Nepali Times
Epidemic proportions


A Silent killer is upon us. If the doctors are to be believed, there is a "sudden, persistent and progressive" growth in Hepatitis B cases since 1997, and which they claim can be signs of the "emergence of an epidemic"
in Nepal.

Researchers put the number of Hepatitis B patients in Nepal at 200,000, and approximately 200 new cases are recorded annually. The incidence of acute Hepatitis B was 9 percent in the five years between 1982-86; it rose to 15 percent between 1987-91, and is projected to have grown by 36 percent between 1997-2000. Doctors warn that there could be more undiagnosed cases.

A major hurdle to controlling the spread of the disease is that an infected person can carry the Hepatitis B virus without showing any symptoms of the disease and transmit it to other healthy people. It is often diagnosed too late, after having exacted its toll and manifested itself in some deadly liver ailment. Studies have shown that Hepatitis B is responsible for 60 percent of chronic Hepatitis, 40 percent of liver cirrhosis and 34 percent of liver cancer in Nepal.

The virus is present in blood and body fluids, and spreads through skin and mucous membranes. The infection is generally from mother to child, child to child, unsafe injections, blood transfusions and sexual contact. When children contract the virus from their mother during birth or during breastfeeding, they become life-long carriers of the virus, infecting other healthy people. However, there is a cure for infected adults.

The infection is detected through blood tests and in case of indications of active liver damage, the patient is recommended for a liver ultrasound and a biopsy. The government's Epidemiology and Communicable Diseases Control Division identifies drug addicts, commercial sex workers, military personnel, migrant workers and patients with chronic kidney problems as particularly vulnerable to the disease.

The problem is there are people who are even sceptical of the existence of the virus, and claim that it is a pharmaceutical industry-engineered scare. However, the people working to raise awareness against the virus dismiss the claim simply as a "misconception". They claim that people developed this misconception as in some adults the virus sometimes just disappears, without ever developing into a serious ailment. The rate at which the virus develops into a chronic infection among adult recipients is also low. Studies show that there is an 80 to 90 percent chance that the Hepatitis B infection develops into a chronic infection if the infection occurs in infancy, less than 50 percent if infection occur in childhood and less than 5 percent if it occurs in an adult.

Sharad Onta of the Resource Centre for Primary Health Care said that the rate of Hepatitis B infection in Nepal is alarming, and that biologically, the Hepatitis B virus is more infectious than HIV. According to him, preventive vaccination is the most effective way to control the spread of Hepatitis B virus. But he was critical about the way the vaccination is administered in the Kathmandu Valley. "What is dangerous is the commer-cialisation of the Hepatitis B vaccination in Nepal. There is neither a price-control mechanism nor follow-up to check if the pharmaceutical companies are selling unnecessary vaccines to the public."

A preliminary report by the Liver Foundation Nepal (LFN) throws up some interesting findings. It shows that certain ethnic groups like Tibetans, Manang-bas and Sherpas have higher Hepatitis B prevalence compared to other ethnic groups in Nepal. "It is because among them, mothers are transmitting the Hepatitis B virus to their children. However, we still need further studies and investigations to establish the real reasons as to why some groups have higher Hepatitis B prevalence," said Dr Santosh Man Shrestha of LFN.

The open border with India, and the large number of young people who travel abroad to find jobs are also to blame for the spread of the disease. The LFN study reveals that 90 percent of Hepatitis B cases in Nepal originated in India via the thousands of Nepali migrant workers. Nepalis migrating for work to other Asian countries are also vulnerable. East Asian countries like Thailand, Singapore, and Taiwan, traditionally favoured by Nepali workers, also have high incidences of Hepatitis B.

Better air links with countries that have a high prevalence of Hepatitis B is also facilitating the spread of the virus. According to the documents made available to us by the Nepal Liver Foundation, China has a Hepatitis B surface antigen (HbsAg) prevalence of 10 percent, Bangladesh 7.5 percent, and Pakistan and India, 5 percent.

The Asian-Pacific Consensus Meeting on Hepatitis B and C, held in Fukuoka, Japan early last year, recommended universal immunisation for newborns as the best way to prevent the spread of Hepatitis B. Nepal's progress in this direction has been tardy. The reasons include widespread ignorance about the disease and the prohibitive cost of the vaccine. Compared to neigh-bouring Bhutan, which supplies the vaccine at about Nepali Rs 35 per dose (Rs 105 per course), Nepalis have to pay five times more, Rs 175 per dose, Rs 525 for a complete course.

There are two types of Hepatitis B vaccine available in Nepal: plasma-derived, prepared from purified Hepatitis B surface antigen taken from persons with chronic Hepatitis B, and a genetically engineered vaccine, prepared by inserting the Hepatitis B surface antigen in yeast. Both kinds are recognised as safe and effective.

The non-governmental sector blames the government for the high price of the vaccine. Until the price of the vaccine is reduced, and there is greater awareness about the need for vaccination, Nepalis will have to protect themselves by avoiding unsafe injections, unsafe blood and blood products, tattoos, acupuncture and dental care, taking proper medical and surgical care and avoiding multiple sex partners.

(11 JAN 2013 - 17 JAN 2013)