Hepatitis is a disease which has long been ignored in developing countries like Pakistan. The fact that it’s a silent disease and the symptoms are visible a bit late also contributes to this factor of ignorance. But in my analysis, the fundamental reason behind this is the lack of knowledge and poor medical practices. A lot of new such cases can be avoided only through increasing the level of knowledge amongst the masses and regulating medical professionals.
According to WHO, the number of deaths per year due to HCV continues to increase. A study from global burden of disease states that number of deaths due to hepatitis C in 1990 was 333,000 in 2010 was 499,000 and in 2013 it was 704,000. This increasing trend is alarming and should be controlled.
The risk of HCV infection varies according to the type of population. For instance, persons who inject drugs have the highest risk of infection. Globally, the prevalence of anti-HCV antibody is 67% among such population. Similarly, the transmission risk is estimated to be around 4–8% among mothers without HIV infection and 10.8–25% among mothers with HIV infection. Fortunately, there is low or no risk of sexual transmission of HCV among HIV-uninfected heterosexual couples and HIV-uninfected men who have sex with men (MSM). The risk of sexual transmission is strongly linked to pre-existing HIV infection. HCV is most commonly associated with unsafe injection practices and procedures such as renal dialysis and unscreened blood transfusion. Over 16 billion injections are administered yearly around the world and 40% of these are considered to be unsafe (Mostly in Africa and Asia).
In the decades following the discovery of the HCV in 1989, treatment of persons with HCV infection became possible. A dramatic improvement in HCV treatment followed the introduction of Oral Medicines (Direct Acting Antiviral – DAA) that directly inhibited the replication cycle of HCV. The introduction of DAA therapy has resulted in an increase in the number of persons treated; however, almost of all of this increase has occurred in high-income countries. For instance, in USA average price per patient for these drugs are around $50,000. A number of countries have obtained access to DAA therapy at much lower prices due to direct negotiations with the manufacturers and by the introduction of generic medicines. An encouraging development is the licensing agreements signed between originator and generic manufacturers, which have resulted in much lower prices.
In global HCV infection, the uncertainty in viraemic prevalence in Nigeria, China and Pakistan account for over 50% of the observed variance, followed by the uncertainty in ratio of HCV prevalence among children to adults. The table below shows Pakistan seconds china for the total viraemic infections for all ages.
The table clearly reveals the urgent need of taking this disease very seriously at the state level else a large population would continue to suffer. A heavy spending is required to educate the masses regarding not to use the used syringes, injections and the blades of other persons. Pakistan still needs to work a lot to minimize HCV infected patients. Masses cannot afford to get themselves treated at private clinics and hospitals whereas; government health care providers are not working to the level which is required from them.
Among private hospitals in Pakistan, Indus Hospital is one such place where the hepatitis program has been initiated in October last year and the treatment is being provided to every patient totally free of cost. The doctors are highly professional and the funds are raised through donors and institutions that support this cause. The clinical team includes a medical officer and clinical nurse. The program manager heads the hepatitis program whereas; research associate and health workers are responsible for the field work. On an average there are around 65 new patients per month and at a time there are 151 on treatment patients. Oral drugs are given to patients and for diagnostics purpose; there are confirmatory tests, Radiology investigations and Assessment of co-morbidities. For patient education, custom made flip charts are made which are used twice a week for health awareness session for patients and a full course of Hepatitis B vaccine is also offered. All these services are absolutely free of cost for the patients and according to international standards of health care.
This is exactly a model which is required in many parts of Pakistan. General public cannot afford the expensive treatment and drugs whereas; government is not taking the required measures. Although, private institutions like Indus can only have a limited scope because the funds are raised for limited number of patients only. But the processes and treatment methods should be adopted by government hospitals to minimize the number of hepatitis patients all over the country.
Another option is public private partnership which encourages collaboration and team work between government and private institutions. The expertise which is found missing at government level can be acquired from private institutions whereas; the funding and financial gap can be filled by the government. This two way partnership is the urgent need of time especially in countries like Pakistan where victims are increasing and healthcare providers can only address to fewer patients due to limited capacity.
WHO HCV Guideline – 2016 Journal of Hepatology Update: Hepatitis C Indus Hospital – Hepatitis Program