GP Study Afternoon: Viral Hepatitis - PowerPoint Presentation

1. GP Study Afternoon: Viral Hepatitis Cockburn Lecture Theatre, St Marys HospitalWednesday 22nd May Prof Ashley BrownImperial Healthcare NHS Trust

2. The cost of NOT treating Viral Hepatitis

3. HBV

4. Everything you ever need to know about HBV serologyHBsAg POSITIVE = REFERHBsAg NEGATIVE = DON’T REFERThere’s no such thing as a healthy carrier – all HBsAg patients should be referred for long-term monitoring

5. Margolis et al, 1991Chronic HBV prevalence (% of population)< 2% - Low2-7% - Intermediate> 8% - HighGlobal Prevalence of Chronic HBVChronic HBV in the UK97% of people living with chronic HBV in the UK were born outside the UK(HPA statistics)99% of chronic HBV is VERTICALLY TRANSMITTED It has nothing to do with sex and drugs (or rock ‘n’ roll!!)

6. Why monitor HBV?In the majority of patients, the immune system will keep the virus under controlLOW VIRAL LOADNORMAL LIVER ENZYMESIn 2-3 % of patients each year, the vrus will escape immune controlHIGH VIRAL LOADRAISED LIVER ENZYMESThe transition is unpredictable and asymptomatic

7. Treatment of HBVEntecavir and Tenofovir are red-listed drugs and should not be stopped abruptlyPatients should be monitored every six months for viral load and renal function. Screen regularly for metabolic bone disease

8. Antenatal Viral Hepatitis ClinicClinic every 2-4 weeks at both SMH and QCCHRun jointly with BBV specialist midwifeReview of ALL women with viral hepatitisGP referral not requiredDiscussion of birth plan and transmission reductionTesting of partner and other childrenDiscussion of vaccination scheduleICHNT achieved KPI’s year-on-year

9. HBV Neonatal Vaccination ScheduleBIR1 Mo2 Mo3 Mo4 Mo5 Mo12 MoBabies born to HBsAg +ve mothers prior to Aug 2017Universal vaccination for all babies born from Aug 2017Babies born to HBsAg +ve mothers prior to Aug 2017HBV monovalent vaccineHBV monovalent vaccine + HBIgNew hexavalent vaccine (inc HBV)

10. Family Hepatitis ClinicOnce a month clinic at SMH run jointly with paediatric IDPost vaccination testing of all children born to HBV/HCV positive mothersScreening of other family membersManagement of infected childrenTransition/adolescent clinicHappy to accept referrals for other children with liver disease

11. HBV VaccinationAlways test for HBsAg BEFORE vaccinatingALL household contacts of an HBV positive patient should be offered vaccinationALL sexual partners of HBV positive patients should be offered vaccinationTHESE VACCINATIONS MUST BE FREE OF CHARGE

12. HCV

13. What everybody knows about HCVWE DO NOT DO LIVER BIOPSIES ANYMOREWE DO NOT USE INTERFERON ANYMORELIVER BIOPSYINTERFERON

14. HCV is the only chronic blood-borne virus that can be CUREDUnlike HIV and HBV it is not a disease for lifeSustained virological response (SVR) = CURESVR: reduced morbidity and mortalityPawlotsky JM. J Hepatol 2006;44:S10–3;Siliciano JD, et al. J Antimicrob Chemother 2004;54:6–9;Lucas GM. J Antimicrob Chemother 2005;55:413–6cccDNA: covalently closed circular DNA

15. The Directly Acting Antiviral DrugsHCV NS3/4A protease inhibitorHCV NS5A inhibitorGrazoprevirElbasvirZepatierHCV NS5B polymerase inhibitorHCV NS5A inhibitorSofosbuvirVelpatasvirEpclusaHCV NS3/4A protease inhibitorHCV NS5A inhibitorGlecaprevirPibrentasvirMaviretHCV NS5B polymerase inhibitorHCV NS5A inhibitorSofosbuvirLedipasvirHarvoni8-12 weeksOnce daily dosingMinimal side-effects>95% cure rate

16. From Virus Discovery to Plans for Elimination in 30 Years 198619891998200120132014201520162018…2011The IFN eraPan-genotypic era“Non-A, non-B” hepatitisEarly era of DAAs“DAA revolution”1989: Identification of HCV2016: The WHO Global Health Sector established the goal of HCV elimination as a major public health target by 2030Pawlotsky JM, et al. J Hepatol 2015; 62:S87–99; Manns MP, et al. Nat Rev Dis Primers 2017; 3:1–19;WHO. Global Health Sector Strategy on Viral Hepatitis 2016–2021. Available at: http://www.who.int/hepatitis/strategy2016-2021/ghss-hep/en/ (accessed March 2019).NHS England have set the target of elimination in England by 2025

17. WHO HCV Elimination Targets: ProgressWHO 2018: Progress report on access to hepatitis C treatment (WHO/CDS/HIV/18.4).1770 million infected13 million diagnosed (19%)1.5 million treated in 2016 (2%) 2030 TARGET90% infecteddiagnosed2030 TARGET80% diagnosedtreated

18. What do we need to achieve eliminationPotent antiviral drugs ✓Short duration therapy ✓Simplification of therapy ✓Universal access to therapy ✓Up-to-date knowledge of HCV treatment for both general public and HCPs✗Expanded treater pool ✗Adequate case findings programmes ✗

19. The ODNs are seen by the government as a way of ensuring equity of access and the responsible use of an expensive resourceEach ODN has a lead who heads an MDT (composed of hepatologists and/or ID physicians, CNS and pharmacists)Each case is presented to the panel to ensure eligibility and to determine the appropriate treatment regimenTreatment can occur at any site within the ODN, but prescribers assume financial responsibilityThe ODN is responsible for policing the system, collecting and reporting data back to NHSEThe English HCV ODN system

20. The duality of HCVHCV AS A LIVER DISEASEHCV AS A PUBLICHEALTHISSUEBENEFIT TO INDIVIDUALBENEFIT TO SOCIETYPrevention of cirrhosis, HCC and premature deathAlleviation of extra-hepatic symptomsPrevention of onward transmissionAchievement of elimination as a public health issue

21. Iatrogenic pre-1989Who are the people living with HCV?Haemodialysis PatientsWomen of Child Bearing AgePeople who use DrugsPrisonersMen who have sex with MenFormer PWID’sImmigrant CommunitiesMICROELIMINATION IN SPECIFIC COMMUNITIES

22. Testing and treatment now available in over 30 sites across NW London sector

23. Hospital Clinics (10)St Marys, Hammersmith, St Charles, Charing Cross, Chelsea & Westminster, West Middlesex, Ealing, Central Middlesex, Northwick Park, HillingdonDrug & Alcohol Services (9)Turning Point Soho, Acorn Hall North Kensington, ARC Willesden, New Coach House Shepherds Bush, Ealing RISEWDP Harrow, CGL Victoria, ARCH Uxbridge, ARC, Hounslow Homeless Hostels (7)Hope Gardens, The Old Theatre, Broadway Centre Shepherds Bush,St Mungos 209 Harrow Rd, King George Hostel, Pound Lane Hostel, St Mungos Edith RoadGP Practices (2)Dr Hickey Practice, Great Chapel StreetSexual Health Clinics (4)Dean Street, Wharfside Clinic, Kobler Centre, Hammersmith BroadwayPrisons (1)HMP Wormwood ScrubsComnunity Pharmacy (1)Portmans PharmacyTesting and treatment now available in over 30 sites across NW London sector

24. Advances in Diagnostics and Point-of-Care TestingFourati S, et al. J Int AIDS Soc 2018; 21:e25058.Saliva testsDried blood spotPoint-of-care HCV RNA testingResults within minutesNo expertise or laboratory requiredCan be self administeredAntibody result onlyMinimal expertise requiredSuitable for mass screeningResults take 2-3 daysCan give viral loadCan test for other BBVMinimal expertise requiredHCV-RNA result in one hourLimited capacityIdeal for instant linkage to care

25. Data in Venn diagram taken from Australian figures.DBS, dried blood spot testing; MDT, multidisciplinary team; OST, opioid substitution therapy; PWID, people who inject drugs.1. Grebely J and Dore GJ. Antiviral Res 2014; 104:62–72.Simplification of the Treatment Pathway in PrisonsThe considerable movements between PWID on OST in the community and in the prison settings provides a unique opportunity to capitalize on these settings as HCV treatment access points1Reducing HCV prevalence in prisons will result in reduced HCV in the community1High turnover and short sentencing require specific pathways11 week for DBS result1 week for doctor review1 week for FibroScan®4 weeks for genotype1 week for MDT12–16 weeks for treatment20 mins for Orasure swab8 weeks for pan-genotypic treatment1 hour for Cepheid HCV-RNA2 weeks for secondary medical review“TRADITIONAL MODEL”22–26 weeks“CONIBEERE MODEL”8–9 weeks

26. So where are the ‘Missing Millions?Haemodialysis PatientsWomen of Child Bearing AgePeople who use DrugsPrisonersMen who have sex with MenFormer PWID’sImmigrant Communities‘THE MISSING MILLIONS’Iatrogenic pre-1989

27. 2763 Untreated Positive HCVAb in West London Primary Care released by PHE

28. Of 2771 HCVAb results, 738 (27%) have no records in West London. Of the remaining 2033…Evidence of NEG HCV-RNA and never positive‘Spontaneous Clearance”35.4%Known to have been treated16.2%No HCV-RNA result found 30.5%Dead 0.1%Known to service but not yet treated 5.6%*Speakers own unpublished data

29. PHE HCV recallPlease review the names on the listArrange HCV-RNA on those who are HCVAb positiveRefer in those who are HCV-RNA positiveAny problems, please discuss

30. Identifying those at riskAnyone on OST or long term opioidsAnyone with a past history of drug-useAnyone with a history of incarcerationAnyone born or raised abroadAnyone who received blood transfusion before 1990Anyone with non-specific symptoms of fatigue or cognitive impairmentAnyone with raised ALT/ASTANYONE WHO ASKS!

31. Positive HCVAbHCVAb PositiveActively ViraemicSpontaneously ClearedPreviously TreatedHCV-RNA NEGHCV-RNA POS

32. Direct access for new HCV-RNA positive referralsUsually seen within 2 weeksJoint consultant/nurse assessment as one-stop-shopMedical assessment, Fibroscan, genotyping and treatment discussionPatient given provisional treatment start dateConsiderable shortening of patient pathwayReduces unnecessary OPD apptsReduces anxietyAdvances the elimination programmeFast-Track HCV Clinic

33. When your patient is on treatment…Encourage adherence to treatment and follow-up appointmentsDo not start any new drugs without checking for DDIsDo not stop the treatment without discussing with HCV teamRemember that HCVAb persists indefinitely

34. WORKING TOGETHER WEST LONDON CAN BE THE FIRST ODN TO ACHIEVE HCV ELIMINATIONImperial.hcv@nhs.net07767 671954