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In China, Hepatitis B Virus and Hepatitis C Virus - viral diseases that inflict severe liver disease and inflammation - have caused high morbidity and mortality rates. (OnHealth, 2019; WHO, 2019). HBV and HCV are commonly referred to as ticking time bombs: an early exposure commonly causes acute infection with flu-like symptoms and, or no symptoms in a patient; in fact, clinical tests may yield normal results making HBV and HCV difficult to detect, leading to their success as pathogens (Natap, 2007). Consequently, in the event of absence of long-term medical treatment, symptoms will begin surfacing, and the disease will be difficult to cure during the late stages can which involve chronic fibrosis (scarring) and liver cancer (MC, 2017). In China, HBV and HCV infection are highly prevalent among all individuals: babies, children, teens, adults, and seniors - no one is safe (WHO, 2019). The underlying forces which contribute towards the acceleration of HBV and HCV in mainland China are underdeveloped economies, lack of access to sufficient medical treatment, antiviral resistance among agents, lack of knowledge among healthcare workers on HBV mother to child transmission, a shortage of vaccines and viable treatments for both HBV and HCV,  use of unsterilized needles in methods of acupunctures and needle-injections, uneducated drug-injecting and needle-sharing users in rural regions, lack awareness on blood-safety, and lack of medical screening equipment.  

Historically, HBV and HCV have emerged and re-emerged as a global plague since the evolution of mankind. Initial accounts of jaundice, a symptom of hepatitis, first were reported circa 3,000 BCE on Sumerian clay tablets. In their cultural lens, the Sumerians believed the liver was the home of the soul bringing them to believe that the factor for liver damage was from a devil named Ahhazu (Trepo, 2013). In Classical Greece circa 400 BCE, Hippocrates documented the first epidemic of jaundice in Europe as being an imbalance of the four humors, noting: “The bile contained in the liver is full of phlegm and blood, and erupts. After such an eruption, the patient soon raves, becomes angry, talks nonsense and barks like a dog.” (Ginsau, 2019.) In the early to mid-1800s to the1940s, specifically during the Napoleonic Wars, the American Revolutionary War, and both World Wars I & II, viral hepatitis had contributed as an infectious catalyst among foot soldiers (Thomas, 2013). During World War II it has been estimated that an excess of 10,000,000 soldiers were critically infected from hepatitis (Thomas, 2013). Here, through repeated history, hepatitis appears as a formidable infection which emerges and re-emerges globally at a continuous rate. Consequently, The Centers for Disease Control and Prevention (CDC) estimated an excess of 257,000,000 people living with chronic HBV and 71,000,000 million people living with chronic HCV worldwide. Likewise, one-third of those infections reside in China - the primary epicenter for HBV and HCV morbidity and mortality, which first erupted in 1992. (CDC, 2019). 

In a seroepidemiological report, HBV infection was identified in China around 1992 when it was found to afflict more than 120,000,000 individuals (Yan, 2014). Infection rating exceeded 60% and the prevalence of HBV surface antigen (HBsAg) carriers was 9.8%. Similarly, the overall prevalence of anti-HCV antibodies was at 3.2% among 66,975 subjects from 30 provinces. In recent years, mainland China has gone from being a highly endemic area for HBV and HCV infection to an intermediate endemic area due to governmental awareness and stringent administration of screening of blood donors and blood-related products (Xu, 2015; Yan, 2014). In fact, the overall prevalence of anti-HCV antibodies decreased significantly, from the initial 3.2% in 1992, to 0.43% in 2006, among people aged 1–59 years - an indication that there were approximately 5,600,000 people infected with HCV. Similarly, WHO reported that HBsAg prevalence declined as well among people aged 1–59 years, from a rating of 9.8% in 1992, to 7.2% in 2006; prevalence in people aged 1–29 years declined from 10.1% in 1992 to 5.5% in 2006 and from 5.5% in 2006 to 2.6% in 2014 (WHO, 2019). However, despite efforts in declining the prevalence of HBV and HCV infection, mainland China continues to suffer from its inability to effectively eliminate or address factors for transmission that influence high rates of morbidity and mortality. Specifically, these factors include the existence of underdeveloped rural regions which lack awareness and formal education on the various routes of transmission for both HBV and HCV, high costs of medical treatment, the absence of medical screening equipment, and a shortage of vaccines and viable treatments for HBV and HCV. Here, these factors impose challenges for maintaining control over HBV and HCV particularly because the successful pathogen is asymptomatic in the short-term but mutates into a chronic form  associated with chronic fibrosis (scarring of liver), liver carcinoma, and antiviral resistance though evading detection (Yan, 2014). In WHO reports, the approximate mortality rate for HBV-cirrhosis declined from 7.45% in 1990 per 100,000 people to 5.82% in 2016, whereas incidence of HBV-carcinoma increased from 12.88% in 1992 per 100,000 people to 16.42% in 2016 (WHO, 2019). In addition, WHO estimated an excess of 130,000,000 HBV and HCV carriers, 30,000,000 chronically infected, and 300,000 HBV and HCV-related deaths annually + 180,000 with HBV-liver cancer; this accounts for nearly 30% of the total global mortality (WHO, 2019; Liu, 2007). Therefore, immediate infection controls must be set as a priority for the Chinese government in order to effectively eliminate the factors for transmission associated with continuing high HBV and HCV morbidity and mortality.  

In rural regions of China, an underdeveloped economy coupled with the lack of access to sufficient medical treatment/resources has influenced the increasing rates of morbidity and mortality. Through semi-structured interviews, Wallace et al. (2017) claimed that China experiences the highest HBV-related liver cancer incidence in the world, which accounts for roughly 55% of global liver cancer deaths. However, only 19% of those chronic HBV patients have ever accessed medical treatment (Wallace, 2017). HBV has been described as an economically catastrophic illness as the direct costs of chronic HBV exceed 40% of household annual incomes in developed areas of China (Wallace, 2017). Likewise, developed areas have the added luxury having more immediate access to treatment as the majority of specialists are located in major cities (Wallace, 2017). Unfortunately, this poses a burden for undeveloped rural areas in China, as less than 5% of patients can afford treatment for a single year; thereby setting financial worry (Wallace, 2017). In fact, a survey in Shanghai showed that annual medical costs for patients with chronic HBV was $3,000, while the per capita Gross Domestic Product at that time was only around $1,000 per annum (Wallace, 2017). Consequently, these economic struggles often require families to relocate into the larger, more developed cities in order to access medical treatment. For example, one male participant stated: “My whole family had the same disease, the financial pressure was unbearable. My wife had to take medication, I had to take medication, and my daughter had to take medication” (Wallace, 2017). Here, this example highlights how an undeveloped economy, specifically in rural settings, instigates the inequalities experienced by impoverished individuals with chronic HBV. The lack of financial backing among these individuals means that families cannot get medically diagnosed or treated, which forces families to not seek the urgent treatment required because it would   send them into deeper financial hardship. However, this negligence treatment ultimately allows for chronic mutations to develop and, or antiviral resistance, which further increases overall morbidity and mortality. Overall, governmental efforts to offer medical and financial aid to families that cannot afford the expensive costs of treatment is urgently needed as this will lower the cases of chronic and non-chronic HBV mortality. 

In China, antiviral resistance against nucleoside analogues (NA) in HBV patients has compounded the difficulty in stabilizing the increasing mortality. NAs, namely lamivudine (LAM), adefovir (ADV), entecavir (ETV), and telbivudine (LDT) have therapeutic effects against chronic HBV infection by suppressing HBV replication mainly by restraining the reverse transcriptase (RT), which leads to improved liver function and reduces incidences of fibrosis, cirrhosis, and hepatocellular carcinoma (Liang, 2015). However, in recent studies, long-term use of NA therapy has been associated with antiviral resistance. For example, Liang et al. (Liang, 2015) noted that LAM resistance develops in 70%-80% of patients after 5 years of treatment, whereas ADV resistance develops in 30% of patients after 5 years (Liang, 2015). Here, the evidence suggests that antiviral resistance creates a major obstacle as the uncontrollable HBV replication ultimately leads to chronic mutations in the long-term. Therefore, in order to mitigate antiviral resistance, it is paramount to monitor the effects of the nucleoside analog therapy and also to begin developing new agents and more effective treatment against HBV. 

In China, mother-to-child transmission (MTCT) is the most common mode of HBV transmission as 39% of those chronically HBV infected are childbearing women, according to WHO (WHO, 2019). Likewise, the Chinese government established a childhood vaccination program for HBV in 1985 which resulted in a monumental success, cutting the rate of HBV transmission from mothers to children by 97% within just 20 years (WHO, 2016). However, despite the achievement, 50,000 infants are born with HBV annually, and 21% of all HBV-related deaths are due to HBV MTCT (WHO, 2019). Therefore, WHO expressed that the overall need for HBV treatment is huge, estimating that only 16,000,000 people with chronic HBV infection are diagnosed and that only 2,800,000 are receiving treatment (WHO, 2019), while less than 1 in 50 people with HCV are receiving moderate treatment (WHO, 2016). In addition, it is important to note that a vaccine capable of protecting against HCV is not available, whereas it exists for HBV (CDC, 2019). Nevertheless, neither HBV and HCV are curable, but they can be moderately treated if adequate resources are available (CDC, 2019).  Unfortunately, the absence of sufficient resources prevents a way of protecting individuals from infection, which allows the infection to rapidly mutate, thereby influencing the high rates of morbidity and mortality. Thus, it is critical that the Chinese government invests their money in order to produce more resources needed to treat people with HBV and HCV, while also investigating ways to create a vaccine for HCV.  

In China, the high rates of morbidity and mortality of HBV MTCT are also attributed to knowledge gaps among healthcare workers. Many lack the fundamental understanding of the various transmission-routes of HBV and how to effectively prevent it (Chen, 2015). The prevention of HBV MTCT is essential towards controlling the epidemic; however, progress towards the goal cannot be accomplished if the goal healthcare workers - those in the front-line of this battle, who are responsible for aiding patients, -lack the comprehensive knowledge on HBV MTCT. In a semi-structured interview, Chen et al. (Chen, 2015) investigated the knowledge of HBV-MTCT among health-care workers through a questionnaire asking the workers about the practices for preventing HBV MTCT, about their awareness of the resources of preventing HBV MTCT, and about HBV MTCT prognosis. From the 503 healthcare workers, it was discovered that in the Guangdong Province of China, an HBV endemic area, the majority of the participants knew the risk factors for HBV MTCT (Chen, 2015). However, approximately 31.6% did not know that high HBV DNA levels better predict HBV MTCT than HBeAg or HBsAg; 24.7% did not know that the HBV vaccine could decrease the risk of HBV infection in the newborn;48.0% did not believe that a child of an HBV-positive mother is at risk of acquiring HBV throughout childhood; 7.8% did not know  that not all HBV-infected mothers have symptoms, clinical signs or elevated liver enzymes; 10% of the respondents did not know that chronic HBV infection’s lead to cirrhosis or cancer; more than 10% were unaware that an individual can be co-infected with both HBV and HIV; and of the participants, 25.6% did not know that babies infected perinatally are at high risk for chronic HBV complications (Chen, 2015). Here, based on the total knowledge scores, it is evident that there is a need for improving education and training among uneducated health-care workers in the subject of HBV MTCT. Further negligence of HBV MTCT training would ultimately cause poor practices to continue as care for the patients and monitoring disease would not be addressed efficiently.; there would be a deficit of monitoring HBV-infected women and their new-born infants, which effectively allows the HBV pathogen to develop into the chronic stages and cause a higher mortality. 

Similarly, uneducated physicians who use unsterilized medical equipment for acupunctures and needle-injection, coupled with uneducated drug-injection by needle-sharing users in rural regions of China, influence the increasing rates of HBV and HCV morbidity and mortality (Clayton, 1993; Xu, 2015). HBV and HCV transmission occurs when a contaminated, unclean needle from an infected individual is re-used by another person (Avert, 2019). In China, needle sharing is difficult as it is regarded to be a socially acceptable practice in certain poorer, uneducated, and or underdeveloped provinces, , whereas in an economically stable province, it is considered a taboo rather than a norm (Avert, 2019). In Chinese culture, the notion of sharing items with peers is believed to facilitate social bonding; therefore, through their lens, it is a positive deed to share needles (Avert, 2019). However, this cultural practice has consequently become the powder-keg for overall HBV and HCV transmission across provinces in China. Therefore, it is critical that HBV and HCV educational intervention brings awareness in order to mitigate transmission.  

In the People’s Republic of China, the use of unsterilized medical equipment for acupuncture and needle-injections by physicians remains as major factors that influence the high rates of morbidity and mortality of HBV. A study conducted by Clayton et al. (1993) investigated village doctors’ sterilization practices of needles. To do this, the researchers contacted the head doctor from each village health station in a rural county and asked them to complete a self-administered questionnaire (Clayton, 1993). From the 260 participants, 98.1% reported never using the same needle twice without sterilizing it (Clayton, 1993). However, it was later discovered that only 23.5% were able to adhere to the national guidelines of “one person, one needle and syringe” (Clayton, 1993), indicating that parts of both the needles and syringes were not sterilized to high enough standards. In terms of methods for sterilization, the national guidelines suggest using glutaraldehyde: a disinfectant, used to sterilize surgical instruments (Clayton, 1993; CDC, 2019). However, despite the suggestions, 91.4% of the doctors sterilized needles with alcohol; this has been proven to be unreliable in destroying HBV (Clayton, 1993). Similarly, 59.6% reported sterilizing needles with pressure cookers - a technique which effectively kills microorganisms under high temperatures (Clayton, 1993). 38.5% reported boiling their needles, 4.2% boiling needles for a sufficient length of time (5 – 15 minutes), and 1.5% washing needles with boiling water; this technique generally does not completely sterilize a needle either (Clayton, 1993). From all the participants, only one doctor reported using chemicals that have been deemed effective for sterilization (Clayton, 1993). Here, the data indicates that only 8.6% of the doctors conformed to the national guidelines, which suggests that a constant use and reuse of unsterilized needles will greatly increase the rates of contracting or transmitting HBV among the general population. In part, it will also increase mortality rates as the pathogen will mutate undetectability in the long-term, which effectively making it considerably more difficult to treat in underdeveloped rural regions because the impoverished individuals cannot viably afford the burden of the medical costs. Therefore, developing and implementing stricter educational interventions which model direct steps and measures on how to effectively sterilize needles for an ethical and efficient use in medical settings will be important for mitigating the increasing rates of morbidity and mortality of HBV.  

From a pilot survey investigating 11 villages, Xu et al. (Xu, 2015) confirmed that the Heben Province was plagued with HCV and HBV infections from the widely accepted practices of drug-injecting and needle-sharing, which sparked the prevalent issue of drug-abuse. From the 852 participants, there were 379 (44.5%) men and 473 (55.5%) women (Xu, 2015). In respects to drug-usage, 425 participants (49.9%) admitted to drug-injecting and needle-sharing at least once, 147 admitted to injecting and sharing at least 1-10 times, 141 admitted to injecting and sharing 10-29 times, and 137 admitted to injecting and sharing >30 times (Xu, 2015). Consequently, 98.2% of the needle-sharing participants aged >40 years tested positive for HCV RNA (Xu, 2015). The overall prevalence was 37.1% for anti-HCV among the participants, 26.6% for HCV RNA, 67.7% for anti-HBc, 10.7% for HBsAg, and 30.0% for HCV/HBV-coinfection, all of which are suggestive of the sharing of used needles (Xu, 2015). Here, the data suggests that HCV and HBV infection was heavily influenced by uneducated participants engaging in unsafe, drug-injecting and needle-sharing activities. In regard to the demographics, the HCV and HBV infection prevalence was significantly higher among men aged >40 than women (70.4% vs. 29.6%) as the activities of injection were more frequent.  Perhaps this was because the men went out to socialize, while the women held domestic roles at home. Furthermore, HCV and HBV prevalence were significantly higher in those aged >40 (41.8%) compared to those aged <40 years (8.3%) (Xu, 2015).  

The lack of awareness or education regarding safe-injecting instigated from the underdeveloped settings has propelled the common practice of drug-injecting and needle-sharing. In effect, it has become the primary causative factor of high morbidity and mortality rates of both HCV and HBV, as these practices sprawled high rates of anti-HCV, HCV RNA, anti-HBc, HBsAg, and HCV/HBV-coinfection among the participants in the small rural villages. Therefore, in order to mitigate the forces contributing towards HCV and HBV transmission, educational programs need to be established in these underdeveloped rural settings to formally expose the ramifications underlying their cultural practice as contributing towards infection. If this method does not work, perhaps the Chinese government can prohibit, or set fines for drug-injecting and needle-sharing, although hopefully this would not be necessary.  

The lack of a comprehensive education among blood donors, and the lack of sufficient medical equipment, both influence the increasing rates of transfusion-transmitted infections (TTIs) - pathogens that are transmitted by infected blood donations to recipients (Liu, 2017). TTIs are a major threat to the general population of China because the lack of knowledge about HBV-infection casts a barrier for individuals towards getting a proper diagnosis and towards needed medical care (Liu, 2017). Similarly, the lack of sufficient medical equipment, notability of a blood donor screener called Nucleic Acid Amplification Testing (NAT) -a tool which detects viruses or bacteria that act as pathogens in human blood, tissue, and urine -, poses health complications as poorer regions of China cannot get properly diagnosed in a timely manner before HBV becomes chronic and incurable (CBS, 2020). Therefore, these combined forces label blood centers as hotspots for HBV-infection.  

In a blood donor HBV-related study, Liu et al. (Liu, 2017) investigated the demographic characteristics of blood donors, as well as the prevalence, incidence, and residual risk (RR) of TT-HBV infections in six large blood centers: Hefei, Dalian, Changzhi, Kaifeng, Muanyang and Fujian (Liu, 2017). From the 558,089 collected donor samples, 1664 samples were found to be HBsAg reactive, and 578 samples were found to be HBsAg positive (Liu, 2017). In total, the seroprevalence of HBsAg from the aforementioned blood centers was estimated to be 0.13% in Hefei, 0.078% in Dalian, 0.16% in Changzhi, 0.07% in Kaifeng, 0.20% in Mianyang, and 0.25% at Fujian (Liu, 2017). The Changzhi Blood Center had the highest uneducated rates: 91.94% received an associate’s degree, a high school diploma, or below, whereas the Dalian Blood Center had an uneducated rate of  56.68% (Liu, 2017.) In addition, Changzhi had the most repeat blood donors, reaching 67.57% (Liu, 2017). Here, the high prevalence of HBV-infection in the proportion of donors in Changzhi Blood Center suggests that the elevated rates of infection are due to having low levels of TTI knowledge. In addition, the overall residual risk of TT-HBV is still high as the lack of screening equipment in blood-centers hinders from exposing the unknowingly infected repeating-blood donors. In order to improve safety of blood donations, this will require more medical screening equipment to stringently monitor blood donors as it identifies underlying health conditions in blood-donors, thereby mitigating risk of TT-HBV. In part, additional educational blood-safety videos  that address TT-HBV should be shown more regularly to increase awareness when donating blood.  

In mainland China, Hepatitis B & C are major health problems, constituting an enormous burden onto those infected. China has been making considerable progress on reducing HBV and HCV incidence in the past three decades; however, the country still faces challenges to reduce the growing morbidity and mortality from the chronic mutations.  These challenges include educating people in underdeveloped rural regions which lack awareness and formal education on the various routes of transmission for both HBV and HCV, addressing or overcoming high costs of medical treatment, more effectively screening for HBV and HCV and providing more  medical screening equipment since it is currently limited, and providing vaccines  and more viable treatments for HBV and HCV. Therefore, the Chinese government needs to impose promotions on education on transmission and blood and injection safety; improve diagnostics and treatment abilities of healthcare workers while also supplying sufficient screening equipment; provide cost-affordable treatment for impoverished individuals in rural settings; improve methods of sanitation and sterilization of needles by enforcing more rigid national guidelines for doctors; enable drug-injecting restrictions and needle-sharing in rural settings, and create alternative HBV and HCV treatments if HBV and HCV infection is to effectively be stopped. 

Work Cited

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