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Oct 16, 2015

Landscape of Viral Hepatitis E in Nepal: Understanding the basics first (Part 1)

I am not an expert but out of curiosity - I am again writing on Viral Hepatitis E as a public health physician and also who understand this disease at personal level out of suffering. Please also read my previous summary post on Understanding HEV in Nepal.

Most of the time, the word "poor" is painful !! This is what  I feel - so why is it painful? Well, being "poor" is after all a package full of "suffering, hunger, diseases and  of course struggle". I am not in a position to ventilate every pains of being poor here, however I would like to bring one public health issue that has plagued our communities since centuries. In the business of being poor and others considering you poor - there is lots of differences and of course paradoxes. Sometime, I feel the concept of "poor" is more of psychological assessment of yourself rather than other labeling you a poor chap or even a poor country !! Here is one example: I meet many shepherds in highlands of Nepal, they do not consider them poor and they are the happiest individuals I have seen and come across. But in the index of modern socio economic scale, he will be considered poor; that's it !! This is one aspect of looking at being poor, however "poverty" is rather a more appropriate word when we correlate the factors associated with enteric disease that I am touching upon in this post. So I would use the word "poverty" more often trying to connect with enteric disease that inflict a community where there are perennial problem related with the provision of adequate water, sanitation and hygiene practices. But sometime, let me be a bit critical - people shades crocodile tear in the name of poor and poverty and do business for their benefit. I have come to realize this inconvenient truth late and of course out of humble understanding that everybody is honest in what they do and work for the noble cause to end the suffering of those in living in poverty stricken community. In this regard, I agree with some of our colleague that one who stays in 5 star hotel and wears a pencil healed shoes can't work for the poverty stricken community. This is another bitter truth !!

Now to the subject of the blog post for now. There are long list of enteric diseases that catches attention of any physician working in low income setting from enteric to vector borne illnesses that can inflict an individual from your head to toe. Here, I am writing few words on enteric disease that has outbreak potential and has been yearly headline in dailies in Nepal. Yes, your guess - viral hepatitis and in particular hepatitis E. Popularly, this enteric disease is known by the name of "viral jaundice" among health professional and layperson in the country.  For our knowledge, this viral hepatitis is a recent discovery in early 1980s in Kashmir, India. Back then, it was known by the name of "epidemic non - A, non - B hepatitis" or "enterically transmitted non - A, non - B hepatitis". However, this disease entity was genetically characterized in 1990s, thereafter named formally Viral Hepatitis E (HEV).
HEV is explained as a spherical, non enveloped virus with a single stranded, positive sense RNA genome. This is the only member of a new genus, Hepevirus, in a new virus family, Hepeviridae. There is a description of 5 genotypes (G). G1 and G2 have been recovered only from humans whereas G3 and G4 are recovered from both humans and swines. G5 is an avian virus. It is clinically difficult to differentiate with other viral hepatitis in terns of clinical presentation, however on careful history taking and examination we are able to delineate from hepatitis B and C. The incubation period (IP) of HEV can approximately of 40 days. It is also reported that HEV infection never progress to chronicity and can be diagnosed by detecting viral RNA (RT - PCR) in the serum and / or feces during IP or early acute phase of disease or can be diagnosed by demonstrating anti - HEV of the IgG class in the serum during late phase or convalescence period of the illness. As a common knowledge, this disease is self limiting illness so need to be treated symptomatically and there is no specific therapy as of now. However, we hear that antiviral drugs are in research phase.
The most dreaded part of HEV infection and why there is so much interest in the HEV vaccine development and its prevention is its grave complication that occur if infect pregnant women. There are numerous reports of maternal deaths with serious (fulminant) hepatic failure or in mild or moderate, it can cause loss of pregnancy. Therefore, HEV has serious public health importance in terms of maternal child health protection. Also, there are lots of other medical complications among those with chronic liver ailment or even other chronic illnesses.

From public health perspective, HEV and other enteric diseases like cholera have been relevant in the backdrop of increasing disaster situation that has led to public health disaster like situation. Name it - very current would our Nepal experiences, though fortunately we did not have major outbreaks but you never know what comes up there in coming days. Last year, there was HEV outbreak in Biratnagar and we all know well - how tough it can be when such outbreak occurs in the center of bustling  town. Much to worry, however, would be if such outbreaks occur in hard to reach areas of the country like the one that occurred in the year 2009/2010 where cholera outbreak took hundreds of lives untimely. It is therefore always in the best of investment that we work on the preparedness now, so we know what, how, where and who kinds of approach when such outbreaks occur in remotest part of the country.

17th Oct, 2015
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