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.
Read more – Explainer: the A, B, C, D and E of hepatitis
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.
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.
Benjamin Cowie receives funding from the Australian Government Department of Health, the Victorian Government Department of Health and Human Services, the Royal Melbourne Hospital Office for Research, and the Cooperative Research Centre for Spatial Information.
Steven Tong receives funding from the National Health and Medical Research Council and has received funding from Gilead for Hepatitis B related research projects.
James Ward does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond the academic appointment above.
Authors: Benjamin Cowie, Director, WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and Immunity