HCV Elimination Campaign and Risk Factors of HCV Infection in Arkhangai Province in Mongolia

Background: Most viral hepatitis deaths in 2015 were due to chronic liver disease (720,000 deaths due to cirrhosis) and primary liver cancer (470,000 deaths due to hepatocellular carcinoma). Mongolia has a relatively high se-ro-prevalence of HCV nationally, approximately 6% (CDA Foundation/Polaris Observatory). Mongolia has a large burden of viral hepatitis, especially chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, which are associated with cancer and cirrhosis. Methods: All adults aged 40 - 65 years being tested for anti-HCV antibodies during the campaign of Arkhangai province. Risk assessment survey questionnaire that includes about behavioral and clinical factors potentially associated with HCV infection was used for optioning data. Statistical analysis that was done using SPSS version 21 was used for data analyzed. The relevant parametric and nonparametric tests were used for data analysis. Result: All 17,601 surveyed of individuals were tested for HCV by using ELISA test for detecting the anti-HCV Ab; 3289 of them were positive and 3049 of them had detected a viral load test. Most of screened population was female (9095, 52.0%), mainly herdsman (7206, 40.9%), tal 10,524 individuals were reported that they had more than 4 risk factors to possibility to getting infected with HCV. Conclusion: In total, 19.5 percent of screened individuals had anti-HCV antibody, and most of them was not known not only mothers and sexual partners but also own infection to HCV. Mongolian prevalence of anti-HCV was relatively high. As would be predicted based on accepted risk factors, HCV-positive participants were more likely to have used injection at the non-medical environment, and had any kind of dental procedure, received blood transfusion, been shared needles/injection at the non-hospital environment. Also variety of personal behaviors like having any kind of tattoos influenced significantly to infected to HCV.


Background
Most viral hepatitis deaths in 2015 were due to chronic liver disease (720,000 deaths due to cirrhosis) and primary liver cancer (470,000 deaths due to hepatocellular carcinoma). Globally, in 2015, estimated 257 million people were living with chronic HBV infection, and 71 million people with chronic HCV infection [1]. Due to the fact that acute HCV infection is usually asymptomatic, few people are diagnosed during the acute phase. In those people who go on to develop chronic HCV infection, the infection is also often undiagnosed, because the infection remains asymptomatic until decades after infection when symptoms develop secondary to serious liver damage [2].
Mongolia has a relatively high sero-prevalence of HCV nationally, approximately 6% (CDA Foundation/Polaris Observatory). Mongolia has a large burden of viral hepatitis, especially chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, which are associated with cancer and cirrhosis. Chronic HBV infection is acquired in early childhood in Mongolia, while HCV and hepatitis delta virus (HDV) transmission is healthcare related. Mongolia also has the highest and increasing rate of liver cancer and mortality from liver cancer in the world. Cancer is the second most common cause of death in Mongolia and liver cancer is responsible for 44% of all cancers. Chronic hepatitis B and C infections are responsible for 95% of liver cancers in the country [3].
Differences in past HCV incidence and current HCV prevalence, together with the generally protracted nature of HCV disease progression, have led to considerable diversity in the burden of advanced liver disease in different countries. Countries with a high incidence of HCV or peak incidence in the recent past will have further escalations in HCV-related cirrhosis and hepatocellular carcinoma (HCC) over the next two decades. The disease progression of chronic HCV infection often accelerates after 20 years of infection, with lifestyle factors key drivers of hepatic fibrosis [4].
Mongolia is a lower-middle-income country located in Central Asia and bor-

Ethical Considerations
The survey methodology was reviewed and got approval from the Mongolian

Study Population
All adults ages 40 -65 years being tested for anti-HCV antibodies during the

Data Collection and Duration
The

Survey Instrument
Based on a literature review regarding HCV risk factors, we developed a risk as- The patient medical record card was created during the treatment period of time and patients who tested positive but didn't meet the criteria for hepatitis C treatment brought to the attention of the expert's team from tertiary level hospital to determine if further hepatitis C management was possible.

Result
All 17601 surveyed of individuals were tested for HCV by using ELISA test for detecting the anti-HCV Ab, from them 3289 individuals were positive and 3049 of them had detected viral load test. Also we had analyzed HBsAg among HCV Significantly high number of female (60.6%), retired people (31.4%), single (13.8%), and people aged 55 -59 years (21.6%) were more HCV-positive than other groups. As expected HCV-positive patients were by 4 year older than the HCV-negative people and they numbers of risk factors were also higher than the HCV-negative people. Annual income level was similar in both HCV positive and negative group of people. As would be predicted based on accepted risk factors, HCV-positive participants were more likely to have used injection at the non-medical environment, had any kind of dental procedure, received blood transfusion, been shared needles/injection at the non-hospital environment. Also variety of personal behaviors like having any kind of tattoos influenced significantly to infected to HCV.
Patients with HCV were more likely than uninfected individuals to have undergone any kind of surgery, wound and bloodletting treatment in life time. In addition, individual's job plays important role to get infected with HCV.
In the logistic regression model, a separate indicator variables were included. While, male individuals were significantly more knew about partner's HCV infection status (Figure 1).
In the questionnaire, all individuals were asked to describe their risk factors.
Only 914 (5.2%) individuals were reported that had no risk factors. 16  of screened individual were reported they had at least 3 types of risk factors. In total 10524 individuals were reported that they had more than 4 risk factors to possibility to getting infected with HCV (Table 2).
In comparison, Table 3

Discussion
Asymptomatic patients with HCV infection identified through screening program could benefit not only from treatment but also from other interventions such as counseling to maintain health and avoid risk behaviors. This might prevent the spread of infection and result in significant public health benefits [12].
Thus, this study aimed to reveal anti-HCV antibody though macro screening among all aged 40 -65 in Arkhangai, in Mongolia. In total, 19.5 percent of screened individuals were had anti-HCV antibody, and most of them were not known not only mothers and sexual partners but also own infection to HCV.    [13].
WHO reported that the simple and effective hepatitis testing strategies and tools are lacking, with less than 5 percent of people with chronic hepatitis infection knowing their status. For this reason, diagnosis often occurs late and appropriate tests to assess liver disease and guide treatment decisions, including when to start treatment, are seldom available [14].
Ludmila [15]  A number of studies indicate that the peak of viral hepatitis transmission was in the 1970s and 1980s before disposable syringes were available in Mongolia.
Poor infection control, re-use of syringes in health settings and administering injections at home led to the rapid spread of viral hepatitis [19]. We defined that among people who aged 40-65 had high risk of history of re-use of syringes not only in the hospital but also at non-hospital environment. Anti-HCV was more prevalent in dental personnel who were older, had more years of practice, and had serologic markers of HBV infection and they are confirming high rates of HBV infection among dental personnel. Risk factor that asked in our survey shows working with sharp items is one of main risk factors of HCV among Mongolian health personnel.
Based on WHO recommendation each country should define the specific populations within their country that are most affected by viral hepatitis epidemics and the response should be based on the epidemiological and social con- In many countries, much transmission of hepatitis B virus and hepatitis C occurs in health care settings and therefore specific populations for focused attention include people who have been exposed to viral hepatitis through unsafe blood supplies and unsafe medical injections and procedures. In settings with high hepatitis B prevalence, mother-to-child transmission of hepatitis B is likely to be a major mode of transmission, along with early childhood infection among Our study has several limitations. Although trained physicians were asked screening questions we used self-reported HCV risk factors. In the questionnaire's some of self-reported risk factors are missing. In our study population might not be representative for the population as a whole but could be present whole population aged 40 -65 in Arkhangai province.
In further cost-effectiveness analysis and public health actions should take into account not only the screening of anti-HCV (Ab) and treatment of HCV infected individuals but also the strategy on prevention of re-infection is essential.