Health responsibility as the road map for 2030 with regards to hepatitis

 Health responsibility as the road map for 2030 with regards to hepatitis

Why is Viral Hepatitis important?

The liver plays a vital role in several physiological processes. [1] Inflammation of the liver - hepatitis, [2] thus compromises the quality of life for a patient manifold. Hepatitis can set off by alcoholism, metabolic syndrome, drug toxicity, autoimmune processes and infection. [2][3] Why then should viral hepatitis, in specific, be considered by legislators and public health specialists with fervent concern?

The answer lies in its potent capacity to cause communicable hepatitis. A communicable disease prompts drastically different control measures. Achievements in viral hepatitis control over the last ten years, presage an opportunity to further quell its spread and sequelae. At first glance, it is easy to appreciate that those communities that are socio-economically weak are the most susceptible to all forms of viral hepatitis. Throughout this piece, Hepatitis A and E which spread through water and touch are contrasted against Hepatitis B, C and D which spread through more intimate means – unprotected sexual contact, perinatally, needle prick injuries and percutaneous drug abuse, more in the case of Hepatitis B and D; and through infected blood, more in the case of Hepatitis C. [4] However, socio-economic groups that are vulnerable to these two families of disease broadly overlap. Determiners such as overcrowding, poverty and poor sanitary habits foster the spread of all forms of hepatitis. [5]

The interplay of factors influencing viral hepatitis and how they lead to a roadmap

In general, public health specialists have not been ignorant of these realities. Indeed, with economic development, infection rates for all types have come down. However, there is a caveat - middle income countries suffer from high hepatitis A infection rates. The truth is that sanitation reduces childhood infection rates and hence herd immunity. This leads to an increase in adult infection rates and more diagnosed cases. With further development, infection rates definitely drop. [5]

However, the world still suffers from challenges regarding Hepatitis. Pharmacotherapy of hepatitis B and C is very expensive, this makes it virtually absent in the road map for 2030 in developing countries. [6][7] Vaccination on the other hand is accessible. Most countries have included vaccination for hepatitis B in their national immunisation schedules. Further, medical workers - who are at risk are additionally vaccinated against hepatitis B. This is significant, as Hepatitis B has a propensity to cause hepatocellular carcinoma. [5] Cancer is devastating in terms of suffering caused and financial costs imposed on the sufferer; the hepatitis B vaccine is thus resembling of the proverbial ‘Vaccine for Cancer’.

 Upon consideration of cost and potential benefit, it doesn’t seem necessary to vaccinate the entire populace against Hepatitis A. Still, vaccinating particular groups can ameliorate the hepatitis A case significantly. For example, food handlers and vegetable vendors. Secondly, vaccination against hepatitis A should be recommended in those suffering from Hepatitis B and C in order to allay the potential fulminant hepatitis birthed by super infection. Local authorities should maintain contact with those infected with hepatitis B and C, to ensure they don’t engage in spread promoting activities and to prevent hepatitis super infection.

Hepatitis A and a few other conditions that share its transmission route and clinical presentation tend to affect clusters of the overall population; for instance, those groups sharing access to a single water supply. These tendencies are locally dictated, therefore it is pertinent for the local Governments of a particular region to identify target groups for Hepatitis A vaccination. Illustrating this tendency – India’s festival season has the potential to bring with it increased Hepatitis A and E caseloads. This is where WASH - water, sanitation and hygiene - comes into play. [8] Encompassing the tenets of hepatitis spread, this acronym allows dissemination of information and the creating of evaluation checklists. In the case of hepatitis E, special care must be afforded to pregnant women, for they are at higher risk of hepatitis E related morbidity and mortality. [5]

As for the control of those constituents of the eco system that initiate a vicious cycle enabling Hepatitis infection, it is easy to delegate these to the overall process of development. Indeed, Sustainable Development Goals 3.3 and 6, dealing with communicable disease and water, sanitation and hygiene embody these facets of progression [9]; still other sustainable development goals [10] are related to the umbrella of hepatitis prevention. Yet, gaining cognizance of the importance of Hepatitis, its potential controllability inspite of a country’s poor economic status should be critically examined.

Community participation in the roadmap

Community participation is key in the control of viral Hepatitis. Previously, community participation played a massive role in the control of polio and although polio differs in many ways from viral Hepatitis, it may be argued that abstract principles that apply to one disease can lend themselves to others. For instance, surveillance of water sources is once strategy that India uses to control polio resurgences [11]; similar activities, albeit at an accelerated pace can accentuate Hepatitis A and E eradication.

 In today’s context, community participation crosses the bounds of what it meant 20 years ago. Improving social conditions, the internet and changing notions of citizenship have all contributed to increased community participation, in many ways the present generation assumes more responsibility for what they perceive theirs - including their body. [12] But this responsibility does not always manifest itself in a productive manner – in must be directioned appropriately. 

Having thus far established a basis that a country can exceed those limits imposed by economic state, it is imperative to analyse how that is possible in our study subject. Previous mass drives, for vaccination and health related behaviours such as social distancing gained credence in the eyes of the public through celebrity endorsement. [13][14] The success wrought by the COVID 19 vaccination program highlights that campaigning and presenting a dire picture in terms of the consequences arising from not getting vaccinated begets mass vaccination; stimulating a similar environment for hepatitis B will promote vaccination, particularly for the most vulnerable. Celebrities addressing masses in vernacular languages through media such as Whatsapp and Twitter is a potentially far reaching method in encouraging Hepatitis A vaccination safe sex practices including the use of condoms and hygiene.  ‘Water drives’ involving Surveillance Hepatitis A and E cases, monitoring of water sources and undertaking corrective measures in those regards found to be Hepatitis accelerating is a potent plan of action. Similarly addressing those infected with Hepatitis B to discourage sexual practices, especially in key groups such as sex workers is prime. 

Drawing from COVID [14], personalized ‘Do It Yourself’ content regarding household sanitary measures apparent minutiae such as toilet hygiene and hand washing as well as measures of isolating systematic individuals can be circulated through the same channels. Discouraging paid blood donation through the encouragement of voluntary blood donation is powerful in reducing transfusion related Hepatitis C. [15] Continued screening of donated blood samples for Hepatitis B and C is important. The provision of screening methodology such as those established by NACO [16] for Hepatitis B and C, as well as community extension of screening drives in areas with high positive predictive value can enable succinct tracking as well as chain tracing.

Changing the role of the populace

The jury is out on the factors causing the spread of disease – the spread of relevant information, in a manner that disrupts the information asymmetry around viral hepatitis, can set into motion social enforcement of Hepatitis preventing sanitary measures. Exemplary are the toilet construing schemes [17]of the Government of India that established social contracts, discouraging public defecation with those having defecated in public being excluded from village activities and schemes.

These ideas can be extended further into the decentralized model of health governance. The Government, in constitutional terms, represents the will of the people and its actions are in fact theirs. Gaining recognition of the tumultuous nature of public health discourse, the Panchayat Raj model seems the only way forward. In recent times, the counter culture concept of the body being the defining limit if an individual’s individuality [12] and the violation of it a sin has spilled into the main stream. A populace which takes responsibility for their own health is one where the citizen plays an active as opposed to a passive role in their health. Such a populace may never exist – giving into Socrates’ ideas of the city state. However, health as its best is an endeavour to make human life better and more enabling of achievements. As for 2030, it may see wanton to surmise that such can transpire in such a short period of time. For that, it can be said if it is possible for a series of events to initiate the COVID pandemic within months it is very much possible for Hepatitis roadmap to be community based. Secondly, history has always been ironic in its trappings – Governments have tumbled and lives have been lost that seemed unlikely, drawing inspiration from this the march towards constraining Hepatitis must continue.

References

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16. NACO. National Guidelines for HIV Testing - Naco [Internet]. http://www.naco.gov.in/. 2015 [cited 2022Jul31]. Available from: http://naco.gov.in/sites/default/files/National_Guidelines_for_HIV_Testing_21Apr2016.pdf 

17. Reese H, Routray P, Torondel B, Sinharoy SS, Mishra S, Freeman MC, et al. Assessing longer-term effectiveness of a combined household-level piped water and sanitation intervention on child diarrhoea, acute respiratory infection, soil-transmitted helminth infection and nutritional status: A matched cohort study in rural Odisha, India. International Journal of Epidemiology. 2019;48(6):1757–67.