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May 19, 2019

Assessment of feasibility and cost of Hepatitis C elimination in Pakistan


May 19, 2019

In a very interesting study published in the May supplement of the prestigious journal of American Medical Association (JAMA) by two scientists of Pakistani descent working in North America, Dr Fasiha Kanwal and Naveed Janjua along with their other colleagues have highlighted the importance of understanding the HCV infection dynamics in Pakistani population and havocs in terms of preventable deaths and health related costs expected to be incurred if the patients are left untreated.

A very serious question has been raised on the issue of possibility to “eliminate HCV from Pakistan by 2030 as per the guidelines from WHO and the costs.” This analytical model study found that an estimated 25 million people would need to be screened every year to diagnose 900,000 hepatitis C virus infections and 700,000 patients would need treatment per year to eliminate hepatitis C virus infection in Pakistan. This strategy was estimated to be associated with 323,000 liver-related deaths averted and cost savings of $2.6 billion till 2030.

In case an effective intervention as per the directions of WHO in terms of scaling up the case identification, establishment of strong linkage to care and drug and doctor availability to the mostly ignorant and illiterate community is not made at the earliest, i.e. a status quo is maintained, the expected impact is going to be huge. Some 1.44 million people are projected to die of HCV infection; 48% of deaths would be among people younger than 50 years. To achieve HCV elimination in Pakistan, HCV testing would need to be scaled up to at least 25 million people to diagnose 900,000 persons and treatment to 700,000 people per year. Compared with the status quo, the elimination scenario would avert 323,000 liver-related deaths and 13.0 million HCV-associated disability-adjusted life-years from 2015 to 2030. The elimination scenario is expected to be associated with cost savings of $2.6 billion from 2018 to 2030 with use of a point-of-care test for population-wide antibody screening and detection of viremia and treatment response.

In the past important initiatives have been taken by the government of Punjab in line with SDG's 2030 and WHO guidelines to eliminate hepatitis from its member countries. Pakistan is unfortunately one of the high HCV viremic countries of the world and need to upgrade the already substantial efforts made in this regard. Hepatitis clinics have been established with the required human resource at all the autonomous teaching medical institutes, more than 125 DHQ and THQ hospitals across the Punjab province along with a back up of liver transplant center in the form of Punjab Kidney and Liver Institute and newly created GI units attached with teaching institutes to cater for the needs of liver patients developing complications. Medicines and diagnostic kits have been made available at the sentinel sites and up till now more than 120,000 patients have been treated at these centers.

Doctors, nurses and paramedics have been provided treatment to scale up the treatment facilities at the sentinel sites. Specialized Healthcare department and Primary and Secondary Healthcare departments are collaborating effectively to meet the challenge of scaling up the treatment facilities but a challenge remains to find the 'missing millions of HCV patients' which are ignorant of their disease or they are ignoring the importance of an early treatment.

The news of spread of HIV is an eye opener for all of us and effective measures need to be adopted by society to control the spread of blood-borne infections. It is pertinent to point out that the mechanism of spread of hepatitis B & C and HIV are similar. It is important to identify the gaps in the screening, awareness, diagnosis and treatment. Linkage to care which though already exists but needs further strengthening.

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