“You Don’t Have To Be A Specialist To Make An Impact…”
Humans of Medicine #50
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Dr. Ng Rong Xiang is a dedicated medical lecturer at Universiti Malaya (UM), an infectious disease physician at Universiti Malaya Medical Centre (UMMC), and a specialist at the UM Specialist Centre (UMSC), with a deep-rooted commitment to improving lives through science, service, and advocacy. Dr. Ng is armed with a medical degree and postgraduate training from Universiti Malaya. He holds a Master's in Internal Medicine and a Clinical Fellowship in Infectious Diseases from University Malaya Medical Centre (UMMC). He also holds membership of the Royal Colleges of Physicians (MRCP, UK) and a Diploma in Tropical Medicine and Hygiene (DTMH, UK).
His areas of expertise span antimicrobial resistance, clinical microbiology, and health system accessibility, hepatitis occasionally intersecting with his clinical work.
Dr Ng is well known for his nuanced approach to medical care and his gift for demystifying complex diseases. He brings the lens of both a front-line physician and a public health advocate.
In this special feature for World Hepatitis Day 2025, Dr. Ng joins MMI Humans Of Medicine and reflects on common misconceptions, progress, and the path forward in his own words.
Dr. Ng Rong Xiang, Infectious Disease Physician with experience in co-infections and viral hepatitis care
Breaking the Silence: Myths and Misunderstandings
One of the biggest misconceptions I encounter is that Hepatitis is always symptomatic, especially with jaundice (yellow discolouration of the eyes). Many patients are shocked to learn that they have had Chronic Hepatitis B or C for years without knowing it because they assume hepatitis means immediate jaundice and severe illness, for example, fever, vomiting, or abdominal pain; however, the reality is that chronic viral hepatitis is often completely silent until advanced liver disease develops. In fact, in Hepatitis B, one can develop cancer (hepatocellular carcinoma) without the process of cirrhosis (scarring of the liver).
Another major misconception is confusing the different types of hepatitis, for example, confusing hepatitis A with hepatitis B and C. Patients often believe all hepatitis is the same, that they are caused by contaminated food or water, or that they always resolve on their own. I spend a considerable amount of time explaining to patients that hepatitis B and C are blood-borne viruses that can cause lifelong infections and require specific medical management.
In addition to this, there is also a significant stigma around hepatitis B and C. Patients often feel shame because they associate these infections with drug use or sexual transmission, when in reality, many of my patients acquire their infections through medical procedures, blood transfusions before screening was available, or vertical transmission from mother to child. So, if you happen to come across a case of chronic hepatitis B, always advise the family to screen for hepatitis B because you want to catch the disease before it progresses.
Lastly, another misconception is that some people believe that hepatitis is untreatable, but we now have highly effective cures for hepatitis C and excellent treatments to control hepatitis B. So come forward for treatment if you have hepatitis, and allow the doctor to assess and explain to you. However, if you happen to be cured of hepatitis C, and there is an ongoing exposure to risk of acquiring hepatitis C, it can increase your chances of reinfection; therefore, we will need to screen and check for hepatitis C again if we happen to notice abnormal liver function tests or symptoms.
Understanding the Virus Spectrum
From a clinical standpoint, I categorize hepatitis (A, B, C, D, E) into two distinct groups based on chronicity potential: acute self-limited ones like A and E, and chronic players like B, C, and D.
Hepatitis A and E, as mentioned, are primarily acute infections that resolve completely in immunocompetent individuals. Hepatitis A virus (HAV) spreads through the fecal-oral route, contaminated food, water, or close contact. We have an effective vaccine for HAV, which I highly recommend for travelers to endemic areas and high-risk groups to take, especially if they are not immune to it.
Although Hepatitis E virus (HEV) is similar in transmission to HAV, it has some critical clinical distinctions. While it typically causes acute self-limited illness, HEV can cause chronic infection in immunocompromised patients, particularly in solid organ transplant recipients and HIV patients with low CD4 counts.
Clinically, when I come across a patient with jaundice, diarrhea, abdominal pain, and vomiting after exposure to areas with poor sanitation or contaminated water, especially if they are HAV-vaccinated or HAV-immune, I have a higher index of suspicion for hepatitis E I always check for recent outbreaks in the area, especially among returning travelers. Unlike HAV, there is no widely available vaccine for HEV, which makes travel precautions regarding food and water safety crucial.
Moving forward, hepatitis B, C, and D are the chronic players. Hepatitis B virus (HBV) is transmitted through blood, sexual contact, and from mother to child during pregnancy. It can cause both acute and chronic infections, with chronicity rates being highest when the disease occurs in infancy.
Hepatitis C virus (HCV) is primarily blood-borne, with the highest transmission rates through injection drug use and contaminated medical equipment. However, we are also seeing transmission through intranasal drug use, sharing straws or other paraphernalia (equipment needed for a particular activity) for snorting drugs can transmit HCV through microscopic blood contact from damaged nasal mucosa. This is particularly relevant in chemsex contexts where drug use may be combined with sexual activity that can cause mucosal trauma; many students are not aware of this.
Hepatitis D virus (HDV) only occurs as a co-infection or superinfection with HBV, and it tends to accelerate liver disease progression.
The long-term impact is where these infections really differ; chronic HBV and HCV can lead to cirrhosis, liver failure, and hepatocellular carcinoma over decades. HDV co-infection makes HBV disease more aggressive. What is encouraging is that we now have highly effective treatments for HCV with cure rates over 95% and excellent suppressive therapy for HBV.
Remarkable Medical Advancements
The transformation in hepatitis C treatment has been remarkable. When I started practicing, we were using interferon-based regimens with cure rates of around 50-60% and significant side effects. However, we now have direct-acting antivirals (DAA) that cure over 95% of patients with 8-12 weeks of well-tolerated oral therapy. The pan-genotypic regimens simplified treatment enormously.
For hepatitis B, while we don't yet have a cure, our monitoring and treatment strategies have become more sophisticated. We have a better understanding of when to initiate treatment based on HBV DNA levels, ALT levels, and liver fibrosis assessment. The newer nucleoside analogs, such as tenofovir and entecavir, have high genetic barriers to resistance.
Diagnostically, we've made considerable improvements in point-of-care testing and simplified testing algorithms. The World Health Organisation (WHO)’s recommendation for HCV antibody followed by core antigen testing has made diagnosis more accessible in resource-limited settings. In fact, for HBV, quantitative HBsAg levels are helping us better predict treatment responses and disease progression.
Notably, our elimination strategies include simplified "test-and-treat" models in primary care and harm reduction programs, which are key to elimination.
Why Screening and Treatment Matter
Screening is absolutely critical because chronic viral hepatitis is asymptomatic, mainly until advanced disease develops. By the time patients have signs of decompensated cirrhosis or hepatocellular carcinoma, we've missed years of opportunity for intervention.
For hepatitis B screening, WHO's April 2024 guidelines have updated the approach based on local epidemiology, where HBsAg seroprevalence exceeds 2%. WHO now recommends that all adults have access to HBsAg testing.
Beyond this broader approach, we should conduct targeted screening for high-risk groups, including migrants from endemic regions, household contacts of HBV-positive individuals, healthcare workers, people who inject drugs, people in prisons and closed settings, men who have sex with men, sex workers, HIV-positive individuals, and all pregnant women for prevention of mother-to-child transmission.
Additionally, for hepatitis C, the screening strategy is similar in terms of target populations but different technically. In high-prevalence settings with a prevalence of HCV antibodies of more than 2%, the WHO’s April 2024 guidelines support broader testing approaches; however, the screening test used is HCV antibody, not HCV antigen.
We focus on the same high-risk groups: migrants from endemic regions, healthcare workers, people who inject drugs, people in prisons and closed settings, men who have sex with men, sex workers, and HIV-positive individuals. However, unlike HBV, where HBsAg directly indicates chronic infection, HCV antibody-positive patients need confirmatory testing with either HCV RNA or HCV core antigen to distinguish current infection from resolved infection.
What's particularly important is linking screening to care. Finding someone who's HBsAg or HCV antibody positive but then losing them to follow-up doesn't help anyone. We need robust systems to ensure confirmatory testing, linkage to treatment, and completion of therapy.
The Power of Prevention
Hepatitis B vaccination has been one of our most significant public health successes. The introduction of universal infant vaccination has dramatically reduced new infections in younger generations. However, we still see gaps in adult vaccination, particularly in high-risk groups.
The biggest challenge I come across is catching up on vaccinations for adults who missed their childhood vaccinations. Many healthcare workers, people with multiple sexual partners, and those with occupational exposures remain unvaccinated. There's also inconsistent vaccination of household contacts of HBV-positive individuals.
For hepatitis A, vaccination is crucial for travellers to endemic areas and people with chronic liver disease from other causes. It is important not to underestimate hepatitis A; patients with chronic HCV develop fulminant hepatitis A because they weren't vaccinated.
The gaps are often in access rather than awareness. Adult vaccination can be expensive without insurance coverage, resulting in missed opportunities in healthcare settings. We need better integration of vaccination into routine adult care and improved access in community settings.
To summarize, gaps occur due to missed birth-dose Hep B vaccinations in some regions, low awareness of adult vaccination needs, such as among travelers or healthcare workers. Additionally, there is currently no vaccine for hepatitis C, making harm reduction essential.
Facing the Public Health Challenge in Malaysia
One of the biggest challenges in Malaysia is the hidden burden of disease. We have significant populations of chronic HBV and HCV carriers who remain undiagnosed. It could be that they are from communities with limited healthcare access or undocumented populations who fear engaging with healthcare systems, or they are not aware that chronic hepatitis can be asymptomatic for a long time before having complications.
Other challenges include stigma, which prevents patients from testing or seeking treatment, as it may be associated with “unclean/dirty or having risky behaviour”.
Access to healthcare services also remains a challenge, as rural areas often have limited diagnostic and treatment capabilities. Lastly, funding for DAAs for hepatitis C and lifelong hepatitis B therapies or vaccines requires sustainable financing, which poses a threat as well.
“Hepatitis is treatable and often preventable, but people need to know,” Dr. Ng, reflecting on community challenges in Malaysia.
Why I Chose Infectious Diseases
I was drawn to Infectious Diseases (ID) because I can envision a cure for many diseases. Additionally, ID sits at the intersection of clinical medicine, epidemiology, and public health. With hepatitis, I saw how a preventable and treatable disease could still devastate lives, and often because people didn't know they were infected or couldn’t access care, and this is such a shame.
There’s also something deeply human about infectious diseases, about how they reflect our behaviours, our systems, and our inequities. Working in this field gives me the chance not just to treat, but to advocate and intervene at a population level.
What makes ID unique is that you’re not just caring for the patient in front of you; you also have to think about preventing the disease from spreading to others. For example, during the COVID-19 pandemic, we had to consider not only how to treat the patient but also how to protect those who had been in contact with them, including the surrounding patients who were exposed to the key patient, and how to keep the healthcare workers treating them safe. This broader perspective is a crucial component of infectious disease care.
A Case That Changed My Practice
I once cared for a young man who presented with liver failure, he was only in his 20s. He wasn't aware of the fact that he had hepatitis B. His diagnosis came too late for curative treatment, and it deeply affected me. It was that case that reinforced the need in me for upstream action which was early screening, vaccination, and patient education.
Ever since that particular event, I made it a point to screen and educate every patient of mine if possible, more so, in patients with abnormal liver function tests or having risk factors for it, because the consequences of missed opportunities are real, but it is preventable.
To Medical Students and Young Doctors
You don’t have to be a hepatologist or an infectious diseases specialist to make an impact.
Firstly, don't underestimate the power of routine screening. Every time you order appropriate hepatitis screening, you are potentially identifying someone who could benefit from life-saving treatment or monitoring.
Secondly, become comfortable with these conditions because you will be encountering them in every specialty. Whether you are in family medicine, internal medicine, surgery, or even psychiatry, you will have patients with viral hepatitis. Understanding the basics of management and knowing when to refer can prevent complications and save lives. Don’t be afraid of this disease.
Third, think beyond individual patient care. Consider the public health implications of your actions. When you treat someone with HCV, you're contributing to elimination efforts. When you ensure appropriate vaccination, you're preventing future infections.
Finally, be advocates for your patients. These conditions still carry significant stigma, and patients need healthcare providers who approach them with compassion and without judgment. Your attitude can make the difference between a patient engaging in care or being lost to follow-up.
Dr. Ng remains optimistic: “We already have the tools, what we need now is sustained commitment from every level of society.”
Elimination is Possible, But It Starts With Us
World Hepatitis Day is observed each year on the 28th of July to raise awareness of viral hepatitis.This year’s theme is titled Hepatitis: Let’s Break It Down which calls for urgent action to dismantle the financial, social and systemic barriers, including stigma that stands in the way of hepatitis elimination and liver cancer prevention.
From my perspective, there are steps that can be taken at the individual, community, and national level to move towards this goal.
On the individual level, it is essential to first know your status, get tested if you are in a risk group or have never been screened. If you happen to test positive, engage in care and complete treatment if indicated. Practice safe behaviours to prevent transmission and ensure that family members are screened and vaccinated appropriately.
In addition to this, healthcare providers should integrate hepatitis screening into routine care, stay updated on treatment advances, and approach patients without stigma. Every provider should be comfortable with basic hepatitis management or know when and where to refer.
At the community level, community-based screening programs can be one of the ways to go, such as in community centres, places of worship and harm reduction facilities. Community health workers can play crucial roles in education, linkage to care and follow up support.
Harm reduction programs are essential for preventing new HCV infections which can include needle exchange programs, opioid substitution therapy and integrated HCV testing as well as treatment in substance use treatment facilities.
At the national level, we need sustained funding for viral hepatitis elimination. This includes ensuring universal access to DAA treatment for HCV, expanding screening programs, and maintaining high vaccination coverage for HBV.
Our healthcare system also requires strengthening, this means training more providers, developing clear care pathways, and integrating hepatitis services into primary care. We also need robust surveillance systems to track our progress toward elimination goals.
Finally, we must address the social determinants that put people at risk: poverty, lack of access to clean injection equipment, and barriers to healthcare access. Elimination won't happen through medical interventions alone, it requires addressing the underlying conditions that perpetuate transmission.
In summary, the goal of elimination is ambitious, but absolutely achievable. We already have the tools: effective vaccines, curative treatments, and reliable diagnostic tests. What we need now is sustained commitment, from individuals to get screened and vaccinated, from communities to raise awareness and reduce stigma, and from health systems to ensure that no one is left behind.
Future doctors, public health leaders, and advocates, like many of you, possess a vital role in keeping hepatitis on the agenda. As the WHO Global Hepatitis Strategy, endorsed by all WHO Member States, outlines we aim to reduce new hepatitis infections by 90% and deaths by 65% between 2016 and 2030.
That vision can only be realised if the next generation steps up, and I believe you will.
