Chronic hepatitis B care in regional Australia: implications for clinical practice and public health policy

BACKGROUND

Australia is struggling to meet its National Hepatitis B Strategy care targets, particularly in nonmetropolitan settings. It is vital to engage priority populations and improve their access to recommended care to reach these targets.

AIMS

This retrospective study examined people living with chronic hepatitis B (CHB) in regional North Queensland, Australia, and determined whether their care adhered to current national CHB management guidelines. The analysis aimed to identify gaps in care that might be addressed to improve future outcomes.

METHODS

All individuals referred to the gastroenterology clinic at the Townsville University Hospital in regional North Queensland, Australia, for CHB care between January 2015 and December 2020 were identified. Their linkage to care, engagement in care and receipt of guideline-recommended CHB care were determined.

RESULTS

Of 255 individuals, 245 (96%) were linked to care; 108 (42%) remained engaged in care and 86 (38%) were receiving guideline-recommended care in 2021. There were 91/255 (36%) who identified as Indigenous Australians. Indigenous status was the only independent predictor of not being linked to care (odds ratio (OR): 0.13 (95% confidence interval (CI): 0.03-0.60), P = 0.01), not being engaged in care (OR: 0.19 (95% CI: 0.10-0.36), P < 0.0001), not receiving guideline-recommended CHB care (OR: 0.16 (95% CI: 0.08-0.31), P < 0.0001) or not being engaged in a hepatocellular carcinoma surveillance programme (OR: 0.08 (95% CI: 0.02-0.27), P < 0.0001).

CONCLUSION

Current approaches are failing to deliver optimal CHB care to Indigenous Australians in regional North Queensland. Targeted strategies to ensure that Indigenous Australians in the region receive equitable care are urgently needed.

Hepatitis B genotypes in Aboriginal and Torres Strait Islander Australians: correlation with clinical course and implications for management

BACKGROUND

The prevalence of chronic hepatitis B (CHB) in Aboriginal and Torres Strait Islander Australians in Far North Queensland (FNQ) is greater than twice that of the general Australian population. CHB is common in Torres Strait Islanders diagnosed with hepatocellular carcinoma (HCC) - and in Aboriginals with HCC living in the Northern Territory - however, Aboriginals diagnosed with HCC in FNQ very rarely have CHB. The explanation for this apparent disparity is uncertain.

AIMS

To determine the HBV genotypes in the FNQ Aboriginal and Torres Strait Islander population and their correlation with clinical phenotype.

METHODS

We determined the HBV genotype of Aboriginal and Torres Strait Islander Australians living with CHB in FNQ and correlated this with demographic and clinical findings.

RESULTS

134/197 (68%) enrolled individuals had a sufficient viral load for genotyping. All 40 people with HBV/D genotype had Aboriginal heritage, whereas 85/93 (91%) with HBV/C had Torres Strait Islander heritage (P < 0.0001). Individuals with HBV/D were younger than those with HBV/C (median (interquartile range) age: 43 (39-48) vs 53 (42-66) years, P = 0.0002). However, they were less likely to be HBeAg positive (1/40 (3%) vs 23/93 (25%), P = 0.001). All three HCCs developed in Torres Strait Islanders; two-thirds were infected with HBV/C14; genotyping was not possible in the other individual. All 10 diagnoses of cirrhosis occurred in Torres Strait Islanders, 6/10 were infected with HBV/C14, genotyping was not possible in the other four individuals.

CONCLUSIONS

HBV genotypes in Aboriginal and Torres Strait Islander Australians in FNQ differ markedly, which could explain the significant differences in the clinical phenotype in the two populations and might be used to inform cost-effective CHB care in the region.

Hepatocellular carcinoma surveillance in Australia: current and future perspectives

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide, and is increasing in incidence in Australia. For most people with cirrhosis and chronic hepatitis B, HCC screening and surveillance is recommended with 6-monthly ultrasound. However, most patients with HCC are still diagnosed outside of surveillance with incurable disease. While HCC surveillance almost certainly reduces cancer-related mortality, the potential harms of surveillance are incompletely understood. Surveillance uptake remains suboptimal in many contexts, and stems from a combination of patient, clinician and system level barriers. Improved case-finding strategies may be required to identify high risk individuals in need of surveillance, as cirrhosis and viral hepatitis are often asymptomatic. HCC prediction models and novel surveillance tools such as biomarker panels, computed tomography and magnetic resonance imaging may have a future role in personalised HCC surveillance. Analyses suggest surveillance may be cost-effective, but Australian data remain limited. A centralised HCC surveillance program may ultimately have a role in delivering improved and more equitable care.

The high burden of comorbidities in Aboriginal and Torres Strait Islander Australians living with chronic hepatitis B in Far North Queensland, Australia, and the implications for patient management

BACKGROUND

Aboriginal and Torres Strait Islander Australians living with chronic hepatitis B virus (HBV) infection have a significant burden of hepatocellular carcinoma (HCC). The prevalence of comorbidities that increase the risk of HCC in this population is incompletely defined.

METHODS

This cross-sectional study was performed in remote tropical Queensland, Australia in January 2021. All individuals living with chronic HBV in the region were identified; the prevalence of relevant comorbidities was determined by reviewing medical records.

RESULTS

All 236 individuals in the cohort identified as Aboriginal and Torres Strait Islander Australians; their median (interquartile range (IQR)) age was 48 (40-62) years; 120/236 (50.9%) were female. Of the 194/236 (82.2%) engaged in HBV care, 61 (31.4%) met criteria for HBV therapy and 38 (62.2%) were receiving it. However, 142/236 (60.2%) were obese, 73/236 (30.9%) were current smokers and 57/236 (24.2%) were drinking alcohol hazardously; 70/236 (29.7%) had ≥2 of these additional risk factors for HCC, only 43/236 (18.2%) had none. Among the 19 patients with confirmed cirrhosis, 9 (47%) were obese, 8 (42%) were currently-or had a history of-drinking alcohol hazardously and 5 (26.3%) were current smokers. Patients also had a median (IQR) of 3 (2-4) cardiovascular risk factors (cigarette smoking, hypertension, impaired glucose tolerance, dyslipidaemia, renal impairment/proteinuria). Only 9/236 (3.8%) did not have one of these 5 comorbidities.

CONCLUSIONS

Aboriginal and Torres Strait Islander Australians living with chronic HBV in this region of remote Australia have a high engagement with HBV care and the majority of individuals eligible for antiviral therapy are receiving it. However, a significant comorbidity burden increases their risk of cirrhosis, HCC, and premature death. It is essential to integrate chronic HBV care with management of these comorbidities-rather than focusing on HBV alone-to achieve optimal health outcomes.

Cancer survival differentials for Aboriginal and Torres Strait Islander peoples in Queensland: the impact of remoteness

PURPOSE

In Australia, Aboriginal and Torres Strait Islander peoples (First Nations population) often have low overall cancer survival, as do all residents of geographically remote areas. This study aimed to quantify the survival disparity between First Nations and other Queenslanders for 12 common cancer types by remoteness areas.

METHODS

For all Queensland residents aged 20-89 years diagnosed with a primary invasive cancer during 1997-2016, we ran flexible parametric survival models incorporating age, First Nations status, sex, diagnosis time period, area-level socioeconomic status, remoteness categories and where appropriate, broad cancer type. Three survival measures were predicted: cause-specific survival, survival differences and the comparative survival ratio, each standardised to First Nations peoples' covariate distributions.

RESULTS

The standardised five-year cause-specific cancer survival was 60% for urban First Nations and 65% for other Queenslanders, while remote residents were 54% (First Nations) and 58% (other). The absolute survival differential between First Nations and other Queenslanders was often similar, regardless of remoteness of residence. The greatest absolute difference in five-year standardised cancer survival was for head and neck cancers, followed by cervical cancer. The five-year comparative survival ratio (First Nations: other Queenslanders) for urban cancer patients was 0.91 (95% CI 0.90-0.93), similar to outer regional, inner regional and remote areas. The greatest comparative survival differential was for oesophageal cancer.

CONCLUSION

First Nations' survival inequalities are largely independent of geographical remoteness. It remains a priority to determine the contribution of other potential factors such as the availability of culturally acceptable diagnostic, management and/or support services.

Cancer care disparities among Australian and Aotearoa New Zealand Indigenous peoples

PURPOSE OF REVIEW

Persistent and significant inequalities for Indigenous people with cancer around the globe exist, arising from colonial settlement of Indigenous land with profound social, economic and cultural impacts. We summarize recent publications concerning cancer disparities affecting Australian Aboriginal and Torres Strait Islander Peoples and Aotearoa New Zealand Māori Peoples.

RECENT FINDINGS

Cancer-free survival and overall survival statistics testify to the urgent need to 'close the gap'. For Indigenous peoples in Australia and New Zealand, disparity persists along the cancer care pathway, from increased risk factors to lower screening access, health resource utilization and survivorship care. Recent publications highlight multimorbidity as contributing to poor cancer outcomes in Indigenous populations. The implementation of tailored Optimal Care Pathways is described, as is the validation of tailored tools capturing the perspectives of Indigenous persons. Finally, the importance of Indigenous-led research is emphasized.

SUMMARY

Cancer-specific outcomes in Indigenous people of Australia and New Zealand remain poor with many widening disparities compared to non-indigenous populations. A growing body of epidemiological, health service and clinical research is documenting both the problems and potential solutions. Further work is needed in both broad health policies and the workforce, in building cultural competence to optimize individual care encounters.