Hepatitis A prevention – Journalist making recommendations

Dr. P K Sasidharan

Please read an article in The Hindu today.
Is vaccination a strategy to prevent hepatitis A? Who can make recommendations for vaccinations? Is it possible to stop hepatitis A by vaccination?
Why does hepatitis A behave differently in some people?
If in case, we have a strategy who all should be vaccinated?
What will be the cost of massive vaccination, especially when the immunity by it is not lifelong?
It does not anyway give lifelong immunity whereas natural infection gives lifelong immunity.

Why the western countries have no cases of Hepatitis A?
How much would be the money needed to cover all people with vaccinations?
Isn’t that money enough to provide safe drinking water trough pipes?
Whom are we trying to help by a vaccination strategy for hepatitis A?

Even many of the doctors are not capable of making a recommendation. Doctors like me who are managing such patients and are in touch with public health issues would recommend providing safe drinking water through pipes as in developed countries – because that is the only solution.

They have prevented hepatitis A and many other water-borne diseases by this method long back.
For the time being, as a stop gap arrangement, temporarily during an outbreak, the neighbouring people of affected cases can be vaccinated.
But do we need a vaccination strategy to give vaccination during an outbreak?
A strategy means compulsory vaccination.
A doctor or journalist should be talking on behalf of the public and not for technology or industry.

Why hepatitis A is not at all a problem in developed countries?
They have invested money on safe drinking water through pipes- that is the only thing we need to do in Kerala too to prevent hepatitis A. But safe drinking water is not chlorination or boiling the water or drinking mineral water.

Please realise that water in wells and water bodies get contaminated by unhygienic practices of people and closeness of septic tanks to the wells in cities. Vaccine cannot improve the hygienic practices or such environmental engineering issues anyway!
The water in wells in each small plot will get contaminated due to the closeness of septic tanks and wells- the distance needed is 15 meters but most often it is less than ten meters
Why there is more morbidity and mortality now?
It is not due to the changed behaviour of virus- it is due to the changed lifestyle habits of the individuals who get the disease.

Those who develop problems after infection have underlying fatty liver or liver damage due to alcohol or indigenous medicines or autoimmune diseases and the mortality is not due to the virus. We need to have public health strategies on modifying the lifestyle and diet of every individual.
Those who do not manage these kinds of patients can never speak on how to prevent it in the community. A journalist or even a virologist or single system specialist is not the ideal person to make recommendations on public health strategies. Only those who are experts in individual health and managing these patients should make recommendations on public health.

WHO recommendation of hepatitis vaccination is meant for the people travelling to endemic countries – Which are these endemic countries?
India is the most endemic country now.
What should the endemic countries do then? Vaccinate all their people?
Let us provide safe drinking water through pipes as a priority and improve sanitation
Let us invest in potable drinking water through pipes and better sanitation.
With limited resources even Sri Lanka has done that
Public health is a neglected orphan in India
Therefore vaccine for hepatitis A is not the priority for us.

Let us invest first on ensuring safe drinking water through the public taps
Next step – since it is a self-limiting disease, except in some vulnerable people, let us modify their vulnerability and vaccinate selected people only as and when needed or as decided by treating doctors
On a similar note, we cannot prevent typhoid with vaccination in an endemic country like India
Please note- the entire USA has only 450 typhoid cases in one year. Similar is the situation of hepatitis A. These are the patients who visit USA from India, Pakistan, Bangladesh and Mexico
They recommend vaccines only when their people visit these endemic countries
What about us who live here?
But vaccination is the right approach in diseases, where the disease itself is fatal and immunisation gives lifelong immunity.

When disease itself is not fatal, vaccination has minor role only.
When there is an effective public health strategy in hepatitis A, Typhoid, dysentery and cholera vaccine has very little role
Next question- Is it possible to provide safe drinking water through pipes? We have enough resources for vaccination and any kind of ultramodern treatment and setting up wellness centres under AYUSH, hence if we have the will we can provide safe drinking water and it will prevent several water borne diseases.
In all the countries I visited tap water is safe for drinking and they do not have indigenous cases of hepatitis A, cholera, dysentery and typhoid.

We doctors must tell the authorities that it is possible to prevent typhoid, cholera, dysentery and hepatitis A by public health measures.