Most of the 10 million people estimated to be carrying the Hepatitis B virus (HBV) in Bangladesh do not know they have the infection and are putting others at risk, doctors have warned.
Expert researchers have said the primary test for the virus can often yield false negatives and that rigorous testing is required for diagnosis, in particular for pregnant women who can infect their unborn children in the womb.
“About 4-7% of the population is HBV infected, and 3.5% of pregnant women have the virus,” Professor Dr Mohammad Ali, secretary general of National Liver Foundation of Bangladesh told the Dhaka Tribune.
“These virus-infected persons are the potential source of infection to their neonates, members of the family and other individuals,” he added.
According to the National Liver Foundation, about 60-70% of the infected individuals are not aware about the existence of HBV in their body.
For every 100 children under four weeks old, hepatologists estimate there are 70-80 cases of physiological jaundice and of these, 10 to 11 are born with HBV. Sometimes half of them do not show any symptoms at an early age.
Bangladesh Institute of Child Health (BICH) research published in July found that of the 100 children up to the age of 15 who were admitted to the Dhaka Shishu Hospital with acute viral hepatitis in 2016, four had acute HBV infection.
“The children were found to be HBV positive. This mostly happens due to lack of awareness and failure of blood test screening,” Dr Salahuddin Mahmud, BICH assistant professor of pediatric gastroenterology, hepatology and nutrition, told the Dhaka Tribune.
The World Health Organisation (WHO) believes that globally, this lack of awareness and poor access to diagnostic tests means 95% of the 400 million people who live with Hepatitis may not know they are infected.
People become infected with Hepatitis B by receiving unsafe blood, typically through a blood transfusion. The primary test for the virus is the HBsAg test but it can yield false negatives.
A joint study by the WHO, the Directorate General of Health Services (DGHS), and the Institute of Epidemiology, Diseases Control and Research (IEDCR) found that one third of the blood tests taken at blood transfusion centres across Bangladesh were incorrect when compared with the results obtained at IEDCR.
Among the incorrect results, missed diagnoses of HBV were pre-eminent.
WHO recommends the mandatory screening of all blood donations for HIV, Hepatitis B, Hepatitis C, and syphilis according to the quality system requirements.
However, the organisation cites an irregular supply of test kits as one of the most commonly reported barriers to screening. In countries like Bangladesh, WHO says only two thirds of blood donations are screened following basic quality procedures.
Professor Dr Syed Shafi Ahmed, the head of Pediatric Gastroenterology, Hepatology and Nutrition at BICH, said false positive and negative results may occur in the most common “rapid strip” test.
“Although so-called proper donor screening is done prior to blood transfusion every time, they are unable to prevent viral hepatitis which includes Hepatitis B and Hepatitis C,” said Professor Dr Syed Shafi Ahmed and Dr Salahuddin Mahmud, assistant professor of the same department, in a research paper. “It is not recommended by WHO as a universal screening of blood donors.”
Professor Shafi suggested that the blood transfusion departments of medical colleges, institutes and specialised hospitals should perform Enzyme immunoassays (EIAs) and Chemiluminescent immunoassays (CLAs) for blood screening, in addition to the current system of rapid testing.
During pregnancy, doctors give mothers the HBsAg test but often do not prescribe further tests.
Experts said under four conditions the HBsAg test yields a false negative. These four conditions are: incubation of HBV infection, window period of HBV infection, occult HBV infection and genetic mutation of the HBV. So aside from HBsAg, the Anti-HBc Total and Anti-HBs tests are required for a complete screening of HBV.
Research shows that these further tests can detect the infection 99% accurately.
BICH assistant professor Dr Salahuddin said: “If a mother has the infection the child is given an immunoglobulin injection within 24 hours of birth, and three doses of the HBV vaccine, which can prevent their infection.”
“Mothers whose infections are not detected can infect their children, which is one of the major reasons of increasing prevalence of the HBV.”
One example given was that of a 40-year-old mother from Feni and her three children – aged 22, 18 and 10 – who were diagnosed with Hepatitis B two years ago after she was brought to Dhaka for tests.
“During my pregnancies, I used to suffer from high fever so local doctors gave me Typhoid medication after doing several blood tests,” the woman said.
The doctors in Dhaka said she may have been living with the virus from an early age and then passed this to her children at birth.
Prevention and ‘NOhep’ campaigning worldwide
The number of global deaths in 2015 attributable to hepatitis has been estimated at around 1.3 million. This figure includes deaths from acute hepatitis, and liver cancer or cirrhosis due to hepatitis. In the same year, an estimated 257 million people were living with HBV infection.
Dr Mohammad Ali of the National Liver Foundation said viral hepatitis causes around 4,000 deaths in the world every day, with about 70% of HBV infected individuals living in the South East Asia Region.
To combat the virus, infants are given three doses of Hepatitis B vaccine (a priority intervention). And while global coverage reached 84% among infants in 2015, Bangladesh is doing significantly better according to World Health Statistics 2017, vaccinating 94% of infants. But that still leaves 6% of children vulnerable to infection.
At the 69th World Health Assembly in Geneva, 194 governments adopted WHO’s Global Strategy on Viral Hepatitis, which includes a goal of eliminating Hepatitis B and C in the next 13 years. The community responded by launching ‘NOhep’, the first ever global movement to eliminate viral hepatitis by 2030.
The National Liver Foundation of Bangladesh also runs a countrywide awareness campaign as part of ‘NOhep’, and will take part in the next World Hepatitis Summit later this year.
However, Bangladesh is yet to organise awareness programmes for viral hepatitis and has not yet adopted a national guideline to prevent viral hepatitis.