A B C of Hepatitis


28th July is declared as ‘World Hepatitis Day’.  I thought I will share some information with you to help and prevent major illness affecting the liver causing nearly 1 million deaths annually world wide.

Hepatitis is a viral infection of the liver.   There are Hepatitis viruses A,B,C,D,E, but the most relevant are A, B & C.

Hepatitis A is relatively an innocuous viral infection, normally spreads by contamination of food and water and can be prevented by good hygiene. Nearly 1.4 million people across world get Hepatitis A.  Many of us including me, had mild jaundice in childhood and in a week’s time cleared off.  The infection occuring once, provides immunity for the rest of our life.  Hepatitis A vaccination is available and if one member of family has Hepatitis A, then others can take vaccine. Good hygiene and sanitation are most effective measures for  prevention.

Hepatitis B, on the other hand is a much more sinister virus.  More than 240 million people have chronic (long-term) liver infections. About 600 000 people die every year due to the acute or chronic consequences of hepatitis B.

This is actually a preventable disease.  Now an effective vaccine is available and  has been made mandatory as part of immunization program for neonates.  But in earlier days it was not mandatory.  You may not be sure whether you had Hepatitis B immunization in your childhood and it is worthwhile particularly if you are active and are likely to sustain some injury etc., to go in for a booster dose of Hepatitis B.

The biggest risk is that Hepatitis B spreads by body fluids through skin and mucosal injuries just like the AIDS virus but it is nearly 50 times more resistant than AIDS virus.  In fact, the AIDS virus is a very fragile virus which can just die on drying up.  But Hepatitis B, on the other hand, can stay on in moist surfaces for a period of atleast a week.  That is a big risk. There are so many places that can lead to spread- hospitals, clinics, unsafe sex, sex workers etc.

Hepatitis B virus does not enter through intact skin or mucus but if there is injury, there is all the more reason that you need to have protection.  Also when you go in for a procedure, you have to insist on the healthcare worker on wearing gloves while handling your wound or doing any examination.  Blood, body fluids, contaminated needles, unnatural sex are high risk factors for Hepatitis B.

So the best way to prevent is  vaccination or booster dose appropriately.

Please vaccinate the newborn and if you don’t know your immunization status, take a booster.

Hepatitis B, once it enters, can linger on in the liver and can be detected by a blood test called HBsAg.  So in case an adult gets jaundice and it clears off, it is definitely both Hepatitis B and C infections are to be tested for.

Sequelae of Hepatitis B: What happens to Hepatitis B or C when they infect the liver ? They produce cell necrosis.   When the liver cells die, there is always scarring, just like a scar forms after a wound on the skin.   The repeated internal scarring produces  ‘fibrosis or cirrhosis’ of the liver.  The liver becomes firm and fibrotic.  This takes a long time of may be even 10 years and can be detected. Nowadays cirrhosis can be easily picked up by Scans including CT, Ultrasound or Fibro Scan and one can limit the progress of the cirrhosis.

liver image

Liver Cancer The big risk of Hepatitis B & C viruses unfortunately is development of liver tumors.  Given enough time, at least a third of them develop liver cancer ,which are aggressive involving a large part of the liver.

Unlike kidneys, liver is a single large organ, a huge organ of the body to metabolize all the nutrients, drugs, etc.  So nearly 80% of the liver has to be damaged before there are any signs outside and that is a big reason why most liver diseases are silent and can only be detected much later when the damage is extensive.  So it is very very important for us to make sure that we undergo appropriate diagnostic measures to identify them in the early stage.

Hepatitis C also has a similar mode of transmission as Hepatitis B.  The most unfortunate thing however, is that Hepatitis C has no vaccine so far developed though there have been attempts on that.  But Hepatitis C has effective treatment.

Recently, a rich philanthropist who has been harboring Hepatitis C virus almost 30 years came to me with cirrhosis and liver cancer. Many told him that Hepatitis C has no treatment.  Fortunately it is not true.  Hepatitis C has effective treatment now  and should be treated.  This will prevent further progression into cirrhosis and liver  tumours and also chronic liver disease.

In brief, therefore, Hepatitis A is self-limiting, Hepatitis B is preventable and Hepatitis C is treatable.  So it is all good news for you – provided you take adequate care in your life.

WHO fact sheet on Hepatitis : http://www.who.int/mediacentre/factsheets/fs204/en/

I lost my childhood friend

Not all stories of cancer have a happy ending.  It is a reality that we still lose patients. But if they are young, proactive and have a new family, you certainly feel sad.  My friend from childhood was playful and always helpful. He had his ups and downs but was always cheerful and faced life with equanimity.  He was diagnosed as CLL ( chronic Lymphatic Leukemia), a type of malignancy of blood and lymph nodes. He fought on gamely for  more than 5 years knowing the seriousness of disease.  He was doing well, active physician in his profession, willing to help others and look after sick patients. But as fate would have it, suddenly the disease took over and he started succumbing to infections that led to further complications.

One often wonders again, as I said in the last blog, “Why good people should have bad outcomes”?  It applies not only to cancer but many other incidents, like accidents, cardiac illness.   How do you define fate? How to justify this as ‘Karma’? One of my patients recently asked- he never had a drink, never smoked and enjoyed teaching students and always helped others -why should he get a gastric malignancy?Did he do bad Karma is last birth? No evidence at all.

Frankly speaking, these are random, unfortunate events, rather unfortunate accidents that alter the course of life. Just as you have ‘stroke of luck’, you occasionally get ‘a bolt of bad Luck’.  Yes, I do believe in doing good, but that is not to expect that I will have great time rejoicing in heaven.  Mostly, the goodwill of those who receive your help sustains you and also gives you the positive energy.

Coming back to my friend, many advanced therapies were proposed.  Some of the drugs unfortunately are now not available in India. With a lot of difficulty a drug was flown in but as any new drug , it had its own side effects. This is the problem of modern medicine.

I feel the pain on loss of a dear friend, but what choice do we have but to get on with life.

I can only say that fight on gamely even if you know that the outcome may not be good.  That’s the best we can do.

A mile, NOT an apple a day keeps the doctor away

Earlier I mentioned about the beneficial effects of exercise not only during treatment but also to prevent illness. 

I was actually curious to know the origin of the phrase ‘An apple a day keeps the doctor away’.  It turns out that it is actually a Welsh proverb, originally came in print in February 1866 edition of ‘Notes and Queries’ Magazine, a Pembrokeshire proverb- “Eat an apple on going to bed and you will keep a doctor earning his bread”. That’s scary that a doctor CANNOT earn his bread. What are people upto. Thank God some one has the wisdom to modify the proverb.!! Let me tell you that apples are not a favourite fruit in my own family. Of course they do not want to keep the doctor away and nor do they want to keep him earning his bread.  They just don’t like apples and that actually is fine with me.

 On a bit of reading, I did find that apples are healthy.  They do contain Vitamin C, Pectin which adds to the fibre, zero cholesterol and also boron and quercitin, a beneficial flavonoid.  Certainly an apple a day is not the best way to keep the disease and doctor away. 

A stunningly simple fact !!.  

Exercise is something that we are all advised and it’s also something we don’t like, including ME. But it’s the simplest way to keep away two big Cats – Cardiac and Cancer from coming anywhere near you.  Physical activity of, say, walking a mile a day, clearly reduces Cancer and Cardiac risk as shown in multiple studies. 

Exercise helps in controlling weight, improves bones, muscles and joints, reduces blood pressure by 10 mm and also risk of diabetes, apart from being a great stress-buster and certainly reduces the risk of heart disease.

What about cancer?  We know that cancer can be caused by different mechanisms, but can exercise really reduce the cancer risk?

The answer to that is YES.   NCI (National Cancer Institute) statement on physical activity and cancer risk gives exhaustive information on various cancers. In brief, colon cancers have been very well studied and the risk can be reduced by nearly 30% by reducing the BMI and having atleast 30 minutes of moderate to vigorous physical activity per day.  Does it mean that all those who exercise will never get cancer?  The answer is NO but certainly, it is the easiest way to reduce the risk and certainly is the best way.

 The same is true for breast cancer.   Existing evidence shows that the risk of breast cancer is substantially lowered on exercise and limiting weight gain.  There are multiple mechanisms involved like estrogenic storage in fat, immune responses etc.

It is very simple, that if you exercise you will reduce colonic cancer, breast cancer and endometrial cancer which is cancer of the uterus, all very common diseases. Not only that, it also, as I said earlier, increases the survivorship by a better compliance with treatment.

The most difficult step is to start exercising regularly and I am guilty of the same.   You keep looking for excuses to skip the daily routine of physical activity.  It just needs 20 minutes, a brisk walk, a treadmill or stationary bike.  I know that we do not have green spaces and parks to walk around but you certainly could have a little space for a treadmill or stationary bike. 

 ‘If you can manage 30 minutes every day for 5 days a week’, you are a winner.  Let me tell you the positive benefits are so many, on your joints, on your overall personality that when I do my treadmill for 30 minutes, I have the energy to go through my surgeries the whole day and that I think is the single most benefit, whatever are the other benefits are the additional benefits for me. 

Come on guys,  wake up and walk up.  Walking up, infact, is the simplest way to exercise.  I thought I will talk to you later on simple programme of ‘STEP UP’, which is so remarkably simple that anyone can follow it.  I will highlight on this and the positive benefits of this in my next write-up. Meanwhile, definitely go through National Cancer Institute information if you want detailed information on the physical activity and cancer risk. 

So walk a mile and of course you can also have an apple and certainly keep the doctor away from you.  Don’t wait for tomorrow, START TODAY.