Poster

ABS 21005 Public Awareness and Knowledge on Liver Diseases and

Liver Health in Singapore
Gilead Sciences, Inc.
333 Lakeside Drive
Foster City, CA 94404
Tel: (650) 574-3000
Fax: (650) 578-9264

Chee-Kiat Tan¹, George Boon-Bee Goh¹, Jin Youn², Jacques Chak-Kwan Yu², Shikha Singh³
¹Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore; ²Gilead Sciences, Hong Kong; ³Kantar, Health Division, Singapore

BACKGROUND AND AIMS RESULTS, CONTINUED

Background:
 In Singapore, hepatocellular cancer was ranked as the second most common cancer-causing mortality in Figure 1. Knowledge level regarding hepatitis B and C and their transmission risks
20181,while liver cirrhosis attributed to 0.9% of deaths2.
A B
 Complications arising from chronic viral hepatitis infection, predominantly caused by hepatitis B virus (HBV) or Hepatitis B or C can/is… … touching an infected person
(agree)

By touching
an infected
(Disagree)
hepatitis C virus (HCV), contribute to majority of hospitalised cirrhosis cases3 and common indications for liver

person
100%

Proportion of respondents (%)

90% … mosquito bites (disagree)
transplants in Singapore4, respectively.

By mosquito
(Disagree)
bites
80%
… sharing non-sterile needles or via
 In Singapore, the estimated prevalence rate of non-alcoholic fatty liver disease (NAFLD) was 40.0%5,6. 70%
needlestick injuries (agree)

needles�ck

non-sterile
needles or

By sharing
through
(Agree)
injuries
60%
… blood contact with an open wound
Aim: 50%
(agree)

contact with
blood e.g.
40%

Through
an open
(Agree)
wound
 To assess the awareness and knowledge regarding liver diseases and liver health among the general population in 30%
20%
… pregnant mother to her baby at
birth (agree)

mother to her
baby at birth

pregnant
(Agree)

From
Singapore. 10% ... receiving tattoos, body piercing from
places with poor infection control
0%

poor infec�on

piercing from
ta�oos, body
se�ngs with

By receiving
standards
(Agree)

control
Cause liver Increases
failure the Bacterial
risk of …infection standards (agree)
Cause
… cause chronic … cause … increase aViral infection
… a viral(agree)… beAirborne
Prevented (disagree)
Hereditary
by … airborne (disagree)
… hereditary

METHODS
inflammation of the(agree) liver cirrhosis and(disagree) vaccination (agree only … dining together with an infected
chronic liver liver failure risks of liver bacterial infection prevented by (disagree) (disagree)
liver (agree) cancer development for HBV)
person (disagree)

together (e.g.
sharing food)
inflammation (agree) cirrhosis (agree) & infection (agree) vaccination†

(Disagree)

By dining
infected
with an
person
(agree) cancer (disagree)
development … sharing razors or toothbrushes
Study Population: (agree)

toothbrushes

By sharing of
(Agree)

razors,
(agree)

… sexual intercourse (agree)

 500 eligible respondents aged at least 18 years old and had provided informed consent.

intercourse

Through
(Agree)

sexual
… fecal-oral route usually through
 Study duration: February and March 2020. Hepatitis B (n=425) Hepatitis C (n=253)
contaminated food (disagree)

properly wash

contaminated

route usually
contaminate

food e.g. An
hands a�er
using toilet
(Disagree)

forgets to

Fecal oral
the food.

infected

through
person
and
Correct Incorrect “Not Sure” Correct Incorrect “Not Sure”
Response † Response Response Response † Response Response
Questionnaire: … eating contaminated or raw

contaminated
seafood e.g.
(Disagree)
seafood e.g. shellfish (disagree)

By ea�ng
shellfish

or raw
 The 30-minute web-based survey was developed and consist of three parts: 0% 20% 40% 60% 80% 100%
Note: correct responses are indicated in brackets – (agree) or (disagree), unless otherwise indicated
Proportion of respondents (%)
i) General liver health and care, †correct responses for “…be prevented by vaccination” are “agree” for hepatitis B and “disagree” for hepatitis C, respectively.

ii) Knowledge and awareness of liver diseases, risk factors as well as liver screening and diagnosis,
 More respondents heard of hepatitis B than hepatitis C (85% vs. 51%) (Figure 1A).
iii) Preferred liver information topic(s) and choice of information channel(s).
 Majority (85%) of those aware of hepatitis C did not know that hepatitis C is not preventable by vaccination (Figure 1A)
Analysis:
 Descriptive data analysis of respondents were summarised by frequencies and percentages.  More than half of the respondents misperceived that HBV and HCV was transmissible by:
- “fecal oral route usually through contaminated food” (HBV: 52%; HCV: 52%)
RESULTS - “eating contaminated raw seafood e.g., shellfish” (HBV: 66%; HCV: 57%) (Figure 1B).

Table 1. Demographic profile of respondents participating in the study Figure 2. Awareness of NASH and its associated risk factors
Respondents (n=500) Respondents (n=500)
A B
n % n % Have you heard about AF-NASH? (n=375) Perceived risk factors of AF-NASH (n=500)
50%
Age Group (years) Household Income Yes
No
< 25 80 16% < SGD 2,500 43 9%

Proportion of respondents (%)

12% 40%
25 - 34 100 20% SGD 2,500 - 4,499 96 19%
30%
35 - 44 110 22% SGD 4,500 - 6,499 81 16%
45 - 54 110 22% SGD 6,500 - 8,499 78 16% 20%
88%
≥ 55 100 20% SGD 8,500 - 10,499 82 16%
Gender ≥ SGD 10,500 107 21% 10%

Male 270 54% Declined to answer 13 3% 0% Lack of exercise Obesity Alcohol consumption Higher ALT or AST Diabetes High blood lipid Hypertension Heart Disease Insulin resistance Don’t know

†
Level of Education Medical Insurance
or excessive alcohol levels levels
intake

Primary School 1 0% Private insurance - Self Pay 358 72%

Secondary school 124 25% Private - Corporate insurance 122 24%
AF-NASH, advanced fibrosis non-alcoholic steatohepatitis; ALT, alanine aminotransferase; AST, aspartate aminotransferase
Vocational certificate 6 1% Public insurance [e.g. national
347 69%
Junior college 9 2% (e.g. Medishield) or subsidized]
 Only 12% among those who associated fatty liver and NASH with liver disease (n=375) were aware of AF-NASH
Polytechnic 42 8% None of the above 27 5% (Figure 2A).
University 241 48% Self-reported health screening status (in recent 2 years)
 Top three AF-NASH risk factors identified were
Postgraduate 77 15% Yes 327 65%
†Each respondent could have more than one medical insurance attribute
1) Lack of exercise (46%)
2) Obesity (45%)
 64% of respondents were aged 35 years and older.
3) Alcohol consumption or excessive alcohol intake (43%) (Figure 2B)
 Most of the respondents had completed at least university education (64%) and 53% had a monthly household income
 ~One-quarter perceived diabetes, high blood lipid levels and hypertension as potential risks of AF-NASH (Figure 2B).
of SGD 6,500 and higher.
 Majority of respondents (95%) have either private or public insurance or both.
Table 4. Knowledge and awareness of screening and diagnostics tests for liver diseases
 6 in 10 had recent health screening done in the recent 2 years (Table 1).
Question (correct answer) Proportion (%)
Others have told us what do elevated liver enzymes such as AST/ALT levels mean to them.
Table 2. Knowledge and awareness of liver function and liver health Which of the following applies to you? (n=500)
Agree Disagree Not sure

Proportion (%) [n=500] Elevated AST/ALT levels are main indicators of the damage to the lungs (disagree) 39% 9% 52%
Agree Disagree Not Sure Elevated AST/ALT levels could indicate infection with viral hepatitis (agree) 45% 5% 50%
Based on your understanding of the function of your liver, please indicate whether you agree or disagree with the following Elevated AST/ALT levels could indicate risk of liver cancer (agree) 48% 4% 48%
statements: Elevated AST/ALT levels are indicators of damage to the liver (agree) 50% 4% 47%
Liver helps to clean blood by taking harmful substances out of the blood 86% 6% 8% Elevated AST/ALT levels could indicate bacterial infection (disagree) 43% 6% 51%
Liver stores vitamins and minerals 49% 20% 31% Elevated AST/ALT levels could indicate risk of having NASH or NAFLD (agree) 45% 3% 52%
Liver stores nutrition/energy we take in from food 52% 23% 25%
Which of the following tests are you aware of for diagnosis of Hepatitis B and C? (n=500) Hepatitis B Hepatitis C
Liver makes bile that helps digest food 71% 14% 15%
Anti-HCV antibody test 27% 28%
Liver helps with blood clotting, which helps in stopping the bleeding when there is a cut/wound 46% 27% 27%
HBsAg test 24% 22%
Liver produces cholesterol which our body needs for normal growth and health 59% 14% 28% Liver function tests such as liver enzyme levels [AST/ALT levels] 41% 34%
How can you protect your liver and keep it healthy? None of the above 40% 47%
By exercising regularly 84% 9% 8% Apart from liver biopsy, are you aware of any non-invasive tools for screening of AF-NASH?
By eating a balanced diet 94% 3% 3% (n=46)†
By drinking alcohol modestly 70% 20% 10% Yes 87%
By practicing safe sex 69% 15% 16% †Among those who had indicated “Yes” to “have you heard of AF-NASH?”
AF-NASH, advanced fibrosis non-alcoholic steatohepatitis; ALT, alanine aminotransferase; AST, aspartate aminotransferase; HBsAg, hepatitis B surface antigen; NAFLD, non-alcoholic fatty liver disease; NASH, non-alcoholic
Follow directions on all medications 85% 6% 8% steatohepatitis

By getting vaccinated 83% 6% 11%

Go for regular screening to keep a check the liver 91% 4% 5%  About 40% of respondents were aware of the implications of blood transaminase enzyme levels (AST/ALT) (Table 4).
By taking liver supplements on my own 55% 23% 21%  About one-quarter correctly identified the specific diagnostic tests for hepatitis B and C (Table 4)
By sleeping well with good quality of sleep 88% 5% 7%
- More than 40% wrongly declared none of the tests indicated were applicable for diagnosing HBV and HCV (Table 4)

 Majority (86%) were aware of the detoxification function of the liver

Figure 3. Reception towards information regarding liver diseases
- Only at least 40% were knowledgeable about the other functions of the liver (Table 2) A B
Preferred disease information topics Channels preferred for receiving disease information
 91% agreed that going for regular screening to keep check on the liver is a way to protect liver health (Table 2). 100% 60%
90%
- Yet, only 65% attended health screening in recent 2 years (Table 1)
Proportion of respondents (%)

Proportion of respondents (%)

50%
80%
70% 40%

Table 3. Awareness and knowledge of liver diseases and the associated risks. 60%
50%
30%

40%
Question (correct answer) Proportion (%) [n=500] 20%
30%
Based on what you understand about liver diseases, please indicate if you agree or 20% 10%
Agree Disagree Not Sure
disagree with the following statements: 10% 0%
Doctor's consultation TV Patient Mobile phone apps Internet Forum Newspaper (Paid hard
Liver diseases are only caused by alcohol consumption (disagree) 19% 72% 9% 0%
Prevention
Prevention
Disease symptoms and
Disease
Treatment
Treatment
Route of transmission
Route
Disease prevalence
Disease
leaflets/pamphlets copy)

potential complications

Hepatitis is an inflammation of the liver (agree) 62% 9% 29% symptoms &

complications
of transmission prevalence

Cirrhosis can lead to number of complications including organ failure, liver cancer or death
64% 5% 31%
(agree)
Long term injury/inflammation to the liver leads to excessive scar tissue formation called fibrosis  Top preferred information channels were “Doctor’s
65% 4% 32%  “Prevention” (83%) was the most highly sought
(agree)
information topics (Figure 3A) consultation” (51%), “Internet search” (50%) and
Cirrhosis is the final stage of scarring and it can have a serious effect on the health (agree) 56% 4% 40%
“TV”(44%) (Figure 3B).
Yes No Not sure
Do you know that viral hepatitis is one of the key causes of liver failure in the world? 42% 32% 26%
CONCLUSIONS
Do you know that chronic viral hepatitis can cause liver cancer? 53% 22% 25%
Are you aware that World Health Organization (WHO) has stated that viral hepatitis if left untreated
could lead to complications such as liver failure or liver cancer?
51% 28% 22%  Singapore general public’s knowledge and awareness about liver disease and liver health was
Are you aware of the various staging of liver scarring/fibrosis? 21% 79% suboptimal.
Do you know liver fibrosis and cirrhosis is a key determinant of progression for liver disease related
death or ill-health?
39% 61% • While people were generally aware about hepatitis, there were still knowledge gaps about risk
factors and disease-associated complications of untreated liver diseases including NAFLD in the
 6 in 10 respondents were aware: development of liver cirrhosis/cancer or liver-related deaths.
- long-term liver inflammation could lead to fibrosis,  Future patient and public health education efforts should focus on correcting misconceptions and
- cirrhosis is the final stage of liver scarring and could lead to complications such as liver failure/cancer/death (Table 3). raising awareness about liver-related diseases given the increasing prevalence of NAFLD/NASH.
 About half recognized chronic hepatitis infection could cause liver failure and cancer (Table 3).
• Efforts to provide accessible information to the public should be done through the preferred
 21% comprehended the various stages of liver scarring/fibrosis & 61% reported not knowing liver fibrosis and cirrhosis information channels of the public.
are key determinants of liver progression-related ill health (Table 3).

REFERENCES
1. The Global Cancer Observatory. Singapore | Source: Globocan 2018 [Internet]. International Agency for Research on Cancer | World Health Organization; 2020 Oct [cited 2020 Dec 3] p. 2. Available from: https://gco.iarc.fr/today/data/factsheets/populations/702-singapore-fact-sheets.pdf | 2. Epidemiology & Disease Control Division, Singapore Burden of Disease and Injury Working Group. Singapore Burden of Disease
Study 2010 [Internet]. Epidemiology & Disease Control Division | Ministry of Health, Singapore; 2014 Jun. Available from: https://www.moh.gov.sg/docs/librariesprovider5/resources-statistics/reports/singapore-burden-of-disease-study-2010-report_v3.pdf | 3. Muthiah M, H Chong C, G Lim S. Liver Disease in Singapore. Euroasian J Hepato-Gastroenterol. 2018;8(1):66–8. | 4. Wai CT, Da Costa M, Sutedja D, Lee YM, Lee
KH, Tan KC, et al. Long-term results of liver transplant in patients with chronic viral hepatitis-related liver disease in Singapore. Singapore Med J. 2006 Jul;47(7):588–591. | 5. Ngu J, Goh G, Poh Z, Soetikno R. Managing non-alcoholic fatty liver disease. Singapore Med J. 2016 Jul;57(07):368–71. | 6. Goh GBB, Kwan C, Lim SY, Venkatanarasimha NK, Abu-Bakar R, Krishnamoorthy TL, et al. Perceptions of non-alcoholic
fatty liver disease – an Asian community-based study. Gastroenterol Rep. 2016 May;4(2):131–5.

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