Proportion of People Who Are Positive for HBsAg and Anti-HCV Antibody Among Participants in a Community Screening Campaign in Malaysia

Background: The epidemiology of Hepatitis B (HBV) and C (HCV) remains poorly documented in Malaysia. Available statistics are based on data from mostly small studies in special populations. Objectives: In this study, we provide estimates of the proportion of people who are positive for HBs Antigen (HBsAg) and anti-HCV antibody (Ab) among participants in a community screening campaign. Methods: A total of 10,914 subjects participated in the hepatitis screening campaign organized by Hepatitis Free Pahang in 2018 and 2019. A low-cost point-of-care test, which has previously been validated, was used to screen for HBsAg and anti-HCV Ab. All screened positive subjects were recalled to undergo confirmatory serologic tests (enzyme-linked immunosorbent assay) and nucleic acid tests (Real-time Polymerase Chain Reaction. Results: We estimated that 1.17% of adults aged 20 or older who participated in the screening campaign were positive for HBsAg+, and only 0.71 percent were positive for anti-HCV Ab+. Young adults below 30 years of age had a very low proportion of HBsAg+ (0.09%). Women had a lower proportion of HBsAg+ and HCV- Ab+, Chinese had the highest proportion of HBsAg+, while Malay had the highest proportion of anti-HCV Ab+. Conclusions: Among adult participants of screening in Malaysia, chronic HBV is still common, especially among older and Chinese people. Adults with positive anti-HCV Abs are much less common.

Duration of Hepatitis B Vaccine-Induced Protection among Medical Students and Healthcare Workers following Primary Vaccination in Infancy and Rate of Immunity Decline

Since the introduction of hepatitis B virus (HBV) vaccines, the numbers of HBV infections and complications have significantly decreased. However, the evidence on whether primary vaccination of infants confers lifelong immunity varies. We aimed to assess long-term immunity among healthcare workers and medical students, and the rate of decline of HBV surface antigen antibodies (anti-HBs). Hepatitis B status among participants born after 1 January 1992 was reviewed at Chulabhorn Royal Academy, Thailand. Participants were stratified by intervals since primary vaccination. HBV immunity was determined and analyzed as anti-HBs decline rate in participants with multiple follow-ups. A total of 464 participants were analyzed, with a median age of 23. Protective immunity against HBV (anti-HBs ≥ 10 mIU/mL) at 16–20, 21–25 and 26–28 years post-primary vaccination was 28%, 51.7% and 60%, respectively. The overall declining rate of anti-HBs was −42.39 mIU/mL per year. Participants with anti-HBs levels of >100–1000 mIU/mL at baseline had a faster decline rate than those with anti-HBs levels of 10–100 mIU/mL. Primary vaccination may not provide lifelong protection since HBV immunity deteriorates over time. Individuals with higher initial HBV immunity levels may experience a faster decline rate.

Hepatitis Screening and Treatment Campaign in Malaysia-Validation of Low-cost Point of Care Screening Tests and Nucleic Acid Tests for Hepatitis B and C

Background

Two major challenges in implementing budget-constrained Hepatitis screening and treatment campaign in Malaysia are the availability of low-cost point of care tests (POCT) and nucleic acid tests (NAT) for hepatitis C virus ribonucleic acid (HCV RNA) and hepatitis B virus dioxyribo nucleic acid (HBV DNA). We evaluated the performance of these tests in this study.

Methods

We conducted a cross-sectional study to evaluate the diagnostic performance of four POCT brands at 12 sites in Malaysia. We assessed the sensitivity and specificity of the POCTs for the detection of HBsAg and anti-HCV in a finger-stick capillary or venepuncture whole-blood samples compared with test results from lab-based enzyme immunoassay (EIA) or chemi-luminescence immunoassay (CLIA) assay as the reference standard. We also conducted a cross-sectional study on 30 to 139 serum specimen panel to evaluate the diagnostic performance of a low-cost in-house Applied Biosystem^®TaqMan real-time polymerase chain reaction (PCR) assay (ABS) for the detection of HCV RNA and HBV DNA, compare with Roche Cobas^® Ampliprep/TaqMan assay (COBAS).

Results

Between March and December 2017, we enroll 295 participants for the evaluation of POCT for HBsAg and another 307 participants for POCT anti-HCV evaluation. Three of the four POCT brands dropped out of evaluation early on account of sub-optimal sensitivity. The sensitivity of the remaining POCT for HBsAg was 95.2%and specificity 100%, while the POCT for anti-HCV has a sensitivity of 98.1% and specificity 100%.

Hepatitis B virus dioxyribo nucleic acid and HCV RNA concentrations detected by the ABS were systematically higher than those measured by COBAS (mean bias +0.10 and +0.17 log10 IU/mL respectively). The 95% limits of agreement between the two assays are -1.28 to 1.47 log10 IU/mL for HBV DNA and –0.41 to 0.75 log10 IU/mL for HCV RNA.

Conclusion

We found adequate evidence for the diagnostic validity of a low-cost POCT for anti-HCV and HBsAg, as well as for an in-house nucleic acid tests (NAT), to provide support for their broader use in our Hepatitis screening and treatment campaign.

Abbreviations

ABS: Applied Biosystem^®TaqMan real-time PCR assay, CI: Confidence interval, CLD: Chronic liver disease, CLIA: Chemi-luminescence immunoassay, COBAS: Roche Cobas^® Ampliprep/ TaqMan assay, DAA: Direct Acting Anti-Viral drugs, EIA: Enzyme immunoassay, HBV: Hepatitis B virus, HCV: Hepatitis C virus, HFPM: Hepatitis Free Pahang Malaysia, LOA: Limits of agreement, LOD: Limit of detection, MOH: Ministry of Health, Malaysia, NAT: Nucleic Acid Tests, POCT: Point of Care Tests, SD: Standard deviation, WHO: World Health Organization

How to cite this article: Radzi AHM, Tan SS, Mohamed R, Jaya F, Senamjit K, Aun AC, Kutty GA, Wong HS, Abdullah R, Seman MR, Mahtab MA, Morad Z, Lim TO. Hepatitis Screening and Treatment Campaign in Malaysia-Validation of Low-cost Point of Care Screening Tests and Nucleic Acid Tests for Hepatitis B and C. Euroasian J Hepatogastroenterol, 2018;8(2):101-107.

Hepatitis A and B among newly arrived refugees: Vaccinate all, or test first for immunity?

AIM

When screening newly arrived refugees, physicians must decide whether to vaccinate against hepatitis A and B at first encounter, thereby minimising missed opportunity, or to test for immunity and vaccinate only the susceptible, minimising unnecessary intervention. Better knowledge of hepatitis A and B immunity in refugee populations from different parts of the world is needed.

METHOD

Overseas and domestic medical records of refugees from Africa, Asia, and the Middle East who entered Marion County (Indiana) between 1 September 2016 and 31 December 2017 were reviewed.

RESULTS

Of 1191 refugees, 1163 and 1153 were tested for immunity to hepatitis A and B respectively. Among <19 year-olds, immunity to hepatitis A ranged from 52.1% to 79.6%, and immunity to hepatitis B ranged from 75.5% to 87.6%. Among ≥19 year-olds, immunity to hepatitis A was greater than 90% for each of the three regions, whereas immunity to hepatitis B ranged from 19.3% to 94.4%. 96% of refugees in the subset of Burmese ≥19 years old were immune to hepatitis B. Of individuals immune to hepatitis B, immunity was due to vaccination in 94.1% of <19 year-olds and 57.4% of ≥19 year-olds. 10% of refugees with at least three documented doses of hepatitis B vaccine were negative for hepatitis B surface antibody. 34.1% of uninfected refugees with no documented doses of hepatitis B vaccination were positive for hepatitis B surface antibody.

CONCLUSION

It is reasonable to begin hepatitis A vaccination of <19 year-olds in this refugee population at first encounter but to test first for hepatitis A susceptibility before vaccinating those ≥19 years old. Similarly delaying hepatitis B vaccination might be appropriate only for a subset of Burmese adults.

Hepatitis in Malaysia: Past, Present, and Future

Malaysia is multiethnic, with a population of 31,127,247 comprising a mixture of Malays (50.1%), Chinese (22.6%), Indians (6.7%), Aborigines (11.8%), others (0.7%), and noncitizens (8.2%). Like other countries in the region, viral hepatitis is an important public health problem in Malaysia. The 3 most common causes for hepatitis in Malaysia are hepatitis A, B, and C. Hepatitis A has been a reportable disease in Malaysia since 1988. Due to the introduction of government control programs, the national incidence rate has dropped steadily. It is now estimated that 50% of Malaysians less than 30 years of age do not have antibodies to hepatitis A and are therefore susceptible to the disease, which can be prevented by reinforcing the hygiene status of the general population. Malaysia is a country of medium seroprevalence for the hepatitis B virus (HBV) surface antigen (HBsAg) in the general population (1.5-9.8%). The major route of transmission is from infected mother to fetus. There are an estimated 1 million people chronically infected with hepatitis B in Malaysia. Approximately 75% of all viral hepatitis cases are due to hepatitis B infection, with a male-to-female ratio of 2:1. Chronic hepatitis B (CHB) accounts for more than 80% of the hepatocellular carcinoma (HCC) cases seen in Malaysia and HCC is the 3rd most common malignant neoplasm and among the 10 leading causes of death. Most common genotypes are B and C. Incidence rates among Chinese, Malays, and Indians are 36, 26, and 15% respectively. The hepatitis B vaccination program for children was introduced in 1989, which successfully managed to reduce the seroprevalence of infection among Malaysians to 0.01% (graph 4, 2014). But the disease burden will still remain high for some time as the infected people are getting older and living longer. Hepatitis C virus (HCV) infection is a growing problem in Malaysia. An estimated 453,700 people were living with HCV infection in Malaysia in 2009 (2.5% of the population aged 15-64 years), of whom 59% acquired their infection through injection and the most common genotypes found are genotype 3 and 1. The HCV-related disease burden is already high and is forecast to rise steeply over the coming decades under current levels of antiviral treatment. Increased governmental resources to improve HCV screening and treatment rates and to reduce transmission are essential to address the high projected HCV disease burden in Malaysia.

How to cite this article

Raihan R. Hepatitis in Malaysia: Past, Present, and Future. Euroasian J Hepato-Gastroenterol 2016;6(1):52-55.

Protection Provided by Hepatitis B Vaccine in Adult Population of Chaharmahal and Bakhtiari Province, Iran in 2013

INTRODUCTION

Hepatitis B vaccination has been integrated into National Expanded Program on Immunization in Iran since the year 1993 and young adult national vaccination project was done in 2008. So we have three subpopulations with vaccination coverage for hepatitis B and different antibody levels. Consisting of Subpopulation 1 born after 1993, subpopulation 2 born between 1989 and 1993 and receiving vaccination under adult national project, and subpopulation 3 born prior to the year 1989.

AIM

The present study was conducted to investigate community protection by hepatitis B vaccine in adult population in an accessible population in Iran and compare vaccination coverage, HBs Ab level, and its effective titration among the three above-mentioned subpopulations.

MATERIALS AND METHODS

This cross-sectional study was done on a 3000-individual adult population from all seven counties of Chaharmahal and Bakhtiari province enrolled by clustering. After obtaining written consent and filling out a questionnaire of demographic data and history of hepatitis B vaccination by trained interviewers, necessary blood sample was taken and HBs Ab titration was checked. The data were analysed by chi-square in SPSS 19. The level of significance was considered as 0.05 and effective Ab titration as ≥ 10.

RESULTS

The mean age of the participants was 38.4±16.3 years. Of the participants 48.2% had effective titration. For vaccination coverage, 77.4% were unvaccinated, 20% completely vaccinated, and 2.6% incompletely vaccinated with a significant association with effective titration (p<0.001). Eighty six percent of the subpopulation 1 and 79% of the subpopulation 2 were completely vaccinated, with a significant difference in effective titration between them (p<0.001). Vaccination coverage was higher in men and the single but equal in cities and villages. The effective titration was significantly associated with being married and residence place (p=0.003). There was a significant association between effective titration and the time at vaccination (p<0.001).

CONCLUSION

Protection provided by hepatitis B vaccine in adult population is relatively suitable especially in the youth population; however, catch-up programs of the groups exposed to risk are recommended.