Newsday - November 2, 1997
Laurie Garrett - Staff Correspondent

Of the seven major types of hepatitis virus, three are known to be wildly out of control in the region already: A, B and C. And the lack of testing equipment and expertise makes it unclear whether the others are a problem as well.

No class of viruses - including HIV - is as easily transmitted through blood contact as hepatitis. Once these small, hearty viruses get into a country's hospitals, blood system or dental practices, they have historically spread like wildfire to people of all ages, until rigid infection-control practices can bring them under control. And they are far from benign, causing cirrhosis of the liver over the short run, and cancer after years of infection.

While vaccines are available to prevent hepatitis A and B, they are relatively new and costly, and are generally not available for use in the cash-poor former Soviet Union. There are no vaccines for any of the other forms of hepatitis, including the rapidly spreading type C. And though a vaccine exists for type A, it is controlled in most of the rest of the world through careful monitoring of food and water - monitoring that doesn't occur on an extensive basis in Russia.

"Hepatitis is really everywhere," said Dr. Evgeny Bocharov, an infectious disease expert in Novosibirsk, where the registered rate of hepatitis B and C now approaches 180 cases per 100,000 people, or 18 times higher than in the United States. "It's like the common cold. We've seen a five-fold increase just since 1995, and who knows what's under the surface."

And health experts say the epidemic is unique, exhibiting characteristics unlike those seen elsewhere.

Since AIDS appeared in 1981, physicians worldwide have found that climbing HIV rates are often followed in specific risk groups, such as drug addicts, by rising hepatitis B rates. But in the former Soviet world, hepatitis tends to precede the appearance of HIV. Experts say this may mean that HIV will find extraordinarily fertile ground in a region in which tens of thousands of drug users, their immune systems already busy battling hepatitis, are unable to muster even token resistance to HIV.

And where hepatitis C and D have tended to surface later in the same group worldwide, here it's rapidly spreading in groups other than drug users as well, thanks to poor infection-control practices in the medical systems.

Even more surprising is that hepatitis A is spreading among drug users in some areas in the region - a phenomenon that experts agree has never occurred elsewhere. Normally spread via fecal contamination of food or water, hepatitis A is not usually a needle-borne virus. Researchers in the region speculate that the virus is taking advantage of the living conditions of young addicts, which are squalid even by post-Soviet standards.

"We first saw a big jump [in hepatitis] in 1993," said Dr. Alla Shcherbynska of the L.V. Gromashevski Epidemiological and Infectious Diseases Research Institute in Kiev. "At that time we saw types A, B, C and D all rising," with most of the A cases traceable to Kiev's terribly contaminated water supply. By 1996, she said, the combined incidence of hepatitis in Ukraine reached 100 cases per 100,000 population, more than six times the U.S. rate.

And now, Shcherbynska said, more than 90 percent of intravenous drug users in Odessa and Kiev are infected with either B, C, or both.

In Odessa, meanwhile, spot testing of young adults suffering from liver disease at the city's Infectious Disease Hospital last year turned up 1,013 cases of hepatitis A, 475 cases of hepatitis B and 125 cases of C, D or E, which look similar without the use of extremely expensive testing equipment. "We're clearly in an epidemic," said Dr. Konstantin Servetskiy, the hospital chief.

More than 1,000 miles to the north in the Baltic nation of Estonia, Dr. Lea Tammai, an infectious disease expert at Merimetsa Hospital, also has documented a huge jump in hepatitis B and C levels, primarily among drug users under the age of 21. Between 1990-96, hepatitis B rates in Estonia quadrupled, she said, and C rates doubled. And though the numbers are low compared with Ukraine (with combined hepatitis incidence in 1996 less than eight cases per 100,000), Tammai is worried.

"Unfortunately, in the first three months of 1997, we have seen as many cases of hepatitis B and C as we saw in all of 1996," Tammai said.

But nowhere is the trend as steep as Russia, where hepatitis is emerging from obscurity into a full-fledged epidemic. Officially, Russia had a combined hepatitis incidence of 26.7 cases per 100,000 adults and 5.9 cases per 100,000 children in 1996, a doubling of the rate since 1992. But in a report filed at the end of 1996 to President Boris Yeltsin by the Russian Academy of Medical Sciences, the toll appears far graver.

In 1995, the report states, more than 52,000 Russians were hospitalized for viral hepatitis, primarily types B and C. The incidence of type B alone topped 36 per 100,000 Russians, the report said, and combined viral type hepatitis was said to be far higher, though no precise estimate was given.

When the Soviet Union fell apart in 1991, less than 6 percent of all hepatitis cases in Russia were among intravenous drug users. By 1995, however, 21 percent of all Moscow hepatitis hospitalizations were drug users and the figure rose to 40 percent in St. Petersburg, the report said.

In the short run, treatment costs for these cases are minimal, experts say, because there's not much Russian hospitals can do for viral hepatitis short of nutritional support and gamma globulin shots to boost immune systems. But 10 years from now, Russia could face tough economic choices as advanced cases of cirrhosis and liver cancer appear.

In the United States, an individual with advanced hepatitis-associated disease is treated with either antiviral and cancer chemotherapy, or a liver transplant. But the procedures are costly (about $200,000 over six months for antiviral chemo that is less than 20 percent effective) and complicated.

Exacerbating the problem of diagnosis and treatment is the fact that patients often fail to seek medical help until their infections are acute.

Once hepatitis viruses find their way into a hospital - via a drug-using cirrhosis patient, for example - they can spread to the general population with terrifying efficiency.

At the Oblast Hospital in Odessa, Dr. Vasiliy Gogulenko knows the odds of contamination are high. "To be infected," he said, health care workers "need to have less than a drop of blood exposure."

Nurses on the surgical staff here have asked the hospital to supply protective hepatitis B vaccines, which cost about 15 percent of a nurse's monthly wages, when they get paid at all. But they are not hopeful, because they have no leverage, says senior nurse Lila Brynchuk - it is illegal in Russia for health care workers to go on strike.

Gogulenko doesn't trust the Odessa blood bank supplies, either, because some transfusion recipients have developed hepatitis. He urges his physicians and nurses to give patients their blood - he does the same - or to have patients bank supplies of their own blood before they undergo surgery.

None of the nation's blood supply is routinely tested for hepatitis C, and test kits for hepatitis B are in short supply.

In the Caucasus nation of Georgia, less than half of the blood supply in the capital city is tested for hepatitis B or C, and almost none outside Tbilisi is screened, said Dr. Tengiz Tsertsvadze, who is in charge of testing. He said 5 percent of the tested donations are infected with hepatitis B, an equal percentage with hepatitis C.

Sources in western embassies, meanwhile, have said they routinely tell employees and visitors that Georgia's blood supply is unsafe, and urge them to leave the country even for emergency procedures.

It's not hard to see why. The central blood bank system of Georgia fell apart during its 1992-95 civil war and a chaotic hodgepodge of hospital banks and blood donation clinics has emerged in its place.

One blood clinic seen in Tbilisi had only sporadic electricity to ensure safe storage of its three refrigerators full of whole blood and two small freezers of plasma. The majority of its blood is donated by individuals who do it in exchange for money. As often as not, they use the pay to buy liquor or opium extract, blood bank director Bella Kvachantivadze said.

On a recent visit, Yuri Nevandovski and Viktor Yakovlev reek of alcohol as they stick their arms through a portal in a glass wall. On the other side of the barrier a nurse takes their blood donation.

Afterwards, the men pocket their laris - worth about $9.60 - and stagger off in search, they say, of some strong Georgian wine.
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