Australia falling behind on hepatitis B elimination targets

Tracking progress towards Australia’s elimination targets for hepatitis B isn’t just about measuring progress, it’s about providing tools for driving progress towards health equity and saving lives.

Chronic hepatitis B is a leading cause of liver disease and liver cancer in Australia, affecting an estimated 200 000 people and leading to over 450 attributable deaths per year. Liver cancer is now the seventh most common cause of cancer death in Australia, and chronic hepatitis B is a leading cause. The majority of chronic hepatitis B-attributable deaths are preventable through the early detection of chronic infection and the provision of effective clinical care, including antiviral treatment where indicated. Appropriate therapy has been shown to reduce the risk of liver cancer by up to 80% in just five years, and is subsidised in Australia through the Pharmaceutical Benefits Scheme. However, uptake of clinical care is below optimal levels, and late diagnosis of hepatitis B remains common, even though evidence demonstrates that most people living with chronic hepatitis B are connected with health care services.

Public health interventions for hepatitis B often focus on primary prevention, especially immunisation. Immunisation is highly effective, cost-saving, and has prevented millions of cases of chronic hepatitis B and future deaths from liver disease and liver cancer globally since its introduction. Although immunisation against hepatitis B in Australia is important, it will have minimal impact on deaths due to chronic hepatitis B in coming decades, as more than 95% of new chronic infections enter our population through migration, not through local incident infections progressing to chronicity. What is therefore critical to addressing the burden of hepatitis B in Australia is increasing access to diagnosis, treatment and care for this chronic condition that affects more Australians than human immunodeficiency virus (HIV) infection and hepatitis C combined.

The burden of hepatitis B also has impacts on the quality of life of people living with chronic hepatitis B, as lack of accurate information regarding the condition can be a contributor to negative social and psychological outcomes, and a consistent care relationship provides opportunities for the provision of appropriate support.

Understanding regional differences in hepatitis B care

Given that most people living with chronic hepatitis B in Australia were born overseas, or are Aboriginal and/or Torres Strait Islander people, this care must be delivered in a culturally respectful and safe manner with a focus on the needs and priorities of these priority populations.

The diversity of the population affected by chronic hepatitis B is reflected in profound epidemiological differences in the prevalence of hepatitis B by geographic area, which in turn is manifested in areas with a substantially greater incidence of liver cancer. There is therefore a need to understand in detail regional differences in the uptake of treatment and care for chronic hepatitis B care to allow for efforts to improve access to care to be focused where the need is greatest.

We generated population estimates using a mathematical model that incorporates key data inputs including migration, births and deaths, demographic information, chronic hepatitis B prevalence for every country, immunisation and treatment coverage, and natural history information. This model allows for detailed estimation of the population affected by chronic hepatitis B over time, prediction of future trends, and — when combined with communicable disease notifications and Medicare data — estimates of access to diagnosis, treatment and care. This model also allows estimation of future deaths due to chronic hepatitis B under current levels of access to care, but also in the setting of improved levels of service delivery. The model is generated for each state and territory in Australia, allowing assessment of variation and gaps for each jurisdiction. These estimates are key components of measuring progress towards the goals identified in Australia’s Draft Fourth National Hepatitis B Strategy.

Australia falling behind

Our work shows that, currently, Australia is not on track to meet the targets, with the largest gap being in the provision of regular monitoring. Of all people living with chronic hepatitis B, it is estimated that less than one-quarter are receiving clinical care in line with current guidelines, and less than half of the 29% of Australians estimated to meet the criteria for antiviral treatment for chronic hepatitis B are currently receiving it. We also identified substantial variation according to state and territory. For example, treatment coverage was nearly twice as high in New South Wales (NSW) as in Western Australia. Treatment and care were highest in NSW, Victoria, the Australian Capital Territory and the Northern Territory (NT), but trends over time varied substantially. The most significant increase occurred in the NT, which has the highest prevalence of chronic hepatitis B in the country (1.73%), and where treatment uptake increased by eightfold between 2011 and 2020, more than double the national increase.

Various causes exist for these notable differences. Although there have been gradual shifts over time towards primary care management of chronic hepatitis B, it remains overwhelmingly managed by tertiary specialists, who wrote more than 75% of Australia’s hepatitis B antiviral prescriptions in 2021. In the absence of dedicated, resourced outreach models, this limits access for patients residing outside capital cities. There is also likely an impact on increased community engagement and awareness in those areas with a higher proportion of the population living with chronic hepatitis B, creating a correlation between prevalence and uptake of treatment and care.

Focused effort needed to reach targets

The exceptional progress seen in the NT also demonstrates that even in geographically challenging locations, high uptake can be achieved with focused effort and dedicated support. Hep B PAST is a comprehensive program of education and health promotion, care enrolment and coordination which has had an enormous impact and serves as a model for partnership approaches to addressing chronic hepatitis B.

Tracking progress towards Australia’s elimination targets for hepatitis B isn’t just about measuring progress, it’s about providing tools for engagement and advocacy and driving further progress towards health equity and saving lives. Doing so at the local level allows recognition and learning of where things are working, and sharing these lessons where progress is lagging. Such localised information to guide action and monitor outcomes will be essential to give Australia any chance of meeting our commitment to eliminate hepatitis B as a public health threat by 2030.

Jennifer MacLachlan is an epidemiologist with appointments at the World Health Organization (WHO) Collaborating Centre for Viral Hepatitis at the Doherty Institute and at the University of Melbourne.

Professor Benjamin Cowie is an infectious diseases physician and epidemiologist, with appointments at the Royal Melbourne Hospital, the Doherty Institute, and the University of Melbourne.

Nicole Romero is an epidemiologist with appointments at the WHO Collaborating Centre for Viral Hepatitis and at the University of Melbourne.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

Subscribe to the free InSight+ weekly newsletter here. It is available to all readers, not just registered medical practitioners. 

If you would like to submit an article for consideration, send a Word version to mjainsight-editor@ampco.com.au.