2. The changing pattern of viral hepatitis in Saudi Arabia Yousef Qari, MD, FRCP(C), ABIM Gastoenterologist King Abdulaziz University Hospital

3. Epidemiology of Hep B Worldwide 2 billion people are infected with this virus 350 million Chronic HBV infection. 10th leading cause of death in the world

4. Route of Transmission of HepB High endemicity –Perinatal (vertical) –Acquired in preschool years. Low endemicity –Early adult life Intravenous drug use Unprotected sexual activities

5. The prevalence of HBsAg and other markers of HBV among residents of Jizan Ayoola AE Saudi Med J. 2003; 24(9):991-5

6. Prevalence of HBV, HCV among blood donors in a teaching hospital in the Central region of Saudi Arabia. 24000 patients El-Hazmi MM Saudi Med J. 2004; 25(1):26-33 Saudi Med J. 2004; 25(1):26-33

7. HBV and HCV prevalence among dialysis patients in Bahrain and Saudi Arabia Qadi AA Am J Infect Control. 2004; 32(8):493- 5 (ISSN: 0196-6553)Am J Infect Control. 2004; 32(8):493- 5

8. Prevalence of hepatitis C virus among Bilharziasis patients in Eastern Saudi arbia Khan ZA Saudi Med J. 2004; 25(2):204-6 Saudi Med J. 2004; 25(2):204-6

9. Worled Prevalence of Hep B

10. The decline of hepatitis B viral infection in South- Western Saudi Arabia. Ayoola AE Saudi Med J. 2003; 24(9):991-5

11. Hepatitis C virus Seroprevalence rate among Saudis Shobokshi OA. Saudi Med J. 2003; 24 Suppl 2:S81-6 Saudi Med J. 2003; 24 Suppl 2:S81-6

12. Worled Prevalence of Hep C

13. Pattern of liver diseases at a University Hospital in Western Saudi Arabia. 246 liver histology 123 (50%) Ch.Infammation 82 (33.3%) Ch.hepatitis 59 (23.9%) Ch. HCV 21(8.5%) Ch. HBV 2 (0.8%) Ch.HCV+HBV 20 (8%) Cirrhosis 16 (6.5%) HCV 4 (1.6%) HBV 103 (42%) Others Mansoor I. Saudi Med J. 2002; 23(9):1070-3Saudi Med J. 2002; 23(9):1070-3

14. Overview of Epidemiology of viral Hepatitis in Saudi Arabia The prevalence rate is high in Saudi Arabia. –HBV 8%-10% –HCV 2%-6% Age distribution: –HAV, is mainly a disease of the young –HBV, a disease of adolescents and adults –HCV, a disease of the elderly. Male: Female ratio: –Equal in HAV and HCV –More males were affected with HBV than females. Memish Z Mil Med. 2003; 168(7):565-8 Mil Med. 2003; 168(7):565-8

15. The natural history of HCV infection cont‘d. Factors that contribute to the chronicity –Male gender –Age –Alcohol intake, and –The degree of liver fibrosis on initial biopsy. Extrahepatic complication (EHC). Extrahepatic complication (EHC). –38% will have at least one EHC –The most important EHC is mixed cryoglobulinemia.

16. Natural History of Hep C

17. The natural history of HCV infection in Saudi Arabia. Similer pattern was noted for the rate of progression to cirrhosis and HCC Al-Quaiz MN Saudi Med J. 2003; 24 Suppl 2:S67-70 Saudi Med J. 2003; 24 Suppl 2:S67-70

18. Natural History of Hep C HBV Infection Chronic Hepatitis Cirrhosis HCC 15-40% HBV

19. Hepatocellular carcinoma in Saudi Arabia: Role of hepatitis B infection. N=118 Ayoola EA J Gastroenterol Hepatol. 2004; 19(6):665-9 J Gastroenterol Hepatol. 2004; 19(6):665-9 1.9 per 1000 (2.3 in men, 1.2 in women).

20. The prevalence of hepatitis B core antibody positivity in donors for liver transplantation in Saudi Arabia. Non-Saudi (41.3%) Saudi nationals (16.7%). Al-Sebayel MI. Saudi Med J. 2002; 23(3):298-300 Saudi Med J. 2002; 23(3):298-300

21. The challenge of finding donors for living donor liver transplantation in Saudi Arabia. Khalaf H Transplant Proc. 2004; 36(8):2222-3 Transplant Proc. 2004; 36(8):2222-3

22. Hepatitis C genotypes/subtypes among chronic hepatitis patients in Saudi Arabia 1.Shobokshi OA Saudi Med J. 2003; 24 Suppl 2:S87-91Saudi Med J. 2003; 24 Suppl 2:S87-91 2.Al-Traif I Saudi Med J. 2004; 25(12):1935-8 Saudi Med J. 2004; 25(12):1935-8

23. Chronic hepatitis C. Genotypes and response to anti-viral therapy among Saudi patients. Al-Traif I Saudi Med J. 2004; 25(12):1935-8 Saudi Med J. 2004; 25(12):1935-8

24. Peg IF + Ribavirin compared with IF + Ribavirin for initial treatment of Ch. HCV in Saudi patients with genotype 4. 96 patients with chronic HCV End of treatment (48 weeks) Sustained (72 weeks) Alfaleh FZ Liver Int. 2004; 24(6):568-74

25. Conclusion The most prevalent genotype in the Kingdom of Saudi Arabia is –genotype 4 –genotypes 1a and 1b. –Genotype 5 was identified exclusively in the Western province and nowhere else. –Genotypes 2a,/2b, 3 and 6 are very rare in the Kingdom of Saudi Arabia.

26. Conclusion 86% of Saudi chronic hepatitis C cases are due to genotypes 1 and 4. The low prevalence of HBsAg in children, provides evidence for the effectiveness and efficacy of the integration of hepatitis B vaccination into the extended program of immunization in KSA. The significant decline of HBV markers among unvaccinated Saudi adults indicated an indirect effect of other factors like health education and socio-economic progress

27. Conclusion Hepatitis B virus constitutes a major risk factor and HCV contributes a less significant role in the development of HCC. The ongoing program of HBV vaccination may significantly decrease the prevalence of HBV-associated HCC in Saudi Arabia The present public health schemes have been effective in reducing hepatitis C infection in the general community in the Kingdom of Saudi Arabia but the infection among high risk groups remain a major problem that needs to be actively addressed.

28. Conclusion In Saudi Arabia, donor availability as well as recipient characteristics may limit the value of LDLT in overcoming organ shortage. Therefore, efforts should be directed to improve the number and quality of available cadaveric organs. Until then, LDLT may be the only way forward to save patients from dying on the waiting list.

30. Hepatitis E virus infection in haemodialysis patients: a case-control study in Saudi Arabia. Ayoola EA J Med Virol. 2002; 66(3):329-34J Med Virol. 2002; 66(3):329-34 83 Saudi patients on chronic haemodialysis

31. Treatment of patients with HCV with normal liver enzymes in a Saudi population. Akbar HO Saudi Med J. 2002; 23(3):301-4 Saudi Med J. 2002; 23(3):301-4 Both groups treated with: IF 3mu thrice / w + Ribavirin

32. The natural history of HCV infection. The natural history of HCV infection is not fully understood. Early studies of natural history reflected the more severe end of the spectrum of the disease.