By Dr. Zubia Waqar
Standing in the hospital corridor silently, with the blood reports of his 21 years old son, he realized that the coming years of his son’s life will be filled with pain, sadness and illness. His son started experimenting different drugs early in his life and although he was able to fully recover from his addictions, but just because he himself took his habits as a social norm, he never tried to stop his son. He had no idea, since when his son had switched to injections and now suddenly, diagnosed with Hepatitis C…
Maheen who grew up healthy and happy all her life, was unaware of the fact that her mother passed on the hepatitis virus to her at birth. She found out about her infection through a routine blood test during her first pregnancy in 2004. When Maheen was born, there was no hepatitis B vaccine available to prevent this infection. Had she been immunized within 12 hours of birth, she would be free of infection today…
Shoaib aged 45 living with chronic, active hepatitis C infection, contracted the virus in 1992 during a blood transfusion. His battle begins late at night when he has nothing better to do than lay in bed and think about his bleak situation. The thought that this may very well be the last time he close his eyes in a peaceful sleep, if he can sleep at all. It continues when he sleeps with a headache, nausea, listlessness, and stabbing pain in his side. Then, he directs his attention to overcoming the effects of the 9 micrograms of interferon that was injected into his body the night before. By noon, the fatigue sets in and he is pretty much done for the day, so he sits quietly and wonders what the future holds for him.
These are just few stories out of many, as today around 2 billion are living with hepatitis B globally and more than 400 million have been chronically infected and living as carriers of this disease. However, there is now a new epidemic in the town that’s hepatitis C. It is also known as ‘silent epidemic’. Hepatitis C has infected approximately 170 million people globally. Subsequently, there are 1 million people who die each year as a result of these two highly prevalent infectious diseases. Apart from this increased global burden, now hepatitis B & C infections have started emerging as a threat to public health in many developing countries. Unfortunately, Pakistan is also one of those countries, facing an increased burden of hepatitis. It is due to lack of awareness, prevention and non-availability of treatment. For the ease of identification hepatitis viruses are classified under 5 types to include: A, B, C, D & E hepatitis viruses.
Hepatitis A & E spread through fecal contaminated of food or drinking water, whilst B, C & D spread through blood, sexual contact, use of infected syringes and from mother to child route. Hepatitis D is caused by an incomplete virus that cannot survive without HBV. As there is no treatment for the Delta virus mortality rates in these cases are the highest.
Acute hepatitis B in adults has shown more than 90% recovery rates with only 10% living as infected carriers of this disease. However, in children a reversed trend has been observed indicating 90% population living as carriers and only 10% recover from this disease making children prime victims. With regards to hepatitis C, the sources of transmission are same however; the severity is far higher than HBV virus, indicating that only 20% of the cases recover, whilst 80% develop chronic liver disease over the next 10-15 years.
According to the results of prevalence survey in Pakistan approximately 12 million have been exposed of either of these two infections. Mother to child transmission of HBV has been reported as the primary route of transmission in Asia and vaccination is the most appropriate answer to prevent it. Despite the fact that Hepatitis B childhood vaccination has shown to result in a significant reduction of hepatitis B infections among vaccinated cohorts: It is unfortunate that according the World Health Organization, “In Pakistan, no newborn infant in 2011 received the first dose of hepatitis B vaccine within 24 hours of birth and 56% of one-year-olds (ages 12–23 months) received three doses of hepatitis B vaccine”. Therefore, implementation of a proper immunization policy is one of the crucial steps in preventing vertical/Perinatal (mother to child) transmission of HBV in lower middle/income population in countries like Pakistan.
According to United Nations Office on Drugs & Crime (2013), 6.45 million, of the population in Pakistan aged between 15 and 64 used drugs in the last 12 months. The studies also reveal that there are around 420,000 people who inject drugs- a higher number than previously reported. The use of contaminated injecting equipment among drug users is one of the major routes of HIV transmission. Almost three-quarters of opiate-using individuals share injecting equipment. Hepatitis prevention and care services remain in short supply throughout Pakistan and, as such, many drug users and their sexual partners are at serious risk of transmitting hepatitis infection and other communicable diseases.
Health care professionals are another group at risk due to increased chances of their exposure to blood. Although, there is a specific national strategy for preventing HBV & HBC in health care professionals, with a strong emphasis to vaccinate health care workers prior to joining such vocation. However, there is a lack of evidence to indicate that these guidelines have been followed by all health providing institutions and organizations. Another interlinked challenge in this context is the management of the hospital waste.
HCV is such a crafty little bug that does not die quite soon (unlike HIV that dies quite soon). Air-borne HCV bites without knowing and how do they know if they or anyone of them have it? They don’t, because the effects of the drugs leave them feeling lethargic, withdrawn and forgetful and this is also what HCV bug does.
Certainly, there is a dire need for a national policy on needle safety in health care settings. There are two sub categories of problems related to needle safety. Firstly, there is an extreme lack of single-use or auto-disable syringes, needles and canula in healthcare facilities. Secondly, according to government officials; health care professionals annually administer twenty percent surplus injections. A reduction in futile injections alongside availability of disposable/auto-disable syringes would surely promote safety measures in health care settings.
Lack of confidentiality and fear to get discriminated also causes taboo among people. As people testing for both hepatitis B and hepatitis C, register by name and there is an open access to their names. Formation of an in-country hepatitis control cell/registry would not only lessen the burden of hidden cases, but will also encourage individuals/subgroups from different ethnic origins to easily communicate with health agencies/organizations. The cost to treat patients with chronic hepatitis B virus or hepatitis C virus infection far outweighs the cost of implementing prevention programs. The government spends approximately Rs 200–300 million (US$ 2.1–3.2 million) per province, annually, on publicly funded treatment for hepatitis B and hepatitis C. However, the budget is incomparably low as compared to the disease prevalence.
Last but not the least, low awareness of viral hepatitis, both in the general population and among key populations, lack of birth dose vaccine, alongside an inter-collaborative approach between government, civil society and mass media has been considered as main stumbling block. Increasing awareness among health care providers and general population would be the only key in making hepatitis a larger part of the local, national and regional health care/prevention agenda.
The writer of the article is a Doctor Alumni from Fatima Jinnah Dental College, Karachi