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Chronic liver disease and cirrhosis : The current situation in South Asia

The burden of liver disease is increasing rapidly in South Asian countries . In this article , we highlight the major causes of chronic liver diseases , which are dominant in South Asian countries , and methods that can be implemented to reduce their burden
Anand Kulkarni AIG Hospitals , Hyderabad , India
Hepatitis is an inflammation in the liver , and inflammation persisting for < 6 months is termed acute hepatitis . Common causes of acute hepatitis are : viral ( hepatitis A , B and E ); drug-induced ; and alcohol-associated . Chronic hepatitis is the presence of inflammation in the liver for more than six months . Chronic liver disease ( CLD ) is a broad term that includes all the causes of chronic inflammation : that is , chronic hepatitis B and C ; non-alcoholic fatty liver disease ; autoimmune hepatitis , etc . The term CLD in clinical practice is ( generally ) also used for cirrhosis . Cirrhosis is irreversible damage to the liver wherein there is nodule formation and architecture loss and is discussed in detail further in this handbook . Cirrhosis can be compensated , which indicates a lack of any complications attributed to cirrhosis ; by contrast , decompensated cirrhosis suggests the development of complications including jaundice , ascites , hepatic encephalopathy , and variceal bleeding . In this article , we discuss the burden and causes of CLD and cirrhosis in South Asian countries .
Burden Because of its population density , the Asia-Pacific region accounts for more than 50 % of deaths attributed to cirrhosis worldwide , more than 70 % of deaths attributed to hepatocellular carcinoma and acute viral hepatitis . 1
Causes of CLD and cirrhosis Hepatitis B The World Health Organization ( WHO ) estimates that 296 million people were living with chronic hepatitis B ( HBV ) infection in 2019 , with 1.5 million new infections each year . In 2019 , hepatitis B resulted in an estimated 820,000 deaths , mostly from cirrhosis and hepatocellular carcinoma ( HCC ; primary liver cancer ). Hepatitis B and C together constitute a major aetiology of cirrhosis of the liver , especially in the Asia-Pacific region . Most common routes of transmission are vertical ( from mother to child ), horizontal ( from infected to uninfected siblings ), sexual contact with the infected individuals , and through needlestick injuries and injected drug misuse . Hepatitis B is also known to be one of the most common causes of hepatocellular carcinoma in the Asia-Pacific region . China and India contribute to a significant proportion of the population . China accounts for a large proportion of the regional burden of viral hepatitis , particularly HBV , with a prevalence of more than 80 million estimated chronic infections in 2018 . 1 In India , the seroprevalence of HBV is 2.4 %– 4 % whereas the seroprevalence of HBV in China , Indonesia , and Bangladesh is between 5 % and 7 %. 1 With the widespread availability and incorporation of HBV vaccination in national immunisation programmes , the prevalence of hepatitis B is expected to decrease . Taiwan has achieved a significant decrease in the incidence of HBV owing to mass vaccination efforts .
Hepatitis C HCV is a bloodborne virus and most infections occur through unsafe injection practices , unsatisfactory sterilisation and contaminated instruments in healthcare , transfusion of unscreened blood and its products , shared injection drug practices and sexual practices that lead to exposure to blood . 2 Globally , an estimated 58 million people have chronic HCV infection , with about 1.5 million new infections occurring per year . According to the WHO ,
Because of its population density , the Asia- Pacific region accounts for more than 50 % of the deaths attributable to cirrhosis worldwide in 2019 , approximately 290,000 people died from hepatitis C , mostly from cirrhosis and HCC . 2 A major hindrance to preventing the rise in infection is the lack of vaccines for HCV . A systematic review reported that the pooled anti-HCV antibody prevalence in India is 0.44 – 0.88 %. 3 The prevalence was highest in IV drug misusers and those on haemodialysis . HBV / HCV coinfection is reported to be approximately 1.9 % in India . 4
Ways of reducing the burden of liver diseases attributed to HBV and HCV include :
• Compulsory testing of donated blood for HBV and HCV at blood banks
• National policies to raise awareness , promoting partnerships , and mobilising resources to prevent transmission
• Improved accessibility to affordable drugs
• Scaled-up screening – screen any individual
• Safe and appropriate use of health care injections
• Safe handling and disposal of sharps and waste
• Provision of comprehensive harm-reduction services to people who inject drugs
• Training of health personnel , and
• Promotion of safe sexual practices .
Non-alcoholic fatty liver disease Individual and societal factors such as urbanisation , and
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