Nicole Allard

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.

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.

Mapping progress in chronic hepatitis B: geographic variation in prevalence, diagnosis, monitoring and treatment, 2013–15

Objective: To measure progress towards Australias National Hepatitis B Strategy 2014–17 targets, and assess geographic variation in disease burden and access to care for those living with chronic hepatitis B (CHB).

Factors associated with poor adherence to antiviral treatment for hepatitis B

Antiviral therapy for hepatitis B is effective and reduces the risk of progression to cirrhosis and liver cancer but is often required for an indefinite duration. Treatment adherence is important to prevent the development of resistance and optimize outcomes. Pharmacy adherence measures can be used to assess treatment adherence, with the medication possession ratio being less susceptible to bias than physician‐ or self‐reported adherence. The aim of this study was to measure adherence in public hospital outpatients over a 3‐year period and to examine factors associated with nonadherence. A retrospective study of pharmacy records of patients dispensed antiviral therapy for hepatitis B from four major hospitals in Melbourne between 2010 and 2013. Hospital record numbers were linked with and de‐identified demographic information including age, sex, Indigenous status, country of birth, interpreter requirement, spoken language and postcode of residence. The medication possession ratio was the outcome measure with poor adherence defined <.90. Univariate logistic regression and multivariate logistic regression were performed to examine associations with nonadherence. Records of 1026 patients were included in the analysis. Twenty per cent of all participants met the definition of poor adherence. Significant factors affecting adherence included age <35 years (P=.002), hospital site and treatment by multiple doctors within shorter time periods. This is the largest study examining detailed factors associated with adherence to hepatitis B treatment. Understanding poor adherence in clinical settings, and the factors associated with lower adherence, is important to inform efforts towards promoting treatment adherence for hepatitis B.

Disparities in hepatitis B vaccine funding in Australian jurisdictions: limiting access for priority populations

Despite considerable progress in reducing the incidence of newly acquired hepatitis B virus (HBV) infection through Australia’s universal infant and adolescent catch-up vaccination programs, new infections continue to occur. Between 2005 and 2010, more than 700 hospitalisations and 62 deaths were attributed to acute hepatitis B1,2 and 1,583 notifications were reported to the National Notifiable Diseases Surveillance System,3 although the estimates of true incidence are at least 10 times higher.4

Hepatitis B in men who have sex with men and HIV-infected individuals: missed opportunities and future challenges

Hepatitis B transmission in priority populations continues to occur in Australia despite the availability of a safe, effective vaccine for over 30 years. In this edition of Sexual Health, Body et al. report an incidence of 1.8 hepatitis B virus (HBV) infections per 1000 person years in the Victorian HIV database (VHIVSD), a cohort of HIV-infected individuals receiving care at a tertiary referral hospital in Melbourne. A similar incidence of infection (1.98 per 1000 person-years) was found by Gamagedara et al. among men who have sex with men (MSM) attending a community sexual health centre, also in Melbourne. This incidence of infection is more than 10 times the estimated incidence in the general population and is evidence of ongoing transmission in these priority populations despite being part of clinical cohorts and therefore occurring in people linked to care. Both of these recent studies highlighted missed opportunities for screening, vaccination and follow-up testing to ensure the protection of individuals at particular risk of HBV infection. This new evidence reinforces the need for a greater focus on comprehensive testing and vaccination of priority populations, including HIV-infected individuals and MSM – particularly given recent reports of increasing sexual risk practices in MSM and corresponding increases in sexually transmissible infections, including HIV. With an estimated 218,00 people (1.0% of the population) living with chronic hepatitis B (CHB) in 2011, Australia is generally a low-prevalence country, with the main burden of disease experienced by those born overseas in endemic areas, and by Aboriginal and Torres Strait Islander people. MSM are estimated to account for ~4.4% (around 9700 individuals) of those living with CHB and are identified as a priority population for prevention of infection in the First National Hepatitis B Strategy 2010–2013. The higher incidence of acute HBV infection and prevalence of CHB in HIV-infected individuals and MSM is multifactorial. The increased incidence of infection relates to shared modes of transmission, including sexual, injecting drug use or both. Globally, areas with a high or increasing population prevalence of HIV are often also endemic for CHB, making coinfection with HBV more common in HIV-infected individuals born in these countries who now reside in Australia. HIV infection is associated with both an increased risk of developing CHB if exposed to HBV and an increased risk of complications, including cirrhosis and liver cancer. In the retrospective cohort reported by Body and colleagues, 23% of patients with incident HBVinfection went onto to develop CHB – far greater than the expected 5% progression observed in immunocompetent adults. Both studies highlight the need for further improvements in access to HBV testing. In the study reported by Gamagedara et al., ascertainment of immunity status was high but markers of infection were less commonly tested: hepatitis B surface antibody (anti-HBs) was tested in 96% of patients, compared with testing for core antibody (anti-HBc) in 79% and surface antigen (HBsAg) in 26% of patients. As the authors comment, incomplete testing raises the possibility of missed incident and chronic infections. Similarly, Body et al. report that HBsAg and anti-HBc testing were not performed in 32% of HIV-positive individuals. The National Hepatitis B Testing Policy released in 2012 recommends testing for all three markers of HBV infection in those at higher risk of CHB, including MSM and HIVinfected individuals. The use of alternative screening algorithms can lead to missing chronic infections, and creates the need for unnecessary vaccination, recall and repeat testing of individual patients. The panel of three tests (HBsAg, anti-HBs and anti-HBc) is Medicare rebatable and is advised for any person at risk of having CHB. For individuals in the VHIVSD in whom HBV infection was documented, the median estimated time between HIV diagnosis and HBV infection was 4.6 years (range: 4 months to 17 years). These results indicate missed opportunities for prevention through vaccination, and suggest infrequent routine testing to determine anti-HBs status and promote vaccination. Together, they suggest that the prevention of HBV infection in HIVinfected individuals needs greater attention. Vaccination is recommended for susceptible MSM and HIVinfected individuals. However, eligibility for a funded CSIRO PUBLISHING

Deaths from liver cancer continue to rise in Australia: is elimination by 2030 possible?: Letters to the Editor

Two recently released data sets highlight the increasing health burden associated with viral hepatitis in Australia, and the importance of scaling up prevention and treatment to avert adverse outcomes in those affected. Estimates from the Global Burden of Disease (GBD) Study 2015 demonstrate a continued increase in deaths attributable to cirrhosis and liver cancer caused by viral hepatitis in Australia (Fig. 1). Of all 167 causes of death in Australia analysed by the GBD study, liver cancer had the fifth highest annual percentage increase in mortality between 1990 and 2015. While the fact that liver cancer is the fastest increasing cause of cancer death in Australians has previously been highlighted, these GBD findings emphasise the relative importance of liver cancer among all causes of death of Australians. Liver cancer also remains an outlier in the otherwise continued positive progress in cancer prevention and care, and the latest Australian Institute of Health and Welfare cancer report further demonstrates that: