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Year : 2004  |  Volume : 1  |  Issue : 1  |  Page : 249-255
Comments on the prevention of hepatitis B infection in India


Fox Chase Cancer Center, 7701 Burholme Ave., Philadelphia PA 19111, USA

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How to cite this article:
Blumberg BS. Comments on the prevention of hepatitis B infection in India. Hep B Annual 2004;1:249-55

How to cite this URL:
Blumberg BS. Comments on the prevention of hepatitis B infection in India. Hep B Annual [serial online] 2004 [cited 2020 Jan 18];1:249-55. Available from: http://www.hepatitisbannual.org/text.asp?2004/1/1/249/27930


The hepatitis problem in India

Before proceeding to a discussion of mass prevention of hepatitis B virus (HBV) infection, it would be appropriate to discuss the general problem of hepatitis in India. It is also important to emphasize that there are many similarities in the transmission of hepatitis B virus and the virus that causes AIDS. The methods that are used to prevent AIDS are, in many cases, similar to those that should be used to prevent HBV infection. Therefore, prevention programs for both viruses can, in some cases, be combined for increased economy (see below).

There are several viral agents which cause the common forms of viral hepatitis. Hepatitis A is caused by an enteric RNA virus quite different in shape and structure from HBV. It can cause acute but rarely chronic hepatitis, and is often spread in epidemics by water or food contaminated by the feces of individuals infected with hepatitis A. There is no vaccine for hepatitis A, but the administration of human gamma globulin can provide protection for 2-3 months following the injection.

Hepatitis B can cause both acute and chronic hepatitis and many people may become asymptomatic carriers for long periods of their lives. HBV is spread by many means, by transfer of blood from an infected individual to another, sexually, from mother to child, intimate contact as in families, and probably by insects. It may also be spread by the fecal-oral route, i.e. contaminated food and water, but this is not generally thought to be an important mechanism of epidemic diffusion. This question is still unresolved.

There are also other viruses which affect the liver which have not been characterized. These are called "non-A non-B" hepatitis virus since they are neither A nor B; but since they have not yet been identified, a letter designation has not been assigned to them. One of these viruses has characteristics of hepatitis A virus, and in some of these there is a high mortality rate. This is probably the single most common form of viral hepatitis in India.

There is another form of the non-A non-B virus which is similar to B in that it is transmitted by blood and produces chronic disease. In India this appears to be less common than the non-A non-B virus which is similar to hepatitis A. There is no vaccine against the non-A non-B virus.

Probably the most important single public health measure which could be taken to decrease hepatitis in India is the control of human waste and the protection of drinking water and food from fecal contamination. Since fecal contamination is the cause of a great deal of disease in addition to hepatitis in India, its control would probably be the most effective method available to help achieve the goal of "Health for all" in India by the year 2000. This is, of course, well known to medical and public health authorities, but the immense logistic effort required has prevented its complete implementation.

I have learned from colleagues in India that, in urban areas, the problem may have increased in recent years because of the rapid growth of city populations. The infrastructure for water supply and piped sewage disposal were in many cases installed years ago and are now inadequate for the increased population. Multiple breaks may exist in the water and sewage lines and, if they are proximate to each other, contamination can occur. This is particularly true when the water supply is inadequate and the pipes are empty for a portion or all of a day. A partial vacuum can result and sewage can enter the water lines if they too are ruptured.

In rural areas, deep bores may provide uncontaminated water, but its distribution after it reaches the surface may allow fecal contamination if proper facilities for control of waste are not used. A major regional and national program directed to providing adequate waste management and clean water and food would result in enormous rewards in health improvement.

Training in Public Health

One of the most important approaches that could be taken toward the control of hepatitis and of other infectious diseases is the establishment of a series of high-standard Schools of Public Health. I have learned from my Indian colleagues that there are a very small number of such establishments currently in the country. In order to ensure high quality for these institutions, it might be appropriate to base them on or close to the campus of existing prestigious institutions such as the Indian Institute of Science, Indian Institute of Technology and other national and regional health and technology institutions. In order to attract the highest caliber professional staffs and students, the basis of these institutions should be academic with a strong research compo-nent, in addition to the obvious applied character of their activities.

Prevention of hepatitis B infection

It has been estimated that HBV is probably the second most common cause of viral hepatitis (after A-like non-A non-B), and it is probably the most common cause of chronic liver disease, including the deadly primary hepatocellular carcinoma. There are estimated to be about 25 million carriers of HBV in India making it, after China (with about 100 million carriers), the second largest concentration of this chronic infection in the world.

Hepatitis B infection from medical procedures

There are several specific strategies that can be used for the prevention, and possibly the eventual elimination of HBV. Prior to the discovery of the methods for detection of HBV in blood, post-transfusion hepatitis (PTH) was extremely common in the United States. In some patients receiving large numbers of transfusions (such as heart surgery), the incidence of PTH events reached 50%. Beginning in the 1970s, testing of donor blood for HBV was required by regulation and/or law in many United States jurisdictions and in other countries. PTH due to HBV has now essentially disappeared, although PTH due to other viruses (non-A non-B) still occur.

A Government of India law of 1976 requires the testing of all donor blood, but for a variety of reasons this has not been accomplished; the Indian Council for Medical Research estimates that only 30% of donor bloods are tested. There are relatively few systematic studies, but the frequency of carriers varies from about 4% in some volunteer blood donor groups to over 20% in professional donors. It has been difficult for me to obtain a figure for the number of blood donor units used in India; 10 million per year has been one estimate. If we assume that an average patient receives two units of blood, then there will be about 5 million recipients of these 10 million units. If we assume a 5% frequency of carriers among the donors (probably a low figure since many donors are professionals), then about 10% of the 5 million recipients will receive at least one unit of blood containing HBV. Based on a prospective study, Dr. Jacob John of Vellore has estimated that about one third of patients receiving positive blood from donors will develop clinical hepatitis. Hence, it can be estimated that about 165,000 patients per year will develop hepatitis B from the blood transfusion system.

Another mode of hepatitis infection is the re-use of venepuncture or injection needles or other equipment exposed to human blood. It is difficult to remove encrusted blood from a needle, and ordinary sterilization will not kill HBV. The amount of virus which can cause hepatitis in susceptible hosts may be extremely small; an amount contained in the dregs of the needle or other instruments (i.e. blood syringes) could be sufficient.

It is difficult to estimate how many cases can be caused in this manner, but it is probably not less than that caused by transfusions. The preventive measures for these cases are obvious. All donor bloods require testing for HBV using the sensitive enzyme assay (ELISA), radioimmunoassay (less convenient), or a method of equivalent sensitivity. At present there is inadequate indigenous production of the reagents for these assays, and the imported reagents are too expensive for widespread use. The encouragement of local manufacture could remedy the problem.

Facilities for the manufacture of sharp disposable needles at low cost would decrease the dependence on re-used needles and instruments. Local manufacture of other disposable blood collecting equipment (i.e. syringes, plastic containers for the units of blood) will also be of value in preventing this mode of infection. It is obvious that the collection of blood from donor groups with a low frequency of HBV carriers (i.e. volunteer donors) would alleviate the situation and probably decrease infection with non-A non-B and possibly other viruses as well.

Prevention of infection with the virus which causes AIDS

There are remarkable similarities between the modes of transmission of HBV and the virus which is thought to cause Acquired Immune Deficiency Syndrome (AIDS). This virus is now called Human Immunodeficiency Virus (HIV) but was formerly called LAV/HTLV3. Methods similar to those used for preventing blood borne transmission of HBV can be used for preventing blood borne transmission of HIV. A serological test of donors for HIV (and antibodies against it) can be performed on the same serum specimen required for testing for HBV. Much of the same equipment can be used for the two tests. The techniques described above to prevent transmission of HBV by needles and other equipment will also be effective for preventing transmission of HIV.

There is a great demand in India for the prevention of blood borne AIDS. The implementation of both the HIV and HBV programs can be done together, thus effecting large savings in public health expenditures.

Vaccine to prevent hepatitis B infection

In the 1970s we introduced a vaccine which, in field tests conducted in several locations, has proven to be highly effective and very safe. Several million doses of this vaccine have now been used in Asia, Africa, the Americas and Europe. It appears to provide protection in 90% or more of those vac-cinated and, to the present, there have been no reports of detrimental side effects. Public Health programs for the vaccine are mostly directed towards the protection of newborn children and infants (about three months of age). Children born to mothers who are carriers are particularly susceptible to infection and the development of the carrier state, but other children are also at risk. The vaccine is given over six months (in some places, one year) in three or four doses.

In the summer of 1986 a program to vaccinate all newborn children was started in People's Republic of China. All newborn children in Taiwan are vaccinated as are many newborns in Japan and Korea. All newborn children in The Gambia, West Africa are to be included in the vaccination program, and there are also large programs in Italy, the United States and elsewhere.

Most of the programs use the vaccine derived from blood. China has recently built several factories to produce sufficient vaccine for the country's program, and there are several other locations where the vaccine is produced. The production in China is at a sufficiently low cost to sustain the program.

Recently, a vaccine produced by recombinant DNA methods has been introduced. Although this has not been used as widely as the blood-derived product and does not cost significantly less, it may in due course provide a satisfactory method of manufacture.

Hepatitis vaccine can be included in the general childhood vaccination programs, and the WHO has recommended that this be done. The decision on the use of hepatitis vaccine in India will obviously depend on economic, technical, medical and other factors. However, based on the worldwide experience already available, it is highly likely that if used, it will contribute significantly to the health of India.

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Correspondence Address:
Baruch S Blumberg
Fox Chase Cancer Center, 7701 Burholme Ave., Philadelphia PA 19111
USA
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Source of Support: None, Conflict of Interest: None


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