World Hepatitis Day is marked every year on July 28 to raise awareness of the global burden of viral hepatitis. It is estimated that worldwide, 290 million people are living with viral hepatitis unaware. The theme for this year’s world hepatitis day is to raise awareness to “find the missing millions”.
The liver is located in the right upper quadrant of our abdomen. It performs many critical functions that affect our metabolism, mainly bile production, which is essential to digestion, filtering out toxins, excretion of bilirubin, cholesterol, hormones and drugs, breakdown of carbohydrates, fats, proteins, storage of sugar in form of glycogen, minerals, and vitamins, synthesis of blood proteins and synthesis of clotting factors. Hepatitis refers to an inflammatory condition of the liver. It’s commonly caused by a viral infection, but there are other possible causes as well. These are broadly divided into two- infective and non-infective. Infective pathology is usually due to viral and bacterial infection and the non-infective hepatitis is caused due to excessive alcohol consumption and other toxic material like over use or overdose of certain medication which are mainly metabolised in liver, exposure to poison and rarely hepatitis is caused due to faulty immune system. The drug induced hepatitis usually caused in our country is due to anti tubercular drugs, anti epileptic drugs and certain painkillers which can cause serious damage to the liver. People suffering from chronic hepatitis B and C should avoid alcohol because it may accelerate liver disease and liver failure.
An auto immune disorder occurs when our immune system attacks and destroys healthy body tissue because of altered programming. When we have an auto immune disorder the immune system does not differentiate between healthy cells and potentially harmful pathogen. The exact cause of auto immune disorders is still not known.
In acute hepatitis, patients usually have fever and pain in upper right quadrant of abdomen and loss of appetite and weight. In later stages, when the liver is damage significantly then the colour of urine and stool becomes dark yellow just like turmeric. If the colour of eye and skin is changing to yellow then it is a sure sign of hepatitis and liver damage. The diagnosis can be confirmed with blood test, ultrasound abdomen and liver biopsy.
Hepatitis deranges the functions of digestive system, metabolism of carbohydrates, fats and proteins. The other serious problem which is associated with hepatitis is altered clotting. The clotting function is essential to stop any bleeding from the body after any injury, be it accidental injury or surgically induced injury. If clotting function is deranged then there will be excessive bleeding from the all tissues which may lead to excessive blood loss which could be fatal particularly in acute hepatitis and acute liver failure. Here I would like to emphasise that these patients not only need blood replacement but also need correction of clotting factor too. The complication of chronic hepatitis B or C can lead to more serious health problem like chronic liver disease, liver cirrhosis, liver cancer and liver failure.
According to ICMR report, it is estimated that currently about 40-45 million are HBV carriers and 10 million people are infected with HCV in India. Viral hepatitis is the leading cause of liver cirrhosis and hepatic cancer. Hepatitis virus is of five types, hepatitis A virus (HAV), B virus (HBV), C virus (HCV), D virus (HDV) and E virus (HEV).
HAV is the most common cause of acute hepatitis all over the world. HBV and HCV are chronic viral infection. According to global hepatitis report 2017, HBV and HCV are major public health problems. It is more common in Asian and African countries probably due to prevailing low socio economic conditions, leading to poor hygiene and sanitation. Hepatitis B and C virus can spread after sharing an injection needle which is quite a common practice in drug addicts. It can also spread through sharing of an infected razor blade.
As HBV and HCV are found in blood and body fluids, it spreads through infected needle, infected blood, blood product and other body secretions. It can be prevented by using single use disposable needle and syringe, transfusing only screened blood from an authorised blood bank, disposing infected material through appropriate medical waste disposal authorities and having safe sex with protective measures.
Hepatitis B is occupational hazard for any health worker. Hepatitis B virus (HBV) is 100 times more infectious than HIV/AIDS. Surgeons have an ethical obligation to render care to the hepatitis infected patients as to other patients. The risk of transmission of HBV from patient to the surgeon is greater than that of surgeon to patient. High viral load increases the risk of transmission post contact. The actual risk of hepatitis B and C are many times more than the HIV infection in healthcare workers. About 37.6% of HBV, 39% HCV and 4.4% of HIV in healthcare workers around the world are due to needle stick injury. A study by a French surgeon estimated that general surgeons have 6.9% lifetime risk of contracting HCV and 0.15% lifetime risk of contracting HIV.
Being an orthopaedic surgeon, I can say for sure that orthopaedic surgeons are more vulnerable to unintentional injury due to metal sharps than any other surgeon because orthopaedic surgeons deal with many sharp tipped instruments and implants in addition to general instruments. The fractures ends are often sharp and surgeon or assistant are at greater risk of an injury during reduction of fracture even after wearing thick gloves.
Needle stick or sharps injury can be prevented by using safe practice during work and getting vaccinated against the infection. Surgeons should continue to use the highest standard of infection control, universal safety precautions and accepted measures to prevent blood exposure.
(The writer is an orthopaedic surgeons based in Dehradun)
Tuesday, 28 July 2020 | Dr Gaurav Sanjay| Dehradun