World Hepatitis Day 2013: Confronting a "Silent Epidemic"
World Hepatitis Day 2013: Confronting a "Silent Epidemic"
Hepatitis is a personal disease for me. Some years ago, I spent two weeks leading training workshops for faculty at the University of Costa Rica in San Jose, Costa Rica. The work and the participants were delightful, as we worked together to improve medicine prescribing practices. Every day I ate lunch at a local seafood restaurant, often joined by a colleague. One Friday, two weeks after returning home, I felt exhausted—so tired that I could not continue working. By Sunday I was orange as a pumpkin, unable to walk or keep food down. I visited my physician and was diagnosed with acute, severe hepatitis A. I felt like I was dying. I lost 6 weeks of work and 25 pounds before I was able to return to normal functioning. I discovered that the colleague who had joined me for lunch developed hepatitis A with the same intensity and duration, and at the same time. We traced this “point source outbreak” to some uncooked mussels that the restaurant used in a fish sauce that transmitted the hepatitis A virus to us both.
This is Hepatitis: Know It
July 28 is World Hepatitis Day. This year's theme—"This is hepatitis. Know it. Confront it."—underscores the asymptomatic nature of some types of the virus as it slowly infects the liver (many people who have viral hepatitis don't know it), and the lack of global awareness about the extent of the disease.
Hepatitis is an inflammation of the liver, usually caused by infectious viruses, but occasionally by medications or chemicals. There are five hepatitis viruses: A, B, C, D, and E. Hepatitis A and E are spread orally by contaminated water or food. Hepatitis A may cause no symptoms at all (the asymptomatic carrier state) or a mild flu-like illness for about 90 percent of cases. The other 10 percent show severe symptoms, like I did. Each year, about 1.4 million people are infected by hepatitis A, most with mild symptoms and infections that resolve spontaneously. But in many resource-poor countries, people with weakened immune systems, due to malnutrition, HIV, or other diseases, have a higher mortality risk. Hepatitis A is now preventable by early vaccination against the disease; but, few people outside the industrial world receive the vaccine.
Hepatitis B, C, and D, by contrast, are blood borne diseases, spread by contact with infected blood or blood products, such as blood transfusions, contaminated needles, intravenous drug use, and even mother-to-child transmission. Both hepatitis B and C do not normally cause an acute symptomatic infection, but both can cause chronic, active hepatitis that can ultimately lead to cirrhosis or liver cancer, both of which are fatal.
Hepatitis B and C are "silent epidemics" in many countries and contribute to high death rates in adults. In fact, hepatitis B is one of the top 10 infectious causes of death in the world. Each year, about 600,000 people die from hepatitis B complications. Studies in Afghanistan show that 8 percent of adults over the age of 30 have chronic active hepatitis B, and the rate of infection increases with the number of injections received over a lifetime.
Prevalence of chronic hepatitis B or C varies widely, but in some countries can be astonishingly high. In Egypt, for example, nearly 20 percent of adults have chronic active hepatitis C due to widespread use of unsterile injectable treatments for schistosomiasis in the Nile Basin decades ago. Untreated, half of those with chronic hepatitis C infection will die of either liver failure or liver cancer. Even in the USA, 3 percent of adults are estimated to be carriers of the disease, and the U.S. Centers for Disease Control and Prevention (CDC) recommends that all "baby boomers" be tested for hepatitis C.
This is Hepatitis: Confront It
Unlike hepatitis C, a vaccine can prevent hepatitis B. People at higher risk for blood exposure—such as health care workers—and infants (who can contract hepatitis B from their mothers) are routinely immunized. With support from the US Agency for International Development (USAID) and GAVI Alliance, MSH worked closely with the Afghanistan Ministry of Public Health to support inclusion of the hepatitis B vaccine in the Expanded Program of Immunizations (EPI) for infants. The EPI program that includes hepatitis B can help, within a generation, to significantly decrease the percentage of adults with chronic hepatitis B. There is no vaccine for hepatitis C at all, so early detection and treatment are the only approach for people already infected. However, the treatment is much too expensive for many countries to be able to provide it.
“Many of the measures needed to prevent the spread of viral hepatitis disease can be put in place right now, and doing so will offset the heavy economic costs of treating and hospitalizing patients in future,” said Dr. Sylvie Briand, Director of the World Health Organizations (WHO) Pandemic and Epidemic Diseases in an announcement of the WHO's first-ever country-based report on hepatitis prevention and control.
Infection prevention is one of the most effective approaches to reducing high rates of hepatitis in a majority of countries. For hepatitis A, point of source water treatment with chlorine products or boiling water before use, combined with frequent hand washing, cooking of food, and cleaning of all vegetables and fruit before eating will prevent disease. For hepatitis B and C, introduction of sterile techniques into health care services, using disposable needles, safety boxes for needle disposal, incinerators for disposal of medical waste, protective equipment for health care workers, screening of blood donors, and condom use, are very effective in preventing bloodborne and sexual transmission within a community. However, maintaining a continuous supply of infection prevention commodities is a major challenge in many countries.
MSH has introduced effective infection prevention programs into the countries where we work, from hospitals to health center to community levels. Starting with a country-wide program in Afghanistan for infection prevention (IP) in hospitals and health centers and supported by USAID and other donors, we have now expanded our IP worldwide in multiple languages over the past ten years. Combined with improved commodity management programs to ensure uninterrupted supplies, infection prevention programs have significantly reduced the spread of hepatitis B and C in many countries. As universal access to health care becomes a reality in most countries, universal use of effective infection prevention programs can significantly reduce the prevalence of these “silent” killers.
A. Frederick Hartman, MD, MPH is Global Technical Lead on malaria and other communicable diseases at MSH.