AARYABHATTA KNOWLEDGE UNIVERSITY,

PATNA, BIHAR -80001

A PROJECT REPORT ON LIVER DISEASE

A project report submitted in partial fulfilment of the requirements for the
award of the degree of

BACHELOR OF PHARMACY

BY

SANTOSH KUMAR

191091620030

UNDER THE GUIDANCE OF

MR. VIKASH TIWARI

(ASSOCIATE PROFESSOR)

CHANAKYA COLLEGE OF PHARMACY

AND MEDICAL SCIENCE, BHOJPUR

CHANAKYA COLLEGE OF PHARMACY AND MEDICAL SCIENCE, BHOJPUR

(ARYABHATTA KNOWLEDGE UNIVERSITY,PATNA,BIHAR)

 DECLARATION CERTIFICATE

This is to certify that the work presented in the project report

entitled” A Review on Liver” in partial fulfilment of the requirement
for the award of Degree of B. Pharm of Narayan Institute of
Pharmacy submitted to Gopal Narayan Singh University, Jamuhar,
Bihar is an authentic work carried out under my supervision and
guidance. To the best of my knowledge, the content of this project
does not form abasis for the award of any previous degree to anyone
else.

Mr.Vikash Tiwari

Dean (Guide)

Chanakya College of Pharmacy Aryabhatta Knowledge University

And medical science , Bhojpur Patna, Bihar
 CERTIFICATE OF APPROVAL

The foregoing project work entitled “SYSTEMIC REVIEW ON

LIVER DIEASES” is hereby approved as a creditable study on the
topic of Research /REVIEW/CASE study and has been presented
satisfactorily warrant its acceptance as a prerequisite to the degree
for which it has been submitted.

It is understood that by this approval, the undersigned does not

necessarily endorse any conclusion drawn or opinion expressed
therein, but approve the thesis for the purpose for which it is
submitted

(Internal examiner) (external examiner)

 DECLARATION

I do hereby declare that the present project entitled “SYSTEMIC

REVIEW ON LIVER DIEASES”, submitted to Gopal Narayan
Singh University, Jamuhar, Bihar for partial fulfilment of degree in
pharmacy is an original one and has not been submitted earlier tom
any other degree of this University or any other University.

Date: MR VIKASH TIWARI

Place B. Pharm final year

ROLL NO:- 19109162030

 AKNOWLEDGEMENT

It is a great pleasure for me to submit this project on the topic

SYSTMIC REVIEW ON LIVER DIEASES as a part of the
curriculum for the award of “Bachelor of Pharmacy” of Narayan
institute of pharmacy, Sasaram, Rohtas, Bihar.

I would like to thank MISS. Srishti Tiwari associate professor,

Narayan institute of pharmacy, Sasaram, Rohtas, BIHAR, for
sharing his outstanding knowledge and pharmaceutical concepts
with me.

At last, I would like to thank almighty & my family member who

provides me with mental strength and motivation whenever I got
disappointed.
 LIVER

ABSTRACT

Liver disease is the major cause of death every year. Approximately

29 million people suffer from a chronic liver condition (Bleachier
M. et al. (American liver foundation 2017). Liver diseases is the fifth
big common causes of liver disease worldwide are chronic hepatitis
B and C. alcohol and non-alcoholic steatohepatitis associated with
obesity and metabolic syndrome (HEPAMAP. 2007). Around 10
lakh patients of liver cirrhosis are newly diagnosed every year in
India. Liver disease is the tenth most common cause of death in India
as per the World Health Organization. Liver disease affect every one
in five Indians. Liver disease kills more people than diabetes and
road deaths. Liver diseases does not usually cause any obvious signs
or symptoms until it's fairly advanced and the liver is damaged. A
number of liver function test are available to test the proper function
of the liver.

KEYWORDS: Liver, Hepatitis, Liver Cirrhosis

 INTRODUCTION

Liver is the second largest organ in human body, more than 5,000
separate bodily functions including helping blood to clot. cleansing
the blood of toxins to converting food into nutrients to control
hormone levels. fighting infections and illness, regenerating back
after injury and metabolizing cholesterol, glucose, iron and
controlling their levels. Most people never give their liver a thought
until something goes wrong. yet. liver diseases on rise, affecting one
in ten. Liver diseases can be inherited or caused by a variety of
factors that damage the liver. In fact, there are many types of liver
diseases that can be caused by a virus, damage from drugs or
chemicals, obesity, diabetes or an attack from own immune system,
when the condition is left untreated, it can become left threatening
and can permanently damage the liver or the bile duct. This damage
leads to malignancy and cause liver cancer.

The liver is the largest of the abdominal viscera, occupying a

substantial portion of the upper abdominal cavity.

It performs a wide range of metabolic activities necessary for

homeostasis, nutrition and immune defence.

It is composed largely of epithelial cells (hepatocytes), which are

bathed in blood derived from the hepatic portal veins and hepatic
arteries.

Hepatocytes are also associated with an extensive system of minute

canals, which form the biliary system into which products are
secreted.
 The liver has the enormous task of maintaining the body's metabolic
homeostasis. This includes the processing of dietary amino acids,
carbohydrates, lipids and vitamins; synthesis of serum proteins
including coagulation factors; and detoxification and excretion into
bile of endogenous waste products.

DEFINATION

 It is the largest gland in the body (about 2.5% of the body mass in
adults). i.e. 1500 gm Receives blood 25% of cardiac output.

 In the late fetus in which it also serves as a hematopoietic organ, it

is proportionately twice as large (5% of body weight). From early
childhood onward, it occupies almost all of the right hypochondrium
and epigastrium.

 In adults: the liver lies in the right hypochondrium, epigastrium, and

left hypochondrium.

 In normal individuals, it should not be palpable below the right costal

margin.

 Its surfaces are in contact with the diaphragm and the anterior
abdominal wall.

 The falciform ligament attaches the liver to both of these structures.

 In most living persons the liver is a soft reddish brown organ.

 Glisson's capsule surrounds the liver as a strong connective tissue.

 The liver receives venous blood returning from the GI tract through
the portal vein.
 This venous blood is laden with the products of digestion, especially
fats.

 In addition to its many metabolic activities, the liver is a storehouse

for glycogen and it secretes bile.

Fig: 1

Main functions of liver

 It secretes bile and stores glycogen.

 It synthesizes the serum proteins and lipids. - It detoxifies blood from

endogenous and exogenous substances (e.g., Toxins, drugs, alcohol,
etc.) that enter the circulation

 It produces hemopoietic cells of all types during fatal life.

 Location of liver

 The liver almost fully occupies:

 The right hypochondrium.

 Upper part of the epigastrium.

 And part of the left hypochondrium up to the left lateral

(midclavicular) line.

 It extends upward under the rib cage as far asthe 5th rib anteriorly
on the right side (below)the right nipple) and left 5th intercostal
space

 The sharp inferior border crosses the midline at the level of trans
pyloric plane (at the level of L1 vertebra.

Fig:2

SHAPE, SIZE AND COLOUR

 Shape

 The liver is wedge shaped and resembles a four sided pyramid laid
on one side with its base directed towards the right and apex directed
towards the left.\

Weight

 In males:1.4 to 1.8kg

 In females 1.2 to 1.4kg

 In newborn:1/8th of the body weight

 At birth :150g

 Proportional weight: in adult 1/40th of the body weight

Colour

It is red – brown in colour.

Blood flow in liver

The liver gets a dual blood supply from the hepatic portal vein and
hepatic arteries. Suppling approximately 75% of the liver blood
supply, the hepatic portal vein carries venous blood drained from the
spleen, gastrointestinal tract, and its associated organs. The hepatic
arteries supply arterial blood to the liver according to the reminder
of its blood flow. Oxygen is provided from both source;
approximately half of the liver’s oxygen demand is met by the
hepatic portal vein, and half is met by the hepatic arteries. Blood
flows through the liver sinusoids and empties into the central vein of
each lobule. The central veins coalesce into hepatic veins, which
leave the liver

Fig:3

Biliary flow in liver

The bile produced in the liver is collected in bile canaliculi, which

merge to form bile ducts. Within the liver, these ducts are called
intrahepatic bile ducts, and once they exit the liver they are
considered extrahepatic. The intrahepatic ducts eventually drain into
the right and left hepatic ducts, which merge to form the common
hepatic duct. The cystic duct from the gall bladder joins with the
common hepatic duct to form the common bile duct. Bile either
drains directly into the duodenum via the common bile duct, or is
temporarily stored in the gallbladder via the cystic duct. The
 common bile duct and the pancreatic duct enter the second part of
the duodenum together at the hepatopancreatic.

Fig:4

LIVER ENZYMES

Enzyme is a chemical that accelerates (speeds up) chemical reactions within the
body. There are several enzymes in the liver. including alanine transaminase
(ALT), aspartate transaminase (AST), alkaline phosphatase (ALP), and gamma-
glutamyl transpeptidase (GGT). Elevated liver enzymes, found with a blood test,
indicate inflamed or injured liver cell.

Enzyme Increased Enzyme Decreased Enzyme

Increase level affecting A low level of ALT in
other parts of the body. the blood is expected and
 Nevertheless, injury to is normal. Liver disease
organs other than the is the most common
liver, such as the heart reason for higher than
(ALT) and skeletal muscle, can normal levels of ALT
cause elevations of ALT. (more than 10 times
For example, small hepatitis, sometimes due
increases may be seen to a viral for higher than
with skeletal muscle normal levels
damage or heart attack
1.A high AST level is a Low levels of AST in the
sign of liver damage, but blood are expected and
it can also mean you are normal. Very high
(AST) have damage to another levels of AST (more than
organ that makes it, like 10 times normal) are
your heart or kidney usually due to acute
2. Typically the range for hepatitis, sometimes due
normal AST is reported to a viral infection.... In
between 10 to 40 units most types of liver
per liter and ALT disease, the ALT level is
between 7 to 56 units per higher than AST and the
liter. Mild elevations are AST/ALT ratio will be
generally considered to low
be 2-3 times higher than
the normal range. In
some conditions, these
enzymes can be severely
elevated, in the 1000s
rang
 High levels may also Low levels having
indicate an issue related lower-than- normal ALP
to the bones such as levels in your blood is
rickets Paget's disease, rare, but it can indicate
bone cancer, or an malnutrition, which
(ALP) overactive parathyroid could be caused by
gland. In rare cases, high celiac disease or a
ALP levels can indicate deficiency in certain
heart failure, kidney vitamins
cancer, other cancer,
mononucleosis, or
bacterial infection
(GGT) High levels of GGT in They may also be caused
the blood could ndicate by alcohol abuse,
that the enzyme is alcoholic liver disease,
leaking out of the or use of drugs that are
enzyme is leaking out of toxic to the liver. A low
the liver cells and into or normal GGT test
the blood, suggesting result indicates that it is
damage to the liver or unlikely that you have
bile ducts. A typical liver disease or have
range for GGT levels in consumed any alcohol
adults and children is
between 0 and 30
international units per
liter (IU/L)
 Some of the conditions cardiovascular disease
that result increased and 2 diabetes, as well as
GGT include: all-cause mortality in
1.overuse of alcohol. both men and women,
2.chronic viral hepatitis. when GGT
3.lack of blood flow to concentrations exceeded
the liver. the lowest 25% of
4.liver tumor. normal population
5.cirrhosis, or scarred ranges
liver.
6. overuse of certain
drugs or other toxins.
7.heart failure.
8.diabetes

Alanine aminotransferase (ALT) 7-55 U/L

Aspartate aminotransferase (AST) 8-48 U/L
Alkaline phosphatase (ALP) 45-115U/L
Gamma-glutamyl transpeptidase 8-61U/L
(GGT)
5’- nucleotidase 0-15U/L
 Pathophysiology of Hepatitis

Definition

 Hepatitis means inflammation of the liver - Hepat (Liver) + itis

(inflammation)=Hepatitis.

 Viral hepatitis means there is a specific virus that is causing your

liver to inflame (swell or become larger than normal)

 The liver is a vital organ that processes nutrients, filter the blood, and
fight infections. When the liver is inflamed or damaged, its function
can be affected.

 The condition can be self-limiting or can progress to fibrosis

(scarring) , cirrhosis or liver cancer . Hepatitis viruses are the most
common cause of hepatitis in the world but other infections ,toxic
substances (e.g. alcohol, certain drugs), and autoimmune diseases
can also cause hepatitis.

Types of Hepatitis

 Hepatitis A

 Hepatitis B

 Hepatitis C

 Hepatitis D

 Hepatitis E
 HEPATITIS “A”

INTRODUCTION

Hepatitis A virus (HAV), the causative agent of hepatitis A, is a non-

env

eloped, single-stranded RNA virus, which is a member of the

Hepatovirus genus of the family Picornaviridae. HAV displays a
high degree of genetic conservation throughout its genome and there
is only one serotype. There is enough genetic diversity though, to
define six genotypes consisting of three that infect humans (1,1 and
III) and three simian strains (IV. V and VI). Former human genotype
VII has now been incorporated into the genotype II clade.

HAV is the most common cause of infectious hepatitis worldwide

with more than 1.5 million cases each year. In Australia there are
approximately 300 to 500 cases of HAV infection reported annually
and this has been declining since the 1990s. HAV is transmitted via
the faecal-oral route through direct contact of an infected person, or
by ingestion of contaminated food or water. Risk factors for
acquisition of HAV include low socioeconomic status, large
household size, overcrowding, living in a rural area and having
limited access to clean water sources or sanitation facilities. HAV is
stable in the environment for up to month and is inactivated by
temperatures exceeding 85°C and by some disinfectants; including
chlorine and formalin. Ture chronic hepatitis attributable to HAV
has not been documented. However a small proportion of patients
may have persisting HAV replication and transaminitis for up to a
year or longer. Relapsing illness within weeks of apparent recovery
with reappearance of HAV in the faeces has also been described.

Fig:- 4( Hepatitis A VIRUS)

Geographical distribution

Geographical distribution areas can be characterized as having high,

intermediate or low levels of hepatitis A virus infection. However,
infection does not always mean disease because infected young
children do not experience any noticeable symptoms.

Infection is common in low- and middle-income countries with poor

sanitary conditions and hygienic practices, and most children (90%)
have been infected with the hepatitis A virus before the age of 10
years, most often without symptoms (2). Infection rates are low in
high-income countries with good sanitary and hygienic conditions.
Disease may occur among adolescents and adults in high-risk
groups, such as persons who inject drugs (PWID),men who have sex
with men (MSM), people travelling to areas of high endemicity and
in isolated populations, such as closed religious groups. In the United
States of America, large outbreaks have been reported among
persons experiencing homelessness. In middle-income countries and
regions where sanitary conditions are variable, children often escape
infection in early childhood and reach adulthood without immunity.

TRANSMISSION

The faecal-oral route is the main way that the hepatitis A virus
spreads, and it occurs when an uninfected individual consumes food
or water that has been contaminated by the excrement of an infected
person. Families may experience this due to contaminated hands
when an infected person prepares food for the family. Even if they
don't happen often, waterborne outbreaks are frequently linked to
untreated or sewage-contaminated water. Although casual contact
between individuals does not spread the virus, close physical contact
(such as oral-anal sex) with an infectious person can.

SYMPTOMS

The incubation period of hepatitis A is usually 14–28 days.

Symptoms of hepatitis A range from mild to severe and can include

fever, malaise, loss of appetite, diarrhoea, nausea, abdominal
discomfort, dark-coloured urine and jaundice (a yellowing of the
eyes and skin). Not everyone who is infected will have all the
symptoms. Adults have signs and symptoms of illness more often
than children. The severity of disease and fatal outcomes are higher
in older age groups. Infected children under 6 years of age do not
usually experience noticeable symptoms, and only 10% develop
jaundice. Hepatitis A sometimes relapses, meaning the person who
 just recovered falls sick again with another acute episode. This is
normally followed by recovery.

AT RISK

Anyone who has not been vaccinated or previously infected can get
infected with the hepatitis A virus. In areas where the virus is
widespread (high endemicity), most hepatitis A infections occur
during early childhood. Risk factors include:

o poor sanitation;

o lack of safe water;

o living in a household with an infected person;

o being a sexual partner of someone with acute hepatitis A infection;

o use of recreational drugs;

o sex between men; and

o travelling to areas of high endemicity without being immunized.

DIAGNOSIS

Cases of hepatitis A are not clinically distinguishable from other

types of acute viral hepatitis. Specific diagnosis is made by the
detection of HAV-specific immunoglobulin G (IgM) antibodies in
the blood. Additional tests include reverse transcriptase polymerase
chain reaction (RT-PCR) to detect the hepatitis A virus RNA and
may require specialized laboratory facilities.
 TREATMENT

There is no specific treatment for hepatitis A. Recovery from

symptoms following infection may be slow and can take several
weeks or months. It is important to avoid unnecessary medications.
Acetaminophen, paracetamol and medication against vomiting
should be avoided.

Hospitalization is unnecessary in the absence of acute liver failure.

Therapy is aimed at maintaining comfort and adequate nutritional
balance, including replacement of fluids that are lost from vomiting
and diarrhoea.

PREVENTION

Improved sanitation, food safety and immunization are the most

effective ways to combat hepatitis A.

The spread of hepatitis A can be reduced by:

 adequate supplies of safe drinking water;

 proper disposal of sewage within communities; and

 personal hygiene practices such as regular handwashing before

meals and after going to the bathroom.

Several injectable inactivated hepatitis A vaccines are available

internationally. All provide similar protection from the virus and
have comparable side effects. No vaccine is licensed for children
younger than 1 year of age. In China, a live attenuated vaccine is also
available.
 WHO response

In May 2016, the World Health Assembly adopted the first Global
health sector strategy on viral hepatitis, 2016–2021. The strategy
highlighted the critical role of universal health coverage and sets
targets that align with those of the Sustainable Development Goals.
The strategy proposed the elimination of viral hepatitis as a public
health threat by 2030 (defined as a 90% reduction in new chronic
infections and a 65% reduction in mortality, compared with the 2015
baseline), and included a roadmap towards elimination by
implementing key prevention, diagnosis, treatment and community
interventions strategies. In May 2022 the 75th World Health
Assembly noted a new set of integrated global health sector
strategies on HIV, viral hepatitis and sexually transmitted infections
for the period of 2022–2030. Based on these previous and now new
strategies, a broad range of Member States have developed
comprehensive national hepatitis programmes and elimination
strategies guided by the global health sector strategy.

WHO is working in the following areas to support countries in

moving towards achieving the global hepatitis goals under the
Sustainable Development Agenda 2030:

 raising awareness, promoting partnerships and mobilizing

resources

 formulating evidence-based policy and data for action

 increasing health equities within the hepatitis response

 preventing transmission
 scaling up screening, care and treatment services.

WHO organizes annual World Hepatitis Day campaigns (as 1 of its

9 flagship annual health campaigns) to increase awareness and
understanding of viral hepatitis. For World Hepatitis Day 2022,
WHO focuses on the theme “Bringing hepatitis care closer to you”
and calls for simplified service delivery of viral hepatitis services,
bringing care closer to communities.

GRAPH: -1
 HEPATITIS B

 Hepatitis B is a viral infection that attacks the liver and can cause
both acute and chronic disease.
 The virus is most commonly transmitted from mother to child during
birth and delivery, as well as through contact with blood or other
body fluids during sex with an infected partner, unsafe injections or
exposures to sharp instruments.
 Hepatitis B is a potentially life-threatening liver infection caused by
the hepatitis B virus (HBV). It is a major global health problem. It
can cause chronic infection and puts people at high risk of death from
cirrhosis and liver cancer.
 2019, hepatitis B resulted in an estimated 820 000 deaths, mostly
from cirrhosis and hepatocellular carcinoma (primary liver cancer).
 Hepatitis B can be prevented by vaccines that are safe, available and
effective.
 The hepatitis B virus can survive outside the body for at least 7 days.
During this time, the virus can still cause infection if it enters the
body of a person who is not protected by the vaccine. The incubation
period of the hepatitis B virus ranges from 30 to 180 days. The virus
may be detected within 30 to 60 days after infection and can persist
and develop into chronic hepatitis B, especially when transmitted in
infancy or childhood.
 Transmission

highly endemic areas, hepatitis B is most commonly spread from

mother to child at birth (perinatal transmission) or through horizontal
transmission (exposure to infected blood), especially from an
infected child to an uninfected child during the first 5 years of life.
The development of chronic infection is common in infants infected
from their mothers or before the age of 5 years.

Hepatitis B is also spread by needlestick injury, tattooing, piercing

and exposure to infected blood and body fluids, such as saliva and
menstrual, vaginal and seminal fluids. Transmission of the virus may
also occur through the reuse of contaminated needles and syringes
or sharp objects either in health care settings, in the community or
among persons who inject drugs. Sexual transmission is more
prevalent in unvaccinated persons with multiple sexual partners.

Hepatitis B infection acquired in adulthood leads to chronic hepatitis

in less than 5% of cases, whereas infection in infancy and early
childhood leads to chronic hepatitis in about 95% of cases. This is
the basis for strengthening and prioritizing infant and childhood
vaccination.

SYMPTOMS
 Diagnosis

 Since it is impossible to distinguish between hepatitis B and other

viral hepatitis on the basis of clinical findings, laboratory
confirmation of the diagnosis is crucial. Hepatitis B patients can be
diagnosed and monitored using a variety of blood tests. They can be
used to differentiate between acute and persistent infections. To
maintain the safety of blood and prevent unintentional transmission,
the WHO advises that all blood donors be screened for hepatitis B.

 As of 2019, 30.4 million individuals—or 10.5% of those predicted

to have hepatitis B—knew they had the disease, and 6.6 million
(22% of those who had been diagnosed—were receiving treatment.
The percentage of children under five who have chronic HBV
infection has decreased to slightly under

1%, per the most recent WHO data. 1% in 2019 compared to 5% in

the 1980s to the early 2000s, which was the pre-vaccine era.

 WHO advises that all people have access to and be offered HBsAg
testing with linkage to prevention, care, and treatment services as
needed in settings with high Hepatitis B surface antigen
seroprevalence in the general population (classified as >2% or >5%
HBsAg seroprevalence).

TREATMENT

 Acute hepatitis B does not have a particular treatment. In order to

ensure comfort and a balanced diet, including replacing fluids lost
through vomiting and diarrhoea, care is given. Avoiding unneeded
medication is of utmost importance. Acetaminophen, paracetamol,
and antiemetic drugs should be avoided.
 Medication for chronic hepatitis B infection is available, including
oral antiviral medications. Cirrhosis can be treated to delay its
course, lower the risk of liver cancer, and increase long-term
survival. Depending on the setting and eligibility requirements, the
WHO predicted that 12% to 25% of patients with chronic hepatitis
B infection may need treatment in 2021.

 The most effective medications to inhibit the hepatitis B virus are

oral therapies (tenofovir or entecavir), according to the WHO. Most
patients who begin hepatitis B treatment must do so for the rest of
their lives.

 Oral medicines (tenofovir or entecavir) are the most efficient drugs

to block the hepatitis B virus, according to the WHO. The majority
of individuals who start hepatitis B therapy are required to continue
it for the remainder of their lives.

PREVETION

 The WHO advises that all new borns get the hepatitis B vaccine as
soon as possible after delivery, preferably within 24 hours, and then
get 2 or 3 doses of the vaccine spaced at least 4 weeks apart to finish
the series. Protection is likely lifetime and lasts at least 20 years. For
people who have finished the 3-dose vaccination programme, WHO
does not advise booster shots.

 WHO advises the use of antiviral prophylaxis in addition to baby

vaccination to stop the mother-to-child transmission of hepatitis B.
Transmission can also be prevented by employing safer sex
procedures and blood safety tactics, such as limiting the number of
partners and using barrier protection measures (condoms).
 WHO response

May 2016, the World Health Assembly adopted the first Global
health sector strategy on viral hepatitis, 2016–2020. The strategy
highlighted the critical role of universal health coverage and sets
targets that align with those of the Sustainable Development Goals.
The strategy proposed the elimination of viral hepatitis as a public
health threat by 2030 (defined as a 90% reduction in new chronic
infections and a 65% reduction in mortality, compared with the 2015
baseline), and included a roadmap towards elimination by
implementing key prevention, diagnosis, treatment and community
interventions strategies. In May 2022 the 75th World Health
Assembly noted a new set of integrated global health sector
strategies on HIV, viral hepatitis and sexually transmitted infections
for the period of 2022–2030. Based on these previous and now new
strategies, a broad range of Member States have developed
comprehensive national hepatitis programmes and elimination
strategies guided by the global health sector strategy

To support countries in achieving the global hepatitis elimination

targets under the Sustainable Development Agenda 2030, WHO is
working to:

 increase public awareness, foster collaboration, and mobilise

resources

 provide data and policy that are based on evidence for action

 a greater focus on health equity in the hepatitis response

 a greater focus on health equity in the hepatitis response

 scale up screening, care and treatment services.

For World Hepatitis Day 2022, WHO emphasises the topic

"Bringing hepatitis care closer to you" and asks for
streamlining viral hepatitis service delivery to bring care closer to
communities.

MEDICINE USE IN HEPATITIS B