#80 • January 2019
Community News
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Correspondence: Please send all correspondence to The Editor at PO Box 782, Kent Town, SA 5071, or email editor@hepatitissa.asn.au. Editor: James Morrison
Contents
1 New BBV Strategies 2 Fatty Liver Disease 4 Natural HCV Immunity
Chair Arieta Papadelos
6 Considering Treatment?
Vice Chair Bill Gaston
10 Ilbijerri Theatre
Secretary Deb Perks Treasurer Michael Larkin Ordinary Members Julio Alejo Catherine Ferguson Sharon Jennings Maggie McCabe Sam Raven Kerry Paterson (EO)
ISSN 2651-9011 (Online)
8 Detox or Not? 12 SA Health Awards 13 What’s On? 14 Research Update 16 Healthcare Workers & BBVs: New Guidelines Disclaimer: Views expressed in this newsletter are not necessarily those of Hepatitis SA. Information contained in this newsletter is not intended to take the place of medical advice given by your doctor or specialist. We welcome contributions from Hepatitis SA members and the general public. SA Health has contributed funds towards this program.
Five More Years
Launch of the BBV Strategies
P
eak viral hepatitis, HIV, sexual health and community organisations welcomed the December release of five new National Blood Borne Virus (BBV) and Sexually Transmissible Infections (STI) Strategies by the Australian government. The organisations, including Hepatitis Australia and the Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM), were closely involved and consulted heavily in the development of the strategies, ensuring they provide a strong platform for a high-quality and coordinated national response to BBVs and STIs over the coming five years.
The release was accompanied by the announcement from Federal Health Minister Greg Hunt of $5 million in
“The strategies profile the critical role of primary care in supporting a sustained and accelerated response to BBVs and STIs. ASHM are excited to continue to support primary care and other healthcare professionals to provide effective care for all people living with BBV and STI,” said Alexis Apostolellis, Chief Executive Officer of ASHM. “Identifying and scaling up successful innovative models of STI service delivery tailored to the needs of priority populations and subpopulations (including multidisciplinary team approaches and shared-care models) is a key action point in the Fourth National STI Strategy."
public health threat, and to reduce the impact of STIs for all Australians. The five new National BBV and STI Strategies are available at health.gov.au/ sexual-health. v
The groups involved, along with associated organisations such as Hepatitis SA, are committed to supporting the implementation of the strategies to work towards the elimination of BBVs as a January 2019 • HEPATITIS SA COMMUNITY NEWS 80
Artwork by Keisha Thomason for the National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy
“We have a big task ahead to realise the goals within these strategies, but it can be done,” said Helen Tyrrell, Chief Executive Officer of Hepatitis Australia. “Hepatitis Australia looks forward to working in partnership with all stakeholders to engage each of the hepatitis B and hepatitis C communities in goldstandard prevention and care and continue efforts to help individuals to live free from stigma and discrimination.”
initial funding to support the implementation of the strategies at a national level, with further investment to be announced in coming months.
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NASH
An introduction to fatty liver disease
F
atty liver disease is the unhealthy build-up of fats in liver cells. It is most commonly developed by people who are overweight, or who have diabetes. It can also be caused by drinking large amounts of alcohol. It can also be caused by hepatitis C, and is especially common for those living with genotype 3 of hepatitis C. Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease in Australia. Roughly 30% of Australian adults are thought to be affected by it. Its prevalence is also significantly rising in Australia, and it is currently the most common cause of liver disorder in Australia and western countries. Aside from viral infection, poor quality nutrition, including excess saturated fats, refined sugars and processed foods have all been associated with an increasing trend in weight gain, obesity and fatty liver disease which are risk factors for the development of non-alcoholic steatohepatitis.
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A fatty liver, by itself, rarely leads to severe liver damage. However, the associated causes (such as obesity, hepatitis or diabetes) can lead to further liver damage. It is not always clear why fats start to build up in the liver, but high levels of cholesterol or blood fats (also known as triglycerides) can contribute, since the liver is the body’s main organ for processing nutrients and waste and these fats must pass through it. The liver turns some excess calories into fat, and stores it in the liver cells. The amount of fat in the liver may decrease when overweight people lose weight, when diabetics have well-controlled blood sugars, and when cholesterol and triglyceride levels are lowered. A fatty liver can become inflamed over time. Fatty liver inflammation is known as steatohepatitis. This is usually split into two types—alcoholic steatohepatitis (ASH) or non-alcoholic steatohepatitis (NASH)—depending on the cause. Inflammation is
HEPATITIS SA COMMUNITY NEWS 80 • January 2019
dangerous because it can lead to cirrhosis (scarring of the liver). This scar tissue makes the liver inflexible and damages its ability to function properly. It may also lead to liver cancer. In addition, people who have fatty liver disease have an increased risk of heart attack and stroke. Most people with fatty liver disease show no symptoms, although someone living with hepatitis C may show them more obviously. Some people may complain of fatigue, malaise, and dull abdominal pain. Although rare, mild jaundice—a yellowing of the skin and eyes due to liver waste products—may develop. More usually, that a person has a fatty liver is discovered accidentally through tests for other medical conditions. Ultrasound or Fibroscan tests, which use inaudible sound or tiny shockwaves to measure consistency and density of the liver, can also be used to diagnose fatty liver disease. Sometimes a liver biopsy, where a sample of tissue is taken with a long needle through the abdomen, may be
needed to properly measure the extent of the disease. Fortunately, there are ways to treat fatty liver disease and reduce the problems it causes. The exact treatment depends on the underlying cause. For example, for people with non-alcoholic fatty liver disease who have no evidence of inflammation, a gradual weight loss is often the only treatment needed. In more serious cases,
medications that decrease insulin resistance, fat cells development, and those that induce weight loss have been shown to improve liver function. If the fatty liver has been caused by hepatitis C, then the highly effective hepatitis C direct-acting antiviral (DAA) medications have a greater-than-95% probability of curing the disease and allowing the liver to recover.
Adelaide has a multidisciplinary Nonalcoholic Steatohepatitis Liver Clinic at the Lyell McEwin Hospital. The site was chosen in part because in the northern suburbs of Adelaide, obesity levels are among the highest in the state, and so are levels of fatty liver disease. You can contact Lyell McEwin Hospital’s Gastroenterogical Unit on 8182 9909, or talk to one of the Viral Hepatitis Nurses (see p7). v
January 2019 • HEPATITIS SA COMMUNITY NEWS 80
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Born HCV-Proof
The evolution of our vulnerability to hepatitis C
V
irologist Connor Bamford and Professor John McLauchlan, both of the University of Glasgow, explain how their research shows that not all people are equally vulnerable to hepatitis C. The hepatitis C virus (HCV) infects around 1% of the human population and is a devastating pathogen. In most people, it silently infects the liver for decades, and can cause life-threatening inflammation, scarring and even cancer. How the virus achieves this feat has long puzzled scientists. In our latest study, published in the journal PLOS Pathogens, we found that a molecule that defends against HCV and other pathogens is weaker in humans than in our closest relative, the chimpanzee. This weakened molecule might have made it easier for some viruses, such as HCV, to infect humans and cause disease. As humans, we are not completely defenceless against HCV. Our liver responds to infection by producing antiviral molecules called interferons. You can think of these molecules as the antiviral alarm system. Interferons are made rapidly once an invader has been spotted inside a cell. They are then released by
the infected cell and begin to float across the nearby cells, sending chemical signals that warn them that a virus is near, and forcing them to defend themselves by making hundreds more antiviral molecules. In particular, we produce what are known as lambda interferons against HCV that work well in liver cells. Strangely, one particular kind of interferon lambda, called IFNL4, is associated with a reduced chance of clearing HCV, making it easier for the virus to silently infect the liver for decades. How an antiviral molecule appears to help a virus to sustain infection over such a long time, and how this may have evolved, remains a mystery. The long evolution of humans in Africa and our later global spread has resulted in genetically diverse populations of humans, each adapted to suit local environments and diseases. In our recent study, we searched through all the known genetic diversity of the IFNL4 gene, including that of chimpanzees, to identify whether people who carried different versions had different abilities to block viral replication. We hoped this would shine a light on the paradoxical role of IFNL4
during HCV infection. What we found surprised us. A very rare version of IFNL4, which is only found in pygmies (hunter-gatherers from central Africa), was far better able to inhibit HCV infection in the lab. Even more surprisingly, this version had similar properties to the chimpanzee IFNL4. Nearly all humans, except this group of huntergatherers, produce a weaker version of IFNL4. This more antiviral version of IFNL4, found in chimpanzees and a small pocket of Central African hunter-gatherers, was better able to turn on hundreds of antiviral molecules when it was added to cells in the lab. This heightened antiviral response was similar to what was found when we compared the genes produced in the liver in response to HCV in people and in chimpanzees. That is, chimpanzees appeared to mount a greater antiviral response to HCV than humans, turning on anti-HCV molecules and enhancing the immune response. Chimpanzees are the only animal—other than humans—that can be infected by HCV, which is the reason they were used to study the virus and find effective antiviral drugs and
vaccines. However, testing in chimpanzees is now banned. Correlating with this stronger antiviral response is the fact that HCV infection in chimpanzees is less pronounced than in humans. Chimpanzees don’t develop serious hepatitis C. The virus appears to replicate more slowly, and it might be more difficult for HCV to gain a foothold in chimpanzees. Also, despite searching, scientists have been unable to find natural HCV infection in chimpanzees in the wild.
One remaining mystery is what evolutionary pressures drove early humans to reduce the antiviral activity of IFNL4, and why do a handful of people retain it? We may not have the answers yet, but studying the immune responses in our chimpanzee cousins in the wild, or in people who still carry the more antiviral version of IFNL4, may unlock some of the mysteries behind the role of IFNL4 in virus infection. v
Photo CC Max Chiswick
Our finding that very early in human evolution we evolved an antiviral molecule with a reduced ability to block viral infections, might help explain the insidious nature of HCV—and possibly other viral infections—in humans.
BaAka children, naturally resistant to hepatitis C, playing in the Central African Republic
January 2019 • HEPATITIS SA COMMUNITY NEWS 80
5
Considering Treatment? All the steps toward being cured of hep C are easy!
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n the times before the Direct Acting Antiviral treatments became available in 2016, people needed to have an often painful and medically intrusive liver biopsy, whereby a small sample of liver was taken. Thankfully those days are gone and for the vast majority of people, treatment work up is just blood testing, a fibrosis scan and sometimes an ultrasound. Fibrosis Scanning is a noninvasive method of assessing fibrosis, which is liver tissue that has hardened and scarred, forming fibres. Fibrosis, when not managed can lead to cirrhosis which increases the risk of and can lead to liver cancer. We often refer to fibrosis scanning as a fibroscan. Fibroscans are becoming a standard monitoring tool for hepatitis C and liver
damage. Having a fibroscan prior to treatment helps to determine the impact that the hepatitis C virus has had upon the liver. Liver function testing by blood tests alone do not show the full picture of liver health. Symptoms of hepatitis C are not a good indication of liver health either, as people can live with hepatitis C for many years before any symptoms arise, even while damage to the liver is occurring. A series of fibroscans over time can show an increase, decrease or stability in liver fibrosis. In South Australia our Viral Hepatitis Nurses have portable fibroscan equipment that they regularly take to outreach locations, including the Fibroscan Clinics organised by Hepatitis SA. Fibroscan are free and results are immediate, so there is no waiting time after the scan
is completed for a score that will indicate if you have any fibrosis. All viral hepatitis nursing support services are free. Performed at the bedside in the clinic, a mechanical pulse of sound, inaudible to human ears, is generated at the skin surface by a probe. This pulse passes through the liver. The velocity of the wave is measured by ultrasound. The speed of this wave correlates with the “stiffness” of the liver, which in turn reflects the degree of fibrosis: generally, the stiffer the liver, the greater the degree of fibrosis.
What will happen?
There is no pain, and no need for sedation. However, ideally you should fast for at least two hours beforehand, as eating may affect the result.
FIBROSCAN REPORT CARD 2.5
7.5
F0/F1
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HEPATITIS SA COMMUNITY NEWS 80 • January 2019
9.5
F2
12.5
F3
F4
Liver Nurse Lucy performing a fibroscan
You will lie on your back with your right arm behind your head. The probe is placed on the right-hand side of your body, over your liver. The probe generates a mechanical pulse. You will feel a slight tap as the probe sends this pulse of sound into the liver. The probe takes 10 measurements to give a true reading. This reading is given in kilopascals (KPa) and is the middle of the 10 scores. • Scores lower than 7KPa indicate no or insignificant liver fibrosis. • Scores between 7KPa and 12KPa indicate moderate fibrosis. • Scores higher than12KPa indicate severe fibrosis or cirrhosis. Allow 30 minutes for the check-up. The actual fibroscan should only take around 15 minutes. A Fibroscan can give an accurate assessment of liver fibrosis and help you make
decisions about lifestyle changes or treatment. Attend or make a booking for your fibroscan at one of these locations on this page.
For more information contact Lisa Carter, CoordinatorOutreach Hepatitis C Peer Education & Support Project, on 8362 8443. v
Free Fibroscan Clinics (No bookings required) • • •
Hutt Street Day Centre: 3rd Wednesday of each month, 9.30–11.30am, 258 Hutt St, Adelaide SA 5000 WestCare Services; 4th Thursday of each month, 9.30–11.30am, 11/19 Millers Ct, Adelaide SA 5000 Wonggangga Turtpandi Aboriginal Primary Health Care Service (Pt Adelaide CNP); 1st Wednesday of each month, 9.30–11.30am, 11 Church St, Port Adelaide SA 5015
Bookings required • •
Anglicare Elizabeth Mission; 2nd Friday of each month, 9.30am–12pm, 91-93 Elizabeth Way Elizabeth (Bookings via reception in person, or call 8209 5400) Noarlunga GP Plus; fortnightly, Alexander Kelly Dr, Noarlunga Centre SA 5168 (Bookings via Noarlunga CNP Peer, or by calling Rosalie on 0466 777 876)
Or contact your local Viral Hepatitis Nurse; • Central Adelaide: Margery (0423 782 415) or Jeff (0401 717 953) • Northern Adelaide: Lucy (0401 717 971) or Michelle (0413 285 476) • Southern Adelaide: Rosalie (0466 777 876) or Office (8204 6324)
January 2019 • HEPATITIS SA COMMUNITY NEWS 80
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Detox? Or Not!
Feeling better without fads
Are you feeling run down after the Christmas season and want to do a detox to start the year off right? Unfortunately, the idea that we can detoxify our bodies is a myth. We look at why and suggest some ways to take care of yourself that will genuinely make you feel better. It’s the time of year when articles about the magical benefits of detoxing flood the media. A fresh start is always appealing, especially when you’ve over-indulged. Unfortunately, detoxing – the idea that you can flush away stored toxins from bad food, alcohol or drugs is a myth, our bodies simply don’t work that way. To begin with, these toxins aren’t stored in our bodies. Luckily for us, our liver, kidneys, lungs and skin are breaking down and removing them all of the time. Nothing we do can make this system work better, aside from being healthier. Nevertheless, the idea of a quick-fix detox is big business and a multi-billion dollar industry takes advantage of the fact that their products are unregulated.
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HEPATITIS SA COMMUNITY NEWS 80 • January 2019
Fresh juice might taste good but it won’t detoxify your liver
Manufacturers try to lure us in with promises of renewed energy, glowing skin and healthier livers. The truth is they can’t prove these miraculous results and some detox products even contain ingredients that could be harmful for your liver. This is particularly worrying for people with viral hepatitis or liver disease. Strict diets and juice fasts are also promoted as a way to detox but these won’t affect how quickly your body deals with toxins either. Depending on the diet you may feel better or worse, it’s anybody’s guess. In contrast, looking after yourself properly has real benefits that can’t be matched by any mythical detox. Here are our top tips for feeling better this year:
Regularly eat good foods Fresh fruit and vegetables, good carbohydrates (like those in vegetables, whole grains, legumes, etc), good fats (like those in tofu, nuts, seeds, avocados, etc), lean sources of protein and lowfat dairy (or substitutes) are all high on the list of foods
that are good for you and make you feel good.
Get enough sleep
Our liver has a clock and needs a good block of sleep at night to perform some of its most important functions. Aim for 7-8 hours most nights, a bit more if you need it. (See k3myliver.org. au/liver-clock.html for more information)
Move as much as you can
We all have different capabilities but some form of exercise is beneficial for most people, most of the time. Low intensity, unfocussed exercise such as a stroll around the park can really lift your mood. Regular, moderate exercise can improve fitness, wellbeing and quality of life. Think about what is possible and enjoyable for you and aim to do a bit more than you do now, building up over time.
Don’t drink too much
People with viral hepatitis or liver disease need to be especially careful about the amount of alcohol they drink. If you want to drink it’s best to discuss it with your doctor or specialist so you know
what’s right for you. Drinking more than your liver can handle can make you feel bad now and damage your liver in the long term.
Give up smoking
Not only does smoking increase the risk of developing liver cancer for people with viral hepatitis but it makes you feel bad, mentally and physically. If you still smoke, quitting can make a real difference to your health and how well you feel day to day. The Quitline can help: ring 13 78 48. Most importantly, make sure you are getting the proper care or treatment for your viral hepatitis or liver disease. You can’t control all aspects of how viral hepatitis makes you feel but, if you haven’t been getting the care you need, be sure to visit your doctor. People with hepatitis C can now be treated with an over 95% success rate and people with hepatitis B or liver disease need regular monitoring and care. Call our Helpline for more information, on 1800 437 222. v Rose Magdalene
January 2019 • HEPATITIS SA COMMUNITY NEWS 80
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Viral: Are You the Cure? Ilbijerri Theatre Company’s new Hep C drama
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n early 2018, Hepatitis SA and the Aboriginal Health Council of SA were successful in securing a grant from the Department for Correctional Services to bring Melbourne-based theatre company Ilbijerri to Adelaide to perform their latest play, Viral: Are You the Cure?
big plans—she just wants a better life for her baby.”
This is the third play that has been produced looking at increasing awareness of hepatitis C among Indigenous communities in Australia.
The play was performed six times over four days at various sites in South Australia. Day one was at The Adelaide Youth Training Centre. The second day took the performance to Taoundi College. This was a community performance open to anyone. Day three was off to Yatala Labour
Viral: Are You the Cure? tells the story of Ally, and as the play description states, “things aren’t the best right now for Ally, but she has
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The play follows Ally, who is ready to make a life changing decision, all while being filmed for an explosive new documentary. The play is fast-paced, with many very funny moments as well as heartfelt real-life situations.
HEPATITIS SA COMMUNITY NEWS 80 • January 2019
Prison, where two shows were performed in the one day, and finally on the fourth day the show went to Mobilong Prison at Murray Bridge, with two more shows performed. At each of the six shows, the audience were captivated throughout. A total of 203
people (approximately 127 of whom were Aboriginal) saw the play over the four days. At the end of the play, the set was transformed in to a Yarning Circle, and audience members were invited to join the circle to talk about the play. During the yarning circle, some of the comments from
Kamarra Bell-Wykes, Creative Director of Ilbijerri Theatre Company, Playwright and Director I am a Jagera/Butchulla woman from South-Eastern Queensland. I contracted hep C when I was 15 (in 1995) through shared IV use. I struggled with my hep C status for 20 years while simultaneously writing the hepatitisinspired works performed by Ilbijerri. the audience included, “I will pass the information on to my community,” and “I only came for the popcorn and Coke, but thought it was amazing and found a connection with the characters”. Another commented, “it was the first play I have seen, and I felt goosebumps.” Hepatitis SA and the Aboriginal Health Council of SA hope to secure more funding to bring the play back and show it to more audiences across South Australia. v
I successfully cleared the virus in 2010 and finally felt empowered to openly discuss my status and begin using my personal experience as a tool of advocacy. I have advocated for understanding around the lived experience of the virus and smashing related stigma in the Indigenous community over the last 15 years through the works Chopped Liver, Body Armour and Viral: Are You the Cure? Hep C is not an individual virus: it impacts our community as a whole and as long as the virus remains a dirty secret and something shrouded in stigma, we will not be able to seek the healing we all need. The power for change starts with us and the facts are simple—hep C is a serious virus and it can kill you. Treatment is available, it’s safe and free. The only thing that can keep hep C viral is us and how we view it. We need to overcome it, instead of using it as a weapon of judgment and shame. v January 2019 • HEPATITIS SA COMMUNITY NEWS 80
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SA Health Awards
Viral Hepatitis Nurses win well-deserved award
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ALHN’s Viral Hepatitis Nurses have deservedly won the Out of Hospital Strategies and Care award at the SA Health Awards for 2018. The citation noted that “the Central Adelaide Local Health Network viral hepatitis nurses have developed innovative models of care to treat patients safely and efficiently in the community, particularly marginalised patients who are unlikely to access mainstream healthcare facilities. The service is delivered through education, diagnostic testing, community clinics, and links with prison health and other community services. As a result, the proportion of patients who started
treatment in the community substantially increased from 2016 to 2018.” Nurse Jeff Stewart explained: “It’s a service that provides a treatment access point for people with hepatitis C, and we do that both here at Port Adelaide, the Queen Elizabeth Hospital and the Royal Adelaide Hospital, and we work with infectious disease teams and hepatology teams to get people into treatment and have scripts written up for them, so they can go to community pharmacies and access treatment. “95% of people who have hepatitis C now are curable if they take the medication, and this service provides a way for those people to access that treatment.”
Nurse Margery Milner elaborated: “It’s opportunistic, it’s also remote, so we see patients where it’s best suited for them. We see people at drug and alcohol services, we do go into two of the prisons in SA. It’s about actually taking our treatment to the person, instead of the person going to the hospital. “It’s really worked well in that we’re now seeing 75% of all people treated on a nurse-led program. Our marginalised communities such as the homeless, people that are still injecting and Aboriginal client numbers have greatly increased. Our goal is to eliminate hepatitis C by 2030 in Australia.” v
Viral Hepatitis Nurses Jeff Stewart (centre) and Margery Milner (right)
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HEPATITIS SA COMMUNITY NEWS 80 • January 2019
Affected by he
Affected by hepatitis C? Photo © S. Allen
Hepatitis C peer educators are available to provide treatment information and support to clients at the following services: Free Fibroscan Clinics (No bookings required) •
Calming the C
•
• Information and support in a confidential, friendly environment • Speak to others who have had treatment • Partners, family and friends welcome
Now meeting ELIZABETH HACKNEY: 3 Hackneyat RdHACKNEY, PORT ADELAIDE: Wonggangga Turtpandi 12.30–2.30pm and PORT ADELAIDE • • • • • • •
12–2pm For15 information, phone 8362 8443 Tuesday, January Tuesday, 5 February Tuesday, 12 March See over for• dates • Tuesday, 2 April Tuesday, 7 May • Tuesday, 28 May Tuesday, 2 July • Tuesday, 23 July Tuesday, 27 August • Tuesday, 17 September Tuesday, 22 October • Tuesday, 12 November Tuesday, 17 December
Free, after-hours support is available for anyone struggling with addictive behaviour. The SMART (Self Management and Recovery
•
Training) Recovery group meetings run for 90 minutes each Wednesday, from 5.30pm at 3 Hackney Road, Hackney, in the meeting room at the rear of Hepatitis SA.
Hutt Street Day Centre: 3rd Wednesday of each month, 9.30–11.30am, 258 Hutt St, Adelaide SA 5000 WestCare Services; 4th Thursday of each month, 9.30–11.30am, 11/19 Millers Ct, Adelaide SA 5000 Wonggangga Turtpandiand support • Information Aboriginal Primary Health friendly environment Care Service (Pt Adelaide • Speak to others who hav CNP); 1st Wednesday of each • Partners, family and frien month, 9.30–11.30am, 11 Church St, Port Adelaide SA 5015
Calming
Bookings Now required meeting •
•
at HACKN
Anglicare Elizabeth Mission; and PORT ADE 2nd Friday of each month, information, 9.30am–12For pm, 91-93 Elizabeth phon Way Elizabeth (Bookings See via over for reception in person, or call 8209 5400) Noarlunga GP Plus; fortnightly, Alexander Kelly Dr, Noarlunga Centre SA 5168 (Bookings via Noarlunga CNP Peer, or by calling Rosalie on 0466 777 876)
The program can assist with any problematic behaviours, including addiction to drugs, alcohol, cigarettes, gambling, food, shopping, internet and others. Focus is upon the addictive behaviour, not the substance itself. For more information, call Lisa on 8362 8443, or visit smartrecoveryaustralia.com.au.
January 2019 • HEPATITIS SA COMMUNITY NEWS 80
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Blood Supply Failure
Liver failure caused by attack on blood vessel cells
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n severe cases, a viral hepatitis infection can result in liver failure. Researchers have now discovered how this occurs: by immune cells attacking cells in the vascular system, which disrupts the organ’s blood and nutrient supply. This is responsible for the overwhelming damage that causes the liver to fail. Using an animal model, the researchers were then able to identify an agent to prevent this lethal process. An infection of the liver with viral hepatitis, such as the hepatitis B virus, can progress in very different ways: the liver inflammation can heal again without any problems; it can become chronic and require lifelong medication; or it can take a fulminant—i.e.
potentially fatal—course. In the latter case, the immunemediated damage to the liver is so severe that the organ fails, leaving a liver transplant as the last remaining treatment option. Hepatitis viruses target the liver cells, or hepatocytes. The immune system tries to bring the infection under control by attacking and destroying the infected liver cells with the help of certain immune cells, known as killer T-cells. It was previously assumed that this process was also responsible for the severe organ damage that accompanies acute hepatitis. Now, though, Dr. Dirk Wohlleber, Research Group Leader at Munich University, and Percy Knolle, Professor of Molecular Immunology, have arrived
Experimental liver cells showing different degrees of damage from hepatitis
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HEPATITIS SA COMMUNITY NEWS 80 • January 2019
at a completely different explanation. In collaboration with colleagues from the universities of Würzburg and Bonn in Germany, they discovered that this organ failure is not in fact caused by the death of liver cells, but by defects in the vascular (blood vessel) system.
Blood supply disrupted by immune cells The liver is home to important cells called liver sinusoidal endothelial cells, or LSECs for short. These connect the cells of the liver to the vascular system and regulate the exchange of nutrients and oxygen with the blood. They also have the ability to present small fragments of viruses on their outer membrane, in a similar way to immune system cells. The researchers observed that the killer T-cells specifically detected these viral particles, mistaking the LSECs for infected liver cells and destroying them. To this end, they used proteins that integrate into the cell membrane of the target cell and form a pore. Known as perforins, these proteins perforate the membrane and destroy the cell. “We observed that the elimination of LSECs by
HCV Vaccine
Promising early trial the immune cells has an enormous impact on the liver tissue. Blood flow within the liver is hugely disrupted, with large numbers of liver cells—even those not infected—dying as a result. This immune response has a much more dramatic effect than the attack on liver cells that are actually infected,” Wohlleber explained.
Perforin inhibitors as a therapeutic tool
(at 0 and 8 weeks), followed by a booster dose at 6 months.
When complete, the GLS6150 study will evaluate a total of 24 people who have a sustained virologic response (SVR) following treatment for Hepatitis C, as well as an additional 8 healthy controls to compare immune responses. The test vaccinations are given as either a 3-dose priming series (at 0, 4 and 12 weeks) or as a 2-dose priming series
The key to a successful hepatitis C vaccine will be its ability to activate the body’s immune system to prevent or treat infection by a challenging virus with multiple and mutating strains. Efforts to develop a hepatitis C vaccine started more than 25 years ago when the hepatitis C virus was first identified, but progress has been slow because the hepatitis C virus is more variable than are the viruses that cause hepatitis A and B. The hepatitis C virus occurs in at least six genetically distinct forms (genotypes) with multiple strains--about 50 subtypes have been identified to date. The experimental GLS-6150 vaccine is not limited to one specific strain of virus, so it’s hoped that the results of the trial, late in 2019, will demonstrate its efficacy against hepatitis C in general. See bit.ly/2TRSKqh for more. v
partnership between two pharmaceutical companies (Inovio Pharmaceuticals and GeneOne Life Science) have dosed the first patient in an early study designed to evaluate a preventive vaccine against hepatitis C infection. Further patients have been recruited in South Korea for the study, which is trialling the experimental GLS-6150 vaccine to boost immunity in people who have been treated and cleared of the virus. If the trial is successful, this vaccine could be employed to prevent infection and reinfection.
Read the research article at go.nature.com/2LXLTsE. v
January 2019 • HEPATITIS SA COMMUNITY NEWS 80
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Image CC Sandra Rugio
“Only now that we have pinpointed the actual destructive mechanism in acute hepatitis can we consider new treatment strategies and specifically target this process,” Knolle explained. The researchers were able to show that a new active substance can prevent fulminant hepatitis. This is a perforin inhibitor, which stops the killer T-cells from forming pores and thus safeguards the LSECs from attack. This agent successfully protected experimental mice from developing fulminant hepatitis, since the LSECs remained intact, preserving the blood supply to the liver cells. Tests on human patients are now planned.
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BBV Guidelines
More freedom for healthcare workers living with BBVs
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ew national guidelines endorsed by the Australian Health Ministers’ Advisory Council have been released in January 2019 for healthcare workers who perform exposureprone procedures, and for healthcare workers living with a blood-borne virus (BBV). These are the Australian National Guidelines for the Management of Healthcare Workers Living with Blood Borne Viruses and Healthcare Workers who Perform Exposure Prone Procedures at Risk of Exposure to Blood Borne Viruses. Exposure-prone procedures (EPPs) are procedures where there is a risk of injury to the healthcare worker, with exposure of the patient’s open tissues to the blood of the health care worker. All healthcare workers who perform EPPs are required to take reasonable steps to know their blood borne virus status and to follow these guidelines. Previously, healthcare workers living with BBVs were excluded from performing exposure-prone procedures, but these new guidelines reflect the effectiveness of current antiviral treatment for hepatitis B, hepatitis C
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and HIV. These changes are also consistent with those made in other countries.
Why do we have these guidelines? Some procedures undertaken as part of medical care carry an extremely low chance of patients becoming infected with a blood-borne virus from a healthcare worker living with a BBV, even when usual infection prevention and control practices are followed. While still extremely unlikely, there are certain procedures where the healthcare workers are at a higher risk of getting a BBV from a patient and also of passing a BBV to a patient. However, when healthcare workers living with a BBV are complying with the guidelines, this risk is minimised. The guidelines also support healthcare
HEPATITIS SA COMMUNITY NEWS 80 • January 2019
workers to get timely testing and treatment. A broad range of health professional groups were consulted and provided feedback during the development of the new guidelines.
Will I know if my doctor or other healthcare professional has a BBV? No. Healthcare workers have the same right to confidentiality and access to confidential testing, counselling and treatment as the general population. The guidelines are in place so that all patients can feel confident that their procedure is being performed in a way that protects their health and safety. To read the guidelines, visit bit.ly/2RDrv5e. v
Useful Services & Contacts Hepatitis SA Free education sessions, printed information, telephone information and support, referrals, clean needle program and library. (08) 8362 8443 admin@hepatitissa.asn.au www.hepsa.asn.au Hepatitis SA Helpline 1800 437 222 (cost of a local call) Adelaide Dental Hospital A specially funded clinic provides priority dental care for people with hepatitis C with a Health Care Card. Call Hepatitis SA on 1800 437 222 for a referral. beyondblue Mental health information line
Hutt St Centre Showers, laundry facilities, visiting health professionals, recreation activities, education and training, legal aid and assistance services provided to the homeless.
P.E.A.C.E. HIV and hepatitis education and support for people from nonEnglish speaking backgrounds.
258 Hutt St, Adelaide SA 5000 (08) 8418 2500
SA Sex Industry Network Promotes the health, rights and wellbeing of sex workers.
Lifeline National, 24-hour telephone counselling service.
(08) 8351 7626
13 11 14 (cost of a local call) www.lifeline.org.au
SAMESH South Australia Mobilisation + Empowerment for Sexual Health www.samesh.org.au
Mental Health Crisis Service 24 hour information and crisis line available to all rural, remote and metropolitan callers. 13 14 65
1300 224 636 www.beyondblue.org.au
MOSAIC Counselling Service For anyone whose life is affected by hepatitis.
Clean Needle Programs in SA For locations visit the Hepatitis SA Hackney office or call the Alcohol and Drug Information Service.
(08) 8223 4566
1300 131 340 Community Access & Services SA Alcohol and drug education; clean needle program for the Vietnamese and other communities. (08) 8447 8821 headspace Mental health issues are common. Find information, support and help at your local headspace centre 1800 650 890 www.headspace.org.au
Nunkuwarrin Yunti An Aboriginal-controlled, citybased health service with clean needle program and liver clinic.
(08) 8245 8100
Youth Health Service Free, confidential health service for youth aged 12 to 25. Youth Helpline: 1300 13 17 19 Parent Helpline: 1300 364 100 Vincentian Centre Men’s night shelter run by St Vincent de Paul Society. Assistance hotline: 1300 729 202
(08) 8406 1600 Viral Hepatitis Community Nurses Care and assistance, education, streamlined referrals, patient support, work-up for HCV treatment, monitoring and follow-ups. Clients can self-refer. Contact nurses directly for an appointment. Central
Margery - 0423 782 415 margery.milner@sa.gov.au Jeff - 0401 717 953 North
Lucy - 0401 717 971 Michelle - 0413 285 476 South
Rosalie - 0466 777 876 rosalie.altus@sa.gov.au
NEW NEW SAFE SAFE TREATMENTS TREATMENTS CAN CAN CURE CURE HEPATITIS HEPATITIS C C
TT U O B U A O B R A O T R C O O T D C O R U O RD Y U O O Y T O K AK T SSP EA PE
Your tiredness might be something more. Hepatitis C affects thousands of people living in Australia and is even more common overseas. It may be transmitted if you’ve had a blood transfusion, a dental or medical procedure here before 1990 or overseas. Hepatitis C can be cured with a simple new treatment. See your doctor about getting tested for Hep C.
LIVE LIVE FREE FREE FROM FROM THE THE WORRY WORRY OF OF HEP HEP C C 2
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