Viral Hepatitis B and C in North African Countries Prevalence, Risk factors and How to prevent Prof. Ossama Rasslan President, ESIC ICAN, Vice-Chair ICAN 2014, Harare, Zimbabwe, Nov 3rd 5th
Overview Viral hepatitis is a serious global public health problem affecting billions of people worldwide. These two diseases are the cause of significant global mortality and morbidity with approximately 1 million deaths each year.
Worldwide two billion people have been infected with the HBV and more than 350 million have chronic, lifelong infections. The global burden of disease due to liver cirrhosis and HCC is high (approximately 2% of all deaths). HBV infection varies according to geography, with chronic HBV prevalence ranging from 0.2% to 20%.
? 45% of the world s population lives in highly endemic areas, such as Africa & Asia-Pacific region. Chronic liver disease related to viral hepatitis has emerged as a leading public health problem in the Eastern Mediterranean Region (EMR). Studies indicate that more than 75% of cirrhosis and HCC in the EMR is attributable to HBV or HCV infection.
Despite the availability of effective prevention strategies, HBV and HCV transmission occurs throughout EMR. WHO estimates that around 4.3 million persons are infected with HBV and 800 000 persons with HCV in the EMR each year. Many of these infections are acquired in the health care settings.
Prevalence The prevalence of Hepatitis B and C infection was estimated in different regions of Sudan ; Hepatitis B surface antigen was detected in 4.91% of patients, while anti-hepatitis C virus antibodies were detected in 1.82%. In Morocco, HCV and HBV- seropositivity was documented in 1.58% and 1.81%, respectively, among the general population
The study in Morocco confirmed the intermediate endemicity for HCV infection and pointed to a decreasing trend of HBV incidence. In Addis Ababa, Ethiopia: Hepatitis B surface antigen was detected in 35.8% and anti-hcv antibody 22.5% patients clinically diagnosed to have chronic liver diseases. The study showed that 2.5% had dual hepatitis B and C virus co-infection.
Based on the prevalence of HBV chronic carriers amongst adults in the general population, countries are classified as having low <2%, intermediate 2-8%, or high endemicity >8% of infection (WHO, 2004). Even with the effective vaccines available, hepatitis B remains a stubborn, unrelenting health problem, especially in Africa and other developing areas.
These groups of chronic carriers include apparently healthy adults, school children, infants, pregnant women, blood donors and healthcare staff (WHO, 2004). Studies in the Middle East showed that the prevalence of HbsAg ranged from 3% to 11% in Egypt.
The most prevalent genotype in Egypt is genotype D especially in CAH and HCC patients while the mixed type D/F is mostly encountered in AH. The prevalence of hepatitis B surface antigen and anti-hcv antibody was high in patients below 50 years of age.
HCV is a viral pandemic and a leading cause of chronic liver disease. Approximately 2% 3% (130 170 million) of the world s population has been infected with HCV. In many developed countries, including USA, the prevalence of HCV infection is <2%. The prevalence is higher (>2%) in Latin America, Eastern Europe, former Soviet Union, and certain countries in Africa, Middle East, and South Asia.
Data on HCV infection in Africa are scarce; meaning hepatitis C is still a neglected disease in many countries. Limited data exist in literature on HCV in Africa. Africa has the highest WHO estimated regional HCV prevalence (5.3%). Egypt has the highest prevalence (17.5%) of HCV in the world. ( Review Article in Pan African Medical Journal)
Risk factors The most common risk factors for hepatitis infection and carrier status are the risk of prenatal transmission. Maternal history of schistosomal infection was significantly associated with the prenatal transmission. The prevalence of anti-hcv and HBsAg among blood donors, in a wide scale multicenter study, was 0.62% and 0.96% respectively.
HBV is transmitted by contact with contaminated blood, blood products, and other body fluids (e.g. semen), or through activities that may increase the likelihood of contaminated blood or body fluid exposure. Travelers may be at increased risk due to engaging in casual and unprotected sex, having medical procedures in areas where blood may not be screened, or even through tattoos or acupuncture.
The risk for HBV infection in travelers may be higher in countries where the prevalence of chronic HBV infection is high or intermediate.
HCV is blood borne and occurs mainly through sharing drug-injection equipment, transfusion of unscreened blood, or untreated clotting factors. In developing countries, unsterile medicinal and other injection practices account for many HCV infections. Although infrequent, HCV can be transmitted through other procedures that involve blood exposure (e.g. tattooing) and during sexual contact.
The following activities can result in blood exposure: Receiving blood transfusions that have not been screened for HCV Having medical or dental procedures Activities such as acupuncture, tattooing, public shaving, or injection drug use in which equipment has not been adequately sterilized, or reused.
Working in health care fields (medical, dental, or labs) that entail direct exposure to human blood. Unsterile tattooing can transmit hepatitis C virus. People with HCV were found almost four times more likely to report having a tattoo. Hepatitis C can be spread if poor IPC methods are used.
Various risk factors for acquiring HCV infection were identified; age, dental treatment, use of glass syringes and surgical history. In addition to these factors, sexual risk behaviors were found to be associated with higher prevalence of hepatitis C.
Prevention Prevention is the only safeguard against spread of viral hepatitis, through avoiding the practices that increase the risk of infection. A comprehensive strategy is urgently needed to prevent the transmission.
Recommended strategies include sustainable Hepatitis B vaccination of all infants within the first 24 hours of life. Protection of HCWs is crucial. Legislation is needed to ensure that all persons with occupational exposure to blood are vaccinated and educated about the risk of blood-borne pathogen transmission.
Schools for health care professionals should ensure all students are vaccinated with Hepatitis B vaccine prior to clinical rotations and educate all students about the risk of blood-borne pathogen transmission in HC setting.
Urgent efforts are needed to ensure patient safety, injection safety, safe dental care and quality assurance in health care. Studies are needed to characterize the epidemiology of disease, using a unified protocol to enable comparison of data between countries & assess the impact of prevention strategies.
Ministries of Health need to take a role in raising parliamentary awareness of the problem and the actions needed, such as legislation, regulations, and financial allocation, to ensure proper implementation of all recommended strategies. Adoption of a regional target of reduction in the prevalence of chronic hepatitis B virus infection to <1% among children over 5 years of age, by 2015.
Hepatitis prevention and control programs are multifaceted and may involve immunization, blood screening, injection safety, public health awareness &education, sexual health programs, surveillance, drug &alcohol services, and blood testing &ttt access. Strategic planning and coordination are therefore essential.
Lack of accurate prevalence data on hepatitis is widely recognized as inhibiting more effective prevention and control at both international and national levels. Worldwide, one-third of countries have no prevalence data available and more than two-thirds request assistance with surveillance.
The diverse components required for effective prevention and control mean that effective programming can be very complex. This complexity also offers opportunities both to integrate viral hepatitis into existing programs and to introduce new policies that may positively impact other high priority public health issues such as HIV/AIDS and intravenous drug use.
Hepatitis B vaccine must be given to high risk groups as HCWs especially those having jobs involving exposure to blood and individuals living in low socio-economic standard. Careful screening of blood, blood products, adequate sterilization of reusable surgical and dental instruments, professional and public health education and implementation of IPC practices in all health facilities should be followed to control spread of Hepatitis B.
Testing and Treatment Access to testing and treatment is very variable and in some regions both are extremely limited. Just 2 in 5 people live in countries where testing is accessible to more than half of the population, and only 4% of low income countries report that testing is accessible. More than half of the population lives in countries with no provision for free testing and 41% in countries where no government funding exists for treatment of hepatitis B or C.
In addition to access to testing, improving diagnosis requires awareness of risks and routes of transmission among those who may have been exposed to hepatitis B or hepatitis C. Innovative examples should provided to improve IPC of viral hepatitis Two-thirds of governments do need assistance in initiating or improving awareness raising activities.
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