Liver diseases in developing countries

Abstract

Liver diseases are an important and largely neglected health issue in low and middle income countries, which carry the highest burden. In this Topic Highlight, experts review hepatitis B and E, alcoholic liver disease, hepatic diseases in human immunodeficiency virus -infected individuals, hepatocellular carcinoma. Numerous gaps in our knowledge that need to be filled are outlined and feasible solutions to the several problems related to diagnosis and management of liver diseases in developing countries are suggested.

INTRODUCTION

Liver diseases are an important and largely neglected health issue in developing countries, which carry the highest burden but receive little attention. The scientific literature is engulfed with manuscripts describing the apparently high load of liver diseases in developed, high income countries, and one can get the misleading impression that liver diseases are prominent in those very countries where they are not.

The aim of this Topic Highlight is to raise awareness of the burden of liver diseases in low and middle income countries.

TOPIC HIGHLIGHT

Hepatitis B virus infection is a huge health problem in many low and middle income countries. Franco et al[1] (Department of Public Health, Tor Vergata University, Rome, Italy) outline that the most common route of infection remains vertical transmission from mother to child, and that screening of all pregnant women and passive immunization with human hepatitis B immunoglobulins are not affordable for many developing countries. Even anti-hepatitis B vaccination is not affordable for some countries. Abbas et al[2] (Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan) advocate for a definition of the minimal requirements for delivery of care to patients with chronic hepatitis B and call for the establishment of research institutions that can ascertain the natural history and response to treatment in developing countries. They rightly outline that the mere extrapolation of treatment protocols used in developed countries is of little use due to lack of resources.

Teshale et al[3] from the Centers for Disease Control and Prevention, Division of Viral Hepatitis, Atlanta, United States, review hepatitis E epidemiology and draw attention to the fact that this virus is responsible for major outbreaks of acute hepatitis in developing countries, especially in Africa and Asia. Although more than one vaccine candidate has been shown to be safe and efficacious in clinical trials, none are currently available for use in the very countries where they are most needed. There is no specific therapy for acute hepatitis E, and the death rate is considerable in pregnant women.

Alcohol consumption is high in developing countries and alcoholic liver disease is therefore obviously present. However, this form of liver disease receives little, if any, attention in low income countries. Bruha[4] from Charles University in Prague, Czech Republic, reminds us that severe acute alcoholic hepatitis is associated with a mortality rate of up to 50%, and that treatment of this form is extremely difficult. There is an absolute need for abstaining from alcohol of patients with chronic liver disease; the lack of policies to this effect is a serious concern that must be addressed.

Crane et al[5] (Monash University and The Alfred Hospital, Melbourne, Australia) describe liver disease in HIV-infected individuals, in the absence of co-infection with HBV or HCV, as an emerging issue. While antiretroviral therapy-related toxicities are an obvious cause, evidence is emerging that HIV infection may have a direct impact on the pathogenesis of liver fibrosis, non-alcoholic fatty liver disease and non-alcoholic steatohepatitis.

Professor Kew et al[6] (Department of Medicine, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa) describes a gloomy but realistic picture of hepatocellular carcinoma, a tumor that occurs commonly and with increasing frequency in developing countries, where it also carries an especially poor prognosis. Non implementation of hepatitis B vaccination and unavoidable dietary exposure to aflatoxin B1 play an important etiological role. Unfortunately, prevention of hepatocellular carcinoma in developing countries is unlikely in the foreseeable future.

CONCLUSION

I hope that the readers will enjoy this Topic Highlight and will be stimulated to conduct research that will fill the numerous gaps in our knowledge and will suggest feasible solutions to the several problems highlighted.