Millennium Post

Silent assassin

Other hospitals, particularly the All India Institute of Medical Sciences, receive over 1,000 such cases and Ganga Ram Hospital, which undertakes five to ten liver transplant surgeries in a month, faces more than 1,500 chronic liver failure cases in a year.

But a much more horrific experience occurs in cases of acute liver failure, which happens all of a sudden without showing prior symptoms or indications. Victims  with a healthy, perfectly functioning liver suddenly succumb to an infection. Most of them can walk, talk, move or do anything like a regular human being, until one fine day when they just succumb to a failed liver.

‘Acute liver cases are those where it takes just six months for a person’s normal liver to completely fail in carrying out its physiological functions. The most common cause of an acute liver failure is an infection either by Hepatitis E or Hepatitis A virus,’ says Dr Anil Arora, HOD Gastroenterology and Hepatology, Sir Ganga Ram Hospital in Delhi.

He further says, ‘Liver failures are even quicker in cases of acute-over-chronic failures, where the patient already has a diseased liver – either due to overconsumption of alcohol or Hepatitis B, mostly untreated or undiagnosed. In such circumstances, even one sudden transmission of water-borne Hepatitis A or Hepatitis E in his body can lead to a liver failure within a week. Among all kinds of hepatitis variants, Hepatitis B claims the highest number of lives. Around 240 million people worldwide are chronically infected with Hepatitis B virus, of which, around 7,80,000 die every year, say World Health Organisation (WHO) records.

In India, around 90 per cent of Hepatitis B cases have been found to be those resulting from mother-to-child transmission. However, general causes of getting infected with this virus are usually blood contact or close proximity to other bodily fluids of an infected person, through any means. ‘Hepatitis B usually runs in the family line. So, our suggestion is, if anyone in the family is diagnosed with Hepatitis B, then the entire family should first get themselves screened and then vaccinated,’ says Dr Shiv K Sareen, director of ILBS in Delhi.

There are vaccines to prevent Hepatitis B, but once a person is already diagnosed as infected, the vaccine doesn’t work. Then it needs disciplined adherence to a proper diet rich in protein and a life-long healthcare routine including injection of drugs like Tenofovir and Entecavir, which cost around Rs 6,000 a month. ‘The government should make these drugs free of cost, or at least, heavily subsidised, like they have done in cases of tuberculosis and HIV.

If you look into the economic conditions, more than half of the Indian population can’t afford that,’ says Dr Sareen. He was also a part of the Yellow Ribbon campaign, following which Delhi became the first Indian state to provide Hepatitis B vaccines to all newborns in 2001 and finally in the year 2007 it was included in Government of India’s Universal Immunization Programme (UIP).

In the chart of fatalities, Hepatitis B is followed by Hepatitis C. It claims up to half a million lives a year worldwide. According to WHO records, around 150 million people globally are infected with Hepatitis C, of which, around 15 million, about 10 per cent, are Indians. Hepatitis C is also blood-borne and the most common causes of this infection are blood transfusion and unsafe injection practices. There is no preventive vaccine for Hepatitis C. ‘Once a person is infected, the patient has to be constantly monitored, unlike Hepatitis B where the patient could be prescribed drugs, suggested a diet and discharged unless the virus is diagnosed to be causing chronic liver damage,’ says Dr Rakhi Maiwall, assistant professor of Hepatology at ILBS.

Patients infected with Hepatitis C are treated with drugs like Ribavirin and Interferon, but they are quite expensive and they cannot be prescribed for pregnant women, children, people with heart or kidney ailments, or people who already come with a diseased liver. In this context, it becomes very important to talk about Directly Acting Anti-Viral (DAA). ‘They are oral drugs which attack stages of viral replication. They are safe and have been proven to be effective. I call it the biggest revolution in any branch of medicine in the past one decade,’ says Dr Sareen. For Hepatitis C, there is a DAA oral medication too, but is extremely expensive, since the entire therapy can cost up to Rs 15 lakh.

Patents for this DDA are held by three major pharmaceutical players in the world market, and they refuse to sell it in nations where they are asked to relax their pricing policies. ‘Now Egypt has an agreement with US, where it procures these drugs at one-tenth the cost on the ground of bulk purchase. It’s not that India doesn’t trade with US, then why can’t our policy-makers go for such agreements for something as vital as DAA,’ asks Dr Sareen.

‘Most adults in India, who are diagnosed with Hepatitis C, are people who had gone for blood transfusion before 1996. During that time, technology available in India wasn’t sufficient to screen Hepatitis C in blood, at least things have changed now,’ explains Dr Maiwall.

Hepatitis E is transmitted mainly through contaminated drinking water. It is usually a self-limiting infection and resolves within four to six weeks. Unfortunately, if that doesn’t happen, nothing much can be done even today. ‘There have been cases where a dosage of Ribavirin has proven to have worked for Hepatitis E, but there is no certain drug to treat Hepatitis E yet,’ says Dr Arora. As per WHO records, around 20 million people are infected with Hepatitis E worldwide every year and the virus claims around 56,600 lives annually. WHO also says, Hepatitis E can induce a mortality rate of 20 per cent among pregnant women in their third trimester.

In our childhood, many of us must have had a jaundice chapter, which is Hepatitis A. The virus spreads through ingestion of food or water that is contaminated with faeces of an infected person. ‘It doesn’t cause chronic liver failure and is rarely fatal, but if it attacks an already diseased liver, it can lead to an acute liver failure, unless the patient comes to the doctor at the right time,’ says Dr Maiwall

Every year, there are around 1.4 million cases of Hepatitis A worldwide, says WHO records. ‘There are vaccines to prevent from Hepatitis A, but again, these vaccines are highly expensive. It becomes difficult to recommend them to all,’ says Dr Sareen. The worst part is, even after so many years, the cost of Hepatitis A vaccine hasn’t come down.

When it comes to Hepatitis A, we Indians are yet to break the conventional cures through restrictive diet. The conventional way of putting a hundred restrictions on the patient’s diet is very wrong. ‘When a person gets Hepatitis A, the liver is actually in need of protein. So the person should eat regular food – including meat, fish, eggs, milk and everything – with no restrictions,’ insists Dr Maiwall.

However, when a person’s liver fails,  a liver transplant is need of the hour. ‘It is one of the most expensive and longest surgeries known to human beings,’ says Dr Arora. He further says, ‘The surgery can take from 8 to 12 hours, and the patient has to spend at least 30 days under intensive care after the surgery. Liver transplant package at the Ganga Ram hospital costs around Rs 20 lakh and at ILBS it costs around Rs 11.5 lakh, excluding the charges for hospital stay. ‘The cost goes up when the patient comes to us at an extremely critical stage. Especially, in acute liver failure cases, the patient can walk, talk, move and do daily activities normally, so it becomes difficult for the patient to accept that he/she might be needing a transplant immediately,’ says Dr Maiwall.

For a liver transplant surgery, a part of the liver of the patient’s first line relatives – parents, children – are accepted, but a number of things have to be seen apart from a matched blood group and Rh factor: the donor’s liver has to be healthy, donor’s medical history and receptivity of the patient with the failed liver. ‘When any of these things fail, second line relatives are considered,’ says Dr Arora. But the worst part is, if the person comes with a liver failure due to Hepatitis B – which runs in the family line – there are high chances that the patient’s relatives will have the same infection too. In such cases, it becomes too difficult to do the transplant, says Dr Maiwall.
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