Saturday, May 7, 2011

HEPATITIS IS A SILENT KILLER IN PAKISTAN.


HEPATITIC LIVER

A person may have hepatitis virus while not being aware of it as sometimes in the case of HBV infection, the primary cause of the disease, has no symptoms at all. The newborns are at particular risk as they can get HBV at birth. The failure of the government to include hepatitis B in the immunization programme and the absence of creating the public awareness that the situation demands, is putting millions of new born at high risk. This is more fearful as Pakistan already has a high infant mortality rate of 88 per 1000 and under-five mortality rate of even higher as 123 per 1000. While children are at particular risk, the huge majority of adult population is also at the risk due to lack of public awareness in Pakistan. Even the medical profession, which should have played its due role to create the public awareness, has failed to fulfil its obligations to a great extent. For instance, a fairly educated father of a new born baby was given a vaccination card by the doctor at the clinic where his son was delivered. While the card listed six fatal diseases— poliomyelitis, neo-natal tetanus, pertussis, diphtheria, tuberculosis and measles, included on the Extended Programme of Immunization (EPI) of the government, it only mentioned hepatitis B vaccination as optional. This is also the case with the majority of the maternity hospitals as the government has not officially included the hepatitis B vaccination in the EPI. The majority of population, not only the vast number of illiterates but also many in the fairly educated group, are thus unaware that hepatitis B vaccination is no more optional but a must. The mass unawareness and the lack of concern on the part of the government are putting the lives of the majority of newborns at grave risks. Sources in the medical profession, who chose to remain anonymous, blamed the indifference of the government to include hepatitis B in the national immunization programme on account of non-allocation of funds. As is, the health sector has been allocated a meagre Rs 2.7 billion in the Budget 1999-2000 which translates into just 2.3 per cent of the funds allocated for the development expenditure only a part of which will go the existing EPI. Sources blamed the reluctance on the part of the government to officially include the hepatitis B in the national immunization programme as it would mean making provisions for funds. As hepatitis B vaccination is fairly expensive the inclusion would mean an allocation of Rs 3.25 billion to vaccinate about 5 million babies every year. However, the economic justification is medically and morally unacceptable as it put the lives of babies at great mortal risk. The cost of hepatitis B vaccination, which is administered in three doses over two months, is high for a poor country like Pakistan where many find it unaffordable. Unlike developed countries where hepatitis vaccines cost no more than buying a bottle of mineral water in a restaurant, the cost of the vaccination in Pakistan, which is totally dependent on imported vaccine, is highly expensive. Hepatitis B vaccination in Pakistan costs Rs 645 for children and almost Rs 1,100 for adults for all three doses. While the government has chosen not to play a role in the vaccination of hepatitis B, the Pakistan Medical Association (PMA) has been trying to create public awareness on the issue for the last two years. However, it was only recently that the PMA initiated a media campaign to set up hepatitis B vaccination centres in the country.
The PMA has established 12 centres in Karachi offering hepatitis B vaccination for both, adults and children, at a ‘discounted rate’. PAGE visited one of the twelve centres, at PMA House, on two consecutive days and found not a single administration of the vaccination. The attendant, however, claimed that the campaign, started two weeks ago (to end on August 15), vaccinated some 30-35 persons per day initially and some 65 persons a day in its finishing phase. Half of those administered vaccination were children, he added.

The multinational pharmaceutical company, SmithKline Beecham, is providing the hepatitis B vaccine, imported from its parent company in Belgium, at a discounted rate for the PMA campaign. Beecham is providing the two dosages of the Vaccine— 10 mcg for person’s up to 19 years of age and 20 mcg for all those above— at four per cent discount. While the vaccine is available for Rs 205 and Rs 340 at the designated vaccination centres as compared to Rs 214 and Rs 354 in the open market, the centres does not charge for disposable syringes and the fee, a saving of about Rs 30. Sources told PAGE that while the PMA awareness drive, over the last two years, has been able to create a greater awareness about the hepatitis B, much remains to be done as not even one per cent population of Pakistan is vaccinated against the deadly disease. Though the awareness has grown somewhat in the urban centres, the bulk of population still remains oblivious to the risk that hepatitis B poses to their health. The situation in the rural areas, which houses the majority of Pakistan’s population, is worse.
Even in the urban centres, such as Karachi, the campaign has elicited diametrically opposite response from basically two segments of the populace, those who can afford it and those who cannot. Sources told PAGE that the lower income group has shown much greater interest in the campaign as compared to those who could easily afford it. However, despite the overwhelming response the former are finding it difficult to afford. On the other hand only a small portion of those who can afford it, has chosen to get vaccinated, PAGE was informed.
HEPATITIS CAN BE PREVENTE AND CONTROL IF…
  1. Government should established Screening / diagnosis centres for hepatitis at Teaching & DHQ level Hospitals free of cost, that every one 
  2. Government and NGOs provide Counselling and treatment facilities of chronic liver diseases at Provincial, District and Tehsil level hospitals in a phased manner.
  3. Establishment of Reference water quality control laboratories at National institute of health (NIH) and at Provincial level.
  4. Improvement of health care provider’s knowledge for prevention of Hepatitis through focus on injection safety.
  5. Safe blood transfusion practices.
  6. Hospital Waste Management System.
  7. Introduction of lab based surveillance system for evidence based policy decisions and creating opportunity for epidemiological research studies mainly community based and establishment of provincial satellite offices of the Provincial Coordinator.
  8. Advocacy and Behaviour Change Communication (BCC) Strategy development and execution on persistent basis for prevention of Hepatitis by creating awareness among general masses for adoption of healthy practices.
  9. Strengthening of routine immunization services of Hepatitis B vaccine for infants through provision of immunization against Hepatitis B in children below one year of age by using Expanded Program of immunization infrastructure.
  10. Reduction of vulnerability to Hepatitis in medical staff of public sector and other High Risk Group.
In addition to receiving vaccinations against hepatitis A and B, here's how to protect yourself against hepatitis virus infection:
Ø  Don't have unprotected sex.
Ø  Avoid intravenous drug use and sharing of drug paraphernalia.
Ø  Wash your hands before handling food and after using the bathroom.
Ø  Be sure tattoo or piercing shops sterilize needles and other equipment properly.
Ø  Don't share toothbrushes or razors. Hepatitis can be transmitted through sores or cuts.
Ø  Avoid eating raw shellfish (such as clams or oysters). You could put yourself at risk for hepatitis A if the shellfish was harvested from contaminated water.
Ø  Hepatitis infection can be serious, but knowing what puts you at risk can help protect you.

Sunday, May 1, 2011

Hepatitis is big challenge in Pakistan.

 Hepatitis C virus (HCV) is well known etiological agent for causing chronic hepatitis, liver cirrhosis and hepatocellular carcinoma in developing as well as developed countries. An estimated 170 million people are chronically infected with HCV and 3–4 million people are newly infected each year. The World Health Organization estimates that approximately 3% of the world population has been infected with HCV.
HCV infections are serious public health concern in Pakistan. The first description of HCV in Pakistan was in 1992 and since then there is no proper review. With approximately 6% of the population being affected by it (approximately 10 million), it is becoming a Herculean challenge. With the current disease burden, Pakistan has Left behind all the major developed countries like Japan, USA and Europe. The annual incidence of HCV in the industrialized nations has fallen in recent years, primarily because of effective blood screening efforts and increased education on the dangers of needle sharing. Contrary to that the burden of HCV related chronic liver disease (CLD) in Pakistan has increased. Studies from the past showed that of all patients presenting with CLD, 16.6% were anti-HCV antibody positive but more recent data shows nearly 60–70% patients with CLD tend to be positive. Medical literature had also reported that nearly 50% patients with hepatocellular carcinoma (HCC) in Pakistan are anti- HCV antibody positive. Past medical literature reports a highly variable seroprevalence of HCV from different studies in different population and the trend continues within the same province. The reason is primarily attributed to HCV being a blood-borne infection, spreads rather sporadically or in micro epidemics. The most predominant HCV genotype is genotype 3 (75-90%), followed by genotypes 1, 2, and 5. In Pakistan, several population groups have been described as being at increased risk of HCV infection. In several published studies, the proportion of patients with HCV infection who received injections is in the range of 16% to 100%. High prevalence of HCV has been recorded among middle-aged (40-50 years) people[6]. Haemodialysis patients were also noted to be at high risk of HCV infection. High HCV prevalence (23.7% to 68.0%) has been noted in this group of patients, and particularly those on long-term haemodialysis. There are about 1.5 million units of blood products transfused each year in Pakistan. Data on the safety of this transfusion process is rare which may be due to the lack of system of reporting infectious or non-infectious adverse events. The risk of HCV transmission through blood transfusion in Pakistan is still unknown but is considered to be high due to a lack of appropriate screening of blood. Also, number of studies have shown the relationship between therapeutic injections using non-sterile needles and the transmission of HCV. There is an enormous dependence on parenteral therapy for treatment, both in the form of injections and infusion of drips, driven by cultural beliefs in the power of parenteral therapy. The general population of Pakistan typically prefers to be treated by injection rather than oral medication. Thus, patient demands and financial incentives for doctors favor the use of injectable treatment in patient care. Another significant risk factor of HCV transmission which had previously been reported from different regions of Pakistan is daily face and armpit shaving at community barber shops. The delicate skin of the face and armpit are susceptible to micro trauma, Hepatitis C in Pakistan- A neglected challenge leading to possible exposure to HCV through a contaminated traditional long-handled razor. Additional risk factors that may be important modes of transmission include ear piercing and non-sterile surgical and dental practices of unqualified health care workers. The HCV epidemic in Pakistan continues to rise due to lack of education and awareness of the disease, shortage of medically qualified and scientifically trained health care workers and lack of health infrastructure. The government of Pakistan had taken some steps in this area in the past, by announcing a national blood policy in 2003. In 2001–2002 Pakistan received a grant from the Global Alliance for Vaccines and Immunization (GAVI) that has enabled the introduction of Hepatitis B vaccination in routine Expanded Program on Immunization (EPI). Vaccination for HBV as part of EPI was launched in a nationwide vaccination campaign in 2004. Unfortunately, HCV infection is not a notifiable disease in Pakistan and there is no national data collection system for evaluation of routine risk factors. In March 2009, government officials reported the Senate that around 8,800,000 people in Pakistan are suffering from deadly hepatitis C while another 5,600,000 are affected by hepatitis B and that availability of diagnostic facilities and awareness campaigns have un-earthed the hidden burden of the disease. The Prime Minister Programme for Prevention and Control of Hepatitis was launched in August 2005 with a total cost of Rs 2.594 billion for a period of five years. The number of patients with the disease since then has increased significantly as the government started to provide free treatment, though on a limited scale. When the programme was launched in 2005-06 the number of patients, most of them poor, who were registered and treated at government hospitals were 10,815 and 1,000 for hepatitis C and B respectively. For the year 2008-09 the figure is 84,773 and 7,204 respectively for the two categories of the disease. If we critically analyze the figures with the present disease burden, we confront with the harsh fact that the gap between people getting affected each year and getting treatment is too wide and only a small population is seeking care with yet uninvestigated numbers of actually getting rid of the disease. The picture gets even gloomier if we realize that this what government is reporting and the ground reality may be even worse. The increasing HCV epidemic is likely to progress to a considerable increase in disease burden over the coming years. The pillars of HCV infection control are blood safety, the prevention of needle sharing among Intravenous Drug Users (IVD), the strict implementation of standardized preventive measures in healthcare settings, screening of at risk groups and treatment of chronic hepatitis with multiple drug therapy (pegylated interferon and ribavirin). Despite its public health importance, however, how surveillance systems for hepatitis C should be designed is still a matter of debate. Cross sectional surveys on at risk population or groups are essential to estimate the burden of HCV infection and to describe affected persons who will need to be targeted for screening and treatment. However, they reflect past transmission routes, provide no information on the current dynamics of HCV transmission and no data on people currently getting infected. Although the world is now hearing about Hepatitis awareness specially after commencement of the Hepatitis awareness day On May 19th every year from 2008, numerous efforts are required to prevent this day from becoming an event of seminars, lectures and conferences and the rest of the year , we forget about the disease. We are living unfortunately without HCV vaccine, because of the virus high mutation rate and substantial heterogeneity of the genome of HCV. Still it is largely treatable and HCV infection can be cured by the existing antiviral drugs in more than 50% of the patients. So efforts should be made to save the waste of at least 50% of these needless lives. Hepatitis preventing measures should include a situational analysis and a realistic assessment of the blood requirement in the area, followed by recruitment and maintenance of voluntary, non-remunerated blood donors and standardization and regulation of appropriate blood screening procedures. IDUs are numerous in Pakistani society and though they have a disproportionately high burden of health problems, they have been inadequately studied. Disseminating adequate information about all aspects of HCV is essential in developing patient understanding of the disease. It appears such information can only be effectively and reliably disseminated through effective awareness strategies. We also propose that for health promotion action, programmed should be made to increase awareness and use of specially prepared video clips for the prevention of disease. Media is one of the instrumentalities which facilitates and gives a directional Thrust to the efforts to cure the disease if not to treat it. If medicine can treat Hepatitis, media is capable to prevent it with an ultimate goal to cure it through its capabilities to impart education through entertainment.

Hepatitis vaccination center in Nowshera


Sajid Iqbal Daudzai Advocate Nazim ( Mayor ) Union council
Azakhel Bala Noshera Pukhtoon khwa.

Nowshera District (Khyber pukhtoon khwa, Pakistan) is known for its various types of industries located on the bank of river Kabul. It has borders with Peshawar on the west and Punjab province on the east. Most of the population is Pushto speaking. The district has about 200 villages.Viral Hepatitis is a cause of great concerns the world over and more so in the developing countries especially in Pakistan. Its incidence has already increased to alarming proportions and is likely to increase further in the near future. Among the hepato-celluler viruses, B and C tend to be more severe and lead to chronic conditions, co-morbidity and high case fatality rates. In Pakistan, the following factors are responsible for the spread of these viruses,
1.    Invasive surgical practices,
2.    Infected syringes
3.    Unsafe blood transfusion,
4.    Unhygienic instruments used by barbers and vertical transmission from mother to child during pregnancy.
More than one cause was reported to be risk factor for transmission of the disease by our study group. However the most common causes reported were repeated use of disposable syringes, dental apparatus, nail cutting, and sexual contact amongst many others.
Local studies shows that carrier rate of Hepatitis B Virus (HBV) is 4-10%. It is estimated that 7% of all blood donors, 3.5% of all children and 13% of all cases requiring hemodialysis are Hepatitis B surface Antigen (HBsAg) positive. HBV infection has been reported to cause 31% of acute viral hepatitis cases, 60% of patients with chronic liver disease and 51% of cases of hepato-cellular carcinoma. Whereas, the sero-prevalence of Hepatitis C Virus (HCV) is 6.7% in women and 1.3% in children in Pakistan.3 In Italy about 4,00,000 new cases occur each year. About 200,000-300,000 new cases of Hepatitis B occur annually in the USA Hepatitis C accounts for approximately 20% of cases of acute hepatitis, 70% of chronic hepatitis and 30% of end stage liver disease in the USA. This study was undertaken to assess then knowledge of rural communities in regard to HBV and HCV in 10 villages of District Nowshera, Kyber Pukhtoon khwa, Pakistan. Nazim Sajid Iqbal Daudzai Advocate Nazim (Mayor) union council azakhel bala request from NIH ( National institute of health) to make hepatitis vaccination center in DHQ Hospital Nowshera. Now NIH has vaccination center in DHQ hospital Nowshera. Peoples of nowshera now no need to go NIH or PIMS islamabad for vaccination.