1. INSERVICE AN INTERACTIVE JOURNEY BY NICK AND JONO

2. CASE 1: Liver-ing it Up Joan Walgett is a 43 year old mother of two well known to the practice. She presents today with mild flu-like symptoms, a sore stomach, some nausea and vomiting, and has been feeling tired. What could be wrong?

3. Hepatitis Symptoms Symptoms last a few weeks and include: o Flu-like illness o Loss of appetite o Nausea and vomiting o Aches o Fever o Jaundice o Dark urine

4. CASE 1: Liver-ing it Up What are some important considerations in a history from this patient?

5. Case 1: Liver-ing it Up Important points to cover in history: o Risk factors/spread o Surrounding people at risk o Symptoms – only 1/3 experience symptoms

6. Transmission of Hepatitis Mother to Child Sex Contaminated personal items Blood Transfusions Piercings and tatoos IVDU

7. Necessary Conversations How do you think you should tell the patient they have hepatitis B?

8. How to Break Bad News SPIKES: o Setting o Perception o Invitation o Knowledge transfer o Empathy o Summarise and Strategies

9. Case 1: Liver-ing it Up Joan wants to know more about her illness and the risks associated with it, she has two young kids and is worried for their safety. What does she need to know?

10. Patient Education o Mode of transmission o Surfaces contaminated with body fluids need to be cleaned and disinfected o Don’t share personal items like razors o Don’t donate blood or body parts o Safe sex o You can have unprotected sex with a hep B positive person if adequately immunised (positive serology result) o Importance of treating hepatitis B positive mothers before birth o Notify medical/dental workers of condition

11. How do we catch it? 77,000 NSW residents are estimated to have hepatitis B o Indigenous Health Check – (Medicare item 715) o Contact Tracing o Initial symptomatic presentation

12. Contact Tracing Identification – sexual contact in the last 6 months, newborn children, people in close contact Reportable – tell public health as it is a reportable disease Only confirmed cases with laboratory evidence must be reported Detection of HBsAg in a patient shown to be previously negative OR detection of HBsAg or IgM to HBcAg unless prior hepatitis B infection OR detection of hepatits B virus by nucleic acid testing and IgM to HBcAg N.B – transient HBsAg positivity can occur after hepatitis B vaccine, but is unlikely to persist after 14 days * The treating doctor is responsible for following this up!

13. Prevention NSW Hep B Strategy 2014-20: o Hepatitis B childhood vaccine coverage (95%) o All pregnant women are screened for hepatitis B o All babies with infected mothers are given immunoglobulins o Reduce sharing of injecting equipment o Increase antiviral treatment

14. Consequences of Hepatitis B What do you think the consequences of hepatitis B are?

15. Consequences of Chronic Hep B o Cirrhosis o Hepatocellular Carcinoma o Decreased QoL due to symptoms

16. Monitoring and Management o Local Health Districts o Build support systems o Targeted education o Increased investigations for screening of liver cancer o Government o Supporting GPs and Nurse Practitioners in Hep B management and treatment through the Highly Specialized Drug Program o Educate about diet, exercise, and alcohol o Limit alcohol o Regular exercise o Dietary restrictions

17. THANKS FOR LISTENING!!

18. References o Baile, Walter F., et al. "SPIKES—a six-step protocol for delivering bad news: application to the patient with cancer." The oncologist 5.4 (2000): 302-311. o Australian Indigenous HealthInfoNet (2008) Summary of hepatitis A/B among Indigenous Australians. Retrieved [4/11/2015] from http://www.healthinfonet.ecu.edu.au/infectious- conditions/hepatitis/reviews/our-review-abhttp://www.healthinfonet.ecu.edu.au/infectious- conditions/hepatitis/reviews/our-review-ab o Hepatitis B Communicable Disease Factsheet, NSW Health (2013) Communicable Diseases Department, http://www.health.nsw.gov.au/Infectious/factsheets/Factsheets/hep-b.pdf, accessed 6/11/2015http://www.health.nsw.gov.au/Infectious/factsheets/Factsheets/hep-b.pdf o NSW Hepatitis B Strategy 2014-2020, NSW Ministry of Health (2014) http://www.health.nsw.gov.au/hepatitis/Publications/HepatitisBStrategy.pdf, Retrieved [4/11/2015] o Hepatitis B Communicable Disease Protocol, NSW Health (2015) Communicable Diseases Department http://www.health.nsw.gov.au/Infectious/controlguideline/Documents/hepatitisB.PDF, accessed 7/11/2015