The Stealthy Yellow Killer

If you’re still wondering what it is, join the legion of ignoramuses who haven’t even heard of the hepatitis B virus (HBV), let alone the fact that they might be harbouring it, although everybody knows about jaundice, the immune system’s way of telling you that you may have the virus.

By and large the virus capitulates to the body’s superior defence mechanism but in several cases it might persist, eventually causing liver cancer. Of the seven known viruses causing liver diseases, A to G, B is by far the most prolific killer. And for good measure, its presence in the body becomes an open invitation for the low-profile but equally dangerous hepatitis C virus. "But," explains S. Acharya of AIIMS, "because it kills silently and slowly, not dramatically like cholera or plague viruses, the Government and the medical community have tended to ignore it. Hence the widespread ignorance about the disease and its agent." 

Ponder the various ways the virus can get to you—barber’s razor, piercing of ears and noses with infected needles, tattooing, acupuncture, blood transfusion, sexual intercourse, an infected person licking a fresh wound, human bite, surgeons operating on infected patients, possibly bugs and mosquitoes, and last and most dangerously, an infected mother’s fluids entering her baby during delivery. And mind you, it takes only 0.00004 ml of infected blood to transmit it whereas HIV needs 10,000 times the amount. 

The virus is a silent killer. Though 90 per cent of the carriers overcome the invader soon after infection, about 10 per cent of them, mostly infected during early childhood, become permanent homes. Once the virus tires the immune system into resignation, it hibernates for years and then suddenly fulminates into disaster. The victims feel forever fatigued and weak and suffer frequent attacks of jaundice, which eventually evolve into either liver failure or cancer. 

So while an apathetic Government was taking it easy, the virus was stealthily spreading its evil empire. Over the last decade, the number of carriers have gone up by seven million. "Embarrassingly for us," says B.N. Tandon of AIIMS, "during the same period, many countries such as Japan, Taiwan, Singapore, China, Thailand and Malaysia launched concerted offensives with vaccines on this scourge. All of them have recorded impressive decline of infection as well as disease." 

Obvious question: why didn’t we do the same? For one, we were too complacent as our carrier rate was not as alarming as that of China or Taiwan. For another, the vaccines needed to combat the virus are very expensive, each dose costing about Rs 300. Says Subrata Panda of AIIMS: "But we could have checked the disease in other ways such as screening blood donors for the virus, proper sterilisation of surgical instruments, and selective immunisation of infected would-be mothers. Let alone immunisation, we haven’t even taken the first two precautions seriously. About 30 to 50 per cent of donated blood still goes through unwinnowed for the HBV virus. "

 However, the persistent clamour created by a group of concerned physicians seems to have stirred the Government out of its complacency. There is talk about starting universal infant immunisation by 1997 as recommended by the World Health Organi-sation (WHO). Indeed, a small pilot experiment monitored by the National Institute of Communicable Diseases (NICD) is already on in east Delhi where children are being inoculated with vaccines donated to the WHO by SmithKline Beecham, one of the largest producers of HBV vaccines in the world.

BUT can we really afford universal infant immunisation? At current rates of Rs 300 per dose (Rs 900 for three) certainly not. But even at Rs 30 per dose, the rate the WHO is offering if we buy it in bulk, the cost of immunising only the newly-borns, which constitute about one-third of the total carriers, works out to be approximately Rs 300 crore a year. Considering the total budget for India’s Universal Immunisation Programme is Rs 75 crore, this is practically impossible.

Even so, immunising all infants seems to be the best, and least expensive, strategy. For, those infected at birth have a 90 per cent chance of developing liver cancer later while for those infected after the age of six the risk is only 10 per cent. Says Prof A.K. Sarin of G.B. Pant Hospital: "So by vaccinating all the newly-borns, not only can we avoid one-third of would-be carriers, we will also rid our posterity of this scourge."

 But what about the rest, doctors, nurses, haemophiliacs, homosexuals, drug abusers, high-risk groups more vulnerable to the HBV infection? Studies suggest that post-transfusion HBV infection is as high as 60-70 per cent but if the donors are screened for HBV, the rate falls dramatically to about 7 per cent. Says S.K. Mittal, chief pae-diatrician at the Maulana Azad Medical College: "Universal precautions for prevention of blood-borne infections and selective immunisation, admittedly difficult, will have to continue till universal infant immunisation achieves more than 90 per cent coverage and is sustained at that level for several years." Interestingly, the campaign for universal infant immu-nisation has little support from paediatricians. Many are openly critical of the move. "I don’t see much justification in spending Rs 300 crore every year on HBV vaccination when malnutrition, unsafe drinking water, and lack of birth care continue to claim millions of lives every year," points out Mittal.

Apart from these prohibitive costs, the logistics of reaching infants within 48 hours of birth is daunting, considering that almost 85 per cent of all births occur outside hospitals and no more than 50-60 per cent of these births are attended even by a trained midwife, leave aside a nurse or a doctor needed for administering the intramuscular HBV vaccine.

Mittal is also critical of the pilot HBV vaccination experiment in east Delhi: "They are administering the vaccine six months after birth, a practice which must be condemned, as this will not prevent perinatal transmission, which may be responsible for 50 per cent of chronic carriers in our country. What it means is we are giving only half the value of the money spent by parents for buying HBV vaccines for their children. The vaccine must be given within 48 hours of birth."

 Many, however, see this campaign as a plot by the WHO and drug majors to exploit the huge HBV vaccine market in India. With HBV declining in the West and China, which has the largest number of carriers, making its own vaccines, India looks like a very fine prospect. Already hectic lobbying is on for the two vaccines available in the market—the plasma-derived vaccine marketed by Bharat Serum in collaboration with a Korean firm, and the genetically engineered vaccine marketed by SmithKline Beecham. Both vaccines, however, have been shown to be equally effective.

 The plasma-derived vaccine at Rs 100 per dose is cheaper than the genetically-engineered one. But the latter is fast replacing the former all over the world, for two reasons. The genetically-derived vaccine, not being dependent on infected plasma like its rival, can be produced fast and in very large quantities. Two, it is safer than the plasma-derived one because the latter could be carrying other undetected viruses which might finally end up in your blood stream. But since economics is paramount, and the safety argument is still speculative, many doctors are pushing for the plasma-derived vaccine.

Whichever vaccine is used, it will not be enough to immunise all the 24 million babies born in a year. Also, to achieve any success in immunising the current pool of 40 million carriers, the immunisation endeavour will have to be sustained for at least 30 years. Whether the Government can do that, considering that about 30 per cent of all births are still not covered by the Universal Immunisation Programme, seems doubtful.