Large gaps in Malaysians’ self-awareness of hepatitis B infection

Seven-in-eight Malaysians living with hepatitis B infection may not know it, with concerning ramifications for public health, according to a recent study.

In a retrospective data analysis of 10,436 participants in a series of community-based hepatitis B virus (HBV) screening campaigns, a total of 200 HBV-positive adults aged 20 and older were identified. However, only an estimated 13.1 percent (n=33, 95 percent CI 7.7–18.5) of them reported being previously aware they carried the virus. Of these, only 1 percent (n=2, 95 percent CI 0.0–1.6) reported having received antiviral treatment for their condition. [medRxiv 2020; doi: 10.1101/2020.06.15.20131409]

In addition, the link to post-screening care “was broken in substantial number of patients,” with only 58 percent (n=115) of those identified HBV-positive seeking care and being on follow-up. Of those, only 3 percent (n=6) subsequently received antiviral treatment. This was despite offers for free follow-up HBV DNA testing and repeated calls and reminders from healthcare providers.

Among common risk factors for HBV infection identified were perinatal transmission indicated by maternal (30 percent) or sibling (52 percent) history of HBV; living with others with HBV (55 percent); acupuncture or cupping (bekam) treatment (42 percent); tattoo or other body piercing (25 percent); and needle-stick injury (38 percent).

Published in June, this study is currently in preprint and has not yet been peer reviewed. The sampled data was derived from campaigns conducted by Hepatitis Free Pahang Malaysia (HFPM) and associated NGO partners between 2018 and 2019. The subsequent study was conducted in collaboration between HFPM and specialists from University Malaya Medical Centre, Universiti Sains Malaysia, Hospital Selayang, and the MOH Clinical Research Centre.

Factors with associated social stigma or legal issues such as drug use, transgender identity, or a history of sex with other men were considered underreported due to non-anonymous questionnaire administration. To avoid skewing prevalence estimates, NGOs representing high-risk populations were also excluded from the study.

Asked about how traditional treatments such as cupping—which do not involve needle sticking—affected HBV risk, study corresponding author and HFPM president Dr Lim Teck Onn said that any treatment with improperly sterilized shared equipment and micro-injury potential could increase risk.

Closing gaps in the care cascade

In 2016, the WHO established a global strategy to eliminate HBV by 2030 through five core interventions. The study authors highlighted that while the first four WHO interventions focus on preventive measures, the fifth—termed the ‘cascade of care’—focuses on the continuum of services for persons with chronic HBV, ranging from screening to diagnosis to treatment to chronic care.

“Few Malaysian adults with HBV were aware of their infection and even less received antiviral therapy,” wrote the authors. “Concerted public health efforts are urgently needed to improve HBV screening and [the] care cascade in order to meet [the] WHO’s targets for HBV elimination.”

Lim highlighted that HFPM offers free HBV test kits at no cost to GPs who want to offer testing in their clinics.

Discussing the low awareness as well as follow-up and treatment rates, the study authors identified three key gaps in the Malaysian HBV care cascade that needed to be closed, namely poor access to low-cost HBV DNA testing; mobilization of local primary care workers to treat uncomplicated chronic HBV; and non-adherence to chronic care recommendations, whether due to ignorance or social and/or cultural barriers.

Among the study limitations identified by the authors was the overrepresentation of participants from Pahang and from certain ethnic-based groups due to the campaigns being conducted through local NGOs. There were more women and older participations than in the general population. They also noted that individuals already aware of their HBV status might also be more reluctant to participate in voluntary screening programmes.