On this World Hepatitis Day, let’s join hands to eliminate hepatitis from the country

Viral hepatitis is emerging as an important global public health challenge. Infectious diseases such as HIV and TB have been the hot topics for discussion, but, according to the World Health Organization (WHO), viral hepatitis is the 2nd major killer infectious disease after tuberculosis (TB), and 9 times more people are infected with hepatitis than HIV. Viral hepatitis is now the 7th most important cause of death worldwide, as per the World Hepatitis Alliance, moving up three ranks from the 10th position in 1990.

Hepatitis is preventable, treatable and in the case of hepatitis C, curable. Yet its prevalence is rising. This is because in its early stages, viral hepatitis is mostly asymptomatic. Many people are unaware that they are infected because jaundice appears only in the later stages. But asymptomatic patients are as infectious as those who have symptoms. This scenario highlights the role of “silent transmission” in spread of the disease.

It is very important to not underestimate the threat of hepatitis.

Viral hepatitis is being recognized as a major public health problem in India as well. Hepatitis A and E viruses are important causes of acute viral hepatitis and acute liver failure. Chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection accounts for a large percentage of cases of hepatocellular carcinoma and cirrhosis in the country.

Viral hepatitis and HIV coinfection is a common problem and challenging to treat. Progression of liver disease is faster in individuals with HIV and viral hepatitis coinfection and they may not respond as well to treatment; they are also at increased risk for serious, life-threatening health complications. Hence, all people living with HIV should be tested for hepatitis B and C infections as well.

This year, in February, the government launched the National Action Plan - Viral Hepatitis, which provides a strategic framework, based on which National Viral Hepatitis Control Program was framed and launched last year on this day. The aim is to eliminate viral hepatitis in the country by 2030, achieve significant reduction in the infected population, morbidity and mortality associated with Hepatitis B and C viz. cirrhosis and hepatocellular carcinoma and hepatitis A and E (Press Information Bureau, February 24, 2019).

The program offers free drugs and diagnostics for hepatitis B and C besides preventive and promotive interventions, the need of the hour. Timely diagnosis means the disease can be cured.

Bangladesh, Bhutan, Nepal and Thailand have become the first countries in WHO South-East Asia Region to achieve Hepatitis B control, with the prevalence falling to less than 1% among five-year-old children. 

We hope India too would soon join this list and in a step further, eliminate viral hepatitis from the country.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Hepatitis B and Hepatitis C Program should be integrated with National AIDS Control Program

India has the world's third largest number of people with HIV, next to South Africa (7.1 million) and Nigeria (3.2 million). As per HIV Estimations 2017 report, India has around 21.4 lakh people living with HIV (PLHIV) with adult prevalence of 0.22% vs 3.2% in Nigeria vs 18.8% in South Africa.

India has a National AIDS Control Programme (currently NACP IV) since 1992, when NACP I was launched and the National AIDS Control Organization (NACO) was constituted to implement the programme.

The main objective of NACP IV is to reduce new infections by 50% (2007 Baseline of NACP III) and provide comprehensive care and support to all persons living with HIV/AIDS and treatment services for all those who require it. 

The HIV Estimations 2017 has acknowledged the significant impact of the National AIDS Control Programme on new infections and AIDS-related deaths. There has been more than 80% decline in estimated new infection from peak of epidemic in 1995 as well as 71% decline in AIDS-related deaths since its peak in 2005.

However, challenges still remain.

One such challenge is co-infection with hepatitis B and hepatitis C viruses. Important thing is prevention of AIDS should also reduce isolated cases of hepatitis B and C.

This is of public health concern because HIV and viral hepatitis coinfection can complicate the management of HIV infection. Also, progression of liver disease to cirrhosis and hepatocellular carcinoma is faster in co-infection; moreover, they may not respond well to treatment. Mortality is higher in these patients.

HIV, hepatitis B and hepatitis C have similar routes of transmission. They spread by contact with infected body fluids such as blood, semen and vaginal fluid or sexual contact with an infected person or via injection drug use (sharing contaminated needles, syringes) or from a mother to her baby during pregnancy or delivery. Needle stick injuries or exposure to splashes of blood are major routes of hepatitis B transmission.

Because of these shared routes of transmission, people at risk for HIV infection are also at risk for hepatitis B or hepatitis C infection and also vice versa. 

Of the three blood-borne viruses (Hepatitis B, hepatitis C and HIV), hepatitis B is the most infectious. The HIV virus lives for 24 hours in dried blood at room temperature. Hepatitis C virus can survive on environmental surfaces for up to 16 hours. It can also spread from infected fluid splashes to the conjunctiva.

The hepatitis B virus can survive in dried blood on floors and tables at room temperature for up to 7 days and remains capable of causing infection. Hepatitis B is therefore a more dangerous infection than HIV. Preventing hepatitis B will also prevent HIV.

The government launched a National Viral Hepatitis Control Program for the prevention and control of viral hepatitis in India. With this program, India aims to eliminate Hepatitis C by 2030 and achieve significant reduction in the infected population, morbidity and mortality associated with Hepatitis B and C (cirrhosis and hepatocellular carcinoma).

Instead of a separate national program for viral hepatitis (hepatitis B and hepatitis C), it should be integrated with the National AIDS Control Program. There can be a separate program for hepatitis A, which can also be made a part of National Diarrheal Diseases Control Program again because of shared routes of transmission.

The budget allocation for NACP should also incorporate the allocated budget for viral hepatitis.

The barrier method of contraception (condom) should also be a part of this program as they protect against STIs including HIV.

Take home points

·         Prevention of hepatitis B (and C) also means prevention of AIDS.

·         AIDS prevention with condoms is also linked to prevention of unwanted pregnancies.

·         Hepatitis C is curable; hepatitis B and  HIV are manageable.

·         One national health program with common budget should handle both the prevention and the treatment.

Dr KK Aggarwal

Padma Shri Awardee

President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Past National President IMA

Timely hepatitis B vaccination is key to preventing chronic liver disease

Hepatocellular liver carcinoma is the third leading cause of annual deaths due to cancer

New Delhi, 10^th December 2018: Most liver diseases are silent. By the time the symptoms appear, there is already about 50% or more damage done. In the absence of timely detection and treatment, cirrhosis (scarring) of the liver sets in, especially in viral Hepatitis B and C.

Apart from this, in cirrhotic cases, tumor may develop any time. In about 70% of the cases, cirrhosis leads to liver cancer, which is one of the fastest growing cancers today.

An effective vaccination programme plays an important role in preventing HBV infection. It is known to decrease the incidence of chronic liver disease and hepatocellular carcinoma (HCC) or liver cancer.

The vaccination protocol

1^st Vaccine: Zero day

2^nd Dose: Between 1-2 months

3rd Dose: Between 4-6 months

Speaking about this, Padma Shri Awardee, Dr KK Aggarwal, President, Heart Care Foundation of India said, “The liver helps in removing toxins and other chemical waste products from the blood and readying them for excretion. As all the blood in the body passes through it, the liver is unusually accessible to cancer cells traveling in the bloodstream. The liver is made up of several kinds of cells, due to which different types of tumors can form there. They could be benign (noncancerous), or cancerous and can spread to other parts of the body (metastasize). These tumors have different causes and are treated differently. More than half of all people diagnosed with primary liver cancer have cirrhosis — a scarring condition of the liver commonly caused by alcohol abuse.”

Some common symptoms of liver cancer include loss of weight and appetite; nausea or vomiting; enlarged liver and spleen; pain in the abdomen or near the right shoulder blade; swelling or fluid build-up in the abdomen; itching; and yellowing of the skin and eyes (jaundice).

Adding further, Dr Aggarwal, who is also the Group Editor-in-Chief of IJCP, said, “There are 4 main T stages – T1 to T4. The main factors that doctors take into account are the size of the liver tumours and whether the cancer has grown into any blood vessels in the liver. This may mean that the cancer is obviously growing into or around a vein or artery. Or it may mean that there is microscopic growth of cancer cells into the vein or artery wall.”

Some tips from HCFI

• Limit the use of alcohol and tobacco. If you cant go for harm reduction
• Consumption of excess alcohol is a major risk factor for developing liver cancer over a period of time.
• Eat healthy and consume plenty of fruits, vegetables, and whole grains. These are rich in antioxidants and prevent the formation of free radicals in the body.
• Aim to get at least 30 minutes of exercise every day. This will not only keep you fit but also reduce excess weight.
• Get vaccinated for Hepatitis B.

Missed doses — An interruption in the vaccination schedule does not require restarting the entire series of vaccination or adding extra doses.

If the vaccination series is interrupted after the first dose the second dose should be administered as soon as possible

For those receiving a three-dose series, the second and third doses should be separated by an interval of at least two months. If only the third dose is delayed, it should be administered when convenient.

Longer than recommended intervals between doses do not reduce final antibody concentrations, although protection might not be attained until the recommended number of doses has been administered

Emedinews : Hepatitis B Vaccination update

• The regimen for the vaccine is three doses at one and six months apart.

• Longer than recommended intervals between doses do not reduce final antibody concentrations, although protection might not be attained until the recommended number of doses has been administered.(1-5)

• A positive immune response to the vaccine is defined as the development of hepatitis B surface antibody (anti-HBs) at a titer of >10 mIU/mL.

• An interruption in the vaccine schedule does not require restarting the entire series of vaccination or adding extra doses.(6,7)

• If the vaccination schedule is interrupted after the first dose, the second dose should be administered as soon as possible.(8)

• The second and third doses should be separated by an interval of at least two months.

• If only the third dose is delayed, it should be administered when convenient.

• Protective anti-HBs titers may be attained in some after only one or two doses of vaccine, completion of the full course (three doses) is recommended to maximize the anti-HBs titer and duration of protection.

• Anti-HBs titers decrease with time but the duration of protection is long (15 -22 years after the primary vaccination schedule).(9-13) Routine booster injections are not required.(14,15)

• Patients with serologic markers of past HBV infection (anti-HBc and anti-HBs positive) do not need HBV vaccination even if they have low titers of anti-HBs.

• Vaccines should be given intramuscularly since deposition of the vaccine into adipose tissue result in a lower seroconversion rate.(16)

• Deltoid is the preferred site in adults for vaccination.

• Longer needles should be used in overweight individuals.

• Hepatitis B vaccine is effective not only in preventing HBV infection but also in preventing the sequelae of chronic HBV infection.

• It is the first example that cancer can be prevented by vaccination.

References

1. Wiström J, Ahlm C, Lundberg S, et al. Booster vaccination with recombinant hepatitis B vaccine four years after priming with one single dose. Vaccine 1999;17:2162.

2. Zechowy R, Rubin LG. Effect of the time interval between the first and second doses of hepatitis B vaccine on the antibody titer achieved after the third dose. Child Hos Q 1997;9:67.

3. Middleman AB, Kozinetz CA, Robertson LM, et al. The effect of late doses on the achievement of seroprotection and antibody titer levels with hepatitis b immunization among adolescents. Pediatrics 2001;107:1065.

4. Halsey NA, Moulton LH, O'Donovan JC, et al. Hepatitis B vaccine administered to children and adolescents at yearly intervals. Pediatrics 1999;103:1243.

5. Heron LG, Chant KG, Jalaludin BB. A novel hepatitis B vaccination regimen for adolescents: two doses 12 months apart. Vaccine 2002;20:3472.

6. Saito K. Introductory remark of Dr. Rokuzo Kobayashi's achievements. Keio J Med 2002;51 Suppl 2:2.

7. Hepatitis B vaccine: What you need to know. Available at: www.cdc.gov/vaccines/pubs/vis/downloads/vis-hep-b.pdf (Accessed on October 20, 2009).

8. Hoofnagle JH. Toward universal vaccination against hepatitis B virus. N Engl J Med 1989;321:1333.

9. Liao SS, Li RC, Li H, et al. Long-term efficacy of plasma-derived hepatitis B vaccine: a 15-year follow-up study among Chinese children. Vaccine 1999;17:2661.

10. Lin HH, Wang LY, Hu CT, et al. Decline of hepatitis B carrier rate in vaccinated and unvaccinated subjects: sixteen years after newborn vaccination program in Taiwan. J Med Virol 2003;69:471.

11. Yuen MF, Lim WL, Chan AO, et al. 18-year follow-up study of a prospective randomized trial of hepatitis B vaccinations without booster doses in children. Clin Gastroenterol Hepatol 2004;2:941.

12. McMahon BJ, Bruden DL, Petersen KM, et al. Antibody levels and protection after hepatitis B vaccination: results of a 15-year follow-up. Ann Intern Med 2005;142:333.

13. Zanetti AR, Mariano A, Romanò L, et al. Long-term immunogenicity of hepatitis B vaccination and policy for booster: an Italian multicentre study. Lancet 2005; 366:1379.

14. Lu CY, Chiang BL, Chi WK, et al. Waning immunity to plasma-derived hepatitis B vaccine and the need for boosters 15 years after neonatal vaccination. Hepatology 2004;40:1415.

15. Jan CF, Huang KC, Chien YC, et al. Determination of immune memory to hepatitis B vaccination through early booster response in college students. Hepatology 2010;51:1547.

16. Shaw FE Jr, Guess HA, Roets JM, et al. Effect of anatomic injection site, age and smoking on the immune response to hepatitis B vaccination. Vaccine 1989;7:425.

Emedinews: Makesure: A patient missed his second dose of Hepatitis B vaccine and developed Hepatitis B.

Situation: A patient missed his second dose of Hepatitis B vaccine and developed Hepatitis B.
Reaction: Oh my God! Why was the vaccine not given between 1–2 months?
Lesson: Make sure that all patients who missed their second dose of vaccine at one month are given the same upto second month (1–2 months).

Emedinews : World Hepatitis Day - Hepatitis B more deadly than HIV

Hepatitis B more deadly than HIV

Over 200 diseases can be transmitted from exposure to blood; the most serious infections are hepatitis B virus, hepatitis C virus and HIV.

HIV, Hepatitis B and Hepatitis C all can be transmitted through blood and blood products and /or by sexual route. The prevalence of HIV is only 0.3% in the general population the same of hepatitis C is up to 5%.

Hepatitis B virus is the most infectious of the three blood borne viruses. It gets transmitted by percutaneous and mucosal exposures and HUMAN BITES.

Hepatitis B can also be transmitted by FOMITES such as FINGER STICK BLOOD SUGAR CHECK, multi dose medication vials, jet gun injectors, and endoscopes.  Hepatitis B virus can SURVIVE ON COUNTER TOPS FOR UPTO SEVEN DAYS and remain capable of causing infection.

Testing of health care workers for hepatitis c virus (HCV) should be performed after needle sticks, sharp injuries, mucosal, or non intact exposure to hepatitis C virus positive blood.

The average incidence of sero conversion to hepatitis C virus after unintentional needle sticks or sharps exposures from an hepatitis C virus positive source is 1.8 percent (range, 0-7 percent).

Transmission of hepatitis C virus can occur from infected fluid splashes to the conjunctiva. Hepatitis C virus can survive on environmental surfaces for up to 16 HOURS.

The first step after being exposed to blood or bodily fluids is to wash the area well with soap and water.  EXPRESSING FLUID BY SQUEEZING the wound will not reduce the risk of blood borne infection.

Give Hepatitis B Vaccine to all unvaccinated persons after exposure to blood. If the exposed blood is positive for HBV and the exposed person is unvaccinated, treatment with hepatitis B immune globulin is recommended.

New weapons of war are HIV kanya, HIV blood transfusions after kidnapping, HIV positive syringes for extraction of money and infected hepatitis C, hepatitis B and HIV combined blood (most deadly weapon ever possible).