akistan may have to revise its targets for the elimination of hepatitis B and C by 2030. The country is falling behind its global promise of ensuring a fitting response to eradicating viral infections under the Sustainable Development Goals (SDGs).

The major goals of WHO’s Global Health Sector Strategy (GHSS) on viral hepatitis are to reduce hepatitis incidence by 90 percent and mortality by 65 percent by 2030.

To achieve this target, Pakistan needs to treat 850,000 patients per annum. However, this year its capacity to treat viral hepatitis stands at 75,000. This makes it unlikely to meet the target within the stipulated timeframe.

“The number of patients receiving treatment has declined in recent years after all healthcare resources were diverted to combat the Covid-19 pandemic. Pakistan, however, is gradually catching up with its plan to treat 150,000 patients next year,” says Dr Shahid Magsi, project director of the Punjab Hepatitis Control Programme.

The Coalition for Global Hepatitis Elimination (CGHE) recently launched Pakistan’s National Hepatitis Elimination Profile (N-HEP). The country, as per previous estimates, has the second highest burden of HCV with 9.8 million people living with chronic HCV globally. “With recent advances in Egypt, Pakistan may now be the highest-burden country,” it noted.

Pakistan and Egypt are among 21 member states of the Eastern Mediterranean Regional Office (EMRO), where more than 15 million people are chronically infected with hepatitis C and 21 million with hepatitis B. Pakistan and Egypt together account for 80 percent of this disease burden in the region.

“Egypt, however, has adopted a very robust model of screening/ testing people, provision of medicines to patients and then following-up to ensure compliance that has put the country on course to eliminating hepatitis C by 2030,” says Prof Dr Kashif Malik, consultant gastroenterologist and head of Department of Gastroenterology at Shaikh Zayed Hospital, Lahore.

Pakistan’s commitment to eliminating viral hepatitis by 2030 has to be revised as the country’s response has been limited to targeted population in pockets alone unlike Egypt’s screening and treatment on a mass scale.

Prof Kashif Malik, who is also the president of the Pakistan Society of Hepatology, says that Pakistan does not have the latest consolidated data and demography of hepatitis prevalence to plan a response to the challenge. The last national survey, conducted in 2005-06, registered a prevalence of 5 to 6 percent of hepatitis C and 2 to 4 percent of hepatitis B in the country. The prevalence of hepatitis in Pakistan on an average has reached 10 percent. Saying the current prevalence is likely to double, he emphasises the need to establish a national registry for taking a census of hepatitis in Pakistan.

As many as 12 million people are suffering from hepatitis in the Punjab having a population of around 120 million. However, as per the Punjab Hepatitis Control Programme data, less than 20 percent of the estimated 12 million infected people have been registered at hepatitis clinics established at DHQ, THQ hospitals and teaching hospitals across the Punjab. Out of 2.242 million registered patients, roughly 20 percent (416,392 HCV patients and 46,427 HBV patients) are getting treatment at these facilities. This suggests that a majority of the registered patients are not accessing treatment while others remain unaware.

A large number of people in Pakistan suffering from chronic hepatitis remain unaware of their condition.

A large number of people in Pakistan suffering from chronic hepatitis remain unaware of their condition. Chronic hepatitis is known as a silent killer because symptoms may develop decades after exposure, when significant damage to the liver has already occurred. This irreversible stage of advanced liver disease, known as cirrhosis, can lead to liver cancer and/ or liver failure and death.

“According to an estimate, only 10 percent of people with hepatitis B are aware of their diagnosis and only 21 percent of people with hepatitis C, the world over, are aware of their infection,” says Dr Aasim Yusuf, consultant gastroenterologist at the Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore. He says that the treatment of liver cancer is both clinically challenging and resource intensive, emphasising the importance of prevention, early diagnosis and treatment of hepatitis B and C.

Unlike water and food-borne hepatitis A and E, hepatitis B, C and D are transmitted by infected blood and body fluids. Hepatitis D occurs only among patients suffering from hepatitis B. The major causes of these infections are unsafe injection practices, transfusion of un-screened blood, quackery or unsafe surgical/ dental practices, mother to child, ear/ nose piercing, barber/ beautician’s contaminated instruments and unsafe sex, etc. Lack of awareness, absence of screening programmes, non-affordability and paucity of treatment facilities make matters worse.

Acute hepatitis – hepatitis B in general and A & E in particular – has a duration of one to six months as hepatitis A & E are self-limiting. Chronic hepatitis, usually hepatitis C, goes beyond six months with no symptoms. It is only detected after screening at an early stage or development of complications at a later stage.

Hepatitis E among pregnant women is life-threatening with up to 30 percent chances of death. Therefore, it is extremely important for women to eat and drink healthy during pregnancy and get the available vaccines for hepatitis E and B.

Dr Israr ul Haque Toor, a consultant gastroenterologist at the Lahore General Hospital and president of the Punjab chapter of the Pakistan Society of Gastroenterology, says that Pakistan has one of the highest numbers of injections per patient ratio in the world, as on an average, eight injections are administered per person per year in the country. The number is linked to the risk of hepatitis B and C infection.

He says that the vaccine against hepatitis B is available and that the government has included it in the Expanded Programme of Immunisation (EPI). Although, the EPI has considerably reduced the incidence of hepatitis B in urban areas, it is still an epidemic in South Punjab, Balochistan, interior Sindh and rural parts of Khyber Pakhtunkhwa. Therefore, he says, coordinated and sustained efforts are needed to identify missing millions, who are suffering from hepatitis without being aware of it through screening and start their treatment in order to defeat the disease.

According to the Coalition for Global Hepatitis Elimination (CGHE), Pakistan’s Covid-19 response has led to a large increase in the capacity for PCR testing, electronic health reporting and improved coordination across provinces and the federal capital as far as the pandemic is concerned. Otherwise, generally, there is a lack of coordination across federal, provincial and local governments with regards to hepatitis response. In the absence of a centralised oversight, there is also a lack of effective monitoring and evaluation of the provincial hepatitis control programmes.

CGHE claims that approximately half of all blood donors are not screened for HCV, HBV, and HIV in Pakistan; a scale-up of point-of-care testing is needed for early detection in order to disrupt the cycle of infection and transmission.

As the world commemorates the International Day of Epidemic Preparedness on December 27, given the lack of political commitment and resources, the prospects of Pakistan’s target of eliminating viral hepatitis by 2030 being met do not appear bright.

The writer is an investigative journalist associated with The News International, Pakistan. An EWC and GIJN fellow, he also contributes to various international media outlets. He tweets at @AmerMalik3