ABC of Viral Hepatitis

Dr Lalit Kant, Sr Advisor-Infectious Diseases, Public Health Foundation of India, and Senior Country Advisor, Indian Network of Neglected Tropical Diseases, on the eve of World Hepatitis Day, opines that India’s success in reducing illness and deaths due to viral hepatitis is pivotal for the global targets to be achieved

July 28th is observed as World Hepatitis Day. Hepatitis means inflammation of liver and viral hepatitis is believed to result in an estimated 1.4 million deaths per year worldwide. It has silently overtaken tuberculosis (1.3 million deaths) to become the second biggest cause of death after HIV/AIDS (1.6million). The World Health Organisation (WHO) believes that globally around 500 million people are living with viral hepatitis. Alarmed at these rising numbers, at the recently held 69th World Health Assembly, 194 states made a historic commitment to eliminate viral hepatitis by 2030 and adopted Global Viral Hepatitis Strategy, where it was pledged to eliminate viral hepatitis transmission and everyone living with viral hepatitis has access to safe, affordable, and effective care and treatment. The strategy includes a set of prevention and treatment options which if reached, will reduce deaths by 65 per cent and increase treatment to 80 per cent, saving 7.1 million lives globally.

The viruses of greatest concern are Hepatitis A virus (HAV), Hepatitis B virus (HBV), Hepatitis C virus (HCV), Hepatitis D virus (HDV), and Hepatitis E virus (HEV), because majority of illness and deaths are caused by them.

Hepatitis A and E are mostly transmitted through consumption of food and water contaminated with faeces from an infected person. Hepatitis B and C generally occur as a result of receiving unscreened and contaminated blood transfusion or blood products like platelets. Invasive surgical procedures (like surgery, tooth extraction, dialysis etc.) performed by using contaminated instruments, using non-sterile syringe and needles for injections also transmit these viruses. Hepatitis B is more likely than HCV to be transmitted from mother to her child during birth and by unprotected sexual contact. Hepatitis D virus almost always piggy backs on HBV.

Vaccines are available to prevent HAV and HBV infection. China has produced and licensed a vaccine against HEV, but it is not yet available globally. No vaccines are available against HCV.

Jaundice, fever, nausea, loss of appetite, vomiting, and abdominal pain are common symptoms of viral hepatitis. Acute infections with HAV, HBV, HCV, and HEV are usually self-limiting, only supportive therapy is required. Rare complications in older children and adults can cause liver failure and death. Pregnant women are at greater risk of complications and death if they get HEV infected. In some cases, when the HBV and HCV infections persist, it leads to chronic sequela like cirrhosis of liver (fibrous tissue replaces liver cells), liver cancer, liver failure and death. Viral hepatitis is responsible for nearly 80 per cent cases of liver cancer. Drugs are available that prevent development of complications after HBV and HCV infection. The medication only suppresses HBV virus multiplication and may need to be taken life-long. The WHO recommended medicines which are readily available as generics and are relatively inexpensive and affordable. The cost is around $5 per person per month.

Until recently, treatment for Hepatitis C involved taking medicines both orally and by injection, with a cure rate of about 50 per cent or lower. They had unpleasant side-effects which made continuation of treatment a challenge. A new class of medicines called direct anti-retroviral agents (DAA) given in combination with other anti-viral drugs have revolutionised the treatment and have brought hope to millions of sufferers. The medicines are more effective, safer, taken orally and better tolerated. Taken between eight and 48 weeks, the treatment assures cure. The cost of new combination treatment between $80,000 and 150000 per course, puts these drugs beyond the reach of many who need them the most as about 85 per cent of world’s chronic HCV population live in low and middle income countries.

This reminds of a similar situation when the drugs for management of HIV became available. They were beyond the reach of people in developing world. Like the HIV medicines, the HCV drugs are also covered by patent. India, by manufacturing generic HIV medicines, has played a pivotal role in making them affordable. The cost of one year’s treatment came down from $10000 per person to under $80. Agreements have been signed with 11 Indian generic pharmaceutical companies to manufacture and sell the medicine(s) in about 100 countries. This mechanism is likely to pull down the price by bringing multiple generic companies on to the market. Independently, the Drugs for Neglected Diseases initiative (DNDi), a product development partnership in Geneva aims to make the generic drug combination available at or below $200 for a 12 week course as against about $100000 today.

There are no authentic figures of the burden of viral hepatitis in India. Nearly 140000 cases of all-cause viral hepatitis were reported in India in 2014. It is estimated that about 15-30 per cent of acute hepatitis in India is due to HBV. There are an estimated 30-40 million HBV carriers (15 per cent of global pool). Near about 50 per cent of chronic liver diseases are due to HBV and 20 per cent are due to HCV. There are about six to 12 million cases of HCV. Approximately 2.5 lakh patients die of viral hepatitis and its sequela. Given the environmental conditions and ecosystem of healthcare, it is believed that these figures are an under-estimate.

India needs to generate data, develop evidence-based policies, implement and expand preventive measures like vaccinations; improve injection, blood and surgical safety; raise awareness and management of viral hepatitis. It is important for India to establish treatment guidelines and include drugs for hepatitis C in its list of essential medicines. India’s success in reducing illness and deaths due to viral hepatitis is pivotal for the global targets to be achieved.

EH News Bureau