Jennifer H. MacLachlan

The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study 2013

BACKGROUND With recent improvements in vaccines and treatments against viral hepatitis, an improved understanding of the burden of viral hepatitis is needed to inform global intervention strategies. We used data from the Global Burden of Disease (GBD) Study to estimate morbidity and mortality for acute viral hepatitis, and for cirrhosis and liver cancer caused by viral hepatitis, by age, sex, and country from 1990 to 2013. METHODS We estimated mortality using natural history models for acute hepatitis infections and GBDs cause-of-death ensemble model for cirrhosis and liver cancer. We used meta-regression to estimate total cirrhosis and total liver cancer prevalence, as well as the proportion of cirrhosis and liver cancer attributable to each cause. We then estimated cause-specific prevalence as the product of the total prevalence and the proportion attributable to a specific cause. Disability-adjusted life-years (DALYs) were calculated as the sum of years of life lost (YLLs) and years lived with disability (YLDs). FINDINGS Between 1990 and 2013, global viral hepatitis deaths increased from 0·89 million (95% uncertainty interval [UI] 0·86-0·94) to 1·45 million (1·38-1·54); YLLs from 31·0 million (29·6-32·6) to 41·6 million (39·1-44·7); YLDs from 0·65 million (0·45-0·89) to 0·87 million (0·61-1·18); and DALYs from 31·7 million (30·2-33·3) to 42·5 million (39·9-45·6). In 2013, viral hepatitis was the seventh (95% UI seventh to eighth) leading cause of death worldwide, compared with tenth (tenth to 12th) in 1990. INTERPRETATION Viral hepatitis is a leading cause of death and disability worldwide. Unlike most communicable diseases, the absolute burden and relative rank of viral hepatitis increased between 1990 and 2013. The enormous health loss attributable to viral hepatitis, and the availability of effective vaccines and treatments, suggests an important opportunity to improve public health. FUNDING Bill & Melinda Gates Foundation.

The burden of chronic hepatitis B virus infection in Australia, 2011.

Objective: The number of Australians living with chronic hepatitis B (CHB) is thought to be increasing, as are adverse outcomes including cirrhosis and liver cancer, however, robust, up‐to‐date estimates of this burden are limited. Contemporary estimates of the prevalence of CHB in Australia are essential to guide appropriate public health and clinical responses.

Hepatitis B Virus Epidemiology

The epidemiology of hepatitis B virus (HBV) infection is geographically diverse, with population prevalence, age and mode of acquisition, and likelihood of progression to chronic infection mutually interdependent. The burden of chronic HBV infection is increasingly being recognized, with cirrhosis and liver cancer attributable to HBV continuing to increase. The outcomes of chronic HBV infection are affected by a range of factors, including viral genotype, the presence of coinfections with other blood-borne viruses, and the impact of other causes of liver disease. The increased recognition of HBV infection as a leading cause of death globally has resulted in the development of new structures and policies at the international level; immediate attention to implementing these strategies is now required.

Liver cancer is the fastest increasing cause of cancer death in Australians.

MJA 197 (9) · 5 November 2012 492 IN REPLY: The letters of Morgan and Fullerton correctly emphasise the importance of palliative care in the management of patients with metastatic melanoma. They also draw attention to the immense cost of new drugs for melanoma, and their limited efficacy in life extension — something I also emphasised.1 Much ignored in this debate is the rapid and dramatic improvement in quality of life experienced by nearly all melanoma patients on BRAF inhibitors,2 an example of where medical oncology and palliative care should, and must, work hand in hand in optimising patient comfort. We strive toward this goal in our multidisciplinary teams. However, it is in the adjuvant setting that the new antimelanoma drugs are likely to show large improvements in survival and where reimbursement of drug costs will become an increasing challenge. Morgan refers to the utility of adjuvant radiation therapy for cerebral metastases and quotes an uncontrolled retrospective series, from which, due to selection bias and other factors, only highly restricted conclusions can be made. Prospective randomised evidence for the benefit of adjuvant whole-brain radiation therapy awaits completion of an ongoing study by the Australia and New Zealand Melanoma Trials Group.

Mortality due to viral hepatitis in the Global Burden of Disease Study 2010: new evidence of an urgent global public health priority demanding action.

The recently published Global Burden of Disease Study 2010 (GBD 2010) contains accurate, contemporary estimates of human morbidity and mortality, with substantial changes in the patterns of illness observed over the last two decades. One of the most significant alterations to these estimates has been the recognition that viral hepatitis is a leading cause of human mortality, with an estimated 1.29 million deaths worldwide in 2010. The global community must act to address emerging health priorities identified by GBD 2010, including the need to provide treatment and care to people living with viral hepatitis, especially in resource-poor settings.

Effect of Latitude on Seasonality of Tuberculosis, Australia, 2002–2011

Seasonal variation in tuberculosis diagnoses recently has been reported in various populations. In Australia, seasonality of tuberculosis diagnoses was more pronounced in areas where UV exposure is reduced and vitamin D deficiency is more prevalent. Our findings suggest vitamin D deficiency as a factor in disease activation.

The cascade of care for Australians living with chronic hepatitis B: measuring access to diagnosis, management and treatment.

Objective: To estimate the level of access to diagnosis, management and treatment for people living with chronic hepatitis B (CHB) in Australia, and to identify the gaps in clinical care for people living with CHB.

Estimating the global prevalence of hepatitis B

The substantial global burden of hepatitis B virus (HBV) infection is increasingly recognised. Recent estimates suggest that HBV infection caused 686 000 deaths in 2013, placing HBV in the top 20 causes of human mortality. Despite this, comprehensive reviews of data regarding the burden of chronic HBV at regional and national levels have been scarce. This is an area of particular importance in view of the global diversity in chronic HBV prevalence, and the disproportionate burden experienced by people living in low-resource settings. In The Lancet, Aparna Schweitzer and colleagues report the most robust estimates to date of the prevalence of chronic HBV by country and region. Their findings highlight both the substantial global burden of chronic HBV, and the concentration of the epidemic in specific countries. This systematic review collated data from HBsAg seroprevalence studies including 109 415 627 individuals, across 161 countries, published between 1965 and 2013. Overall the authors estimate that 3·61% (95% CI 3·61–3·61) of the global population is living with chronic HBV infection. Prevalence by country varied from as low as 0·01%, in Norway and the UK, to greater than 20% in countries such as South Sudan (22·38%, 20·10–24·83) and Kiribati (22·70%, 20·19–25·41), building on previous work that has shown the diversity in prevalence according to region. These results highlight both the successes achieved, and the continuing challenges experienced, in the global response to HBV. Previous assessments indicate that there has been a clear decrease in prevalence of chronic HBV in many areas, including some countries in the South East Asian, Eastern Mediterranean, and Western Pacific WHO regions. This decrease applies mostly to countries where routine infant immunisation programmes were implemented and have achieved high coverage. The study by Schweitzer and colleagues also suggests a decrease in HBV prevalence at the global level in many countries between the two time periods 1957–1989 and 1990–2013. However, the burden of disease persists in many low-income and middleincome countries, and in some countries the prevalence of HBV is increasing. The number of affected individuals was highest in the Western Pacific (95·3 million, prevalence estimate 5·26%, 95% CI 5·26–5·26) and African (75·6 million, prevalence estimate 8·83%, 8·82–8·83) regions, which together included nearly 70% of the global burden. The findings should also be considered in the context of global evidence regarding adverse outcomes from chronic HBV, specifically liver cancer, which is now the third leading cause of cancer deaths, and which disproportionately affects developing countries. Schweitzer and colleagues excluded studies specific to population groups at particular risk of chronic HBV infection, such as migrants from endemic areas resident in low-prevalence countries. Since in some countries these groups form a substantial part of the population and represent the majority of those living with chronic HBV infection, this exclusion leads to an underestimate of the total burden of HBV. For example, the number of people living with chronic HBV in the USA was estimated as 843 724 (estimated prevalence 0·27% [95% CI 0·24–0·30]); however a recent meta-analysis suggested that 1·7 million people, of whom 1·3 million were migrants, were living with chronic HBV in the USA, an estimate double that of the present study. The increasing prevalence of chronic HBV infection in these populations is contributing to the rising incidence of liver cancer, which is now the fastest increasing cause of cancer deaths in the USA. Unavoidable limitations in this type of study include sparse or absent seroprevalence data in some countries. Improvement of the range and quality of HBV prevalence data is important, as is accurate and

Limited provision of diagnostic services to Victorians living with hepatitis C antibodies, 2001–2012: a multi-level modelling analysis

Objective: To determine what percentage of Victorians with a history of notified hepatitis C exposure received appropriate follow‐up diagnostic services between 2001 and 2012.

Hepatitis D virus in Victoria 2000–2009

Hepatitis D virus (HDV) coinfection can adversely affect prognosis and complicate management of chronic hepatitis B. The epidemiology and clinical practices surrounding HDV in Australia are poorly understood, with no robust estimates of the burden of disease, and the extent of appropriate testing and clinical follow up is unknown.