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Drug induced liver injury is quite common. Herbal and non-licensed medicines taken without doctor’s consultations are on the rise as a cause of liver injury and liver failure. Even innocuous looking Chinese tea has been associated with liver failure and death.Beware of all the drugs that you take.

With this era of self-medication and taking various non-licensed products for reasons like weight loss, cosmetic improvement, better digestion and even liver protection are the reasons for liver failure. In western world, paracetamol is the most common cause of acute liver failure. In India besides the drugs taken for tuberculosis, herbal products are the cause of liver injury. Painkillers are often the culprit.

Most of the times, DILI just presents with worsening of liver tests without causing any symptoms initially. Only when the liver injury is severe enough does it cause symptoms. You can have nausea, vomiting, abdominal pain and even jaundice. They tend to resolve with stoppage of medicines. However, on occasions it can progress to liver failure and may even need liver transplantation.

There is no test which can predict liver injury caused by drugs. The only safe way is to be aware about it and avoid taking any unnecessary non-prescribed medicines.

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Hepatitis A is a Hepatotrophic virus that predominantly affects liver. Besides Hepatitis A, other Hepatotrophic viruses are Hepatitis B, Hepatitis C, Hepatitis D and Hepatitis E. All of them are contagious and some are life threatening too. Hepatitis A and E are waterborne; Hepatitis B, C and D are transmitted by bodily fluids (via syringes, needles, injections, toothbrush, razors).

Incidence

Hepatitis A is the most common form of acute viral hepatitis worldwide. Nearly 119,000 cases of all cause viral hepatitis were reported in India in 2012. The Integrated Disease Surveillance Programme of the NCDC received notification of 290,000 cases of acute viral hepatitis in 2013. In addition to improving access to sanitation and clean drinking water, immunization plays an important role in prevention of Hepatitis A infection.

Transmission

The virus is present in stools of infected person. It is also believed to have foodborne and water borne transmission, bloodborne transmission and perinatal transmission by contaminated maternal blood or feces intrapartum. Risk factors for HAV include socio economic status, household size, limited access to sanitation facilities, travel, immigration, intravenous drug use, homosexuality, and childcare employees. Millions of HAV infections occur worldwide annually.

Prevelance

Hepatitis A has worldwide but uneven distribution between geographical regions and population groups. About 15 years ago in India, the cord blood anti- HAV antibody levels in newborns was nearing 100 per cent, which in turn reflected the maternal antibody prevalence. In recent studies, this level has come down to 50-60 percent – reflective of good sanitation.

Clinical Features

The incubation period is 15 to 45 days. It is unknown why hepatitis A is an age-dependent disease and most of children under six years of age develop subclinical or in apparent infections. Symptomatic hepatitis increases with age, being much more common in older children and adults. HAV infection is asymptomatic in 84% of children 1 and 2 years of age, 50% of children 3 and 4 years of age and 20 % of children over 5 years of age. Fifty percent of hepatitis A infections in adults above 60 years require admission. The case fatality which is 0.1% in children less than 15 years increases to 1.8% in patients above 50 years of age. The clinical illness starts with prodromal phase with symptoms of malaise, weakness, fever, anorexia and non-specific symptoms and lasts from a period of days to weeks. It is followed by an icteric phase lasting 2 to 4 weeks and is characterized by jaundice where the person turns yellow, the eyes and urine are prominently appearing yellow. During this phase bilirubin rises and can exceed 20 mg/dl and transaminases rise to a range of 500-2000 IU/L. In the final Convalescent phase of the disease, the virus is cleared, the patient recovers and biomarkers become normal.

Few patients develop relapsing hepatitis with worsening of jaundice and bilirubin even after it has started falling once. There could be a prolonged hepatitis A where the icterus may persist for even six months.

A small proportion of patients develops severe hepatitis and may develop fulminant hepatitis and acute liver failure (ALF). It can even cause acute on chronic liver failure (ACLF) in persons suffering from some form of chronic liver disease. In India, HAV forms the most common cause of ALF in pediatric age group below 10 years. Autoimmune hepatitis can be triggered by HAV infection in individuals with a genetic predisposition to the disease.

Prevention

As there is no specific treatment the best alternative is prevention. It can be prevented by three general approaches. Because the predominant mode of HAV transmission is by poor sanitation, improving access to adequate hygiene and sanitation, including the appropriate disposal of human waste and provision of clean drinking water, is an important contributor to prevention of HAV. Good hand washing, can contribute to preventing transmission. Another modality is active immunization to those individuals at risk. Ask your doctor for a vaccination for yourself and your child if you are negative for protective antibody. A third approach is passive immunization with immunoglobulins only suitable after specialist consultations

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Hepatitis B is a serious global health problem, responsible for 1.4 million deaths every year compared to 1.5 million deaths from HIV/AIDS and 1.2 million from each of malaria and TB. India has over 40 million Hepatitis B infected patients, second only to China, and most people with chronic Hepatitis B or C are unaware of their infection, putting them at serious risk of developing cirrhosis or liver cancer which are life threatening.

Why is hepatitis B testing important?

The disease is transmitted parentally by unsafe injections, blood transfusion, iv drug use, unsafe sexual practices as well as from mother to child. The risk of transmission is 100 times greater than the most feared virus HIV. Most of the individuals who get infected in childhood turn to be chronic and virus remains in their blood for decades. During long run, this can not only cause cirrhosis of liver and its complications like vomits of blood, fluid collection in abdomen, unconsciousness or jaundice but even cancer of liver. In our country hepatitis B is the leading cause of liver cancer. Most importantly, not all patients exposed with this virus will develop jaundice. The virus can be present even in asymptomatic individuals and the only way to detect the virus is to get tested by a simple investigation with minimal costs. All individuals irrespective of their age, gender or living standards should get him tested.

How can you protect yourself?

The reason testing is important because, early detection can lead to a better outcome of treatment. Nowadays there are safe and one pills a day treatment available for the virus if detected. These drugs, if taken appropriately with regular monitoring, can decrease the risk of complications. However, the best way to protect oneself from the virus is to be vaccinated. Indian immunization program has now included hepatitis B vaccination for all children in our state. However, children delivered in few other states and adults are not protected at present and should get vaccinated. All doctors get themselves vaccinated as we know that the only sure shot method to protect oneself is Hepatitis B vaccination.

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In India 1% population is affected with hepatitis C. Though it seems less as compared to other diseases, the sheer number of patients in terms of population is huge. Hepatitis C, unlike the food borne virus hepatitis A/E does not present with jaundice routinely.

Hepatitis C presents directly when the liver is shrunken and cirrhotic. So it is of utmost importance to identify the infection early. Anybody who has been transfused before 2003 in India should get themselves tested as the virus was not screened before that time in India.

A study carried out in US showed that of 4.1 million affected, only 1.7 million get diagnosed, and only 388 are under care of doctors while only 40 are treated. If such is the scenario in US, it is expected to be worse in India.

The treatment of hepatitis C has always been difficult as it entailed weekly injections for a year and a drug with severe side effects. A lot of patients had to stop treatment because of side effects. Even after going through such a treatment the success for the treatment remain poor. With the conventional treatment of peg interferon and ribavirin the success remained nearly 40% for genotype 1 and 70% for genotype 3, the two most commonly found genotype in India.

Starting from 2011, the scenario for hepatitis C has changed. Newer drugs became available for the treatment and the duration of treatment became shorter. Two initial drugs, bocepravir and telapravir never made it to Indian market. However, in 2015 February, Sofosbuvir became available and that increase the treatment success rate to nearly 90%. But even after that drug, weekly injections were required in majority, which still had side effects.

The picture is completely different. Hepatitis C can be cured even with a single pill to be taken for 12-24 weeks. The efficacy is more than 97% and the side effects are negligible. If you have Hepatitis C, it is now safe and effective to get treated.

Viral hepatitis, caused by any of the five hepatotropic viruses, i.e., hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV), and hepatitis E virus (HEV), represents a major health problem worldwide.Its prevalence is highest in some parts of Africa, South America, Romania, Russia and the Mediterranean region included Southern.

In Northern India, the prevalence of hepatitis D in HBsAg-positive individuals from New Delhi was reported to be 8.1% in 1996 and 10.6% in 2005. This virus is only seen in individuals affected by hepatitis B. Majority of HDV infections are acquired through parenteral and sexual routes, which is similar to Hepatitis B. It has been estimated that ~5% of the HBV carriers are also co-infected with HDV, resulting in ~15 million people infected with HDV worldwide. The picture is similar to Hepatitis B but is more severe. The treatment of Hepatitis D is linked to treatment of Hepatitis B.

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Viral hepatitis, caused by any of the five hepatotropic viruses, i.e., hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV), and hepatitis E virus (HEV), represents a major health problem worldwide.All of them are contagious and some are life threatening too. Hepatitis A and E are waterborne; Hepatitis B, C and D are transmitted by bodily fluids (via syringes, needles, injections, toothbrush, and razors).

Incidence

Hepatitis E is the most common form of acute viral hepatitis in adults in India. The first well-documented epidemic of hepatitis E infection in India was the epidemic of 1955–56 in New Delhi, affecting a total of 29 000 people; this occurred due to fecal contamination of drinking water.Based on the 2010 global burden of diseases study, it has been estimated that as many as 20.1 million people were infected with HEV genotypes 1 and 2 in 2005. This represents 71% of the world’s population, with 3.4 million symptomatic cases, 70 000 deaths, and 3000 stillbirths. The death rate was higher among symptomatic pregnant women that among symptomatic non-pregnant women

Transmission

The virus is present in stools of infected person. It is also believed to have foodborne and water borne transmission, blood-borne transmission and perinatal transmission by contaminated maternal blood or feces intra-partum. Risk factors for Hepatitis E include socio economic status, household size, and limited access to sanitation facilities, travel, immigration, intravenous drug use, homosexuality, and childcare employees. Millions of HEV infections occur in south-east Asia annually.

Clinical Features

The incubation period is 15 to 45 days. The clinical illness starts with prodromal phase with symptoms of malaise, weakness, fever, anorexia and non-specific symptoms and lasts from a period of days to weeks. It is followed by an icteric phase lasting 2 to 4 weeks and is characterized by jaundice where the person turns yellow, the eyes and urine are prominently appearing yellow. During this phase bilirubin rises and can exceed 20 mg/dl and transaminases rise to a range of 500-2000 IU/L. In the final Convalescent phase of the disease, the virus is cleared, the patient recovers and biomarkers become normal.

A small proportion of patients develops severe hepatitis and may develop fulminant hepatitis and acute liver failure (ALF). It can even cause acute on chronic liver failure (ACLF) in persons suffering from some form of chronic liver disease. In India, HEV forms the most common cause of ALF in pregnant females. It is advisable to avoid eating any outside/unhygienic food during pregnancy, especially during the third trimester as the chance of developing liver failure is more than 20%.

Prevention

As there is no specific treatment the best alternative is prevention. It can be prevented by general approaches. Because the predominant mode of virus transmission is by poor sanitation, improving access to adequate hygiene and sanitation, including the appropriate disposal of human waste and provision of clean drinking water, is an important contributor to prevention of HAV. Good hand washing, can contribute to preventing transmission.

If you are suffering from any of the above mentioned symptoms or would like to know more about the disease Contact US