Hepatitis, an inflammation of the liver primarily caused by viral infections, some of which can be fatal poses a significant health challenge globally. Besides hepatitis viruses, other factors such as alcohol consumption, certain medications such as NSAIDs, ATT, etc, and autoimmune diseases are the leading causes of hepatitis.
Hepatitis has been termed a formidable global health challenge after analysing its impact on many countries’ public health and economic development.
Global data and trends
According to the report of the World Health Organisation, more than 354 million individuals globally are living with chronic hepatitis B and C. Nearly 1.1 million patients die every year due to hepatitis and its complications such as liver cirrhosis and cancer.
The prevalence of hepatitis B and C viruses among people is high in developing and underdeveloped countries such as Nepal which have minimal access to preventive measures and healthcare delivery services.
Types and classification of Hepatitis
Hepatitis has been classified into five main types: hepatitis A, B, C, D, and E based on the strain of the causative virus. Besides these, there are autoimmune and drug-induced hepatitis which are not associated with any of these types of viruses. Each type has its particular characteristics, symptoms, preventive measures, and modes of transmission.
- Hepatitis A:
It is the viral inflammation of the liver caused by the hepatitis A virus. Hepatitis A is mostly transmitted from one person to another through the feco-oral route by the ingestion of contaminated water or food. - Hepatitis B:
It is the inflammation of the liver due to Hepatitis B virus. Hepatitis B can be acute and chronic. It is transmitted from one person to another through contact with infectious body fluids, such as blood, semen, and vaginal secretions. - Hepatitis C:
Hepatitis C is an asymptomatic viral inflammation of the liver initially, which if untreated for a long time can lead to liver cirrhosis and cancer. It is caused by the hepatitis C virus. HCV is transmitted from one person to another primarily through blood-to-blood contact, often during intravenous drug use and unsafe medical practices. - Hepatitis D:
Hepatitis D is an opportunistic viral inflammation of the liver which occurs only in those who are infected with hepatitis B. As HDV requires the hepatitis B virus for replication, the symptoms of hepatitis D are similar to hepatitis B but can lead to more severe liver diseases. - Hepatitis E:
Hepatitis E is a viral liver inflammation by the hepatitis E virus. It usually manifests the symptoms of acute infection but with higher severity in pregnant women. Hepatitis E is mostly transmitted from one person to another through ingestion of contaminated water or undercooked meat by feco-oral route.
Autoimmune Hepatitis
Hepatitis is termed an autoimmune when our body’s immune system starts to attack its own healthy hepatocytes, leading to liver inflammation. The exact cause of autoimmune hepatitis is still under research. If left untreated for a long time, autoimmune hepatitis also may lead to liver cirrhosis and then liver cancer and failure. Patients of autoimmune hepatitis rely on the constant use of anti-inflammatory and immuno-suppressing drugs.
Drug-Induced Hepatitis
The metabolism of many drugs takes place in the liver. During this process, many toxic compounds are released into our body which might cause liver inflammation. If such medications aren’t stopped on time they can damage the liver resulting in drug-induced hepatitis. Chlorpromazine, ciprofloxacin, ofloxacin, cimetidine, phenytoin, naproxen, and diclofenac are some drugs with hepatic-toxic effects.
Symptoms
Symptoms of acute hepatitis include fever, loss of appetite, diarrhoea, nausea, abdominal discomfort, malaise, and fatigue. Where in chronic hepatitis patients dark-coloured urine, pale stools, skin rashes, joint pain, jaundice, and slightly enlarged, tender liver (hepatomegaly) are common.
Diagnosis
Hepatitis can be suspected provisionally by different clinical features it possesses and palpation of the liver which is further confirmed after blood and instrumental examination. Hepatitis may express the clinical features of acute inflammation as mentioned above whereas they might sometimes be asymptomatic. A thorough history, and physical examination to identify potential risk factors such as recent travel, drug use, alcohol abuse or exposure to infected individuals can be key factors in the diagnosis of hepatitis.
The diagnosis of hepatitis is made easier by blood tests such as polymerase chain reactions, viral hepatitis panels, and liver function tests which aid a physician to determine the type of hepatitis virus causing the inflammation, the extent of liver damage, and whether the liver is inflamed. Imaging tests such as MRI, CT scan, and USG offer detailed images of the liver.
They aid in the detection of anomalies like tumours and fibrosis. FibroScan is sometimes used to measure the liver’s stiffness, which might be a sign of diagnosing cirrhosis or fibrosis The liver biopsy can be informative in determining the extent of liver damage and choosing the best course of treatment for hepatitis.
Modes of Transmission
A better understanding of the modes of transmission for each type of hepatitis is crucial for its effective prevention and control. Hepatitis A and E are transmitted through contaminated food and water via the feco-oral route.
Whereas, hepatitis B, C, and D are blood-borne infections which are transmitted through direct contact with infected body fluids including sharing the same needles, unprotected sex, and unsafe medical procedures. Another important way that hepatitis B is spread is vertically, from mother to child during childbirth.
Prevention strategies
As we know, prevention is always better than care. Timely vaccination, safe and self-limiting practices, and public health and sanitation measures play a big role in preventing hepatitis. Vaccines available for hepatitis A and B are effective and provide long-term protection against HAV and HBV.
As hepatitis D can only co-exist with hepatitis B, vaccination against hepatitis B is particularly crucial, as it also prevents HDV infection. Better sanitation, access to clean water, and proper food handling can prevent us from hepatitis A and E to a great extent.
Hepatitis B vaccine given at birth strongly reduces transmission risk from mother to child. Similarly, hepato-toxic drugs should be limited and distributed only under the close supervision of a physician or professional health worker.
For blood-borne hepatitis (B, C, D), prevention strategies include:
• Safe Injection Practices:
Sterile needles and syringes should be used in medical settings and harm reduction programs for intravenous drug users should be launched at the government level.
• Screening and Blood Safety:
To prevent transmission through transfusions, hepatitis screening programs should be integrated into the centres where regular blood donations take place. Intravenous drug users and employees of rehab centres should be periodically monitored for HBV and HCV.
• Safe Sexual Practices:
The use of condoms should be promoted at a mass level to educate the general public about hepatitis to reduce the risk of sexual transmission.
• Mother-to-Child Transmission Prevention:
Vertical transmission of hepatitis can be reduced significantly by administering antiviral treatment to pregnant women with HBV and HCV and providing HBV vaccination to newborns.
Treatment and cure
Not all types of hepatitis are serious and life-threatening. Hepatitis A and E typically may resolve on their own, whereas chronic hepatitis B and C require professional medical interventions. Chronic hepatitis B can’t be cured completely. However, several antiviral medications available in modern days can prolong the life of hepatitis patients, lower the risk of liver cancer and its damage, stop the transmission of hepatitis B to others, and reduce the progression of liver cirrhosis. As HDV requires HBV for its replication, the treatment of hepatitis B acts as the prevention of hepatitis D itself. Due to their few adverse effects, direct-acting antiviral medications are now often utilised in hepatitis C patients.
Due to the high costs of medicines, limited healthcare infrastructure, and lack of skilled manpower and awareness access to treatment of hepatitis remains a challenge in many regions of Nepal. hinder effective treatment and management of hepatitis. Various NGOs and the Nepal government have seriously tried improving access to medications by implementing affordable prices or distributing them free of cost. Integrating hepatitis care into the primary healthcare system could play a milestone in the history of the treatment of hepatitis.
Actions by NGOs and governments
Numerous NGOs and governments worldwide including the Nepal government are actively working to combat hepatitis through awareness campaigns, vaccination programs, and improved healthcare services. The WHO has set ambitious targets to eliminate viral hepatitis as a public health threat by 2030. This includes reducing new hepatitis infections by 90% and mortality by 65%. It has become a challenge for the global community to make significant strides toward eliminating hepatitis as a public health threat from the world.
• World Health Organization (WHO):
WHO has announced various programs such as the Global Hepatitis Program and World Hepatitis Day with the motive of reducing hepatitis at the global level. The Global Hepatitis Program aims to enhance hepatitis surveillance, improve prevention, and expand the general public’s access to testing and treatment methods for hepatitis. World Hepatitis Day is observed worldwide on July 28 to raise awareness and promote actions to combat hepatitis.
• World Hepatitis Alliance (WHA):
WHA works with patient groups, governments, and healthcare providers in the field of advocacy and awareness to improve hepatitis care and policy. Through the Find the Missing Millions Campaign, WHA has exclusively focused on identifying undiagnosed or newly diagnosed hepatitis cases and linking them to healthcare facilities for further management.
• Governments:
Many countries have developed their national strategies and hepatitis plans to address various issues related to hepatitis, including proper vaccination, public education, free condom distribution and healthcare improvements. Various efforts have also been made by many countries to incorporate hepatitis prevention and treatment strategies into existing government healthcare programs, such as HIV/AIDS and maternal health services.
• NGOs and Civil Society:
Various NGOs and Civil societies in Nepal provide sterilised needles, opioid substitution therapy, and education through Harm Reduction Programs to reduce transmission among drug users. Mobile clinics and community outreach programs are regularly conducting Community-Based Screening and Treatment programs to improve access to hepatitis testing and care in underprevlised areas.
