Hepatitis B care pathway in Saudi Arabia: Current situation, gaps and actions

Epidemiologic and clinical updates on viral infections in Saudi Arabia

In the past two decades, the world has witnessed devastating pandemics affecting the global healthcare infrastructure and disrupting society and the economy worldwide. Among all pathogens, viruses play a critical role that is associated with outbreaks due to their wide range of species, involvement of animal hosts, easily transmitted to humans, and increased rates of infectivity. Viral disease outbreaks threaten public health globally due to the challenges associated with controlling and eradicating them. Implementing effective viral disease control programs starts with ongoing surveillance data collection and analyses to detect infectious disease trends and patterns, which is critical for maintaining public health. Viral disease control strategies include improved hygiene and sanitation facilities, eliminating arthropod vectors, vaccinations, and quarantine. The Saudi Ministry of Health (MOH) and the Public Health Authority (also known as Weqayah) in Saudi Arabia are responsible for public health surveillance to control and prevent infectious diseases. The notifiable viral diseases based on the Saudi MOH include hepatitis diseases, viral hemorrhagic fevers, respiratory viral diseases, exanthematous viral diseases, neurological viral diseases, and conjunctivitis. Monitoring trends and detecting changes in these viral diseases is essential to provide proper interventions, evaluate the established prevention programs, and develop better prevention strategies. Therefore, this review aims to highlight the epidemiological updates of the recently reported viral infections in Saudi Arabia and to provide insights into the recent clinical treatment and prevention strategies.

Treatment Patterns and Recommendations for Improving the Management of Hepatocellular Carcinoma in Saudi Arabia

Hepatocellular carcinoma (HCC) is the sixth most common type of cancer in the world associated with high morbidity and mortality. Despite being a significant healthcare burden there is limited information on the unmet needs and current treatment practices for intermediate and advanced-stage HCC in Saudi Arabia. This article analyzes the gaps and provides expert consensus on the management strategies for unresectable HCC in Saudi Arabia. A pre-meeting online questionnaire, comprising 20 objective questions about the treatment landscape and diagnosis of HCC in Saudi Arabia, was distributed to experts in the field of HCC management. An advisory board meeting including a panel of 13 experts was held in September 2022 where the responses to the survey questionnaire were reviewed and discussed. The survey results and experts' discussion highlighted the growing incidence of liver cancer in Saudi Arabia. HCC comprised the majority of all liver cancer cases due to rising rates of chronic viral infections and lifestyle-related risk factors. Most physicians in Saudi Arabia follow the Barcelona Clinic Liver Cancer guidelines as a prognostic tool for the detection and staging of patients with HCC. Most of the patients with HCC in Saudi Arabia are diagnosed in the intermediate or advanced stages with poor prognoses and limited therapeutic options. Establishing evidence-based surveillance techniques, a multidisciplinary approach to diagnosis, and better accessibility of treatment options is vital for the management of HCC in Saudi Arabia.

Awareness of Hepatitis B Virus (HBV) Screening Before Marriage and Pregnancy Among Adults in the Al-Baha Region, Saudi Arabia

Background Hepatitis B is a global public health concern. Understanding the awareness, testing practices, and vaccination status of individuals is crucial for effective prevention and control strategies. This study aims to assess these aspects among participants in the Al-Baha region, Saudi Arabia. Methodology A cross-sectional study was conducted among 440 participants. Demographic data, awareness of hepatitis B, knowledge of transmission modes, symptoms, and complications were collected through a structured questionnaire. Participants' testing and screening practices, sources of information, and vaccination status were also assessed. Data were analyzed using descriptive statistics and associations were explored using chi-square tests. Results The majority of participants were females (51.8%) and aged 18-25 years (55.2%). While most participants had heard of hepatitis B (85.7%), only a small percentage correctly identified sexual contact as a mode of transmission (38.6%). Knowledge regarding symptoms and complications was moderate, with 52.3% correctly identifying symptoms and 69.8% recognizing liver damage and cirrhosis as complications. Although awareness of screening was high (84.8%), the actual practice was low (35.0%). Education was the least reported source of information, while the internet (46.7%) and health care provider (27.6%) were commonly mentioned. Approximately half of the participants reported receiving the hepatitis B vaccine (48.9%), but a significant proportion had not completed all vaccine doses (55.0%). Conclusion The study revealed moderate awareness of hepatitis B among the participants, but knowledge gaps existed regarding transmission modes and complete symptom recognition. Testing and screening practices were suboptimal, with low rates of screening despite high awareness. Vaccination uptake was moderate, but incomplete vaccine schedules were prevalent. Targeted educational campaigns are needed to address knowledge gaps, promote testing and completion of vaccination schedules, and enhance the role of healthcare providers in disseminating accurate information. Improving knowledge and practices related to hepatitis B can strengthen public health efforts, enhance prevention, and control strategies.

Epidemiology of Hepatitis B in Saudi Arabia from 2006 to 2021

Background

This study describes the epidemiological pattern of acute hepatitis B virus (HBV) infection in Saudi Arabia from 2006 to 2021. It explores case frequency and the crude incidence rate (CIR) by year of diagnosis, age group, region, gender, and nationality of patients.

Methods

Retrospective data on acute hepatitis B cases diagnosed across 20 regions of Saudi Arabia during January 2006 to December 2021 were obtained from the Saudi Ministry of Health's Statistical Yearbook. Statistical analyses were conducted using SPSS version 20.0, employing both parametric and non-parametric tests.

Results

The highest CIR was reported in the regions of Qunfudah, Jeddah, Tabuk, and Taif (28.6, 25.2, 25.1, and 23.4 per 100,000 people). In contrast, the lowest CIR was documented in the regions of Hail, Qurayyat, Jouf, and Hafr AL-Baten (3.6, 3.5, 2.9, and 1.2 per 100,000 people). Incidence rates were notably elevated in those aged 45 years and above (30.6 per 100,000 individuals), followed by the 15-44 age group (14.2 per 100,000 individuals), and were lowest in children aged 0-14 years (0.8 per 100,000 individuals). Regarding gender differences, HBV infection rates were 1.4 times higher in Saudi males than females and 2.2 times higher in non-Saudi males compared to females. Overall, Saudi nationals had a 4.2 times higher HBV infection rate than non-Saudis during the study period.

Conclusion

This study highlights diverse acute Hepatitis B infection rates across Saudi regions, with higher rates in Qunfudah, Jeddah, Tabuk, and Taif, and lower rates in Hail, Qurayyat, Jouf, and Hafr AL-Baten. Predominance among ages 45+, followed by 15-44, and lowest in 0-14 age groups was observed. Gender variations showed notably higher rates in Saudi and non-Saudi males. The notably higher prevalence among Saudi nationals implies key considerations for public health strategies.

Epidemiology of communicable diseases in Jazan region: Situational assessment, risk characterization, and evaluation of prevention and control programs outcomes

The incidence of communicable diseases has witnessed a reduction in Saudi Arabia during the last 4 decades. Nonetheless, the Jazan region has been indicated as one of the main regions affected by various communicable conditions. The geographical, socioeconomic, and climate characteristics of Jazan have made it vulnerable to communicable and vector-borne diseases. This review aims to provide a comprehensive overview of the epidemiology of communicable diseases in Jazan, Saudi Arabia. This review also gives a historical description of infectious diseases in the region and the relevant prevention and control measures. Prevention and control efforts in the Jazan region successfully eliminated Rift Valley fever and reduced the number of locally acquired malaria and chickenpox cases. Hepatitis B, dengue fever, and pulmonary tuberculosis have exhibited an increased incidence in recent years, suggesting a need for further epidemiological investigations and the application of relevant prevention and control measures.

Aflatoxins in food products consumed in the Kingdom of Saudi Arabia: A preliminary dietary risk assessment

Aflatoxins (AFs) are hepatotoxic, mutagenic, genotoxic, and immunosuppressive toxins. Several food commodities consumed in the Kingdom of Saudi Arabia (KSA) are susceptible to AF contamination because of improper storage practices and the warm and humid climate of the country. Therefore, the occurrence of AFs in 2388 food samples was measured and the estimated daily intake (EDI) of AFs in Saudi adults was assessed. The risks of AFB1 exposure were characterized using the margin of exposure (MoE) approach and by estimating the number of possible hepatocellular carcinoma (HCC) cases in the KSA. The results revealed that 12.1% of the analyzed samples were contaminated with AFs and the highest concentration of total AFs was observed in the nut and seed group. The mean EDI of AFB1 was estimated to be 0.21 and 0.55 ng/kg body weight (bw)/day for the lower bound (LB) and upper bound (UB) scenarios, respectively. The MoEs were estimated to be 1902.4 and 722.1, while the estimated liver cancer risk ranged from 0.002 to 0.008 cancer cases/year/100,000 persons. Based on the study's findings, contamination with AFs in the KSA is low; however, AFs are considered potent genotoxic contaminants, and therefore, exposure through food should be kept as low as possible.

Strategy for immunological analysis of pro-inflammatory cytokine marker studies with chronic hepatitis B virus in Southwestern region of Saudi Arabia

BACKGROUND

Hepatitis B Virus (HBV) is one of the leading causes of infectious disease in the global population, and its prevalence has been increasing globally. Human HBV infection is complex, involving both innate and adaptive immune systems. Cytokines play a role in both physiologic and pathologic processes in the liver. This study was designed to screen serum levels using an enzyme linked immunosorbent assay (ELISA) and genetic variants in the TNF-α and IL6 genes using polymerase chain reactions (PCR). The aim of this study was to screen the serum levels and genotype levels with TNF-α (C-308 T/G-308A) and IL-6 (G-174 C) genes in HBV patients and control subjects.

METHODS

In this study, we have selected 50 HBV patients and 40 control subjects from Saudi Population. Patient serum samples was used for measuring the serum levels and PCR analysis using RFLP analysis. Prior to this, HBV patients were confirmed with PCR analysis followed by Sanger sequencing analysis.

RESULTS

The current study results confirmed positive association in serum levels (p < 0.05) and negative association with both genotype and allele frequencies in TNF-α (C-308 T) and IL-6 (G-174 C) genes among HBV patients and controls (p > 0.05). Positive associations between blood levels of TNF-α and IL-6 were confirmed, while negative associations were found between PCR investigations involving the TNF-α (G-308A) and IL-6 (G-174 C) genes with the HBV prevalence in the Saudi population.

CONCLUSION

This study confirmed serum levels are strongly associated with HBV patients in the Saudi population. However, PCR studies showed the negative association with the couple of variants selected for this study.

Knowledge and Attitude of Undergraduate Health Professions Students towards Hepatitis B and C

The current study sought to establish the attitude and knowledge level of medical science students in Tibah University towards hepatitis B and C. A cross-sectional study involving 369 students drawn from the faculties of medicine, dentistry, applied medical sciences, pharmacy, nursing, and medical rehabilitation sciences was conducted where a standardised questionnaire was used to determine the attitude and knowledge level of undergraduate students drawn from the college of medicine in Tibah University, Saudi Arabia, regarding viral infections. With a mean of 0.71, 0.69, and 0.66 and a standard deviation (SD) of 0.24, 0.34, and 0.24 for virology and transmission, symptoms and clinical outcomes, and treatment and prevention, respectively, the knowledge level of the health professions students towards hepatitis B and C infections was significant. The knowledge level about the infections was higher among male students than among female students. Similarly, students in their final years of medical school had significantly higher knowledge levels about hepatitis B and C than their counterparts in their first years of medical school. There was also a positive correlation between the attitude of the health professions students towards the disease and their knowledge levels of the disease. Findings indicate that enhanced instruction on the nature, virology, transmission, symptoms, treatment, clinical outcomes, and prevention of hepatitis B and C can help improve the knowledge levels and attitude of the health professions students towards the disease and its management.

Hepatitis B virus infection in Saudi Arabia and the UAE: Public health challenges and their remedial measures

BACKGROUND

Hepatitis B virus (HBV) infection is a major public health concern globally with higher prevalence in Middle Eastern countries. Both Saudi Arabia and the UAE face critical challenges in HBV treatment and management despite the implementation of a mass vaccination program. This review aimed to understand the gaps and unmet needs related to HBV infection, public health challenges associated with its diagnosis, and treatment barriers in Saudi Arabia and the UAE. Additionally, the review aimed to provide the best practices in the HBV care pathway for effective remedial measures and disease reduction.

METHODS

The literature search was done from Pubmed.

RESULTS

The lack of disease awareness and knowledge about disease transmission among patients and their family members and healthcare professionals, lack of proper screening, underdiagnosis, social stigma, lack of established referral system, and treatment cost are the primary barriers to HBV diagnosis and management.

CONCLUSION

Appropriate healthcare initiatives should be undertaken to lower the disease burden in Saudi Arabia and the UAE.

Prevalence of Hepatitis B Virus, Hepatitis C Virus, and HIV Infections in Hemodialysis Patients at Kano Kidney Center

Background Hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) infections are more prevalent in hemodialysis patients compared to the general population. The objective of this study was to evaluate the prevalence of HBV, HCV, and HIV infections in hemodialysis patients dialyzing regularly at Kano Kidney Center (KKC) in the Eastern Health Cluster of Saudi Arabia in 2022. Methods This retrospective study included all hemodialysis patients who were dialyzed regularly at KKC during 2022. Their electronic medical records were reviewed for the results of HBV, HCV, and HIV along with the patient's demographics, comorbid conditions, and dialysis history. The study was approved and monitored by the Institutional Review Board of Dammam Medical Complex. Results A total of 239 regular hemodialysis patients were included, consisting of 142 males and 97 females (59.41% and 40.59%, respectively), with a mean age of 52.71±15.83 years. Most of the patients were Saudis (156 patients, 65.27%) with the non-Saudi patients being composed mostly of Arabian patients. Nine patients (3.77%) tested positive for hepatitis B surface antigen (HBsAg), the serologic hallmark of HBV infection. Two patients (0.84%) had resolved HBV infections as evidenced by positive hepatitis B core antibody (anti-HBc) and hepatitis B surface antibody (anti-HBs). However, the majority (226 patients, 94.56%) were never tested for anti-HBc. Anti-HBs, which can imply long-term immunity against HBV from prior immunizations or infections, were positive in 165 patients (69.04%). A protective anti-HBs level of ≥ 10 IU/L was detected in 158 patients (66.11%) including 104 patients (43.51%) having ≥ 100 IU/L. Eighteen patients (7.53%) had reactive HCV antibodies. Four patients (1.67%) had chronic HCV infection as they had detectable HCV RNA. The remaining 14 patients (5.86%) cleared HCV either spontaneously (seven patients, 2.93%) or by medications (seven patients, 2.93%). HIV screening tests were negative in all 239 patients (100%). HBsAg-positive patients did not have any statistically significant differences from HBsAg-negative patients. On the other hand, the patients who were positive for HCV antibodies were older than the patients who were negative for HCV antibodies (60.66 vs 52.05 years on average, p-value <0.05). They also contained a statistically larger proportion of non-Saudi patients than the patients with no evidence of prior infections (61.11% vs 32.13%, p-value <0.05). Conclusions The study found that the prevalence of HBV and HCV infections among hemodialysis patients in KKC at 3.77% and 1.67%, respectively, is higher than that reported in the general population in Saudi Arabia, with non-Saudis having a higher prevalence rate of HCV infection than Saudis. However, the current prevalence rate is lower compared to the previous studies that were conducted in Saudi Arabia in the first decade of the 21st century, and there were no cases of HIV infections. Nevertheless, a significant proportion of patients had unprotective or negative anti-HBs antibody titers, indicating the need for strict vaccination protocols and monitoring of antibody titers to ensure optimal protection.

Prevalence and trends of transfusion transmissible infections among blood donors in Basra, Iraq

BACKGROUND

Despite saving millions of lives through blood transfusion, transfusion-transmissible infections (TTIs) still threaten the lives of patients requiring blood transfusion. Hence, screening blood donors and studying the prevalence of TTIs among blood donors may display the burden of these diseases among our population. The aim of this study was to assess the seroprevalence rates of transfusion transmitted infections among blood donors in Basra, Iraq from 2019 to 2021 as groundwork for providing safe blood transfusion in Iraq.

METHODS

A cross-sectional study was carried out in the blood banks in Basra, Iraq from 1 January 2019 to 31 December 2021. A total of 197 898 samples were collected and screened for hepatitis B surface antigen (HBsAg), anti-hepatitis B core (HBc), anti-hepatitis C virus (HCV) and syphilis immunologically.

RESULTS

The prevalence rates of seropositive of viral hepatitis for the year 2019, 2020, 2021 were as following: hepatitis B virus (HBV) rates 1.54%, 1.45% and 1.14% with significant declined trend by 26%; anti-HCV rates were 0.14, 0.12 and 0.11% with significant declined trend by 21.4%; and the syphilis rates were 0.38, 0.47, 0.36 with marked declined trend 5.3%, respectively.Of those donors showed HBV positive, 2503 (1.26%) had positive anti-HBc results, while only 173 (0.0874) showed positive test results for both anti-HBc and HBsAg.

CONCLUSION

Prevalence rates of viral hepatitis and syphilis showed a steady decline between 2019 and 2021, and these rates were much lower in Basra than in other parts of Iraq and neighbouring countries. The importance of using the anti-HBc test in the screening of blood donors was indicated in this study. These findings would contribute in improving the understanding of TTIs epidemiology and supporting health authorities controlling bloodborne diseases.

Molecular and Genetic Characterization of Hepatitis B Virus (HBV) among Saudi Chronically HBV-Infected Individuals

The study aimed to characterize the genotype and subgenotypes of HBV circulating in Saudi Arabia, the presence of clinically relevant mutations possibly associated with resistance to antivirals or immune escape phenomena, and the possible impact of mutations in the structural characteristics of HBV polymerase. Plasma samples from 12 Saudi Arabian HBV-infected patients were analyzed using an in-house PCR method and direct sequencing. Saudi patients were infected with mainly subgenotype D1. A number of mutations in the RT gene (correlated to antiviral resistance) and within and outside the major hydrophilic region of the S gene (claimed to influence immunogenicity and be related to immune escape) were observed in almost all patients. Furthermore, the presence of mutations in the S region caused a change in the tertiary structure of the protein compared with the consensus region. Clinical manifestations of HBV infection may change dramatically as a result of viral and host factors: the study of mutations and protein-associated cofactors might define possible aspects relevant for the natural and therapeutic history of HBV infection.

Genotypes of Hepatitis C Virus and Efficacy of Direct-Acting Antiviral Drugs among Chronic Hepatitis C Patients in a Tertiary Care Hospital

Hepatitis C virus (HCV) chronic infection is a major causative factor for several chronic liver diseases, including liver cirrhosis, liver cell failure, and hepatocellular carcinoma. The HCV has seven major genotypes. Genotype 4 is the most prevalent genotype in the Middle East, including Saudi Arabia, followed by genotype 1. The HCV genotype affects the response to different HCV treatments and the progression of liver disease. Currently, combinations of direct-acting antiviral drugs (DAAs) approved for the treatment of HCV achieve high cure rates with minimal adverse effects. Because real-world data from Saudi Arabia about the efficacy of DAAs are still limited, this study was conducted to assess the effectiveness of DAAs in treating patients with chronic hepatitis C and to identify the variables related to a sustained virologic response (SVR) in a real-world setting in Saudi Arabia. This prospective cohort study included 200 Saudi patients with chronic HCV who were 18 years of age or older and had been treated with DAAs at King Abdul-Aziz Specialized Hospital in Taif, Saudi Arabia, between September 2018 and March 2021. The response to treatment was assessed by whether or not an SVR had been achieved at week 12 post treatment (SVR12). An SVR12 was reached in 97.5% of patients. SVR12 rates were comparable for patients of different ages, between men and women, and between patients with and without cirrhosis. In addition, the SVR12 rates did not differ according to the infecting HCV genotype. In this study, the presence of cirrhosis and the patient's gender were independent predictors of who would not reach an SVR12 (known here as the non-SVR12 group) according to the results of univariate and multivariate binary logistic regression analyses based on the determinants of SVR12. In this population of patients with chronic HCV infection, all DAA regimens achieved very high SVR12 rates. The patients' gender and the presence of cirrhosis were independent factors of a poor response.

Prevalence of transfusion-transmitted infections in Saudi Arabia blood donors: A nationwide, cross-sectional study

OBJECTIVES

To establish a nationwide epidemiological profile of transfusion-transmittable infection (TTI) markers among seemingly healthy blood donors to update policies required to ensure blood safety.

METHODS

A nationwide, cross-sectional study was designed to examine donor demographics and TTI prevalence during 2020 using data provided by the Ministry of Health, Saudi Arabia.

RESULTS

Collectively, a total of 375,218 whole blood units were donated, of which 32,758 (8.7%) were excluded due to TTI-related risk. The exclusion was based on a positive nucleic acid amplification test (NAT) or seroreactivity to hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), human T-cell lymphotropic virus (HTLV-I/II), syphilis, or malaria. Notably, the central (37.6%) and southern (33%) regions were the epicenters of TTI-reactive blood donors. Hepatitis B virus markers accounted for 85.7% and were the overall most prevalent of TTI-positive donations, followed by HCV at 5.9% and syphilis at 5.6%. In particular, anti-HBc and HBsAg were most prevalent in the south, while HBV NAT was highest in the center.

CONCLUSION

Hepatitis B virus, HCV, and syphilis carry the greatest risk of TTI in Saudi Arabia. Including HBsAg screening is a necessary precautious measure to maintain blood safety.

Patterns of Hepatitis B, Hepatitis C and HIV Among Blood Donors in Samtah-Jazan Region

BACKGROUND AND OBJECTIVE

Transfusion-transmitted infectious agents are amongst the major health burden worldwide. The purpose of this study was to evaluate the prevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV) among blood donors in Samtah General Hospital, Jazan region, Saudi Arabia.

MATERIAL AND METHODS

In this retrospective study, blood donation records of all blood donors recruited between January 2019 and August 2020 were included for data acquisition. A total of 4977 blood donors' records were reviewed and data were analysed.

RESULTS

Hepatitis B profile showed 0.60% blood donors positive for hepatis B surface antigen (HBsAg). Nucleic acid testing (NAT) showed the presence of HBV-DNA in 0.4% of the blood donors. Anti-HBs and anti-HBc antibodies were reactive in 3.34% and 7.31% blood donors' units, respectively. Anti-HCV antibodies were reactive among 54 (1.09%) blood donors. Upon reviewing the NAT analysis results, 0.16% (08) blood donors showed the presence of HCV-RNA in their blood units. Anti-HIV antibodies were reactive in 8 (0.16%) blood donors.

CONCLUSION

It is concluded that the frequency of HBsAg is comparatively lower while anti-HCV positivity is higher in Samtah, Jazan as a region compared to other regions of the country. Further studies are warranted to evaluate the cause of HCV infection in this area. Frequency of HIV is uncommon in this area.

Prevalence and Association of Transfusion Transmitted Infections with ABO and Rh Blood Groups among Blood Donors in the Western Region of Saudi Arabia: A 7-Year Retrospective Analysis

This study was aimed at determining the prevalence estimate and association of transfusion-transmitted infections (TTIs) with ABO and Rh blood groups among blood donors at the King Faisal Specialist Hospital and Research Center (KFSH & RC) in the western region of Saudi Arabia. A retrospective study was conducted at the blood bank center of KFSH and RC from 1 January 2013 to 31 December 2019. Data on ABO and Rh blood group testing, serological testing, molecular investigations, serological assays, nucleic acid testing (NATs), and socio-demographic information were gathered. During the study period, there were 959,431 blood donors at the KFSH and RC. The overall 7-year cumulative prevalence estimate of blood transfusion-transmitted infections among blood donors was low at 7.93%, with an average prevalence estimate of 0.66%. Donors with the O blood group, the O RhD +ve blood group, in particular, were more at risk of developing TTIs, whereas donors with the AB blood group, the AB RhD −ve blood group, in particular, were at the lowest risk of developing TTIs. In total, 96.9% of the blood donors were males (n = 916,567). Almost half of the blood donors belong to the O blood group (49.4%). A total of 861,279 (91.0%) donors were found to be RhD positive. The percentages of TTIs were found to be higher in RhD +ve donors compared with RhD −ve donors. The prevalence estimate of the hemoglobin C (HbC) infection was the most common TTI among the blood donors being 3.97%, followed by malaria being 2.21%. The least prevalence estimate of TTI in the present study was for NAT HIV being 0.02%. Significant associations were observed between RhD +ve and RhD −ve among the malaria-infected donors (A: χ2 = 26.618, p = 0.001; AB: χ2 = 23.540, p = 0.001; B: χ2 = 5.419, p = 0.020; O: χ2 = 68.701, p = 0.001). The current 7-year retrospective study showed a low level of TTIs among blood donors. However, we urge that more research encompassing the entire country be conducted in order to obtain more representative results in terms of the prevalence estimate and association of transfusion-transmitted infections with ABO and Rh blood groups in communities.

Aflatoxin M1 in milk does not contribute substantially to global liver cancer incidence

BACKGROUND

For 60 y, it has been known that aflatoxin B1 (AFB1), a mycotoxin produced by Aspergillus fungi in certain food and feed crops, causes hepatocellular carcinoma (liver cancer; HCC) in humans. The annual global burden of AFB1-related HCC has been estimated. However, much less is known about the potential carcinogenic impact of a metabolite of AFB1 called aflatoxin M1 (AFM1), which is secreted in milk when dairy animals consume AFB1-contaminated feed. The cancer risk of AFM1 to humans from milk consumption has not yet been evaluated.

OBJECTIVES

We sought to estimate the global risk of AFM1-related liver cancer through liquid milk consumption, accounting for possible synergies between AFM1 and chronic infection with hepatitis B virus (HBV) in increasing cancer risk.

METHODS

We conducted a quantitative cancer risk assessment by analyzing extensive datasets of national population sizes, dairy consumption patterns, AFM1 concentrations in milk in 40 nations, and chronic HBV prevalence. Two separate cancer risk assessments were conducted: assuming a possible synergy between AFM1 and HBV in increasing cancer risk in a manner similar to that of AFB1 and HBV, and assuming no such synergy.

RESULTS

If there is no synergy between AFM1 and HBV, AFM1 may contribute ∼0.001% of total annual HCC cases globally. If there is synergy between AFM1 and HBV infection, AFM1 may contribute ∼0.003% of all HCC cases worldwide. In each case, the total expected AFM1-attributable cancer cases are ∼13-32 worldwide.

CONCLUSION

AFM1 exposure through liquid milk consumption does not substantially increase liver cancer risk in humans. Policymakers should consider this low risk against the nutritional benefits of milk consumption, particularly to children, in a current global situation of milk being discarded because of AFM1 concentrations exceeding regulatory standards.

Seroprotection of Hepatitis B Vaccine in Dental Students Two Decades after Infant Immunization and the Possible Need for Revaccination

OBJECTIVES

 This study aimed to assess hepatitis B surface antibody (anti-HBs) persistence among dental students two decades after infant vaccination and immune response after revaccination or booster dose in nonimmune groups.

MATERIALS AND METHODS

 A cross-sectional study was performed using laboratory reports for anti-HBs performed to dental students at the Umm al-Qura University from 2016 to 2020. Reports were classified according to baseline antibody titer into group I (titer <10 mIU/mL), group II (titer 10 to <100 mIU/mL), and group III (titer ≥100 mIU/mL). The basal antibody titer of each group was correlated to student's gender and birth year and compared with postrevaccination or booster dose titer in groups I and II.

STATISTICAL ANALYSIS

 Data of baseline and postrevaccination anti-HBs antibody titers were analyzed using Statistical Package for Social Science (SPSS). One-way ANOVA was used to compare between different means for antibody titers of students as well as baseline and postrevaccination antibody levels for nonimmune students with nonprotective antibody titers. Pairwise multiple comparison of the difference between baseline and postrevaccination anti-HBs antibody titers were done by post hoc Tukey's honestly significant difference (HSD) test. Chi-squared test was used for comparing between the frequencies. A p-Value of ≤0.05 was considered significant and p < 0.01 was considered highly significant.

RESULTS

 A significant percentage (73.6%) of students had antibody titer <10 mIU/mL, while only 4.8% had antibody titer ≥100 mIU/mL with nonsignificant difference between both genders (χ ² =3.784, p = 0.151). A statistically nonsignificant difference was also found between the three categories of anti-HBs antibody titers among students with different birth dates (χ ² = 13.817, p = 0.182). After revaccination of nonimmune students, 100% of them showed strongly protective antibody titers with mean of 842.88 to 844.58 mIU/mL. A highly significant difference was observed between the mean baseline and postrevaccination antibody titers in both genders, with a higher mean of post revaccination (p = 0.000).

CONCLUSION

 Two decades after infant immunization, a significant percentage of dental students failed to maintain the anti-HBs seroprotective titer. So titer measurement should be made compulsory before they begin their clinical training and revaccination or booster dose should be given to nonimmune students to maintain a high protection level.

Long-term Immunity Against Hepatitis B Virus After Routine Immunization Among Adults Visiting Primary Care Centers in Riyadh, Saudi Arabia

Objective

This study aimed to determine the persistence of induced immunity against hepatitis B virus (HBV) among adults routinely vaccinated during their infancy and correlate the level of induced immunity with participant characteristics.

Methodology

This was a cross-sectional study conducted among visitors to primary care centers of the Ministry of Health (MOH) in Riyadh, the Kingdom of Saudi Arabia (KSA) during the period from August 2020 to January 2021. The study population included healthy adults of both genders who had received full doses of the HBV vaccine in infancy. Data related to participant characteristics were collected using a self-administered questionnaire. A blood sample was then taken from each participant to measure the serum level of hepatitis B surface antigen (HBsAg), antibodies against HBsAg (anti-HBs), and antibodies against hepatitis B core antigen (ani-HBc).

Results

A total of 400 subjects participated in the study; the mean age of the cohort was 25 years. Almost all of them were Saudis (99.30%), and more than half (57.50%) were males. Only 24.30% had an anti-HBs antibodies level of ≥10 IU/L, and all respondents were negative for HBs antigen. No significant association between participant characteristics and anti-HBs antibody levels was found.

Conclusion

A decline in immunity many years after HBV vaccinations taken in infancy has been well-documented. However, for low-risk populations, the boosting of HBV vaccines is probably unnecessary since the immune memory provides sufficient protection despite low or undetectable anti-HBs antibodies.

Trends of cancer incidence in Qassim Region, a descriptive analysis of data from the Saudi Cancer registry 2002-2016

Objectives

The objectives of the study was to describe cancer incidence in the Qassim region and compare it with the national incidence rate for all reported cancer sites over 15-years (2002-2016).

Methods

A descriptive analysis was conducted using the Saudi Cancer Registry (SCR) data. The annual percentage change (APC) was computed using Joinpoint regression software.

Results

The Qassim region contributed to 4.3% (n = 6118) of the total cancer burden in Saudi Arabia (SA). Cancer incidence increased throughout the study period; however, it did not reach statistical significance. The age-standardized rate (ASR) per 100,000 persons was higher in females 68.8 (95% CI: 60.2-77.3) than in males 57.0 (95% CI: 51.9-62.12), P < 0.001. Since 2011, colon and rectal cancers have replaced non-Hodgkin lymphoma (NHL) and liver cancer as the leading cancer types among men. In women, the breast is the leading cancer type, and since 2014, the colon and uterus replaced the thyroid and NHL as the second and fourth-most common cancers. ASR of nasopharyngeal, esophageal, and Hodgkin's lymphoma were significantly higher in Qassim as compared to SA. The following cancer types showed significant APC (2002-2016): in males; colon: APC = 7.3%, rectum: APC = 6.1%, bone: APC = 8.3%, and esophageal: APC -5.1%. In females; breast: APC = 6%, colon: APC = 7.2%, uterus: APC = 10.1%, kidney: APC = 15.3%, bone: APC = 8.1%, skin non-melanoma: APC = -8.1%, and myeloid leukemia: APC -14.2%.

Conclusion

The significant changes in cancer incidence in Qassim warrant further studies on the risk factors and preventive measures.

Evaluation of a universal hepatitis B vaccination program and antenatal screening for hepatitis B surface antigen: Results from a real-world study 2015-2016

BACKGROUND AND AIMS

Universal vaccination against hepatitis B virus (HBV) in infancy was implemented in Israel in 1992. This population-based study aimed to evaluate the coverage rate and cost-benefit of the HBV vaccination program among infants in Israel and the Hepatitis B surface antigen (HBsAg) status in their mothers.

METHODS

Using the database of a health maintenance organization with 2 million members, we retrospectively identified, all the infants born in 2015-2016 and their mothers. Maternal data collected included age, ethnicity, country of birth and HBsAg status during pregnancy. HBV vaccination coverage among infants was calculated. A cost-benefit analysis of the HBV vaccination program was conducted based on the actual costs of HBV infection treatments in all HBsAg positive mothers.

RESULTS

Our cohort included 72,792 mothers who gave birth to 77,572 live infants. A total of 71,107 (97.7%) mothers were screened for HBV during pregnancy, of them 124 (0.2%), who gave birth to 132 infants were HBsAg positive. HBV vaccination coverage rates were 94%, 93% and 89%, for the first, second and third dose, respectively. Birth dose coverage of 95% among infants born to HBsAg positive mothers was significantly higher compared to HBsAg negative or unscreened mothers (p < 0.001). The percentage of HBsAg positivity among mothers who were born in Israel, the Former Soviet Union or Ethiopia, were 0.1%, 0.8% and 5%, respectively (p < 0.001). Ethnic differences were not found between HBsAg positive and HBsAg negative mothers. Calculated benefit-to-cost ratios were 1.24:1 and 4.15:1, with and without antenatal HBsAg screening, respectively.

CONCLUSIONS

The Israeli vaccination program against HBV infection is epidemiologically and economically justified. High coverage rates among infants born to HBsAg positive mothers reflect very good adherence to the vaccination program and antenatal screening. Higher HBsAg positivity rates among immigrant mothers identify a high-risk population for HBV infection.

Alsagaby S, Mir SA, Alaidarous M, Bin Dukhyil A, Alshehri B, Banawas S, Alturaiki W, Alharbi NK, Azad TA, Al Abdulmonem W. Seroprevalence of Viral Hepatitis B and C among Blood Donors in the Northern Region of Riyadh Province, Saudi Arabia

BACKGROUND

Hepatitis B and C viral infections, which are the most common cause of liver infection worldwide, are major health issues around the globe. People with chronic hepatitis infections remain at risk of liver cirrhosis and hepatic carcinoma, while also being a risk to other diseases. These infections are highly contagious in nature, and the prevention of hepatitis B and C transmission during blood transfusion is a major challenge for healthcare workers. Although epidemiological characteristics of hepatitis B and C infections in blood donors in Saudi Arabia have been previously investigated in multiple studies, due to targeted cohorts and the vast geographical distribution of Saudi Arabia, there are a lot of missing data points, which necessitates further investigations.

AIM OF THE STUDY

This study aimed to determine the prevalence of hepatitis B and hepatitis C viral infections among blood donors in the northern region of Riyadh, Saudi Arabia.

METHODS

To determine the given objectives, a retrospective study was performed which included data gathered from serological as well as nucleic acid test (NAT) screening of blood donors. Clinical data of 3733 blood donors were collected for a period of 2 years (from January 2019 to December 2020) at the blood bank of King Khalid General Hospital and the associated blood banks and donation camps in the region. Statistical analysis of the clinical data was performed using SPSS.

RESULTS

The blood samples of 3733 donors were analyzed to determine the seroprevalence of hepatitis B and C among the blood donors in the northern region of Riyadh, Saudi Arabia. Among the total of 3733 blood donors, 3645 (97.65%) were men and 88 (2.36%) were women. Most of the donors were younger than 27 years of age (n = 1494). The most frequent blood group in our study was O-positive (n = 1534), and the least frequent was AB-negative (n = 29). After statistically analyzing the clinical data, we observed that 7 (0.19%), 203 (5.44%) and 260 (6.96%) donor blood samples were positive for the HBV serological markers HBsAgs, HBsAbs and HBcAbs, respectively, and 12 (0.32%) blood samples reacted positively to anti-HCV antibodies. Moreover, 10 (0.27%) and 1 (0.027%) samples were NAT-HBV positive and NAT-HCV positive, respectively.

CONCLUSION

In the current study, low prevalence rates of HBV and HCV were observed in the blood donors. Statistical correlations indicated that both serological tests and NATs are highly effective in screening potential blood donors for HBV and HCV, which, in turn, prevents potential transfusion-transmitted hepatitis.

Changing trends in seroprevalence rates of transfusion-transmitted diseases among blood donors in Jordan

Background

Hepatitis B and C infections and transmission are a serious challenge to all healthcare systems. We studied seroprevalence rates of Transfusion Transmitted Diseases (TTD) among blood bank donors in Jordan from 2014 to 2019 as a follow-up study of our previously published work. In addition, we wanted to explore the efficacy of the mandatory vaccination of infants against hepatitis B virus (HBV) which was implemented by the Ministry of Health since 1995 for the eradication of HBV infection in Jordan.

Methods

We reviewed blood bank donors’ records at King Hussein Cancer Center (KHCC) from January 1st, 2014, until December 31st, 2019. Results of seropositivity prevalence rates for HBsAg, anti-HBcore, and anti-HCV, using Enzyme-Linked ImmunoSorbent Assay (ELISA) were compared to seropositivity rates from our previously published data. In addition, our results were compared to data obtained from other blood banks in Jordan, as well as compared to published information from blood banks in neighboring countries.

Results

The prevalence rates (%) of seropositive blood donors for viral hepatitis for the years 2014, 2015, 2016, 2017, 2018, and 2019, were as follows: HBsAg rates were 0.3386, 0.2108, 0.1801, 0.1898, 0.2068, and 0.2741; anti-HBcore rates were 4.1112, 3.2271, 2.9748, 2.8405, 2.6879 and 3.0986; and anti-HCV rates were 0.1129, 0.0486, 0.0548, 0.0654, 0.0782, and 0.0839, respectively. There was a significant increase in the prevalence of HBsAg, Anti-HBcore and Anti-HCV antibodies in 2019 (one sample z-score test, p < 0.00001).

Conclusions

Prevalence rates of hepatitis B and C infections among Jordanian blood bank donors showed a steady decline between 2009 and 2017, and these rates were much lower in Jordan than in neighboring countries. However, an increase in the prevalence rates of hepatitis B and C infections among blood bank donors was documented in 2019. While the reasons for this increase are not clear yet, these findings highlight the importance of renewed efforts to increase public health awareness of HBV and implement effective measures to prevent the transmission and infection with HBV, including national vaccination programs.

Changing trends in seroprevalence rates of transfusion-transmitted diseases among blood donors in Jordan

BACKGROUND

Hepatitis B and C infections and transmission are a serious challenge to all healthcare systems. We studied seroprevalence rates of Transfusion Transmitted Diseases (TTD) among blood bank donors in Jordan from 2014 to 2019 as a follow-up study of our previously published work. In addition, we wanted to explore the efficacy of the mandatory vaccination of infants against hepatitis B virus (HBV) which was implemented by the Ministry of Health since 1995 for the eradication of HBV infection in Jordan.

METHODS

We reviewed blood bank donors' records at King Hussein Cancer Center (KHCC) from January 1st, 2014, until December 31st, 2019. Results of seropositivity prevalence rates for HBsAg, anti-HBcore, and anti-HCV, using Enzyme-Linked ImmunoSorbent Assay (ELISA) were compared to seropositivity rates from our previously published data. In addition, our results were compared to data obtained from other blood banks in Jordan, as well as compared to published information from blood banks in neighboring countries.

RESULTS

The prevalence rates (%) of seropositive blood donors for viral hepatitis for the years 2014, 2015, 2016, 2017, 2018, and 2019, were as follows: HBsAg rates were 0.3386, 0.2108, 0.1801, 0.1898, 0.2068, and 0.2741; anti-HBcore rates were 4.1112, 3.2271, 2.9748, 2.8405, 2.6879 and 3.0986; and anti-HCV rates were 0.1129, 0.0486, 0.0548, 0.0654, 0.0782, and 0.0839, respectively. There was a significant increase in the prevalence of HBsAg, Anti-HBcore and Anti-HCV antibodies in 2019 (one sample z-score test, p < 0.00001).

CONCLUSIONS

Prevalence rates of hepatitis B and C infections among Jordanian blood bank donors showed a steady decline between 2009 and 2017, and these rates were much lower in Jordan than in neighboring countries. However, an increase in the prevalence rates of hepatitis B and C infections among blood bank donors was documented in 2019. While the reasons for this increase are not clear yet, these findings highlight the importance of renewed efforts to increase public health awareness of HBV and implement effective measures to prevent the transmission and infection with HBV, including national vaccination programs.

Revealing Hepatitis B Virus as a Silent Killer: A Call-to-Action for Saudi Arabia

BACKGROUND

The Kingdom of Saudi Arabia (KSA) was the first country in the Middle East to adopt the hepatitis B virus (HBV) vaccine. Despite an expanded HBV immunization program and significant progress in HBV prevention in the country, HBV infection is a significant public health burden. This review lists coordinated solutions for healthcare stakeholders, patients, and health authorities to curb HBV and its impact in KSA. It further aims to draw policymakers' attention to key priorities to bridge HBV care gaps in the country.

METHODS

As part of the pre-engagement activity, medical experts across KSA were interviewed to gain a preliminary understanding of the current unmet needs in HBV management in the country. Top-recommended action points derived from the pre-engagement activity were discussed. Key priority action points to curb the impact of HBV in KSA were identified.

RESULTS

The priority action points together with the challenges and unmet needs in the management and care of HBV in KSA were: (a) establish a national-level registry, (b) implement screening campaigns, (c) improve linkage of care between primary care physicians (PCPs) and specialists, and (d) increase PCP education and awareness.

CONCLUSION

This work is an endeavor to set the stage for a strategic policy framework aimed at eliminating HBV in KSA. The action points/steps for the identified priorities must run parallelly across various regions in KSA, to successfully manage and further eliminate the threat of HBV.

SASLT practice guidelines for the management of Hepatitis B virus - An update

Infection with hepatitis B virus (HBV) remains an important public health problem with a high burden worldwide. The Saudi Association for the Study of Liver diseases and Transplantation formed a working group to develop HBV practice guidelines in Saudi Arabia. The methodology used to develop these guidelines was based on reviewing the available evidence, local data, and major international practice guidelines on the management of HBV. The aim of these guidelines is to assist healthcare providers in the management of HBV in Saudi Arabia. These updated guidelines summarize the latest local studies performed on HBV epidemiology, major changes in the prevalence of this virus, and advances in disease management.

Hepatitis B-C and human immunodeficiency virus: seroprevalence and associated factors among health students in Saudi Arabia

OBJECTIVES

To assess the seroprevalence of Hepatitis B (HBV), Hepatitis C (HCV), and Human Immunodeficiency Virus (HIV) among newly admitted health track students in a large university in the Eastern Province of Saudi Arabia, and determine the students' immunity against HBV, and bloodborne viral infection risk factors or practices among them.

METHODS

Information about the 1145 students, vaccination history, and exposure to bloodborne viral infections risk factors/practices were collected using a structured questionnaire during August 2020. The results of serological data were obtained from students' electronic files.

RESULTS

All students tested negative for HBV, HCV, and HIV infections. The seroprevalence of positivity against HBV was 25.8%, and the frequencies of students with protective levels of anti-HBV were inversely related to their age. The majority (70.8%) of students had 1 or 2 identifiable risk factors for bloodborne diseases, and the most frequent risk factor was history of dental intervention. Female students were more than four-times likely to be in the high-risk group for bloodborne infections than males (OR = 4.4; 95% CI: 3.3-5.9). Being from the Central Province of Saudi Arabia (OR = 1.9; 95% CI: 1.2-3.1) and having a mother's educational level of master or doctorate (OR = 3.0; 95% CI: 1.3-6.7) were found to be independent predictors of being in the high-risk group. On the other hand, having a family member in the healthcare field was found as a predictor of being in the low-risk group for bloodborne diseases (OR = 0.7; 95% CI: 0.5-0.9).

CONCLUSION

About three-fourth of students in this study were susceptible to HBV. Our findings stress the need to develop policies to raise awareness regarding bloodborne infectious diseases, in addition to expanding access to HBV vaccination for healthcare staff, especially in older ages.

Demyelinating polyneuropathy associated with chronic inactive hepatitis B infection

This is a case report of a 42-year-old female patient with chronic inactive hepatitis B virus (HBV) infection who presented with relapsing chronic inflammatory demyelinating polyneuropathy (CIDP). Her initial attack was of acute onset (ie, acute CIDP) resembling Guillain-Barré syndrome that responded well to intravenous immunoglobulin (IVIG) therapy. The second episode was chronic and refractory to IVIG. She was managed with plasma exchange, long-term corticosteroids, immunosuppressants and HBV antiviral therapy. She showed both clinical and electromyographic improvement, with no recurrence after 2 years of follow-up.

Epidemiology screening and genotyping analysis for Hepatitis B virus in Southwestern region of Saudi Arabia

Hepatitis B virus (HBV) is a global human pathogen that can cause life-threatening liver disease including persistent hepatitis, cirrhosis of the liver and hepatocellular cancer. The aim of this present study was to investigate the infection of HBV epidemiology and also examine the HBsAg genotype distribution in the southwestern region of Jizan city in the Saudi Arabia. Since 2015-2018, epidemiological study has been conducted within the city premises of Jazan region. HBsAg genotyping with the molecular biology grade techniques was performed in 50 subjects. In this study, 1888 subjects in the Jazan city of the Southwestern region were diagnosed as positive for HBV. The mean age of the participants was found to be 44.5 ± 16.9 years. Over 68% of males and 31% of females participated in this epidemiological study. Approximately, 88% of Saudi nationalities were recruited with 12% involving non-Saudi subjects Genotyping analysis confirmed that 90% of subjects confirmed genotype-D and 10% confirmed genotypes A, H and E. Anova analysis could find no significant association between the genotype analysis and the clinical data (p > 0.05). The prevalence of HBV in the Jazan region was found to be high based on the clinical data from epidemiological studies conducted in the Southwestern region. Since 2015-2018, a total of 1888 samples have been found to be positive at Jazan premises. The HBsAg genotyping studies confirm in this study 90% of the genotyping-D was documented.

HIV in the Kingdom of Saudi Arabia: Can We Change the Way We Deal with Co-Infections

The first incidence of acquired immunodeficiency syndrome (AIDS) from the Kingdom of Saudi Arabia (KSA) was reported back in 1984, and by the end of 2013, around 1509 patients were diagnosed with HIV infection. Recently in 2018, the Saudi ministry of health released that the incidence of HIV in Saudi Arabia is 3 cases of HIV for every 10,000 of the population. Having said that, the surveillance of HIV will face a range of challenges in KSA despite proper medical care, counseling, family planning, diagnostic, evaluation, and the use of effective anti-retroviral therapy. Patients who underwent anti-retroviral therapy showed significant reduction in morbidity as well as mortality. On the other hand, further targeted treatment and preventive strategies are warranted to control HIV co-infections in the KSA. In addition, progress towards meeting the WHO 90-90-90 goals for HIV not only at KSA but at the MENA region too, which is that of the population, 90% are diagnosed, 90% undergoing treatment, and 90% under viral control, is not being systematically monitored. In this review, we discuss the common co-infections with HIV infections that are reported in KSA, which when compared to international trends, it is similar for both viral hepatitis and tuberculosis. Although those co-infections exist, they are presented in different ratios and percentages when compared to the international reported data. These differences mandates defining and introducing new resilient methods of treatment and preventive measures. In this review, we offer an insight into healthcare policymakers to be compliant with UNAIDS 2020 vision program. We also discuss some of the gaps and recommendations to achieve the WHO 90-90-90 goal.

Time trends of causes of upper gastrointestinal bleeding and endoscopic findings

BACKGROUND

Upper gastrointestinal bleeding (UGIB) is a frequent cause for emergency endoscopy and, in a proportion, requires the application of endotherapy. We aim to evaluate the proportion of variceal and nonvariceal upper gastrointestinal bleeding (NVUGIB), the endoscopic findings that were detected, as well as the temporal trends of endoscopic findings over a period of 13 years.

METHODS

This is a retrospective study of patients who underwent an esophagogastroduodenoscopy with an indication of UGIB or presented with hematemesis, melena, or both, as well as those who had hematochezia, from January 2004 to December 2016 (13 years).

RESULTS

A total of 2075 patients were included with a mean age of 56.8 years (range 18-113) and males constituted 67.9%, while 65.9% had at least one comorbidity. Symptoms on presentation included hematemesis (52.5%), melena (31.2%), both hematemesis & melena (15.1%), and hematochezia (1.2%). The majority of UGIB were from a NVUGIB source (80.5%) and a variceal source was found in 13.1%, while no endoscopic findings were found in 6.4% of cases. The most common endoscopic diagnosis was gastroduodenal erosions (23.8%), duodenal ulcers (23.5%), reflux esophagitis (16.0%), esophageal varices (12.1%), and gastric ulcers (10.8%). There was no change in the endoscopic findings over the time period of the study. A third of duodenal ulcers (33.3%) as well as 21.9% of gastric ulcers were actively bleeding at the time of endoscopy, while 3.3% of duodenal ulcers had an adherent clot.

CONCLUSIONS

NVUGIB composed the majority of cases presenting with UGIB and variceal bleeding was lower than that described in prior studies, but there were no clear trends in the proportion of causes of UGIB during the study duration.

A tool to measure the economic impact of Hepatitis B elimination: A case study in Saudi Arabia

BACKGROUND

No virologic cure exists for hepatitis B virus (HBV) infection, and existing therapies are designed to control viral replication. We aimed to estimate the national prevalence of HBsAg in 2017 and study the impact of an enhanced diagnosis rate and universal treatment administration on HBV-related outcomes in Saudi Arabia.

MATERIALS AND METHODS

A dynamic transmission and disease burden model was developed to estimate the future economic burden of HBV infection. The infected population was tracked by age and gender-defined cohorts; direct costs (healthcare, screening, diagnostics and treatment) and indirect costs (disability-adjusted life years and the value of a statistical life year) were calculated. The impact of two intervention scenarios (Achieve WHO Targets: diagnose 90% of infections and treat 80% of high viral load patients by 2030; and Diagnose and Treat All: diagnose and treat all infected patients by 2022) were compared against the Base Case scenario (no policy action), with near-universal vaccination coverage rates held constant. A sensitivity analysis of future treatment cost was also conducted.

RESULTS

In 2017, HBsAg prevalence was estimated at 1.7%, corresponding to 574,000 infections. The same year, there was an estimated incidence of 490 cases of decompensated cirrhosis, 1500 cases of hepatocellular carcinoma (HCC) and 1740 liver-related deaths (LRD). HBsAg prevalence was 0.1% among 5-year-olds and <0.1% among infants. Disease burden outcomes by 2030, as compared with 2015, were as follows - Base Case: LRDs and HCC incidence were projected to increase by 70%. WHO Targets: A 30-35% decline in both HCC incidence and LRDs. Diagnose and Treat All: A 50-55% decline in HCC incidence and LRDs. In all scenarios, HBsAg prevalence among infants and 5-year-olds declined to <0.1% with the Diagnose and Treat all scenario resulting in a prevalence approaching zero in this age group. Annual direct costs are projected to increase and peak by 2022 in both intervention scenarios due to expansion of treatment and diagnostics. However, these are offset by the reduction of indirect economic costs, starting immediately in the WHO Targets scenario and by 2023 in the strategy to diagnose and treat all. Achieving WHO Targets is estimated to achieve a positive return on investment (ROI) by 2021 when examining direct costs and indirect economic losses at a treatment price of $2700 USD per patient yearly. Diagnosing and treating all patients, however, would require at least a 50% reduction in the unit cost of treatment to achieve a positive ROI by 2029.

CONCLUSIONS

Increased diagnosis and treatment rates of HBV would lead to substantial declines in HCC and LRD. This effect would be dramatically enhanced by administering treatment to all HBV cases regardless of viral load and estimated to be highly cost-effective if treatment prices can be substantially reduced.

The Incidence Rate of Liver Cancer in Saudi Arabia: An Observational Descriptive Epidemiological Analysis of Data from the Saudi Cancer Registry (2004-2014)

Objective

This study describes the epidemiological pattern of liver cancer in all regions of Saudi Arabia. It explores the frequency of cases diagnosed, the age-specific incidence rate (AIR), the crude incidence rate (CIR), and the age-standardised incidence rate (ASIR) stratified by age group, year of diagnosis, and region.

Methods

A retrospective descriptive epidemiological analysis of all liver cancer cases documented in the Saudi Cancer Registry (SCR) between 2004 and 2014 was performed. The data were analysed using descriptive statistics, t-test, Kruskal–Wallis, and sex ratio with the Statistical Package for the Social Sciences version 20.0 (SPSS).

Results

A total of 4723 liver cancer cases were registered in the SCR between January 2004 and December 2014. The highest overall ASIR of liver cancer among Saudi males was observed in the regions of Riyadh, Najran, and Tabuk at 10.4, 7.7, and 7.0 per 100,000 males, respectively. Furthermore, Riyadh, Eastern Region, and Tabuk recorded the highest overall ASIR among Saudi females at 4.9, 2.8, and 2.6 per 100,000 females, respectively. Jazan had the lowest overall ASIR (1.7 per 100,000 males) of liver cancer among male Saudis, while the Northern region and Baha had the lowest overall ASIR (0.6 and 0.9 per 100,000 females, respectively) of liver cancer among female Saudis. However, the overall ASIR of liver cancer was statistically higher in males than females (P-value <0.05), and the overall male-to-female ratio in ASIR of liver cancer in Saudi Arabia was 2.4 per 100,000.

Conclusion

There was a slight increase in the CIRs and ASIRs of liver cancer in Saudi Arabia between 2004 and 2014. Riyadh, Najran, and Tabuk were the areas most affected by liver cancer among Saudi males, and Riyadh, Eastern Region, and Tabuk among female Saudis. The areas least affected by liver cancer were observed in Jazan among Saudi males, and the Northern region and Baha among Saudi females. The rates of liver cancer in Saudi Arabia were significantly higher among males compared with female Saudis.

Molecular epidemiology, phylogenetic analysis and genotype distribution of hepatitis B virus in Saudi Arabia: Predominance of genotype D1

Despite the implementation of various vaccination programs, hepatitis B virus (HBV) poses a considerable health problem in Saudi Arabia. Insight on HBV evolutionary history in the region is limited. We performed a comprehensive epidemiological and phylogenetic reconstruction based on a large cohort of HBV infected patients. Three hundred and nineteen HBV-infected patients with different clinical manifestations, including inactive and active chronic carriers and patients with cirrhosis and hepatocellular carcinoma (HCC), were enrolled in this study. The full-length large S gene was amplified and sequenced. Phylogenetic analysis was performed to determine the genotype and subgenotypes of the isolates. Phylogenetic tree analysis revealed that genotype D is the most dominant genotype among patients. Moreover, this analysis identified two strains with genotype E isolated from active carriers. Detailed phylogenetic analyses confirmed the presence of four HBV D subgenotypes, D1 (93%, n = 296), D2 (0.02%, n = 5), D3 (0.003%, n = 1), and D4 (0.003%, n = 1). In addition, six genotype D strains were not assigned to any existing HBV D subgenotype. The large S gene of eight strains showed signatures of genotype recombination between the genotypes D and A and between D and E. Several strains harbored medically important point mutations at the protein level. Along with the dominance of the HBV genotype D, isolation of the E genotype and several recombinant strains from patients with Saudi Arabian origin is an essential result for decisions involving therapeutic measures for patients. Development of vaccines and detection of diagnostic escape mutations at antigenic epitopes on the HBsAg will be valuable to public health authorities. Furthermore, the diversity at the nucleotide and amino acid levels and different proportions of dN/dS at the PreS1, PreS2, and HBsAg reveal the selective pressure trend from inactive status towards advanced liver diseases.

Quantitative HBsAg levels do not identify hepatic fibrosis in HBeAg-negative chronic hepatitis B patients

BACKGROUND/AIMS

Quantitative serum hepatitis B surface antigen (qHBsAg) has been evaluated in limited patient groups as a marker of histological fibrosis. The accurate identification of inactive chronic hepatitis B virus (HBV) carriers from those with active carriers is difficult because of wide and frequent HBV DNA fluctuations. We aimed to assess the utility of qHBsAg in distinguishing histologically significant fibrosis in untreated HBeAg-negative chronic HBV patients.

PATIENTS AND METHODS

qHBsAg levels were measured at baseline as single-point quantification and correlated with virologic and biochemical profiles of consecutive carriers (median, 29; range, 12-110 months). HBeAg-negative patients (n = 75) with HBV DNA <2000 (n = 5), 2000-20,000 (n = 16) and >20,000 IU/mL (n = 54) were included and all had liver biopsy. A qHBsAg cutoff point of 1000 IU/mL was assessed to demonstrate whether it better delineated patients with non-significant histology (F0-1, inflammatory grade A0-1).

RESULTS

Mean age of the patients was 39.4 ± 11.4 years and 58 (77.3%) were male. Patients with qHBsAg levels >1000 IU/mL were more likely to be males (84.5%, P = 0.006) or with elevated AST (68.4%, P = 0.0002) and ALT levels (72.4%, P < 0.0001), higher HBV DNA (log₁₀ 6.4 ± 1.4, P < 0.0001) and those with F2-4 fibrosis (48.3%, P = 0.028). Serum log₁₀ qHBsAg were significantly lower in patients with HBV DNA <2000 (2.80 ± 1.47) and HBV DNA 2000-20,000 (2.71 ± 0.83) vs. >20,000 IU/mL (3.89 ± 0.61, P < 0.0001). Overall, qHBsAg were not different in patients with F0-1 (3.44 ± 0.91) and F2-4 fibrosis (3.74 ± 0.85, P = 0.161). Serum qHBsAg were higher in patients with significant (A2-3) inflammation (3.85 ± 0.72) compared to A0-1 (3.38 ± 0.95; P = 0.018). Serum qHBsAg demonstrated poor accuracy (AUROC, 0.61, P = 0.111) in identification of F2-4 fibrosis.

CONCLUSION

Serum qHBsAg levels do not help differentiate between those with HBV DNA <2000 or 2000 - 20,000 IU/mL or distinguish patients with significant fibrosis. Moreover, more than half of the patients with non-significant fibrosis have a qHBsAg level greater than 1000 IU/mL.

Knowledge, awareness, attitude, and practice of health-care professionals toward hepatitis B disease and vaccination in Saudi Arabia

Objectives: Health-care professionals (HCPs) are at very high risk for accidental exposure to hepatitis B virus (HBV) from infected patients; as such, this study aimed to investigate the knowledge, awareness, attitude, and practice of HCPs toward hepatitis B vaccination.Methods: We conducted a cross-sectional study with a pre-tested, validated questionnaire in seven major cities in Saudi Arabia from January to April 2015. The questionnaire consisted of four sections: demographics, knowledge, awareness of hepatitis B infection, and attitude of HCPs toward HBV. We analyzed the data collected from study participants using SAS® V9.2.Results: Approximately 16.5% of participants reported that they had not received the hepatitis B vaccine; however, the majority of participants believed that hepatitis B is common (73.2%) and that vaccination is an effective strategy to reduce disease incidence (75%). Availability of the vaccine was a major barrier to vaccination (48.7%), together with safety concerns surrounding the vaccine (37%).Approximately 31.2% of non-vaccinated participants believed the hepatitis B vaccine is not safe, while only 8% possessed this belief in the vaccinated group. Additionally, 36.4% of non-vaccinated participants were unsure of the effectiveness of the vaccine, compared to 24.3% in the vaccinated group. Inability to afford the vaccine was reported by 18.2% of the non-vaccinated group compared to only 4% of vaccinated participants.Conclusion: There is notable hepatitis B vaccination coverage among HCPs, but observed levels are below global standards. We believe the hurdles preventing non-vaccinated HCPs from being immunized must be addressed.