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Sunday, 28 July 2013

Love your liver! World Hepatitis Day today

A look at one of the most insidious infectious in the world 

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

Dr Syed ... Patients diagnosed with hepatitis B and C need to come for their annual check-ups to catch signs of liver damage in the early stages. – LOW LAY PHON/The Star
Dr Syed ... Patients diagnosed with hepatitis B and C need to come for their annual check-ups to catch signs of liver damage in the early stages. – LOW LAY PHON/The Star

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% 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% in the first year to 12% 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.


Related Notes:

Hepatitis A
Transmitted through the oral-faecal route, usually through water or food that has been contaminated with the faeces of an infected person. Prevalent in places with poor hygiene and sanitation. There are an estimated 1.4 million cases of hepatitis A every year worldwide. Symptoms include fever, malaise, loss of appetite, diarrhoea, nausea, abdomi -nal discomfort, dark-coloured urine and jaundice. There is no treatment, but the immune system is usually able to get rid of the infection by itself. There are a number of vaccines available.

Hepatitis D
Transmitted through bodily fluids, usually through sex, contact with the blood of an infected person, sharing of sharp objects like needles, razors or syringes, and from mother to child in the womb. Requires the presence of the hepatitis B virus to replicate, and as such, is usually found together with hepatitis B as a co-infection or a superinfection. Not usually tested for in a clinical setting. Treatment and vaccination for hepatitis B is equally effective for hepatitis D.

Hepatitis E
Transmitted through the oral-faecal route, usually through contaminated drinking water and eating products from an infected animal. Every year, there are 20 million infections, over three million acute cases, and 57,000 deaths. Over 60% of infections occur in East and South Asia. Symptoms include jaundice, anorexia, an enlarged, tender liver (hepatomega -ly), abdominal pain and tenderness, nausea, vomiting and fever. There is no treatment, but the immune system is usually able to get rid of the infection by itself. However, complica -tions may arise in pregnant women. The first vaccine was registered in 2011 in China, but is not currently available globally.

Sources: WHO, the US Centres for Disease Control and Prevention, and consultant hepatologist Dr Syed Mohd Redha Syed Nasir.

There are vaccines available for hepatitis A, B and E, but the vaccine for hepatitis E is only available in China. – AFP

Facts an figures -by the Numbers:
  • There are over 400 million cases of  HEPATITIS every year, compared to 34 million cases of  HIV/AIDS cases (IN 2011) and almost 29 million cases of CANCER  (in 2008).
  • HEPATITIS B & C infections cause an estismated  57% of liver cirrhosis cases and 78% primary liver cancer. Liver cancer is the SIXTH most common cancer worldwide.
  • Around 240 million people have chronic Hepatitis B, with 600,000 dying every year due to complications from the infection.
  • The percentage of  those who develop chronic Hepatitis B infections are: 80-90% of infants infected before he age of one, 30-50% of children infected before six and <5% of otherwise healthy adults.
  • The Hepatitis B vaccine is administered at ZERO (at birth), one and six months of age in Malaysia. It is 95% effective at preventing infection.
  • About 150 million people have chronic Hepatitis C, with over 350,000 dying every year due to complications from the infection.
  • Around 80% of peopole do not exhibit any symptoms follwoing initial Hepatitis C infection.
  • Around 75-85% of Hepatitis C patients develop chronic infection, of which 60-70% develop chronic liver disease. 2-20% will develop cirrhosis, with 1-5% dying from cirrhosis or liver cancer. Hepatitis C causes 25% of liver cancer cases.
  • July 28 was chosen for World Hepatitis Day in honur of the birthday of Nobel Laureate Prof Baruch Samuel Blumberg, who discovered the Hepatitis B virus.

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