ABOUT VIRAL HEPATITIS PROGRAM IN INDIA

1. Viral Hepatitis: Elimination
Challenges and Progress
K. NARAYANASAMY
INSTITUTE OF HEPATOBILIARY SCIENCES
MADRAS MEDICAL COLLEGE

2. Introduction :
• Viral hepatitis refers to a pathologic condition wherein an infection due to
hepatitis viruses causes inflammation of the liver.
• Hepatotropic viruses that replicate in the liver and for which the liver is the
main target.like Hepatitis A,B,C,E,D.
• Non hepatotropic viruses The liver can be affected as part of a generalized
host infection with viruses that primarily target other tissues, like herpes
viruses (Epstein-Barr virus, cytomegalovirus [CMV], herpes simplex virus),
parvovirus, adenovirus and severe acute respiratory syndrome (SARS)-
associated coronavirus.

3. Why should we know about it ?
• Globally, over 300 million people are living with viral hepatitis.
• WHO, the regrouped - 1.34 million deaths globally in 2015,
• Viral hepatitis – 2nd major killer among infectious diseases after
tuberculosis (1.37 million) and higher than HIV (1.06 million) and malaria
(0.44 million).
 Hepatitis B virus (HBV)
infection.
• More dreaded virus
• 100 times infectious than HIV
• Silent killer
• 80% liver cancer

4. • 370 million (1 in 20)
chronic HBV
• ~ 8,87,000 die / year
• Every 30–45
seconds, one die
Global (Apr 2017):
•40 million carriers (2–5%
of general population)
• ~ 1 million infants each
year
• ~ 1,00,000 die / year
• India is slowly moving
towards High prevalence
zone.
http://www.who.int/hepatitis/en/
India (Second highest number of Hepatitis
B infected)

5. GLOBAL HEALTH SECTOR STRATEGY ON VIRAL HEPATITIS:
TARGETS AND PROGRESS
• The 5 areas, in which efforts are required to eliminate
hepatitis by 2030:
(1) HBV vaccination
(2) Prevention of mother to child transmission of HBV
(3) Injection and blood safety
(4) Harm reduction
(5) Test and treatment of HBV and HCV.
2016, World Health Assembly adopted the Global Health
Sector Strategy on viral hepatitis to eliminate hepatitis
by 2030.
World Hepatitis Alliance has started an initiative named
“Find the Missing Millions”, to find the millions of
undiagnosed people living with viral hepatitis.

6. GHSS is to reduce hepatitis incidence from
6-10 million cases to 0.9 million cases to
reduce annual hepatitis deaths from 1.4
million to 0.5 million by 2030
• By November 2017, 84 countries had developed hepatitis control programs.
• Lack of international investment in viral hepatitis programs, only a few countries included
hepatitis treatment and prevention strategies for all patients in their national hepatitis
programs.
• According to Polaris data, only 12 countries, namely Australia, Iceland, Switzerland , Italy,
Mongolia, Spain, Egypt, France, Georgia, Japan, Netherlands, and United Kingdom are
on track to achieve the WHO hepatitis elimination targets.

7. Hepatitis control through multi-disease testing
• In 2016, 2.75 million HIV patients also suffered HCV coinfection .
• Coinfections results in progressing to an advanced stage, costly care and management at
the patient level.
• Also high potential for HIV transmission, its progression, and associated mortality.
Necessitates the need for screening up for HIV and other coinfections in high-risk
populations.
• Identify the presence of multiple infections and variations in the pathogen along with
associated antimicrobial resistance.
• Help in streamline and simplify diagnosis and further management of multiple infectious
diseases, thereby reducing cost, improving access for patients, and eventually controlling
these outbreaks.

10. Differences between hepatitis C and B elimination

11. How to decentralize and simplify the service
delivery in the hepatitis B elimination program

12. Micro-elimination strategies of hepatitis B
• Micro-elimination strategies target individual population segments for which
treatment and prevention interventions can be delivered quicker and more
efficiently.
• these programs may focus on antenatal screening, infant vaccination, catch-up
vaccination, vaccination of persons who inject drugs, prisoners, decompensated
cirrhosis, veterans, or patients with haemophilia and homosexuals
• Micro-elimination strategies are tailored with realistic and well-defined targets
and goals.
• Micro-elimination projects may generate a template in a small geographically
defined population which may then be used to model services for larger
intervention programs
• Micro-elimination of hepatitis B, appear cost-effective and will have a positive
impact on longterm outcomes with screen and treat or vaccinate strategy
compared with no intervene

13. Lessons from the successful Egyptian program
• All hospitals and rural health centres were involved.
• A screening centre was set up in every village.
• Mobile units were made available.
• A huge media campaign was started through TV, radio, social media, paper
media, and SMS (short message service).
• A successful awareness campaign was run and society pressure generated.
• A person could walk into any screening centre
• Rapid diagnostic tests were made available instead of ELISA
• Seropositive patients were immediately referred to an evaluation centre.
• Free investigations and treatment were available

15. • Despite the growing momentum created by the WHO for eliminating viral
hepatitis as a public health threat by 2030, the global response is still slow and
more actions are needed to meet the elimination goals, especially in low-income
and middle-income countries.
• Japan is one of a handful of countries currently on track to achieve the WHO
hepatitis elimination targets by 2030.
• To better understand the successful control of viral hepatitis in Japan, it is
important to recognize the role of the patient association for viral hepatitis,
known as the “Japan Hepatitis Council”, which celebrates its 50th anniversary in
2021.
• The greatest impact of the Japan Hepatitis Council has been in achieving wider
access to antiviral treatments for viral hepatitis.
• The example of Japan and the Japan Hepatitis Council highlights the need for the
engagement of civil society and patient groups to ensure equitable access to
hepatitis services and to accelerate the global hepatitis elimination

16. In 1971, the JHC, initially named as the “Hepatitis Association”,
was established by Dr Hiromichi Nakajima in Tokyo

17. How to scale up elimination and meet the targets
• It is impossible to control hepatitis without the availability of free tests and
treatment facilities.
• Guidelines to diagnose and treat patients with hepatitis B are to be made
simplified,
• Infrastructure to test and treat should be expanded and
• Targets should be set up to test and treat in local health care centres.
• Sufficient funds should be allocated ad Innovative financing strategies should be
devised to raise the money

18. National Action Plan Combating Viral
Hepatitis in India NVHCP 2018
AIMS :
• Combat hepatitis and achieve country wide elimination of Hepatitis C by 2030.
• Achieve significant reduction in the infected population, morbidity and mortality associated with Hepatitis B
and C (Cirrhosis and Hepatocellular carcinoma).
• Reduce the risk, morbidity and mortality due to Hepatitis A and E

19. Strategy and Model:

20. GOALS
STRATEGIES
OUTCOMES
HIGHLIGHTS
Journey of Hepatology Department
for elimination of hepatitis

21. HBV: Tamil Nadu scenario
Ref: T. Kurien, S.P. Thyagarajan, L. Jeyaseelan, A. Peedicayil, P. Rajendran, S. Sivaram, S.G. Hansdak, G.
Renu, P. Krishnamurthy, K. Sudhakar, J.C. Varghese & STD Study Group, Community prevalence of hepatitis
B infection & modes of transmission in Tamil Nadu, India, Indian J Med Res 121, May 2005, 670-675.
• A community study in 2005, 1981 subjects were
screened
• HBsAg prevalence was 5.7%
• Higher than general prevalence of India
Till 2006, no special focus was given
to liver diseases

22. Took a unique and innovative approach
TO ADDRESS THE LIVER DISORDERS, SPECIFICALLY
towards ELIMINATION of HEPATITIS and
to start a liver clinic in Madras Medical College
STARTING UP OF LIVER CLINIC
Ref:
Liver clinic sanctioned as per G.O. Ms. No. 134, H&FW (E1), Dated:
07.08.2006
No adequate Human Resources
No Diagnostic facilities
No Infrastructure facilities
No Financial support

23. GOALS
• To estimate prevalence of Hepatitis and
elimination of Hepatitis from the Tamil
Nadu
Purpose
• Primary prevention: Stopping spread of
infection by vaccination
• Secondary prevention: Treating patients
diagnosed with Hepatitis infection with
specific drugs & follow up lifelong,
thereby ensuring that they don’t go in for
end stage liver disease/ liver cancer
Priorities
1. Awareness
2. Education
3. Lectures
4. Mass
screening
5. Vaccination
STRATEGIES

24. Strategy 1. Awareness
 Issuing pamphlets
 Wall posters
 Lectures to common people
 Organizing human chain - Madras Medical College entrance
 Exhibitions with liver specimens and regarding healthy
lifestyle in Govt General Hospital
School children as ambassador for creating awareness
among the public
 Celebration of World Hepatitis Day
 Rallies
 Street plays & dramas at crowded places like beach
 Taken pledge in special assembly by school children
Ref: 1) Permission for one week awareness and screening camps for hepatitis B, L. No. 20154/E2/2010-1, H&FW, Dt - 10.05.2010
2)Permission for awareness on world hepatitis day at schools assembly for children, L. No. 28810/P2/2015, H& FW, Dt - 16.07.2015

25. http://www.thehindu.co
m/todays-paper/tp-
national/tp-
tamilnadu/celebrities-
join-hands-to-fight-
against-hepatitis-
b/article2303893.ece
Strategy 1. Awareness

26. http://www.thehindu.com/todays-paper/tp-national/tp-tamilnadu/Awareness-programme-
on-hepatitis-infections/article15231667.ece
Strategy 1. Awareness

27. Ref: Screening and Awareness programme on world hepatitis day – The Times
of India 30.05.2008
Strategy 1. Awareness

28. Ref: Awareness programme on World Hepatitis Day– Deccan Chronicle 27.07.2012
Strategy 1. Awareness

29. Ref: Vaccine at free of cost announced on World Hepatitis Day
programme – Thinamani 29.07.2011
Strategy 1. Awareness

30. Ref: Hepatitis patients treated - Dinamalar 28.06.2012
Strategy 1. Awareness

31. Ref: Queries on liver disease addressed on World Hepatitis Day –
Deccan Chronicle 25.07.2015
Strategy 1. Awareness

32. Strategy 1. Awareness posters - 2022

33. Publication of books and booklets
Ref: World Health Organization Report - cited the efforts for the
book published title "Hepatitis Past, Present, Future”, 2011
www.worldhepatitisalliance.org
Strategy 1. Awareness

35. oNursing students of School of Nursing & College of
Nursing (11.6.2011).
oHealth care workers of Govt General Hospital (12.
6.2011).
oMedical Students studying in Madras Medical College,
Dental professionals at Madras Dental College
(29.12.2011).
o Hepatitis education modules were distributed to the
health care workers.
Strategy 2. Education

36. Guest Lecture on
oHealth care workers and doctors of institutes:
 ESI Hospital - K.K. Nagar (19. 7.2007)
 Stedford Hospital -Ambattur (12.7.2008)
oWorkers at CVRDE, Avadi (12.5.2009)
oInstitute of Obstetrics & Gynecology campus
(29.6.2010)
Strategy 3. Lectures

37. Screening camps - conducted periodically in different
areas of Chennai and other districts of Tamil Nadu
Camps - arranged with the help - local administrative
authorities like ward councilors, MLAs, MPs and other
Voluntary Health Organisations
All the patients - registered and given a unique ID for
reference - with their informed consent Blood -
drawn for specific Hepatitis B viral markers (HBsAg)
Ref: Permission for one week awareness and screening camps for hepatitis B.
Letter. No. 20154/E2/2010-1, H&FW, Dated - 10.05.2010
Strategy 4. Mass Screening

38. Area Districts Place
Number of
places
Number of
days
Month,
Year
HBV
Positivity %
Rural
Tiruvallur
Uthukottai 3 3 May 2009 4.76
Velliyur 2 2 June 2010 0.58
Manavur 1 1 April 2011 3.44
Periyapalayam 3 3 April 2013 4.67
Minjur 1 1 July 2014 1.25
Palavedu 2 2 April 2013 0.16
Theni Pannaipuram 3 3 May 2014 3.54
Urban
Chennai
Royapuram Constituency 7 7 July 2012 4.3
Harbour Constituency 7 7 June 2012 5.37
Kolathur 2 2 May 2013 3.45
Vellore Vellore 4 4 July 2011 4.97
Semi –
urban
Kanchipuram
Tambaram 2 2 February 2012 1.22
Madhavaram 2 2 February 2011 1.01
Porur 3 3 April 2012 1.56
Poonamalle 3 3 April 2013 1.62
Tribal Nilgiris Sholurmattam 2 2 July 2013 0
Overall 35 35 2.61 %
SCREENING CAMPS PLACES IN CHENNAI & OTHER
DISTRICTS OF TAMIL NADU

39. HOSPITAL SCREENING
(RGGGH - LIVER CLINIC)
• All the patients those who are entering into liver clinic were screened every
day (2006 to till date)
• Family screening of the Hepatitis carrier is also being done
“World Health Organization Report has cited the efforts
elimination of hepatitis through liver exhibition, Human
chain and awareness rally in the year 2012”
https://globalhepc.files.wordpress.com/2012/11/summary-report-
2012-world-hepatitis-alliance.pdf
Male Female Children Total
screened
86,540 74,523 15,117 1,76,180

40. ANTENATAL WOMEN SCREENING
(IOG, Egmore )
All the antenatal women, those who are
attending OPD, IOG, Egmore were screened
every day (2009 to 2012).
Total
screened
HBV Positive Prevalence
12,722 675 5.31%
Age group Prevalence
21-25 82 (7.58%)
26-30 45 (5.21%)
>35 3 (3.29%)
Ref: K.Narayanasamy et al., Int J Reprod Contracept Obstet Gynecol. 2016;5(1):170-174

41. S.
No
Place
Target
Group
Month,
Year
HBV
Positivity %
1 Dental College Dental
professional
January 2012 1.9
2 International drivers ‘day-Hyundai Drivers April 2012 2.02
3 Govt. Children Home, Rayapuram Children October 2012 8.64
4 Madras Medical College – Matron
office
Nurses July 2012 0.81
5 Madras Medical College – Health
inspector office
Health care
workers
July 2012 7.89
6 Madras Medical College – College
office
Office workers June 2013 1.09
7 Stanley Medical College Hospital workers July 2012 1.19
8 Tamil Nadu Science and Technology,
Adyar
Staffs January 2013 0.00
9 World Women’s Day - Institute of
Obstetrics and Gynecology, Egmore
Pregnant women March 2013 2.47
10 Kancheepuram Physically
challenged
April 2013 2.31
Overall 2.83
SPECIAL SCREENING PROGRAMS
ON WORLD HEPATITIS DAY

42. FIELD SCREENING RESULTS IN DETAILS
MASS FIELD SCREENING
• HBV general prevalence – 3.3.% with variability in rural, urban
HOSPITAL SCREENING
• HBV prevalence – 9.8 % with variability in male, female and children

43. Ref: Permission for screening camps and to “adapt village for making hepatitis B free” at
keelachery village as per letter. No. 27596/P2/2016-1, H&FW, Dated - 25.07.2016
• Adopted a village - First of its kind -
Keelachery, Kancheepuram district
(27.7.2016) – HBV Positivity: 1.83 %
•A view to extend it to other villages
HEPATITIS FREE VILLAGE

44. http://www.dinamalar.com//news_detail.asp?id=1572965

45. Strategy 5. Vaccination
(free of cost – Department of Hepatology)
Only one vaccine which prevents a cancer is –
Hepatitis B vaccine (liver cancer)
“100% PREVENTABLE”

46. AWARENESS CREATION AND
VACCINATION
“Till now about 5 lakh public were
vaccinated in hospital and field camps”
“Every year hepatitis B awareness
programmes will be conducted and so far
13 programmes were conducted in Govt.
general hospitals”

47. IHBS Screening
3424
3968
4965
5985
10895
12066
12294
10083
9500
3000
312
290
190
373
853
921
1215
1413
1499
393
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
HOSPITAL BASED SCREENING
TOTAL NO CASES HBV POSITIVE

48. Treatment :
0
1000
2000
3000
4000
5000
6000
2012 2013 2014 2015 2016 2017
HEPATITIS B TREATMENT
MALE FEMALE

49. IHBS : Vaccination data
800 700
900 1000
4000
5000
4550
6900
5500
3000
4000
3400
500
2300
1700
0
1000
2000
3000
4000
5000
6000
7000
8000

50. • Special liver lab
• Diagnostic / Therapeutic Endoscopic services
• Imaging Facilities (OP, IP)
• Liver ICU for end stage patients
"FIBRO SCAN“ (1.2 crore) non-
invasive testing of chronic liver
disease & liver cancer -
surpassing invasive liver biopsy”
“First time in the history of the
service to patients”
INFRASTRUCTURAL FACILITIES CREATED
TO TREAT HEPATITIS PATIENTS

51. BARRIERS FOR DEVELOPING COUNTRIES

52. INDIAN : Challenges

53. COVID 19 IMPACT ON PROGRAMS:

54. Indian Progress:In NVHCP Program :
• The NVHCP made commendable progress within a short period after its launch.
• Before the end of the 1st year, a network of national and state reference laboratories for
the diagnosis and model treatment centers at the state level for treatment have been set
up .
• Support district-level laboratories and treatment centers.
• Operational guidelines and manuals have been developed and training to strengthen the
capacities of the respective staffs was undertaken.
• Strategic information is key for advocacy, program planning, and monitoring.
• Surveillance of viral hepatitis is as complex and varied as the course of its infection,
manifestations, and outcomes.

55. • Outbreaks of hepatitis A and hepatitis E are already monitored through the Integrated
Disease.
• Surveillance Project and chronic hepatitis surveillance for HBV and HCV will be
implemented through the HIV Sentinel Surveillance among pregnant mothers, sex
workers, men who have sex with men, and people who inject drugs.
• Guidelines have proposed that NVHCP will collaborate with the department of health
research for carrying out operation research.
• The public health community has a great role to play in leading the program toward its
goal.
• Areas of impact are particularly three: 1)Operations research, 2)Strengthening hepatitis B
vaccination with reference to birth dose 3)Treatment adherence which is a key to program
success.

56. Ref: Hepatitis cases in TN lowest in country - New
Indian Express 26.7.2015
• During 2012 - 2022 about 66,132 Hepatitis
patients treated with monthly medications
utilizing funds through CMCHIS
“Chief Minister’s Health insurance scheme”
Institute of Hepato Biliary Sciences stands
(Medical Departments all over the state)
Utilizing the scheme benefits for the betterment
of poor & needy hepatitis patients
PROGRESS OF Institute of Hepatobiliary sciences :

57. Summary :
• Control of hepatitis B is feasible in the next 10 years or so through an aggressive national strategy
that requires
• Political will
• Strategic plans with timelines
• Multiple stakeholders’ involvement
• Strong infrastructure
• Public awareness
• Funding (domestic and international resources)
• A scale-up in screening is required to keep pace with the increase in treatment
• The availability of generics would make this endeavour more effective.