World Hepatitis Day has arrived! Check out this YouTube video from the World Health Organization (WHO)
Don’t let hepatitis tear your life apart
Hepatitis affects everyone, everywhere. KNOW IT. CONFRONT IT.
This World Hepatitis Day message by Dr. Philanbangchang, WHO South-East Asia addresses some of the many challenges of viral hepatitis in the South-East Asia region, and also applies to other areas of the world.
However, it is interesting to first note some fast facts specifically about hepatitis B…
And now a message from Dr. Philanbangchang…
Viral hepatitis kills more people than any other communicable disease in the South-East Asia Region. In the next 10 years, over five million people in the region is projected to die from this disease and its consequences.
Today, more than 130 million people in South-East Asia alone, carry the hepatitis B or C virus, even though they may appear healthy. It usually strikes people at their most productive age.
The hepatitis B virus is 50 to 100 times more infectious than HIV, and just as lethal. Hepatitis E results in 2700 still births every year. For such a major public health threat, hepatitis has a low profile, among policy-makers and the public.
Recognising hepatitis as a threat to public health, the World Health Assembly passed a resolution to prevent and control the disease last year. The World Health Organization has decided to observe July 28 this year as the world’s first ever World Hepatitis Day.
It is thus an opportune time to ask if we are doing enough to protect ourselves from this disease?
Many people recognise the symptoms of jaundice by the yellowing of the eyes and skin. Yet, jaundice is only the face of the disease and the common symptom for any of the four common types of viral hepatitis. These are easily contracted from drinking water to casual contact to sexual intercourse. Even then, not every infected person shows symptoms.
WHO is developing guidelines, strategies and tools for surveillance, prevention and control of this disease. Prevention and focussing on the source and mode of spread of the virus, is crucial to control this disease.
Chronic hepatitis B and C are among the leading causes of preventable deaths in 11 countries of the region. About 100 million hepatitis B carriers, and 30 million hepatitis C carriers, live in South-East Asia.
However, about 60 percent of the infected are unaware of their status until the disease manifests as cirrhosis or liver cancer – an aggressive cancer without a cure. Hepatitis C, in particular, has no vaccine or effective cure. Those who undergo blood transfusion, as well as injecting drug users, are at risk.
Due to lack of knowledge and resources among healthcare workers, many providers in the region do not comply with WHO’s and national guidelines and recommendations for hepatitis B and C screening, prevention, treatment and follow-up services. A patient requiring transfusion may receive blood that has been screened for HIV, but not for hepatitis B or C.
The hepatitis B vaccine can go a long way to prevent hepatitis B. It is more than 95 percent effective in preventing infections and their chronic consequences, and is the first vaccine that protects against a major human cancer. In WHO’s South-Asia Region, more than 130 million infants have received the three required doses of hepatitis B vaccine.
Hepatitis infection is also linked to personal hygiene, sanitation and urban health – hepatitis A and E are both commonly spread through eating or drinking contaminated food or water. Pregnant women are at high risk of hepatitis E. Hepatitis E acquired during pregnancy is also associated with prematurity, low birth weight and an increased risk of perinatal mortality.
In countries of WHO’s South-East Asia Region, more than 6.5 million people are infected with hepatitis E annually accounting for half the cases worldwide, leading to an estimated 160 000 deaths.
Hepatitis E outbreaks often occur in urban areas when leaky underground water pipes are contaminated with sewage. In developing countries, with increasing population pressure and rapid urbanisation leading to people living in close, unsanitary conditions, such diseases are likely to increase rapidly.
So what can be done to prevent and control hepatitis?
To begin with, all countries, especially those urbanising rapidly, need to make hepatitis a health priority. Lives could be saved through simple preventive measures such as hand washing, eating cooked food and boiled water, using condoms and not sharing needles.
Countries need to make screening of all blood and blood products for hepatitis B and C mandatory. Governments should ensure that children are adequately immunised against hepatitis B. Healthcare workers, and the public, need to be educated on the risks and the surveillance system for hepatitis needs to be strengthened.
Unless we act now to create greater awareness among policymakers, healthcare workers, and the public, viral hepatitis will remain a major public health threat.
Dr Samlee Plianbangchang
(If you missed it, see part I) The second trip entailed the training of rural doctors. During the training course, we used a number of simple visuals to better get some basic ideas across. We wanted to drive home how common HBV was in China, and the number of Chinese people infected. We asked 10 people to stand up. They smiled with pride, having been selected, until they realized they were being identified as one of those possibly infected with HBV. The numbers dwindled as we went through the process of asking some to sit down representing those that had been infected, but resolved the virus, until finally, the last one standing represented someone with chronic HBV. This person was clearly horrified. This visual certainly drove the point home, but perhaps we were the ones educated by this process.
The Chinese people love children. I had a photo album of my children, which many enjoyed during the break. There was one photo with a picture of both my two children and my colleague’s two children. My colleague and I were traveling with two of the children and had not identified if either were infected. (As a result, we sat at every meal where most assuredly there was a large serving spoon in every dish…) There was only one child that could be “safely” identified. When I pointed the child out to them, I could hear them, speaking in English, saying “Yes, I knew it. Look at her. She’s sick… doesn’t look well.” I can’t even imagine what was said in Chinese. HBV is nearly always asymptomatic in children. All four children in the photo appeared equally healthy. At that moment, I was grateful these children were spared the taunts.
During the course of the visit, we made an impromptu stop at a hospital on the outskirts of one of the cities. We were shocked when we were permitted to enter the compound without pre-approval. It was not a sanitized visit like all of the other stops we made. We were traveling with a U.S. doctor, and I think the Chinese doctor we met was interested in speaking with her. The facility was well below the standards we had encountered elsewhere. The largest building on the compound was the “women’s facility”. We were not allowed in the building, nor were any pictures permitted of that particular building.
In another city we met with a conventionally trained doctor who had grown up in a very rural province, and was sometimes requested due to her rural background and familiarity. She told us of a recent rural visit, where hundreds of women had been infected with an STD. As a result of migration of workers into the cities, these women villagers are more often victims of diseases previously not seen in these areas. Sadly, many of the women were being infected due to the lack of precautions taken during the annual examination of women. The major culprit was the reuse of speculums that were not disinfected.
Finally, we met so many interesting, young Chinese, and heard so many wonderful stories like the one about a young university graduate who started the first online community of hbvers (that’s what they like to call themselves.) It would turn out to be the biggest in the world, and would provide much needed support for many isolated Chinese, living with HBV. There were also other stories, too, of how Chinese hbvers fought against discrimination by using a stand-in – either a paid “professional”, or other, loyal friends for their compulsory medical blood tests. Imagine living with the fear of losing everything just because of the results of a simple blood test.
I went to China, naively thinking I would make a difference. I was overwhelmed with the dire situation of those living with HBV. The experiences and stories were sobering and haunted me for months after returning. It was so personal. I certainly cannot fix this global problem on my own, but I will do everything possible, so that others may understand, just a little, the impact of living with hepatitis B in China.
Sadly, like many Americans, until I came face-to-face with hepatitis B, I had no idea of the global implications. Over the years, raising HBV awareness has been a quiet mission. In 2002 and 2003 I was fortunate to travel to China, and help present train-the-trainer programs that were to be used in Chinese orphanages, presented to Chinese foster families, and used as training sessions for rural doctors. The training programs were successful, and well received, but of course they were only a small contribution in a country where HBV infection is endemic. In fact one in ten Chinese are chronically infected with hepatitis B. Nearly one half-million die per year from HBV related liver cancer, or one Chinese person every 60 seconds. As an American, I was aware of the discrimination faced by those living with HBV in the U. S., but I had no idea how widespread discrimination was throughout China. For some naïve reason, I thought HBV infection would be better accepted in a country where so many are living with HBV. I was very wrong.
Training participants listened with earnest as we reviewed infection control techniques and modes of transmission. All were interested in the details. Perhaps what was more sobering were the interactions in between and following these training sessions. I found myself quietly met by a number of tentative women with downcast eyes. They waited in the bathrooms, and stepped out of tiny alley-ways as we walked back to our hotel. They quickly surveyed the area, their eyes darting back and forth, before they asked their questions about HBV treatment, and outcomes. The despair was was palpable.
We were invited to visit a local city orphanage. The rooms were somewhat sterile, but cheerful and the care takers were very good with the children. However, when we met with the staff, we learned of their concern of HBV infection among the children under their care. They were concerned about transmission. However, they continued to treat infant illnesses with injections and IV drugs, rather than an alternate, oral medication. An orphanage is often a world unto it’s own, yet children with HBV are often segregated from the other children. Children diagnosed with HBV outside of the orphanage environment may also be refused entry into school, although this practice may vary with the province, the city, or even the official in charge. That doesn’t leave a child identified with HBV much of a future.
Perhaps one of the most sobering experiences was meeting with HBV-listserve members at a local tea house. We were seated upstairs, away from other guests, which is not uncommon when foreigners are present, but it was clear this was more for their privacy. They scanned the room and were careful not to speak when the server entered the room. This was the first time they had met in person, and it was clear their hearts were heavy with the burden of living with HBV. Throughout the evening, no names were used, and all members referred to one another by their screen names. Most felt very isolated with their illness and were desperate for information. Many were shunned by family and friends, were humiliated and forced to eat separately, or carry their own bowl and chopsticks. They lived alone with the knowledge of their infection, as widespread discrimination loses jobs and ruins families. There were a number of treatment questions. Many were interested to know how long they needed to take the antiviral drugs, and whether or not they could stop for a while – if they were feeling better. We told them that stopping and re-starting treatment was not good, and they should speak with their doctor. We didn’t realize that few were under the care of a doctor for their HBV.
Later, while traveling in Shanghai, we visited a lavish pharmacy. All oral, prescription medications were available in China without being prescribed by a doctor. Only injectable drugs required a physician’s prescription. As a result, it was likely my listserve friends were self-medicating without the advice of a liver specialist. The drugs were likely cost prohibitive, so the need to start and stop antiviral treatment was more a function of expense. It was apparent that most were not being treated and monitored by a specialist. The prospect was sad, all the way around.
Please join us as Thursday’s blog concludes “A Personal Reflection on China for World Hepatitis Day….
I have been active in the HBV community for over twelve years, and during this time and I have been fortunate to make the acquaintance of some wonderful people, many who I consider good friends. The story below was relayed to me by a friend, though it’s possible you may have seen it in the Chinese news.
This is a story about a very brave, Chinese girl with hepatitis B. She studied in Japan, got her Masters, and married a PhD from China. Last year, she took all her savings, about 10,000 Yuan, with the blessing of her husband who was finishing his thesis in Japan, and went back to China. For the next twelve months, she traveled to major cities in China, all by herself.
At each stop, she held up a placard with a sign inviting passersby to have dinner with her, a person with hepatitis B, and that she would pay for the dinners – You eat, I pay. Of course, she repeated her story to the media to emphasize that it is safe to eat with a person that has HBV. A few nights ago, she appeared on CCTV, with another young hero, and they demonstrated how shaking hands with a person with HBV will not pass on the virus. There was instant testing of the cloths wiping the hands of the infected women. Of course, they tested their saliva too, since Chinese people use chopsticks, and pick food from common plates. All this was presented in front of a live audience, and millions of viewers at home. It brought tears to my eyes.
The original graduate from Japan has stopped touring and is now making a documentary. Her husband left Japan on a boat to return to China, the day before the earthquake struck. He is now home with his wife.
However the baton is taken up by another young Chinese lady, with the support of the other activist, and the tour is on again.
The actions taken by these young, Chinese activists are inspiring, and are true acts of bravery – especially in a country like China, where HBV discrimination is rampant. Perhaps we are not all comfortable going public with our information, but we can all work behind the scenes, and help raise global, HBV awareness. Tell us your story, or share it on the World Hepatitis Alliance Wall of Stories.
Summer is here, and it’s time for a smorgasbord of your favorite, fresh seafood. All good, but if you have hepatitis B, you’re going to want to take precautions to ensure you don’t get sick, or even die, from the seafood that you eat.
There are a couple of variations on what is considered shellfish, but basically it includes oysters, clams, mussels, shrimp, crab, and lobster. Oysters and clams are the only shellfish eaten raw, so they present the greatest danger. Raw oysters are the main culprit, although all raw or undercooked shellfish from warm coastal waters, especially during the summer months, are a risk. It’s difficult to ensure the origin of your seafood, despite labeling requirements, and whether or not it was frozen, or partially unfrozen at some time. As a result, it’s best to treat all seafood equally. And of course it’s not the shellfish itself, but rather a microbe called Vibrio vulnificus. In fact this hearty microbe may exist in warm, salt-water directly, and care should be taken to avoid exposure of open wounds to potentially contaminated water.
V. vulnificus is very virulent with a 50% mortality rate. The microbe may enter the blood stream via an open wound, or the GI tract where it may cause sepsis. This is especially perilous for people that are immunocompromised, or have liver damage due to chronic infections such as viral hepatitis – specifically hepatitis B. Symptoms may include fever, chills, vomiting, diarrhea, and abdominal pain. It is very serious, and may lead to septic shock and death. Septic infections are carry a high mortality rate of 50% in individuals without liver disease. Those that are immunocompromised or suffer from liver disease are 80 to 200 times more likely to develop septicemia from V. vulnificus than those without liver disease. Those are pretty serious odds.
Please keep in mind that this is not to be confused with basic food poisoning from “bad seafood”. There are no visible signs of the bacterium. Contaminated shellfish smell and taste fine. If you believe you may have been infected, you need to seek immediate medical attention.
If you must eat shellfish, please follow precautions. Be sure shellfish are thoroughly cooked. Cook all oysters, clams and mussels until the shells open and continue boiling for five additional minutes. If steaming, cook for an additional nine minutes. Boil shucked oysters for at least three minutes, or fry them in oil for at least ten minutes at 375 degrees F. Wear protective gloves when handling and cleaning raw shellfish, and avoid exposure to open wounds. (This warning actually includes exposure of open wounds to infected waters, so be careful when vacationing.) Take care to keep raw seafood and all other foods separate. Eat when cooked, and immediately store leftovers in the fridge.
I’ve never been a fan of raw shellfish, and with my HBV awareness, I instilled a sense of fear in my children regarding raw shellfish, or any raw seafood. If it’s got a shell – especially oysters, clams and mussels, they don’t touch it, and they gag at the sight of raw seafood. Okay, so maybe I carried that a bit too far, but at least I can check that one off my danger list. V. Vulnificus is dangerous! If you have HBV, it would be best to avoid shellfish.
World Hepatitis Day is Thursday, July 28th! Join the World Hepatitis Alliance. The theme is “This is Hepatitis”, which is aimed at raising global awareness. Globally, two billion people have been infected with hepatitis B, (one out of three), and 400 million live with a chronic, lifelong infection. Although there are excellent treatments available, there is no cure for hepatitis B. However, there is a safe and effective HBV vaccine. If you are infected, be sure loved ones and household contacts are screened and vaccinated. If you are not infected or not vaccinated, get vaccinated and help eliminate the spread of this virus, worldwide.
Show your support by adding a World Hepatitis Day PicBadge to your facebook and twitter profile pictures. This makes a great visual statement. You can also add the widget to your website or blog. Take a look at HBF’s website, and note the slider at the top with “World Hepatitis Day”. Check out the details on how to add the World Hepatitis Day PicBadge to your profiles and website. Select the “add to profile picture” button. Follow the instructions and the badge will be added to your FB and/or twitter profile pics. (FYI.. I use hootsuite to manage my tweets, and it wasn’t initially obvious that it picked it up, but it worked fine. ) Check out HBFs FB and twitter profile pics to get an idea of how it looks. Once you make the modifications, the PicBadge program will post the badge to your wall and tweet an invite to others to join with their support. You can also have picbadge send a request to FB friends so they may lend their support.
On a personal note, consider sharing your story on the World Hepatitis Alliance’s “Wall of Stories” Please feel free to share your story in your native language. The more personal the stories, the better!
Be sure to let us know what you or your organization is up to for World Hepatitis Day! No contribution is too small in the fight against viral hepatitis!