dna Conversations: Hepatitis - the silent killer stalking Indians

To discuss this killer disease, dna invited a panel of experts comprising (in alphabetical order) Dr. Deepak N Amarapurkar, Senior Gastroenterologist, Bombay Hospital, Mumbai; Dr. Somnath Chattopadhyay, senior consultant and Hepato-Pancreato-Biliary and Transplant Surgeon, Global Hospitals, Mumbai; Dr Gourdas Choudhuri, Director and head of Department of Gastroenterology, Fortis Memorial Research Institute, Gurgaon; Dr. Harsh Kapoor, Chairman and Senior Consultant, Institute of Digestive and Hepato-Billiary Sciences, Primus Super Specialty Hospital, New Delhi; and Dr. Jayshri A Shah, Senior Consulting Gasteroenterologist and Endoscopist, Lilavati Hospital, Mumbai​.

The discussion, moderated by RN Bhaskar and with editorial support from Maitri Porecha, threw up issues that are startling, and immensely relevant to our lives. Given below are edited excerpts:

Kapoor: Types of infection in Hepatitis range from A to G,  but we mainly talk about the more prominent types which are - A, B, C, D and E. Of these B and C will group in a category because they can cause long-term or chronic liver disease, though the treatments are different. Whereas D can only happen in people who have B. 

On the other hand, A and E are mainly water borne kind of diseases, which are self limiting and can be easily cured.

Choudhuri:  Hepatitis A and E work together, these are water borne or food borne or viral infections.  Prevention can be practiced by using potable water supply, maintaining cleanliness and hygiene.

On the other hand for Hepatitis B and C, these are transmitted usually through body fluids.  So it is through blood transfusions, unsafe sex, needle transfusion, injection with non-disposable needles and syringes, which therefore means reusable needles and syringes. 

So the entire spectrum of spread for Hepatitis A/E and B/C is very different. The problem with B and C is that both of them are very stealthy infections. Once they get entry into the body, they remain in the liver for years together and produce a degenerative condition called 'Liver Cirrhosis.' Apart from this as the liver fails due to the longstanding infection, it also disposes the liver to develop Hepatocellular Cancer. So the focus and the approaches to the two groups of viral infections are quite different, and I think we should be able to discuss the strategies and ways to how to prevent and treat them differently.

Amarapurkar:  Now generally people do not differentiate between Hepatitis and jaundice. Most persons keep talking about jaundice as a disease, but it is not a disease. It is a symptom.

The symptom of jaundice can manifest itself because of Hepatitis. Now Hepatitis patients, most of the time, have jaundice. However, Hepatitis can exist without an outwardly manifestation of jaundice as well. For each patient that presents himself with jaundice, there are ten non-jaundice patients that have been exposed to the infection, recovered temporarily on their own and never realized that an infection is breeding inside their body, unless they are subjected to a blood test. So, those people who come with jaundice-like symptoms infected with Hepatitis are only a tip of the iceberg.

dna: What is the depth of the problem in India?

Amarapurkar: If you look at the prevalence of Hepatitis B and C, which are chronic infections, in the country's population, 3% account for Hepatitis B and 0.5%-1% for Hepatitis C infections.

Shah: Hepatitis simply means inflammation of the liver. In simple terms,  it means an angry liver. Unfortunately with Hepatitis B and C, a very small proportion of patients will come to a doctor with  symptoms of jaundice, abdominal pain, nausea, vomiting. But majority of the patients will have no symptoms.  And the biggest problem is that it is a silent killer.  Silent, because, it is present in your body and you don't know you have it until it is too late. The symptoms of Hepatitis B and C will start manifesting, when the liver is already damaged, when you already have complications related to Cirrhosis.

dna: Could you be a walking cirrhotic and not have any symptoms?

Shah: There is phase in the disease when the liver function gives way, which is called 'Decompensated Cirrhosis.' The patient vomits blood, there is inset of deep jaundice, contusions, loss of appetite, loss of weight, and then it is realized that the patient may have problems of the liver. 25% of the patients with Hepatitis B or C may progress to Cirrhosis and amongst those Cirrhotic patients at least 5%, will progress to liver cancer. Four to five crore Indians are carrying this virus and are unaware about it.

Also, we have about ten lakh people at the risk of developing Hepatitis B every year. One lakh people die from this infection annually, without knowing what caught them.

dna: So it is a silent killer?

Shah: Yes. Now likewise with C, there are up to 1.8 crore persons carrying the virus, which produces same complications as Hepatitis B. The disease burden on the country thus is huge.

It does not manifest itself with symptoms, so patients do not present themselves early enough to the doctors.

One should therefore go for a whole-body checkup. Get your eyes checked annually. Get your teeth checked  annually. Also, blood check ups including Liver Profile, need to be conducted. However, a normal Liver Profile Test does not mean you don't have Cirrhosis. So I would recommend that we look into what is called as 'Liver Wellness,'  just like we are obsessed with 'Cardiac Wellness.'

Chattopadhyay: Unlike HIV/AIDS,  which has been discussed, due to media and all the  various government programmes, Hepatitis B and C are not.  What is lacking probably is the awareness even amongst medical specialists. They miss out on doing routine ultrasounds, which is a very basic tool to detect cancers in hepatitis B. Only one in five to fifteen patients will develop a cancer in Hepatitis B.

Amarapurkar:  The job of the media is to not to intimidate, but to give a complete proper perspective. Close to 3% of the population are infected, of which only 25% get into trouble.  75% never get into the trouble. A similar thing is true about hepatitis C.  Therefore, when a common statement is met that HIV and Hepatitis B are equally dangerous or that Hepatitis B is more dangerous than the HIV, these are half true statements. When a patient, who is detected to be Hepatitis B positive, hears these things, it's like a sky falling on him. He may be just an inactive carrier without any significant liver disease, whose lifetime prognosis can be excellent.

dna: The prevalence that 3% of the population has Hepatitis B, how does it compare with global statistics? Is India worse off? Or is India better off? Is it a serious one?

Kapoor: Hepatitis is a broad term. We are only discussing viral Hepatitis today.  But Hepatitis can also be caused by alcohol, as also through auto-immune diseases. 

True, 3% of the population is amongst the group of diagnosed carriers. But there are a lot of people roaming around in the population not diagnosed but carrying the virus.  And if you look at the world population chart, India has been put in the intermediate-burden epidemic area. 

In highly endemic areas in India, the prevalence can go up to 8%, which is to say that there are lot of people, who have not been screened, roaming in the population and still positive for Hepatitis B and C.

Choudhuri: So, you know, most parts of the developed world they have now prevalence rate of Hepatitis B which is 1% or less. In developed countries, especially in China, Taiwan and Sub-Saharan Africa, once upon a time, there was a prevalence of up to 15%. That means 15 out of every 100 have been positive in some countries including Taiwan 25 years ago, for Hepatitis B and C. 

Due to the advent of technology, which basically consists of testing, prevention, vaccination and so on, many countries have brought down their prevalence rate from above 15% to 1% or 1.5%.  In India, we have not quite taken the bus on time and that is the reason why our prevalence rates seem to be more or less stagnant at about 3% to 4% for quite some time. And it's about time that we also join the bandwagon and try to improve the situation. 

Very recently, Hepatitis B vaccination has been included in the expanded program of immunization.  So there were about 150 odd countries which had it for the last, I think, about eight years or so, imbibed in their immunization programme, and India was surprisingly one of the countries which was not a part of it until two years ago or three years ago. This means we are actually reacting to the situation a little late…

Shah: The prevalence of Hepatitis B is about 3% to 4% and the prevalence of Hepatitis C has been pointed out to be 1%.  And on the other hand, if you look at A and E, which are waterborne and the food borne infections, you find that there has been an epidemiological shift towards Hepatitis A.

There was a time when you would say that 95% of the people would get their immunity of Hepatitis A from their mother, because children would fight this infection as they would be exposed to the infection within the first few years of their life.  But that has been changing, because there are certain pockets of India which are urbanizing, following correct sanitation and hygienic methods, and therefore we are having extremely split infection rates in different parts of the country.  

As far as Hepatitis A infection goes, 99 out of 100 will spontaneously clear the virus with just supportive treatment -- no antiviral medication is required. So out of 100 people, who get their Hepatitis A infection and manifest with symptoms, only 1% will land up having a liver failure.  Now, most of these will not present with symptoms.  Some of them will, and that one-tenth of the people presented with clinical Hepatitis from Hepatitis A will totally recover.  

On the other hand, in Hepatitis E, you will find the prevalence is more in the second and the third decade of a person's life as compared to Hepatitis A, which is more prevalent in the first decade of life. And again as I pointed out, progressively, the age limit has been going high.  Hepatitis E seems to be more common in young adults and it can present with clinical jaundice more frequently.  

In the overall prevalence, you will see that hepatitis E usually occurs in between 40% to 60% of the population from various reported studies in India. Moreover, there is no vaccine for hepatitis E.

dna: There is a general perception that only liquor causes Cirrhosis of the liver and jaundice or failure of the liver.  Your views? 

Amarapurkar: Coming to alcoholism, alcohol is a cause of a chronic liver disease. In India, more than 50% of the Cirrhosis is because of the alcohol, around 20% is because of the Hepatitis B, around 7-10% is Hepatitis C, and remaining amount are non-alcoholics and diabetics, who may be coming up quite largely because of obesity, which is becoming epidemic in this country. As also diabetes is becoming epidemic in India.  

dna: Will alcohol induced Hepatitis be A or E?

Amarapurkar: In fact, if you want to look at the A, B, C, D of liver diseases in India, A is for alcohol, A is for Hepatitis A, B is for Hepatitis B, C is for Hepatitis C, D is for Hepatitis Delta, and diabetes, and Hepatitis E, can cause an acute liver disease.

Choudhuri: In Mumbai, there was a very interesting study that alcohol is accordingly the ominous cause for liver cirrhosis. Whereas if you go to other sections of the society in Mumbai itself, for instance if you are looking at females, or if you are looking at certain ethnic groups, alcohol is not present there. And yet B and C viruses take top-most positions. For instance, in most of the Muslim countries, where alcohol is normally a taboo starting from Bangladesh to Pakistan, most of the diseases are not alcohol related, but are basically Hepatitis C or D.

Shah: You can have just alcohol-related early damage where the liver becomes fatty. These are silent manifestations of Hepatitis. So, what happens is that your normal liver cells, which should not have more than 5% fat, start building up fat and then it goes up to 30% or 60% and so on and so forth. It manifests itself in the ultrasound imaging only when the accumulation is over 30%. You may still have a fatty liver and not know about it because ultrasound cannot pick up less than 30% fat in imaging. So, those alcoholics, who are drinking alcohol and go for a routine health check, they find that their Liver Function Tests and ultrasounds are normal; they then think that everything is hunky-dory, when it is not.  Now, there comes the second group of patients, who after building fat in their liver, start showing damage.  It is similar to a patient who gets an injury, cuts his hand, and gets a scar. Here the damage in the skin can be seen through a scar. The same thing happens to liver, except that the injury agent is not a needle or a knife, but it is the fat, which is causing recurrent inflammation and then scarring of the liver. 

Among alcoholics Hepatitis can be very bad compared to the Hepatitis of A and E. Their mortality from a very severe attack of alcoholic Hepatitis is to the tune of 50%, whereas in a bad or acute attack of Hepatitis A or E, only one out of 100 will die, because of liver failure. That alcohol and liver disease are always connected is not true any more.  There are patients who come to the clinic and they swear, they have never touched a drop of alcohol, but have still got Cirrhosis. 

dna: Which of these different strains of Hepatitis have vaccines and which of them do not have vaccines?

Kapoor: Now, we can have a vaccine for Hepatitis A. We can have one for B. Rest of the categories we are looking into that, but we are not yet there. It is possible, that these soon will come into the picture.

Chattopadhyay: Alpha and Beta.

Shah: That means A and B

Chattopadhyay: The vaccine against Hepatitis E is around the corner. It has actually been marketed and launched in China, but it has hardly been there in the rest of the world. So it hasn't been evaluated as yet. 

dna: Of all the different strains in Hepatitis, of the 100 that come up, how many would go in for transplant?

Chattopadhyay: Only 1% of the patients who get this infection will develop something which is known as acute liver failure, which is like a very rapidly deteriorating liver condition. Hepatitis B patients, the immunity of body can clear up this virus in probably around 70% to 80% of the patients, and only probably 20 to 25 of the patients will end up developing chronic hepatitis B, of which in one in 20 patients will develop a cancer along with Cirrhosis and may need a liver transplant. 

Maybe, one in 20 will develop a cancer of the liver, a liver tumor, which may require some kind of a surgery or transplant.  For hepatitis C, it is the other way around, probably 75% to 80% will end up getting a chronic liver condition, of which 10% to 30% will develop cirrhosis and may require transplant and the incidence of cancer would be around the same too.

Most of our patients around 40% have been due to non-alcoholic liver disease or Steatohepatitis, which occurs due to diabetes and obesity. Alcohol probably, being a reason for around 20% cases and viral hepatitis is the cause for around 20%. And probably, the rest have been cases of acute liver failure.

dna: How easy is it to get donors for liver transplants?

Chattopadhyay: There are two types of donors. One is when a living person donates a part of his liver, a partial liver donation. It is called a live donor transplant.  And the second is a cadaveric donation or a person who has been declared brain dead, and whose kin decide to donate the whole liver or part of the liver. 

Shah: Cadaver donation in India, or at least in Mumbai, is like a lottery. Currently, in the state zonal transplant committee registry, there are a thousand people on the waiting list to receive a liver.  Also, living donor liver transplant is concern, as it depends on how much your family loves you and if they are willing to sacrifice a part of their liver and if they are medically fit to do that.

dna: How are best standard practices maintained abroad?

Kapoor: What happens in Canada and America is that when you go for your driving license approval and registration, there is a question asked, donor? : yes or no. If you say yes, they will write down in your license that you are a donor. And suppose you have an accident and you die then there is no question involved or consent required from the family. You are automatically taken up as a donor. Whereas in India, when a person dies there is a lot of you know emotional play.  That is why in India it is very hard to get organ transplant from a dead person.

dna: When it comes to cadaver transplant, does the doctor have a say in deciding whether liver should be given to a person who does not have lifestyle bad habits -- alcohol or whatever or to a person who has maintained his body properly? 

Kapoor: In case of a patient who requires transplant in an alcohol-related Cirrhosis case, if he has got at least six months of absenteeism from the alcohol, then the transplant is possible, otherwise you are probably wasting an organ by putting it in the patient. The US law mandates the patient should not have had alcohol for at least six months before the transplant. 

Shah: As far as Mumbai is concerned, it has recently moved, or trying to move it, from six months to three months. And I think that if we are also looking at anybody with alcohol-related liver damage, we should seek psychiatric liaison advisory on that patient and document his/her ability to abstain from alcohol. 

Data in literature suggests that it is not the period of abstinence, which dictates whether the person will relapse into taking alcohol after his transplant, but it is the social circumstances and all the other network support that these people have.  It depends on what a person does prior to them having a transplant. 

We make it quite mandatory in transplant centers for them to enforce the policy in cases of alcohol related liver disease. We have a psychiatrist who confirms if a patient is fit for transplant from alcohol abstinence, point of view. Also when the patient is on the waiting list, we have a four-weekly follow-up on these patients and when the hepatologist sees these patients through regular follow-ups, does a blood test so that we can tell whether they have truly been abstinent, or not. 

dna: What do you think the government should be doing to make India more sensitive towards the treatment of Hepatitis-related ailments?

Kapoor: Much must be done with regards to public education. What we have seen in India so far is a lot of resources being pumped either from pharmaceutical companies, from institutions for supporting the  Continuous Medical Education or CME for doctors.  But very little is being spent to educate the population itself. 

Choudhuri: For Hepatitis B, the main method of transmission that keeps the prevalence high of up to 3% is actually mother to child transmission. The government has now woken up to this and have now made ante-natal screening for Hepatitis B mandatory for all the pregnant mothers. In Taiwan, this was done almost twenty years ago. India has started very late and now, as per the rule, the ante-natal test for mother is important because if she is found to be Hepatitis B positive then the child needs to be vaccinated within the first 12 months of being born. 

The second important step is including Hepatitis B in the expanded immunization program for kids, which again India has started. 

Now both these two things the government has done, but it has done rather late. So somewhere along the way the implementation of the Hepatitis B strategy has been lagging behind. And that is the reason why the prevalence is likely to still remain high for the next 15 years, unless we do something more active. 

Hepatitis C, on the other end, is not so much transmitted from mother-to-child. It is mainly through blood banking practices, tattooing, and scarification and so on. Blood banking practices have improved because there have been laws passed by the government. So from 2004 onwards most of the blood is being adequately screened, and therefore blood transfusion related Hepatitis C has really come down. All those persons who underwent a blood transfusion before 2004, for a surgery or an emergency, are at a higher risk of contracting the infection. Currently, the transmission of Hepatitis C is more through usage of non-disposable needles and syringe use, tattooing, scarification and in fact even circumcision.

Chattopadhyay: One thing which is lacking is the government support for transplants. In India, transplants are mainly carried forward by the private sector and demand and supply is very disproportionate. The transplants should be made available in public hospitals or major medical colleges or that they should enter some sort of a public/private partnership, so that transplant can be made affordable. 

Also, the government should work at bringing down the cost of Hepatitis C treatment further. The cost of the new Hepatitis treatment in the U.S. would be a $1000 for six months, which in India would be around Rs two lakhs. 

The cost of drugs, though, has reduced. Therefore, while in the US, for a six month treatment, it can be Rs 1.5 crore, in India the same treatment for six months costs about Rs 70,000, which is actually 1% of the international price. So that is a major advantage. But then, even though Indian costs are just 1% of the international price, it still comes to Rs.12,000 rupees a month, which for the average Indian family can be quite an enormous amount.

dna: So the need for the government to come in with a subsidy or some other scheme is imperative?

Choudhuri: The new thing, which has actually been started is that there are many players who seem to be interested in buying these medicines from India and exporting into other parts of the world because of the differential pricing. So the low pricing could become a major racket.  

Kapoor: The Indian pharmaceutical companies have a license to produce in India.  They have also acquired license to supply the quota to other countries around the world.  We are not only producing and subsidizing it as much as we can, but we are giving these drugs to other parts of the world. That is a god service, even though some people may be abusing it. 

Shah: The government should probably look at the condition of Viral Hepatitis from two aspects, as far as the preventive strategies are concerned. 

So as far as A and E is concerned, they are food and water borne illnesses. We know that, we have a vaccine for A and we do not have a vaccine for E.  So we need to look at certain pockets where immunization with Hepatitis A will help us.  

At this stage, we are not in a position to randomly vaccinate everyone with Hepatitis A, because our prevalence is already so high because of automatic exposure. On other hand, while there is no vaccination for Hepatitis E, it can produce clinical jaundice and significant disease in people and it is a morbidity situation for general public. We should improve our sanitation, our hygienic measures, patient education; simple things like washing our hands, before eating food and drinking boiled water. 

And then we are talking about hawker zones in Mumbai.  We had a recent review where the food from the hawkers was sent for sampling to the FDA and the presence of significant gram negative organisms, which can cause deadly infections, was found in the samples. Despite publishing this in the newspapers, no measures have been taken by the government to abandon these foods, that may be sold on the roadside. 

If we continue the way we are, we are only promoting Hepatitis A and E and in spite of knowing that there is a killer infection out there, which is causing jaundice in people, which is causing bad gastroenteritis in people, we are allowing it a free hand. Also, we know what the state of water supply is in Mumbai.  There is acute water shortage in some areas and then we know that there are slums. There is overcrowding.  There are no sanitation measures.  

There is a vaccine for Hepatitis B and I think everybody should be alerted regarding this.  Good thing to start by is to give this vaccine to all the newborns, to do the antenatal screening. I think screening for Hepatitis B and C in all the population, at least once in their lifetime is a must, considering we have a 3% to 4% prevalence of Hepatitis B and it is a vaccine preventable disease.  

Also, we do not have any national guidelines for disinfection as far as endoscopy practices are concerned. The biggest risk of spread of infection is through endoscopy units. So is it with all the medical facilities, not only endoscopy. I specifically pointed out endoscopy, because as gastroenterologist and liver specialists we are involved with doing these procedures. There is no society in India, which is pulling up the socks of hospitals or nursing homes and telling them, ?ook, your disinfection methods are inappropriate or are not meeting international standards  There is no such body.  There is no regulation whatsoever and we need to wake up to that call.

Choudhuri: Hepatitis B and C, I would say are a kind of a Shakespearean Tragedy.  The reason why I say this is because the instruments for prevention and cure are present.  But somewhere along the way it has not been publicized enough. You go to the streets of small towns in Bihar and Uttar Pradesh everybody has heard about HIV, and the reason is that it has been the Bill Gates Melinda Gates Foundation, which has promoted awareness of HIV to such an extent that people know about it.

Hepatitis B the prevalence rate is actually 10 times that of HIV.  While the prevalence of HIV in a general population is 0.3%, almost 3% of the entire population is afflicted with Hepatitis B. In spite of this; the awareness about the virus is pathetically low. 

Kapoor: Hepatitis C is almost curable now and Hepatitis B can be very well controlled with the present medication.  So it will be a shame, even if a single patient going through the system is not being screened and not diagnosed at an appropriate time.

Shah: To screen the population for Hepatitis B and C is mandatory. At the moment, it is like a lottery. People come to know they have Hepatitis B or C, because they have a surgery for something else, and then they discover the silent disease. They may also discover it if they are going for jobs out of the country, and for visa purposes they ought to do the Hepatitis B and C tests.