Estimates and projections of hepatitis B-related hepatocellular carcinoma in Australia among people born in Asia-Pacific countries

Hospitalisation costs of primary liver cancer in Australia: evidence from a data-linkage study

ObjectiveThis study aimed to estimate the public hospital costs associated with primary liver cancer (PLC) in the first and second years following the cancer diagnosis.MethodsThis study linked administrative datasets of patients diagnosed with PLC in Victoria, Australia, from January 2008 to December 2015. The health system perspective was adopted to estimate the direct healthcare costs associated with PLC, based on inpatient and emergency costs. Costs were estimated for the first 12 months and 12-24 months after the PLC diagnosis and expressed in 2017 Australian dollars (A$). The cost estimated was then extrapolated nationally. The linear mixed model with a Box-Cox transformation of the costs was used to explore the relationship between costs and patients' sociodemographic and clinical characteristics.ResultsFor the first 12 months, the total and annual per-patient cost was A$211.4 million and A$63 664, respectively. Costs for the subsequent year were A$49.7 million and A$46 751, respectively. Regarding the cost extrapolation to Australia, the total cost was A$137 million for the first 12 months after notification and A$42.6 million for the period from 12 to 24 months. Higher costs per episode of care were mostly associated with older age, hepatocellular carcinoma type of PLC, metropolitan hospitals, and Asian birth region.ConclusionThis study showed the public hospital admission and emergency costs associated with PLC and the substantial economic burden this cancer has placed on the Australian health system.

A Systematic Review and Narrative Synthesis of Health Economic Evaluations of Hepatocellular Carcinoma Screening Strategies

OBJECTIVES

Many economic evaluations of hepatocellular carcinoma (HCC) screenings have been conducted; however, these vary substantially with regards to screening strategies, patient group, and setting. This review aims to report the current knowledge of the cost-effectiveness of screening and describe the published data.

METHODS

We conducted a search of biomedical and health economic databases up to July 2020. We included full and partial health economic studies if they evaluated the costs or outcomes of HCC screening strategies.

RESULTS

The review included 43 studies. Due to significant heterogeneity in key aspects across the studies, a narrative synthesis was conducted. Most studies reported using ultrasound or alpha fetoprotein as screening strategies. Screening intervals were mostly annual or biannual. Incidence, diagnostic performance, and health state utility values were the most critical parameters affecting the cost-effectiveness of screening. The majority of studies reported HCC screening to be cost-effective, with the biannual ultrasound + alpha fetoprotein standing out as the most cost-effective strategy. However, few studies considered the utilization rate, and none considered the diagnostic performance of ultrasound in the context of central adiposity. Computed tomography and magnetic resonance imaging were also evaluated, but its cost-effectiveness was still controversial.

CONCLUSIONS

Although many studies suggested HCC screening was cost-effective, substantial limitations of the quality of these studies means the results should be interpreted with caution. Future modeling studies should consider the impact of central adiposity on the precision of ultrasound, real-world utilization rates and projections of increased HCC incidence.

Increasing incidence and mortality related to liver cancer in Australia: time to turn the tide

OBJECTIVE

Assess national and jurisdictional incidence and mortality trends for primary liver cancer in Australia.

METHODS

Analysis of Australian Cancer Incidence and Mortality data published in 2017 by the AIHW. Age-standardised rates (ASR) for 1982 to 2014/2015. Piecewise linear regression was used to assess temporal trends. For the purposes of comparison, data were also extracted for all cancers with greater burdens of disease (lung, colorectal, breast, prostate, pancreatic, and brain cancers and melanoma of the skin).

RESULTS

Since 1982, the average annual percentage change (AAPC) for ASR incidence of liver cancer was 4.858% (95%CI 4.558-5.563). This marked a 306% increase from 1.822/100,000 persons (95%CI 1.586-2.058) in 1982 to 7.396/100,000 persons (95%CI 7.069-7.723) in 2014. AAPC for ASR mortality was 3.013% (95%CI 2.448-3.521): an increase of 184% from 2.323/100,000 persons (95%CI 2.052-2.594) in 1982 to 6.593/100,000 (95%CI 6.290-6.896) in 2015. ASR incidence and mortality were highest in the NT (12.607/100,000 persons), VIC (8.229/100,000) and NSW (7.798/100,000). In comparison to the other selected cancers, higher AAPC for both incidence and mortality of liver cancer were observed.

CONCLUSION

Incidence and mortality associated with liver cancer have increased substantially in the past three decades, in contrast to the improved outcomes observed for many other cancers. Jurisdictional incidence rates reflect higher prevalence of hepatitis B and C. Implications for public health: In the context of Australian cancer prevention and care programs, liver cancer is an outlier. Strategies to mitigate risk factors and improve surveillance of liver health for at-risk groups are urgently required.

Utilisation of hepatocellular carcinoma screening in Australians at risk of hepatitis B virus-related carcinoma and prescribed anti-viral therapy

AIMS AND OBJECTIVES

To investigate hepatocellular carcinoma screening utilisation and factors associated with utilisation among patients prescribed hepatitis B virus anti-viral therapy and at risk of hepatocellular carcinoma.

BACKGROUND

The incidence of hepatocellular carcinoma has increased in Australia over the past three decades with chronic hepatitis B virus infection a major contributor. hepatocellular carcinoma surveillance programs aim to detect cancers early enabling curative treatment options, longer survival and longer times to recurrence.

DESIGN

Multi-site cross-sectional survey.

METHODS

An online study questionnaire was administered to eligible participants attending three Sydney tertiary hospitals. Data were grouped into six mutually exclusive hepatocellular carcinoma risk factor categories as per American Association for the Study of Liver Diseases guidelines. All analyses were undertaken in STATA. Logistic regression was used to assess the associations between covariates and screening utilisation. Multivariate models described were assessed using the Hosmer-Lemeshow goodness of fit.

RESULTS

Of the 177 participants, 137 (77.4%) self-reported that US had been performed in the last six months. Awareness that screening should be performed and knowing the correct frequency of US screening were independently associated with screening utilisation. Participants who knew that screening should be undertaken were three times more likely to have had pretreatment education or were prescribed hepatitis B virus anti-viral treatment for >4 years. Participants reporting a family history of hepatocellular carcinoma were less likely to know that screening should be undertaken every 6 months.

CONCLUSION

While utilisation of hepatocellular carcinoma surveillance programs was higher in this study than in previous reports, strategies to further improve surveillance remain necessary.

RELEVANCE TO CLINICAL PRACTICE

Findings from this research form the basis for proposing strategies to improve utilisation of hepatocellular carcinoma screening, inform hepatitis B virus-related clinical practice and for the delivery of care and nursing education to people receiving hepatitis B virus anti-viral therapy and at risk of developing hepatocellular carcinoma.

Epidemiology of Hepatocellular Carcinoma in the Asia-Pacific Region

Hepatocellular carcinoma (HCC) is the predominant primary liver cancer in many countries and is the third most common cause of cancer-related death in the Asia-Pacific region. The incidence of HCC is higher in men and in those over 40 years old. In the Asia-Pacific region, chronic hepatitis B virus and hepatitis C virus infections are the main etiological agents; in particular, chronic hepatitis B infection (CHB) is still the major cause in all Asia-Pacific countries except for Japan. Over the past two decades, the incidence of HCC has remained stable in countries in the region except for Singapore and Hong Kong, where the incidence for both sexes is currently decreasing. Chronic hepatitis C infection (CHC) is an important cause of HCC in Japan, representing 70% of HCCs. Over the past several decades, the prevalence of CHC has been increasing in many Asia-Pacific countries, including Australia, New Zealand, and India. Despite advancements in treatment, HCC is still an important health problem because of the associated substantial mortality. An effective surveillance program could offer early diagnosis and hence better treatment options. Antiviral treatment for both CHB and CHC is effective in reducing the incidence of HCC.

Factors associated with HBV virological breakthrough

BACKGROUND

Little is known about non-adherence to HBV therapy. This study aimed to investigate the relationship between self-reported missed days of antiviral therapy and HBV virological breakthrough and factors associated with virological breakthrough.

METHODS

A cross-sectional survey of 211 HBV patients receiving oral antiviral therapies was undertaken at three tertiary hospitals in Sydney, Australia. Associations between 0 to >6 missed days in the last 30 days and virological breakthrough (defined as >10-fold rise in serum HBV DNA above nadir or after achieving virological response in the last 12 months) were examined. Logistic regression analyses determined the number of missed days most strongly associated with virological breakthrough and the associated factors. We report odds ratios (ORs) and relative risks (RRs).

RESULTS

Of the 204, 32 participants (15.6%) had quantifiable HBV DNA levels (>20 IU/ml); 15 (46.8%) of them experienced virological breakthrough. Participants reported never missing medication (n=130, 63.7%) or missing 1 day (n=23, 11.3%), >1 day (n=23, 11.3%), 2-6 days (n=15, 7.3%) and >6 days (n=13, 6.4%). The most discriminating definition of non-adherence was missing >1 day of medication (RR=8.3; OR=10.2, 95% CI 3.1, 33.8, receiver operating characteristic curve 0.76). Factors independently associated with virological breakthrough included non-adherence (OR=9.0, 95% CI 2.5, 31.9) diagnosed with HBV ≤14 years (OR=5.3, 95% CI 1.0, 26.2) and age ≤47 years (OR=5.4, 95% CI 1.1, 26.9).

CONCLUSIONS

Results provide an evidence-based definition of non-adherence to inform clinical practice and provide a basis for key patient education messages. Closer monitoring of groups at risk of viral breakthrough is required.

Barriers faced by migrants in accessing healthcare for viral hepatitis infection

BACKGROUND

The morbidity and mortality of hepatitis B virus- and hepatitis C virus-related complications are disproportionately higher in the culturally and linguistically diverse population (CALD) when compared with Australian-born individuals.

AIM

This project aims to elucidate the barriers faced by the CALD population in accessing viral hepatitis management.

METHOD

CALD outpatients attending a viral hepatitis clinic in a tertiary teaching hospital were invited to participate in interviews. Questions pertained to: reason for screening for viral hepatitis, barriers to healthcare, perceived community view of viral hepatitis, main source of information of viral hepatitis and suggestions to engage members of CALD to seek healthcare.

RESULTS

The total number of participants was 60. The two major countries of birth included China (40%) and Egypt (17%). In 40% of the cohort, viral hepatitis was identified through screening programmes. Importantly, 37% were diagnosed as a result of complications of hepatitis infection, presenting late in the stage of disease. Forty-five per cent of participants perceived language to be a chief barrier. twenty-two per cent reported cultural barriers to accessing healthcare. Of these, 53% reported fear of discrimination/stigma. The lack of knowledge of available treatments/options was stated as a major obstacle in 40%. The two prevailing recommendations were greater education and awareness (85%) and changes in the health system itself (11%).

CONCLUSION

Substantial hurdles identified by participants include cultural differences, language difficulties, cultural beliefs, stigma and misinformation. These data demonstrate the need for the greater dissemination of information in culturally and linguistically appropriate mediums to raise awareness about viral hepatitis, pathogenesis and available treatments.

Hepatitis B and C infection in international travelers

BACKGROUND

Hepatitis B and C virus (HBV and HCV) cause significant morbidity and mortality worldwide. With the rise in international travel over the last three decades, many travelers are at risk of HBV and HCV infection.

METHODS

This review focuses on the epidemiology of HBV and HCV in international travelers, the modes of transmission, and the prevention of infection in travelers.

RESULTS

The risk of HBV and HCV infection varies widely and depends on the prevalence of the destination country, the duration of travel, and the activities undertaken while abroad. Travelers commonly undertake high-risk activities that place them at risk of both HBV and HCV infection. Poor uptake of preventative health measures and poor adherence to health recommendations are also common. The monthly incidence of HBV infection for long-term travelers to endemic countries ranges from 25 to 420 per 100,000 travelers. HBV infection can be prevented through timely vaccination of travelers. HBV vaccination is safe and efficacious with protective levels of antibodies achieved in >90% of recipients. Information regarding the risk of HCV acquisition is scarce and until recently was limited to case reports following medical interventions.

CONCLUSIONS

This review demonstrates international travelers are at risk of HBV and HCV infection and provides evidence-based information enabling health practitioners to provide more appropriate pre-travel advice. HBV vaccination should be considered in all travelers to countries with a moderate to high HBV prevalence (HBsAg ≥ 2%) and the risk and benefits discussed with the individuals in consultation with the health practitioner. There is no duration of travel without risk of HBV infection. However, it is apparent that those travelers with a longer duration of travel are at greatest risk of HBV infection (ie, expatriates). Travelers should also receive advice regarding the modes of transmission and the activities that place them at risk of both HBV and HCV infection.

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.

METHODS

This study used census-based methodology attributing risk of CHB by country of birth and Aboriginal and Torres Strait Islander status, augmented with priority risk-group based estimates. Deterministic mathematical modelling was used for comparison and for validation of census-derived estimates.

RESULTS

An estimated 218,000 Australians (plausible range 192,000-284,000) are living with CHB, a significant increase over previous estimates. The prevalence derived using mathematical modelling was similar, at 204,000. Notable differences were observed by geographic area in both prevalence and the populations predominantly affected. It is estimated that only 56% of people living with CHB in Australia have been diagnosed and notified.

CONCLUSIONS

The prevalence of CHB in Australia is increasing, with 1% of the population now estimated to be affected. The majority of the burden is experienced by people born overseas in endemic areas, with more than 95% of new cases of CHB entering the population through migration.

IMPLICATIONS

It is imperative that more attention and greater resources are devoted to addressing CHB in Australia; to increase the proportion of Australians affected who have been diagnosed and who are on treatment, in accordance with the First National Hepatitis B Strategy.

Trends in transfusion-transmissible infections among Australian blood donors from 2005 to 2010

BACKGROUND

Routine monitoring of trends in transfusion-transmissible infections (TTIs) is essential to maintaining and improving transfusion safety. Although periodic studies have been published there is no comprehensive trend analysis for TTIs in Australian donors. This study determined recent trends in TTIs for which testing is conducted in Australia and described key attributes of infected blood donors.

STUDY DESIGN AND METHODS

This is a retrospective analysis using data on donation testing for TTIs (2005-2010) from the national blood service donor database and data on postdonation interviews with TTI-positive donors (2008-2010) from a risk factor database incorporating responses to standardized interview questions. The study measured the prevalence and incidence of TTIs in Australia and assessed their time trends. Multivariate analysis of time trends was conducted using Poisson regression models.

RESULTS

Overall, the prevalence and incidence of TTIs in 2005 to 2010 remained low and steady. The prevalence of hepatitis C virus decreased (rate ratio [RR], 0.93; 95% confidence interval [CI], 0.89-0.97) and the prevalence of active syphilis increased (RR, 1.51; 95% CI, 1.15-1.99) significantly during the study period. Prevalence of TTIs among Australian blood donors was substantially lower than that in the general population and no unique risk factors were identified in test-positive blood donors when compared with the general population.

CONCLUSION

Both the prevalence and the incidence of TTIs in Australian blood donors remained low, with a steady or declining trend for most infections except active syphilis. The lower prevalence of TTIs in blood donors compared with the general population reflects the effectiveness of donor education and donor selection measures in Australia.

Cost of treating chronic hepatitis B: Comparison of current treatment guidelines

AIM: To compare program costs of chronic hepatitis B (CHB) screening and treatment using Australian and other published CHB treatment guidelines.

METHODS: Economic modeling demonstrated that in Australia a strategy of hepatocellular cancer (HCC) prevention in patients with CHB is more cost-effective than current standard care, or HCC screening. Based upon this model, we developed the B positive program to optimize CHB management of Australians born in countries of high CHB prevalence. We estimated CHB program costs using the B positive program algorithm and compared them to estimated costs of using the CHB treatment guidelines published by the Asian-Pacific, American and European Associations for the Study of Liver Disease (APASL, AASLD, EASL) and those suggested by an independent United States hepatology panel. We used a Markov model that factored in the costs of CHB screening and treatment, individualized by viral load and alanine aminotransferase levels, and calculated the relative costs of program components. Costs were discounted by 5% and calculated in Australian dollars (AUD).

RESULTS: Using the B positive algorithm, total program costs amount to 13 979 224 AUD, or 9634 AUD per patient. The least costly strategy is based upon using the AASLD guidelines, which would cost 34% less than our B positive algorithm. Using the EASL and the United States Expert Group guidelines would increase program costs by 46%. The largest expenditure relates to the cost of drug treatment (66.9% of total program costs). The contribution of CHB surveillance (20.2%) and HCC screening and surveillance (6.6%) is small - and together they represent only approximately a quarter of the total program costs.

CONCLUSION: The significant cost variations in CHB screening and treatment using different guidelines are relevant for clinicians and policy makers involved in designing population-based disease control programs.

Risk factors for hepatocellular carcinoma in a cohort infected with hepatitis B or C

BACKGROUND AND AIM

The incidence of hepatocellular carcinoma (HCC) has increased in Australia in recent decades, a large and growing proportion of which occurs among a population chronically infected with hepatitis B virus (HBV) or hepatitis C virus (HCV). However, risk factors for HCC among these high-risk groups require further characterization.

METHODS

We conducted a population-based cohort study using HBV and HCV cases notified to the New South Wales Health Department between 2000 and 2007. These were linked to cause of death data, HIV/AIDS notifications, and hospital records. Proportional hazards regression was used to identify significant risk factors for developing HCC.

RESULTS

A total of 242 and 339 HCC cases were linked to HBV (n = 43 892) and HCV (n = 83 817) notifications, respectively. For both HBV and HCV groups, being male and increasing age were significantly associated with risk of HCC. Increasing comorbidity score indicated high risk, while living outside urban areas was associated with lower risk. Hazard ratios for males were two to three times those of females. For both HBV and HCV groups, cirrhosis, alcoholic liver disease, and the interaction between the two were associated with significantly and considerably elevated risk.

CONCLUSION

This large population-based study confirms known risk factors for HCC. The association with older age highlights the potential impact of HBV and HCV screening of at-risk groups and early clinical assessment. Additional research is required to evaluate the impact of improving antiviral therapy on HCC risk.

Trends in mortality after diagnosis of hepatitis B or C infection: 1992-2006

BACKGROUND & AIMS

Chronic hepatitis B (HBV) or C (HCV) virus infection has been associated with increased risk of death, particularly from liver- and drug-related causes. We examined specific causes of death among a population-based cohort of people infected with HBV or HCV to identify areas of excess risk and examine trends in mortality.

METHODS

HBV and HCV cases notified to the New South Wales (NSW) Health Department between 1992 and 2006 were linked to cause of death data and HIV/AIDS notifications. Mortality rates and standardised mortality ratios (SMRs) were calculated using person time methodology, with NSW population rates used as a comparison.

RESULTS

The study cohort comprised 42,480 individuals with HBV mono-infection and 82,034 with HCV mono-infection. HIV co-infection increased the overall mortality rate three to 10-fold compared to mono-infected groups. Liver-related deaths were associated with high excess risk of mortality in both HBV and HCV groups (SMR 10.0, 95% CI 9.0-11.1; 15.8, 95% CI 14.8-16.8). Drug-related deaths among the HCV group also represented an elevated excess risk (SMR 15.4, 95% CI 14.5-16.3). Rates of hepatocellular carcinoma (HCC)-related death remained steady in both groups. A decrease in non-HCC liver-related deaths was seen in the HBV group between 1997 and 2006, but not in the HCV group. After a sharp decrease between 1999 and 2002, drug-related mortality rates in the HCV group have been stable.

CONCLUSIONS

Improvements in HBV treatment and uptake have most likely reduced non-HCC liver-related mortality. Encouragingly, HCV drug-related mortality remained low compared to pre-2002 levels, likely due to changes in opiate supply, and maintenance or improvement in harm reduction strategies.

Hepatitis B Knowledge, Testing, and Vaccination Among Chinese and Vietnamese Adults in Australia

Hepatitis B is a significant public health challenge within some subpopulations in Australia, including Chinese and Vietnamese migrants. There has been limited research on hepatitis B knowledge and actions in these communities. The authors conducted a self-administered survey among 442 Chinese and 433 Vietnamese in Brisbane. Generally, the knowledge is best described as “moderate.” One in 2 could not identify the sexual transmission risk and less than one third knew that sharing foods or drinks did not spread the disease. The majority of Vietnamese (80%) and 60% of Chinese respondents indicated prior testing. Vaccination was reported in 60% of the Vietnamese and in 52% of the Chinese. Knowledge was better among Chinese people who had been tested and vaccinated compared with those who were nontested and nonvaccinated. Only 3.5% of the Chinese, but 11.6% of the Vietnamese, indicated having a positive test result hepatitis B virus. This study helps identify strategies for programs targeting both communities and practitioners.

The linguistic demography of Australians living with chronic hepatitis B

OBJECTIVE

The prevalence of chronic hepatitis B virus (HBV) infection is increasing in Australia, and most affected individuals were born overseas. Estimating the English literacy of predominantly affected populations and determining the languages other than English (LOTE) spoken is essential for the development of appropriate resources.

METHOD

Data from the Australian Bureau of Statistics and Department of Immigration and Citizenship were used to estimate the number of Australian residents by birth country, English literacy and LOTE spoken, with a focus on those arriving in the past two decades. Prevalence of chronic HBV infection was estimated using source country seroprevalence. The results were compared to Victorian surveillance notification data and published Australian epidemiological and clinical studies.

RESULTS

Chinese languages and Vietnamese are the dominant languages spoken by Australians living with chronic HBV infection who speak limited or no English. Estimates of predominant source countries for people living with chronic HBV infection derived from Census data were generally coherent with existing epidemiological and clinical studies but differences exist, particularly for groups targeted for screening such as humanitarian entrants.

CONCLUSIONS

This study emphasises the need for LOTE resources for Australians living with chronic HBV infection and suggests priority languages. The notable differences observed between Census-derived estimates and surveillance data suggest there are particularly under-diagnosed groups within the community.

IMPLICATIONS

This study has clear implications for prioritising the translation of resources targeting Australians living with chronic HBV infection.

Using a population-based approach to prevent hepatocellular cancer in New South Wales, Australia: effects on health services utilisation

BACKGROUND

Australians born in countries where hepatitis B infection is endemic are 6-12 times more likely to develop hepatocellular cancer (HCC) than Australian-born individuals. However, a program of screening, surveillance and treatment of chronic hepatitis B (CHB) in high risk populations could significantly reduce disease progression and death related to end-stage liver disease and HCC. Consequently we are implementing the B Positive pilot project, aiming to optimise the management of CHB in at-risk populations in south-west Sydney. Program participants receive routine care, enhanced disease surveillance or specialist referral, according to their stage of CHB infection, level of viral load and extent of liver injury. In this paper we examine the program's potential impact on health services utilisation in the study area.

METHODS

Estimated numbers of CHB infections were derived from Australian Bureau of Statistics data and applying estimates of HBV prevalence rates from migrants' countries of birth. These figures were entered into a Markov model of disease progression, constructing a hypothetical cohort of Asian-born adults with CHB infection. We calculated the number of participants in different CHB disease states and estimated the numbers of GP and specialist consultations and liver ultrasound examinations the cohort would require annually over the life of the program.

RESULTS

Assuming a 25% participation rate among the 5,800 local residents estimated to have chronic hepatitis B infection, approximately 750 people would require routine follow up, 260 enhanced disease surveillance and 210 specialist care during the first year after recruitment is completed. This translates into 5 additional appointments per year for each local GP, 25 for each specialist and 420 additional liver ultrasound examinations.

CONCLUSIONS

While the program will not greatly affect the volume of local GP consultations, it will lead to a significant increase in demand for specialist services. New models of CHB care may be required to aid program implementation and up scaling the program will need to factor in additional demands on health care utilisation in areas of high hepatitis B sero-prevalence.

Hepatitis B-related hepatocellular carcinoma: epidemiological characteristics and disease burden

Worldwide, 350 million people are chronically infected with hepatitis B virus (HBV) who are at greater risk of hepatocellular carcinoma (HCC) compared with uninfected people. The relative risks of HCC among people infected with HBV ranges from 5 to 49 in case-control studies and from 7 to 98 in cohort studies. More than 50% of HCC cases worldwide and 70-80% of HCC cases in highly HBV endemic regions are attributable to HBV. Incidence of HCC (per 100,000 person/year) among people with chronic HBV infection ranges from 400 to 800 in male and from 120 to 180 in female. Factors associated with increased risk of HCC include demographic characteristics (male sex and older age), lifestyles (heavy alcohol consumption and smoking), viral factors (genotype C, D F, high level of HBV DNA, core/precore mutation) and clinical factors (cirrhosis, elevated alpha-fetoprotein (AFP) and alanine aminotransferase (ALT)). HBV-related HCC has extremely poor prognosis with median survival less than 16 months. Survival rates of HBV-related HCC ranged from 36% to 67% after 1 year and from 15% to 26% after 5 year of diagnosis. Older age, liver function impairment, vascular invasion, tumour aggressiveness and elevated AFP are associated with HCC survival. Global burden of HBV-related liver disease is still a major challenge for public health in the 21st century. While decreases in incidence of HBV infection have been observed in birth cohorts following the introduction of universal infant HBV vaccination programme, HBV-related HCC incidence in is projected to increase for at least two decades because of the high prevalence of chronic HBV infection and prolonged latency to HCC development. To reduce HBV-related HCC continued expansion of universal infant HBV vaccination is required along with antiviral therapy targeted to those individuals at highest risk of HCC. Broad public health strategies should include routine testing to identify chronic HBV infection, improved health infrastructures including human resource to provide diagnosis and treatment assessment.

Chronic hepatitis B infection in an Australian antenatal population: seroprevalence and opportunities for better outcomes

BACKGROUND

In the antenatal population, screening for Hepatitis B virus (HBV) carrier status is routinely undertaken to guide preventative measures for the newborn. There is scarce information in the literature, however, regarding the subsequent management of Hepatitis B surface antigen (HBsAg) positive mothers.

AIMS AND METHODS

Thus, we undertook this retrospective study to (i) determine the prevalence of HBsAg positivity among mothers attending two teaching hospital birth centers; (ii) determine whether HBsAg mothers received HBV education and underwent further evaluation of HBV infectivity status; and (iii) determine whether these mothers had further follow up for HBV infection post delivery.

RESULTS

Between January 2003 and December 2006, 14, 857 mothers were screened for hepatitis B virus infection. Among these, 295 mothers were positive with HBsAg seroprevalence of 2%. A more detailed review of the available 206 medical records revealed that the majority (78%) had previous documentation of infection in earlier pregnancies. However none had received education regarding HBV infectivity. In addition, liver function tests were only performed in 78% of the mothers while Hepatitis B e antigen was tested in 65% of cases. Further, 93% of the mothers had no documentation of further follow up plans or referrals for their HBV infection.

CONCLUSION

It is clear that chronic HBV infection is prevalent in the antenatal population. However, there are no strategies to ensure that infected mothers subsequently undergo further education for HBV or evaluation of infectivity. Clearly strategies are required to ensure improved follow up of hepatitis B infected mothers.

Predictors and survival in hepatitis B-related hepatocellular carcinoma in New South Wales, Australia

BACKGROUND AND AIM

Incidence and mortality of hepatocellular carcinoma (HCC) has increased markedly over the last three decades in Australia. An increasing proportion of HCC cases is related to chronic viral hepatitis including hepatitis B virus (HBV) infection. However, there is very limited data on HBV-related HCC survival.

METHODS

Data on HBV-related HCC cases was obtained from a community-based linkage study. HCC cases notified to the New South Wales (NSW) Central Cancer Registry (CCR) during the period 1994-2002 were linked to HBV notifications from the NSW Health Department. Age, sex, country of birth, year of diagnosis, tumor stage were extracted from the CCR database. Survival analysis was conducted to determine median survival and identify predictors of survival.

RESULTS

Over the 9-year study period, 278 HCC cases were linked to chronic HBV infection. The majority of cases were male (83.5%) and overseas-born (93.6%); Asian-born cases accounted for 72.1%. Median survival following HCC diagnosis was 15.0 months. HCC survival was poorer among older age groups (P < 0.0001), and among cases with regional spread (hazard ratio, 3.23; 95% confidence interval, 1.83-5.69; P < 0.0001) and distant metastases (hazard ratio, 3.85; 95% confidence interval, 2.44-6.08; P < 0.0001). Sex, region of birth and study period (1994-1997 vs 1998-2002) were not associated with HCC survival.

CONCLUSION

The vast majority of HBV-related HCC were overseas-born, however, region of birth was unrelated to HCC survival. The continued extremely poor HCC survival, including lack of improvement in HCC survival in more recent years, suggests low uptake of HCC screening programs. Public health strategies including early diagnosis and appropriate referral for antiviral therapy assessment and increased HCC screening among high-risk populations are required to reduce HCC incidence and improve HCC survival.