Abstract
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Use of syringes to inject medicinal or addictive drugs is very high in Pakistan as compared with other countries of the world. A brief analysis of Pakistan Medical Research Council Survey and Pakistan Demographic Health Survey reports showed that around 731 ± 867 million syringe shots (5.1 ± 12 injections per head) are given annually in Pakistan, and about 52–77% Pakistanis receive at least one injection in every 12 months (23). In Pakistan, reuse of syringes and nonstandard medical waste disposal methods are the most common causes of HCV spread. WHO also reported that the main cause of HCV infection in children is use of unsafe syringes (38).
Unsafe blood transfusion could be another major contributory factor in transmission of HCV infection. In Pakistan, ∼1.5 million units of blood products are transfused each year (39). Although it is in the guideline to prescreen the blood for blood-borne viruses before transfusion, owing to lack of awareness and resources, standard operational procedures are not followed properly. Similarly, prevalence of high HCV incidence (23.7–68%) in patients on hemodialysis raises a question on the proper blood screening and sterilization procedures (8,10,24,25,34,41). Patients on dialysis for more than 2 years showed significantly higher proportion of HCV infection (43.5%) than patients on dialysis for <2 years (9.5%) (41).
Foul dental procedures are another route of HCV transmission. In Pakistan, only 12,515 professional dentists are registered with Pakistan Medical and Dental Council (29). Most of these professionals are working in urban areas of the country, whereas about 70% of Pakistanis who are living in rural areas have no or very limited access to these professionals. As a result people go to quacks, according to the International Dental Federation fact sheet 2003 (15), there were 40,000 nonqualified dental practitioners working in Pakistan. It is estimated that after more than a decade because of poor socioeconomic status of the country, this number has increased. Most of these quack dentists have small private dental clinics or road-side open clinics, with almost no sterilization facilities. As a result, these quacks spread massive viral infection. Owing to unavailability of a proper epidemiological surveillance system and lack of available scientific reports, it is difficult to estimate the role of substandard dental procedures/quacks in HCV prevalence in the community. According to limited available data (only two reports available) (8,14), 14.28% and 4.1% dental patients were anti-HCV positive. There is an urgent need of large scale studies across the country to estimate the role of unhealthy/substandard dental procedures in spread of HCV in the country.
Ear/nose piercing is a very common practice among females in Pakistan. Most of the piercers are illiterate and are unaware of the HCV infection and its transmission routes. Small data are available on this silent HCV transmission route, but it shows that ear/nose piercing is a risk factor for HCV infection in 37.6% females (31).
In Pakistan, unregistered barber shops on pedestrian pathways are very common, and most of HCV-positive patients have a history of facial/armpit shaving by barbers. In rural areas of Pakistan, barbers are even involved in incision, circumcision, and drainage of abscesses. These barbers are totally unaware of the mode of transmission of infections or sterilization of instruments. Even in metropolitan cities, knowledge about the mode of HCV transmission is very poor; only 12–30% of barbers know that hepatitis can be transmitted through shaving instruments (20,21,35).
HCV infection prevalence in pregnant women varies across the world and it is higher in developing countries. The major route of HCV transmission in pregnant women is unsafe blood transfusions. Analysis of previous published reports showed that HCV prevalence in pregnant women is 4.65% in Pakistan (6,10,34). As the current available information is from very limited number of cases mostly from big cities, it is possible that HCV prevalence might be higher in rural areas of the country. According to WHO (2013), around 48 million women are in child-bearing age in Pakistan and annual number of births were 4.5 million (37). With an average of 5% HCV prevalence during pregnancy, it is expected that 225,000 pregnant women may carry HCV. It is evident that with a vertical HCV transmission rate of 5% (33), about 11,000 infants would acquire congenital HCV per year in Pakistan. Although mother-to-child transmission (MTCT) is the leading source of HCV infection among children in Pakistan, the pathophysiology of vertical transmission is not fully clear and only HCV viral load and HIV coinfection are identified as risk factors. The role of C-section and breast feeding is not clear yet (1).
Furthermore, there is no effective treatment to avoid MTCT during pregnancy or delivery. As all available antiviral treatment options (interferon based, ribavirin, and direct acting antivirals [DAAs]) are stopped during pregnancy, however, it is highly recommended that HCV carrier pregnant women must take antiviral treatment after delivery. Taking antiviral treatment before subsequent pregnancies and achieving sustain virological response might be an effective strategy to completely eradicate HCV vertical transmission in the future. There is no study about the actual vertical transmission of HCV in Pakistan; in the absence of complete HCV screening, the majority of the victims remain undiagnosed. Few studies on general pediatric population from different cities of Pakistan showed that prevalence of HCV ranged from 1.4% to 9.8% (9,11,12,17,19).
Pakistan is a resource-constrained country and a small budget is allocated for health. There is no health insurance system in Pakistan, so most of the patients have to pay the cost of treatment (4,5). Currently in Pakistan, the standard care antiviral treatment is switching from interferon and ribavirin to DAAs. These DAAs are very costly and it seems practically not affordable by the poor inhabitants of the country. Although Sofosbuvir is available on heavily discounted price, it is still genotype specific. Interferon-based antiviral will be the choice of treatment in Pakistan unless the availability of pan-genotypic DAAs on discounted price is made sure (32).
It is estimated that ∼240,000 new cases are diagnosed in Pakistan every year (30). As HCV is a preventable disease, its prevalence in developed countries is negligible. We can also decrease the HCV disease burden by following the standard practices employed in these countries (7,26). Currently, WHO, Ministry of Ministry of National Health Services, Regulations and Coordination (NHRC), Pakistan Health Research Council, and health ministry of Pakistan are taking initiatives to manage the disease and control its future spread (27,28, 40). A Technical Advisory Group on Hepatitis in Pakistan is established with the help of WHO and is now working in collaboration with NHRC. These platforms can be used for conducting training workshops for physicians, pathologists, and medical superintendents.
The government took the initiative to implement hospital waste management rules in 2005 in the government sector. But many healthcare setups operate as small private hospitals/clinics, in these units regulation regarding blood transfusions, surgical procedures, disposal of contaminated syringes, and waste management are mostly ignored. Currently, education programs for HCV awareness in the general population are working at a limited scale. For instance, few awareness walks are organized by certain organizations on world hepatitis day and some advertisements on print/electronic media are done by the government. Some researchers organize community education programs in their parent institutes, like the University of Management and Technology organizes lectures and workshops on HCV transmission routes and how to avoid them for university students. Other researchers and university professors must also step forward to start such activities across the country, which may be of great help in educating the youth. These students will be future trainers for their families and general community.
Counseling programs for the general population, higher risk groups, and untreated patients are an effective preventive strategy against HCV across the world (7,16,18,22,26). In light of the mentioned facts, it is very clear that community education is the key for future HCV containment in Pakistan. It is ironic that in Pakistan despite high burden of HCV, there is no concept of infection control in the general population as well in high-risk groups. Community education programs should be designed for general people and those in high-risk occupations for safe usage of instruments and syringes such as dentists, midwives, medical doctors, barbers, piercers, and pregnant women; in addition to these safety measures, regular use of condoms in case of infected partner should be practiced. Low literacy rate and nonexistence of standard healthcare facilities in rural areas make people more vulnerable. Therefore, special emphasis and focus are required for awareness campaigns in rural areas about the spread routes of the virus. A well-organized surveillance system for HCV infection is needed to identify the hot spots across the country. Moreover, community education is highly warranted in vulnerable areas to lower the future burden of HCV.
Implication for Health Policy Makers/Practice/Research/Medical Education
In Pakistan, the major reason of viral infections is poor knowledge about the transmission routes in the general population as well as in high-risk groups. So keeping in view this scenario, it is proposed that there should be an effective HCV monitoring system across the country to identify the hot spots. Moreover, community education campaigns should be arranged on a regular basis to generate awareness across the country to control viral spread. Researchers should come up with massive HCV epidemiological studies in the general population as well in high-risk groups. There must be a well-defined policy by the ministry of health for healthcare workers regarding the education of enrolled patients and their attendants about the transmission routes of HCV. Awareness about the transmission routes of HCV will help to contain the infection. It is important for policymakers to keep an eye on HCV prevalence kinetics across the country and run the massive community education campaign across the country.
Footnotes
Acknowledgment
The author would like to thank Mahvish Kabir for her help in English language editing and proofreading the article. There is no role of any funding agency in this study.
Author Disclosure Statement
No competing financial interests exist.