At the end of 2020, an estimated 222,559 people were living with chronic hepatitis B in Australia, that equates to approximately 1 in 100 people in Australia¹. Around a quarter of those – more than 55,000 – have not been diagnosed and so are unaware of their infection².

As in many areas of healthcare, the disruption caused by the COVID-19 pandemic has taken a toll on efforts to tackle hepatitis B. Fortunately, Australia could still be in a strong position to meet goals on virus elimination but some strategic efforts are required.

According to the Third National Hepatitis B Strategy, hepatitis B virus (HBV) is the most common blood borne virus (BBV) in Australia and a leading cause of primary liver cancer.

Australia has endorsed the World Health Organization (WHO) Global Health Sector Strategy on Viral Hepatitis 2016–2021, which set the goal of eliminating viral hepatitis as a major public health threat by 2030.

With only seven years to reach this ambitious target, Australia is making good progress on activities to reduce HBV infection.

One of the challenges in reaching the goal is ensuring consumers have access to information and support services. That is why Hepatitis Australia has established the National Hepatitis Infoline, which was launched at Parliament House by Assistant Minister for Health and Aged Care, the Hon Ged Kearney MP.

“People affected by hepatitis B or hepatitis C can feel incredibly overwhelmed. The National Hepatitis Infoline supports people to engage in testing, diagnosis and treatment by enabling access to accurate information and support,” said Carrie Fowlie, CEO of Hepatitis Australia.

While HBV is a global challenge, from a diagnostic perspective the landscape in Australia is different to other countries in several ways;

• Australia has larger and centralised pathology laboratory networks, covering more geography than most other countries.
• Following investment in pathology infrastructure resulting from the COVID-19 pandemic, there is increased access to molecular testing platforms (PCR or NAT) throughout the country.
• In recent years many health services have focused on improving access to testing in remote and under-served communities through the use of point-of-care test systems, alongside laboratory-based testing.

Current challenges

Hepatitis Australia notes that there are a number of priority areas for action which require resourcing and focus if Australia is to achieve its 2030 elimination goal:

“These include ensuring access to culturally and linguistically appropriate testing, treatment and ongoing care for affected communities, establishing a hepatitis B specific community workforce, and prioritising research which focuses on hepatitis B cure,” said Ms Fowlie.

In addition, there are a number of clinical priority areas which need to be addressed as a part of the 2030 elimination efforts, including detecting and treating reactivation of HBV.

HBV reactivation is a syndrome defined by the reappearance of HBV particles in patients with previously resolved HBV, or an increase in levels of HBV detected in patients with previously inactive chronic hepatitis B (CHB). Reactivation can occur spontaneously, but it is usually triggered by immunosuppressive (IS) therapies.

Immunosuppressant therapies are used increasingly in cancer treatment and for treating some autoimmune conditions. Reactivation of HBV can cause significant morbidity and mortality, but it is preventable if patients who are at risk are quickly identified through screening. These patients can then be provided antiviral prophylaxis treatment, where indicated.

Occult HBV infection is also a challenge, this is defined as the presence of (replication-competent) HBV DNA in the blood or liver of patients who test negative for Hepatitis B surface Antigen (HBsAg).

The prevalence of occult HBV infection both globally and in Australia is not well understood, however it is an important area for consideration when seeking to effectively eliminate the virus. According to a recent study in The Lancet; “Emerging evidence suggests that HBV might be transmitted from individuals carrying occult HBV infection through blood transfusion, and people with occult HBV infection might be at increased risk of cirrhosis and hepatocellular carcinoma.”

Access to a highly sensitive and specific test is important for both reactivation and occult HBV infections. Some older laboratory assays may struggle to accurately detect these cases, leaving patients more at risk of viral complications, and providing an avenue for individuals to unknowingly transmit the virus to others.

An assay that can offer earlier detection of diverse HBV genotypes and mutants, as well as vaccine breakthrough infections supports better outcomes for patients and the wider community.

Rapid tests are also excellent tools in the global fight to tackle HBV. Rapid tests for HBV will likely become important for use in Australia too, as the geography of the country presents settings where follow up with patients is challenging, such as in rural areas where people live long distances from health services, or for transient populations. 

The next 7 years

The Australian Government is currently working to develop the next national strategy for HBV covering 2023-2030.

With the next generation of diagnostic tools now available in Australia we are well placed to make progress, but every aspect of the strategy is important; vaccination, testing and treatment. However, the first step is improving understanding about HBV, particularly amongst those most at risk.

In Australia high risk groups include Aboriginal and Torres Strait Islander people, and people born overseas in countries where HBV is more common. Others who are at risk include those with tattoos or piercings acquired overseas, sex workers or people engaging in unprotected sex and injecting drug users.

In the lead up to the World Hepatitis Summit 2022, Hepatitis Australia’s CEO highlighted some of the barriers to tackling the disease:

“Inequality, racism and stigma drive the viral hepatitis epidemics in Australia causing the burden of disease for hepatitis B to disproportionately be experienced by First Nations people and migrant Australians. The Australian prison system is a primary source of hepatitis C transmission and people in custodial settings have no access to regulated prevention strategies,” said Ms Fowlie, “Australia has the tools but we need to ramp up momentum.”

The new Infoline will certainly be a useful tool in providing trusted information, supporting people with a hepatitis diagnosis, and dispelling myths about the disease.

“We encourage anyone, including health workers to contact the National Hepatitis Infoline, no matter what your question might be,” said Ms Fowlie.

To access the service, people can visit the website at www.nationalhepatitisinfoline.org.au or call 1800 HEP ABC (1800 437 222). Face-to-face services are also available, and some services may be available via webchat, text or email.

References

1.     McCulloch K, Romero N, MacLachlan JH, Cowie BC. National Surveillance for Hepatitis B Indicators: Measuring the progress towards the targets of the National Hepatitis B Strategy – Annual Report 2020. Melbourne: WHO Collaborating Centre for Viral Hepatitis, The Doherty Institute, 2021.

2.     MacLachlan JH, Stewart S, Cowie BC. Viral Hepatitis Mapping Project: National Report 2020. Darlinghurst, NSW, Australia: Australasian Society for HIV, Viral Hepatitis, and Sexual Health Medicine (ASHM), 2020; https://www.ashm.org. au/programs/Viral-Hepatitis-Mapping-Project/ p19