tag:theconversation.com,2011:/nz/topics/hepatitis-26830/articlesHepatitis – The Conversation2023-03-31T14:48:33Ztag:theconversation.com,2011:article/2029092023-03-31T14:48:33Z2023-03-31T14:48:33ZWe investigated the cause of an unexplained outbreak of hepatitis in children in the UK – here’s what we found<figure><img src="https://images.theconversation.com/files/518526/original/file-20230330-1278-f0yj13.jpg?ixlib=rb-1.1.0&rect=33%2C0%2C7315%2C4902&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cropped-shot-african-american-father-holding-726936529">LightField Studios/Shutterstock</a></span></figcaption></figure><p>In the spring of 2022, a paediatric gastroenterologist treating children in the Queen Elizabeth University Hospital in Glasgow issued an alert to Public Health Scotland (PHS), warning of an unusual outbreak of hepatitis cases in her clinic. </p>
<p>Hepatitis refers to <a href="https://www.nhs.uk/conditions/hepatitis/">inflammation of the liver</a>, and is usually caused by viral infections, toxins (including alcohol), medications, autoimmune conditions or inherited conditions. Hepatitis is unusual in children and when it does occur, cases are generally isolated. </p>
<p>The children had presented to hospital mostly with a history of gastrointestinal illness weeks earlier, with jaundice, and in some cases with severe liver failure. PHS initiated an urgent investigation of these cases which were noted to affect children of nursery or primary school age, most of whom had been otherwise fit and healthy. </p>
<p>PHS officials informed their counterparts in England at the UK Health Security Agency (UKHSA), who noted that they too were seeing <a href="https://www.gov.uk/government/publications/acute-hepatitis-technical-briefing">an increase</a> in such cases.</p>
<p>The UK public health agencies alerted the <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON400">World Health Organization</a> (WHO), and by the summer of 2022, more than 1,000 children around the world were reported to have been affected – the majority in Europe and the Americas. Around half of the European cases occurred in the UK. </p>
<p>The consequences for some children were severe: 22 died and 46 required a liver transplant.</p>
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<p>We still don’t fully understand what caused this outbreak, which has now subsided. But <a href="https://www.nature.com/articles/d41586-023-00570-8">three new studies</a> published in Nature offer important clues.</p>
<h2>A real-time investigation</h2>
<p>As soon as the alert was raised, PHS engaged a team of experts to investigate the outbreak in Scotland, while a UKHSA technical science group was assembled in England. </p>
<p>Children who had been diagnosed with hepatitis were invited to give blood samples with consent from their parents or guardians. The scientists looked for viruses that commonly cause hepatitis in children, as well as for rarer conditions and toxins. </p>
<p>These tests didn’t reveal a clear cause, although it was noted that many of the children had tested positive for the <a href="https://theconversation.com/hepatitis-outbreak-in-children-explainer-on-adenovirus-type-41-the-possible-culprit-181959">human adenovirus F41</a> (HAdV F41) – a common cause of gastrointestinal infection in children, but not hepatitis.</p>
<p>Samples from the Scottish children were then transferred to the <a href="https://www.gla.ac.uk/research/az/cvr/">MRC-University of Glasgow Centre for Virus Research</a>, where my colleagues and I investigated further. Our centre has expertise in the use of <a href="https://asm.org/Articles/2019/November/Metagenomic-Next-Generation-Sequencing-How-Does-It">next generation sequencing</a> (called metagenomic sequencing) to look for new or emerging viruses that are not routinely identified in NHS diagnostic tests. In parallel, samples from affected English children were sent to University College London (UCL) for similar testing. </p>
<p>Both laboratories identified that most of the children with hepatitis had evidence of a virus called adeno-associated virus 2 (AAV2) in their bloodstream, and also in the liver samples from those children who had required a liver biopsy. For example, we detected AAV2 in 26 out of 32 cases of hepatitis, compared with only five out of 74 healthy children we studied as a comparison group. </p>
<p>HAdV F41 was also detected in several (but not all) cases, in blood, liver and gastrointestinal samples. </p>
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<a href="https://theconversation.com/hepatitis-cases-are-increasing-among-children-in-the-uk-could-covid-have-a-role-to-play-181303">Hepatitis cases are increasing among children in the UK – could COVID have a role to play?</a>
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<p>AAV2 <a href="https://www.sciencedirect.com/topics/biochemistry-genetics-and-molecular-biology/adeno-associated-virus-2">belongs to a group</a> of viruses called <em>Dependoparvovirus</em>. It is known to replicate in the liver, but to do so it usually requires a “helper” virus such as an adenovirus like HAdV F41 (hence its name), or other viruses such as herpesviruses. AAV2 has not previously been found to cause illness. </p>
<p>In our research, we were able to see AAV2 in diseased liver cells using a technique called <a href="https://www.ncbi.nlm.nih.gov/probe/docs/techish/">in situ hybridisation</a>. We also measured the immune response to AAV2 in affected children, and found most of these children had evidence of <a href="https://www.britannica.com/science/immune-system/Classes-of-immunoglobulins">IgM antibodies</a> in their bloodstream, which indicates a recent infection. </p>
<p>Our results suggest that AAV2 may have been the cause of this outbreak of hepatitis in children. However, as it co-occurs with adenovirus infection, it could be that HAdV F41 is responsible as well. Further studies will be required to confirm which virus is the most likely cause.</p>
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<img alt="An illustration of an adenovirus." src="https://images.theconversation.com/files/518739/original/file-20230331-16-746co7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/518739/original/file-20230331-16-746co7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=339&fit=crop&dpr=1 600w, https://images.theconversation.com/files/518739/original/file-20230331-16-746co7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=339&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/518739/original/file-20230331-16-746co7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=339&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/518739/original/file-20230331-16-746co7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=426&fit=crop&dpr=1 754w, https://images.theconversation.com/files/518739/original/file-20230331-16-746co7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=426&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/518739/original/file-20230331-16-746co7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=426&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">Adenovirus has been linked to the recent outbreak of hepatitis cases in children.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/virus-cells-adenovirus-family-icosahedral-shape-1532059787">Christoph Burgstedt/Shutterstock</a></span>
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<p>Working with experts around Scotland, we also found that most of affected children had an underlying genetic susceptibility. Some 93% of the children with hepatitis carried a gene that’s linked with the immune response directed by <a href="https://www.britannica.com/science/T-cell">T cells</a>, compared with 16% in the control group. The presence of this gene means that hepatitis in these cases is likely to have been related to an over-reactive immune response.</p>
<h2>What about COVID?</h2>
<p>These research findings are published in two new articles in Nature, one from <a href="https://www.nature.com/articles/s41586-023-05948-2">my team</a> in Scotland and the other from the <a href="https://www.nature.com/articles/s41586-023-06003-w">UCL researchers</a>. A <a href="https://www.nature.com/articles/s41586-023-05949-1">third study</a> published in the same edition reports the detection of AAV2 in affected children in the US, also using metagenomic sequencing.</p>
<p>The UK and US authors concluded that changes in the circulation of viruses after COVID lockdowns may have increased the chances of children being exposed for the first time to multiple viruses. Our paper shows that a wave of adenovirus infection immediately preceded the paediatric hepatitis cases in Scotland, but samples were not available to look at the circulation of AAV2. </p>
<p>Interestingly, <a href="https://wwwnc.cdc.gov/eid/article/29/4/22-1878_article">a recent publication</a> from Ireland confirmed that both adenovirus and AAV2 viruses peaked in sewage samples taken from the Ringsend wastewater treatment plant in Dublin immediately before a similar outbreak of paediatric hepatitis in Ireland. </p>
<p>While these findings suggest strongly that AAV2, HAdV F41 and the immune response to one or both of these viruses underlie the cases of hepatitis seen around the world, larger studies are needed to confirm the findings. We also need to develop and test new treatments for affected children in case a new outbreak occurs.</p><img src="https://counter.theconversation.com/content/202909/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emma Thomson receives funding from the Medical Research Council, UKRI, Wellcome and PHS.</span></em></p>An unexplained rise in cases of hepatitis among children around the world in 2022 may be linked to a virus known as AAV2, according to three new studies.Emma Thomson, Clinical Professor of Infectious Diseases and Associate Director, MRC-Centre for Virus Research, University of GlasgowLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1937052022-11-22T13:25:50Z2022-11-22T13:25:50ZScientists uncovered the structure of the key protein for a future hepatitis C vaccine – here’s how they did it<figure><img src="https://images.theconversation.com/files/496217/original/file-20221118-14-r6a8me.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1999%2C1499&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Imaging the proteins on the surface of HCV has been challenging because of the virus's shape-shifting nature.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/hepatitis-c-virus-particles-illustration-royalty-free-illustration/1042127452">Juan Gaertner/Science Photo Library via Getty Images</a></span></figcaption></figure><p>The <a href="https://www.cdc.gov/hepatitis/hcv/index.htm">hepatitis C virus, or HCV</a>, causes a chronic liver infection that can lead to permanent liver scarring and, in dire cases, cancer. It affects around <a href="https://doi.org/10.1007/s42399-020-00588-3">71 million people worldwide</a> and causes approximately 400,000 deaths each year. While <a href="https://www.uptodate.com/contents/direct-acting-antivirals-for-the-treatment-of-hepatitis-c-virus-infection">treatments are available</a> for HCV-related infections, they are expensive, hard to access and do not protect against reinfection. A vaccine that can help prevent HCV infection is a major unmet medical and public health need. </p>
<p>One major reason there hasn’t been an HCV vaccine yet is that scientists have yet to identify the proper antigen, or the part of the virus would trigger a protective immune response in the body.</p>
<p>Decades of research have pinpointed <a href="https://doi.org/10.1038/nrmicro3098">HCV E1E2</a>, the only protein on the surface of the virus, as the most promising vaccine candidate. However, developing an HCV vaccine based on that protein is limited by uncertainty around what it looks like. Knowing the structure of the protein is necessary to figure out how the immune system responds to the virus.</p>
<p>So how do researchers capture the structure of single protein on a shape-shifting virus? </p>
<p>We are researchers who specialize in <a href="https://scholar.google.com/citations?user=Xejfx54AAAAJ&hl=en">microscopy</a> and <a href="https://scholar.google.com/citations?user=iQj9rSwAAAAJ&hl=en">vaccine design</a>. With new technology, we were able to <a href="https://doi.org/10.1126/science.abn9884">visualize the molecular details</a> of this elusive protein, unlocking key insights into how this virus works and offering a potential blueprint for a future vaccine.</p>
<p>This is how we did it.</p>
<h2>Challenges of capturing a shape-shifting virus</h2>
<p>One reason it has been so difficult to capture the structure of the HCV E1E2 protein is that it is both <a href="https://doi.org/10.1016/j.celrep.2022.110859">flexible and fragile</a>. It changes its shape so often and is so easily broken that it’s challenging to purify. </p>
<p>As an analogy, imagine a bowl of spaghetti drenched in tomato sauce. Now imagine trying to take a picture of each individual piece of spaghetti in the same position over time while the bowl is shaking. Hard to do, right? That’s what it was like to image the full E1E2 protein.</p>
<p>There were also <a href="https://doi.org/10.1126/science.1251652">technological barriers</a>. Until recently, available imaging techniques were limited in their ability to view microscopic proteins. <a href="https://chem.libretexts.org/Bookshelves/Analytical_Chemistry/Supplemental_Modules_(Analytical_Chemistry)/Instrumentation_and_Analysis/Diffraction_Scattering_Techniques/X-ray_Crystallography">X-ray crystallography</a>, for instance, is unable to capture molecules that frequently change and shape-shift, like HCV. Moreover, other options, such as <a href="https://chem.libretexts.org/Bookshelves/Analytical_Chemistry/Physical_Methods_in_Chemistry_and_Nano_Science_(Barron)/04%3A_Chemical_Speciation/4.07%3A_NMR_Spectroscopy">nuclear magnetic resonance spectroscopy</a>, required cutting large parts of the protein or chemically manipulating it in a way that would transform its physiological state and potentially alter its function.</p>
<p>So to examine the structure of E1E2, we needed a way to extract and purify, stabilize and trap the entire shape-shifting protein into one configuration.</p>
<h2>How to take a picture of protein</h2>
<p><a href="https://doi.org/10.1038/d41586-020-01658-1">Cryo-EM, or cryo-electron microscopy</a>, is a type of imaging technique that views specimens at cryogenic temperatures, in this case the boiling point of nitrogen: minus 320.8 degrees Fahrenheit (minus 196 Celsius). With temperatures that cold, ice freezes so quickly that it doesn’t have time to crystallize. That creates a beautiful glasslike frame around the protein of interest, allowing an unhindered view of every structural detail. Cryo-EM also requires very little protein to work, reducing the amount of material we would need to purify. </p>
<p>Winner of the <a href="https://www.nobelprize.org/prizes/chemistry/2017/press-release/">2017 Nobel Prize in chemistry</a> and <a href="https://doi.org/10.1038/nmeth.3730">Nature magazine’s 2015 “Method of the Year</a>” award, cryo-EM is superb for imaging biological macromolecules in their native, or natural, state in the aqueous environment of human blood. Cryo-EM was also pivotal for characterizing the <a href="https://doi.org/10.1038/nature17200">structure of the COVID-19 virus</a> and its variants.</p>
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<figcaption><span class="caption">Cryo-EM has allowed researchers to see complex proteins they weren’t able to before.</span></figcaption>
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<p>So how do you take a picture of a protein? </p>
<p>First, we embedded the genetic code to make E1E2 in human cells in a petri dish so we would have sufficient amounts of protein to study. After purifying the protein, we <a href="https://caic.bio.cam.ac.uk/electron-microscopy/SpecimenPrep/PlungeFreezing">plunged it into liquid ethane</a> followed by liquid nitrogen. Liquid ethane is used to freeze the protein because it has a higher boiling point than liquid nitrogen. This means it is able to capture more heat before turning to a gas, allowing the protein to freeze much more quickly than it would in liquid nitrogen and avoid structural damage. </p>
<p>Once the protein was vitrified, or in a glasslike ice state, we were able not just to see its overall structure, but also to capture multiple individual configurations of the protein that it takes when it shape-shifts, including its less stable forms.</p>
<p>At this point, our protein was ready for its close-up. We employed a microscope that <a href="https://www.ccber.ucsb.edu/ucsb-natural-history-collections-botanical-plant-anatomy/transmission-electron-microscope">uses a beam of focused, high energy electrons</a> and a very fancy camera that detects how the elections bounce off the protein’s surface. This created a 2D image that we then mathematically transformed into a 3D model. And that was how we got the coveted “close-up” of HCV’s surface protein. </p>
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<figcaption><span class="caption">This video shows the newly identified 3D structure of the E1E2 protein on the surface of the hepatitis C virus. The two main subunits of the protein are colored in pink and blue. Sugar molecules are colored in green.</span></figcaption>
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<p>Our next step was then to assess the location of each amino acid, or building block of the protein, in 3D space. Because every amino acid has a unique shape, we used a computer program that could identify each one in our 3D map. This allowed us to manually reconstruct a high-resolution model of the protein, one building block at a time.</p>
<h2>A new tool to design an HCV vaccine</h2>
<p>Our 3D map and model of the HCV E1E2 protein supports previous research describing its structure while providing new insights into features that will help pave the way for a long-sought vaccine design against this virus. </p>
<p>For example, our structure reveals that the interface between the two main parts of the protein is stabilized by sugars and hydrophobic patches, or areas that push out water molecules. This creates sticky binding hubs along the protein and keeps it from falling apart – a potential site for protective antibodies and new drugs to target. </p>
<p>Researchers now have the tools to design antiviral drugs and vaccines against HCV infection.</p><img src="https://counter.theconversation.com/content/193705/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisa Eshun-Wilson receives funding from the National Science Foundation. </span></em></p><p class="fine-print"><em><span>Alba Torrents de la Peña receives funding from Netherlands Organization for Scientific Research (NWO) Rubicon Grant 45219118. </span></em></p>Using a Nobel Prize-winning technique called cryo-EM, researchers were able to identify potential areas on the hepatitis C virus that a vaccine could target.Lisa Eshun-Wilson, Postdoctoral Scholar in Molecular and Cell Biology, The Scripps Research InstituteAlba Torrents de la Peña, Postdoctoral Fellow in Integrative Structural and Computational Biology, The Scripps Research InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1808432022-10-11T12:18:13Z2022-10-11T12:18:13ZBody piercings may be artistic, but they bring risks of infection, allergic reactions, scarring and urine leakage<figure><img src="https://images.theconversation.com/files/468874/original/file-20220614-14-17d8fw.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4970%2C3492&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Infections, scarring and hepatitis B and C are just some of the health problems caused by body piercing.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-woman-wearing-nose-and-lip-jewelry-portrait-royalty-free-image/DA23334?adppopup=true">Laurence Monneret/The Image Bank via Getty Images</a></span></figcaption></figure><p>Throughout history, body piercing <a href="https://allthatsinteresting.com/history-of-piercing">has been a symbol of beauty</a>, sexuality, ritual initiation and rites of passage. </p>
<p>Mayan royalty had their <a href="https://www.historyonthenet.com/the-maya-concept-of-beauty">tongues and genitals pierced</a>; during the Victorian era, many women <a href="https://www.thevintagenews.com/2018/11/04/victorian-fashion-fad/">pierced their nipples</a>. After World War II, tongue, nipple and genital piercings occurred in Germany. Today, body piercing remains <a href="https://www.newsweek.com/earliest-facial-piercing-africa-ancient-skeleton-1484600">common in tribal societies</a> throughout Africa, Asia and South America. </p>
<p>In the U.S., piercing <a href="https://doi.org/10.1016/j.jadohealth.2007.09.014">became mainstream during the 1990s</a> and is perhaps more popular than ever. </p>
<p>I am a <a href="https://www.umassmed.edu/derm-residency/meet-the-residents/">physician specializing in dermatology</a>. My colleagues and I have seen the medical complications that body piercing can cause. While people shouldn’t necessarily avoid piercings, they should be aware of the risks and best practices. It’s also critical to distinguish relatively safe ear piercings from more problematic and potentially dangerous piercings.</p>
<h2>Infections, scarring and nerve damage</h2>
<p>Medical problems arising from body piercings happen a lot; the incidence of complications could be as high as <a href="https://doi.org/10.1016/j.jadohealth.2007.09.014">one out of every five</a> individuals. </p>
<p>Some problems are relatively minor: jewelry allergy, bleeding, scarring and the formation of keloids, which are thick overgrowths of scar tissue. Nerve damage complications <a href="https://doi.org/10.2165/11593220-000000000-00000">are also possible</a> – and sometimes they affect internal organs or lead to <a href="https://www.sepsis.org/sepsisand/tattoos-body-piercings/">sepsis, a potentially fatal illness</a> that <a href="https://theconversation.com/sepsis-still-kills-1-in-5-people-worldwide-two-icu-physicians-offer-a-new-approach-to-stopping-it-175650">requires immediate medical attention</a>. </p>
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<figcaption><span class="caption">Should children have their ears pierced? A pediatric physician offers advice.</span></figcaption>
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<p>Other complications, less common, include <a href="https://doi.org/10.1086/345755">brain abscess</a> and <a href="https://doi.org/10.1016/j.jadohealth.2008.02.008">endocarditis</a>, a heart inflammation that can be life-threatening. It is unclear how these complications occur, but one hypothesis is that they are caused by infections from needles, perhaps from contaminated equipment used during the piercing.</p>
<p>Body piercing is also associated with transmission of <a href="https://doi.org/10.1097/MD.0000000000001893">hepatitis B and hepatitis C</a>. The risk may be from the piercing procedure. However, it’s also possible that piercings are not the problem; instead, the cause is other high-risk behaviors – drug use, gang affiliations and school truancy, for example – <a href="https://doi.org/10.1016/j.adolescence.2005.06.001">that can be associated with piercings</a>. </p>
<p>It is not uncommon for me to see skin inflammations caused by contact with jewelry metal. The <a href="https://doi.org/10.2165/11593220-000000000-00000">prevalence of the jewelry allergy increases</a> with the increase in the number of piercings a person has. </p>
<p>Up to 30% of people with body piercings are allergic to nickel, which is a common metal found in jewelry. If you have a nickel allergy, you can still wear jewelry, but just avoid nickel and wear platinum, stainless steel or gold instead. But don’t wear white gold – it may contain nickel. </p>
<h2>A warning on tongue and genital piercings</h2>
<p>Oral piercings – which include piercings of the upper or lower lip and tongue – can be associated with <a href="https://doi.org/10.3390/ijerph17020613">gingivitis, teeth chips, cracks and fractures, and gum recession</a>. These are caused by continuous traumatization of teeth and gums when the individual plays with the piercing.</p>
<p>Those with tongue piercings often experience <a href="https://doi.org/10.2165/11593220-000000000-00000">temporary tongue swelling, pain, difficulty eating and excessive salivation</a>. When the tongue or penis are pierced, a small amount of bleeding is expected, but <a href="https://pubmed.ncbi.nlm.nih.gov/12723842/">severe bleeding sometimes can occur</a>.</p>
<p>Indeed, many men with genital piercings <a href="https://doi.org/10.2165/11593220-000000000-00000">have reported complications</a>. The Prince Albert piercing – occurring at the end of the penis – is associated with a narrowing of the opening for urine; sometimes, new tracts are created that leak semen and urine. Rarely, it is associated with <a href="https://doi.org/10.1111/j.1743-6109.2010.01818.x">squamous cell carcinoma of the penis</a>. </p>
<p>Although piercings are generally safe when proper hygiene is followed, it’s critical to know the risks. Make sure you know the safety precautions and <a href="https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/piercings/art-20047317">insist that they are used</a>. Piercing salons may vary in terms of cleanliness and the experience of the practitioner. If you have questions about the establishment performing the piercing, you might try checking with your medical provider.</p>
<p>And a special word of warning for children who are undergoing a piercing: An experienced technician, nurse or doctor should perform the procedure. And because proper care is crucial to <a href="https://doi.org/10.1542/pir.2017-0218">decrease the chances of infection</a>, piercings should occur only once the child is mature enough to care for the area.</p><img src="https://counter.theconversation.com/content/180843/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Vijaya Daniel does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Millions of Americans wear jewelry that pierces the ear, nose, lips, tongue and genital areas. But adorning yourself with metal body art can be a health hazard.Vijaya Daniel, Dermatology Resident, UMass Chan Medical SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1877142022-07-27T11:06:07Z2022-07-27T11:06:07ZHepatitis in children: scientists have found a possible cause for the mystery outbreak<figure><img src="https://images.theconversation.com/files/476255/original/file-20220727-27-ejyizd.jpg?ixlib=rb-1.1.0&rect=12%2C0%2C8474%2C4784&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Adenoviruses are common in children, causing infections such as mild colds and pinkeye.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/virus-cells-adenovirus-family-icosahedral-shape-1532059790">Christoph Burgstedt/ Shutterstock</a></span></figcaption></figure><p>Between April and July of this year, 1,010 cases of severe hepatitis <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON400">without any explainable cause</a> were reported in children in more than 35 countries. Nearly half of these cases were in Europe, including over a quarter in the UK. </p>
<p>Usually, childhood hepatitis is caused by an infection from one of the hepatitis viruses (such as hepatitis A or hepatitis C). But although children were presenting with elevated levels of hepatitis markers in their blood, no traces of hepatitis viruses were detected in these children, nor in any of the related cases since. </p>
<p>Initial investigations found a potential link between <a href="https://theconversation.com/hepatitis-cases-are-increasing-among-children-in-the-uk-could-covid-have-a-role-to-play-181303">adenovirus infection</a> and these cases of hepatitis. Adenoviruses are very common viral infections, especially in children. They typically cause infections such as mild colds, pink eye (conjunctivitis) or stomach problems. However, if they get to the liver they can on rare occasion cause hepatitis.</p>
<p>However, given how common adenoviruses are in children – and because they rarely cause hepatitis in healthy people – it was difficult to say this was the probable cause.</p>
<p>A new study suggests that the spate of severe hepatitis cases seen in children may be the result of <a href="https://www.medrxiv.org/content/10.1101/2022.07.19.22277425v1">three factors</a> working together: adenovirus, adeno-associated virus 2 (AAV2) and an underlying genetic predisposition to the disease. </p>
<h2>A potential cause emerges</h2>
<p>In a pre-print study (which means it has not yet been reviewed by other scientists), a team of researchers looked at nine of the original hepatitis cases in April and conducted a large range of tests, seeking to find new or previously undetected viruses or genetic factors that may have caused hepatitis in the children. </p>
<p>The team found that all nine children had been infected with adeno-associated virus 2. They then compared their findings with 13 healthy children and 12 children who’d had adenovirus infections but no hepatitis. Adeno-associated virus 2 was not detected in any of these children. This was a strong indicator that AAV2 was a cause of these mystery hepatitis cases. </p>
<p>Adeno-associated virus 2 belongs to a group of viruses called <em>Dependoparvovirus</em> which infects both humans and some primates. But what’s particularly interesting about AAV2 is that in order to infect the host, it requires another virus to also be infecting the host at the same time. It uses this helper virus in order to replicate inside human cells. The most common helper viruses of AAV2 are <a href="https://pubmed.ncbi.nlm.nih.gov/14325163/">adenovirus</a> and <a href="https://journals.asm.org/doi/10.1128/jvi.40.1.241-247.1981">herpesvirus</a>.</p>
<figure class="align-center ">
<img alt="A young girl is tucked in bed with a cold. She blows her nose with a tissue." src="https://images.theconversation.com/files/476256/original/file-20220727-17-8b4b0n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/476256/original/file-20220727-17-8b4b0n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/476256/original/file-20220727-17-8b4b0n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/476256/original/file-20220727-17-8b4b0n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/476256/original/file-20220727-17-8b4b0n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/476256/original/file-20220727-17-8b4b0n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/476256/original/file-20220727-17-8b4b0n.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">
<figcaption>
<span class="caption">AAV2 needs a helper virus – such as an adenovirus – to infect someone.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/runny-nose-little-sick-girl-lying-1074804356">YAKOBCHUK VIACHESLAV/ Shutterstock</a></span>
</figcaption>
</figure>
<p>The researchers found that six out of the nine patients they looked at had an adenovirus, while three had signs of a herpes virus. This makes it’s likely these hepatitis infections were caused by a combination of AAV2 and one of these helper viruses. </p>
<h2>Immune systems and infections</h2>
<p>But both AAV2 and infections such as adenovirus and herpes virus are <a href="https://pubmed.ncbi.nlm.nih.gov/21697954/">quite common in children</a>, and most children infected with these don’t go on to develop hepatitis. This means there must be an additional factor at play here, perhaps even at the genetic level.</p>
<p>The team of researchers then analysed the children’s genomes to look for specific immune system markers, called <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628004/">human leucocyte antigens</a>. Immune system cells use human leucocyte antigens to detect other viruses and pathogens, and engulf them. </p>
<p>This then sends a signal to other immune cells which come along and destroy the pathogen. There are many different types of human leucocyte antigens, and depending on why type a person has can determine which infections they may be more susceptible to. </p>
<p>The researchers found that eight out of the nine children had a higher genetic prevalence of a certain type of human leucocyte antigen, which may have increased their likelihood of getting hepatitis symptoms from these viral infections. This type is also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251294/">more common in people of European descent</a>, which may further explain why these hepatitis cases were mainly seen in Europe.</p>
<p>Although it appears from this study that a combination of factors may explain the sudden, severe hepatitis cases spotted in children, the study itself was small and only conducted on participants in Scotland. A much larger, peer-reviewed study will need to be done in order to fully figure out the exact link and how best to protect children going forward. </p>
<p>Another factor that might have played into this were COVID-19 restrictions, which meant many children weren’t being exposed to these viruses and developing immunity at the ages they normally would have. This meant that when restrictions were lifted, children were exposed to these viruses all at once, which would overwhelm their immune system which is not prepared to deal with it. </p>
<p>However, research will need to be done in order to investigate whether or not this really played a role in the severe hepatitis cases. But if it is shown to be a cause, then it’s likely we will see fewer and fewer cases of hepatitis in children as the months pass since the last lockdown.</p><img src="https://counter.theconversation.com/content/187714/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Conor Meehan 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>Over 1,000 cases of severe hepatitis without any explainable cause have been reported in children so far this year.Conor Meehan, Senior Lecturer in Microbiology, Nottingham Trent UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1829142022-05-16T13:56:37Z2022-05-16T13:56:37ZHepatitis spike in children linked to dogs – but the evidence is weak<figure><img src="https://images.theconversation.com/files/463132/original/file-20220515-17-lem0pi.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3020%2C2010&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/child-dog-1173086182">Nina Buday/Shutterstock</a></span></figcaption></figure><p>The recent <a href="https://www.euronews.com/next/2022/05/11/unexplained-hepatitis-cases-rise-to-348-worldwide-as-who-looks-into-role-of-covid">spike in cases</a> of sudden, severe hepatitis in children around the world has been widely reported. Recently, several news outlets have highlighted a <a href="https://www.dailymail.co.uk/health/article-10789789/Health-chiefs-probing-DOGS-blame-mysterious-hepatitis-outbreak.html">possible link</a> between cases and contacts with pet dogs. However, the data suggesting this link is extremely weak – in fact, probably a lot weaker than most of the alternative hypotheses that have been proposed.</p>
<p>The spike in hepatitis cases in children was <a href="https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2022.27.15.2200318">first noticed in the UK</a>, but has now been reported in <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON376">Europe, Asia and the Americas</a>. Although the numbers worldwide are still very low, the disease has been severe and some children have needed a liver transplant. At least <a href="https://www.ecdc.europa.eu/en/news-events/epidemiological-update-hepatitis-unknown-aetiology-children">11 children</a> have died, and there are suggestions that <a href="https://www.msn.com/en-gb/health/medical/mysterious-hepatitis-outbreak-in-children-will-continue-in-summer/ar-AAXfadj">it may continue for some time</a>.</p>
<p>Hepatitis in humans is normally caused either by toxicity, such as alcohol, or by infections with one of several different viruses. However, none of the usual viruses have been identified in these children. </p>
<p>The <a href="https://ukhsa.blog.gov.uk/2022/05/09/an-increase-in-hepatitis-cases-in-children/">UK Health Security Agency</a> (UKHSA), the agency responsible for public health protection in the UK, is working to find the cause of the disease so that it can be effectively controlled and treated.</p>
<h2>Dog exposure</h2>
<p>In a <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1073704/acute-hepatitis-technical-briefing-2.pdf">recent briefing paper</a>, the agency reported a high number of “dog exposures” in these cases of severe childhood hepatitis. However, before parents stop their children from going near their family dog, it’s worth looking at the results in detail.</p>
<p>The UKHSA found that 70% of patients (64 of 92, where data was available) were from dog-owning families or had “other dog exposures”. Yet <a href="https://www.pfma.org.uk/pet-population-2021">33% of households in the UK own dogs</a>, and many more children from non-dog-owning households will be exposed to dogs when they visit or play with their friends. Seventy per cent exposure to dogs may be completely normal. </p>
<p>To suggest a link, it’s important to show not only that exposure to dogs in patients is high, but that it’s higher than in unaffected children. Until that’s checked in what’s known as a <a href="https://statisticsbyjim.com/basics/case-control-study/">case-control study</a>, any link is nothing more than a suggestion.</p>
<p>A second problem with the data is that if you ask enough questions, there’s a strong probability that the answers to one or more questions may seem linked to cases. </p>
<p>Where we collect very large amounts of data retrospectively, this kind of spurious association can easily occur. In fact, there’s <a href="http://www.tylervigen.com/correlation_project/">a website devoted to collecting them</a>. Here’s an example: the divorce rate in Maine between 2000 and 2009 seems to be strongly linked to per capita margarine consumption. </p>
<figure class="align-center ">
<img alt="Graph showing a spurious link between margarine consumption and divorce rates it Maine, US." src="https://images.theconversation.com/files/463299/original/file-20220516-15-netjya.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/463299/original/file-20220516-15-netjya.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=294&fit=crop&dpr=1 600w, https://images.theconversation.com/files/463299/original/file-20220516-15-netjya.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=294&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/463299/original/file-20220516-15-netjya.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=294&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/463299/original/file-20220516-15-netjya.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=369&fit=crop&dpr=1 754w, https://images.theconversation.com/files/463299/original/file-20220516-15-netjya.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=369&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/463299/original/file-20220516-15-netjya.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=369&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="http://www.tylervigen.com/correlation_project/">Tyler Vigen</a></span>
</figcaption>
</figure>
<p>The important point about links identified by retrospective data is that they are hypotheses. They always need to be checked by collecting further data around new cases. If the link is real, it will continue to show up in new data. If it’s spurious, it won’t.</p>
<p>One of the associations on the spurious-correlation website shows another important problem. Between 2000 and 2009, per capita cheese consumption in the US appears to be linked to deaths as a result of becoming tangled in bedsheets. </p>
<p>It’s actually not hard to think that this might happen as a result of cheese-induced nightmares. The fact that we can think of a mechanism underlying the link gives us more confidence that it might be true, <a href="https://www.bbc.com/future/article/20211117-does-cheese-really-give-you-vivid-dreams">even if the mechanism is quite far-fetched</a>. We tend to put more weight on associations where we can think of a reason, even when the evidence is poor.</p>
<p>So what are the possible causes of the spike in hepatitis cases in children, and might any of them be linked to dogs? One virus in particular, <a href="https://theconversation.com/hepatitis-outbreak-in-children-explainer-on-adenovirus-type-41-the-possible-culprit-181959">an adenovirus</a>, has been detected in the blood of 72% of patients tested (for comparison, SARS-CoV-2 was detected in only 18%). </p>
<p>Where it was possible to identify the type, it was found to be <a href="https://www.science.org/doi/10.1126/sciadv.abe0974">adenovirus 41 (Ad41), a human type normally causing diarrhoea in children</a>. Although dogs have their own adenoviruses that cause respiratory disease or hepatitis, they are not known to infect humans, and Ad41 has no known association with dogs. </p>
<p>The cases in children don’t suggest that infection is passing between children – there are too few cases, too widely distributed for that. Equally, the distribution of cases doesn’t suggest that this is a novel virus being transmitted from dogs to children. Cases have appeared in other countries much faster than a dog virus would spread between dogs.</p>
<h2>Possible causes</h2>
<p>Are there other possible causes? It has been suggested that the severity of the hepatitis is a result of the immune system working incorrectly – either too strongly or not strongly enough. <a href="https://academic.oup.com/ofid/article/8/7/ofab133/6175246">Social distancing</a> during the pandemic has reduced the transmission of a whole range of diseases, and a lack of exposure to them may have left some children unprepared for infections that normally wouldn’t cause a problem. </p>
<p>Equally, the lack of exposure to dirt as a result of handwashing, sterilising surfaces and other hygiene measures may have predisposed children to <a href="https://www.frontiersin.org/articles/10.3389/fimmu.2021.635935/full">over-reactive immune responses</a> (as has been suggested for allergic diseases), and the hepatitis may be caused by the immune response rather than a virus. Finally, and not surprisingly, it’s been suggested that previous COVID infections may have predisposed children to hepatitis.</p>
<p>All of these are no more than theories at the moment, and the available data is insufficient to prioritise any of them or to use them to suggest control measures. Fortunately, the incidence is still extremely low, and until there is better data parents should probably concentrate more on <a href="https://www.imperial.ac.uk/news/236414/hepatitis-outbreak-children-what-know/">keeping an eye out for any symptoms in their children</a> than on reducing their exposure to dogs.</p><img src="https://counter.theconversation.com/content/182914/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mick Bailey 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>Just because many of the children in the current severe hepatitis outbreak were exposed to dogs, doesn’t mean dogs are the cause.Mick Bailey, Professor of Comparative Immunology, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1823872022-05-09T13:11:10Z2022-05-09T13:11:10ZWhat your eyes reveal about your health<figure><img src="https://images.theconversation.com/files/461968/original/file-20220509-14-6e7qaq.jpg?ixlib=rb-1.1.0&rect=8%2C4%2C2986%2C1989&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/eyes-woman-young-beautiful-freckles-face-346433627">Irina Bg/Shutterstock</a></span></figcaption></figure><p>Scientists at the University of California, San Diego, have <a href="https://www.universityofcalifornia.edu/news/diagnosing-neurological-disease-home">developed a smartphone app</a> that can detect early signs of Alzheimer’s disease and other neurological conditions. The app uses the phone’s near-infrared camera to track changes in the size of a person’s pupils at a sub-millimetre level. These measurements can then be used to assess that person’s cognitive condition.</p>
<p>As technology evolves, the eyes will prove more and more useful as a means of diagnosing all kinds of diseases and conditions because, by being transparent, the eye requires far less invasive methods of examination than other body parts. </p>
<p>But even without technology, it is possible to detect a number of health problems simply by looking at the eyes. Here are some of the warning signs.</p>
<p><strong>Pupil size</strong></p>
<p>The pupil responds instantly to light, becoming smaller in bright environments and larger in dimmer conditions. Sluggish or delayed responses in pupil size can point to several diseases that can include serious conditions such as <a href="https://www.frontiersin.org/articles/10.3389/fneur.2019.00360/full">Alzheimer’s disease</a>, as well as effects of medications and evidence of drug use. Dilated pupils are common in those who use stimulant drugs, such as cocaine and amphetamine. Very small pupils can be seen in heroin users.</p>
<p><strong>Red or yellow eyes</strong></p>
<p>A change in the colour of the sclera (the “whites of the eyes”) suggests that something is not right. A red, bloodshot eye can be triggered by excess alcohol or drug abuse. It can also be caused by an irritation or infection that, in most cases, passes within days. </p>
<p>If the change in colour is persistent, it can signal a more serious infection, inflammation, or a reaction to contact lenses or their solutions. In extreme cases, a red eye indicates <a href="https://www.moorfields.nhs.uk/condition/glaucoma">glaucoma</a>, a sinister disease that can lead to blindness. </p>
<p>When the sclera become yellow, this is a most obvious sign of <a href="https://www.nhs.uk/conditions/jaundice/">jaundice</a> and a diseased liver. The underlying causes of jaundice vary widely. They include inflammation of the liver (hepatitis), genetic or autoimmune conditions, and certain medications, viruses or tumours.</p>
<figure class="align-center ">
<img alt="An eye with yellow sclera." src="https://images.theconversation.com/files/461962/original/file-20220509-23-m9kf2e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461962/original/file-20220509-23-m9kf2e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461962/original/file-20220509-23-m9kf2e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461962/original/file-20220509-23-m9kf2e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461962/original/file-20220509-23-m9kf2e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461962/original/file-20220509-23-m9kf2e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461962/original/file-20220509-23-m9kf2e.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">
<figcaption>
<span class="caption">Yellow sclera is a possible sign of liver disease.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-girls-eye-yellow-sclera-caused-1427849894">sruilk/Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>Red spot</strong></p>
<p>A blood-red spot on the white of the eye (subconjunctival haemorrhage) can look frightening and is always the result of a small localised blood vessel that has burst. Most times, there is no known cause, and it disappears within days. However, it can also be <a href="https://www.medicalnewstoday.com/articles/324752">an indication</a> of high blood pressure, diabetes and blood-clotting disorders that cause excessive bleeding. Blood-thinning drugs such as aspirin can also be the cause, and if the problem is frequent, might suggest that the dosage should be reviewed. </p>
<figure class="align-center ">
<img alt="Man with a blood spot on his eye." src="https://images.theconversation.com/files/462004/original/file-20220509-25-ujg4ki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462004/original/file-20220509-25-ujg4ki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462004/original/file-20220509-25-ujg4ki.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462004/original/file-20220509-25-ujg4ki.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462004/original/file-20220509-25-ujg4ki.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462004/original/file-20220509-25-ujg4ki.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462004/original/file-20220509-25-ujg4ki.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">
<figcaption>
<span class="caption">A bleed in the eye is rarely as serious as it looks.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/man-having-ruptured-blood-vessels-his-1044680488">YewLoon Lam/Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>Ring around the cornea</strong></p>
<p>A white or grey ring around the cornea is often linked to high cholesterol and an increased <a href="https://pubmed.ncbi.nlm.nih.gov/21742308/">risk of heart disease</a>. It can also reveal alcoholism and is sometimes seen in the eyes of older people, which is why the medical name given to it is <a href="https://www.aao.org/eye-health/diseases/what-is-arcus-senilis">arcus senilis</a>.</p>
<figure class="align-center ">
<img alt="An eye with arcus senilis." src="https://images.theconversation.com/files/461965/original/file-20220509-26-wt576b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461965/original/file-20220509-26-wt576b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461965/original/file-20220509-26-wt576b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461965/original/file-20220509-26-wt576b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461965/original/file-20220509-26-wt576b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461965/original/file-20220509-26-wt576b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461965/original/file-20220509-26-wt576b.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">
<figcaption>
<span class="caption">Arcus senilis is common in older people.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-arcus-senilis-during-ophthalmic-examination-650829127">ARZTSAMUI/Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>Fatty lump</strong></p>
<p>Sometimes the most alarming features that can appear on the eyes are actually the most benign and easy to treat. A yellowish fatty lump that can appear on the white of the eye is a <a href="https://www.specsavers.co.uk/eye-health/pinguecula">pinguecula</a> (pronounced pin-GWEK-you-la), a small deposit of fat and protein that may be easily remedied by eye drops or removed by a simple operation. </p>
<p>A <a href="https://www.webmd.com/eye-health/pterygium-surfers-eye">pterygium</a> (pronounced tur-RIDGE-ium) that appears as a pinkish growth over the white of the eye is not a danger to sight until it starts to grow over the cornea (the coloured part of the eye). </p>
<p>Fortunately, pterygia grow very slowly. As with pinguecula, it can easily be removed. Indeed, it should be removed well before it reaches the cornea. If allowed to keep growing, the pterygium will form an opaque “film” over the cornea that will obstruct vision. One of the major causal factors for both pinguecula and pterygium is believed to be chronic exposure to ultraviolet light from the Sun.</p>
<figure class="align-center ">
<img alt="An eye with a pinguecula." src="https://images.theconversation.com/files/461964/original/file-20220509-20-ahmmn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461964/original/file-20220509-20-ahmmn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461964/original/file-20220509-20-ahmmn9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461964/original/file-20220509-20-ahmmn9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461964/original/file-20220509-20-ahmmn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461964/original/file-20220509-20-ahmmn9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461964/original/file-20220509-20-ahmmn9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A pinguecula is a yellowish raised growth on the conjunctiva.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/macro-womans-eye-primopiano-on-pinguecula-2128388876">sruilk/Shutterstock</a></span>
</figcaption>
</figure>
<p><strong>Bulging eyes</strong></p>
<p>Bulging eyes can be part of a normal facial feature, but when eyes that were not previously bulging start to protrude forward, the most obvious cause is a problem with the <a href="https://www.nhs.uk/conditions/bulging-eyes/">thyroid gland</a> and needs medical attention. A single eye that is bulging can be caused by an injury, infection or, more rarely, a tumour behind the eye. </p>
<figure class="align-center ">
<img alt="Person with bulging eyes." src="https://images.theconversation.com/files/461995/original/file-20220509-15-v6m87i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/461995/original/file-20220509-15-v6m87i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=390&fit=crop&dpr=1 600w, https://images.theconversation.com/files/461995/original/file-20220509-15-v6m87i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=390&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/461995/original/file-20220509-15-v6m87i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=390&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/461995/original/file-20220509-15-v6m87i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=490&fit=crop&dpr=1 754w, https://images.theconversation.com/files/461995/original/file-20220509-15-v6m87i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=490&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/461995/original/file-20220509-15-v6m87i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=490&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Bulging eyes can be a sign of a thyroid problem, such as Graves’ disease.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=16115992">Jonathan Trobe/Wikimedia Commons</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p><strong>Swollen or twitching eyelids</strong></p>
<p>The eyelids can also indicate many diseases. These are mostly related to minor conditions of the glands in the eyelids. A common condition is the <a href="https://www.moorfields.nhs.uk/condition/styes">stye</a> or <a href="https://www.moorfields.nhs.uk/condition/chalazion-0">chalazion</a>, which appears as a red lump on the upper and, less often, lower eyelid and is caused by a blocked oil gland. A stye generally disappears on its own or with warm compresses. If it persists, it needs to be removed with a simple procedure. </p>
<p>A twitching eyelid (ocular myokymia) can be an irritation, even an embarrassment, and often feels far worse than it looks. In most cases, it is perfectly harmless and can be <a href="https://www.nhs.uk/conditions/twitching-eyes-and-muscles/">linked to</a> stress, nutrient imbalance or consuming too much caffeine.</p><img src="https://counter.theconversation.com/content/182387/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Barbara Pierscionek receives funding from EU (Marie-Skłodowska-Curie Doctoral Training Centre) and Rayners (consultancy grant. She has been funded by EPSRC, Fight for Sight (charity) and Essilor International (industry) </span></em></p>The eyes can reveal many health problems, from high cholesterol to thyroid disease.Barbara Pierscionek, Professor and Deputy Dean, Research and Innovation, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1819592022-04-28T09:35:31Z2022-04-28T09:35:31ZHepatitis outbreak in children: explainer on adenovirus type 41, the possible culprit<figure><img src="https://images.theconversation.com/files/460036/original/file-20220427-24-s2oeys.jpg?ixlib=rb-1.1.0&rect=8%2C8%2C5742%2C3819&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/child-hand-catheter-on-bed-533930812">Africa Studio/Shutterstock</a></span></figcaption></figure><p>A recent spate of severe liver inflammation (hepatitis) has been reported in previously healthy children. As of April 21, there have been <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON376">169 confirmed cases</a> of “acute hepatitis of unknown origin” in children in 12 countries, with the vast majority of cases (114) occurring in the UK. Many of the children are under ten years old.</p>
<p>What has been very concerning for health professionals reporting on these cases is the severity of the disease in these young, otherwise healthy children. Seventeen have needed a liver transplant, and one child has died of liver failure. </p>
<p>The number of transplants is far higher than what has been typically seen over similar time periods in previous years. While acute hepatitis is not unheard of in children, these latest figures are unprecedented, and so far, only partly explained.</p>
<p>One suspect is infection by an adenovirus. According to the UK Health Security Agency, adenovirus was the most common pathogen found in <a href="https://www.gov.uk/government/news/increase-in-hepatitis-liver-inflammation-cases-in-children-under-investigation#full-publication-update-history">40 of 53 confirmed cases</a> tested in the UK. The agency said that “investigations increasingly suggest that the rise in severe cases of hepatitis may be linked to adenovirus infection but other causes are still being actively investigated”.</p>
<h2>Adenoviruses</h2>
<p>Adenoviruses are a large group of viruses that can infect a wide range of animals as well as humans. They got their name from the tissue they were initially isolated from: the adenoids (tonsils). </p>
<p>Adenoviruses have at least seven distinct species, and within those species, there are genetic variants just like we see with coronaviruses and other viruses. In this case, instead of variants, they are referred to as adenovirus subtypes. </p>
<figure class="align-center ">
<img alt="Transmission electron micrograph of two adenovirus particles." src="https://images.theconversation.com/files/460096/original/file-20220427-24-6967hm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/460096/original/file-20220427-24-6967hm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=317&fit=crop&dpr=1 600w, https://images.theconversation.com/files/460096/original/file-20220427-24-6967hm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=317&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/460096/original/file-20220427-24-6967hm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=317&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/460096/original/file-20220427-24-6967hm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=398&fit=crop&dpr=1 754w, https://images.theconversation.com/files/460096/original/file-20220427-24-6967hm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=398&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/460096/original/file-20220427-24-6967hm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=398&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Two adenovirus particles.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=3921907">Graham Colm/Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Adenoviruses cause mild illness in humans, most of the time. Some species cause respiratory-like illnesses, such as croup in young children and babies. Others cause conjunctivitis, and a third group causes gastroenteritis. </p>
<p>The subtype associated with the current acute hepatitis outbreak in children is called adenovirus subtype 41, with the virus detected in <a href="https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON376">at least 74 cases</a> so far. Subtype 41 belongs to the adenovirus clustering that is typically associated with mild-to-moderate gastroenteritis; essentially a stomach bug with symptoms of diarrhoea, vomiting and abdominal pain. </p>
<p>In most children and adults with a healthy immune system, adenoviruses pose a mere annoyance, resulting in an illness expected to pass in a week or two. Viral hepatitis from infection by adenoviruses has only been reported previously as a <a href="https://www.gov.uk/government/news/increase-in-hepatitis-liver-inflammation-cases-in-children-under-investigation#full-publication-update-history">rare complication</a>.</p>
<p>Because of the number of cases and the severity of the disease in children, scientists are urgently investigating the cause of the outbreak. Early in the outbreak, epidemiologists sought to identify contact links with these cases and, of course, to identify what the cause of the viral hepatitis was. It quickly became apparent that this wasn’t just a small, isolated cluster of cases. </p>
<p>Data from the <a href="https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2022.27.15.2200318">Scottish National Health Service</a> revealed that none of these children lived in a discernible geographical pattern (such as near an open water source), that the average (median) age at hospital admission was four years old, and no other obvious traits, such as ethnicity or sex, were found to be associated with the disease. <a href="https://www.cdc.gov/media/releases/2022/s0421-hepatitis-alert.html">Similar findings</a> were reported by the US Centers for Disease Control and Prevention. </p>
<p>Because some of the COVID vaccines used adenoviruses, some people on social media wondered if the vaccines were the <a href="https://twitter.com/OneMoreVoice79/status/1519039495508836353?s=20&t=cdSFWncsWNha-6Wffn0r-g">cause of the outbreak</a>. However, none of the cases reported in the UK had received a COVID vaccine and the COVID vaccines that do use adenoviruses use an unrelated virus that cannot multiply. </p>
<h2>Questions that need to be answered</h2>
<p>Researchers still need to find a direct causative link between adenovirus 41 and these cases of hepatitis. Are there any other complicating factors that contribute towards serious disease, such as co-infection with another virus, such as coronavirus? </p>
<p>Sampling the population (both adults and children) to get an idea of how prevalent adenovirus 41 is in these reporting areas versus other areas of low to no incidence would help firm up the link. Scientists also need to discover the genetic makeup of the virus. Has it changed significantly from the reference information we have on it? </p>
<p>It will be crucial to understand the immune response in these cases versus other mild adenovirus infections. And research into prevention (vaccination) and treatment options, such as antiviral medication, also needs to commence.</p>
<p>Hopefully, we will have some answers – and treatments – soon. In the meantime, parents should be vigilant for hepatitis symptoms in their children, including yellowing of the eyes and skin (jaundice), dark urine, pale poo, itchy skin, feeling tired and tummy pain.</p><img src="https://counter.theconversation.com/content/181959/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cheryl Walter is affiliated with Reckitt. </span></em></p>Scientists are urgently trying to find the cause of the global outbreak of severe liver disease in young children. So far, adenovirus seems to be the best lead.Cheryl Walter, Lecturer in Biomedical Science, University of HullLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1813032022-04-19T08:06:50Z2022-04-19T08:06:50ZHepatitis cases are increasing among children in the UK – could COVID have a role to play?<figure><img src="https://images.theconversation.com/files/458404/original/file-20220418-26-xlqn7o.jpg?ixlib=rb-1.1.0&rect=52%2C0%2C5882%2C3695&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mother-holding-childs-hand-who-fever-1108828922">Beenicebeelove/Shutterstock</a></span></figcaption></figure><p>There has been a sharp increase in severe hepatitis cases among children under ten in the UK over recent months. The <a href="https://www.gov.uk/government/news/increase-in-hepatitis-liver-inflammation-cases-in-children-under-investigation">UK Health Security Agency</a> has been informed of 74 cases since January 2022, with 49 of these in England, 13 in Scotland and the remaining 12 spread between Wales and Northern Ireland. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1513891413561425920"}"></div></p>
<p>Other <a href="https://www.statnews.com/2022/04/14/u-s-u-k-investigating-unusual-cases-of-hepatitis-in-young-children/">isolated cases</a> of severe acute hepatitis in children have been identified in the US, Spain and Ireland.</p>
<p>Severe hepatitis in children is very rare and we don’t yet know what’s causing this highly unusual <a href="https://www.who.int/emergencies/disease-outbreak-news/item/acute-hepatitis-of-unknown-aetiology---the-united-kingdom-of-great-britain-and-northern-ireland">rise in cases</a>. The leading theory is that it’s some kind of viral infection, perhaps even SARS-CoV-2, the coronavirus that causes COVID-19. </p>
<p>But how likely is it that these hepatitis cases are linked to COVID? Or is there a more likely cause to be found elsewhere?</p>
<p>First let’s break down what hepatitis is and how it’s linked to viral infections.</p>
<p>Hepatitis is the medical term for <a href="https://www.nhs.uk/conditions/hepatitis/">inflammation of the liver</a>. Inflammation is a general immune response to an infection or injury – a sign the body is trying to fight off a potential disease. Symptoms in children usually include some (but not all) of the following: dark urine, grey-coloured faeces, yellowing of the skin and eyes (called jaundice) and a high temperature. </p>
<p>With the right medical attention the condition can usually be treated, but some patients may require a liver transplant. The World Health Organization has reported that <a href="https://www.who.int/emergencies/disease-outbreak-news/item/acute-hepatitis-of-unknown-aetiology---the-united-kingdom-of-great-britain-and-northern-ireland">six of the children</a> affected in the UK have undergone a transplant so far.</p>
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Read more:
<a href="https://theconversation.com/with-all-the-focus-on-coronavirus-lets-not-forget-the-other-respiratory-viruses-141633">With all the focus on coronavirus, let's not forget the other respiratory viruses</a>
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<p>The causes can be varied but in children, hepatitis is usually associated with viral infections. The most common of these are the five hepatitis viruses: hepatitis A, B, C, D and E. Other viruses such as adenoviruses can cause hepatitis, but this is rare.</p>
<p>What is unusual about these cases in children is that none of the five hepatitis viruses have been detected in any of the patients. This rules out the most common cause of these symptoms, leaving public health authorities searching for answers.</p>
<h2>Adenoviruses and hepatitis</h2>
<p>Adenoviruses are a very common viral infection in humans, especially children. Nearly every child has at least one adenovirus infection <a href="https://www.sciencedirect.com/science/article/pii/S2319417021001098">before the age of ten</a>. </p>
<p>Usually, these viruses cause infections of the lungs and airways, resulting in common cold symptoms and sometimes pneumonia. In some cases, mostly in children aged five and over, adenoviruses can cause what’s sometimes referred to as “pool fever”, resulting in a sore throat, fever and inflammation of the eyes. </p>
<p>In immunocompromised patients (anybody with an immune system that’s not functioning properly, such as those undergoing organ transplants or cancer treatments), adenoviruses can on rare occasions <a href="https://journals.lww.com/ajsp/Abstract/2017/06000/Adenovirus_Hepatitis__Clinicopathologic_Analysis.11.aspx">cause hepatitis</a>.</p>
<p>But to see it on this scale is extremely rare, especially in children who don’t appear to be immunocompromised. If adenovirus is the cause of these cases, it could mean that a new variant of adenovirus has emerged that more easily causes hepatitis.</p>
<figure class="align-center ">
<img alt="An illustration of the hepatitis virus surrounding the liver." src="https://images.theconversation.com/files/458405/original/file-20220418-22-d2a6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/458405/original/file-20220418-22-d2a6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=386&fit=crop&dpr=1 600w, https://images.theconversation.com/files/458405/original/file-20220418-22-d2a6k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=386&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/458405/original/file-20220418-22-d2a6k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=386&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/458405/original/file-20220418-22-d2a6k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=485&fit=crop&dpr=1 754w, https://images.theconversation.com/files/458405/original/file-20220418-22-d2a6k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=485&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/458405/original/file-20220418-22-d2a6k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=485&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hepatitis refers to inflammation of the liver.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/hepatitis-virus-human-liver-3d-illustration-1667884225">Explode/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Other potential causes</h2>
<p>Adenovirus seems to be the <a href="https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2022.27.15.2200318#r9">most likely</a> explanation, as it’s a common infection in children and can cause hepatitis. But there are some alternative scenarios that should be explored.</p>
<p>Autoimmune hepatitis, where the body itself attacks the liver (as opposed to a virus or other pathogen attacking it), could potentially cause such cases. But this is a rare condition, affecting roughly <a href="https://britishlivertrust.org.uk/information-and-support/living-with-a-liver-condition/liver-conditions/autoimmune-hepatitis/">10,000 people</a> in the UK and usually found in women around the age of 45. With these things in mind, autoimmune hepatitis is very unlikely to be the cause of a cluster of cases in children. </p>
<p>There have been suggestions that COVID could be behind these cases of hepatitis, as SARS-CoV-2 <a href="https://www.who.int/emergencies/disease-outbreak-news/item/acute-hepatitis-of-unknown-aetiology---the-united-kingdom-of-great-britain-and-northern-ireland">has been detected</a> in some of the children. Isolated cases of hepatitis have been reported in COVID patients, but this is even rarer than autoimmune hepatitis, and has mostly been observed in adults with <a href="https://www.nature.com/articles/s41591-020-0968-3">severe COVID</a>.</p>
<p>Importantly, none of the children diagnosed with hepatitis in the UK have received a <a href="https://www.gov.uk/government/news/increase-in-hepatitis-liver-inflammation-cases-in-children-under-investigation">COVID vaccination</a>, so there’s no basis to believe COVID vaccines have anything to do with this spike.</p>
<p>Another possibility is that this is a new symptom resulting from interaction between viruses (perhaps adenovirus and coronavirus both infecting the same child, for example). Alternatively, it could be caused by a totally different virus that hasn’t been detected yet.</p>
<h2>What now?</h2>
<p>The <a href="https://www.gov.uk/government/news/increase-in-hepatitis-liver-inflammation-cases-in-children-under-investigation">UK Health Security Agency</a> is advising parents and carers to be alert to signs of hepatitis in children.</p>
<p>While adenovirus currently looks to be the most likely cause here, further investigation will be needed to confirm this, and rule out other possible explanations such as novel viruses. It may even turn out that the cause is not common among all cases.</p>
<p>As the COVID pandemic continues, we must routinely consider coronavirus as a possible cause for unusual healthcare scenarios. At the same time, we shouldn’t assume there’s always necessarily a link. Such thinking carries the risk of blinding us to what’s really going on.</p>
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Read more:
<a href="https://theconversation.com/we-have-a-good-chance-of-curing-the-common-cold-in-next-ten-years-a-scientist-explains-96478">We have a good chance of curing the common cold in next ten years – a scientist explains</a>
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<p>If adenovirus is found to be the main cause, what can we do to protect against it, and in turn minimise any risk of serious complications? Adenoviruses <a href="https://academic.oup.com/jid/article/194/7/877/862744">spread</a> through the air and via touch. The main preventative measure is proper handwashing – by kids and adults alike – along with good respiratory hygiene, such as coughing into your elbow.</p><img src="https://counter.theconversation.com/content/181303/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Conor Meehan 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>While COVID-19 hasn’t been ruled out as a potential cause, the leading contender is actually adenovirus, a common infection in children that can lead to hepatitis on rare occasions.Conor Meehan, Senior Lecturer in Microbiology, Nottingham Trent UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1707722022-01-24T13:31:35Z2022-01-24T13:31:35ZHow mRNA and DNA vaccines could soon treat cancers, HIV, autoimmune disorders and genetic diseases<figure><img src="https://images.theconversation.com/files/441838/original/file-20220120-9603-u5kjhi.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3840%2C2160&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nucleic acid vaccines use mRNA to give cells instructions on how to produce a desired protein.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/messenger-rna-or-mrna-strand-3d-rendering-royalty-free-image/1295693748?adppopup=true">Libre de Droit/iStock via Getty Images</a></span></figcaption></figure><p><em>The two most successful coronavirus vaccines developed in the U.S. – the Pfizer and Moderna vaccines – are both mRNA vaccines. The idea of using genetic material to produce an immune response has opened up a world of research and potential medical uses far out of reach of traditional vaccines. <a href="https://scholar.google.com/citations?user=eNprtJEAAAAJ&hl=en&oi=ao">Deborah Fuller is a microbiologist</a> at the University of Washington who has been studying genetic vaccines for more than 20 years. We spoke to her about the <a href="https://theconversation.com/mrna-vaccines-asteroid-missions-and-collaborative-robots-what-to-watch-in-science-in-2022-podcast-174413">future of mRNA vaccines for The Conversation Weekly podcast</a>.</em> </p>
<p><em>Below are excerpts from that conversation which have been edited for length and clarity.</em> </p>
<h2>How long have gene-based vaccines been in development?</h2>
<p>This type of vaccine has been in the works for <a href="https://doi.org/10.1038/356152a0">about 30 years</a>. Nucleic acid vaccines are based on the idea that DNA makes RNA and then RNA makes proteins. For any given protein, once we know the genetic sequence or code, we can design an mRNA or DNA molecule that prompts a person’s cells to start making it. </p>
<p>When we first thought about this idea of putting a genetic code into somebody’s cells, we were studying both DNA and RNA. The mRNA vaccines did not work very well at first. They <a href="https://www.nature.com/articles/nrd.2017.243">were unstable</a> and they caused pretty strong immune responses that were <a href="https://doi.org/10.1038/nrd.2017.243">not necessarily desirable</a>. For a very long time DNA vaccines took the front seat, and the very <a href="https://dx.doi.org/10.1038%2Fnrg2432">first clinical trials were with a DNA vaccine</a>.</p>
<p>But about seven or eight years ago, mRNA vaccines started to take the lead. Researchers solved a lot of the problems – notably the <a href="https://doi.org/10.1038/mt.2008.200">instability</a> – and discovered <a href="https://doi.org/10.1073/pnas.1209367109">new technologies to deliver mRNA</a> into cells and ways of modifying the coding sequence to <a href="https://doi.org/10.1038/nrd.2017.243">make the vaccines a lot more safe to use in humans</a>.</p>
<p>Once those problems were solved, the technology was really poised to become a revolutionary tool for medicine. This was just when COVID-19 hit. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/441840/original/file-20220120-8772-9mk8e5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A scanning electron microscope image of blue lumpy sphere of a T cell." src="https://images.theconversation.com/files/441840/original/file-20220120-8772-9mk8e5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/441840/original/file-20220120-8772-9mk8e5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/441840/original/file-20220120-8772-9mk8e5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/441840/original/file-20220120-8772-9mk8e5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/441840/original/file-20220120-8772-9mk8e5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/441840/original/file-20220120-8772-9mk8e5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/441840/original/file-20220120-8772-9mk8e5.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>
<figcaption>
<span class="caption">DNA and mRNA vaccines are much better at producing T cells than are normal vaccines.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/niaid/5950870236/in/photolist-2mEvEdt-a4RLoY-2mEn5zV-bo51Vz-MSuhWU-bo5rrZ-2kLN4tU-2kLN4uF-SjQFf7-2ewYf1r-rx2LVN-su1wdR-2j4icVg-2iKmbjG-2mfURRa-a7RGBX-xvJ8TV-2hVm2XZ-2hVhUoD-2iKjyJj-51svu9-51ojDi-51sByA-ni2rkv-2iKgNob-Fwbp7g-EpF3rg-HKERqY-51sBff-51ojop-2mfSkUp-2mfMhmB-2mfLV8V-2mfQZZp-2mfLTAG-2mfVWsD-2mfRRSs-2mfQJMF-2mfUQ1m-2mfSjPU">NIAID/NIH via Flickr</a></span>
</figcaption>
</figure>
<h2>What makes nucleic acid vaccines different from traditional vaccines?</h2>
<p>Most vaccines induce antibody responses. Antibodies are the primary immune mechanism that blocks infections. As we began to study nucleic acid vaccines, we discovered that because these vaccines are expressed within our cells, they were also <a href="https://www.gavi.org/vaccineswork/what-are-nucleic-acid-vaccines-and-how-could-they-be-used-against-covid-19#:%7E:text=Nucleic%20acid%20vaccines%20use%20genetic,immune%20response%20against%20it">very effective at inducing a T cell response</a>. This discovery really prompted additional thinking about how researchers could use nucleic acid vaccines not just for infectious diseases, but also for immunotherapy to treat cancers and chronic infectious diseases – like HIV, hepatitis B and herpes – as well as autoimmune disorders and even for gene therapy.</p>
<h2>How can a vaccine treat cancers or chronic infectious diseases?</h2>
<p>T cell responses are very important for identifying cells infected with chronic diseases and aberrant cancer cells. They also play a big role in eliminating these cells from the body.</p>
<p>When a cell becomes cancerous, it <a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/neoantigen">starts producing neoantigens</a>. In normal cases, the immune system detects these neoantigens, recognizes that something’s wrong with the cell and eliminates it. The reason some people get tumors is that their immune system isn’t quite capable of eliminating the tumor cells, so the cells propagate.</p>
<p>With an mRNA or DNA vaccine, the goal is to make your body better able to recognize the very specific neoantigens the cancer cell has produced. If your immune system can recognize and see those better, it will <a href="https://doi.org/10.1038/d41586-019-03072-8">attack the cancer cells and eliminate them from the body</a>. </p>
<p>This same strategy can be applied to the <a href="https://www.genengnews.com/insights/immunotherapy-targets-emerging-infectious-diseases/">elimination of chronic infections</a> like HIV, hepatitis B and herpes. These viruses infect the human body and stay in the body forever unless the immune system eliminates them. Similar to the way nucleic acid vaccines can train the immune system to eliminate cancer cells, they can be used to train our immune cells to recognize and eliminate chronically infected cells. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/441842/original/file-20220120-9349-1yi871k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A syringe inserted into a vaccine vial." src="https://images.theconversation.com/files/441842/original/file-20220120-9349-1yi871k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/441842/original/file-20220120-9349-1yi871k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/441842/original/file-20220120-9349-1yi871k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/441842/original/file-20220120-9349-1yi871k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/441842/original/file-20220120-9349-1yi871k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/441842/original/file-20220120-9349-1yi871k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/441842/original/file-20220120-9349-1yi871k.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"></a>
<figcaption>
<span class="caption">There are dozens of ongoing trials testing the efficacy of mRNA or DNA vaccines to treat cancers or chronic diseases.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/syringe-and-coronavirus-vaccine-royalty-free-image/1287271384?adppopup=true">Stefan Cristian Cioata/Moment via Getty Images</a></span>
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<h2>What is the status of these vaccines?</h2>
<p>Some of the very first clinical trials of nucleic acid vaccines happened in the 1990s and <a href="https://doi.org/10.1073/pnas.90.23.11307">were for cancer</a>, particularly for <a href="https://doi.org/10.1038/nrg2432">melanoma</a>.</p>
<p>Today, there are a <a href="https://www.cancernetwork.com/view/messenger-rna-vaccines-beckoning-of-a-new-era-in-cancer-immunotherapy">number of ongoing mRNA clinical trials</a> for the treatment of melanoma, prostate cancer, ovarian cancer, breast cancer, leukemia, glioblastoma and others, and there have been some promising outcomes. Moderna recently announced promising results with its phase 1 trial using mRNA to <a href="https://www.businesswire.com/news/home/20211112005897/en/Moderna-Announces-Presentation-of-Interim-Data-from-Phase-1-Study-of-mRNA-Triplet-Program-at-2021-SITC-Annual-Meeting">treat solid tumors and lymphoma</a></p>
<p>There are also a lot of ongoing trials looking at cancer DNA vaccines, because DNA vaccines are <a href="https://doi.org/10.1186/s13046-019-1154-7">particularly effective in inducing T cell responses</a>. A company called Inovio recently demonstrated a significant impact on cervical cancer caused by human papilloma virus in women <a href="https://ir.inovio.com/news-releases/news-releases-details/2021/INOVIO-Highlights-Key-Updates-on-Phase-3-Program-for-VGX-3100-its-DNA-based-Immunotherapy-for-the-Treatment-of-Cervical-HSIL-Caused-by-HPV-16-andor-HPV-18/default.aspx">using a DNA vaccine</a>.</p>
<h2>Can nucleic acid vaccines treat autoimmune disorders?</h2>
<p>Autoimmune disorders occur when a person’s immune cells are actually attacking a part of the person’s own body. An example of this is multiple sclerosis. If you have multiple sclerosis, your <a href="https://www.mayoclinic.org/diseases-conditions/multiple-sclerosis/symptoms-causes/syc-20350269">own immune cells are attacking myelin</a>, a protein that coats the nerve cells in your muscles.</p>
<p>The way to eliminate an autoimmune disorder is to modulate your immune cells to prevent them from attacking your own proteins. In contrast to vaccines, whose goal is to stimulate the immune system to better recognize something, treatment for autoimmune diseases seeks to dampen the immune system so that it stops attacking something it shouldn’t. Recently, researchers created an mRNA vaccine encoding a myelin protein with slightly tweaked genetic instructions to prevent it from stimulating immune responses. Instead of activating normal T cells that increase immune responses, the vaccine caused the body to <a href="https://doi.org/10.1126/science.aay3638">produce T regulatory cells</a> that specifically suppressed only the T cells that were attacking myelin.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/441841/original/file-20220120-8832-1sa98ad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A diagram showing DNA turning into mRNA which turns into proteins." src="https://images.theconversation.com/files/441841/original/file-20220120-8832-1sa98ad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/441841/original/file-20220120-8832-1sa98ad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=618&fit=crop&dpr=1 600w, https://images.theconversation.com/files/441841/original/file-20220120-8832-1sa98ad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=618&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/441841/original/file-20220120-8832-1sa98ad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=618&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/441841/original/file-20220120-8832-1sa98ad.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=776&fit=crop&dpr=1 754w, https://images.theconversation.com/files/441841/original/file-20220120-8832-1sa98ad.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=776&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/441841/original/file-20220120-8832-1sa98ad.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=776&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many diseases result when people have mutations or are missing certain genes, and nucleic acid vaccines could act as temporary replacements for the missing genes.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/mrna-and-protein-synthesis-difference-royalty-free-illustration/1323350905?adppopup=true">ttsz/iStock via Getty Images</a></span>
</figcaption>
</figure>
<h2>Any other applications of the new vaccine technology?</h2>
<p>The last application is actually one of the very first things that researchers thought about using DNA and mRNA vaccines for: gene therapy. Some people are born missing certain genes. The goal with gene therapy is to supply cells with the missing instructions they need to produce an important protein. </p>
<p>[<em>Over 140,000 readers rely on The Conversation’s newsletters to understand the world.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-140ksignup">Sign up today</a>.]</p>
<p>A great example of this is cystic fibrosis, a genetic disease caused by mutations in a single gene. Using DNA or an mRNA vaccine, researchers are investigating the feasibility of essentially replacing the missing gene and allowing someone’s body to <a href="https://www.cff.org/gene-therapy-cystic-fibrosis#rna-therapy">transiently produce the missing protein</a>. Once the protein is present, the symptoms could disappear, at least temporarily. The mRNA would not persist very long in the human body, nor would it integrate into people’s genomes or change the genome in any way. So additional doses would be needed as the effect wore off.</p>
<p>Research has shown that this concept is feasible, but it still needs some work.</p><img src="https://counter.theconversation.com/content/170772/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Deborah Fuller is co-founder of Orlance, Inc, a biotechnology company developing a needle free technology to deliver RNA and DNA vaccines. She also serves as a scientific advisor for HDT Bio, a biotechnology company developing RNA vaccines for COVID19 and other infectious diseases; scientific advisor for Abacus, Inc., a biotechnology company developing cancer vaccines and scientific advisor for SQZ Biotech, a biotechnology company developing cell-based therapies for cancer and infectious diseases. She is also serving as a vaccine expert for Wilmerhale on legal matters. She receives funding supporting basic and translational research in RNA and DNA vaccines from the National Institutes of Health.</span></em></p>DNA and mRNA vaccines produce a different kind of immune response than traditional vaccines, allowing researchers to tackle some previously unsolvable problems in medicine.Deborah Fuller, Professor of Microbiology, School of Medicine, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1730182021-12-15T14:32:03Z2021-12-15T14:32:03ZHepatitis B in Nigeria: fresh data to inform prevention and care<figure><img src="https://images.theconversation.com/files/436140/original/file-20211207-23-1nwp7ma.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Hepatitis B is an infectious disease caused by the hepatitis B virus (HBV). <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">Nearly 300 million people worldwide</a> live with this virus, which resulted in an estimated <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">820,000 preventable deaths</a> in 2019. The virus is most commonly spread from mother to child during birth and through contact with the bodily fluids of an infected person. Infection in infancy and early childhood leads to chronic hepatitis in about 95% of cases.</p>
<p>Patients with <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">chronic HBV infection</a> have an increased risk of progressive liver damage and scarring, liver disease, liver cancer and even death. It can be prevented through vaccination, but there is no cure for it yet. Medications are available to reduce the viral load and slow the progression of liver cancer.</p>
<p>Reliable national data on the number of people infected with HBV are crucial to design public health control measures. Unfortunately, these data for most low- and middle-income countries are either <a href="https://www.sciencedirect.com/science/article/pii/S014067361561412X?casa_token=uGRpKHNwLBwAAAAA:6GmgeN6prvSR5YTgwsxEbpjdL7HU88f4rVwgzKX5eDTA_AQ2FzQNtz7elkNx2FtGyBnTNXtYkaA">lacking</a> or <a href="https://www.njcponline.com/article.asp?issn=1119-3077;year=2015;volume=18;issue=2;spage=163;epage=172;aulast=Musa">outdated</a>. This is due to inadequate surveillance of disease patterns, ill-equipped laboratories, and poor healthcare services. This makes it difficult to develop <a href="https://pubmed.ncbi.nlm.nih.gov/9190027/">evidence-based</a> policy and decisions for timely action.</p>
<p>The World Health Organisation (WHO) recognises HBV as a leading cause of death <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">worldwide</a>. In 2016, WHO outlined a <a href="https://apps.who.int/iris/bitstream/handle/10665/246177/WHO-HIV-2016.06eng.pdf?sequence=1">goal to end viral hepatitis</a> as a public health problem by 2030. Up-to-date national and sub-national data on infection levels in the community is key to measuring progress towards this goal.</p>
<p>In a recent review, we systematically collected data to estimate the levels of HBV infection in Nigeria. This information will be critical for meeting <a href="https://apps.who.int/iris/bitstream/handle/10665/246177/WHO-HIV-2016.06eng.pdf?sequence=1">global</a> and <a href="http://www.hepb.org/assets/Uploads/Nigeria-Hepatitis-Guidelines-TX-guidelines.pdf">national elimination goals</a>.</p>
<p>We found a prevalence of 9.5% – which is nearly 20,083,000 Nigerians. That is a high percentage. Infection rates differed by geographical area. The results point to the size of the potential liver disease crisis in Nigeria and where to focus prevention and care efforts with limited resources. </p>
<h2>Our research</h2>
<p>We conducted a <a href="https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-021-06800-6">meta-analysis</a>, consisting of studies published between 2010 and 2019, to determine HBV prevalence. There were 47 studies and a sample size of 21,702 people. </p>
<p>The prevalence rate of 9.5% that emerged from our analysis means that Nigeria meets the <a href="https://apps.who.int/iris/bitstream/handle/10665/67746/WHO_CDS_CSR_LYO_2002.2_HEPATITIS_B.pdf?sequence=1#page=39&zoom=100,-162,846">WHO’s criteria for high endemicity</a>.</p>
<p>Importantly, we found differences in infection levels across different geo-political zones and settings. Higher rates of HBV infection were found in the North-West geo-political zone (12.1%), compared with the South-East (5.9%). HBV infection rates in rural areas were also much higher (10.7%) than those in the cities (8.2%). Our study could not provide the reasons for this, but it is possible that it may be due to inequities in access to health services, and due to differences between culturally diverse groups.</p>
<p>Cultural beliefs can create barriers to <a href="http://www.scielo.org.za/pdf/hts/v71n3/45.pdf">HBV care</a>. For example, in northern Ghana, spiritual poisons, curses and witchcraft have been identified as the main <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0225830">cultural beliefs</a> associated with causing HBV in rural communities. </p>
<p>Also, the <a href="https://www.hepb.org/blog/journey-hepatitis-elimination-nigeria/">allocation of healthcare resources</a> in Nigeria is skewed towards secondary and tertiary services, which are mostly in urban areas.</p>
<h2>What does this mean for Nigeria?</h2>
<p>HBV infection in Nigeria requires ongoing efforts towards improving identification and testing, and treatment as part of routine care, along with vaccination to prevent new infections.</p>
<p>Despite the existence of a <a href="https://www.hepb.org/assets/Uploads/Nigeria-Hepatitis-Guidelines-TX-guidelines.pdf">national response to viral hepatitis</a>, less than 5% of people with viral hepatitis B have ever used clinical services. This is particularly important for rural dwellers, who make up a significant community of people with HBV in Nigeria. To improve access to prevention and care for rural populations, the national viral hepatitis plans need to be sensitive to diverse cultural attitudes. This may enhance communication and the likelihood that patients will accept healthcare providers’ recommendations.</p>
<p>Ensuring all Nigerians with hepatitis B are diagnosed early and receive appropriate care is critical to avert a liver disease crisis in Nigeria. Given the limited availability of funds at the global level, hepatitis response plans need to be adequately funded through national health budgets. This will minimise out of pocket costs, and ensure access to relevant services without financial hardship to any patients.</p>
<h2>Meeting the 2030 elimination targets</h2>
<p>In February 2020, <a href="https://aidswatchafrica.net/heads-of-states-and-government-from-african-union-member-states-endorse-the-cairo-declaration-on-viral-hepatitis/">heads of states and governments from African Union member states</a>, including the Nigerian government, pledged to eliminate hepatitis as a public health threat by 2030. Despite the challenges of COVID-19, with renewed political commitments, clearly defined targets, and financial support, Nigeria can prevent hundreds of thousands of unnecessary deaths.</p>
<p>To be on course to the elimination targets, Nigeria must improve access to affordable diagnosis and care for its population. People living with HBV should not have to wait for care until their infection becomes chronic and liver disease reaches an advanced stage. HBV diagnostics need to be affordable and accessible now, so people can be linked to care in a timely manner.</p>
<p>Ensuring high uptake of the vaccine at birth for babies is crucial to prevent new infections. In Nigeria, the current coverage for HBV vaccination is <a href="https://www.who.int/immunization/monitoring_surveillance/data/nga.pdf">57%</a> and offers room for improvement. Other measures, such as robust pre-conception screening, and the implementation of “test and treat” interventions at low cost for infected couples, are important to prevent mother-to-child transmission of infection.</p>
<p>Stigma and discrimination are notable barriers that prevent people from accessing health services, which can delay diagnosis and care. Marginalising populations who are vulnerable to HBV, such as people who inject drugs, often leads to their exclusion from testing and clinical care. Hepatitis B elimination will only be possible if we ensure that no one is left behind.</p><img src="https://counter.theconversation.com/content/173018/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Busayo Ajuwon is supported by funding from RSTMH Grants Programme in partnership with National Institute for Health Research (NIHR). He is affiliated with the Department of Microbiology, Kwara State University, Malete, Nigeria. He is a member of the Nigerian Society for Microbiology and the Data Science Nigeria AI+ Community.</span></em></p><p class="fine-print"><em><span>Meru Sheel receives funding from Westpac Scholars Trust. </span></em></p><p class="fine-print"><em><span>Katrina Roper 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>HBV cases in Nigeria point to a potential liver disease crisis. Prevention and care efforts are needed.Busayo I. Ajuwon, PhD Candidate, Australian National UniversityKatrina Roper, Honorary Senior Lecturer, Australian National UniversityMeru Sheel, Epidemiologist | Senior Research Fellow, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1650302021-07-27T09:35:29Z2021-07-27T09:35:29ZThis is no time to neglect hepatitis - 70 million Africans are infected<figure><img src="https://images.theconversation.com/files/413142/original/file-20210726-27-154wnlm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A childhood vaccine given at birth is effective.</span> <span class="attribution"><span class="source">BSIP/Universal Images Group via Getty Images</span></span></figcaption></figure><p>In 2016, the World Health Organisation (WHO) set an <a href="https://www.afro.who.int/publications/hepatitis-scorecard-who-africa-region-implementing-hepatitis-elimination-strategy">ambitious target</a> to eliminate viral hepatitis by 2030. This was followed by commitments from governments – including African countries – to develop national strategic plans for viral hepatitis and earmark resources to eliminate the disease. </p>
<p>Hepatitis results in the inflammation of the liver. There are different forms of hepatitis – A, B, C, D and E – each attributed to a different type of virus. Unfortunately, most people who have the most serious forms of the disease, particularly the B and C viruses, are unaware of infection. This allows the infection to spread unchecked, leading to serious damage to the liver.</p>
<p>This year World Hepatitis Day is marked under the theme “Hepatitis Can’t Wait”. It is a clear call to improve efforts towards eliminating a disease that globally kills <a href="https://www.who.int/campaigns/world-hepatitis-day/2021">one person every 30 seconds</a>.</p>
<p>Many African countries that committed to eliminating the disease have either not ratified their guidelines or not increased access to hepatitis care. Of the 47 countries in the WHO Africa region, <a href="https://www.afro.who.int/publications/hepatitis-scorecard-who-africa-region-implementing-hepatitis-elimination-strategy">28 have developed national plans to eliminate the disease. However, only 13 countries have disseminated them</a>. </p>
<p>The childhood vaccine given at birth is effective, but in <a href="https://www.tandfonline.com/doi/full/10.1080/21645515.2018.1460987">many rural and remote parts of Africa</a> <a href="http://immunizationinafrica2016.org/releases/2017/1/31/historic-commitment-from-african-heads-of-state-to-advance-immunization-in-africa">over 40%</a> of children are still unable to get the vaccines when they need them. Reasons for this include erratic vaccine supplies and outdated vaccination schedules.</p>
<p>These challenges have been further compounded by the COVID-19 pandemic, which has eroded some of the gains that had been made in the <a href="https://gh.bmj.com/content/6/1/e004275">past few years</a>. With movement restrictions and social distancing as part of the responses to curb the spread of infections, people have been less able to use services to prevent and cure <a href="https://www.thelancet.com/journals/langas/article/PIIS2468-1253(20)30238-7/fulltext">hepatitis and other diseases</a>.</p>
<h2>The disease</h2>
<p>In Africa, 70 million people are infected and 200,000 die annually from hepatitis. This is despite the <a href="https://www.afro.who.int/health-topics/hepatitis">availability of treatment</a>. </p>
<p>Hepatitis B is the most <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">common form of the illness</a>. It is spread through infected body fluids, either through sex with an infected partner, at birth (from an infected mother to her baby), direct contact with open wounds or blood of an infected person, sharing syringes, razors or toothbrushes with infected persons. </p>
<p>The mainstay strategy for managing hepatitis B is prevention through the administration of a vaccine. It is also treatable, through oral antiviral drugs which in most cases must be taken for life. This is because the treatment, in most people, only leads to the suppression of the virus and not its complete eradication. </p>
<p>To prevent its progression, it is highly recommended that treatment begins within the first three months of infection.</p>
<h2>Positive lessons</h2>
<p>The call again this year is therefore for renewed efforts to ensure that no baby is born with hepatitis, pregnant women get tested and treated, awareness is raised about the disease as well as testing and treatment, and governments invest more in efforts to end the disease. More concerted efforts are needed to keep services going even amid the disruptions caused by the pandemic.</p>
<p>Countries need to commit more domestic resources to fast-track elimination.</p>
<p>Cape Verde, Uganda and Rwanda provide positive lessons. They have committed more resources to ensure a 99% birth dose vaccination rate, free national hepatitis B treatment and free treatment for hepatitis B and C. This shows what political will <a href="https://www.afro.who.int/publications/hepatitis-scorecard-who-africa-region-implementing-hepatitis-elimination-strategy">can achieve</a>. </p>
<p><a href="https://www.afro.who.int/news/cabo-verde-sets-bar-ending-mother-child-transmission-viral-hepatitis">Cape Verde’s</a> government funds all vaccine services and implemented hepatitis screening for pregnant women in 2002 and the pentavalent vaccine in 2010. (This is a combination vaccine which protects against five killer diseases: diphtheria, pertussis, tetanus, hepatitis B and Hib.) The country has maintained almost 98% vaccine coverage for decades, an example other countries in the region need to follow. This is <a href="https://www.afro.who.int/news/cabo-verde-shows-us-health-care-progress-we-want-see-across-africa">as a result</a> of its commitment to using an equity lens to its health and social services combined with a multisectoral approach to health and wellbeing.</p>
<h2>Next steps</h2>
<p>Mobile health services have effectively worked in Madagascar and South Africa in <a href="https://www.scientificamerican.com/article/mobile-clinics-can-help-reduce-health-inequity/">increasing access</a> to vaccines and family planning services. Using <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-020-01175-7">mobile clinics</a> that can reach communities in far-flung areas could enable health workers to provide hepatitis screening and treatment services. </p>
<p>These <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4248563/">would be supported</a> by mainstream and social media platforms, as well as opinion leaders, to create more awareness about the disease and planned community outreach services. Platforms like this are also needed to conduct more advocacy to raise awareness and generate more support for prevention and treatment programmes. Successful campaigns have been run to create awareness about HIV/AIDS, the dangers of drugs and substance abuse and road safety among others. </p>
<p>Through virtual spaces, communities of practice can be <a href="https://www.researchgate.net/publication/221305931_Virtual_Communities_of_Practice_Collaborative_Learning_and_Knowledge_Management">created to share best practices</a> that would enhance awareness and resources essential in the elimination of the disease.</p>
<p>Hepatitis services are not as adequately funded as other priority areas such as HIV, immunisation and reproductive health. This means that hepatitis care needs to be integrated in some of the programmes promoting access to healthcare. For instance, this would help ensure that regular hepatitis screening is made available to women who go to health facilities for antenatal services or to patients under treatment for HIV infection. </p>
<p>Integration of services has effectively worked for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396431/">HIV and tuberculosis</a>. These successes need to be considered for hepatitis management. </p>
<p>And because of the important role vaccinations serve, more efforts need to be invested in ensuring that women and children receive their vaccines on time.</p>
<p>Though the pandemic presents challenges to eliminating hepatitis, African countries can recover some of the lost time. It requires taking more innovative approaches to promoting access to information and services.</p><img src="https://counter.theconversation.com/content/165030/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pauline Bakibinga receives funding from National Institute for Health Research (NIHR) Global Health Research Unit on Improving Health in Slums using UK aid from the UK Government to support global health research. The views expressed in this publication are those of the author and not necessarily those of the NIHR or the UK Department of Health and Social Care.</span></em></p>World Hepatitis Day is a clear call to improve efforts towards eliminating a disease that globally kills one person every 30 seconds.Pauline Bakibinga, Associate Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1510892020-12-07T16:07:02Z2020-12-07T16:07:02ZGenetic engineering transformed stem cells into working mini-livers that extended the life of mice with liver disease<figure><img src="https://images.theconversation.com/files/373147/original/file-20201205-17-veyobm.jpg?ixlib=rb-1.1.0&rect=56%2C155%2C9364%2C9250&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A cross section of lab-grown human liver tissue. The green shows the network of blood vessels.</span> <span class="attribution"><span class="source">Velazquez et al. Cell Systems </span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p><strong>Takeaways</strong></p>
<ul>
<li><p><strong>Scientists have made progress growing human liver in the lab.</strong></p></li>
<li><p><strong>The challenge has been to direct stems cells to grow into a mature, functioning adult organ.</strong></p></li>
<li><p><strong>This study shows that stem cells can be programmed, using genetic engineering, to grow from immature cells into mature tissue.</strong></p></li>
<li><p><strong>When a tiny lab-grown liver was transplanted into mice with liver disease, it extended the lives of the sick animals.</strong> </p></li>
</ul>
<hr>
<p>Imagine if researchers could program stem cells, which have the potential to grow into all cell types in the body, so that they could generate an entire human organ. This would allow scientists to manufacture tissues for testing drugs and reduce the demand for transplant organs by having new ones grown directly from a patient’s cells. </p>
<p>I’m a researcher working in this new field – called synthetic biology – focused on creating new biological parts and redesigning existing biological systems. <a href="https://www.cell.com/cell-systems/fulltext/S2405-4712(20)30420-8">In a new paper</a>, my colleagues and I showed progress in one of the key challenges with lab-grown organs – figuring out the genes necessary to produce the variety of mature cells needed to construct a functioning liver.</p>
<p><a href="https://stemcells.nih.gov/info/Regenerative_Medicine/2006Chapter10.htm">Induced pluripotent stem cells</a>, a subgroup of stem cells, are capable of producing cells that can build entire organs in the human body. But they can do this job only if they receive the right quantity of growth signals at the right time from their environment. If this happens, they eventually give rise to different cell types that can assemble and mature in the form of human organs and tissues. </p>
<p>The tissues researchers generate from pluripotent stem cells can provide a unique source for <a href="https://www.fda.gov/drugs/news-events-human-drugs/personalized-medicine-biological-approach-patient-treatment">personalized medicine</a> from transplantation to novel drug discovery. </p>
<p>But unfortunately, synthetic tissues from stem cells are not always suitable for transplant or drug testing because they contain unwanted cells from other tissues, or lack the tissue maturity and a complete network of blood vessels necessary for bringing oxygen and nutrients needed to nurture an organ. That is why having a framework to assess whether these lab-grown cells and tissues are doing their job, and how to make them more like human organs, is critical. </p>
<p>Inspired by this challenge, <a href="https://scholar.google.com/citations?user=C9BfYt0AAAAJ&hl=en">I</a> was determined to establish a <a href="https://ebrc.org/what-is-synbio/">synthetic biology</a> method to read and write, or program, tissue development. I am trying to do this using the genetic language of stem cells, similar to what is used by nature to form human organs. </p>
<h2>Tissues and organs made by genetic designs</h2>
<p>I am a researcher specializing in synthetic biology and biological engineering at the <a href="https://livercenter.pitt.edu">Pittsburgh Liver Research Center</a> and <a href="https://mirm-pitt.net">McGowan Institute for Regenerative Medicine</a>, where the goals are to use engineering approaches to analyze and build novel biological systems and solve human health problems. <a href="https://www.ebrahimkhanilab.com">My lab</a> combines synthetic biology and regenerative medicine in a new field that strives to replace, regrow or repair diseased organs or tissues. </p>
<p>I chose to focus on growing new human livers because this organ is vital for controlling most levels of chemicals – like proteins or sugar – in the blood. The liver also breaks down harmful chemicals and metabolizes many drugs in our body. But the liver tissue is also vulnerable and can be damaged and destroyed by many diseases, such as <a href="https://www.niddk.nih.gov/health-information/liver-disease">hepatitis</a> or <a href="https://www.mayoclinic.org/diseases-conditions/nonalcoholic-fatty-liver-disease/symptoms-causes/syc-20354567">fatty liver disease</a>. There is a shortage of donor organs, which limits liver transplantation.</p>
<p>To make synthetic organs and tissues, scientists need to be able to control stem cells so that they can form into different types of cells, such as liver cells and blood vessel cells. The goal is to mature these stem cells into miniorgans, or <a href="https://www.nature.com/articles/nmeth.4576.pdf?origin=ppub">organoids</a>, containing blood vessels and the correct adult cell types that would be found in a natural organ.</p>
<p>One way to orchestrate maturation of synthetic tissues is to determine the list of genes needed to induce a group of stem cells to grow, mature and evolve into a complete and functioning organ. To derive this list I worked with <a href="http://www.cahanlab.org">Patrick Cahan</a> and <a href="https://www.kianilab.com">Samira Kiani</a> to first use computational analysis to identify genes involved in transforming a group of stem cells into a mature functioning liver. Then our team led by two of my students – Jeremy Velazquez and Ryan LeGraw – used genetic engineering to alter specific genes we had identified and used them to help build and mature human liver tissues from stem cells.</p>
<p>The tissue is grown from a layer of genetically engineered stem cells in a petri dish. The function of genetic programs together with nutrients is to orchestrate formation of liver organoids over the course of 15 to 17 days.</p>
<h2>Liver in a dish</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=205&fit=crop&dpr=1 600w, https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=205&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=205&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=258&fit=crop&dpr=1 754w, https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=258&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/373150/original/file-20201205-13-t5uf9l.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=258&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The three images, from left to right, show sequential growth of liver tissue on a plate of nutrient rich gel over the course of about 15 days. As the tissue matures, it shrinks, self-organizes and contracts. These livers were then transplanted into mice with liver disease.</span>
<span class="attribution"><span class="source">Velazquez et al. Cell Systems</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>I and my colleagues first compared the active genes in <a href="https://doi.org/10.1038/ncomms10243">fetal liver organoids</a> we had grown in the lab with those in adult human livers using a computational analysis to get a list of genes needed for driving fetal liver organoids to mature into adult organs. </p>
<p>We then used genetic engineering to tweak genes – and the resulting proteins – that the stem cells needed to mature further toward an adult liver. In the course of about 17 days <a href="https://www.cell.com/cell-systems/fulltext/S2405-4712(20)30420-8">we generated tiny – several millimeters in width – but more mature liver tissues with a range of cells</a> typically found in livers in the third trimester of human pregnancies. </p>
<p>Like a mature human liver, these synthetic livers were able to store, synthesize and metabolize nutrients. Though our lab-grown livers were small, we are hopeful that we can scale them up in the future. While they share many similar features with adult livers, they aren’t perfect and our team still has work to do. For example, we still need to improve the capacity of the liver tissue to metabolize a variety of drugs. We also need to make it safer and more efficacious for eventual application in humans.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>Our study demonstrates the ability of these lab livers to mature and develop a functional network of blood vessels in just two and a half weeks. We believe this approach can pave the path for the manufacture of other organs with vasculature via genetic programming. </p>
<p>The <a href="https://www.cell.com/cell-systems/fulltext/S2405-4712(20)30420-8">liver organoids provide several key features of an adult human liver</a> such as production of key blood proteins and regulation of bile – a chemical important for digestion of food.</p>
<p>When we implanted the lab-grown liver tissues into mice suffering from liver disease, it increased the life span. We named our organoids “designer organoids,” as they are generated via a genetic design.</p><img src="https://counter.theconversation.com/content/151089/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mo Ebrahimkhani receives funding from National Institute of Health, University of Pittsburgh and Arizona Biomedical Research Council.</span></em></p>New strategy helps build synthetic organs from scratch. This enabled the researchers to grow functioning liver tissue in the lab that could be transplanted into mice with liver disease.Mo Ebrahimkhani, Associate Professor of Pathology and Bioengineering, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1475532020-10-07T17:17:29Z2020-10-07T17:17:29ZHow an Alberta researcher’s discovery of hepatitis C led to the Nobel Prize and saved lives<figure><img src="https://images.theconversation.com/files/362247/original/file-20201007-24-1eo4lzg.jpg?ixlib=rb-1.1.0&rect=107%2C44%2C2766%2C1917&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hepatitis C led to an estimated 400,000 deaths in 2016.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>This year, the Nobel Prize in physiology or medicine was awarded to virologists Harvey J. Alter and Charles M. Rice and biochemist Michael Houghton for the <a href="https://www.nobelprize.org/prizes/medicine/2020/summary/">discovery of the hepatitis C virus</a>. This recognition is yet a further testimonial of the need for discovery research to address the ravages of viral disease.</p>
<p>Hepatitis C infection led to <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-c">an estimated 400,000 deaths in 2016</a>. Similar to the SARS-CoV-2 virus that causes COVID-19, hepatitis C is an RNA virus. However, hepatitis C enters the body through the blood stream, where it then attacks the liver to lead to cirrhosis and liver cancer. </p>
<p>There is no vaccine for hepatitis C virus, but the basic science discoveries of the Nobel laureates have contributed to the development of <a href="https://www.nobelprize.org/prizes/medicine/2020/press-release/">antiviral drugs</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="From left, Harvey J. Alter, Michael Houghton and Charles M. Rice." src="https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/362013/original/file-20201006-18-16erik4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This combination of photos shows, from left, Harvey J. Alter, Michael Houghton and Charles M. Rice, who jointly won the Nobel Prize for medicine on Oct. 5, 2020, for their discovery of the hepatitis C virus. The major source of liver disease affects millions worldwide.</span>
<span class="attribution"><span class="source">(Rhoda Baer/National Institutes of Health, Richard Siemens/University of Alberta, AP Photo/John Minchillo)</span></span>
</figcaption>
</figure>
<h2>Chimpanzee No. 910</h2>
<p>In 1989, Houghton — alongside biochemist Qui-Lim Choo, geneticist Amy Weiner and virologists George Kuo, Lacy Overby and Daniel Bradley — reported the <a href="http://doi.org/10.1126/science.2523562">discovery of a new virus they named hepatitis C</a>. At the time, nothing was known about this virus. </p>
<p>So, how did the researchers go about deciphering experimental information to come up with the identification of a new virus? The team infected chimpanzees with <a href="https://doi.org/10.1111/j.1478-3231.2008.01925.x">serum from a patient diagnosed with hepatitis of unknown cause</a>. The key experimental animal was a chimpanzee named No. 910; DNA and RNA were extracted from its plasma. </p>
<p>Using molecular biology techniques of the time, complementary DNA was made in the test tube to the nucleic acids extracted from the chimpanzee plasma. The complementary DNA was then inserted into a bacterial virus known as a bacteriophage lambda. These bacterial viruses are used to infect E. coli to make proteins in large quantities. </p>
<h2>New virus discovery</h2>
<p>To the amazement of Houghton and his team, the serum from a hepatitis patient contained antibodies that recognized proteins made in this way. These antibodies had detected a previously unknown lethal virus. Further experimentation with rigorous controls established that this represented a new RNA virus. A <a href="http://doi.org/10.1126/science.2496467">blood test</a> was developed to detect patients infected with this virus they had discovered.</p>
<p>In 1975, Howard Alter discovered a form of lethal hepatitis in <a href="https://doi.org/10.1016/S0140-6736(75)90234-2">some patients who had received blood transfusions</a>. Later, Charles Rice proved <a href="http://doi.org/10.1126/science.277.5325.570">that the virus Houghton and his colleagues had discovered was the cause of this form of hepatitis</a>.</p>
<h2>Biotech Nobels</h2>
<p>The Nobel Prize recognizes the work he conducted at the biotech company Chiron Corporation. The discovery is not the first Nobel Prize given to a biotech discovery — the polymerase chain reaction method, or PCR, used today to test for the SARS-CoV-2 virus is also a consequence of a biotech discovery. This <a href="https://www.jstor.org/stable/24996713">discovery was made by Kary Mullis</a>, who received the <a href="https://www.nobelprize.org/prizes/chemistry/1993/mullis/facts/">1993 Nobel Prize in chemistry</a> for his work done at Cetus Corporation, one of the first biotechnology companies. </p>
<p>The innovations exemplified by these two Nobel Prizes heralds a new direction in discovery research through the talent and resources attracted to biotechnology via venture capital.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/the-road-to-covid-19-testing-the-role-of-a-canadian-biotech-pioneer-143176">The road to COVID-19 testing: The role of a Canadian biotech pioneer</a>
</strong>
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<hr>
<p>Houghton and his team developed a hepatitis C vaccine that is now in pre-clinical testing. He is also at the front lines of addressing the COVID-19 pandemic. His current research — <a href="https://cihr-irsc.gc.ca/e/52175.html">funded by the Canadian Institutes of Health Research</a> — aims to develop a vaccine against the key protein of these viruses that infects humans.</p>
<p>Houghton was recruited to Canada in 2010 in part through the Canada Excellence Research Chair program. Houghton’s 10 years in Edmonton as Director of the Li Ka Shing Applied Virology Institute has already <a href="https://edmontonsun.com/opinion/columnists/hicks-on-biz-u-of-a-researchers-hot-on-the-trail-of-covid-19">led to the development of drugs for hepatitis C, as well as others that might be used to treat COVID-19</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/tlDN9hkUIUw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Michael Houghton was named as the Canada Excellence Research Chair in Virology in 2010.</span></figcaption>
</figure>
<p>Until recently, Canadian health research leaders could be funded for their research through the <a href="https://cihr-irsc.gc.ca/e/51524.html">Foundation Grants program of CIHR</a>. Regrettably, this <a href="https://cihr-irsc.gc.ca/e/51431.html">program has now been terminated</a>. This may be jeopardizing our hope for sustained excellence at the highest level to assure that we have the best talent for discovery research.</p>
<p>The recognition to Houghton in Alberta will hopefully embolden efforts to support our trailblazers throughout Canada, as we navigate through the COVID-19 pandemic.</p>
<p><em>John Bergeron gratefully acknowledges Kathleen Dickson as co-author.</em></p><img src="https://counter.theconversation.com/content/147553/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Bergeron 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>Michael Houghton, an Edmonton-based virologist, was one of the recipients of this year’s Nobel Prize for physiology or medicine for the discovery of hepatitis C.John Bergeron, Emeritus Robert Reford Professor and Professor of Medicine, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1435502020-08-02T08:34:27Z2020-08-02T08:34:27ZA hard journey to a future free of hepatitis in Africa<figure><img src="https://images.theconversation.com/files/349896/original/file-20200728-21-wyefi2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Sub-Saharan Africa has a low uptake of the Hepatitis B vaccine compared to the rest of the world.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The World Health Organisation has announced additional efforts to <a href="https://www.who.int/hepatitis/strategy2016-2021/ghss-hep/en/">eliminate</a> hepatitis by <a href="https://www.who.int/news-room/detail/27-07-2020-world-hepatitis-day-fast-tracking-the-elimination-of-hepatitis-b-among-mothers-and-children">2030</a>. The overall strategy calls for the prevention of new infections through universal implementation of the hepatitis B birth-dose vaccine. It also calls for full vaccine coverage, and access to affordable diagnostics to identify and care for infected individuals.</p>
<p>Hepatitis refers to the inflammation of the liver and is commonly caused by viral infections. It is major global public health problem, accounting for more than <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30579-7/fulltext">1.4 million deaths every year</a>. It can also be caused by medications, substance abuse, toxins, alcohol and autoimmune conditions. </p>
<p>There are different strains of the virus, causing hepatitis A, B, C, D, and E. Of major concern in sub-Saharan Africa is <a href="https://www.openaccessgovernment.org/viral-hepatitis/67856/">hepatitis B</a>. With a prevalence of 6.1%, it is more common in the region than HIV, which stands at prevalence of 4.9%. In the WHO African region, <a href="https://apps.who.int/iris/bitstream/handle/10665/78616/WHO_IVB_12.11_eng.pdf?sequence=1">mother-to-child transmission and horizontal transmission</a> during early childhood are the leading causes of hepatitis B infection.</p>
<h2>Early protection is vital</h2>
<p>Women who are have hepatitis B are more than <a href="https://www.hindawi.com/journals/heprt/2014/159206/">10 times</a> more likely to pass on the infection to their newborns. The risk of becoming a chronic carrier of hepatitis B stands at <a href="https://apps.who.int/iris/bitstream/handle/10665/259637/HepatitisFram-eng.pdf?sequence=1%26isAllowed=y">95%</a> for infections acquired during the perinatal period.</p>
<p>The current WHO strategy to end mother-to-child transmission of hepatitis B includes routine screening of all pregnant women, the treatment of highly infectious infected mothers, birthdose vaccination and the administration of hepatitis B immunoglobulin for exposed infants.</p>
<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3882411/">Infant vaccination</a> has been shown to reduce the risk of developing hepatitis B by more than three times. This is particularly the case if the vaccine is administered within the first three days after birth. </p>
<p>But none of these practices are rigorously enforced in many parts of Africa. This is because of an absence of evidence based <a href="https://www.who.int/immunization/monitoring_surveillance/routine/coverage/WUENIC_notes.pdf?ua=1">policies</a>. </p>
<h2>The challenge</h2>
<p>A major challenge in the control of hepatitis globally is the <a href="https://www.who.int/mediacentre/commentaries/better-estimates-hepatitis/en/">limited attention</a> that it has received in the past from governments and funding agencies. This is largely due to the difficulty in attribution of death as a result of infections. </p>
<p>The complications that can result from hepatitis, such as liver cancer, generally get highlighted as a standalone cause of death. Hepatitis is not noted as the reason for death. As a result, more money has been invested in other areas of public health, such as HIV/AIDS and tuberculosis control. This is despite deaths due to hepatitis being more numerous than those caused by HIV/AIDS and comparable to those caused by tuberculosis in the world and in <a href="https://www.openaccessgovernment.org/viral-hepatitis/67856/">sub-Saharan Africa</a> in particular.</p>
<p>In addition, there is a dearth of <a href="https://apps.who.int/iris/bitstream/handle/10665/259637/HepatitisFram-eng.pdf?sequence=1%26isAllowed=y">information</a> on the burden and patterns of the disease. This is despite a <a href="https://www.who.int/mediacentre/news/releases/2014/WHA-20140522/en/#:%7E:text=22%20May%202014%20%7C%20GENEVA%20%2D%20The,cancers%2C%20heart%20disease%20and%20stroke">2014</a> World Health Assembly resolution that urged member states to develop and implement coordinated multi-sectorial national strategies for the prevention, diagnosis and treatment of viral hepatitis based on local epidemiological context.</p>
<p>These were to be supported by targeted health promotion and prevention actions and appropriate and effective viral hepatitis surveillance systems. The absence of evidence based policy actions continues to limit the establishment of effective responses.</p>
<p>For example, women continue to present at maternity centres for delivery without ever having been screened for hepatitis B. The worry is that some are symptomatic, as a recent study from <a href="https://www.longdom.org/open-access/prevalence-and-factors-associated-with-hepatitis-b-surface-antigen-positivity-among-women-receiving-antenatal-care-at-mbarara-regi-44175.html">Uganda</a> showed.</p>
<p>The hepatitis B vaccine has been available since 1982 and immunisation is an effective strategy. But poor uptake and coverage in the region persists. This is despite various strategies to ensure full <a href="https://www.who.int/news-room/fact-sheets/detail/immunization-coverage">vaccination</a> coverage. </p>
<p>The hepatitis B vaccine coverage in sub-Saharan Africa is estimated to be at <a href="https://www.who.int/immunization/monitoring_surveillance/routine/coverage/WUENIC_notes.pdf?ua=1">6%</a> compared to the global coverage of <a href="https://www.who.int/immunization/monitoring_surveillance/routine/coverage/WUENIC_notes.pdf?ua=1">43%</a>. And the immunisation schedules in this region remain a challenge since it’s often difficult to get babies vaccinated within the first hours or days <a href="https://apps.who.int/iris/bitstream/handle/10665/259637/HepatitisFram-eng.pdf?sequence=1%26isAllowed=y">after birth</a>.</p>
<p>These challenges are further compounded by weak health systems with limited healthcare budgets that make diagnostics and treatment unavailable to the wider population. All these challenges have been further expanded by the COVID-19 pandemic. </p>
<h2>Closing the gaps</h2>
<p>In the journey to a hepatitis free future, several actions are needed.</p>
<p>There needs to be more deliberate action to screen all pregnant women. More targeted efforts need to be implemented to reach women, especially those in marginalised and far-flung areas, to ensure that they get antenatal care.</p>
<p>Governments also need to <a href="https://www.who.int/mediacentre/news/releases/2014/WHA-20140522/en/#:%7E:text=22%20May%202014%20%7C%20GENEVA%20%2D%20The,cancers%2C%20heart%20disease%20and%20stroke">allocate</a> resources for epidemiological studies to inform country level control strategies.</p>
<p>And there’s an urgent need to increase uptake and coverage of both new and old vaccines. For example, <a href="https://www.gavi.org/sites/default/files/document/ppc-meeting-18-19-october-2018---vis-06a---annex-c--hepatitis-b-birth-dose-investment-casepdf.pdf">estimates</a> show that between 2021 and 2035, Nigeria could prevent between 0.3 and 1.2 million deaths if sufficient investments were made for the inclusion of the hepatitis B vaccine as part of the birthdose round of immunisations. </p>
<p>Innovations to ensure continuity of care including access to vaccine services are needed. These could involve the use of technology and mobile clinics.</p>
<p>Taking lessons from the HIV/AIDS control measures is invaluable. Co-opting hepatitis B into the HIV/AIDS prevention and treatment messages would also help register quick gains as the viruses have similar routes of transmission.</p>
<p>Success in attaining a hepatitis B free future also requires strengthened partnerships between the WHO, governments and funding agencies.</p>
<p>The additional recent WHO recommendations, informed by additional evidence on the safety and efficacy of tenofovir (an antiviral drug), is increasing its use. All pregnant women who test positive for hepatitis B infection and have a high viral load can be given preventive treatment with tenofovir from the 28th week of pregnancy. The other change is that, in contexts where hepatitis B viral load testing is not available, <a href="https://www.who.int/news-room/detail/27-07-2020-world-hepatitis-day-fast-tracking-the-elimination-of-hepatitis-b-among-mothers-and-children">HBeAg</a>, a low cost test, can be used to determine eligibility for preventive antiviral treatment.</p><img src="https://counter.theconversation.com/content/143550/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pauline Bakibinga receives funding from the Medical Research Council (UK), the UK Department for International Development, National Institute for Health Research (UK) and Comic Relief(UK). None of the agencies had a role in the decision to write and/or publish this piece</span></em></p><p class="fine-print"><em><span>Aheisibwe Hillary is a Director at Neocare Clinic and Fertility centre.
Aheisibwe has also previously received research funding from the First Mile Project and MESAU-MEPI, all at Mbarara University of Science and Technology.
</span></em></p>HIV/AIDS receives more funding than hepatitis, which is responsible for more deaths.Pauline Bakibinga, Associate Research Scientist, African Population and Health Research CenterAheisibwe Hillary, Obstetrician and Gynecologist, Mbarara University of Science and TechnologyLicensed 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/1323082020-03-16T17:17:03Z2020-03-16T17:17:03ZSt. Patrick’s Day: A time to toast … your liver<figure><img src="https://images.theconversation.com/files/320007/original/file-20200311-116232-diesgx.jpg?ixlib=rb-1.1.0&rect=44%2C77%2C7304%2C4693&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">St. Patrick and Ireland may be mostly on your mind on March 17, but it's also a time to toast your liver.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/two-girls-wig-cap-photographed-bar-1015699546">VGstockstudio/Shutterstock.com</a></span></figcaption></figure><p>St. Patrick’s Day is here, and even though <a href="https://theweek.com/speedreads/901061/boston-cancels-st-patricks-day-parade-abundance-caution">most big celebrations have been canceled</a> because of coronavirus, we still have something to cheer over – our livers. </p>
<p>If St. Patrick is celebrated for his unselfish commitment converting Ireland to Christianity, we should also celebrate the magnanimous dedication of our liver not only to process alcohol, but keep our whole body fed and alive.</p>
<p>I am a <a href="https://scholar.google.com/citations?user=AOwEmrsAAAAJ&hl=en">biochemist</a>, and every time I teach liver metabolism, I am in awe of all its accomplishments.</p>
<p>Here are four reasons to be grateful to your liver.</p>
<h2>It metabolizes alcohol and other bad molecules</h2>
<p>The alcohol we consume can’t be directly excreted - it has to be transformed to be eliminated. Degrading alcohol is a multi-step process that happens in the liver, where cells metabolize it using a series of enzymes working in a tidy cascade of reactions.</p>
<p>These enzymes will turn alcohol into a final product that is used by the body to make other nutrients such as fats. That is why, in part, an excessive alcohol consumption can lead to an <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4434621/">alcohol-induced fatty liver disease</a> characterized by an over accumulation of fat in the liver.</p>
<p>Processing alcohol produces acetaldehyde, a toxic molecule. This toxic compound normally doesn’t linger in the liver and is quickly transformed into a nontoxic molecule. </p>
<p>If you consume alcohol faster than your body can process it, your metabolic system gets clogged, the toxic molecule accumulates and the liver is under stress. If you repeat this process on a regular basis and over long periods of time, the liver can develop an inflammation known as <a href="https://www.mayoclinic.org/diseases-conditions/alcoholic-hepatitis/symptoms-causes/syc-20351388">alcoholic hepatitis</a> and eventually <a href="https://liverfoundation.org/for-patients/about-the-liver/diseases-of-the-liver/cirrhosis/">cirrhosis</a>that can irreversibly scar the liver.</p>
<p>About a third of East Asians have an inherited slower ability to process alcohol, which manifests as <a href="https://doi.org/10.1371/journal.pmed.1000050">facial flushing</a> due to the toxic effect of that molecule.</p>
<p>The liver also processes a large number of <a href="https://www.merckmanuals.com/professional/clinical-pharmacology/pharmacokinetics/drug-metabolism">pharmaceutical drugs</a>, such as acetaminophen. And along with the spleen, it participates in degrading hemoglobin, the red pigment contained in your red blood cells, into fragments that can be eliminated in the intestines and the feces (that is why, in part, feces are brownish). </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/320008/original/file-20200311-116240-c1w7y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/320008/original/file-20200311-116240-c1w7y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=454&fit=crop&dpr=1 600w, https://images.theconversation.com/files/320008/original/file-20200311-116240-c1w7y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=454&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/320008/original/file-20200311-116240-c1w7y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=454&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/320008/original/file-20200311-116240-c1w7y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=570&fit=crop&dpr=1 754w, https://images.theconversation.com/files/320008/original/file-20200311-116240-c1w7y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=570&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/320008/original/file-20200311-116240-c1w7y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=570&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It may be homely, but your liver is extremely helpful. You can’t live without it.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-illustration-abstract-medical-background-diseased-1118711141">Explode/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Your liver makes nutrients</h2>
<p>Beside degrading toxins and other molecules, the liver is also a maker of large and complicated structures such as <a href="https://www.britannica.com/science/cholesterol">cholesterol</a>. Despite its bad reputation, cholesterol is important, as from cholesterol the body produces steroid hormones like cortisol and testosterone or makes vitamin D in the skin.</p>
<p>If you have heard of bile, you may know that it comes from the gallbladder. <a href="https://doi.org/10.1002/cphy.c120023">Bile</a> is in fact produced by the liver from cholesterol and then stored in the gallbladder. Bile is a yellowish-greenish fluid released from the gallbladder into the intestine to help in the digesting fats.</p>
<p>But that is not all. The liver is also the birth place of a number of blood plasma proteins in circulation in your bloodstream and of the various proteins that create a clot when you are bleeding.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/GYFJ8oqNdCE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The wonderful workings of the liver.</span></figcaption>
</figure>
<h2>Your liver stores nutrients</h2>
<p>The liver is the first organ to receive the nutrients absorbed by the intestine. As we eat, food moves down the digestive track and is processed into molecules that are small enough to cross the intestinal wall and move into the circulation. Nutrient-rich blood coming from the intestine is immediately captured by a large vein and sent to the liver.</p>
<p>It’s also a gatekeeper. It senses the overall state of nourishment of the body and stores nutrients such as sugar or fat when they are abundant in the blood circulation. It also stores some vitamins such as <a href="https://medlineplus.gov/ency/article/002403.htm">vitamin B12</a>. </p>
<p>And it stores, sugars as <a href="https://www.ncbi.nlm.nih.gov/books/NBK21190/">glycogen</a> (the starch of the human body) and fat and keep that these nutrients for later use.</p>
<p>Thus, if we are well fed, we will have reserves of sugar and fat present in our liver. But an overabundance of food can overwhelm the system and the liver’s ability to store and <a href="https://pubmed.ncbi.nlm.nih.gov/27213358-the-natural-course-of-non-alcoholic-fatty-liver-disease/?from_term=non-alcoholic+fatty+liver+disease+&from_filter=simsearch2.ffrft&from_filter=pubt.review&from_pos=10">non-alcoholic fatty liver disease</a> can develop.</p>
<h2>Your liver nourishes and protects other organs</h2>
<p>In times of need, when our blood sugar levels are low with no meal immediately in sight, the liver taps into its reserve and releases the nutrients needed.</p>
<p>Without this constant surveillance of the liver you would not be able to spend an uninterrupted night of sleep. Why? Your brain relies on sugar as a source of energy to perform, and a regular income of sugar is vital. It’s under the watch of the liver that the brain receives the needed amount of sugar when you are asleep or awake.</p>
<p>There are <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/glycogen-storage-disease">diseases</a> in which people lack the ability to store or release sugars from the liver reserve. They depend on special diets with slow release of carbohydrates to go about their days and to have a full night of sleep.</p>
<p>Finally, we don’t tend to think of the liver as part of the immune system but it’s an organ that is part of our first line of response against viruses and bacteria. The liver is filled with cells that participate in your <a href="https://www.annualreviews.org/doi/full/10.1146/annurev-immunol-051116-052415?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub++0pubmed">immune defense</a> and that can gobble up microorganisms trying to invade our body.</p>
<p>For St. Patrick’s Day, let’s not forget our liver and all its magnanimous contributions to our health. Let’s not forget that St. Patrick asked for just <a href="https://theconversation.com/the-truth-about-st-patricks-day-111396">“a wee drop of whiskey”</a> to celebrate his memory. </p>
<p>Wishing the whole of you a Happy St. Patrick’s Day.</p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=youresmart">You can read us daily by subscribing to our newsletter</a>.]</p><img src="https://counter.theconversation.com/content/132308/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marie-Pierre Hasne does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>St. Patrick’s Day is typically a day of drinking and revelry, if not reverence for Ireland’s patron saint. In this year’s subdued celebration environment, a biochemist suggests thanking our livers.Marie-Pierre Hasne, PhD, Pharm.D. Lecturer, College of Medicine-Tucson, University of ArizonaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1228612019-10-24T05:54:58Z2019-10-24T05:54:58ZWe have a vaccine for hepatitis B but here’s why we still need a cure<figure><img src="https://images.theconversation.com/files/294935/original/file-20191001-173375-3bdmuj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Around 5% of adults and 90% of babies who contract hepatitis B go on to have life-long infection that can only be managed with regular medication.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/521751805?src=YyMFtMJUoJy-6i72m0aOog-1-0&size=huge_jpg">Ronald Rampsch/Shutterstock</a></span></figcaption></figure><p>Hepatitis B is blood-borne virus that packs a punch. Worldwide, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6523454/">more than 1.3 billion people</a> have been infected with hepatitis B, and 257 million people have developed a life-long infection. This includes 240,000 Australians, <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.12049">many of whom are Indigenous</a>. </p>
<p>Globally, transmission most commonly occurs from mother to baby or in early life. But it’s possible to be infected in adulthood, through sex or blood-to-blood contact. </p>
<p>Most people who are infected in adulthood develop a short infection which their immune response controls. But in around 5% of adults and <a href="https://www.cdc.gov/hepatitis/HBV/PDFs/HepBPerinatal-ProtectWhenPregnant.pdf">90% of babies</a>, the immune response is ineffective and chronic infection develops. </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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<p>Hepatitis B virus causes <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.12049">almost 40% of all liver cancer</a>, which is the fifth most common cancer and the second leading cause of cancer-related death worldwide. </p>
<h2>Australian discovery</h2>
<p>Hepatitis B virus was <a href="https://jamanetwork.com/journals/jama/article-abstract/654843">discovered</a> in the serum of an Indigenous Australian in 1965 and was <a href="https://theconversation.com/explainer-the-a-b-c-d-and-e-of-hepatitis-54739">first known</a> as the “Australia antigen”.</p>
<p>This quickly led to the development of an effective vaccine in the 1980s, which is now available worldwide. The vaccine has been given to Australian infants since <a href="https://www1.health.gov.au/internet/publications/publishing.nsf/Content/cda-cdi31suppl.htm%7Ecda-cdi31suppl-3.htm%7Ecda-cdi31suppl-3d.htm">May 2000</a>. </p>
<p>(If you weren’t vaccinated as a baby, you might want to consider doing so through your GP, particularly if you plan to travel to Asia and Africa where hepatitis B is common.) </p>
<p>Unfortunately the vaccine doesn’t do anything for the 240,000 or so Australians who currently live with chronic hepatitis B. Only around 60% of these people <a href="https://doi-org.ezp.lib.unimelb.edu.au/10.1111/1753-6405.12693">have been diagnosed</a>; the rest don’t know they’re infected and don’t receive appropriate care. </p>
<h2>How is it currently treated?</h2>
<p>There is no cure for chronic hepatitis B virus. </p>
<p>In most cases, treatment requires taking a pill every day for life to remain effective and to reduce the risk of liver cancer. Even then, it doesn’t eliminate the risk.</p>
<p>Chronic hepatitis B hasn’t been cured so far in part because current therapies have failed to destroy the viral reservoir, where the virus hides in the cell. </p>
<p>This is in contrast to hepatitis C virus, which has no such viral reservoir and can now be cured with as little as 12 weeks of treatment.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/in-contrast-to-australias-success-with-hepatitis-c-our-response-to-hepatitis-b-is-lagging-122547">In contrast to Australia's success with hepatitis C, our response to hepatitis B is lagging</a>
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</p>
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<p>Despite the huge <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/1753-6405.12049">human and economic toll</a> of chronic hepatitis B, research to cure the disease remains underfunded. There is a misconception that because there is a vaccine, hepatitis B is no longer a problem. </p>
<p>The availability of effective cures for the unrelated hepatitis C virus has also led people to believe that “viral hepatitis” is no longer a problem. </p>
<p>Experts estimate that liver cancer deaths will <a href="https://www.ncbi.nlm.nih.gov/pubmed/16879891">substantially increase</a> in coming decades without a cure for hepatitis B, despite deaths from <a href="https://www.ncbi.nlm.nih.gov/pubmed/26181261">most cancers</a> decreasing. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/298464/original/file-20191024-31438-hi3416.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/298464/original/file-20191024-31438-hi3416.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/298464/original/file-20191024-31438-hi3416.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/298464/original/file-20191024-31438-hi3416.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/298464/original/file-20191024-31438-hi3416.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/298464/original/file-20191024-31438-hi3416.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/298464/original/file-20191024-31438-hi3416.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">Hepatitis B causes 40% of all liver cancer.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/529109200?src=I1nxyDNoGf8TNS0JpEeW7Q-1-21&size=huge_jpg">Napocska/Shutterstock</a></span>
</figcaption>
</figure>
<h2>How far have we got?</h2>
<p>Some exciting research is underway around the world, including the recent <a href="https://elifesciences.org/articles/00049">identification of the “cell receptor”</a> which allows the virus to infect the body. This has enabled studies of the complete virus replication cycle including the viral reservoir that is untouched by current therapies. </p>
<p><a href="http://ice-hbv.org/update-on-hbv-cure-at-ilc-2018/">New approaches</a> to a possible cure include mechanisms to block the virus’ entry into the cell and to stop the virus from making the proteins it needs to replicate and infect new cells. </p>
<p>Studies are also underway to enhance patients’ immune responses so their own natural defences can control or even eliminate the virus. This is similar to immunotherapies already being used to treat some cancers. </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>
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<p>It’s likely a hepatitis B cure will require a dual-pronged approach, directly targeting the virus while also enhancing the immune response in people who are infected. </p>
<p>The goal is to reduce the amount of virus in the body and restore the person’s immune responses. This is called a “functional cure” and is similar to what happens when a person naturally gets rid of the virus. It would also mean they didn’t need to take drugs any more. </p>
<p>Some of these approaches are now in early stage human clinical trials. <a href="http://ice-hbv.org/update-on-hbv-cure-at-ilc-2018/">More than 30 drugs have been developed</a> and are being tested in people with chronic hepatitis B. However, much more work needs to be done to achieve a cure.</p><img src="https://counter.theconversation.com/content/122861/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Revill has received research funding from Gilead Sciences.</span></em></p><p class="fine-print"><em><span>Margaret Littlejohn receives funding from the Australian Centre for HIV and Hepatitis Virology</span></em></p>Babies in Australia have been vaccinated against hepatitis B since May 2000, but 240,000 Australians still live with the disease.Peter Revill, Senior Medical Scientist at VIDRL, Royal Melbourne Hospital, The Peter Doherty Institute for Infection and ImmunityMargaret Littlejohn, Medical Scientist, Melbourne HealthLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1249932019-10-13T19:02:20Z2019-10-13T19:02:20ZOrgans ‘too risky’ to donate may be safer than we think. We crunched the numbers and here’s what we found<figure><img src="https://images.theconversation.com/files/296582/original/file-20191011-188829-1xxdbsn.jpg?ixlib=rb-1.1.0&rect=4%2C5%2C994%2C660&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Accepting a donor kidney with a small risk of carrying HIV or hepatitis B or C might be worth thinking about.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/759443860?src=-Yku0Hm6B8U7E0GT9EdjXQ-1-2&size=medium_jpg">from www.shutterstock.com</a></span></figcaption></figure><p>Organs from potential donors once rejected as being unsafe to transplant may not be as risky as once thought, new Australian research shows.</p>
<p>Our study, <a href="https://onlinelibrary.wiley.com/doi/10.5694/mja2.50315">published</a> in the Medical Journal of Australia, suggests organs from injecting drug users or men who have sex with men, for instance, could safely open up the pool of available organs. That’s so long as donors test negative for blood-borne infections, such as HIV, and hepatitis B and C.</p>
<p>Currently, organs from this and other groups considered high risk are often rejected outright, for fear of transmitting hidden infections to the recipient.</p>
<p>If transplant criteria were based on viral status rather than belonging to a particular group, we estimate this could mean up to 30 more people could receive a transplant a year in NSW alone.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-are-only-some-viruses-transmissible-by-blood-and-how-are-they-actually-spread-75460">Why are only some viruses transmissible by blood and how are they actually spread?</a>
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<h2>Which high-risk groups are usually rejected as donors?</h2>
<p>Many infections can potentially be transmitted as a result of an organ transplant. But this happens <a href="https://www.notifylibrary.org/sites/default/files/UNOS%20DTAC%20rpt.pdf">very rarely</a> due to strict governance, involving careful screening and selection of donors.</p>
<p>Blood-borne viruses, such as hepatitis B, hepatitis C or HIV, are a particular concern, because historically these had the most potential to have devastating consequences for the organ recipient.</p>
<p>Some potential organ donors have behaviours that put them at increased risk of infection. <a href="https://www.tsanz.com.au/TSANZ_Clinical_Guidelines_Version%201.3%5B6986%5D.pdf">National</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3675207/">international guidelines</a> perceive high-risk groups for these viruses to include:</p>
<ul>
<li><p>people who inject illicit drugs</p></li>
<li><p>men who have sex with men</p></li>
<li><p>sex workers</p></li>
<li><p>people who have recently been in jail</p></li>
<li><p>sexual partners of any of these groups, or of people with a blood-borne virus. </p></li>
</ul>
<p>People from these groups are <a href="https://www.tsanz.com.au/TSANZ_Clinical_Guidelines_Version%201.3%5B6986%5D.pdf">often declined</a> as organ donors, even when tests for blood-borne viruses are negative, and sometimes without even being tested.</p>
<p>That’s because of the worry about the risk of the donor being recently infected but that infection not yet showing up in blood tests. This is know as the “window period”. If a window-period infection occurred, people could unwittingly transmit the virus.</p>
<h2>When we used Australian data, here’s what we found</h2>
<p>So how big a risk are we talking about? </p>
<p>Until recently, Australian guidelines have relied on US estimates of risk, although there are important differences in the prevalence of blood borne viruses in the US and elsewhere compared with Australia.</p>
<p>We believed the risk of window-period infection in Australia was likely to be lower, possibly much lower, than was appreciated. So, we were concerned some potential donors might be turned away who could actually have donated safely. </p>
<p>So, we identified data from sources including journal articles, government reports and conference abstracts between Jan 1, 2000 and Feb 14, 2019 to see how common blood-borne viruses were in people with high-risk behaviours in Australia.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/charlie-sheen-and-ten-million-dollars-worth-of-hiv-stigma-50909">Charlie Sheen and ten million dollars worth of HIV stigma</a>
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<p>We found, as expected, men who have sex with men have the highest risk of HIV in Australia. But for each person who tests negative for HIV, the risk of transmitting the virus was around one in 6,500. This is lower than the US estimate, which sits at <a href="https://www.ncbi.nlm.nih.gov/pubmed/21366859">one in 2,500</a>. The difference was more pronounced for injecting drug users in Australia, where one in 50,000 would have a window period infection, compared to one in 2,000 in the US.</p>
<p>The window period risk was higher for hepatitis C. Among the riskiest groups, this was around one in 500, similar to overseas studies. There were no studies overseas to compare to for hepatitis B. We found the risk of a window period infection was at most one in 200 from the riskiest group (although we may being cautious and over-estimating this risk).</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>
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<h2>What does this mean?</h2>
<p>First, we suggest all potential organ donors with high-risk behaviours be assessed with the test that gives the shortest window period, to minimise the chance of missing a recent infection.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/296585/original/file-20191011-188787-1ol4zcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/296585/original/file-20191011-188787-1ol4zcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296585/original/file-20191011-188787-1ol4zcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296585/original/file-20191011-188787-1ol4zcf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296585/original/file-20191011-188787-1ol4zcf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296585/original/file-20191011-188787-1ol4zcf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296585/original/file-20191011-188787-1ol4zcf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296585/original/file-20191011-188787-1ol4zcf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">All potential donors with an increased risk of infection should have blood tests, then their risk of transmission assessed.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/medical-equipment-blood-test-327930539?src=6asbIJsvdt2r3mY2bLXUQg-1-3">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>This means testing for the presence of the virus itself (via DNA or RNA testing) rather than relying on tests that look for markers of infection (serological testing).</p>
<p>For potential donors who test negative, our data can be used to help clinicians put the small risks of infection transmission in context for organ recipients. </p>
<h2>What’s the alternative?</h2>
<p>For most people, an organ transplant is the best treatment for organ failure and can be life-saving. </p>
<p>For people with <a href="https://kidney.org.au/cms_uploads/docs/kha-economic-impact-of-eskd-in-australia-projections-2020.pdf">kidney failure</a>, the alternative is dialysis. But this gives shorter survival, poorer quality of life, and incurs higher costs to the health system than treatment with a kidney transplant. For the heart, liver and lungs, there are no other long-term options; without a transplant, people whose organs fail will eventually die.</p>
<p>But there are not enough organ donors to go round. Around <a href="https://www.anzdata.org.au/anzod/reports/organ-waiting-list/">1,500 Australians</a> are waiting for a transplant.</p>
<p>Even so, the option of receiving a donor organ with even a very small risk of transmitting infection may not seem immediately appealing. But this needs to be balanced against the considerable health consequences of foregoing a transplant and remaining on the waiting list.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/296346/original/file-20191010-188797-1n6jsoi.jpg?ixlib=rb-1.1.0&rect=2%2C1%2C995%2C661&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/296346/original/file-20191010-188797-1n6jsoi.jpg?ixlib=rb-1.1.0&rect=2%2C1%2C995%2C661&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296346/original/file-20191010-188797-1n6jsoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296346/original/file-20191010-188797-1n6jsoi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296346/original/file-20191010-188797-1n6jsoi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296346/original/file-20191010-188797-1n6jsoi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296346/original/file-20191010-188797-1n6jsoi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296346/original/file-20191010-188797-1n6jsoi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">For most people, an organ transplant is the best treatment for organ failure and can be life-saving.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-brings-organ-donation-transplantation-op-1045064908?src=oJ8mad2oFr6KYz17_jTfoQ-1-0">from www.shutterstock.com</a></span>
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</figure>
<p><a href="https://www.anzdata.org.au/report/anzod-annual-report-2019/">In 2018 in Australia</a> there were 554 deceased donors who donated organs to 1,543 transplant recipients. Over the same period, 39 people died while waiting for a transplant, and a further 236 were removed from the waiting list due to ill health.</p>
<p>Even with our newly calculated low risk of transmission, there are ways of minimising the risks further, or with new treatments, curing the viral infections if they are transmitted.</p>
<p>For instance, with HIV, medications could be provided to recipients, to further reduce the risk of transmission. If the recipient develops hepatitis C, there are now drugs that can cure it completely. And, for hepatitis B, many people are now vaccinated, which prevents transmission. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/three-ethical-ways-to-increase-organ-donation-in-australia-42744">Three ethical ways to increase organ donation in Australia</a>
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</em>
</p>
<hr>
<h2>What’s happening internationally?</h2>
<p>Donors at increased risk of blood-borne viruses are used internationally. </p>
<p>In the US, <a href="https://www.cdc.gov/mmwr/volumes/68/wr/mm6803a2.htm">over 25% of organ donors</a> now fit these criteria, mainly due to the opioid epidemic and associated increased deaths from overdose.</p>
<p>This strategy has led to <a href="https://optn.transplant.hrsa.gov/news/unexpected-hcv-donor-derived-transmissions-on-the-rise/">an increase</a> in hepatitis C transmissions from donors to recipients. But hepatitis C can be cured with an <a href="https://annals.org/aim/article-abstract/2696495/twelve-month-outcomes-after-transplant-hepatitis-c-infected-kidneys-uninfected">eight-week course of treatment</a>, even among transplant recipients.</p>
<p>Researchers have also shown an <a href="https://www.ncbi.nlm.nih.gov/pubmed/29116674">increase in survival</a> for patients who accepted kidneys from people at increased risk of viral infection compared to those who opted to remain on the waiting list. </p>
<h2>Does this mean more people could have transplants?</h2>
<p>So could our work make a tangible impact on the number of Australians receiving transplants? </p>
<p>Our preliminary work suggests there could have been up to a <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/nep.12887">5% increase in donors in NSW</a> alone between 2010-2015, if we had accepted donors with risk behaviours but negative test results. There could have been five more donors a year, who can each donate to up to six recipients (so up to 30 additional recipients a year). </p>
<p>Our early results on the risk of infection were recently incorporated into <a href="https://www.tsanz.com.au/TSANZ_Clinical_Guidelines_Version%201.3%5B6986%5D.pdf">national guidelines</a> produced by the Transplantation Society of Australia and New Zealand for organ transplantation. </p>
<p>In Victoria, people waiting for a kidney transplant <a href="https://journals.lww.com/transplantationdirect/Fulltext/2019/04001/Abstracts_of_the_Conference_Connecting_Donation.2.aspx">can now consent</a> to receiving organs with these risks when they are put on the waiting list. </p>
<p>We hope our research sparks discussion among patients and doctors to consider what risks are important to patients, and where their values and preferences lie. Better evidence for decision-making should certainly help.</p><img src="https://counter.theconversation.com/content/124993/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Karen Waller receives funding from the National Health and Medical Research Council (NHMRC).</span></em></p><p class="fine-print"><em><span>Angela Webster receives research funding from Sydney Health Partners, the NHMRC, Kidney Health Australia, and the NSW Ministry of Health.</span></em></p>Organs from gay men or injecting drug users, often rejected for transplants, could safely be used, so long as donors test negative for infections such as HIV, and hepatitis B and C.Karen Waller, PhD candidate, University of SydneyAngela Webster, Professor of Clinical Epidemiology, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1208542019-07-26T09:00:56Z2019-07-26T09:00:56ZThe WHO wants to rid the world of hepatitis by 2030: why it’s a tough ask<figure><img src="https://images.theconversation.com/files/285818/original/file-20190726-43114-15geppk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hepatitis is a major public health burden.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Four years ago the World Health Organisation (WHO) rolled out its <a href="https://www.who.int/hepatitis/strategy2016-2021/ghss-hep/en/">global strategy</a> to eliminate hepatitis by 2030 four years ago. Known as a “silent killer” disease, hepatitis is a viral disease that causes inflammation of the liver. </p>
<p>Hepatitis is a major public health burden. In 2015 the WHO estimated that <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">328 million people</a> globally were living with hepatitis B and C. In the same year there were 1.34 million deaths from viral hepatitis. That’s higher than deaths caused by AIDS and comparable to TB fatalities. It’s the seventh leading cause of death worldwide. In sub-Saharan Africa, hepatitis B is the most common form of the illness. Last year it was reported that <a href="https://www.who.int/news-room/fact-sheets/detail/hepatitis-b">6.1%</a> of the population was infected. </p>
<p>Hepatitis B is spread through infected body fluids. This can either be through sex with an infected partner, at birth from an infected mother to her baby or through direct contact with an infected person’s open wounds or blood. There is also risk from sharing syringes, razors or toothbrushes with infected persons. </p>
<p>The key strategy for managing hepatitis B is prevention by being vaccinated. Hepatitis B is also manageable, through oral anti-viral drugs which in most cases must be taken for life. This is because the treatment, in most people, only leads to the suppression of the virus and not its complete eradication. To prevent its progression, the recommendation is that treatment begins within the first three months of infection. </p>
<p>Many countries in sub-Saharan Africa have made vaccination and post-infection therapy available. But the number of those infected annually and dying from viral hepatitis remains high. </p>
<p>The WHO’s 2030 deadline is feasible. But it may not be achieved because of the prevailing low vaccination coverage in sub-Saharan Africa coupled with <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)32750-8/fulltext">limited healthcare budgets</a> that are unable to make diagnostics and treatment available to all.</p>
<h2>The challenges</h2>
<p>There are different forms of <a href="https://www.who.int/features/qa/76/en/">hepatitis, ranging from A, B, C, D, and E</a>. Each is caused by a different type of virus. Unfortunately, most people who have the most serious forms of the disease – particularly the B and C viruses – are unaware of infection. This allows the infection to spread unchecked, leading to serious damage to the liver. This means that the organ can’t carry out its main function which is to filter blood coming in from the digestive system before directing it to the rest of the body, and detoxification. </p>
<p>Part of the plan calls for the effective prevention of new infections through a universal roll-out of the hepatitis B birth-dose vaccine, ensuring that all children receive their vaccines on time, increased access to affordable diagnostics to identify Hepatitis B-infected individuals, and improve linkages to care and antiviral therapy. </p>
<p>The low prevalence of chronic hepatitis B infection in children younger than 5, estimated at 1.3% in 2015, can be attributed to the widespread use of the hepatitis B vaccine. However, while the health body recorded a 43% birth dose vaccination rate globally in 2017 (against its 50% target by 2020), sub-Saharan Africa still presents a challenge: there, vaccination coverage is at <a href="https://apps.who.int/iris/bitstream/handle/10665/324797/WHO-CDS-HIV-19.7-eng.pdf?ua=1">10%</a>. </p>
<p>But the number of those infected annually and dying from viral hepatitis remains high because there’s a lack of awareness about infection status, the rapid spread of liver disease and limited treatment options, particularly in developing countries. In the developed world, liver transplant is sometimes used as a form of therapy for those at an advanced stage of infection.</p>
<p>There are, however, positive developments. For example, the cost of treatment in the past three years has greatly reduced due to generic manufacturing. This and other initiatives to expand access make affordable diagnostic and treatment services for many more in developing countries a possibility. </p>
<h2>What’s needed</h2>
<p>Many countries have included the global strategy’s initiatives in their national hepatitis elimination plans and stepped activities to ensure prevention through vaccination and making drugs readily available in public health facilities. </p>
<p>In sub-Saharan Africa, Uganda presents a success story of what is possible as one of the first countries in Africa to fund domestic initiatives to eliminate hepatitis. Through community mobilisation and awareness and a free <a href="https://www.afro.who.int/news/uganda-leads-charge-against-viral-hepatitis">hepatitis B screening campaign in 2015</a>, people were screened and those found to be positive can now receive treatment. </p>
<p>The East African country recently convened a regional <a href="https://www.who.int/hepatitis/news-events/first-african-hepatitis-summit/en/">stakeholders’ forum</a> to rally more support towards the prevention and elimination of hepatitis. This was the first such meeting in the WHO’s Africa region. Such gatherings serve to provide avenues for sharing best practices, as seen in Uganda.</p>
<p>But more partnerships and greater domestic and international funding efforts are needed to promote prevention, diagnosis and treating efforts. Public-private partnerships are critical to efforts to eliminate hepatitis, as elsewhere in the health sector. </p>
<p>Given the reduced funding for global health, it is important that governments create opportunities for private-sector investors to support access to diagnostics and treatment. These, together with national vaccination and awareness campaigns with emphasis on hard to reach populations will help to ensure that “no one is left behind”, in the spirit of reaching the 2030 goals.</p>
<p>In addition, there is need for more evidence on existing services, pathways and barriers to access to diagnostics and care. Aggregation of data in-country (at the sub-national and national levels) and integrated testing for HIV and hepatitis (7.4% of people living with HIV are also infected with hepatitis B) should also be rolled out in many more countries.</p><img src="https://counter.theconversation.com/content/120854/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pauline Bakibinga 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>Many countries in sub-Saharan Africa have made vaccination and post-infection therapy available. But the number of those infected annually and dying from viral Hepatitis continues to be high.Pauline Bakibinga, Associate Research Scientist, African Population and Health Research CenterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/970492018-05-23T14:49:02Z2018-05-23T14:49:02ZJaundice in newborns could be an evolutionary safeguard against death from sepsis<figure><img src="https://images.theconversation.com/files/220120/original/file-20180523-51121-18kjdfv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Yellow peril. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/newborn-child-baby-having-treatment-jaundice-624535592?src=fCLtwpRr2ja8PIb7-cm8MA-1-0">Petr Bonek</a></span></figcaption></figure><p>In newborn babies, jaundice is so common as to be termed physiological. It affects around 60% of term babies and around 80% of preterm babies in the first week of their lives. Clinicians need to monitor it carefully and sometimes treat it, since it can lead to conditions like <a href="https://medlineplus.gov/ency/article/007309.htm">acute bilirubin encephalopathy</a> and <a href="https://www.nhs.uk/conditions/jaundice-newborn/complications/">kernicterus</a> that can damage the infant’s brain and cause developmental problems. </p>
<p>But it now looks as though this jaundice is not merely one of the pitfalls of entering the world. <a href="https://www.nature.com/articles/s41598-018-24811-3">New research</a> just published in Scientific Reports, in which we have been involved, suggests that it is one of the gifts of evolution. Humans may develop jaundice as newborns to protect from something even more serious: sepsis. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/220122/original/file-20180523-51121-s8364d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/220122/original/file-20180523-51121-s8364d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/220122/original/file-20180523-51121-s8364d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=654&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220122/original/file-20180523-51121-s8364d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=654&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220122/original/file-20180523-51121-s8364d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=654&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220122/original/file-20180523-51121-s8364d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=822&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220122/original/file-20180523-51121-s8364d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=822&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220122/original/file-20180523-51121-s8364d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=822&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Bilirubin molecule.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/bilirubin-heme-breakdown-product-molecular-model-138171362?src=FcgjidycRAh37V_cRQMYlA-2-3">Molekuul_b</a></span>
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</figure>
<p>When most people think of jaundice, they probably think of yellow skin. This is caused by too much of an orange-yellow pigment known as bilirubin in the blood. Bilirubin is released when old red blood cells are being broken down. </p>
<p>Normally it travels to the liver to be converted into a water-soluble form before being excreted in both faeces and urine, but this process can go awry when there has been some upset to the liver that prevents it doing its job properly. In adults, this can be a sign of <a href="https://www.nhs.uk/conditions/jaundice/">underlying conditions</a> ranging from hepatitis to alcoholic cirrhosis. </p>
<p>With newborns, the situation is slightly different: the body needs to make the transition from fetal to adult blood, but the liver does not yet have the capacity to cope with the bilirubin released in the turnover of red blood cells. The resulting jaundice usually passes uneventfully. </p>
<p>The risk of complications like encephalopathy and kernicterus comes when the bilirubin circulates in high levels for prolonged periods, enabling it to cross the blood-brain barrier and deposit deep within the brain. As a result, neonatologists treat high bilirubin levels with blue and white light phototherapy lamps, which convert the bilirubin into a more water-soluble form – temporarily doing the liver’s job. Complications are <a href="https://www.nice.org.uk/guidance/cg98/update/CG98/documents/appendix-b-health-economics2">now thankfully</a> extremely rare as a result – at least in wealthy countries.</p>
<h2>The unexplained why</h2>
<p>In this lies a mystery: why have humans not evolved to overcome this temporary bilirubin problem? Richard started wondering about this when he was doing his PhD in gut microbiology at the University of Aberdeen, while regularly working on call at the neonatal unit as a registrar at the city’s maternity hospital. </p>
<p>One night he was looking after a baby boy who had <a href="https://www.nhs.uk/conditions/sepsis/">sepsis</a>, which is where the immune system goes into overdrive to protect against infection, potentially leading to severe inflammation, organ failure and death. This baby was profoundly unwell in intensive care, suffering from inflammation and a strikingly high bilirubin count that was only just being controlled with three phototherapy lamps. Usually this kind of difficult jaundice is caused by an immune reaction between mum’s and baby’s blood groups, but not in this case. </p>
<p>Richard began wondering if the bilirubin was directly linked to the infection, and if it was part of the baby’s body’s attempt to clear the sepsis (in this case the baby survived). He started thinking about the problem in evolutionary terms – if jaundice can harm the baby, what benefit does it offer to balance this?</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/220121/original/file-20180523-51105-1nimn9s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/220121/original/file-20180523-51105-1nimn9s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/220121/original/file-20180523-51105-1nimn9s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220121/original/file-20180523-51105-1nimn9s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220121/original/file-20180523-51105-1nimn9s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220121/original/file-20180523-51105-1nimn9s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220121/original/file-20180523-51105-1nimn9s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220121/original/file-20180523-51105-1nimn9s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Jaundiced baby being treated with blue light.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/neonatal-hyperbilirubinemia-newborn-high-bilirubin-under-573576205?src=FcgjidycRAh37V_cRQMYlA-1-31">Happypix</a></span>
</figcaption>
</figure>
<p>Looking at the literature, most people were talking about the fact that bilirubin has <a href="http://pediatrics.aappublications.org/content/113/6/1776.full">antioxidant effects</a> that might counteract <a href="https://www.hindawi.com/journals/omcl/2016/2768365/">oxidative stress</a> caused by birth. But the timing looked unconvincing: when jaundice develops in most babies, the highly oxidant process of being born is usually at least 24 hours in the past. </p>
<p>Thinking about babies in caves in days gone by, with no healthcare and certainly no antibiotics, Richard realised that the biggest threat to their life after surviving delivery would probably be overwhelming sepsis in the first few days – exactly when the bilirubin level rises naturally. Could jaundice be an evolutionary mechanism to protect against this?</p>
<h2>The search begins</h2>
<p>Richard got to work with an 11-strong team at the University of Aberdeen and NHS Grampian, recruiting a willing medical student to spend his summer holiday working with blood plates, bilirubin and bacteria grown originally from neonatal blood cultures taken from septic babies. </p>
<p>Some early signals supporting the hypothesis first emerged in 2009 when the team found that bilirubin seemed to impact the growth of the bacteria that most commonly causes early sepsis in babies, <a href="http://www.ppdictionary.com/bacteria/gpbac/agalactiae.htm">Gram-positive <em>Streptococcus agalactiae</em></a>. With other bacteria implicated in sepsis, the results were mixed: bilirubin also affected some types of <em>Staphylococci</em>, but not Gram-negative <em>Escherichia coli</em>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/220125/original/file-20180523-117628-1rnyme0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/220125/original/file-20180523-117628-1rnyme0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/220125/original/file-20180523-117628-1rnyme0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/220125/original/file-20180523-117628-1rnyme0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/220125/original/file-20180523-117628-1rnyme0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/220125/original/file-20180523-117628-1rnyme0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/220125/original/file-20180523-117628-1rnyme0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/220125/original/file-20180523-117628-1rnyme0.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">Colonies of Streptococcus agalactiae.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/holding-plate-bacterial-colonies-streptococcus-agalactiae-645102790?src=g5dBkb4WEHqkAMK0alT7Lw-1-0">angellodeco</a></span>
</figcaption>
</figure>
<p>It was enough to secure a PhD grant from the Medical Research Council and develop ideas further. This went to Sophie Gibson, who developed a new liquid culture system to test the hypothesis further and look at the direct impact on the bacteria. </p>
<p>The results of this project have <a href="https://www.nature.com/articles/s41598-018-24811-3">just been</a> published. Our team have shown that even modest concentrations of bilirubin reduced by one third the growth of Gram-positive <em>Streptococcus agalactiae</em>. We also showed that bilirubin may alter substrate metabolism in the bacteria. </p>
<p>In short, it looks like the hypothesis is bearing out. We now need to do more work, probably in animal experiments of sepsis. This will enable us to think about whether clinicians should raise the accepted bilirubin threshold for <a href="https://www.sepsis.org/sepsis-and/children/">babies at risk</a> of sepsis – those born prematurely, for example. </p>
<p>It feels like we’re discovering something new about the physiology of newborn babies. It’s the excitement of being a clinician scientist: taking an idea from a real patient into the laboratory and testing then developing it to hopefully help future patients. When newborn babies develop jaundice in future, we’ll still need to treat it carefully. But quite possibly we will also be thankful that it’s protecting them from something potentially life-threatening. </p>
<hr>
<p><em>More on articles about pregnancy and babies, written by researchers:</em></p>
<ul>
<li><em><a href="https://theconversation.com/folic-acid-in-pregnancy-mthfr-gene-explains-why-the-benefits-may-differ-95302?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement">Folic acid in pregnancy – MTHFR gene explains why the benefits may differ</a></em></li>
<li><em><a href="https://theconversation.com/women-need-more-freedom-during-labour-not-a-medicalised-birth-script-to-follow-92079?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement">Women need more freedom during labour, not a medicalised birth script to follow</a></em></li>
<li><em><a href="https://theconversation.com/babies-prefer-the-sounds-of-other-babies-to-the-cooing-of-their-parents-95825?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement">Babies prefer the sounds of other babies to the cooing of their parents</a></em></li>
</ul><img src="https://counter.theconversation.com/content/97049/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Hansen receives funding from the Chief Scientist Office, Scotland; NHS Research Scotland; National Institute for Health Research; Glasgow Children's Hospital Charity; Crohn's in Childhood Research Association; Crohn's and Colitis UK; CORE; British Society of Paediatric Gastroenterology, Hepatology and Nutrition; and the Catherine McEwan Foundation.</span></em></p><p class="fine-print"><em><span>Elaina Collie-Duguid received funding from BBSRC for capital equipment used in this study. </span></em></p><p class="fine-print"><em><span>Georgina Hold received Medical Research Council Funding including the funding for a PhD studentship to Sophie Gibson, who was the first author on this study.</span></em></p>No mother wants their baby to develop jaundice, but it turns out that they should probably be grateful.Richard Hansen, Honorary Clinical Associate Professor, University of GlasgowElaina Collie-Duguid, Manager, Centre for Genome-Enabled Biology & Medicine, University of AberdeenGeorgina Hold, Professor of Gut Microbiology, UNSW SydneyLicensed 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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<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>
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<hr>
<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>
<figure class="align-center ">
<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">
<figcaption>
<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>
</figcaption>
</figure>
<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/772482017-08-06T20:12:36Z2017-08-06T20:12:36ZMan flu is real, but women get more autoimmune diseases and allergies<figure><img src="https://images.theconversation.com/files/174351/original/file-20170619-28752-13fgjzi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women's immune systems mount a significantly stronger response against invaders.</span> <span class="attribution"><span class="source">wavebreakmedia/Shutterstock</span></span></figcaption></figure><p><em>Men and women respond differently to diseases and treatments for biological, social and psychological reasons. In this series on <a href="https://theconversation.com/au/topics/gender-medicine-39178">Gender Medicine</a>, experts explore these differences and the importance of approaching treatment and diagnosis through a gender lens.</em></p>
<hr>
<p>We know that sex hormones drive characteristic male and female traits such as breast enlargement and hip widening in women, or increased muscle mass and growth of facial hair in men. But now we also recognise they have a major impact on the immune system - our body’s inbuilt mechanism that helps fight and protect us against disease. </p>
<p>Research suggests this has an evolutionary basis: survival of the species may mean men are harder hit by viruses, but a woman’s reactive immune system leaves her more susceptible to autoimmune diseases and allergies.</p>
<h2>Viruses see men as weaker</h2>
<p>Men die significantly more often from infectious diseases than women. For instance, men are 1.5 times <a href="https://www.nature.com/articles/ncomms13849">more likely to die</a> from tuberculosis, and <a href="http://www.nejm.org/doi/full/10.1056/NEJMoa023141#t=article">twice as likely to develop Hodgkin’s lymphoma</a> following Epstein–Barr virus (EBV) infection. Men are also <a href="https://www.ncbi.nlm.nih.gov/pubmed/26908748">five times more likely</a> to develop cancer after infection with human papillomavirus (HPV), than women. </p>
<p>This is because women’s immune systems <a href="http://www.nature.com/nri/journal/v16/n10/abs/nri.2016.90.html">mount a stronger response</a> against foreign invaders, particularly viruses. While the male hormone testosterone tends to dampen immune responses, the female hormone oestrogen increases the number of immune cells and the intensity of their response. So women are able to recover more quickly from an infection.</p>
<p>All this may reflect a sneaky evolutionary trick used by viruses to enable their survival. Women have developed multiple mechanisms to transmit infections; mainly through passing bugs from mother to child during gestation or birth, or through breastfeeding. So women are better vessels for viruses.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/176378/original/file-20170630-8218-69xuhy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176378/original/file-20170630-8218-69xuhy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176378/original/file-20170630-8218-69xuhy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176378/original/file-20170630-8218-69xuhy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176378/original/file-20170630-8218-69xuhy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176378/original/file-20170630-8218-69xuhy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176378/original/file-20170630-8218-69xuhy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176378/original/file-20170630-8218-69xuhy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Viruses may have signalled men out as the weaker sex.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/nettsu/4930723793/in/photolist-8vHfpc-7qya7y-5G9zxM-dxJE2Z-2oDy2-dQqL4r-G3bsiR-r3AYqG-6sNPQ-98jgYM-9xG6x3-6hPyJL-drZJV1-8ANF8f-xzyhC-6SmQJL-5D85tk-5CVeXc-5xDCuo-gBPC68-p4Mqsi-hFQiZn-7eFh9U-4UcGzA-5xDuQ9-7ghyXX-5uV6qy-7aUQ3y-6Qh5Y9-5xDvtm-6ir2Hv-EBxjqy-dmWoQW-awzCAe-s1Zok-5w8HcJ-8TQmFT-9eYL6n-8ANF7Y-6iVshX-5xz7oe-8NNM53-9XqHKi-5xDsk1-5xz4Ja-ftPooe-7gvGr3-s9p6Pb-5xDAvN-7sbeHf">Michael Verhoef/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Meanwhile, viruses have singled men out as the weaker sex. While popular culture has come up with the term “man flu”, suggesting men are over-dramatising flu symptoms, <a href="https://www.nature.com/articles/ncomms13849">evidence suggests</a> they may in reality be suffering more due to this dampening down of their immune responses.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/health-check-is-man-flu-real-59909">Health Check: is man flu real?</a>
</strong>
</em>
</p>
<hr>
<p>However, this increased susceptibility of men to infection may not be an advantage for the long-term (over tens of thousands of years) survival of a disease-causing organism (pathogen), if it induces such severe disease that it results in the death of the host. </p>
<p>Pathogens modify themselves so they can be transmitted by women during pregnancy, birth or breast feeding. Because of this, many have adapted to be less aggressive in women allowing wider infection, generally across a population. </p>
<p>However, this feature alone is not likely to be sufficient to ensure the ongoing survival of a virus. The fitness of both sexes is necessary to reproduce long-term and thus provide new hosts for invading pathogens. Thus, the hit to the male sex must somehow be balanced by other advantages to their immune system. </p>
<h2>Autoimmune diseases</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/174372/original/file-20170619-5799-1je6tzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/174372/original/file-20170619-5799-1je6tzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/174372/original/file-20170619-5799-1je6tzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/174372/original/file-20170619-5799-1je6tzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/174372/original/file-20170619-5799-1je6tzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/174372/original/file-20170619-5799-1je6tzr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/174372/original/file-20170619-5799-1je6tzr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/174372/original/file-20170619-5799-1je6tzr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Women are good hosts for viruses.</span>
<span class="attribution"><span class="source">Romanova Anna/Shutterstock</span></span>
</figcaption>
</figure>
<p>The most striking sex differences in the immune system are seen in autoimmune diseases. Autoimmune disease affects about 8% of the population, but 78% of those affected are women. Women are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2527069/">three times more likely</a> than men to develop these types of disease.</p>
<p>Autoimmune diseases occur when the immune system turns on and <a href="http://trove.nla.gov.au/work/14306149?selectedversion=NBD4045379">attacks the body’s own cells or tissues</a>, initiating a chronic cycle that results in damage or destruction of specific organs. These diseases include type 1 diabetes, lupus, rheumatoid arthritis, multiple sclerosis, and up to 80 different diseases that affect systems such as the intestine, bones, joints and nervous systems.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-are-autoimmune-diseases-22577">Explainer: what are autoimmune diseases?</a>
</strong>
</em>
</p>
<hr>
<p>In the case of lupus, the immune system mistakenly attacks the person’s own DNA (the structure that carries a person’s genetic code) causing damage to multiple organs that will lead to weight loss, anemia and eventually heart and kidney failure. Nine out of ten patients with lupus are women and <a href="https://www.allergy.org.au/patients/autoimmunity/systemic-lupus-erythematosus-sle">clinical observations suggest</a> that, again, hormones are the culprits. </p>
<p>These differences of susceptibility between males and females tend to appear after puberty, and flare-ups increase during pregnancy. On the contrary, menopause is associated with a lower disease severity.</p>
<p>Studies have linked oestrogen levels with the exacerbation of lupus. Oestrogens directly act on a <a href="http://www.bloodjournal.org/content/119/2/454.long?sso-checked=true">particular immune cell</a> (called the plasmacytoid dendritic cell) to promote their capacity to secrete inflammatory signals, which exacerbate lupus symptoms. Although these dendritic cells are generally important for fighting viral infections, in the context of lupus and multiple sclerosis, they cause significant harm.</p>
<h2>Hormones and allergies</h2>
<p>One in nine Australians (more than 2.5 million in total) <a href="https://www.nationalasthma.org.au/">suffer from asthma</a> – a disease that causes swelling and narrowing of the airways. This makes it difficult to breathe when we encounter environmental allergens such as pollen. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/174368/original/file-20170619-5774-1wwky00.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/174368/original/file-20170619-5774-1wwky00.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/174368/original/file-20170619-5774-1wwky00.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/174368/original/file-20170619-5774-1wwky00.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/174368/original/file-20170619-5774-1wwky00.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/174368/original/file-20170619-5774-1wwky00.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/174368/original/file-20170619-5774-1wwky00.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/174368/original/file-20170619-5774-1wwky00.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>
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<span class="caption">Twice as many women develop asthma compared to men.</span>
<span class="attribution"><span class="source">Photosmatic/Shutterstock</span></span>
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</figure>
<p>Twice as many women develop asthma compared to men. Interestingly, males are more susceptible to asthma before to the onset of puberty but, after puberty, females are more affected and develop more severe asthma than men. Until now, the reasons for this were not obvious, but hormones were speculated to play a role. </p>
<p>In a recent study, we showed that <a href="http://jem.rupress.org/content/early/2017/05/05/jem.20161807">high levels of testosterone</a> in males protect them against the development of allergic asthma. During puberty, the level of testosterone increases. </p>
<p>Testosterone acts as a potent inhibitor of a recently discovered immune cell called an innate lymphoid cell (ILC2), which accumulates in the lungs and initiates asthma. ILC2 cells release inflammatory signals that drive the swelling and airway narrowing characteristic of asthma when people are exposed to pollen, dust mites, grass or other common allergens. Testosterone reduces the numbers of ILC2 in the lungs of males, while female hormones provide no protective effect.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-kids-grow-out-of-childhood-asthma-61277">Do kids grow out of childhood asthma?</a>
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</em>
</p>
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<p>Immunity and sex are far more intricately linked than we had previously appreciated. More research needs to be done to better understand the triggers involved in the different responses of males and females. But the recent discoveries open the door for tactics to potentially target hormonal pathways or receptors that are preferentially expressed on male or female immune cells.</p>
<hr>
<p><strong><em>Read other articles in the series:</em></strong></p>
<p><em><a href="https://theconversation.com/medicines-gender-revolution-how-women-stopped-being-treated-as-small-men-77171">Medicine’s gender revolution: how women stopped being treated as ‘small men’</a></em></p>
<p><em><a href="https://theconversation.com/women-have-heart-attacks-too-but-their-symptoms-are-often-dismissed-as-something-else-76083">Women have heart attacks too, but their symptoms are often dismissed as something else</a></em></p>
<p><em><a href="https://theconversation.com/biology-is-partly-to-blame-for-high-rates-of-mental-illness-in-women-the-rest-is-social-75700">Biology is partly to blame for high rates of mental illness in women – the rest is social</a></em></p>
<p><em><a href="https://theconversation.com/what-happens-in-the-womb-affects-our-health-as-adults-but-girls-and-boys-respond-differently-76016">What happens in the womb affects our health as adults, but girls and boys respond differently</a></em></p>
<p><em><a href="https://theconversation.com/both-men-and-women-need-strong-bones-but-their-skeletons-grow-differently-across-ages-75915">Both men and women need strong bones, but their skeletons grow differently across ages</a></em></p><img src="https://counter.theconversation.com/content/77248/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nothing to disclose.</span></em></p><p class="fine-print"><em><span>Gabrielle Belz 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>Women have evolved to have stronger immunity than men. But this comes with downsides -
women are more likely to have autoimmune diseases due to their “reactive” immune systems.Gabrielle Belz, Professor, Molecular Immunology, Walter and Eliza Hall InstituteCyril Seillet, Senior research scientist, Walter and Eliza Hall InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817602017-07-31T06:05:17Z2017-07-31T06:05:17ZAustralia leads the world in hepatitis C treatment – what’s behind its success?<figure><img src="https://images.theconversation.com/files/180287/original/file-20170731-15340-1wjpi3b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tens of thousands of Australians have been cured of Hepatitis C since March 2016.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>The Australian government has <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2017-hunt072.htm">listed yet another drug</a> to cure hepatitis C on the Pharmaceutical Benefits Scheme (PBS). The drug Epclusa® – a combination of sofosbuvir 400mg and velpatasvir 100mg – is the first of the <a href="https://theconversation.com/weekly-dose-sofosbuvir-whats-the-price-of-a-hepatitis-c-cure-63208">direct-acting antiviral treatments</a> effective for all types of the disease. It will cost most patients A$38.80, and A$6.30 for concession card holders. Before the PBS listing, the cost exceeded A$20,000.</p>
<p>A number of <a href="http://www.pbs.gov.au/info/healthpro/explanatory-notes/general-statement-hep-c">hepatitis C treatments</a> have been listed on the PBS since March 2016. The government has committed to investing A$1 billion over five years to treat the <a href="http://www.hepatitisaustralia.com/inquiry-facts/">230,000 Australians</a> living with the disease. </p>
<p>Australia is a leading country in the global response to hep C. Since March 2016, around 40,000 people with hep C have <a href="https://kirby.unsw.edu.au/news/chronic-cured-could-australia-be-first-country-world-eliminate-hep-c">had treatment</a>. An estimated 95% of them have been cured.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-sofosbuvir-whats-the-price-of-a-hepatitis-c-cure-63208">Weekly Dose: sofosbuvir – what's the price of a hepatitis C cure?</a>
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<p>The <a href="http://www.who.int/mediacentre/factsheets/fs164/en/">World Health Organisation</a> recently set ambitious goals for the “elimination of hepatitis C as a major public health threat”. These included having 80% of people treated and an 80% reduction in the spread of the virus by 2030. Given there are around 70 million people infected with hep C worldwide, only 20% diagnosed, and no effective vaccine, the task ahead is enormous. </p>
<p>But Australia is impressively heading towards these targets and may present a model for other countries to adopt. A recent <a href="https://kirby.unsw.edu.au/news/chronic-cured-could-australia-be-first-country-world-eliminate-hep-c">report by the Kirby Institute</a> estimated Australia was on track to eliminate hepatitis C by 2026 – four years earlier than the WHO goal.</p>
<h2>Why are we doing this?</h2>
<p>The government has taken such a proactive approach to treating hepatitis C for several reasons. </p>
<p>The first is the large burden of serious liver disease, such as liver cancer and liver failure. A recent report from the <a href="http://www.aihw.gov.au/publication-detail/?id=60129559785">Australian Institute for Health and Welfare</a> showed rates of liver cancer increased five-fold from 1982 to 2013, with hep C the major cause. Nearly <a href="https://liver-cancer.canceraustralia.gov.au/statistics">1,500 Australians died from liver </a> cancer in 2011-2012 and that number could more than double over the coming decade. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/three-charts-on-cancer-rates-in-australia-where-liver-cancer-is-on-the-rise-while-other-types-fall-79572">Three charts on: cancer rates in Australia, where liver cancer is on the rise while other types fall</a>
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<p>Secondly, most people affected with hepatitis C are injecting drug users. Although Australia has led harm-reduction strategies, such as needle syringe programs and access to methadone for people who inject drugs, several thousand <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">new infections continue</a> to occur each year.</p>
<p>A third reason is the appeal of the new direct-acting antiviral treatments themselves, which can cure 95% of people treated and have the capacity to prevent serious liver disease and spread of hep C. By contrast, treatments such as Harvoni (sofosbuvir plus ledipasvir) and Zepatier (grazoprevir plus elbasvir), which were added to the PBS in March 2016 and January 2017 respectively, are highly effective, but only active against one or two of the hep C strains. </p>
<p>The latest treatment, <a href="http://www.pbs.gov.au/info/industry/listing/elements/pbac-meetings/psd/2016-11/sofosbuvir-plus-velpatasvir-psd-november-2016">Epclusa</a>, is one tablet, to be taken daily, which combines two existing drugs – sofosbuvir and velpatasvir. It is highly effective against all six hep C strains, has a treatment duration of around three months and minimal side effects. </p>
<p>Another treatment effective for all the strains – which combines glecaprevir and pibrentasvir – is <a href="https://www.pbs.gov.au/industry/listing/elements/pbac-meetings/agenda/pdf/pbac-meeting-agenda-july-2017.doc">expected to be available</a> in Australia in 2018. Treatment duration will be only two months for patients without advanced liver disease.</p>
<h2>What’s behind Australia’s success?</h2>
<p>Australia has managed to develop a program of unrestricted access to treat people with hepatitis C – all adults with hep C are eligible. Most countries have restricted access to those with more advanced disease. <a href="http://www.journal-of-hepatology.eu/article/S0168-8278(17)30450-6/abstract">Many have denied access</a> to people with ongoing drug and alcohol use.</p>
<p>The key to this universal access was the Australian government’s capacity to negotiate much lower drug prices than in other high-income countries, following strong advocacy from the hepatitis C sector. For instance, Australia paid an estimated <a href="http://www.sciencedirect.com/science/article/pii/S0168827817302064?via%3Dihub">ten-fold lower price per patient</a> treated in 2016 than did Germany.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180289/original/file-20170731-16184-k7iz2h.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>
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<span class="caption">Many countries restrict access to hep C treatment for injecting drug users.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>In December 2015, the government <a href="http://www.health.gov.au/internet/ministers/publishing.nsf/Content/health-mediarel-yr2015-ley154.htm">committed to providing sizeable funding</a> for tackling hepatitis C for five years with a cap in expenditure and no cap in the treatment number. Australia also managed to involve non-specialists in hep C treatment, who from March 2016 were able to prescribe the new treatments. </p>
<p>General practitioners and other non-specialists now write at least <a href="https://kirby.unsw.edu.au/sites/default/files/kirby/report/Monitoring-hep-C-treatment-uptake-in-Australia_Iss7-JUL17.pdf">half of prescriptions</a> for the new antivirals, with around 80% of treatments dispensed in community pharmacies.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-new-hepatitis-c-drugs-could-tackle-liver-cancer-too-73455">How new hepatitis C drugs could tackle liver cancer, too</a>
</strong>
</em>
</p>
<hr>
<p>In <a href="http://www.journal-of-hepatology.eu/article/S0168-8278(17)30450-6/abstract">almost all other countries</a>, treatment of hep C is largely through specialist hospital-based clinics. In many countries only specialists can prescribe. Australia’s history of GP involvement in HIV antiviral treatment and drug dependency treatment was an important foundation to build a concerted hep C education and training program on.</p>
<p>Australia has also reached highly marginalised populations in large numbers. An estimated 20% of <a href="https://kirby.unsw.edu.au/report/australian-nsp-survey-national-data-report-2012-2016">people who inject drugs</a> have access to the new treatments, and numbers treated through the prison system are expanding rapidly. As mentioned, Australia has been a world leader in harm reduction for people who inject drugs (resulting in <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">only 1% being HIV-infected</a>), and has also led the world in evaluating the new treatments in this key population group. </p>
<p>Most Australian jurisdictions are developing programs for new treatment access in drug and alcohol services and prisons. All these measures have provided the optimal framework for taking advantage of the incredible curative potential of the hep C treatments and their capacity to improve quality of life, prevent advanced liver disease, and limit the spread of hep C. </p>
<h2>How to sustain momentum</h2>
<p>A key to ensuring momentum of the initial surge of hep C treatment will be ongoing screening of high-risk populations. These include people with current or past injecting drug use and immigrants from high-prevalence countries, such as Egypt and Pakistan, where unsafe medical procedures have been responsible for most infections. In Australia, around 20% of people with hepatitis C <a href="https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016">remain undiagnosed</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/eliminating-hepatitis-c-an-ambitious-but-achievable-goal-24485">Eliminating hepatitis C – an ambitious but achievable goal</a>
</strong>
</em>
</p>
<hr>
<p>Finally, raising awareness through days like World Hepatitis Day and overcoming the stigma many people with hep C carry will be fundamental to success. The potential of revolutionary hep C treatments to empower the whole sector, together with continued advocacy and government support, should see Australia head towards elimination of the disease over the next decade.</p><img src="https://counter.theconversation.com/content/81760/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Greg Dore consults to Gilead, Merck, Abbvie, and Bristol-Myers Squibb. He receives research funding from NHMRC, National Institutes of Health, Australian Government Department of Health, and NSW Health; Gilead, Merck, Abbvie, and Bristol-Myers Squibb. He is affiliated with Kirby Institute, UNSW Sydney. </span></em></p>Australia has been subsidising drugs to cure hepatitis C since March 2016. Unlike in many other countries, these are available to everyone with the disease and are much cheaper for our government.Gregory Dore, Professor of Medicine, Clinical Researcher and Epidemiologist, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/733772017-03-10T03:07:25Z2017-03-10T03:07:25ZHow hepatitis became a hidden epidemic in Africa<figure><img src="https://images.theconversation.com/files/160237/original/image-20170309-21034-1nv7qgj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Health centre in Sainte Dominique, Dakar, Senegal.</span> <span class="attribution"><a class="source" href="http://www.indigo.ird.fr/en">Jean-Jacques Lemasson/IRD</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>The five strains of viral hepatitis (A, B, C, D and E) affect <a href="http://www.who.int/hepatitis/en/">400 million people</a> around the world. Hepatitis B and C are the most deadly; these <a href="http://www.who.int/hiv/pub/guidelines/hepatitis/en/index.html">infections</a> are blood borne, transmitted mainly through unsafe medical practices or injection drug use.</p>
<p>International awareness has grown following <a href="http://www.hepcoalition.org/?lang=fr">activist mobilisation</a> denouncing the exorbitant prices of new drugs that can cure hepatitis C <a href="https://www.nytimes.com/2014/08/07/upshot/why-the-price-of-sovaldi-is-a-shock-to-the-system.html?_r=0">such as Solvadi, priced at US$1,000 a pill</a>.</p>
<p>Viral hepatitis is a global epidemic with distinct regional patterns. In Europe, hepatitis C is mostly <a href="http://www.emcdda.europa.eu/publications/insights/hepatitis-c-among-drug-users-in-europe">associated with injecting drugs</a> but on the African continent, <a href="https://humanitaire.revues.org/3142">it is a generalised epidemic</a> and a major public health issue.</p>
<p>In <a href="http://www.wpro.who.int/hepatitis/wha67_r6-en.pdf">both 2010 and 2014</a>, the World Health Organisation (WHO) called for action on the diseases and has since produced <a href="http://www.who.int/hepatitis/publications/hepatitis-testing-recommendation-policy/en/">guidelines for testing</a> for hepatitis B and C.</p>
<p>The case of viral hepatitis sheds light on the key challenges faced by health systems in Africa in relation to the prevention of infection, barriers to accessing care and treatments and social and economic equity.</p>
<h2>A deadly epidemic</h2>
<p><a href="http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=10351&Itemid=2593">It is estimated</a> that 100 million people are affected by chronic hepatitis B in Africa, most of whom don’t know they have the infection; 19 million adults have hepatitis C.</p>
<p>Despite a lack of accurate epidemiological data at national levels, various estimations put hepatitis B prevalence at around <a href="http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=10351&Itemid=2593">8-10% of the population</a> in many countries. It is a generalised epidemic, not confined to specific segments of the population or high-risk groups.</p>
<p>This epidemic is even more worrying when we consider how hard it is to get treated – only 1% of chronic carriers can access treatment. When patients test positive for hepatitis they must undergo a series of biological and molecular tests that are, at the moment, unacceptably expensive in Africa.</p>
<p>It costs between €200 and €400 to have a complete pre-therapeutic assessment for hepatitis B or C in Cameroon and around €210 for an assessment for hepatitis B in <a href="http://www.ajtmh.org/content/early/2016/10/20/ajtmh.16-0398.abstract?related-urls=yes&legid=tropmed;ajtmh.16-0398v1">Burkina-Faso</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/159942/original/image-20170308-24187-1dzrw87.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/159942/original/image-20170308-24187-1dzrw87.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159942/original/image-20170308-24187-1dzrw87.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159942/original/image-20170308-24187-1dzrw87.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159942/original/image-20170308-24187-1dzrw87.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159942/original/image-20170308-24187-1dzrw87.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159942/original/image-20170308-24187-1dzrw87.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">Pharmaceuticals, Am Timan market, Chad.</span>
<span class="attribution"><a class="source" href="http://media.msf.org/media/MSF184616.html">Abdoulaye Barry/MSF</a></span>
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<p>After these tests, very few patients make it to the antiretroviral treatments. which are available for HIV patients but not for those affected by hepatitis B. In the case of hepatitis C, a single injection of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3513870/">pegylated interferon</a> can cost as much as €230 in Côte d’Ivoire or Cameroon, and patients need 46 injections minimum.</p>
<p>If a hepatitis patient cannot access regular treatment, they end up hospitalised, affecting entire families both emotionally and financially. The people who die young of the diseases represent the workforce in many countries. As in the early years of AIDS, the shape of Africa’s future is affected by these infections. </p>
<h2>A history of neglect</h2>
<p>And just as the AIDS epidemic <a href="http://onlinelibrary.wiley.com/doi/10.1038/sj.embor.embor856/full">embodied colonial violence</a> and weak health systems, so does viral hepatitis. </p>
<p>In Cameroon, the hepatitis C virus was transmitted through colonial medical campaigns in the late <a href="http://onlinelibrary.wiley.com/doi/10.1002/jmv.20343/abstract">1950s to 1960s</a>. In Ebolowa, it is associated with intravenous treatment of malaria that today’s older people received when they were young; hepatitis C therefore affects more than 50% of people older than 50 in certain regions. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/159945/original/image-20170308-24177-j6nov2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/159945/original/image-20170308-24177-j6nov2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=587&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159945/original/image-20170308-24177-j6nov2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=587&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159945/original/image-20170308-24177-j6nov2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=587&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159945/original/image-20170308-24177-j6nov2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=737&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159945/original/image-20170308-24177-j6nov2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=737&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159945/original/image-20170308-24177-j6nov2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=737&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Group shot of seven Europeans at the opening of the first Mengo Hospital, Uganda, 1897.</span>
<span class="attribution"><a class="source" href="https://upload.wikimedia.org/wikipedia/commons/0/0f/Opening_of_the_first_Mengo_Hospital%2C_Uganda_Wellcome_L0038281.jpg">Wellcome</a></span>
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<p>Transmission of hepatitis C might not be acute <a href="http://linkinghub.elsevier.com/retrieve/pii/S1473309915000055">today</a>, but certain medical procedures do carry the risk of infection. In Cameroon, those who undergo <a href="http://www.who.int/mediacentre/factsheets/fs279/fr/">repeated blood transfusions are at greater risk</a> of contracting HCV, just as health workers, exposed in the workplace.</p>
<p>Viral hepatitis also sheds light on global healthcare priorities. The hepatitis B vaccines arrived late to the African continent: though the extent of hepatitis B and liver cancer were known in the late <a href="http://www.sciencedirect.com/science/article/pii/S0140673681919085">1970s in Senegal</a> and stimulated the development of a vaccine, once manufactured this vaccine was not made accessible in Africa until mid-1990s. Even today, populations are not fully covered by <a href="http://www.sciencedirect.com/science/article/pii/S0264410X08012772">vaccination</a>. </p>
<p>In the 1980s the HIV epidemic obscured the extent of hepatitis. Today, the free antiretroviral drugs provided through the support of <a href="http://www.theglobalfund.org/en/">Global Fund</a> against HIV, TB and malaria are perceived as unfair by many of those affected by hepatitis.</p>
<h2>People’s science</h2>
<p>In the fight against hepatitis, many lessons can be drawn from HIV, as well as from the recent Ebola outbreak. </p>
<p>Massive international interventions cannot just target access to drugs and biomedical interventions. Chances of surviving Ebola were considerably increased when patients could access basic measures, including intensive care and rehydration. </p>
<p>And instead of trying to change people’s behaviour, history shows it is wiser to understand the social, economic and political context of epidemics and to trust local knowledge and experience. In his recent <a href="http://www.irinnews.org/feature/2017/01/26/%E2%80%9Cpeople%E2%80%99s-science%E2%80%9D-how-west-african-communities-fought-ebola-epidemic-and-won?utm_source=IRIN+-+the+inside+story+on+emergencies&utm_campaign=3fcec0be6e-RSS_EMAIL_CAMPAIGN_ENGLISH_AFRICA&utm_medium=email&utm_term=0_d842d98289-3fcec0be6e-29278049">book on Ebola</a>, anthropologist Paul Richards asserts that the epidemic ended not just because of international support, but also thanks to community work, even despite the lack of effective treatment. </p>
<p>Communities responded, and they produced their own science of the disease. They mobilised techniques to protect themselves, for instance by using plastic bags or other materials while attending to their sick loved ones. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/159589/original/image-20170306-20767-16lxweg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/159589/original/image-20170306-20767-16lxweg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159589/original/image-20170306-20767-16lxweg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159589/original/image-20170306-20767-16lxweg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159589/original/image-20170306-20767-16lxweg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159589/original/image-20170306-20767-16lxweg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159589/original/image-20170306-20767-16lxweg.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">Freetown Ebola burial team carefully lowers the corpse of a small child into its grave.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/dfid/22829160875/in/album-72157658576159753/">Simon Davis/Dfid</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
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<p>Today, in places like Cameroon, many physicians, patients and families have similarly developed ways to cope with hepatitis, jaundice or liver pathologies. Their insight and experience should be at the centre of future policies.</p>
<p>Many professionals deplore the <a href="http://www.scirp.org/JOURNAL/PaperInformation.aspx?PaperID=8534">lack of universal protection</a> from hepatitis transmission and the risk of infection in hospitals is high. Health workers are not immunised correctly, and they lack critical equipment such as gloves and sterilising material.</p>
<p>Another efficient way to prevent transmission is to vaccinate for hepatitis at birth instead of starting at six weeks. </p>
<p>There is also an urgent need to address pain management and palliative care as the complications of hepatitis (liver cancer and cirrhosis) can be very debilitating and inhumane experiences, often leading to death.</p>
<h2>Urgent action</h2>
<p>Across the African continent, hepatitis does not today receive the same kind of attention from NGOs and civil society as HIV did in the 2000s. </p>
<p>But other forms of mobilisation are emerging among clinicians, as national professional associations combine scientific and medical work and advocate to their respective governments for <a href="https://devsante.org/articles/conference-internationale-des-acteurs-de-lutte-contre-les-hepatites-en-afrique-francophone-appel-de-dakar">sustained pan-African collaboration</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/159940/original/image-20170308-24198-yd2ctq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/159940/original/image-20170308-24198-yd2ctq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/159940/original/image-20170308-24198-yd2ctq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/159940/original/image-20170308-24198-yd2ctq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/159940/original/image-20170308-24198-yd2ctq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/159940/original/image-20170308-24198-yd2ctq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/159940/original/image-20170308-24198-yd2ctq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Democratic Republic of Congo. Young people are vaccinated to prevent measles, hepatitis and whooping cough.</span>
<span class="attribution"><a class="source" href="http://media.msf.org/media/MSF184692.html">MSF</a></span>
</figcaption>
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<p>Clinicians in Africa and in Europe are also joining forces through scientific and medical cooperation and are calling for action to fight these unacceptable <a href="http://www.journal-of-hepatology.eu/article/S0168-8278(14)00737-5/abstract">global inequalities</a>. Their insights should be combined with strong social support for patients and their families.</p>
<p>The viral hepatitis response also requires urgent infrastructure interventions to ensure access to clean water, hospital hygiene and blood safety. </p>
<p>The WHO Regional Committee for Africa <a href="http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=10223&Itemid=2593">promotes</a> a public health approach that includes vaccination at birth, integration of testing services and linkage to care. </p>
<p>If making drugs available is a priority, it is also imperative to avoid catastrophic health expenses and include diagnostic tests, treatments and follow-up tests in national projects for universal health coverage.</p><img src="https://counter.theconversation.com/content/73377/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fanny Chabrol is affiliated to the European Research Council GlobHealth (<a href="http://globhealth.vjf.cnrs.fr/">http://globhealth.vjf.cnrs.fr/</a>) project.</span></em></p>Viral hepatitis sheds light on key challenges faced by health system in Africa and how social and culture factors can help in prevention.Fanny Chabrol, Postdoctoral fellow in Global health, InsermLicensed as Creative Commons – attribution, no derivatives.