Assignment

Scholarly paper

Topic :Prevelence Of Hepatitis In Pakistan

Subject:Behavioral Psychology

Faculty:Madam Shehla Arshad

Submitted by: Hashmat Ali

Year III Semester 6th

Class# 36
 Prevelence Of Hepatitis In Pakistan, page 1

Viral hepatitis is a serious global public health problem. At present, six distinct types of

hepatitis virus have been identified and called as hepatitis A, B, C, D, E and G viruses. For

hepatitis A virus (HAV) and hepatitis E virus (HEV), the primary source of infection is the

feaces with fecal-oral route being the most predominant mode of transmission. Hepatitis B virus

(HBV), Hepatitis C Virus (HCV), and Hepatitis D virus (HDV) are blood born viruses and are

primarily transmitted through a breach in the skin (percutaneous) or mucosa (mucosal). All

hepatitis viral infection are acute but hepatitis B, C and Delta can also result in chronic infections

Every 10th person in the country is suffering from one type of hepatitis or the other and the viral

infection varies in severity from a self-limited condition with total recovery to a life-threatening

or lifelong disease.

Over 20 million people in Pakistan are infected with hepatitis B and C virus including around 15

million with C and five million with B and the disease is swelling at an alarming rate.

Senior consultant and Principal Gujranwala Medical College Prof Aftab Mohsan

Said to the national news that “Preventive measures including infection control at hospitals,

proper disposal of clinical waste and regular screening are a key to check spread of hepatitis B

and C.

By taking all preventive steps and treatment of 2 lakh patients every year, we can control

hepatitis in 20 years,” said Prof Aftab Mohsan who has also previously supervised Hepatitis

Control Program in the country.Hepatitis is inflammation of liver that may be caused by

different viruses, bacteria, drugs, or excessive alcohol intake. The most common causative

viruses are hepatitis A, B, C, D, E, F and G. Hepatitis A and B viruses were identified before 1970.

In 1977 delta agent was identified.

 Prevelence Of Hepatitis In Pakistan, page 2

It occurs as a coinfection or superinfection in persons who have suffered from hepatitis B

recently or in the past. Non A--Non B hepatitis has been identified as hepatitis C virus and

hepatitis E virus. Hepatitis C includes most of the transfusion associated hepatitis. An epidemic

form of hepatitis in the Asian continent has been designated as Hepatitis E virus (HEV). All

forms of viral hepatitis pose serious public health problems worldwide. In the United States viral

hepatitis ranks second among the reportable communicable diseases. In our country the

prevalence rate is very high and it falls in the intermediate to high endemicity zone of hepatitis

prevalence. Hepatitis A has a worldwide incidence. The prevalence decreases with increasing

age and increases with low socio-economic status. Hepatitis B is endemic in Africa, Eastern

Europe, the Mediterranean, Asia, and South America. In these areas more than 50 percent of the

population have been exposed to Hepatitis B virus. Delta hepatitis is also found in areas of high

hepatitis B prevalence. Hepatitis C has a prevalence rate of 0.2 to 1.5 percent in random blood

donors in the United States. Europe and Japan have a high rate of about 80 percent in high risk

groups such as intravenous drug abusers. Hepatitis E is endemic in areas of overcrowding, unsafe

water supplies and inadequate disposal of human waste. It is found as acute disease in young

adults. Hepatitis A and E are transmitted via oral fecal (enteric) route. Hepatitis B, D and C are

transmitted via parenteral route through exposure to contaminated blood, primarily through

transfusion of infected blood or the sharing of infected needles. Sixty to eighty percent of babies

born to HBV infected mothers become carriers of infection and spread the virus for the rest of

their lives. Classic symptoms of hepatitis include jaundice, fever and abdominal pain. Many

patients have flue like symptoms. The viruses can only be differentiated through specific

serologic testing.
 Prevelence Of Hepatitis In Pakistan, page 3

Hepatitis is one of the 10 reportable diseases in Pakistan. Hepatitis A is a childhood disease. In

cases of hepatitis under ten 60 percent of the cases are due to Hepatitis A, 30 percent HEV, 10

percent HBV. About 70 percent of the children under ten have IgG antibodies against hepatitis A

and they last longer and protect them from hepatitis A in future. Seventy percent of the all new

born have trans placental IgG antibodies against hepatitis A that last about 8 months of age. In

adults more than 66 percent of our population is immune to hepatitis A. Ninety five percent of

the. Blood donors had IgG antibodies against hepatitis A. It is equally prevalent in male and

female and there is no significant difference in rural and urban populations.

Pakistan is endemic area for viral hepatitis B. It is more aggressive due to co-infection and super-

infection with delta virus. The case fatality rate with delta infection is 30.2 percent in Sind and

Punjab. Intra-familial spread of hepatitis B is quite high. The highest reported in spouses is 23.5

percent. Pakistan has a high carrier rate of hepatitis B. It is between 10 to 14 percent with ELISA

and RIA techniques respectively. Hepatitis B is more prevalent in males as compared to females

(8.13% / 6.7% respectively). Trans placental transmission from mother to infant is not the major

route of transmission for HBV, as none of the infants of HBV positive mothers had HBsAg in

cord blood. The route of transmission of hepatitis B in infants is horizontal from mother to

infants as they are close to mothers during infancy. Hence infants of hepatitis B positive mothers

must be vaccinated against hepatitis B. Sub types of hepatitis B have different geographical

distribution. The four major sub types of HBsAg are ayw, adw, adr, and ayr. In our country, the

most prevalent sub type is ayw (78-95%), adw prevalence is (2.4-14%), adr (1.0-7.7%) and ayr

(2.4%). Delta hepatitis poses a common community health problem in Pakistan.In patients with
 Prevelence Of Hepatitis In Pakistan, page 4

chronic and fulminant type of hepatitis 52 percent of the cases among hepatitis B patients had

delta infection. The death rate in cases with delta infection was 30 percent and it was associated

with fulminant type of hepatitis. It was also studied in dialysis patients and the incidence of delta

infection was 14 percent in patients who had hepatitis B during dialysis. The persons who have

recovered after hepatitis B infection develop antibodies against hepatitis B. More than 17.6

percent of the random blood donors were found positive for anti-HBs. Immune status of medical

and para medical staff was 45 percent as compared to 28 percent in matched controls. In a

number of studies the prevalence of anti-HBs was 12.2 - 40 percent.

Nonea Non B is now identified as hepatitis C and E virus infection. Its incubation period is 6 to 8

weeks. It causes a milder form of acute hepatitis than Hepatitis B but 50 percent individuals

develop chronic infection following exposures. It may cause chronic liver disease and

hepatocellular carcinoma. It spreads through blood products, blood transfusion, organ donation,

and intravenous drugs abusers. Hepatitis C may be community acquired but the mechanism is

not clear. It is endemic worldwide and has high incidence in Japan, Italy, Spain and South

Africa. In Pakistan at least four percent of the blood donors have HCV antibodies. Hepatitis E is

identified as the cause of enterically transmitted water borne epidemics. HEV epidemics have

been reported from different parts of our country. The cause was contaminated water supply.

HEV is becoming a threat because of increasing population and the rusting of the water supply

pipes. The largest outbreak of Hepatitis E was reported in 1993-1994 in the capital city of

Islamabad. It affected 3827 people and was due to contamination of water supply with sewage.

Nearby areas with independent and clean water supply were spared . Chronic Hepatitis B is a
 Prevelence Of Hepatitis In Pakistan, page 5

serious clinical problem in Pakistan. It is the second most important cause of liver cirrhosis and

hepatocellular carcinoma following Hepatitis C. Since there has been a significant addition of

new scientific knowledge in recent times regarding the management strategies of Hepatitis B, the

Pakistan Society for the Study of Liver Diseases (PSSLD) decided to develop updated local

guidelines in its annual meeting held in November 2008. Practicing hepatologists and

gastroenterologists from all over the country attended the meeting and participated in the

discussion. The members of the panel made presentations on different aspects of the disease. The

objectives were to incorporate the existing data and simplify the complex issues for better

understanding of our healthcare providers who are managing all kinds of liver related problems.

Risk factors for Hepatitis B spread include the number of therapeutic injections received per

year, improper sterilization of invasive medical devices including surgical and dental

instruments, circumcision and cord cutting instruments, and re-use of razors by street barbers.

Horizontal transmission in early childhood is an important mode of transmission. A proportion of

children become HBV positive from HBsAg-positive siblings and this risk increases with age.

Vertical transmission from infected mothers to their neonates is also a contributing factor in

Pakistani population.

Hepatitis C virus (HCV) is a major cause of liver disease and has a high potential to cause

significant morbidity and mortality. Prevalence of HCV in Pakistan is among the highest in the

world and estimated to be 4.8%. Although, 10 million people are infected with HCV in Pakistan,

very little is known about its epidemiology and there is scarce reliable information about its

prevalence in different areas of the country .The major modes of HCV transmission in Pakistan
 Prevelence Of Hepatitis In Pakistan, page 6

are use of contaminated needles and instruments in medical practice, unsafe blood and blood

product transfusion,intravenous drug use, face and armpit shaving with unsterilised instruments

by barbers, ear and nose piercing, poor personal hygiene habits and quackery (poor medical

practice by non-qualified people). The single most important cause of HCV transmission in the

country is lack of proper screening of the transfusion blood. HCV infection has serious sequale;

it can lead to acute hepatitis, chronic hepatitis or a chronic carrier state and may ultimately lead

to end stage liver disease, cirrhosis or hepato-cellular carcinoma (HCC), all of which are

irreversible conditions. More than half of all HCV infections lead to chronic liver disease, and

majority of HCC cases in Pakistan are associated with HCV. No vaccine or post exposure

prophylaxis is available for HCV as yet, treatment cost is very high and response to treatment is

variable. However, its spread can be curtailed by adopting certain preventive measures, such as,

ensuring safe blood supply, better injection practices, reducing injection drug use and education

and awareness of the masses.It is feared that HCV prevalence may be considerably higher in the

Hazara Division, particularly in the aftermath of October 2005 earthquake, which took more than

100,000 lives. Use of unscreened blood for transfusions and surgeries performed without

meticulous sterilisation form the basis of this fear. However, the fact remains that no reliable

baseline information is available on HCV prevalence in the area. Only a handful of studies have

attempted to estimate HCV prevalence in Hazara. The availability of accurate baseline data is

essential to monitor the trend of a disease and to measure the impact of any intervention in a

particular area.Recent research shows that HCV knowledge and awareness is very low among

general population in Pakistan, particularly among women and less educated people . Keeping in
 Prevelence Of Hepatitis In Pakistan, page 7

view the low literacy and high poverty rates in Hazara, HCV awareness is expected to be very

low. In addition, limited healthcare facilities, preponderance of unqualified practitioners and less

penetration of the mass media make it very prone to HCV spread. However, no attempt has been

made to estimate the prevalence of HCV in Tehsil Oghi, to date.

An international non-governmental organization (NGO) working in the area took the initiative

and sanctioned a research study in three most populous Union Councils (UCs) of Tehsil Oghi.

The aim of this study is to estimate the prevalence of HCV and to assess knowledge and

awareness of the general population regarding HCV in Union Councils Oghi, Shamdhara and

Kathai.Pakistan is a developing country with high population density and limited resources so it

is hard to afford high cost of treating hepatitis and hepatitis associated with complications.

Currently, the best way should be to know the exact prevalence of hepatitis in the country and

also the major risk and infection factors so they could be targeted specifically. It is necessary to

establish regional laboratories in each province to have exact estimate of hepatitis burden in

Pakistan. There should be one central institute for hepatitis research, which should be linked

with all the regional laboratories as well as treatment centers/hospitals and also make

recommendation for government on prevention and treatment options. In addition, the

institute will run and monitor the clinical trials with new and emerging treatment which could

be provided to patients in the future.

In Pakistan there an urgent need to raise the public awareness about importance of properly

screened blood transfusion, use of disposable needles and using new blades for shaving and

haircuts especially at barbers shops. In our study, the important contributors for different types of

hepatitis were blood transfusion, surgical procedures and history of piercing.

 Prevelence Of Hepatitis In Pakistan, page 8

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