Dire Strains

When a neighbour’s child died from a hepatitis C infection three years ago, some sixth sense told Poonam Khanna of Delhi to get her 12-year-old son Udit tested. Udit tested positive for hepatitis C, a result of transfusion of blood not screened for the virus. Says Poonam: "There were no outward symptoms but the doctor warned us it was infectious and could lead to liver failure." She ensured that her then seven-year-old younger son was careful about contact with his brother while she herself wore gloves when administering Interferon injections to Udit.

The sixth sense, however, cannot work always when most in India today are still unaware that viral hepatitis is a silent disease, that can turn into a killer, which is creeping up insidiously. Compared nowadays with HIV characteristics, those affected can remain carriers for life exhibiting no symptoms, yet infecting others who may develop the disease in its full-blown form. And it is not contracted through contaminated water, food or unhygienic conditions alone. Today, some of its strains are transmitted in a way similar to HIV, through body fluids. Untreated chronic viral hepatitis ultimately leads to liver failure due to cirrhosis and liver cancer. Says Dr Anupam Sibal, paediatric gastroenterologist and hepatologist at Delhi’s Apollo Hospital: "We call it the hepatitis alphabet because of the strains ranging from A to G."

Sibal is just one among the increasing tribe of doctors who feel that India better wake up fast to this growing menace. The A virus is the most common and only in one per cent of the cases causes liver failure. Even then over the last 24 months, 22 children were admitted to Apollo Hospital with acute liver failure, 13 due to hepatitis A, of whom five died and one needed a liver transplant. However, the concern today is concentrated more on the B and C viruses because of the mode of transmission and resultant liver diseases.

India, according to experts in the field, has the second largest pool of HBV carriers after China-an estimated 45 million-and about two million HBC carriers. These strains are the most dangerous because they are contracted as a result of sexual contact or because of multiple sexual partners, or through blood and infected syringes and result in a large number becoming carriers and infecting others. There is therefore a concerted effort afoot by experts to begin combating the menace by immunisation through the A and B vaccines now available in India. The government, however, remains unconvinced that the vaccines should be part of the primary health immunisation programmes which now involves tuberculosis, diphtheria, whooping cough, tetanus, polio and measles. Viral hepatitis is low on the priority list.

Says Dr S.K. Acharya, professor of gastroenterology at Delhi’s All India Institute of Medical Sciences: "I strongly believe that immunisation against the A and B viruses and an awareness programme about the various strains should be started. Multiple hepatitis epidemics have already happened in India but they’ve gone unnoticed because of skewed government priorities."

Belgium-based Dr Francis Andre, an expert on different hepatitis viruses and closely associated with the development of the A and B vaccines, cites the example of an epidemic in the 1950s when 40,000 pregnant women in Delhi alone were infected with the E strain, of whom 20 per cent died. He explains: "The situation in India is rather ironical. While many of the viral infections are caused because of poverty and unhygienic conditions, there is also a reverse trend working." Children who contract the virus till age five have better chances of combating the disease and developing immunity than adolescents and adults. With improvement in sanitation and hygiene awareness on the rise, children from the higher strata of society are not coming into contact with the viruses which are spread by contaminated water (like Hepatitis A) and therefore are at a greater risk to fall prey to the infection later in life.

The government argues that the costs are huge-Rs 190 crore a year. Arguing its defence, Alok Mukhopadhyaya, director, Voluntary Health Association of India (vhai), says: "Can this country afford to spend so much on just the viral hepatitis A and B vaccines? The health budget is minuscule. Tradeoffs are necessary. Do you put your money in safe drinking water and sink a tubewell for the cost of six vaccines or spend the money on immunisation? The products are available in the market, people are free to use them."

Dr P.N. Sehgal, former director of the National Institute of Communicable Diseases, and now consultant with vhai, however both agrees and disagrees. Says he: "The vaccine is easily available in our country today and should be introduced. Nobody disputes the need. But simultaneously we have to take care of nutrition, sanitation, etc. Therefore when we have limited resources, the question of prioritisation comes in. But awareness is the need of the hour so that those who can afford it can use it to begin with."

Why can’t the government begin to make cuts in the aids awareness programmes now, fumes Sibal. He rationalises the expense saying that the cost of treating a child or adult for hepatitis B or C is Rs 1.5 lakh involving painful injections at the end of which there is at best a 50 per cent chance of getting rid of the infection. Add to it the cost of investigation, monitoring, all of which amounts to almost Rs 4 lakh. More than 2,500 children can be vaccinated for that amount. What according to experts is also not taken into account is the cost for cirrhosis, loss of income and the fact that costs can go up by Rs 12 lakh should one need a liver transplant. In the case of the B virus, a liver transplant can cost Rs 25 lakh. That money can vaccinate up to 16,000 children and a fair share of transmission takes place during birth from mother to child. "The B vaccine costs Rs 100 now. If the government were to buy it, it would be even less," adds Sibal.

"The government is being shortsighted," asserts Dr Acharya, who deals with an increasing number of viral hepatitis-linked liver diseases at AIIMS every day. In 1992, the who had recommended that countries where hepatitis B is endemic should include the vaccine in their national immunisation schedule by 1997. Ninety developing countries have so far complied and the encouraging results are already evident.

The scenario seems grimmer when one realises that viral hepatitis is not just all about jaundice. And while the debate rages on about whether the vaccines should be a must, about vested interests and priorities, millions more are being silently infected, with no real solution in sight.