Globally, transmission most commonly occurs from mother to baby or in early life. But it’s possible to be infected in adulthood, through sex or blood-to-blood contact.
Most people who are infected in adulthood develop a short infection which their immune response controls. But in around 5% of adults and 90% of babies, the immune response is ineffective and chronic infection develops.
Hepatitis B virus causes almost 40% of all liver cancer, which is the fifth most common cancer and the second leading cause of cancer-related death worldwide.
Hepatitis B virus was discovered in the serum of an Indigenous Australian in 1965 and was first known as the “Australia antigen”.
This quickly led to the development of an effective vaccine in the 1980s, which is now available worldwide. The vaccine has been given to Australian infants since May 2000.
(If you weren’t vaccinated as a baby, you might want to consider doing so through your GP, particularly if you plan to travel to Asia and Africa where hepatitis B is common.)
Unfortunately the vaccine doesn’t do anything for the 240,000 or so Australians who currently live with chronic hepatitis B. Only around 60% of these people have been diagnosed; the rest don’t know they’re infected and don’t receive appropriate care.
How is it currently treated?
There is no cure for chronic hepatitis B virus.
In most cases, treatment requires taking a pill every day for life to remain effective and to reduce the risk of liver cancer. Even then, it doesn’t eliminate the risk.
Chronic hepatitis B hasn’t been cured so far in part because current therapies have failed to destroy the viral reservoir, where the virus hides in the cell.
This is in contrast to hepatitis C virus, which has no such viral reservoir and can now be cured with as little as 12 weeks of treatment.
Despite the huge human and economic toll of chronic hepatitis B, research to cure the disease remains underfunded. There is a misconception that because there is a vaccine, hepatitis B is no longer a problem.
The availability of effective cures for the unrelated hepatitis C virus has also led people to believe that “viral hepatitis” is no longer a problem.
Some exciting research is underway around the world, including the recent identification of the “cell receptor” which allows the virus to infect the body. This has enabled studies of the complete virus replication cycle including the viral reservoir that is untouched by current therapies.
New approaches to a possible cure include mechanisms to block the virus’ entry into the cell and to stop the virus from making the proteins it needs to replicate and infect new cells.
Studies are also underway to enhance patients’ immune responses so their own natural defences can control or even eliminate the virus. This is similar to immunotherapies already being used to treat some cancers.
It’s likely a hepatitis B cure will require a dual-pronged approach, directly targeting the virus while also enhancing the immune response in people who are infected.
The goal is to reduce the amount of virus in the body and restore the person’s immune responses. This is called a “functional cure” and is similar to what happens when a person naturally gets rid of the virus. It would also mean they didn’t need to take drugs any more.
Some of these approaches are now in early stage human clinical trials. More than 30 drugs have been developed and are being tested in people with chronic hepatitis B. However, much more work needs to be done to achieve a cure.
But the situation is much less promising for Australians living with hepatitis B, which is now the most common blood-borne viral infection in Australia. It affects more people than hepatitis C and HIV combined.
In our research published today, we show Australia is falling short of its targets to reduce the burden of hepatitis B. Looking to the way we’ve responded to hepatitis C may set us on a better path.
Hepatitis C treatment
There were an estimated 182,144 people living with chronic hepatitis C in Australia at the end of 2017.
A number of important drugs were listed on the Pharmaceutical Benefits Scheme (PBS) from 2016, making curative treatments available to nearly all Australians living with hepatitis C.
The number of treatments being initiated has fallen significantly since the early peak, and significant differences exist in who has accessed the treatments across Australia. Nonetheless, Australia’s response to hepatitis C is highly regarded as an example of how to rapidly scale up hepatitis C treatment in a population, including among people who inject drugs.
Recent data from New South Wales demonstrate access to hepatitis C cures has led to a drop in the number of people with hepatitis C dying from liver cancer, with the bend in the curve coinciding with listing of these new treatments on the PBS in 2016.
There were an estimated 221,420 people living with chronic hepatitis B in Australia in 2017. Along the trajectory of the disease, those who have liver disease or are at risk of developing liver disease require treatment.
Unlike hepatitis C, hepatitis B cannot be cured with current treatments, so ongoing antiviral therapy is required. This is similar to the treatment received by someone with HIV.
Although not a cure, the available treatments are effective. Current hepatitis B treatments have been associated with reducing the risk of liver cancer by around 50% in the first five years of treatment.
Scaling up such treatment and care will be a critical element in reversing the increasing tide of liver cancer deaths in Australia.
By 2030, the World Health Organisation has set out that 90% of people with hepatitis B should be diagnosed, 80% of those who meet criteria for treatment should be treated, and deaths due to hepatitis B should be reduced by 65% relative to 2015 globally.
In Australia, our Third National Hepatitis B Strategy sets targets to be achieved by 2022, including diagnosing 80% of people, engaging 50% of people in care, treating 20% of people, and reducing deaths due to hepatitis B by 30%.
Measuring progress towards these targets is complicated and requires consideration of a range of demographic and other factors. Considering most people living with hepatitis B in Australia were born overseas or are Aboriginal or Torres Strait Islander peoples, up-to-date estimates of Indigenous status and migration flows into and out of Australia are essential. Estimates of the prevalence of hepatitis B in different groups and detailed information about the natural history of hepatitis B in individuals over time is also important.
Taking these complexities into account, we’ve constructed a mathematical model simulating the burden of hepatitis B in the Australian population from 1951 to 2030. We wanted to see how Australia is faring in terms of meeting national and international targets.
By 2022, if current trends continue, the proportion of people diagnosed will reach 71% (short of the 80% goal). Some 11.2% of Australians living with hepatitis B will be on treatment (short of the 20% target). But we estimate the proportion who actually need treatment is around 30%, so we have a long way to go.
In related work mapping the burden of hepatitis B and estimating differences in treatment and care nationally we estimate only 20% of people living with hepatitis B are engaged in care (either being appropriately monitored or receiving treatment). Again, this is well short of the 50% target.
So why aren’t we meeting these targets?
Broader inequities in health access and outcomes for culturally and linguistically diverse groups and Aboriginal and Torres Strait Islander peoples play a substantial role. Together they represent over two-thirds of Australians living with hepatitis B.
Current delivery of treatment and care differs across the country. The experience and strategies used in those areas with higher levels of treatment and care should be examined and shared to address the inequities observed across Australia.
Like hepatitis C, Australia’s response to the needs of people living with HIV is viewed as being of a high standard. Two elements central to our responses to hepatitis C and HIV are currently missing for hepatitis B.
The first is strong, ongoing community engagement and leadership of the response by those affected. While organisations representing people living with HIV have existed since the 1980s and for hepatitis C since the 1990s, engagement with people living with hepatitis B has lagged well behind.
The second is treatment and care primarily being delivered in the community by primary care clinicians (especially GPs) – rather than in hospitals and by specialists, as is the case for most people living with hepatitis B. Many patients prefer seeing GPs and find this more convenient than waiting for hospital appointments and seeing specialists. This can be especially true for people living far from major hospitals, reflected in the fact hepatitis B treatment uptake is much lower than average in regional and rural areas of Australia.
Making it happen
Although both factors are priorities for action in the National Hepatitis B Strategy, progress will require ongoing funding and coordinated efforts by the Commonwealth, state and territory governments, primary health networks, and other partners.
The impact will be measured, not just in modelled estimates, but in real lives saved. While we’re not yet on track to meet our targets for hepatitis B in Australia, our modelling suggests even with the relatively low current uptake of treatment and care, 2,300 Australian lives were saved between 2000 and 2017, which otherwise would have been lost to liver cancer and liver failure caused by hepatitis B.
If we can translate what has been learned in our HIV and hepatitis C responses to increase access to essential care for Australians living with hepatitis B, thousands more lives can be saved in the next decade and beyond.
at 6 p.m. on April 24, Pastor Lou Yuanqi of Xinjiang Uyghur Autonomous Region was released from prison under the provision of “bailed out waiting for trial, ” a legal procedure called “qu bao hou shen.”
ChinaAid said: “Though this provision allows for future arrest and prosecution, Pastor Lou was released and permitted to return home. The provision’s purpose is also to prevent Pastor Lou or his family from filing an administrative lawsuit against the state for compensation for illegal detention time.”
The media release explains that Xinjiang authorities could not find evidence sufficient to continue his prosecution and indictment. According to family members, Pastor Lou looked fragile, because of the horrible conditions he suffered in prison. He suffers from hepatitis B, and is in great need of medical attention.
It adds: “Pastor Lou’s faith is very strong, and he, his wife Wang Wenxiu and their three children are overwhelmed by the response from the international community.”
According to ChinaAid, Pastor Lou was first detained on May 17, 2008 at 1 p.m. in Qingshuihe town, Huocheng county of Xinjiang Uyghur Autonomous Region. Pastor Lou stood trial on December 15, 2008 on charges of “utilizing superstition to undermine the law.”
ChinaAid stated: “Those close to the case say the authorities’ motivation for the charge was to stop Lou’s house church from meeting in his home. Immediately after Lou’s trial, his daughter, Lou Tiantian, 18, was beaten by court police when she tried to speak with her father as he was being put into a police car.”
ChinaAid says that later, the court issued a statement, declaring “the facts [in Pastor Lou’s case] unclear and the evidence insufficient.” Despite this ruling, Pastor Lou continued to be imprisoned until his release on April 24.
Two other Xinjiang Christians, Alimujiang Yimiti and Wusiman Yiming, are currently suffering in prison for their faith, according to the ChinaAid media release.
Alimujiang Yimiti, a Uyghur Christian, was first detained on the charge of “endangering the security of the state,” then was officially arrested on February 20, 2008 for “suspicion of inciting secession and organizing people in stealing, spying, buying and illegally providing state secrets or intelligence to overseas organizations.”
However, ChinaAid says sources say the real reason for his detention is because of his Christian faith and witness among the Uyghur people. Alimujiang was seen March 31 around 10 a.m. (local time) at Nongsanshi (Military Farm) Hospital in Kashgar. His hands were bound and he was observed being roughly escorted by police and a prison doctor while repeatedly crying out to onlookers in Chinese, “I’m sick. Tell my lawyer to come quickly to see me.”
Wusiman Yiming, another Uyghur Christian, was sentenced to two years of re-education through labor in September 2007 for “revealing state secrets” and “illegal proselytizing.”
ChinaAid sources say that he was, in fact, sentenced because of his boldness as a Christian and a leader in the Uyghur church. Sources report that he has aged dramatically in the labor camp and his health is deteriorating due to harsh conditions.
“We welcome the release of this innocent pastor who has been arbitrarily detained for more than a year simply for his Christian faith related activities,” said ChinaAid’s Bob Fu.
“We urge the Xinjiang authorities to release other innocent people of faith such as Alimujiang Yimiti and Wusiman Yiming.”