Screening and management of viral hepatitis and hepatocellular carcinoma in Mongolia: results from a survey of Mongolian physicians from all major provinces of Mongolia

Abstract

BackgroundAccording to Globocan, Mongolia has the highest worldwide hepatocellular carcinoma (HCC) incidence (78.1/100 000, 3.5× higher than China).Aims and methodsWe conducted an anonymous survey of physicians from major provinces who attended an educational liver symposium, analysing their demography, practice, knowledge, perceptions and proposed solutions. Multivariate logistic regression was used to estimate OR relating demography and practice factors with higher provider knowledge and improvement.ResultsOf the 121 attendees, 44–95 (36–79%) responded to each question. Most were female (87%), young (79% age <50), subspecialists (81%), university-affiliated (74%), and practised in urban areas (61%). The mean pretest and post-test scores per physician were 60.4±20.4 and 65.6±21.3, with no observed significant predictors for baseline knowledge or improvement. Most (>80%) noted that <50% of patients who need hepatitis or HCC screening receive it. The main perceived barriers to screening were inability to pay for tests, lack of guidelines and poor patient awareness. Hepatitis treatment rates were low; 83% treated hepatitis C virus in <10 patients in the past year, and 86% treated hepatitis B virus in <10 patients/month. Treatment barriers were multifactorial, with cost as a principal barrier. Proposed solutions were universal screening policies (46%), removal of financial barriers (28%) and provider education (20%).ConclusionsPhysicians from major regions of Mongolia noted low screening for viral hepatitis, even lower treatment rates, financial barriers and the need for increased educational efforts. We advocate broad-based medical education tailored to local needs and based on needs assessment and outcome measurements.

Prevalence of Chronic Hepatitis B and C Infection in Mongolian Immigrants in the Washington, District of Columbia, Metropolitan Area, 2016–2017

“…Over one-third (36.8%) of participants had no immunity to HBV. Universal HBV immunization for newborns was not implemented in Mongolia until 1991 (19). This may have contributed to the lack of immunity for this study’s immigrant group of predominantly middle-aged adults (mean age >40 y).…”

“…Since HBV is a strong risk factor for the development of HCC, vaccination can prevent liver cancer (11,14). While vaccination initiatives substantially decreased the incidence of HBV in children worldwide, unvaccinated adults still represent an ongoing risk for HBV infection and HCC (14,19).…”

The genomic landscape of Mongolian hepatocellular carcinoma

“…In Mongolia, where cancer is the second most common cause of death accounting for nearly a fifth of all deaths, HCC is the most prevalent cancer type accounting for~40% of all cancers. Besides chronic infection with HBV and/or HCV, present in more than 90% of Mongolian HCC cases 6,7 , the etiology of Mongolian HCC may also be related to the extraordinarily high prevalence of hepatitis delta virus (HDV) 8,9 , which depends on HBV for its life cycle. Among HBV-infected Mongolian subjects, 60% were found HDV-coinfected, compared to the~5% global estimate 9 .…”

Physician perspectives on the management of viral hepatitis and hepatocellular carcinoma in Myanmar

“…In addition, the majority of physicians (74.3%) saw only <10 liver disease patients per week. The same format of symposium was given in Mongolia in 2015 with a very different audience from all the major provinces and 38.8% from the rural areas [ 9 ]. Furthermore, in contrast to the Burmese attendees, the majority of whom managed <10 patients per week and were not specialists, 78.1% of the Mongolian physicians managed ≥10 patients per week with liver disease and 81.1% were sub-specialists [ 9 ].…”

“…The same format of symposium was given in Mongolia in 2015 with a very different audience from all the major provinces and 38.8% from the rural areas [ 9 ]. Furthermore, in contrast to the Burmese attendees, the majority of whom managed <10 patients per week and were not specialists, 78.1% of the Mongolian physicians managed ≥10 patients per week with liver disease and 81.1% were sub-specialists [ 9 ]. In many ways, the audience is reflective of the disparities in Myanmar, with attendees mostly from larger institutions in Yangon rather than treating physicians from rural areas attending the symposium.…”