This article is part of a series of hepatitis C (HCV) elimination in Pakistan and other high-risk countries around the world. Forthcoming articles in this series will cover the Pakistani provinces of Sindh and Punjab. Scroll to the bottom of the article for the full list. 

Hepatitis C virus (HCV) is a major public health concern in Pakistan. The nation has one of the world’s highest rates of HCV infection and reports around 24,000 HCV-related deaths every year. Even as attention from Pakistani health authorities has shifted to the COVID-19 pandemic, HCV-related conditions—such as decompensated cirrhosis and hepatocellular carcinoma—still kill more people in an average day than the SARS-CoV-2 virus.

To better understand strategies for getting this problem under control, the Lab Insights team spoke with Dr Zaigham Abbas, Head of Gastroenterology at Ziauddin University Hospital, Clifton Karachi, Pakistan. Dr Abbas also serves as the President of Pakistan Society for the Study of Liver Diseases (PSSLD) and plays an active part of Pakistan’s HCV elimination efforts.

Drivers of high HCV prevalence in Pakistan

Of the many causes for Pakistan’s high HCV prevalence, inadequate screening is a major factor. “We are not really able to find the missing millions—people who are the source of infection,” says Dr Abbas. “This is still a problem despite all of the public awareness campaigns.”

Undetected, the disease continues to spread throughout the population. Nosocomial transmission is common. “In remote areas or small towns, proper sterilisation facilities are not available,” notes Dr Abbas. “Traditional medicine and quackery are still there, and proper screening of blood has not been properly implemented.”

One major problem is the enduring belief that intravenous (IV) injections are more effective than other medication. “It is estimated that we are getting about 8-14 IV injections per year per person. More than 90% of these are not required at all,” says Dr Abbas. Furthermore, most of these injections are administered under unsafe practices such as reusing syringes and not changing personal protective equipment between patients.

Other situations where improper sterilisation is an issue include tattooing, ear piercing, and ‘traveller barbers’ who use the same razor blade from person to person.

HCV burden in Pakistan

Pakistan’s HCV screening landscape

To help uncover the ‘missing millions’ and stem the tide of HCV infection, several HCV screening programmes have been initiated by the national government and provincial authorities over the past few decades. However, most were ultimately deprioritised for various reasons and there is no national screening programme in place today.

In 2005, for example, provincial hepatitis control programmes led to the establishment of many sentinel sites with diagnostic and treatment facilities, but funding for these programmes were later redirected to primary care. The national government later announced a countrywide policy to scale up HCV prevention, testing, and treatment in 2019, but this has since been delayed by COVID-19.

“I hope that when things settle down, we’ll be able to embark again on some real programmes, but I don’t think we can achieve all the goals by 2030 that the WHO has set—that 90% of patients should be diagnosed, 80% of patients should be treated, and a 65% reduction in mortality rate should be achieved,” says Dr Abbas.

At present, HCV screening is taking place primarily in gastroenterology clinics for patient visits, in blood banks for donors, and as part of employment requirements. Non-governmental organisations are also carrying out different ‘microelimination’ campaigns, some of which involve doing point-of-care (POC) testing in high-prevalence areas.

Local screening protocols

For the subset of patients with access to screening services, primary screening typically happens at the point of care using rapid immunochromatography (ICT) devices. PCR is generally used for confirmatory HCV testing due to the wide availability of facilities, even in rural areas (although there is room for improvement in terms of test quality and equipment maintenance).

Supplementary tests may also be included in primary care protocols. These include liver function tests, ultrasound, complete blood counts and hepatitis B virus testing, all of which can impact treatment decisions. The degree of fibrosis in the patient is usually measured by FIB-4 or APRI scores. Although suggested in literature as a cost-effective measure [3], re-screening is not performed except in regular blood donors.

To help build local capacity, the PSSLD launched a ‘Teach Hepatitis’ programme which consists of 4-5 weekly courses, each lasting 2 hours, aimed at teaching primary care physicians about how to screen, identify risk factors, treat and prevent HCV infection. “We are also educating them on how to provide treatment, not only screening, so HCPs are aware if someone tests positive for HCV by ICT, what the next steps should be and what other tests should be performed,” Dr Abbas explains.

Key learnings from Pakistan

Drawing upon his experience in Pakistan and across Asia, Dr Abbas offers four pieces of advice to other countries with similar socioeconomic profiles that want to implement HCV screening and elimination programmes.

1. Government funding is crucial. “Keep pressuring the government so politicians become aware of the severity of the situation and don’t get disheartened if you don’t get a proper response initially.”
2. Develop robust cost-effectiveness models. “If you can, screen and link patients to treatment and preventive measures; this is cost-effective and will reduce overall healthcare expenditure in the long-run.”
3. Improve workforce training. “Societies are making efforts to train family and primary care physicians on how to properly diagnose and treat patients. We also need to concentrate on training laboratory personnel in how to handle equipment.”
4. Consider ‘microelimination’ strategies. “Identify pockets of high prevalence and assess those pockets for factors leading to high prevalence of hepatitis. Some of these programmes concentrate on treatment and provide medicine to those who do not have access.”

References:

[1] Qureshi H, Bile KM, Jooma R, Alam SE, Afridi HUR. Prevalence of hepatitis B and C viral infections in Pakistan: findings of a national survey appealing for effective prevention and control measures. East Mediterr Health J. 2010;16 Suppl:S15-23.

[2] WHO | 15 million people affected with hepatitis B and C in Pakistan: Government announces ambitious plan to eliminate hepatitis. WHO. Accessed April 21, 2021.

[3] Lim AG, Walker JG, Mafirakureva N, et al. Effects and cost of different strategies to eliminate hepatitis C virus transmission in Pakistan: a modelling analysis. The Lancet Global Health. 2020;8(3):e440-e450.

To learn more about the growing burden of HCV in Pakistan and the Asia Pacific, check out these other case studies on Lab Insights:

• HCV screening in Egypt: key elements of a successful national screening programme
• HCV elimination in Northern Pakistan: Prof Aamir Khan on treating patients in KPK province and the Afghan borderlands
• Tackling HCV in Punjab: local experts share strategies for success
• HCV elimination in Sindh province: insights from Prof Muhammad Sadik Memon and Dr Zaigham Abbas
• Pakistan’s national HCV elimination programme: insights from Dr Huma Qureshi

To learn more about the broader challenges posed by liver disease in Asia Pacific, check out this video Q&A with Prof Pierce Chow of the National Cancer Centre Singapore.