One bottle of blood
A sonography showed a pockmarked shrunken liver typical of cirrhosis. Further tests disclosed she was positive for Hepatitis C. That single bottle of blood had transmitted it. It was just a single transfusion, likely not needed, which almost sealed Sunanda’s fate.
Sanjay Nagral
Oct 9, 2020, Mumbai Mirror
Sunanda is now like any homemaker who looks after her grandchildren at her Navi Mumbai home. At a rather young age of 32, she underwent surgery for removal of a uterine fibroid. During this surgery she was transfused one bottle of blood. In her late 40s, she noticed swelling in her feet. She ignored it at first, but soon started feeling abnormally fatigued. Blood tests revealed low platelets and abnormal liver function. A sonography showed a pockmarked shrunken liver typical of cirrhosis. Further tests disclosed she was positive for Hepatitis C. That single bottle of blood had transmitted it. Typical of this virus, there were no immediate symptoms but delayed liver damage after many years. And typical of many patients, it was just a single transfusion, likely not needed, which almost sealed Sunanda’s fate.
Sunanda is not alone. Thousands of unsuspecting individuals all over the world were infected with Hepatitis C before the 1990s due to infected blood and blood products. It was a time when the focus was on Hepatitis B virus which had been described in 1965. Before that the Hepatitis A virus was identified; it causes typical jaundice outbreaks through food and water. Now we know that such outbreaks in adults are more often caused by another virus labelled Hepatitis E. For years before the Hepatitis C virus was identified, it was called ‘non-A non-B hepatitis’. ‘D’ is a rare virus which only coexists with the B virus. The propensity of the ABCDE viruses for the liver is indeed intriguing.
The spread of the C virus is very similar to HIV. Sometimes they infect together.
Contaminated blood, sexual transmission and shared injections, especially amongst drug pushers, are common routes. In India, Punjab and the North East have seen high prevalence rates likely related to substance abuse. It is estimated that there are around six to eight million patients in India, a majority of them asymptomatic. India started testing blood bottles for Hepatitis C in 2000, around eight years after western countries. Hepatitis C is dangerous not only because it causes cirrhosis but also a high chance of liver cancer.
One of the early Hepatitis C patients in India was the lawyer Rani Jethmalani. She had received blood for sudden haemorrhage in a Mumbai Hospital. By the mid-1990s she was terminally ill with cirrhosis. At a time when it was not available in India, only the powerful and wealthy could travel abroad for a liver transplant. When I was training in a London Hospital, Rani was one of the very few patients from overseas transplanted with a cadaveric liver. I remember her as a feisty patient even as she recovered from a humongous operation. She resumed practice in the Supreme Court but passed away in 2011.
When Sunanda consulted us in 2012, she was on a costly, toxic injection called Interferon which at that time was the only treatment for the C virus. Like a majority of patients, she was showing a poor response. Soon she was a candidate for liver transplantation. She was lucky that within six months of being on the waiting list she got a liver from a young accident victim. I remember travelling in an ambulance on a very rainy night after removing the liver from the donor, worried that we may not make it in time to transplant it. We did and Sunanda improved with her new liver. Her son got married and a beaming Sunanda received us at his reception.
She tested positive for Hepatitis C again in 2015. This is not uncommon after a transplant but may not affect liver function. Sunanda was twice lucky. Around this time, several new drugs with dramatic efficacy against the C virus were found. Almost 95 per cent of patients now get cured. The drugs were originally priced astronomically. Like in other diseases, there was a battle by global groups against patent laws that increased costs. Indian companies also got into their manufacture, making them cheaper and accessible to all patients. It was a repeat of the HIV drugs struggle.
Unlike Hepatitis B, which has been subdued by an effective vaccine, there is as yet no vaccine for C. The availability of effective oral drugs may slow down research in this area. Effective testing of transfused blood, interventions in substance abuse and a national programme, which offers free medicines, are making a dent in India. But of course, one of the lessons we may yet need to learn is the danger of using blood and products casually. Practices like “Give one blood so that the wound heals faster”, or “Give platelets to the dengue patient because they have fallen below 30,000” needs to change.
The 2020 Nobel Prize in Medicine was awarded this week jointly to Harvey Alter, Michael Houghton and Charles Rice for the discovery of Hepatitis C virus. One wonders why the Nobel Committee chose to honour them after so many years. Maybe it’s to serve as a reminder about the world’s collective taming of a killer virus. And highlight rigorous collaborative science, public health measures and improved access to treatment. Sunanda, of course, reminds us to avoid ‘one bottle of blood’.