the changing pattern of viral hepatitis in saudi arabia yousef qari, md, frcp(c), abim...
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The changing pattern of viral The changing pattern of viral hepatitis in Saudi Arabiahepatitis in Saudi Arabia
Yousef Qari, MD, FRCP(C), ABIMYousef Qari, MD, FRCP(C), ABIM
GastoenterologistGastoenterologist
King Abdulaziz University HospitalKing Abdulaziz University Hospital
Epidemiology of Hep B WorldwideEpidemiology of Hep B Worldwide
2 billion people are infected with this virus2 billion people are infected with this virus
350 million Chronic HBV infection.350 million Chronic HBV infection.
10th leading cause of death in the world10th leading cause of death in the world
Route of Transmission of HepBRoute of Transmission of HepB
High endemicityHigh endemicity– Perinatal (vertical)Perinatal (vertical)– Acquired in preschool years.Acquired in preschool years.
Low endemicityLow endemicity– Early adult lifeEarly adult life
Intravenous drug use Intravenous drug use Unprotected sexual activitiesUnprotected sexual activities
The prevalence of HBsAg and other markers The prevalence of HBsAg and other markers
of HBV among residents of Jizanof HBV among residents of Jizan
5.4 5.1
9.7
0.9
0
2
4
6
8
10
12
Blood doners14,883
Communityvolounteers
1172
Inpatients 4,692
Children 229
% w
ith
po
siti
ve H
BsA
g
Ayoola AE Saudi Med J. 2003; 24(9):991-5
Prevalence of HBV, HCV among blood donors in a Prevalence of HBV, HCV among blood donors in a teaching hospital in the Central region of Saudi Arabia.teaching hospital in the Central region of Saudi Arabia.
1.5
0.4
0
1
2
3
4
5
6
7
8
9
10
HBV HCV
Blood Doners
% o
f p
ati
en
ts
24000 patients
El-Hazmi MMSaudi Med J. 2004; 25(1):26-33
HBV and HCV prevalence among dialysis HBV and HCV prevalence among dialysis patients in Bahrain and Saudi Arabiapatients in Bahrain and Saudi Arabia
5.88
9.24
0
2
4
6
8
10
12
14
16
18
20
Hemodialyss
% o
f p
ati
en
ts
HBV
HCV
Qadi AA Am J Infect Control. 2004; 32(8):493-5 (ISSN: 0196-6553)
Prevalence of hepatitis C virus among Prevalence of hepatitis C virus among
Bilharziasis patients in Eastern Saudi arbiaBilharziasis patients in Eastern Saudi arbia
39 patients with Schistosomiasis
17.1 %
Schistosomiasis Schistosomiasis + HCV
Khan ZA Saudi Med J. 2004; 25(2):204-6
The decline of hepatitis B viral infection in South-The decline of hepatitis B viral infection in South-Western Saudi Arabia.Western Saudi Arabia.
12
5.1
8.8
0.90
2
4
6
8
10
12
14
1985 1998
Adults
Children
Ayoola AE Saudi Med J. 2003; 24(9):991-5
Hepatitis C virus Hepatitis C virus Seroprevalence rate among SaudisSeroprevalence rate among Saudis
55.7
14
1.1 0.7 0.10
10
20
30
40
50
60
70
Haemodialysis Drug Addicts Blood doners Pregnancy Children
% o
f S
ero
pre
va
len
ce
of
HC
V
Shobokshi OA . Saudi Med J. 2003; 24 Suppl 2:S81-6
Pattern of liver diseases at a University Pattern of liver diseases at a University Hospital in Western Saudi Arabia.Hospital in Western Saudi Arabia.
246 liver histology
123 (50%)Ch.Infammation
20 (8%)Cirrhosis
82 (33.3%)Ch.hepatitis
59 (23.9%)Ch. HCV
21(8.5%)Ch. HBV
2 (0.8%)Ch.HCV+HBV
16 (6.5%)HCV
4 (1.6%)HBV
103 (42%)Others
Mansoor I. Saudi Med J. 2002; 23(9):1070-3
Overview of Epidemiology of viral Overview of Epidemiology of viral Hepatitis in Saudi ArabiaHepatitis in Saudi Arabia
The prevalence rate is high in Saudi Arabia. The prevalence rate is high in Saudi Arabia. – HBV 8%-10% HBV 8%-10% – HCV 2%-6%HCV 2%-6%
Age distribution: Age distribution: – HAV, is mainly a disease of the youngHAV, is mainly a disease of the young– HBV, a disease of adolescents and adultsHBV, a disease of adolescents and adults– HCV, a disease of the elderly.HCV, a disease of the elderly.
Male: Female ratio:Male: Female ratio:– Equal in HAV and HCVEqual in HAV and HCV– More males were affected with HBV than females. More males were affected with HBV than females.
Memish Z Mil Med. 2003; 168(7):565-8
The natural history of HCV infection cont‘d.The natural history of HCV infection cont‘d.
Factors that contribute to the chronicityFactors that contribute to the chronicity – Male genderMale gender– AgeAge– Alcohol intake, and Alcohol intake, and – The degree of liver fibrosis on initial biopsy.The degree of liver fibrosis on initial biopsy.
Extrahepatic complication (EHC). Extrahepatic complication (EHC). – 38% will have at least one EHC38% will have at least one EHC– The most important EHC is mixed cryoglobulinemia. The most important EHC is mixed cryoglobulinemia.
The natural history of HCV infection in The natural history of HCV infection in Saudi Arabia.Saudi Arabia.
77
43
85
45
0
10
20
30
40
50
60
70
80
90
100
Old studies New studies
% o
f H
CV
pa
tie
nts
wit
h
pro
gre
ss
ion
to
ch
ron
icit
y
Similer pattern was noted for the rate of progression to cirrhosis and HCC Al-Quaiz MN Saudi Med J. 2003; 24
Suppl 2:S67-70
Natural History of Hep CNatural History of Hep C
HBV Infection
Chronic HepatitisCirrhosis
HCC
15-40%
HBV
Hepatocellular carcinoma in Saudi Arabia: Hepatocellular carcinoma in Saudi Arabia: Role of hepatitis B infection.Role of hepatitis B infection.
6.7%
67%
0102030405060708090
100
HCC Healthy control
% o
f H
BsA
g p
osi
tivi
ty
Prevalence of HBsAg in patients with HCC & Healthy control
N=118 N=118
Ayoola EA J Gastroenterol Hepatol. 2004; 19(6):665-9
1.9 per 1000
(2.3 in men, 1.2 in women).
The prevalence of hepatitis B core antibody positivity in The prevalence of hepatitis B core antibody positivity in donors for liver transplantation in Saudi Arabia.donors for liver transplantation in Saudi Arabia.
145 liver doners
35.2%
Doners Doners with positive AntiHBc
Non-Saudi (41.3%)
Saudi nationals (16.7%).
Al-Sebayel MI . Saudi Med J. 2002; 23(3):298-300
The challenge of finding donors for living donor The challenge of finding donors for living donor liver transplantation in Saudi Arabia.liver transplantation in Saudi Arabia.
39 potential LDLT assessed
7.6%
92.4%
Not done Done
36 potential LDLT rejected
20.5
17.9
15.47.7
5.15.1
5.15.1
2.67.7
Psychosocial Fatty liver
Recipient issues Later refusal
Unfavorable anatomy Liver volume
LFT HCV
Liver Histo Other medical issues
Khalaf H Transplant Proc. 2004; 36(8):2222-3
Hepatitis C genotypes/subtypes among chronic Hepatitis C genotypes/subtypes among chronic
hepatitis patients in Saudi Arabiahepatitis patients in Saudi Arabia
62
24.1
7.4 5.9
64.5
30.6
0
10
20
30
40
50
60
70
80
90
100
Gen 4 Gen 1 Gen 2 Gen 3
% o
f p
ati
en
ts
All regions S.AShobokshiCentral S.A Al-Traif I
1. Shobokshi OA Saudi Med J. 2003; 24 Suppl 2:S87-912. Al-Traif I Saudi Med J. 2004; 25(12):1935-8
Chronic hepatitis C. Genotypes and response to Chronic hepatitis C. Genotypes and response to anti-viral therapy among Saudi patients.anti-viral therapy among Saudi patients.
42.8 40
15.7 16.6
0
10
20
30
40
50
60
70
80
90
100
Gen 4 Gen 1
IF 3mu 3/w +Ribavirin
IF 3mu 3/w
Al-Traif I Saudi Med J. 2004; 25(12):1935-8
Peg IF + Ribavirin compared with IF + Ribavirin for initial Peg IF + Ribavirin compared with IF + Ribavirin for initial
treatment of Ch. HCV in Saudi patients with genotype 4.treatment of Ch. HCV in Saudi patients with genotype 4.
70.8
43.852.1
29.2
0
10
20
30
40
50
60
70
80
90
100
ETR SVR
PEG IF 100 micg/w+ Ribavirin
IF 3mu Thrice/w + Rebavirin
96 patients with chronic HCV
• End of treatment (48 weeks)
• Sustained (72 weeks)
Alfaleh FZ Liver Int. 2004; 24(6):568-74
ConclusionConclusion
The most prevalent genotype in the Kingdom of The most prevalent genotype in the Kingdom of Saudi Arabia isSaudi Arabia is– genotype 4genotype 4– genotypes 1a and 1b. genotypes 1a and 1b. – Genotype 5 was identified exclusively in the Genotype 5 was identified exclusively in the
Western province and nowhere else. Western province and nowhere else. – Genotypes 2a,/2b, 3 and 6 are very rare in the Genotypes 2a,/2b, 3 and 6 are very rare in the
Kingdom of Saudi Arabia. Kingdom of Saudi Arabia.
ConclusionConclusion
86% of Saudi chronic hepatitis C cases are due 86% of Saudi chronic hepatitis C cases are due to genotypes 1 and 4.to genotypes 1 and 4.The low prevalence of HBsAg in children, The low prevalence of HBsAg in children, provides evidence for the effectiveness and provides evidence for the effectiveness and efficacy of the integration of hepatitis B efficacy of the integration of hepatitis B vaccination into the extended program of vaccination into the extended program of immunization in KSA. immunization in KSA. The significant decline of HBV markers among The significant decline of HBV markers among unvaccinated Saudi adults indicated an indirect unvaccinated Saudi adults indicated an indirect effect of other factors like health education and effect of other factors like health education and socio-economic progresssocio-economic progress
ConclusionConclusion
Hepatitis B virus constitutes a major risk factor and HCV Hepatitis B virus constitutes a major risk factor and HCV contributes a less significant role in the development of contributes a less significant role in the development of HCC.HCC.
The ongoing program of HBV vaccination may The ongoing program of HBV vaccination may significantly decrease the prevalence of HBV-associated significantly decrease the prevalence of HBV-associated HCC in Saudi ArabiaHCC in Saudi Arabia
The present public health schemes have been effective The present public health schemes have been effective in reducing hepatitis C infection in the general in reducing hepatitis C infection in the general community in the Kingdom of Saudi Arabia but the community in the Kingdom of Saudi Arabia but the infection among high risk groups remain a major problem infection among high risk groups remain a major problem that needs to be actively addressed.that needs to be actively addressed.
ConclusionConclusion
In Saudi Arabia, donor availability as well as In Saudi Arabia, donor availability as well as recipient characteristics may limit the value of recipient characteristics may limit the value of LDLT in overcoming organ shortage. Therefore, LDLT in overcoming organ shortage. Therefore, efforts should be directed to improve the number efforts should be directed to improve the number and quality of available cadaveric organs. Until and quality of available cadaveric organs. Until then, LDLT may be the only way forward to save then, LDLT may be the only way forward to save patients from dying on the waiting list.patients from dying on the waiting list.
Hepatitis E virus infection in haemodialysis Hepatitis E virus infection in haemodialysis patients: a case-control study in Saudi Arabia.patients: a case-control study in Saudi Arabia.
4.3
00.3
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Dialysis pat In-patients Healthy control
IgM
Ayoola EA J Med Virol. 2002; 66(3):329-34
83 Saudi patients on chronic haemodialysis
Treatment of patients with HCV with normal Treatment of patients with HCV with normal
liver enzymes in a Saudi population.liver enzymes in a Saudi population.
90
60
40 43.3
0
10
20
30
40
50
60
70
80
90
100
% o
f p
atie
nts
ETR SVR
NormalTransaminases
ElevatedTransaminases
Akbar HOSaudi Med J. 2002; 23(3):301-4
Both groups treated with:
IF 3mu thrice / w + Ribavirin
The natural history of HCV infection.The natural history of HCV infection.
The natural history of HCV infection is not fully The natural history of HCV infection is not fully understood.understood.
Early studies of natural history reflected the Early studies of natural history reflected the more severe end of the spectrum of the disease. more severe end of the spectrum of the disease.