Background

Empirical, updated country-level estimates on the proportion of cirrhosis attributable to viral hepatitis are required. We estimated the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection in patients with cirrhosis at country, regional, and global levels as an approximation for the fractions of cirrhosis attributable to viral hepatitis.

Methods

In this systematic review, we searched MEDLINE, Embase, Web of Science, and Scielo between Jan 1, 1993, and Aug 1, 2021. Studies were eligible if they reported on the prevalence of both HBV and HCV infection in representative studies of at least 20 patients with cirrhosis. Studies were excluded if they used first-generation HCV assays or were from a selected population of patients with cirrhosis (eg, patients selected based on specific causes, veterans, injecting drug users). Two authors (CJA and CdM) selected and extracted aggregated data from the selected publications. Data were extracted for study recruitment period, age, sex, and cause of cirrhosis, among others. Data about heavy alcohol consumption and non-alcoholic fatty liver disease (NAFLD) were also extracted when available. Aggregated data from studies from key publications were requested from the authors of the original study if selection of patients was unclear or information on causes was missing. We estimated the country-specific prevalence of causes of cirrhosis by pooling study-level data from the same country using a random-effects model. Subsequently, we estimated the regional (WHO region and UN subregion) and global prevalence by weighting the country-specific prevalence by the number of new liver cancer cases that occurred in 2020, as estimated in GLOBOCAN. The study was registered with PROSPERO, CRD42020149323.

Findings

Our database searches identified 21 338 records, and a further nine records were identified by scanning references of key publications. After excluding duplicates and assessing full-text articles for eligibility, 520 publications from 86 countries or territories (and reporting on 1 376 503 patients with cirrhosis) were included in the systematic review. The prevalence of HBV infection was lower among patients with cirrhosis in Europe, the Americas, and Oceania (UN subregional prevalence ranges 3–14%) than in Africa and Asia (8–61%). HCV infection prevalence was heterogenous, even within regions (12–83%). The combined prevalence of HBV and HCV infection exceeded 50% in most Asian and African regions. Globally, among patients with cirrhosis, 42% had HBV infection and 21% had HCV infection. The contribution of heavy alcohol use was highest in Europe (country range 16–78%), the Americas (17–52%), and Oceania (15–37%) and lowest in Asia (0–41%). Data on NAFLD were limited.

Interpretation

HBV and HCV could account for almost two thirds of the global burden of cirrhosis. With the availability of effective interventions for the prevention or treatment of HBV and HCV, the data presented in this study will help to effectively allocate resources towards viral hepatitis elimination and to design interventions at the country level.

Funding

International Agency for Research on Cancer, World Health Organization.

中文翻译：

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乙型肝炎病毒和丙型肝炎病毒在国家、地区和全球各级肝硬化患者中的全球流行情况：一项系统回顾

背景

需要对可归因于病毒性肝炎的肝硬化比例进行经验性的、更新的国家级估计。我们估计了国家、区域和全球各级肝硬化患者乙型肝炎病毒 (HBV) 和丙型肝炎病毒 (HCV) 感染的患病率，作为病毒性肝炎引起的肝硬化分数的近似值。

方法

在本系统综述中，我们检索了 1993 年 1 月 1 日至 2021 年 8 月 1 日期间的 MEDLINE、Embase、Web of Science 和 Scielo。如果研究至少在代表性研究中报告了 HBV 和 HCV 感染的流行率，则研究符合条件肝硬化患者20例。如果研究使用第一代 HCV 检测或来自选定的肝硬化患者人群（例如，根据特定原因选择的患者、退伍军人、注射吸毒者），则这些研究被排除在外。两位作者（CJA 和 CdM）从所选出版物中选择并提取了汇总数据。提取了研究招募期、年龄、性别和肝硬化原因等方面的数据。有关大量饮酒和非酒精性脂肪性肝病 (NAFLD) 的数据在可用时也被提取出来。如果患者选择不明确或原因信息缺失，则要求原始研究的作者提供关键出版物研究的汇总数据。我们通过使用随机效应模型汇集来自同一国家的研究水平数据，估计了特定国家肝硬化病因的患病率。随后，我们根据 GLOBOCAN 估计的 2020 年新发肝癌病例数对特定国家/地区的患病率进行加权，从而估算了区域（世卫组织区域和联合国次区域）和全球患病率。该研究在 PROSPERO 注册，CRD42020149323。我们通过使用随机效应模型汇集来自同一国家的研究水平数据，估计了特定国家肝硬化病因的患病率。随后，我们根据 GLOBOCAN 估计的 2020 年新发肝癌病例数对特定国家/地区的患病率进行加权，从而估算了区域（世卫组织区域和联合国次区域）和全球患病率。该研究在 PROSPERO 注册，CRD42020149323。我们通过使用随机效应模型汇集来自同一国家的研究水平数据，估计了特定国家肝硬化病因的患病率。随后，我们根据 GLOBOCAN 估计的 2020 年新发肝癌病例数对特定国家/地区的患病率进行加权，从而估算了区域（世卫组织区域和联合国次区域）和全球患病率。该研究在 PROSPERO 注册，CRD42020149323。

发现

我们的数据库搜索确定了 21 338 条记录，并且通过扫描主要出版物的参考文献确定了另外 9 条记录。在排除重复文章并评估全文是否合格后，来自 86 个国家或地区的 520 篇出版物（以及关于 1 376 503 名肝硬化患者的报告）被纳入系统评价。欧洲、美洲和大洋洲肝硬化患者的 HBV 感染率（联合国次区域感染率范围为 3-14%）低于非洲和亚洲（8-61%）。HCV 感染率存在异质性，即使在区域内也是如此 (12–83%)。在大多数亚洲和非洲地区，HBV 和 HCV 感染的合并流行率超过 50%。在全球范围内，肝硬化患者中，42% 感染了 HBV，21% 感染了 HCV。大量饮酒的贡献在欧洲（国家范围 16-78%）、美洲（17-52%）和大洋洲（15-37%）最高，在亚洲最低（0-41%）。NAFLD 的数据有限。

解释

HBV 和 HCV 可能占全球肝硬化负担的近三分之二。随着预防或治疗 HBV 和 HCV 的有效干预措施的可用性，本研究中提供的数据将有助于有效地分配资源以消除病毒性肝炎并设计国家级的干预措施。

资金

国际癌症研究机构，世界卫生组织。