Patients call for urgent action against rising Viral Hepatitis in Assam

State leads Viral Hepatitis cases in Northeast
Low awareness and lack of screening sighted as the biggest concerns

Guwahati, May 19, 2014: Today Assam, the gateway to north-eastern India, witnessed a patient led initiative to combat one of the biggest global health concerns of current times, Viral Hepatitis. The state saw the launch of the Assam State Chapter by the National Liver Foundation, where patients engaged with practitioners, policy makers and the public to create awareness around the severity of the disease and call for an urgent action.

According to the recently released data by the Ministry of Health and Family Welfare, Assam saw 419 registered viral hepatitis cases in 2013, the maximum in the north-eastern part of the country. These included co-infected patients, who have been infected with both Viral Hepatitis and HIV;with Hepatitis B witnessing a greater incidence.

With the higher incidence of Hepatitis B in Assam, Dr. B.D. Goswami, Head of the Department of Gastroenterology of Guwahati Medical College and Hospital explained how this infection finds prey. He said, “Hepatitis B spreads when blood, semen or other body fluid infected with this virus enters the body of a person who is not infected. Also, people could be infected by birth (from an infected mother); sex with an infected partner; sharing needles, syringes or any other drug injection equipment; sharing food that has been pre-chewed by an infected persons; direct contact with blood or open sores of an infected person and exposure to blood from used needles or other sharp instruments”.

Underlining the gravity of the disease burden in India, Dr. Bobby John, Executive Director of Global Health Advocates (GHA) India, said “The widespread lethal effect of this disease can be calculated from an estimation that Hepatitis B and C are prevalent in between 25 and 40 million people in India, which is very much higher than the occurrence of HIV or any cancer. As many as 12 million people may be chronically infected in India and most are unaware of it. The disease, often being termed as silent killer, has so far not attracted the attention of the policy makers”.

The criticality of addressing this vital health concern was reiterated by Ms. Jahnabi Goswami, Hepatitis Patient Activist and public figure, “Prevention and screening is pivotal. Lack of disease awareness and the dormant symptoms of Viral Hepatitis poses an urgent need for key stakeholders at both state and center level to formulate effective screening, prevention and control strategies.” She adds, “the burden of treatment cost is another concerning matter. We should be taking cues from the north eastern states of Nagaland and Mizoram where medicines have been made free of cost, especially for HIV/HCV co-infection cases.”

The WHO in its Global Policy Report (2013) has noted that India neither has any national policy nor established any goal to eliminate viral hepatitis. There is no routine surveillance in the country, and on top of that deaths caused due to the virus are not being reported to a central registry. There is an urgent need to formulate effective screening, prevention and control strategies, and the launch of state chapters like in Assam is a step towards this direction.

National Liver Foundation has taken the mantle of reaching out to key policy makers for appropriate intervention required to curb further damage.  After successful execution of State Chapters in Punjab, Haryana, Gujarat, Rajasthan and Madhya Pradesh,National Liver Foundation has brought patients from the remote districts of Assamto mobilize all stakeholders.

About National Liver Foundation
The National Liver Foundation (NLF) is a voluntary, non-profit organization promoting awareness and prevention of liver diseases in India. It offers help, information, and supports to those suffering from liver disease and their families. In addition, NLF reaches out to support programmes involving diagnosis, prevention and treatment of liver- related diseases.

Since its inception, the NLF has attempted to spread awareness about preventable hepatic diseases and reaching out to people suffering from chronic or advanced diseases through:

  • Various educational and training programmes including seminars
  • Patient support groups
  • Mobilizing funds for providing treatment to patients at considerably subsidized rates
  • Campaigns for promoting organ donation and other activities
  • Vaccinate Hepatitis B vaccine to all medical students and para-medical entrants

About Global Health Advocates India
Global Health Advocates India is a non-governmental organization that focuses on engaging all sections of society to fight diseases that disproportionately affect people living in poverty, and are also the leading causes of people living in poverty. In particular, Global Health Advocates India works towards the formulation and implementation of effective public policies to fight disease and ill health in India.

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Sedentary lifestyle in Mumbai leading to increased cases of liver disease

Sedentary way of living is as bad as excessive drinking as it leads to Non-Alcoholic Fatty Liver Disease, warn city doctors. 

Courtesy: DNA

Alcohol is no more the only cause of end-stage liver disease in the city. Doctors say sedentary lifestyle has led to an increasing numbers of Mumbaikars getting the fatty liver problem leading to liver cirrohosis (advance liver disease).

For a long time, excessive consumption of alcohol was considered as the root cause of a damaged liver. But even teetotallers who are overweight, with high abdominal obesity or waist circumference, can suffer from liver disease, say gastroenterologists and liver surgeons.

“The kind of lifestyle people have these days has by and large led to fatty liver disease becoming common among people, and the number is going to increase even further,” said Dr SK Mathur, liver transplant expert at Fortis hospital. Fatty liver affects up to 10% of the urban population.

According to health experts, Non-Alcoholic Fatty Liver Disease (NAFLD) can reach epidemic proportions in the years to come, considering the improper lifestyles our youth are tempted to adopt today. Doctors say that in the last few years, there has been a rapid increase in the number of liver cancer patients in India, especially in urban cities, because of unhealthy lifestyles.

NAFLD may cause the liver to swell (steatohepatitis). A swollen liver may cause scarring (cirrhosis) over time and may even lead to liver cancer or liver failure.

Dr Pravin Rathi, head of gastroenterology, BYL Nair Hospital and Bombay Hospital, said, “Obesity is more dangerous than alcohol. Globalisation and westernisation has led to many people getting NAFLD. As obesity and diabetes are correlated with fatty liver, there is an upward trend to the latter. NAFLD is increasing mainly due to wrong dietary habits and high intake of fats and carbohydrates and less of proteins.”

While obesity is a cause for concern amongst the youth of India, doctors warn against rapid weight loss regimes. “Rapid weight loss regimes can lead to severe damage to liver. Therefore, people trying to lose weight should go for a gradual loss programme and adopt a healthy lifestyle,” added Rathi.

The article appeared in DNA on April 19th, 2014. 

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Pay more attention to the ABC disease

Once while on assignment in one of the northern districts, I felt an insurmountable urge to use a restroom.

The locals were kind enough to point me in the direction of a hut. I rolled up my trousers’ hems and hastened my steps to empty my almost bursting bladder. But I was in for a shock. There was no pit latrine; this was just a flat muddy floor with slime and urine spluttered all over.

At the sight, even my previously misbehaving muscles tensed up and held my waste in check. I dashed out of the ‘latrine’, tripping over a soft lumpy object, which turned out to be poop deposited at the hut’s door step.

Sadly, the residents have no clue that this unhygienic practice promotes the spread of Hepatitis, a devastating inflammation of the liver. According to Dr Isa Makumbi, the head of the Emergency Operations Centre (EMOC), Hepatitis  is caused by a group of hepatitis viruses including, A, B, C, D and E viruses.

Dr Makumbi says they all lead to the inflammation of the liver.

“Hepatitis is considered mild when it lasts less than six months and chronic when it lasts longer,” Dr Makumbi says.

Hepatitis A

Hepatitis A is caused by the hepatitis A virus (HAV).

“The virus is transmitted through the faecal-oral route where people do not wash their hands after using the toilet and touch or prepare other people’s food when they are infected,” says Dr Jane Ruth Aceng, the Health ministry’s director general of health services.

The HAV may also be transmitted through infected blood and drinking contaminated water. Majority of the Hepatitis A patients remain without symptoms.

Dr Aceng says unlike Hepatitis B, C and D, Hepatitis A does not develop into chronic hepatitis and most people infected usually recover with no permanent liver damage.

Hepatitis B

Hepatitis B is caused by the hepatitis B virus (HBV) found in blood and body fluid such as semen. It is spread through unprotected sex with an infected person, piercings by sharp instruments such as needles and clippers that have been used by an infected person.

The virus has an incubation period of four to 25 weeks. Its symptoms include nausea, fatigue, jaundice and poor appetite, but Dr Aceng says these may be mild so much that the carriers of the virus may not be aware.

However, for some people, the infection becomes chronic, leading to liver failure, liver cancer or cirrhosis. “HBV is a hundred times more infectious than HIV and 70 per cent of people who get infected with it will be affected with cancer of the liver and 30 per cent will have dry livers,” Dr Fred Okuku, an oncologist at the Uganda Cancer Institute, says.

World Health Organization (WHO) estimates that more than two billion people have had hepatitis B infection and 600,000 of these die annually. Dr Okuku advises people to avoid sharing sharp instruments, practise safe sex, and sterilise sharp instruments used on them.

Hepatitis C

Hepatitis C is caused by the hepatitis C virus (HCV) found in blood and certain body fluids. Like the HBV, it is spread through contact of blood or body fluids from an infected person. Babies born to mothers with Hepatitis C can get infected during childbirth.

“Hepatitis C is not spread by casual contact, kissing, hugging, sneezing, coughing, breastfeeding or sharing utensils or cups,” Dr Makumbi says.

Hepatitis D

It is caused by the hepatitis D virus (HDV), a virus that needs the hepatitis B virus to reproduce it. Chronic Hepatitis B virus carriers are at risk of infection with HDV.

It is spread by having unprotected sex with a Hepatitis D infected person or contact with his or her body fluids.

A WHO document says: “Since no effective antiviral therapy is currently available for treatment of type D hepatitis, liver transplantation may be considered for cases of acute and end-stage chronic hepatitis D.”

Hepatitis E

This is caused by the Hepatitis E virus (HEV) and more severe in pregnant women resulting in abortions, premature babies and death. Like Hepatitis A and C, patients of Hepatitis E remain asymptomatic.

“Only between 30 and 50 per cent develop symptoms such as fever, abdominal pain, nausea, jaundice, vomiting and loss of appetite,” Dr Aceng says.

It is spread through poor personal and food hygiene, contact with infected blood and drinking contaminated water. Currently, the disease is prevalent in Napak district, having been confirmed on December 1.

As of March 17 this year, 983 patients and 24 deaths were registered by the health ministry; 14 of these deaths were of pregnant women.
It has also spread to Kotido, Abim, Moroto, Amuria and Katakwi districts.

Dr Aceng says major drivers of the disease include open defecation that leads to contamination of water bodies and poor hand-washing practices.

“A vaccine against HEV is still under assessment,” she says.

Although patients with HEV recover on their own, she advises washing of hands before eating and after visiting the toilet, proper human waste disposal and boiling of drinking water.

The article appeared in Observer on April 1st, 2014.

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WHO issues its first hepatitis C treatment guidelines

WHO has issued its first guidance for the treatment of hepatitis C, a chronic infection that affects an estimated 130 million to 150 million people and results in 350 000 to 500 000 deaths a year.

The publication of the “WHO Guidelines for the screening, care and treatment of persons with hepatitis C infection” coincides with the availability of more effective and safer oral hepatitis medicines, along with the promise of even more new medicines in the next few years.

“The WHO recommendations are based on a thorough review of the best and latest scientific evidence,” says Dr Stefan Wiktor, who leads WHO’s Global Hepatitis Programme. “The new guidance aims to help countries to improve treatment and care for hepatitis and thereby reduce deaths from liver cancer and cirrhosis.”

WHO will be working with countries to introduce the guidelines as part of their national treatment programmes. WHO support will include assistance to make the new treatments available and consideration of all possible avenues to make them affordable for all. WHO will also assess the quality of hepatitis laboratory tests and generic forms of hepatitis medicines.

“Hepatitis C treatment is currently unaffordable to most patients in need. The challenge now is to ensure that everyone who needs these drugs can access them,” says Dr Peter Beyer, Senior Advisor for the Essential Medicines and Health Products Department at WHO. “Experience has shown that a multi-pronged strategy is required to improve access to treatment, including creating demand for treatment. The development of WHO guidelines is a key step in this process.”

Nine key recommendations

The new guidelines make nine key recommendations. These include approaches to increase the number of people screened for hepatitis C infection, advice as to how to mitigate liver damage for those who are infected and how to select and provide appropriate treatments for chronic hepatitis C infection.

Screening

WHO recommends a screening test for those considered at high risk of infection, followed by another test for those who screen positive, to establish whether they have chronic hepatitis C infection.

Mitigating liver damage

Since alcohol use can accelerate liver damage caused by hepatitis C, WHO now advises that people with chronic hepatitis C infection receive an alcohol assessment. The Organization also recommends providing counseling to reduce alcohol intake for people with moderate or high alcohol use. In addition, the guidelines provide advice on the selection of the most appropriate test to assess the degree of liver damage in those with chronic hepatitis C infection.

Treatment

The guidelines provide recommendations on existing treatments based on interferon injections as well as the new regimens that use only oral medicines. WHO will update recommendations on drug treatments periodically as additional antiviral medicines are registered on the market and new evidence emerges.

Prevention

The 2014 recommendations also summarize for policy makers and health care workers interventions that should be put in place to prevent transmission of hepatitis C, including measures to assure the safety of medical procedures and injections in health care settings and among persons who inject drugs. Rates of new hepatitis C infections remain unacceptably high in many countries because of the reuse of injection equipment and lack of screening of blood transfusions.

“Many people remain unaware – sometimes for decades – that they are infected with hepatitis C,” says Dr Andrew Ball, Senior Advisor for Policy, Strategy and Equity for WHO’s HIV/AIDS Department where the Global Hepatitis Programme is housed. “Today’s launch highlights the need for more awareness and education on hepatitis for the general public. Greater awareness on the risks associated with hepatitis C should lead to a demand for services and expansion of laboratory capacity and clinical services so that more people can be tested, treated and cured.”

There are five main hepatitis viruses, referred to as types A, B, C, D and E. Hepatitis B and C have the greatest public health impact because they cause chronic infection which can progress to cirrhosis and liver cancer. Hepatitis A and E, spread though unsafe water and contaminated food, have the potential to cause outbreaks in certain populations.

Hepatitis C virus is most commonly transmitted through exposure to contaminated blood. Those at risk include people undergoing invasive medical procedures and therapeutic injections where there is poor infection control. Also at risk are those exposed to contaminated injecting and skin piercing equipment, including through injecting drug use, tattooing and body piercing.

The WHO Guidelines for the screening, care and treatment of persons with hepatitis C infection were launched on the eve of the opening of the 2014 International Liver Congress, attended by around 10 000 delegates in London.

 

Source: WHO

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Will Indian healthcare manifesto up its “HEP”ness quotient?

On World Health Day, an appeal to the political parties to make India Hepatitis free

Deemed as one of the biggest general elections of the Indian political history, all major political parties are trying to instill hope and come up with creative manifestoes addressing the increasing inflation, law and order situation and corruption to name a few. Amid the cacophony of many a social and economic policy changes, has healthcare made the cut? Specially considering the catastrophic viral hepatitis that is silently but consistently edging towards the nation?

The global policy report on prevention and control of viral hepatitis 2013 by the WHO reflects that five million hepatitis-related deaths could occur in South East Asia alone, in the coming decade. With approximately 100 million hepatitis B and 30 million hepatitis C patients in this region about three-fourth are unaware of their hepatitis status owing to the silent nature of the disease and lack of surveillance. Greater than 50 per cent of the global burden of hepatitis E is from South East Asia alone.

The number of chronic hepatitis B carriers in India alone was estimated to be around 40 million in 2006, which increased from 36 million reported in 1996.Additionally, the WHO has noted that India neither has any national policy nor established any goal to eliminate the viral hepatitis.

On World Health Day, Dr. Samir Shah, the Founder Trustee of National Liver Foundation (NLF) and Head of the Department of Hepatology, Global Hospitals, Mumbai, said “The hepatitis virus can remain in the body for years without showing any symptoms of its presence, leading to more fatal consequences. Sadly, due to the lack of proper surveillance, the diagnosis in more than 60 percent of the patients is being done at a stage when the disease is irreversible”.

“The viruses are significantly different when it comes to epidemiology, natural history, prevention, diagnosis and treatment. The widespread lethal effect of this disease can be calculated from a fact that its prevalence is much higher than HIV or any form of cancer,” Dr. Bobby John, Executive Director of Global Health Advocates (GHA) India, said.

Criticality of government intervention to tackle viral hepatitis is evident in the recently accomplished polio eradication success story. With no polio cases registered for three consecutive years, India has been certified as WPV transmission free. Effective implementation of intensive immunization and surveillance activities against polio by the Indian government won us the battle.

Similar national policies are required to deal with viral hepatitis, rooted as one of the deadliest diseases of our times.

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Cautionary Tale: 56 kids get HIV, hepatitis after blood transfusion

JODHPUR: At least 56 children suffering from thalassaemia tested positive for HIV, hepatitis B and hepatitis C after receiving blood transfusion at government-run Umaid hospital in Jodhpur. They are among the 130 thalassaemic children registered with Jodhpur’s Marwar Thalassaemic Society, said a source.

In the last one-and-a-half years, at least eight thalassaemic children in the city were found to be HIV positive while 46 others were infected by hepatitis B virus prompting a probe by the state government.

In December 2008, five children tested positive for HIV and 29 for hepatitis C virus. In May 2010, three more children were found HIV positive and 17 suffered from hepatitis C.

According to the Thalassaemic Society, if all the children who received blood transfusion are tested, the numbers may go up. Unless new techniques for testing are introduced, the hazard will remain, felt society members.

Recently, members met the principal of S N Medical College and the divisional commissioner and demanded nucleic acid test at Umaid Hospital blood bank to prevent infection during transfusion.

Medical college principal R K Aseri said a proposal for nucleic acid test which is a more advanced blood test has been sent to Rajasthan government which is now studying the expenses involved. The college has also formed a three-member committee to probe if there are any flaws in the blood bank’s testing methods.

The Society also demanded special consideration for families below poverty line and adequate staff and resources at Umaid Hospital’s thalassaemia ward.

Society secretary Vipin Gupta said, “We want the blood banks to have better technology.”

However, Raj Shree Behra, in-charge of Umaid Hospital’s blood bank, said there is no way to reduce to zero the window period, that is the time taken for seroconversion after exposure to the HIV virus.

Seroconversion is the development of detectable antibodies in blood to fight an infectious agent. It normally takes some time for antibodies to develop after the initial exposure to an infection.

If infected blood has been taken from any donor before the formation of detectable antibodies, there is no technology which can detect them in the stored blood at any point of time, said Behra.

Antibodies will develop only when the infected blood is given to any other person. Currently, ELISA test has a longer window period disabling it to detect any antibody at early stage in the donated blood. It is certified by National AIDS Control Organisation.

The article appeared in The Times of India on July 13th, 2010. 

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Hepatitis-C virus, not HIV, bigger epidemic in northeast

GUWAHATI: With little awareness about increasing Hepatitis-C cases in the northeast, activists and medical practitioners warned that unless effective programmes were implemented, there would be a further escalation in the number of people falling prey to the dreaded virus.

Often referred to as a viral time bomb, the disease is widespread among intravenous drug users (IDUs). Manipur’s Surachanpur and Bishnupur districts have the highest number of people carrying the Hepatitis-C virus (HCV), with prevalence rates among the districts’ IDUs being nearly 90 per cent and 78 per cent respectively.

In Nagaland’s Wokha and Phek districts, the prevalence rate, as per an Integrated Bio Behavioural Assessment Round 2 Testing, conducted in 2009 by the Indian Council of Medical Research and others, was 20.8 per cent and 8.7 per cent respectively. Prior studies showed that in Manipur, the prevalence rate of HCV is 55 to 80 per cent among IDUs, as opposed to 22 to 33 per cent HIV prevalence among them.

“The main objective is to create awareness about viral Hepatitis in the region. The epidemic is at our doorstep, with people getting infected, testing positive and some deaths being reported. However, NGOs and the government continue to ignore the spread of the disease,” said Ketho, general secretary of Hepatitis Coalition of Nagaland (HEPCON).

With much of the focus being restricted to HIV-AIDS and cancer awareness, HCV often escapes attention. With no proper cure or vaccine, course-related HCV treatment is also considered too expensive. People with HCV are prone to develop chronicity that can lead to liver damages. Research show that close to 75 to 85 per cent HCV patients develop chronicity, as opposed to Hepatitis-B patients (HBV).

“Intravenous drug users are the most vulnerable. HCV prevalence is much higher than that of HIV. This indicates that there is a bigger pool of HCV patients among IDUs,” said Gajendra Kumar Medhi, doctor and scientist with the Indian Council of Medical Research.

Another factor responsible for the high prevalence of HCV amongst IDUs is needle-sharing. Even with efforts to promote safe injecting practices, the prevalence of needle-sharing is quite high. Users may lessen sharing of syringes, but indirect sharing is widely practiced. Nearly 50 to 70 per cent IDUs admitted to sharing accessories like common containers for drug preparation, filter cotton and rinse water.

The article appeared in The Times of India on March 11th, 2014.

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