Hepatitis B

1
Hepatitis B CA quick update(October)

• Frances Cieslak
• Victorian Viral Hepatitis Educator
• frances.cieslak_at_svhm.org.au

2
Impact of Hepatitis

• Hepatitis can be caused by
• Harmful consumption of alcohol
• Some chemicals and drugs
• Viruses 5 known A, B, C, D E
• Inflammation of the liver natural
• response to injury
• Scar tissue Fibrosis
• Extensive scarring Cirrhosis
• HBV HCV require long term monitoring

3

• One in 12 people worldwide are
• living with chronic hepatitis B or C
• World Hepatitis Alliance
• Chronic hepatitis B C are responsible for over
  80 of the worlds liver cancer (HCC)
• ASHM/NSWCC 2008

4
Hepatitis B At A Glance ASHM/CCNSW 2008

• 2 billion people infected world wide (350 million
  chronic)
• 1 million HBV related deaths each year
• A leading cause of hepatocellular carcinoma (HCC)
  
• Screening people at risk is critical
• Treatment is available to control the virus
• Vaccination prevents NEW cases but will not
  impact on current chronic hepatitis B burden

5
Global Prevalence of chronic HBV CDC 2006
6
Chronic Hepatitis B in Australia

• Low prevalence (lt2), but high in some
  populations
• Eg. People from China Vietnam sub-Saharan
  Africa Indigenous Australians
• 50-65 of chronic HBV (in Aus) in people born
  in Asia
• 160,000 Australians have chronic HBV (Gidding
  2007)
• 45,000 people with chronic HBV in Victoria
• 1500-2000 new cases notified in Victoria each
  year (Cowie 2008)

7
Transmission of HBV

• Percutaneous or mucosal exposure to
• infected blood body fluids
• Semen, vaginal secretions, saliva breast milk
• Mother to child
• Globally perinatal transmission is most common
• HBIG vaccine should eliminate theoretical risk
  of acquisition through breast feeding
• Foetal scalp monitoring should NOT be used
• No evidence that mode of delivery (vaginal or
  caesarean) affects risk of infection

8
CHB - Who Should Be Screened? GESA Chronic
Hepatitis B Recommendations 2008

• HIGH risk populations
• Any person born in/parents born in an endemic
  country
• Indigenous populations
• IDUs (previous or current)
• Household/sexual contacts of HBsAg positive
  person
• History of HCV or HIV
• All pts undergoing chemo/immuno-suppressive
  therapy
• Those on renal dialysis
• Antenatal screen for ALL pregnant ? (RANZCOG)
• Pre Post test discussion

9
Natural History of HBV Acquired at Birth
Digestive Health Foundation 2000
HBV DNA ( pg/mL)
CHRONIC HEPATITIS
CIRRHOSIS (30)
HCC
ALT

- - - - - - - - - - - - - - -
Clearance phase
HBeAg
ALT normal range
AGE (years)
40
10
20
30
Immune escape Reactivation- Pre-core mutant
Immune tolerant Replicative phase
Immune clearance Immuno-active phase
Immune control Low replicative phase
10
Diagnosis Treatment

• Mum HBV Serology LFTs
• Infant If mum HBV HBV serology LFTs at 2-6
  mnths
• S100 medications - Currently Liver biopsy
  required
• Pegylated interferon (weekly injection)side
  effects
• Antiviral medication (tablets) Long term
  usually well
• tolerated, viral resistance is possible
• Mum Preferably NOT treated during pregnancy
  but may be if high viral load resistance is
  an issue
• Infant Not usually treated due to disease
  phase, viral resistance , need for further
  research in children

11
Vaccination

• Advised for ALL people at risk of contact with
  blood or body fluids
• Funded for some groups encourage IDUs
• Can ? perinatal transmission risk from 90 to 5
  (when mum has active HBV markers - HBsAg and
  HBeAg) if
• HBIG (12hrs) 1st HB vaccination (24hrs no gt 7
  days)
• Adult 3 injections Now, 1 5 months later
• Infants 4 injections birth, 2, 4 6 (or 12
  months)

12
Hepatitis C at a glance

• 170 million people chronically infected
  globally (3-4 million new infections each year)
  WHO
• 284,000 Australians infected with HCV
• 211,700 people chronically infected
• ( 17,444 people are living with HIV) NCHECR
  2009
• NO VACCINE However treatment is available
  CURE is possible
• A leading cause of liver transplant in Australia
  NCHECR 2008
• Slow acting virus often asymptomatic

13
Prevalence of Hepatitis C infection6 Genotypes
WHO. Wkly Epidemiol Rec 2002 77 41
14
Transmission of HCV - Blood to blood

• Risk Factors
• Sharing injecting equipment
• Recipient of blood products lt 1990
• History of incarceration
• Unsafe tatooing body piercing (traditional
  practices)
• Place of birth mass vaccination programs
• Sharing of blood contaminated household items
• Mother to child - 5 risk
• - Foetal scalp NOT to be used No
• - Mode of delivery no affect on risk
• - Breastfeeding OK except if nipples
• cracked
• -

15
Natural history of hepatitis C Potential outcomes
Approximately 1 of every 4 people (25) who
contract hepatitis C will clear their infection
naturally within the first 6-12 months. The
remaining 3 out of 4 people (75) will develop
chronic hepatitis C.
45 may not develop liver damage
47 may develop mild to moderate liver damage
7 may develop cirrhosis of the liver
1 may develop liver failure or liver cancer
45 may not develop liver damage
31 may develop mild to moderate liver damage
20 may develop cirrhosis of the liver
4 may develop liver cancer or liver failure
16

• Hepatitis C is a highly stigmatised condition
• Support from health professionals is important
• Disclosure
• In most situations there is no legal obligation
  to disclose
• Examples of discrimination lack of knowledge
• Mum wearing colored arm band babys cot
  labelled universal precautions
• Labelling expressed breast milk Hepatitis C
• Education is key

17
Diagnosis

• Antenatal screen for recommended in pregnant ?
  (RANZCOG)
• Pre Post test discussion
• Mum HCV serology (Abs Virus) LFTs
• Infant Counselling Implications of testing
• Can check for virus with PCR test gt 2 months
• Can check Abs gt 18mnths due to maternal
• If Mum positive for virus refer to liver clinic
• If infant positive refer to paediatric
  gastroenterologist

18
Treatment

• S100 Medications - NOT during pregnancy or breast
  feeding
• Pegylated Interferon - weekly S/C injection
  side effects
• Ribavirin tablets BD - teratogenic
  contraception!
• Infants not usually treated some children -
  compassionately
• Aim Sustained Virological Response (SVR)
• undetected virus
• gt 6 months CURE

19
How can you help?

• Educate
• Transmission prevention (including vaccination)
• Tests available
• Treatments available to control (HBV) cure
  (HCV)
• Importance of monitoring for possible liver
  damage HCC
• Refer
• To GP for screening/testing refer on to
  specialists
• For ongoing monitoring for liver damage HCC
• For counselling mental health, drug alcohol
  services

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Thank youAny questions or comments?
21
Education and Support Services

• Victorian Viral Hepatitis Educator
• Information for Health Professionals
• 0407 865 140 or 9288 3586
• frances.cieslak_at_svhm.org.au
• Hepatitis C Victoria
• Ph 9380 4644
• InfoLine 1800 703 003
• Refer to Commonwealth Infection Control
  Guidelines (ICG)
• The Australian Immunisation Handbook

22
Key Documents

• B Positive all you wanted to know about
  hepatitis B
• A guide for primary care providers (2008)
  Produced funded by ASHM The Cancer Council
  NSW
• C Change - Report of the enquiry into hepatitis C
  related discrimination
• Anti-discrimination board of NSW 2001
• Giles, M.L, Pedrana, A, Jones, C, Garland, S.,
  Hellard, M. and Lewin, S.R. Antenatal screening
  practice for infectious diseases by general
  practitioners in Australia Australian and New
  Zealand Journal of Obstetrics and Gynaecology
  2009, 49, 39-44
• Hepatitis viruses and the newborn Clinical
  manifestations and treatment, http//www.uptodate.
  com Uptodate January 2009 American Continued
  Medical Education Program Royal College
  Association of Physicians
• HIV, Viral hepatitis and STIs A guide for
  primary care ASHM 2008
• HIV/Aids, Viral Hepatitis and Sexually
  Transmissible Infections in Australian Annual
  Surveillance Report NCHECR 2008

23
Key Documents

• Impact Information about Heptatits C 5th Ed.
  Hepatitis Victoria 2008
• National Hepatitis C Resource Manual 2nd Ed.
  Dept. of Health Ageing 2008
• Overview of hepatitis B virus infection in
  children Uptodate January 2009 American
  Continued Medical Education Program Royal
  College Association of PhysiciansVictorian
  Infectious Diseases Bulletin 11 (3) Sep 2008 DHS
  Victoria
• Temple-Smith, M., Jenkinson, K., Lavey, J.,
  Gifford, SM Morgan, M. Discrimination or
  discretion? Explorying dentists views on
  treating patients with hepatitis C Australian
  Dental Journal 2006 51 (4) 918-929
• Wiseman, E., Fraser, MA, Holden, S, Glass, A,
  Kidson, BL, Heron, LG, Maley, MW, Ayres, A,
  Locarnini, SA, Levy, MT Perinatal transmission of
  hepatitis B virus An Australian Experience MJA
  Research 2009 190 489-492
• Wallace, J., McNally, S., Richmond, J. (2007)
  National Hepatitis B Needs Assessment ARCSHS
  Latrobe University

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Hepatitis Treatment Centres

• Geelong Liver Clinic
• Maroondah Hospital
• Monash Medical Centre - Clayton
• - Springvale Liver Clinic
• - Cranbourne Liver Clinic
• Northern Hosp. Liver Clinic
• Royal Melbourne Hospital
• St. Vincents Hospital
• St. Kilda First Step
• Warrnambool Western Region
• Alcohol and Drug (WRAD) centre
• Werribee Hepatitis Clinic

• Alfred Hospital - Prahran
• Bayside Hepatitis Clinic
• (Cheltenham)
• Aubury / Wodonga by appt
• Austin Hospital
• Ballarat Liver Clinic
• Bairnsdale Hospital
• Bayside Gastroenterology
• (Frankston)
• Bendigo Health Infectious Diseases
• Liver Clinic
• Box Hill Hospital
• Fitzroy Inner Space
• Footscray Western Hospital
• Frankston Peninsula Liver Clinic