Community health workers' dissemination of COVID-19 information and services in the early pandemic response: a systematic review.

BACKGROUND: Community health workers (CHWs) had important roles mitigating the impact of the COVID-19 pandemic in vulnerable communities. We described how CHWs supported the dissemination of COVID-19 information and services during the early pandemic response. METHODS: Online article searches were conducted across five scientific databases, with review article reference lists hand searched to identify grey/unpublished literature. Articles were included if they reported on a program that engaged CHWs and aimed to prevent/control COVID-19. RESULTS: Nineteen relevant programs were identified from 18 included articles. CHWs were widely engaged in the pandemic response, especially in low- and middle-income countries and in vulnerable communities. CHWs' ability to effectively disseminate COVID-19 information/services was enabled by community trust and understanding community needs. CHWs were often underfunded and required to work in difficult conditions. Pre-existing services incorporating CHWs rapidly adapted to the new challenges brought by the pandemic. CONCLUSIONS: We recommend establishing programs that employ CHWs to disseminate health information and services in communities at-risk of misinformation and poor health outcomes during non-pandemic times. CHWs are well-placed to deliver interventions should an infectious disease outbreak arise. Having pre-existing trusted relationships between CHWs and community members may help protect vulnerable groups, including when outbreaks occur.

Evaluating a peer-to-peer health education program in Australian public housing communities during the COVID-19 pandemic.

BACKGROUND: The cohealth Health Concierge program operated in Melbourne, Australia from July 2020 to 30 June 2022. It provided peer-to-peer support to culturally and linguistically diverse residents of high-rise public housing. During this time, the COVID-19 public health response changed frequently and included movement restriction, testing and vaccination. We conducted a mixed-methods evaluation to determine the Health Concierge program's impact on residents' engagement with health services and public health activities. METHODS: The evaluation, informed by a Project Reference Group, used the RE-AIM framework. We analysed data from 20,901 routinely collected forms describing interactions between Concierges and residents from August 2021 to May 2022. Additional evaluation-specific data were collected between March and May 2022 in four housing estates; we surveyed 301 residents and conducted 32 interviews with residents, Concierges and program stakeholders. RESULTS: Concierges promoted COVID-safe behaviours; linked residents with support, testing and vaccination services; and disseminated up-to-date information. Of the 20,901 recorded interactions, 8,872 (42%) included Concierges providing support around COVID-19 vaccination. Most surveyed residents (191/301, 63%) reported speaking with a Concierge in the previous six months. The self-reported two-dose COVID-19 vaccine uptake was 94% (283/301). Some residents described having meaningful, appreciated conversations with Concierges, and some described superficial interactions. While residents initially welcomed the program, many felt it failed to evolve. Poorly defined management and hiring criteria led to variable program implementation. A need for bicultural workers to continue linking residents with services was discussed. CONCLUSIONS: Concierges' impact on residents may have contributed to high community uptake of COVID-19 testing and vaccination, and had benefits beyond the COVID-19 remit. We recommend the program be revised and continued to inform further preparedness planning and support service access generally. Program models such as this have potential to inform and reassure high-risk communities during a pandemic. In addition, such programs can help overcome vaccine hesitancy and promote protective health behaviours, regardless of whether a pandemic is currently occurring. Ensuring these programs remain responsive to the changing needs of end-users needs over time is imperative.

Missed opportunities for diagnosis of hepatitis B and C in individuals diagnosed with decompensated cirrhosis or hepatocellular carcinoma.

BACKGROUND AND AIM: This study aimed to assess utilization of health-care services in people with decompensated cirrhosis (DC) or hepatocellular carcinoma (HCC) and a "late diagnosis" of hepatitis B or hepatitis C. METHODS: Hepatitis B and C cases during 1997-2016 in Victoria, Australia, were linked with hospitalizations, deaths, liver cancer diagnoses, and medical services. A late diagnosis was defined as hepatitis B or hepatitis C notification occurring after, at the same time, or within 2 years preceding an HCC/DC diagnosis. Services provided during the 10-year period before HCC/DC diagnosis were assessed, including general practitioner (GP) or specialist visits, emergency department presentations, hospital admissions, and blood tests. RESULTS: Of the 25 766 notified cases of hepatitis B, 751 (2.9%) were diagnosed with HCC/DC, and hepatitis B was diagnosed late in 385 (51.3%). Of 44 317 cases of hepatitis C, 2576 (5.8%) were diagnosed with HCC/DC, and hepatitis C was diagnosed late in 857 (33.3%). Although late diagnosis dropped over time, missed opportunities for timely diagnosis were observed. Most people diagnosed late had visited a GP (97.4% for hepatitis B, 98.9% for hepatitis C) or had a blood test (90.9% for hepatitis B, 88.6% for hepatitis C) during the 10 years before HCC/DC diagnosis. The median number of GP visits was 24 and 32, and blood tests 7 and 8, for hepatitis B and C, respectively. CONCLUSIONS: Late diagnosis of viral hepatitis remains a concern, with the majority having frequent health-care service provision in the preceding period, indicating missed opportunities for diagnosis.

Australian consensus recommendations for the management of hepatitis B.

INTRODUCTION: The prevalence of hepatitis B virus (HBV) infection in Australia is nearly 1%. In certain well defined groups the prevalence is far greater, yet an estimated 27% of people living with HBV infection remain undiagnosed. Appropriate screening improves detection, increases opportunity for treatment, and ultimately reduces the significant morbidity and mortality associated with the development of liver fibrosis and hepatocellular carcinoma (HCC). MAIN RECOMMENDATIONS: This statement highlights important aspects of HBV infection management in Australia. There have been recent changes in nomenclature and understanding of natural history, as well as a newly defined upper limit of normal for liver tests that determine phase classification and threshold for antiviral treatment. As the main burden of hepatitis B in Australia is within migrant and Indigenous communities, early identification and management of people living with hepatitis B is essential to prevent adverse outcomes including liver cancer and cirrhosis. CHANGE IN MANAGEMENT AS A RESULT OF THIS GUIDELINE: These recommendations aim to raise awareness of the current management of hepatitis B in Australia. Critically, the timely identification of individuals living with hepatitis B, and where appropriate, commencement of antiviral therapy, can prevent the development of cirrhosis, HCC and mother-to-child transmission as well as hepatitis B reactivation in immunocompromised individuals. Recognising patient and viral factors that predispose to the development of cirrhosis and HCC will enable clinicians to risk-stratify and appropriately implement surveillance strategies to prevent these complications of hepatitis B.

The COVID Positive Pathway: a collaboration between public health agencies, primary care, and metropolitan hospitals in Melbourne.

OBJECTIVES: To assess the capacity of the COVID Positive Pathway, a collaborative model of care involving the Victorian public health unit, hospital services, primary care, community organisations, and the North Western Melbourne Primary Health Network, to support people with coronavirus disease 2019 (COVID-19) isolating at home. DESIGN, SETTING, PARTICIPANTS: Cohort study of adults in northwest Melbourne with COVID-19, 3 August - 31 December 2020. MAIN OUTCOME MEASURES: Demographic and clinical characteristics, and social and welfare needs of people cared for in the Pathway, by care tier level. RESULTS: Of 1392 people referred to the Pathway by the public health unit, 858 were eligible for enrolment, and 711 consented to participation; 647 (91%) remained in the Pathway until they had recovered and isolation was no longer required. A total of 575 participants (81%) received care in primary care, mostly from their usual general practitioners; 155 people (22%) received care from hospital outreach services, and 64 (9%) needed high tier care (hospitalisation). Assistance with food and other basic supplies was required by 239 people in the Pathway (34%). CONCLUSIONS: The COVID Positive Pathway is a feasible multidisciplinary, tiered model of care for people with COVID-19. About 80% of participants could be adequately supported by primary care and community organisations, allowing hospital services to be reserved for people with more severe illness or with risk factors for disease progression. The principles of this model could be applied to other health conditions if regulatory and funding barriers to information-sharing and care delivery by health care providers can be overcome.

Understanding how to live with hepatitis B: a qualitative investigation of peer advice for Chinese people living with hepatitis B in Australia.

BACKGROUND: Hepatitis B is a chronic viral infection, a leading cause of primary liver cancer and identified as a major public health priority by the World Health Organization. Despite a high proportion of people in Australia who have been diagnosed with hepatitis B, significant gaps remain in health care access and in accurate knowledge about hepatitis B. Most people with hepatitis B in Australia were born in China, where the infection has an intergenerational impact with significant social implications resulting from the infection. Understanding how people of Chinese ethnicity with hepatitis B understand and respond to hepatitis B is imperative for reducing morbidity, mortality, and the personal and social impact of the infection. METHODS: Qualitative semi-structured interviews with people with hepatitis B of Chinese ethnicity recruited through a specialist service identified the advice people with hepatitis B thought was important enough to inform the experience of people newly diagnosed with hepatitis B. A thematic analysis of the data privileged the lived experience of participants and their personal, rather than clinical, explanations of the virus. RESULTS: Hepatitis B infection had psychological and physical consequences that were informed by cultural norms, and to which people had responded to with significant behavioural change. Despite this cohort being engaged with specialist clinical services with access to the most recent, comprehensive, and expert information, much of the advice people with hepatitis B identified as important for living with hepatitis B was not based on biomedical understandings. Key suggestions from people with hepatitis B were to form sustainable clinical relationships, develop emotional resilience, make dietary changes, regulate energy, and issues related to disclosure. CONCLUSIONS: The study highlights conflicts between biomedical and public health explanations and the lived experience of hepatitis B among people of Chinese ethnicity in Australia. Beliefs about hepatitis B are embedded within cultural understandings of health that can conflict with bio-medical explanations of the infection. Acknowledging these perspectives provides for insightful communication between health services and their clients, and the development of nuanced models of care informed by the experience of people with hepatitis B.

Modeling Progress Toward Elimination of Hepatitis B in Australia.

BACKGROUND AND AIMS: Chronic hepatitis B (CHB) is a significant global health concern, and the most prevalent blood-borne virus in Australia. World Health Organization (WHO) member states have committed to global elimination, with targets to diagnose 90% of people living with CHB, treat 80% of those eligible, and reduce attributable deaths by 65% by the year 2030. Australia has committed to national targets of 80% diagnosed, 20% on treatment, and a 30% reduction in deaths by 2022. APPROACH AND RESULTS: We constructed and implemented a mathematical model to estimate the burden of CHB incorporating vaccination, phases of infection, cirrhosis progression, and mortality attributed to decompensated cirrhosis and hepatocellular carcinoma and examined the population-level impact of antiviral therapy. Diversity was integrated according to migration patterns, CHB prevalence by country of birth, Indigenous status, and age. Modelled outcomes were subjected to multivariate uncertainty analysis. Of the estimated 221,420 people living with CHB in Australia in 2017, 68% were diagnosed and 8.7% were receiving treatment (less than one-third of those estimated to be eligible). Based on current trends, the proportion of people living with CHB who have been diagnosed will reach 71% by 2022 and 81% by 2030, and treatment uptake will rise to 11.2% by 2022 and 12.9% by 2030, resulting in a 5.7% reduction in CHB-attributable deaths from 2015 to 2030. CHB treatment has prevented approximately 2,300 deaths in Australia between 2000 and 2017. CONCLUSIONS: Australia is not on track to meet local and global targets regarding CHB. Comprehensive and regularly updated modelling approaches accounting for diversity within the population are a useful tool to measure progress and impact of interventions, and quantify further improvements required to meet elimination goals.

Adding saliva testing to oropharyngeal and deep nasal swab testing increases PCR detection of SARS-CoV-2 in primary care and children.

OBJECTIVE: To compare the concordance and acceptability of saliva testing with standard-of-care oropharyngeal and bilateral deep nasal swab testing for severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in children and in general practice. DESIGN: Prospective multicentre diagnostic validation study. SETTING: Royal Children's Hospital, and two general practices (cohealth, West Melbourne; Cirqit Health, Altona North) in Melbourne, July-October 2020. PARTICIPANTS: 1050 people who provided paired saliva and oropharyngeal-nasal swabs for SARS-CoV-2 testing. MAIN OUTCOME MEASURES: Numbers of cases in which SARS-CoV-2 was detected in either specimen type by real-time polymerase chain reaction; concordance of results for paired specimens; positive percent agreement (PPA) for virus detection, by specimen type. RESULTS: SARS-CoV-2 was detected in 54 of 1050 people with assessable specimens (5%), including 19 cases (35%) in which both specimens were positive. The overall PPA was 72% (95% CI, 58-84%) for saliva and 63% (95% CI, 49-76%) for oropharyngeal-nasal swabs. For the 35 positive specimens from people aged 10 years or more, PPA was 86% (95% CI, 70-95%) for saliva and 63% (95% CI, 45-79%) for oropharyngeal-nasal swabs. Adding saliva testing to standard-of-care oropharyngeal-nasal swab testing increased overall case detection by 59% (95% CI, 29-95%). Providing saliva was preferred to an oropharyngeal-nasal swab by most participants (75%), including 141 of 153 children under 10 years of age (92%). CONCLUSION: In children over 10 years of age and adults, saliva testing alone may be suitable for SARS-CoV-2 detection, while for children under 10, saliva testing may be suitable as an adjunct to oropharyngeal-nasal swab testing for increasing case detection.

Hepatitis B in the Northern Territory: insights into the changing epidemiology of an ancient condition.

BACKGROUND: Aboriginal and Torres Strait Islander people are disproportionately affected by hepatitis B virus (HBV) infection. A proposed mismatch between standard vaccines and the HBV/C4 sub-genotype prevalent in Aboriginal people in the Northern Territory (NT) may reduce vaccine effectiveness. AIMS: To determine HBV prevalence in the NT by Indigenous status and to explore patterns of immunity following implementation of universal vaccination, using a large longitudinal diagnostic dataset. METHODS: A retrospective analysis of all available HBV serology results in the NT from 1991 to 2011 was conducted, with HBV prevalence and vaccination status analysed according to adigenous status, age and sex using individuals' patterns of HBsAg, anti-HBs and anti-HBc serology over repeated tests. RESULTS: 100 790 individuals were tested (33.4% Indigenous) between 1991 and 2011 (26.1% of the 2011 NT population), with a total of 211 802 tests performed. In 2011, the proportion of HBV positive individuals in the NT was 3.17% (5.22% in Indigenous populations) compared to previous 2011 estimates of 1.70% (3.70% in Indigenous populations). The vaccine failure rate was lower than expected with only one presumed vaccinated person subsequently developing HBsAg positivity (0.02%). Evidence of suboptimal vaccine efficacy by breakthrough anti-HBc positivity in vaccinated individuals was demonstrated in 3.1% of the vaccinated cohort, of which 86.4% identified as Indigenous (HR 1.17). No difference in HBeAg positivity or seroconversion was observed between Indigenous and non-Indigenous individuals living with CHB. CONCLUSIONS: The burden of CHB in Indigenous people in the NT has previously been underestimated. A higher HBV prevalence in the NT than described in previous cross-sectional studies was found, including a higher prevalence in Indigenous people. Evidence of suboptimal vaccine efficacy was demonstrated predominantly in Indigenous individuals.

Adherence in chronic hepatitis B: associations between medication possession ratio and adverse viral outcomes.

BACKGROUND: Antiviral therapy for chronic hepatitis B (CHB) is effective and can substantially reduce the risk of progressive liver disease and hepatocellular carcinoma but is often administered for an indefinite duration. Adherence has been shown in clinical trials to maximize the benefit of therapy and prevent the development of resistance, however the optimal threshold for predicting clinical outcomes has not been identified. The aim of this study was to analyse adherence using the medication possession ration (MPR) and its relation to virological outcomes in a large multi-centre hospital outpatient population, and guide development of an evidence-based threshold for optimal adherence. METHODS: Pharmacy and pathology records of patients dispensed CHB antiviral therapy from 4 major hospitals in Melbourne between 2010 and 2013 were extracted and analysed to determine their MPR and identify instances of unfavourable viral outcomes. Viral outcomes were classified categorically, with unfavourable outcomes including HBV DNA remaining detectable after 2 years treatment or experiencing viral breakthrough. The association between MPR and unfavourable outcomes was assessed according to various thresholds using ROC analysis and time-to-event regression. RESULTS: Six hundred forty-two individuals were included in the analysis. Median age was 46.6 years, 68% were male, 77% were born in Asia, and the median time on treatment was 27.5 months. The majority had favourable viral outcomes (91.06%), with most having undetectable HBV DNA at the end of the study period. The most common unfavourable outcome was a rise of < 1 log in HBV DNA (6.54% of the total), while 2.49% of participants experienced viral breakthrough. Adherence was linearly associated with favourable outcomes, with increasing risk of virological breakthrough as MPR fell. Decreasing the value of MPR, at which a cut-point was taken, was associated with a progressively larger reduction in the rate of unfavourable event; from a 60% reduction under a cut-point of 1.00 to a 79% reduction when the MPR cut-point was set at 0.8. CONCLUSION: Lower adherence as measured using the MPR was strongly associated with unfavourable therapeutic outcomes, including virological failure. Optimising adherence is therefore important for preventing viral rebound and potential complications such as antiviral resistance. The evidence of dose-response highlights the need for nuanced interventions.

A survey of Australian general practitioners' hepatitis C knowledge and management 2 years after subsidised direct-acting antiviral therapy became available.

In 2016, hepatitis C direct-acting antivirals (DAAs) became available in Australia. A group of general practitioners (GPs) were surveyed twice to assess hepatitis C knowledge and management; 191/1000 (19.1%) responded at baseline, 164/938 (17.5%) at follow up. Participants' mean Knowledge score increased: baseline 5.75 (95% CI 5.61-5.91), follow up 6.09 (95% CI 5.95-6.22; P <0.01). At follow up, 36/163 (22%) had prescribed DAAs compared with 23/187 (12%) at baseline (χ2(1) = 5.95, P = 0.02); however, 67/150 (45%) were unsure of treatment eligibility for people who inject drugs. Additional support for GPs is warranted to ensure optimal hepatitis C management in primary care.

Knowing and telling: how African-Australians living with chronic hepatitis B understand hepatocellular carcinoma risk and surveillance.

African-Australians have a high prevalence of chronic hepatitis B (CHB) and an increased risk of liver cancer (hepatocellular carcinoma, HCC) at a younger age than other affected groups living with CHB. The prevention of HCC-related mortality is possible with timely diagnosis of CHB, regular monitoring including liver cancer surveillance and appropriate treatment with antiviral therapy. Currently, little is known about how African-Australians living with CHB understand their condition, their risk of liver cancer and the need for regular monitoring. There were 19 semi-structured interviews conducted with African-Australians who have CHB. The interviews explored the participants' knowledge of CHB, their perceptions of future health risks and experiences and understanding of healthcare. The three major themes identified in the analysis were (i) the risks to physical health including liver cancer, (ii) risks to social and emotional wellbeing from diagnosis and disclosure and (iii) the fear and worry associated with being infectious. The understanding of risk and mitigation of that risk was framed by their understanding of health, ageing, as well as participants' educational background and faith. Our findings show the importance of engagement with the broader social and emotional effects of CHB by clinicians and services, and can assist in developing interventions to increase participation in healthcare, including liver cancer surveillance.

A survey of hepatitis C management by Victorian GPs after PBS-listing of direct-acting antiviral therapy.

BACKGROUND: To increase access to hepatitis C virus (HCV) treatment, the Pharmaceutical Benefits Scheme (PBS) enabled general practitioners (GPs) to prescribe direct-acting antiviral (DAA) therapy. We conducted a survey to identify GPs' knowledge and management of HCV. METHODS: A questionnaire consisting of 20 items about HCV knowledge and management was sent to 1000 GPs. RESULTS: One hundred and ninety-one GPs (19.1%) responded; 74% answered correctly that antibody and RNA positivity is diagnostic of HCV. Only 12% could directly request transient elastography. Although 53% of respondents reported interest in prescribing DAAs, 72% continued to refer all patients to specialists. Fifty-five per cent were unsure if people who currently inject drugs were eligible for treatment. DISCUSSION: Most respondents were interested in prescribing DAAs, but education, access to transient elastography and clear consultation pathways are required to translate this interest into increased treatment availability. PBS eligibility of current injectors needs promotion.

The challenge of liver cancer surveillance in general practice: Do recall and reminder systems hold the answer?

BACKGROUND: Hepatocellular carcinoma (HCC) surveillance reduces mortality in at-risk people living with chronic hepatitis B (CHB), but is difficult to achieve in practice. The objective of this study was to measure participation and adherence to liver cancer HCC surveillance in eligible patients in a community health centre, following support from the Integrated Hepatitis B Service (IHBS). METHODS: A retrospective analysis of the medical records of patients with CHB who met the indications for HCC surveillance over a 4.5-year period of IHBS involvement was conducted. Data collected included the date of ultrasound examinations and HBV DNA viral load tests. RESULTS: Sixty-seven patients underwent HCC surveillance, representing 213 person years. The participation rate was 75%. Adherence to surveillance was considered good in 18 (27%) patients, suboptimal in 29 (43%) patients and poor in 20 (30%) patients. A greater proportion of patients were receiving HCC surveillance at the final audit (56%) than at baseline (10%; P DISCUSSION: It is difficult to achieve optimal adherence to HCC surveillance, even with additional support.

Knowledge and practices of chronic hepatitis B virus testing by general practitioners in Victoria, Australia, 2014-15.

BACKGROUND: More than one-third of people living with chronic hepatitis B virus (HBV) in Australia have not been diagnosed. The aim of this study was to assess general practitioners' (GPs') knowledge and practices regarding chronic HBV diagnosis, and identify opportunities to improve testing rates. METHODS: A cross-sectional survey was conducted with GPs working in Victoria, Australia. Statistically significant adjusted odds ratios for high knowledge, and ordering two or more HBV tests per week were calculated. RESULTS: Of 1000 GPs who were invited to participate, 232 completed the survey. Chronic HBV knowledge, use of interpreters, and awareness of HBV testing guidelines were low. Chronic HBV knowledge and testing were associated with age and graduation from a medical school outside Australia. Testing was also associated with gender. DISCUSSION: This study identified gaps in GPs' knowledge about chronic hepatitis. Several barriers to improving testing rates among at-risk populations were identified. We recommend revision of the guidelines for prevention in general practice, and educational activities to improve knowledge of at-risk populations for chronic HBV in Australia.

Evaluating a novel model of hepatitis B care, Hep B PAST, in the Northern Territory of Australia: results from a prospective, population-based study.

Background: The Northern Territory (NT) has the highest prevalence of chronic hepatitis B (CHB) in Australia. The Hep B PAST program aims to improve health outcomes for people living with CHB. Methods: This mixed methods study involves First Nations peoples living in the NT. We used participatory action research principles across three steps: 1. Foundation step: establishing hepatitis B virus (HBV) status and linkage to care; 2. Capacity building: training the health workforce; 3. Supported transition to primary healthcare: implementation of the "Hub and Spoke" model and in-language resources. Analysis occurred at three time points: 1. Pre-Hep B PAST (2018); 2. Foundation step (2020); and 3. Completion of Hep B PAST (2023). Evaluation focuses on four key indicators, the number of people: 1) with documented HBV status; 2) diagnosed with CHB; 3) receiving care; and 4) receiving treatment. Findings: Hep B PAST (2018-23) reached 40,555 people. HBV status was documented in 11% (1192/10,853), 79.2% (26,075/32,915) and 90.8% (28,675/31,588) of people at pre-Hep B PAST, foundation step, and completion respectively. An estimated 99.9% (821/822) of people were diagnosed, 86.3% (709/822) engaged in care, and 24.1% (198/822) on antiviral treatment at completion. CHB prevalence in the study population is 2.6%, decreasing from 6.1% to 0.4% in the pre- and post-vaccination cohorts. Interpretation: Hep B PAST is an effective model of care. Partner health services are exceeding elimination targets. This model could enable other countries to enhance the cascade of care and work towards eliminating HBV. Funding: National Health and Medical Research Council.

Water vapour in the atmosphere of a transiting extrasolar planet.

Water is predicted to be among the most abundant (if not the most abundant) molecular species after hydrogen in the atmospheres of close-in extrasolar giant planets ('hot Jupiters'). Several attempts have been made to detect water on such planets, but have either failed to find compelling evidence for it or led to claims that should be taken with caution. Here we report an analysis of recent observations of the hot Jupiter HD 189733b (ref. 6) taken during the transit, when the planet passed in front of its parent star. We find that absorption by water vapour is the most likely cause of the wavelength-dependent variations in the effective radius of the planet at the infrared wavelengths 3.6 mum, 5.8 mum (both ref. 7) and 8 mum (ref. 8). The larger effective radius observed at visible wavelengths may arise from either stellar variability or the presence of clouds/hazes. We explain the report of a non-detection of water on HD 189733b (ref. 4) as being a consequence of the nearly isothermal vertical profile of the planet's atmosphere.