Each year, on July 28 the World Health Organization (WHO) and other health organizations mark World Hepatitis Day. This year’s theme “This is Hepatitis. . .Know it. . .Confront it” sends a strong message to the world to recognize hepatitis as a forefront runner in communicable diseases.
We must now move from acknowledging the disease to confronting it with actionable planning and commitment. The burden of this disease is unparalleled. To give a better picture, consider this: the death rate from Hepatitis is nearly twice that of AIDS. In Pakistan, there are over 12 million people suffering from Hepatitis B and C; around 8 million suffer from Hepatitis C and 4 million from Hepatitis B.
Our health care is crippled with patients suffering from chronic liver disease due to hepatitis. What makes matters infinitely worse is the fact that the rural population in Pakistan - already reeling from poverty and illiteracy - receive little to no education on prevention of disease spread. As a result, the prevalence of Hepatitis C is much higher in the rural population, as research studies have shown. With over 60% of Pakistan’s population living in rural areas – this is a cause of major concern.
What is Hepatitis?
The Hepatitis virus exists in five different types, A to E. Hepatitis A is the most common form of Hepatitis. This type is contracted from oral ingestion of the virus, most commonly from contaminated water sources and foods. Over 90% of Pakistan’s population is exposed to Hepatitis A by the age of 5 and 98-99% by adulthood. Fortunately, this form of Hepatitis is self limiting and resolves completely in a majority of patients. Very rarely does it ever progress to a life threatening chronic form.
The real worry comes with Hepatitis B and C – these viruses can lead to chronic liver disease or worse, cancer.
The main reason for such high Hepatitis B and C numbers is the lack of awareness and the subtle symptoms that the disease presents itself with. Hepatitis C progresses to a fatal chronic form or cancer in 80% of the infected persons and it rarely presents with an acute symptomatic phase. Majority of the patients experience fatigue as the most common presenting complaint and it is for this reason that the disease goes unnoticed until it has progressed to a severely debilitating stage.
Many patients transmit the disease to others unknowingly. The spread of disease to an intra-family member, especially spouse is reported as high as 23% in one study.
The most common method of transmission for the B and C types of hepatitis in Pakistan are from the use of substandard syringes, reuse of syringes, poor screening of blood products before transfusions, contaminated dental and medical equipment, sex workers practising unprotected sex, barbers sharing razors, and intravenous drug abusers sharing needles.
Many experts have pointed to specific dangerous practises which play a significant role in the spread of this disease in our society.
Noreen Jiwani, of Agha Khan University Hospital, in her paper “A Silent Storm: Hepatitis C in Pakistan”, points to improper disposal of hospital waste as a critical factor in spread of Hepatitis C.“In Karachi, a very young scavenger of waste products, around 18 to 20 years of age sells 20 to 25 syringes per day to the health care waste dealers against money and the same child gets needle stick injury around none to three times per week”.
The already used needles are recycled illegally and put back into the market for unsuspecting buyers. This practise can only be controlled by strict regulations and installation of much needed hospital waste disposal facilities.
However, the prevention of this disease is not all that simple. In a nation where close to half the population is illiterate and an economy that’s spiralling downwards, there is an urgent need for the implementation of programs that engage communities in urban and rural areas. There is a dire need for people to understand this virus and how to prevent it. With limited resources and funding, it becomes difficult to motivate already underpaid health care workers to assert the necessary influence that is required in educating the general public on prevention of disease. Health care workers play a critical role in providing treatment, education, psychological and family counselling as well as regular follow-ups. A great deal of motivation is required to fulfil these duties and the onus falls on the government to allocate greater funding of programs that focus on confronting Hepatitis head on.
Additionally, the learned general public must also play a role to voluntarily pass on information. Simple advice on just the importance of hygiene can go a long way. Moreover, educating people on safe practices - for example only buying syringes from reputable manufacturers, taking your own pair of scissors and shaving razors to the barber, only visiting reliable and reputable dentists and medical facilities, practising safe sex and making sure that blood is screened for hepatitis prior to being transfused into a patient - can all make a big difference in controlling the disease in urban centers.
Hepatitis C has remained a death sentence for a majority of the population affected in Pakistan. However, there is some good news on the horizon for patients suffering from this virus; advances in pharmaceutical research has led to significant strides in detecting the specific genotype of the disease more accurately and manufacturing targeted therapy against it.
Sofosbuvir is a new drug still in its late trial phase. This drug has all the potential to be a game-changer in treatment of Hepatitis C. Many prestigious medical research institutes in the US have expressed immense faith in the new therapy. Whether it will be feasible for an average Pakistani, though, is yet to be determined.
The issue of feasibility in Hepatitis C treatment is a cause of major concern. It is disconcerting that only 2% of Pakistani’s suffering from Hepatitis C are able to afford the necessary treatment. In the past, locally made and affordable therapy was sidelined by bureaucracy and red tape.
Dr. Sheikh Riazuddin and his team of researchers at the Centre of Excellence in Molecular Biology (CEMB) of the Centre of Applied Molecular Biology (CAMB) successfully manufactured a version of interferon (current standard of treatment for Hepatitis C) for just Rs. 50. The locally manufactured drug was tested and approved for use by labs in both the US and Germany. The drug could easily replace the exorbitantly priced imported interferon which costs approximately Rs. 1000.
Sadly, this idea had its wings clipped by law-makers who succumbed to pressure from various multi-national pharmaceutical lobby groups.
Pharmaceutical giants exert a strong influence on which drugs are available and at what price. Too often, locally made medications do not serve profit driven interests of multi-national companies. Millions of lives can be saved and a great burden lifted off our health care if only the lawmakers act in the interest of the people.
While eradication of hepatitis is a far cry. Our best hope is to bring the attack rate down by implementing better preventive programs. Our lawmaker’s must play a pivotal role in turning this around. By directing more funds and resources towards programs that educate the general public, we can drastically reduce the spread of the disease. Provision of affordable medication for the general public will also serve to save millions and reduce the occupancy of hospital beds in government hospitals. Last, staying up to date with breakthrough treatment options should always be discussed and options to make those treatments available for people should be weighed.
We must confront hepatitis with serious efforts before it’s too late.
The writer a doctor based in Toronto, Canada
