Dr Homie A Razavi is the founder and managing director at Colorado- (United States) based Centre for Disease Analysis Foundation (CDAF), who recently visited Pakistan. Since 2008, Dr Razavi has led a team of epidemiologists and modellers to quantify the epidemiology of hepatitis, forecast the future disease burden and help countries/ territories develop national strategies. The area of focus of the centre is liver diseases. Its mission is to eliminate suffering, adverse societal impact and mortality caused by preventable, treatable diseases. The centre is working in 130 countries now. It recently conducted a detailed study hinting at an alarming rise and spread of hepatitis B and C infections, the two most harmful variants of the disease, in Pakistan. The News on Sunday spoke to Dr Razavi about this situation. 

The News on Sunday: Tell us about the spread of hepatitis study and its outcomes.

Dr Homie Razavi: Liver diseases are some of the fastest-spreading in the world. Right now, the hepatitis C variant (HCV) and hepatitis B variant (HBV) are surpassing HIV and tuberculosis figures. When I decided to start this non-profit, the first idea was to focus on liver disease. We conducted a detailed study with nearly 100,000 samples with the help of local partners and collaborators with extensive work in provinces in the past couple of years. Today sadly, Pakistan has the most hepatitis B and C infections worldwide. We estimate that Pakistan has around 10 million hepatitis C and nearly five million hepatitis B infected persons. We believe that the disease is still underreported as people do not go for screenings, and if they are positive, they do not go for treatment. This number is nearly four percent of the country’s population and rising yearly.

TNS: This is an alarming number. Are people aware of the risks of being an HBV or HCV carrier?

DHR: This is a serious problem. The risks associated with the hepatitis C infection are grave. It can cause liver cancer. The risk of cancer is the same as smoking one pack of cigarettes daily. This virus inflames the liver and leads to cancer. It can take 15-20 years for the virus to damage the liver truly, but in the end one can get liver cancer. However, if the patient was never screened for HCV, it can be difficult to tell if HCV or other factors caused the cancer.

Also, the risk of death is 65 percent in people infected with HCV who remain untreated. We estimate that every 20 minutes, someone dies in Pakistan because of HCV. While around 10 to 20 percent develop cancer, which is one in five. A patient can also develop cirrhosis, which is a severe liver disease. We call it a silent epidemic. There are other hepatitis variants like E, A and delta in Pakistan but B and C are the most harmful.

TNS: Why has Pakistan not been able to curb the spread of these hepatitis variants?

DHR: The key reason for this situation is lack of screening and treatment. This is increasing the number and widening the gap compared to other countries. In 2015, China and Pakistan had nearly the same number of active infections, but in 2022, Pakistan has surpassed Chinese figures. In 2015, Pakistan had 9.8 million infected people, it is crossing 10 million now, while China is trying to contain the disease by treating the patients. Half a million came in the past five years; many died. Our estimates are that as many as 27,000 die each year in Pakistan due to liver cancer, the leading causes of which include the HCV.

TNS: What is the hepatitis B infection situation in Pakistan?

DHR: Currently, around five million people in Pakistan are HBV carriers. Fifty-two percent of all new HBV infections are transmitted from infected mother to child, and 48 percent from blood and sexual encounters. Variant C spreads through syringes and unsafe medical procedures and, but HBV is a little different.

We should bear in mind that by taking treatment, the risk of transmission drops to zero. Currently, most people in Pakistan are unaware of the risks involved in these infections. They are not aware of the disease and its impact.

An estimated 12,000 infants become chronically infected with HBV each year in Pakistan. Since 1985 there has been a vaccine to eradicate HBV. Infant vaccination has become somewhat common since 2002. The good news is that because of this vaccination, children can now be protected from HBV infections; however, the number of affected adults is still quite high. If a child is vaccinated quickly after birth, the virus will not transmit to the child. We need to increase that ratio in Pakistan.

TNS: What does this situation of HBV and HCV mean for Pakistan?

DHR: Most importantly, it has a very serious impact on the economy. Pakistan has a large work force that can face challenges in working abroad as many countries do not allow people infected with B and C. Also, there is quite a bit of stigma attached to the disease in the country.

TNS: What is the way forward for Pakistan to better control the fatal hepatitis B and C variants?

DHR: Serious measures are needed to control the spread of hepatitis B and C. We are talking to the government too and trying to convince them. Luckily, Pakistan is among the countries with the lowest price of medicines for treating hepatitis B and C worldwide. The projections show hepatitis B and C are decreasing in the rest of the world and rising in Pakistan. We should remember that the HCV can be fully cured and is not transmitted after the treatment. Pakistan needs only $350 million to test its whole population and treat it for these two fatal variants of hepatitis. What we need to do first is to test the whole population through a massive door-to-door campaign. The big problem is the government needs to spend the money. If Global Fund is willing to support the screening of pregnant women as part of triple elimination (HBV, HIV and STI), then vaccination of infants born to infected women becomes the least costly program to implement. This strategy will require BD vaccination of only 92,000 infants compared to BD vaccination of 6 million infants under a universal vaccination programme. The treatment of high viral load pregnant women will require treatment for 21,000 women each year. Pakistan has signed the World Health Organisation memorandum to eliminate B and C variants by 2030. We fear that it is not going to meet the target, considering the current situation. The main challenge is having a vaccine programme for the HBV. The 20-year vaccine programme has already seen a positive drop in numbers. We should keep in mind that by taking treatment, the risk of transmission drops to zero. Currently, most people in Pakistan are unaware of the risks involved in these infections. They are not aware of the disease and its impact.

TNS: What is your message for people?

DHR: A survey in the recent past showed that as many as 45 percent of people carrying these infections are aware of the consequences. Most people do not know that hepatitis C is a cancer-causing variant. Also, if one donates blood its screening for these variants is free in Pakistan. My key message is for people to go for testing and donate blood for free testing. If you are tested positive, you must go for treatment. The treatment for C costs $35 only.

TNS: Are there some good examples within developing countries?

DHR: Egypt is a significant example. It started a presidential programme to eliminate hepatitis B and C in 2016 and screened all adults. Today, Egypt has pretty much eliminated the disease. Georgia is another good example. Among the high-income countries, Australia, France, Canada and Denmark have made good progress. However, some countries, like Pakistan, Ukraine and United States, are not making progress at the required level.

The author is a staff reporter. He can be reached at vaqargillani@gmail.com