 |
       |
|
|
SHOULD WIDE SPREAD H-PYLORIDIS ERADICATION,HEPATITIS B-VACCINATION AND BLOOD TESTS FOR HIV BE OFFERED ROUTINELY?
OP Kapoor
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
Most of the family physicians are finding it difficult to answer questions raised by the patients who read the health news from newspapers about the harmful effects of H-pyloridis, about the protection offered by the hepatitis B vaccination as well as regarding the dangerous disease of AIDS.
Really speaking, H-pyloridis is proved to be one of the strong aetiological factors in an endoscopically proved, single chronic duodenal ulcer and gastric cancer. Fortunately, the latter is not very common in our country. It will not be safe to keep the patient of gastric cancer under your treatment, once the diagnosis has been made, even if you wish to give him a course to eradicate H-pyloridis. Yes, all the duodenal ulcer patients should be given a course to eradicate H-pyloridis but most of the times the disease relapses because the patient continues to smoke, take tobacco and alcohol and does not change dietary habits.
Apart from these two diseases in clinical practice, H-pyloridis has no role to play and the family physicians cannot be expected to treat all other patients of reflux oesophagitis, non-ulcer dyspepsia and irritable colon which form more than 90% of GI practice for H-pyloridis.
Regarding hepatitis B vaccination - this question will not arise in future because at present, all the paediatricians are advising Hepatitis B vaccine to be included in the programme of vaccination. If this trend continues, in future, there will be very few patients who will suffer from chronic active hepatitis, cirrhosis and cancer of the liver.
What about the adults who have not been vaccinated in childhood? All the paramedical people, technicians working in the laboratories, operation theatres, endoscopy units, dentists, patients on dialysis, wives of patients who are hepatitis B carriers, all doctors and all the people coming in contact, should be vaccinated.
All alcoholic patients who are not likely to give up alcohol can be offered this vaccine because chronic hepatitis in an alcoholic will have a very bad course of illness.
The question arises when patients ask a straight forward question, "Can we take a dose of Hepatitis B vaccine"? There are others who grumble and grudgingly ask, "Why did you not advise hepatitis B vaccination?"
The answer is difficult but the GP should be prepared to explain. Ideally, anybody who is prepared to spend around Rs. 3000/- should be advised to take this vaccine.
Regarding many social organisations who offer very cheap vaccines in order to get sympathy of the public for their votes or other benefits, two things have to be kept in mind. First of all, the reliability of these vaccines. There are a lot of duplicate, fake and ineffective preparations in the market.
Secondly, during these vaccination campaigns, routine blood tests for HBsAg and Anti HBs are not carried out. Patients who have anti HBs positive will not benefit by the vaccination. All other patients who had so-called cheap or free vaccination should be told to get their blood test done for anti HBs after a few months to make sure that they have received effective vaccines.
Of course, no harm is done if the vaccine is given without doing these tests, but then how will you know that the patient already had Anti HBs antibodies and did not require vaccination for which he spends at least some money, besides additional time and money for commuting and standing in the queue.
Vice versa, patients already having HBsAg in the blood should have spent a little amount of money in getting the tests of HBe and Anti HBe and liver function tests done to find out:
1. Are they safe?
2.Are they prone to chronic infection of the liver in future?
3.Do they need active treatment to eradicate the virus?
4.Should their wives or sexual partners be vaccinated after the initial blood test?
Finally, coming to the HIV blood test, ideally if it is done free, the whole population should have HIV test done. A difficult question arises in private practice, when the patient comes for other ailments and illnesses and has already got tension and financial burden then it may not be the right time, to inflict on him an additional psychological burden of showing a positive HIV blood test and can be done after some time.
Also, since an Elisa test for HIV costs around Rs. 300-500/-, and if it is found positive, the patient has to spend an additional Rs. 1500/- (Western blot method) to rule out false positive, which may be found even in a patient suffering from malaria. Thus, the family physicians should ask positively for an HIV test in the following patients:
1.Bachelors
2.College boys and girls
3.Who have promiscuous sexual habits
4.Who have had sexual intercourse with a girl friend (extra marital)
5.Who are homosexual or bisexual
6.Who have received blood transfusion or have undergone surgery specially in small hospitals and nursing homes
7.Having symptoms or signs or abnormal pathological tests where no diagnosis can be thought of and iatrogenic illnesses have been excluded
8.Who have lost weight without any evidence of tuberculosis, diabetes mellitus or thyrotoxicosis
9.All PUO patients
10.All patients of extra Pul. and Pul. Tuberculosis
11.All patients having routine reports of markedly raised ESR
12.All patients coming from out of Bombay (interior and rural areas)
13.All patients who are going for health check up.
As mentioned above this list can become quite long and ideally all affording patients should have an HIV test done whenever they go for other routine pathological blood tests.
The family physicians should know that HIV test does not mean presence of AIDS. The AIDS sets in a couple of years after the blood test becomes positive for HIV. Conversely the HIV test can remain negative during the window period of few weeks after sexual intercourse.
Thus when suspected it should be repeated after a few weeks or a superior blood test like HIV PCR should be asked for, which of course is very costly (more than Rs. 3000/-).
 |