Hepatitis: The silent killer

It kills one person every 30 seconds, a death rate that is three times as high as HIV/AIDS, affects more than one million people in Asia every year and every third person around the globe. And no, it is not HIV or malaria. Analysis of new data from the Global Burden of Disease Study (GBDS) 2010 published in the Lancet late last year reveals that the number of deaths related to viral hepatitis is significantly higher than previously thought, also that the Asia-Pacific is where an overwhelming majority of these occur (70 per cent). The study conducted by the Institute of Health Metrics and Evaluation at the University of Washington measures the impact of hundreds of diseases, injuries and risk factors across 21 regions across the world. Viral hepatitis is almost rubbing shoulders with HIV and outscores deaths from malaria when it comes to Asia, having almost doubled in the region since the study was done last in 1990. Not only this, the disease has higher mortality rates than even tuberculosis, which should leave no doubt about how infectious it is, considering the other three are the most prevalent infectious diseases known till date. With one more in its kitty, the world, however, is still grappling.

The disease burden

“Three-quarters of the total hepatitis B infected population lives in countries within the South-East Asia and Western Pacific regions.” Charles Gore President, World Hepatitis Alliance

Out of the five kinds of hepatitis viruses- A, B, C, D and E, hepatitis B and C are the major cause of concern in the APAC region. Elaborates Charles Gore, President of the World Hepatitis Alliance, “In Asia Pacific, the number of people dying each year from viral hepatitis has increased by over 315,000 since 1990. Three-quarters of the total hepatitis B infected population lives in countries within the South- East Asia and Western Pacific regions, with 20 percent of the total hepatitis C population living in South-East Asia.” It is also to be noted that there are now over 450,000 more deaths as a result of viral hepatitis infection each year compared to 1990, he adds. Within Asia, India houses the second largest number of hepatitis B patients after China with two to four percent of the population affected with it. The hepatitis B virus (HBV) is transmitted through exposure to infected blood, semen, and other body fluids. In regions and countries where maternal screening and the use of immunoglobulin is not available, mother-to-child transmission remains a major route of infection. Referred to as vertical transmission, this remains the concern in both India and China.

“It is not only the patients who are unaware, but even physicians maybe unable to pinpoint a cause, given the silent nature of the disease.” Samir Shah HOD-Hepatology, Director, Global Hospitals, Mumbai

The hepatitis C virus (HCV) is mostly transmitted through exposure to infected blood (transfusions of HCV-infected blood and blood products, contaminated injections during medical procedures, and sharing of needles and syringes among injecting drug users). In India, prevalence of hepatitis C has been observed to be relatively higher in Punjab, Andhra Pradesh, Puducherry, Arunachal Pradesh and Mizoram. While in Punjab, the incidence is highest at four per cent of the population, the North East has more cases of HIV co-infection alongwith hepatitis C by drug users, blood transfusion is responsible for cases in Western part of India and needle stick injuries have been responsible for large scale outbreaks in Gujarat, informs Dr Samir Shah, HOD, Hepatology, Director, Global Hospitals, Mumbai. The incidence of hepatitis C is a bit lower with 0.8 per cent to 1.5 percent of the Indian population currently infected with it. Although Government of India (GoI) has mandated the use of auto disable syringes for use since 2005, 95 per cent of injections administered are subject to the risk of reuse which in turn accounts for transmission which can be as high as 40 per cent in case of hepatitis C.

Stepping up screening and awareness

“All family members in an index family need to be screened, vaccination of positive patients will not help which is what is being practised currently.” Dr S K Sarin Professor and Head, Department of Hepatology & Director, ILBS

Even as we have been able to get a bit of grip on the numbers, the largely asymptomatic nature of the disease coupled with low awareness and the resultant lack of effective screening procedures means that there is a huge chunk of population carrying the virus are unaware of it and yet transmitting it. Hence, it becomes even more important to step up the ante on these fronts. “The problem is we do not know who to screen. Because it is a silent disease, the infection manifests later in life. Only 10 per cent of those affected show symptoms. If someone in the family is positive, all family members in such an index family need to be screened, vaccination of positive patients will not help which is what is being practised currently,” asserts Dr SK Sarin, Professor and Head, Department of Hepatology, and Director, Institute of Liver and Biliary Sciences (ILBS). WHO Framework for Global Action, also asserts development of guidelines for screening as an important part of a coordinated public health response to viral hepatitis, particularly in resource-poor settings.

“Inclusion of the HBV vaccine in national immunisation programmes is crucial to Hepatitis B prevention and has been one of the major global achievements in the past two decades.” D S Chen Chair, Coalition for the Eradication of Viral Hepatitis in Asia Pacific (CEVHAP)

It is with this in mind that as a part of its Global Hepatitis Programme, WHO launched a new initiative called the Global Hepatitis Network in June this year supported by the Coalition to Eradicate Viral Hepatitis in Asia Pacific (CEVHAP). “The patient lobby has typically been much smaller and much quieter compared with other diseases, with many people often reluctant to speak out owing to the stigma attached to the diseases. Raising awareness is one of the four axes of the WHO Framework for Global Action, and the new Global Hepatitis Network hopes strengthen international collaboration by sensitising policy-makers, health professionals, and the public,” exhorts Gore, founding member of CEVHAP. Poor screening leads to a laxity in controlling transmission. In India it was only in 2002 that it was made mandatory for blood banks to screen blood for hepatitis C, with most of the statistics on hepatitis C cases coming from people who would go for blood donation. And so, it is important to screen anyone who falls in the high risk group of those who received a blood transfusion before 2002, stresses Dr Shah. He also informs that it is not only the patients who are unaware, but even physicians maybe unable to pinpoint a cause, given the silent nature of the disease.

The solution

Given the complexity of the problem, it needs a multi-pronged approach, more so, a well developed strategy by the country that could further control the spread. In 2011, the Health Ministry gave a nod for the inclusion of hepatitis B vaccine shot as a part of the National Immunisation programme.

WHO also recommends universal vaccination with the first dose to be given at birth as the best protection against hepatitis B. However, to date, less than half of WHO Member States have a policy to provide HBV vaccine at birth and it is estimated that only 27 per cent of newborns globally receive this vaccine. Taiwan is perhaps the best example, the country was able to reduce the incidence of hepatitis B from 16 per cent to 0.9 per cent 20 years after they implemented universal vaccination. These are early days for India, the benefits are yet to trickle in terms of reduction in disease burden.

While some states like Andhra Pradesh have implemented vaccination completely, Maharashtra has only achieved 50 per cent. This becomes even more important since physicians indicate that pregnant mothers should also be tested to rule out the HBV given that vertical transmission is responsible for most of the cases.

However, for those who have not been vaccinated at birth, and the infection is chronic, treatment comes in the form of antiviral medicines that need to be taken lifelong, to keep the viral load under control and cost Rs 30-60 a day, whereas a six-month to one-year medication for hepatitis C comes costs Rs 1.5 to 3 lakhs, informs Dr Shah. But treatment is to the cure, elucidates Dr Sarin. “If treated properly, the patient can become non-viral, but viral clearance does not occur, the virus is part of the subject, you cannot get rid of the infection. Hence the current treatments are suboptimal,” he asserts.

It is estimated that there are 45 million carriers in India right now and 60 percent of these have a viral count above one lakh, which increases their risk of liver cancer by 11 fold.

“Hepatitis B is declared as a carcinogen. We have shown in two landmark studies that those who have the virus and their mother is HBV positive, 40 per cent of these with normal SGPT have liver disease,” he further reiterates.

Summing up, the fight to eradicate hepatitis is a long one, it begins with awareness first and then a targetted effort from all stakeholders to take sufficient steps to ensure the spread of the virus is controlled in time.

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