Hepatitis B - Medical, Personal and Contextual Issues

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  • Hepatitis B - Medical, Personal and Contextual Issues

    1. 1. Hepatitis B Medical, contextual & personal issues Bill Cayley MD MDiv
    2. 2. Learning objectives <ul><li>Learners should be able to: </li></ul><ul><li>Describe clinical assessment of a patient with Hepatitis B </li></ul><ul><li>Discuss patient-centered management of viral hepatitis </li></ul><ul><ul><li>Social and contextual issues </li></ul></ul><ul><ul><li>Personal issues </li></ul></ul>
    3. 3. Facets of care Personal Contextual Medical
    4. 4. Mr Wilbur L <ul><li>56 y.o. male with bloating & reflux </li></ul><ul><ul><li>Bloating x 1 year, worse over past few weeks, more discomfort and reflux </li></ul></ul><ul><ul><li>Denies nausea, diarrhea or constipation </li></ul></ul><ul><ul><li>Concerned about Hepatitis B </li></ul></ul>
    5. 5. Mr Wilbur L <ul><li>Medical History: </li></ul><ul><li>NKDA </li></ul><ul><li>Hep B diagnosis 6 months prior </li></ul><ul><ul><li>Requested eval 6 weeks after girlfriend (+) </li></ul></ul><ul><ul><li>Liver enzymes normal </li></ul></ul><ul><ul><li>Hep B S Ag, Hep B S Ab, Hep B C Ab (+) </li></ul></ul><ul><ul><li>No further f/u due to finances </li></ul></ul><ul><li>Family History: </li></ul><ul><ul><li>Insignificant </li></ul></ul><ul><li>Social History: </li></ul><ul><ul><li>Sexually active with girlfriend, monogamous x 1 year </li></ul></ul><ul><ul><li>No tobacco use, only social EtOH use. </li></ul></ul>
    6. 6. Mr Wilbur L <ul><li>Physical Examination: </li></ul><ul><li>Afebrile, BP 144/88, WD WN NAD </li></ul><ul><li>Heart RRR, no M/G/R. Lungs CTA. </li></ul><ul><li>Abd </li></ul><ul><ul><li>Tender epigastrium, mild hepatomegally </li></ul></ul><ul><li>Labs: </li></ul><ul><li>Alk Phos 68, ALT 108, T Bili 0.5 </li></ul><ul><li>Hb 15.7, WBC 4.0 </li></ul>
    7. 7. What is your assessment?
    8. 8. What is your assessment? <ul><li>Medical issues: </li></ul><ul><ul><li>Hepatitis B </li></ul></ul><ul><ul><li>Reflux and bloating </li></ul></ul><ul><li>Contextual issues: </li></ul><ul><ul><li>Lack of health insurance </li></ul></ul><ul><ul><li>Relationship with girlfriend </li></ul></ul><ul><li>Personal issues: </li></ul><ul><ul><li>Coping & responsibility </li></ul></ul><ul><ul><li>Prevention </li></ul></ul>
    9. 9. Hepatitis B <ul><li>1/3 of world infected, 1 million deaths/year </li></ul><ul><li>Transmission </li></ul><ul><ul><li>Body fluids: blood, semen, saliva </li></ul></ul><ul><li>Seqeullae (due to immune response) </li></ul><ul><ul><li>Acute infection: </li></ul></ul><ul><ul><ul><li>nausea, anorexia, fatigue, fever, RUQ or epigastric pain </li></ul></ul></ul><ul><ul><li>Chronic infection: </li></ul></ul><ul><ul><ul><li>Cirrhosis </li></ul></ul></ul><ul><ul><ul><li>Hepatocellular carcinoma (HCC) </li></ul></ul></ul><ul><ul><ul><li>12-15% risk of death from cirrhosis or HCC </li></ul></ul></ul>
    10. 10. Hepatitis B serology Source: Centers for Disease Control (http://www.cdc.gov/ncidod/diseases/hepatitis/b/Bserology.htm) Four interpretations possible * Negative Positive negative HBsAg anti-HBc anti-HBs     Chronically infected     Positive Positive Negative Negative HBsAg anti-HBc IgM anti-HBc anti-HBs    Acutely infected    Positive Positive Positive Negative HBsAg anti-HBc IgM anti-HBc anti-HBs Immune due to hepatitis B vaccination** Negative Negative Positive HBsAg anti-HBc anti-HBs      Immune due to natural infection     Negative Positive Positive HBsAg anti-HBc anti-HBs     Susceptible    Negative Negative Negative HBsAg anti-HBc anti-HBs   Interpretation Results Tests Interpretation of the Hepatitis B Panel
    11. 11. Chronic Hepatitis B infection <ul><li>Chronic disease </li></ul><ul><ul><li>HBsAg positive for longer than six months </li></ul></ul><ul><ul><li>Serum HBV DNA > 100,000 copies per mL </li></ul></ul><ul><ul><li>Persistent or intermittent elevation of ALT or AST </li></ul></ul><ul><ul><li>Liver biopsy showing chronic hepatitis </li></ul></ul><ul><li>Inactive HBsAg carrier state </li></ul><ul><ul><li>HBsAg positive for longer than six months </li></ul></ul><ul><ul><li>HBeAg negative, anti-HBe positive </li></ul></ul><ul><ul><li>Serum HBV DNA < 100,000 copies per mL </li></ul></ul><ul><ul><li>Persistently normal ALT and AST </li></ul></ul><ul><ul><li>Liver biopsy to confirm absence of significant hepatitis </li></ul></ul><ul><li>Resolved disease </li></ul><ul><ul><li>History of acute or chronic hepatitis B </li></ul></ul><ul><ul><li>Presence of anti-HBc, with or without anti-HBs </li></ul></ul><ul><ul><li>HBsAg negative </li></ul></ul><ul><ul><li>Normal ALT </li></ul></ul>
    12. 12. Hepatitis B evaluation <ul><li>History and physical </li></ul><ul><ul><li>Evaluate for S/Sx portal hypertension & liver failure </li></ul></ul><ul><ul><li>Family history of liver disease or HCC? </li></ul></ul><ul><li>Labs: ALT & AST, serum albumin, PT/INR, CBC, renal function </li></ul><ul><li>Viral status: HBeAg, anti-HBe, hepatitis B virus DNA </li></ul><ul><li>Screen for other parenterally transmitted viruses (HIV, Hepatitis C) </li></ul><ul><li>Test for immunity to Hepatitis A and vaccinate if necessary </li></ul><ul><li>Assessment for other sexually transmitted diseases </li></ul><ul><li>Liver biopsy to grade and stage disease </li></ul><ul><li>EGD to screen for esophageal varices </li></ul><ul><li>Screen for hepatocellular carcinoma </li></ul><ul><ul><li>ultrasound & alpha-fetoprotein levels </li></ul></ul><ul><ul><li>Sources: BMJ 2004;329:1080-6 & AFP 2004;69:75-82 </li></ul></ul>
    13. 13. Chronic Hepatitis B follow-up <ul><li>ALT q 3-6 months </li></ul><ul><li>If ALT levels are between 1-2 x ULN </li></ul><ul><ul><li>Recheck ALT q1-3 months </li></ul></ul><ul><ul><li>Consider liver biopsy if age 40, or ALT borderline </li></ul></ul><ul><li>Consider treatment if moderate/severe inflammation or significant fibrosis on bx. </li></ul><ul><li>If ALT > 2 x ULN for 3-6 months and HBeAg +, HBV DNA > 20,000 IU/ml, consider liver biopsy and treatment. </li></ul><ul><li>Consider screening for HCC </li></ul>
    14. 14. Costs of investigations <ul><li>Labs: </li></ul><ul><li>ALT $30.10  </li></ul><ul><li>Serum Albumin $28.50  </li></ul><ul><li>PT/INR $26.60  </li></ul><ul><li>CBC $88.70   </li></ul><ul><li>Serum Creatinine $26.30  </li></ul><ul><li>Viral Titres: </li></ul><ul><li>Hep B DNA  $294.60  </li></ul><ul><li>Anti-Hep C ab $171.70  </li></ul><ul><li>Anti-Hep A ab  $51.40  </li></ul><ul><li>HIV serology $91.90  </li></ul><ul><li>Procedures </li></ul><ul><li>EGD: </li></ul><ul><ul><li>Inpatient $20,443 </li></ul></ul><ul><ul><li>Outpatient $3,000  </li></ul></ul><ul><li>Liver biopsy $1100  </li></ul><ul><li>Abd ultrasound  $223.00 </li></ul>
    15. 15. Uninsurance <ul><li>Scope of problem (Jan – Sept 2006) </li></ul><ul><ul><li>US Population 14.9 % (43.8 million) </li></ul></ul><ul><ul><li>For part of prior year 18.7 % (54.7 million) </li></ul></ul><ul><ul><li>For all of prior year 10.5 % (10.5 million) </li></ul></ul>
    16. 16. Uninsurance <ul><li>Per capita medical expenditures (2001) </li></ul><ul><ul><li>Private insurance $2484 </li></ul></ul><ul><ul><li>Government insurance $2385 </li></ul></ul><ul><ul><li>Uninsured $1253 </li></ul></ul><ul><ul><ul><ul><li>Int J Health Serv. 2004;34(4):729-50 </li></ul></ul></ul></ul><ul><li>Percent w/o usual source of care (2004) </li></ul><ul><ul><li>Insured children (<18) 3% </li></ul></ul><ul><ul><li>Uninsured children (< 18) 29% </li></ul></ul><ul><ul><li>Insured adults (18-64) 10% </li></ul></ul><ul><ul><li>Uninsured adults (18-64) 50% </li></ul></ul><ul><li>Percent not getting care due to cost (2004) </li></ul><ul><ul><li>Insured 2% </li></ul></ul><ul><ul><li>Uninsured 20% </li></ul></ul><ul><ul><ul><ul><li>Health, United States, 2006 . </li></ul></ul></ul></ul>
    17. 17. Do patients tell us??? <ul><li>Survey of 660 chronically ill adults </li></ul><ul><ul><li>35% never addressed costs with clinician </li></ul></ul><ul><ul><li>ONLY… </li></ul></ul><ul><ul><ul><li>28% reported physician or nurse ever asked if prescriptions could be afforded </li></ul></ul></ul><ul><ul><ul><li>31% of those who reported addressing costs ever were given a less expensive alternative </li></ul></ul></ul><ul><ul><ul><ul><li>Arch Intern Med. 2004 Sep 13;164(16):1749-55 </li></ul></ul></ul></ul>
    18. 18. Future of family medicine <ul><li>Family physicians </li></ul><ul><ul><li>are committed to continuing, comprehensive, compassionate, and personal care… </li></ul></ul><ul><ul><li>must practice scientific, evidence-based, patient-centered care … </li></ul></ul><ul><ul><li>must accept a measure of responsibility for the appropriate and wise use of resources … </li></ul></ul><ul><ul><ul><ul><li>Annals of Family Medicine 2:S3-S32 (2004) </li></ul></ul></ul></ul>
    19. 19. Uninsurance dilemmas <ul><li>Referal to “safety net provider” </li></ul><ul><li>Forgo indicated tests and therapies </li></ul><ul><li>Reduce fees (Waivers? Adjust billing?) </li></ul><ul><ul><ul><ul><li>J Gen Intern Med. 2001 Jun;16(6):412-8 </li></ul></ul></ul></ul>
    20. 20. Uninsured care: guidelines <ul><li>Ask about financial concerns </li></ul><ul><li>Be knowledgeable about resources available </li></ul><ul><li>Take into account the loss of continuity of care </li></ul><ul><li>Physician may be forced to provide a nonstandard approach </li></ul><ul><li>Physicians should actively work to lower the cost of their services </li></ul><ul><li>Physicians must address issues of social justice outside of the office </li></ul><ul><ul><ul><ul><li>J Gen Intern Med. 2001 Jun;16(6):412-8 </li></ul></ul></ul></ul>
    21. 21. Moral career of poor patients <ul><li>Survey of 94 free clinic patients in France </li></ul><ul><li>Attendance Experiences </li></ul><ul><li>I. Occasional Humiliation </li></ul><ul><li>Pragmatism </li></ul><ul><li>II. Regular Initiation to regular care </li></ul><ul><li>Settling into care-receiving </li></ul><ul><li>Demanding for care </li></ul><ul><li>III. Inconsistent attendance </li></ul><ul><li>Instrumentalisation of services </li></ul><ul><li>Crisis of marginality </li></ul><ul><ul><ul><ul><li>Soc Sci Med. 2005 Sep;61(6):1369-80 </li></ul></ul></ul></ul>
    22. 22. Interpersonal issues <ul><li>Those w/ Hep B should : </li></ul><ul><li>Have sexual contacts vaccinated </li></ul><ul><li>Use barrier protection for sexual intercourse </li></ul><ul><li>Not share toothbrushes or razors </li></ul><ul><li>Cover open cuts and scratches </li></ul><ul><li>Clean blood spills with detergent or bleach </li></ul><ul><li>Not donate blood, organs or sperms </li></ul><ul><li>Those w Hep B can: </li></ul><ul><li>Participate in all activities including contact sports </li></ul><ul><li>Share food, utensils or kiss others </li></ul><ul><li>AND </li></ul><ul><li>Should not be excluded from daycare or school </li></ul><ul><li>Should not be isolated from other children </li></ul><ul><li>Source: Chronic Hepatitis B, AASLD </li></ul>
    23. 23. Personal issues <ul><li>Finances </li></ul><ul><ul><li>Insurance </li></ul></ul><ul><ul><li>Testing & treatment </li></ul></ul><ul><li>Coping with chronic disease </li></ul><ul><ul><li>Lifestyle decisions </li></ul></ul><ul><li>Relationships </li></ul><ul><ul><li>Blame? Responsibility? </li></ul></ul><ul><li>Mental health </li></ul><ul><ul><li>Depression? </li></ul></ul>
    24. 24. Discussion <ul><li>Medical care? </li></ul><ul><li>Recommendations for further care? </li></ul><ul><li>Cost-effective management? </li></ul><ul><li>Context </li></ul><ul><li>Discussion of options? </li></ul><ul><li>Would you: Refer? Forgo tests? Reduce fees? </li></ul><ul><li>Discussing impact on: </li></ul><ul><li>Relationships? Lifestyle? Health? </li></ul>
    25. 25. Screening for Hepatitis B <ul><li>Household & sexual contacts of HBsAg-(+) persons </li></ul><ul><li>Persons who have ever injected drugs </li></ul><ul><li>Persons with multiple sex partners or h/o STDs </li></ul><ul><li>Men who have sex with men </li></ul><ul><li>Inmates of correctional facilities </li></ul><ul><li>Individuals with chronically elevated ALT or AST </li></ul><ul><li>Individuals infected with HCV or HIV </li></ul><ul><li>Patients undergoing renal dialysis </li></ul><ul><li>All pregnant women </li></ul>
    26. 26. Hepatitis B immunization Source: http://www.immunize.org/catg.d/2081ab.htm 0, 1, 6 mos. 3 1.0 ml 10 µ g 20 years & older 0, 4–6 mos. 2 1.0 ml 10 µ g 11 thru 15 yrs. Infants: birth, 1–4, 6–18 mos. of age Alternative for older children: 0, 1–2, 4 mos. 3 0.5 ml 5 µ g 0–19 years Recombivax HB (Merck & Co.) 0, 1, 6 mos. 3 1.0 ml 20 µ g 20 years & older Infants: birth, 1–4, 6–18 mos. of age Alternative for older children: 0, 1–2, 4 mos. 3 0.5 ml 10 µ g 0–19 years Engerix-B (Glaxo-SmithKline) Schedule* # Doses Volume Dose Age group Vaccine Recommended dosages and schedules of hepatitis B vaccines
    27. 27. Physician resources <ul><li>Hepatitis B. Am Fam Physician. 2004;69:75-82 ( http://www.aafp.org/afp/20040101/75.html ) </li></ul><ul><li>Aggarwal R, Ranjan P. Preventing and treating hepatitis B infection. BMJ. 2004;329:1080-6. ( http://www.bmj.com/cgi/content/full/329/7474/1080 ) </li></ul><ul><li>Lok AS, McMahon BJ. Chronic hepatitis B. Alexandria (VA): American Association for the Study of Liver Diseases; 2004. (https://www.aasld.org/eweb/docs/chronichep_B.pdf) </li></ul><ul><li>CDC: Viral Hepatitis B (http://www.cdc.gov/ncidod/diseases/hepatitis/b/) </li></ul><ul><li>Johns Hopkins Gastroenterology & Hepatology Resource Center ( www.hopkins-gi.org ) </li></ul>
    28. 28. Patient resources <ul><li>Hepatitis B (FamilyDoctor.org) ( http://familydoctor.org/online/famdocen/home/common/infections/hepatitis/032.html ) </li></ul><ul><li>Hepatitis B (PatientUK) ( http://www.patient.co.uk/showdoc/27000754/ ) </li></ul><ul><li>CDC: Viral Hepatitis B (http://www.cdc.gov/ncidod/diseases/hepatitis/b/) </li></ul>
    29. 29. THANKS!

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