Hepatitis B - Medical, Personal and Contextual Issues

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