Hepatitis B and C: A lifelong sentence

MALAYSIA - Many people are unaware that being diagnosed with hepatitis B and C is a lifelong sentence.

Many ancient civilisations rightfully believed that the liver is one of the most crucial organs in our body.

Although their understanding was not based in scientific fact - for example, the Babylonians, Estrucans, Romans and Greeks believed that the liver was the seat of all emotions and the organ closest to divinity, while in traditional Chinese medicine, it purportedly helps to regulate the flow of qi and blood in the body, and governs anger - the liver is indeed vital to our existence.

Like the heart, we cannot function without our liver.

It is one of the most hardworking organs in our body, performing over 500 different functions, including processing and storing nutrients, manufacturing proteins and hormones, neutralising toxins, breaking down drugs and removing waste from our body.

It is the second largest organ in the body after the skin, and the only one that has significant regenerative capabilities, being able to grow back to full size from as little as a quarter of its cells.

However, even this ability cannot overcome the insidious presence of the two hepatitis viruses that cause chronic infection in the liver.

These viruses work silently - often residing in the infected person's body quietly, slowly damaging the liver without causing any outward signs of illness, until it is too late.

Passed on through bodily fluids, they can be contracted through sex, the sharing or reuse of unsterilised sharp objects like needles, razors, and even earrings, from mother to child in the womb, and basically, any activity that can result in the transference of blood, semen, vaginal fluid and saliva directly from the infected person to someone else.

The virus usually gains access into the body via the bloodstream through minor wounds, like nicks or cuts, that one may not even notice.

But because these viruses rarely cause any specific symptoms during the acute stage, people are unaware that they have been infected, and may go on to infect other people unknowingly.

This is why, according to consultant hepatologist Dr Syed Mohd Redha Syed Nasir, the most important form of transmission is perinatal or early childhood transmission.

He explains: "If someone in the family has hepatitis B, it is likely that someone else will have it too; that's why we have to screen everyone in the house."

This is especially in the case of children whose immune systems have not completely matured yet.

As a rule, hepatitis is usually only picked up upon screening, or when patients have already developed complications from the disease.

A chronic problem

Despite being considered a major global health threat - it is one of only four diseases that the World Health Organisation (WHO) considers crucial enough to mark with an international World Day, the awareness of hepatitis is still disturbingly low among the general population.

This infectious disease, which causes inflammation of the liver, is caused by five viruses: hepatitis A, B, C, D and E.

Of these, hepatitis B and C are the most worrisome as they can become chronic infections, which may result in liver cirrhosis (also known in layman's terms as scarring or hardening) and liver cancer. (See Acute infections for more information on the three other viruses.)

These two viruses are also the main focus of the World Hepatitis Day campaign.

According to the World Hepatitis Alliance website, "The long-term objective of the campaign is to prevent new infections and to deliver real improvements in health outcomes for people living with hepatitis B and C."

In Malaysia, hepatitis B is an important enough health concern that the vaccine is part of the compulsory national immunisation programme for all babies.

Despite that, Dr Syed says that around 5 per cent of the population still has hepatitis B.

There is no vaccine for hepatitis C; neither is there any local data on the spread of hepatitis C or the three other hepatitis viruses in the country, according to him.

"In our setting, from my experience, we often encounter patients, who are diagnosed to have hepatitis B in particular, many years ago.

"Little do they realise that hepatitis B is a chronic infection that has the potential to cause long-term damage to the liver," he says.

The doctor, who was previously with the national referral centre for liver diseases at Hospital Selayang and is now in private practice, adds that this often results in the patient being unaware of the importance of long-term follow-up, and creates the tendency for them to skip their annual check-ups.

"For these patients, you can't be sure whether their infection will become active again, or develop into liver cancer.

"A few years down the road, they will come and you discover they have liver cirrhosis, and it is already a lost battle."

He says that most patients tend to come in when they already have decompensated liver cirrhosis, which presents with abdominal swelling, with or without accompanying leg swelling, and either vomiting or passing motion with blood.

Some may also come in with a yellowish complexion (jaundice), episodes of losing awareness of their surroundings (hepatic encephalopathy), and other bacterial infections, as the liver is part of the immune system.

Too late to treat

While treatment is available for both hepatitis B and C, Dr Syed cautions that patients need to be carefully evaluated before the decision to start treatment is made.

This evaluation is to determine the degree of viral activity, as well as the level of liver damage. Both these factors need to be carefully balanced in order for treatment to be fully effective.

"When we give treatment, we must make sure it is indicated, because it is for life. For example, if a patient is 25 years old, he has to take it for the next 40 to 50 years (until he dies)," he says.

The development of resistance to the antiviral medication given for the disease is also another reason why doctors need to make the decision to treat judiciously.

Aside from oral antiviral drugs, patients may also be treated with interferon injections, which are typically given for the period of one year.

Dr Syed explains: "Interferon modulates your immune system, as well as clears the virus, so there is an added effect. After one year, your immune system will be able to clear the virus on its own."

According to studies, the percentage of patients on interferon in which the virus can no longer be detected increases from 3-5 per cent in the first year to 12 per cent five years after completing their treatment.

However, he adds that this treatment is often not an option for most Malaysian patients, as the damage to the liver is already too advanced by the time they go see the doctor.

Unfortunately, the reality of the situation in Malaysia is that most patients with chronic hepatitis only see the doctor when their condition is so advanced that they are already well on the way to requiring a liver transplant.

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