Thomas R. Schulz

Using stool antigen to screen for Helicobacter pylori in immigrants and refugees from high prevalence countries is relatively cost effective in reducing the burden of gastric cancer and peptic ulceration

Objectives Refugees and immigrants from developing countries settling in industrialised countries have a high prevalence of Helicobacter pylori (H. pylori). Screening these groups for H. pylori and use of eradication therapy to reduce the future burden of gastric cancer and peptic ulcer disease is not currently recommended in most countries. We investigated whether a screening and eradication approach would be cost effective in high prevalence populations. Methods Nine different screening and follow-up strategies for asymptomatic immigrants from high H. pylori prevalence areas were compared with the current approach of no screening. Cost effectiveness comparisons assumed population prevalences of H. pylori of 25%, 50% or 75%. The main outcome measure was the net cost for each cancer prevented for each strategy. Total costs of each strategy and net costs including savings from reductions in ulcers and gastric cancer were also calculated. Results Stool antigen testing with repeat testing after treatment was the most cost effective approach relative to others, for each prevalence value. The net cost per cancer prevented with this strategy was US

Telehealth: experience of the first 120 consultations delivered from a new refugee telehealth clinic.

111,800 (assuming 75% prevalence),

Improvements in patient care: videoconferencing to improve access to interpreters during clinical consultations for refugee and immigrant patients

132,300 (50%) and

Genotypic profiles of hepatitis B in African immigrants and their clinical relevance

193,900 (25%). A test and treat strategy using stool antigen remained relatively cost effective, even when the prevalence was 25%. Conclusions H. pylori screening and eradication can be an effective strategy for reducing rates of gastric cancer and peptic ulcers in high prevalence populations and our data suggest that use of stool antigen testing is the most cost effective approach.

Hepatitis B among immigrants from Myanmar: Genotypes and their clinical relevance

In 2011, the Australian Government introduced Medicare item numbers for telehealth consultations. This is a rapidly expanding method of healthcare provision.

Regional challenges: evaluation of a hepatitis outreach programme using transient elastography (FibroScan) in Victoria

OBJECTIVE To demonstrate the suitability of accessing interpreters via videoconference for medical consultations and to assess doctor and patient perceptions of this compared with either on-site or telephone interpreting. METHODS We assessed the suitability and acceptability of accessing interpreters via videoconference during out-patient clinical consultations in two situations: (i) when the doctor and patient were in a consulting room at a central hospital and the interpreter sat remotely; and (ii) when the doctor, patient and interpreter were each at separate sites (during a telehealth consultation). The main outcome measures were patient and doctor satisfaction, number of problems recorded and acceptability compared with other methods for accessing an interpreter. RESULTS Ninety-eight per cent of patients were satisfied overall with the use of an interpreter by video. When comparing videoconference interpreting with telephone interpreting, 82% of patients thought having an interpreter via video was better or much better, 15% thought it was the same and 3% considered it worse. Compared with on-site interpreting, 16% found videoconferencing better or much better, 58% considered it the same and 24% considered it worse or much worse. CONCLUSIONS The present study has demonstrated that accessing an interpreter via videoconference is well accepted and preferred to telephone interpreting by both doctors and patients.

Telehealth for Hepatitis C care in the DAA era; ensuring everyone can access a cure

Hepatitis B virus (HBV) from 40 adult African immigrants in Australia was characterized to determine the prevalence of different HBV genotypes and subgenotypes. A mutational analysis was then performed to determine the presence of clinically significant mutations and correlate them to clinical outcomes. Initial sequencing analysis revealed 13 with genotype A (32.5%), 13 with genotype D (32.5%), and 14 with genotype E (35%). Serology showed that 37 were HBeAg negative. Phylogenetic analysis identified a high prevalence (25%) of HBV subgenotype A1 in our cohort, a subgenotype which has been associated with more aggressive clinical disease. BCP/PC sequencing was obtained for 38 patients. BCP and/or PC mutations were identified in 36/38 (95%). The median viral load of all patients was 2995 IU/mL and most of the pathology results were within the normal range. Only one patient had an increased APRI score of 1.1 suggestive of cirrhosis. We present novel information on the HBV genotypes amongst the African population in Australia along with clinical correlates. The high prevalence of A1 subgenotype in this population supports the current Australian recommendation to commence hepatocellular carcinoma screening in Africans with chronic HBV from 20 years old.

Fertility is significantly reduced by female genital tuberculosis: a case series.

Hepatitis B virus (HBV) from 76 adult immigrants in Australia from Myanmar was characterized to determine the prevalence of different HBV genotypes and subgenotypes. A mutational analysis was then performed to determine the presence of clinically significant mutations and correlate them to clinical outcomes. Initial genotyping revealed 68 patients with genotype C (89.5%) and eight patients with genotype B (10.5%). Phylogenetic analysis revealed the large majority of the genotype C infections were of subgenotype C1 (67/68). Sequencing of the HBV polymerase gene (and overlapping surface gene) revealed no mutations associated with antiviral resistance. HBV surface gene mutations were detected in 10 patients with subgenotype C1. HBV BCP/PC sequencing was obtained for 71/76 (93%) patients. BCP and/or PC mutations were identified in 57/71 (80%) of PCR positive patients. Treatment had been commenced for 15/76 (18%) patients, a further 26 untreated patients were in a stage of disease where HBV treatment would be considered standard of care. It was identified that genotype C1 is the predominant sub‐genotype in this population. Genotype C is known to be associated with increased risk of development of HCC. This highlights the need for screening for HCC given the potential for the development of liver cancer. It was also identified that people with HBV were potentially not receiving optimal therapy in a timely fashion.

The limitations of polymerase chain reaction in the setting of possible recurrent tuberculosis: 2 instructional cases

Evaluation of an outreach programme using a mobile transient elastography (TE) device (FibroScan) to improve liver disease assessment in different clinical settings.

Hospitalised adult patients with pandemic (H1N1) 2009 influenza in Melbourne, Australia

Abstract Background The Victorian Infectious Diseases Service currently provides telehealth care for rural and regional patients with hepatitis C. From March 2016 direct acting antiviral therapy (DAA) for Hepatitis C has been subsidised for all Australian adults with Hepatitis C. The wide geographic distribution of Australia’s population means patients have to travel considerable distances to access specialist care. The increasing availability of web-based videoconferencing platforms have provided unprecedented capacity to manage patients remotely. The primary aim of this study is to determine whether telehealth delivered hepatitis C management achieves virological outcomes comparable to that achieved in randomised clinical trials. Methods The study is part of a quality audit of the hepatitis and outreach service. Measured outcomes were; (i) proportion of patients achieving a sustained virological response (SVR); (ii) failure to attend rate (FTA); (iii) frequency of technical difficulties; (iv) patient travel kilometres saved through not attending clinic in person; (v) Reduced carbon production due to reduced travel; and (vi) Consultation duration time. Results In 1 year from March 1, 2016, 58 patients have been commenced on Hepatitis C treatment and managed either partially or completely via telehealth. Of those who have so far completed therapy (29 patients) an SVR rate of 97% has been achieved. Expected SVR genotype 1 (>95%); genotype 3 (>85%). The average travel avoided for each telehealth consultation was 616km and each patient had a 
median of two telehealth consultations. Technical difficulties occurred in less than 10% of consultations with FTA of 17%. Consult duration averaged 15 minutes or less. Conclusion Our completed patient cohort results demonstrate comparable virological outcomes for telehealth managed patients as compared with onsite management, even when adjusted for age, gender and hepatic fibrosis status. This suggests efforts to improve access to care can be achieved without compromising patient outcomes. Following the 2017 Infectious Diseases Society of America (IDSA) position statement on Telehealth and Telemedicine, we discuss the challenges and benefits of outpatient ID telehealth services as we enter the era of digitally enabled healthcare. Disclosures All authors: No reported disclosures.