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Jul 28, 2015

Understanding Viral Hepatitis E (HEV) in Nepal - Getting yellow with liver pain

(This article is posted on the occasion of World Hepatitis Day - 28th July 2015. This is a summarized version of my previous 6 posts on viral hepatitis E. The author believes in the prevention of any enteric illness through comprehensive and integrated measures that is provision of Water Sanitation and Hygiene (WASH) in the community. However, there are times we have to act using available tools like vaccine in the situation of humanitarian crisis when we do not have option other than to act!!)


We are accustomed to hearing “Jaundice”, which is itself not a disease but one of the myriad manifestations of liver ailments. Among them, hepatitis of viral origin is what concerns me the most because I have myself been the victim of this preventive illness. The term “hepatitis” simply means the inflammation of the liver, which is considered body’s both storehouse and factory that produces essential biochemical essential for normal body functions. Among viral hepatitis E (in short HEV) may sound new for you.  You may even brush aside saying, "Well, this is none of my business!!" If you are thinking in that line, wait a minute!! Let me share you all our common suffering that we face every year in the name of viral jaundice. HEV is rampant in areas where water supply, sanitation and hygiene practices are compromised whereby drinking water gets contaminated with human soils. Once you become symptomatic, then you will be bed ridden for few weeks. During the illness, you feel so miserable and lethargic that you lose your appetite, complete aversion to anything called “food” or even its smell and white of your eye bulb turns yellow. Remember, this disease has potential for outbreaks that can affect thousands of people in the community. The worst and the most dreaded part is when it affects pregnant women, there is high chance losing your precious pregnancy and even death of mothers due to fulminant hepatic failure.

Where are we in its understanding?

HEV takes approximately 40 days from the time for infection to the start of illness. This is the most important cause of viral “Jaundice” among adults in the Indian Subcontinent. This is highly infectious and pregnant women are at special risk for severe liver complications in endemic regions like Nepal. HEV can be viewed like “bush fire” potential to inflict huge toll of sufferings and deaths in impoverished community. So saying, HEV is a public health problem in Nepal, would not be an over exaggeration. We know that viral Jaundice that includes HEV cause havoc in many parts of the country every year. For example, two outbreaks stand out and help us to understand the gravity of HEV problem in our country. One was in the premise of prime ministerial official residence in the year 2007, where then prime minister himself, some cabinet ministers along with other staffs caught this viral illness and bedridden for weeks, while the second is recent in the months of May and April in 2014. This outbreak occurred in the heart of Biratnagar,  where thousands of local residences were taken ill and some of them even died. Both outbreaks caught national and international headlines and the root cause was fecal contamination of municipality supplied drinking water. These examples definitely spark a sense of urgency demanding public health address with available effective preventive tools. 

Preventive measure 

Undoubtedly, the golden rule for its primordial and primary preventions would be health education, clean water and sanitation and hygiene practices. Sadly, this disease has not caught much of global attention unlike those of recent Ebola Virus Diseases outbreak, Tuberculosis, HIV and Malaria.  However, on positive note, we have safe and effective measure in our fight against this disease through vaccine along with preventive measures that adapted to the local situation. For this measure, HEV vaccine can be used as an effective public health measure to control its outbreaks in Nepal. To support his argument, he brings out the recent use of SA 14 - 14 - 2, a live attenuated vaccine against Japanese encephalitis (JE), which was used to effectively control and prevent JE in Nepal.  This vaccine was not then prequalified by World Health Organization (WHO). However, Nepalese health authority decided timely to use the available vaccine in endemic districts based on its public health merits. JE vaccination started in campaign mode and later introduced into routine immunization. Now, we see such a visible public health impact that anybody can hear such a dramatic success stories of JE prevention in the country. The key strength that lies hidden in this endeavor is the robust surveillance of Acute Encephalitis Syndrome (AES), which provided clear epidemiological picture of the disease, so policy makers were able to sketch pragmatic vaccination strategy in the country. This brings us to one pertinent question related to HEV vaccination “how long do we have to wait for HEV vaccine so people can get its benefit and get protected against this ailment? When I remember those days of extreme weakness, bouts of vomiting with incessant nausea that gripped your guts, I can even now feel the suffering. Nonetheless, it is comforting to know how much we understand the basic epidemiology including the genotypic distribution of HEV circulating in Nepal. Notably, some early human phases of HEV vaccine clinical trials were also conducted in Kathmandu among Nepalese population. We have to be honest, however that the concern raised by medical as well as public health fraternity, “why is HEV vaccine still not in public health use or even in private market?” is very relevant.

Final Thoughts

Viral hepatitis especially HEV is an area that is need of much advocacy from the community level in countries like Nepal / India / Ethiopia. We should also be able to advocate in the global health community. This means we should work simultaneously from both end - at international fora and also at the community level. Only then, we can reach a meeting point where funders and community health leaders can sit together and have a meaningful outcome from the entire penny invested in such studies related with HEV or any other vaccines. Whereas in Nepal, we should also be able to bring academician and public health professionals on board and educate the community well. Above all, the onus lies on us how efficiently we advocate on this issue at national or international level would be decisive and most important. Otherwise, we will always have to face the sad reality of yearly unexpected outbreaks in middle of some rainy seasons with national headlines as always – “Urban life disrupted with Viral Jaundice outbreak in the city”

Anuj Bhattachan

Anuj in Himalayas

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