doi:10.1111/j.1440-1746.2011.06974.

S P E C I A L A RT I C L E jgh_6974 238..247

Liver disease in Viet Nam: Screening, surveillance,

management and education: A 5-year plan and call to action
Robert G Gish,* Tam D Bui,† Chuc T K Nguyen,¶ Duc T Nguyen,‡ Huy V Tran,** Diem M T Tran,††
Huy N Trinh§ and International Group for Liver Health in Viet Nam
*Division of GI Hepatology, University of California, San Diego, †Internal Medicine, San Francisco, ‡School of Business and Information
Technology, Northwestern Polytechnic University, Fremont, and §San Jose Gastroenterology, MC, San Jose, California, USA; and ¶Department of
Family Medicine, Hanoi Medical University, Hanoi, Vietnam and **Departments of Gastroenterology and Hepatology, and ††Immunology and
Pathology, Hue College of Medicine & Pharmacy, Hue, Vietnam

Key words Abstract

alcoholic liver disease, hepatitis B, hepatitis C,
hepatocellular carcinoma, Vietnam.
Accepted for publication 29 September 2011.
Correspondence
Robert G Gish, Division of GI Hepatology,
University of California, San Diego, 200 West
Arbor Drive, MC8413, San Diego, CA
92103-8413, USA. Email: rgish@ucsd.edu
Despite a high prevalence of liver disease in Viet Nam, there has been no nationwide
approach to the disease and no systematic screening of at-risk individuals. Risk factors
include chronic hepatitis B (estimated prevalence of 12%), chronic hepatitis C (at least 2%
prevalence), and heavy consumption of alcohol among men. This combination of factors
has resulted in liver cancer being the most common cause of cancer death in Viet Nam.
There is a general lack of understanding by both the general public and health-care
providers about the major risk to health that liver disease represents. We report here the
initial steps taken as part of a comprehensive approach to liver disease that will ultimately
include nationwide education for health-care providers, health educators, and the public;
expansion of nationwide screening for hepatitis B and C followed by hepatitis B virus
vaccination or treatment of chronic hepatitis B and/or hepatitis C; education about alco-
holic liver disease; long-term surveillance for liver cancer; reduction of infection transmis-
sion related to medical, commercial, and personal re-use of contaminated needles, syringes,
sharp instruments, razors, and inadequately sterilized medical equipment; and ongoing
collection and analysis of data about the prevalence of all forms of liver disease and the
results of the expanded screening, vaccination, and treatment programs. We report the
beginning results of our pilot hepatitis B screening program. We believe that this compre-
hensive nationwide approach could substantially reduce the morbidity and mortality from
liver disease and greatly lessen the burden in terms of both lives lost and health-care costs.

alcoholic liver disease. Without proper intervention, the combina-

Introduction
There is a high prevalence of liver disease in Viet Nam, much of
which results from preventable causes, including chronic infection
with hepatitis viruses,1–4 as well as high consumption of alcohol
among men.5 Since chronic infection with hepatitis viruses,
including hepatitis B virus (HBV) and hepatitis C virus (HCV),
can lead to cirrhosis and liver cancer, with alcohol consumption
increasing those risks, it is not surprising that a recent nationwide
study found that liver cancer is the most common cause of cancer
death in Viet Nam.6
One large study has predicted an enormous liver disease burden
in Viet Nam over the next 15 years from chronic hepatitis B (CHB)
alone,7 a burden that includes the loss of many years of healthy life
due to the complications of liver failure, liver cancer, and death in
many people as well as the monetary costs associated with the
disease. The overall liver disease burden will be greatly increased
by the addition of substantial numbers of people living with other
forms of the disease, including chronic hepatitis C (CHC) and
tion of all of these could make the ultimate costs to both individu-
als and society quite staggering.
Unfortunately, there has been no systematic nationwide screen-
ing in Viet Nam of individuals at risk for liver disease, and no
nationwide comprehensive response to the disease. There is a
general lack of understanding by both the general public and
health-care providers about the major risk to health that liver
disease represents. Many things contribute to the lack of informed
awareness about liver disease, including cultural misconceptions,
misinformation and mythology about the disease, inadequate
access to care, and a lack of educational programs about liver
disease directed to the Vietnamese population and to health-care
professionals.
What we have proposed and presented to the government of Viet
Nam through a white letter signed by 36 physicians from the USA,
Viet Nam, and Australia is the development of a comprehensive
approach to liver disease in Viet Nam that includes: (i) education
and training for health-care providers, health educators, and the

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RG Gish et al. Liver disease in Viet Nam

Table 1 Addressing liver disease in Viet Nam: eleven tasks

Task 1: Educating the Vietnamese public about liver disease, with particular emphasis on education related to HBV screening, vaccination, and
treatment, HCV screening and treatment, and the contribution to the overall burden of liver disease from alcohol consumption.
Task 2: Training health providers to update and improve their knowledge base regarding all aspects of liver disease in Viet Nam
Task 3: Collecting and analyzing data on HBV, HCV, alcoholic liver disease, and liver cancer in Viet Nam
Task 4: Expanding screening for HBV and HCV and vaccination for HBV
Task 5: Providing linkage to care and treatment for CHB and CHC
Task 6: Providing education and resources for addressing alcoholic liver disease
Task 7: Reducing infection transmission related to medical, commercial, and personal re-use of contaminated needles, syringes, sharp
instruments, razors, and inadequately sterilized medical equipment
Task 8. Developing, testing and evaluating a toolbox to educate the Vietnamese public and their health-care providers about the relationship
between HBV and liver cancer
Task 9: Training health educators to improve their knowledge, awareness, attitude and behavior related to the high risk of HBV and HCV, and the
need for screening for both viruses, vaccination against HBV, and treatment for CHB and CHC
Task 10: Designing and promoting methods to manage health-care costs while maintaining quality.
Task 11: Performing process evaluation for each of the tasks defined here, as well as outcome evaluation for the entire project

For in-depth information on these tasks, please see Appendix I.

CHB, chronic hepatitis B; CHC, chronic hepatitis C; HBV, hepatitis B virus; HCV, hepatitis C virus.

public about the various forms of liver disease; (ii) expansion of

nationwide screening for HBV and HCV followed by, as appro-
priate, HBV vaccination or treatment and/or HCV treatment; (iii)
education about alcoholic liver disease, with identification of
resources to address this; (iv) in patients with identified liver
disease, long-term surveillance for liver cancer; (v) reduction of
infection transmission related to medical, commercial, and per-
sonal re-use of contaminated needles, syringes, sharp instruments,
razors, and inadequately sterilized medical equipment; and (vi)
ongoing collection and analysis of data about the prevalence of all
forms of liver disease and the results of the expanded screening,
vaccination, and treatment programs.
The white letter was presented to Viet Nam’s Vice Minister of
Health, Trinh Quan Huan, and Director of Health, Tran Thi Giang
Huong, at a signing ceremony on 23 March 2010. Afterwards, the
International Liver Foundation for Viet Nam was founded, and
both Vietnamese Deputy Prime Minister Truong Vinh Trong and
Minister of Health Nguyen Quoc Trieu declared their support for
the project. The Vice Minister of Health then ordered his health
officers to begin implementation of the tasks described in the white
letter as necessary for addressing liver disease nationwide, as
shown here in Table 1. Since then, six Vietnamese institutions,
including the four largest medical schools (Hue College of Medi-
cine and Pharmacy, Ho Chi Minh City University of Health Sci-
ences, Hanoi Medical University, and Can Tho University of
Medicine and Pharmacy) and the two largest hospitals (Bach Mai
Hospital, Hanoi, and Cho Ray Hospital, Ho Chi Minh City) have
pledged their support and accepted responsibility for carrying out
specific tasks in the areas of screening, vaccination, education,
research, data collection and training.
We present here our overview on the current situation with liver
disease in Viet Nam and the beginning results of the screening and
vaccination efforts. We believe that this type of comprehensive,
science-based, nationwide approach to liver disease is urgently
needed, and that when the tasks described in Table 1 are carried
out, they could substantially reduce the morbidity and mortality
from this disease and greatly lessen the burden in terms of both
lives lost and health-care costs.
Chronic hepatitis B virus infection
Viet Nam has one of the highest rates of chronic HBV infection in
the world. In a recent very large study that assessed blood test
results from all patients visiting 12 hospitals in Viet Nam from
2005 to 2008 (excluding patients from groups defined as being at
“high risk” of infection with HBV, HCV, and HIV) it was found
that 12% were hepatitis B surface antigen (HBsAg)-positive.8
Thus, even with the exclusion of high-risk groups, it can be esti-
mated that approximately 10 million people are living with CHB.
As shown in Table 2, the CHB prevalence is high in both urban and
rural areas, with an estimated prevalence of 10–14% in Ho Chi
Minh City and Hanoi1,2 and as high as 18.8%3 to 19%4 in some
rural areas. Unsurprisingly, the prevalence of CHB in patients with
liver disease is even higher, an estimated 31.2%1 to 47%.10 Coin-
fection with both HBV and HCV has been reported in 7.7% of
liver disease patients.1 Without medical monitoring and treatment
of CHB, the risk of developing cirrhosis and hepatocellular carci-
noma (HCC) with sequelae of liver failure and death is
25–30%.11–15 Using age-specific HBV prevalence rates from Viet-
namese community-based studies, it has been projected that by the
year 2025, CHB could result in 58 650 patients with cirrhosis,
25 000 patients with HCC, and 40 000 deaths.7
There are many factors underlying the high rate of HBV infec-
tion in Viet Nam, and the inadequate use of vaccination for pre-
vention. First, many people in the general public and many
health-care providers have no real understanding of the risks and
long-term consequences of untreated infection and the need to
vaccinate the uninfected, and are unaware that there are safe and
effective treatments for those already infected. In a country with
a low average per capita income, there are also many people for
whom treatment is not affordable. For Viet Nam to effectively
address HBV disease there is an urgent need to move forward
with a nationally supported program that includes education and
screening, followed by, as appropriate, vaccination and treat-
ment, with government coverage for these for all those who
could not otherwise afford it. Health-care providers should be
educated about the high HBV prevalence; the need for screening,

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Liver disease in Viet Nam
Table 2 Prevalence of chronic HBV infection in Viet Nam
Investigators Population studied
Tran HT et al., 20031 Urban, Ho Chi Minh City, low & high risk
Nakata S et al., 19942 Urban, Ho Chi Minh City and Hanoi, low & high risk
Hipgrave DB et al., 20033 Rural, Thanh Hoa province
Nguyen VT et al., 20074 Rural, Thai Binh province
Duong TH et al., 20099 Rural, Thai Nguyen province
Nguyen HD et al., 20108 Greater Mekong sub-region, both urban and rural, low risk
Kakumu S et al., 199810 Urban, Ho Chi Minh City, high risk; rural, Dalat City, low risk
HBV, hepatitis B virus.
vaccination, and effective management of CHB, including treat-
ment and liver cancer surveillance; and up-to-date guidelines for
treatment. The general public must be educated on the risks and
taught that vaccination can provide lifelong protection and that,
in those already infected, CHB can be effectively and safely
treated.
Neonatal HBV vaccination to prevent perinatal transmission is
not yet universal; it had only been implemented in 70% of the
provinces by 2004.16 A recent study in four provinces in Viet
Nam identified several factors that affected birth-dose timeliness
and coverage, including family perceptions, perceived contrain-
dications, community-based pregnancy tracking practices, and
relationships of the vaccination program with both private mater-
nity services and large urban hospitals.17 Addressing all such
factors that have so far prevented neonatal HBV vaccination
from becoming truly universal could greatly reduce and ulti-
mately virtually eliminate vertical transmission. One important
step for reducing transmission will be to ensure that all hospitals
and clinics have an established policy for newborn hepatitis B
vaccination. Children born to CHB mothers should also be
screened between ages 1 and 5 as 5–10% of infants will become
infected despite the vaccination. In addition, an effective
catch-up vaccination program could provide protection for chil-
dren and adolescents not previously successfully vaccinated.
Screening prior to vaccination should be mandatory to preclude
giving already infected children the vaccine; the latter could
provide false reassurance of protection and result in those chil-
dren never receiving treatment. To prevent horizontal transmis-
sion, effective approaches to screening must be established
nationwide in order to identify and increase vaccination rates
among the susceptible, while also identifying and informing indi-
viduals with immunity and those who are infected, referring the
latter for assessment and treatment.
It will also be very important to educate both the general public
and health-care providers about all the risk factors for transmission
of HBV, including: (i) unsafe sex with an infected partner; (ii)
exposure to blood via re-use of syringes, needles or sharp instru-
ments (including not only in the health-care setting but also in the
home or when used for tattoos or in traditional medicine prac-
tices); (iii) inadequately sterilized medical equipment; (iv) sharing
such items as razors or toothbrushes; (v) direct contact with an
240
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RG Gish et al.
Chronic HBV infection
Low risk: 10%
High risk: 31.2%
10%–14%
Infants: 12.5%
Children: 18.4%
Adolescents: 20.5%
Adults: 18.8%
19%
8.8%
12%
Low risk: 5.7%
High risk: 47.0%
infected person’s blood or open sores; and (vi) sharing needles,
syringes, or other drug-injection equipment. Household contact
with a person with liver disease, sharing of razors, and reuse of
syringes have been identified as major risk factors for HBV infec-
tion in Viet Nam.4 Transmission of HBV in the health-care setting
via contaminated needles, syringes, and inadequately sterilized
hospital equipment also occurs much too frequently, with recent
studies showing that major risk factors include a history of hospi-
talization and a history of acupuncture,4 as well as a history of
surgery.9 It will be crucial to identify and address any barriers to
screening. Although social stigma and discrimination against those
identified as HBsAg-positive are generally thought to be substan-
tially less in Viet Nam than has been seen in some other countries,
providing free anonymous testing sites may be important to
increase the willingness to be tested. It will also be important to
provide simplified guidelines for proper use and interpretation of
HBV screening assays.
Point-of-care (POC) testing is a key innovation that will revo-
lutionize patient screening and dramatically reduce per-patient
cost. A pilot project is being carried out in Viet Nam by a sub-
group of the coauthors (R.G. Gish, T.D. Bui and D.M.T. Tran)
using Bioland (Chungbuk, Korea) tests for HBsAg (NanoSign
HBs) and anti-HBs (NanoSign anti-HBs), which can be carried
out on-site, with a 20-min turnaround to obtain results. The per-
person cost for both test kits was approximately $US1.00. In the
population of 526 students at Hue College of Medicine and Phar-
macology so far tested, there was a prevalence of HBsAg of
9.12%; 126 (23.95%) were found to be anti-HBs+. As part of our
pilot project, additional screening and vaccination efforts have
been carried out with 1520 children in Bavi, Hanoi (with the
collaboration of government health officers in December 2010)
and with 18 000 junior high students at Long An (with the col-
laboration of government health officers and public junior high
school principals in March 2011).
POC tests need to include HBsAg (if positive, indicating infec-
tion), anti-HBc (indicating exposure), and anti-HBs (indicating
immunity) to assist in proper patient allocation to vaccination or
linkage to care, or to determine that the patient has cleared infec-
tion and needs no further intervention. Further refinements of the
development of POC testing will include validation via compari-
son with licensed global assays.
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RG Gish et al.
Table 3 Prevalence of chronic HCV infection in Viet Nam
Investigators Population studied
Tran HT et al., 20031 Urban, Ho Chi Minh City, low & high risk
Nakata S et al., 19942 Urban, Ho Chi Minh City and Hanoi, low & high risk
Nguyen VT et al., 20074 Rural, northern Viet Nam, low risk
Nguyen HD et al., 20108 Greater Mekong sub-region, both urban and rural, low risk
Kakumu S et al., 199810 Urban, Ho Chi Minh City, high risk; rural, Dalat City, low risk
Quan VM et al., 200918 Rural, northern Viet Nam, high risk
Nguyen VT et al., 20074 Rural, northern Viet Nam, low risk
Clatts MC et al., 201029 Urban, Hanoi, high risk
HCV, hepatitis C virus.
Chronic hepatitis C virus infection
As shown in Table 3, the prevalence of chronic hepatitis C in Viet
Nam has been estimated to range from only 1.0% in low-risk
groups to as high as 87% in high-risk groups. In the study already
mentioned that assessed blood test results from all patients visiting
12 hospitals in Viet Nam from 2005 to 2008 (excluding high-risk
patients) the HCV prevalence was found to be 2.89%.8 The preva-
lence in patients with liver disease has been reported to be much
higher, with one study showing that 23% of liver disease patients
in Ho Chi Minh City were seropositive for HCV antibodies, with
detectable HCV-RNA in 61% of these.10 In another study, HCV-
RNA was detected in 19.2% of liver disease patients, with 7.7%
reported to be coinfected with both HBV and HCV.1 The preva-
lence of HCV is particularly high in drug users (87%) and patients
who require medical treatment that potentially exposes them to
HCV through contaminated medical devices or blood products,
including patients on maintenance hemodialysis (54%) and those
with hemophilia (29%).2 Nosocomial transmission of HCV is high
in developing countries because too often contaminated syringes
and needles are re-used in medical, paramedical and dental
procedures.19,20 Community re-use of needles for tattoos is also
common. In one study of patients without liver disease, the two
main risk factors associated with HCV acquisition were hospital
admission and tattoos.21
Approximately 25% of people with chronic HCV will eventu-
ally develop cirrhosis,22 and a substantial percentage will subse-
quently develop HCC. As with CHB, most people with CHC will
remain symptom-free and unaware that they are infected until a
late disease stage when they develop obvious signs of cirrhosis or
HCC. Thus, screening with an antibody test to allow for early and
accurate diagnosis is essential. It will be important to provide
simplified guidelines to health-care workers for proper diagnosis
of CHC, including use of confirmatory tests, such as HCV-RNA
quantification, as well as for appropriate treatment.
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Liver disease in Viet Nam
Chronic HCV infection
Low risk: 2%
High risk: 19.2%
Low risk, Ho Chi Minh: 9%
Low risk, Hanoi: 4%
High risk, drug users, Ho Chi Minh: 87%
High risk, drug users, Hanoi: 31%
High risk, hemodialysis patients, Ho Chi Minh: 54%
High risk, hemophiliacs, Ho Chi Minh: 29%
Low risk: 1.0%
Low risk: 2.89%
Low risk: 1%
High risk: 23%
High risk, drug users: 74.1%
Low risk: 1.0%
High risk, drug users, 10 or fewer months of injection
risk: 30%
High risk, drug users, 30 or more months of injection
risk: 70%
Alcoholic liver disease
Alcoholic liver disease (ALD) is another major contributor to the
overall burden of liver disease in Viet Nam. A recent study of nine
sites in five Asian countries found very high rates of alcohol
consumption by men in Viet Nam.5 In fact, of the nine sites
assessed, the two in Viet Nam had by far the highest rates (31.4%
and 17.3%) of male at-risk drinkers, defined as men consuming
five or more standard drinks per day. Another 53.2% and 68.5% of
men at the two sites in Viet Nam were rated as moderate drinkers
(consuming up to four drinks per day). As part of the overall
approach to liver disease, it will be important to educate health-
care workers about alcoholic liver disease and about the resources
available for addressing it. When alcoholic liver disease is appar-
ent, it will be appropriate for health-care workers to refer patients
to counseling and alcohol support groups.
Liver cancer
A recent nationwide study which collected data from almost all
(94.6%) of the 10 769 commune health stations which provide
health services in Viet Nam found that liver cancer is the most
common cause of cancer death in Viet Nam,6 accounting for 27.1%
of cancer deaths (31.04% in men and 19.91% in women). It is
thought that over 90% of these liver cancer deaths reflected the
high prevalence of HBV infection in Viet Nam.23 Alcohol and
HCV infection are other likely contributors to this high rate of liver
cancer. In one study of patients diagnosed with HCC, the majority
(85%) had evidence of CHB; almost one in seven patients had
evidence of HCV.24
For prevention of liver cancer in Viet Nam, the first long-term
focus should be HBV vaccination, thus effecting primary preven-
tion of all liver cancers that are related to this virus. In addition, it
will be important to use the best available treatments to profoundly
suppress HBV and HCV in the chronically infected to lessen HCC
241

Liver disease in Viet Nam
risk. It will also be important to address alcoholic liver disease
well before it reaches the stage that can lead to cancer.
Overcoming challenges
There are many challenges that exist in Viet Nam related to pro-
viding the type of total integrated approach to liver disease that
could substantially decrease both morbidity and mortality.
Medical care resources
Although 70–75% of Viet Nam’s 84 million people dwell in rural
and mountainous regions where medical care is substantially
limited, almost all of the 10 769 communes have a health center
which provides both primary health care and preventive health-
care activities,25 a potentially valuable resource for addressing
liver disease. Providing the health centers with simple accurate
guides on proper screening and vaccination procedures for HBV,
screening for HCV, and treatment for those with CHB and CHC
could guide them to proper care of liver disease patients. Because
these commune health centers already have information flowing to
and from the Ministry of Health, a national mandate to improve
liver disease services could efficiently reach the local commune
level. It will also be important to enlist private health-care provid-
ers as in some areas there are more private providers than public
ones.26 The non-profit health organizations that provide health care
in Viet Nam are also valuable resources. All provinces and most
communes (95.7%) have a Red Cross Society branch that provides
free health checks for the poor and other vulnerable groups,
including children, the elderly, and women,25 so enlisting their
help in the campaign against liver disease might be invaluable.
Infection transmission in health-care settings
Re-use of contaminated needles, syringes, and inadequately ster-
ilized medical equipment is another major challenge that must be
addressed. Recent Vietnamese studies have identified as major risk
factors for HBV infection a history of hospitalization and of acu-
puncture4 as well as a history of surgery.9 HCV prevalence is
particularly high in patients on maintenance hemodialysis (54%)
and those with hemophilia (29%).2 It is particularly troubling to
consider that the failure to address the use of contaminated
medical equipment and contaminated blood products could leave
patients with such chronic conditions as kidney disease and hemo-
philia with only the terrible choice of remaining untreated, or
being treated but at the risk of acquiring a very serious infection.
Education on the risks and absolute unacceptability of re-using
needles and syringes and of inadequate hospital sterilization mea-
sures will be very important, preferably combined with govern-
mental initiatives and mandates against these vectors of infection.
In addition, clear guidelines on universal precautions can reduce
risks for health-care workers, while guidelines regarding the man-
agement of health-care workers who are infected with HBV, HCV,
and/or HIV can protect patients.27
Screening for HIV, HBV, HCV, malaria and syphilis is compul-
sory for all blood donations. According to the World Health Orga-
nization (WHO), Viet Nam has made substantial progress on
transmission of HBV or HCV via blood transfusions and other
242
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RG Gish et al.
blood products, increasing the rate of voluntary blood donations,
the safest source of blood, from less than 15% in 1994 to more
than 65% currently.28 To further reduce risks, WHO recommends
developing quality assurance systems in blood centers and blood
banks nationwide and creating a national blood service and a
national blood policy in Viet Nam.
Reuse of needles, syringes, and razors
Re-use of contaminated needles and syringes by injecting drug
users (IDU) is another substantial risk factor, with the prevalence
of HCV shown to be extremely high (87%) in IDU in Ho Chi
Minh2 and northern Viet Nam (74.1%).18 The prevalence of HBV
among IDU in northern Viet Nam is also extremely high
(80.9%).18 Researchers have strongly recommended interventions
that target new heroin users.29 A 1998 study indicated the feasibil-
ity of establishing needle/syringe exchange programs in Viet
Nam.30 The Vietnamese government has supported harm-reduction
through needle/syringe exchange,31 and a recent study has shown
that it contributes to safe injecting practices as well as safe disposal
of used needles/syringes.32 Alas, despite the government’s support,
the overall access to clean syringes/needles nationwide remains
quite limited, with one recent study showing that 90% of IDU in
seven provinces had no access to sterile injection equipment,33 so
substantial expansion of harm-reduction programs is needed.
It is not uncommon for needles and knives to be re-used in tattoo
shops. In one study, tattoos were one of the two main risk factors
for HCV.21 Since household sharing of razors is a risk factor for
HBV,4 the same risk would apply to commercial re-use. Educating
barbers and tattoo shop personnel about such risks is very
important.
Cost-effectiveness
This is a developing country with a relatively low annual per capita
income (approximately $US1024)34 and very limited annual per
capita spending on health care (according to WHO, approximately
264 international dollars, 2006). A large percentage of people in
Viet Nam do not have any type of health insurance or other health-
care coverage and even those who do may not have full coverage.
Thus, much of the expense of vaccination, screening tests, and any
treatments is currently paid by patients or their families. It will be
important to consider the cost-effectiveness of providing free vac-
cination nationwide, as well as free or low-cost treatment, where
needed, as part of a strategy to reduce the impact that low income
has on successful prevention of liver disease.
Looking at the cost-effectiveness of a program to prevent liver
disease means looking at the costs of screening, vaccination, treat-
ments, and other interventions that could ultimately help prevent
liver disease and comparing those up-front costs to the potential
benefits down the line from the disease prevention versus the
outcome if there is no intervention. In looking at outcomes, cost-
effectiveness studies incorporate loss of quality of life as well as
actual loss of years of life by using what is called the disability-
adjusted life year (DALY), with one DALY equal to the loss of one
healthy year of life.
According to the WHO, an intervention is defined as “cost-
effective” when each DALY averted costs between one and three
Journal of Gastroenterology and Hepatology 27 (2012) 238–247

RG Gish et al.
times the gross domestic product (GDP) per capita. An interven-
tion is defined as “very cost-effective” if each additional DALY is
prevented at a cost less than the per capita GDP.35 A major review
of studies of the cost-effectiveness of hepatitis B vaccination found
that in areas of low, intermediate and high endemicity, universal
vaccination is generally cost-effective.36 A cost-effectiveness
analysis of universal childhood HBV immunization in low-income
countries with intermediate endemicity found it to be very cost-
effective.37 Although a national study to assess the cost-
effectiveness of a nationwide program to prevent CHB in Viet
Nam has not yet been done, a recent study in China gives strong
support for the likelihood that it would be very cost-effective,
showing that if China spent $US423 million on free “catch-up”
vaccination, it would produce a net return in the economy of
$US840 million from lower health-care costs.38
Studies have also shown the cost-effectiveness of substituting
safe injection practices in health-care settings for the re-use of
syringes and needles that currently leads to transmission of mul-
tiple infections.39,40 One large study showed that in all regions of
the world studied, policies for the safe and appropriate use of
injections would be highly cost-effective.39
Overall, it is highly likely that the costs of a proactive approach
to liver disease that includes institution of safe injection practices,
nationwide neonatal and catch-up HBV vaccination, nationwide
screening for HBV infection with follow up that includes vacci-
nation or treatment, appropriate screening for HCV with follow up
that includes assessment and, where possible, treatment, and
monitoring for liver cancer combined with education on liver
disease for both the public and health-care providers would be
very cost-effective when compared to the ultimate costs of failing
to address liver disease and allowing millions of people to progress
toward cirrhosis, liver cancer, and death.
Conclusion
It is both timely and extremely urgent to create a scientifically
based project that addresses the fast-growing problem of liver
disease among the Vietnamese population. The comprehensive
approach we describe here combines updated public health
methods with a state-of-the-science medical approach that
includes screening, immunization, detection, and treatment. With
the looming threat of a rapidly growing liver disease burden in Viet
Nam, this program needs to be strategically planned and effec-
tively implemented as soon as possible.
The 5-year project will include the design and implementation
of a comprehensive health promotion program to educate the Viet-
namese public, to train health professionals, and to provide screen-
ing, vaccination, and treatment services to the Vietnamese
population. Integration with current health systems in Viet Nam
and strong government support will be an essential part of this
program development. In order to achieve the goal of culturally
sensitive and competent health systems, our project includes the
eleven major tasks outlined in Table 1.
The combined results of an integrated approach to liver disease
in Viet Nam are highly likely to significantly help to turn the tide
against this disease, preventing HBV infection of the uninfected,
providing effective treatment of the causes of liver disease, to the
greatest extent possible, substantially lowering the risk of liver
cancer and the death rate due to acute and chronic liver disease,
Journal of Gastroenterology and Hepatology 27 (2012) 238–247
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14401746, 2012, 2, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/j.1440-1746.2011.06974.x by Readcube (Labtiva Inc.), Wiley Online Library on [03/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Liver disease in Viet Nam
and substantially decreasing the future need for liver transplanta-
tion, thus generally improving the lives of affected individuals
while greatly reducing the associated health-care burden.
Acknowledgments
The authors extend their gratitude for the funding for this program
which was made possible through the Grants & Disbursement
Committee of California Pacific Medical Center Foundation. The
authors would like to thank Robert W. Osorio, MD, FACS, Chair,
Barry S. Levin Department of Transplantation, California Pacific
Medical Center, and Hamila Kownacki, RN, VP Operations, CAO,
California Pacific Medical Center, for their seminal vision in sup-
porting this program. The authors would also like to express their
deep gratitude and appreciation to all their colleagues at universi-
ties, in hospitals, and within the government in Viet Nam whose
assistance in planning an effective approach to liver disease in Viet
Nam has been invaluable. In addition, our deep thanks go to Dr
Lark Lands for her invaluable assistance in preparing the manu-
script for publication.
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Appendix I
Eleven tasks for addressing liver disease in
Viet Nam
Task 1: Education of the Vietnamese population
One of the most important parts of our project will be educating
the Vietnamese public about liver disease, with particular empha-
sis on education related to HBV screening, vaccination, and treat-
ment, HCV screening and treatment, and the contribution to the
overall burden of liver disease from alcohol consumption and
non-alcoholic fatty liver disease. This program will apply three
major communication channels, including person-to-person,
group education, and mass media. Structured interviews, surveys,
and focus groups will identify the best educational intervention
strategies, the most efficient messages, the most cost-effective
messengers, and the most effective materials.
The strategies will be selected and applied depending on the
educational targets, including patients, the public, health profes-
sionals, and health policy makers. The strategies used will depend
on the targets’ educational levels. We will test and use a variety of
resources for educational messages. For example, celebrity
endorsement, dramatic interaction, documentary, or factual pre-
sentation formats might be selected for video spots. The actual
approaches for each medium will be assessed by focus groups in
order to review and decide on the most effective presentation
approaches to communicate with the targeted audience. In general,
Journal of Gastroenterology and Hepatology 27 (2012) 238–247

RG Gish et al.
what is called the Shoemaker’s four-stage approach will be applied
to provide knowledge and create awareness of the population
(Stage 1), to convince people to change attitudes and behaviors
(Stage 2), to lead people to make decisions about changing (Stage
3), and to help people confirm and continue the changes (Stage 4).
Stages 1 and 2 are usually relatively easy to achieve, but Stages 3
and 4 can be very difficult.
The commune health centers in Viet Nam could be an extremely
valuable resource for achieving success with Task 1. Because these
commune health centers already have information flowing to and
from the academic and hospital community, the Ministry of
Health, the Provincial Health Bureaus, and the District Health
Divisions, a national mandate to improve HBV education, screen-
ing, vaccination, and treatment could efficiently reach the local
commune level. As almost all of the 10 769 communes have a
health center where commune health workers already work to
provide both primary health care and most preventive health-care
activities, they could be trained both to provide education on HBV
infection and CHB and to carry out screening, followed by vacci-
nation and treatment, where indicated. In addition, the District
Health Divisions already have teams that provide education and
assistance in specific areas (such as Hygiene and Epidemiologi-
cal). Thus, these health workers at both the commune and district
levels could be an invaluable resource for this project when prop-
erly educated about screening, vaccination, and treatment.
Where necessary, additional health educators can be selected
and trained in health education on liver disease, so that they can
perform person-to-person health education activities in such set-
tings as policy makers’ offices, health centers, physicians’ offices,
pharmacies, barber shops, and hair salons, as well as group edu-
cation sessions at gathering points, such as waiting rooms in hos-
pitals, churches, temples, senior centers, community centers,
schools, universities, music performances, health fairs, and food
markets. In addition, the mass media can promote awareness via
articles in Vietnamese- or English-language newspapers and
magazines, posters, pamphlets, flyers, and television or radio talk
shows.
Task 2: Training of health providers
This program will include both regular classroom educational
seminars and online Continuing Medical Education (CME)
courses. With the collaboration of expert consultants, we will
design and conduct CME seminars to update and improve the
knowledge base of medical professionals regarding all aspects of
liver disease in Viet Nam. While the classroom setting continues to
be a popular format for CME, research indicates that it results in a
significantly lower level of behavior change than the computer-
based CME approach, often referred to as internet or e-learning
CME. Because time available to physicians for CME is so limited,
the approach must be flexible, permitting physician learners to
re-review the materials as frequently as desired.
Online CME courses will consist of a series of e-learning
modules for health professionals focusing on screening, vaccina-
tion, and treatment of HBV; screening and treatment of HCV; and
the prevention, early detection and case management of liver
cancer. There will also be CME courses to provide education on
the risks and absolute unacceptability of re-using needles and
syringes and of inadequate sterilization measures related to hos-
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Liver disease in Viet Nam
pital equipment. In addition, there will be a CME course on guide-
lines for health-care providers who are infected with HBV, HCV,
and HIV; the guidelines on this, recently released by the Society
for Health-care Epidemiology of America (SHEA) can be used
as the basis for this CME.1 The complete guidelines are avail-
able online at: http://www.shea-online.org/Assets/files/guidelines/
BBPathogen_GL.pdf. Additional CME courses will provide infor-
mation on treating and preventing alcoholic liver disease and non-
alcoholic fatty liver disease. These internet CME courses will be
available to all health professionals nationwide, including physi-
cians, public health professionals, pharmacists, and nurses.
Task 3: Data collection and analysis
We will create a comprehensive nationwide hepatitis B and C
surveillance system. There will be targeted active surveillance to
collect and monitor data on incidence and prevalence of hepatitis
B and C virus infection, as well as capturing data on alcoholic liver
disease and liver cancer. As part of this, the program will include
conducting scientific samples of the population, using the medical
records of hospitals and health centers, to collect and analyze data
on the incidence and prevalence of all of these liver diseases. Both
a Health Information System and Health Information Technology
will be established to build reliable and valid databases on hepa-
titis, liver diseases, and liver cancer in the Vietnamese population.
Electronic Medical Record (EMR) and Personal Health Record
(PHR) systems will be partially established.
Task 4: Screening and vaccination
Another crucial part of our project is to expand screening for HBV.
Screening for HBV will be performed at the Commune Health
Centers and at the gathering points indicated in Task 1. After the
screening, recommendations will be made to individuals with
negative results who are not immune to do the vaccination series
either at the Commune Health Center, or at the office of their
primary care physician, or through the community screening
events that are part of our project. Three vaccination shots are
required within a six-month period. Patients with test results that
show that they have chronic infection with HBV will be referred to
the Commune Health Centers, to primary care physicians, or to
physician specialists for assessment. In addition, as part of this
task we will work to help ensure that all hospitals and clinics have
in place a written policy for newborn hepatitis B vaccination, and
that health-care providers are knowledgeable about this standard
of care.
Since the prevalence of HCV infection is suspected to be higher
than 2% overall, HCV screening should also take place in the
initial sites for HBV screening. Based on the data for the first 5000
patients screened for HBV and HCV, a decision can be made on
whether to call for nationwide HCV screening or to focus on
high-risk groups only.
Task 5: Treatment of CHB and CHC and linkage to care
CHB can be effectively treated in a way that leads to durable viral
suppression and reversal of liver disease, substantially decreasing
the risk of progression to cirrhosis, liver cancer, death, or the need
for liver transplantation. CHC is also treatable and in some cases
245

Liver disease in Viet Nam
curable. Educational programs and materials will be developed to
help ensure that up-to-date information on treating CHB and CHC
is available to Commune Health Centers, primary care physicians,
physician specialists, and private health care providers so an
appropriate treatment program can be recommended to patients
who are screened and found to have chronic infection with one or
both viruses.
Task 6: Addressing alcoholic liver disease
Alcoholic liver disease (ALD) is another major contributor to the
overall burden of liver disease in Viet Nam. ALD in combination
with CHB and/or CHC is an even more serious disease. Educa-
tional materials on alcoholic liver disease and resources available
for addressing it will be developed as part of this project. In
addition, we will look into setting up a consultation network con-
cerning alcoholic liver disease.
Task 7: Reducing infection transmission related to
medical, commercial, and personal re-use of
contaminated needles, syringes, sharp instruments,
razors, and inadequately sterilized medical equipment
A key step for countering liver disease in Viet Nam will be to
address the current high risk of infection with hepatitis viruses
from re-use of contaminated needles, syringes, and inadequately
sterilized medical equipment in health-care settings, including not
only in both public and private hospitals, clinics, and physician’s
offices but also in traditional medicine practices. As part of this
project, we will seek to work in partnership with the Ministry of
Health, the National Institute of Hygiene and Epidemiology, and
other government entities in Viet Nam which provide guidance on
infection control.
We will also seek to cooperate with other organizations already
working in this area, including the US President’s Emergency Plan
For AIDS Relief (PEPFAR). Currently, in collaboration with the
Ministry of Health’s Vietnam Administration for HIV/AIDS
Control (VAAC) and the World Health Organization (WHO),
PEPFAR is helping develop national injection safety guidelines,
providing training related to dissemination of these guidelines, and
procuring sharps-disposal equipment for eight focus provinces. As
part of our project, we will assess what we may contribute to these
efforts.
We will also assess how we may contribute to the development
and nationwide dissemination of guidelines for proper sterilization
of medical equipment, such as that used for dialysis. The goal will
be to help ensure that health-care providers nationwide will have
clear guidance on the risks and absolute unacceptability of re-use
of contaminated needles, syringes, and inadequately sterilized
medical equipment, and that all health-care settings will adhere to
the guidelines for injection safety and proper disposal of injection
equipment, as well as to guidelines for proper sterilization of
medical equipment. Within this task, we will also assess how to
best reach traditional medicine practitioners with clear information
on these risks, and training on properly following injection safety
guidelines.
As part of this task, we will also assess how we might provide
additional resources to help expand the success of harm reduction
projects, including needle/syringe exchange programs. Although
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RG Gish et al.
most such efforts to date have focused on reducing HIV infection
rates, there is also an extremely high risk of acquisition of both
HBV and HCV from needles and syringes re-used by IDU. As
discussed in the main text of this paper, a recent peer educator-
based syringe/needle exchange program carried out in northern
Viet Nam showed both the feasibility of carrying out such pro-
grams, and their potential to reduce unsafe injection practices
while providing safe disposal of used injection equipment, thus
protecting community members from accidental exposure to con-
taminated equipment. As part of our task we will reach out to the
ongoing programs working in this area to see how we might
contribute.
It will also be important to address the risk of infections from
commercial re-use of needles and other sharp instruments in tattoo
parlors, and of razors in barbershops. As part of this task, we will
investigate the best approaches for reaching out to these commer-
cial enterprises in order to provide guidance on eliminating unsafe
practices by barbers and tattoo artists nationwide.
Task 8: Liver cancer toolbox
We will develop, test and evaluate an educational toolbox of
medical interventions and educational materials to inform and
educate the Vietnamese public and their health-care providers
about the relationship between HBV and liver cancer. We will use
a variety of assessment tools to determine the most effective inter-
vention strategies and the best educational messages.
The toolbox will incorporate Vietnamese culture and medical
ethics, particularly the Ethics for Vietnamese Health Professionals
by Hai Thuong Lan Ong, a Vietnamese physician in the 18th
century. Briefly, Hai Thuong Lan Ong listed the 8 “Do’s” for
physicians, including concern for others, brightness, intelligence,
virtue, generosity, honesty, modesty, studiousness, and the 8 “Do
Not’s” for physicians, including laziness, stupidity, immorality,
narrow-mindedness, cruelty, lying, stinginess, and eagerness for
money. As we go forward with our project, we will pledge to
uphold the highest standards of medical ethics, as expressed in The
World Medical Association Declaration of Geneva in 1948 and the
International Code of Medical Ethics in 1949. Key principles of
these codes that we pledge to follow include “respect and gratitude
to the teachers,” “extreme confidentiality to the patients,” “broth-
erhood between colleagues,” and “honor to the noble traditions of
the medical profession.”
Task 9: Training of health educators
We will include as part of our project approaches to improving the
knowledge, awareness, attitude and behavior of health educators
related to the high risk of HBV and HCV, and the need for screen-
ing for both viruses, vaccination against HBV, and treatment for
CHB and CHC. We will select, train and manage educators and
messengers who can plan and perform effective intervention tasks,
either in community health centers or in outreach activities.
The goal will be to increase screening, testing and, for HBV,
vaccination rates, followed by treatment of CHB and/or CHC,
where appropriate, ultimately leading to reduction of illness and
death rates from these infections. The health educators that are part
of the current health system will play an important role in carrying
out this task.
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RG Gish et al. Liver disease in Viet Nam

In addition, where needed, additional health educators may be Task 11: Project and performance evaluation
selected among health professionals (such as nurses, pharmacists,
An expert evaluation team will perform process evaluation for
physicians, public health educators, and social workers) as well as
each of the tasks defined here, as well as outcome evaluation for
other people who regularly come in contact with the public, such
the entire project. Both qualitative information and quantitative
as musicians, singers, teachers, hair stylists, and barbers. Health
data will be collected, analyzed, and reported by the evaluators
educators will be tested for qualification and performance and then
for adjustment under formative evaluation and for final report
will be trained in health education, counseling, health behavior,
under a formal/summative evaluation. Convenient samples of
and cultural adaptation. Assessment of existing educational mate-
patients who have been screened or vaccinated for hepatitis B
rials and development and testing of new materials will be per-
will be acquired from commune health centers, selected clinics,
formed to select materials that can be effectively used within the
and selected pharmacies and statistically analyzed for effective-
constraints of the Vietnamese language, behavior, and culture.
ness. Samples of people who have been provided with liver
Website material delivery will be applied to satisfy on-demand
disease education at the gathering points will be selected for pre/
printing and the quick download of digital audio-visual and pre-
post knowledge, attitude, and practice changes. Evaluation forms
formatted educational tools.
at health education training meetings and health professionals’
training sessions will be analyzed to assess training effectiveness
Task 10: Cost and health-care quality
and trainers’ performance. Evaluation reports will be submitted
As part of this project, we will work to design and promote during and after the project life to indicate the achievement of
methods which can manage costs while maintaining quality. project goals and objectives.
Quality must be controlled using quality assurance and quality
improvement methods, including practice guidelines, criteria,
Joint Commission standards, and indicators. Costs must be con-
sidered and justified by analyses showing cost-effectiveness.
Reference list
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order to incorporate loss of quality of life as well as actual loss of hepatitis B virus, hepatitis C virus, and/or human immunodefi-
years of life in our cost-effectiveness analyses. Based on such ciency virus. Infect. Control Hosp. Epidemiol. 2010; 31: 203–32.
assessments, decisions can be made about which approaches are
the worst and the best values.

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