Hepatitis B virus (HBV) and hepatitis C virus (HCV) infection pose a significant public health concern as they can lead to cirrhosis and hepatocellular carcinoma, potentially resulting in mortality in Korea and the world [1-3]. Mainly, viral hepatitis is the leading cause of liver-related morbidity and mortality [2,4]. While effective antiviral agents could alleviate the burden of viral hepatitis [5], which remains a persistent threat, the current lack of awareness, which can hinder timely screening and treatment, poses a significant concern. A significant proportion of patients with viral hepatitis remain unaware of their infection status in the US [6,7]. However, no studies have assessed individuals’ awareness of viral hepatitis and advanced fibrosis in Korea. We examined the current burden and the level of awareness among individuals with viral hepatitis and advanced fibrosis in the Korean general population from 2012 to 2022.

This study analyzes data from the recent Korea National Health and Nutrition Examination Survey (KNHANES), covering 2012, when anti-HCV data were first included, through 2022 [8]. Adults (≥19 years) who completed questionnaires and laboratory examinations were enrolled (n=61,508). We defined HCV infection as a positive anti-HCV and HBV infection as a positive hepatitis B surface antigen. Awareness of viral hepatitis among individuals with viral hepatitis was defined according to the participant’s response to a specific KNHANES question, “Have you ever received a clinical diagnosis of hepatitis B or C from a physician?”. The participants were considered “aware” of ever having viral hepatitis if they answered “Yes”. We categorized individuals with viral hepatitis into three groups based on FIB-4 score: low (<1.30), intermediate (1.30–2.67), and high probability for advanced fibrosis (>2.67) [9]. Using the KNHANES’ complex sample design, we applied the appropriate weights to reconstruct populationlevel data and presented weighted prevalences of awareness with a 95% confidence interval (CI).

The mean age of the population (weighted sample: 40.1 million) was 47.0 years (95% CI 46.8–47.3), with 50.1% identifying as men. The weighted prevalence of HBV infection was 3.19% (95% CI 3.02–3.37), representing approximately 1.28 (95% CI 1.21–1.35) million individuals in Korea. The weighted prevalence of HCV infection was 0.70% (95% CI 0.63–0.78), corresponding to 0.28 (95% CI 0.25–0.31) million individuals in Korea (Fig. 1A). Diabetes and hypertension affected 12.8% and 31.0% of individuals with viral hepatitis, respectively. The proportion of advanced fibrosis (12.7%, 95% CI 10.0–15.9) in HCV infection was significantly higher than in HBV (7.4%, 95% CI 6.2–8.7). The weighted prevalence of awareness of liver disease among individuals with HBV infection was 21.1% (95% CI 18.9– 23.5), while the prevalence of awareness among those with HBV-related advanced fibrosis (32.5%, 95% CI 24.7–41.4) was slightly higher (Fig. 1B). The prevalence of awareness of liver disease among individuals with HCV and HCV-related advanced fibrosis was 17.3% (95% CI 13.6–21.7) and 37.1% (95% CI 26.7–48.9). The prevalence of awareness of liver disease was substantially higher in men for both HBV (26.0%) and HBV-related advanced fibrosis (36.5%) compared to women (15.0% and 27.6%, respectively; Fig. 1C). We observed a similar trend in awareness across both sexes among individuals with HCV and HCV-related advanced fibrosis (Fig. 1D). Significant alcohol consumption was slightly higher among individuals unaware of viral hepatitis (22.0%) than those aware (18.7%), though the difference was not statistically significant. Proportions of current or past smokers were similar in both groups.

In this population-based study in Korea, the key findings are: (1) the current prevalence of HBV and HCV infection is 3.2% and 0.7%, respectively; (2) the proportion of significant fibrosis is 7.4% for HBV and 12.7% for HCV; (3) only one-fifth individuals with viral hepatitis are aware of their liver disease; (4) awareness slightly increases with the stage of viral hepatitis, (5) the lower awareness are observed among women. A recent study based on the US NHANES 2017–2020 reported that the prevalence of awareness of liver disease among adults with HCV and HBV was 49.6% and 39.5%, respectively [7]. In contrast, awareness of liver disease among Korean adults with viral hepatitis is exceptionally low. This finding indicates that nationwide initiatives, such as designating a specific day as Hepatitis Awareness Day and the Know More Hepatitis campaign, have not substantially reached those needing care. Rather, community-driven initiatives may be more effective [10]. Through coordinated efforts and community-level organization, enhancing awareness of viral hepatitis requires implementing educational programs, expanding screening efforts, and increasing the connection between the general population and healthcare campaigns across Korea. Our study has several limitations. First, we could not obtain liver histological samples. Second, awareness data relied on self-report questionnaires, possibly subject to recall bias. In conclusion, while slightly more adults with viral hepatitis and significant fibrosis were aware of their liver disease, approximately 80% of Korean adults with viral hepatitis were unaware of their liver disease. Therefore, it is essential to implement educational programs, increase screening efforts, and connect the general population to healthcare campaigns throughout Korea.