Hepatitis C is the leading cause of liver cancer deaths and liver transplants worldwide. Is alarming that most of those infected don’t know they have it!
Hepatitis is the inflammation of the liver that can be caused in a variety of ways. Most common cause of hepatitis is the viral infection of three different viruses, named A, B and C. Hepatitis can also be caused by heavy alcohol use and certain drugs. Hepatitis A is caused by the hepatitis A virus and hepatitis B is caused by the hepatitis B virus (HBV), while hepatitis C is caused by the hepatitis C virus (HCV). Worldwide, there are 1.45 million viral hepatitis deaths per year, mainly due to hepatitis B and hepatitis C (Hep C) as shown in the 2014 Lancet study with more deaths caused by viral hepatitis than HIV/AIDS. This is likely due to the fact that there are 400 million people living with hepatitis B or hepatitis C compared to HIV sufferers. InfoMed spoke to Professor Dr. Rosmawati Mohamed, the co-chairperson for WHO Strategic and Technical Advisory Committee for Viral Hepatitis (STAC-Hep) and founding member of the Coalition to Eradicate Viral Hepatitis in Asia Pacific.
THE BURDEN OF UNDER-DIAGNOSED HEPATITIS C
In her opening comments, she made the point of how under-diagnosed hepatitis C is, with three out of four people living with hepatitis C being unaware of their condition. Considering hepatitis C is the leading cause of liver cancer deaths and liver transplants worldwide, it is alarming loophole of medical awareness. The problem she says is because chronic hepatitis C is a slow and silent process. There are no obvious symptoms, and by the time jaundice and water retention is noticeable, the liver disease is already too advance for treatment. Early detection is absolutely vital, she stresses, because even though no vaccine is available, unlike HIV or hepatitis B, hepatitis C can be cured. The key is early detection.
WORLDWIDE MORTALITY FROM VIRAL HEPATITIS (2012)
deaths per year
Rest of the World
deaths per year
You are more likely, by three times to die from viral hepatitis than HIV/AIDS
EXCERPTS OF THE INTERVIEW WITH PROF. DR. ROSMAWATI
In terms of global impact of hepatitis, definitely we are seeing lot more deaths due to hepatitis, mainly hepatitis B and hepatitis C, the two diseases that causes serious complications such as liver cirrhosis and liver cancer. The main reason for transmission of hepatitis B is mother to child transmission.
Good news for hepatitis B is that with the advent of universal neonatal vaccination for newborn since 1989, we are seeing less and less cases of hepatitis B for those born after 1989.
But for hepatitis C, we are still seeing new cases, mainly due to sharing of needles and equipment like tattoos and razors. Testing for hepatitis C was only available worldwide since the early 1990’s, and since 1993, transmission of hepatitis C through transfusion of blood or blood products does not arise at the hospital settings and is not an issue in Malaysia.
Treatment is available for hepatitis B and C. The aim of treatment for hepatitis B is to suppress the viral replication but for hepatitis C, we can achieve complete clearance of the virus with specific therapy. New drugs for hepatitis C, the direct antiviral agents, can achieve cure rates close to 100% with just 12 weeks of treatment and some are already available in Malaysia (these were only approved recently).
The standard treatment for all types of hepatitis C since 2003 is the combination of Pegylated Interferon, given as an injection once a week, and oral ribavirin.
Hepatitis C shows significant genetic variation, referred to as genotypes. There are at least 6 genotypes and the commonest in Malaysia is genotype 3 in about 60% of cases, followed by Genotype 1 in about 36%. The duration of treatment and the cure rates depend on the genotype. The standard duration of treatment for Genotype 3 is 24 weeks whereas for Genotype 1 is 48 weeks. The cure rate with the combination of Pegylated Interferon and ribavirin for genotype 3 is 80% but for genotype 1 the best at 40% to 50%. So with the new drugs we should expect cure rates of more than 90% and some approaching 100%.
A priority action to address the hepatitis C disease burden is to enhance hepatitis C detection among those who are at risk. Possible risk factors and for hepatitis C would include those who had received blood transfusion before 1994, those who had shared needles or sharp instruments which may contain and those on haemodialysis. The prevalence of hepatitis C among the IV drug users can be as high as 60 to 70%. A lot more contagious then we thought. Strengthening harm reduction programs such as the needle exchange program has helped to reduce transmission of hepatitis C. The reduction program has to be optimised.
In Malaysia, the prevalence of hepatitis B is higher than hepatitis C and the former is the major cause of liver cancer. Although hepatitis B vaccination can reduce the prevalence of hepatitis B amongst the vaccinated group (those born after1989), the liver cancer prevalence among adults who are infected with hepatitis B is still high. Worldwide, hepatitis C is the leading cause of liver cancer deaths and liver transplant.
KEY FACTS 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 few weeks to a serious, lifelong illness.
- The hepatitis C virus is a bloodborne virus and the most common modes of infection are through unsafe injection practices; inadequate sterilization of medical equipment; and the transfusion of unscreened blood and blood products.
- 130-150 million people globally have chronic hepatitis C infection.
- A significant number of those who are chronically infected will develop liver cirrhosis or liver cancer.
- Approximately 500,000 people die each year from hepatitis C-related liver disease.
- Antiviral medicines can cure approximately 90% of persons with hepatitis C infection, therby reducing the risk of death from liver cancer and cirrhosis, but access to diagnosis and treatment is low.
- There is currently no vaccine for hepatitis C; however research in this area is ongoing.
(Media Centre World Health Organisation)
WITH THAT IN MIND, PROF. DR. ROSMAWATI GAVE INFOMED A DEEPER LOOK INTO HEPATITIS C IN MALAYSIA.
InfoMed: What is the most up-to-date number of prevalence and incidence of hepatitis C in Malaysia?
Rosmawati: The estimated prevalence is 2.5% of the population aged 15 to 64 years (which is more than 500,000 individuals) based on a recent study, and 60% are related to IV drug use.
InfoMed: How does the Ministry track these numbers? Rosmawati: Data from the Ministry is based on notified cases, as it is compulsory to report all cases of hepatitis B and hepatitis C in Malaysia.
InfoMed: Are there any active campaigns being done that seek to reduce the problem?
Rosmawati: Most campaigns are in conjunction with WHO designated World Hepatitis Day on 28 July. There is a need for a coordinated national response to address issues relating to viral hepatitis. A National Strategic Plan for Viral Hepatitis is required to ensure specific policies and tools are incorporated to reduce the burden related to viral hepatitis.
InfoMed: What makes the disease/ infection a cause for serious concern?
Rosmawati: High prevalence and the rising disease burden for hepatitis C.
InfoMed: Who are the most vulnerable groups in Malaysia to hepatitis C?
Rosmawati: Hepatitis C is mainly transmitted through contaminated blood. Those who had received blood transfusion before 1994 are at risk of contracting hepatitis C. Other ways of hepatitis C transmission include sharing of infected needles, unsafe practices such as tattooing and sharing of sharp instruments such as razors and patients with kidney failure who are on haemodialysis. Mother to child and sexual transmission are uncommon modes of transmission.
InfoMed: What are some easy prevention methods that people can do (in Malaysia)?
Rosmawati: Knowing the risk factors for hepatitis C is an important step to prevent new infections.
InfoMed: How often do you get checked?
Rosmawati: Only one time test is required for those at risk.
InfoMed: Where can people do so?
Rosmawati: You can get checked at any general practitioners (GP) clinic or hospital.
InfoMed: If you are infected, what treatment options are available in Malaysia?
Rosmawati: Pegylated interferon and ribavirin. New treatment options are now available for Genotype 1.
InfoMed: Based on the current prevalence of hepatitis C, where would Malaysia be in five years in terms of new cases and management of the disease? Rosmawati: The prevalence of hepatitis C virus (HCV) infection in Malaysia has been estimated at
2.5% of the adult population. A recent research article by McDonald SA, Dahlui M, Mohamed R, Naning H, Shabaruddin FH, Kamarulzaman
A (2015) titled, “Projections of the current and future disease burden of hepatitis C virus infection in Malaysia” concluded, “The HCV-related disease burden is already high and is forecast to rise steeply over the coming decades under current levels of antiviral treatment. Increased governmental resources to improve HCV screening and treatment rates and to reduce transmission are essential to address the high projected HCV disease burden in Malaysia”
InfoMed: What can the general public do now to reduce the incidence?
Rosmawati: Avoid the risk factors.
InfoMed: What about general practitioners, what is their role in managing hepatitis C in Malaysia? Rosmawati: Counsel and take the test on their patients at risk for Hepatitis C.
HCV INFECTION IS DIAGNOSED IN 2 STEPS:
Screening for anti-HCV antibodies with a serological test identifies people who have been infected with the virus. If the test is positive for anti-HCV antibodies, a nucleic acid test for HCV RNA is needed to confirm chronic HCV infection because about 15–45% of people infected with HCV spontaneously clear the infection by a strong immune response without the need for treatment. Although no longer infected, they will still test positive for anti-HCV antibodies.
(Media Centre World Health Organisation)