Amber Malik Interview

Amber Malik has become the Principal Project Officer - Viral Hepatitis at SA Health, after joining the Communicable Disease Branch in May. She has a fascinating international healthcare background, and was kind enough to talk with us about her personal experiences and her thoughts on hepatitis elimination in Australia.

You’ve worked on major health projects in Pakistan, Geneva, and Australia: what’s brought you to focus on viral hepatitis?

As a public health professional, I understand that simple modifications in an individual’s behaviours and health practices can prevent the transmission of viral infections.

In Pakistan I was managing integrated primary health care projects such as water, sanitation and hygiene (WASH), mother, neonate, and child health care (MNCH), sexual and reproductive health care (SRH), and immunisation. It was complicated, working to eliminate and control communicable diseases in culturally and geographically diverse communities. Working with the UN and Red Cross in Pakistan and Geneva, I was supporting health systems in preventing communicable diseases as per the international standards. I supported government health facilities by establishing infection prevention and waste management systems, providing personal protective equipment (PPE), training, waste segregation, and correct disposal of equipment. I was also providing autoclaves for sterilisation and even funding the construction of waste incinerators.

I was drawn to viral hepatitis, probably for the same reasons that any public health professional would be. The first reason is that, even though hepatitis is considered as the seventh leading cause of deaths worldwide, the epidemic was basically neglected until 2015, the year the global burden of disease figures were released.

I believe my specific background gives me an advantage because I have seen both sides of health practices and know how the lack of ownership of health professionals and government badly affects and contributes to the vicious cycle of infection transmission, even when awareness-raising and health promotion activities are being provided at a community level.

I have always wanted to work with the world’s best health practices, where basic diagnostic and treatment facilities are available to everyone without any cultural, geographical, or socio-economic disparity. Now that I’ve had the opportunity to observe the best health practices around the world, I believe my knowledge will help eliminate viral hepatitis through various harm reduction strategies.

What is the level of hepatitis awareness in Pakistan? Is there much government support for education, testing, and treatment?

In fact, the primary cause of viral hepatitis spreading so rapidly in the Pakistani population is a lack of education and awareness of the disease, as well as a shortage of medically qualified and scientifically trained health care workers, and an overall lack of health infrastructure. This has resulted in a decreased emphasis on screening, especially in the case of hepatitis C testing, since a person with a hepatitis C infection often appears and feels fine.

Blood transfusion is still one of Pakistan’s leading causes of hepatitis C transmission. Even though hepatitis C virus detection is essential in blood screening, it is sometimes limited in developing countries due to a lack of resources and other technicalities. Despite widespread awareness of disease transmission via blood transfusion, mismanagement and a scarcity of medical facilities contribute significantly to the spread of hepatitis C via blood from infected donors as well as service providers receiving needlestick injuries.

Other contributing factors include poor health practices, parental ignorance, and a lack of prenatal and postnatal testing resulting in children being born with HIV and hepatitis C co-infection. Injecting drug use, simple medical procedures being done without adequate PPE, and the improper disposal of syringes and needles due to inadequate hospital waste management systems all add to the problem.

In hospital settings, syringes and needles are usually discarded into general waste and dumped into open pits outside the hospital. These pits are known sources of syringes and needles, and desperate people will go there to collect them.

Another more sinister outcome of the inadequate hospital waste management system has been the opening of a black market for ‘cleaned’ used syringes and needles, with facility staff taking used equipment, ‘cleaning it’, and then selling it. Cleaning the syringes and needles is usually only done with water and Dettol, but some—those with a guilty conscience— will use the hospital’s chlorine stock to disinfect them, proving that they know they are putting people at risk by selling them. These black-market syringes and needles are then purchased by ‘quacks’ to use in their practices and by some people who inject drugs that can afford them and believe these needles and syringes to be safer to use than ones collected directly from the hospital waste pits. And of course, these same syringes and needles are then shared within the purchaser’s circle of friends.

What differences have you found in terms of population and country size, in terms of health services and education? Pakistan, for example, has nearly 10 times the population of Australia in around a tenth of the physical space.

In Pakistan, blood-borne viral diseases (HCV, HBV, HIV) and sexually transmitted infections share a significant disease burden. Nearly 12 million people are infected with hepatitis B and C, with more than 100,000 new cases reported yearly. Any national response or process has yet to be planned and launched.

Furthermore, in the absence of data collection, analysing the progress of current national interventions is challenging. The most recent surveillance was in 2007! There is an urgent need to collect hepatitis data from across the country. Although the private and non-governmental sectors are contributing, the size of the problem is often overwhelming. The distribution of benefits is unbalanced between urban and rural areas—rural areas suffer when services are available in urban areas.

The health system in Pakistan is divided into primary, secondary, and tertiary levels of care. The lack of diagnostic services at the primary level of care poses a significant burden on hospitals and the patients paying for tests. Most of the population pays for any test from a private laboratory out of pocket, which means they often delay getting tested for a long time. Then there’s the lack of notification of results, often no referrals to a specialist, and a lack of GPs training to initiate immediate treatment after diagnosis or to refer the patient to hospitals where a specialist is available to provide treatment. This all causes delays and not only makes the patient’s physical condition worse, but also leaves them in limbo without any help and education to prevent further transmission within their family and community.

What are the challenges of working with blood-borne viruses in SA in the COVID era?

I think the biggest challenge that health services have faced to date has been maintaining services while implementing the required COVID restrictions, such as lockdowns, physical distancing, reducing face-to-face services, and staff shortages due to redeployment, isolating or being ill. That so many health services have met these challenges and embraced new service delivery methods to continue providing services to their clients in such a short time has been incredible.

Now that we are starting to come out of the restrictions era of the pandemic, the next challenge will be getting people back to accessing testing for blood-borne viruses. Since the start of the pandemic, there has been a notable decrease in the number of people accessing testing for these in South Australia. A whole-sector approach will be required to get people at risk of blood-borne viruses to start accessing testing again.

Australia has agreed to targets to eliminate hepatitis by 2030. Do you think this is achievable? What do we need to do to make it happen?

I feel privileged and at ease living in Australia, one of only a few countries with unrestricted access to direct-acting antiviral (DAA) treatments. Over five years, the Australian Government has provided approximately $1.2 billion to fund DAA treatments so that every Australian living with hepatitis C could receive treatment at a low out-ofpocket cost ($39.50 per month or $6.40 per month for concession holders, and no out-of-pocket costs for Indigenous Australian patients).

I believe that by combining prevention and treatment to combat viral hepatitis, the WHO target of 90% diagnosis and 80% treatment by 2030 is achievable. Prevention is a low-cost method and can reduce the rate of new infections.

But it is essential to assess whether the current testing and treatment trend is sufficient to sustain the treatment uptake level required for elimination. I have a few suggestions in mind:

1. Targeted diagnostic and treatment plans for high-risk population groups and high-risk settings may help increase testing and treatment.

2. Point-of-care antibody testing and subsequent RNA testing may reduce the number of patient visits required for a diagnosis in community mental health services, prisons, and opioid substitution therapy clinics.

3. Access to Information and Quality of Care – The patient-doctor relationship is critical, and I believe it would be beneficial to investigate trends in diagnosis and treatment by analysing the prescriptions of different prescribers.

4. Evaluating viral hepatitis-related national and statewide data collection mechanisms may also help assess the current state of data compilation and access mechanisms for seeking expert advice based on data evidence.

5. The use of technology in developing userfriendly mobile applications may be a good option for timely notification, sending testing reminders, and discussing treatment plans with a doctor via the telehealth system.

Thank you, Amber!