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Tackling hepatitis

The World Health Organization (WHO) annually celebrates July 28 as World Hepatitis Day. The date was chosen for World Hepatitis Day in honor of the birthday of Nobel laureate Professor Baruch Samuel Blumberg, who discovered the hepatitis B virus, then known as Australia antigen. In fact the World Hepatitis Alliance first launched World Hepatitis Day in 2008. Under the theme of “We’re Not Waiting” World Hepatitis Day is being observed throughout the world this year. One life, one liver is also a slogan taken this year. It has become an annual event and provides focus for patient groups and people living with hepatitis, particularly hepatitis B and C, which can cause chronic liver disease, liver cirrhosis and liver cancer. Hepatitis B and C are the silent killer. Many people do not know even if they are infected. So, let’s get checked was one of the theme of earlier Hepatitis Day. The WHO has targeted to eliminate hepatitis by the year 2030, but there is a Herculean task ahead.

World Hepatitis Day is one of only four WHO disease specific days. The other three disease specific days are tuberculosis (March 24), malaria (April 25) and AIDS (December 1).  World Hepatitis Day provides international focus for patient groups and patients living with viral hepatitis, particularly hepatitis B and C. The WHO and partners mark World Hepatitis Day to increase the awareness and understanding of viral hepatitis and the diseases caused by hepatitis virus infection.

What is liver?

The liver is the second largest organ beside skin and the largest solid organ in the human body. It is located in the upper right abdomen, beneath the diaphragm and mostly shielded by the lower right rib cage. In an average it weighs about one and half kilogram in an adult and is reddish-brown in color. The liver has many important functions, more than 500 in number. However, following are its important functions.

Detoxification of the blood: Whatever we eat, it goes to the liver via blood after it enters in the intestine. The liver removes toxins from the blood, such as alcohol, drugs, and any other harmful substances that is not native to our body.

Production of bile: Bile is a fluid that helps with digestion. It breaks down fats in food so that they can be absorbed by the body. So, unlike what we general people think, liver do not help in digestion except for the fat.

Energy storage: The liver stores glucose, a type of sugar, in the form of glycogen. When the body needs energy, the liver breaks down glycogen and releases glucose into the bloodstream. If liver is damaged, the sugar control mechanism is hampered.

Production of proteins: The liver produces many proteins that are essential for blood clotting, immune function, and other bodily functions. It is the only organ that produces albumin. Albumin is needed for carrying different substance to different organs of the body. If there is less albumin, we get swollen body, low blood pressure etc.

Clearing waste products: The liver removes waste products from the blood, such as ammonia. In patients with chronic liver disease, there is inability of liver to clear the harmful substances and there are mental changes causing altered sensorium and even coma.

Making hormones and enzymes: The liver produces many hormones and enzymes. It is also responsible for making substances that maintain thinness of the blood and prevent blood clots.

Fighting infection: The liver helps the body fight infection by producing white blood cells. The Kuppfer cells in the liver are mainly responsible for this

The liver is a very resilient organ and can regenerate itself if it is damaged. Most of the people think that a small piece of liver is enough to regenerate and make whole liver. However, if the liver is chronically and severely damaged, it may not be able to recover and may need to be transplanted.

Know about hepatitis virus

Hepatitis viruses are those which have special affinity to the liver and they cause damage to the liver. Viral hepatitis leads to inflammation (damage) of liver cells by those viruses also known as hepatotrophic virus. There are hepatitis A, B, C, D and E that can cause acute and chronic infection. Hepatitis A and E are transmitted by feco-oral route, which means by taking fecal contaminated food and drinks. Both of them cause acute viral hepatitis. Although this disease is often self-limiting, it causes morbidity and work or study loss. However, they can sometimes cause acute liver failure and even death if proper treatment is not instituted. Pregnant women are at risk along with newborn, elderly and people with chronic liver diseases. It is estimated that about 1400,000 new hepatitis A virus infections occur globally each year and underdeveloped country bears the greatest burden. Every year there are 20 million hepatitis E infections, over three million acute cases of hepatitis E, and 70,000 hepatitis E related deaths!

In Nepal, after contracting these hepatitis infection, most of the patients go for alternative medicine due to presence of jaundice. The disease is prolonged due to taking of inappropriate medications and restriction of diet. Many land in the Intensive Care Unit in a state of liver failure. Most of them die in absence of liver transplantation.

Hepatitis B and C cause chronic inflammation of the liver that can lead to cirrhosis and liver cancer. These viruses constitute a major global health risk. the WHO estimates that there are about 2000 million people, who have been infected with hepatitis B worldwide. More than 290 million are chronically infected and require treatment. Between 500,000 and 700,000 people die every year due to hepatitis B related cirrhosis and liver cancer. At the same time it is estimated that about 71 million people are chronically infected with hepatitis C virus. The potent antiviral medicines have decreased the diseased population to half in the last one decade. More than 350,000 people are estimated to die from HCV-related liver diseases each year worldwide.

How to confront it?

Hepatitis A and E can be prevented by maintaining good personal hygiene. Avoiding unsafe uncooked food and taking processed water can control this disease. Vaccine against hepatitis A is available, while vaccine against hepatitis E is awaiting mass production. More than us, it is the duty of the government to tackle the problem. Because of poor water supply system and inefficient sewerage system, the end of hepatitis A and E is still far from the target elimination.

Viral hepatitis B and C places a heavy burden on the health-care system because of the high costs of treatment of liver cancer and liver failure from cirrhosis. The actual burden of disease related to hepatitis B and C infection is not exactly known in our country. In fact, the problem has not been addressed in a comprehensive way so far by the stakeholders. The researchers and the clinicians are also to be blamed as there are no such researches so far. Because of the fact that the most people do not develop any symptoms when they become infected and that they remain free of symptoms often for decades until they develop chronic liver disease. This has largely resulted in “the silent epidemic” that we, the clinicians, are experiencing today. Moreover, most people with chronic infection with hepatitis B or C are unaware that they continue to carry the virus and unknowingly transmit the virus to other people. Hepatitis B vaccination is the best way to deal with this disease. It has been included in EPI schedule and this job is commendable. However, it is still not available in every district. Early detection is paramount as it is curable as well as prevent from developing complications. Those who are at risk should be tested. In our country, there are free medications available for HIV infected patients but there is no such facility for hepatitis patients. The tragedy is that Tenofovir, which is a potent medicine for hepatitis B virus is a part of free ART but not available for hepatitis B patient. Treatment of hepatitis C is very costly. The heartbreaking information is that it is the lone virus waiting for vaccine to be developed. Prevention is better than cure. Intravenous (IV) drug abuse, which constitute >90% of transmission source should be discouraged. Universal precaution should be practiced in health care institute.

Treatment of Hepatitis virus

Hepatitis A and E do not require any treatment. They are self-limiting, and good food, rest and proper diet are essential to get rid of this virus. Once we are infected with hepatitis A virus, there is life-long immunity. It is also rare to get re-infection with hepatitis E virus. It can cause chronic infection in immunocompromised post-transplant patients.

There is medicine for the hepatitis B. But it does not guarantees cure. The infection can be controlled and complications can be prevented. Treatment is very much necessary to prevent transmission to others. Hepatitis C virus can finally be cured with potent antiviral drugs. The success rate is 90-99% if treated appropriately on time. One good thing is that our government is recently providing free treatment for hepatitis C patients who are co-infected with HIV. Hepatitis C can be eliminated from Nepal if the government wants to do it!

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