Despite medical advances, repeated outbreaks of Hepatitis continue to make people sick in Kashmir

Viral hepatitis was originally known to Hippocrates 2400 years ago when he wrote about infectious icterus. Of course, we can’t say for sure if this was a case of hepatitis A, hepatitis E, or some other kind of chronic liver illness. However, it cannot be denied that throughout the Middle Ages, large human calamities like wars, famines, or earthquakes sometimes preceded or followed epidemics. In World War I, the hepatitis pandemic ravaged the armed troops on both sides of the Western Front; in World War II, the German army was hit especially hard by the disease. Although the hepatitis A virus was unquestionably to blame for these devastating epidemics, the idea that viruses might be spread via tainted food or water was still novel during World War II.

Understanding what Hepatitis is: Past to present

Hepatitis A, which spreads by the fecal-oral route, (today associated with hepatitis B or C) was first detected in 1885, albeit it was not identified as an infectious disease at the time. In the same year of discovery, explosive outbreaks were reported by scientists among workers and asylum inmates. In 1908, McDonald, noteworthy in his psychic abilities had the foresight to predict symptomatic hepatitis could be an infectious illness spread by a pathogenic virus. The medical establishment of Continental Europe took even longer to be convinced, and it took many decades and several misinterpretations before this unique, even revolutionary thought could achieve recognition in the English-speaking world. The era of viral hepatitis is a good example of how hard it can be to embrace new scientific studies and ideas when they go against established beliefs and absolutist dogmatism.

Hepatitis is often brought on by hepatovirus A, B, C, D, and E. The primary vectors for the dissemination of hepatitis A and E are tainted food and drink. While most cases of hepatitis B are shared via sexual contact, the virus may also be transmitted from mother to child through contaminated blood during pregnancy or delivery. Needle sharing among IV drug users is one possible vector for the transmission of hepatitis C because of the fluid exchanged between the two users. The only persons vulnerable to contracting hepatitis D are those who already have hepatitis B. Hepatitis A, B, and D are vaccine-preventable diseases. Hepatitis may cause varying degrees of illness in humans and animals. In some cases, the disease shows no outward signs while in others, symptoms such as jaundice, loss of appetite, vomiting, fatigue, stomach discomfort, and diarrhea manifest. If the symptoms of hepatitis disappear within six months, the condition is considered acute; otherwise, it is classified as chronic. Abrupt hepatitis may either go away on its own, turn into chronic hepatitis, or (very rarely) cause acute liver failure. Liver cancer, liver cirrhosis, and liver failure are all possible outcomes of chronic hepatitis. 

How the disease got to Kashmir valley 

This severe disease has marked its explosive infectious epidemics from time to time in India. It was in 1955-56, the national capital of the country witnessed the outbreak of hepatitis virus with more than 29000 cases (Viswanathan R, 1957) followed by 934 cases reported from Ahmedabad city of Gujarat (Sreenivasan et al.,1977) resulting in high death rates among pregnant women with a high penchant for young individuals. The valley of Kashmir has also not been spared from this severe yet curable disease. In fact, it was in 1978 when an epidemic of severe hepatitis in the Kashmir Valley led to the discovery of hepatitis E by a native gastroenterologist Dr Mohammed Khuroo. The outbreak emanated 52000 clinical cases with 1560 deaths engulfing around 200 villages with 6,00,000 population. This waterborne outbreak was confined to the mountainous region of the Baramulla district, where the inhabitants had a common source of drinking water, the Ningli Nalla, a mountainous watercourse that flows down to the Jhelum River in the town of Sopore. 

Picture showing Dr Mohammed Khuroo in Sopore town of District Baramulla at an unprotected water source during the 1978–1979 winter epidemic (Source: Khuroo, 2011)

Since that time hepatitis E virus  (HEV) rebounds creating melancholy and mortality in the valley. Between 1978 and 2013 HEV has been responsible for ten jaundice outbreaks in the Kashmir valley turning 19,68398 people sick with the virus with 1775 deaths. The overall population case fatality rate (CFR) reported among the general population is 3.19% and 22% in pregnant women. 

What is the situation today? How bad has it gotten?

Almost every year Hepatitis A is reported from different villages mostly from the southern parts of the valley and the outbreak mostly follows the monsoon season. The outbreak has now become very common among the people living in the upper reaches of Banihal town where every year people get infected by the virus after consuming the spring-fed water channels during or after the monsoon. The heedlessness of the concerned authorities adds to the pain of residents. Although the matter gets limelight and media coverage during the days of the scourge nothing is done to restrict and control the outbreak for years to come. In 2022,  the outbreak was reported from Turka Tachloo village of Anantnag district with two fatalities. All the cases were reported from a school where students were believed to have consumed tainted water. Learning from the historical outbreaks of hepatitis virus in the valley, the administration and concerned authorities should be much more vigilant especially when we have enough evidence regarding the cause of the virus being spread by the consumption of contaminated water. People who are either too ignorant or too stubborn to learn from the past are doomed to repeat it. Apart from the seasonal spread of hepatitis A and E related to the consumption of contaminated food and water, the prevalence of hepatitis B and C is also reported by health officers to be common these days among the young generation. Approximately 60% of reported cases of hepatitis B and C are of drug addicts/IV users. Drug trafficking has made Jammu and Kashmir a major transit point. According to a recent survey, over 4.6% of the population of the Union Territory of Jammu Kashmir is connected in some way with drugs. More specifically, 90% of these drug users fall between the ages of 17 and 33. Injecting illegal substances like heroin and brown sugar is common among them. Dangerously, exposing them to several transmitted diseases including hepatitis C and hepatitis B. 

How to thrive with Hepatitis

• The importance of getting your loved ones vaccinated.

Everyone has a chance of contracting hepatitis B at some time in their lives. Make sure your loved ones have had the hepatitis B vaccine. WHO advises that all children under the age of 18 be vaccinated.

• Engage in physical activity, but proceed with care.

As a general rule, physical activity has positive effects on both the body and the mind. Even if you’re too tired to go for a long walk, just a few minutes of walking around the block may help you stretch out your muscles and get some fresh air, both of which can have a positive effect on your hepatitis symptoms. Individuals with hepatitis may have a broad range of symptoms, so it’s important to talk to your doctor before beginning any new fitness regimen. 

• Bandage up any wounds.

Transmission of hepatitis B occurs mostly via blood and other bodily fluids. Consequently, any wounds should be bandaged, and no items used for personal hygiene or medicine that could come into contact with blood should be shared.

• Do NOT indulge in tobacco, drugs, or alcohol.

The liver processes everything that enters the body, including food, liquids, drugs, tobacco, topical, and inhaled substances. The liver is responsible for breaking down and flushing out any and all potentially hazardous chemicals, including alcohol and narcotics. The liver is taxed beyond its capacity to process noxious compounds if there are too many of them.

• Consider your feelings.

Depression and anxiety are widespread in patients with HBV because of the stresses of living with the disease. Nonetheless, reaching out to others who are empathic helps stop your feelings from descending into a chasm of isolation. The capacity to cope may be greatly improved with the correct kind of help, according to studies. You may easily locate a hepatitis support group by searching the internet or inquiring with your doctor about available options in your area.

References 

• Khuroo MS. 2011. Discovery of hepatitis E: The epidemic non-A, non-B hepatitis 30 years down the memory lane. Virus Res 161: 3–14.

• Sreenivasan MA, Banerjee K, Pandya PG, Kotak RR, Pandya PM, Desai NJ et al (1977) Epidemiological investigations of an outbreak of infectious hepatitis in Ahmedabad city during 1975–76. Indian J Med Res 67:197–206

• Viswanathan R (1957) Infectious hepatitis in Delhi (1955–56): a critical study; epidemiology. Ind J Med Res 45(suppl 1):1–30