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 

Worled Prevalence of Hep BWorled Prevalence of Hep B

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 

Worled Prevalence of Hep CWorled Prevalence of Hep C

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.

Natural History of Hep CNatural History of Hep C

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.