Know your Hepatitis ABCs

A human liver with both cirrhosis and cancer (the black areas). Cirrhosis is the end result of chronic liver damage caused by chronic liver diseases, and an important causal agent is chronic hepatitis C infection.

World Hepatitis Day was designated by the World Health Organisation (WHO) in 2010 to mark the importance of viral hepatitis as an important health issue that requires worldwide attention.

The sanctioning of World Hepatitis Day is deemed as a highly visible way to raise awareness of viral hepatitis, and drives forward actions to improve prevention, diagnosis and treatment of hepatitis B and C.

Hepatitis is a health condition defined by inflammation of the liver, and is characterised by the presence of inflammatory cells in the tissues of the organ.

Broadly, there are five different forms of viral hepatitis: A, B, C , D and E, and the first three are the most common.

Hepatitis A is the least serious of these diseases, and it is an acute condition that is usually self-limiting. Most people get well after an extended period of rest, and the body will be able to totally get rid of the virus.

The greater burden on the healthcare system would be the hepatitis B (HBV) and C (HCV) as they cause longstanding or chronic infection (defined as existing for more than six months).

It is estimated that more than 500 million people worldwide are living with either chronic hepatitis B or C, thus representing one of the biggest threats to global health, killing approximately one million people a year.

However, awareness of HBV and HCV is comparatively low, a situation made worse by the fact that a large proportion of those infected do not know that they carry the virus.

According to Prof Rosmawati Mohamed, consultant hepatologist (liver specialist) at the University of Malaya Medical Centre (UMMC), awareness about hepatitis here is low. "It is pretty much limited to the general notion that one can get all forms of hepatitis from ingesting contaminated food and/or water. For example, there is the misconception that you get hepatitis from eating cockles or shellfish, but that is true only for hepatitis A.

"This is not the case for HBV and HCV, which is spread through contact with infected bodily fluids such as blood and other secretions."

Addressing the media at a press conference recently to announce the observance of World Hepatitis Day 2012, Prof Rosmawati said that authorities must now put more emphasis on HBC and HCV as these two diseases are now having a huge impact worldwide, especially in the Asia Pacific region.

Of particular importance to specialists like her is HCV. "The emphasis for this year is to diagnose hepatitis C early and to treat it early, with effective treatment now available. With chronic HCV, the continuous inflammation damages liver cells - eventually killing them and leaving behind scar tissue. Scarring makes it harder for the liver to function and may lead to liver failure over time. And the liver is an organ people can't live without, making the disease potentially fatal."

Worldwide, it has been estimated that 170 million people have HCV, while the prevalence in South-East Asia is about 30 million, or 2.2 per cent of the population. In Malaysia, estimated prevalence is about 2 per cent.

"HCV screeing has only been available in most parts of the world since the early 1990s, and Malaysia implemented HCV screening for donated blood in 1993," said Prof Rosmawati, who added that HCV is estimated to kill over 350,000 people annually, while adding that three to four million new cases occur each year.

"The majority of patients have no symptoms, but by the time they present themselves to hospitals, it may already be too late to offer any treatment. The lack of symptoms contribute to late diagnosis, or underdiagnosis. This has grave consequences as HCV is an important causal factor in end-stage liver cancer. " HCV gives few clues as to how much damage it may be causing as the infected person may not look or feel sick. If symptoms do develop, they often are non-specific (like nausea, fatigue, vague abdominal discomfort).

With chronic HCV, liver damage is unpredictable, advancing slowly in some and quickly in others. "It can take many years after being exposed to the virus for visible damage to the liver to be detected," said Prof Rosmawati.

Studies show that about 10 per cent to 20 per cent of chronically infected persons progress to cirrhosis (final stage of chronic liver disease) over an average of 20 years.

Faster rates of progression (some as early as five years after diagnosis) are seen in persons who are infected at an older age, or who have contributing risk factors such as moderate or heavy alcohol consumption, human immunodeficiency virus (HIV), or other coexisting liver diseases.

It is rare for someone to be able to completely get rid of the HCV virus on his own without any medication. Even then, most of the treatment modalities using pegylated interferons and antivirals like ribavirin out there cannot guarantee total success even after several courses over several years.

As such, many individuals carry the HCV virus for life, though several clinical trials are now in place to come up with more effective combination therapies to combat the disease (see sidebar, Battling HCV, on a new drug called boceprevir from Merck).

Those who are most at risk of contracting HCV are intravenous drug abusers (more than 20 per cent in most cases), healthcare workers who are exposed to sharps like syringes as well as blood or blood products, those who obtained tattoos and body piercings, those undergoing haemodialysis, those with multiple sexual partners, as well as children born to mothers with the disease.

In Malaysia, another unique group of high-risk persons are those who had blood transfusions or organ transplants before 1994 (as screening for HCV in the blood banks started only in 1993).

The first screening for HCV in 1993 found that 53 out of 3,540 blood donors were infected with the disease. Similarly, 162 out of 190 intravenous drug users also have the virus.

There are no vaccines to prevent hepatitis C infection, but the risk can be reduced by avoiding unnecessary injections, body piercing with contaminated equipment, sharing of personal items (like nail clippers, razors, toothbrushes, manicure/pedicure tools) that may be contaminated with infected blood, and avoiding unprotected sexual contact, especially with multiple partners.

Aware of the huge burden of the disease, Prof Rosmawati, who is also an executive member of the Coalition to Eradicate Viral Hepatitis in Asia Pacific (CEVHAP), and is working with her fellow professionals to push through initiatives that can lead to a nationwide screening for HCV in high-risk individuals, especially through this year's World Hepatitis Day events.

"People do not normally associate HCV with liver disease. But one in every five people infected with the virus will get scarring of the liver that could lead to cancer. We need to stress that the disease is potentially life-threatening."

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