Water borne epidemic diseases are known to hit larger cities of Pakistan during the monsoon season. The problem arises in the flood-afflicted areas where water sanitation is compromised by botched sewage pipelines that lead to cross contamination.
Each year, Hepatitis claims 1.4 million lives globally, hence its elimination is a goal highlighted in the United Nations 2030 Agenda for Sustainable Development.
Pakistan and Egypt bear 80 percent of the viral Hepatitis disease burden in the Eastern Mediterranean region. Around 12 million people suffer from Hepatitis B or C in Pakistan and around 150,000 new cases are added to this number every year. Hepatitis E alone is responsible for 3.3 million symptomatic cases each year globally. Though challenges for the HCV and HBV demand committed efforts, the seasonal epidemic out breaks due to Hepatitis E virus can be controlled and regulated with timely detection and treatment.
Inflammation Of Liver
Hepatitis viruses cause inflammation and damage of liver. Common symptoms of infectious Hepatitis include: loss of appetite, abdominal pain, weight loss, yellowing of skin, change in coloration of urine and faeces. Depending on the type of the causative virus, it can be of seven types of Hepatitis — A, B, C, D, E, F and G. Hepatitis A, E and F are transmitted due to contamination in food or water sources, mainly due to poor sanitation. Hepatitis B, C, D and G viruses only transmit via blood or body fluids i.e. sexual contact or contaminated blood transfusions. Hepatitis B virus (HBV) is a major killer, leading to 880,000 deaths each year, from Cirrhosis (liver damage by scarring) or Hepatocellular Carcinoma (liver cancer).
The prophylactic vaccine available for HBV is not effective for a large number of chronically infected individuals (around 260 million); and formulation of the therapeutic vaccine TherVacB is still in progress. Hepatitis C spreading through blood and body fluids is treatable with Pegylated interferons and antiviral drugs as per studies, but no vaccine is as yet available for Hepatitis C virus. The Hepatitis Delta that is caused by HDV, co-infects HBV patients, and is responsible for the super-infections or co-infections.
Around 12 million people suffer from Hepatitis B or C in Pakistan and around 150,000 new cases are added to this number every year.
Hepatitis E virus can show increased transmission during heavy rainfall and flooding as observed in the recent HEV cases in Chad due to lack of sanitation, clean drinking water and hygiene. Since there have been other sources of transmission anticipated for HEV infections other than the waterborne and foodborne routes, efforts for its mitigation must extend beyond basic hygiene. HEV vaccine, Hecolin, though licensed for use in China is still under safety trials for approval from other countries.
Let’s dissect the point of care in early detection and timely diagnosis of viral Hepatitis, especially in the lower and middle income countries (LMICs). Liver Function Test (LFT) helps detect and monitor liver damage by the measure of certain enzymes and proteins in blood. As per WHO guidelines, the enzymes alanine transaminase (ALT) and aspartate transaminase (AST) are particularly important in detection of liver damage due to HBV and HCV infection. The rapid diagnostic testing (RDT) include: i) Lateral Flow Rapid Diagnostic Tests, where serum based antigens and antibodies are detected; ii) Nucleic-Acid-Based RDT usually involves a GeneXpert system for automated detection of virus and host nucleic acid by PCR; iii) Dried Blood Spot (DBS)/Microsample Specimen Collection in cases where shipment facilities are not available for blood/serum samples, patient blood is dried on specialized blotting paper and later sent for testing in laboratory. While issues of lower sensitivity, false positive results may be associated with RDTs, these are facilitating in terms of affordability and mass screening of the virus infections especially in LMICs.
In case of HEV diagnosis, RT-PCR is the most frequently used detection method in the developing countries. For an effective diagnosis of acute Hepatitis E, RT-PCR can be combined with anti-HEV IgM ELISA. Unfortunately no ‘gold standard kit’ is as yet available for easy and reliable detection of Hepatitis E in the developing countries. This adds to the difficulty of comparing results and understanding the prevalence of HEV within the developed and developing countries.
Better Sanitary Hygiene Conditions Lessen HEV Burden
HEV infections do not prevail in areas with clean living conditions. They tend to arise in places of humanitarian crisis or in derogatory living environments where water supply is mismanaged and waste materials, mainly excreta, are improperly disposed of. While in the developing countries, an emphasis on personal and community cleanliness can assist in prevention of HEV, the developed countries can regulate the consumption of raw food items and promote consumption of cooked food for this purpose, since HEV RNA can persist in contaminated food products. A major prevention check for HEV virus at blood donation center, including HEV screening prior to blood transfusion, can aid in detection and prevention of Hepatitis E.
The free testing and medication facility for patients suspected of Hepatitis E infection are direly required in the flood-struck areas of Balochistan and KP in present-day circumstances.
Challenge Of Policy Implementation In Health Sector
At present, Pakistan has enhanced PCR testing, viral load testing via GeneXpert, free of cost anti-HCV and HBsAg testing in the public sector, but the challenges towards Hepatitis elimination goals still exist. One such challenge is the lack of effective policy implementation by provincial governments regarding the Sustainable Development Goals (SDG) target 3.3 of eliminating Hepatitis. Two recent reports by the Punjab and Sindh governments have confirmed an alarming rise in the number Hepatitis cases, especially HCV due to hazardous blood transfusion, unsterilized injections, barber’s tools and dentistry equipment.
According to the Punjab Planning and Development Board, despite spending Rs4 billion during 2017-2021, the Prevention & Control of Hepatitis Programme could treat only a few thousand patients, failing to restrict massive transmission of Hepatitis B and C viruses in Punjab. Similarly a survey from Sindh shows a threatening increase in the number of Hepatitis C cases during 2019-2020. We must strive hard to make Hepatitis elimination programme a success by ensuring rigorous screening of the virus infection among masses along with extensive vaccination drives throughout the country.
Coalitions And Actions For Viral Hepatitis Elimination In Pakistan
At present around 12 leading corporate companies are supporting the government of Pakistan’s efforts towards eliminating viral Hepatitis. At national level, public and private groups such as Ferozsons and Nai Zindagi Trust are doing a commendable job in provision of testing and treatment aids against HBV and HCV. Internationally, The Task Force for Global Health, World Health Organization (WHO) and Roche are helping Pakistan in local clinical studies and awareness campaigns against Hepatitis.
The public hospital facilities are providing free of cost screening and testing services for Hepatitis B and C, mainly in Punjab and Sindh. The free testing and medication facility for patients suspected of Hepatitis E infection are direly required in the flood-struck areas of Balochistan and KP in present-day circumstances. The federal and provincial governments must ensure rigorous testing for Hepatitis E in the affected regions so that an impending epidemic can be controlled on time by treatment of infections in their acute phase. This will ensure a lower Hepatitis burden for Pakistan in the longer run, ensuring the success of the strategy devised for the Hepatitis elimination from Pakistan by 2030.