Hepatitis care in India: Country's awareness and prevention strategy is working but still has a long way to go
Hepatitis B is one of the leading causes of liver failure and liver cancer. Every 12th person in the world is infected.
According to WHO, around four of every 100 Indians are infected, amounting to 40 million infected persons in India. Most are blissfully unaware as the virus produces few symptoms for long periods. By the time symptoms of liver disease appear, the disease is often found to be advanced.
Hepatitis B is one of the leading causes of liver failure and liver cancer. Every 12th person in the world is infected, and liver disease is the 12th leading cause of death. And the tragedy is that it is preventable. The health impact of Hepatitis B and C is at least 10 times that of HIV while awareness and funding about them are lagging far behind that of AIDS.
Criticism of the government’s reluctance to include vaccination for Hepatitis B in the infant immunisation program had till recently fallen on deaf ears. In 2010, infants in around 150 countries accross the world were routinely given the vaccine. This strategy has led to 20 fold reduction in Hepatitis B in certain countries like China. Our government had stood resolute citing lack of funds, and had made the world wonder how a country that organises the IPL with such lavish fanfare could really mean that.
India started late with its Hepatitis B awareness and prevention strategy and is quickly trying to catch up. It used the services of Amitabh Bachchan in its campaign, introduced vaccination in the infant immunisation program towards the beginning of this decade, and has very cleverly introduced Hepatitis B screening in the antenatal check up; this is crucial as the cycle of infection uses the mother-infant route. Hence, interrupting it during deliveries with prompt recognition and timely vaccination is a very sensible approach.
Moreover, the vaccine, which includes three doses delivered as injections at 0, 1 and 6 months, is now easily available and affordable. It used to cost Rs 500 for each dose in the 1990s, but now costs around Rs 50.
Another virus, the Hepatitis C virus, is also emerging as a major cause of liver cirrhosis and liver cancer. Screening studies have shown that one percent of the Indian population may be unknowingly infected, often spreading it to others through transfused blood or re-used needles for injections. It is estimated that 10 million Indians have the infection. Unlike Hepatitis B, however, there is no vaccine yet for Hepatitis C.
Here, India acted with tremendous promptness. When the new generation oral tablets such as sofosbuvir, ledipasvir, daclatasvir and velpatasvir were introduced in the western world as game-changing molecules in 2014-15, they were priced at US $1000 per tablet, to be taken for 90 days. Clearly, that put these therapies beyond the reach of Indians. Our government allowed manufacturing, marketing and selling of these compounds at one percent of the international price, making this new therapy accessible for most.
Hepatitis B virus may infect other members of the family; hence, all members of the family of an infected person should undergo screening tests. In a study in which families of 225 patients who had tested positive for Hepatitis B were screened, additional infected individuals were detected in 45 (20 percent).
How are they transmitted?
Hepatitis B and C are transmitted by infected blood or blood products, non-disposable needles and syringes, reused inadequately sterilised catheters and equipment, tattooing, ear-piercing, sharing of blades and razors etc. Infected mothers may pass Hepatitis B unknowingly to their offspring. It may also be transmitted through sexual contact with an infected partner.
Hepatitis B and C are not transmitted by food, water or sharing of utensils or shaking hands.
Who are at risk and should be tested?
Any person with a history of blood transfusion or surgery, or a history of jaundice, or if a family member has liver disease, should undergo testing. It is a must for all health care workers (employees of hospitals, nursing homes, blood banks or laboratories). Patients with blood disorders such as thalassemia, who require blood transfusions regularly, are at high risk.
Are they treatable?
Both are treatable.
Hepatitis B can now be treated with oral medicines: There are at least five drugs that are approved and marketed. Treatment is required for only those who have an active infection, and has to be taken for long periods, often years. If the liver is grossly damaged and is unable to perform its work, it may have to be replaced by a liver transplantation.
Hepatitis C is also treatable, and requires the combined use of weekly injections and oral drugs for periods of 6 to 12 months. If the disease is too advanced, these medicines cannot be used and the liver has to be replaced.
For both Hepatitis B and C, treatment is most effective if initiated at an early stage.
Finally, India is witnessing a reduction in prevalence rates of Hepatitis B. The rates for Hepatitis C are still high, though largely due to increase in IVDU in northern and eastern states. But attention now needs to shift from the clinic to the community, creating increased awareness, wider prevention strategies and bringing more patients under the treatment umbrella early in the infection.
The author is Director and Head, Department of Gastroenterology and Hepato-Biliary Sciences, Fortis Medical Research Institute (FMRI).
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