Curbing hepatitis a challenge
New hepatitis B and C cases have gone down by 10%, but it’s still way off the WHO target of eliminating new hepatitis B and C cases by 50% this year.
MUCH has been written about hepatitis, or inflammation of the liver.
Although it is a highly curable condition, when left untreated, hepatitis can progress to fibrosis (scarring), cirrhosis or liver cancer.
Since the liver is a hardy, resilient organ that is capable of regenerating itself, symptoms of the inflammation tend to only appear 20 to 30 years later.
Infection with a hepatitis virus is the most common cause of hepatitis in the world, but other infections, toxic substances (e.g. alcohol and certain drugs) and autoimmune diseases can also cause hepatitis.
There are five main hepatitis viruses, referred to as types A, B, C, D and E, and vaccines are available for types A and B respectively.
Hepatitis B and C are the ones that lead to chronic disease.
The burden of illness and death they cause, and the potential for outbreaks and an epidemic are a big concern.
The prevalence, or frequency, of hepatitis B is expected to decrease in Malaysia due to the successful implementation of the hepatitis B vaccination programme in newborns by the Health Ministry in 1989.
In contrast, there is no vaccine for hepatitis C, and studies have shown that our numbers for this infection are high, with an estimated 380,000 adults in Malaysia living with the virus.
Globally, an estimated 71 million people have chronic hepatitis C infection.
In 2016, the 194 member states of the World Health Organization (WHO) adopted the global hepatitis strategy to eliminate viral hepatitis as a major public health problem by 2030.
The elimination targets are a combined 90% reduction in new cases of hepatitis B and C; treatment of 80% of patients with chronic hepatitis B and C; and a 65% reduction in death caused by these infections.
WHO’s interim target for this strategy was for new hepatitis B and C cases to be reduced by half by the end of this year.
However, only 12 countries are on track to reach this target so far.
Malaysia’s estimated reduction target for this year is only 10%, making for a lot of catching up to do in the next 10 years.
Disrupted by Covid-19
With attention shifted to the Covid-19 pandemic, there have been plenty of disruptions at both government hospitals and clinics during the movement control order.
“We are concerned about this as it has impacted hepatitis care here,” says Professor Dr Rosmawati Mohamed, co-chair of The Coalition to Eradicate Viral Hepatitis in Asia Pacific (Cevhap).
“Active screening at the community level did not take place due to the diversion of healthcare services, although some (hepatitis) clinics were still running.
“Treatment was accorded using triaging, prioritising those with cirrhosis and liver cancer. Only the follow-up patients were diverted.”
Cevhap is an independent, multidisciplinary body that advocates for public policy reform to reduce the burden of viral hepatitis in Asia Pacific, with the ultimate goal to eradicate it.
At a webinar in conjunction with World Hepatitis Day last month, the Universiti Malaya consultant hepatologist presented the results of a WHO survey titled Disruption in HIV, Hepatitis and STI services due to Covid-19, carried out from April to June.
She noted that the highest levels of service disruption were reported in the Western Pacific region, which includes Malaysia.
The disruptions included diversion of health services to combat Covid-19, travel and transport restrictions limiting access to hepatitis services, reduced continuity of hepatitis treatment and drug stock outages.
An alarming reduction in cancer services was also highlighted, with 80% of countries reporting disruptions in services for cancer and other non-communicable diseases.
These disruptions were the highest in countries with the most widespread Covid-19 cases.
There was also an average of 65% reduction in clinical trial enrolment, causing some trials to be suspended or abandoned altogether.
This has important negative implications for the longer term development of new hepatitis treatments.
Says Prof Rosmawati: “Delaying hepatitis C treatment for three months will not jeopardise a patient’s health, particularly if the disease is mild, but patients with cirrhosis should not delay treatment any further as they are likely to have complications.
“However, there are some positives that may come from this pandemic as we have all had to rethink how to improve our services and help patients.
“For example, a number of governments (including Malaysia) are using multi-month dispensing (providing three to six months’ worth of medicine at one time) and changing community delivery services, offering benefits over the long term, and at the same time, promoting innovation in peoplecentred service delivery.
“So, Covid-19 has accelerated digital health services.”
Now in clinics
A fortnight ago, the Health Ministry announced that those at risk of getting hepatitis C can now get tested and treated at any government clinic (Klinik Kesihatan) nationwide.
Previously, these services were only available at government hospitals.
The clinics are equipped with
Prof Rosmawati notes that the Covid-19 pandemic has accelerated the development of digital health services for the benefit of patients, including those with hepatitis. — Filepic
hepatitis C antibody rapid diagnostic test (RDT) kits and direct acting antivirals (DAAs).
This decentralisation is a big step towards combating hepatitis C as more people can now get screened more conveniently.
Explains Prof Rosmawati: “We’re replicating the University of New Mexico’s model of patient management by providing mentorship to medical officers and primary care clinicians at distant sites.
“This task-shifting is one way to address the shortage of liver specialists in the country and to extend capacity in terms of testing and treatment.
“It will also reduce the patient’s visits to the hospital as full treatment can be carried out at these clinics.
“The severity of the disease will also be identified at the clinic.
“Most of our patients are noncirrhotic and can easily be treated at these clinics, but those with advanced stages of cirrhosis and complications will be referred to specialists.”
The high risk group for hepatitis C, which transmits mainly through blood, includes intravenous drug users who share needles, those who had blood transfusions or organ transplants before 1994, and those who share sharp personal items such as razors, have accidental injuries while handling contaminated needles and are on dialysis.
Those with tattoos and body piercings are possibly at risk too.
Awareness needed
Prof Rosmawati explains: “When a person has been exposed to the hepatitis C virus, they develop antibodies, so the first thing we do is the antibody RDT test via a finger prick.
“If the test results are positive, the next step is to do a confirmation test to check if the virus is still active or has been cleared.”
The second test checks the viral load and detects whether you were merely exposed to the virus or if you actually have an infection.
If that test is positive, then a genotype test is done to find out what kind of hepatitis C you have, before treatment can commence.
Not all patients infected with the hepatitis C virus require treatment, as some people’s immune system can clear the virus by itself.
However, when the infection becomes chronic, treatment is necessary.
WHO’s updated 2018 guidelines recommends therapy with DAAs.
The treatment duration is short (usually 12 to 24 weeks), depending on whether there is cirrhosis.
DAAs remain expensive in many high and upper middle-income countries.
However, prices have dropped dramatically in many countries, including Malaysia, due to the introduction of generic versions of these medicines.
“We’re certainly nowhere near reaching the target,” admits Prof Rosmawati, “because the numbers are increasing and we need to actively look for those infected.
“We have to hone in on increasing awareness so that people at risk come forward to test.
“We need to look at things positively as the government is taking big steps to close the gap between diagnosis and treatment.
“Our numbers are considered small in terms of those diagnosed, but the number of patients actively seeking treatment is even lower.
“Some people know they are infected, but they are not linked to care, so we also have to address this problem.
“If they feel well, they may not present themselves to the hospital – they wait to get symptoms, and unfortunately, it might be too late by then.
“Yes, you can still get treated at a later stage, but it has less chances of working.
“Peer support is crucial to promote testing among the young community, because when they see their peers are well, with no side effects from the medication, they will come forward.”
To illustrate further, she suggests visualising a scar.
When the infection is well established, the scarring will not go away, just like if you have a huge scar on your skin.
“So even if you are cured of hepatitis C, if you already had cirrhosis when you started your treatment, you need to be monitored for life as you would be at risk of liver cancer.
“A liver transplant is only done to replace the whole liver or if the patient has developed advanced liver cancer and treatment is not helpful,” she says.
Waist size matters
To take care of liver heath, one needs to be of healthy weight and waistline as being overweight or obese is a major cause of metabolic-associated fatty liver disease (formerly called non-alcoholic fatty liver disease).
This new term refers to a spectrum of conditions characterised by the accumulation of fat within the liver that is not caused by alcohol consumption or the hepatitis virus.
However, the damaging effects to the liver are the same.
“The damage can be severe enough to cause cirrhosis or liver cancer, and this is a worrying trend we are seeing, as 50% of us are fat and have expanded waist circumference.
“The other factors are diabetes and high blood cholesterol,” says Prof Rosmawati.
“Most patients with fatty liver are not necessarily fat, but slightly overweight.
“The weight around the waistline determines how much fat goes to the liver.
“Hence, waist circumference is a better way of looking at the risk of getting fatty liver, as opposed to body mass index (BMI), which is not the best assessment of fatty liver.
“In Asians, your risk is high if your waist is more than 80cm for females and more than 90cm for males,” she explains.
Studies have shown that if you lose even 7-10% of your weight by exercising moderately for 150 minutes a week, you can potentially reverse some of the effects of fatty liver.
As for alcohol, the amount consumed and duration (years of drinking) make a difference as the detrimental effects are accumulated over the years.
Abstinence after decades of drinking isn’t going to help.
What is considered a safe limit for some may be damaging for others with underlying medical issues.
Some people swear by traditional or herbal remedies to cleanse their livers, but many of these have not been scientifically proven.
“They may not be safe either, although the manufacturer may claim the product is natural – we don’t know what the active ingredients in it are.
“When supplements come in the form of pills or sachets, that’s not natural – the most natural form is the plant itself,” says Prof Rosmawati.
“The strongest evidence of improving liver function naturally comes from drinking coffee.
“If you have liver problems, you might want to consider drinking two cups of coffee a day – but not the pre-mixed ones.
“Coffee without creamer, milk or sugar is best as it doesn’t have calories,” she advises.
It’s not quite clear how coffee may influence liver damage, but findings suggest it may contain certain compounds that play a role in fighting inflammation.
When your body digests caffeine, it makes a chemical called paraxanthine that slows the growth of the scar tissue involved in fibrosis.
That may help fight liver cancer, alcohol-related cirrhosis, metabolic-associated fatty liver disease and hepatitis C.