According to the World Health Organization, “Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis B virus (HBV). It is a major global health problem. It can cause chronic infection and puts people at high risk of death from cirrhosis and liver cancer.”
WHO estimates that 296 million people were living with chronic hepatitis B infection in 2019, with 1.5 million new infections each year. World Hepatitis Day takes place every year on 28th July to bring the world together under a single theme to raise awareness of the global burden of hepatitis especially with more focus on viral hepatitis and to influence real change.
To discuss the same we had a panel of experts: Dr Anil Arora, Head of Gastroenterology Dept, Sir Gangaram Hospital; Dr. Sanjeev Sehgal, Principal Director, Liver and Hepatology, from Max Chain of Hospitals; Dr Sudeep Khanna, Senior Consultant, Gastroenterology Dept, Apollo Chain of Hospitals.
Dr. Sehgal, why is hepatitis such a crucial problem? According to WHO reports a person dies of Hepatitis dies every 30 second.
Dr. Sanjeev Sehgal: Hepatitis is a huge burden in our country as it is worldwide. Hepatitis basically means inflammation of the liver ad the prime reason for this are the hepatitis viruses which are of four types primarily: Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D. Hepatitis A and E are self-limiting and spread through feco-oral route by contaminated food and water. Hepatitis B and C are huge burden in our country and spread through parenteral route, that is by blood and body fluids. In India, Hepatitis B has a prevalence of 2-7% and Hepatitis C is 0.5-1.5%. They constitute a huge number if patients in the county and are very important cause of liver related deaths in the country. They also cause liver failure, liver cancer and so on. Thus, it should be our topmost priority to treat and cure this disease.
40 million people in India are HBV infected and constitute about 11% of the global rate. What would you say Dr. Arora?
Dr. Anil Arora: This topic is very pertinent as Covid will come and go but the illnesses like Hepatitis have not gone ever since. Certain viruses are spread through contaminated water and infected fluid, which are totally preventable. This is a prevalent issue in developing countries like India and South Asian nations whereas it has been totally eradicated in developed countries. Simple provision of safe drinking water and hygiene can prevent Hepatitis A & E. Virus spread through parental route are problematic. Hepatitis B & C are neglected, and like you said there are 40 million carriers of the infection unaware of the fact that they are infected, hence they are not only potentially disease developers but are also becoming a threat for their families. By increasing awareness, we can prevent this.
Dr. Khanna would you agree with Dr. Arora that there is a problem of awareness that needs to be tackled right away?
Dr. Sudeep Khanna: I would like to add something to it, people know that something like this exists but they are not ready to accept it. A recent study conducted on 1 lakh children from India concluded that only 50% of the children were vaccinated against Hepatitis B.
Isn’t it covered under Universal Health Immunization? Then why aren’t people getting vaccinated?
Dr. Sudeep Khanna: For the same reason as why they wouldn’t get anti-covid vaccine. This becomes a problem for us to help people. The vertical and horizontal transmission from mother to baby and during close contact is the most common cause of Hepatitis B. People need to be tested, treated and educated.
Dr. Arora, we rightly spoke about how people are not even ready to accept it. So what can people do to prevent this stigma?
Dr. Anil Arora: A wonder drug called DAA has been discovered which can cure almost any type of Hepatitis C and hence it is as curable as any other disease but Hepatitis B is problematic. They are not aware of the fact that they may be carrying the virus in their blood for ages before they come down with advanced diseases like Cirrhosis and Carcinoma. My advise will be that anybody with a history of liver transplant, blood transmission, surgery, needle prick trauma or even dental manipulation should get a checkup for Hepatitis B. Now coming to vaccination, Hepatitis B vaccines has been available for over three decade at very low rate and very efficient.
There are about 1.1 million who have died due to Hepatitis, and 3 million are still carrying the disease worldwide. How do we really address this in India especially with the urban rural divide?
Dr. Sudeep Khanna: Multimedia and TV are such a big medium and still unused to their full capacity. A lot of people don’t know about Hepatitis C and lack of initiative from the authorities and doctor bodies are causing this. The disease is significantly asymptomatic and by the time they are symptomatic it is too late. So it is all about awareness.
Dr. Arora, what can one do if one is already infected with Hepatitis B? What about cure?
Dr. Anil Arora: There are two aspects of patient suffering from Hepatitis B, unlike other illnesses, if someone gets an infection today, there are 5% chances that as an adult they will carry the virus in the blood for the next 6 months that is called chronic carrier state and may develop the disease later in life. They remain asymptomatic and thus do not bother about it. This is where screening is needed and if a person is accidentally positive for Hepatitis B, he can be treated with antiviral therapy or else he may spread it to his family. In early diagnosis, regular follow up goes a long way in preventing the chronic illness.
Dr. Sehgal, can a patient of Hepatitis B follow up with their checkup if infected with Covid?
Dr. Sanjeev Sehgal: Patients ask that if I am Covid positive then what happens with the other problems of mine and if you look at Hepatitis, the patients are consulting specialist doctors, and hence can manage with a teleconsultation and it is not required to come to the hospital. If there is an emergency, then they should visit the hospital no doubt. If a Hepatitis patient is Covid positive and taking the concerned medications, I would recommend that they don’t stop taking medicines for Hepatitis as this may provide a flare to the disease.
Dr. Khanna, are the patients with Hepatitis at a greater risk if they get Covid? Are they furthermore immunosuppressed like we have seen in Cirrhosis?
Dr. Sudeep Khanna: If one has Cirrhosis, they are not at higher risk of getting infected. If in case the liver function goes down, the risk of Covid complication increases. Similarly, being infected with Hepatitis B or C does not mean that you are at higher risk of getting Covid. There should be no fear of vaccination.
Dr. Arora, what would you say on the point “ No fear of vaccination”?
Dr. Anil Arora: Liver is a vital organ in many functions including metabolism and immunity. Once you have severe Covid, liver gets involved in the immunity in many patients. Patients who have underlying liver disease should be given vaccine on a priority basis. Because liver handles all the drugs given to the covid patient.
In what conditions in Covid patients does it lead to diseases like Cirrhosis other complications?
Dr. Sanjeev Sehgal: If you develop Jaundice due to contaminated food or water, it is a small chance that they may develop rapid deterioration and altered sensorium thus may have to be admitted to ICU. If someone has chronic disease like Hepatitis B or C and catch infection like Pneumonia, Covid, etc. then they may develop a liver failure. These are the two situation which may cause rapid deterioration and both the type of patients should be diagnosed early and quick treatment can save these patients.
How can the person know that they are carrying the Hepatitis infection?
Dr. Sudeep Khanna: For most of the patients, the disease is asymptomatic. And hence is it not possible for them to diagnose through symptoms. Tiredness, although is a primary symptom so if you have fatigue throughout the day, you may have Hepatitis. One other way is to know if a family member is diagnosed with Hepatitis, one may be a carrier for the disease. Also, screening the high risk population is a way out.
Dr. Arora, we spoke about who all should get tested, what will be your suggestion to all the policy makers?
Dr. Anil Arora: the only way to pick it up early and diagnose is by testing. So my suggestion is that whenever going for any sort of blood test or screening, get tested for Hepatitis B and C. and executive check up is becoming a routine. It should be mandatory and if an asymptomatic patient is not checked up early, the cost of long-term disease treatment is enormous. While it is very cost effective in early stages.
Dr. Sehgal, is there anything that we can do to prevent it other than screening or vaccination?
Dr. Sanjeev Sehgal: As we discussed, we have to identify the high risk population. We need to look for any family member with Hepatitis. If you have a liver problem, you should get it checked. Then you need to avoid contaminated food and liquid. Be careful in interpersonal relationships. Dialysis and following all protocols strictly may help diagnose and treat Hepatitis. We should follow universal practice of screening people. Be aware and screen people which may help people to curb the disease.
What do you suggest policy makers, institutions and common people to eliminate the disease?
Dr. Sudeep Khanna: As an individual I can only think of vaccine being made mandatory which is very difficult in the democracy. Other than that nothing is going to help.
Since we all go to annual checkups, our panelists suggest that do get checked up for Hepatitis on a routine basis, avoid contaminated food and get proper vaccination.
Dr Naveen Polavarapu
Sr Consultant Gastroenterologist and Transplant Hepatologist, Apollo Hospitals, Jubilee Hills.
Dr K.S. Soma Sekhar Rao.
Consultant Gastroenterologist and Hepatologist, Apollo Hospitals, Jubilee Hills.
Dr D K Raghu,
Consultant Gastroenterologist and Hepatologist, Apollo Hospitals, Jubilee Hills.
Dr Sarathchandra G
Consultant Gastroenterologist and Hepatologist, Apollo Hospitals, Jubilee Hills.
On world hepatitis day today, here are some facts about liver, causes of hepatitis, symptoms, diagnosis and prevention of the disease complications.
According to WHO, Liver cancer is the fastest growing cancer in the World currently and a person is dying every 30seconds from hepatitis related illness even in the current COVID-19 crisis. World Hepatitis Day takes place every year on 28th July to bring the world together under a single theme to raise awareness of the global burden of hepatitis especially with more focus on viral hepatitis and to influence real change.
What is Liver and what does it do?
Liver is the largest organ in the human body which performs more than 500 vital functions. All the food that we eat including carbohydrates, fats, minerals gets metabolised in the Liver after getting absorbed from the intestines. It produces important proteins which help in clotting of the blood. Liver along with kidneys work like a filter removing all the toxins and acids from the body. It also plays a crucial role in maintaining adequate sugar levels in the body and also acts like a storage organ.
What is hepatitis?
Hepatitis means inflammation of the liver which if unchecked will lead to significant permanent damage to the Liver and life risk. The most common causes of Liver damage are Viral Hepatitis (mainly B,C), fatty Liver and alcohol. Along with these there are more than 100 different causes of Liver damage which will lead to Cirrhosis (end stage Liver disease).
Why is it important to know about Viral Hepatitis?
Hepatitis B directly has been causing 10 lakh deaths every year for the last few decades. It is estimated that around 200 crores population is currently or previously infected with Hepatitis B and around 35 crore population is currently infected and carrying this Hepatitis B virus. Around 75% of these infected people are in Asia and Africa. People with Hepatitis B have 100 times more risk of developing Liver cancer compared to people who do not have Hepatitis.
Similarly Hepatitis C is estimated to be present in 18 crore populations worldwide and most often cause long-term significant damage to the Liver leading to irreversible cirrhosis and Liver cancer. In fact 2 out of 3 Liver cancer deaths are related to Viral Hepatitis.
What are the symptoms and signs of hepatitis?
Liver is such a brilliant organ that it copes until it is at least more than 80% damaged and by the time symptoms appear it is often too late, hence Liver is like a silent killer.
9 out of 10 people don’t even know that they have the virus and often it gets picked up whilst doing routine testing for other reasons.
Common symptoms they present with are Jaundice, tummy swelling, leg swelling, blood vomiting or black stools, confusion and drowsiness. These symptoms appear only when the Liver is significantly damaged.
How can I get checked if I have the virus?
Detection of these viruses is with a simple blood test, which is widely available. Once these viruses are detected then the Liver specialist will evaluate the stage of the virus and also the amount of the damage that has happened to the Liver. Based on these we can offer further treatment.
Are there any treatments available?
If recognised early, Hepatitis is treatable and sometimes curable too. We can arrest the progression to cirrhosis by early recognition of these viruses and early commencement of the medications.
There are excellent medications available now to completely cure the Hepatitis C. You just need to take one tablet a day for generally 3 months with almost 99% chance of completely curing the virus therefore eradicating the risk of future Cirrhosis and Liver cancer.
For Hepatitis B also there are excellent medications to control the virus. Of course there are excellent vaccinations available for Hepatitis B and A.
We at Apollo Hospitals have been running dedicated Liver clinics specifically designed to treat and cure these deadly viruses. We have the state of the art equipment and expertise to identify and treat these viruses with excellent cure rates. In patients who have developed advanced Liver disease, we have been treating them with excellent outcomes and in patients who need Liver transplant as the only mode of survival, we have been doing them at our centre successfully for nearly 10 years.
The theme of World Hepatitis Day 2021 is “Hepatitis can’t wait” to raise the awareness among masses. It is strongly recommended that all of us get checked for these deadly silent killing viruses and if negative then let us get vaccinated.
In fact WHO goal is to make the HEPATITIS FREE WORLD BY 2030 and it is achievable by all of us doing our part in coming forward, getting checked and treated if positive or vaccinated if negative. And we all know that prevention is better than cure.
Involving civil society must be a key strategy in working towards the elimination of viral hepatitis, Cary James, chief executive officer, World Hepatitis Alliance, has said.
He said civil society, particularly those living with viral hepatitis, must be equitable partners in the planning, implementation, monitoring, and governance of hepatitis programmes, speaking at a virtual conference organised by Chennai Liver Foundation (CLF) on Saturday ahead of World Hepatitis Day on July 28. He believes that by involving civic society and working directly with communities, hepatitis programmes will become more effective. He emphasised the importance of combating misconceptions and stigma surrounding viral hepatitis, especially Hepatitis B and C.
B.B. Rewari from the South East Asia Regional Office (SEARO) of World Health Organisation, stressed on the need for decentralising testing and treatment coverage in India in tackling Hepatitis B and Hepatitis C. He said that although vaccination, testing and treatment were available in the country through a structured programme, they were largely centralised in tertiary care centres. Highlighting the inadequacy in testing and treatment coverage in rural districts and tier-2 and tier-3 cities, he stressed on the need for training more healthcare professionals from these areas.
J.A. Jayalal, national president of Indian Medical Association, said that Hepatitis B and Hepatitis C did not receive the advocacy available for other diseases such as AIDS and tuberculosis. He said that IMA would work towards creating a programme to strengthen the understanding of viral hepatitis among physicians.
R.P. Shanmugam, founder of CLF, stressed on the need for increased awareness about Hepatitis B and Hepatitis C, particularly in proactive screening of vulnerable populations.
Vivekanandan, liver transplant surgeon and managing trustee at CLF, highlighted the need for policy level changes to enable screening and vaccination of more people.