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Newsletter, August 2013

August 2013 – Newsletter


Dear Reader,
It is a pleasure to introduce the summer issue of the Hepatitis B & C Public Policy Association’s newsletter which features two articles from our new editorial board members Prof. Federico Villamil, Argentina and Prof. Seng Gee Lim, Singapore. In his contribution Prof. Villamil briefly discusses the clinical and socio-economical impact of the universal anti-hepatitis A virus vaccination program that was introduced in Argentina in 2005. Prof. Seng Gee Lim, Chairman of the recent APASL liver week 2013 Congress in Singapore, together with Dr. Guan-Huei Lee takes us through the most recent data presented in Singapore last month on epidemiology of Hepatitis in Asia. Newly appointed EASL Secretary General, Prof. Markus Peck, illustrates the most recent EASL initiatives aimed at fostering scientific exchange, education and public awareness of liver diseases in Europe. Finally, Prof. Stefan Zeuzem introduces the 2nd edition of the Viral hepatitis Congress to be held in Frankfurt in September.
Alessio Aghemo, Editorial Board Member, Massimo Colombo, Editor-in-Chief

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Contents


News from EASL – by Prof. Markus Peck-Radosavljevic

EASL Current and Future Initiatives

Prof. Markus Peck-Radosavljevic, M. D
Secretary General, EASL

It is a pleasure for me to introduce myself to you as the new Secretary General of EASL, the European Association for the Study of the Liver. EASL’s mission is to foster scientific exchange, education, and public awareness of liver disease and their management. EASL acts as an advisory to European Health Authorities in relation to issues dealing with liver disease and liver health.

As one of EASL’s most important public policy activities, we launched the “EASL white paper on the burden of liver disease in Europe” this February, which is a literature review of the burden of liver disease in Europe. Even though there are serious gaps in the literature on a variety of liver diseases in different European countries, this is an important first step to emphasize the importance of liver disease to our European Authorities in Brussels as well as to local authorities in European countries. As expected, chronic viral hepatitis is the second most common cause of end stage liver-related disease and liver-related death in Europe, highlighting the importance of introducing effective public policy measures in all of Europe to tackle chronic viral hepatitis in our region.

In the year to come we are focusing our EU public affairs agenda on developing a road map to liver disease research in Europe. And we will be reaching out more to our Eastern European colleagues to support them in their fight against liver diseases as well as integrate them more actively into our activities. EASL Schools of Hepatology will take place in Belgrade and Moscow and the Monothematic Conference will take place in Eastern Europe in 2015.

Viral hepatitis has always been big on the agenda of EASL but in these exciting times of rapid and very effective drug development to tackle not only chronic hepatitis B but also chronic hepatitis C, viral hepatitis takes center stage in many of our activities. During this year’s International Liver Congress (ILC) in Amsterdam, a large number of exciting phase-III data dealing with treatment of chronic hepatitis C with new directly acting antivirals (DAA’s) either in combination with interferon and ribavirin or without interferon have been presented and next year’s ILC in London will feature viral hepatitis as the topic of the most important educational session during this meeting, the postgraduate course.

But EASL is not only dedicated to viral hepatitis: we are actively promoting research and development in all kinds of liver diseases, most notably alcoholic liver disease and non-alcoholic fatty liver disease. EASL is regularly publishing and updating clinical practice guidelines of a great variety of liver diseases to help guide clinical practice in the most up-to-date way possible. Next year we expect to release the updated clinical practice guidelines on the management of chronic hepatitis C as well as the clinical practice guidelines on the management of patients with hepatic encephalopathy. Several other clinical practice guidelines are currently in preparation.

EASL’s official journal, The Journal of Hepatology, is the second highest ranking journal in liver disease and of great value for researchers in liver disease as well as practicing physicians with a focus on managing patients with liver disease. In the last years we invested considerable efforts on developing electronic tools for education clinic practice alike. Today we are happy to offer iLiver, a free smartphone app to be used as a quick reference guide at the bedside or the outpatient clinic. The newly launched liver tree is our premiere electronic tool for online education as well as a rich resource of slides for presentations on liver diseases.

EASL will not only try to preserve the success of the last decade but try to evolve in new areas that have not been covered in the last several years. I invite you to actively participate by becoming a member to EASL, which will allow you to get access to the most interesting and up to date information relating to liver diseases in Europe and around the world and at the same time will become a part of our overgrowing family of liver doctors trying to improve in our fight against liver diseases.

Kind regards,
Markus Peck-Radosavljevic, M. D
Secretary General, EASL
Stellvertretender Abteilungsleiter
Universitätsklinik für Innere Medizin III
KLINISCHE ABTEILUNG FÜR GASTROENTEROLOGIE UND HEPATOLOGIE
Währinger Gürtel 18-20,
A-1090 Wien
markus.peck@meduniwien.ac.at

The Viral Hepatitis Congress Frankfurt – by Prof. Steven Zeuzem

The Viral Hepatitis Congress, Frankfurt 26-28 September 2013

Prof. S. Zeuzem
Professor of Medicine, JW Goethe University Hospital, Frankfurt

The management of viral hepatitis has advanced steadily but slowly over the past several decades, with interferon-based regimens being the mainstay of treatment. However, as we enter an era that brings the promise of new therapies and wider treatment choices, increased understanding of the latest clinical research and new therapeutic landscape will allow patients to benefit from informed and individualised clinical decisions.

In September 2012, the inaugural Viral Hepatitis Congress was held in Frankfurt, Germany. Co-Chaired by Professors Ira Jacobson (WeillCornell Medical College, New York, USA) and Stefan Zeuzem (Johann Wolfgang Goethe University Hospital, Frankfurt, Germany), the Congress focused on the latest progress and innovations in the management of viral hepatitis. More than 400 participants heard presentations from a broad international faculty.

This year The Viral Hepatitis Congress will return once again to the historic city of Frankfurt. The Congress will be held at the Frankfurt Messe Congress Centre, from 26–28 September 2013, and promises a relevant, meaningful and topical scientific programme. There will be a particular focus on the latest developments and innovations in the practical aspects of disease management, including:

• A look at the strengths, weaknesses, opportunities and threats of the currently available anti-HCV therapies
• An in-depth review of the new era of HCV therapies, including the potential for IFN-free regimens
• Special considerations for patients with HCV comorbidities
• A case-based approach to clinical challenges in hepatitis C management
• The latest advances in screening and diagnostic technologies
• Dedicated sessions on Hepatitis B, D and E, and hepatocellular carcinoma
• Industry symposia
• Poster presentations

The Congress scientific committee and faculty includes experts from across Europe, the USA, Canada and New Zealand, offering delegates the chance to discuss clinical experiences and key knowledge with the leading authorities in the viral hepatitis field.

In order to broaden the reach of the Congress and bridge the gap to the virtual audience, a core goal is to extend the learnings beyond the Congress itself. This will be accomplished in a number of ways:

• Abstracts will be published as a supplement to the Journal of Viral Hepatitis
• Interviews with faculty will be available on a dedicated YouTube channel: ViralHepatitisTV
• Speakers’ presentations will be recorded and webcast on www.viral-hep.org
• Posters presented at the Congress will be brought together as online, interactive books

For more information and the latest updates on The Viral Hepatitis Congress 2013, visit
www.viral-hep.org or contact the organising secretariat. Congress registration is open until 6 September 2013.

Enquiries to:
The Viral Hepatitis Congress, Organising Secretariat: hep@kp360group.com

Results of the Universal Vaccination Program for Hepatitis A in Argentina – by Federico G. Villamil, MD

Federico G. Villamil, MD
Director of Liver Transplantation, Hospital Británico, Argentina

Background

Prior to 2005, when universal vaccination was introduced, Argentina was an area of intermediate endemicity for hepatitis A virus (HAV) infection. Gonzalez et al showed in 1997 that among 3699 children from Argentina, anti-HAV was detected in 46% at 5 years of age and 68% at 10 years. Marked differences in the prevalence of HAV exposure was observed in different regions ranging from 29.4% in the city of Buenos Aires to 81.4 % in the city of Tucuman, located in the Northwest of the country (1). Not surprisingly, HAV was by far the most frequent etiology of acute viral hepatitis in children, and represented 93% of 3120 cases in the study reported in 2000 by Ciocca et al (2). However, the most striking feature of HAV infection in Argentina, and the one of greatest concern, was the high prevalence of acute liver failure (ALF) in the pediatric age. Ciocca et al showed that between 1982 and 2002 HAV was responsible for 61% of 210 ALF in children with a mean age of 5.3 years (3). At that time, hepatitis A was regarded as a benign etiology of ALF with spontaneous recovery in most cases. This was not the case for Argentina. Among the 128 children with fulminant hepatitis A reported by Ciocca et al, only 40 (31%) survived with medical therapy, 33 (26%) died and 55 (43%) underwent liver transplantation. Similar results were observed in a survey carried out by the Argentina Society of Transplantation in 2001 (Villamil FG, unpublished observations) including 219 children with ALF referred to 5 transplant centers. Death or transplantation occurred in 71% of patients. Munné et al showed that all HAV isolates from Argentina (n=82), obtained both from sporadic cases and epidemics, belonged to the IA subgenotype (4)

Rationale for Universal HAV Vaccination

In 2005, and following the recommendations of the Pediatric and Liver Societies, the Argentina Ministry of Health devised a plan for universal immunization for HAV using a single dose of formaldehyde-inactivated vaccine administered at 12 months of age. HAV vaccine was incorporated into the National Immunization Calendar and was given simultaneously with the triple (MMR) vaccine (5). The rationale for the single dose strategy at 12 months after birth was based on several facts. During the first year of life most children are protected by antibodies transferred from their mothers, living in a country where anti-HAV is detectable in >80% of adults. HAV-related disease usually manifests after 1 year of age and children aged 1-2 years are thought to be the main source of transmission. If this hypothesis was correct, then administration of a highly immunogenic vaccine at 12 months should be effective to prevent the spread of HAV infection. In addition, it was speculated that the high circulation of HAV in Argentina could act as a “natural booster” making a second dose of vaccine unnecessary

Results of HAV

Vaccination Universal vaccination with HAV vaccine resulted in robust health and economic benefits. According to data reported by the Argentina Ministry of Health, reviewed by Gentile et al (6) and Vacchino MN (7), the number of cases of acute hepatitis A decreased from 26,475 in 2005 to only 329 in 2010 and the corresponding rates of infection from 113.3/100,000 to 1.4/100,000 respectively, a reduction of 88.3% . Vaccine coverage throughout the country was 95% in 2006 (7) and 92.4% in 2011 (6). Importantly, ALF and need for transplantation due to hepatitis A substantially and rapidly declined after universal vaccination and has almost disappeared in recent years. Cervio et al (8) showed that the proportion of children with ALF due to HAV infection decreased from 54.6% in 2003-2008 (165/367) to 27.7% in 2006 (18/65) with no cases being reported after 2006 (6). A recent study from the Argentina Ministry of Health (Vizzotti et al, unpublished data) showed that 4 years after vaccination 93% of 1138 children had protective titers (>10 mIU/mL) of anti-HAV(6). Finally, universal vaccination for HAV in Argentina was found to be highly cost-effective. Lopez et al estimated that, with a 95% national vaccination coverage, 352,405 cases of hepatitis A would be prevented annually including 121,587 symptomatic cases and 428 deaths (9). The program would thus save US$ 23,989,963 annually which is equivalent to US$ 3,429 per life-year gained

Conclusions

Universal HAV vaccination in childhood was highly effective not only to decrease substantially the rate of infection in children but to eradicate also severe forms of acute hepatitis A leading to death or liver transplantation. Argentina was the first country to adopt the cost-effective strategy of single dose vaccination at 12 months of age. Four years after vaccination, more than 90% of immunized children developed protective anti-HAV serum concentrations.

References: 
1. Gonzalez J, Fay O, Canero-Velasco MC, Fernandez E, Carchio E, Moreiro R et al. Hepatitis A virus infection in children in Argentina: a pilot study. Acta Gastroenterol Latinoam 1997; 27:331-314

2. Ciocca M. Clinical course and consequences of hepatitis A infection. Vaccine; 2000: 18 (Suppl 1):S71-74

3. Ciocca M, Ramonet M, Cuarterolo M, López S, Cernadas C, Alvarez F. Prognostic factors in paediatric acute liver failure. Arch Dis Child 2008; 93:48-51

4. Munné MS, Vladimirsky S, Otegui L, Soto S, Brajterman L, Castro R et al. Molecular characterization of hepatitis A virus isolates from Argentina. J Med Virol 2007; 79:887-894

5. Gentile A. The need for an evidence-based decision-making process with regard to control of hepatitis A. J Viral Hepat 2008; 15 (Suppl 2):16-21

6. Gentile AG, Ramonet MD, Ciocca M. La introducción de la vacuna contra hepatitis A en el Calendario Nacional de vacunación: Una nueva realidad. Arch Argent Pediatr 2013; 111:155-161

7. Vacchino MN. Incidence of Hepatitis A in Argentina after vaccination. J Viral Hepat 2008; 15 (Suppl 2):47-50

8. Cervio G, Trentadue J, DÁgostino D, Luque C. Decline in HAV-associated fulminant hepatic failure and liver transplantation in Argentina after the introduction of a universal hepatitis A vaccination program. Hepatic Medicine: Ev Res 2011; 3:99-106

9. Lopez E, Debbag R, Coudeville L, Baron-Papillon F, Armoni J. The cost-effectiveness of universal vaccination of children against hepatitis A in Argentina: results of a dynamic health-economic analysis. J Gastroenterol 2007; 42:152-60
Author: Federico G. Villamil, MD

Affiliation and correspondence
Director of Liver Transplantation
Hospital Británico, Perdriel 74, CABA (C1280AEB), Argentina
Telephone and fax: 5411 43096545
E-mail: fgvillamil@hotmail.com

Epidemiology and Prevention of Hepatitis in Asia – by Prof. Seng Gee Lim and Prof. Guan-Huei Lee

Enquiries to: Corporate Secretary, Hepatitis B & C Public Policy Association asbl