Alarming situation of Hepatitis

[sparklingway]

This is actually a small demographics based survey. The worst affected region is that of Southern Punjab, especially Khanewal and Hafizabad where the incidence has been reported to be as high as 35%.

Even a cursory look at EBSCO or any other academic resource will reveal what the situation is, even through the limited medical publications from our country. The conclusions cited by everyone read that use of infected syringes and personal unhygienic habits are the biggest reasons for the spread of HCV.

According to the Minsitry of Heath's National Programme for Prevention and Control of Hepatitis (NPCHV), the prevalence of is between Hepatitis B: 3-4% and that of Hepatitis C is between 5-6%. This is a grossly under-reported number. HCB prevalence according to most studies is now between 6-7% and HCV prevalence is reaching 15% nationally.

This presents a very big problem as the cost of the HCV medications will become a burgeoning burden on the state as most people cannot afford this on their own.

19.1% population infected with hepatitis C​

Health professionals term situation alarming

Sunday, July 04, 2010
Muhammad Qasim

Rawalpindi

The finding of a screening camp has revealed that the prevalence of hepatitis C among local residents in the area of Wah Gardens is 19.1 per cent that hints towards an alarming situation as according to data, a total of 7.4 per cent population in Pakistan is infected with both hepatitis B and C.

Health experts from Benazir Bhutto Hospital including post-graduate trainees conducted the screening camp in Wah Gardens area on June 22 under supervision of Professor of Medicine at Rawalpindi Medical College and Head of Medical Unit at BBH Dr. Muhammad Shoaib Shafi.

Giving details, the head of medical team informed ‘The News’ on Saturday that keeping in view a significant influx of hepatitis C patients from Wah Gardens area, his team decided to conduct a detailed study of the concerned area with the assistance of a notable of Wah Gardens and philanthropist Colonel (r) Amir Saleem and Professor of Community Medicine at Wah Medical College Dr Mussarat Ramzan.

The team comprising Dr. Umar Saeed, Dr. Amjad Niazi, Dr. Ambreen, Dr. Seemi, Dr. Shehr Bano and Dr. Sana visited the area and initially 1,000 patients were screened out of which 191 turned out to be positive for hepatitis C. PCR was also carried out for 96 selected cases which turned out to be positive in 43 patients.

Dr Shoaib said that the patients would be provided treatment free of cost in Medical Unit II of the BBH as it was decided at the time of organisation of the screening camp. “The prevalence of hepatitis C in 19.1 per cent population in a single community is really alarming and the matter needs special attention of the government authorities,” he said.

He added that the outcome of the screening camp raised great concern among medical community as 19.1 per cent prevalence rate is much more than the data collected by Pakistan Medical Research Council.

It is important that according to a survey conducted by Pakistan Medical Research Council (PMRC) in 2009, the prevalence of hepatitis B antigen among healthy population of Pakistan is 2.5 per cent while hepatitis C is 4.9 per cent.

Hepatitis can be defined as the inflammation and necrosis (the affected cells become oxygen deprived) of the liver cells by the action of viruses named Kypfer cells. Hepatitis is either acute self-limited or persistent or recurrent that causes chronic inflammations and leads to hepatic cirrhosis that is cancer of liver. It mostly leads to death but the stage comes rarely in patients who take proper treatment, studies reveal.

The major causes of HCV infection worldwide are use of unscreened blood transfusions and re-use of needles and syringes which have not been adequately sterilized. HCV is a major cause of acute hepatitis and chronic liver diseases. Studies reveal that hepatitis C virus infection is the leading cause of cirrhosis, considered as the end-stage liver disease. Most of the people develop distension of abdomen due to accumulation of water, many present with vomiting of blood as the veins in the food passage rupture due to raised pressure of the portal circulation. As a complication of the disease, a number of patients develop disturbance of mental function and go into coma.

Health experts fear that cirrhosis of the liver which takes around 15-20 years to develop would emerge out as the leading cause of death in future and vomiting of blood, and coma might claim greater number of lives within next five to seven years. Hepatitis C is one of the ten leading infectious diseases causing death worldwide and according to a rough estimate, nearly 250,000 deaths per year can be attributed to HCV.

To a query, Dr Shoaib said that the prevalence of hepatitis C in 19.1 per cent population in a single locality convinced the medical team to demand the government and especially the health department to adopt appropriate measures to save the people from becoming the victim of Hepatitis C.

Dr Umar Saeed, a senior member of the team, expressed to ‘The News’ that initial investigations into the high prevalence rate of hepatitis C in Wah Gardens area revealed that the major causes of the disease might be the re-use of syringes, administration of unnecessary injections, bad medical practice and quackery.

The team members requested the district government, municipal and health authorities to take strict action against the quacks who were spreading the disease in healthy citizens and steps should be taken for making proper medical treatment facilities available in the area.


Here's the conclusions from a medical publication on the issue. The study was conducted in Karachi. Prevalence turns out to be 23.8%:-

Prevalence of anti-hepatitis C virus

Of the 1997 participants, 476 (23.8%, 95% CI: 21.1&#8211;26.5) were positive for anti-HCV antibody, and the prevalence of HCV increased with age (Cochran&#8211;Armitage Trend Test, P < 0.0001, Fig. 1). The prevalence of HCV was higher among women 26% (351/1348) than men 19% (125/ 649).

In our study, receiving medical injections was one of the associated risk factors in the overall sample and among women; however, it was not a significant risk factor among men. Injection overuse is very common in Pakistan. Most of the injections are provided with previously used injection equipment. The patients_ poor knowledge about risk associated with injections and beliefs in the therapeutic efficacy of injections, and practitioners_ economic incentives as well as beliefs that patients want injections are major determinants of injection use [7,26&#8211;28]. Thus, a large proportion of health care visits results in injection prescription and use. Women are at a higher risk of receiving injections because of their greater health care needs when compared to men. Hence, a reduction in reuse of injection equipment and over-use of unnecessary injections would be a major step towards reducing transmission of HCV among women and resultant disease burden. The government of Pakistan has recently launched the hepatitis prevention and control program. Results from this study emphasize the need for more concerted efforts towards prevention including behaviour change of both healthcare recipients and providers for reducing injection overuse.

The association of other health care risk factors found significant in our study (blood transfusion and dental treatment among women and hospitalization among men) has also been reported as risk factors of HCV among male blood donors in Karachi and Rawalpindi [4,5] and a survey from Punjab [13]. A recent study of risk factors among women found hospitalizations and the number of gestations as significant risk factors for HCV also [6]. Blood transfusions occur during hospitalization, and our study highlights that blood transfusions during hospitalization are associated with HCV infection among women.

Transfusion-associated HCV transmission in Pakistan is in sharp contrast with the situation in the developed world where the risk is nearly zero because of the implementation of effective virus inactivation procedures for blood derivatives (1987), and the introduction of effective anti-HCV testing of blood donations (1992) [29&#8211;31]. In Pakistan, much of the blood collection and distribution still occurs through private blood banks which are poorly regulated, while the acquisition of blood for individual patient needs remains dependant on direct purchase or family donors [32]. A study on blood bank practices in Karachi found that only 23% of blood banks screen for anti HCV and that 33% of blood units collected were distributed to obstetric and gynecology wards or maternity homes [32]. Hence, our findings of blood transfusion as a major risk factor for HCV transmission can be explained by the use of both unscreened blood and family donors. Only lately laws have been enacted by the federal and provincial governments for mandatory screening of blood in an attempt to regulate blood banking in the country, although implementation and monitoring needs to be strengthened. Furthermore, there is a need to create public awareness vis-a-vis voluntary blood donations and importance of screened blood for their patients [33].

A peculiar feature of male behaviour in the developing world, particularly in rural and peri-urban areas, is the dependence on local barbers for regular facial shaving and the practice of razor sharing. In our study, a facial shave from barbers at least once in a week was a significant risk factor for HCV infection, as has been found previously in Pakistan [5,34]. Studies from Italy and Thailand have also reported barber shaving and razor sharing as risk factors for HCV [35,36]. Additionally, we have previously reported that knowledge of barbers about hepatitis B and C is very low, and hence reuse and sharing of razors is common [37]. We therefore propose that media campaigns for awareness about hepatitis should include possibility of HCV transmission through razor use practiced at barber shops.

Sexual transmission of HCV is a controversial issue, with studies of monogamous couples reporting little risk of transmission[38,39] but studies involving multiple sex partners report an increased risk of transmission of HCV through sexual contact [40,41]. Pakistan is a Muslim country where extramarital sex is considered a taboo and therefore earlier studies have not evaluated the association of high-risk sexual intercourse and HCV infection in our population. In our study, extramarital sexual intercourse was significantly associated with HCV infection after adjusting for age, even though study participants might have underreported their sexual behaviour. However, at the time of interview, study participants did not know about their HCV status, thus underreporting is expected to be similar among HCV positive and negative participants. Thus, non differential misclassification of exposure may have diluted the measure of association. Other studies of HCV risk factors from Karachi and other parts of Pakistan have also reported extramarital sexual intercourse as a risk factor for HCV infection [4,13]. Extramarital sexual intercourse has important implications for HCV, HBV and HIV transmission in Pakistan, because of denial of its existence. However, recently the National AIDS Control Program has started addressing this issue among high risk groups. Thus, there is a need to develop broader behaviour change strategies for safe sex practices relevant to the local cultural and religious context.

Our findings should be interpreted in the light of following methodological issues: Use of EIA antibody test may not detect recent infections as antibodies take few weeks to develop. Thus, with using an antibody test, we may have misclassified few recent HCV positives to negatives and thus diluting the true effect size. This is a cross-sectional study investigating a chronic asymptomatic infection, thus the temporal relationship between exposure and outcome cannot be established.

There was an under-representation of men in our study. The study was conducted during day-time when many men are likely to be away for work, resulting in low participation of men. The study team also visited households during weekends but under-representation of men still persisted. We did not collect information on those who were not able to participate, thus we cannot compare characteristics of those who participated with those who did not to assess if it had any impact on results. In conclusion, the high prevalence of HCV in this population and in Pakistan in general has significant implications in terms of the future burden of chronic disease because of HCV infection as well as ongoing transmission of infection. Unsafe health practices and personal behaviours are driving the HCV epidemic in Pakistan.

Our results about the healthcare transmission of HCV infections among women highlight widespread breaches in overall infection control practices in the health care setting in Pakistan. To address the high disease burden and transmission, there is a need for a comprehensive prevention and disease management program including prevention through regulation of patient safety practices in the health care setting, behavioural changes of the population and health providers in the community, and planning and making resources available for education and treatment needs of those already infected with HCV. Because most of the transmission occurs in the health care setting, regulating and monitoring health care practices could be a first step towards reducing transmission.