Dr G. Yunupingu’s legacy: it’s time to get rid of chronic hepatitis B in Indigenous Australia

News of the tragic death of Dr G. Yunupingu last week in Darwin at only 46 years of age has again highlighted the unacceptable gap in life expectancy between Aboriginal and Torres Strait Islanders and other Australians. Yunupingu had been living with chronic hepatitis B since early in life, and experienced complications of this condition including liver and kidney disease.

Hepatitis B infections, which can lead to liver disease and cancer, are unacceptably high in Indigenous Australians. In Northern Australia, 10-20% of the Indigenous population is infected with the virus. Eliminating the impact of this infection in Indigenous Australians would make a substantial contribution to closing the gap in life expectancy.

Hepatitis B in Indigenous Australia

Hepatitis B is the most prevalent form of viral hepatitis worldwide. It’s also the leading cause of liver cancer. Interestingly, hepatitis B used to be known as the “Australia Antigen” as it was first discovered in Australian Aboriginal people in the 1960s.

Hepatitis B is around ten times more prevalent in Indigenous communities than in the rest of Australia. Of the nearly 240,000 Australians estimated to be living with chronic hepatitis B, over 20,000 are thought to be Indigenous people. New infections with hepatitis B remain three times as common in Indigenous people as in non-Indigenous Australians.

The chance of developing chronic hepatitis B depends on an individual’s age at the time of infection. Around 90% of those who were exposed as infants develop chronic hepatitis B, but only 5% of those who were exposed as adults will develop chronic infection. Most people living with chronic hepatitis B were infected as young children – often, through mother-to-child transmission at the time of birth. This is why vaccination during infancy is particularly important.

The prevalence of chronic (long-term) hepatitis B in Indigenous Australians varies significantly between regions. It is most prevalent in remote areas of Australia, with the Northern Territory having the highest prevalence of any Australian jurisdiction. Around 1.8% of the NT population live with the disease.

The prevalence of hepatitis B and other communicable diseases such as skin infections and influenza in Indigenous communities is intensified by the social, economic, environmental and political situation in which Indigenous Australians find themselves.

Liver disease

In some people, chronic hepatitis B can cause severe liver scarring (cirrhosis) or liver cancer. Less commonly, hepatitis B can damage other parts of the body, including the kidneys and blood vessels.

Chronic liver disease contributes significantly to the Indigenous life expectancy gap. Liver cancer is the fastest-increasing cause of cancer deaths in Australia. In 2016, it was the sixth-most-common cause of cancer deaths. However, for Indigenous people it is the second-most-common cause of cancer-related death after lung cancer.

Compared to non-Indigenous Australians living in the NT, the rate of death due to liver cancer is six times greater in Indigenous Australians.

Cure is rare with liver cancer, and most Indigenous Australians die within a few months of being diagnosed. In the NT, a range of factors contribute to the unequal burden of liver cancer in Indigenous Australians, but hepatitis B is the most important cause.

Hepatitis B vaccine is one way

A safe, effective vaccine for hepatitis B has been provided for all infants in Australia since 2000 – and in the Northern Territory since 1990. As a result, new hepatitis B infections in children born since 2000, as well as those who received adolescent catch-up vaccination from 1998 onwards, have fallen markedly.

However, funded hepatitis B vaccine for Indigenous adults is available only in some states and territories. This limits access for Indigenous people who remain at much higher risk of infection. A recent study suggested a funded catch-up vaccination program for Indigenous adults could rapidly eliminate disparity in hepatitis B incidence.

Vaccination has no effect for those who already have chronic hepatitis B. It is believed over 90,000 Australians living with hepatitis B have never been diagnosed and are unaware of their infection. Only 15% of those infected are receiving treatment or monitoring for their condition.

Unlike hepatitis C, hepatitis B is not yet curable, but current treatments are very well tolerated and effective at preventing liver disease and liver cancer. The profound lack of access to treatment and care among Indigenous people contributes to the disproportionate impact of hepatitis B on this population.

Other ways to reduce infections

An example of innovative care has been operating in Dr G. Yunupingu’s home community of Galiwin’ku for over five years. Under the management of Miwatj Health, an Aboriginal community-controlled health organisation, a hepatitis specialist visits regularly three to four times per year.

The specialist brings necessary diagnostic equipment and effectively provides a “one-stop shop” for individuals living with hepatitis B in Galiwin’ku. Just as importantly, a local healthcare practitioner champions the cause of hepatitis B treatment and elimination. Those infected are contacted and encouraged to see the specialist team.

Several other regions in the world with large Indigenous populations and high hepatitis B prevalence, such as Alaska and New Zealand, have developed programs to test most of the population and identify those with hepatitis B infections. Affected individuals are offered regular follow-up and care to prevent cirrhosis and liver cancer.

When delivering such care to Indigenous communities, it’s essential to develop trust and ensure culturally appropriate approaches. Also important is partnering with communities and their health workers to develop new ways of building awareness of hepatitis B as an important health issue.

With comprehensive public health initiatives, long-term commitment to funding and policy – including significant workforce development to ensure as many people as possible are tested and appropriately followed up – the impact of hepatitis B on Indigenous communities can be eliminated.

This article was written by Benjamin Cowie, James Ward and Steven Tong and originally published in The Conversation.

Hepatitis C - PBS listing: 'Medical miracles welcome, but barriers to elimination remain'

Federal Government funding of a breakthrough antiviral medicine that can cure all forms of hepatitis C must be matched by a concerted effort to reconnect people living with the liver-destroying virus with clinical care.

Speaking on World Hepatitis Day (28 July), CEO of Hepatitis Australia Helen Tyrrell welcomed the Federal Health Minister’s announcement that the first pan-genotypic antiviral, Epclusa® would be PBS listed from 1 August. The new therapy is more than 90 per cent effective in achieving a cure within 12 weeks, regardless of hepatitis C genotype.

“Australians living with hepatitis C now have unprecedented access to curative therapies; however this is only the first step to eliminating hepatitis C as a public health threat in Australia,” Ms Tyrrell warned.

“Equipping health care professionals to feel confident engaging their patients in conversations about hepatitis C and the availability of cures must now become a focus,” she said.

“We must also communicate to those living with the condition that a life free from hepatitis C can be a reality.”

Epclusa (sofosbuvir 400 mg/velpatasvir 100 mg) is a pan-genotypic regimen for the treatment of adults with genotype 1-6 chronic hepatitis C virus infection. The therapy is used in combination with ribavirin in patients with cirrhosis.

New campaign to prevent syphilis in remote Indigenous communities

A new radio, television and social media campaign has been launched to help prevent the spread of syphilis in remote Indigenous communities.

There are now 1,400 diagnosed cases among young people across four states, after an outbreak six years ago.

The South Australian Health and Medical Research Institute hopes its community education and awareness program about the Sexually Transmitted Infection, will cut through.

Featured: Professor James Ward, SA Health and Medical Research Institute



New initiative to prevent the spread of syphilis in remote Indigenous communities

On Saturday, 1 July, the South Australian Health and Medical Research Institute’s (SAHMRI) Infection and Immunity Theme will launch a new multifaceted community education and awareness program in the fight against syphilis in remote Aboriginal and Torres Strait Islander communities.

The campaign, entitled ‘Young, Deadly, Syphilis Free’, will utilise mediums including two television commercials, social media, local radio and a new website to communicate to young Aboriginal and Torres Strait Islander people who live in remote communities the importance of being tested for syphilis, a sexually transmitted infection (STIs) that when left untreated, can have devastating effects.

Why is this campaign so important?

This project, funded by the Commonwealth Government Department of Health, has the ultimate objective of increasing testing rates among young Aboriginal people in the affected areas so that rates of syphilis are reduced in these communities.

Since 2011, there has been a sustained outbreak of infectious syphilis occurring in remote areas spanning northern, central and South Australia among Aboriginal and Torres Strait Islander people predominantly aged between 15 and 35 years. The accrued number of cases is now over 1,400 including four neonatal deaths and several other cases of congenital syphilis notified. Worryingly, syphilis continues to spread into new areas, and this needs to be stopped.

In addition to targeting young people, this campaign will have focus on healthcare services and providers, through the use of supporting resources and education materials, such as videos, posters and animations. Clinicians will play an important part in the success of this project and they are encouraged to consider talking more broadly about the syphilis outbreak among people of influence in their community to raise awareness.

Furthermore, the project will trial social media ambassadors, who will be young people from remote communities to help spread the campaign and its objectives.

Improving outcomes for young Aboriginal and Torres Strait Islander people

Associate Professor James Ward, Head of Infectious Disease Research - Aboriginal and Torres Strait Islander Health at SAHMRI said that education and awareness about syphilis transmission and its consequences is vital if we are to make a difference.

“This multifaceted approach to educate young people is well overdue,” Associate Professor Ward said.

“The resources that have been developed and focus tested with young people will go a very long way in improving outcomes in the community.”

Useful links:

TVC #1: https://youtu.be/mbOcqXiE7Ac
TVC #2: https://youtu.be/XGxnPbSo0uA
Facebook: https://www.facebook.com/youngdeadlysyphilisfree/
Instagram: https://www.instagram.com/youngdeadlysyphilisfree/
Website: https://youngdeadlyfree.org.au/young-deadly-syphilis-free/