Australasian Society for HIV Medicine

Reviewed by: Dr Benjamin Cowie

Physician, Victorian Infectious Diseases Service, Royal Melbourne Hospital; Medical Epidemiologist, Victorian Infectious Diseases Reference Laboratory

The Centers for Disease Control and Prevention (CDC) in the United States recently published revised recommendations for the identification and management of people living with chronic hepatitis B virus (HBV) infection (1). A fundamental component of these recommendations is the expansion of routine testing to include many more people at risk of having chronic HBV than was previously the case (see box).  

The impact of these new testing recommendations will be profound if implemented in Australia. Approximately 30 per cent of us were born overseas, the majority in countries with intermediate or high prevalence of HBsAg (2). Therefore some 3.4 million Australians, being among the nearly 90 per cent of humans born in areas with HBsAg prevalence above 2 per cent (1) would be candidates for routine HBV screening under this single criterion alone.  

In the Australian context it is imperative to include Indigenous people in such testing recommendations given the higher prevalence of chronic HBV in Indigenous Australians (3). There are other groups for whom testing has been recommended which are not included in the CDC criteria; the recently published ASHM/Cancer Council NSW monograph B Positive - all you wanted to know about hepatitis B: a guide for primary care providers (4) (available at http://www.ashm.org.au/b-positive/) includes extensive information on HBV epidemiology and testing recommendations, particularly in chapters 1 and 3.  

These new recommendations come at a time when there are increasing calls in Australia for a profound shift in both public policy and clinical management relating to chronic HBV infection. This year has seen the publication of both the B Positive monograph and the National Hepatitis B Needs Assessment (5) (available at http://alliance.hepatitis.org.au/index.php?page=research). Both documents describe the failure of Australia’s public health response to HBV. There is still no National Strategy to co-ordinate an urgently needed, broad-based approach to this ‘poor cousin’ of HCV and HIV. The prevalence of  HBV infection is increasing in Australia, with the most recent national seroprevalence data suggesting 160,000 Australians are chronically infected (6), one quarter of whom can be expected to die as a result of cirrhosis and/or hepatocellular carcinoma (HCC) (7). The disease burden in this country cannot be overstated; in New South Wales, HCC incidence is rising faster than any other cancer (8).   

The CDC document goes much further than simply advising more people be tested for chronic HBV. A rationale for this expansion is provided, including favourable cost effectiveness analysis, and it is demonstrated that testing for chronic HBV meets long-established World Health Organisation criteria for disease screening (9). Critically, with the recent rapid expansion of effective treatment options for chronic HBV, the opportunities for modifying the natural history of the disease – and reducing further transmission - have improved. Enrolment in regular monitoring to assess disease activity and for HCC screening where appropriate is also most important, with randomised controlled trial evidence supporting previous observational data that HCC surveillance significantly reduces cancer mortality (10). 

Finally, the new recommendations call for a change in the way public health authorities respond to notifications of chronic HBV – a disease which has only been nationally notifiable in the USA since 2005 (11). Significantly expanding the role of surveillance registries of notified cases of chronic HBV is advised, with the ‘minimum’ approach being similar to that undertaken in Australia. The CDC recommends building on this foundation in a tiered fashion, to develop chronic HBV registries into tools for public health intervention and clinical management. The expanded roles discussed include:

·         Facilitating and tracking the follow-up of notifications with chronic HBV

·         Assisting with notification of contacts and co-ordinating testing and vaccination as indicated

·         Communication with or referral to health care providers

·         Providing geographic and temporal estimates of the epidemiology of chronic HBV

·         Linkage with cancer registries and mortality data to establish robust disease burden estimates 

Such an expansion would obviously require significantly increased funding devoted to hepatitis programs, and the first three elements are more akin to the approach taken for HIV and tuberculosis notifications in the USA and also in Australia. Depending on the intensity of the expansion, the resources required could be considerable, not least when one considers annual notifications of non-incident HBV currently range between 6000 and 8000 in Australia, some three times the number for HIV and tuberculosis combined. However the current approach involves little or no public health follow up of notified cases of chronic HBV infection, despite the fact that these people have a treatable disease associated with significant mortality. It could be argued that our standard practice of compiling lists of infected people and archiving their contact details without making any attempt to help inform them regarding their illness or their options is programmatically flawed, and even ethically questionable. 

Perhaps the most important point to reflect on when considering the new CDC recommendations is that policy changes can only make a difference if implemented. Reference is made to a study from New York of over 18,000 primary care clinic attendees in 2005-2006, which demonstrated nearly half of those born in high HBV prevalence countries had not been tested in line with the existing CDC recommendations at that time (12). There is no reason to suspect we do any better in Australia. Most clinicians would probably agree that failing to opportunistically test patients with a 1 in 50 or greater chance of having a communicable, treatable and potentially fatal disease is unacceptable.   

References 

1.         Weinbaum CM, Williams I, Mast EE, Wang SA, Finelli L, Wasley A, et al. Recommendations for identification and public health management of persons with chronic hepatitis B virus infection. MMWR Recomm Rep. 2008 Sep 19;57(RR-8):1-20.

2.         Australia: Country of birth of person by sex, 2006 (Cat. No. 2068.0). Canberra: Australian Bureau of Statistics, Commonwealth of Australia; 2007.

3.         O'Sullivan BG, Gidding HF, Law M, Kaldor JM, Gilbert GL, Dore GJ. Estimates of chronic hepatitis B virus infection in Australia, 2000. Aust N Z J Public Health. 2004 Jun;28(3):212-6.

4.         Matthews G, Robotin M, editors. B Positive - all you wanted to know about hepatitis B: a guide for primary care providers. Darlinghurst: Australasian Society for HIV Medicine; 2008.

5.         Wallace J, McNally S, Richmond J. National Hepatitis B Needs Assessment. Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University; 2008.

6.         Gidding HF, Warlow M, MacIntyre CR, Backhouse J, Gilbert GL, Quinn HE, et al. The impact of a new universal infant and school-based adolescent hepatitis B vaccination program in Australia. Vaccine. 2007 Dec 12;25(51):8637-41.

7.         Lavanchy D. Hepatitis B virus epidemiology, disease burden, treatment, and current and emerging prevention and control measures. J Viral Hepat. 2004 Mar;11(2):97-107.

8.         Robotin MC, George J, Supramaniam R, Sitas F, Penman AG. Preventing primary liver cancer: how well are we faring towards a national hepatitis B strategy? Med J Aust. 2008 Mar 17;188(6):363-5.

9.         Wilson JMG, Jungner G. Principles and practice of screening for disease. Public Health Paper no. 34. Geneva: World Health Organisation; 1968.

10.       Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular carcinoma. J Cancer Res Clin Oncol. 2004 Jul;130(7):417-22.

11.       Guidelines for Viral Hepatitis Surveillance and Case Management. Atlanta: Centers for Disease Control and Prevention; 2005.