world digestive health day 2007 newspaper

8/14/2019 World Digestive Health Day 2007 Newspaper

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The presence o HBsAg aects all age groups.Indices o 10% are common in children under4 years o age. 60% o children were inected byage 10 and markers o inection (anti-HBs) canbe ound in 60% o 14-year-olds. Prior to 1994,7.4% o deaths in the State o Amazonas wereattributed to hepatitis, more than twice thosedue to Malaria (3.3%). The Amazon Brazilianbasin is also a high endemic area or hepatitisdelta virus (HDV) inection, with a prevalenceo 26.9 %, whereas it is virtually non-existent in

the rest o Brazil. Liver cirrhosis due to HBVand HDV inections is one o the ten majorcauses o death in the State o Amazonas.Several actors contribute to the disseminationo HBV in our region. Horizontal transmissionis the main mode o spread. Family contacts, ahigh need or early dental care, early sexualactivity, promiscuity, and poor socio-economicand sanitary conditions all play important rolesin the dissemination o the virus. Vertical trans-mission is surprisingly rare. (continued on next page

Jos Carlos Ferraz da Fonseca,Professor of Federal University of Amazonas, BrazilDepartment of Medicine Tropical and Infect iousDiseases (e-mail : [email protected])

Introduction

In Brazil, inection by the hepatitis B virus(HBV) is a major public health problem,particularly in some areas o the north Amazonregion and especially in the State o Amazonas.

Hepatitis B inection exhibits dierent regionallevels o endemicity (gure 1). In the south andsoutheast regions o the country, the prevalenceo inection is generally low, whereas in thenortheast and the center-western regions, inec-tion rates are intermediate. Beore the programo vaccination, elevated rates o HBV carriage

were ound, principally in the west. In 1998, the

prevalence o asymptomatic carriers o HBsAgin the State o Amazonas was estimated to be16.7% (220,000 carriers).

Eradication of Hepatitis B virus infection in the State of Amazonas

World Digestive Health Day:Viral HepatitisMay 29, 2007

Figure 1. Prevalence o hepatitis B virus in Brazilbased on HBsAg prevalence rates.(Fonseca JCF et al, 1987)

A small village in the rural zone o the Stateo Amasonas, Brazil where HBV and HDVinection are endemic. (J. Fonseca)

ditor: Douglas R. LaBrecque, MDsst. Editor: Molly Donohueesign: Shawn Roach

DHD Committeeenry Cohen (Uruguay)ouglas LaBrecque (USA)

o-Chairmen

ham Mostafa Abdulrehim (Alexandria)amal Esmat (Egypt)ozef Glaza (Slovak Republic)aeed Hamid (Pakistan)aseem Hamoudi (Jordan)zef Holoman (Slovak Republic)eorge Lau (China)usanne Lopes (Portugal)uilherme Macedo (Portugal)asao Omata (Japan)

ushar Patel (USA)hiv Sarin (India)hivaram Prasad Singh (India)

ublished by theorld Gastroenterology Organisation

ww.worldgastroenterology.org

DHD has been endorsed by:ociacion Interamericana deGastroenterologia (AIGE)

ternational Association for theStudy of the Liver (IASL)

rican Association for the

Study of Liver Diseases (AfASLD)EALS of the Southational Coalition of STD Directorse Hepatitis C Caring AmbassadorsProgram

e Hepatitis C Truste Hepatitis Support Associatione Title II Community AIDS National Network

is newsletter received unrestricted supportom Concordat members Alcona/Nycomed andympus as well as Schering-Plough


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Strategies to control Hepatitis B infection in theState of Amazonas, Brazil.Based on this inormation, we devel-

oped a project to control HBV inectionin the State o Amazonas in September1987. This project was supported bythe Brazilian Ministry o Health and

Amazonas Government. The authorso this Project were: Jos Carlos Fer-raz da Fonseca, Leila Melo Brasil and

Wornei Miranda Braga (researchers othe Fundao de Medicina Tropical do

Amazonas). Strategies were based onrecommendations made by the ViralHepatitis Consultative Commission othe Ministry o Health, Brazil. In 1988,

our rst task was to develop a programwhich educated local populations livingin 11 hyperendemic areas about thebenets o immunization. The program

was implemented in two phases.Phase I In hyper-endemic areas o HBVand HDV inection, including the ruraland urban populations o 11 counties,all children 0 to 9 years old were vac-cinated (without previous screening).The target group included 27,893 inurban areas and 56,127 in rural areas.

In Phase II, vaccination was graduallyextended to the remaining counties othe western Amazon region, vaccinatingchildren 0-4 years o age.

Following these campaigns, vaccinationwas targeted toward: a) all newborns(integration o the vaccine into theNational Programme o Immunization);b) immigrants to the north Amazonarea; c) all health care providers;d) multi transused patients; e) chronicrenal disease patients undergoing dialy-

sis; ) Hansens disease patients;g) institutionalized (high risk patients);i) those o Asian origin; j) militarypersonnel; k) indigenous populations;l) householders o HBsAg positivepeople; m) high risk groups (malehomosexuals, sex workers, intravenousdrug abusers).In October, 1989 (urban area), the vac-cination program against HBV inec-tion was initiated, using three doses,

10 mcg recombinant DNA hepatitis Bvaccine, on a 0, 1, 6 month vaccinationschedule. In January, 1990 the program

was extended to the rural areas. Parallelto this special program, we conducteda pilot study to evaluate the immuno-genicity o two dierent doses (10 mcgand 20 mcg) o this vaccine in the vil-lage o Codajs (Solimes River, State o

Amazonas), an HBV and HDV hyperen-demic area.

Ater one year this special programwas extended to 14 municipalities inthe State o Amazonas, along with theinitiation o the vaccination program

among health workers. During 1991, thevaccination program covered all chil-dren rom 0 to 4 years old living in the60 municipalities in our area. In 1992the vaccine against HBV inection wasintegrated into the Regional Program oImmunization o the State o Amazonas,Brazil. HBV vaccination was incorpo-rated into the National Program oImmunization in 1995, including PublicHealth workers and high risk groups opatients.

Results of hepatitis B vaccination programin the State of Amazonas, BrazilIn the rst year, coverage o HB vac-cine (special program) was extremelyhigh with an estimated 82,020 children

vaccinated. 97.5% o the target popula-tion received the rst dose, 89.6% thesecond dose and 78.1% the third dose.

Four years ater the start o vaccination,the percentageo seroconver-sion (anti-HBs

> 10 IU/l) was79% (10mcg)and 95,2% (20mcg), p


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Every year on May 29, the World Gastroenterology Organisation celebrates World Digestive Health Day in order todraw the attention o the global medical community to an urgent and overlooked world health issue. In 2007, we will spot-

light viral hepatitis. Almost 400 million people are chronically inected with hepatitis B, and about 200 million are chroni-cally inected with hepatitis C; together, these diseases are responsible or the majority o hepatocellular cancer cases, thethird leading cause o cancer death worldwide. A number o projects are planned or World Digestive Health Day 2007:Viral Hepatitis. We thank the members o the WDHD committee and the multiple authors and national societies who havecontributed to the many projects listed below.

WDHD NewsletterThis newsletter is intended to put a human ace on viral hepatitis. It will be distributed during Digestive Diseases Week 2007and on the WGO website. This publication tells the story o hepatitis in various countries around the world, ocusing onproblems in individual countries and eorts to solve them. We have gathered and edited articles and photographs thatprovide an overview o the current state o hepatitis around the world and approaches that are being taken to address thisproblem in various countries. In some cases the articles had to be abridged slightly to t our ormat. Reerences and somepictures were also edited but will be included when the articles become available on the WGO website. In toto, the variousauthors provide a remarkable picture o this major public health problem and the need to attack it aggressively.

Hepatitis B GuidelineIn May 2007, WGO will release a new Hepatitis B Guideline which will be distributed on the website and at UEGW 2007(and possibly AASLD 2007) in pocket ormat. This guideline will be developed using our cascade technique, whichprovides recommendations or management and treatment, regardless o what resources are available. The Project Teamworking on this guideline is chaired by Proessor Jenny Heathcote and includes a group o world-renowned hepatologistsrepresenting all regions o the globe.

Hepatitis VademecumA compendium o the most important, reely accessible articles on viral hepatitis has been compiled. The list will be distrib-uted at our booth during DDW and is available on the WGO website.

National Member Society activitiesWGO member societies have answered the call to organise events on WDHD. A variety o additional activities related to

World Digestive Health Day 2007: Viral Hepatitis will thereore take place around the world as organized by local membersocieties.

We believe these projects are absolutely essential to publicize and educate the global community about the importance,prevalence and care o hepatitis. World Digestive Health Day is an important global educational event that has the power toimprove the quality o lie or millions o patients worldwide. We look orward to the active participation and support o our99 member societies and almost 50,000 individual members, as well as national and regional societies, government bodiesand industry.

World Digestive Health Day 2007Viral Hepatitis

Henry Cohen, MDSecretary General, WGO

Douglas R. LaBrecque, MDTreasurer, WGO

W O R L D D I G E S T I V E H E A L T H D AY : V I R A L H E P A T I T I S 3

Co-chairmen World Digestive Health Day


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4 W O R L D D I G E S T I V E H E A L T H D AY : V I R A L H E P A T I T I S

Shivaram Prasad Singh, MBBS, MD, DMHead, Department of Gastroenterology,

S.C.B. Medical College,CUTTACK 753007,Orissa, INDIA.

Hepatitis B virus [HBV] is probably themost important chronic viral inectionaecting Indians. However, despite thedevelopment o an eective vaccineagainst HBV, this inection remainsa serious threat to public health inIndia. Several studies rom India havereported a HBV prevalence rate o 3%to 6%. However, these data are known

to underestimate the prevalence ochronic HBV Inection or a numbero reasons. India has a population o

approximately 1000 million today, andassuming a lower prevalence rate o

3%, India still harbors approximately30 million HBV carriers. HBV is a lead-ing killer among all inectious agents,and a modest estimate would put thenumber o deaths occurring due toHBV inection per year in India to bearound 100,000.

HBV is responsible or about 68% ocirrhosis o the liver, and 80% o hepa-tocellular carcinoma in India. In spiteo the act that HBV is a major killerin India and the inection is easily

preventable, its a shame that this killeris allowed to continue its deadly attackon the Indian population. A deci-

sion-analytical model estimates that inIndia, vaccination would save 25 lives

per 100,000 population per year. Howlong can this be allowed despite thetremendous strides made in the eld oHBV prevention?

Control o Hepatitis B inection by vac-cination is now within our grasp, andelimination o HBV inection has con-sequences ar beyond the prevention oacute disease. Hence, it is very unor-tunate that very little is being donein India to contain this continuingcarnage. Compare this with the AIDS

scenario and the contrast is striking.Diagnosis o a ew cases o AIDS is su-cient to make headlines in this part o

Hepatitis B Eradication Day: Its Never too Late !!


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W O R L D D I G E S T I V E H E A L T H D AY : V I R A L H E P A T I T I S

tion is deprived o the benets o theseadvances partly due to the high costsinvolved, but also to a large extentdue to a lack o commitment on thepart o the health delivery system. The

later not only includes the governmenthealth care machinery but also thedoctors. Doctors have ailed to moti-vate the government to evolve steps tocontain the killer at large. The medicalcommunity has done little to use themedia to educate the public about thesilent killers other than HIV whichare lurking around in the dark. Thehapless victims continue to remain illinormed and ill prepared to deendthemselves.

Its time we act and take appropriatemeasures to remove the darkness bygenerating public awareness about di-erent aspects o the disease, includingthe preventive aspects, and arrest thekiller by evolving and adopting theoptimum strategies or preventing viralhepatitis B. We must enlighten andconvince the government holisticallyabout the magnitude o the problemso viral hepatitis and the need to in-

clude hepatitis B vaccination in Indiasimmunization program straightaway asper WHO recommendations.The steps taken by the Kalinga Gastro-enterology Foundation in this regardare laudatory. The Kalinga Gastroen-terology Foundation [KGF] has beenobserving Hepatitis B Eradication Dayevery year on 28 July [since 2001], thebirthday o Nobel Laureate Pro BSBlumberg who discovered the Hepati-tis B Virus and developed the rst vac-cine against Hepatitis B. The two apexbodies in the eld o Gastroenterology

and Liver diseases in India, the INDI-AN Society o Gastroenterology [ISG]& Indian Association or Study o theLiver [INASL] have also come togetherand have been organizing HEPATI-TIS B ERADICATION DAY on 28thJuly. This has boosted the campaignto educate the public about HepatitisB and to spread the message o thenecessity o vaccination or Hepatitis Bto eradicate the killer inection. ComeJoin the War against Hepatitis B. Togenerate greater awareness amongst

the masses and to give the HepatitisB Eradication Movement a much-needed stimulus, Hepatitis B denitelydeserves a day dedicated to this cause.Gastroenterologists and hepatologistsall over the world are exhorted to jointhis ght and join us and prevail uponothers to observe 28th July as HEPATI-TIS B ERADICATION DAY. It is nevertoo late !!

the world while thousands o patientswith severe liver disease due to thisviral inection languish and die withouta squeak. Special cells have been setup in dierent parts o the country to

monitor and check AIDS and regularworkshops are organized with undsfowing in abundance to take care othese activities.

Hepatitis B and its sequelae occurpredominantly in young people, whichposes a high and avoidable economicburden on society and a pathetic wasteo precious human capital. Unortu-nately, the vast majority o researchersand healthcare proessionals workingin this area are just busy computing

the prevalence o dierent viral mark-ers in dierent subsets o patients andtreating the afuent minority afictedwith this inection .The vast majoritycannot aord the costly medical treat-ment and the State does not und thetreatment o the poor who are afictedwith this inection. Thus, despite allthe advances made in serodiagnosis,vaccines and treatment o HBV inec-tion, a large proportion o the popula- Budhia Singh, the amazing marathon runner, agging off the

Hep B Awareness Rally on Hep B Awareness Day.


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By Gamal Esmat, MD andMaissa El -Raziky, MD, Cairo University

In Egypt, schistosomiasis was tradition-ally the most important public healthproblem and inection with Schistosomamansoni was the major cause o liver dis-ease. The story o viral hepatitis in Egyptdates back many years and is closely tiedto that o Schistosoma mansoni. A newportion o the story is revealed everytime a serological marker or a new virusthat causes hepatitis is discovered.

Enterically Transmitted Viral Hepatitis

Hepatitis A: Hepatitis A viral inection(HAV) used to be a universal childhoodinection. Earlier studies in childrenbelow 10 years o age revealed 98-99.8%seropositivity or previous HAV inec-tion. In this age group the disease isusually mild and passes unnoticed orproduces minimal symptoms and abenign, uncomplicated, short course.During the past decade an age shit oHAV inection was documented due toimprovement o sanitary environmentalconditions. HAV now requently inectsadolescents and young adults result-

ing in a prolonged disease course andcomplications. This age shit warrantsthe use o hepatitis A vaccine in certaingroups on an individual basis, but it isnot included in the compulsory vaccina-tion program.

Hepatitis E: The epidemiology o hepa-titis E virus (HEV) is not ully under-stood. Prevalence o HEV antibodiesin rural Egyptian communities is veryhigh, reaching 70% in some locations.However, cases o HEV-caused jaundice

and liver disease are rare and the severeacute hepatitis documented elsewhereas occurring with high requency inpregnant women has not been reported.Reasons or the lack o clinical hepatitisremain unclear but it could be attrib-uted to early childhood HEV expo-sure, producing long-lasting immunityand/or modiying subsequent responsesto exposure. Alternatively, the predomi-nant HEV strain(s) in Egypt may be less

virulent than those ound in South Asia.

Parenterally Transmitted Viral Hepatitis

Hepatitis B and C (HBV, HCV) are, and

will remain or some time, major healthproblems in Egypt. Both inections canlead to an acute or silent course o liverdisease, progressing rom liver impair-ment to cirrhosis and decompensatedliver ailure or hepatocellular carcinoma(HCC) over a 20-30 year period. Prog-nosis may be worse with schistosomiasiscoinection.

Hepatitis B: The preva-lence o HBsAgdecreased rom 10%

in the 1980s to ap-proximately 3% in thelast decade. This co-incided with a declinein the relative contri-bution o HBV to thedevelopment o HCC.Blood bank screening,using sterile needlesor injection, and thecompulsory vaccina-tion o newbornsimplemented in 1993,are the main preven-

tive measures undertaken to reducethe risk o inection. However, HBV isstill responsible or about 30% o adultpatients presenting with acute viralhepatitis.

Hepatitis D: Also known as Delta inection,HDV accompanies HBV as a co-inectionor as a super-inection. It was ound in asmany as 10% o chronic HBV patients.Delta inection oten worsens the out-come in these subjects.

Hepatitis C: While not identied until 1989,the hepatitis C virus has been aroundor a very long time. Many inectedpeople do not know that they have the

virus because it is usually asymptomaticand the symptoms o complications maynot show up or 20 to 30 years. Fromthe 1950s until the 1980s, the EgyptianMinistry o Health undertook large cam-paigns to control schistosomiasis usingintravenous tartar emetic, the standardtreatment or schistosomiasis, as com-

munity-wide therapy. This commendableeort to control a major health problemunortunately established a very large

reservoir o HCV in the country. It is be-coming a daily scenario in medical prac-tice that a young person unexpectedlydiscovers the presence o HCV inectionduring his pre-employment screening.

As a result, all his plans, priorities andquality o lie are changed.

Egypt has a population o 75 millionand contains the highest prevalence o

hepatitis C inthe world. Thenational preva-

lence rate oHCV antibodypositivity wasestimated to bebetween 10-15%in1996. Geno-type 4 repre-sents over 90%o HCV casesin Egypt. Since30-40% o indi-

viduals clear theinection shortlyater exposure,

based on national studies and villagestudies in Egypt, the estimated adjustednational prevalence rate o chronichepatitis C inection is 7.8% or 5.3 mil-lion people. Only one third o these in-dividuals (2.5-3 million) are estimated tohave chronic liver disease; among them,700 thousand subjects will develop livercirrhosis and 140 thousand HCC.

In spite o practicing screening o bloodor transusion and using sterile, dispos-able needles, the prevalence o HCV in

those under age 20 is still approximately5-8%, demonstrating the continuedpresence o signicant inapparentmodes o hepatitis C transmission inEgypt.

The availability and cost o treatment orhepatitis C in Egypt is quite prohibitive.But the Ministry o Health is implement-ing a health care insurance program toreduce the cost o therapy to one thirdo its initial price.

Viral Hepatitis and Schistosomiasis in Egypt

6 W O R L D D I G E S T I V E H E A L T H D A Y : V I R A L H E P A T I T I S


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possible treatment. WDHDis a abulous opportunity or

us to help raise much-neededawareness about hepatitis C.Recognizing that hepatitisC knows no boundaries andaects people o all ages,races, and ethnicities, HC-CAP conducts educationaland awareness activities ina variety o venues, with arange o ormats, and diering targetaudiences. For example, HCCAP has

worked closely over the years with themarketing club (DECA) o RobinsonHigh School in Fairax, Virginia. WithHCCAPs help, DECA has conductedhepatitis C awareness campaigns in the

Washington, D.C. area that includeda rally on the steps o the Capitol (seephotos). Together, HCCAP and DECA

were successul in getting a Congres-sional hearing with the House Govern-ment Oversight and Reorm Committeeto review the ederal response and gapstherein with respect to a national strat-egy and initiative or hepatitis C controland prevention. HCCAP has also beeninstrumental in urging the introductiono ederal legislation during the pasttwo Congressional sessions, and will be

working hard through the current ses-sion or the reintroduction and passageo the Hepatitis C Epidemic Controland Prevention Act.

HCCAP is alsothe editingbody and pub-lisher o thebook, Hepati-

tis C Choices.The bookis a patient-oriented textthat com-prehensivelyaddresses notonly hepatitisC manage-ment choices,but also issueso day-to-day

living that challenge those with hepatitisC. Although the book was conceivedand written or a patient audience, it isin high demand by many in the publichealth community, and among primaryand mid-level practitioners. In 2005,HCCAP distributed nearly 7,000 copieso Hepatitis C Choices to clinics andpublic health agencies in 35 states.Hepatitis C Choices is available elec-tronically ree-o-charge on HCCAPsinternet site at www.hepcchallenge.org.HCCAP will be conducting many specialevents and activities, and collaborat-ing with the more than 20 memberorganizations o the National HepatitisC Advocacy Council throughout themonth o May to draw attention to themagnitude o the hepatitis C problemand to raise public awareness. Our pri-mary goal is to have the general publicunderstand enough about hepatitis C tobe able to sel-identiy as possibly havingbeen exposed so that they are able toseek counselling and testing, notedDr. Tina M. St. John, Executive andMedical Director o the Caring Ambas-sadors Program. We have an obligationto educate people about the potential

sources o exposure to hepatitis C, toprovide them the opportunity to availthemselves o the treatments available, ineeded.

Distribution o educational materials,spot advertising, and internet-basedactivities will round out the HepatitisC Awareness activities. Log-on to www.hepcchallenge.org or the latest updates onHepatitis C Awareness Month activities.

Tina M. St . John, MD for the Hepatit is CCaring Ambassadors Program,a division of the Caring AmbassadorsProgram, Inc.

Hepatitis C is the most common, blood-borne chronic viral illness in the UnitedStates, with 1 in 50 persons alreadyinected with the virus. The diseaseburden o chronic hepatitis C among

Americans is three to ve times that oHIV/AIDS. Despite the enormity o theproblem, nongovernmental organiza-tions are conducting the yeomans shareo hepatitis C education eorts.

The Hepatitis C Caring AmbassadorsProgram (HCCAP) has been at the oreo hepatitis C inormation, education,and advocacy eorts since 1999. Anational nonprot organization, HC-CAP is involved in numerous activitiesthroughout the country each year, allto accomplish the mission o improvingthe health and longevity o people living

with hepatitis C.

We are thrilled that WGO has selectedhepatitis as the ocus o World Digestive

Health Day 2007, said Lorren Sandt,Program Manager o HCCAP. Withall o the resources we are so ortunateto have in the U.S., it is truly mind-bog-gling that an estimated 75% o Ameri-cans with hepatitis C have yet to bediagnosed let alone be evaluated or

C the Problem: Be Part of the Solution


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atrics and Internal Medicine. SeveralTV programs, popular journals and

magazines, regularly address HepatitisC. Also some patients organizations(like SOS Hepatitis) bring the generalpublic close to the experts and opinionmakers on these topics.

The viability o creating a NationalStrategy Plan or Prevention andControl o Hepatitis C is now underdiscussion. This ambitious plan standson the tripod o quality inormation,reinorced prevention and cost-eec-tive treatment modalities. It intends to

coordinate the eorts o many soci-ety groups, including health relatedauthorities, Scientic Societies beyondthe conventional Gastro/HepatologyAssociation, Pharmaceutical Compa-nies, Patient Organizations, and, ocourse, Politicians and the Media.To underline WDHD 2007, severalactivities are being designed, and willinvolve many o the Portuguese opin-

ion leaders on viral hepatitis. HepatitsC and Hepatitis B will be specically

addressed in the National Congress oGastroenterology and Hepatology inearly June. Several hospitals will pro-mote a social event based on HepatitisAwareness Day. Pharmaceutical Com-panies will actively support the logisticsor nationwide TV/radio interviewsthroughout the week. The ocus willbe a massive inormation campaignoriented to the general public, bring-ing together the patients and healthproviders in an integrated collabora-tion and cooperation.

May 2007 will make a dierence inPortugal. It will improve the level oknowledge about viral hepatitis. Doc-tors, Public and Health Authorities willbe challenged to recognize their ownrole in the noble task o improving thequality o lie o each and every one inany part o world.

1970s. Mass vaccination programs,or prophylaxis in Portuguese troops

going to Arica, did not use dispos-able needles, and tattoing was alsocommon, sharing the devices. Also,in the wake o the 1974 PortugueseRevolution, almost 1 million peoplereturned rom Arica, and youth pro-test movements included the adoptiono high-risk behaviors such as sporadic(today orgotten) intravenous druguse. Furthermore, bizarre medicalpractices such as intravenous gamma-globulin use or immune strengthor as memory inducers, and intra-

venous calcium or chronic astheniaand tetany, without proper asepticuse o needles and syringes, may havemade a signicant contribution to theestimated 150,000 people inected (ina l0-million population).Until now, 2 major National Consen-sus Meetings adressed Hepatitis C.Guidelines were published, specicstandards and management rules wereset, diagnosticand therapeuticprocedures wereimplementedbased on thoserecommenda-tions, supportedby the PortugueseAssociation orthe Study o LiverDiseases, Portu-guese Society oGastroenterol-ogy, and Min-istry o Health

Representatives.Those consensusdocuments werewritten by largecommittees, in-cluding relevantscientic societiesbeyond Gastroen-terology, includ-ing InectiousDiseases, Pedi-


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1 0 W O R L D D I G E S T I V E H E A L T H D AY : V I R A L H E P A T I T I S

Prof. Jozef Holom, MD, PhD, President,Slovak Society of Hepatology

Assoc. Prof. ubomr Jurgo, MD, PhD, Presi -dent, Slovak Society of GastroenterologyAssoc. Prof. Jozef Glasa, MD, PhD, Scient ificSecretary, Slovak Society of Hepatology

For more than 20 years, the problemo viral hepatitis in the Slovak Re-public (SR), has been dealt with in acomplex, comprehensive manner. Astep-by-step development o a system omanagement and care or liver patients,including those with viral hepatitis, hasbeen successully coupled with institu-

tional developments by the proessionalscientic societies o the Slovak Medical

Association (SMA) The Slovak Societyo Hepatology and the Slovak Society oGastroenterology taking the lead, andspecialized institutions responsible orsetting up and auditing the standardso prevention, diagnostics and therapy.These are designated the nationalreerence centres (NRCs): The NRC orManagement and Therapy o ChronicHepatitis (clinical aspects, therapy) andThe NRC or Viral Hepatitis (laboratory

diagnostics).

The NRCs are active in developingnational guidelines or therapy and di-agnostics o viral hepatitis (VH), as wellas the principles o necessary ministe-rial regulations or recommendations.The rst such guidelines were issued asa consensus document in 1998 ap-proved jointly by the relevant scienticproessional societies o SMA (hepatol-ogy, gastroenterology, and inectious dis-eases), ministry o health, and the insur-

ance companies. The actual guidelineswere published in November (hepatitisB) and December (hepatitis C) 2004.The ministerial regulation on diagnos-tic, preventive and ollow up measuresin hepatitis A D in was developed in2000 (pending actualization in 2007).Specic standards and procedures omanagement and care or VH patientssteming rom particular risk groupsare being developed and implementedsince 2005 (intravenous drug users,

prison inmates, health workers, positiveblood donors). The consensus mannero approval o the national guidelines

and recommendations provides also orull nancial coverage o the preventive,diagnostic and therapeutic measures(agreed as being the standard ones) bythe health insurance companies. Theyare also used in the health care qualityauditing and inspection procedures bythe relevant state authorities, and bythe authorised health care providersthemselves.

Comprehensive care or patients with vi-ral hepatitis is then provided by special-

ized hepatology centres approvedboth by the state health policy(the Ministry o HealthSR), and all health insur-ance companies operat-ing in SR (14 centres orthe country o about 5.5 millioninhabitants, prevalence o HBV about0,3 0,5 %, HCV about 0,5 0,7%).The broadest public access to the rel-evant scientic, health related inorma-tion is ostered by a ree telephone helpline (established in 2005), as well as by

an appropriate involvement o media(especially TV, radio, popular journalsand magazines). In 2006, a nation wideinormation campaign oriented to thegeneral public was successully com-pleted. More recently, special attentionhas also been paid to specic activities symposia or meeting the experts

workshops devoted to the general pub-lic, especially in regions with a higherprevalence o VH. Those are to deal

with the local problems, including thepsychological and health policy issues,

brought about by the higher prevalenceo VH in those communities. In 2006,an independent organization o patients

with viral hepatitis was established tocomplete the system rom the side othe users.

The system, as described, allows orspeedy update and harmonization onationally implemented standard pro-cedures and practices as detailed in theapproved guidelines, regulations, or rec-

ommendations. It will be supplementedby an ocial national program, as a parto the comprehensive National program

on prevention o chronic liver diseases,to be launched in the SR in 2007.

Activities Planned in the Slovak Republic on theOccasion of the WDHD 2007WDHD 2007, devoted to the problemso VH, presents an opportune occasionor urther development and renemeno the system o VH management in theSR, especially with regard to its integra-tion into the comprehensive Nationalprogram. It should urther strengthenand deepen the collaboration o the key

players in VH manage-ment mentionedabove, and give the

problem necessaryprominence and momentum at th

public and political level. It should alsomaintain the high ethical standards setup years ago in the SR concerning thenecessary academic industrial cooperation.

To mark WDHD 2007,the ollowingspecial activities are planned in the SR,

organised in close collaboration andmutual support by the Slovak Societies oHepatology and Gastroenterology whoare taking the lead among other relevanstake holders:1. Special program on VHs during

the annual national congress ohepatology (May 24 26, 2007),

2. Monothematic working day o theSlovak Society o Hepatology(December 2007),

3. Publication o the new MinisterialRegulation on Diagnostic, Preventive

and Follow-up Measures in ViralHepatitis (estimated May 2007),

4. Launch o the National Program onPrevention o Chronic Liver Diseases(second hal o 2007).

It is believed that these activities, whilebuilding on the progress and goodresults achieved so ar, will make a strongcontribution toward urther improve-ment in the quality o the patient oriented care o VHs in Slovakia.

Systemic Approach to the Problem of Viral Hepatitis in Slovakia


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Evidence supporting the role o largeamily size in increasing the risk o HBV

inection came rom the observation opronounced amilial clustering o HBVinection in Jordan. A signicant cor-relation was ound between amily sizeand the proportion o HBsAg positiveamily members.In addition, there was asignicantly greater HBsAg prevalencein the lower (14.4%) than the upper(2.4%) socioeconomic classes. Anotherstudy showed the prevalence o HBsAgto be 11% and 4% respectively amongstlow and high socioeconomic groups?

From the early eighties o the last cen-tury, Jordan applied blood screeningor HBsAg and disposable needles andsyringe use. In addition, close monitor-ing or adequate sterilization o surgicalequipment and instruments are prac-ticed. Universal inant immunizationbegan in 1995 as a combined eort othe Friends o the Liver Patients Societyin Jordan and the Ministry o Health.The vaccination coverage o the popula-tion has been good overall (90%) or allrecommended doses by 1 year o age.In 2001, Jordan introduced vaccinationtargeted at high-risk groups. It is impor-tant to mention that all the vaccinationcosts, tests and treatment or inected

patients are ree o charge and coveredcompletely by the Ministry o Health.

Toukan et al. estimated that HBV inec-tion might account or up to 2% o alleventual deaths in the Middle East birthcohort. In addition, there is a higherprevalence o HBsAg in patients withchronic liver disease (54%) than inasymptomatic carriers (10%). In Jordanintra country dierences have been at-tributed to socioeconomic status.

Our biggest hurdle in combating thisdisease is inorming the public that thisdisease is not a catastrophe per se, but

ignorance and not acing the truth thatJordan is a high endemic country re-garding HBV prevalence is the problem

Also teaching methods o prevention,vaccinating the partners and contacts isanother problem.

In Jordan people ear this disease, andpatients, when is told that they areinected try their best to hide this romrelatives and contacts, not changingtheir way o lie, and thus risking inec-tion o more individuals.

In the uture, we plan to screen all preg-nant women or HBV and include theHBV test in the prenuptial tests.

Dr. Waseem HamoudiGastroenterologist & Hepatologist

Celebrating the WDHD on May 29, 2007with the title o hepatitis B is importantto us because the people o the MiddleEast generally and Jordan especiallyhave an intermediate to high endemicityo HBV inection.

The majority o countries in the MiddleEast have intermediate or high endemic-ity o chronic carriers. Jordan is consid-ered a high endemic area with a preva-lence o around 2.6-10%.

Studies showed higher rates in the com-munity based studies than in studiesconducted amongst blood donors. Inaddition, they showed signicant dier-ences in carrier rates between villages,ranging rom 5.7% in one village to12.8% in another.

In the Middle East, the majority oinections occur through childhood andperinatal transmission. Toukan et al.suggested that person-to-person non-sexual, non-parental and interamilialcontact was the major mode o transmis-sion between asymptomatic HBV carri-ers and susceptible individuals.

Thereore, HBV inection and carrierstatus in Jordan is associated primarily

with perinatal transmission, amily size,socioeconomic status, and educationalstatus, history o previous blood transu-sion, surgery or contact with a jaundicedperson.

Jordan and Hepatitis B Virus, Do We Have to Worry?


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Dr Eduardo FassioHospital NacionalProf. Alejandro PosadasEl Palomar, Buenos Aires, [email protected] A (HAV) and hepatitis E(HEV) are both enterally transmittedbut there are some dierences betweenthem: HAV is mainly transmitted romperson to person via the ecal-oral route

with a high secondary attack rate; HEVinections are mostly due to ingestion ocontaminated water or ood. Recently,some studies have proposed that zoo-notic ood-borne transmission o HEV

through the ingestion o undercookedpig liver or intestine may play an impor-tant role. Both HAV and HEV cause sel-limited inections and are not respon-sible or chronic hepatitis cases. In Latin

America (LA), the burden o diseaseproduced by HAV and HEV inectionsis very dierent: HAV prevalence is veryhigh and studies in the 80s have shownanti-HAV seroprevalence greater than90% in voluntary blood donors in mosto countries, while anti-HEV rangesrom 1.2 to 8% in studies rom Uruguay,

Cuba, Argentina, Brazil and Chile.Recent studies have identied a shitrom high to moderate endemicity oHAV inection in LA countries, second-ary to improvements in sanitary condi-tions in urban regions. This means thatmost inections are not occurring in therst years o lie but in late childhood,adolescence or in young adults. As aconsequence, the incidence o hepati-tis A is lower than previously but morecases are now symptomatic and severe.In act, hepatitis A is the main etiologyo ulminant hepatitis in children, caus-ing 64, 71 and 83% o cases in Argen-tina, Chile and Brazil, respectively. Inthis setting, with high prevalence o the

virus and many susceptible individualsin the population, hepatitis A becomesa public health problem and universal

vaccination policies should be imple-mented.In contrast, prevalence o anti-HEV indierent populations rom LA is low,although it is always a bit higher in

people with poor socioeconomic condi-tions, like the Araucanian indians in

Chile (17%) or in rural Amerindians inVenezuela (5.4%) . Among 170 hospitalemployees studied in Campinas, Brazil,prevalence was signicantly higher incleaning service workers (13%) thanin proessionals (3%) Clinically, HEVhas been the etiologic agent in 9% o93 non A, non B, non C acute hepatitiscases and in 9% o pediatric ulminanthepatitis cases o unknown etiology in

Argentina.

Hepatitis B (HBV) has a heterogeneousdistribution around the world with areas

o high, intermediate or low endemicity.Most o countries in LA are included inthe last group (HBsAg seroprevalencelower than 2%). In Central America(CA), the Dominican Republic, Hondu-ras and Haiti have a moderate preva-lence (HBsAg rates o 4.1, 3 and 2.7%,respectively). In SA, there is a reservoiro high endemicity in the Amazon Basin(that includes areas rom northwesternBrazil, Peru, Colombia and Venezuela)

where the prevalence o chronic carri-ers ranges rom 5 to 15% (see separate

artilcle by Proessor Fonseca concern-ing HBV in Amazonia). In these rural,aboriginal populations, most o the in-ections occur in the perinatal period orduring childhood. Thus, an impressiveanti-HBs rate o 70% has been shown inthose younger than 20 years o age inthe Amazonia state in Brazil; anti-HBcrate was 66% among children aged 1-4

years in the Upper Orinoco Basin. Incontrast, in the other countries, most othe inections occur in young adults whousually do not become chronic carriers.In these low prevalence areas, the mainroute o inection is sexual transmission.In Argentina, where the HBsAg ratein blood donors has been consistentlybelow 1%, HBV causes approx. 15% oulminant hepatitis in adults and 18%o chronic viral hepatitis. PredominantHBV genotypes in LA are F and H.

Hepatitis D (HDV) is a deective virusthat only replicates in HBV carriers.There are in LA 2 well dierentiatedareas: in most countries o SA, HDV

prevalence is negligible while in theAmazon Basin anti-HDV is ound in24-34% o asymptomatic HBsAg carriersand the percentage may be much higherin chronic hepatitis B cases.

Anti-HCV is present in 0.5-1% o blooddonors in LA and hepatitis C (HCV) isthe main cause o chronic hepatitis inurban areas o Mexico, Chile, Argentinaand Brazil. In Argentina, HCV was theetiology in 82% o 1219 chronic viralhepatitis cases (Sentinel Units Reports,2000-2002). Among 701 cases at ourhospital, median age 43 years, male:emale ratio 1.6, a history o intravenousdrug use was the main risk actor or

inection (35%) but there were dier-ences between genders: IDU was presentin 50% o men and in 13% o women

while a history o blood transusionwas present in 10% o men and 35% owomen. Hepatitis C is also the rst etiol-ogy among adult patients on the waitinglist or liver transplant in our country.Furthermore, a retrospective studyound that chronic alcoholism and HCV

were the 2 main causes o cirrhosis (ap-prox. 40% each one) among 507 caseso hepatocarcinoma. Prospective studies

on the etiology o hepatocarcinoma arelacking in Latin America. Genotype 1is ound in more than 60% o cases inBrazil, Argentina and Venezuela.

Viral Hepatitis in Latin America

1 2 W O R L D D I G E S T I V E H E A L T H D AY : V I R A L H E P A T I T I S

CUBA

COLOMBIA

PERU

BOLIVIA

CHILE

MEXICO

BELIZE

HONDURAS

NICARAGUAEL SALVADOR

GUATEMALA

COSTARICA

PANAMA

SURINAME

TRINIDAD ANDTOBAGO

REPUBLICDOMINICAN

JAMAICA

PARAGUAY

B R A Z I L

GUYANA

URUGUAY

ECUADOR

ARGENTINA

VENEZUELA

HAITI PuertoRico


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hepatitis A. Ironically, this is likely dueto improvements in our socio-economicstatus.

Hepatitis E has been reported in Kenyaamongst reugees in the northeasternpart o the country. It may be the causeo some undiagnosed cases o hepatitis.Hepatitis D (delta) has a prevalence o40% in hepatitis B cases.Hepatocellular carcinoma is a commonproblem due mainly to hepatitis B. Itpresents in very young people and has a

very rapid course. As elsewhere there isno successul treatment. The only hopeis vaccination against hepatitis B whichprevents inection with the virus. This

vaccine has been incorporated into theexpanded program o immunization.

We hope hepatocellular carcinomaprevalence will reduce in the uture asa result o this intervention. Dr. Fred Okoth

HBV/HCV/HIV coinfection in KenyaSince the start o the HIV epidemic,cases o viral hepatitis presenting inpatients with chronic HIV inection arebecoming common. HBV/HIV coinec-tion is currently the bigger problem

with various reports giving prevalencerates rom as low as 4% to as high as

40%, depending on the groups in-cluded. The impact o this coinectionon either disease is still being studied,although cases o ulminant disease areon the increase. With increasing re-ports o lamivudine resistance, this hastreatment implications leading to use onon rst line backbones including drugslike tenoovir and emitricitabine.Unlike in the West, where HCV is thecommonest hepatitis virus in chronicHIV disease, it remains quite low in theindigenous Kenyan. Most o the patients

seen locally come rom neighbouringcountries like Somalia, Ethiopia andRwanda. The commonest genotype inthese patients and the ew Kenyans istype 4, which has obvious treatment im-plications. Pegylated intereron alphaand ribavarin are available and havebeen used in a ew o these patients.Final response rates are eagerly awaited.

Dr. Godfrey Lule

Viral hepatitis in KenyaKenya is in the high endemicity zoneor hepatitis B virus with a carrier rate o>8%. Studies carried out in the early 80srevealed a prevalence o >10% amongstblood donors. However, with the onseto the HIV pandemic in mid 1980sand subsequent changes in the pat-tern o blood donors, the prevalence ohepatitis B virus has dropped to about4% as high risk donors are avoided. Theprevalence o chronic liver disease dueto hepatitis B during the same period,however, has remained constant.Hepatitis C virus is not common in Ke-nya. A prevalence o


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Saeed Hamid, Hasan Hamza*, Wasim Jafri ,Khalid Pervez+, Anwar Siddiqui^.

Departments of Medicine, FamilyMedicine* and Biomedical Sciences^,Aga Khan University, Karachi, and HANDS+,Landhi, Pakistan.

Pakistan is considered an area o inter-mediate endemicity or hepatitis B virus(HBV) and hepatitis C virus (HCV) in-ections. However the burden o diseaseis thought to be much higher in someareas o the country, assuming epidemicproportions. We sought to determinethe prevalence o HBV and HCV in a

peri-urban area o Karachi, where localexperience had suggested prevalence

was high, and to identiy associated riskactors in this population.

A cross-sectional survey was conductedto cover an estimated 59,000 adultsrom the selected areas. A systematicrandom sampling strategy was adoptedto include every 5th household. Trained

workers obtainedwritten inormedconsent rom 2219

individuals. A pre-tested questionnaire

was administeredand blood samples

were analyzed orHBsAg and HCVantibody using 3rdgeneration ELISA(ABBOTT).

Preliminary analy-sis o 1963 subjectsound the ollow-

ing: mean age was30 13 years, 32%

were males, averagemonthly householdincome was 80 USdollars, almost all be-longed to one o thetwo ethnic groups(Sindhi or Balochi),65% were illiterateand only 12% hadreceived HBV vac-

cination. 101 (5%) were positive or HB-sAg, 447 (23%) were positive or HCV

and 21(1%) or both inections. Femalegender, history o blood transusion,previous dental treatment, illiteracy andover crowding were strongly associated

with HCV inection (p


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world digestive health day 2007 newspaper

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