Conscience imperative of providing information and knowledge in hepatology: The Portuguese approach

Abstract

The last 25 years have been a thrilling time for the Portuguese hepatologists. Our national meetings have been providing the forum for the exchange of scientific ideas and the presentation of clinical research in clinical Hepatology, a growing world of knowledge in medical care. Bridging the gaps between technology and clinical daily practice, the latest development and the almost humble bedside care, has been a challenge for the increasing numbers of doctors devoted to the diagnostic and treatment of liver disease. We have been trying to be very persuasive among the Portuguese medical community in demonstrating that cultural vectors may influence the origin and pattern of liver disease among us. Viral hepatitis and alcoholic liver disease are paradigms of this assumption. Chronic liver disease is responsible for 3% of the deaths in Portugal, which accounts for the top ten causes of death in our country. The recognition by public health authorities of this fact along with the national net of hepatology outpatient consultation in public hospitals, has brought liver diseases under the lights of doctors concerns and an increased public awareness of its dimension.

Key Words: Alcohol; Cirrhosis; Hepatology; Liver; Public health

Core tip: The last 25 years have been a thrilling time for the Portuguese Hepatologists. Nowadays our main efforts are devoted both at the level of training and pregraduate teaching, especially in the large university hospitals but also in addressing the public directly, aiming essentially in giving information on three major topics: Alcohol, viral hepatitis and the obesity epidemics.

TO THE EDITOR

The last 25 years have been a thrilling time for the portuguese hepatologists. Our national meetings, either the portuguese association for the study of liver disease annual meeting or the portuguese digestive disease week, have been providing the forum for the exchange of scientific ideas and the presentation of clinical research in clinical hepatology, a growing world of knowledge in medical care. Bridging the gaps between technology and clinical daily practice, the latest development and the almost humble bedside care, has been a challenge for the increasing numbers of doctors devoted to the diagnostic and treatment of liver disease.

Nowadays our main efforts are devoted both at the level of training and pregraduate teaching, especially in the large University Hospitals but also in addressing the public directly, aiming essentially in giving information on three major topics: Alcohol, viral hepatitis and the obesity epidemics.

We have been trying to be very persuasive among the Portuguese medical community in demonstrating that cultural vectors may influence the origin and pattern of liver disease among us. Viral hepatitis and alcoholic liver disease are paradigms of this assumption. Chronic liver disease is responsible for 3% of the deaths in Portugal, which accounts for the top ten causes of death in our country[1]. The recognition by Public Health authorities of this fact along with the national net of hepatology outpatient consultation in public hospitals, has brought liver diseases under the lights of doctors concerns and an increased public awareness of its dimension. Furthermore, although liver transplantation only begun 20 years ago, there are about 250 patients yearly transplanted, in 3 centers, serving a ten million population[2].

It is true that alcoholic liver disease is a dominant concern in this country and several reasons may contribute to this fact: Portugal, with temperate climate from Atlantic and Mediterranean origins, has a rich tradition in wine processing, and for years, many rural communities were actively involved in those processes. Alcohol consumption is thus a widespread habit, and in the traditional good-eating-and-drinking land (many times advertised abroad), it became a deep cultural characteristic lasting for decades. This creates a great challenge for us doctors, while trying to explain everyone, the risks, the facts and the fancies about chronic alcohol consumption.

If we accept WHO reports claiming for recent evidence suggesting association between alcohol abuse induced disorders and HIV/AIDS[3,4], it is easy to extrapolate that this may also play a role and background for viral hepatitis liver injury. Binge drinking for example is associated with non-protected, unexpected and multiple partners sex behaviour[3]. So prevention has been a major task for public health authorities concerning alcohol abuse, under the judicious guidance and advice of hepatologists. The social and individual impact of more than 50 alcohol-induced disorders, obviously remain as a leading topic for medical attention.

Interestingly many other features related to viral hepatitis have had a significant change in the last years in Portugal. If we take hepatitis A, 25 years ago, we had a high level of endemicity, and several reports showed that the adult anti hepatitis A virus (HAV) prevalence was above 90%: Infection was almost universal at around 5-6 years old[5,6]. The profound changes in basic hygienic and sanitary conditions of both urban and rural population, made now a different reality, with only a seroprevalence less than 35% of anti HAV in modern adolescents[5]. Although we know that if acquired in adult it may have a fulminant course with 2% mortality[1], in the meantime universal vaccination and its inclusion in the National Vaccination Program has not been advocated. Our policy is checking anti-HAV previously to vaccination, if considered after the age of 15.

Hepatitis B also has changed recently among us. At the end of the millennium, HBsAg prevalence was shown to the 1.25%[6], bringing Portugal to a low prevalence area. Recently it has been claimed to be less than 1%, in a national serological survey[7], with an anti HBs prevalence of 47%, reflecting the vaccination policy adopted years ago. The overall prevalence of anti-HBc is now of 6%[8]. Among us, hepatitis B virus vaccine is included in the National Vaccination Program since 1993 for adolescents aged 10-13, and for all newborns since year 2000. The ongoing strategy is vaccination, of all newborns and adolescents, with additional recommendation of risk group vaccination as defined by regulatory ministerial documentation. Recent challenges however have been brought up by the intensive immigration from eastern European countries where Hbs Ag prevalence shifts between 1%-7%[9] reproducing the same scenario as 40 years ago, when Angola and Mozambique citizens came back to mainland.

Still the predominant form of chronic hepatitis B is the negative chronic hepatitis, accounting for more than 80% of the cases, as a recent nationwide hospital survey showed, underlining our Mediterranean connections[1]. Despite the vaccination Program regularly undertaken, the fact is that there is a growing interest on this topic, related to the increased identification of long standing “carriers”, now truly reclassified as chronic hepatitis patients, and to the questions raised by the immunosuppressive drugs regimen (e.g., biologics, chemotherapy), urging the need for appropriate prophylaxis.

Hepatitis C also, has clearly gained full media and patient attention in recent years. Our estimated anti-hepatitis C virus (HCV) prevalence (based on blood donors statistics, and many clinical observations ranges between 1% and 1.5% (100000-150000 subjects)[2]. Interesting cultural and historical facts made a significant contribution for this: Sports, for example. Portuguese people share with Brazilians not only the language and many cultural roots, but also an overriding enthusiasm about soccer. It is the national Portuguese sport, practiced all over the country, with passionate supporters following major Portuguese teams’ performances and successes in European champion leagues. After thorough questionnaires and observations, we found several cases of young, otherwise healthy adults who had, as a single risk factor for HCV infection, the sharing of needles or glass reusable syringes by the paramedics of amateur soccer clubs in the eighties and nineties[1]. This occurred whenever multivitamin complexes were intravenously administered (sometimes weekly!) or when anti-inflammatory drugs were repeatedly given intramuscularly. We found that it was a widespread habit, to strengthen athletes’ performance. However, other sources for percutaneous transmission of HCV, such as contaminated instruments and equipment, should always be kept in mind when we deal with our patients. Many Portuguese, as young people, had prolonged sojourns in Africa and were involved in the colonial war of late 1960s and early 1970s. ln those days, mass vaccination programs for prophylaxis in Portuguese troops going to Africa, did not use disposable needles, and tattooing with device sharing was also very common. Also, in the wake of the 1974 Portuguese Revolution, almost 1 million people returned from Africa, creating new sociological challenges in main land, at the same time fuelled by proper stimuli from the brave new world of musical scene which paved the way for youth contestation movements to include the adoption of high-risk behaviours such as sporadic (nowadays “forgotten”) intravenous drug use. Furthermore, bizarre and folk medical practices such as intravenous gammaglobulin use for “immune strength” or as “memory inducers” and intravenous calcium for chronic asthenia and tetany, without proper aseptic use of needles and syringes, may have given a significant contribution to the estimated 150000 infected people[2]. Nowadays, special attention has been given on the risk of further iatrogenic exposures to the transmission of HCV infection, beyond the overall care of health providers and the educational tools given to those involved in cosmetic procedures (tattooing, body piercing), trying to avoid what has been seen recently in developed countries from Europe, United Stated or Australia: Preparation and delivery of injectable medications, particularly in the anaesthetics setting, has been intensively addressed by those concerned with HCV epidemiological new unexpected features.

Portuguese Hepatologists have been trying to discuss the viability of creating a National Strategy Plan for prevention and control of hepatitis C. This ambitious plan stands on the tripod base of quality information, reinforced prevention and cost-effective modalities, and intend to gather many society vectors like health related authorities, scientific societies - beyond the conventional gastroenterology and hepatology association - pharmaceutical companies, patients organizations, and of course, politicians and the media. This tremendous effort set the stage and the pace for a unique agreement between health authorities and Industry, allowing the recent access of thousands of patients exclusively to all-oral hepatitis c treatment agents.

Step by step we have managed to reach public interest and media attention: In 2010 spring time, we promoted the “Liver on Tour”, a special Project devoted to increase public awareness on Liver health and Liver disease. All counties in Portugal were visited in a road show, with lots of simple, reliable and practical information on liver problems. Members of the Portuguese Association for the study of liver diseases board of directors were literally on the road, claiming for attention and protection for the liver. In 2011-2015 another several “out of the box” meetings addressed this anthropological insight of liver Health: Sports and the liver (along with major conferences from well-known Portuguese sportsmen), sexuality and liver health, with two more symposia on the liver and Social Exclusion, showing how liver diseases promote exclusion and how exclusion itself is a vector for liver diseases.

Building these projects, we show clearly that silence will not be an option for those devoted in Portugal in caring for liver problems: Information and knowledge will remain to be, as demonstrated in these busy and passionate last years, a conscience imperative.