This content is part of a paid partnership with the WA Department of Health.
By Adam Gregson, Hepatology Nurse Practitioner, Royal Perth Hospital
Chronic hepatitis B (CHB) causes hepatocellular carcinoma (HCC). CHB is the most common cause of HCC worldwide. For those living with CHB, the risk of developing HCC is up to 100 times higher than those who don’t.
Liver cancer is the fastest growing cause of cancer death in Australia. Between 20-25% of people with CHB die from complications of the disease, specifically cirrhosis and HCC.
Globally that is one death every 44 seconds or about the time it takes to read this paragraph. With optimal monitoring and treatment, these deaths are largely preventable, and HCC can be detected early.
Overseas migrants and Aboriginal people are at highest risk of CHB and HCC.
An estimated 220,000 Australians are living with CHB, with 10% in WA. Overseas migrants (61%) and Aboriginal and Torres Strait Islander people (11%) are the populations most affected, and also have the highest rates of HCC.
Antiviral medication is the best way to prevent HCC in CHB. When treatment is commenced at the right time, the risk of HCC is reduced by 30% in patients with cirrhosis and 80% in patients without.
Commencing eligible patients on treatment is only one part of the solution. Over 30% of people with CHB remain undiagnosed, and fewer than 25% are engaged in regular monitoring.
This is concerning for those marginalised yet overrepresented patient groups who already face a range of health inequities and worse outcomes.
We are far from achieving the targets in the 4th National Hepatitis B Strategy, including 22% of patients with CHB to be receiving treatment (by 2025, and 27% by 2030).
Estimates from the Doherty Institute show WA only reaching 8.4%, possibly due to low GP confidence in interpreting CHB blood results, as well as a difficulty in maintaining competency when numbers of CHB patients at practices may be low.
RELATED: Empowering GPs with a new hepatitis B service
GPs play a vital role in screening and diagnosis, and providing optimal lifelong monitoring of CHB, as well as timely antiviral therapy and HCC surveillance. Royal Perth Hospital has established an innovative statewide project to support GPs to manage CHB in their practices, providing training to build confidence and competence.
The role of GPs and primary health care
As a chronic disease, primary care is the ideal setting for CHB management. GPs are best placed to provide quality holistic chronic disease oversight acknowledging that involvement of s100 prescribers or specialists may be required along the way. Support is available to help guide your management:
- The ASHM Hepatitis B Decision Making Tool
- Hep B Hub WA: a statewide clinical advice service that provides GPs with online and in-person support, education, and advice to manage CHB with responses within two business days. Hepatitis B medication prescribing can also be requested if you are not an s100 prescriber yourself. You can email HepBHubWA@health.wa.gov.au
- Hepatitis B Outreach clinics: currently available to metropolitan general practices and primary care health services, providing onsite support to manage and treat your CHB patients, including providing access to a Fibroscan® in your practice to guide care planning. Contact the Hep B Hub WA for more information.
- This link will take you to an array of patient CHB resources that are invaluable in the provision of care and education to your patients.
The following patients with chronic hepatitis B are a high risk of HCC and need 6-monthly HCC surveillance comprising of an abdominal ultrasound and serum AFP:
- People with cirrhosis
- People 40+ years with a family history of HCC in a first-degree relative
- People from sub-Saharan African aged 20+ years
- Aboriginal and Torres Strait Islander people aged 50+ years
- Asian-Pacific males aged 40+ years and females aged 50+ years.
The important role of GPs in managing CHB can be broken down into three key areas:
1 – Timely testing and diagnosis (or vaccination)
The biggest pitfall when testing a patient for CHB is insufficient ordering on pathology requests, and not acting on the results. It is not enough to write “Hep B serology”, as different labs will test different things.
To get the most out of your opportunity to test, request the following three items with “? chronic hepatitis B” or similar stated in the clinical details:
- Hepatitis B surface antigen (HBsAg)
- Hepatitis B surface antibody (HBsAb)
- Hepatitis B core antibody (HBcAb).
These three tests provide you with enough information to confirm active/previous disease and immunity. Following up with non-immunity is important, and if there was a reason to test for CHB, there is often a reason to vaccinate if indicated.
It is essential that you offer testing to everyone who is susceptible. An accurate list of those groups, along with a guide to interpreting blood test results can be found on the ASHM Hepatitis B Decision Making Tool or by emailing the Hep B Hub WA.
2 – Regular monitoring of CHB and treating when required
There is no such thing as a “healthy carrier” for hepatitis B, but the myth persists. Anyone with a positive hepatitis B surface antigen (HBsAg) has active infection and requires six-monthly monitoring.
CHB can seem complicated and overwhelming to clinicians who see it infrequently. Support is available using the ASHM Hepatitis B Decision Making Tool and resources from Hepatitis Australia.
Hep B Hub WA can also be contacted to provide clinical advice and support with the aim of keeping CHB management within primary care.
Treating at the correct time significantly reduces HCC risk and Hep B Hub WA will guide you through the process and can provide prescriptions if required.
Training to become an s100 prescriber for CHB treatment can be accessed via ASHM.
There are opportunities for patient-finding within your practice to help identify and re-engage patients with CHB who need linking back into care, and this process can form part of your CPD hours (in particular Measuring Outcomes (MO) and Reviewing Performance (RP) required as part of your role. Contact the Hep B Hub WA for more details.
3 – Six-monthly HCC surveillance
All patients with CHB should have an abdominal ultrasound as a baseline, and certain high-risk groups need six-monthly surveillance (as outlined in the grey box) consisting of abdominal ultrasound and serum AFP.
The use of AFP in HCC surveillance along with ultrasound has been disputed. But AFP is useful for early detection, to validate concerning ultrasound findings as well as highlighting potential HCC where there is no sonographic evidence.
HCC and Hepatitis B: Key learnings
- CHB is a chronic disease and primary care is the ideal setting for its management.
- Timely testing and diagnosis of CHB is vital and can be done by requesting the three main tests – HBsAg, HBsAb, HBcAb. Remember to check immunity and vaccinate if required, if HBsAg is negative.
- There is no such thing as a “healthy carrier” for CHB. Everyone who is HBAg positive requires 6-monthly monitoring with antiviral treatment at the correct time.
- Explain to your patients with CHB that they are at-risk from HCC. Those with cirrhosis and those with CHB at high-risk should have an abdominal ultrasound and serum AFP 6-monthly. Remember to do a baseline ultrasound on all patients with CHB whether on surveillance or not.
Need help?
Refer to the ASHM Hepatitis B Decision Making Tool.
Contact the Hep B Hub WA: a state-wide clinical advice service providing GPs with online and in-person support, education, and advice to manage and treat CHB with responses within 2 business days. You can email: HepBHubWA@health.wa.gov.au
This clinical update is CPD verified. Complete your self-reflection and claim your CPD time here.
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