Hepatitis is a major cause of morbidity and mortality worldwide and a rising concern in Asian countries.

Developing countries are at a high risk of infection with oro-fecal pathogens. Food-borne viral hepatitis includes hepatitis A and E. In Pakistan, poor sanitary conditions and lack of hygiene practices lead to 90 percent of children being infected with hepatitis A before reaching 10 years of age. Hepatitis E has occurred in outbreaks and sporadic cases in circumstances involving clustering of large numbers of people in areas where the water supply was contaminated. Overcrowding reflects poor sanitation and lifestyle in this patient population. The disease has produced catastrophic effects in pregnant women across the country, resulting in maternal mortality rates ranging between 20 and 29.3 percent and peri-natal mortality rate of up to 30.3 per 1,000 live births. In the light of the significant morbidity and mortality caused by HEV infection, it is imperative to have accurate means of detection to facilitate early diagnosis and management for better outcomes.

According to statistics compiled by the World Health organisation, 2 to 5 percent of the Indian subcontinent is affected by hepatitis-B whereas 4 to 5 percent of the Pakistani population is suffering from hepatitis C, resulting in one of the highest infection rates in the world. Almost a third of hepatitis-B infected population in Pakistan has been shown to be co-infected with hepatitis-D virus.

The hepatitis infection is more common in rural populations and in multiparas and primigravidas. Pregnant women are at risk for contracting blood-borne infections because they often develop severe anemia or postpartum hemorrhage, incurring need for blood transfusion that might not be safe as standard international guidelines are not followed by all blood banks in Pakistan. A history of previous surgeries, which includes caesarian section, laparotomy and DnC, has been implicated as a major risk factor in this patient population. A recent study conducted on a large scale found that children born to hepatitis-B positive mothers have an 80 percent greater risk of contracting hepatitis-B virus.

The surveillance data from our country is the one reported by FELTP (2009-2011). Out of 712 patients, newly reported HCV patients 53.2 percent and 10.8 percent were newly reported HBV patients. A majority of them were males (>62 percent).

Almost a third of hepatitis-B infected population in Pakistan has been shown to be co-infected with hepatitis-D virus.

History of therapeutic injections, dental/ surgical procedures, body piercing and visit to beauty salon were found significant factors associated with hepatitis-B and -C. In case of hepatitis-B the attributable risk for therapeutic injections was 3.5 percent, for reuse of syringes 2.7 percent, for practice of being shaved by a barber 2.1 percent and for nose/ ear piercing 1.4 percent. In case of hepatitis-C infection, the attributable risk was 11.3 percent , 6.2 percent , 7.9 percent, 5.9 percent and 5 percent for therapeutic injections in the past year, reuse of syringes, shaved at a barber shop, practice of ear/ nose piercing among females and tattooing, respectively. This simply means that burden of disease can be significantly reduced if these factors can be controlled.

Despite measures taken to control viral hepatitis in Pakistan, there is a lot more to do. The burden of hepatitis-A and -E will not be controlled unless basic facilities including safe water supply and better sanitary conditions are ensured across country. There is a need to establish a central registry for outbreaks, mortality related to hepatitis and liver diseases, HCC and surveillance system for viral hepatitis need expansion.

Implementation of universal vaccination of newborns and high-risk groups for hepatitis-B virus and better compliance will reduce the burden of hepatitis-B in the future.

Awareness among healthcare providers to avoid unnecessary therapeutic injections, safe blood transfusion services, use of auto-disable syringes, better utilisation of available resources are key steps in the prevention and management of hepatitis-B and -C.

The writer is a consultant physician, internal medicine specialist, hepatologist, general physician, gastroenterologist, and a family physician