(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!!)
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| Courtesy: http://worldhepatitisday.org/ |
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
28/07/2015
