Sunday, April 7, 2002		Fitness

Prevention is always better than cure in viral hepatitis
B.K. Sharma

HIMACHAL Pradesh is in (medical) news again. There has been an outbreak of jaundice in the Mandi area and more than 200 cases of patients suffering from jaundice with viral hepatitis have been reported. Press reports and a visit by microbiologists from the National Institute of Communicable Diseases, New Delhi followed the outbreak. The infection has been traced to contaminated water in the area. In 1957 there was a huge outbreak of hepatitis in New Delhi many thousands of patients were reported to be suffering from the disease and there were a number of deaths. What is, perhaps, not known to the public at large is that hepatitis does not occur only in the form of these outbreaks but the endemic cases (occurring sporadically) occur all the time. This form of hepatitis is caused by viral infection and we need to know the modes of its spread so that preventive measures can be taken.

Viral hepatitis is a systemic infection mainly affecting the liver but not limited to that. There are a large number of viruses which can cause hepatitis. But viral hepatitis is generally caused by five viral agents (named A, B, C, D, E) which predominantly affect the liver leading to jaundice. Viral hepatitis is, however, more than jaundice. A typical case starts with a loss of appetite, fatigue, malaise and sometimes nausea and vomiting. Some patients may also suffer from ache and pain in the muscles, headache, symptoms like cough and bad throat resembling influenza and occasionally accompanied by high grade fever. Yellowish eyes and dark yellowish urine is noticed by the patient in the first few days of the illness. There may be some enlargement of the liver and occasionally spleen. Jaundice may last from 2-10 weeks and during the course of the illness the patient may experience a lot of itching and the stool may be clay coloured because of lack of bile pigments in the stool. A majority of patients recover but viral hepatitis can take a serious turn and in certain patients, particularly of hepatitis B and E, a severe degree of liver necrosis or what is known as fulminant hepatitis can occur. Sometimes cases of hepatitis B and C can become chronic, leading to cirrhosis, cancer of the liver, certain form of kidney disease and neuropathy. Incidence of chronicity is particularly high in the case of hepatitis C.

We knew for a long time that the viral hepatitis used to occur either through contaminated water and food or through blood or other methods transmitting infected blood. The former disease was known as hepatitis A and the latter was called hepatitis B, even before it was known what kind of virus was producing it. During the last about 30 years these virsues have been further differentiated and the details of their methods of spread and disease patterns have been worked out. We now know that hepatitis A and E are transmitted through infected water and food contaminated with such water. Virus hepatitis A predominantly affects children and is relatively benign in its course. Hepatitis E occurs more often in adults and can take a severe course, including fulminant hepatitis. The outbreak in Mandi as well as in Delhi during 1957 was due to hepatitis E virus.

Hepatitis B and C are transmitted through contaminated blood, injections (this disease was called ‘syringe jaundice’), any surgical procedure carried out without proper sterilisation or through unprotected sex with an infected person. This explains why this kind of hepatitis is common in drug addicts sharing syringe and health workers who are at risk of being exposed to injected blood during the course of their work. Hepatitis D almost follows hepatitis B and has the same route of spread.

It is quite clear from the route of spread of these viruses that the disease is preventable. This becomes particularly important when we know that there is no specific treatment available for viral hepatitis. In fact most of the time treatment is only supportive. In case the hepatitis becomes chronic as in the case of hepatitis B and C, anti-viral treatment is now available. But it costs over Rs 50000-60000 per month and lasts over a long time and hence it is beyond the reach of most people. Prevention therefore is the way out.

These viruses spread through contaminated water and food. As has been reported in the Press, the water of the river in Mandi area has been found to be contaminated and the people have been advised to take only filtered water or boil the river water before consuming it. But the real solution lies in public health measures to be taken by the government, municipalities and panchayats. In fact, this is now a legal function of these bodies. The Municipal Solid Waste Rules, 2000, has been issued by the central government under the Environment Protection Act. It is incumbent on these civil bodies to provide clean drinking water and arrange for safe disposal of garbage, including its collection, segregation and final disposal. It is unfortunate that not even half our population has access to clean drinking water and therefore our population, particularly the rural population, is exposed not only to this disease but also other water-borne diseases like cholera, gastroenteritis, typhoid etc. Similarly, since 1996 the Biomedical Waste Management Rules have been made mandatory by the Government of India for the disposal of biomedical waste by hospitals, nursing homes and similar other agencies. Rag pickers searching through garbage dumps near hospitals are a serious public health hazard.

As mentioned earlier hepatitis B, C and D enter through the blood, skin or other parts of the body when the virus in the contaminated blood, needle or an instrument gets into the body. It can also spread through sexual contact with an infected person. Here the solution lies in using safe blood, and thoroughly sterilised syringes, needles, instruments and other material used during the surgical and dental procedures. Here again, unfortunately, the practice of reusing the syringes in certain quarters is widespread and many hospitals have introduced the practice of destroying the needles and syringes after use. There has been a lot of progress in providing safe blood and since 1992 it has been made mandatory to test every unit of blood for hepatitis B, AIDS and syphilis. Since June 2001, testing for hepatitis C has also become mandatory. Although the step was considered essential even earlier but was not implemented due to financial constraints. Because of stringent rules enforcing the use of safe blood, the incidence of hepatitis B and C infection has come down considerably in industrialised countries and we hope that we will be able to achieve the same in the near future.