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| EDITORIAL |
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| Year : 2019 | Volume
: 63
| Issue : 4 | Page : 275-276 |
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Elimination of viral hepatitis: Evolution and India's response
Dandu Chandra Sekhar Reddy
Member, Advisory Board, Indian Journal of Public Health; Former Professor, Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh; Former National Professional Officer, WHO, New Delhi, India; Chair, Technical Resource Group on Surveillance of Viral Hepatitis, 77, Type IV, SGPGI (Old Campus), Raebareli Road, Lucknow - 226 014, UP, India
| Date of Web Publication | 18-Dec-2019 |
Correspondence Address:
Dandu Chandra Sekhar Reddy
Member, Advisory Board, Indian Journal of Public Health; Former Professor, Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh; Former National Professional Officer, WHO, New Delhi; Chair, Technical Resource Group on Surveillance of Viral Hepatitis, 77, Type IV, SGPGI (Old Campus), Raebareli Road, Lucknow - 226 014, UP
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/ijph.IJPH_581_19
How to cite this article:
Reddy DC. Elimination of viral hepatitis: Evolution and India's response. Indian J Public Health 2019;63:275-6 |
Viral hepatitis is a liver inflammation caused by any of the five different viruses labeled as hepatitis A (HAV) to hepatitis E (HEV). HAV and HEV are transmitted by fecal–oral route and cause sporadic outbreaks of acute hepatitis and acute liver failure. HBV, HCV, and HDV are transmitted parenterally and cause chronic hepatitis with remote sequelae such as liver cirrhosis and hepatocellular carcinoma, which are responsible for majority of the deaths attributable to viral hepatitis. HDV occurs as a coinfection with HBV and increases the probability of mortality.
Viral hepatitis had come to be recognized as a global public health challenge at the start of this decade. Prior to that although it figured in the context of other prevention initiatives such as hepatitis B vaccination and blood safety, it was never treated as a stand-alone public health threat. This is because till 2010, estimation of viral hepatitis mortality considered deaths from acute viral hepatitis only, directly contributed by respective ICD-10 codes. Deaths from sequelae of chronic viral hepatitis remained a component of either liver cirrhosis or liver cancer and were not included in viral hepatitis mortality until the Global Burden of Disease project accounted for them.[1] Globally, 57% of deaths from liver cirrhosis and 78% of primary liver cancer are attributable to HBV and HCV infections.[2] As per the WHO, the regrouped estimates accounted for 1.34 million deaths globally in 2015, and viral hepatitis stood as the second major killer among infectious diseases after tuberculosis (1.37 million) and higher than HIV (1.06 million) and malaria (0.44 million). Unlike HIV, tuberculosis and malaria, which are showing a decline, viral hepatitis is on the rise.[3] This recognition has culminated in the United Nation General Assembly Resolution to combat hepatitis by 2030 (Sustainable Development Goal 3.3),[4] which led the WHO to set targets for its elimination (reduction of infections by 90% and deaths by 65%) and put forth the Global Health Sector Strategy 2016–2021 (GHSS) toward accomplishing this goal.[5] This initiative pushed many countries, including India, into action. GHSS provides five strategic directions: (a) strong strategic information for focused action, (b) interventions for impact, (c) equitable coverage, (d) financing for sustainability, and (e) innovation for acceleration. It also proposes a set of six core interventions and services: (i) hepatitis B vaccination, (ii) prevention of mother-to-child transmission of hepatitis B, (iii) blood and injection safety in health-care settings, (iv) harm reduction for people who inject drugs, (v) hepatitis testing and treatment, and (vi) care for those with chronic infections.
Viral hepatitis is a major health problem in India as well. It is hyperendemic for hepatitis A and hepatitis E. Nearly 100% of individuals are positive for anti-HAV antibodies by the time they reach adolescence.[6] In some of the recent outbreaks of HAV [7],[8],[9] and HEV,[10] failure of water supply [7] was identified as the cause. Poor sanitation and hygiene also promote the transmission of HAV and HEV. Perusal of disease outbreak alerts published by the Integrated Disease Surveillance Program clearly indicates that sporadic outbreaks of acute viral hepatitis due to both HAV and HEV occur across the country periodically.
India is mesoendemic for HBV. From a meta-analysis, the prevalence of HBV among general population was reported to be 2.4% (2.2–2.7) and among tribal population 15.9% (11.4–20.4).[11] Although predominant mode of transmission is horizontal,[12] vertical transmission also plays a significant role in India.[13] The pooled prevalence of HCV in general population is 0.85% and among pregnant women is 1.03%.[14] However, there is considerable diversity in the distribution of HBV and HCV in different subpopulations as well as in different geographical areas. Barring a few, almost all the studies in viral hepatitis are on blood donors, pregnant women, or hospital attending patients. With paucity of population-based studies, the available information is inadequate for extrapolation to national level, identification of hotspots, and estimation of the disease burden.
India is a signatory to the UN Resolution on Sustainable Development Goals. In response to the call of the WHO, the Ministry of Health and Family Welfare launched National Viral Hepatitis Control Program (NVHCP) on World Hepatitis Day (July 28) of 2018. The aims of the program are to (a) combat hepatitis and achieve countrywide elimination of hepatitis C by 2030, (b) achieve significant reduction in the infected population, morbidity and mortality associated with hepatitis B and C, namely liver cirrhosis and hepatocellular carcinoma, and (c) reduce the risk, morbidity and mortality due to hepatitis A and E. The key components of the program include (a) prevention through awareness generation, immunization, blood and injection safety in health-care settings, harm reduction for people who inject drugs and provision of safe drinking water, and hygiene and sanitary toilets; (b) diagnosis and treatment including screening of pregnant women in areas where institutional deliveries are <80% and free screening at all levels of healthcare overtime, ensuring adherence through community/peer support and linkages to private sector and nonprofit organizations for treatment; (c) establishment of systems for surveillance, monitoring and evaluation, and research; and (d) training and capacity building of laboratory personnel and treatment and care providers.[15]
Every public health program, in its initial phase, encounters several challenges and barriers. HBV and HCV were similar to HIV in many aspects such as routes of transmission, long asymptomatic period, stigma and discrimination, marginalized and susceptible population groups, and challenges pertaining to cost reduction of medicines, the experiences gained in National AIDS Control Pogramme in its early phase are of help in addressing similar challenges and barriers.[16] Other issues which are of common interest to both the programs are injection and blood safety in health-care settings, harm reduction initiatives for key populations, mother-to-child transmission, and serosurveillance in different population groups. Similarly, NVHCP shares interest with immunization program in the implementation of hepatitis B vaccination, with emphasis on birth dose, which forms the key intervention to prevent mother-to-child transmission. Prime Minister's initiatives such as Swatch Bharat and Ayushman Bharat have immense potential to contribute to NVHCP; the former as a key intervention in tackling HAV and HEV transmission and the latter in ensuring Universal access to hepatitis treatment and care. These opportunities provide a head start to NVHCP. Effective collaboration and convergence with programs of common interest will increase the efficiency of implementation and accelerate our journey toward the goal.
The NVHCP made commendable progress within a short period after its launch. Before the end of the 1st year, a network of national and state reference laboratories for the diagnosis and model treatment centers at the state level for treatment have been set up which, in turn, will support district-level laboratories and treatment centers. Operational guidelines and manuals have been developed and training to strengthen the capacities of the respective staffs was undertaken.
Strategic information is key for advocacy, program planning, and monitoring. Surveillance of viral hepatitis is as complex and varied as the course of its infection, manifestations, and outcomes. Outbreaks of hepatitis A and hepatitis E are already monitored through the Integrated Disease Surveillance Project and chronic hepatitis surveillance for HBV and HCV will be implemented through the HIV Sentinel Surveillance among pregnant mothers, sex workers, men who have sex with men, and people who inject drugs. Acute surveillance and surveillance for sequelae will be implemented through ten preselected sentinel sites across the country. On monitoring and evaluation front, M and E indicators, tools, and guidelines have been developed and are in place. It is proposed that NVHCP will collaborate with the department of health research for carrying out operation research.
The public health community has a great role to play in leading the program toward its goal. Areas where they can impact are particularly three: operations research, strengthening hepatitis B vaccination with reference to birth dose, and treatment adherence which is a key to program success.
 References | |  |
| 1. | Stanaway JD, Flaxman AD, Naghavi M, Fitzmaurice C, Vos T, Abubakar I, et al. The global burden of viral hepatitis from 1990 to 2013: Findings from the global burden of disease study 2013. Lancet 2016;388:1081-8.  |
| 2. | Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol 2006;45:529-38. |
| 3. | World Health Organization. Global Hepatitis Report 2017. Geneva: World Health Organization; 2017. |
| 4. | United Nations General Assembly Resolution A/RES/70/1 – Transforming our World: The 2030 Agenda for Sustainable Development. Sustainable Development Goals, Target 3.3: “By 2030, end the Epidemics of AIDS, Tuberculosis, Malaria and Neglected Tropical Diseases and Combat Hepatitis, Water-Borne Diseases and other Communicable Diseases. Available from: http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/70/1&Lang=E. [Last accessed on 2019 Sep 15]. |
| 5. | World Health Organization. Global Health Sector Strategy on Viral Hepatitis 2016-2021. Towards Ending Viral Hepatitis. World Health Organization; 2016. |
| 6. | Acharya SK, Madan K, Dasgupta S, Panda SK. Viral hepatitis in India Natl Med J India 2006;19:203-17. |
| 7. | Rakesh PS, Sherin D, Sankar H, ShajiM SS, Shbhagan S, Salila S. Investigating a community wide outbreak of hepatitis A in India J Glob Infect Dis 2014;6:59-64. |
| 8. | Acharya SK, Batra Y, Bhatkal B, Ojha B, Kaur K, Hazari S, et al. Seroepidemiology of hepatitis A virus infection among school children in Delhi and North Indian patients with chronic liver disease: Implications for HAV vaccination. J Gastroenterol Hepatol 2003;18:822-7. |
| 9. | Arankalle VA, Sarada Devi KL, Lole KS, Shenoy KT, Verma V, Haneephabi M. Molecular characterization of hepatitis A virus from a large outbreak from Kerala, India. Indian J Med Res 2006;123:760-9. |
| 10. | Chauhan A, Dilawari JB, Jameel S, Kaur U, Chawla YK, Sharma ML, et al. Common aetiological agent for epidemic and sporadic non-A, non-B hepatitis. Lancet 1992;339:1509-10. |
| 11. | Batham A, Narula D, Toteja T, Sreenivas V, Puliyel JM. Systematic review and meta-analysis of prevalence of hepatitis B in India. Indian Pediatr 2007;44:663-74. |
| 12. | Gupta S, Gupta R, Joshi YK, Singh S. Role of horizontal transmission in hepatitis B virus spread among household contacts in North India. Intervirology 2008;51:7-13. |
| 13. | Dwivedi M, Misra SP, Misra V, Pandey A, Pant S, Singh R, et al. Seroprevalence of hepatitis B infection during pregnancy and risk of perinatal transmission. Indian J Gastroenterol 2011;30:66-71. |
| 14. | Goel A, Seguy N, Aggarwal R. Burden of hepatitis C virus infection in India: A systematic review and meta-analysis. J Gastroenterol Hepatol 2019;34:321-9. |
| 15. | Ministry of Health and Family Welfare. National Hepatitis Control Programme: Operational Guidelines. Ministry of Health and Family Welfare. Government of India, New Delhi; 2018. |
| 16. | |
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