he near-eradication of hepatitis E during Covid-lockdowns in Pakistan highlights the importance of prevention as the single most effective instrument in achieving the World Health Organisation’s (WHO) target of eliminating hepatitis C by 2030.

“People avoided contaminated cooked foods from markets and mostly consumed hygienic homemade foods during lockdowns resulting in a very low incidence of food-borne hepatitis E virus in hospitals during that period. But it is again on the rise since lockdown restrictions have been lifted,” says Prof Dr Kashif Malik, consultant gastroenterologist and head of Department of Gastroenterology at Shaikh Zayed Hospital, Lahore.

Just as the prevalence of food-borne hepatitis A and E was contained through the use of hygienic food and clean water during the Covid-lockdown period, the prevention tool can be employed by consciously avoiding contact with infected blood and blood products to overcome proliferation of blood-borne hepatitis B and C viruses.

The lack of awareness about prevention tools or preventive measures among public remains a major stumbling block in controlling the rapid spread of hepatitis disease in the country. The World Hepatitis Day 2022, through this year’s theme, I Can’t Wait, calls on people from across the world to take action and raise awareness of hepatitis. Every 30 seconds, a person dies from a hepatitis-related illness in the world. The WHO has set ambitious targets of eliminating viral hepatitis as a public health concern by 2030, which means a 90 percent reduction in incidence and a 65 percent reduction in mortality compared to the 2015 baseline.

The prevalence of hepatitis in Pakistan has reached up to 10 percent with almost 12 million people estimated to be suffering from hepatitis B or C.

Pakistan is part of the World Health Organisation’s Eastern Mediterranean region, 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 put the country on the course to eliminating hepatitis C by 2030. Pakistan lags far behind in achieving the target,” says Prof Kashif Malik.

As many as 12 million people are suffering from hepatitis in the Punjab having a population of around 120 million. However, according to the Hepatitis Control Programme (HCP), Punjab, only 2,242,339 people have been registered at 281 hepatitis clinics established at DHQ, THQ hospitals and teaching hospitals across the Punjab so far. This is roughly 18.68 percent of the estimated 12 million infected people in the province. Out of these 2.242 million registered patients, only 416,392 patients of Hepatitis C and 46,427 patients of Hepatitis B have been provided treatment at these facilities. This suggests that a majority of the registered patients are missing while others remain unaware.

The Central Hepatitis PCR Lab has performed 619,675 PCR tests for hepatitis C and 80,423 PCR tests for hepatitis B so far.

Prof Kashif Malik underscores the need to establish a national registry for taking a census of hepatitis in Pakistan, saying that the last national survey, which registered 5 to 6 percent hepatitis C and 2 to 4 percent hepatitis B prevalence, was conducted in 2005-06.

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 the situation worse.

A large number of people in Pakistan suffering from chronic hepatitis remain unaware of their condition. Chronic hepatitis is often called 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 liver 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 Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH&RC), Lahore.

In 2020, according to the WHO, liver cancer ranked as the third most common cause of cancer deaths in the world. A study published by SKMCH&RC, Lahore, analysed survival from hepatocellular carcinoma and found that 61 percent of liver cancer patients had evidence of prior infection with hepatitis B or C, while only 14 percent of patients were suitable for treatment due to the advanced stage of their disease. “The treatment of liver cancer is both clinically challenging and resource intensive, underscoring the importance of prevention, early diagnosis and treatment of hepatitis B and C,” Dr Asim Yusuf adds.

Dr Israr ul Haque Toor, a consultant gastroenterologist at the Lahore General Hospital and president of the Punjab chapter of 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 Pakistan government has included it in the Expanded Programme of Immunisation (EPI). A breakthrough treatment is available for hepatitis C for a complete cure at an early stage and treatable at the advanced stage. 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 must be directed towards identifying those missing millions suffering from hepatitis, without being aware of it, and ensure access to screening and treatment in order to fight this disease effectively.

The precautions for family members of hepatitis B and C patients include not sharing comb, toothbrush, towel, nail-cutter, jewelry, etc, of the patient; however, they may shake hands, hug and have meals together.

Acute hepatitis – hepatitis B in general, and A and E in particular – stays from 1 to 6 months and presents with yellow eyes, dark urine, lack of hunger, nausea, vomiting, fever etc.

Chronic hepatitis, usually hepatitis C, stays beyond 6 months with no symptoms. Chronic hepatitis is only detected after screening at an early stage or development of complications at a later stage. It, however, can be diagnosed at an early stage through blood test and ultra sound. Acute hepatitis i.e., food-borne hepatitis A and E are caused by contaminated water and rotten food; it is self-limiting, recovers in 4 to 6 weeks and leaves no trace behind. However, if it gets complicated, which is commonly in less than 1 or 2 percent cases, it may cause severe complications leading to liver failure.

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 vaccine for hepatitis E, along with hepatitis B.

Screening is imperative for early detection. The pre-employment screening of employees in organisations, admissions in educational institutions, and voluntary annual screening can promote early detection allowing immediate treatment and thus, disrupting the cycle of infection and transmission.

The writer has been a long-form investigative journalist for over 15 years. He is currently associated with The News International. A fellow of East West Centre, he also contributes to national and foreign media outlets as a freelancer. He tweets at @AmerMalik3