Kerala steps up fight against Hepatitis A, turns to ‘PLEX’ as cases pile up

With 119 confirmed cases and 367 suspected cases reported in June alone, and a total of 20 fatalities this year, authorities are taking a multi-pronged approach.

ByDileep V Kumar

Published Jun 09, 2024 | 8:00 AM Updated Jun 09, 2024 | 3:17 PM

Kerala steps up fight against Hepatitis A, turns to ‘PLEX’ as cases pile up

Stepping up its fight against the ongoing Hepatitis A outbreak, the Kerala Health Department is set to implement a new treatment strategy for severe cases.

With 119 confirmed cases and 367 suspected cases reported in June alone, and a total of 20 fatalities this year, authorities are taking a multi-pronged approach.

On 7 June, 19 new confirmed cases were reported across the state.

In response, the department has announced the introduction of Plasma Exchange (PLEX) therapy for patients with severe Hepatitis A. This follows the development of a Standard Operating Procedure (SOP) for the treatment.

PLEX therapy involves removing infected blood plasma and replacing it with healthy plasma. Recent studies have shown promise, said the department in the SOP, indicating an increase in survival rates for patients with acute liver failure after undergoing PLEX.

While the exact cause of the outbreak is still under investigation, the department emphasized the importance of good hygiene practices, which includes proper sanitation, handwashing, and consuming clean water

The authorities also urged people to be vigilant.

Also read:Mutation worries add to Hepatitis-A woes of Kerala

Spectrum of acute hepatitis A, available treatments

As per the SOP, acute hepatitis A(HAV) infection can be acute hepatitis, acute liver injury, acute liver failure (ALF), and acute-on-chronic liver failure (ACLF).

While patients with uncomplicated HAV do not die, deaths are seen in patients with HAV-induced severe acute liver injury. Death rate further increases in patients with acute liver failure.

Quoting a study from Kolkata, where, 3 of 33 patients hospitalized with severe acute liver injury due to HAV progressed to ALF and one of the three patients died, it has been pointed out that about 10 percent of patients with HAV-induced severe acute liver injury will progress to ALF.

It also warns that more severe illness may be seen in pregnant women, older age, patients with cirrhosis, and patients on immunosuppressive medications.

Though effective anti-viral medicines are not available at present to treat hepatitis A, sedative drugs and urgent liver transplantation are the other options.

However, the use of sedative drugs in patients with acute liver dysfunction might lead to cerebral edema, a serious condition that causes fluid to build up in the brain and increase the pressure inside the skull.

Also read: Kerala ‘One Health’ approach for unified public health solutions

Choosing PLEX

Referring to various studies, the SOP stated that there is an increase in survival among the patients with ALF, after treatment with PLEX.

It also pointed out that based on the volume of plasma exchanged during each session, PLEX for ALF can be classified into high volume, standard volume, and low volume.

“PLEX may be used both as a stand-alone treatment and as a bridge to liver transplantation in patients with viral hepatitis-induced ALF. It may also be used to treat patients with underlying chronic liver disease or cirrhosis,” read an excerpt from the SOP.

“The efficacy or the survival benefit of PLEX to treat patients with ALF may be superior to that in patients with acute on chronic liver failure,” it said.

At the same time, the conditions for introducing PLEX among patients with acute liver injury and acute liver failure have been taken from the Indian Society of Gastroenterology’s Tamil Nadu chapter.

It rolled out the guidelines for the management of rodenticidal hepatotoxicity (liver damage caused by the ingestion of rodenticides – substances used to kill rodents).

The SOP is of the assessment that early institution of PLEX in patients meeting criteria, as laid out in the guideline, may favourably alter the course of the illness in patients with severe acute liver injury or acute liver failure.

Meanwhile, practitioners were asked not to go with PLEX among patients with hemodynamic instability (a condition or state in which a person’s cardiovascular functions become unreliable, insufficient, or otherwise problematic due to an underlying condition, such as high blood pressure) and active sepsis.

At the same time, among pregnant women and children, PLEX can be introduced to treat acute hepatitis A.

It has been mandated that informed consent will have to be obtained from patients or their kin, who opt for PLEX treatment after counselling about all the treatment options.

Also Read: Kerala govt issues guidelines on preventing rabies infection in school children

What do studies say?

Earlier, in an article titled ‘Growing Evidence for Survival Benefit with Plasma Exchange to Treat Liver Failure’ published in the Journal of Clinical and Experimental Hepatology in 2023, it was pointed out that the accruing data suggest a survival benefit with PLEX compared with standard medical treatment to treat ALF and ACLF patients, in randomized controlled trials done world-over.

It also highlighted that most matched cohort studies done from India which recruited patients with a specific etiology of ALF or ACLF report survival benefit with PLEX compared to standard medical treatment.

The survival benefit with PLEX appears more pronounced in ALF patients rather than in ACLF patients.

The article was written by a group of doctors belonging to the Departments of Hepatology and Transfusion Medicine and Immunohematology, at Christian Medical College in Vellore, Tamil Nadu.

(Edited by Shauqueen Mizaj)