Weekly Health Advice from PMGH – World Hepatitis Day - 28th July 2016

Welcome to another health update from the Port Moresby General Hospital.

With World Hepatitis Day this week on the 28th of July, we would like to share with you some important information on hepatitis including the types of hepatitis, signs and symptoms and preventative measures.

For more information, please contact info@portmoresbygeneralhospital.com 

(WHO) World Hepatitis Day 28th July 2016
Ahead of World Hepatitis Day, 28 July 2016, WHO is urging countries to take rapid action to improve knowledge about the disease, and to increase access to testing and treatment services.

Today, only 1 in 20 people with viral hepatitis know they have it. And just 1 in 100 with the disease is being treated.

"The world has ignored hepatitis at its peril,” said Dr. Margaret Chan, WHO Director-General.

“It is time to mobilize a global response to hepatitis on the scale similar to that generated to fight other communicable diseases like HIV/AIDS and tuberculosis.

“Around the world, 400 million people are infected with hepatitis B and C, more than 10 times the number of people living with HIV. An estimated 1.45 million people died of the disease in 2013 – up from less than a million in 1990. 

In May 2016, at the World Health Assembly, 194 governments adopted the first ever Global Health Sector Strategy on viral hepatitis and agreed to the first-ever global targets. The strategy includes a target to treat 8 million persons for hepatitis B or C by 2020. The longer term aim is to reduce new viral hepatitis infections by 90% and to reduce the number of deaths due to viral hepatitis by 65% by 2030 from 2016 figures.

The strategy is ambitious, but the tools to achieve the targets are already in hand. An effective vaccine and treatment for hepatitis B exists. There is no vaccine for hepatitis C, but there has been dramatic progress on treatment for the disease in the past few years. The introduction of oral medicines called direct-acting antivirals, has made it possible to potentially cure more than 90% of patients within 2-3 months. But in many countries, current policies, regulations and medicine prices put the cure out of most people’s reach.

“We need to act now to stop people from dying needlessly from hepatitis,” said Dr. Gottfried Hirnschall, WHO's Director of the HIV/AIDS Department and Global Hepatitis Programme. “This requires a rapid acceleration of access to services and medicines for all people in need.”

Improving Treatment: Some countries, however, are finding ways to get services to the people who need them. These efforts are made easier by the declining price of hepatitis C medicines. Prices are now dropping, particularly in countries that have access to generic drugs. In 2015, a preliminary analysis estimated that 300 000 people living in low- and middle-income countries had received hepatitis C treatment based on the new direct-acting antivirals. In Egypt – a lower–middle-income country with one of the world’s highest prevalence rates of hepatitis C, 200 000 people were treated during the past 12 months, and the price of hepatitis C treatment for each person dropped from US$900 in 2014 to less than US$200 in 2016. Other countries have stepped up efforts against hepatitis C. Brazil and Pakistan are already expanding treatment coverage rapidly, and Georgia has announced a plan to eliminate the disease.

Preventing Hepatitis: Hepatitis B and C infections are transmitted through contaminated blood as well as through contaminated needles and syringes in healthcare setting and among people who inject drugs. The viruses can also be transmitted through unsafe sex and from an infected mother to her newborn child. As of 2014, 184 countries vaccinate infants against hepatitis B as part of their vaccination schedules and 82% of children in these states received the hepatitis B vaccine. This is a major increase compared with 31 countries in 1992, the year that the World Health Assembly passed a resolution to recommend global vaccination against hepatitis B. In addition, implementing blood safety strategies, including quality-assured screening of all donated blood and blood components used for transfusion, can help prevent transmission of hepatitis B and C. Safe injection practices, eliminating unnecessary and unsafe injections, can be effective strategies to protect against transmission. Harm reduction services for people who inject drugs are critical to reduce hepatitis in this population. Safer sex practices, including minimizing the number of partners and using barrier protective measures (condoms), also protect against transmission. How much do you know about hepatitis? Test your knowledge: http://www.who.int/campaigns/hepatitis-day/2016/quiz/en/

What Is Hepatitis?
World Health Organization: Hepatitis is an inflammation of the liver. The condition can be self-limiting or can progress to fibrosis (scarring), cirrhosis or liver cancer. Hepatitis viruses are the most common cause of hepatitis in the world but other infections, toxic substances (e.g. alcohol, certain drugs), and autoimmune diseases can also cause hepatitis. There are 5 main hepatitis viruses, referred to as types A, B, C, D and E. These 5 types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread. In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer. Viral hepatitis affects 400 million people globally every year while 6-10 million people are newly infected. World Health Organization states that a huge 95% of people with hepatitis don’t know they are infected. Talk to your doctor about hepatitis today.

Remember: Your liver is a vital organ responsible for many functions in the body some of which include cleansing your blood, hormone regulation, processing everything you eat/drink, assists in fighting off infection, blood clotting, produces cholesterol, storing, producing and supplying glucose and regulates the supply or essential vitamins and minerals.

Types of Hepatitis
There are 5 types of Hepatitis A,B,C,D,E.

Hepatitis A: Hepatitis A is mainly spread through eating or drinking water that has been contaminated by the faeces of an infected person which can occur through poor sanitation, poor personal hygiene and a lack of clean water. Almost everyone recovers fully from hepatitis A with a lifelong immunity while a small proportion die from fulminant hepatitis. To prevent Hepatitis A it is important to practice good personal hygiene such as washing your hands after going to the toilet, after changing nappies, before eating or preparing food. Cleaning commonly used surfaces with disinfectant regularly and having access to clean water are also important. Talk to your doctor about vaccination.
Hepatitis A Symptoms: with an incubation period of 14-18 days those infected can experience mild to severe symptoms including: fever, malaise, loss of appetite, diarrhoea, nausea, abdominal discomfort, dark-coloured urine and jaundice (a yellowing of the skin and whites of the eyes). 
Hepatitis A Treatment: There is no specific treatment for hepatitis A, recovery may take several weeks or months. It is important during this time to maintain proper fluid balance by replacing fluids that are lost due to diarrhoea and vomiting. Nutritional balance should also be monitored however hospitalization is unnecessary in the absence of acute liver failure. Avoidance of unnecessary medications such as Acetaminophen / Paracetamol and medication against vomiting should not be given unless advised by a doctor.

Hepatitis B: Hepatitis B infection kills more then 686 000 people every year due to complications (cirrhosis and liver cancer). Hepatitis B is transmitted through blood and bodily fluids including, semen and vaginal fluids such as through: sexual contact, sharing injecting equipment, reuse of unsterilized needles such as tattoo and body piercing, needle stick injuries, sharing personal items (razors, toothbrushes, nail clippers) and mother to baby transmission. Hepatitis B is NOT spread by contaminated food or water, and cannot be spread through casual or social contact such as kissing, sneezing or coughing, hugging, or eating food prepared by a person with hepatitis B. When preventing hepatitis B it is important to always practice safe sex (use a condom for all sexual activity), avoid sharing personal hygiene items, always use new syringes, tattoo/piercing and injecting equipment, cover all cuts or open sores with bandages and talk to your doctor about vaccination.
Hepatitis B Symptoms: Most people do not experience any symptoms during the acute infection phase however, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain. A small subset of persons with acute hepatitis can develop acute liver failure which can lead to death. In some people, the hepatitis B virus can also cause a chronic liver infection that can later develop into cirrhosis of the liver or liver cancer.
Hepatitis B Treatment: There is no specific treatment for acute hepatitis B. Care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids lost from vomiting and diarrhoea. Chronic hepatitis B infection can be treated with drugs, including oral antiviral agents. Treatment can slow the progression of cirrhosis, reduce incidence of liver cancer and improve long term survival. WHO recommends the use of oral treatments - tenofovir or entecavir which are the most potent drugs to suppress the hepatitis B virus and rarely lead to drug resistance. In most people, however, the treatment does not cure hepatitis B infection, but only suppresses the replication of the virus. Therefore, most people who start hepatitis B treatment must continue it for life.

Hepatitis C: Hepatitis C is a liver disease caused by the hepatitis C virus: the virus can cause both acute and chronic hepatitis infection, ranging in severity from a mild illness lasting a few weeks to a serious, lifelong illness. Globally, between 130–150 million people globally have chronic hepatitis C infection. Approximately 700 000 people die each year from hepatitis C-related liver diseases. A significant number of those who are chronically infected will develop liver cirrhosis or liver cancer. The hepatitis C virus is a blood borne virus most commonly transmitted through: injecting drug use through the sharing of injection equipment; the reuse or inadequate sterilization of medical equipment, especially syringes and needles in healthcare settings; and the transfusion of unscreened blood and blood products. HCV can also be transmitted sexually and can be passed from an infected mother to her baby; however these modes of transmission are much less common. Hepatitis C is not spread through food, water, breast milk or by casual contact (hugging, kissing) or by sharing food or drinks with an infected person. There is no vaccine for hepatitis C, therefore prevention of HCV infection depends upon reducing the risk of exposure to the virus.
Reduce the Spread: Those infected with hepatitis C can take simple precautions to minimize the risk of transmitting the virus to others such as reducing any opportunity where others may come in contact with their blood, never sharing injecting equipment, not sharing any personal hygiene items, keeping cuts and wounds covered, always practicing safe sex and securing any bloodstained items in a plastic bag before putting them in a rubbish bin (wound dressings, tampons, sanitary pads).
Hepatitis C Symptoms: The incubation period for hepatitis C is 2 weeks to 6 months. Following initial infection, approximately 80% of people do not exhibit any symptoms. Those who are acutely symptomatic may exhibit fever, fatigue, decreased appetite, nausea, vomiting, abdominal pain, dark urine, grey-coloured faeces, joint pain and jaundice (yellowing of skin and the whites of the eyes).
Hepatitis C Treatment: Hepatitis C does not always require treatment as the immune response in some people will clear the infection, and some people with chronic infection do not develop liver damage. When treatment is necessary, the goal of hepatitis C treatment is cure. The cure rate depends on several factors including the strain of the virus and the type of treatment given.

Hepatitis D: hepatitis D is a liver disease caused by the hepatitis D virus, a defective virus that needs the hepatitis B virus to exist. Hepatitis D infection cannot occur in the absence of hepatitis B virus. The co-infection or super infection of HDV with HBV causes a more severe disease than HBV mono-infection. Approximately 15 million people across the world are chronically co-infected with HDV and HBV. Hepatitis D infection can occur as a co-infection, which means it occurs at the same time as hepatitis B infection; or it can occur as a superinfection in people who already have chronic hepatitis B. Prevention and control of HDV infection requires prevention of HBV transmission through hepatitis B immunization, blood safety, injection safety, and harm reduction services although hepatitis B immunization does not provide protection against HDV for those already HBV infected.
Hepatitis D Symptoms: Acute hepatitis: simultaneous infection with HBV and HDV can lead to a mild-to-severe or even fulminant hepatitis, but recovery is usually complete and development of chronic hepatitis D is rare (less than 5% of acute hepatitis). Superinfection: HDV can infect a person already chronically infected with HBV. The superinfection of HDV on chronic hepatitis B accelerates progression to a more severe disease in all ages and in 70‒90% of persons. HDV superinfection accelerates progression to cirrhosis almost a decade earlier than HBV mono-infected persons, although HDV suppresses HBV replication. The mechanism in which HDV causes more severe hepatitis and a faster progression of fibrosis than HBV alone remains unclear.
Hepatitis D Treatment: (WHO) - There is no specific treatment for acute or chronic HDV infection. Persistent HDV replication is the most important predictor of mortality and the need for antiviral therapy. Pegylated interferon alpha is the only drug effective against HDV; antiviral nucleotide analogues for HBV have no or limited effect on HDV replication. The optimal duration of therapy is not well defined, nor how long patients need to be HDV RNA negative after the end of therapy to achieve a sustained virological response. More than 1 year of therapy may be necessary. The overall rate of sustained virological response remains low, including in children, and most patients relapse after discontinuation of therapy. Liver transplantation may be considered for cases of fulminant hepatitis and end-stage liver disease.   ​

Hepatitis E: Every year, there are an estimated 20 million HEV infections worldwide, leading to an estimated 3.3 million symptomatic cases of hepatitis E, and 56 600 hepatitis E-related deaths according to World Health Organization. Hepatitis E is transmitted via the faecal-oral route mainly through the contamination of drinking water and in less common cases ingestion of undercooked meat/meat products from infected animals; transfusion of infected blood products; and from a pregnant woman to her fetus. Prevention relies heavily on having access to clean water.
Hepatitis E Symptoms: The incubation period following exposure to the hepatitis E virus ranges from 2-10 weeks, with a 5-6-week average. Those infected with hepatitis E are known to excrete the virus around a few days before to 3-4 weeks after onset. Those infected may experience some of the following: mild fever, reduced appetite, nausea/vomiting, abdominal pain, skin rash, itching, joint pain, jaundice (yellowing of the skin), dark urine, pale stools and a slightly enlarged/tender liver.
Hepatitis E Treatment: There is no specific treatment capable of altering the course of acute hepatitis E. Bed rest and replacement of lost fluids is advised with those who experience vomiting and diarrhea. Hospitalization is generally not required unless in cases of those with fulminant hepatitis and pregnant women, particularly those in the second or third trimester as they are at an increased risk of acute liver failure, fetal loss, and mortality. Case fatality rates as high as 20–25% have been reported by World Health Organization among pregnant women in their third trimester.

Picture source: EASL

Press Release