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Hepatitis Delta: The virus of the poor

Hepatitis D is a public health problem, especially in Brazils Western Amazon region. The disease strikes the most invisible, as riverside and ‘quilombola’ populations


The Hepatitis D virus acts as a parasite and must link to Hepatitis B virus for the infection to occur

Hepatitis D, also known as Delta, is considered the most severe form of viral hepatitis in humans. Data calls attention by evidencing that great part of the cases are spreading in an endemic area in Brazils Western Amazon (Acre, Amazonas, Rondonia and Roraima), precisely the poorest areas in the country. Known as labra black fever by Amazonia residents, the disease was first reported in the late 1960s in this city. Outside the country, it is described in Central Africa and Southern Italy. Some studies point the disease in ‘quilombola’ communities in Maranhão, what could mean the existence of other ‘quilombos’ in Brazil. Little is known about its distribution throughout the rest of the Country, and the absence of systematic studies and even of the availability of tests with anti-delta IgG antibody detection in the Unified Health System (SUS) have hampered the assessment of the infections incidence and prevalence outside of the Amazon.

To better understand the Delta virus, Rondonia is developing some researches  aiming to amplify the virus complete genome, both among indigenous and non-indigenous populations. According to the Rondonia Hepatitis Ambulatorys Director, Dr. Juan Miguel Villalobos Salcedo, currently it is known that the genotypes circulating in Rondonia are Type III (the most important) and Type I (the least important). Regarding the relation with clinical evolution, he stresses that until now it has not been identified if mutations can affect the course. We noticed that there are probably no interferences in the treatment, he says.

Dr. Salcedo, who also lectures at Rondonia Federal University (Unir) and is a Fiocruz-Rondonia researcher, says Hepatitis Delta is one of the most neglected, however, in the past five years, Health Ministry authorities and research entities have given it some recognition. The Health Ministry, represented by the Department of Surveillance, Prevention and Control of Sexually Transmitted Diseases (IST), HIV/Aids and Viral Hepatitis (DIAHV), headed by Dr. Adele Benzaken, launched in 2017 a package to control the disease, involving initially Amazonas, Pará and Acre States. These are actions towards diagnostic and treatment of affected patients, in order to reduce the diseases prevalence. Besides this, the Brazilian Society of Hepatology and Infectology has approached the theme in their recent national conferences, he says.

Plan of Viral Hepatitis Confrontation in the North Region focused on Hepatitis Delta

The Plan aims to increase access to prevention, diagnostic and treatment of viral hepatitis, focused on hepatitis B and Delta, in the states in the North region. The priorities include epidemiological surveillance, prevention, assistance and articulation with the civil society. According to information from the DIAHV, this strategy should be gradually replicated in the Countrys other regions. The goal is to map health services for prevention, diagnostic and treatment, besides identifying the therapy route for effective actions; enhance actions for epidemiological surveillance of hepatitis B, C and D; encourage the expansion of vaccination coverage and actions to reduce vertical transmission of hepatitis B. The Plan also intends to increase access from the perspective of full attention to viral hepatitis through strategies able to reach the greatest number of infected patients, while creating actions towards preventing new cases.

According to the DIAHV, the Plan is currently in its first phase, until 2019. The first selected states (Amazonas, Acre and Pará) were chosen due to the epidemiological profile, difficult access specific populations and difficulties accessing health services. This first phase includes six municipalities: Barcarena and Santarém (PA), Tabatinga, Benjamin Constant and Atalaia do Norte (AM) and Sena Madureira (AC). With a focus on Hepatitis Delta, Manaus held from July 17 to 19, 2017, the Regional Meeting of the Viral Hepatitis Confrontation Plan in the North Region. The event stressed the need to create the Plan, as well as the need to gather efforts between the cities, States and Federal governments, pursuing its implementation in a sustainable way, based on the World Health Organizations 2030 agenda. During three days, representatives of the governments, health services and Civil Society organizations had the opportunity to debate and propose alternatives able to effectively confront viral hepatitis in Amazonas, Acre and Pará States until 2019.

After the meeting in Manaus, the DIAHV met with states coordinations of viral hepatitis, currently involved in the Amazon Plans phase I, to create the instrument that will monitor future activities developed with the study of two new technologies: filter paper for hepatitis B viral load, and the use of an accelerated vaccine scheme for hepatitis B in Alto Solimões, given the logistics challenge to reach difficult access populations.

How to prevent from Hepatitis Delta

 The Hepatitis Delta virus acts as a parasite and needs to link to the Hepatitis B virus in order of the infection to occur. Transmission and prevention are also similar to type B, however, there is no vaccine against Hepatitis D. We are still waiting for new drugs, which are currently in Clinical Development Phases I and II, to better treat patients. Our group has perform Clinical Assays for Hepatitis Delta treatment with promising results, emphasizes Dr. Salcedo. The problems faced by people infected with the disease range from lack of information access and assistance, especially due to geographic conditions, to inexistence of treatment-specific medications.

The most effective way to prevent is with the Hepatitis B vaccine. Besides this, every sexual intercourse should be protected, as well as not sharing needles, syringes, nail pliers and other sharp objects. In beauty salons, the recommendation is to bring the personal use material. If one intends to get their body pierced of a tattoo, the procedure should be held in safe environments observing if all material is disposable and/or sterilized. Pregnant women should test for Hepatitis, since the diagnostic allows the physician to point the best way to avoid transmission to the child.

Data about Hepatitis Delta in Brazil

From 1999 to 2016, the Notification Information System of Diseases (Sinan) notified 3,791 cases (0.7%) Hepatitis D cases. During this period, 212,031 notified cases of Hepatitis B were confirmed along with 3,791 cases of Hepatitis Delta; the North region notified 30,213 cases of B and 2,911 of Delta – representing around 80% of all cases in Brazil. (2017 Viral Hepatitis Epidemiological Report)

While the North responds for 76.8% of the cases, Southeast, South, Northeast and Middle-West regions reported respectively 9.8%, 5.3%, 5.0% and 3.1%. For Dr. Salcedo, the concentration of the Delta virus in West Amazon, probably is corresponds to facts related to past migratory movements and, maybe, to the formation of a transmission pocket that remained concentrated in that place, and in the past, with the difficult access, restricted the dissemination to the outside. We have also studied the possibility of non-human primates being the reservoir of this virus in the region, he points.

The notified cases demonstrate that the infected population is the youngest; 52.3% age from 20 to 39 years-old. Approximately 15.3% have over 50 years-old. The predominance is among males (57.2%), although the difference between men and womens cases has decreased in the past years. Most cases affect brown people (65.0%), followed by white (19.3%), indigenous (8.4%), black (5.6%) and yellow (1.8%).…