilirubins,so the jaundices,

continues to increase over timeand is not coming back down again. if i did, as i would,do a coagulation profile, if there was an abnormally elevated inr,for instance, that would herald thatthe synthetic function of the liver is becoming impaired,that is a sign of fulminant disease. hepatitis a,you either die or get better. most people get better. how many people die? very, very infrequently.

it's less than 1%and probably of the order of .2%, .3%. one of the important issues here is thatpeople who have other illnesses, particularly liver disease, who havechronic hepatitis b or c for instance or other causesof baseline liver disease are at higher riskof more serious outcomes of infection. that's why we prioritise vaccinationagainst hepatitis a for people living with liver disease. in terms of spreading, would you immunise close contacts?

absolutely. household transmission of hepatitis ais extremely common. one of the reasons it's notifiableby clinicians throughout the country is that there's a window of opportunityto either give immunoglobulin or give active vaccination to householdcontacts and to other close contacts to prevent infection. how do you make that decision betweenimmunoglobulin and immunisation? traditionally been immunoglobulin. that's a precious resource -a blood product.

there's been recent clinical trialswhich have showed that hepatitis a vaccine isequally effective. so it's increasingly used,hepatitis a vaccine, in the setting of preventionof transmission. norman: you give a boostersix months later? you give a booster six months laterto then get lifelong immunity. just to nail that,we're talking about faecal-oral route? for hepatitis a, absolutely. is there any blood transmission notedin the literature,

or sexual transmission? well, sexual transmission, again,certainly that is the case. there have been clustersof hepatitis-a infections amongst people injecting drugs, but how much of that isthrough the faecal-oral spread, because we've mentionedthis is a very infectious virus and if you've got high ratesof household transmission, any substantial contactcan be associated with transmission. how long are you infectious for?

some weeks, maybe two to three months. once they have become acutely ill,infectivity starts to fall. you'd certainly be worriedfor at least a couple of weeks after the illness started. what advice about alcohol and so on? as with any liver injury, reduce anyhepatotoxin to zero if you possibly can. no paracetamol and stuff like that? no. avoid those thingsthat may just aggravate the injury and complicate the interpretationof the liver tests.

tell me about hepatitis e. hepatitis e is the second faecal-orallytransmitted hepatitis virus infection. it's a disease which has beenreported well in india, thailand - has caused significant epidemics there. the number of cases in australia peryear is only about 50, so it is here. a number of clinicians were not aware,even two or three years ago, that it is around, but it's nota major issue in this country. norman: we can test for it?- certainly. you'd think about it for anybodywith an acute hepatitis

who was negative to the oneswe would normally do. this is the one that's worsein pregnant women? yeah. e virus seems to be more dangerousin the pregnant-women population, with a significant mortality. so you'd routinely test in somebodywith jaundice? if they hadn't been overseasand were living in sydney, there'd a very low risk that it was e, but i'd look for itif i couldn't find another virus. talk to me about hepatitis b, ben.

ok. hepatitis b is a common problemin australia, and it's an extremely important oneworldwide. the who estimates that it's the tenthmost common cause of human death. tenth most common cause of human death? of preventable human death,that's right. chronic or acute hepatitis b? chronic hepatitis b. in medical school, they said,acute hepatitis b, you die of that one. attributable mortality of acutehepatitis b is probably .2%, .3% -

high in peoplewith baseline liver disease. similar to hepatitis a, in fact? yeah, it is. but if you've got someonewith chronic hepatitis b, and i'd like to stress, withoutappropriate treatment and care, up to one quarter of those peoplewill die from cirrhosis or liver cancer. we guess later on how many people areliving with hepatitis b in australia, so i won't drop that one yet, but worldwide, 350 million peopleare living with chronic hepatitis b. it's the second most importanthuman carcinogen after tobacco.

we've got these statisticsabout hepatitis c - of 100 people who get it,how many people who are untreated end up with cirrhosis? what are the figures for hepatitis b? the fundamental determinant of the riskof progression to chronic hepatitis b, so after exposure, what proportion go onto chronic infection, is age. if infection,as occurs in the majority of the world, happens at birth or early in childhood, for a neonate, the riskof chronic disease is about 90%,

whereas for an adult who acquiresinfection, it's of the order of 5%. that's why high-prevalence countries have traditionally stayedhigh-prevalence countries, because of high progression. there's the image showing the prevalenceof hepatitis b worldwide. the areas in dark green are wheremore than 8% of the population have chronic hepatitis b. in the light green is whereit's between 2% and 8%. the tiny minority,places like australia,

less than 10% of the global population,where it's less than 2%. norman: by now,people have answered that question, so we can talk aboutmodes of transmission. the only one that doesn't apply in the australian context, or in anycontext, is uncontaminated water. it's not spreadthrough the enteric route. other factors - blood-to-blood contact,injecting-drug use and sexual contact - if i had to pick one from thoseas an epidemiologist, i'd say, what is the major determinantof transmission within australia?

that's through injecting-drug use. that would be the number-one prevention,apart from vaccination of infection that occurs here. norman: not sexually? that's number two. on a global perspective, the vast majority of hepatitis bthat progresses in chronicity is acquired at birthor early in childhood years. norman: vertical transmission?

that's why vaccination of all infants, including the first dosewithin the first 24 hours, has been who policy globally since 2009. and that's through breastmilk? no, breastfeeding does notincrease the risk of transmission, nor does mode of delivery. the one thing that can be doneto reduce the risk is vaccination. can i emphasise that pointabout vertical transmission? what happens, from our experience,is when we have a clinician

who deals with peoplefrom a non-english-speaking background who are not familiar with the context,that people have different experiences and a different way of transmission. when we explain hepatitis bas a sexually transmitted disease, we're actually running the riskof impacting on their relationship and mistrust between the couple. we have dealt with a number of cases where divorce happenedas a result of not engaging meaningfully with peoplefrom a non-english-speaking background.

it's very, very important,i cannot emphasise this enough, to differentiate betweensexually transmitted infection versus mother-to-baby infection. talk to me about infectivity andthe surface antigen and the e-antigen. what's the story here? the fundamental determinantof infectivity is the hepatitis b viral load, so how much viral applicationis occurring. norman: like hiv?- like all these blood-borne viruses.

e-antigen is a protein which is a markerof a high degree of viral replication. that's a correlate of infectivity, but it's fundamentallythe hepatitis b viral load. prisons are breeding groundsfor hepatitis c. are they breeding grounds for hep bas well? they are,hepatitis b is in the community, but because very few adultskeep the virus as a chronic infection, there's not a lot of infectivityin that group. but if you look at a groupof injecting-drug users,

most of them have been exposed tohepatitis b. most of them have cleared it because they were adultswhen they were infected. jessica dawson, a pharmacy studentin south australia, asks, 'how effective is post-exposureimmunisation with hep a and b, and when should it be used?' we've spoken about hep a.what about hep b? giving the vaccine after exposure, i don't think there's solid data whichsuggests it is worthwhile doing.

there's pretty solid data. in a way, when we look at preventionof vertical transmission, that's what we're doing - giving vaccinationafter exposure of the infant, after the infant has passed throughthe birth canal. that was some of the first datathat suggested that post-exposure prophylaxiswas a good idea - the fact that you could prevent the vast majorityof hep b transmitted to babies at birth. who should you be doing hep b testingon?

this relates to the prevalenceof hepatitis b in the community. if somebody has acute hepatitisyou would do it? but there are undiagnosed peoplewith chronic hepatitis. yeah. for people living with hepatitis bchronically, there's two priority populationsidentified in australia - people born overseasin high-prevalence countries, and this slide demonstrates thisby state and territory. these data are a little old. it doesn't add upto the correct number anymore.

the estimate for the number of peopleliving with hepatitis b currently is about 170,000 peoplein australia. it's people born overseas,in high-prevalence countries. the second priority population is aboriginaland torres strait islander people. those two groups probablyrepresent more than three quarters of peopleliving with chronic hepatitis b. there are other priority populationswhom it's important to test, including people who inject drugs,men who have sex with men

and peoplewho may be occupationally exposed. the other important reasonto test those groups is because they are at higher risk. we've got a vaccine. unlike hepatitis c, unlike hiv,this is a vaccine-preventable disease. the vaccine is not therapeuticin any sense. it doesn't have any effectonce you've got it? no. it can prevent infectionafter exposure, but if you've already got hepatitis b,it has no therapeutic value.

can i go back also to the prison? you say it's more commonfor hepatitis c within prison. i want to alert everyonethat people in detention centres, such as asylum seekers, they come fromhigh-prevalence countries. there is evidence that hepatitis b isincreasing within our detention centres. - we're getting transmission?- yeah. they come with the virus. - with a high viral load?- mm. instead of vaccine,if somebody is exposed to hep b,

there's the hyperimmune-globulinapproach. norman: does that work?- that works, yes. norman: that's specific to hep b? yeah. that's usually given in combination - vaccine and immune-globulin to infantsborn to mothers who are infected, but also to people exposed sexually. talk me through the progressionto chronicity. we've mentioned risks of transitionto chronicity based on age.

once someone has chronic hepatitis b, there have been four predominant phasesidentified, particularly for those infectedearly in life, which we have a graphic of. for most peoplewho have chronic hepatitis b and acquired it early in life,for the first 20 or 30 years or so, they're in what's calledthe immune-tolerance phase. there's no active,or very limited active liver damage, but they're very infectious.

their hep-b viral load is highand they're e-antigen-positive. immune clearance occurs typicallyin the 20s or 30s. liver-function tests become abnormal. the e-antigen is positive, but the immune systemis fighting a virus. for hepatitis b,that's what causes all the damage. it's not the virus causing damageto the liver, it's the immune systemseeking to eradicate the virus. the hope is that people willachieve this immune-control phase.

this is what we used to callhealthy carriers. we never use that term anymore. this is characterised by lowor undetectable dna and normal liver-function tests,and they're e-antigen-negative. the reason we don't call these peoplehealthy carriers anymore is that in approximately 25%of those individuals, the virus will mutateto escape from that immune control. that's why we call the fourth phaseimmune escape. this is a group typicallyin their middle age,

their hep-b viral load comes up,liver-function tests may be abnormal. they're at high risk or progressionto advanced liver disease and to liver cancer. that's why we try to engage peoplepreviously called healthy carriers back into care to receive treatment. from stage 4, what proportionwill come down with hepatoma? up to 25% of peopleliving with chronic hepatitis b, active hepatitis b, will diefrom either cirrhosis or liver cancer. - it's an extraordinary percentage.- it's huge.

if you've got someone living withhepatitis b who is cirrhotic, there's a 2% - 3% chance every yearof them developing liver cancer. - one in five after ten years?- exactly right. even higher in some populationsfor various reasons. one of the groups we talked about,people from sub-saharan africa, are at higher risk from liver cancerearlier in life than people born in asia. lucy mckinnon, a general practitionerfrom victoria, asks, 'could you tell usabout the clinical use of e-antigen

and antibody in practice?' i've used the antigen a lot because we grew up with thatbefore we had hbv dna testing. it still is a useful serological test. if it's positive,the virus will be highly active, replicating at a higher ratethan if they are e-antibody-positive. we do it, but in this day and age,dna testing is also very important. we shouldn't see oneas excluding the other. that's different from viral load?

- viral load is hbv dna.- that is part of it. it's medicare-rebatable for anyoneliving with chronic hepatitis b. anyone who is positive, medicare willrebate a hepatitis-b dna once a year. a gp sitting in his or her surgerywanting to test for hepatitis b, what's the test they order? we need to separate this into thosewanting to diagnose someone or to assess their statusfor hepatitis b, then the tests orderedfor someone who has hepatitis b to try and determine what phaseof infection they're in.

for someone wanting to test patientsthat may be at risk of hepatitis b, there's three tests - the surface antigen, the surfaceantibody and the core antibody. one of the take-home messages is, if you order all three specifically onthe order form, you can get the results, which will allow you not only to testif someone has hep b or not, but if they've been vaccinatedor are immune, if they're immunethrough previous infections so they don't require further testingor vaccination,

or if they are susceptibleand need vaccination. doing those three tests allows you tocategorise someone's hepatitis-b status. without having to send themfor another test? without having to order the labor bring the patient back. - dna is for established infection?- correct. it's for people who aresurface-antigen-positive. doing the liver-function test, the e-antigen and e-antibodyand hep b, d and a allows you to determine what phaseof hepatitis b that person is in.

let's take a look atour next case study that focuses on dr jill benson's work, who's medical director of the kakarrarawilurrara health alliance. she explains what is happeningwith hepatitis in remote indigenous communities. aboriginal people havean enormous burden of chronic disease that really starts at a very early age. we know that diabetes, cardiovasculardisease, respiratory disease, renal failure, injuries -they're much higher.

one of the forgotten things ishepatitis b. hepatitis b was originallythe australia antigen because it was discovered in the bloodof australian aboriginal people. most of the people with hepatitis bin remote communities have vertically transmitted hepatitis b. this means thatit's come from their mother. it means that 90% of those peopleare not going to clear that virus. they have it for life. getting good health carefor those people,

especially for those peoplewho live in rural/remote areas, has been almost impossible because in the past, hepatitis b hasinvolved having a liver biopsy before you could have treatment. that's only really donein major centres. most remote aboriginal peopledon't like going to major centres. it also means that those peoplehaven't had treatment because the treatment can only be givenfrom a major centre. there's all sorts of difficultieswith the treatment

for both hepatitis b and c that make the transient natureof aboriginal people a real barrier to having that care. we have become used tothe hepatitis-b vaccination program, which in australia is very, very good, and we forget the high risk thataboriginal people still have. the first thing isto make sure we're screening people. every aboriginal personwho's seeing a gp, that gp should know whattheir hepatitis b status is,

because being an aboriginal personstill makes you at higher risk of getting horizontally transmittedhepatitis b because there's so much hepatitis bin the community. the risks of alcoholneed to be discussed. aboriginal people who have been in jailshave a high burden of hepatitis c. the treatment of hepatitis cinvolves treatment with interferon over six months or a year. that needs to be continuous treatment. it's very difficult to haveif you're moving around a lot.

for hepatitis b, treatment has involvedtaking medication every day. it's really important that 80% of that medication be taken80% of the time. that's difficult, again,if you're transient, if you're moving around from one placeto another and that other place doesn't havethat medication, you've forgotten it. there's very few remoteaboriginal people in south australia that are having hepatitis-b or -ctreatment because of those difficulties. jill benson.

we'll come back to indigenous issuesin a moment with a case study. we've got a question from piergiorgiomoro from hepatitis victoria - 'do we have any idea how many adultsin australia get hepatitis b but then clear it?' if we're looking at peoplewho have been infected as adults, then 95% of people will clear. if the question is, what's the prevalenceof previously cleared hepatitis b, there's more than a million peopleliving in australia

who have antibodies that showthey've been exposed to hepatitis b but have cleared it. - it's not bad news for everybody?- no. it does demonstrate that previousexposure is very common. how well do you think we're dealing withindigenous issues that jill was outlining, bob? modestly well,but not as well as we ought to be. this disease has been known to beaffecting the community for a long time. the vaccination program is going well,

but not all children stay aroundfor the three doses of the vaccine, so that creates a problem. there have been a number of casesof acute hepatitis b in children of age 12, 13, 14in the territory and in other parts of the country, suggesting the vaccineeither didn't get given fully or they didn't seroconvert. as far as delivering services to peoplewith hepatitis b, it's really quite patchy.

those living in remote areas haven't been able to access biopsiesfor treatment easily. that's now changing in terms of the biopsy having beendropped for hepatitis-b treatment. even those that don't need a biopsymay not find it easy to get their medication suppliedregularly. which comes to having gp prescribers,which we're agonisingly moving towards. it's fantastic. six states and territories haveagreed to be part of a pilot.

we've got five nurse practitionerschamping at the bit. we're going to try and poach traceyacross to hepatitis b. bob: it won't work. she's committed. norman: let's go to our next case study.sorry... i just wanted to raise the issuefor migrant communities. we have to acknowledgethat health-literacy level is quite low. we need to really engage with themin a creative way - use metaphors. there are a number of strategies, and i would be more than happyto support people

and share with themwhat we do with people. one fundamental issue, especially womenwho are put on treatment. we all know that treatmentcan affect the quality of life while they're on treatment. in the meantime,they have a role to play. they have to clean the house,they have to cook. it affects their lifestyle. the rest of the family are not awareof what's going on. they just all of a sudden feel thiswoman is no longer a good woman.

it has a lot of cultural impactthat none of us have thought about. the other issue, i'll quicklymention linguistic problems - the use of interpreters. often, we are dealing with peoplewho come from cultures and languages that are not accredited. we use interpreterswho we really don't know whether... who have health-literacy problemsthemselves because they're notmainstream languages. it becomes a challenge for us.

we really need todevelop different ways, such as train bilingual workers, so they're not really interpreters,they're bilingual workers, which we do at peace program. they are specially trainedon how to explain things. hepatitis b is very complex,as we have just learned. try and explain immune escape to me,much less somebody who speaks sudanese. let's go to our next case study, stuart. he's 37 years old, an indigenous man

living in a remote community. he's hepatitis b surface-antigen-positive, as are his brothers. his mother died recently of liver failure. he doesn't drink or have diabetes. he's hep b e-antigen-positive, has rising liver enzymes,

normal alpha-foeto-protein and a viral load of over 170 million. he's anxious at the thought of leaving his community. what will you do for him, ben? clearly, this is a gentlemanwho has chronic hepatitis b. he's probably enteringthe immune-clearance phase, manifested by the fact his liver-function tests are becoming abnormal with no other clear cause identified.

we know that his viral load is high. this is a gentleman we would prioritise for further investigationand management. up until tuesday last week,we would have had to do liver biopsy to access treatment.that's no longer required. as we've pointed out, there's increasing focus oncommunity-based care for hepatitis b. this is an individuali'd want to investigate further with a view to embarking onantiviral therapy.

if he's anxious to leave his community,how will you do that? that's why we're seeking to engagewith primary-care clinicians and nurses involved in the treatment of indigenouspeople in remote communities. the liver-biopsy removalis a fundamental part of that. the next fundamental part is increasingeducation regarding hepatitis b for doctors, nursesand aboriginal-health workers around supporting themin the management of their patients. i would ideally like to see treatmentbeing given to patients like stuart without him needingto leave his community,

through the aboriginal medical service,who has been appropriately funded and resourced to do this, and harnessing some of the otherchronic-disease management work that's been done for other importanthealth issues for indigenous people, such as diabetes and heart disease. what are the treatment options? for hepatitis b,there's two broad classes - antiviral drugs, direct-acting antivirals.

first-line therapies thesedays are either entecavir ortenofovir. the other broad class is the immune-modulatingagents, like pegylated interferon. the vast majority of people go on to an antiviral, be it entecavir ortenofovir. it's important to focus on thefact

that these drugs have been shown to substantially reduce thechance of developing livercancer. if people are treated for hepatitis b within only a few years, the development of livercancer drops by50%. recent systemic reviews showedthat. norman: is this lifelong therapy?

it's indefinite therapyfor the antivirals. for the oral antiviral agents,they're extremely well tolerated. there's almost no side effects. but it does require adherenceto therapy, and it's indefinite for the majorityof individuals. for interferon, it's a defined courseof therapy for only a year. it does involvea higher side-effect profile, although not as marked as it is in the treatment of peopleliving with hepatitis c.

the vast majority of people do end upgoing on antiviral medication, and that is often indefinite. monitored by viral load? yeah. so every three months - medicare funds hep b viral loadthree-monthly for people who are being treatedfor viral hepatitis b - and also monitoring with liver-function tests, et cetera. the take-home points for antivirals is

that we need to use drugs that have a high barrier to resistance. lamivudine, which is what we did use, 70% of individuals had a resistant virus five years into therapy. for entecavir and tenofovir, it's less than 2%at similar durations. there are now effective options for people who have virus

made resistant through previous attempts at treating it. these drugs are well tolerated. we really hope to see an increasing proportion of people being treated. currently, only 2.5% of people livingwith hep b are receiving treatment. what's hepatitis d in all this? because this is related to hep b,isn't it, bob? yes. hepatitis d wasdiscovered in the '70s in italy.

it's a virus which cannot infectan individual on its own. it needs the coat of hepatitis bto get into the liver cell to cause a clinical illness. people who have got hep bcan contract hep d at the same time as they get hep b. that group often have a much more severeclinical illness and may die. the other situation may be someonewho's chronically hep-b infected then meets hepatitis dand gets a superinfection, sometimes with a flare of hepatitisat that stage.

it's an unusual findingin the human situation. in plant species, there are quite a fewof these viral particles that need another one to allow themto infect the individual plant. we certainly have seen people,particularly from africa, with coinfection. as young as under the age of 25have hepatitis b and d, which really significantly lowerstheir quality of life and the possibility of developing livercancer or advanced liver problems. we have seen 27 and less than 25 yearsold have lost their life to liver cancer

as a result of these two infectionsin south australia. it's nasty to have it, but if you vaccinate against a hep band clear hep b out of the community, hep d can't cause a problem. i've got a question from adele shanomin south australia - 'is there concern about starting peoplewith treatment for hep b for patients with concomitant hiv?does this promote resistant hiv?' presumably because you'reusing anti-hiv drugs as well. those drugs are usedin hiv therapy too.

it's an excellent question. all the questions tonight havebeen really good. it's great. there is a problem if someone seeksto start monotherapy for hepatitis b with one of the agents that's activeagainst both hepatitis b and hiv. examples include lamivudineor tenofovir. we even know now that entecavir, which we originally thoughtdidn't have any hiv activity, actually does select forresistance mutations in hiv as well. that's the downside.

does haart - highly activeantiretroviral therapy - treat hep b? it does. that was the upside. if you treat the hiv with agentsthat include a backbone that is active against hep b,so tenofovir and emtricitabine or tenofovir and lamivudine, then you'll treat both the hivand the hepatitis b simultaneously. tracey, hepatitis c. - but this is a different beast.- yes. not just in terms of the virus,but also the groups who get it?

yes. norman: you're most forthcoming.(all laugh) they'll have advanced to the questionby now. tell us about modes of transmissionin at-risk groups. certainly injecting-drug usersor people who have ever injected drugs, people from countriesof high prevalence. there's a risk of vertical transmission. we don't consider this to bea sexually transmittable disease. it has been recorded, hasn't it?

well, yes. certainly in america, if you ask them,it happens all the time. there's been a recent studyin melbourne that shows thatmen who have sex with men have an increased prevalenceof hepatitis c. ben: typically if they'rehiv-positive anyway. yes, thank you. what is it about being hiv-positivethat increases the risk of hep c, is that sexual behaviourmore than anything?

- that's possible. did you want to...- no. that's one possibility. hiv also affects the degreeof viral application of hepatitis c. by suppressing the immune system,it means the viral load of the person who has hep c is elevated. there may be a degree of serosorting,so people who are hiv-positive having sex with other peoplewho are hiv-positive because there's no riskof new infection of hiv, but then transmission of hep coccurring.

do you want to talk about the differencebetween prevalence and incident? for migrant communities,it's specifically important to understand the older generationwho arrive to australia would have chronic hepatitis c as opposed to insidious,newly acquired hepatitis c. - do you want to talk about this?- ben can. very briefly, probably more than 90%of new infections of hepatitis c are through injecting-drug use, but the proportion of peopleliving with hepatitis c

who acquired it through injecting-druguse may be slightly lower, in the order of 80% and maybe 10% also,based on modelling studies - this is mathematical modelling - were through migrationfrom endemic countries. sorry. i'll stop talking. there's also blood transfusions andblood products received prior to 1990. norman: before there was testing?- yes. it's interesting, there are still peoplecoming through the system now that had absolutely no idea.

often that's children - premature babies that receivedblood transfusions after delivery. also, going home to their country -vietnam, china, wherever, and do their dental care therebecause it's much cheaper, but they don't really look atthe quality of care there. any health-promotion programs needto take this into consideration. it's not just injecting drugs, although we know 90%of the new infection is related to sharing injecting drugs.

also, if you're talking aboutsharing injecting drugs, drugs in a different culture,we're not talking about illegal drugs. sometimes diabetes - diabetic people sharinginjecting equipment. it's quite common. tracey, tell me about the guidingprinciples in the hep-c strategy. tracey: the guiding principles, yes, they're in the hep-c strategy, but these are the guiding principles that we should be following.

everyone has the right to participate in the community without stigma or discrimination. everyone should have the same right to appropriate health care, regardless of whether they've got hep c or not. for me, hep c doesn't define individuals,

hep c is part of that individual, that person. of 100 people who get hep c... it's cirrhosis we're worried about hererather than hepatoma? well, there's still 1% to 4%that may develop liver cancer. it's still a real issue. the reality of where we're atat the moment is because people are takingresponsibility for their health and making the lifestyle changeswe've been recommending for 20 years,

they're living longerwith advanced liver disease, which means more peoplewill develop liver cancer, because that's the natural history. the modelling we're quoting nowwas done quite some time ago. we're going to have to revise. what proportion clear the viruswithout any treatment? about 25%. - so 75% retain the virus?- yes. of them, how many willprogress to cirrhosis or hepatoma?

- well...norman: without treatment? hep c is a chronic, lifelong thing. cirrhosis developsover a long period of time. if the person's not having any alcohol or contributing to the advancementof that liver disease, over a 40-year period, about 20%. so, who gets treatment? anybody who wants it,has the will to participate, and is prepared to, i guess,abide by the rules.

norman: there's different treatmentaccording to the type of hep c? tracey: there is, yes. people perceive genotype 1as the worst genotype to have because they equate thatwith worst disease. that's actually not the case at all. genotype 1 is more resistant to therapy, therefore it's more difficultto eradicate, hence the longer period of treatment. genotypes 2 and 3are easier to eradicate

or are more susceptibleto current therapy, hence the shorter duration of therapy. but you have to take thatinto consideration along with all of the otherpsycho-social factors for an individual. people contemplatinggoing onto treatment, it's a massive event that affects notjust them but everybody around them. i've got one patient,it's taken him seven years to be in a placewhere he's ready to access treatment for the very first time.

what we know from our research is, thefirst time people ever access therapy is the best time. you do need to work with peopleto get them to a place where they can start and finishand potentially sustain a cure. unfortunately,we don't have immunisation yet for hep c but maybe one is around the corner.i'm not so sure about that. let's go to our next case study, which features the placewhere enaam works - the peace multicultural servicein adelaide,

raising awareness and knowledgeof hepatitis in culturally and linguistically diversecommunities. they work with individuals, familiesand communities by providing information, supportand referral services. i've been a gp for over 30 years. for the last 11 years i've workedin mostly cross-cultural areas. one of my jobs isat the migrant health service, a state government-funded servicehere in south australia. we are a multidisciplinary team.

our core business is refugeesin the first 12 months after they arrive in south australia. peace stands for personal educationand community empowerment. we're funded to work with people who are affected by viral hepatitisin particular, amongst the many topics that we do. as you can see,we don't just work in the office or in our little comfort zone. we often are on the road,meeting clients in coffee shops

and community libraries, in their homeand wherever it suits them. relationships australia has a programcalled peace, which is really helpful for peoplewith blood-borne viruses. they've got lots of reallyhighly trained community workers, who have health trainingin blood-borne viruses. those people support the clientelewe send them in the system and in understanding their illnessand in supporting them in what is sometimesa very difficult diagnosis for them because it's something thathas a lot of different meaning

in their country of originto what it has here. what we really need to understand is, people from non-english-speakingbackgrounds, they come often from culturesthat are significantly different than mainstream communities. they come, for example,from a collective way of thinking. so, my issues is not just my own issues. it's not only my own private issues,it's the whole family's issues. if you've diagnosed a personwith liver failure

and you know the prognosisis not very good, you do not tell that individualdirectly. this bad news is told to significantpeople in that person's life. if people do have hepatitis b or c, we spend a lot of time talking to themabout what that means here, because as soon as we talk aboutvirus in your blood, people immediately think hiv,and they're absolutely petrified. so we have to move very slowlyin our discussions about what hepatitis b and c mean.

the education and health-promotion partof what we do is enormously important. that's one of the reasonsthat peace exists here at relationships australia, because they can spend that timewith people educating them and making sure that they and theirfamily and their community understand what these viruses mean in australia. we have social workers, counsellors,qualified caseworkers, and we have bilingual workers. the bilingual workers becomethe foundation of our work.

those bilingual workers,they live, breathe, they're everywhere in the community. they are our eyes, our ears. they listen to stories, they knowwhat's going on in the community and they link their communities' issuesback to our service. therefore, we design our services basedon what's happening in the community and what's going on in the lifeof the communities. hi, everyone. my name is simon. i'm from the republic of sudan.

i'm 29 years old. i've got two boys. my role involves case managementand casework as well. i support other support workersto work with clients. that is basically most of my role. i also do health-promotion educationin the community. my wife left mebecause of this sickness. that is what has happened. when we were in africa,

we had someone who got a liver problem. we'd think that, oh, that guy won'tbe alive because there is no medicine. maybe he think, i will not be alive,or whatever. when they send someone onan appointment, they send me a copy. when they send me a copy,i make sure that i remind them of whether he's aware thatthe appointment is coming on a particular date. but we certainly have workedand have had clients being referred to us from country areas.

initially, we used skype. local people in the community helped usto help the client. for those particular clientsi'm referring to, we got a staff member from our officein the country area to help the client access skype and meet one of our counsellorsor caseworkers and work and direct themand encourage them and empower them to go back to their local services. gps can refer clients to usand other service providers.

we strongly believe in partnership. i always say, when you work with peoplewho come new to this country, you have to remember - we have to be curious about, what wastheir life like back in their country? what can i offer them here, and how can we merge the two together? find out the old, tell the new and work togetherto merge the old with the new. the peace service in south australia.

briefly, enaam, people have got to learnhow to do this for themselves. you can't have a centre like thateverywhere to do all the work. no. you have to have the will. when there is a will, there is a way.collaboration is the key. a question come in - is adherence to medications for hep cand hep b as important as hiv? absolutely, and even more soin the current climate, where the new direct-acting agents areabout to land on our doorstep. it's going to becomeabsolutely critical.

when is interferon actually needed, ben? in the context of hepatitis b,when would we use that? particularly in young peoplewho have a high lt, e-antigen-positive, relatively low viral load.women tend to do better. that's the sort of peoplewe try to prioritise for interferon. goran jovanov from south australia asks, 'are people aware thatafter clearance of hep c, of the virus, that they're still at riskof liver cancer?' once you've cleared the virus,liver disease settles down

and the risk of cancerfrom that infection goes back to zero. but these patients are at riskof reinfection, which is a real concern. he might be thinking aboutcirrhotic patients, though. if you're left with cirrhosis, there's a small chanceyour cirrhosis will reverse, in which case your hcc riskgoes back down. but if you continue cirrhotic,your risk of hcc is real. what training and education is availablefor professionals, tracey? for nurses, particularly through ashm,

there's specific hepatitis-c courses, both online and face-to-face. next year, there will bethe first hepatitis-b course run. there has been some discussionabout practice nurses, although i've found thata number of gp-practice nurses come to the advanced courseswith hepatology nurses, because they get that opportunityfor networking and it creates a better collaborativerelationship between nursing sectors. briefly, ben,the new testing guidelines or rules?

the national hep-c testing policyis currently being revised. this is coordinated by ashm and sponsored bythe department of health and ageing through various committees. the new thing is, we'll have our first national hepatitisb testing policy developed next year, again, coordinated by ashm. norman: go to the ashm websiteto find out more? yeah. there's lots of resources there,in both hep b and hep c.

take-home messages? there are so many. you've got about 20 seconds, enaam. we need to be creative, to find a wayof engaging more effectively with people fromnon-english-speaking backgrounds. test. go find it.find people. i'm sure you will. - go a-huntin' and fishin'.- yes. tracey? the guiding principlesthat were in the strategy

are relevant to all chronic diseases,not only hep c. hep c is curable, and lifestyle modifications are criticalfor the whole person for any chronic disease. ben? liver cancer, the vast majority of whichis attributable to chronic hepatitis, is the equal fastest-increasing causeof cancer death in this country. both the national hep b and c strategiesprioritise innovative models of care, including nursesand primary-care clinicians.

we need to invest in that processto make a difference. know the appropriate at-riskpopulations, test accordingly and offer treatment when it's available. thank you all very much. great program. i hope you've enjoyed the program tooon viral hepatitis. thanks to the department of health andageing for making the program possible. also, we've been helped by gilead sciencesfor additional support. above all,thanks to you for taking time to attend.

special thanks torelationships australia and jill benson. if you're interested in obtainingmore information about issues raised in the program,there are a number of resources available on the rural health educationfoundation website: don't forget to complete and send inyour evaluation forms to register for cpd points. i'm norman swan. i'll see you next time. funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs.

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