An overview of the DHHS approach to viral hepatitis Western Victoria Regional Viral Hepatitis Forum – Tuesday 21 November 2017
Elizabeth Birbilis, Senior Policy Officer, Sexual Health and Viral Hepatitis, DHHS
The Strategies • Victorian Hepatitis B Strategy 2016-2020 • Victorian Hepatitis C Strategy 2016-2020
Victoria’s Viral Hepatitis strategies - Vision Hepatitis B
Hepatitis C
By 2030, Victoria will eliminate Hepatitis B as a public health concern and Eliminate stigma and discrimination associated with the disease
By 2030, Victoria will eliminate Hepatitis C as a public health concern and Eliminate stigma and discrimination associated with the disease
Our objectives
Hepatitis B
Hepatitis C
• Victorians and affected communities are free from hepatitis-B-related stigma and discrimination • Victorians are supported to reduce their risk of contracting hepatitis B • Victorians with hepatitis B know their status • Victorians with hepatitis B have access to best practice treatment and care
• Victorians and affected communities are free from hepatitis-B-related stigma and discrimination • Victorians are supported to reduce their risk of contracting hepatitis C • Victorians with hepatitis C know their status • Victorians with hepatitis C are cured of the disease
Priority populations Hepatitis C
Hepatitis B •
• • •
people born in high-prevalence countries, particularly Southeast Asian and sub-Saharan African countries and parts of the Middle East Aboriginal Victorians children born to mothers with chronic hepatitis B unvaccinated adults at higher risk of infection including: • people living with, or in intimate contact with, people who have an acute or chronic hepatitis B infection • people who inject drugs • men who have sex with men • people in prison • sex workers • people with HIV or hepatitis C or both • refugees and asylum seekers.
• • • • • •
people who currently inject or have ever injected drugs Aboriginal Victorians people in prison sex workers HIV-positive men who have sex with men people from culturally and linguistically diverse backgrounds.
Our targets Hepatitis B
Hepatitis C
The proportion of people experiencing and reporting hepatitis-B-related stigma and discrimination will be 0%
The proportion of people experiencing and reporting hepatitis-C-related stigma and discrimination will be 0%
Between 2016 and 2030, the number of new transmissions of hepatitis B will be reduced by 90 %
Between 2016 and 2030, the number of new transmissions of hepatitis C will be reduced by 90 %
The proportion of all people living with chronic hepatitis B who are diagnosed will be 90 %
The proportion of all people living with chronic hepatitis C who are diagnosed will be 90 %
The proportion of people living with chronic hepatitis B who are cured of the disease will be 90 %
The proportion of people living with chronic hepatitis C who are cured of the disease will be 90 %
Victoria’s Viral Hepatitis strategies System enablers Strengthening the Victorian health system will: •
•
•
ensure the Victorian workforce has the skills, knowledge and attitudes needed to deliver best practice hepatitis B/C prevention, testing, treatment and care VHHITAL integrate systems and settings to meet the needs of people affected by hepatitis B/C – Hep C clinical pathways PHN Alliance improve the quality and completeness of hepatitis B/C data collection and support research - Burnet
Partnership approach • The department takes a partnership approach of working with key agencies/programs such as Hepatitis Victoria, Harm Reduction Victoria, VHHITAL, VACCHO, Primary Health Networks, Multicultural Health and Social Support and the Burnet Institute. Examples include: o VHHITAL program and its delivery of comprehensive education and training for GPs on the diagnosis, treatment and management of viral hepatitis
o Hepatitis Victoria and its work around stigma and discrimination and promotional work around ramping up testing on hepatitis C o Primary Health Networks and their work in the development of Health Pathways for all PHNs and the delivery of training to GPs, nurses and pharmacists and the development of local networks to connect GPs to tertiary specialists o VACCHO and their work in developing an Aboriginal specific test and treat communication campaign
Current work in progress • Integrated Hepatitis C Service o Established in 2010 across 12 sites in Victoria o Deloitte review in October 2015
o Letters to CEOs of IHCS Health Services in January 2017 flagging DAAs and the need to treat non complex cases in primary care o Integrated Hepatitis C Service Workshop – 5 May 2017 o An internal working group has been meeting, members include the Sexual Health and Viral Hepatitis team, Continuing Care, Specialist Clinics and Primary Care o We are looking at convening another meeting to discuss next steps for supporting IHCS in developing a consistent primary & community care focussed approach in partnership with VHHITAL and the EC project.
11 December 2017
Current work in progress • Nurse practitioners o The Department of Health and Human Services, through the Victorian Nurse Practitioner Project (VNPP), is providing funding for the development and implementation of nurse practitioner service models, and associated candidate support packages where eligible. A call for submissions against published criteria was made and applications closed on 17 November. Health services were invited to provide a submission to develop a hepatology model of care. • In addition to the expansion of hepatitis B vaccines to all Aboriginal people last year, in the 2017 – 2018 State Budget (Cancer Plan Funding), $0.3 million per year ongoing was made available to expand hepatitis B vaccinations to people from high prevalence countries. • RACGP – Red Book and Green Book updates o Supporting the work to get viral hepatitis more prominent in these guides
Promotion / Resources • CHO Advisory – Viral hepatitis training for AOD and OST workforces o The Alcohol and other drug workforces are an important point of integration to get people into care, we worked with Hepatitis Victoria and the Chief Health Officer to develop a Chief Health Officer Advisory, which was releases on 8 November 2017, promoting the range of training we have available in Victoria. • GP Factsheet
o The department has developed a new fact sheet -Hepatitis C management and support for general practitioners - FAQs https://www2.health.vic.gov.au/public-health/preventive-health/sexualhealth/resources-for-sexual-health-and-viral-hepatitis, under the heading Viral hepatitis / STIs.
Additional information Sexual Health and Viral hepatitis • Policies and strategies • Programs and Services • Resources for viral hepatitis and sexual health https://www2.health.vic.gov.au/public-health/preventive-health/sexual-health
Chief Health Officer • CHO Alerts and Advisories https://www2.health.vic.gov.au/about/key-staff/chief-health-officer
Immunisation • Immunisation information and newsletters https://www2.health.vic.gov.au/public-health/immunisation/immunisationnewsletters
Global burden of viral hepatitis and progress towards elimination
Benjamin Cowie Director, WHO Collaborating Centre for Viral Hepatitis Peter Doherty Institute for Infection and Immunity, Melbourne
www.doherty.edu.au/whoccvh
Declaration of Interest I receive no funding of any kind from any pharmaceutical or other for-profit health-care-related company
Advisory For people living with viral hepatitis
Global Burden of Disease Study 2016 www.healthdata.org/gbd/ www.thelancet.com/gbd
• HIV/AIDS: 1.03 million deaths in 2016, falling since 2005 (1.7m) • TB: 1.2 million deaths in 2016; falling since 1990, incidence and prevalence falling since 2000
• Malaria: 720,000 deaths in 2016; falling since 2004 Global Fund to fight AIDS, TB and Malaria • Viral hepatitis: 1.3 million deaths in 2016, steadily increasing (895,000 in 1990) Naghavi 2017, Stanaway 2016
Leading causes of mortality and trends, 1990 - 2013
Stanaway et al, Lancet 2016
Fitzmaurice 2017 Jama Oncol
• Globally, liver cancer the 4th leading cause of cancer deaths – Nearly 10% of all cancer deaths are due to liver cancer • However liver cancer is ranked 2nd in years of life lost
Comparison of Global and Western Pacific Mortality by Major Communicable Diseases, 2013* 1,500,000
1,200,000
900,000
Tuberculosis Malaria HIV/AIDS
600,000
Hepatitis related
300,000 0 Global
Western Pacific
*GBD 2013 Mortality and Causes of Death Collaborators. Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015 Jan 10;385(9963):117-71.
80,000,000
Current epidemiological estimates of hepatitis B in countries of the Western Pacific Region, 2014-16
5.49%
70,000,000 60,000,000
50,000,000
Over 90% of the HBsAg+ cases are in China, Vietnam, and Philippines
40,000,000
Numer of people HBsAg
30,000,000 20,000,000 10.79%
10,000,000
8.40%
4.36%
1.02%
14.59%
8.74%
The Republic of Korea
Japan
Papua New Guinea
Laos
0 China
10,000,000
VietNam Philippines
0.80%
9.07% Mongolia
0.74%
4.09%
2.60%
18.83%
0.37%
Malaysia Singapore New Solomon Zealand Islands
Australia
17.54% Vanuatu
4.80% Fiji
4.05% Cambodia
Current epidemiological estimates of hepatitis C in countries of the Western Pacific Region, 2014-16
8,000,000 Over 90% of the chronic hepatitis C cases are in China, Japan, and Vietnam
6,000,000 4,000,000 2,000,000
1.10%
0
China
Japan
1.20%
VietNam
Source: Gower et al 2014, Schweitzer et al 2015, CDA/WHO
0.60%
The Philippines
1.10%
1.20%
Malaysia
Australia
6.80%
0.40%
Mongolia Republic Of Korea
1.70%
1.10%
Cambodia New Zealand
Elimination targets in the GHSS for viral hepatitis
Regional target: 50% of eligible people treated by 2020
HBV
HCV
10 CORE INDICATORS FOR THE RESULT CHAIN Context
Inputs
Output & outcomes
Impact
Cascade of care Epidemic patterns
System
Prevent
Test
C2. Testing facilities
C4. Needle syringe for PWID
Heal
17 ADDITIONAL
C.6 People diagnosed
C.7 C.8 Viral indicators from Treatment supression C.10 coverage /other programmes (HBV) or initiation Mortality cure (HCV)
(A.11-A.27)
C5. Injection safety
New infections Deaths C.9 Incidence
C3. Vaccine coverage
C1. Prevalence
Treat
from HCC, cirrhosis
• <5 yo: 9.9% 0.3% HBsAg + 1992-2014 • ~ 30 million chronic infections averted • Over 5 million future deaths prevented
Australian Cascade of care - HBV
HCV Treatment cascade, Australia : 2014
Kirby Institute, UNSW Annual Surveillance Report 2015
HCV treatment in Australia
IFN-based
21
Slide credit: Prof Greg Dore, Kirby Institute, UNSW
IFN-free
Hajarizadeh B, et al. J Gastro Hepatol 2016 [updated]
HCV treatment in Australia
IFN-based
22
Slide credit: Prof Greg Dore, Kirby Institute, UNSW
IFN-free
Hajarizadeh B, et al. J Gastro Hepatol 2016 [updated]
HCV treatment in Australia
Slide credit: Prof Greg Dore, Kirby Institute, UNSW
32,550 =14% chronic HCV IFN-based
23
IFN-free
Hajarizadeh B, et al. J Gastro Hepatol 2016 [updated]
Modelling HCV Elimination in Australia Estimated year Australia meets World Health Organization target compared to 2015 estimates
Treatment scenario WHO target
Pessimistic
Intermediate
Optimistic
80% reduction in new chronic infections
2028
2026
2023
80% of people living with chronic HCV treated
2031
2026
2021
2029
2024
2021
65% reduction in HCV-related deaths
Slide credit: Prof Greg Dore, 24 Kirby Institute, UNSW
Kwon A, et al. AVHEC 2017
Itâ&#x20AC;&#x2122;s not all about generics. . .
Slide credit: DrAndrew Hill, University of Liverpool Presented at World Hepatitis Summit, SĂŁo Paulo, 2017
Treatments can be affordable right now
Slide credit: DrAndrew Hill, University of Liverpool Presented at World Hepatitis Summit, SĂŁo Paulo, 2017
Costs of the same medicines across borders
Slide credit: DrAndrew Hill, University of Liverpool Presented at World Hepatitis Summit, SĂŁo Paulo, 2017
Mongolia: Aggregate 2016 viral hepatitis B and B-D co-infection care cascade
PLHBV = people living with hepatitis B virus; Number diagnosed uncertain data quality (indicated with diagonal lines); Note that some services included B-D co-infection in their total numbers HBV diagnosed and in care and others did not; (%) in horizontal access is represented as a percentage of PLHBV for hepatitis B cascade numbers only; Range for â&#x20AC;&#x153;on treatmentâ&#x20AC;? for HBV only represents range from reported by treatment services (min) through reported by insurance data (max)
Testing and treatment represent a large proportion of elimination costs
Global resourcing for HIV, 2000-2015
Slide credit: Stefan Wiktor and Gottfried Hirnschall, WHO
Global elimination of viral hepatitis is the goal
Acknowledgements WHO Collaborating Centre for Viral Hepatitis VIDRL, Doherty Institute â&#x20AC;&#x201C; Epidemiology Unit Nicole Allard, Chelsea Brown, Kylie Carville, Jennifer MacLachlan, Karen McCulloch, Ashleigh Qama, Nicole Romero, Laura Thomas
Research & Programmatic Funding Department of Health and Ageing, Australian Government Department of Health and Human Services, Victoria Melbourne Health Office for Research & RMH Foundation Cooperative Research Centre for Spatial Information Peter Doherty Institute for Infection and Immunity
www.doherty.edu.au/whoccvh
Hepatitis C Diagnosis and Management
Declaration of Interest I receive no funding of any kind from any pharmaceutical or other for-profit health-care-related company
Advisory for people living with viral hepatitis Contains medical information, medical diagrams
Hepatitis C globally â&#x20AC;˘ 71 million persons are infected with HCV globally â&#x20AC;˘ 1.75 million new infections /year (IDU and unsafe health care)
1. Hajarizadeh, B. et al. (2013) Nat. Rev. Gastroenterol. Hepatol. 10, 553-562. 2. Gower E. et al (2014) J Hepatology 61 (1):S45-57. 3. Global Hepatitis Report 2017. Geneva: World Health Organization; 2017
Hepatitis C nationally 3,606 in NT
HCV genotypes in Australia
20,549 in WA 47,356 in QLD
227,306
80,700 in NSW
11,682 in SA 3,591 in ACT 55,261 in VIC 4,561 in TAS Kirby Inst. HIV, viral hepatitis and sexually transmissible infections in Australia. Annual Surveillance Report 2016
Victorian Infectious Diseases Reference Laboratory (VIDRL) (data on file)
Hepatitis C nationally
199,412
3,606 in NT
HCV genotypes in Australia
20,549 in WA 47,356 in QLD
227,306
80,700 in NSW
11,682 in SA 3,591 in ACT 55,261 in VIC 4,561 in TAS Kirby Inst. HIV, viral hepatitis and sexually transmissible infections in Australia. Annual Surveillance Report 2016
Victorian Infectious Diseases Reference Laboratory (VIDRL) (data on file)
HCV treatment in Australia
IFN-based
6
Slide credit: Prof Greg Dore, Kirby Institute, UNSW
IFN-free
Hajarizadeh B, et al. J Gastro Hepatol 2016 [updated]
HCV treatment in Australia
IFN-based
7
Slide credit: Prof Greg Dore, Kirby Institute, UNSW
IFN-free
Hajarizadeh B, et al. J Gastro Hepatol 2016 [updated]
HCV treatment in Australia
Slide credit: Prof Greg Dore, Kirby Institute, UNSW
32,550 =14% chronic HCV IFN-based
8
IFN-free
Hajarizadeh B, et al. J Gastro Hepatol 2016 [updated]
HCV treatment in Australia: Prescriber type Gastro
ID
Other specialist
GP
Other
Slide credit: Prof Greg Dore, 9 Kirby Institute 2017 (http://kirby.unsw.edu.au/research-programs/vhcrp-newsletters) Kirby Institute, UNSW
Treatment Unlike HIV and HBV infection, HCV infection is curable • No integration into host genome Cure = Undetectable HCV RNA at 12 weeks after completion of antiviral therapy for chronic HCV infection = Sustained Viral Response (SVR 12) • Cure means the virus is gone, but liver damage may still present and need further investigation or ongoing surveillance • Cure is durable but does not provide immunity to re-infection (despite anti-HCV remaining POSITIVE) Aghemo A et al, J Hepatol 2012;57:1326-35; Ghany MG, et al. Hepatology. 2009;49(4):1335-1374; Hill A et al, AASLD 2014
Who to offer HCV testing to • • • • • •
• • • •
•
People who inject drugs or who have ever injected drugs People in custodial settings People with tattoos or body piercing People who received a blood transfusion or organ transplant before 1990 Children born to women living with HCV infection Sexual partners of people living with HCV infection (individuals at higher risk of sexual transmission include men who have sex with men and people with HCV-HIV coinfection) People infected with HIV or chronic hepatitis B People with evidence of liver disease (persistently elevated alanine aminotransferase level) People who have had a needle stick injury Migrants from high-prevalence regions (Egypt, Pakistan, Mediterranean and Eastern Europe African and Asia) AND ANYONE WHO ASKS
Hepatitis C Virus Infection Consensus Statement Working Group. Australian recommendations for the management of hepatitis C virus infection: a consensus statement (August 2017).
Symptoms Acute HCV • Mostly asymptomatic • Non-specific symptoms: nausea, lethargy, anorexia, vomiting, jaundice • Fulminant liver disease (acute liver failure) extremely rare Chronic HCV • Usually nothing specific; and often nothing at all! • Tiredness, lethargy, nausea, intolerance/dislike of certain foods, depression, upper abdominal discomfort, reduced concentration ( “brain fog”) Decompensated Cirrhosis • Abdominal distension, ankle swelling, jaundice, skin lesions (spider angiomas, palmar erythema),leukonychia, confusion
What tests to order In comments or notes section: ? hepatitis C infection. Lab tests ordered for hepatitis C evaluation: hepatitis C antibodies (Anti-HCV) + HCV RNA (qualitative) or HCV quantitative RNA (HCV viral load) + Genotype (still. . . ?)
Interpreting Results
Anti-HCV
Ab
RNA
Antibody test EVER come into contact with HCV
+
+
Ab
RNA
+
-
Ab
RNA
-
-
HCV RNA
Infected with HCV NOW
Infected with HCV in the PAST
Infected with the virus NOW NEVER infected with HCV
Patient Assessment Prior to Therapy After diagnosing HCV infection: •
Define the HCV infection o
Genotype: influences treatment regimen – PBS requirement
o
Viral load: quantitative HCV PCR -
•
•
Determine the impact of HCV infection on the liver o
Likelihood of advanced liver disease / cirrhosis – PBS requirement
o
Previous treatment history: failure with P/R, PI, DAAs
Define other factors that may influence the disease progression and/or the response to treatment o
•
Important for genotype 1 – 8 weeks for sofosbuvir/ledipasvir
Eg, alcohol use, metabolic risk factors, HBV or HIV coinfection
Provide the patient with adequate information to make decisions on treatment
Disease Progression in Chronic Hepatitis C Fibrosis
Cirrhosis
Hepatocellular Carcinoma (with cirrhosis)
Decompensated cirrhosis: may have disordered synthetic function and be associated with: • Jaundice • Low albumin • Coagulopathy • Complications such as ascites, encephalopathy, variceal bleeding • May develop HCC
Compensated cirrhosis: have preserved liver function May develop HCC
Why it is Important to Diagnose Cirrhosis? • • • •
Implications for future prognosis Determines urgency for treatment to prevent complications Determines treatment regimen and duration Counselling: liver cancer screening, need for gastroscopy for oesophageal varices, vaccination e.g. influenza and pneumococcal pneumonia, bone mineral density scanning, managing cofactors: HBV, alcohol, obesity
Non-invasive Serum Marker For Assessing Liver Fibrosis Stage (Available in Australia) Serum biomarkers may be used to exclude the presence of cirrhosis in settings where access to Fibroscan is limited
Fibrosis Assessment - APRI Online Calculators
If APRI >1 : need further assessment to exclude cirrhosis
Hepatitis C Treatment Baseline Investigations:
Hepatitis C Virus Infection Consensus Statement Working Group. Australian recommendations for the management of hepatitis C virus infection: a consensus statement (January 2017). Melbourne: Gastroenterological Society of Australia, 2017.
Drug Interactions •
List of high-level interactions is relatively short o
• •
•
Varies depending on regimen chosen
List of ‘potential interaction’ drugs is longer Review all prescription and OTC meds, herbals/ supplements Be alert for interactions with common drugs o
o
HEP Drug Interactions website
www.hep-druginteractions.org
Eg. Statin, proton pump inhibitor, birth control preparation Some herbs – esp. St John’s Wort
• Ask about PRN usage of other drugs HEP iChart app App store | Google Play
DAA Cure Rates â&#x2030;¥ 95% for people without cirrhosis 100 90 80
SVR 12 rates
70 60 50 40 30 20
10 0 LDV/SOF Viekira 1aViekira 1b GRZ/EBZ SOF/VEL DCV+SOF SOF+RBV SOF/VEL DCV+SOF SOF/VEL GRZ/EBZ SOF/VEL SOF+PR SOF/VEL SOF+PR SOF/VEL GT 1
GT 2
GT 3
GT 4
GT 5
Phase 3 trial results: no head to head trials Zeuzem Z, et al. EASL 2015. Abstract G07; Afdhal N et al. NEJM 2014; Kowdley J et al. NEJM 2014; Afdhal N et al. NEJM 2014; Feld JJ et al. NEJM 2014; Mangia A et al. AASLD 2015. Abstract 249; Ferenci P et al. NEJM 2014; Zeuzem s et al. NEJM 2014; Nelson D et al Hepatology 2015; Lawitz E, et al. NEJM 2013
GT 6
General Statement for Drugs for the Treatment of Hepatitis C Lists the: â&#x20AC;˘ Patient and prescriber eligibility conditions â&#x20AC;˘ Treatment opions available for PBS prescription
http://www.pbs.gov.au/healthpro/explanatory-notes/general-statement-pdf/general-statement-hepatitis-c.pdf
Remote Consultation Form
Can be incorporated into GP software Download from: GESA http://www.gesa.org.au/public/13/files/Hepatitis%20C/Remote%20consultation%20form%20v6%20Jan%202017.pdf ASHM http://www.ashm.org.au/HCV/prevention-testing-and-diagnosis-hepc/making-a-new-hepatitis-c-diagnosis
When to consider specialist referral • Patients with advanced fibrosis or cirrhosis • Patients with extrahepatic manifestations • Patients with other complicating health issues • Patients with significant kidney impairment • Patients with HCV/HBV or HCV/HIV coinfection
• Patients for whom first line DAAs failed • Patients for potential clinical trials of new HCV regimens (still??) • If the patient (or clinician) would prefer – could be to a more experienced GP (or nurse) instead! Australian Recommendations for the Management of HCV Infection: A Consensus Statement 2017
Key Points • All people living with HCV should be offered treatment
• Treating hepatitis C is increasingly straightforward • All GPs (and nurse practitioners) can treat on the PBS • Work with your patient/ pharmacist about supply issues
Epidemiology, trends, and whatâ&#x20AC;&#x2122;s new in chronic hepatitis B Jennifer MacLachlan Epidemiology, The Doherty Institute jennifer.maclachlan@mh.org.au
Regional Spotlight on Hepatitis B 21st Nov 2017
Overview • Epidemiology and determinants of chronic hepatitis B • Priority groups affected • Burden of adverse outcomes • Trends over time and geographic distribution • Recent developments and updates in policies and guidelines The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
The global burden of hepatitis B • An estimated 240 million million living with CHB • 80% of those affected live in Asia-Pacific and Sub-Saharan Africa world regions • 700,000 attributable deaths in 2015 – Cirrhosis, liver cancer
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
The global burden of hepatitis B
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
Schweitzer 2015
The global burden of liver cancer
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
International Agency for Research on Cancer 2012
Hepatitis B in Australia â&#x20AC;˘ Estimated 240,000 Australians living with hepatitis B in 2016
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
MacLachlan 2013, 2015
Hepatitis B in Australia Country of birth
Estimated prevalence
2016 Population
2016 living with CHB
China
7.6%
509,558
40,013
Vietnam
8.2%
219,351
18,564
Philippines
3.0%
232,391
7,299
Italy
2.5%
174,042
4,556
10.4%
46,822
5,066
Thailand
4.9%
66,228
3,393
Cambodia
9.2%
33,152
3,173
Hong Kong
2.9%
86,886
2,632
South Korea
2.5%
98775
2,524
Malaysia
1.7%
138,363
2,449
Taiwan
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
Epidemiology of new cases of hepatitis B • 1,836 cases newly diagnosed in 2016 • 53% male, median age 36 • 94% born overseas, 0.6% Aboriginal and Torres Strait Islander • 3% had a history of injecting drug use • 3% in prison at time of diagnosis The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
Department of Health and Human Services Notifications data, 2017
The local burden of hepatitis B
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
http://www.ashm.org.au/HBV/hepatitis-b-mapping-project/
The local burden of hepatitis B
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
http://www.ashm.org.au/HBV/hepatitis-b-mapping-project/
Hepatitis B in the Grampians • The estimated prevalence of hepatitis B in the Grampians region is below the Victoria state average, similar to other regional areas • One third overseas-born (China, Vietnam, Philippines) • Estimated treatment uptake is below the Victoria state average; lowest of any PHN in Victoria (1.7%) The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
The adverse burden of hepatitis B • Estimated 412 deaths attributable to hepatitis B in 2016 <10 due to acute infection • Projected to continue to increase • Liver cancer now 6th most common cause of cancer death – Most are preventable The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
The local burden of liver cancer
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
Carville 2017
The local burden of liver cancer
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
Carville 2017
The local burden of liver cancer Ethiopia Vietnam Burma Cambodia Sudan Egypt China Hong Kong
Females
Indonesia
Males
Fiji Malaysia Italy Greece Philippines Australia 0.0
50.0
100.0
150.0
200.0
250.0
300.0
350.0
400.0
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
Carville 2017
Hepatitis B trends and future projections Impact of local immunisation on newly acquired infections:
Impact of local immunisation on chronic infections:
8000
6000
4000
2000
Incident HBV infection – no vaccination
Incident HBV infection – current vaccination
Chronic HBV infection – no vaccination
Chronic HBV infection – current vaccination
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
Cowie 2010
Hepatitis B trends and future projections 25
230,000
23
210,000
21
People living with CHB
190,000
19
PLWCHB - projection
170,000
17
Australian Census population
150,000
15 2001
2006
2011
Millions
250,000
2016 The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
McCulloch 2017
Hepatitis B diagnosis, treatment and care 4.6% 5.9% 6.3% 6.8%
Treatment
2013
15%
2014 2015 2016 13.1% 15.4% 15.7% 16.8%
In care
80%
61% 62% 62% 63%
Diagnosed
0%
10%
20%
30%
40%
50%
60%
70%
80%
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
MacLachlan 2017
CHB Treatment uptake by PHN
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
http://www.ashm.org.au/HBV/hepatitis-b-mapping-project/
Epidemiology into practice • The population affected by CHB is highly diverse • CHB is severely under-diagnosed and access to care is poor • Adverse outcomes continue to increase in those affected • Highlights the need for engagement, testing, ongoing care, and a focus on chronic disease management The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
New developments in hepatitis B • Clinical – Only minimal changes to guidelines and policy – Testing and treatment landscape similar
• Policy – Increasing global recognition of need for action
• Research – Initiatives regarding HBV cure The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
http://ice-hbv.org/ http://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/
Summary • 1% of Australians are living with CHB • Most people affected were born overseas or are of Aboriginal & Torres Strait Islander background • Nearly half undiagnosed, adverse outcomes increasing and clustered geographically • Increasing global and local attention • Current technologies provide opportunities • Epidemiology demonstrates opportunities for intervention The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
Acknowledgements •
Epidemiology Unit, The Doherty Institute – Nicole Allard, Benjamin Cowie
• •
The Viral Hepatitis Mapping Project & Surveillance of Hepatitis B Indicators Project funded by the Australian Government Department of Health National Hepatitis B Mapping Project 2012-2016 was a joint project with the Australasian Society for HIV, Viral Hepatitis, and Sexual Medicine – Vanessa Towell, Katelin Haynes
•
Our work also supported by The Royal Melbourne Hospital Research Program and the Department of Health and Human Services
The Peter Doherty Institute for Infection and Immunity A joint venture between The University of Melbourne and The Royal Melbourne Hospital
Thank you With thanks doherty.edu.au
/DohertyInstitute @TheDohertyInst #DohertyInstitute
Spotlight on hepatitis B 2017 Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincentâ&#x20AC;&#x2122;s Melbourne
Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincentâ&#x20AC;&#x2122;s
Intro to hepatitis B…..….….... •
Transmission • Natural history
• Prevention
How is hep B spread? (1) Spread by contact with infected blood & body fluids
1. Perinatal • Mum with chronic hep B → baby • Most common globally
How is hep B spread? (2) 2. Blood to blood contact • Sharing injecting, snorting, tattoo & body piercing equip’t • Medical & dental & alternative therapy procedures, including acupuncture/cupping • Household – eg. Sharing razors/toothbrushes/nail clippers, open wounds • Receipt of blood products & organs • Occupational exposure • History of incarceration • Cultural practices – cutting, scarring…. Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincent’s
How is hep B spread? (3) 3. Sexual transmission • Unprotected sex
4. Early childhood • child/sibling to sibling. • open wounds/biting Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincent’s
How you DON’T get Hep B
Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincent’s
Acute and Chronic Hepatitis B Mum with current hepatitis B infection (HBsAg+) 95%
Acute (recovery)
10%
Adult 5%
90% Chronic (life-long)
Sexual /percutaneous transmission (in Aust)
Vertical Trans’n Infant (HBV vax & HBIG w/i 24 hrs protect ≥90%)
Acute hepatitis B Incubation – up to 10wks
Asymptomatic...or…hospitalised Jaundice, fatigue, itching, RUQ pain, arthralgia Liver function tests (LFTs) Most resolves within 2 months
Surface antigen (HBsAg) disappears Antibody(anti-HBs) to HBsAg appears Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincent’s
Chronic hepatitis B (CHB) • Hep B surface antigen (HBsAg)
persists > 6 months = CHB. • May be asymptomatic liver failure • Without treatment, up to 25% die early
from liver failure/cancer
Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincent’s
CHB - clinical features • • • • • • • • •
fatigue/ lethargy/ tiredness intolerance to alcohol, fatty foods loss of appetite, nausea muscle and joint pain abdominal pain bowel and skin irritations fever Jaundice ALT levels. Men ≥ 30, Women ≥ 19
Often there are NO signs &/or symptoms
Prevention (1) - Vaccinate against Hep B • World’s 1st anti-cancer vaccine
• Infants – at birth, 6-8wks, 4,6 mo. (4 doses) • Adults ≥ 20 yrs – 0,1,6 mo (3 doses) • Catch up for ≤ 20yrs • Refer to Aust’n Immun’n Handbook – 2013
• Health workers (?workplace), the client & their extended family. Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincent’s
Gov’t funded hep B vaccine, Victoria, 2017 • • • • • • • • • •
Household contacts or sexual partners of people living with HBV People who inject drugs or are on OST People living with hepatitis C Men who have sex with men People living with HIV Prisoners & remandees .....& those who didn’t complete course while in custody. Refugees & asylum seekers “Vulnerable citizen” Aboriginal & Torres Strait Islander people Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincent’s
Prevention (2) Standard precautions • hand washing & gloves • personal protective equip’t only if splash risk •
Deakin Uni research (Bouchoucha & Moore, 2017)
Safety with needles/sharps • safe practices • Needle Syringe Program Care with blood – spills, wounds Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincent’s
Prevention (3) Safer sex • Offer condoms/dams
Build capacity in… • strengthen com’y action • health literacy • cultural responsiveness Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincent’s
Australian Commission on Safety & Quality in Healthcare National Statement on Health Literacy – Aug 2014
“There is potential to not only improve the safety & quality of health care, but also to reduce health disparities and increase equity” Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincent’s
1986
Engage affected communities
Listen to them and support actions Reorient health care delivery Engage in care; use â&#x20AC;&#x153;teachbackâ&#x20AC;?
Think outside the box and be bold!
“Master Zanzu’s master class on hepatitis B” - Debbie Nguyen, NSW Cancer Council & students of Cabramatta High School.
www.hepbpositive.com.au/videohomepage/masterzanzu/
Take home messages • Promote vaccination & check status hi risk groups.
• Standard precautions always! • Hep B virus transmitted mainly by blood & sexual
fluids. • Mum to baby transmission most common globally • Hep B virus is dynamic, needs regular
monitoring to guide health care. • Improve our approach & communication
WE have the tools!............its not hard
2018 Health Literacy Course 60 percent of Australians donâ&#x20AC;&#x2122;t know how to find, understand and use information about their health and health care.
Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincentâ&#x20AC;&#x2122;s
Local, evidence based websites www.hepbhelp.org.au
- for clinicians www.ashm.org.au - free resources for HW www.gesa.org.au - Gastroenterology Ass’n http://www.ceh.org.au/ - health literacy/cultural competence www.hepatologyassociation.com.au AHA Nursing guidelines
www.svhm.org.au/home/health-
professionals/specialist-clinics/g/gastroenterology “The hepatitis B story” – education tool/booklets/videos in languages
Acknowledgments • Australasian Society for HIV Medicine (ASHM)
• NSW Cancer Council
Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincent’s
Thank-you Gabrielle Bennett Victorian Viral Hepatitis Educator St Vincentâ&#x20AC;&#x2122;s
gabrielle.bennett@svhm.org.au Ph: 9231 3586 Mob: 0447 865 140
Gabrielle Bennett, Victorian Viral Hepatitis Educator, St Vincentâ&#x20AC;&#x2122;s
Hepatitis C transmission, prevention and natural history Sione Crawford Hepatitis Victoria Western Victoria Regional Forum November 21 2017
Acknowledgement of Country
Copyright © Hepatitis Victoria
Today 1. Some hepatitis C data 2. The Liver & impact of viral hepatitis 3. Transmission of hepatitis C 4. Transmission prevention & harm reduction 5. Testing & Treatment
6. Direct Acting Antiviral Uptake 7. Treatment Journey 8. Stigma & Discrimination
Copyright Š Hepatitis Victoria
Hepatitis C
2016
End: 199412 living with hep C in Australia
HCV by State
48077, 24% ACT VIC NT QLD SA
TAS NSW WA
Approx 35,000 people cured in 2016
Copyright © Hepatitis Victoria
Priority Populations Hepatitis C in Australia concentrated in key populations
PWID who attend NSP: 51% (2016) – down from 62% - 2007*
Prison entrants: 24% in Men and 28% in Women #
Aboriginal people – a 25% increase in notifications rates in those under 25 cf. a decrease in non-Aboriginal people over last 5 years
Overrepresented 9% of people with hep C cf 3% of population Kirby Annual Surveillance Report 2017
* Australian NSP Survey 2016 # New Prison Entrant Survey 2016 Copyright © Hepatitis Victoria
The Liver
Copyright © Hepatitis Victoria
The Liver - Functions
Copyright © Hepatitis Victoria
What is hepatitis? • Hepatitis means inflammation of the liver • Range of causes – Excessive alcohol consumption – Fatty liver disease – Some chemicals and medications – Autoimmune disease
– Viral infection
Copyright © Hepatitis Victoria
Impact
• When the liver is inflamed, scar tissue
can develop - this impairs liver functioning • Scar tissue is known as fibrosis • Extensive scarring is known as cirrhosis Copyright © Hepatitis Victoria
Hepatitis C
• Viruses are organisms that can reproduce and over time, evolve
• That is why there are many types of viral hepatitis and many “genotypes” of hep C • ”
Copyright © Hepatitis Victoria
Hepatitis C Genotypes • Genotypes- sometimes called “strains” are slightly differently evolved versions of the hep C virus • They are numbered: 1a, 1b, 2, 2a, 2b, 3a etc • The most common in Australia and NZ are 1a, 1b, 2, 3a
Copyright © Hepatitis Victoria
Transmission
Only transmitted from the blood
of a person living with Hep C entering into the blood stream
of another person
Copyright Š Hepatitis Victoria
Transmission High Risk in Australia
90% of all new infections
Copyright Š Hepatitis Victoria
Other routes of transmission…..
Copyright © Hepatitis Victoria
Priority populations
Aboriginal people
PWID
CALD Prison Young People
Priority pops In Australia people who inject are the community hepatitis C overwhelmingly affects - 60-70% of current injectors are hepatitis C positive Copyright Š Hepatitis Victoria
Prevention
Harm Reduction and Needle and Syringe Program Biggest contributor to preventing hepatitis C infections
Copyright Š Hepatitis Victoria
Needle & Syringe Programs 1986 – Sydney: 1st illegal programs – drug users already undertaking joined by medical Drs – esp St Vincent’s King’s X • Response primarily to HIV and fear of “3rd wave” • Dramatically successful HIV prevention • Hep C already entrenched and health promotion messages focused on HIV risk
Copyright © Hepatitis Victoria
NSP Return on Investment from 2000-2009, Australiaâ&#x20AC;&#x2122;s NSP distributed 31 million needles & syringes preventing:
32,050 new HIV infections
96,667 new HCV infections
And Saving $4 for every $1 invested
NSPs are one of the most cost-effective public health measures in Australia
*http://www.health.gov.au/internet/main/publishing.nsf/Content/needle-return-2
Copyright Š Hepatitis Victoria
Harm Reduction continued Harm Reduction is common:
Bike helmets Seat Belts Sunscreen
Alcohol limits
None stop the activity that may lead to injury but they reduce harms for those who continue Copyright Š Hepatitis Victoria
Testing Test
Window
Tests for
Antibody
3 months
Exposure only (25% may clear spontaneously)
PCR Test
2-6 weeks Genotype; Viral Load; Virus presence
An antibody test will always be positive even AFTER someone has cleared the virus or cleared through treatment.
Copyright Š Hepatitis Victoria
Screening and testing for Hep C
TYPES
1. Antibody (screening) test 2. PCR (detailed) test
An Antibody Test:
A PCR test confirms:
• Confirms somebody has been exposed to hep C
• Virus presence
• Doesn’t tell us if it has been cleared • 3 month window
• Gentoype • Viral Load • 2-6 week window
up to 25% of people clear hep C naturally – but you can never be immune! Copyright © Hepatitis Victoria
Pre and Post Test Discussion • High proportions report negative experience of diagnosis 7/10* • Informed consent for the test • Understanding what tests they are having and why • What a positive result will mean for them • Are they prepared to receive a positive result?
• Are YOU prepared to give a positive result? • What supports do they have? How much support will they need from you?
• For a negative result how will you address ongoing risk? *Treloar et al, 2004; ASHM 2012
Copyright © Hepatitis Victoria
“Natural History” Natural history is a term which means “the natural progression of an illness, without treatment” Not everyone develops serious damage, but the longer it is untreated, the more likely it becomes Copyright © Hepatitis Victoria
Early Hepatitis C • Seldom diagnosed in acute stages • Hepatitis C is largely asymptomatic • Some may include tiredness, weakness and malaise – so easily mistaken for general weariness
• Drug use can confuse things further • 20-25% of people clear hepatitis C naturally or spontaneously
• Antibody becomes detectable 1-3 months after infection
Copyright © Hepatitis Victoria
Living with hepatitis C
Disease progression Factors that speed this process up
Co-infection: HIV, hepatitis B
Gender
Viral load
Diet/weight
Genes
Stress
Alcohol Copyright Š Hepatitis Victoria
Chronic Disease Management
Moderate Drinking
Healthy Diet
Regular Monitoring Copyright Š Hepatitis Victoria
Fibroscan
Copyright © Hepatitis Victoria
Treatment Revolution – DAA’s
Copyright © Hepatitis Victoria
Copyright © Hepatitis Victoria
Treatment / DAA Uptake
The Kirby Institute. Monitoring hepatitis C treatment uptake in Australia (Issue 7). The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia, July 2017 Copyright Š Hepatitis Victoria
DAA Falloff
The Kirby Institute. Monitoring hepatitis C treatment uptake in Australia (Issue 7). The Kirby Institute, UNSW Sydney, Sydney, NSW, Copyright © Hepatitis Victoria
Copyright © Hepatitis Victoria
PWID who do not access services at all
? ? ?
Isolated from health care system
Copyright Š Hepatitis Victoria
Post Treatment Issues for individuals
• There are a number of post treatment issues arising for people
• Ongoing side effects • Identity issues
• Can I donate blood? • Antibody testing
• Can I have my name taken off notifications?
Copyright © Hepatitis Victoria
Stigma & Discrimination • Hep C association with injecting drug use = large amount of stigma
• Most positive people have a story of discrimination
• Leads to negative health outcomes
• Of particular concern in Aboriginal and CALD communities
Copyright © Hepatitis Victoria
Disclosure By law, a person living with viral hepatitis does not have to disclose This includes telling employers, doctors, dentists, social workers, boyfriend/girlfriend, Centrelink, government officials etc.
Copyright Š Hepatitis Victoria
Disclosure of hepatitis C status
Exceptions to this are: – if you want to join the army/navy
– if you take out health/life insurance – if you donate blood – if you are a healthcare worker doing “exposure prone procedures” – If you participate in sports without the blood rule e.g. cage fighting
Copyright © Hepatitis Victoria
Universal precautions and the blood rule… Treat all blood as a potential risk • Reduce risk • Eliminate the temptation to judge • Eliminate the need to disclose • Anyone could have a BBV • It is the legal responsibility of the workplace to establish and maintain a safe working environment
• Universal precautions are designed to protect the health of both worker and clients
Copyright © Hepatitis Victoria
Thank You
Harm Reduction / Safer Injecting Demo at lunchtime
Copyright © Hepatitis Victoria
Hepatitis Victoria Stigma and Discrimination
Stigma and Discrimination • Stigma and discrimination is often present in the lives of people living with viral hepatitis. • Stigma is a word used to describe negative social attitudes towards an aspect of someone’s behaviour, health, or identity. • Stigma can also be experienced ‘internally’, where someone feels a sense of shame, failure or fear, for example, due to social attitudes. • Discrimination, on the other hand, is a legal term in Australia that defines certain specific behaviours as illegal. • Discrimination laws allow people to make formal complaints or to take legal action about specific occasions of stigmatising behaviours.
Copyright © Hepatitis Victoria
Forms of discrimination • Direct discrimination is when a person treats, or proposes to treat, someone unfavourably because of a personal characteristic protected by law. For example, if an employer refused to employ someone because they have hepatitis B and the employer thinks this will mean an employee needs more sick leave than others, this would constitute discrimination. • Indirect discrimination occurs when a workplace policy, practice or behaviour seems to treat everyone the same, but disadvantages someone because of a personal characteristic such as disability. For example, an expectation that all staff in an organisation will work after hours on certain days may be indirect discrimination. Whilst it might appear fair, as all employees are expected to do it, it could actually disadvantage someone who may experience fatigue in the evenings due to viral hepatitis.
Copyright © Hepatitis Victoria
Legal rights • In Victoria, under the Equal Opportunity Act 2010 (VIC), discrimination is treating, or proposing to treat, someone unfavourably because of what is called a personal or ‘protected characteristic’. • Hepatitis is classed as a protected characteristic and it is therefore illegal to discriminate against anyone living with viral hepatitis.
Copyright © Hepatitis Victoria
Instances where discrimination is legal • There is a real risk to your health, safety or property (or to other people’s) and the discriminatory measures are needed to protect you. • The discriminatory measures were taken to assist people with special needs or disabilities, such as providing accessible services and facilities. • An employer would have to make un-reasonable adjustments to their workplace or work situation so that you could apply for, or perform, a job. • You could not adequately perform a job even if an employer made reasonable adjustments to the workplace or work situation.
Copyright © Hepatitis Victoria
Barriers to service provision • Stigma and Discrimination provide barriers for health service provision to individuals living with viral hepatitis. • This can be due to past instances where individuals may have experienced discrimination, fear discrimination or perceive stigmatising behaviours. • Individuals don’t have to personally experience stigma and discrimination to be wary of accessing services. • These behaviours reduce the likelihood of individuals returning to a service
Copyright © Hepatitis Victoria
What we’re doing • In an effort to reduce instances of stigma and discrimination pertaining to individuals living with viral hepatitis we’re focusing on raising awareness and educate practitioners within the health service provision sector to minimise the occurrences. • This has been done through the creation of a forum to discuss stigma and discrimination within the community. • In addition to the development of specific stigma and discrimination resources to help develop not only an understanding of stigma and discrimination, but also of the routes in which to challenge them within a legal framework.
Copyright © Hepatitis Victoria
State Forum • Did you know under discrimination law, hepatitis B and C are disabilities, and therefore covered by disability discrimination law? • Do you have a good understanding of behaviours that can be stigmatising? Do you know when stigmatising behaviours become discrimination, legally? • Do you know the laws around health information (such as someone’s hepatitis status) and privacy? • Would you know what to do if you, or someone you know, experiences stigma, discrimination or privacy breaches? Copyright © Hepatitis Victoria
FREE State Forum 7th December - Melbourne Town Hall Collins Street Melbourne, Vic, 3000
Registrations online at www.hepvic.org.au
Copyright Š Hepatitis Victoria
Management of Hepatitis C in the community Kirsty Simpson Integrated Hep C Nurse Michelle Orr Community Health Nurse Hep C Health Promotion
Nurse Led Clinics • Horsham Medical Centre (monthly) • Stawell/Ararat Community Health Centre’s (monthly) • Daylesford Medical Centre/Trentham (monthly)
Nurse Led Clinics • Maryborough Community Health (monthly • Nhill Hospital consulting suites (Bi Monthly) • Ballarat Health Services Liver Clinic (Monthly)
Pre-Treatment Assessment & Education • Work up Bloods • Hep C PCR, Geno Type and Log Viral load • Hep A & B serology • FBE, U&E and LFT
• Fasting Lipids and Glucose • Coagulation studies • APRI
• Fibroscan • Ultrasound if required • Clinical Assessment • Education
Client Support during Treatment blood tests • Week 4 LFT • Post treatment 3/12 qualiative PCR viral Load Weekly contact • Phone call • Text • email
Client Support during Treatment Encouraged to have regular appointments with GPâ&#x20AC;&#x2122;s
Aware of support outside of normal working hours
Results since March 2016 •112 clients treated through Nurse Led clinic’s (1 didn’t clear virus) •370 clients in total in the Grampians region
Hep C Health Promotion •Engaging with Community Groups •Youth within school community •Youth not engaged in main stream school •Youth Detox and Rehab groups •Youth AOD •Adult AOD
Hep C Health Promotion •Engaging with Health worker •GP clinic •Council worker •Community Health •AOD workers •Mental Health workers •Justice workers •Homelessness workers
Hep C Health Promotion • Presentations include • • • • •
Risk factors Harm minimisation Myth busting Stigma and discrimination Treatments and referrals
Contact details Michelle Orr PH03 53384505 mobile 0477 344 757 michelleor@bchc.org.au
Referral Pathways Referral via Integrated Hep C Nurse Kirsty Simpson Ballarat Community Health Email: kirstys@bchc.org.au Mobile: 0459 819 601
Referral can be received from GP or Client initiated
Referral Pathways • Ballarat Health Services Liver Clinic Gastroenterology Department • Dr Mohammed Al-Ansari & Dr Raquel Cowan Phone: 5320 4211 • Chloda Sainsbury (Hep C Nurse, BHS) Ballarat Based clients
Referral Pathways •Springs Medical Centre •Dr Albert IP • PH 03 5348 2227
Case Study •40yr old Male •1st referred 2014 •Medical Hx •Chronic back pain •Anxiety and depression •Erectile disfunction
Case Study •Medications •Methadone •Lexapro •Risperadone •Valium •Viagra •Sodium Valporate
Case Study •Social •Disability Pension •Separated from partner •2 children with regular contact •Supportive parent •Lives' independently •No Alcohol since 2013 •Injecting drug use 1998-2014
Case Study •Results •Fibroscan 11.1 •GenoType 3a •Viral load 6.893 •ALT 53 •All other bloods in normal range
Case Study •Treatment •Peg interferon 180mcg •Ribavirin 400mg Mostly compliant with regular contact and visits at the nurse led clinic PCR at Week 12 1.556 Treatment continues PCR at week 24 detected
Case Study •Treatment •2016 •Requesting treatment •Daklinza 24/52 •PCR week 12/24 not detected •PCR 3/12 post treatment SVR •Discharged
Future Plans •Fibroscan Clinic’s •Youth Detox unit •AOD clients •AOD rehab •Homeless support services •Needle exchance