tag:theconversation.com,2011:/fr/topics/hepatitis-a-627/articlesHepatitis A – The Conversation2020-10-05T13:58:29Ztag:theconversation.com,2011:article/1475212020-10-05T13:58:29Z2020-10-05T13:58:29ZA researcher reflects on progress fighting hepatitis C – and a path forward<figure><img src="https://images.theconversation.com/files/361658/original/file-20201005-20-uz1dfq.jpg?ixlib=rb-1.1.0&rect=180%2C167%2C4412%2C2923&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The hepatitis C virus was discovered in 1989 – research that's now earned a Nobel Prize.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/hepatitis-c-virus-hcv-causes-blood-borne-hepatitis-news-photo/1158016725">BSIP/Universal Images Group via Getty Images</a></span></figcaption></figure><p>When I began my medical career in Hong Kong in the early 1980s, I chose to focus on hepatitis B, in part because it was very common and because the hepatitis C virus had not yet been discovered. I witnessed the devastation that this virus caused – cirrhosis, liver failure and liver cancer – and the lack of treatments we could offer to patients.</p>
<p>Back then, scientists knew there was another type of hepatitis, but no one could identify it, so we called it non-A, non-B hepatitis. I would never have imagined that during the course of my career I would witness the <a href="http://doi.org/10.1126/science.2523562">discovery of what came to be known as hep C</a> and the <a href="http://doi.org/10.1056/NEJMoa1402454">development of a cure</a> for nearly all patients with <a href="http://doi.org/10.1056/NEJMoa1402355">chronic hepatitis C in 2014</a>.</p>
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<a href="https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="three scientist projected on screen at announcement" src="https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/361660/original/file-20201005-18-1rtahe6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Announcement that the 2020 Nobel Prize in Physiology or Medicine will go to three researchers who identified the hepatitis C virus.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nobel-committee-members-patrik-ernfors-and-gunilla-karlsson-news-photo/1228905071">Jonathan Nackstrand/AFP via Getty Images</a></span>
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<p>Underscoring the importance of these discoveries for global human health, this year’s <a href="https://www.nobelprize.org/prizes/medicine/2020/summary/">Nobel Prize in Physiology or Medicine</a> was awarded jointly to Harvey J. Alter, Michael Houghton and Charles M. Rice for the discovery of the hepatitis C virus.</p>
<p>The development of treatments over the past 30 years reflects the amazing progress the field has made in tackling hepatitis C in a relatively short period of time. Initially, in the late 1980s, before a diagnostic test became available, some physicians started treating well-characterized cases of non-A, non-B hepatitis (hep C) with interferon, a natural protein that the body makes to fight viruses, and ribavirin, an antiviral drug. These medications were not specifically developed for hepatitis C, had to be given as injections for 6-12 months, had many side effects and resulted in a cure in only half of the patients who received treatment. It took more than two decades for the first direct-acting antiviral drugs to be approved by the FDA. </p>
<p>I remember the excitement when I and my colleagues tested one of the new drug combinations in patients and saw the virus count drop from more than 1 million to less than 20 within two weeks. <a href="http://doi.org/10.1056/NEJMoa1104430">We published the results</a> of our pilot study in the New England Journal of Medicine in 2012. Although the study involved only 21 patients, it was considered a watershed moment because it was the first study to prove that a combination of oral pills without interferon can cure hepatitis C.</p>
<p>Effective treatment for hepatitis C has become even more relevant today in light of the recent surge in new cases of hepatitis C due to rising opioid use.</p>
<h2>A pricey drug and new generics</h2>
<p>The first combo pill with two drugs that inhibits different steps in hepatitis C replication was <a href="http://www.gilead.com/news/press-releases/2014/10/us-food-and-drug-administration-approves-gileads-harvoni-ledipasvirsofosbuvir-the-first-oncedaily-single-tablet-regimen-for-the-treatment-of-genotype-1-chronic-hepatitis-c">approved by the FDA in 2014</a>. This pill is taken once a day for 8-12 weeks, has little to no side effects and improved the cure rate to 90-95%. It was hailed as a magical cure, but it came with a price tag of US$94,500 for a 12-week course of treatment. That led many insurers in the United States and national health departments in other countries to limit access to treatment. </p>
<p>Since then, <a href="http://doi.org/10.1056/NEJMoa1512610">several other</a> <a href="http://doi.org/10.7326/M15-0785">combo pills with</a> <a href="http://doi.org/10.1056/NEJMoa1702417">similar cure rates</a> that are equally well-tolerated have become available, and the cost has markedly decreased. In addition, low-cost generics and special pricing arrangements are available in many resource-limited countries. </p>
<p>While the current price of hepatitis C virus drugs is still very high, one needs to remember that for 95 percent of patients, this is a cure. It is unlike medicines for many illnesses that need to be taken for a long time, sometimes for the rest of the patients’ lives. Indeed, a cure for hepatitis C virus has allowed some patients who were on the liver transplant waiting list to <a href="https://doi.org/10.1016/j.jhep.2016.05.010">reverse their liver failure</a>, making transplantation unnecessary. This is good news not only for these patients but also for others on the waiting list. </p>
<p>The remarkable success of hepatitis C treatment has reenergized efforts to find a cure for hepatitis B. Current treatments can suppress hepatitis B virus replication but do not eliminate it. Most patients need to be on long-term treatment to prevent flare-ups of hepatitis when the virus reemerges after treatment is stopped. </p>
<h2>Deaths from hepatitis B and C infections rising worldwide</h2>
<p>Learning from the hepatitis C experience and with better understanding of the biology of hepatitis B virus and improved animal models, pharmaceutical companies are developing <a href="https://doi.org/10.1002/hep.29323">drugs that target different steps of the hepatitis B virus life cycle</a>. While a cure for hepatitis B will be more challenging because it can integrate into the patient’s DNA, enabling it to evade the patient’s immune response, I am optimistic that we will witness the availability of new combinations of drugs that will move us nearer the goal of a hepatitis B cure. </p>
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<img alt="" src="https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Members of Delhi Network of Positive People, a support group for HIV-positive people, in 2014 urged the Indian government to allow production of generic versions of direct-acting antivirals that could help thousands get affordable oral doses of medicine to control hepatitis C. Infection progresses more rapidly to damage the liver in HIV-positive patients.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/India-Health/14d6bce6d8fe430db7970e2bce717083/4/0">Saurabh Das/AP Photo</a></span>
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<p>But the news is not all positive. While we’ve seen mortality rates from HIV, tuberculosis and malaria decline in recent years, deaths from hepatitis B and C have risen. Globally, an estimated <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">257 million people have chronic hepatitis B virus infection</a>, and <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-c">71 million have chronic hepatitis C virus</a>. Together hepatitis B and C caused more than 1.34 million deaths in 2015. This led the World Health Organization to challenge countries around the world to develop national plans to <a href="http://apps.who.int/iris/bitstream/handle/10665/206453/WHO_HIV_2016.04_eng.pdf?sequence=1">eliminate these two viruses by 2030</a>. </p>
<p>Hepatitis B virus and hepatitis C virus are usually spread through contact with blood or body secretions such as semen from infected persons by sharing needles or sexual exposure. But they can also be spread through contaminated needles used for medical treatment, which continues to happen in many parts of the world. In addition, hepatitis B virus can be spread from infected mothers to newborn babies unless vaccination is given immediately after birth. </p>
<p>For people with hepatitis C virus, roughly two-third suffer chronic infection. For hepatitis B virus, the chance of chronic liver infection decreases the later the patient encounters the virus: the likelihood is 90% if infected during infancy; 20-30% if infected during childhood; and 2-5% if infected in adult life. Some people infected with hepatitis B virus or hepatitis C virus can recover on their own, but many develop chronic infections lasting more than six months and often years or lifelong. Those with chronic infection are at risk of cirrhosis (severe liver damage), liver failure and liver cancer. </p>
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<img alt="" src="https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">In 2017, a San Diego family was among several hundred people living in a campground for the homeless, set up to curb the worst hepatitis A outbreak in the United States in decades.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Homeless-Crisis-on-the-Coast-San-Diego/b0d09b99f82249138623efa6177d2e5f/33/0">Gregory Bull/AP Photo</a></span>
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<h2>Opioid epidemic, homeless lead to rise in hepatitis B and C infections</h2>
<p>In the United States, the number of new hepatitis B virus and hepatitis C virus infections has been decreasing for many years, but <a href="http://doi.org/10.2105/AJPH.2017.304132">this trend has been reversed</a> during recent years <a href="http://doi.org/10.1056/NEJMp1716871">due to the opioid epidemic</a> as more people use injection drugs, share needles or other paraphernalia and practice high-risk sexual behavior. This is particularly true for hepatitis C, where the number of new cases in the past 10 years has more than doubled, highlighting the need for a preventive vaccine, which is a vital tool to eliminate hepatitis C. The increase in number of new cases of hepatitis B is smaller and mainly seen in adults in their 30s because most younger persons have benefited from hepatitis B virus vaccination. </p>
<p>When we talk about viral hepatitis, the focus is on hepatitis B and C because they can cause chronic infection, while hepatitis A causes only acute infection and will not lead to cirrhosis or liver cancer. However, since 2016, many states in the U.S. have witnessed outbreaks of hepatitis A. The Centers for Disease Control and Prevention received more than 2,500 reports of hepatitis A between January 2017 and April 2018 associated with person-to-person transmission, with risk factors in <a href="https://emergency.cdc.gov/han/han00412.asp">two-thirds of these cases being drug use or homelessness</a> or both. In Michigan, where I live, 859 cases of hepatitis A, including 27 deaths, were reported between July 2016 and June 2018. We can prevent hepatitis A through vaccination and improved hygienic conditions. </p>
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<a href="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=863&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=863&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=863&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1085&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1085&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1085&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">World Hepatitis Day is celebrated on July 28, the birthday of Dr. Baruch S. Blumberg, a Philadelphia researcher who shared the 1976 Nobel Prize in physiology or medicine for his discovery of the hepatitis B virus.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Obit-Blumberg/af5f0cf91a8a473582fb4fb5cf5106b8/1/0">Eddie Adams/AP Photo</a></span>
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<p>World Hepatitis Day occurs annually on July 28, a day chosen in honor of the late Baruch Blumberg, who received a Nobel Prize for discovering the hepatitis B virus. Today is another cause for celebration as a second Nobel is awarded for hepatitis research, this time for the discovery of hepatitis C virus. I marvel at how much progress we have made in the last three decades and am delighted to be not just an observer but also a contributor to the progress. Our work is not finished. Much more needs to be done to completely eliminate new cases of viral hepatitis and deaths from chronic hepatitis B and C. </p>
<p><em>This is an updated version of an <a href="https://theconversation.com/the-thrill-of-curing-hepatitis-c-and-the-pain-of-watching-the-disease-surge-with-opioid-abuse-99568">article originally published in July 2018</a>. It has been updated to include news of the 2020 Nobel Prize.</em></p><img src="https://counter.theconversation.com/content/147521/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Suk-Fong Lok has served on advisory panels of Roche, Viravaxx, and Spring Bank. She receives research funding from Bristol-Myers Squibb, Gilead, the National Institutes of Health, and the Patient Center for Outcome Research Institute provided to the University of Michigan. </span></em></p>The 2020 Nobel Prize for Physiology or Medicine goes to the discoverers of the hepatitis C virus. There’s an effective cure but homelessness and the opioid epidemic are driving a surge in infections.Anna Suk-Fong Lok, Professor of Internal Medicine, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1432082020-07-27T16:03:20Z2020-07-27T16:03:20ZWhy Nigeria must find everyone who has hepatitis and doesn’t know it<figure><img src="https://images.theconversation.com/files/349477/original/file-20200726-35-zkdsr6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/nurse-from-the-orange-county-florida-health-department-news-photo/1161105795?adppopup=true">Paul Hennessy/SOPA Images/LightRocket via Getty Images </a></span></figcaption></figure><p>World Hepatitis Day – 28 July – is an opportunity <a href="https://www.who.int/campaigns/world-hepatitis-day">to raise awareness of hepatitis</a> and encourage commitments of governments, policy makers and the public towards eradication of this dangerous disease. </p>
<p>The World Health Organisation has chosen “hepatitis free future” as its <a href="https://www.who.int/campaigns/world-hepatitis-day">theme</a> this year and is focusing on prevention of hepatitis B among mothers and newborns. The World Hepatitis Alliance has chosen the theme <a href="https://www.worldhepatitisday.org/">“find the missing millions”</a> – the millions of people who have hepatitis B but are not aware of it. </p>
<p>In Nigeria alone, there could be <a href="https://www.hepb.org/blog/journey-hepatitis-elimination-nigeria/#:%7E:text=Nigeria%2C%20with%20an%20estimated%20population,Impact%20Survey(NAIIS)%20report.">about 15 million people</a> who are unaware that they are infected. The danger of this is that some of them could go on to develop liver disease, including cancer. They could also continue to infect others around them, especially family members and sexual partners. This is why it is important to screen family members and sexual contacts of anyone diagnosed with hepatitis B virus infection.</p>
<p>Hepatitis means inflammation of the liver and viral causes are the most common. </p>
<p>There are five types of hepatitis virus, named A, B, C, D and E. Hepatitis B (HBV) and C (HCV) are the most common cause of long-term liver damage, accounting for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6232563/">about 90% of deaths</a> from viral hepatitis. Hepatitis D virus is not a complete virus and can only affect those who already had hepatitis B. </p>
<p>Hepatitis A & E viruses are transmitted by faeco-oral routes. Faeco-oral routes means pathogens in faecal particles pass from one person to the mouth of another person. This is usually as a result of poor hygiene and lack of adequate sanitation. </p>
<p>Hepatitis B, C and D are transmitted through vertical transmission, child to child transmission, transfusion of unscreened blood, use of unsterilised equipment for surgical procedures, indiscriminate use of sharp objects such as local circumcision, tribal marking, ear piercing, tattoos, reuse of needles and syringes and unprotected sexual intercourse. Vertical transmission refers to passage of a pathogen from mother to baby immediately before and after birth. It might occur through direct contact during or after birth.</p>
<h2>Prevalence</h2>
<p>HBV and HCV are international public health problems, chronically infecting <a href="https://www.hepb.org/what-is-hepatitis-b/what-is-hepb/facts-and-figures/">292 million</a> and <a href="https://idpjournal.biomedcentral.com/articles/10.1186/s40249-019-0528-6#:%7E:text=Global%20epidemiology%20of%20HCV%20infection,ranging%20from%200.5%20to%206.5%25.">71 million</a> people respectively worldwide. The two viruses cause <a href="https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/">about 1 million deaths annually</a>. But the burden of hepatitis is not evenly spread. The sub-Saharan African and Western Pacific regions account for <a href="https://www.who.int/hepatitis/publications/global-hepatitis-report2017/en/">about 68% of all chronic hepatitis B infections</a>. The reason for this discrepancy is the delay in the availability of vaccines and frequency of risky behaviours in these regions.</p>
<p>A recent <a href="https://www.hepb.org/blog/journey-hepatitis-elimination-nigeria/">study</a> in Nigeria found the prevalence of hepatitis B and C in the country to be 8.1% and 1.1% of the population respectively. This means that about 19 million Nigerians have hepatitis B or C. We found in <a href="https://pubmed.ncbi.nlm.nih.gov/32096684/">our research</a> that about 11% of Nigerian patients with hepatitis B also had hepatitis D. The co-existence of hepatitis B and D is a greater threat to liver health than hepatitis B virus alone.</p>
<p>Unfortunately, most patients with hepatitis B and hepatitis C infections are asymptomatic and can remain so until the liver is significantly damaged. The World Health Organisation has <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">estimated</a> that only about 10% and 19% of patients with chronic HBV and HCV are aware of their infections. Hepatitis B and C viruses could lead to <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b#:%7E:text=A%20small%20subset%20of%20persons,the%20liver">liver cancer</a> if not properly treated. The median survival of patients with hepatocellular carcinoma (liver cancer) in sub-Saharan Africa is <a href="https://pubmed.ncbi.nlm.nih.gov/28403980/">less than three months</a>. </p>
<p>The <a href="https://www.soghin.org.ng/">Society of Gastroenterology and Hepatology in Nigeria</a> advocates in its <a href="https://www.ajol.info/index.php/njgh/article/view/131493">HBV guideline</a> that all unimmunised adults in Nigeria should be screened for hepatitis B infection, especially when they visit a hospital for whatever reason. This is to ensure that the millions of people with asymptomatic infection are diagnosed and treated, if need be. </p>
<p>It’s not known whether all healthcare workers are following this advice.</p>
<h2>Prevention and treatment</h2>
<p>The World Health Organisation <a href="https://apps.who.int/iris/bitstream/handle/10665/246177/WHO-HIV-2016.06-eng.pdf?sequence=1">aims</a> to reduce new HBV infections by 90% and deaths by 65% by 2030. The United Nations also placed combating hepatitis as <a href="https://www.who.int/sdg/targets/en/">the third target of goal 3</a> of its sustainable development goals.</p>
<p>Though HBV has no cure, it is preventable through vaccination and avoidance of risky behaviours that promote its transmission. There is no effective vaccine that can prevent hepatitis C but it is curable with the available medications. </p>
<p>Prevention of mother to child transmission is the most important intervention to reduce the incidence of chronic hepatitis B. This is because, unlike adults who acquire the infection, 90%-95% of children who acquire the infection from their mothers will have persistent infection until adulthood. All pregnant mothers should be screened for HBV but screening and treatment are unaffordable for many of these women.</p>
<p>HBV vaccination has been incorporated into the routine immunisation programme for children in Nigeria since the late 1990s and it is free. Two things that stand in the way of prevention efforts in Nigeria are the cost of the investigations of HBV and HCV, which are not covered by the national health insurance scheme, and the knowledge of health workers. </p>
<p>In another <a href="https://www.researchgate.net/publication/343193627_Knowledge_of_hepatitis_B_virus_and_vaccination_uptake_among_hospital_workers_in_south_west_Nigeria">study</a> we conducted, only 44% of health workers were aware of the mother to child route of transmission of HBV. </p>
<p>Though hepatitis B has no cure, there are effective medications that reduce the possibility of liver damage and cancer. Because they are imported to Nigeria, though, these medications are not necessarily affordable or available. This reduces the compliance of patients on this drug.</p>
<p>As we mark the 2020 World Hepatitis Day, government and nongovernmental organisations should create greater awareness of screening. Those found positive should then be linked with treatment centres. There should be continuous education of all health workers on hepatitis routes of transmission and treatment. </p>
<p>In addition to measures which are free according to <a href="https://www.hepb.org/assets/Uploads/Nigeria-Hepatitis-Guidelines-TX-guidelines.pdf">national policy</a>, screening for HBV and HCV should be free. Large procurement of treatment drugs or encouragement of their local production should also be encouraged so that they are affordable and available. This will help to ensure a hepatitis free Nigeria.</p><img src="https://counter.theconversation.com/content/143208/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kolawole Oluseyi Akande does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>About 19 million Nigerians have hepatitis but most of them don’t know it.Kolawole Oluseyi Akande, Lecturer, Gastroenterology & Hepatology Unit and Consultant Gastroenterologist & Hepatologist , University of IbadanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/995682018-07-27T10:44:04Z2018-07-27T10:44:04ZThe thrill of curing hepatitis C and the pain of watching the disease surge with opioid abuse<figure><img src="https://images.theconversation.com/files/229342/original/file-20180725-194124-1tkmdup.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hepatitis C rates have risen in the U.S. as drug use and opioid abuse have risen. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/male-junkie-hand-trying-grab-injection-1115261123?src=2tTYAQPj0tPMFOFpJMv2yQ-2-1">By Zephyr_p/shutterstock.com</a></span></figcaption></figure><p><em>An updated version of this article was published on Oct. 5, 2020. <a href="https://theconversation.com/a-researcher-reflects-on-progress-fighting-hepatitis-c-and-a-path-forward-147521">Read it here</a>.</em></p>
<p>When I began my medical career in Hong Kong in the early 1980s, I chose to focus on hepatitis B, in part because it was very common and because the hepatitis C virus had not yet been discovered. I witnessed the devastation that this virus caused – cirrhosis, liver failure and liver cancer – and the lack of treatments we could offer to patients.</p>
<p>Back then, scientists knew there was another type of hepatitis, but no one could identify it, so we called it non-A, non-B hepatitis. I would never have imagined that during the course of my career I would witness the <a href="http://doi.org/10.1126/science.2523562">discovery of what came to be known as hep C</a> and the <a href="http://doi.org/10.1056/NEJMoa1402454">development of a cure</a> for nearly all patients with <a href="http://doi.org/10.1056/NEJMoa1402355">chronic hepatitis C in 2014</a>. </p>
<p>The development of treatments over the past 30 years reflects the amazing progress the field has made in tackling hepatitis C in a relatively short period of time. Initially, in the late 1980s, before a diagnostic test became available, some physicians started treating well-characterized cases of non-A, non-B hepatitis (hep C) with interferon, a natural protein that the body makes to fight virus, and ribavirin, an antiviral drug. These medications were not specifically developed for hepatitis C, had to be given as injections for 6-12 months, had many side effects and resulted in a cure in only half of the patients who received treatment. It took more than two decades for the first direct-acting antiviral drugs to be approved by the FDA. </p>
<p>I remember the excitement when I and my colleagues tested one of the new drug combinations in patients and saw the virus count drop from more than 1 million to less than 20 within two weeks. <a href="http://doi.org/10.1056/NEJMoa1104430">We published the results</a> of our pilot study in the New England Journal of Medicine in 2012. Although the study involved only 21 patients, it was considered a watershed moment because it was the first study to prove that a combination of oral pills without interferon can cure hepatitis C. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=863&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=863&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=863&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1085&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1085&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228897/original/file-20180723-189316-y5kfyr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1085&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">World Hepatitis Day is celebrated on July 28, the birthday of Dr. Baruch S. Blumberg, a Philadelphia researcher who shared the 1976 Nobel Prize in physiology or medicine for his discovery of the hepatitis B virus.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Obit-Blumberg/af5f0cf91a8a473582fb4fb5cf5106b8/1/0">Eddie Adams/AP Photo</a></span>
</figcaption>
</figure>
<p>Effective treatment for hepatitis C has become even more relevant today in light of the recent surge in new cases of hepatitis C due to rising opioid use.</p>
<h2>A pricey drug and new generics</h2>
<p>The first combo pill with two drugs that inhibits different steps in hepatitis C replication was <a href="http://www.gilead.com/news/press-releases/2014/10/us-food-and-drug-administration-approves-gileads-harvoni-ledipasvirsofosbuvir-the-first-oncedaily-single-tablet-regimen-for-the-treatment-of-genotype-1-chronic-hepatitis-c">approved by the FDA in 2014</a>. This pill is taken once a day for 8-12 weeks, has little to no side effects and improved the cure rate to 90-95%. It was hailed as a magical cure, but it came with a price tag of US$94,500 for a 12-week course of treatment. That led many insurers in the United States and national health departments in other countries to limit access to treatment. </p>
<p>Since then, <a href="http://doi.org/10.1056/NEJMoa1512610">several other</a> <a href="http://doi.org/10.7326/M15-0785">combo pills with</a> <a href="http://doi.org/10.1056/NEJMoa1702417">similar cure rates</a> that are equally well-tolerated have become available, and the cost has markedly decreased. In addition, low-cost generics and special pricing arrangements are available in many resource-limited countries. </p>
<p>While the current price of hepatitis C virus drugs is still very high, one needs to remember that for 95 percent of patients, this is a cure. It is unlike medicines for many illnesses that need to be taken for a long time, sometimes for the rest of the patients’ lives. Indeed, a cure for hepatitis C virus has allowed some patients who were on the liver transplant waiting list to <a href="https://doi.org/10.1016/j.jhep.2016.05.010">reverse their liver failure</a>, making transplantation unnecessary. This is good news not only for these patients but also for others on the waiting list. </p>
<p>The remarkable success of hepatitis C treatment has reenergized efforts to find a cure for hepatitis B. Current treatments can suppress hepatitis B virus replication but do not eliminate it. Most patients need to be on long-term treatment to prevent flares of hepatitis when the virus reemerges after treatment is stopped. </p>
<h2>Deaths from hepatitis B and C infections rising worldwide</h2>
<p>Learning from the hepatitis C experience and with better understanding of the biology of hepatitis B virus and improved animal models, <a href="https://doi.org/10.1002/hep.29323">drugs that target different steps of the hepatitis B virus life cycle</a> are being developed. While cure for hepatitis B will be more challenging because it can integrate into the patient’s DNA, enabling it to evade the patient’s immune response, I am optimistic that we will witness the availability of new combination of drugs that will move us nearer the goal of an hepatitis B virus cure. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229341/original/file-20180725-194124-1tijt6h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Members of Delhi Network of Positive People, a support group for HIV-positive people, shout slogans during a protest in New Delhi, India, Friday, March 21, 2014. The activists urged the Indian government to allow production of generic versions of direct-acting antivirals, that can help thousands get affordable oral doses of medicine to control hepatitis C. Infection progresses more rapidly to damage the liver in HIV-positive patients, and co-infection of HIV and hepatitis C virus is common among HIV-infected injection drug users.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/India-Health/14d6bce6d8fe430db7970e2bce717083/4/0">Saurabh Das/AP Photo</a></span>
</figcaption>
</figure>
<p>But the news is not all positive. While we’ve seen mortality rates from HIV, TB and malaria decline in recent years, mortality from hepatitis B and C has risen. Globally, an estimated <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">257 million people have chronic hepatitis B virus infection</a>, and <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-c">71 million have chronic hepatitis C virus</a>. Together hepatitis B and C caused more than 1.34 million deaths in 2015. This led the World Health Organization to challenge countries around the world to develop national plans to <a href="http://apps.who.int/iris/bitstream/handle/10665/206453/WHO_HIV_2016.04_eng.pdf?sequence=1">eliminate these two viruses by 2030</a>. </p>
<p>Hepatitis B virus and hepatitis C virus are usually spread through contact with blood or body secretions such as semen from infected persons by sharing needles or sexual exposure. But they can also be spread through contaminated needles used for medical treatment, which continues to happen in many parts of the world. In addition, hepatitis B virus can be spread from infected mothers to newborn babies unless vaccination is given immediately after birth. </p>
<p>For hepatitis C virus, roughly two-third suffer chronic infection. For hepatitis B virus, the chance of chronic liver infection decreases the later the patient encounters the virus: 90% if infected during infancy; 20-30% if infected during childhood; and 2-5% if infected in adult life. Some people infected with hepatitis B virus or hepatitis C virus can recover on their own, but many go on to chronic infection (lasting more than six months and often years or lifelong). Those with chronic infection are at risk of cirrhosis (severe liver damage), liver failure and liver cancer. </p>
<h2>Opioid epidemic, homeless lead to rise in hepatitis B and C infections</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/229340/original/file-20180725-194152-1m3x0hp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In this Nov. 8, 2017, photo, Christine Wade sits among her children in front of their donated tent in the city-sanctioned encampment on a parking lot in San Diego. The Wade family is among several hundred people living in the city’s first campground open for the homeless, set up to curb the worst hepatitis A outbreak in the United States in decades.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Homeless-Crisis-on-the-Coast-San-Diego/b0d09b99f82249138623efa6177d2e5f/33/0">Gregory Bull/AP Photo</a></span>
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<p>In the United States, the number of new hepatitis B virus and hepatitis C virus infections has been decreasing for many years, but <a href="http://doi.org/10.2105/AJPH.2017.304132">this trend has been reversed</a> during recent years <a href="http://doi.org/10.1056/NEJMp1716871">due to the opioid epidemic</a> as more people use injection drugs, share needles or other paraphernalia and practice high-risk sexual behavior. This is particularly true for hepatitis C, where the number of new cases in the past 10 years has more than doubled, highlighting the need for a preventive vaccine, which is a vital tool if we want to eliminate hepatitis C. The increase in number of new cases of hepatitis B is smaller and mainly seen in adults in their 30s because most younger persons have benefited from hepatitis B virus vaccination. </p>
<p>When we talk about viral hepatitis, the focus is on hepatitis B and C because they can cause chronic infection, while hepatitis A causes only acute infection and will not lead to cirrhosis or liver cancer. However, starting late 2016, many states in the U.S. have witnessed outbreaks of hepatitis A. The Centers for Disease Control and Prevention received more than 2,500 reports of hepatitis A between January 2017 and April 2018 associated with person-to-person transmission, with risk factors in <a href="https://emergency.cdc.gov/han/han00412.asp">two-thirds of these cases being drug use or homelessness</a> or both. In the state of Michigan, where I live, 859 cases of hepatitis A including 27 deaths were reported between July 2016 and June 2018. We can prevent hepatitis A through vaccination and improved hygienic conditions. </p>
<p>World Hepatitis Day occurs annually on July 28, a day chosen in honor of the late Baruch Blumberg, who received a Nobel Prize for discovering the hepatitis B virus. I marvel at how much progress we have made in the last three decades and am delighted to be not just an observer but also a contributor to the progress. Our work is not finished. Much more needs to be done to completely eliminate new cases of viral hepatitis and deaths from chronic hepatitis B and C.</p><img src="https://counter.theconversation.com/content/99568/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Suk-Fong Lok has served on advisory panels of Roche, Viravaxx, and Spring Bank. She receives research funding from Bristol-Myers Squibb, Gilead, the National Institutes of Health, and the Patient Center for Outcome Research Institute provided to the University of Michigan. </span></em></p>July 28 is World Hepatitis Day, and with an effective cure for hepatitis C there is much to celebrate. But homelessness and the opioid epidemic are driving a surge in hepatitis infections.Anna Suk-Fong Lok, Professor of Internal Medicine, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/946562018-04-10T11:15:07Z2018-04-10T11:15:07ZWhat is hepatitis A and how can you get it from eating frozen fruit?<figure><img src="https://images.theconversation.com/files/214037/original/file-20180410-75774-18ls1ja.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Imported frozen pomegranate seeds have been linked to hepatitis A infections in NSW.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=N2LFEmh4LN2bZwNhFOTqFw-1-66">from www.shutterstock.com</a></span></figcaption></figure><p><a href="http://mobile.abc.net.au/news/2018-04-07/frozen-pomegranate-linked-to-hepatitis-a-outbreak/9629634?pfmredir=sm">Seven people in New South Wales</a> have been diagnosed with hepatitis A after eating imported frozen pomegranate seeds from Coles. Although still under investigation, the company responsible for production <a href="https://www.productsafety.gov.au/recall/entyce-food-ingredients-pty-ltd-creative-gourmet-pomegranate-arils-180g">recalled the implicated product</a> as a precaution. </p>
<p>Around 40,000 packs of Creative Gourmet Frozen Pomegranate Arils have been sold since hitting the shelves in September 2017. <a href="http://www.health.nsw.gov.au/news/Pages/20180406_01.aspx">NSW Health is advising</a> consumers to immediately dispose of any in their possession. </p>
<h2>What is hepatitis A?</h2>
<p>Hepatitis A is a virus that infects the liver. Symptoms usually take 15-50 days to develop after initial infection and typically last for several weeks or sometimes longer. </p>
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Read more:
<a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Explainer: the A, B, C, D and E of hepatitis</a>
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<p>Symptoms can range from fever, weakness, tiredness, loss of appetite, nausea, muscle aches, vomiting and jaundice (yellow discolouration of the eyes and skin). Sometimes there are no symptoms, particularly among young children.</p>
<p>Liver failure and death from hepatitis A are very rare but occasionally occur among those with existing chronic health conditions, especially those that affect the liver. Hepatitis A vaccination is recommended for those living with hepatitis B and C. </p>
<h2>How does it spread?</h2>
<p>Hepatitis A is spread when a person ingests faecal matter from an infected person. This can occur through person-to-person contact (including through sexual or even seemingly trivial household contact), or consumption of contaminated food and water. </p>
<p>Hepatitis A is quite an infectious virus. Only microscopic amounts of poo are needed to infect people and cause symptoms. People living in the same house with a person with hepatitis A have an <a href="https://www2.health.vic.gov.au/about/publications/researchandreports/The-blue-book">increased risk</a> of acquiring hepatitis A unless receiving preventive interventions.</p>
<p>The virus can survive on hands and other surfaces such as cooking utensils and plates for hours. So it’s important to ensure that infected people properly wash their hands after using the toilet, and completely avoid handling food. </p>
<p>Hepatitis A infections occur infrequently in Australia, with the number of cases detected dropping profoundly in the last 20 years. Most infections are in people who have travelled in countries where hepatitis A transmission is common due to poor sanitation and lack of access to safe water. </p>
<p>When outbreaks occur, they are due to contaminated foods, as we saw with the frozen pomegranate seeds, or person-to-person transmission. This is the case for the <a href="https://www2.health.vic.gov.au/about/news-and-events/healthalerts/alert-hepatitis-a-november-2017">current</a> outbreak in Victoria, which has predominantly been spread between sexual partners, although other routes of transmission have also occurred. </p>
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<img alt="" src="https://images.theconversation.com/files/214038/original/file-20180410-75793-12boag.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/214038/original/file-20180410-75793-12boag.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/214038/original/file-20180410-75793-12boag.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/214038/original/file-20180410-75793-12boag.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/214038/original/file-20180410-75793-12boag.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/214038/original/file-20180410-75793-12boag.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/214038/original/file-20180410-75793-12boag.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Hepatitis A can survive on your hands for hours, so it’s important to wash thoroughly to prevent transmission.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=LqX91-YZ3YGrrQq4iwt2Jg-1-64">from www.shutterstock.com</a></span>
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<h2>How is it treated?</h2>
<p>Although hepatitis A can cause significant illness, the body usually recovers without treatment and becomes immune to future infections.</p>
<p>A highly effective <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-4">hepatitis A vaccine</a> has been available for decades, and once fully vaccinated (two vaccinations spaced at least six months apart), you’re protected for life.</p>
<h2>Has this happened before?</h2>
<p>Pomegranates have been linked to outbreaks <a href="https://www.cdc.gov/amd/stories/hepatitis-a.html">internationally</a> but not in Australia. </p>
<p>Past food-related outbreaks in Australia have occurred in oysters, lettuce, semi-dried tomatoes and frozen berries. </p>
<p>Imported frozen berries from the same producer implicated in the pomegranate associated outbreak were recalled due to linked cases of hepatitis A in <a href="http://www.abc.net.au/news/2015-02-17/fourth-frozen-berry-product-recalled-in-hepatitis-a-scare/6126272">2015</a> and again in <a href="https://www2.health.vic.gov.au/about/news-and-events/healthalerts/alert-hepatitis-a-berries-2-june-2017">2017</a>. </p>
<p>These outbreaks led to some questions regarding the screening and regulations of imported food coming into Australia and prompted <a href="http://www.agriculture.gov.au/import/goods/food/notices/ifn-01-16">new regulations</a> by the Department of Agriculture, requiring the producer of imported berries to be declared. The Department of Agriculture and Food Standards Australia New Zealand (AFANZ) also issued <a href="http://www.foodstandards.gov.au/publications/Documents/Imported%20berries%20hep%20A%20-%20risk%20statement%20WEB.pdf">guidance</a> and recommendations to ensure industry producers are compliant with Australia’s food standards. </p>
<p><a href="http://www.agriculture.gov.au/import/goods/food/inspection-compliance/tests-applied-to-surveillance-category-foods">Microbiological screening</a> tests for imported berries currently only involves testing for the intestinal bacterium <em>E.Coli</em>.</p>
<h2>Why is this happening again?</h2>
<p>Contamination of pomegranates, berries and other food products with hepatitis A can occur at several points of production, through:</p>
<ul>
<li>the use of contaminated water during irrigation</li>
<li>the processing and cleaning stages, or </li>
<li>handling by people infected with hepatitis A who may not have washed their hands prior to processing and packaging the fresh product. </li>
</ul>
<p>Both pomegranates and berries require large amounts of water and handling for processing, so it’s not surprising these types of outbreaks have occurred in Australia and across the world. </p>
<p>These outbreaks tend to be reported in countries such as Australia with low rates of hepatitis A. This is because there are more susceptible people in the population who aren’t immune from natural infections earlier in life. Also, these countries tend to have better functioning surveillance systems and relatively good access to health care.</p>
<p>Freezing fruit does not inactivate the hepatitis A virus, which remains stable and able to cause human infections when consumed. Heat can kill the virus, however the berries need to stay heated at 85 degrees Celsius for at least one minute.</p>
<h2>Should I be worried?</h2>
<p>Although this imported frozen pomegranate product has been linked to hepatitis A, no fresh (or Australian-produced) pomegranate has been connected with the recent hepatitis A cases.</p>
<p>If you have eaten any of the implicated pomegranate seeds within the last few weeks and are experiencing any <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/hepatitis-a">symptoms</a>, see your doctor for a blood test and don’t forget to wash your hands.</p><img src="https://counter.theconversation.com/content/94656/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Benjamin Cowie receives funding from the Australian Government Department of Health, the Victorian Government Department of Health and Human Services, the Royal Melbourne Hospital Office for Research, and the Cooperative Research Centre for Spatial Information.</span></em></p><p class="fine-print"><em><span>Nicole Romero receives funding from the Australian Government Department of Health and the Victorian Government Department of Health and Human Services.</span></em></p>Hepatitis A is a virus that infects the liver. Symptoms usually take 15-50 days to develop after initial infection and typically last for several weeks or sometimes longer.Benjamin Cowie, Director, WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and ImmunityNicole Romero, Epidemiologist, WHO Collaboating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and ImmunityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817682017-10-08T10:04:42Z2017-10-08T10:04:42ZMapping hepatitis in Kenya shows where action is needed<figure><img src="https://images.theconversation.com/files/186595/original/file-20170919-22657-2cazow.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hepatitis is a public health concern globally.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>A study of the different kinds of hepatitis in Kenya showed areas where the government can focus its efforts to prevent infections. One of the findings was a surprise – giving adults the Hepatitis vaccination has been ignored. This is a waiting time bomb, and an area for action that could have been overlooked.</p>
<p>Hepatitis is defined as inflammation of the liver. One symptom is yellowish eyes and skin (jaundice). The most common cause of hepatitis is viral infection. </p>
<p>Viral hepatitis is a <a href="http://www.who.int/immunization/topics/hepatitis/en/">public health concern</a> globally. It is difficult to <a href="http://www.who.int/mediacentre/commentaries/better-estimates-hepatitis/en/">count</a> exactly how many people get hepatitis or how many die from it. One reason is that the infection is caused by five types of virus, named from A to E, and they are passed on in different ways. The other reason is that most hepatitis deaths are not linked directly to the liver infection. Death may result from gradual damage to the liver. </p>
<p>The number of people affected worldwide is known to be hundreds of millions, though.</p>
<p>Our <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4774020/">study</a> set out to discover how common hepatitis A to E is among patients with symptoms of liver disease in different regions of Kenya. It was the first study of its kind in Kenya.</p>
<h2>The Kenyan study</h2>
<p>We studied 389 patients with jaundice at four hospitals:<a href="http://knh.or.ke/">Kenyatta National Hospital</a> (Nairobi), <a href="http://www.mtrh.or.ke/">Moi Teaching and Referral Hospital</a> (Eldoret), New Nyanza Provincial General Hospital (Kisumu) and Coast General Hospital (Mombasa). We collected blood samples from the patients and tested them for acute and chronic hepatitis A to E viruses. </p>
<p>The results showed that the main cause of the disease in this group was chronic hepatitis B infection. A chronic infection is one that stays in the patient for a long time or keeps coming back. The second most common cause was acute hepatitis A. This type of infection is sudden. In this study population, we found no recent infection of hepatitis C, D or E.</p>
<ul>
<li>Hepatitis A virus</li>
</ul>
<p>The study found that 6.3% of the total group of patients were infected with hepatitis A. Kisumu had 9.2% , the capital city , Nairobi had 6.3 % and Mombasa had 5.0%.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pubmed/6439821/">Previous studies</a> have shown that by the age of 10 years, nine out of every 10 children in areas where hepatitis A is common are <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/hepatitis-a">immune</a> to the infection. Therefore due to this immunity, the number of adults who get the disease, reduces. </p>
<p>We did not expect to find that so many adults – 6.3% out of 382 could still get the hepatitis A infection. </p>
<p><a href="http://www.who.int/mediacentre/factsheets/fs328/en/">This virus</a> is passed on in water and food. It can remain in the environment for a long time and can survive processes such as filtration process that are supposed to make food safe. </p>
<p>The finding suggests that adults should be immunised. Prevention efforts should also focus on managing the environment, water and waste.</p>
<ul>
<li>Hepatitis B virus</li>
</ul>
<p>About half (50.6%) of the patients tested had hepatitis B virus. Eldoret in Western Kenya had the highest number of cases at 92.9% of all Hepatitis B patients followed by Mombasa (81.8%), Kisumu (79.8%) and Nairobi (33.8%). Patients with chronic infections numbered 128 out of the 168.</p>
<p><a href="http://www.who.int/immunization/diseases/hepatitisB/en/">Hepatitis B</a> is transmitted through infected blood or other body fluids of an infected person.. It can cause liver cancer and cirrhosis, the long term injury of the liver.</p>
<p>Globally, about <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3321493/">two billion</a> people have been infected with hepatitis B virus and about <a href="http://www.who.int/immunization/diseases/hepatitisB/new_vaccine/en/index3.html">350 million</a> of them have the virus for life. The World Health Organisation has categorised Kenya as an <a href="http://apps.who.int/iris/bitstream/10665/246177/1/WHO-HIV-2016.06-eng.pdf?ua=1">endemic area</a>.</p>
<ul>
<li>Hepatitis C, D and E viruses</li>
</ul>
<p>Of all the samples collected, 3.9% were positive for Hepatitis C, when the positives were confirmed none was positive indicating exposure to the virus without active infection. </p>
<p>Types <a href="http://www.who.int/mediacentre/factsheets/fs164/en/">C</a> and <a href="http://www.who.int/mediacentre/factsheets/hepatitis-d/en/">D</a>, like <a href="http://www.who.int/immunization/diseases/hepatitisB/en/">B</a>, are passed on in blood.</p>
<p>All specimens in the study were negative for hepatitis D virus. </p>
<p>The prevalence of the exposure to hepatitis E virus was 8.1% this is higher than the 6.3% for hepatitis A, which was mentioned above as the second biggest cause of hepatitis and it affected more women than men. Hepatitis E is severe in women than men and in expectant mothers. it causes death among 20% of those infected. </p>
<p><a href="http://www.who.int/mediacentre/factsheets/fs280/en/">Type E</a> is also carried in water and food. In 2015, the World Health Organisation estimated that hepatitis E caused approximately <a href="http://www.who.int/mediacentre/factsheets/fs280/en/">44 000 deaths globally</a> – 3.3% of the deaths due to viral hepatitis. </p>
<h2>Dealing with hepatitis A and B</h2>
<p>Hepatitis A and B are the most serious types of this disease. In our study, the hepatitis A virus was reported in cities where people are crowded into substandard housing without clean water and food.</p>
<p><a href="http://www.who.int/biologicals/areas/vaccines/hepatitis/en/">Sanitation</a> in urban areas needs to be improved urgently. Infections in adults can further be prevented through <a href="https://www.cdc.gov/vaccines/vpd/hepa/public/index.html">vaccination</a>. </p>
<p>Hepatitis B needs urgent attention. People at risk include injecting drug users, unborn babies of pregnant women who have tested positive to the virus and people with kidney failure because of repeated dialysis which is a risk of contracting the disease. A hepatitis B <a href="https://www.cdc.gov/vaccines/hcp/vis/vis-statements/hep-b.html">vaccine </a> is available for these risk groups. This vaccine is mandatory for all health workers.</p>
<h2>Kenya’s hepatitis milestones</h2>
<p>Kenya has put in place the following preventive measures to manage hepatitis related infections.</p>
<ul>
<li><p>developing <a href="http://www.health.go.ke/download/guidelines/">national guidelines</a> on the prevention and management of viral hepatitis</p></li>
<li><p>screening all donated blood and its products for transfusions</p></li>
<li><p>vaccination of <a href="https://pdfs.semanticscholar.org/26ab/b4c3b27691b2d884dbac2f97f506e18d7cf3.pdf">health workers</a> against hepatitis A and B.</p></li>
<li><p>providing safe sterile needles and syringes</p></li>
<li><p>introduction of hepatitis B virus vaccine in the <a href="http://e-cavi.com/wp-content/uploads/2014/11/KENYA-NATIONAL-POLICY-ON-IMMUNIZATION-2013.pdf">immunisation schedule in 2003</a> to prevent mother to child transmission. </p></li>
</ul>
<h2>Way forward</h2>
<p>Public health awareness is needed to avert hepatitis A <a href="https://www.iamat.org/country/kenya/risk/hepatitis-a">outbreaks</a>, as reported in Coastal Kenya where 21 people were admitted to hospital. This means explaining why people should keep their households and surroundings clean.</p>
<p>The hepatitis B infections can also be reduced by encouraging responsible sexual behaviour screening all pregnant women and providing rehabilitation services for injecting drug users.</p>
<p>The government needs to work with other agencies to increase coverage of immunisation for hepatitis B, especially among the most vulnerable people.</p><img src="https://counter.theconversation.com/content/81768/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Hepatitis viruses are serious infections that damage the liver. There is an urgent need to deal with increased Hepatitis B infections in Kenya.Ochwoto Missiani, Research Officer, Kenya Medical Research InstituteJulius Oyugi, University of NairobiSimeon Mining, Professor of Immunology and Director of Research, Moi University Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/842102017-09-21T03:00:01Z2017-09-21T03:00:01ZPunishing one person for STI transmission weakens public health efforts<figure><img src="https://images.theconversation.com/files/186712/original/file-20170920-895-18as0ho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In most Australian states, if you have certain STIs, you have a legal responsibility to notify your potential sexual partners.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Is one person to blame if another gets a sexually transmissible infection (STI)? In most Australian states, if you have certain STIs, you have a legal responsibility to notify your potential sexual partners. </p>
<p>The NSW government <a href="http://www.news.com.au/national/nsw-act/con-or-condom-uproar-over-changes-to-hiv-and-sti-disclosure-law/news-story/7e07c4f76526d4073f5f423e3303da07">last week</a> passed an amendment to the state’s <a href="https://www.parliament.nsw.gov.au/bills/Pages/bill-details.aspx?pk=3426">Public Health Act</a> that increased the associated penalties by doubling the maximum fines and adding potential jail time. </p>
<p>Section 79 (1) of the Act <a href="https://www.parliament.nsw.gov.au/bills/DBAssets/bills/BillText/3426/b2016-144-d26_House.pdf">now reads</a>:</p>
<blockquote>
<p>A person who knows that he or she has a notifiable disease, or a scheduled
medical condition, that is sexually transmissible is required to take reasonable
precautions against spreading the disease or condition.</p>
<p>Maximum penalty: 100 penalty units or imprisonment for 6 months, or both.</p>
</blockquote>
<p>In addition to increasing potential penalties, the amendment removed an earlier provision mandating disclosure of STI status, replacing it instead with the need for “reasonable precautions”. </p>
<p>This is a positive change for the law that reflects the best available research on STIs and transmission. Yet its coupling with increased penalties has sent a mixed message about sexual health in the state. </p>
<p>Further, the idea that punishing STI exposure or transmission will decrease rates of infection is <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2128015">not supported by global research</a> on HIV, and there is no reason to believe this would be any different for other STIs. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/moral-responsibilities-to-disclose-your-hiv-status-to-partners-arent-so-clear-cut-51383">Moral responsibilities to disclose your HIV status to partners aren't so clear-cut</a>
</strong>
</em>
</p>
<hr>
<h2>Laws across Australia</h2>
<p>Health law is pretty complex and mainly left up to each state and territory. Generally speaking, across Australia you risk some kind of punishment for knowingly infecting another person with what are often referred to as “<a href="http://www.health.gov.au/internet/main/publishing.nsf/content/cda-pubs-cdi-2000-cdi2408-cdi2408g.htm">notifiable diseases</a>”. This list covers a range of infections but STIs include chlamydia, gonorrhoea, syphilis, HIV, shigella, donovanosis, and hepatitis a, b and c. </p>
<p>In some states, notably <a href="https://www.legislation.nsw.gov.au/#/view/act/2010/127">New South Wales</a>, <a href="https://www.legislation.tas.gov.au/view/whole/html/inforce/current/act-1997-086">Tasmania</a> and <a href="https://www.health.qld.gov.au/publichealthact">Queensland</a>, it’s an offence just to knowingly expose someone to an infection, even if they don’t actually become infected. While in other states, like <a href="https://www.google.com.au/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwiou86chLPWAhXDTbwKHbZXAYUQFggoMAA&url=http%3A%2F%2Fwww.legislation.vic.gov.au%2FDomino%2FWeb_Notes%2FLDMS%2FPubStatbook.nsf%2Ff932b66241ecf1b7ca256e92000e23be%2F8B1B293B576FE6B1CA2574B8001FDEB7%2F%24FILE%2F08-46a.pdf&usg=AFQjCNHWftaXq4M2CKSHQw-mCoyIC_27lw">Victoria</a> and <a href="https://www.legislation.sa.gov.au/LZ/C/A/SOUTH%20AUSTRALIAN%20PUBLIC%20HEALTH%20ACT%202011.aspx">South Australia</a>, health acts do not specify penalties for exposure or transmission, referring instead to the respective crime acts. For the most part, curable STIs do not rank as serious enough for criminal prosecution.</p>
<p>What is unique about NSW is that it uses the Public Health Act to single out STIs and describe specific punishments above and beyond other infections. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/186724/original/file-20170920-927-cnybuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/186724/original/file-20170920-927-cnybuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/186724/original/file-20170920-927-cnybuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/186724/original/file-20170920-927-cnybuc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/186724/original/file-20170920-927-cnybuc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/186724/original/file-20170920-927-cnybuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/186724/original/file-20170920-927-cnybuc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/186724/original/file-20170920-927-cnybuc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Moving away from mandating disclosure of a person’s STI status to their partner is actually positive.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/search/photos/partners?photo=p3UCTiZIU6M">Photo by Gerrit Vermeulen on Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Although laws in NSW seem unusually fixated on STIs, the move away from mandated disclosure in favour of “reasonable precautions” is a positive step. While disclosure may seem sensible on the surface, it’s not the most effective at preventing transmission. This is because disclosure requires that someone be aware of an infection and many people with an STI don’t realise they are infected. For example, <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">it’s estimated</a> nearly three quarters of chlamydia infections in young people in Australia go undiagnosed every year. Relying on disclosure can, therefore, give people a false sense of security. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/sexually-transmissible-infections-on-the-rise-in-australia-a-snapshot-68681">Sexually transmissible infections on the rise in Australia: a snapshot</a>
</strong>
</em>
</p>
<hr>
<p>There are other more effective strategies than disclosure for protecting someone from infection. With HIV, for example, <a href="https://hptn.org/research/studies/hptn052">successful treatment</a> means the risks of transmitting the virus to another person are virtually nonexistent. Under the amended NSW law, treatment could quite rightly be considered a reasonable precaution to avoid transmitting HIV.</p>
<p>But the state’s Public Health Act is relevant to all STIs, not just HIV. For other infections, it’s less clear what precautions might be seen as reasonable. Condoms can offer protection from some infections, but not all, and they are <a href="http://onlinelibrary.wiley.com/doi/10.1363/3800606/full">rarely used</a> for oral sex. Given more and more chlamydia and gonorrhoea cases are <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">identified in the throat</a>, this is potentially problematic.</p>
<h2>Punishment doesn’t help</h2>
<p>Every year, there are over 100,000 STI <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">diagnoses across Australia</a>, the vast majority of which can be cured using antibiotics. Ultimately, public health initiatives aim to reduce new cases and lower the overall amount of infection.</p>
<p>It’s been suggested by public health experts that criminalising transmission can <a href="http://www.tandfonline.com/doi/full/10.1080/09581596.2015.1052731">undermine public health efforts</a> by reinforcing stigma and causing people to delay accessing testing, treatment and care. </p>
<p>And in <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2128015">a review</a> of legal conditions around the world, researchers found that there was no link between laws criminalising HIV transmission and lower infection rates. The review also found such laws disproportionately impacted those who may experience marginalisation, such as young people and women. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/stigma-and-lack-of-awareness-stop-young-people-testing-for-sexually-transmitted-infections-80265">Stigma and lack of awareness stop young people testing for sexually transmitted infections</a>
</strong>
</em>
</p>
<hr>
<p>In reality, situations where an individual recklessly or wilfully places another at risk of an STI are <a href="http://www.hivmediaguide.org.au/media-tool-kit/hiv-in-the-news/criminal-cases-involving-hiv-transmission-or-exposure/">incredibly rare</a> and health officials have many options besides punishment. </p>
<p>As part of their core work, doctors and clinics counsel on and work with people to prevent onward transmission, and in some cases public health orders can be used to compel people to, among other actions, attend counselling and refrain from activities that might spread an infection. In the most extreme situations, criminal charges can be brought on the basis of grievous bodily harm.</p>
<p>Overall, a special and punitive focus to STIs risks further entrenching stigma and undermining the Act’s intent, which is to manage and reduce infection. If there is any hope of reducing STIs in Australia, laws must aim to foster an environment where people feel comfortable, able and willing to get tested and engaged with their sexual health. </p>
<p>While it seems unlikely a rush to prosecute those who expose others to STIs will spring up from this amendment, the law as it is currently written leaves open that rather serious possibility. In NSW and across Australia, health law consistently places the burden of prevention on one partner. In an ideal world, all parties to a sexual encounter take “reasonable precautions” to protect themselves and each other from infection.</p><img src="https://counter.theconversation.com/content/84210/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Denton Callander receives funding from the Australian Department of Health, the Australian Research Council, the National Health and Medical Research Council, and the New South Wales Ministry of Health. </span></em></p>NSW has changed its laws imposing criminal penalties on someone with an STI who doesn’t take “reasonable precautions” to not infect their sexual partner.Denton Callander, Research fellow, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/814002017-08-28T20:10:18Z2017-08-28T20:10:18ZHealth Check: which vaccinations should I get as an adult?<figure><img src="https://images.theconversation.com/files/181632/original/file-20170810-4244-1cw5cph.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Vaccines are one of the greatest public health achievements in history.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Before vaccines were developed, infectious diseases such as diphtheria, tetanus and meningitis were the <a href="https://www.quora.com/What-is-the-most-common-cause-of-human-death-in-history">leading cause of death</a> and illness in the world. Vaccines are one of the <a href="http://www.who.int/bulletin/volumes/86/2/07-040089/en/">greatest public health achievements in history</a>, having drastically reduced deaths and illness from infectious causes.</p>
<p>There is a large <a href="https://newsroom.unsw.edu.au/news/health/millions-australian-adults-missing-out-free-vaccines">gap between vaccination rates</a> for funded <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/adult-vaccination-fact-sheet.pdf">vaccines for adults in Australia</a> and those for infants. More than 93% of infants are vaccinated in Australia, while in adults the rates are between 53-75%. Much more needs to be done to prevent infections in adults, particularly those at risk. </p>
<p>If you are an adult in Australia, the kinds of vaccines you need to get will depend on several factors, including whether you missed out on childhood vaccines, if you are Aboriginal or Torres Strait Islander, your occupation, how old you are and whether you intend to go travelling.</p>
<h2>For those born in Australia</h2>
<p>Children up to four years and aged 10-15 receive vaccines under the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/national-immunisation-program-schedule">National Immunisation Schedule</a>. These are for hepatitis B, whooping cough, diphtheria, tetanus, measles, mumps, rubella, polio, haemophilus influenzae B, rotavirus, pneumococcal and meningococcal disease, chickenpox and the human papillomavirus (HPV).</p>
<p>Immunity following vaccination varies depending on the vaccine. For example, the measles vaccine protects for a long duration, possibly a lifetime, whereas immunity wanes for pertussis (whooping cough). Boosters are given for many vaccines to improve immunity. </p>
<p><strong>Measles, mumps, rubella, chickenpox, diphtheria and tetanus</strong></p>
<p>People born in Australia before 1966 likely have <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-9">natural immunity to measles</a> as the viruses were circulating widely prior to the vaccination program. People born after 1965 should have received two doses of a measles vaccine. Those who haven’t, or aren’t sure, can safely receive a vaccine to avoid infection and prevent transmission to babies too young to be vaccinated. </p>
<p>Measles vaccine can be given as MMR (measles-mumps-rubella) or MMRV, which includes varicella (chickenpox). The <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-22">varicella vaccine</a> on its own (not combined in MMRV) is advised for people aged 14 and over who have not had chickenpox, especially women of childbearing age.</p>
<p>Booster doses of diphtheria, tetanus and whooping cough vaccines, are available free at age 10-15, and recommended at 50 years old and also at 65 years and over if not received in the previous ten years. Anyone unsure of their tetanus vaccination status who sustains a tetanus-prone wound (generally a deep puncture or wound) should get vaccinated. While tetanus is rare in Australia, most cases we see are in older adults.</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=838&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=838&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=838&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1053&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1053&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183902/original/file-20170830-5016-1ogb0cr.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1053&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In July 2017, the government announced free catch-up vaccinations for all newly arrived refugees. This covers any childhood vaccine on the National Immunisation Schedule which has been missed.</span>
<span class="attribution"><span class="source">Information sourced from betterhealth.vic.gov.au and healthdirect.gov.au/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
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<p><strong>Whooping cough</strong></p>
<p>Pregnant women are recommended to get the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/pregnant-women">diphtheria-tetanus-acellular pertussis</a> vaccine in the third trimester to protect the vulnerable infant after it is born, and influenza vaccine at any stage of the pregnancy (see below under influenza). </p>
<p>Pertussis (whooping cough) is a contagious respiratory infection dangerous for babies. One in <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/whooping-cough">every 200 babies</a> who contract whooping cough will die. </p>
<p>It is particularly important for women from 28 weeks gestation to ensure they are vaccinated, as well as the partners of these women and anyone else who is taking care of a child younger than six months old. Deaths from pertussis are also documented in elderly Australians.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/no-vax-no-visit-if-mum-was-vaccinated-baby-is-already-protected-against-whooping-cough-59374">'No Vax, No Visit'? If mum was vaccinated baby is already protected against whooping cough</a>
</strong>
</em>
</p>
<hr>
<p><strong>Pneumococcal disease and influenza</strong></p>
<p>The pneumococcal vaccine is funded for everyone aged 65 and over, and <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-13">recommended for anyone</a> under 65 with risk factors such as chronic lung disease.</p>
<p>Anyone from the age of six months can get the flu (influenza) vaccine. The vaccine can be given to any adult who requests it, but is only funded if they fall into defined risk groups such as pregnant women, Indigenous Australians, peopled aged 65 and over, or those with a medical condition such as chronic lung, cardiac or kidney disease. </p>
<p>Flu vaccine is matched every year to the anticipated circulating flu viruses and is quite effective. The vaccine covers four strains of influenza. Pregnant women are at increased risk of the flu and recommended for influenza vaccine any time during pregnancy. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/millions-of-australian-adults-are-unvaccinated-and-its-increasing-disease-risk-for-all-of-us-74991">Millions of Australian adults are unvaccinated and it's increasing disease risk for all of us</a>
</strong>
</em>
</p>
<hr>
<p>Health workers, childcare workers and aged-care workers are a priority for vaccination because they care for sick or vulnerable people in institutions at risk of outbreaks. Influenza is the most important vaccine for these occupational groups, and some organisations provide free staff vaccinations. Otherwise, you can ask your doctor for a vaccination.</p>
<p>Any person whose immune system is <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part3%7Ehandbook10-3-3#3-3-3">weakened through medication</a> or illness (such as HIV) is at increased risk of infections. However, live viral or bacterial vaccines must not be given to immunosuppressed people. They must seek medical advice on which vaccines can be safely given.</p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1780&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1780&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183617/original/file-20170828-1549-tkycmv.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1780&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In July 2017, the government announced free catch-up vaccinations for all newly arrived refugees. This covers any childhood vaccine on the National Immunisation Schedule which has been missed.</span>
<span class="attribution"><span class="source">Information sourced from betterhealth.vic.gov.au and healthdirect.gov.au/The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p><strong>Hepatitis</strong> </p>
<p>Australian-born children receive four shots of the hepatitis B vaccine, but some adults are advised to get vaccinations for hepatitis A or B. Those recommended to receive the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-4">hepatitis A vaccine</a> are: travellers to hepatitis A endemic areas; people whose jobs put them at risk of acquiring hepatitis A including childcare workers and plumbers; men who have sex with men; injecting drug users; people with developmental disabilities; those with chronic liver disease, liver organ transplant recipients or those chronically infected with hepatitis B or hepatitis C.</p>
<p>Those recommended to get the hepatitis B vaccine are: people who live in a household with someone infected with hepatitis B; those having sexual contact with someone infected with hepatitis B; sex workers; men who have sex with men; injecting drug users; migrants from hepatitis B endemic countries; healthcare workers; Aboriginal and Torres Strait Islanders; and some others at high risk at their workplace or due to a medical condition.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">Explainer: the A, B, C, D and E of hepatitis</a>
</strong>
</em>
</p>
<hr>
<p><strong>Human papillomavirus</strong></p>
<p>The <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-hpv">human papillomavirus (HPV) vaccine</a> protects against cervical, anal, head and neck cancers, as well as some others. It is available for <a href="https://theconversation.com/boys-should-also-get-the-hpv-vaccine-to-protect-themselves-from-oral-and-genital-cancers-58772">boys</a> and girls and delivered in high school, usually in year seven. There is benefit for older girls and women to be vaccinated, at least up to their mid-to-late 20s. </p>
<h2>The elderly</h2>
<p>With ageing comes a progressive decline in the immune system and a <a href="https://theconversation.com/vaccination-isnt-just-for-kids-a-guide-for-over-65s-27869">corresponding increase</a> in risk of infections. Vaccination is the <a href="http://www.scirp.org/journal/PaperInformation.aspx?paperID=41210">low-hanging fruit</a> for healthy ageing. The elderly are advised to receive the influenza, pneumococcal and shingles vaccines.</p>
<p>Influenza and pneumonia are <a href="http://www.sciencedirect.com/science/article/pii/S0264410X16308520?via%3Dihub">major preventable causes</a> of illness and death in older people. The flu causes deaths in children and the elderly during severe seasons. </p>
<p>The most common cause of pneumonia is streptococcus pneumonia, which can be prevented with the <a href="https://www.cdc.gov/vaccines/vpd/pneumo/public/index.html">pneumococcal vaccine</a>. There are two <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-13">types of pneumococcal vaccines</a>: pneumococcal conjugate vaccine (PCV) and pneumococcal polysaccharide vaccine (PPV). Both protect against invasive pneumococcal disease (such as meningitis and the blood infection referred to as septicemia), and the conjugate vaccine is proven to reduce the risk of pneumonia.</p>
<p>The <a href="http://www.ncirs.edu.au/assets/provider_resources/fact-sheets/adult-vaccination-fact-sheet.pdf">government funds</a> influenza (annually) and pneumococcal vaccines for people aged 65 and over.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181636/original/file-20170810-4244-a2dny2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Vaccination is the low-hanging fruit for healthy ageing.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
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</figure>
<p>Shingles is a reactivation of the chickenpox virus. It causes a high burden of disease in older people (who have had chickenpox before) and can lead to debilitating and chronic pain. The <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-24">shingles vaccine</a> is recommended for people aged 60 and over. The government funds it for people aged 70 to 79. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-how-do-you-get-shingles-and-who-should-be-vaccinated-against-it-64436">Explainer: how do you get shingles and who should be vaccinated against it?</a>
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</em>
</p>
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<h2>Australian travellers</h2>
<p>Travel is a major vector for transmission of infections around the world, and travellers are at high risk of preventable infections. Most <a href="http://www.sciencedirect.com/science/article/pii/S0264410X16306065">epidemics of measles</a>, for example, are imported through travel. People may be under-vaccinated for measles if they missed a dose in childhood. </p>
<p>Anyone travelling should discuss vaccines with their doctor. If unsure of measles vaccination status, vaccination is recommended. This will depend on where people are travelling, and may include vaccination for yellow fever, Japanese encephalitis, cholera, typhoid, hepatitis A or influenza. </p>
<p>Travellers who are visiting friends and relatives overseas often <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5111124/">fail to take precautions</a> such as vaccination and do not perceive themselves as being at risk. In fact, they are at higher risk of preventable infections because they may be staying in traditional communities rather than hotels, and can be exposed to risks such as contaminated water, food or mosquitoes.</p>
<h2>Aboriginal Australians and Torres Strait Islanders</h2>
<p>Indigenous Australians are at <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part3%7Ehandbook10-3-1">increased risk of infections</a> and have access to funded vaccines against influenza (anyone over six months old) and pneumococcal disease (for infants, everyone over 50 years and those aged 15-49 with chronic diseases). </p>
<p>They are also advised to get hepatitis B vaccine if they haven’t already received it. Unfortunately, overall <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/cda-cdi32suppl.htm">vaccine coverage for these groups</a> is low – between 13% and 50%, representing a real lost opportunity.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dr-g-yunupingus-legacy-its-time-to-get-rid-of-chronic-hepatitis-b-in-indigenous-australia-81672">Dr G. Yunupingu's legacy: it's time to get rid of chronic hepatitis B in Indigenous Australia</a>
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</em>
</p>
<hr>
<h2>Migrants and refugees</h2>
<p>Migrants and refugees are at risk of vaccine-preventable infections because they <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12602/full">may be under-vaccinated</a> and come from countries with a high incidence of infection. There is no systematic means for GPs to identify people at risk of under-vaccination, but the new <a href="https://www.humanservices.gov.au/customer/services/medicare/australian-immunisation-register">Australian Immunisation Register</a> will help if GPs can check the immunisation status of their patients.</p>
<p>The funding of catch-up vaccination has also been a major obstacle until now. In July 2017 the government announced <a href="http://www.sbs.com.au/news/article/2017/07/12/refugees-all-ages-now-eligible-governments-national-vaccination-program">free catch-up vaccinations</a> for children aged 10-19 and for all newly arrived refugees. This covers any childhood vaccine on the <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/national-immunisation-program-schedule">National Immunisation Schedule</a> that has been missed. </p>
<p>While this does not cover all under-vaccinated refugees, it is a welcome development. If you are not newly arrived but a migrant or refugee, check with your doctor about catch-up vaccination.</p><img src="https://counter.theconversation.com/content/81400/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C Raina MacIntyre receives funding from NHMRC and ARC. In the past she has received funding for investigator driven research or educational grants from Merck, GSK, Seqirus and Pfizer. </span></em></p><p class="fine-print"><em><span>Rob Menzies has been engaged as a consultant by Seqirus.</span></em></p>The kinds of vaccines adults need depend on several factors, including whether you were born here, how old you are and whether you intend to travel overseas.C Raina MacIntyre, Professor of Infectious Diseases Epidemiology, Head of the School of Public Health and Community Medicine, UNSW SydneyRob Menzies, Senior Lecturer, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/643862016-09-05T18:04:56Z2016-09-05T18:04:56ZGhana must up its game to win the race against hepatitis<figure><img src="https://images.theconversation.com/files/136608/original/image-20160905-4758-1puxjvm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman is examined at a hepatitis ward in Uganda.</span> <span class="attribution"><span class="source">Reuters/James Akena </span></span></figcaption></figure><p><a href="http://www.webmd.com/hepatitis/understanding-hepatitis-basics">Viral hepatitis</a> remains a massive challenge in Africa where around <a href="http://www.ncbi.nlm.nih.gov/pubmed/25457207">100 million people</a> are estimated to have either hepatitis C or B infection. The prevalence of hepatitis viruses in Africa is more than four times the <a href="http://www.ncbi.nlm.nih.gov/pubmed/25457207">23 million</a> infected across resource-rich nations.</p>
<p>And of the almost 1.4 million people who die from complications related to these infections each year, the majority are in resource constrained areas like Africa. </p>
<p>To tackle this problem, the World Health Organisation has set an ambitious target to <a href="http://www.afro.who.int/en/media-centre/pressreleases/item/8921-by-2030-viral-hepatitis-to-be-eliminated-from-the-african-region.html">eliminate viral hepatitis</a> in Africa by 2030.</p>
<p>As part of the <a href="http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=10223&Itemid=2593">plan</a> in the <a href="http://www.afro.who.int/en/media-centre/pressreleases/item/8921-by-2030-viral-hepatitis-to-be-eliminated-from-the-african-region.html">next five years</a> the organisation aspires to reduce chronic hepatitis B and C infection by one third and reduce hepatitis associated deaths by 10% on the continent. </p>
<p>For countries in the region the next 14 years will be a race against time to action these commitments. But for Africa to be successful, countries need to overcome three main hurdles. Firstly, they must develop stronger data systems to understand the burden of the diseases. Secondly, they must plan to prevent the spread of these infections. And thirdly, they need to roll out effective treatment programmes.</p>
<p>In our <a href="http://www.ncbi.nlm.nih.gov/pubmed/26987556">research</a> which highlights Ghana’s high viral hepatitis burden, we found that countries can have challenges in all three areas. New and extraordinary measures are needed on the continent if the 2030 goal is to become a reality.</p>
<h2>Inconsistent figures</h2>
<p>Data is one of the main challenges. Most countries in Africa do not have strong data systems to efficiently track temporal changes in disease burdens. As a result reliable national estimates are often lacking or outdated. What this means, for instance with viral hepatitis, is that the burden could be significantly higher than previously thought or reported.</p>
<p>Ghana is a case in point. According to Ghana’s Health Service, there are <a href="http://www.ghananewsagency.org/health/ghana-develops-national-policy-on-viral-hepatitis-92482">2.5 million people</a> in the country who live with viral hepatitis. </p>
<p>But our <a href="http://www.ncbi.nlm.nih.gov/pubmed/26987556">research</a> estimated the prevalence of chronic hepatitis B infection in Ghana to be 12.3%. This means that there could be as many as 3 million Ghanaians living with hepatitis B alone if <a href="https://esa.un.org/unpd/wpp/Download/Standard/Population/">recent population estimates</a> are used. The level of hepatitis B infection in the country is far higher than the <a href="http://www.ncbi.nlm.nih.gov/pubmed/26231459">global prevalence</a> of 3.61% and the reported prevalence in the <a href="http://www.ncbi.nlm.nih.gov/pubmed/26231459">African region</a> of of 8.83%.</p>
<p>Our <a href="http://www.ncbi.nlm.nih.gov/pubmed/26987556">analysis</a> also showed that pregnant women and Ghanaians aged 16 to 39 face the highest levels of infection. And among HIV patients in Ghana, we <a href="http://www.ncbi.nlm.nih.gov/pubmed/27190544">estimated</a> that almost one in seven people suffer from chronic hepatitis B infection while <a href="http://www.ncbi.nlm.nih.gov/pubmed/27507267">3% of Ghana’s population</a> also suffer from chronic hepatitis C infection. </p>
<p>Our hepatitis C prevalence figure is far higher than the <a href="https://www.ncbi.nlm.nih.gov/pubmed/21091831">previously reported estimate</a> of 1.7%. Our preliminary assessments also indicate that around 1 in 8 Ghanaians show evidence of past hepatitis E infection (unpublished data).</p>
<p>The socio-economic implications of a high viral hepatitis burden in Ghana while not thoroughly documented could be far reaching. <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3504539/">Two of every three</a> pregnant women in Ghana who develop sudden and severe hepatitis E infection are likely to die.</p>
<p>And <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1790825/">research</a> also suggests that chronic hepatitis B infection is implicated in over 40% of liver cirrhosis cases in Ghana. Additionally, one in 14 liver cirrhosis patients in in the country has being found to be chronically infected with hepatitis C. </p>
<p>The challenge is that cost of treating the complications such as liver cirrhosis and cancer which arise from chronic viral hepatitis could run into thousands of dollars. Many Ghanaians cannot afford such treatment and this could significantly deplete national health resources even if it were to be publicly funded. </p>
<p>The economic consequences due to loss of life and absenteeism from work could all come at a significant cost to a country still struggling to <a href="http://www.economist.com/news/middle-east-and-africa/21654648-africas-former-jewel-struggles-regain-its-gleam-mighty-fallen">address its economic problems</a>. These all support economic arguments for intensified prevention efforts to curb the spread of viral hepatitis in the country.</p>
<h2>Lapses in control</h2>
<p>Historically, efforts to control viral hepatitis in Ghana have been too slow and inconsistent. Several practises are hampering effective control of these infectious diseases. </p>
<p>A vaccine for hepatitis B has been available for more than three decades. It has been shown to be safe and 95% effective in <a href="http://www.who.int/mediacentre/factsheets/fs204/en/">preventing infection</a> and chronic disease developing.</p>
<p>Administering the vaccine is an integral part of the Ghanaian government’s <a href="http://www.ghananewsagency.org/health/ghana-develops-national-policy-on-viral-hepatitis-92482">viral hepatitis policy</a>, which was launched in 2015. While children born after 2003 are routinely screened and vaccinated against hepatitis B as part of the Expanded Programme on Immunisation, no publicly funded population-wide vaccination <a href="http://global-report.worldhepatitisalliance.org/files/global_report/download/CS%20regional/regional_report_AFRICA_V4_DIGI.pdf">is currently offered outside the programme</a>. Even pregnant women and HIV patients among whom infection risks remain very high are excluded. </p>
<p>In addition, Hepatitis B immunoglobulin G and vaccines for babies born to mothers with hepatitis B has not been covered under the country’s National Health Insurance Scheme. As a result this has to be <a href="http://global-report.worldhepatitisalliance.org/files/global_report/download/CS%20regional/regional_report_AFRICA_V4_DIGI.pdf">financed out-of-pocket</a>. </p>
<p>Ghana’s blood policy also mandates that donated blood is screened for blood-borne infections. This focuses mainly on <a href="http://www.who.int/bloodsafety/transfusion_services/GhanaNationalBloodPolicy2006.pdf">HIV 1 and 2, syphilis, hepatitis B and hepatitis C</a> but neglects other important viral hepatitis such as hepatitis E. This is despite <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3613652/">growing evidence</a> which shows possible hepatitis E transmission through blood transfusion, especially in endemic regions like Africa. </p>
<p>In addition, hepatitis C screening for high risk groups such as injection drug users is not done. And comprehensive harm-reduction services including offering sterile injecting equipment is not standard.</p>
<h2>The way forward</h2>
<p>The major gaps in hepatitis prevention and care services need to be addressed to tackle these viruses. </p>
<p>But in addition, programmes that help people understand how these viruses are transmitted is a necessity. Many Ghanaians do not know how these <a href="http://www.ncbi.nlm.nih.gov/pubmed/26161183">diseases are transmitted</a> and there are still a lot of misconceptions.</p>
<p>Both the government and public health institutions should engage in extensive efforts to address unhealthy population practices and low living standards that contribute to spread of these infectious diseases.</p>
<p>The World Health Organisation has set a <a href="http://www.afro.who.int/en/media-centre/pressreleases/item/8921-by-2030-viral-hepatitis-to-be-eliminated-from-the-african-region.html">good path</a>. The Ghanaian government, health professionals and all non-state actors must now rally together and intensify efforts towards bringing the burden of viral hepatitis under control.</p><img src="https://counter.theconversation.com/content/64386/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Ofori-Asenso does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Ghana must urgently implement strategies to tackle the high burden of viral hepatitis if it’s to fulfill global targets of eliminating the disease by 2030.Richard Ofori-Asenso, PhD student in the Department of Epidemiology and Preventive Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/547392016-07-28T01:49:44Z2016-07-28T01:49:44ZExplainer: the A, B, C, D and E of hepatitis<figure><img src="https://images.theconversation.com/files/132130/original/image-20160727-5669-1163oug.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The thing all five viruses have in common is they can cause mild to very severe liver damage.</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-276250463/stock-photo-tubes-of-blood-sample-for-testing.html?src=oLBl58Liiq_SORkDiOnCCA-1-44">wk1003mike/Shutterstock</a></span></figcaption></figure><p>Hepatitis means inflammation of the liver. While we usually think of hepatitis A to E viruses, anything that causes inflammation or damage to the liver can be considered as a form of hepatitis. </p>
<p>Hepatitis A, B, C, D and E are very different viruses. Hepatitis A is genetically closer to the common cold than it is to hepatitis B, for example. Hepatitis C is closer to the virus that causes dengue fever.</p>
<p>The thing all five have in common is they can cause mild to very severe liver damage. </p>
<p>Viral hepatitis caused around <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30579-7/abstract">1.45 million deaths</a> in 2013, making it the seventh leading cause of death world-wide; 96% of these were due to hepatitis B and C. </p>
<h2>Hepatitis A</h2>
<p>Hepatitis A is spread by contaminated food and water, and from person to person via faecal transmission, particularly in household settings. </p>
<p><a href="http://www.ijidonline.com/article/S1201-9712(07)00212-3/fulltext">Hippocrates</a> first described epidemics of diarrhoea and jaundice as far back as the fifth century BCE.</p>
<p>Although hepatitis A can cause significant illness, the body usually recovers without treatment and becomes immune to future infections.</p>
<p>Vaccines can prevent hepatitis A; these are <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-4#4-4-7">recommended for travellers and other groups</a> at particular risk of infection. Vaccination given early after exposure can also prevent hepatitis A from developing. </p>
<h2>Hepatitis B</h2>
<p>This is the most prevalent form of viral hepatitis worldwide. It’s also the leading cause of liver cancer. </p>
<p>An estimated <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)61412-X/abstract">250 million</a> people live with hepatitis B worldwide. Around <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12049/abstract">220,000 Australians</a> are thought to be living with chronic hepatitis B. </p>
<p>Hepatitis B can be transmitted from person to person through sex or blood-to-blood contact. But most people living with chronic (long-term) hepatitis B acquired it at birth from their mother, or early in life. Following infection, the chance of developing chronic hepatitis B in infancy is around 90%, but falls to 5% among adults.</p>
<p>A safe and highly effective vaccine has been available for hepatitis B since the 1980s. It has been provided for all infants born in Australia <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home%7Ehandbook10part4%7Ehandbook10-4-5#4-5-3">since May 2000</a>. </p>
<p>In <a href="http://www.sciencedirect.com/science/article/pii/S0264410X0901233X">China</a>, the proportion of children aged under five who had chronic hepatitis B fell from 9.7% in 1992 to 1% in 2006 after a vaccination program was introduced. The program has prevented millions of deaths from liver cancer and liver cirrhosis in China alone.</p>
<p>Effective antiviral treatments are also available for chronic hepatitis B. These can prevent liver damage and liver cancer from occurring. But even in a well-resourced country such as Australia, <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12345/abstract">only a minority</a> of people needing treatment and care for hepatitis B are receiving it. </p>
<h2>Hepatitis C</h2>
<p>This is the most common cause of viral hepatitis in Australia; an estimated <a href="http://kirby.unsw.edu.au/surveillance/2015-annual-surveillance-report-hiv-viral-hepatitis-stis">230,000 people</a> live with chronic infection. </p>
<p>Hepatitis C is the leading cause of liver cancer and liver transplants nationally. </p>
<p>Most hepatitis C infections in Australia were acquired through unsafe injecting drug use. But in some low-resource countries, ongoing transmission of hepatitis C in health care settings is a major problem. </p>
<p>Around 80% of people infected with hepatitis C develop chronic infection; those who do clear the infection naturally remain susceptible to future infections. </p>
<p>No vaccine for hepatitis C is available.</p>
<p>On March 1, new treatments were listed on the Pharmaceutical Benefits Scheme (PBS). Although <a href="https://theconversation.com/what-price-a-life-hepatitis-c-drug-out-of-reach-for-millions-33625">expensive</a>, these treatments represent a huge advance and are a <a href="http://gut.bmj.com/content/early/2016/04/12/gutjnl-2016-311504.abstract">cost-effective way</a> to prevent both new infections and deaths due to existing hepatitis C infections. With cure rates of the order of 90% with 8-24 weeks of tablets, and minimal side effects, these agents have the potential to drastically reduce the impact of hepatitis C.</p>
<p>The real key to unlocking this potential is the very <a href="http://www.pbs.gov.au/info/healthpro/explanatory-notes/general-statement-hep-c">liberal access criteria</a> the Commonwealth government has applied to these treatments. As a result, uptake of treatment for hepatitis C in Australia <a href="http://www.ashm.org.au/HCV/rollout-of-DAAs">has risen</a> more than 20-fold. </p>
<h2>Hepatitis D</h2>
<p>Hepatitis D is a satellite virus that can only infect people who also have hepatitis B. </p>
<p>It is estimated that approximately 5% of people living with hepatitis B globally also have <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3918112/">hepatitis D</a>, which can lead to more severe liver disease.</p>
<h2>Hepatitis E</h2>
<p>Hepatitis E, like hepatitis A, is spread through contaminated food and water. </p>
<p>The first outbreak of hepatitis E infection <a href="https://www.mja.com.au/journal/2016/204/7/first-reported-outbreak-locally-acquired-hepatitis-e-virus-infection-australia">acquired in Australia</a> was reported earlier this year. </p>
<p>While hepatitis E is usually relatively mild, it can cause serious illness late in pregnancy, with a death rate of <a href="http://www.who.int/mediacentre/factsheets/fs280/en/">up to 20%</a> among pregnant women in their third trimester.</p>
<p>A vaccine against hepatitis E has been developed but is currently <a href="http://www.who.int/mediacentre/factsheets/fs280/en/">licensed only in China</a>.</p>
<p>While viral hepatitis remains a substantial public health challenge in Australia and world-wide, with political will, adequate investment and global partnerships, the world can <a href="http://www.worldhepatitisalliance.org/en/news/may-2016/governments-track-eliminate-viral-hepatitis-2030">eliminate viral hepatitis</a> by 2030.</p><img src="https://counter.theconversation.com/content/54739/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Benjamin Cowie receives funding from the Australian Government Department of Health, the Victorian Government Department of Health and Human Services, and the Royal Melbourne Hospital Office for Research. </span></em></p>Hepatitis A, B, C, D and E are very different viruses. Hepatitis A is genetically closer to the common cold than it is to hepatitis B. Hepatitis C is closer to the virus that causes dengue fever.Benjamin Cowie, Director, WHO Collaborating Centre for Viral Hepatitis, The Peter Doherty Institute for Infection and ImmunityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/377522015-02-26T01:48:52Z2015-02-26T01:48:52ZFor safety’s sake, make food labels say what companies already know<figure><img src="https://images.theconversation.com/files/73124/original/image-20150226-1758-kqcht6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Unclear and sometimes misleading country-of-origin labelling in Australia is a source of confusion for consumers.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/dsevilla/14297747541">Diego Sevilla Ruiz/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Prime Minister <a href="http://www.sbs.com.au/news/article/2015/02/26/pm-orders-imported-food-label-review">Tony Abbott has called on</a> two senior ministers to prepare a cabinet submission on country-of-origin labelling laws. The move follows a <a href="https://theconversation.com/berry-scare-heres-what-you-need-to-know-about-hepatitis-a-37758">national outbreak of hepatitis A</a> linked to <a href="https://theconversation.com/scary-berries-how-food-gets-contaminated-and-what-to-do-37629">frozen berries</a> from China and Chile. </p>
<p><a href="https://theconversation.com/angst-over-berries-makes-case-for-good-clean-fair-food-37892">The outbreak</a> was a strong reminder that all is not well in Australia’s food supply. Once the alleged offending ingredient was identified and <a href="http://www.foodstandards.gov.au/industry/foodrecalls/recalls/Pages/Nanna's-Mixed-Berries.aspx">relevant products recalled</a>, consumers claimed <a href="http://www.heraldsun.com.au/news/opinion/consumers-have-right-to-know-if-its-made-in-australia-or-not/story-fni0fhie-1227223949217">they were not aware</a> the berries they were choosing to eat were from China.</p>
<p>But labelling on the berry products complied with <a href="http://www.foodstandards.gov.au/consumer/labelling/coo/Pages/default.aspx">current labelling</a> and <a href="http://www.accc.gov.au/consumers/groceries/country-of-origin">consumer information</a> laws. And despite the recall highlighting the inadequacy of the labelling, the <a href="http://www.theguardian.com/australia-news/2015/feb/18/tony-abbott-says-no-to-tougher-food-tests-labels-after-hepatitis-a-outbreak?CMP=share_btn_tw">prime minister dismissed initial calls for changes</a>. He said it would make life very hard for business, would raise the cost of food and that it was the responsibility of business “not to poison their customers”. </p>
<p>That changed this morning when Abbott asked Agriculture Minister Barnaby Joyce and Industry Minister Ian MacFarlane to submit a proposal to cabinet in March. MacFarlane has already warned <a href="http://www.sbs.com.au/news/article/2015/02/26/pm-orders-imported-food-label-review">consumers may have to bear the cost of the change</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/75041/original/image-20150317-13682-1czs2l8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/75041/original/image-20150317-13682-1czs2l8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/75041/original/image-20150317-13682-1czs2l8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=849&fit=crop&dpr=1 600w, https://images.theconversation.com/files/75041/original/image-20150317-13682-1czs2l8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=849&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/75041/original/image-20150317-13682-1czs2l8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=849&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/75041/original/image-20150317-13682-1czs2l8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1067&fit=crop&dpr=1 754w, https://images.theconversation.com/files/75041/original/image-20150317-13682-1czs2l8.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1067&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/75041/original/image-20150317-13682-1czs2l8.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1067&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>Here’s one problem with this current food-labelling system: “Made in Australia from local and imported ingredients” does not actually reveal where the food comes from. A company can claim a product is made in Australia if at least half the cost of manufacturing that product is incurred here. </p>
<p>Consider a jar of jam: the total cost of production includes the cost of producing the lid, the jar, the label, as well as the jam. Half the cost of production could easily be attributed to the jar itself, leaving room for jam ingredients to be imported and still allowing the label to say it was made in Australia. </p>
<p>The <a href="http://www.foodlabellingreview.gov.au/internet/foodlabelling/publishing.nsf/content/48C0548D80E715BCCA257825001E5DC0/$File/Labelling%20Logic_2011.pdf">2011 report</a> on the effectiveness of Australia’s food-labelling system <a href="http://www.foodlabellingreview.gov.au/internet/foodlabelling/publishing.nsf/content/48C0548D80E715BCCA257825001E5DC0/$File/Labelling%20Logic_2011.pdf">described the challenges</a> for improving transparency. It identified country-of-origin labelling as a particularly contentious issue, and recommended:</p>
<blockquote>
<p>That for foods bearing some form of Australian claim, a consumer-friendly, food-specific country-of-origin labelling framework, based primarily on the ingoing weight of the ingredients and components (excluding water), be developed. </p>
</blockquote>
<h2>Other options</h2>
<p>This recommendation was taken up by Greens leader Christine Milne. She <a href="http://www.comlaw.gov.au/Details/C2013B00117/b6b51a4c-df0c-4f3d-9b64-3ccb0b2f0f28">introduced a bill</a> to improve transparency of country-of-origin labelling just before the berry scare. It calls for <a href="http://greens.org.au/country-of-origin">three items on labels</a> that cover where a product is grown, where it’s manufactured and where it is packaged.</p>
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<a href="https://images.theconversation.com/files/75040/original/image-20150317-13674-1ndgd40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/75040/original/image-20150317-13674-1ndgd40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/75040/original/image-20150317-13674-1ndgd40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=793&fit=crop&dpr=1 600w, https://images.theconversation.com/files/75040/original/image-20150317-13674-1ndgd40.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=793&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/75040/original/image-20150317-13674-1ndgd40.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=793&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/75040/original/image-20150317-13674-1ndgd40.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=997&fit=crop&dpr=1 754w, https://images.theconversation.com/files/75040/original/image-20150317-13674-1ndgd40.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=997&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/75040/original/image-20150317-13674-1ndgd40.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=997&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>Even before this, consumer organisation Choice launched a <a href="http://www.choice.com.au/consumer-action/food-labelling/country-of-origin/better-country-of-origin-labelling.aspx">campaign about country-of-origin labelling</a> in January 2012 after a survey showed 86% of respondents found such labels unclear. </p>
<p>Choice proposes a three-tiered system that specifies “product of” for primary produce such as fruit and vegetables, “manufactured in” and “packaged in”. This last one would cover foods with input from multiple companies, which makes it difficult to isolate single ingredients, and products such as mixed frozen vegetables where each vegetable is from a different country. Choice plans to develop exact wording through consumer testing.</p>
<p>Another simple and practical way to resolve the problem is to include the origin of imported ingredients in the “ingredient list”. Labelling laws mandate that ingredient lists appear on every product. Individual ingredients are listed in order of volume, from most to least. </p>
<p>Take peanut butter as an example. Its ingredients list says roasted peanuts, vegetable oil, sugar and salt. If labelling laws mandated the listing of country of origin for imported ingredients, the list might say roasted peanuts (China), vegetable oil (Chile), sugar (Phillipines) and salt. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/73129/original/image-20150226-1758-17i4cai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/73129/original/image-20150226-1758-17i4cai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/73129/original/image-20150226-1758-17i4cai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/73129/original/image-20150226-1758-17i4cai.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/73129/original/image-20150226-1758-17i4cai.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/73129/original/image-20150226-1758-17i4cai.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=523&fit=crop&dpr=1 754w, https://images.theconversation.com/files/73129/original/image-20150226-1758-17i4cai.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=523&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/73129/original/image-20150226-1758-17i4cai.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=523&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>Ingredients sourced locally wouldn’t need to be declared as made in Australia would the default position; only imported ingredients would need to state the country of origin. </p>
<h2>It’s about time</h2>
<p>Milne’s bill has <a href="http://ausfoodnews.com.au/2013/02/20/country-of-origin-bill-ignites-afgc-anger.html">attracted the ire of the Australian Food and Grocery Council</a>, the peak food, drink and grocery manufacturing body. And food manufacturers have already responded to the prime minister’s announcement. They say <a href="http://ausveg.com.au/media-release/label-change-double-standard-puts-food-manufacturers-to-shame">changing the labelling system</a> would place an unreasonable burden on them.</p>
<p>But changing the wording of a label is different from adding a regime of <a href="http://www.abc.net.au/news/2015-02-17/nick-xenophon-calls-for-food-safety-review-berries-hepatitis-a/6131754">increased testing and reporting</a>. And although <a href="http://www.abc.net.au/news/2015-02-19/how-australia-checks-imported-food/6148576">risk assessment and testing</a> of imported foods is vital, what we now need for consumer confidence is the more cost-effective option of label change. </p>
<p>Food companies track the exact point of origin of each ingredient because of quality-control procedures, supported by Australia’s food laws. All consumers want is for the companies to tell them what they already know. </p>
<p>Changing Australia’s country-of-origin labelling system will effectively give consumers power to make informed decisions in the free market. And it will overcome the current information asymmetry, which keeps them in the dark.</p><img src="https://counter.theconversation.com/content/37752/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melanie Voevodin has been the recipient of an NHMRC Public Health Scholarship (2011-2013).</span></em></p>Prime Minister Tony Abbott has called on two ministers to prepare a cabinet submission about country-of-origin food labelling despite initial reluctance about change.Melanie Voevodin, NHMRC Public Health PhD Scholar, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/378922015-02-24T00:47:49Z2015-02-24T00:47:49ZAngst over berries makes case for ‘good, clean, fair’ food<figure><img src="https://images.theconversation.com/files/72711/original/image-20150223-21904-u8jdm1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Do you care where the food you buy comes from?</span> <span class="attribution"><span class="source">amy/Flickr</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>The public <a href="http://www.smh.com.au/national/nsw-hepatitis-a-patient-very-cranky-with-frozen-berries-debacle-20150219-13jh09.html">reaction</a> to the Hepatitis A scare linked to contaminated <a href="http://www.abc.net.au/news/2015-02-17/fourth-frozen-berry-product-recalled-in-hepatitis-a-scare/6126272">frozen berries imported from China</a> continues. </p>
<p>Consumer confidence in imported food is likely to have suffered a hit, and consumers are questioning the safety of imported food. Public health activists are calling for clear country of origin food labelling. Retailers are promising consumers stricter testing procedures for imported food products. Farmers are demanding a level playing field so they can compete against imports. Government authorities are defending existing food import protocols. And politicians are calling for inquiries. All of these perspectives have some element of truth, but we need to go beyond the immediate reactionary concerns and seek to understand the underlying reasons that have led to this situation in the first place.</p>
<p>Australia is a net food exporter; depending on seasonal conditions we export around <a href="http://www.agriculture.gov.au/about/annualreport/annual-report-2010-11/snapshot">60% of what we produce</a>. In fact, Australia is one of just a handful of countries that are net food exporters. We are a relatively small population occupying a relatively large land. The ratio of arable land per person in Australia (2.07 ha per person) is the <a href="http://data.worldbank.org/indicator/AG.LND.ARBL.HA.PC">highest in the world</a>, which means we really are the lucky country when it comes to food production and food security. </p>
<p>The fact we are a net food exporter does not mean we don’t import more than we export in certain categories. So while we are one of the world’s biggest exporters in beef, wheat, sugar, and wine; we also import processed and frozen foods.</p>
<p>So why does Australia import food? The short answer is price, though other factors include variety and seasonality. </p>
<h2>Cost crunch</h2>
<p>The average Australian household spends $204/week on food and non-alcoholic beverages, or <a href="http://www.abs.gov.au/AUSSTATS/abs@.nsf/Latestproducts/6530.0Main%20Features22009-10?opendocument&tabname=Summary&prodno=6530.0&issue=2009-10&num=&view">17% of total household expenditure</a>, and food prices have increased by 34% over the past decade, so there is a strong argument for keeping downward pressure on food prices. The business model of the big retailers is to drive prices down, but this often means <a href="http://accc.gov.au/media-release/court-finds-coles-engaged-in-unconscionable-conduct-and-orders-coles-pay-10-million-penalties">paying less to farmers</a>. While it is hard to argue against low food prices, there are <a href="http://journals.cambridge.org/download.php?file=%2FPHN%2FPHN15_02%2FS136898001100142Xa.pdf&code=1d245e267b872732c3e652438a6bb5dd">concerns</a> that health and environmental costs associated with unhealthy and unsustainable practices are not adequately captured in the focus on low food prices.</p>
<p>The unfortunate reality is that the big retailers can often source food cheaper from imports than from domestic farmers. The big retailers defend this practice by pointing out consumers benefit from cheaper food. While it is true that price is a major determinant of food purchase behaviour, it is not the only one. <a href="http://webarchive.nationalarchives.gov.uk/20130123162956/http:/www.defra.gov.uk/statistics/files/defra-stats-foodfarm-food-pocketbook-2012-130104.pdf">Other drivers</a> include taste, convenience, and ethical considerations. One of these ethical reasons is a desire to support “local” farmers, however local is defined. So on the one hand many consumers want or need cheap food, on the other, for some at least, there is a desire to support local farmers and rural communities with their food purchases. This ethical dilemma is brought into sharp focus by the Hepatitis A contaminated berry crisis.</p>
<h2>Ethical eating and ‘food literacy’</h2>
<p>How many of those consumers calling for more local food would be willing to pay more for that food? Consumers often prefer local food and may be <a href="http://ac.els-cdn.com/S0921800913000153/1-s2.0-S0921800913000153-main.pdf?_tid=3924440c-bb24-11e4-a960-00000aab0f27&acdnat=1424672678_2c39c63e7d5f77f88cf7e40257f8a30f">prepared to pay more</a> for local food, but often availability is limited and food labelling laws make it difficult for consumers to make ethical food purchases. And while the notion of consumers being willing to pay more for ethically produced food is not without precedent, free range eggs being a prime example, producers themselves are often resistant to consumer opportunities. </p>
<p>The current retail business model (high volume, low margin) is not focused on the ethical consumer. But the big retailers have immense market intelligence, and the growth in products in the organic aisle suggests they are responding to growing demand.</p>
<p>For consumers worried about where their food comes from, part of the long-term solution lies in more food consumers becoming food literate and empowered to exercise their influence as consumers. Ultimately it is you, the consumer, that drives modern food supply chains.</p>
<p><a href="http://search.informit.com.au/fullText;dn=609839497923648;res=IELHSS">Food literacy</a> has three dimensions:</p>
<p>1) knowledge about the impact of our food choices on our health </p>
<p>2) knowledge about the impact of our food choices on our ecological footprint (as an aside, for most people food represents the largest single contributor to their <a href="http://www.epa.vic.gov.au/%7E/media/Publications/1267.pdf">environmental impact</a>, and </p>
<p>3) knowledge about the impacts of our food choices on the businesses and communities that grow and provide our food. </p>
<p>The founder of the <a href="http://www.slowfood.com/">slow food movement</a>, Carlo Petrini, summed this up as “good, clean and fair”. Food systems should be good for our health, clean for the environment and fair for farmers. </p>
<p>Contaminated berries are obviously not good for our health (although in principle snap frozen food retains nutritional quality). Imported berries most likely have a greater environmental footprint than locally produced ones (although I would reserve judgement until a comprehensive <a href="http://ac.els-cdn.com.ezproxy.uws.edu.au/S0959652612001849/1-s2.0-S0959652612001849-main.pdf?_tid=3174a8f0-b980-11e4-961a-00000aab0f6c&acdnat=1424492276_079558aed0d49107716f61decd701cae">Life Cycle Assessment</a> study was undertaken), and the current market and policy settings are clearly unfair to Australian producers, although presumably Chinese producers benefit. </p>
<p>Becoming food literate entails acquiring knowledge across these issues, forming an ethical stance, and making deliberate food choices.</p><img src="https://counter.theconversation.com/content/37892/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bill Bellotti does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In the drive to cut costs on food, Australians often overlook the real impact of food choices.Bill Bellotti, Vincent Fairfax Chair in Sustainable Agriculture & Rural Development, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/377582015-02-19T19:36:27Z2015-02-19T19:36:27ZBerry scare: here’s what you need to know about hepatitis A<figure><img src="https://images.theconversation.com/files/72459/original/image-20150219-20778-14onhon.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Imported frozen berries have been linked to several hepatitis A infections.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/27638993@N08/3766088721">8 Eyes Photography/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>School students in <a href="http://www.theage.com.au/victoria/students-ate-imported-frozen-berries-linked-with-hepatitis-a-20150218-13iajl.html">Victoria</a>, <a href="http://www.sbs.com.au/news/article/2015/02/18/school-kids-caught-hepatitis-berry-scare">South Australia</a>, and <a href="http://www.couriermail.com.au/news/queensland/three-queensland-schools-in-berry-scare/story-fnn8dlfs-1227224731032">Queensland</a> are the latest group thought to have eaten frozen berries linked to hepatitis A, which has now infected 14 people nationally. All food-borne disease outbreaks are frightening, but the good news for this one is that hepatitis A is rarely life-threatening. </p>
<p>Hepatitis is inflammation of the liver and can result from a viral infection by one of five hepatitis viruses, which are called hepatitis A, B, C, D and E viruses. The viruses are unrelated to each other but are joined in name because they all replicate in the liver. </p>
<p>Hepatitis A and E viruses are probably the least serious, although infection is still harmful. On average, the blood-borne hepatitis viruses, namely B, C and D are nastier, mainly because all three can evade the immune system and cause a life-long infection. This can result in continual liver damage over decades.</p>
<h2>Hepatitis A infection</h2>
<p>When someone is infected by the hepatitis A virus they won’t become ill until two to seven weeks later. And they’re infectious around two weeks before and after symptoms. </p>
<p>The infected person will usually experience general “hepatitis” symptoms (tired, feeling sick, muscle aches, fever) for up to two weeks before they start to appear yellowish or jaundiced, as a result of liver damage. Jaundice lasts for between one and three weeks. </p>
<p>Infection could lead to the liver being enlarged so the upper right-hand side of the body may feel tender. Even after the jaundice has faded, hepatitis A infection can leave a patient feeling tired, off their food and weak for some weeks, or even months.</p>
<p>The idea of all viruses is to replicate to enormous numbers so they can be transmitted to new hosts. Hepatitis is no different, and about ten billion hepatitis A viruses are excreted per gram of feces. That’s why washing your hands is so important once you’re infected. It only takes about 1,000 viruses to infect someone – you can do the maths.</p>
<p>The hepatitis A virus is very common in developing countries, where human fecal waste often contaminates food and water supplies because sanitation standards are much lower. But in developed countries, such as Australia, the United States and the United Kingdom, infection with hepatitis A is quite rare; few people encounter the virus unless they travel overseas. This disparity in infection rates between wealthy and poor countries highlights the need for, and should strengthen efforts to, generate clean water supplies.</p>
<p>Like most viral infections, adults fare worse than children. A third of infected adults will get sick from hepatitis A, so the disease tends to be nastier in Western countries where mainly adult infections occur. </p>
<p>Only hepatitis A virus and hepatitis E virus are transmitted through the consumption of food and water contaminated with human feces. The other three are transmitted sexually (hepatitis B) or transmitted through virus contaminated blood (hepatitis B, C, and D).</p>
<h2>Other hepatitis viruses</h2>
<p>Infection with any of the five hepatitis viruses generally causes similar clinical symptoms, which include fever, headache, feeling weak, muscle aches, and loss of appetite, among other things. But infection with the hepatitis A virus is different from hepatitis B, C and D viruses because it seldom results illness lasting for more than a couple of months. In the vast majority of cases, the virus is eliminated from the body and the liver totally recovers. </p>
<p>The story is however different for hepatitis B, C ands D viruses, which can cause lifelong (chronic) infections in some infected people. A chronic infection is when the virus remains permanently in the liver because it cannot be removed by the immune system. </p>
<p>The immune system continually attacks the liver cells where the virus hides, resulting in their destruction and ultimately a reduction in the capacity of the liver to do its many tasks. This means liver damage continues over ten to 20 years and can lead to serious liver disease and liver cancer. This happens in about a quarter of those infected with these viruses. </p>
<p>Along with hepatitis A, hepatitis E also does not cause chronic infection. Having said that, hepatitis E is very dangerous to pregnant women and can be fatal to both mother and offspring.</p>
<h2>Vaccine and treatment</h2>
<p>Vaccines can protect against hepatitis A and hepatitis B infection, but they don’t cure infection. Since 2000, all Australian babies get hepatitis B vaccinations. But as the hepatitis A virus is rare in developed countries and not life threatening, vaccination is largely offered to people travelling to places where the virus is endemic. This makes very good practical sense and it’s cost effective</p>
<p>You should have the vaccine about a month before you travel because it takes between two and four weeks for full immune protection, which lasts about 25 years. Just like mumps and measles, once you’ve had a hepatitis A infection or the vaccine, you’ll probably be immune for life. </p>
<p>Our main weapon against hepatitis A virus are immunoglobulins, antibodies that bind to the virus to prevent further infection of cells. It needs to be administered two weeks after exposure to be effective. Other than this there are no real antiviral treatment options for hepatitis A. People with the virus are clinically supported with management of complications if they arise. </p>
<p>Treatments can suppress hepatitis B virus replication, but stopping it will allow the virus to come back. Only hepatitis C has a treatment that can cure it and these drugs are very new and very expensive.</p><img src="https://counter.theconversation.com/content/37758/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter White does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>School students in Victoria, South Australia, and Queensland are the latest group thought to have eaten frozen berries linked to hepatitis A, which has now infected 14 people nationally. All food-borne…Peter White, Professor in Microbiology and Molecular Biology, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/377122015-02-19T04:07:59Z2015-02-19T04:07:59ZContaminated berries scare unlikely to slow China food exports<figure><img src="https://images.theconversation.com/files/72442/original/image-20150219-20818-mfjw5g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">China's export food safety standards are much more stringent than domestic ones.</span> <span class="attribution"><span class="source">Image sourced from Shutterstock.com</span></span></figcaption></figure><p>Australian Prime Minister Tony Abbott has been forced to respond to <a href="http://www.smh.com.au/federal-politics/political-news/calls-for-tougher-country-of-origin-food-labels-after-hepatitis-a-outbreak-20150218-13iaf0.html">calls for stricter food labelling and inspection</a> of food imports, following a spate of hepatitis A infections suspected of being linked to contaminated frozen berries. </p>
<p>But it is not certain that either measure or other government action could have prevented the current contamination incident. The primary responsibility lies with the suppliers. </p>
<p>At this moment the public is still waiting for scientific results from laboratory tests on what exactly caused the infections. The only evidence so far is that all cases of infections are linked by the consumption of frozen raspberries imported from China by one Australian supplier. </p>
<p>The likelihood is that a contamination of what currently looks like a limited scale was caused by protocol or management failure relating to personal hygiene at the harvesting or processing stage, rather than systemic failure such as contaminated water supply that would affect larger batches of produce. </p>
<p>Government intervention works best to identify systemic issues such as chemical residues which can be picked up by routine inspections, but is less effective when dealing with smaller scale contamination. </p>
<h2>What standards does China have in place?</h2>
<p>Both the Australian and Chinese governments have measures in place to detect and prevent food contamination. China has different food safety systems for domestic food and exported food. Export food safety standards are much more stringent than domestic ones. Food exports are overseen by the ministry-level General Administration of Quality Supervision, Inspection and Quarantine (AQSIQ) and its provincial branches. AQSIQ requires that exported food meet domestic Chinese standards as well as those of the importing company and country. </p>
<p>AQSIQ can enforce radical changes in China’s food export policies. In 2002, for example, a major change in the procurement system for vegetable exports was made after <a href="http://www.foodanddrinkeurope.com/Products-Marketing/Japanese-firms-recall-contaminated-spinach">spinach exported to Japan</a> was found to contain excessive amounts of chemical residues. Chinese export firms were restricted to sourcing vegetable products from registered large-scale farms specialising in exports. </p>
<p>The laboratory test currently under way will give an indication whether government failure is to blame or whether this was an isolated incident that was unlikely to be picked up by a government level inspection regime. If this was an isolated small-scale incident, it is the responsibility of the supplier to ensure that this cannot happen again. </p>
<p>The risk of small-scale contamination is high if one considers what degree of enforcement and monitoring is required to ensure that, for example, all fruit handlers have constant access to hygienic toilet and hand-washing facilities. For good reasons suppliers concentrate their processing on a small number of locations that can be fully supervised. </p>
<h2>The foreign influence</h2>
<p>China’s food processing industry for exports was led and mainly developed by foreign-financed agribusiness. In the early days, foreign agribusiness companies from Japan and Taiwan, for example, provided local farmers with complete packages of production materials including seeds, pesticides and technical assistance. Foreign companies bring in not only technical skills but also managerial skills and advanced management systems. </p>
<p>For Australian farmers this case of food contamination is a reminder that the very strict Australian food regulations protect their position in global markets, not least the Chinese market, and that any incident can have major consequences.</p>
<p>Australian producers have secured a reputation as reliable suppliers of clean and safe food. Australian fresh berries and other produce are at the apex of the Chinese food pyramid as products of unquestioned quality. At the second level of quality are Chinese food products destined for export and supervised by AQSIQ, and at the next level are products under the domestic regime of food supervision which has just been declared a <a href="http://www.reuters.com/article/2015/02/01/us-china-agriculture-idUSKBN0L51AL20150201">government priority for 2015</a>. </p>
<h2>Market realities</h2>
<p>China’s fruit and vegetable exports will continue to grow globally. China is moving away from low value added manufacturing to high value added sectors. Despite being labour intensive, fruit exports have a high added value, and have grown rapidly in China during the last few years. While only a small percentage of domestic production is exported, it is a sizable amount compared with export volumes of other countries. </p>
<p>In 2013, China’s total fruit product export exceeded US$4 billion. Major importing countries include Thailand, Malaysia, Russia, Japan and the Netherlands. Exports of fruit to Australia were relatively small at around 1% of the total volume of fruit exports. </p>
<p>Australian and Chinese fruit exports are linked although they occupy different market segments. Australia has been a successful food exporting nation, with a competitive advantage in high premium agricultural produce. On one hand, Australia is renowned as a producer of premium food and wine from its clean water, clean air and clean soil. On the other hand, Australia’s strong domestic food processing industry which can manage food production and processes safely and effectively has earned Australia global recognition for safe agricultural products. </p>
<p>Globalising Australian agricultural services firms which specialise in areas such as implementing process safety management systems, supply chain management, data management solutions and computerised decision support tools have ample opportunities in improving safety performance and practices for their Chinese suppliers when extending their supply chains into China. </p>
<p>Taking Australian management and agricultural expertise to Chinese suppliers is also the most reliable and efficient way to secure the safety of food imports, as it is quite likely that incidents such as the frozen berry contamination are best prevented by active cooperation and supervision at managerial level.</p><img src="https://counter.theconversation.com/content/37712/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Australian Prime Minister Tony Abbott has been forced to respond to calls for stricter food labelling and inspection of food imports, following a spate of hepatitis A infections suspected of being linked…Hans Hendrischke, Professor of Chinese Business and Management, University of SydneyWei Li, Lecturer, Business School, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/376292015-02-16T19:35:16Z2015-02-16T19:35:16ZScary berries: how food gets contaminated and what to do<figure><img src="https://images.theconversation.com/files/72105/original/image-20150216-6142-g6hcxr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Only a small proportion of people who eat these berries will become infected.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/chiotsrun/3702753026">Chiot's Run/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Food distributor Patties Foods has recalled two brands of frozen mixed berries — <a href="https://www.facebook.com/NannasAU">Nanna’s</a> and <a href="https://www.facebook.com/CreativeGourmet">Creative Gourmet</a> — due to reports of three people in Victoria, four in Queensland and two in New South Wales developing hepatitis A after eating the products. The cause of a <a href="http://www.brisbanetimes.com.au/queensland/three-qld-hepatitis-a-cases-linked-to-frozen-mixed-berries-contamination-20150216-13g33q.html">fourth Queensland case</a> is still in doubt.</p>
<p>Initially, only one-kilogram bags of Nanna’s mixed berries were recalled, but that has now been extended to 300-gram and 500-gram bags of Creative Gourmet mixed berries. The berries came from Chile and China.</p>
<p>Authorities are <a href="http://www.abc.net.au/news/2015-02-15/second-brand-of-frozen-mixed-berries-recalled/6106490">warning people against eating</a> one-kilogram packets of <a href="http://www.foodstandards.gov.au/industry/foodrecalls/recalls/Pages/Nanna%27s-Mixed-Berries.aspx">Nanna’s mixed berries</a> with best-before dates until and including November 22, 2016. For <a href="http://www.foodstandards.gov.au/industry/foodrecalls/recalls/Pages/Creative-Gourmet-Mixed-Berries.aspx">Creative Gourmet</a>, the date ranges are up to and including December 10, 2017 for 300-gram packets and October 6, 2017 for 500-gram packets.</p>
<p>Only product lines that show sufficient evidence of risk to consumers are recalled in outbreaks such as this one. It’s common, though, for the lines affected to change as more information comes to light.</p>
<h2>Hepatitis A</h2>
<p>The berries are linked with an outbreak of <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Hepatitis_A_affects_the_liver">hepatitis A</a>, a viral infection of the liver. Symptoms include fever, nausea, abdominal discomfort, diarrhoea, dark urine and jaundice (yellow skin and eyes). The illness can be quite severe, particularly in people who are already unwell. </p>
<p>Most people recover within several weeks and young children often show mild or no symptoms. But the serious cases result in hospitalisation and liver failure.</p>
<p><a href="http://www.cdc.gov/hepatitis/HAV/">Infection</a> is acquired when people ingest the virus, which is excreted in an infected person’s faeces. Infection can result from close contact with an infected person, eating contaminated food or drinking contaminated water. Symptoms appear between 15 and 50 days after exposure to the virus, which makes it difficult to identify possible sources.</p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=899&fit=crop&dpr=1 600w, https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=899&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=899&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/72109/original/image-20150216-18500-1v8n6x6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hepatitis A is spread through food and water contamination.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/julien_harneis/589718393">Julien Harneis/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>Food-borne outbreaks of the disease occur when a person eats food that has been contaminated by the virus – either by contamination during growing or processing, or when a person prepares food while they are infectious. Sometimes the outbreak is caused by water contaminated by human sewage.</p>
<p>The number of <a href="http://www.health.gov.au/internet/publications/publishing.nsf/Content/cda-cdi34suppl.htm%7Ecda-cdi34suppl-3-vpd.htm%7Ecda-cdi34suppl-3-vpd3.htm">hepatitis A cases in Australia</a> has been declining dramatically since the late 1990s. This is probably due to a range of factors, including a reduction in the number of people in high-risk groups susceptible to hepatitis A virus infection, and vaccination campaigns in target groups, such as Aboriginal and Torres Strait Islander children in 2005 and 2007.</p>
<p>These days Australian health authorities receive reports of a couple of hundred cases each year. Almost all of these are acquired when people who haven’t been <a href="http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/handbook10-4-4">vaccinated against the illness</a> travel overseas.</p>
<iframe src="https://charts.datawrapper.de/Yi60r/index.html" frameborder="0" allowtransparency="true" allowfullscreen="allowfullscreen" webkitallowfullscreen="webkitallowfullscreen" mozallowfullscreen="mozallowfullscreen" oallowfullscreen="oallowfullscreen" msallowfullscreen="msallowfullscreen" width="100%" height="400"></iframe>
<h2>Scary berries</h2>
<p>Berries have caused large outbreaks of gastroenteritis and hepatitis A in the past, <a href="http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20941">particularly in Europe</a> and <a href="http://online.liebertpub.com/doi/pdfplus/10.1089/fpd.2014.1821">the United States</a>. Health agencies have increasingly become aware of fruits, vegetables and herbs as a cause of disease outbreaks. Awareness has grown in parallel with global food distribution networks, which started garnering the attention of food safety authorities in the late 1990s.</p>
<p>In Australia, we haven’t recorded large outbreaks associated with berries, but New Zealand identified an <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2870016/">outbreak of 39 cases of hepatitis A</a> associated with locally grown blueberries.</p>
<p>The main likely sources of fresh food contamination are:</p>
<ol>
<li><p>Being grown in contaminated water.</p></li>
<li><p>Getting contaminated by infected animals, such as livestock, rats, mice or bats, at some stage in the production cycle.</p></li>
<li><p>Being picked by people who are infected with hepatitis A.</p></li>
<li><p>Mixing with other ingredients contaminated with hepatitis A virus during processing.</p></li>
<li><p>Being washed in contaminated water.</p></li>
</ol>
<p>There is evidence that fruits, such as<a href="http://www.ncbi.nlm.nih.gov/pubmed/25662970"> berries</a>, and some vegetables, such as <a href="http://www.ncbi.nlm.nih.gov/pubmed/23377940">tomatoes</a> and <a href="http://www.ncbi.nlm.nih.gov/pubmed/12969285">sprouts</a>, can sometimes internalise bacteria and viruses during growing. This means that the disease-causing agent may actually be inside the fruit and is almost impossible kill except by cooking. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=720&fit=crop&dpr=1 600w, https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=720&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=720&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=905&fit=crop&dpr=1 754w, https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=905&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/72106/original/image-20150216-6128-1l5c4x6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=905&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Throw away any recalled berries you have in the freezer.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/35126681@N07/15932972972">Philippa McKinlay/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p>The hepatitis A virus is easily killed by cooking to more than 85 degrees Celsius, which would deal with most other bacteria and viruses. Washing is useful for getting rid of surface contamination of fruits and vegetables, which is sufficient most of the time. But if there is a possibility that foods, such as berries, are contaminated with disease-causing agents, it is best to avoid them altogether.</p>
<p>After a food recall such as this one, investigations by health and food safety agencies will try to create a picture of what happened and when.</p>
<p>In the meanwhile, the key thing for consumers is to avoid infection by making sure they do not eat any of the recalled berries that may be in their freezer. </p>
<p>It is likely that only a small proportion of people who eats these berries will become infected. But if you have eaten them and started to develop any of the symptoms listed above, you should see a doctor as soon as possible.</p><img src="https://counter.theconversation.com/content/37629/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Martyn Kirk receives funding from the Australian Research Council and the Commonwealth Health Department, Food Standards Australia New Zealand, the ACT Government and the New South Wales Food Authority.</span></em></p>Food distributor Patties Foods has recalled two brands of frozen mixed berries — Nanna’s and Creative Gourmet — due to reports of three people in Victoria, four in Queensland and two in New South Wales…Martyn Kirk, Convener, Master of Philosophy in Applied Epidemiology, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/3302011-06-14T21:01:24Z2011-06-14T21:01:24ZBraving the jab for community immunity<figure><img src="https://images.theconversation.com/files/1064/original/Sanofil_Pasteur.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">If most people in a community are vaccinated, others are also protected. </span> <span class="attribution"><span class="source">Sanofil Pasteur</span></span></figcaption></figure><p>Let’s be clear: immunisations matter. They matter a lot.</p>
<p>We all have a complex and ever-changing ecology of microorganisms and parasites inside our bodies and in our community.</p>
<p>A <a href="http://www.couriermail.com.au/news/fatal-return-of-diphtheria/story-e6freomx-1226048663339">recent</a> fatal case of diphtheria in Brisbane and an <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr11-nr-nr026.htm">ongoing grumbling epidemic</a> of <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Whooping_cough">pertussis</a> (whooping cough) around Australia are reminders of our interdependence in relation to infectious diseases.</p>
<p>Community immunity, often referred to as herd immunity, is the protection individuals gain from others in their community being protected against an infectious disease. </p>
<p>This immunity can come after exposure to natural infection (“wild” organisms), from exposure to related organisms which provide some level of cross-protection, or from immunisation.</p>
<h2>Vaccine protection</h2>
<p>Vaccines protect against disease by presenting parts of “pathogenic organisms” or “subdued whole organisms” to our immune system. This allows our bodies to develop protective immunity against the disease, without paying the price of the disease the full-blown wild organism can cause. </p>
<p>Some vaccines provide stronger immunity than the wild virus – the human papilloma virus (HPV) <a href="http://theconversation.com/the-case-for-vaccinating-boys-as-well-as-girls-against-hpv-6">vaccine</a> given to girls to prevent cervical cancer, for instance. </p>
<p>Even if we’re susceptible to a disease, our chances of being exposed to a disease-causing pathogen are substantially reduced if the people we’re in close contact with have immunity. </p>
<h2>Diphtheria</h2>
<p>The role of vaccinations and community immunity differs from bug to bug. </p>
<p>For <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Diphtheria?open">diphtheria</a>, the organism causes severe and commonly fatal disease only when a particular toxin is present. </p>
<p>The diphtheria vaccine protects against the toxin, not infection with the organism per se, which can occur in the skin, throat or airways. </p>
<p>It is estimated that in a fully susceptible population, a person with diphtheria is likely to infect six or seven other people. </p>
<p>Based on how readily diphtheria spreads, around 85% of a population need to be immune in order to effectively control the disease. </p>
<p>Experience bears this out. In many countries, coverage rates for diphtheria immunisation of around 90% have reduced the number of cases by more than 99.99%. </p>
<p>But while toxin-producing diphtheria strains are around in some regions and can be imported, the disease can recur if high levels of immunisation aren’t maintained. </p>
<p>Following the break-up of the former Soviet Union, disruption to immunisation led to an epidemic of more than 150,000 cases and spread to other regions. </p>
<p>The <a href="http://www.couriermail.com.au/news/fatal-return-of-diphtheria/story-e6freomx-1226048663339">reportedly</a> unimmunised 22-year-old Brisbane woman who recently died of diphtheria is likely to have been infected by a friend who had recently returned from overseas.</p>
<h2>Whooping cough</h2>
<p>Pertussis, or whooping cough, typically occurs in cyclical epidemics every three to five years, when population immunity wanes enough for an outbreak to be sustained. </p>
<p>The current Australia-wide epidemic began in 2008 and has caused the deaths of four infants so far; it shows little sign of waning. </p>
<p>Pertussis is one of the most highly contagious diseases. </p>
<p>For a susceptible population, each infected person infects around 12 to 17 others. More than 92% of people need to be immune for community immunity to be strong enough to provide protection to the remainder of the population. </p>
<p>But pertussis vaccines are typically 80-90% effective in preventing disease. So pertussis can’t be eradicated through immunising children alone. </p>
<p>Nevertheless, if an immunised person is infected with pertussis, the cough and illness tend to be milder and shorter than in the unimmunised.</p>
<p>Unfortunately, immunity against pertussis (from both natural infection and vaccine) wanes after a decade or so. This is why pertussis occurs in people of all ages. </p>
<p>In adolescents and adults, it is one of the most common causes of cough illnesses lasting more than three weeks. </p>
<p>Infant pertussis immunisation (in a combination vaccine) is scheduled at two, four and six months of age, and it takes two doses before protection becomes substantial. </p>
<p>But most severe pertussis infections and almost all deaths occur in infants under three months, before they can be protected through immunisation.</p>
<p>Parents and other household contacts are the most frequent sources of pertussis infection for infants. That’s why governments recommend boosting parental immunisation: to “cocoon” young infants and provide protection against the disease. </p>
<h2>Hib and pneumococcal bacteria</h2>
<p>There are other diseases for which community immunity powerfully augments individual protection. </p>
<p>The <a href="http://www.who.int/mediacentre/factsheets/fs294/en/index.html">Hib bacterium</a> (Hemophilus influenzae type b) causes severe infections in young children, such as <a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Meningitis">meningitis</a>. </p>
<p>Following introduction of Hib vaccine in the Gambia in Africa, Hib disease almost disappeared despite only 60% of children receiving the three vaccine doses that provide full immunity.</p>
<p><a href="http://www.betterhealth.vic.gov.au/bhcv2/bhcarticles.nsf/pages/Pneumococcal_disease">Pneumococcal bacteria</a> also causes meningitis and other serious infections. Worldwide, these bacteria are the most common cause of severe and fatal pneumonia at all ages. </p>
<p>Within a few years of the US introducing its infants pneumococcal conjugate vaccination program, the number of severe infections in young children plummeted, as hoped. But by reducing transmission of the bacteria across the community, more than twice as many infections were prevented in older people – who did not receive the vaccine – as in children who did. </p>
<p>Vaccines against Hib, pneumococci and meningococcal bacteria are so effective in building community immunity because they reduce carriage of the organisms in the nose and throat (where they normally live), thereby reducing transmission.</p>
<h2>Hepatitis A</h2>
<p>One of the most powerful examples of the benefits of herd immunity is the story of hepatitis A in Queensland. </p>
<p>The deaths of several indigenous children from hepatitis A in north Queensland prompted the introduction of hepatitis A immunisation for Indigenous toddlers in north Queensland in 1998. </p>
<p>Despite only 15% of children there being Indigenous, cases of hepatitis A rapidly plummeted, not only among the whole population of north Queensland (Indigenous and non-Indigenous) but across the state.</p>
<h2>Personal responsibility</h2>
<p>By contrast, one disease where community immunity plays no role is tetanus. </p>
<p>Tetanus spores are widespread in soil and the gut of animals, such as horses. Disease occurs when the causative bacterium grows in contaminated wounds and produces a potent toxin. </p>
<p>We can only be protected against tetanus if we are immunised ourselves. Even having tetanus disease doesn’t protect against subsequent attacks.</p>
<p>But for most diseases targeted by vaccines, immunisation substantially reduces not only our individual vulnerability but also our shared exposure. </p>
<p>Keeping our immunisations up to date, at home and when we travel, not only protects ourselves but helps protect our children, partners, friends, patients, work colleagues and wider community.</p><img src="https://counter.theconversation.com/content/330/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tilman Ruff does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Let’s be clear: immunisations matter. They matter a lot. We all have a complex and ever-changing ecology of microorganisms and parasites inside our bodies and in our community. A recent fatal case of diphtheria…Tilman Ruff, Associate Professor, Disease Prevention & Health Promotion Unit, Nossal Institute for Global Health, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.