Rainy Season: Jaundice Prevention and Water Purification

Key Facts:-

• Hepatitis E is involved in most Jaundice outbreaks
• Among the five main Hepatitis causing viruses (A, B, C, D & E) Only Hepatitis E and A, spread by the faecal-oral route
• Usually, Hepatitis A and E are self-limiting and don’t require any specific treatment
• Antibodies against Hepatitis A last lifelong
• Boiling is the surest and very highly effective method to kill germs including viruses in the water. water should be roll boiled for 1 minute and 3 minutes above 6500 feet
• Chlorine Tablets are easily available for disinfection of water and are highly effective.
• Hand washing is the most inexpensive and effective way to prevent infection (mainly by faecal-oral route of transmission)
• there should be no E. coli bacteria in the drinking water. check for other parameters of safe drinking water in the article.
• Rainwater is not as pure as we might think and cannot be assumed safe to drink

We observe the outbreaks of Jaundice along with other water-born diseases during rainy seasons. During 2016 we had a Jaundice epidemic in Shimla (the capital of Himachal Pradesh) which infected more than 1600 people and caused 16 deaths⁶. Shimla had such outbreaks earlier also.

Recently in July 2023, there is an ongoing Jaundice outbreak in the Hamirpur district of Himachal Pradesh (at least 71 affected so far)⁷.

There may be a number of causes of Jaundice but we shall restrict our discussion to Jaundice caused by contaminated water.

Causes of Jaundice in the Rainy Season

• Jaundice means yellow discolouration of skin, sclera and mucus membranes due to an increase in the bilirubin level in the blood (serum)⁴. Jaundice is a sign of either Liver Disease or less often, a hemolytic disorder⁸.

• Jaundice in the rainy season is caused by due contamination of drinking water with faecal matter or sewage. Contamination of drinking water with faecal matter or sewage is commonly confirmed by detecting the coliforms in the water
• Mainly Hepatitis A and Hepatitis E viruses are responsible for Jaundice, though coliforms can also cause the same but can be distinguished by other features and lab investigations. other Hepatitis viruses (Hep B, Hep C and Hep D)spread through infected persons’ blood and body fluids and not by faecal contamination of water.

Recognizing Jaundice Caused by Hepatitis A or E

Symptoms: are suggestive but not specific.

1. Before the appearance of Jaundice:-
   • Nausea (feeling of vomiting)
   • Anorexia- loss of appetite
   • Headache
   • Arthralgia (joint pains), Myalgia (muscle pains)- (when they predate the appearance of Jaundice, is more suggestive of Hepatitis either viral or drug-induced⁸)
   • Dark urine (patient often describes as tea or cola-coloured urine⁸) and Pale stools.
2. Yellowish discolouration of the sclera of the eye or skin along with:-
   • Low-Grade fever (100-102^oF)⁵
   • Abdominal discomfort
   • Vomiting and Diarrhoea

laboratory values of the blood tests:-

1. Total bilirubin- more than 2.5mg/ml
2. ALT (Alanine Transaminase -liver function test)- more than 10 times the upper normal value³

Confirmatory test:- any acute onset of such symptoms in the setting of a number of people getting affected, is usually viral Hepatitis A or E. Serological tests can be used to confirm:-

• IgM anti-HAV antibodies for Hepatitis-A
• IgM anti-HEV antibodies for Hepatitis E

Note:- Most Hepatitis-A infections resolve within 2 months of infection. children less than 6 years usually have no symptoms and infection passes on unnoticed. antibodies produced in response to Hepatitis-A last for life.

Hepatitis-E is also self-limiting but antibodies against Hepatitis-E don’t last for life (unclear) (usually for a few years). that is why Hepatitis-E outbreaks are more often than hepatitis A

Preventing Jaundice in Rainy Season

As we already learned Jaundice in rainy seasons is usually due to contaminated water or eatables that may be caused by the mixing of sewage water, faecal contamination directly or by mechanical carriers like houseflies. it is therefore very important to have safe drinking water and follow hygienic practices to avoid not only Jaundice but all other water-borne diseases.

Water Purification to Prevent Jaundice

Tap water supply is supposed to have pure water but sometimes disruptions in the quality standards are frequently seen, also the people using water from various natural resources like well, baoli, handpumps, borewells etc., can also get contaminated particularly during rainy seasons.

Therefore it is important to be sure that the water we are drinking is pure and free from disease-causing organisms (viruses, bacteria, protozoa, etc.)

Boiling Water

• It is the surest method to kill disease-causing germs including Viruses in the water.¹ it has very high effectiveness in killing viruses.
• Roll boil the water for 1 minute (for 3 minutes in hilly areas with elevation above 6500 feet¹)
• If water is visibly turbid first allow it to settle or filter using a cotton cloth or paper filter before boiling
• In my point of view, it is an almost inexpensive, most effective and practical method to prevent all common water-borne diseases
• Boiling does not remove the chemical contaminants
• tip:- one can use induction base utensils to boil the water on an induction cooktop. boil water in the evening and let it cool overnight after covering it with a lid, (you can also refrigerate it in the morning using clean bottles). using induction to boil the water shall save your LPG cylinder. fortunately, electricity is cheaper in Himachal Pradesh.

Disinfection of water using chemicals

• Disinfection of water can be done using chlorine, chlorine dioxide or iodine.

• Disinfection with these chemicals has high effectiveness in killing germs including viruses but is lower than boiling.
• Also, a number of factors like contact time, the concentration of disinfectant, water temperature, water turbidity, water pH etc. affect the effectiveness of the disinfection method.
• Bleaching- add the required amount of bleach (1/2 tablespoon of bleach powder or 20 drops of bleach (5-9% of Sodium Hypochlorite) in about 20 litres of water, stir it well and let it stand for 30 minutes at least before drinking².
• Chlorine tablets are available for use. they come in various formulations with the same active ingredient (sodium dichloroisocyanurate). kindly follow the instructions on the label for use. [I am sharing links to chlorine tablets for the water storage tank (1 tab for every 500 litres) and for drinking purposes (1 tablet for every 20 litres of water)]
• Water that has been disinfected with iodine is NOT recommended for pregnant women, people with thyroid problems, or those with known hypersensitivity to iodine. It’s also not recommended for continuous use—don’t use it for more than a few weeks at a time.²

Filtration and Other Methods

Disclaimer:- The table below is compiled from the information available at Centres for disease control and prevention⁹.

The various filtration methods discussed above are used in combination or alone by various water purifiers available in the market. most common ones are RO, and UV with pre-filters, alone or in combination.

In the Indian market, a good quality water purifier may cost around 12000-15000 INR. [service cost is not included, may cost around 1500-5000 depending upon any parts to be replaced, after the expiry of the free service period (including any spare parts required)]. there are so many brands you can go with anyone but first ensure the customer service of that brand in your area.

Other Precautions-

Hand Washing and Hygiene

it is the most inexpensive and effective way to prevent infection (faecal-oral route infection). Hand washing can not be overlooked at any cost, especially at some key moments like:-

• After using Washroom
• Before eating/ cooking
• After attending Sick person
• After changing the diaper of a baby

These simple steps like personal hygiene and having safe drinking water, Avoiding street food etc, not only prevent Jaundice but many other diseases like typhoid, diarrhoea, and dysenteries, particularly in the rainy season.

Dealing with Established Jaundice due to Hepatitis A or E

Hepatitis A and E are usually self-limiting. they don’t require any Specific treatment most of the time. Most are managed with supportive treatment.

Supportive Treatment

• Adequate Oral intake (essential)⁴
• Adequate hydration (may require Intravenous fluids in persistent vomiting)
• Vigorous activities are to be avoided but there is no advantage of enforced bed rest⁴
• No specific dietary modification is recommended⁴
• The patient should be monitored for complications (like Acute liver failure)
• Symptomatic treatment- like antipyretics for fever, etc.

Hepatitis A

There is no role for antiviral drugs in therapy for HAV infection. Virtually all previously healthy patients with hepatitis A recover completely with no clinical sequelae. The case fatality is very-very low (~0.1%) but is increased in advanced age and in the presence of underlying debilitating diseases³.

Hepatitis E

• As the disease is usually self-limiting, There is no specific treatment for acute hepatitis E. Therefore, hospitalization is generally not required for a normal person.
• Hospitalization is required for people :
  • with fulminant hepatitis
  • symptomatic pregnant women
  • Immunosuppressed people with chronic hepatitis E (may benefit from specific treatment using Ribavirin, an antiviral drug. In some specific situations, interferon has also been used successfully³)

Other Conditions Similar to Viral Hepatitis

• Enteric Fever
• Falciparum malaria
• Leptospirosis
• Viral hemorrhagic fever
• Drug-induced hepatitis
• Autoimmune liver disease (acute presentation)
• Wilson disease

history taking is very important as it can help in making a provisional diagnosis by ruling out a number of similar conditions. rest can be ruled out on the basis of clinical examination and other imaging or blood tests.

FAQs

What are Common Water-Borne Diseases?

• Typhoid
• Hepatitis A & Hepatitis E
• Diarrhoea due to:
  • E.coli
  • Entamoeba histolytica (Amoebiasis)
  • Cryptosporidium parvum (Cryptosporidiosis)
  • Giardia lamblia (Giardiasis)
  • Vibrio cholera (Cholera)
• Dysentry caused by
  • Salmonella
  • Shigella
• Acute Gastroenteritis illness (caused by Norovirus)-also manifests as diarrhoea, Nausea/vomiting and stomachache.
• Poliomyelitis, etc.

Rainwater: is it safe to drink?

Rainwater is thought to be the purest form of water but CDC says rainwater is not as pure as you might think and cannot be assumed safe to drink.

While collecting Rainwater, it can get contaminated with different types of contaminants like bacteria, parasites, viruses, and chemicals that could make us sick, and it has been linked to disease outbreaks. even dust, smoke, and particles from the air can contaminate rainwater before it lands on your roof¹³.

Avoid using rainwater for drinking, cooking, brushing your teeth, or rinsing or watering plants that you intend to eat¹³.

What are the Parameters of Safe Drinking Water?

It is recommended that the ‘acceptable limit’ is to be implemented. Values in excess of the ‘acceptable limit’ make the water Not suitable, but still may be tolerated in the absence of an alternative source but up to the ‘permissible limit’, above the ‘permissible limit’ sources will have to be rejected¹¹.

Although E. coli is the more precise indicator of faecal contamination, the count of thermotolerant coliform bacteria is an acceptable alternative but Total coliform bacteria are not acceptable indicators, particularly in tropical areas where many bacteria of no sanitary significance occur in almost all untreated supplies

The parameters for other substances can be seen here on the official site of the Central Pollution Control Board

What is the Incubation Period of Various viral Hepatitis Infections?

it is the time period between exposure to infection and the appearance of symptoms.

Roughly we can remember the incubation period as 2-6 weeks for Hepatitis A & E and 2-6 Months for Hepatitis B & C.

Do All Viral Hepatitis are self-limiting

No.

As we discuss earlier Hepatitis A & E are self-limiting and don’t require specific treatment. Among Healthy adults, Acute hepatitis B is self-limiting in 95-99% while hepatitis is self-limiting in only 15% of cases.⁵

Are there any Vaccines Available for Hepatitis A and E?

Vaccinations are available for Hepatitis A & B but not available for Hepatitis C & E.

Vaccination for Heaptitis-B is routinely done in all children under the National immunization programme in India.

The hepatitis A vaccine is also available in India to those who can afford it. it is not integrated into the national immunization schedule, as hepatitis A is highly endemic in India and children usually have an asymptomatic infection which gives them lifelong immunity. But it is not that outbreaks of hepatitis A are not seen in India, outbreaks do happen¹⁴.

Is Hepatitis and Viral Hepatitis the Same?

No.

Hepatitis is a broader term which is inflammation of the liver due to any cause, that may be due to a virus, bacteria, parasite, drug-induced or any other cause. Whereas Viral hepatitis is inflammation of the liver due to viruses only. five main viruses causing viral hepatitis are hepatitis viruses- A, B, C, D, & E

What are the Various Causes of Jaundice?

Before we discuss the various causes of Jaundice, it’s important for us to know some basics about the production & metabolism of Bilirubin.

All Causes of Jaundice (Hyperbilirubinaemia)

1. Indirect or unconjugated hyperbilirubinemia (conjugated bilirubin <15% of total bilirubin⁴):
   • Hemolysis
     • Sickle cell anaemia
     • G-6PD deficiency
     • Spherocytosis
     • Autoimmune hemolysis
     • Microangiopathic hemolytic anaemias
     • Paroxysmal nocturnal hemoglobinuria
     • Spur cell Anemia
   • Bilirubin overproduction
     • Ineffective erythropoiesis
       • Thalassemia
       • Cobalamin deficiency
       • Folate Enzyme deficiency
       • severe Iron deficiency
     • Large hematoma⁴
   • Enzyme deficiencies
     • Crigler-Najjar types I and lI
     • Gilbert’s syndrome- a most common cause of unconjugated hyperbilirubinemia (affects 3-8% of the population)(partial deficiency of UDP-GT)⁴
   • Drugs
     • Rifampicin- unusual and paradoxical effects on serum bilirubin levels
     • Ribavirin
     • Probenecid
   • Miscellaneous⁴
     • Hypothyroidism
     • Fasting
2. Direct or Conjugated hyperbilirubinemia (conjugated bilirubin >20% of total bilirubin⁴):
   • Chronic liver disease
   • Biliary tree involvement in
     • Choledochal cyst
     • Choledocholithiasis
     • Sclerosing cholangitis
     • Ascariasis
   • Liver tumour- primary or secondary
   • Enzyme defects
     • Dubin-Johnson syndrome
     • Rotor syndrome- is rare
   • Infections
     • Sepsis
     • Acute viral Hepatitis
     • Enteric fever
     • Malaria
     • Leptospirosis
   • Infiltration
     • Leukaemia
     • Histiocytosis
   • Miscellaneous
     • Total parenteral nutrition
     • Veno-occlusive disease