Malaysia is a multi-ethnic country, with a population of 23 million, comprising a mix of Malays (50%), Chinese (33%), Indians (9%), and others (8%). It is made up of 14 states, each with variable standards of hygiene and sanitation. Like other countries in the region, viral hepatitis is an important public health problem in Malaysia. During the year 2000, approximately 4067 cases of viral hepatitis cases were seen in Malaysia (Fig. 1). Of this, approximately 497 were due to hepatitis A and 2863 to hepatitis B.
Prevalence of hepatitis B
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 that 80% of the hepatocellular carcinoma (HCC) cases seen in Malaysia.
Figures showing the incidence rate of hepatitis B in Malaysia, demonstrate a steady decrease from 1988 to 1997 due to the universal vaccination of infants, which commenced in 1989, and various control programs. In 1998, however, a sharp increase in reported cases was noted due to the inclusion of mandatory testing of all foreign workers that had arrived in Malaysia (Fig. 2).
The seroprevalence data, thus far, has been obtained through voluntary testing, and seroprevalence studies, as well as from routine screening of blood donors. Voluntary testing carried out on 17 048 healthy volunteers (mean age = 34 years), indicated a hepatitis B s antigen (HBsAg) seropositivity of 5.24%.1 A seroprevalence survey carried out among 5583 school children in the Southern state of Malaysia born before the initiation of universal vaccination program in 1989 revealed an HBsAg and hepatitis B s antibody (HBsAb) positivity of 1.7% and 44.2%, respectively. This group of adolescents (mean age = 15 years), is considered as a target for catch-up vaccination, considering their likely exposure to high risk behavior.2
A recent study looking at a population of 2115 individuals, from all 14 states of Malaysia, showed an overall HBsAg and HBsAb positivity of 6.5% and 51%, respectively. The highest incidence was found in the 0–10 years age group, with 59.6% testing positive for HBsAb and 2.2% positive for HBsAg. It was expected that this cohort would have had a higher prevalence of HBsAb as they had participated in the mass immunization scheme. It is also interesting to note that there had been transmission of hepatitis B in this group. Follow-up activities, to ascertain the significance of these findings, need to be conducted and may include the routine screening of antenatal mothers to ensure that babies of carrier mothers are adequately managed and followed up.
In this study, the HBsAb seroprevalence among the age group 11–20 years was 46.3%, similar to the earlier study carried out in Southern Malaysia. This underpins the need for catch-up vaccination for adolescents. The overall results showed that HBsAg prevalence varied in different regions, being higher in East Malaysia (9.8%), lower in the Malaysian peninsular (6.8%), with the lowest in the central region (4.2%).1
In a survey of 643 chronic hepatitis B patients in five centers in Malaysia, 328 (51%) patients were found to be HBeAg positive. Of these patients, 39.3% were also found to have raised alanine aminotransferase (ALT) levels of greater than two times the upper limit of normal. Of the total 643 patients, 20% will require treatment based on their ALT profile.1
Hepatitis A epidemiology
Hepatitis A has been a reportable disease in Malaysia since 1988. Results from seroepidemiology studies carried out over the past decade have shown that due to the introduction of government control programs, a decrease in the seroprevalence of hepatitis A from 67% in 1986 to 49.4% in 2000 has occurred (Fig. 3),3 similar to those shown in developed countries such as Singapore and the United States. However, within Malaysia there are some geographic differences in the age-related seroprevalence of hepatitis A, with the highest rate in the East Coast of Malaysia. Additionally, the community-wide outbreaks common in the east coast indicate that despite improvements in socioeconomy, hygiene, and sanitary conditions, hepatitis A remains a major public health problem.
Chronic liver disease
Approximately 85% of chronic liver disease (CLD) cases seen in Malaysia are due to HBV infection, 14% are due to hepatitis C virus (HCV) infection, and 10% are a result of mixed HBV and HCV infection. In chronic hepatitis cases, over 77% are due to HBV infection, 1.8% due to HCV infection, and the remaining 4.6% are caused by dual infection. Similarly, cirrhosis and HCC are both largely caused by HBV infection (76% and 81.5%, respectively).
The Ministry of Health (MOH), the largest healthcare provider in Malaysia, has undertaken the problem of tackling hepatitis disease. Although the MOH has found it difficult to focus on one type of disease, as there are many other communicable diseases in Malaysia, in 1989 it succeeded in introducing mass newborn vaccination against hepatitis B. The MOH has also created the infrastructure for further hepatitis research, and the provision of a subspecialty in hepatobiliary in tertiary hospitals. Non-governmental organizations, such as the Malaysian Liver Foundation (MLF), with the aid of local physicians, have introduced nationwide campaigns that aim to advocate blood testing and vaccination, while providing health information to the general public. These campaigns have raised awareness of the disease and increased the accessibility of hepatitis A and B vaccination.
MALAYSIAN LIVER FOUNDATION
The MLF is a charitable, non-profit organization dedicated to the diagnosis, treatment, and prevention of diseases of the liver. Its many activities, put forth to achieve its intended objectives, are mainly concerned with education, research, and training. This organization has been a key player, along with the MOH, in the combat against liver diseases, specifically viral hepatitis. As part of its education program, the MLF has introduced public screening for hepatitis A, B, and C, and aims to educate the Malaysian public on the symptoms associated with viral hepatitis and available treatment options.
One of the other concerns of the MLF has been evaluating the burden of hepatitis disease in Malaysia and the impact of current disease prevention strategies. The general paucity of data on the prevalence of hepatitis A, B, and C has made the assessment of control programs rather difficult. To help overcome this, the MLF has contributed to the Ministry of Health substantial data pertaining to seroprevalence of hepatitis A, B, and C.
In 2000, the MLF, under its research arm, established the Molecular Research Laboratory (MRL) to alleviate the frustration that hepatologists and gastroenterologists were experiencing due to the lack of facilities for viral load testing in the country. The MRL is the only non-profit laboratory that specializes in viral load testing for hepatitis B, C, and HIV, and genotyping for hepatitis B, and C. To date, it has processed over 4000 specimens with clientele from the whole country, comprising government agencies, universities, private hospitals, and clinics, as well as acting as central laboratory for some therapeutic trials. This laboratory has been set up based on principles of Good Laboratory Practice and obtained ISO 17025 accreditation at the end of 2002.
One of the main components of the MLF hepatitis management program consists of ‘Hepatitis Days’. This is usually a weekend event, which serves as a forum for both the public and doctors. Members of the public are encouraged to come forward for screening of their ‘hepatitis’ status using rapid testing, allowing individuals to receive results within 15 min. This rapid method of screening helps to remove the anxiety usually associated with the long waiting period after conventional screening. Depending on the test outcome, individuals can either receive on-the-spot vaccination or be referred for further tests and counseling. Vaccinating individuals who require protection on the same day has proved successful in preventing the take-up loss that can be experienced when subsequent clinic appointments must be made. For individuals that are found to be chronically infected, appropriate counseling and vaccination can be offered to family members and close contacts.
Hepatitis Days, which have been carried out nationwide in Malaysia since 1998, have obtained a high acceptance level among the general public. The campaign travels from state-to-state in Malaysia and is often held in locations that are easily accessible to the public, such as shopping malls and community halls. In addition to blood screening and vaccination, a public forum addressing issues of concern among the public advocates an increase in the awareness of the disease. The MLF normally substantiates these awareness activities by also organizing continuing medical education programs for general practitioners to keep them updated on the latest approaches to the management of liver diseases. Participation by local celebrities, political figures, and national medical associations, as well as press conferences encourages mass media coverage.
Ongoing education organized by the MLF for general practitioners on the diagnosis and treatment of chronic hepatitis has also assisted the overall hepatitis management program. Regional conferences, such as ‘Liver Updates’, which is a biennial conference, and national seminars, are held to educate physicians on current diagnosis, prevention, and treatment options. Continuous training programs have been set in place to ensure that GPs and trainees are kept up-to-date.
In the year 2000, a hepatitis awareness questionnaire was devised to gauge the impact of Hepatitis Days. There were 722 responders, of which 49% were males and 51% females, with an average age of 34 years. Responders were either categorized as professional (45.7%), student, and others (39.1%) or self-employed (15.2%). In terms of ethnic mix, 48.1% were Chinese, 26.3% Malay, 16.9% Indian, and 8.7% others. The general awareness with regards to hepatitis as an infectious disease was 95% and there was no difference due to sex, race, or age. Awareness was, however, higher in individuals with a higher level of education, or higher household income. Individuals in these groups were also more likely to seek and pay for hospital treatment.
The MLF since its inception in 1996 has endeavored to develop a coordinated approach towards the improved care and treatment of liver diseases in Malaysia. Its close liaison with the Malaysian MOH, local medical associations, and corporate bodies has contributed to the success of its many programs. Educating the public, research, and training have been important elements of successful hepatitis disease control programs. Hepatitis Days have been proven to be very successful in raising the awareness of the general public to hepatitis disease. Rapid screening and vaccination has also helped to remove the social stigma associated with the disease, eliminated the need for numerous clinic appointments, and rendered vaccination more accessible to the public. The MLF perspective emphasizes the need for collaborative effort between Government bodies and other agencies, such as non-governmental organizations, laboratories, and the medical fraternity, to ensure the overall success of hepatitis disease management programs.