Recently Bangladesh, Bhutan, Nepal and Thailand became the first countries in World Health Organization (WHO) South-East Asia Region to achieve Hepatitis B control, with prevalence of the deadly disease dropping to less than one per cent among five-year-old children. Taking a leaf out of its immediate neighbours’ books, can India achieve control over the disease that is known to cause more deaths than malaria and dengue combined?
Hepatitis or an infection of the liver is recognised as an important public health problem across the world such that according to WHO estimates, viral hepatitis caused 1.34 million deaths globally in 2015, a number comparable to deaths due to tuberculosis, worldwide.
Considering that in India, it is estimated that there are four crore people suffering from Hepatitis B, according to National Center for Biotechnology Information (NCBI), India falls in the intermediate endemicity zone (with a prevalence of two–seven per cent and an average of four per cent), with a disease burden of about 50 million.
What does it mean? This means that preventing Hepatitis B infection in infancy would reduce chronic infections and cases of liver cancer and cirrhosis (scarring of the liver) in adulthood.
On World Hepatitis Day today, observing this year’s theme ‘Invest in eliminating Hepatitis’, experts suggest that elimination can only happen through prevention that can take place if people are aware of the disease and its treatment measures.
What is HBV?
As a DNA virus, Hepatitis B Virus (HBV) is different from all other viruses in the sense that it is mostly acquired through blood transfusion or blood-contaminated body fluids. “It’s spread when people come in contact with the blood, open sores, or body fluids of someone who has the virus besides needlestick injury, tattooing and piercing,” said Dr Anukalp Prakash, senior consultant – Gastroenterology, Paras Hospitals, Gurgaon.
“The common mode of acquiring it, not so much in India, but in South East Asia, is from mother to child. Because it is a DNA virus, it could lead to chronic infections which means it is very difficult for the body to get rid of it. Therefore, the whole goal is to suppress the virus and keep the viral loads very low,” explained Dr Nivedita Pandey, senior consultant, Gastroenterology/Hepatology, Sitaram Bhartia Institute of Science and Research.
Globally, in 2015, an estimated 257 million people were living with chronic HBV infection, as per Ministry of Health and Family Welfare’s National Action Plan Combating Viral Hepatitis in India, 2019.
Why is there lack of awareness?
In most cases, patients infected with Hepatitis B don’t experience any symptoms until it begins to show signs of liver damage. About a third of the people who have this disease don’t show any symptoms. They only find out through a blood test.
“That is the reason patients remain asymptomatic for a long period of time. In rural India, where prenatal testing is not very common, the virus tends to go undetected in children and they do not know they have it until much later in adulthood. If you live with a family member who has Hepatitis B and you are not vaccinated, there is a high risk of acquiring the virus,” Dr Pandey told indianexpress.com.
When should you get yourself checked by a hepatologist?
*Acute illness with symptoms that last several weeks
*Yellowing of the skin and eyes (jaundice),
*Extreme fatigue, nausea, vomiting
Note: Symptoms may not show up until one to six months after you catch the virus. You might not feel anything.
A blood test can diagnose acute and chronic HBV infection. “Screening is available for people who have a higher risk of HBV infection or complications due to undiagnosed HBV infection which include infants born to mothers with HBV, sex partners of infected persons and sexually active individuals who engage in unprotected intercourse or have multiple partners, injection drug users, people who share a household with someone who has chronic HBV infection, healthcare workers who are at risk of occupational exposure,” said Dr Prakash.
The best way to prevent Hepatitis B is to get vaccinated. It is a three-dose schedule and is safe for all age groups including newborns and pregnant women. Introduced in the Universal Immunisation Programme (UIP) of India in 2002 and scaled-up nationwide in 2011, Hepatitis B vaccination is available for all children to combat Hepatitis B by 2030, as mentioned in the United Nations Sustainable Development Goal 3.3.
India is one of the few countries in the world to offer free diagnostics and life-long drugs.
Since HBV has been known to reactivate itself every time the immunity goes down, any person infected with it needs to be under close supervision of a doctor for a long time. While the disease is not curable, it can be prevented with the Hepatitis B vaccine along with comfort care, managing hydration and avoiding unnecessary medicines, including paracetamol is important. Given its prevention possibilities, Dr Pandey appealed to parents to get their children vaccinated under the UIP.
“Through treatment including oral antiviral agents, one can slow down the progression of cirrhosis, reduce incidence of liver cancer and improve long-term survival,” said Dr Prakash.
How is India faring?
WHO calls on countries to take advantage of recent reductions in the costs of diagnosing and treating viral hepatitis and scale-up investments in disease elimination. As per WHO, ‘By investing in diagnostic tests and medicines for treating Hepatitis B now, countries can save lives and reduce costs related to long-term care of cirrhosis and liver cancer that result from untreated Hepatitis’.
The national immunisation schedule under UIP recommends Hepatitis B birth dose to all infants in first 24 hours, followed by three primary series at six, 10 and 14 weeks to complete the schedule.
Not every patient with Hepatitis B might need treatment, but every patient with Hepatitis B needs proper education, stated Dr Pandey. “It is the most common cause of liver cancers in people in their most productive age group (25-40 years). Therefore, they need to be under the care of a hepatologist. If a person has Hepatitis B and needs to be treated, there are excellent oral medications that can virtually kill the virus and keep it at a level of zero. If there is evidence of cancer or advanced liver disease along with Hepatitis B, the patient might even
require a liver transplant,” said Dr Pandey.
What more needs to be done?
What remains to be a worry is that the HBV birth dose coverage is sub-optimal. As per MoHFW, July 2017 data, of the total live births, the Hepatitis B birth dose coverage was 45 per cent in 2015 and 60 per cent in 2016.
It pointed out that the ‘missed opportunity of about 40 per cent needs to be addressed’. The Hepatitis B birth dose coverage among institutional deliveries was 55 per cent in 2015 and increased to 67 per cent in 2016. The coverage amongst institutional deliveries for the birth dose was reported to be 71 per cent as of March 2017. This means it is important to find those who are infected.
Hepatitis B testing should not be restricted to large set-ups only and the results should be provided within one and two hours, so that the infected can be administered drugs on the same visit, as against waiting for days.
For overcoming the stigma attached to Hepatitis B, its important for the society to dispel myths associated with Hepatitis.