Infections with hepatic viruses HVB and HVC remain a global public health issue, with epidemiology in continuous change, determined by a series of factors, including the vaccination policy and the migration of the populations. These infections represent one of the main causes for the presence of hepatic illnesses across the entire world.
All patients with chronic viral infection HVB present high risk of progression toward cirrhosis and hepatocellular carcinoma (HCC), depending on the host and the viral factors.
Despite medical knowledge in the field being in continuous evolution, there are areas of uncertainty and thus, clinicians, patients and authorities in the domain of public health must often make choices based on clinical evidence.
Approximately 240 million people carry HVB (Ag HBs positive) with decreasing prevalence in a few endemic countries, due to the improvement of living standards, universal vaccination programmes and efficient antiviral treatments.
Nevertheless, the migration of populations has changed the prevalence and the incidence in a few countries with low endemics in Europe, such as Italy and Germany. Deaths due to cirrhosis and/or HCC increased by 33% between 1990-2013. The emergent incidence of cirrhosis varies between 8-20 % in untreated patients, and among them, the progression toward terminal hepatic illness within 5 years is 20%.
The risk of discovering HCC is higher in the case of male patients with cirrhosis, the elderly, alcohol consumers, diabetics, active smokers, and/or a positive HVB family history. The annual risk for HCC emergence in patients with hepatic cirrhosis was reported at between 2-5 %.
The initial evaluation of a patient with chronic HVB infection includes the complete history, the physical examination, the complete analysis of hepatic illness parameters and the complete performance of the HVB viral profile. Moreover, all first-degree relatives and sexual partners of patients infected with HVB must be advised to perform the HVB infection serological markers and be mandatorily vaccinated if these markers are negative.
An abdominal echography is recommended to all patients. Non-invasive tests and a hepatic biopsy must be performed, in order to determine the activity of the illness where biological parameters are non-conclusive.
Among non-invasive tests, the most necessary are the ones that include the measurement of hepatic rigidity and hepatic fibrosis serological markers (fibroscan/fibromax). These tests are very important, because they can exclude advanced fibrosis or hepatic cirrhosis.
Elastography is also studied extensively and seems to be an effective method for detecting advanced fibrosis, which can be confused with severe inflammation in the case of highly increased transaminases (ALT. AST).
The main purpose of the therapy for patients with chronic HVB infection is to increase survival and the quality of life, in order to prevent the progression of the illness and the emergence of hepato-carcinoma, as well as the prevention of the HVB infection being transmitted from mother to child in pregnant women.
The impact of HVC infection long-term is variable, from minimal modifications of mild chronic hepatitis to advanced fibrosis with or without hepato-carcinoma.
The number of patients chronically infected with HVC is estimated to be approximately 180 million worldwide, but there are many patients who are not aware of their illness.
The care of patients with HVC infection has developed considerably in the last two decades, due to the understanding of the illness and the discovery of new methods for diagnosis and treatment, as well as prevention. The main target of the therapy in cases of HVC infection is curing the infection, which happens in 99% of patients.
The diagnosis of chronic HVC infection is based on specific laboratory samples, in the presence of non-invasive tests with typical characteristics of chronic hepatitis.
Screening for HVC is very important, since a major barrier in eliminating HVC is the fact that a substantial proportion of patients with HVC are not aware they are infected. That is why testing for HVC is mandatory for identifying infected people and including them in monitoring and treatment programs, and screening for HVC markers must be implemented for the general population.
There are quick detection tests that can be performed simply, at room temperature, with no special instruments or prior special training.
All patients must also be tested for other viral infections, HVB, HIV, and alcohol consumption must be evaluated and quantified, for special counselling in view of definitive elimination. The association of other illnesses, such as cardiac illnesses, renal failure, autoimmunity, genetic or metabolic diseases and possible hepato-toxicity due to drugs must be evaluated.
Thus, a complete diagnosis is essential, especially in the case of patients aged above 50 years old.
The prophylaxis of HVB and HVC infections is very important in order to reduce the number of chronic viral infections and the illnesses generated by them. This purpose is achieved by implementing blood and blood-derivatives screening programmes, maintaining standard procedures for selecting blood donors, using correct guides for preparing blood derivatives, testing blood and tissue donors, preventing the transmission of the infection through medical and surgical procedures including dental procedures or traditional medical procedures, minimizing professional exposure, and implementing family sanitary education programs.
Prof. dr. Irinel Popescu