Australasian Society for HIV Medicine

Reviewed by Levinia Crooks, CEO, ASHM 

It was interesting that this book arrived on my desk the day it did. I had just finished compiling notes from a multilateral meeting on hepatitis B held in Melbourne in mid-February, had earlier that day finalised details for a contract to start drafting a monograph on hepatitis B and was thinking about the best approach for a patient resource on hepatitis B.

Hepatitis B is a somewhat new virus to me. I have been aware of it for many years, but only as an adjunct to both HIV and hepatitis C, conditions with which I have been far more involved, and in which many health advocates and governments have been more interested. I knew hepatitis B was endemic in many countries and complicated both HIV and HCV management. Lots of people seemed to have been exposed to hepatitis B, but I was not really aware of the significance of this. There was considerable confusion between hepatitis B and hepatitis C and in 2001 this motivated ASHM to produce a monograph which included HBV and HCV with HIV as a way of clarifying these conditions and their shared and disparate features. In 2003 we produced a monograph on HIV and HBV and HCV co-infection.

In 2004 I had the opportunity to attend a meeting of the New Zealand Hepatitis Foundation which was looking at both HBV and HCV. This was really my first introduction to hepatitis B as a stand-alone condition. I had attended the St Vincent's Symposium in Melbourne, arranged by Katrina Watson, but the format of that program had largely allowed me to focus on hepatitis C not hepatitis B. In New Zealand the tables were turned. It was hepatitis B where the epidemiology was remarkable, hepatitis B where surveillance was highly developed and hepatitis B which was on the radar. The Hepatitis B Foundation appeared to be a well-established organisation with considerable reach and impact.

Over the two days of the meeting, I picked up some history of how hepatitis B had come onto the radar, and became aware of a level of tension about the status of hepatitis B, the role of screening and surveillance, and the public health versus individual considerations around management of this condition. The size of the problem, particularly among Maori people, was incredible and reminded me of the discussions I had been involved in during the 1980s when there was concern about how HIV could take off if it became entrenched in indigenous Australian populations. I was shocked at the reach such a virus could have and that we, as such near neighbors could be effectively unaware of this. I then thought about sexual health and dramatic difference between Australia-wide STI data and that of indigenous Australians, and realised that there were considerable parallels.

Battling the Big B was therefore my chance to read how the New Zealand response to hepatitis B had developed. In reading any documentary one must be skeptical of bias and emphasis. I know that the history I would write of the HIV response in Australia would differ considerably from that written by my colleagues.

In setting the scene Edwards gives a fairly straightforward account of the recognition in the mid- to late-1970s of the extent of hepatitis B among Maori and Polynesians living around the Bay of Plenty. She also elaborates on how, rather than vertical transmission accounting for the majority of infections in childhood, it is close contact between young children and domestic cohabitants. The significance of this is that identifying hepatitis B-transmitting mothers, and the treatment of their children, provides no protection to children of uninfected mothers, who may be infected while playing with other children.

The Whakatane group, using the epidemiology they collect from a number of locations, aims for the mass testing, vaccination and follow-up of young people at risk: Maori, Polynesian, Asian and European children in highly integrated communities in the North Island of New Zealand. This seems quite reasonable, but the book gets quite bogged down in a series of claims about delays in rollout. I know, if only vaguely or by reputation, a number of people involved in the book, but I must admit I found some of the politics a little tedious. I'm not sure who the book is aimed at. If it is the public health scholar, then I would have liked a greater analysis of the issues surrounding the introduction or otherwise of population based screening, vaccination and follow-up. If it is aimed at the reader who picks up a book because the subject seems interesting, then the politics could have been minimised. The role of the Whakatane group in modifying vaccination regimens was very interesting, and I was surprised that the closure of the laboratory at Whakatane did not rate greater discussion in the book.

The book came across as fairly one-sided, but I think it would have been virtually impossible either to write or read had this not been the case. It is told through they eyes of Milne, Moyes and the Hepatitis Foundation, and their dedication and perseverance is to be admired. In short, the argument for screening rested on getting to a group of children who had been "missed" at birth, but had a considerable chance of infection in the intervening years. As an Australian reader I had to continually consider the number of people being talked about and the rates of infection. New Zealand's experience differs from Australia's, and with the inclusion of follow-up, then screening and vaccination, was a different model to screening in the absence of the ability to offer any intervention, or vaccinating randomly.

I was concerned at the introduction of diabetes screening to the mix, and I wondered whether this could reflect a desire to screen for everything or use screening as a prevention strategy. Again, one has to go back to the infection rates to assess the virtue of these strategies. As a non-New Zealander the references to previous "problems with cervical and breast screening" remain a mystery.

A theme which ran through the book and kept my interest was the challenge around identifying sub-populations at risk, and managing these at a political and social level. That hepatitis B is transmissible seems to only add to the potential stigma, and thus the greater delicacy with which these issues must be managed. Dealing with this tension alone makes the book a hugely valuable read for anyone entering a politically charged public health arena.

It would appear that the screening program has now finished, the follow-up is continuing and the epidemiological data set relating to a large cohort of people living with hepatitis B in New Zealand continues to develop. Managing those with chronic hepatitis B, particularly as the cohort ages, will be a considerable task for the New Zealand health system. Follow-up of people with chronic hepatitis B is hugely important and Edwards makes us consider how we will each rise to this challenge.

I commend the book to all readers with an interest in the topic, and an interest in public health.