NSW HEPATITIS INFOLINE

What you need to know about hep B | part 4

What you need to know about hep B | part 4

What you need to know about hep B | part 4

This article – part 4 of 8 – was written by Dr Alice Lee , Gastroenterologist and Hepatologist, Concord Repatriation General Hospital.

Liver cancer | part 1

One of the most serious complications of hepatitis B is the development of liver cancer. All people with chronic hepatitis B infection are potentially at risk of developing liver cancer. Even so, some are at higher risks than others. There are screening protocols for those at high risk, regardless everyone with hepatitis B should be considered for screening.

The primary cause of liver cancer is hepatitis B, not alcohol

High risk hepatitis B groups for increased risk of liver cancer are anyone with cirrhosis, a family history of liver cancer, and older people (men over 40 years and women over 50 years). However, people outside of this group can still develop liver cancers and they require close monitoring. As discussed previously, all people with hepatitis B require lifelong monitoring for both the liver condition and for consideration of liver cancer screening.

There are different types of cancers that can affect the liver. Primary liver cancers are cancers that develop in the liver cells – known as “hepatocytes”. Other types of liver cells such as bile duct cells can also lead to cancer, but this is not directly related to hepatitis B. Cancers from other sites can also spread to the liver so that liver cancers can be secondary to cancers that have started elsewhere. This article will discuss the primary type, which is refered to as liver cancer or hepatocellular cancer.

Liver cancer is one of the most common cancers in the world

Primary liver cancer is one of the most common cancers in the world – ranking fifth – and is the second leading cause of cancer related deaths in the world. It is one of the cancers that is continuing to increase in number. Apart from hepatitis B, there are other conditions that can increase the chance of developing liver cancer. This includes cirrhosis from any cause. This could include alcohol, fatty liver, hepatitis C, autoimmune liver disease, iron storage disease as well as metabolic conditions. Cirrhosis is a condition of severe liver scarring that covers a wide spectrum of symptoms, and so some patients may not realise that they have cirrhosis until they are very sick. It can sometimes be picked up early by blood tests as well as some imaging studies. Anyone with ongoing abnormal liver tests should ask their doctor about how their liver is doing.

It’s not easy to find liver cancer – multiple tests are needed

Screening for liver cancer is recommended in groups of patients at increased risk. This is done using a liver ultrasound and, in some cases, a tumour marker blood test – an alpha fetoprotein (AFP) – every six months. Since liver inflammation, cirrhosis and non-related liver diseases such as pregnancy and testicular cancer can cause an elevated AFP, there is ongoing research to try and find an accurate and simple blood test to identify liver cancer early.

Liver ultrasound is simple and safe as there is no radiation exposure. Preparation for the procedure requires fasting. As with all tests, there are limitations. It relies on the skills of the sonographer, the patient’s body build/physique and fasting state. Patients are asked to fast because the bowel can get in the way and overlying gas can limit the views of the liver. In very large patients with fatty liver, the fat in the liver can make visualization difficult so that small liver lesions may not be found. Other liver conditions such as liver cirrhosis and the presence of many cysts can also interfere with getting good visualisation.

Liver cancer is more dangerous without symptoms

In a liver ultrasound, doctors are looking to find new, very small liver spots – often less than 1 cm across. Screening with an ultrasound is usually just a lead-in to other tests that will clarify the nature of any new liver spot. Not all new lesions are cancer, but all new liver lesions in people with underlying risk factor for liver cancer need further close scrutiny.

Next: In Part 5, to be published next week, Dr Lee will write more about liver cancer.

Published 4 February, 2021

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What you need to know about hep B | part 3

What you need to know about hep B | part 3

This article – part 3 of 8 – was written by Dr Alice Lee , Gastroenterologist and Hepatologist, Concord Repatriation General Hospital.

Hepatitis B treatment under other circumstances

There are special groups of patients for whom treatment is needed outside of the standard setting. This includes patients who need to undergo significant immune suppressive therapy; women who are pregnant and at risk of transmitting the virus to their unborn baby; and patients with co-infections such as HIV, hepatitis C or other significant chronic health conditions that place them at increased risk of complications. Family history of complications of liver disease such as liver cirrhosis and cancer are also considered as risk factors.

Our immune system causes liver scarring

The hepatitis B virus itself does not cause direct damage to the liver. Such damage is due to our immune systems response to the virus which causes the liver to become inflamed. Over time, this inflammation can lead to scarring. However, in certain clinical situations, when a person’s immune system is altered by medical treatment, hepatitis B can become “reactivated”. For instance, someone who is having cancer chemotherapy will have medicines to suppress their immune system. When the treatment is finished, their immune system becomes active again and this activity can lead to a flare of hepatitis. This is referred to as immune reactivation. Reactivation can be mild, and seen on routine bloods; but, in rare cases, this can be so severe that it can lead to liver failure. Having prophylaxis with antiviral therapy for hepatitis B can save the patient’s life.

There are non-cancer medicines that are also used to suppress the immune system for a variety of immune related disorders. These can also cause immune reactivation. Hepatitis B treatment is therefore given whilst on immunosuppressive therapy, and after stopping, for about six months. The doctor will test for hepatitis B and will advise what may be needed.

Hep B test for all pregnant women

Pregnant women are the other group of hepatitis B affected people where hep B treatment may be considered as a preventative measure. All pregnant women are screened for hepatitis B. In some cases, it may be the first time they find out they are hepatitis B positive. It is important that you receive lots of counselling about this condition and be assessed to determine whether you should have treatment or not. If you do not need treatment, a special blood test to measure the amount of virus in your blood will be done during pregnancy. This is to see whether there is an increased risk of transmitting the virus to the baby at birth.

Hep B vaccine for all newborn babies

In Australia, all babies (irrespective of their mother’s hepatitis B status) are given a hepatitis B vaccine at birth. For babies born to hep B positive mothers, an additional injection of an immune globulin is also given. Despite this, there is still a risk of the baby acquiring hepatitis B if there is a lot of the virus in the mother’s blood at birth. Hence, viral load during her pregnancy helps to determine whether additional medicines can be given to reduce this further. Tenofovir is the usual drug offered and is given around week 28 of pregnancy and stopped at some time after delivery. An obstetrician will work closely with the liver specialist in making sure the mother and her unborn baby are protected.

In addition to having treatment with regular monitoring, a mum to be needs to ensure that she takes good care of her health. General wellbeing including regular exercise, a well-balanced diet with high fibre, plenty of vegetables and protein is important. Avoiding excessive weight gain will also ensure other health benefits.

Next: In Part 4, to be published next week, Dr Lee will write about liver cancer.

Published 28 January, 2021

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What you need to know about hep B | part 2

What you need to know about hep B | part 2

This article – part 2 of 8 – was written by Dr. Alice Lee , Gastroenterologist and Hepatologist, Concord Repatriation General Hospital.

Diagnosing And Treating Hepatitis B

Once a diagnosis of chronic hepatitis B is confirmed through blood tests, an assessment is made. The assessment will be based on health history (including family history of liver cancer), a physical examination, further blood tests, ultrasound or CT and special imaging called Fibroscan. These are needed to determine whether treatment for hepatitis B is required, or if someone only needs to be monitored for now.

A careful assessment is needed to ensure that someone will benefit from hepatitis B treatment. There are two main reasons for this. Firstly, a person can have a chronic infection without it progressing to complications such as cirrhosis or liver cancer. Secondly, hepatitis B treatment (unlike hep C treatment) is not curative and is, in most cases, long term or lifelong once commenced.

What Is Cirrhosis And Can It Be Treated?

When the liver cells are damaged they become inflamed or swollen – this is called liver fibrosis. Over time this can build up and lead to cirrhosis of the liver – which is actual scar tissue in the liver. The scar tissue reduces blood flow through the liver. The liver then can’t do its work as well as it should.

All patients with cirrhosis should have treatment. Diagnosis of cirrhosis can be simple, but in some cases may require a combination of blood test, scans and a fibroscan that measure liver scarring. A fibroscan is a special type of non-invasive scan, like an ultrasound.

In people without cirrhosis, high liver function (ALT) readings associated with high virus count are indications for hepatitis B treatment. Even where an ALT reads normal, indicating no need for treatment, it can still go up without the person being aware. Hence, the need for regular check-ups – usually every six to twelve months.

Other considerations for treatment are older age, and a family history of liver cancer.

How To Treat Hepatitis?

Treatment for hepatitis B, if required, is very simple. It is one pill per day. There are one of two medicines that are used – entecavir or tenofovir. The medication is best taken at the same time each day (entecavir away from food; tenofovir is not affected by eating). Neither drug is associated with significant side effects but, as with all medicines, side effects are possible.

Tenofovir has been associated with renal issues and a doctor will need to regularly monitor kidney function. Both medicines need to be reduced to a lower dose if the person has reduced kidney function and this needs to be discussed with the doctor.

Once treatment is underway, it is really important that the medicines are taken regularly as resistance can occur, and there is also a risk of worsening liver disease, such as a flare, after stopping the medicine. These tablets are generally prescribed by specialists, but some GPs can also prescribe these medicines.

Regular monitoring whilst on treatment, usually six-monthly, is also critical with blood tests and ultrasound. The medicine is taken to control the amount of hepatitis B virus in the blood, which then leads to decrease in liver damage.

These hep B treatments have been available for decades and have been shown to be lifesaving, preventing and, potentially, reversing liver damage.

Can Hepatitis B Be Cured?

There are currently no cures for hepatitis B.

Liver cancer risks are lowered with treatment, but there is still a need for ongoing screening as the risks are not completely averted. The goals of treatment are initially to improve the liver tests (to get an ALT normalisation) and to stop the virus from replicating . In the long term, some patients have what is referred to as a “functional cure”, where the hep B surface antigen becomes negative.

For the small percentage of people who achieve this, usually after many years of treatment, their treatment can sometimes be stopped. Even after stopping treatment, they will still require ongoing monitoring. Regardless, where cirrhosis is present, lifelong treatment is still recommended.

For those who do not have cirrhosis, it remains critical that they discuss any interruption or cessation of medicines with their doctors.

What Is The New Medicine For Hepatitis B?

Treatments that have been available in the past include medicines such as lamivudine and interferon. There are limited roles for these medicines for special circumstances. New drugs are constantly under development in order to improve outcomes.

A newer version of tenofovir is available (tenofovir alafenamide) which is associated with fewer kidney issues. It is currently not widely available and not government funded.

Other drugs are being studied as ongoing efforts are being made to find a cure for hepatitis B.

Next: In Part 3, to be published next week, Dr. Lee looks at  other issues and circumstances around treatment.

Published 19 January, 2021

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What you need to know about hep B | part 1

What you need to know about hep B - part 1

This article – part 1 of 8 – was written by Dr. Alice Lee , Gastroenterologist and Hepatologist, Concord Repatriation General Hospital.

Referred to as the ‘silent killer, hepatitis B lives up to its name. Despite great efforts around the world to increase awareness of this virus, and to improve prevention, testing and treatment, there has sadly been no decline in global mortality rates. Nearly one million people die from hepatitis B, and its complications, every year.

What makes hepatitis B such a difficult and lethal virus?

Hepatitis B is a highly infectious virus, more so than hepatitis C and even HIV. In some parts of the world, the prevalence rates are very high – up to 20%. For Korean people, the prevalence rates have been markedly reduced by nationwide vaccination programs, but those who already have the infection remain at risk.

Even with vaccination, there are instances where, for those at high risk – such as babies born to mothers who have hepatitis B – vaccination may not be enough to prevent infection. Also, in some cases, one course of hepatitis B vaccine might not be adequate and further vaccination courses may be needed. It is safest for people to have a doctor check their blood tests – looking for protective antibody levels – to ensure that they are not in this group.

How do we test for hepatitis B?

Testing for hepatitis B is done by blood tests, but the levels of bloods tests can change over time whether you have treatment or not. Blood tests detect whether a person has:

  • the virus (hepatitis B surface antigen),
  • had the virus (hepatitis B core antibody) and/or
  • protection against infection (hepatitis B surface antibody).

Anyone living with the virus (hepatitis B surface antigen),will need to have further tests to see if they need to have treatment. The results of the tests can change over time, which can lead to misunderstanding about a person’s status.

Further testing is done through more blood tests and scans. It can be very complex and confusing to patients, but they should continue to check in with their doctors as it can save their life. Even if someone does not need treatment now, they may need to have treatment at a later date. Most people who need treatment are asymptomatic and may feel that they are alright and do not need to have checkups. This can be very dangerous because, if someone leaves it until they feel sick, then it may be too late.

How is hepatitis B monitored?

Hepatitis B can cause liver cirrhosis and liver cancer. While most people will live a normal healthy life with hepatitis B and not have any complications, identifying who is at risk, and who is not, is not so easy. Some key risks includes those who have a family history of liver cancer, other conditions that can increase risk of hepatitis B complications – such as other viruses or those who drink excessively – older patients, patients who have severe scarring of the liver(cirrhosis), have high liver enzymes (ALT) and those with high levels of virus (Hepatitis B DNA). All these factors are taken into consideration over time to decide whether treatment is required, or not, at a particular time.

Liver cancer is the most common cause of death from hepatitis B. It is also asymptomatic until very advanced and the best way to check for it is with regular ultrasounds and blood tests. If there are concerns about spots on your liver, a doctor may advise to have additional tests such as CT or MRI scans. All patients with a family history of liver cancer and all with cirrhosis should have checkups at least every six months.

Whether a person with hepatitis B is receiving treatment or not, screening can save their life. Ultrasounds are safe, there is no radiation, and they do not hurt. Anyone can have an ultrasound, as many times as needed. CT scans require radiation and hence should only be done when advised from a doctor. MRI is also available and accessible through a doctor. The benefits of an MRI is that there is no radiation, but it requires contrast (that is, requires the injection of a dye) and so is indicated for some patients only. People should ask their doctor about this if they have any concerns.

Next: In Part 2, to be published next week, Dr. Lee looks at  treatment options for Hepatitis B.

Published 12 January, 2021

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It was a case of second time lucky for my hep C cure

It Was A Case Of Second Time Lucky For My Hep C CureJames, one of our Community Peer Workers, has written a guest blog post about his experience of living with and being cured of, hepatitis C.

My early life, around Brisbane during the 1970s and 1980s, was difficult. Due to a family breakdown, I began living on and off the streets. Recreational drug and alcohol use became an everyday thing. During the early 1990s, I got an authority for morphine and benzodiazepines to help with the pain and anxiety from spinal injuries. In 2000, my then partner and I had a baby daughter, and we moved to Lismore to gain access to health services and education for ourselves, and to build a better life.

In Lismore, I decided I wanted to try and get off morphine. So, my authority was cancelled, and I was put on methadone maintenance program which I remained on for nearly 15 years. This was a time in my life when I discovered new rock bottoms, and a level of usage that transcended anything that had gone before.

I had resigned myself to live with, and perhaps die from, hepatitis C

A friend who was hep C positive was staying with me and we accidentally mixed up our injecting equipment. At first, I was not interested in getting tested for hep C. I knew the treatment that was available in those days was not suitable for me. Interferon could exasperate depressive conditions, and I didn’t need that in my life.

I had resigned myself to live with, and perhaps die from, hepatitis C; waiting for a better cure that was not even guaranteed. A few years later I was at the local Needle and Syringe Program, and I agreed to be tested for hep C. It came as no surprise to me to be told I was hep C positive.

Hep C related discrimination came from an unlikely source

Very early on I found who I had to disclose to, and who I didn’t have to. Discrimination came from the unlikely source of my family being frightened of dishes and toothbrushes, and so on. Such issues were easily sorted by educating them, and myself, to understand exactly what the risks were.

Just being sick for a long time brings judgment calls from people that don’t understand. Fatigue is seen as laziness, and a slight of character. This is the kind of discrimination I faced, mainly because I am so private. I believe that, with education, there’s no need to have any discrimination around this issue.

I saw my health deteriorate in many ways

Over the next few years I saw my health deteriorate in many ways. However, I wasn’t sure if that was due to the drugs, mental health issues, lifestyle, or all of the above. I believed hep C wasn’t having much effect on most folks living with it, and I was going to wait until new treatments the doctors had started talking about became available.

I had even started to become a stranger to myself

The impact of all of this on my life was quite far-reaching, especially in relationships. I had even started to become a stranger to myself. Some impacts were not at all obvious until after I was eventually cured. Broadly speaking, the symptoms I experienced while living with hep C included:

  • Mood swings and depression;
  • Digestive issues, nausea and poor appetite;
  • Skin problems, eczema, dermatitis; and
  • Lethargy, always tired but hard to rest.

Although I had put most of these down to drug use, and to getting old, after I was cured, I found this was not the case.

My first attempt at hep C treatment was unsuccessful

Around 2016, I got off methadone. I went to a healing centre for 12 weeks to get clean and then walked straight into hep C treatment.

My experience of getting access to treatment through the rehab was made easier by the support of case workers and doctors. As long as I kept my appointments and looked after myself the staff at the liver clinic kept the ball rolling for me. I was able to drop in most days if I needed to talk about treatment.

My first treatment was Harvoni. I was suitable for treatment but unfortunately it was unsuccessful. Apparently, I was a rare exception – the new treatments were usually very successful and almost side-effect free, but not for me. No side-effects, but no cure either.

As disappointing as it was for the first treatment to be unsuccessful, the liver clinic stayed in contact with me. They ensured I was able to get a second treatment as soon as possible.

I anxiously attempted another hep C treatment

Luckily, within a year a “salvage” treatment – Vosevi – became available. I was one of the first half dozen to receive it, and this time it was a success. I was cured!

With Vosevi there were quite a few side-effects, especially in the last four weeks. These side-effects were very similar to hep C symptoms, intensifying in the last four weeks and taking me about 12 weeks to recover from.

But now I feel better than I have felt in years.

The SVR test results – 12 weeks after finishing treatment – was, I think, the most important news I’ve ever been given. Without the SVR test there was no way of knowing if I was cured or not, so I anxiously waited for the results to then be told it was successful and the virus was gone.

Now I have something to give back

I’m grateful for my opportunity to come through this and to be able to put my hand up and say I’m there for anyone who is going through the same thing. The most beautiful thing about being gifted such an experience is that I now have something to give back.

Learn more about hep C by getting in contact with our Hepatitis Infoline on 1800 803 990,
or download one of our free online resources.

Published 25 August, 2020

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A quick guide to hepatitis A and hepatitis E

A Quick Guide to Hepatitis A and Hepatitis E

This article was written by Dr Alice Lee , Gastroenterologist and Hepatologist, Concord Repatriation General Hospital.

There are five varieties of viral hepatitis that affect the liver. Two of these – hepatitis A and hepatitis E – only cause acute hepatitis, or swelling of the liver, with recovery in most cases. These are two different viruses. Neither lead to chronic infection, cirrhosis or liver cancer. While hepatitis B, hepatitis C and hepatitis D often lead to chronic infection and its complications, causing the majority of deaths from viral hepatitis, the viruses for hepatitis A and hepatitis E are very important to understand. Both are preventable and contributes to overall mortality around the world.

What is Hepatitis A?

Hepatitis A is spread through contaminated food or water, or through direct contact with a person who has the virus. Hence, prevention is through access to safe clean water, food safety, and improved sanitation and hygiene. Hand washing is important. Higher rates of hepatitis A are seen in low- and middle-income countries. Other groups at risk of infection are men who have sex with men and people who inject drugs.

After having had hepatitis A, most people will recover and then have a lifelong immunity to the virus. Vaccination is available for those at risk of infection, including travelers to areas where infection is more common.

Most cases cause mild illness, but at times can lead to severe illness and death. Outbreaks can occur due to contaminated food or water. There were over 7,000 deaths around the world from hepatitis A in 2016. This represents less than one percent of deaths from hepatitis. People with underlying liver conditions can suffer with severe illness and, because of this, should be vaccinated.

What are the symptoms of Hepatitis A?

Symptoms from acute viral hepatitis are similar, irrespective of which virus is causing it. “Hepatitis” refers to inflammation of the liver which can cause nausea, fever, poor appetite, dark urine, jaundice (that is, yellow skin and body fluids), and abdominal discomfort. Diarrhoea is also seen with hepatitis A. Blood tests will confirm whether you have been infected recently or have been exposed in the past. Recovery time can be variable. There is no specific treatment apart from supportive care.

All Koreans should consider whether they are candidates for hepatitis A vaccination. Talk to your doctor.

What is Hepatitis E?

Hepatitis E has some resemblance to hepatitis A in that it is spread through similar means, particularly contaminated water. However, it has a different global pattern and is less common in Korea. It is very uncommon in Australia, with most cases being people arriving back from overseas – including from low- and middle-income countries in East and South Asia. Outbreaks are reported in refugee camps and after emergency situations (such as floods or earthquakes) where access to clean water is difficult.

In Australia, sporadic cases without any obvious source can happen, but this is usually associated with eating undercooked meat from infected animals. Globally, there are more than 20 million cases of hepatitis E each year, with about 15% having symptoms.

What are the symptoms of hepatitis E?

Symptoms are very similar to that of hepatitis A and the diagnosis is made based on history of travel as well as special blood tests. Hepatitis E can lead to severe illness, including liver failure. Death rates are highest in pregnant women. There is no specific cure for hepatitis E, treatment consists of supportive care with fluids and managing symptoms. Where needed, some patients may need to be hospitalised. Prevention remains key with good food hygiene and clean water. A vaccine has been developed for hepatitis E but is not widely available or used worldwide.

Prevent and identify viral hepatitis

Although these two viral infections have less overall impact compared with hepatitis B, hepatitis C and hepatitis D – which lead to chronic infection and death in nearly 300 million people globally – hepatitis A and hepatitis E still remain important to prevent and to identify.

Published 7 August, 2020

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