Written for B Informed by Dr. Hasan Irmak and Dr. Zeliha Kocak Tufan, Ministry of Health, Ankara Research & Training Hospital, Ankara, Turkey; and Dr. Abdurrahman Tufan, Hacettepe University Faculty of Medicine, Ankara, Turkey (November 2005).
In Turkey, hepatitis B is one of the main health problems facing the country. There are three to four million people who carry the hepatitis B virus (HBV). The average rate of hepatitis B carriers is about 6%, while the number of those recovered from an infection is 30%. The incidence of HBV, however, varies in different areas of the country.
Hepatitis B Infections
Horizontal transmission" (person-to-person) is the primary route of HBV infection in Turkey. This is significant among affected families, especially school-age children.
Viral hepatitis and HIV screening recently became compulsory among pre-school children and for those seeking a wedding license. In addition, hepatitis screening is frequently required for membership to many organizations, sports centers, and swimming pools. Increasingly, new cases of HBV are being found as result of these screenings.
The Turkish Ministry of Health started free routine HBV vaccination of all infants in 1998 (the vaccine costs about $14 per dose). Children and adults receive free vaccination only if they are in a high-risk group (i.e. healthcare workers, medical students, family members of those who are infected, etc.). This may change, however, and studies are being conducted to evaluate this possibility.
Management and Treatment
For the follow up of inactive HBV carriers, blood tests include AFP and ALT levels every six months. If the ALT is high, then HBV DNA is checked. Ultrasounds are routinely performed every 6 months for the high-risk group (men greater than 45 years or those who have hepatocellular carcinoma in their family) and for those whose AFP is above 20ng/mL. Otherwise, they are done annually for the low-risk group (women and men less than 45 years). For those who have high HBV DNA or intermittent or persistent high ALT levels, monitoring is done every three to six months, a liver biopsy is suggested, and they are evaluated for treatment.
The approved HBV drugs in Turkey include interferon alpha, lamivudine, adefovir dipivoxil and pegylated interferon. Some medical centers are conducting Phase III studies of entecavir and telbivudine. Treatment is free for the poor or those with government insurance. Interferon therapy costs about $900/month, and pegylated interferon costs $1,500/month.
In Turkey, the main cause of cirrhosis is chronic viral hepatitis. A study with 573 cirrhotic Turkish patients revealed that viral hepatitis was the cause for cirrhosis in 55 % of the patients vs. alcoholism in 12%. Additionally, the study revealed that the primary cause of viral hepatitis and cirrhosis was HBV (45.9%) versus HCV (31.3%) and HDV (19.6%).
It is also estimated that viral hepatitis is responsible for 65% of primary liver cancer in Turkey. One study showed the prevalence of primary liver cancer was found to be in 42% of HBV patients, 15% HCV patients, and 8% HDV co-infected patients.
Hepatitis D Infections
Worldwide, 5% of all HBV carriers are thought to be co-infected with the hepatitis D virus (HDV). Fortunately, a decrease in HDV infection rates has been detected over the last few years. This decline is attributed to HBV vaccination, improvement of socio-economic standards, and better health education.
National HDV prevalence rates for the past 10 years have declined from almost 7% in 1991 to as low as 2.9% in 2001. Despite the overall decrease in numbers, hepatitis D is endemic in Turkey. A recent study showed that HBV and HDV co-infections were found to be as high as 20% in Southeastern Anatolia and 6.8% in Istanbul. In addition, a study by H. Degertekin showed that HBV is the cause of almost 69% of all chronic liver disease in eastern and southeastern Turkey.
Looking Forward
The overall prevalence of hepatitis B infections is decreasing in Turkey, and the role of HBV and HDV in chronic liver diseases is also gradually decreasing as well. But HBV remains the country's most significant cause of viral hepatitis and chronic liver disease.
In the near future, the hope is to greatly reduce hepatitis B through vaccination and screening programs that are strongly supported by the government.
BInformed, Winter 2006.
