Raise awareness of the global burden of viral hepatitis & to influence real change

Viral hepatitis continues to be a major public health problem in India and across the world with half the world's population exposed to different heterotrophic viruses. Hepatitis B and C contribute to a high grade of disease burden in the western world. The spectrum of viral hepatitis differs with respect to aetiological agents in different geographical regions of the world. Hepatitis E virus (HEV) infection is the major cause of acute sporadic and epidemic hepatitis in India1234567891011. The frequency of hepatitis C has been reported to be 1-2 per cent among voluntary blood donors12131415. About 15-30 per cent cases of acute hepatitis in India is due to HBV1617, HCV is an uncommon cause of acute icteric hepatitis12 but causes most of the post-transfusion hepatitis12. Hepatitis B virus (HBV) is of intermediate endemicity with nearly four per cent of the population being chronic HBV carriers16. HBV is known to cause about 50 per cent cases of chronic liver disease in India and HCV for 20 per cent infection1617. In India about 250,000 people die of viral hepatitis or its sequelae18. However, our efforts in this regard are constrained due to lack of viral hepatitis registry and good community-based epidemiological and seroepidemiological studies. It is quite astonishing that the hepatitis B surface antigen (HBsAg) prevalence has been reported to be highest in the natives of Andamans and Arunachal Pradesh19. Outbreaks of acute and fulminant hepatitis B still occur mainly due to improperly sterilized needles and syringes, as demonstrated by an outbreak of acute hepatitis B in Modasa town of Gujarat20. A total of 315 outbreaks of viral hepatitis have been reported from 2010 to 2013 and 99 outbreaks in 2013 alone in India by Integrated Disease Surveillance Programme of the National Centre for Disease Control21. Hepatitis A virus (HAV) infection is responsible for 10 to 30 per cent of acute viral hepatitis and 15 to 45 per cent of acute liver failure (ALF) in India. HEV infection is responsible for 10 to 40 per cent of acute hepatitis and 15 to 45 per cent of ALF cases in India22. It is worth mentioning that acute HEV infection has a high mortality rate of 15-25 per cent in pregnant women in the third trimester23. The unfinished challenging task would be to eliminate viral hepatitis from our country. This would need an integrated and holistic approach for educating public and healthcare personnel for identifying persons at risk for viral hepatitis and to ensure appropriate counselling, diagnosis, medical management and treatment. Administration of injection using sterilized needles and syringes should be ensured for health practices. All healthcare workers across the country should be vaccinated as many of them are unsure of their vaccination status and prone to blood-borne infections24. Public health measures to improve sanitation and provide safe drinking water are important for preventing HAV and HEV. Encouraging voluntary blood donation in the blood bank would provide safe blood for donation; but, as a screening tool, individual donors’ nucleic acid testing (NAT) detects infection for HIV, HBV and HCV much earlier than serological tests25. HAV vaccination strategies need to be redefined because of changing epidemiology. HEV vaccine should be made available in our country. Scaling up of infant vaccination has already demonstrated an impact on global HBV prevalence26.

A substantial scale-up in birth dose vaccination coverage is pivotal to reaching WHO 2030 elimination targets27. Improving the diagnosis for HCV screening in the high-risk population. HCV core antigen (HCVCAg) quantification can be used as a surrogate marker for HCV viraemia testing. HCVCAg is a low cost, and a commercially available assay that can be proved as an attractive test for resource-limited settings2829. Employing HCVCAg testing while still dependent on a controlled testing facility can uncouple the sample collection from the testing site through the use of dried blood spot sample282930.

For the management of chronic HBV infection, the WHO guidelines suggest that treatment should be targeted at those with highest risk of disease progression, based on the detection of persistently raised alanine transaminase (ALT) levels and HBV DNA more than 20,000 IU/ml in those older than 30 years31. All cirrhotics should be treated regardless of ALT levels, HBeAg (hepatitis B e antigen) status or HBV DNA levels. There are many unfinished tasks left in prevention and elimination of viral hepatitis in India, but if there is a political will and the Government of India sets up a comprehensive action plan, the target could be reached to make our country free of viral hepatitis by 2030.