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Hepatitis: In search of increased protection for a silent infection


FIFTEEN years before the doctor said to him: “Go home and get your affairs in order because there is nothing further we can do for you”, John was already aware that a problem existed.

Blood had started showing up, infrequently and in small amounts in his stools. “I’d kept this information to myself, mainly due to embarrassment and the possibility that it may only be haemorrhoids, something most people would pass off as not worth the hassle, “ he noted.

Time passed quickly. Blotches started appearing on his skin, barely noticeable at first but becoming larger and more numerous and pronounced as time progressed.

He’d been an I.V. drug user some years before and had always been partial to a drink or two. “My wife had by this time found other interests and moved along saying that I had developed alcoholic dementia. I knew these words were plain cruelty on her part and dismissed them, however I was aware that after maybe even two drinks I did have to stop and think before I spoke as my mind was easily addled”.

John’s liver was trying to tell him something, He did not acknowledge to himself that he may have had something seriously wrong going on in there. Ten years ago he received a call from his ex. saying that she had had a full set of blood tests done and that she had hepatitis C and he should hurry along to the pathologist and have their young son and myself tested. “I proved positive, my son, 15 at the time, negative which was a relief to me.”

Time moved along and he found it more difficult each day to go to work. He had always been self-employed. He began to need to have three or four breaks in the day due to nausea, fatigue and sleepiness, the battle to complete a job within budget becomes impossible.

He was at this time regularly coughing up morning blood, an indication of swollen veins (varices) in the oesophagus and stomach. Nose bleeds were a daily occurrence.

He was soon classified as having inoperable, terminal, liver cancer. He went to hospital having an embolism. “For me it entailed sliding a catheter up through a main artery in my groin area into my liver and shooting a toxic chemotherapy drug into the blood supply feeding the tennis ball size tumour inside my liver.

“This procedure was a last ditch kind of, throw caution to the wind and try anything style of medicine. My doctors may not embrace this description of their work but they were all skilful, caring and very importantly friendly to me.

Early detection is one thing; doing something about it is another. It’s up to the individual, John realised almost too late that he could have avoided all the drama by doing something about his hepatitis C.

“If you find you have just been diagnosed with hepatitis C, no need for panic or for blame or for any self flagellation, just get yourself a good solid plan. If it is caught early enough and you are clever enough to accept that potentially it gets very bad (which is the chair I now sit in) you may quite honestly only have to make minimal life style changes.”

On this year’s will be the annual World Hepatitis Day, July 28, the whole point was to encourage people to find out the facts about hepatitis b and hepatitis c – and by doing this help decrease the stigmas attached to the viruses.

Nigeria has one of the world’s largest burdens of children living with HIV and is highly endemic for hepatitis B. The prevalence of hepatitis B and C infections among HIV-infected children and factors associated with these co-infections are significant. In Nigeria, rates of new infection were highest among people aged 20 to 44 years and lowest among those younger than 15 years of age. This reflects the major modes of transmission of hepatitis B (sexual transmission, illicit drug use, exposure to infected blood) and the effect of universal vaccination of infants.

With a national seroprevalence of 4.1 percent and a population of 148 million, Nigeria is endemic for hepatitis B virus (HBV) infection, a virus that shares similar transmission routes with HIV.

Hepatitis C virus (HCV) has also been reported in the general Nigerian population. HIV co-infections with HBV and HCV have been documented in adults and children, but there is a paucity of data on this subject among children in resource-limited settings.

It is believed that in Africa most hepatitis B infection is acquired horizontally, with the infection being transmitted from child to child before the age of 5 years. This is in contrast to Asia, where vertical transmission is more prominent because of the higher prevalence of hepatitis e antigen. It is possible that in Africa higher HIV/HBV co-infection may be present, as immunosuppression caused by HIV infection acquired vertically may predispose the child to acquiring hepatitis B infection horizontally.

In Nigeria some of the blood that is transfused is not routinely screened for hepatitis C,8 so with many children requiring transfusion for severe anaemia from various causes (notably malaria), the prevalence of hepatitis C may be significant. This would be in addition to vertically acquired HCV, which is said to be more likely if the mother is also HIV infected and has a high HCV viral load.

What it is
The term ‘hepatitis’ simply means inflammation of the liver. Hepatitis may be caused by a virus or a toxin such as alcohol. Other viruses that can cause injury to liver cells include the hepatitis A and hepatitis C viruses. These viruses are not related to each other or to hepatitis B virus and differ in their structure, the ways they are spread among individuals, the severity of symptoms they can cause, the way they are treated, and the outcome of the infection.

The hepatitis B virus is a DNA virus, meaning that its genetic material is made up of deoxyribonucleic (DNA) acids. It belongs to a family of viruses known as Hepadnaviridae. The virus is primarily found in the liver but is also present in the blood and certain body fluids.

Hepatitis B virus consists of a core particle (central portion) and a surrounding envelope (outer coat). The core is made up of DNA and the core antigen (HBcAg). The envelope contains the surface antigen (HBsAg). These antigens are present in the blood and are markers that are used in the diagnosis and evaluation of patients with suspected viral hepatitis.

Scope of the problem
Hepatitis B is an infection of the liver caused by the hepatitis B virus (HBV). It is estimated that 350 million individuals worldwide are infected with the virus, which causes 620,000 deaths worldwide each year.

Risk factors
Medications that can cause damage to the liver include methyldopa (used uncommonly for high blood pressure), isoniazid for tuberculosis, seizure medications (like valproate and phenytoin), chlorpromazine, amiodarone (for irregular heart rhythm), and certain antibiotics (including trimethoprim-sulfamethoxazole and erythromycin).

Others are intravenous drug use, overdosing on acetaminophen — the dose needed to cause damage is close to the effective dose, so be careful to take it only as directed.

Also engaging in risky sexual behaviors (like having multiple sexual partners and unprotected intercourse)

Others are:
Eating contaminated foods
Traveling to an area where certain diseases are common
Living in a nursing home or rehabilitation center
Having a family member who recently had hepatitis A
Using or abusing alcohol
Being an organ transplant recipient
Having HIV or AIDS
Having received a blood transfusion before 1990 (hepatitis C blood test was not available)
Being a newborn of a mother with hepatitis B or C (can be transmitted during delivery)
Being a healthcare worker, including dentist and dental hygienist, because of blood contact
Receiving a tattoo

When a person first gets hepatitis B, they are said to have an ‘acute’ infection. Most people are able to eliminate the virus and are cured of the infection. Some are not able to clear the virus and have ‘chronic’ infection with hepatitis B that is usually life-long.

Generally, the symptoms of hepatitis include:
Abdominal pain or distention, Breast development in males, Dark urine and pale or clay-coloured stools, Fatigue, General itching, Jaundice (yellowing of the skin or eyes), Loss of appetite, Low-grade fever, Nausea and vomiting and weight loss.

Tests and diagnosis
Many people with hepatitis B or C do not have symptoms when first infected and can still develop liver failure later. If you have any risk factors for either type of hepatitis, you should be tested periodically.

A physical examination may show yellowing of the skin, an enlarged and tender liver, or fluid in the abdomen (ascites) that can become infected.Your doctor may order laboratory tests, including:
Hepatitis virus serologies
Liver function tests
Autoimmune blood markers
Abdominal ultrasound
Liver biopsy to determine severity of the liver damage

The outlook depends on many factors, including the cause of the hepatitis and whether or not you have additional illnesses or conditions that complicate treatment or recovery. Many people recover fully. However, it may take months for the liver to heal. Eighty percent of those with hepatitis C go on to have chronic liver disease and, possibly, liver failure (cirrhosis) or liver cancer. Hepatitis C is the number one reason for receiving a liver transplant.

Permanent liver damage, liver failure, or liver cancer can occur. Other complications include spontaneous bacterial peritonitis (when fluid in the abdomen becomes infected), and esophageal varices, which can bleed significantly.

Seek immediate care if you: Have symptoms related to acetaminophen or other medicines — you may need to have your stomach pumped; vomit blood; have bloody or tarry stools, are confused or delirious; you have any symptoms of hepatitis or believe that you have been exposed to hepatitis A, B, or C and you cannot keep food down due to excessive vomiting. You may need to receive nutrition intravenously (through a vein).

Liver injury
The hepatitis B virus reproduces in liver cells, but the virus itself is not the direct cause of damage to the liver. Rather, the presence of the virus triggers an immune response from the body as the body tries to eliminate the virus and recover from the infection. This immune response causes inflammation and may seriously injure liver calls. Therefore, there is a balance between the protective and destructive effects of the immune response to the hepatitis B virus.

Liver disease can also be caused by inherited disorders such as cystic fibrosis and Wilson’s disease, a condition that involves having too much copper in your body (the excess copper deposits in the liver).

Hepatitis may start and resolve quickly (acute hepatitis), or cause long-term disease (chronic hepatitis). In some instances, progressive liver damage, liver failure, or even liver cancer may result.

The severity of hepatitis depends on many factors, including the cause of the liver damage and any underlying illnesses you have. Hepatitis A, for example, is generally short-lived, not leading to chronic liver problems.

Hepatitis B Vaccine
The hepatitis B vaccine contains a protein (antigen) that stimulates the body to make protective antibodies. There are also combination vaccines on the market that provide protection against hepatitis B and other diseases.

Hepatitis B vaccines are effective and safe. Up to 95 percent of vaccinated individuals form effective antibodies when they get the vaccine and are protected from hepatitis B. In healthcare workers, high-risk public safety workers, dialysis patients, and sexual partners of infected persons, a blood test for antibodies is recommended after vaccination to ensure that the person produced antibodies. For the few who do not form antibodies, revaccination may improve response, especially in infants. However, a small proportion of individuals will never respond to hepatitis B vaccination. Side effects from the vaccine are usually mild and include soreness at the site of injection.

Avoid contact with blood or blood products. Take precautions if this is part of your work.
Avoid sexual contact with a person infected with hepatitis or unknown health history. Practice safe sex at all times.
Wash your hands after going to the bathroom and before handling food.
Avoid sharing plates, utensils, or bathrooms with someone who has hepatitis A.
DO NOT share razors, needles, or toothbrushes.
When traveling to endemic areas, DO NOT eat uncooked or partially cooked foods. Drink bottled water.
DO NOT use recreational IV drugs. If you are already an IV drug user, never share needles and seek help from a needle exchange or drug treatment program.
Be cautious when receiving tattoos or piercings.
DO NOT drink alcohol at the same time that you take acetaminophen. If you already have hepatitis, do not use either (to avoid further liver damage).
When to get tested for hepatitis:

Get tested for hepatitis B or C if you had sexual contact or shared needles with someone who may have had one of these viruses. Do this even if you have no symptoms.

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