Islamabad : With around 15 million people living with hepatitis B or C in Pakistan, the second-highest incidence in the world, experts have urged the government to adopt a comprehensive approach to significantly check the spread of the viral liver disease, treat patients and resolve the health crisis.
According to a report of the Economist Intelligence Unit, the world’s leading resource for economic and business research, forecasting, and analysis, a national survey from 2007-08 found a prevalence of 4.8 percent for HCV and 2.5 percent for HBV in Pakistan.
More recently, a survey conducted in Punjab province showed that rates of HCV increased sharply from 6.7 percent in 2008 to 17 percent in 2017. However, the prevalence of HBV decreased slightly to 2.2 percent from 2.4 percent over the same period due to the introduction of an HBV vaccination programme for infants at six weeks of age.
Dr Arshad Altaf, a consultant for the World Health Organisation, said reuse of syringes had been the primary cause of high HCV rates in Pakistan, especially in rural districts.
As it is estimated that 17-50 percent of injections are administered with reused syringes, the highly fragmented healthcare system makes it harder to regulate healthcare providers and control injection safety.
“Private providers have mushroomed everywhere. These are responsible for the majority of the injections administered; patients turn to private providers after government hospitals close at 2pm,” Dr Altaf said.
Combined with little public awareness of the risk factors for blood-borne illnesses, especially in rural areas where illiteracy rates are high, syringe reuse has led to the spread of HCV.
Also, the improper disposal of needles and blades at healthcare facilities spreads the disease, while a lack of prevention programmes for high-risk groups, such as drug users and sex workers, has led to frequent co-infection of HIV and hepatitis, which then spreads to lower-risk groups such as children.
The WHO consultant regretted that prevention had never been the focus of any government in Pakistan as everything had been about treatment because it was visible.
“Pakistan needs to focus on prevention—by doing so, we could save a lot of money.”
The experts said public awareness of risk factors, prevention strategies and access to care was imperative for the success of the government’s programme.
“There is very low public awareness of the [viral hepatitis] disease. Many people believe it is spread through unclean water, contaminated food or other environmental problems,” said Dr Huma Qureshi, former executive director of the Pakistan Health Research Council.
Dr Altaf also called for greater public awareness of hepatitis saying it will create caution around common modes of transmission such as contaminated razor blades used at barbers and salons.
“The government will need to develop a tailored message for its country, and it is essential that this is deployed in regional languages. A large share of the population is uneducated and awareness campaigns in English or Urdu only will not be sufficient,” he said.
Regretting many providers, especially untrained ones, are not aware of all risk factors for HCV, the WHO consultant called for training not only on preventative measures but also to facilitate diagnosis at primary healthcare centres.
At present, diagnosis and treatment take place mainly at the tertiary level.
Injection safety was one of the interventions listed in the National Hepatitis Strategic Framework 2017-2021. The target is to replace half of the syringes with auto-disabled ones by 2021.
“Auto-disabled syringes are expected to be phased in over the next two to three years [across Pakistan],” said Dr Qureshi.
Also, the provincial health commissions have the authority to check up on clinics and they will be given extra powers to compel those who are not following the rules.
The experts said improving injection safety would be one of the most critical interventions in Pakistan’s fight against viral hepatitis.
They said though efforts to implement blood safety reforms had fared better, there continued to be gaps in the system.
The experts said for the anti-hepatitis programme to work, managing the fragmented healthcare system was essential.
“The only way this will be successful is if there is strong buy-in from the provinces if there is a strong collaborative effort with the provinces to make it happen,” said Dr Saeed Hamid, professor of gastroenterology at the Aga Khan University, Karachi.
“This needs political will and the ability to find common ground for the benefit of the whole country.”
The gastroenterologist also said setting up a process for data collection across key performance indicators was pivotal for measuring progress and identifying areas, where more aggressive action was needed.