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Providing hepatitis B care to people in Cape York and the Torres Strait islands, one of Australia’s most remote populations, isn’t a straightforward task.
General and Infectious Disease specialist Dr Josh Hanson and Enrolled Nurse Sharna Radlof spend much of their time coordinating and delivering outreach medical services to these remote communities.
In addition to running fortnightly clinics in Yarrabah, Sharna flies out to the islands every three months and spends two to three days there at a time. These visits can see Sharna taking two separate flights from Cairns to reach her destination.
While rates of hepatitis B in the southern part of Cape York are quite low, the northern region has significantly more cases. Overall, the prevalence of hepatitis B in Far North Queensland sits at 2.76%, well above the national average of 0.86%.
Josh says the proactive approach by the Cairns Sexual Health Service in the health promotion of HIV and hepatitis C has paved the way for greater attention on hepatitis B.
“Hep B is the poor cousin of HIV and hep C and attracts less attention. We saw an opportunity and a need for a greater focus,” Josh says.
A visit to one of the islands involves Sharna lugging a 27kg FibroScan machine on a tiny plane so that patients can receive their 6-monthly scans.
The team sees the FibroScan, an ultrasound-like machine that measures the stiffness of the liver, as a valuable part of the care they provide.
“You get instant feedback. Sharna can incorporate that into her discussion with the patient immediately as opposed to having to wait two weeks to get blood test results back from Brisbane,” says Josh.
Part of the challenge in Sharna’s role is convincing people to receive their regular liver checkups, especially when they’ve just attended the clinic to have a diabetes, heart or kidney check.
“You don’t rock up and there are a thousand people waiting to see you; it’s not like that at all. The first day is a bit slower; we see who comes in. Then you’re calling, you’re going around to people’s houses,” says Sharna.
“The health workers are saying ‘the hep b lady is here to see you’. By the third day, they’re coming in. Generally, by the next visit, there’ll be more people.”
With a high staff turnover in the region, Josh and Sharna split their time between delivering liver clinics for patients and providing day-to-day support for the workforce.
“We were getting lots of questions from local healthcare workers on how to best manage patients with hep B and deliver optimal care in those remote locations,” Josh says.
“ASHM has been very supportive. They’ve organised prescribing courses in Cairns and even on Thursday Island to help get new clinicians up to speed.”
“It’s about getting clinicians confident with hep B, understanding the disease, understanding the tests to order, understanding how to interpret them, and having the confidence to prescribe therapy,” said Josh.
The work Josh, Sharna, and others are doing in Cape York, and the Torres Strait contributes to the region’s higher than average uptake in care.
Despite the challenges faced, the proportion of people with hepatitis B engaged in care in remote Far North Queensland (69.1%) is well above the national average (22.6%).
In addition to providing health care, Josh and Sharna are part of an important research project with the Menzies School of Health Research based in Darwin to try and understand more about the impact of a local genotype of hep B.
Josh explains the genotype they have identified in Far North Queensland’s Aboriginal population has different characteristics to the C4 genotype seen in the Northern Territory, particularly when it comes to liver cancer.
“The early data seem to show the D genotype has very low rates of HCC (hepatocellular carcinoma). In fact, since the year 2000, we haven’t had a confirmed HCC in an Aboriginal person living with this hep B genotype in North Queensland,” says Josh.
“In contrast, we do see HCCs in our Torres Strait Islander patients who predominantly have the C14 genotype, similar to the C4 type in the Northern Territory.”
Josh says the impact of this research could help inform guidelines in taking a more localised approach to care.
“We can spend a lot of time and money and cause a lot of anxiety in doing HCC screening, but if we haven’t picked up an HCC in a person with a D genotype in over 20 years, it’s probably not a high-value intervention.”
“That’s not to say we’re anti-surveillance, surveillance definitely has a role, but I think it needs to be more targeted, particularly when resources for hep B care are finite.”
Josh explains another main focus for the team is on emphasising comorbidities in an effort to reduce deaths.
“One of the reasons our patients can have difficulty accessing healthcare is they get the diabetes doctor, then the heart doctor, then the kidney doctor, the hepatitis B doctor, and they just get a bit overwhelmed,” Josh says.
“We’re trying to “unsilo” hep B and integrate it as part of their general medical care so we can do it efficiently without disrupting their lives too much. “
“If we can address comorbidities, we can not only improve liver health, but we can also reduce the most common causes of death and disability in those communities.”