he World Hepatitis Day (WHD) is observed annually on July 28. Nobel prize-winning scientist Dr Baruch Blumberg discovered the hepatitis B virus (HBV). He went on to develop a diagnostic test and vaccine for it as well. The aim of the WHD is to generate awareness and bring everyone together in the fight against the deadly virus. The day provides an opportunity to align national and international efforts in combating hepatitis.

In order to understand hepatitis better, let’s run through the basics. Hepatitis is inflammation (swelling) of the liver; its causes include viruses (viral hepatitis), medication use, alcohol consumption, various chemicals, genetic or metabolic disorders or autoimmune hepatitis, where the body’s immune system turns against the liver cells. What are the different types of viral hepatitis? Viral hepatitis can be due to hepatitis A, B, C, D and E viruses. They can either cause an acute infection i.e., begin suddenly and last a few weeks or persist and progress to chronic (long term) infection. The chronic hepatitis increases morbidity (illness) and mortality (death) by causing liver cirrhosis and cancer.

Let’s take a look at each of these individually. Hepatitis A, is food-borne illness i.e., spread through contaminated water and food, and is the most common cause of acute hepatitis. It is usually mild and is completely resolved within six months. Rarely, it can cause fulminant hepatitis, which is severe infection leading to liver failure. Hepatitis A does not cause chronic hepatitis. A vaccine is available to prevent hepatitis A.

2-10 percent of immunocompetent individuals will fail to clear hepatitis B surface antigen (HBsAg) from blood and will develop a chronic illness. Hepatitis B can be transmitted through exposure to contaminated blood, re-used needles or by sharing needles, syringes, improper sterilisation of medical equipment, or bodily fluids, sharing of razors at barbers and from mother to baby. It is a chronic disorder and, in some cases, may lead to long-term liver damage, liver cancer and cirrhosis of the liver. Hepatitis D does not occur by itself. It occurs only as a coinfection with hepatitis B. The presence of concomitant infection with hepatitis D should be excluded in all patients with HBV infection.

The hepatitis B vaccine is usually given as 2, 3, or 4 doses. As part of expanded programme on immunisation (EPI), three doses of this vaccine are given to children in Pakistan in the first year for free, at 6 weeks, 10 weeks and 14 weeks of age.

Hepatitis C is spread through contact with infected blood as mentioned above or from mother to newborn during childbirth. Liver cancer and cirrhosis can develop due to hepatitis C virus (HCV) in the long term. HCV causes about 60 to 70 percent cases of chronic hepatitis. The greatest risk factors for HCV transmission include blood transfusions, history of hospitalisation, dental treatment, use of injections, shared razors at barbers and history of surgery.

Hepatitis E spreads through faecal-oral route. Most people recover completely. However, some like pregnant women, can become seriously ill.

Approximately 1.5 million people donate blood annually in Pakistan. A study of 66,308 healthy blood donor samples at the district headquarters teaching hospital in Gujranwala (Cureus, 2021) indicated that 3.25 percent of patients in Pakistan will be positive for HBV, and 6.36 percent will be positive for HCV by 2030.

In Pakistan, 4.55 million people are affected by HBV and 8.74 million people are affected by HCV (Am J of Trop Med & Hyg 2021). Despite the hepatitis control and prevention programme, the prevalence of HBV and HCV is increasing in the country. The major challenges to hepatitis elimination include a lack of coordination across provinces and a lack of screening programmes. The availability of hepatitis information and access to hepatitis care varies from province to province. All provinces have active hepatitis control programmes but there is a need for a more proactive approach and coordination among the provinces. No national prevalence studies have been conducted since 2008; however, studies were conducted for the Punjab province (2018) and Sindh province (2019) recently.

Despite having a national policy for HBV vaccination in Pakistan, the availability of birth dose across the country is an issue. Lack of coordination across federal, provincial, and local governments has led to ineffective monitoring and evaluation of the provincial hepatitis control programmes. The screening of all blood donors for HCV, HBV and HIV is still not happening in some areas, especially in the private sector. This further aggravates an already bad situation. The implementation of general population screening has been a challenge due to financial constraints.

The picture is not all gloomy. Pakistan has made some progress towards addressing these challenges. The Covid-19 response has led to a large increase in the capacity for polymerase chain reaction (PCR) testing, electronic health reporting and improved coordination across provinces and the federal capital. Some provinces have started reporting the number of persons diagnosed and treated with HBV/ HCV. GeneXpert machines have been approved for HBV and HCV viral load testing and are recommended for use in the national guidelines. Anti-HCV and HBsAg testing are available free-of-charge in the public sector. Free HBV treatment is available at public district hospitals and tertiary centres, and free HCV treatment is available in the public sector.

Multiple non-government organisations (NGO) are offering support to the government of Pakistan’s efforts to eliminate viral hepatitis in Pakistan by 2030. There are also a number of successful HCV micro-elimination programmes running in the country, both in the public and private sectors.

We have to face the reality. There is a dire need to bring hepatitis care closer to primary health facilities and communities so that people have better access to treatment and care. The World Health Organisation (WHO) aims to achieve hepatitis elimination by 2030, which is not possible without involving primary care in the diagnosis and management of hepatitis.

Dr Hina Jawaid is an assistant professor in family medicine at the University of Health Sciences Lahore. Dr Abdul Jalil Khan is an assistant professor in family medicine at the Khyber Medical University, Peshawar

Hepatitis elimination

he following steps could help eliminate hepatitis in Pakistan:

u Improve coordination among the provinces and update the National Strategic Framework for the next period of implementation

u Involve stakeholders in both public and private sectors and the civil society in hepatitis response, strengthening governance and public policy

u Generate data to better understand hepatitis epidemics and improve surveillance

u Promoting equitable access to hepatitis services and setting of programmatic objectives

u Increase hepatitis B birth dose vaccination nationally by introducing catch-up vaccination for children older than 5 years and for populations at-risk

u Enhance prevention strategies, and improve access to affordable screening, diagnosis and treatment of hepatitis B and C.

u Increase HCV testing and treatment by engaging with community-based organisations and decentralising HCV treatment to primary health centres and private GPs.