Between the end of 2016 and 2018 more than 20,000 people were cured of hepatitis C thanks to improved access to new treatments during that time.¹

So, is hepatitis C history? Not yet.

Currently there is a two-step testing process to diagnose hepatitis C. A patient receives a screening test that detects hepatitis C antibodies in the blood, and if positive will then receive a confirmation pathology test – a polymerase chain reaction (PCR) test.

Unfortunately, after the first positive screening test not all patients return for follow-up. This is a problem because this test only shows that they have had contact with the virus and does not confirm current infection or if treatment is needed.

International expert Dr Paul Jülicher says that streamlining the screening process for hepatitis C by adding extra pathology tests at the start of the diagnostic process could improve the chances of managing the condition.

Dr Jülicher is Director of Health Economics & Outcomes Research at Abbott Diagnostics Division. At the Australian Association of Clinical Biochemists Annual Scientific meeting he presented research conducted on a population screened for hepatitis C in Russia, which showed that there was a 44.8% drop in participation between the two diagnostic test stages, and which subsequently resulted in only 0.2% of people being cured.²

“Data from several countries indicate a huge amount of people get lost along the testing cascade leading to a high number of incomplete diagnoses,” said Dr Jülicher.

Current direct-acting antiviral therapies allow treatment to be completed within 12 weeks. However, this significant investment cannot be utilised unless more people are getting accurately diagnosed and seek treatment.

Dr Jülicher and his team are recommending the use of an antigen test which has been included by the World Health Organisation in a list of essential diagnostics and cited as an acceptable alternative to current testing protocol which has a PCR test.^2,3

Streamlining this process with fewer consultations could open the door to improved treatment as global research has found that many people do not proceed to the second test, and are less likely to seek treatment, especially if they are not exhibiting symptoms.

“Hepatitis C is essentially curable, which is why, globally, people are looking to reduce the prevalence so that it is a manageable risk.

“What we have to look into is the cascade of testing and where we lose patients between the tests. We are suggesting a different kind of test, which is an opportunity to reduce the number of steps that are traditionally done before a diagnosis.”

“Here, the test results can show beyond whether it is positive or negative for the antibody, but also whether it is an active infection, for which they can further pursue testing and treatment,” says Dr Jülicher.

When the virus is left untreated, hepatitis C leads to progressive liver damage and cirrhosis, that may leave patients needing highly invasive and expensive liver transplants.

“Australia is definitely one of the leaders in terms of how to eliminate hepatitis C. And while the situation in Australia is not as bad as it is in many other countries, that said, I still think it is an enormous burden,” said Dr Jülicher.

Those at highest risk of hepatitis C infection are people who inject drugs or are subject to other exposures through infected needles and similar equipment. Mothers with chronic hepatitis C also have a small chance of passing on the virus to a baby during pregnancy or childbirth. The virus can also be sexually transmitted under certain circumstances.

“From my understanding, the prevalence in Australia is moderate in the general population, but quite high in high-risk groups such as drug users,” said Dr Jülicher.

“And that is the issue with elimination – you can never eliminate or eradicate a disease if there is a high-risk population that is keeping the virus alive.”

Many people who contract hepatitis C will have no symptoms or only mild symptoms and the virus cannot be detected in initial screening tests until approximately 7-8 weeks after exposure when the immune system has produced antibodies.

Faster diagnosis and access to treatment will also help to stem the spread of the virus.

Kevin Marriott, Acting CEO at Hepatitis Australia says, “while we have a relatively good diagnosis rate in Australia, biomedical technology that can streamline the diagnostic process should be considered.”

“Previously we have considered ways to minimise the lag between the initial antibody testing and the confirmatory PCR testing to ensure the person can access appropriate care as quickly as possible, including the opportunity of being cured. Simplifying testing also has particular benefit in primary care settings where GP’s may be less familiar with the process and are busy with short patient appointments” said Mr Marriott.

References

1 https://kirby.unsw.edu.au/report/hiv-viral-hepatitis-and-sexually-transmissible-infections-australia-annual-surveillance

2 https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0219687#abstract0

3 https://www.who.int/medical_devices/publications/Standalone_document_v8.pdf?ua=1

4 https://apps.who.int/iris/bitstream/handle/10665/254621/9789241549981-eng.pdf;jsessionid=7A22A2DC606372775C63597347C013DB?sequence=1

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But what about the technology we rely on, but never see? Similar to the expert pathologists and medical scientists hidden behind the lab doors, the technology used daily in pathology laboratories is vital to delivering high quality, accessible and affordable healthcare to all Australians.

Pathology Technology Australia (PTA) is the body that represents companies in Australia developing innovative testing, analysis and information technologies used by pathology services.

PTA hosted a panel discussion this month; Pathology Technology Disruptors Past and Future, examining the role technology has played to achieve current delivery of pathology services and to discuss ideas of what is coming next.

Scott Jansson, a leading pathology expert with many decades working in public pathology organisations, was part of the panel discussion and he recognised the contribution technology providers have made to pathology so far:

“We have achieved a lot over the last 20-30 years through new technologies in pathology, such as the latest analysers and faster automation as we’ve seen in chemistry immunoassays and haematology coagulation, for example. These technologies are a big part of what has got us to where we are today.”

“We’ve seen a lot of consolidation in pathology services too but there is a limit to what more can be achieved due to the size and capacity of laboratories as well as population distribution and the geography of Australia. We’ve reached a point where we now need to look to new disruptive technologies to deliver further benefits.”

Several themes emerged from the discussion including the challenges that innovators face in bringing new devices, tests and software into labs.

Panel member, Dr Colman Taylor, Director of Health Technology Analysts said:

“We are currently seeing an explosion in innovation in pathology technology but the system for assessing new technologies needs to catch up. Our patients are becoming better educated and making more informed choices, which our industry is responding to and supporting, while continuing to drive efficiency. The challenge we face is demonstrating the value of technological innovation when it is broader than what the assessment system recognises.”

Dean Whiting is CEO of PTA, he agreed that the landscape is changing and that new challenges are facing the sector:

“In Australia, we are very fortunate to have a well-regulated and well-funded health system. The systems we have for assessing new health technologies benefit patients by ensuring strict guidelines are met.

“We are now at a point where we can see many applications for new technologies that can have broad benefits. In the lab these include improving efficiencies and workflow. For patients there are potential outcomes such as reducing GP visits, reducing hospitalisations, improving compliance with medicines and treatment advice, and avoiding further complications of some diseases. This can also result in economic savings, and we need to work together with funders to ensure assessment processes consider patient outcomes, health economic and societal benefits.”

The world of technology might seem isolated but discussion at the event highlighted the importance of working together with a wider pool encompassing universities, think tanks, patient advocacy organisations, industry groups and healthcare providers.

As emerging technologies offer more possible applications, these will require new ways to prove efficacy and to demonstrate that changing an existing approach or system will be worth the investment of budget, time and energy.

Mr Whiting said:

“Collaboration is key in our industry. Coming together and using in-depth insights from across academia, patient advocacy and technology developers means we keep driving innovation that will best serve patients, health professionals and the health system. This is also the best way we can work with government to contribute to evolving guidelines, by proving the broad benefits of emerging technologies.”

Innovators in this space are keenly looking to the future and moving increasingly towards a preventative health model.

Some of the biggest health challenges Australia faces, are our aging population and high rates of chronic diseases.

Mr Whiting explained:

“Tomorrow is where the problem lies. We are moving towards people living longer so supporting healthy ageing, preventing or delaying the onset of chronic disease, and minimising the impact and additional complications of diseases are some of the problems that those at the forefront of technology are looking to tackle. We want to bring people together to create an environment that nurtures clever solutions to these complex problems.”

The post Disruption discussion: looking to the future in pathology technology first appeared on Know Pathology Know Healthcare.

Vitamin D is one such complex area, with data from a 2012 study of Australians aged 25+ finding that vitamin D deficiency affects 39% of Australian women.¹

Vitamin D deficiency in pregnancy has been linked to several conditions including high blood pressure and preeclampsia in expectant mothers, and low calcium levels, rickets and myopathy (muscle disease) in newborns.

An Adelaide team of pathologists led by chemical pathologist Dr Devika Thomas, collated test results over a 12-month period, from blood samples of pregnant women who were referred for a vitamin D test by their doctor.

This data, collected in 2018, was presented at the Australian Association of Clinical Biochemists’ Annual Scientific Conference earlier this month and shows a third of pregnant women in South Australia are vitamin D deficient.

Current guidelines state that only women deemed high risk should have vitamin D levels tested. This includes women with darker skin such as those from Aboriginal, African or South Asian backgrounds, newly arrived refugees, and those whose sun exposure is severely limited, including veiled women.

However, it can be difficult for health professionals looking after pregnant women to know when a woman might be at risk of low vitamin D. Low levels are relatively common in the general population, plus there are many factors affecting sun exposure and vitamin D absorption, including the seasonal and geographical differences.

Dr Thomas says the issue is particularly important for pregnant women:

“Vitamin D deficiency is not uncommon in the general population in Australia but current guidelines for testing in pregnancy cover a limited group of women. We wanted to find out if vitamin D deficiency is identified and corrected during pregnancy. We found that 22% of the women tested at 28 weeks as per guidelines are still deficient.”

Of the 1,352 pathology referrals that were included in the study, there were only 575 that included a request for vitamin D testing. This equates to 43 per cent which is consistent with the proportion of women deemed high-risk in previous studies using comparable demographics.

Current South Australian guidelines recommend that low-risk women should take daily supplements containing 400IU of vitamin D.

Women deemed at high risk of deficiency should be tested at their first antenatal visit and begin taking daily supplements containing 1000IU of vitamin D.

For these women, test results should be checked at the next appointment and dosage reduced if levels are adequate.

Women still found to have low vitamin D levels will continue on higher dose supplements and be tested again at 28 weeks. These results will determine if supplements need to be further increased.

Dr Thomas said, “This approach does not detect and treat all pregnant women who are deficient in vitamin D. The criteria for testing rely on some self-reported data and people may overestimate their sun exposure.

“Although we saw a slight rise in the rates of adequate vitamin D levels in the third trimester, this was not statistically significant, therefore even in those who were deemed high-risk and tested in the first trimester, the majority are still deficient by the third trimester.”

Vitamin D in the mother’s blood needs to be up to the recommended level by week 28 of pregnancy in order for a baby to be born with an adequate level of stored vitamin D.

In other states the approach may be different with some guidelines stating supplementation should not be routinely recommended to all pregnant women, only those tested and found to have low vitamin D levels. This could also create some confusion for patients and their health professionals and points to a need for more research on vitamin D.

“I think further research in this area is needed to determine if offering testing to all women in early pregnancy could detect and treat more women with vitamin D deficiency. Studies looking at adherence to supplements and investigating the optimum level of vitamin D in pregnancy could also help to provide the best outcomes for mothers and babies,” said Dr Thomas.

A/Prof Graham Jones is a chemical pathologist and an ambassador for Pathology Awareness Australia. He pointed out the importance of communication between patients, clinicians and pathology teams:

“During pregnancy women have a lot of pathology tests to monitor their health and the health of their baby. As part of this process they will need to answer questions about medical and family history, lifestyle, diet and medications – including any supplements – to ensure that their treating doctors have all the information they need to order the appropriate tests. This information is also very important for pathology laboratories when interpreting results.

“Vitamin D testing is a particularly complex area with seasonal fluctuations and several factors which can affect whether a woman is at high risk of deficiency. Pregnant women should discuss with their doctor or midwife if testing is appropriate.”

There always needs to be a clinical reason for a doctor to request a test whether vitamin D or anything else – so if in doubt, ask your doctor.

References:

1. Daly RM et al. Prevalence of vitamin D deficiency and its determinants in Australian adults aged 25 years and older: a national, population-based study. Clin Endocrinol 2012. Access: https://www.ncbi.nlm.nih.gov/pubmed/22168576

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Developed in 1884, Gram staining is a staining technique that aids in the identification and characterization of bacteria.

Gram was a Danish physician and bacteriologist who intended to make bacteria more visible in stained sections of lung tissue, and in turn, developed the most widely used method of staining bacterial cells.

“After so many years, we still use Gram staining in labs,” says Dr Petra Derrington, a Queensland based microbiologist.

“Currently all microbiology labs still use Gram stains to give us the initial information about what organism is present in a specimen.

“Therefore, we are able to determine the empiric therapy needed for that patient.”

However, there have been changes to the method since the late-1800’s with the advancements of technology and quality.

“Today there are automated Gram stains done in the lab, which ensures better quality and better reproducibility.”

Microbiologists working in labs today use Gram stains to test patients for the presence of bacteria such as Staphylococcus aureus and Escherichia coli.

Fast diagnosis or ruling out of bacterial infections ensures the correct treatment is provided quickly. This not only helps the patient to recover faster but also aids in the fight against antibiotic resistance by limiting the use of unnecessary antibiotics.

To learn more about what a microbiologist does, check out or profile of Dr Petra Derrington here.

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Member of Parliament for Dunkley Peta Murphy visited a pathology laboratory at Peninsula Health in Frankston.

The aim of the tour was to demonstrate the importance and value of pathology and show to the newly elected Member why Australia has some of the highest quality pathology services in the world.

Know Pathology Know Healthcare ambassador Dr David Clift shared his knowledge with Ms Murphy. Dr Clift has been an anatomical pathologist for the past 40 years and told anecdotes from his extensive career.

One of the highlights on this particular tour was having the chance to see one of the pathologists studying a small intestine for abnormalities in the histopathology department. Witnessing this was not for the faint-hearted!

Ms Murphy also learnt about the importance and role of a hospital blood bank. Blood Bank Senior Scientist Michael Wiggins played some guessing games with the group and encouraged everyone to share what their blood group was. Unsurprisingly, only a few people on the tour knew their blood groups. Michael reassured everyone that this was not something to be too concerned about, as blood groups and antigens would always be thoroughly checked by his team before any blood transfusions.

Ms Murphy took a close look at some unusual slides through a multi-headed microscope in Haematology. This instrument allows multiple people, staff and students alike, to observe the same slide at once and discuss their findings.

Ms Murphy was impressed by the quality of the work and the dedication of the staff at the pathology lab. She has said that she will use her platform to voice the value of pathology and to ensure that more people know about what goes on behind the scenes.

The post Federal MP tours pathology lab after cancer diagnosis speech first appeared on Know Pathology Know Healthcare.

Olympic athlete and Commonwealth Games gold medallist Jana Pittman was diagnosed with a precancerous condition of the cervix whilst having IVF treatment in 2015. Pittman is now studying to become a doctor and wants to specialise in gynaecology.

Pittman visited a pathology laboratory to see how the Human Papilloma Virus (HPV) and cervical cancer are diagnosed. She is an advocate for women to participate in cervical screening, saying;

“I had put off getting tested for quite a few years, not because I didn’t want to be tested but because I was busy and hadn’t prioritised it. I want all women to take part in the screening program, it’s just five minutes and a bit of discomfort to get tested and get that peace of mind.”

More women should participate in the improved cervical cancer screening program to eliminate the disease. The latest data from the National Cervical Screening Program reveals that the new testing system introduced in December 2017 is working well but screening participation rates must increase.

The new test replaces the previous pap smear test – it is more sensitive and detects the the HPV which can cause changes in the cells of the cervix that may later lead to cancer.

The test is capable of detecting an HPV infection many years before a pap smear could find any changes in cells.

The HPV vaccine was introduced in Australia in 2007 and is now offered to teenage girls and boys as part of a school-based vaccination program to protect against strains of the virus that can cause genital warts and several types of cancer, including cervical cancer.

There are over 100 strains of HPV, with 15 strains known to be associated with cancer. The most recent vaccine protects against nine strains of HPV; seven of these can cause cancer and two are linked to genital warts.

The sample for pathology testing is collected in the same way as the previous pap test via a vaginal examination and cervical swab.

Data from the first six months of the new screening program found that a greater number of women were referred for colposcopy, a follow-up examination from an abnormal result, than with the previous pap smear testing system.

Estimates before the program began had predicted an increase in colposcopies, but the rate of referral was about three times higher than expected.

The study, published in Medical Journal Australia (MJA), analysed data from over 150,000 cervical screening samples received in the first six months of the new program.

Key findings were:

• Rates of any cancer-causing HPV were highest in women in the youngest age group of 25–29 years;
• Prevalence of the highest risk HPV types 16 and 18 peaked in the 30–34 age group;
• This age group had the highest number of women classified as ‘high risk’.

Adjunct Professor Annabelle Farnsworth is one of the paper’s authors and a leading expert in the field. She pointed out that many young women will not be aware they are still at risk of developing cervical cancer even though they have been vaccinated.

“The vaccine is very good, and we are lucky to have it in Australia. However, the early HPV vaccine only protected against four types of the virus, two of these are high-risk types. Even people who were vaccinated can still be at risk from other types of HPV. And of course, not all women have been vaccinated, which means it’s really important that every woman takes part in testing. If you have a negative result, you get peace of mind and you don’t need to be tested again for five years.”

According to the Australian Institute of Health and Welfare (AIHW) the participation rate for cervical screening in 2015–2016 was 56%.

A recent survey by the Australian Cervical Cancer Foundation (ACCF) looked at the reasons why women do not participate in screening. They found that over a quarter (26%) of women listed embarrassment and a third (32.3%) listed awkwardness as their reasons to avoid booking appointments for tests.

“Our national research demonstrates that whilst we, as a nation, have made significant gains when it comes to HPV vaccination rates and driving down new cases of cervical cancer, misunderstanding of cervical cancer and of the cervical screening test is rife. It’s imperative therefore that we not only act but react to the new research,” said Joe Tooma, CEO, ACCF.

Adj. Prof. Farnsworth said that women may be put off screening for a range of reasons. To support these women to take part in screening, a self-collect option is now available to eligible women under the new HPV testing system.

“Many women are not aware of the option for self-collection, meaning they can use a swab given by a health professional to collect their own sample in private whilst at the clinic. This may help women who would otherwise not be tested for all sorts of reasons, so we want to encourage women to talk to their GPs or health providers about this option,” said Adj. Prof. Farnsworth.

Adj. Prof. Farnsworth also wants women to be aware that this is a cancer that affects the young;

“HPV transmission typically starts when sexual activity begins and so a persistent infection may start to cause problems in 10–15 years when a woman is still young. The good news is that early detection leads to faster treatment of HPV, a precancerous condition or cancer itself. Women are often able to live a normal healthy life after treatment, including having children.”

According to a study in The Lancet medical journal, Australia is on track to eliminate cervical cancer by 2035. Australians (particularly those working in pathology) should be proud that we are so close to achieving this, however, to get there we must continue to strongly encourage participation in both vaccination programs and cervical screening tests.

The post Olympic athlete Jana Pittman learns about pathology and cervical cancer first appeared on Know Pathology Know Healthcare.

While studying biomedical science at the University of Newcastle, NSW, Michael Wiggins never thought he would find himself following a career in pathology.

“I always loved science; I was a really nerdy kid. While I was fascinated by the human body and health, I didn’t know about pathology. My degree was more research-based, however research didn’t interest me.”

But that all changed quickly for Michael, “we had one lecture in 3^rd year about pathology, and it clicked: this is what I have wanted to do all along.”

After having a lecturer explain the science to him further, Michael enrolled into a TAFE course specific to pathology.

Today, Michael works in Frankston. He is a Blood Bank Senior Scientist.

A passion for the blood bank

When asked about his career, he says “this is what I love, being in the front-line.

“Even when I was studying, the blood bank interested me the most. I loved the critical thinking and investigative side of it.

“I love taking all day to find an answer and bouncing my ideas off others. The penny-drop moment is an amazing feeling!

“From the time I walk into the lab at 7am, I am training people, assisting staff with complicated work, speaking to my manager, to the hospital staff. It’s full-on!” says Michael.

Unusual diagnoses and memorable cases

Throughout his career, Michael had some memorable experiences, despite rarely meeting patients himself.

One unusual diagnosis during his career was passenger lymphocyte syndrome after a liver transplant on a patient.

Passenger lymphocyte syndrome is when lymphocytes from donor blood form new antibodies; normally donor blood is not able to form antibodies. This may also happen after bone marrow transplants.

Michael also tells us he frequently identifies rare and exciting antibodies in blood samples from patients from the area, “there must be something in the water in Frankston!”.

The invisible side of healthcare

Michael has experienced the lack of public awareness of pathology firsthand, in particular friends and other people not really understanding what he does for work.

“We are an ignored science, and it’s not always glamorous, but we’re still an incredibly vital part of healthcare.

“Usually when I tell people I am a scientist, they ask what I’m researching. I then say that I work in pathology, and they think I collect blood,” says Michael.

Looking ahead: the future of pathology

Having worked in pathology for as long as he has, Michael has some sage advice for those in training.

“I tell people who I am training to be passionate and enthusiastic. And that they should constantly be learning. I would tell them to always remember that there is a patient at the end of every sample. They may not know us or what we did, but everything we do helps the patient somehow.

“Although I am a Senior Scientist, I am still learning every day and I love it,” Michael says.

The post “I love being in the front-line” says Blood Bank Senior Scientist first appeared on Know Pathology Know Healthcare.

The Honourable Jim Lloyd, a former Howard Government Minister who served in Parliament from 1996 to 2007 was diagnosed with prostate cancer in 2002. Following his own diagnosis, he is now an advisor for Prostate Cancer Foundation of Australia (PCFA).

With a family history for the condition, Mr Lloyd values the diagnosis process that has helped so many men, not only in his family, but also all across Australia.

Mr Lloyd was joined by the CEO of PCFA Professor Jeff Dunn for the tour around a pathology laboratory in Macquarie Park, to learn about how prostate cancer is diagnosed.

Prof. Dunn says that early detection is an important part of the conversation and seeing the inside of the “engine room” of healthcare was an eye-opener. He is grateful to the pathologists of Australia, acknowledging that the advances in prostate cancer control would not have been possible without the pathology labs and their hard work.

Next month, Pathology Awareness Australia will be hosting the 3^rd PSA Testing Event at Parliament House. Members of Parliament, Senators and their staffers will have the opportunity to receive a PSA test, and learn more about the role of pathology in prostate cancer diagnosis.

The post From Parliament to Pathology – Jim learns about Prostate Cancer Diagnosis first appeared on Know Pathology Know Healthcare.