Awareness and Eradication of Viral Hepatitis

Viral hepatitis, caused by hepatitis viruses A,B,C and E, still remains a major public health problem.India has “intermediate to high endemicity” for hepatitis B surface antigen (HBs Ag) and an estimated 40 million chronic HBV infected people, constituting approximately 11 per cent of the estimated global burden. Population prevalence of chronic HBV infection in India is around 3-4 per cent. There is a wide variation in HBsAg prevalence in different geographical regions in India. Highest prevalence has been recorded in natives of Andamans and Arunachal Pradesh. Chronic HBV infection accounts for 40-50 per cent of hepato cellular carinoma (HCC) and 10-20 per cent cases of cirrhosis in India.

Population prevalence of chronic HCV infection in India is around 1 per cent. Prevalence of hepatitis C has been observed to be relatively higher in Punjab, Haryana, Andhra Pradesh,Telangana, Puducherry, Arunachal Pradesh and Mizoram compared to other States. Besides the well known high risk groups like injecting drug users (IDUs), truckers, and attendees of sexually transmitted disease (STD) clinics, other disease conditions requiring blood products transfusion, different risk factors have been highlighted which are believed to have led to the relatively higher prevalence of the condition in particular areas. For example, history of surgery, unprotected sex (in Punjab), unscrupulous practices of healthcare providers in Ratia block of the Fatehabad district, Haryana, intra venous drug users (IVDU) in north-east India, cultural practices such as tattooing, traditional medicine (e.g. bloodletting), rituals among pilgrims (e.g. scarification) and body piercing (in Andhra Pradesh).

HAV and HEV are important causes of acute viral hepatitis and acute liver failure in India. A total of 315 outbreaks of viral hepatitis have been reported from 2010 to 2013 and 99 outbreaks in 2013 alone by Integrated Disease Surveillance Programme (IDSP) to National Centre for Disease Control (NCDC). HAV infection is responsible for 10-30 per cent of acute viral hepatitis and 5-15 per cent of acute liver failure (ALF) cases in India. HEV infection is responsible for 10-40 per cent of acute hepatitis and 15-45 per cent of ALF in India. Acute HEV has inordinately high mortality rate of 15 to 25 per cent in pregnant women in the third trimester.

Spread of viruses causing hepatitis has three components, an infectious source, a susceptible host and an established route of transmission. Various strategies for control of viruses causing hepatitis would include control of infectious source, immunization of the host (susceptible subjects) and interruption of all routes of transmission.

Control of infectious source and providing free treatment of existing patient pool

Control of infectious source can be achieved for hepatitis B and C by treating the existing subjects infected with HBV and HCV so that viral load can decrease to undetectable levels, and the infection does not spread rampantly. However, the cost of treatment for chronic HBV and HCV infections is prohibitive for a large proportion of patients. There is a need to develop a mechanism to provide free drugs to needy patients, in similar lines to National AIDS Control Organization (NACO) providing free HIV drugs to patients infected with HIV. This is one of the most important ways to prevent further transmission of HBV and HCV and needs to be implemented on priority.

For hepatitis A and E, there are no specific treatments having a bearing on the control of infectious source. However, safe water and food and awareness on public health measures need to be rapidly implemented.

Immunization of the host (susceptible subjects)
The other strategy is to protect the susceptible host by immunization, and this is the most effective strategy. The hepatitis B vaccine has been included in the Global Alliance on Vaccines and Immunization (GAVI) since 2000. HBV vaccine had been included in the national immunization programmes of nearly 175 WHO member countries by the end of 2009. Hepatitis B vaccination along with Hepatitis B Immunoglobulin should be administered to babies within 24 hours of birth when mother is hepatitis B infected.

Hepatitis A (HAV) is endemic in India and most of the population is infected asymptomatically in early childhood with lifelong immunity. Hepatitis A infection in adults often leads to serious complications. In highly endemic countries large scale immunization efforts are not recommended and in low endemicity areas immunization of high risk populations is recommended. India has traditionally been a high endemicity area. There is evidence of epidemiological shift from high endemicity to intermediate endemicity for the affluent population in various cities across India. In the absence of appropriate steps, epidemics of hepatitis A are likely to occur in the susceptible population with severity of the disease increasing with age. Although there is some evidence of changing epidemiology in select areas, mass or targetted HAV vaccination should not be recommended for India as a public health policy.

HEV vaccine is likely to be available soon in India. Pregnant women and patients with cirrhosis would be priority groups for HEV vaccination.

Interruption of routes of transmission
Interruption of transmission of viral hepatitis can be achieved by education and increasing the awareness of the public and medical personnel; improved sanitation and safe drinking water (for HAV/HEV prevention); and emphasizing the importance of safe blood and injections.

Increasing the awareness of the public and medical personnel: Education of public and health care professionals will help in identification of persons at risk for viral hepatitis and ensure appropriate counselling, diagnosis, medical management, and treatment. In India, it has been reported that more than 93 per cent of injections are unsafe. Improperly sterilized needles and syringes are still an important cause of transmission of hepatitis B in India . A large proportion of health care workers (HCWs) in India are not vaccinated and many are unaware of their vaccination status, thus making them vulnerable to blood borne infection. There is an urgent need for implementing mandatory vaccination and immunization for all HCWs in India. There is also a need for strict implementation and monitoring of safe injection practices in Indian health care system.

Encouraging voluntary testing for Chronic hepatitis ( Hepatitis B and Hepatitis C) can be achieved by increasing the awareness about these viruses to the public .

World Hepatitis Day on 28th July is one of eight official global public health campaigns marked by the World Health Organization. December 4 is celebrated officially in Delhi as “Hepatitis Awareness Day” since 1998 and it plays an important role in spreading awareness amongst public and health care professionals about hepatitis in Delhi, India.
Improved sanitation and safe drinking water

Blood safety is a challenge in India because of the high prevalence of HIV, HCV, and HBV, the relatively low percentage of volunteer donors and the lack of standardization of screening procedures among the multitude of blood collection centers. Centralized NAT screening centres are hugely successful all over the world. This tool could provide the next large step in improving the safety of blood supply in our country.

Therefore Awareness about the disease , routes of transmission , voluntary testing , treatment options and possibility of cure and preventing cirrhosis and liver cancer should be stressed upon in education of public and healthcare workers . With a clear plan and execution , eradication of Hepatitis ( Chronic Hepatitis) is possible in next 25 – 30 years .

We would like to do our part in spreading the awareness , Our Programmes would be

Emphasizing on improvement of sanitation and safe drinking water .
Free screening tests for Hepatitis B and Hepatitis C .
Free Counseling for patients with Hepatitis ( Chronic Hepatitis ) .
Affordable Treatment initiatives to all patients.