Hepatitis B is a major viral infection that affects about 40 million people in India. What makes it worse is the fact that once infected, there is high risk of long term infection. If we go by the latest data by the National Family Health Survey (NFHS 4), about 60 per cent of children receive the hepatitis B vaccine within a year of birth. With more than one-third of our children vulnerable to the infection, hepatitis B is a threat to public health across the nation.
There remain multiple challenges which need to be addressed to counter the disease. One needs to realize that there is a big population in adolescent and adulthood that hasn’t been vaccinated yet. The chances of a population size contracting Hepatitis B infection are significant, and an understanding of how the infection is transmitted helps in mapping out ways to counter its spread.
Transmission of hepatitis B virus
Hepatitis is the inflammation of liver that can be self-limiting or progressive in nature and cause liver fibrosis (scarring), cirrhosis, or liver cancer. There are many types of hepatitis viruses such as A, B, C, D and E. Hepatitis A and E are water borne and spread through contaminated water or food. With clear manifestations such as jaundice, these last for short duration and are treatable through medicines. On the other hand, hepatitis B, C and D(rare in India) are blood borne; hepatitis D causes infection only in the presence of hepatitis B. Apart from the lack of all-cure treatment, swift permeability makes the virus deadly and difficult to contain. The mode of transmission is either horizontal – the virus is transmitted from one person to other by sexual activity with an infected person, unsafe blood transfusion or through the use of unsterilized needles. Health workers too are likely to get infected if they come in contact with body fluids of the infected patient. However, increased awareness and vaccination has brought down the number of infected health workers from 10 per cent in 1990s to 1.4 per cent in the current decade. The other way is perinatal or vertical transmission where a child is infected by mother.
Vaccination is the most important step
The universal immunization against hepatitis B in India began as a pilot project in 2002-03 and is now a part of universal program all over the nation. Hospitals have been proactive is giving hepatitis B vaccine to a newborn child within 24 hours of birth to reduce the chances of transmission if the virus from a mother to the child, followed by three more doses at 6, 10 and 14 weeks. In fact, preventive measures are taken right from the time a woman conceives. Now, testing for hepatitis B (HBsAg) is mandatory during pregnancy. If a mother tests positive, immediate vaccination to the newborn helps. However, some mothers may need to be treated with oral medications during pregnancy to reduce the viral load and risk of passing the infection down to the child. India has made headway in stemming the viral infection from mother to child. Prevalence of hepatitis B in pregnant women has decreased from 3.7% in 1987 to 0.9% in 2011.
But how about those who remained outside the ambit of universal immunization? A large number of people who are five years or older born before the universal immunization program was introduced had not received the vaccine as an infant or a child. Hepatitis B vaccine provides lifetime protection against the virus, and these people may have a chance to save themselves if we make them aware of their health risk and get vaccinated against hepatitis B. though population-based data is sparse, the World Health Organization (WHO) estimates hepatitis B affects 3 to 4 per cent of the population and claims about 1 to 2 per cent of patients every year.
Safe and hygienic blood transfusion practices go a long way
To give contaminated blood to a person with Thalassemia, liver or kidney disease, or leukemia is as good as getting serving a death warrant. One of the most significant steps in getting healthy blood was imposing a ban on paid blood donation in 1995 as often people with communicable diseases appeared for paid donation. Initially, there was a shortage but it saved the money and effort of the blood banks to get the donated blood tested and checked the tendencies to skip it altogether. Besides, technical advancement has provided the blood banks with an opportunity to test the donated blood comprehensively and reduce chances of infections through transfusion. The use of single-use, disposable and sterile syringes too have helped in containing the spread of hepatitis B while awareness about other hygienic practices such as staff washing their hands before administering the injection, cleaning the area of the injection adequately, and not touching the injection with their hands is also increasing. Safer blood bank practices and the use of better testing has significantly decreased the prevalence of hepatitis B in Thalassemia patients from 65 per cent in 1995 to 2 per cent in 2011.
In rural and remote areas where healthcare facilities are inadequate, we need to improve the access to medical instruments and make the health workers aware of the importance of the safe practices. One million newborns in India run a lifetime risk of chronic hepatitis B every year and out of 3 Billion injections administered, 1.89 billion are considered unsafe due to poor sterilization or reuse of syringes.
Awareness among all stakeholders improves efficacy of vaccines
Treatment options for hepatitis B have expanded over the last two decades right from injections (interferons) to oral tablets, and the latest medicines have good viral suppression and low resistance in case of long term use. Due to the indigenous manufacturing by the Indian pharmaceutical companies and price control measures by the government, the cost of treatment in India is relatively low. Besides, advancements in and more widespread availability of liver transplantation have made the complications related to hepatitis B such as cirrhosis better managed.
With influx of people into urban areas and significant changes in lifestyle of the urban population, the threat of hepatitis epidemic looms large. In order to contain hepatitis B, lifestyle and awareness are very important and there is a pressing need to create awareness among people who have so far ignored hepatitis as a health and development priority.