Burden of chronic liver disease in Australia – It’s time to act
Staggering statistics have recently highlighted the impact of chronic liver disease globally on the health of individuals and communities and in the global arena, writes Associate Professor Amany Zekry.
“... the current data of the burden of chronic liver disease in our society calls for a coordinated effort among stakeholders and policy makers to address the impact of such preventable disease on our society.”
Globally, cirrhosis of the liver was the cause of a million deaths in 2010, 33 per cent more than in 1990.(1) Liver cirrhosis is the second leading cause of digestive disease–related mortality, preceded only by colorectal cancer. In Australia, the commonest causes of liver cirrhosis are non-alcoholic fatty liver disease (NAFLD) in the context of obesity and type II diabetes mellitus (DM), viral hepatitis from hepatitis B virus (HBV) or hepatitis C virus (HCV), and alcoholic fatty liver.(2) Liver disease is responsible for one quarter of all organ transplants.
NAFLD is particularly becoming an increasing problem in Australia in parallel with the growing epidemic of obesity. The burden of NAFLD in our community is evident with an alarming prevalence of 15 percent among school children and 40 percent among individuals over the age of 60.(3-5) The latter prevalence is the context of increased metabolic problems such as hypertension, type II diabetes mellitus (DM) and hypercholesterolaemia. Among patients with type II DM, the presence of NAFLD was significantly associated with an increased risk of death (HR1.7, 95 per cent CI1.04–2.7), with liver related death accounting for 20 percent of all deaths of patients with NALFD and type II DM.(6) Life style modifications and early control of metabolic risk factors (obesity, type II diabetes, hypertension and hypercholesterolaemia) associated with NAFLD are crucial in halting the progression of this liver disease.
With respect to viral hepatitis, two billion individuals are believed to be infected with hepatitis B (HBV) worldwide, with 350 million likely to have chronic infection, including 100,000 Australians, mostly people from migrant countries. Hepatitis B is the leading cause of liver cancer in Australia and globally.(1, 7) There is an effective vaccine against hepatitis B virus. This vaccine is reliable in preventing the transmission of hepatitis B virus. For those patients with chronic HBV, there is effective treatment for chronic hepatitis B virus infection.
As for HCV, a blood transmissible virus, cases are primarily documented in injecting drug users. The Hepatitis C Sub-Committee of the Ministerial Advisory Committee on AIDS, Sexual Health and Hepatitis (2006) estimated around 264,000 people living with HCV antibodies in Australia in 2005. There were an estimated 2,550 deaths from hepatitis C in 2012 in Australia. Hepatitis C virus related liver disease is the commonest cause of liver transplant in Australia. An effective HCV vaccine is many years away. Chronic hepatitis C infection is potentially CURABLE with antiviral treatment.
Primary liver cancer, or hepatocellular carcinoma, is mainly a complication of liver cirrhosis. Liver cancer is Australia’s fastest growing form of cancer, in Australia, the total number of cases of primary liver cancer was estimated as 1,451 in 2012. (2)
Globally and in Australia, NAFLD is becoming an increasing risk for the development of liver cancer even in noncirrhotic livers. Viral hepatitis from HBV or HCV is linked to 30 per cent of cases of liver cancer in Australia. (7, 8) In NSW, liver cancer incidence rates have been rising faster than any other cancer, with an average annual increase recorded between 1997 and 2006 of 5.3 per cent for males and 8.8 per cent for females, surpassing cancers of the prostate, thyroid, skin (melanoma) and oesophagus.(9)
Also, liver cancer incidence rates are 5-10 times greater in Indigenous than in non-Indigenous Australians.(10) During 1991–2000, the Indigenous populations in the Northern Territory had substantially higher death rates from liver and gallbladder cancer, compared with the total Australian population (RR 5.7, 95 percent CI: 4.2–7.6). (11)
Importantly, liver disease affects people in the prime of their life, and hence the burden of this disease on our society is quite significant. In this context, a recent report commissioned by the Gastroenterological Society of Australia/ Australian Liver Association has shown that the burden to our society from liver disease was primarily due to lost lifetime earnings by individuals who died prematurely due to liver diseases and productivity losses associated with lower employment participation.
Surveys from around Australia have demonstrated that barriers to offsetting the burden of liver disease in Australia are multi-factorial and include: lack of knowledge among health professionals of risk factors of the presence and progress of liver disease, lack of knowledge among the community of the impact of liver disease on their health and life expectancy and lack of timely access to specialised liver centres due to long waiting time (12-14) With respect to the latter, the management of these patients remains primarily dependant on the congested tertiary institutes.
It is recognised that knowledge of the burden of disease is crucial for planning interventions, and informing policies. Hence, the current data of the burden of chronic liver disease in our society calls for a coordinated effort among stakeholders and policy makers to address the impact of such preventable disease on our society. In this regard, education and increased awareness of our community and health professionals about liver disease, and its related complications are a necessity. Models of care supporting community based prevention and treatment programs must be employed allowing early intervention. Finally, recognition of liver disease, as a chronic disease by policy makers is a crucial step to start implementing effective strategies.
1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, Abraham J, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2095-2128.
2. report GA-D. Burden of Chronic liver disease in Australia. 2013.
3. Oddy WH, Herbison CE, Jacoby P, Ambrosini GL, O’Sullivan TA, Ayonrinde OT, Olynyk JK, etal. The Western dietary pattern is prospectively associated with nonalcoholic fatty liver disease in adolescence. Am J Gastroenterol 2013;108:778-785.
4. Booth ML, George J, Denney-Wilson E, Okely AD,Hardy LL, Aitken R, Dobbins T. The population prevalence of adverse concentrations and associations with adiposity of liver tests among Australian adolescents. J Paediatr Child Health 2008;44:686-691.
5. Frith J, Day CP, Henderson E, Burt AD, Newton JL.Non-alcoholic fatty liver disease in older people. Gerontology 2009;55:607-613.
6. Adams LA, Harmsen S, St Sauver JL, Charatcharoenwitthaya P, Enders FB, Therneau T, Angulo P. Nonalcoholic fatty liver disease increases risk of death among patients with diabetes: a community-based cohort study. Am J Gastroenterol 2010;105:1567-1573.
7. Amin J, O’Connell D, Bartlett M, Tracey E, Kaldor J,Law M, Dore G. Liver cancer and hepatitis B and C in New South Wales, 1990-2002: a linkage study. Aust N Z J Public Health 2007;31:475-482.
8. Amin J, Dore GJ, O’Connell DL, Bartlett M, Tracey E, Kaldor JM, Law MG. Cancer incidence in people with hepatitis B or C infection: a large community-based linkage study. J Hepatol 2006;45:197-203.
9. Registries AIoHaWaAAoC. 2006.
10. Wan X, Mathews JD. Primary hepatocellular carcinoma in aboriginal Australians. Aust J Public Health 1994;18:286-290.
11. Condon JR, Barnes T, Cunningham J, Armstrong BK. Long-term trends in cancer mortality for Indigenous Australians in the Northern Territory. Med J Aust 2004;180:504-507.
12. Guirgis M, Yan K, Bu YM, Zekry A. General practitioners’ knowledge and management of viral hepatitis in the migrant population. Intern Med J 2012;42:497-504.
13. Preston-Thomas A, Fagan P, Nakata Y, Anderson E. Chronic hepatitis B--care delivery and patient knowledge in the Torres Strait region of Australia. Aust Fam Physician 2013;42:225-231.
14. Wallace J, McNally S, Richmond J, Hajarizadeh B, Pitts M. Challenges to the effective delivery of health care to people with chronic hepatitis B in Australia. Sex Health 2012;9:131-137.
Amany Zekry, MBBS, PhD, FRACP
Amany Zekry is an Associate Professor of Medicine at the University of New South Wales. She is also the director of Gastroenterology and Hepatology at St George Hospital in Sydney. After finishing her training in Gastroenterology and Hepatology, she undertook a PhD and subsequently post doctoral research in liver disease. A/Prof Zekry has an active clinical and research agenda in liver disease. She is actively working with her colleagues in the Australian Liver Association to raise awareness of liver disease in Australia.
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