Electronic Appendix

Hepatitis in Saigon – Vietnam
José M Bengoa, Geneva University Hospital

We have started to study the epidemiology of viral hepatitis in Saigon and we have begun educational programs for hepatitis infection prevention. Data collected since 2003 in a city hospital has been reported in scientific meetings and several information booklets for patients have been published in Vietnamese.

Viral hepatitis is a major cause of chronic liver disease and a worldwide public health problem. It is estimated that 400 million persons are infected with hepatitis B virus (HBV) and over 250 million with hepatitis C (HCV). Hepatitis represents a leading cause of death with cirrhosis and liver cancer in Vietnam where most of HBV infection results from perinatal transmission and most HCV from health care associated procedures.

The Research Project:
High rates of positive viral hepatitis serology in patients attending city hospitals challenge healthcare providers in Saigon.

Community based studies indicate a very high HBV prevalence of 10-20%. A study performed before expanding programs of infant vaccination reported that 18.8 % of adults were HBsAg positive. A current estimate of HBV prevalence was 8.4 million cases in Vietnam and consequently liver disease related burden of cirrhosis and liver cancer will continue to rise for years to come. HCV prevalence of 1% to 4 % has been found with healthcare related risk factors of infection. With these high rates of infection the risks of transmission in hospitals are greatly increased both for patients and health care professionals. We have focused our research on the screening of patients coming to the hospital for appropriate guidance on preventive measures and indications for treatment.

Results of studies presented at scientific meetings

HBV: In a patient population attending a hospital in Saigon the observed prevalence of 26 % HBsAg positive was higher than the rate of 18.8% reported in a community study in a rural area five years ago. A total of 67.5% of patients had markers of present or past HBV infection. In the HBV cohort 29% were HBeAg positive with high viral loads putting them at high risk of chronic liver disease and justifying complete evaluation for indication to treat.  In HBeAg negative patients 65% had HBV-DNA detectable a condition requiring treatment. Among the 41.5% anti-HBc positive cases many may have occult hepatitis B and retain a significant risk of disease. (Prevalence of HBV in Switzerland 0.5%).

HCV: The prevalence of 6.5% anti-HCV positive was several folds higher than the 1% reported in a rural area in the north of Vietnam but similar to values found in other Mekong River regions. Genotypes 1 and 6 accounted for 86% of HCV infection. Genotype 1 is considered difficult-to-treat and the response rate of genotype 6 is not well documented to date. Co-infection HBV and HCV is common, a condition requiring complete evaluation of both viruses before treatment decisions. (Prevalence of HCV in Switzerland 0.7%).

Liver Biopsy: A case series description of 100 consecutive HCV liver biopsies recorded for epidemiology, laboratory and histology were examined by multivariate analysis. The group included 50% men, 98% Vietnamese, mean age 47.5 years, BMI <23 in 63%. Risk factors were previous invasive medical procedure in 48%, blood transfusion in 25%, acupuncture in 18%, and heroin injection in 2%. Only 17% drank more than 20g of alcohol. HCV genotypes were 66% type 1, 7% type 2, 1% type 3, and 23% type 6. Metavir scores of fibrosis were F0/F1 in 69%, F2/F3/F4 in 31%. Multivariate analysis showed that APRI score was the only independent variable predictive of advanced fibrosis (p<0.01). Age, sex, BMI, viral load and risk factors for infection were not predictive of fibrosis. Genotype 1 and genotype 6 were most prevalent. One third of cases had advanced fibrosis.

Application
These results highlight the magnitude of the hepatitis problem in Vietnam where there is no medical insurance coverage. HBV prevalence is 30-50 times higher and HCV is 10 times higher than in Switzerland. Although effective therapy is now available for viral hepatitis access to very expensive treatment is restricted. Therefore the bulk of the effort must be directed towards preventive measures and identification of cases through mass screening. 

Educational programs are a major commitment of GFMER, a foundation that has been organising post-graduate courses on research methodology for medical doctors from developing countries for many years in cooperation with WHO. GFMER develops research programs with direct application and establishes collaborations with public and private institutions in developing countries.

For our project three illustrated booklets on hepatitis B and hepatitis C have been published in Vietnamese (see Fig. 2) and largely distributed to the patients. Several leaflets on hepatitis B vaccine and maternal-infant transmission of hepatitis B have been produced. Guidelines for health care professionals have been given to raise concern on potential conditions of infection in hospital.

Through this cooperation Swiss hepatologists provide valuable expertise and participate in the training of Vietnamese hepatologists which will foster ongoing clinical research to improve management and treatment of patients in Vietnam. 

Key messages

• Hepatitis B and hepatitis C have epidemic prevalence in Saigon
• Hospitals are high risk areas for transmission of infection
• Preventive measures and guidelines are a very high priority

Partner Institutions

• Geneva Foundation for Medical Education and Research, Switzerland   www.gfmer.ch
  a WHO collaborating center for medical teaching in developing countries
  
• Geneva University Hospital, Division of Gastroenterology and Hepatology, Switzerland a center of excellence in liver diseases
  
• FV Hospital, 6 Nguyên Luong Bang, Quân 7, Ho Chi Minh City, Vietnam
  a new tertiary care facility in south Saigon   www.fvhospital.com
  
• Dr José M Bengoa     jmbengoa@hin.ch           Dr Pierre-Jean Malè    pjmale@hin.ch