Intended for healthcare professionals

Editorials

Control of hepatitis B and C worldwide

BMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4431 (Published 28 October 2009) Cite this as: BMJ 2009;339:b4431

Global Perspectives on Hepatitis C: The View from Pakistan

The recent World Hepatitis Day (May 19th, 2009) highlighted the
global struggle against
chronic viral hepatitis. Although global solidarity against this menace is
needed, one
should not overlook the diverse circumstances of this disease in different
parts of the
world. The hepatitis C (HCV) problem in Pakistan presents one such unique
scenario.

A recent population-based study revealed a 4.9% prevalence of
hepatitis C infection in
Pakistan (1). With a population of 160 million, that translates to 8
million people
infected with hepatitis C! Unlike in the West where the incidence of
hepatitis C
infections is declining, in Pakistan the number of new infections does not
appear to be
falling. Why is this? With an official literacy rate of 50% (with literacy
defined as being
able to write one’s name), and a lower functional literacy rate, the
Pakistani populace is
susceptible to myths and misconceptions about health and disease, illness
and healing.
One prevalent and relevant myth concerns the concept of “therapeutic
injections”. It is
widely believed here that medicines given by parenteral (injection) routes
are more
powerful and effective than medicines given orally. A related belief is
that intravenous
infusions (known here as “drips”) of saline or dextrose water provides
significant relief of
symptoms of illness, weakness, or fatigue. Instead of educating patients,
many healthcare
providers are complicit in their ignorance and comply with patient demands
for
“therapeutic injections” and “drips”. These practices become particularly
dangerous in a
country that lacks a proper system for medical waste disposal and where
scavengers,
often children, go through open trash bins outside medical facilities and
clinics and
retrieve used disposable needles and syringes and then wash, repackage and
sell them (by
the pound) for reuse. Studies have confirmed the relationship between
therapeutic
injections and the hepatitis C prevalence in Pakistan (2). There is no
better example of
how illiteracy, poverty, and ill health can be a self perpetuating cycle.
Unfortunately the
medical community here also bears significant responsibility for this
problem by failing
to educate patients about the risks of these often unnecessary injections
and by agreeing
to provide these treatments, often with needles that are being reused.
There are anecdotal
stories of patients lined up outside rural clinics, all of whom are there
to get a “drip” and
all of whom are subject to the same needle.

Data from the World Health Organization suggest that every year, the
average South
Asian gets five injections, one from a sterile needle and four from
unsterilized ones. The
result is that more than 80% of hepatitis C infections in Pakistan are
attributed to the
reuse of dirty needles. Blood transfusions are another problem. There is
an excessively
liberal practice of blood transfusion in the medical community here and
this is
compounded by poor screening facilities in many medical centers. In a
study conducted
in Pakistan’s largest city of Karachi (with a population of approximately
13 million), only
23% of blood banks were screening blood products for hepatitis C (3).
Finally, there is a
growing suspicion among health care professionals, not yet supported by
published data,
that poor sterilization techniques by barbers and poorly trained dentists
may also be
contributing to the hepatitis C epidemic in the country.

Hepatitis C is rampant in Pakistan due, in part, to poor government
oversight of medical
waste disposal, blood bank screening practices, and the training and
practice of
physicians. This latter deficiency has resulted in large numbers of poorly
trained doctors
and untrained healthcare providers, called “quacks” (practicing
“quackery”) in practice
throughout the nation. By some estimates, there are close to one million
such “quacks”
in practice in the country and these poorly trained healthcare providers
are the ones
primarily responsible for the practice of reusing disposable needles.

The current standard of care for hepatitis C therapy is pegylated
interferon given with
ribavirin. In Pakistan, standard (or non-pegylated) interferon is widely
used. Why is
this? Perhaps the silver lining on the dark clouds cast over this
“cirrhotic state” is the
overwhelming predominance of HCV genotype 3 with prevalence rates of
approximately
80% based on published studies. This is important because the HCV genotype
3 is a
more susceptible strain to interferon-based therapy than the genotype 1
that is more
common in the West. In one study, the sustained virologic response (SVR)
rate of
genotype 3 infection was 79% with standard interferon and 82% with
pegylated
interferon (4). A six month course of standard interferon costs Pakistani
Rupees 60,000
($750) while a six month cost of pegylated interferon costs approximately
Pakistani
Rupees 300,000 ($3,750). The cost difference is critical in a country
where the average
person makes $650 per year and where there is no health insurance system.
Based on this
data and the financial realities of practicing medicine in a third world
country, the
Pakistan Society of Gastroenterology guidelines on Hepatitis C published
in 2003
recommended standard interferon and ribavirin as first-line therapy for
treatment-naive
patients with chronic hepatitis C (5). The rationale is that the
significantly lower cost of
standard interferon outweighs the decreased efficacy compared with
pegylated interferon.

There are more challenges in treating hepatitis C infected patients
in Pakistan. Interferon
needs to be refrigerated and cold chain maintenance is critical. But what
to do in a
country where power outages are routine and in peak seasons can last for
more than 12
hours everyday and the current average temperature is 89°F? Most
pharmaceutical
companies that sell interferon provide a free delivery service to the
patient’s doorstep
with cold chain maintenance. But after delivery it is difficult to keep
the interferon at the
appropriate temperature when there is no electricity. Given the large
market for hepatitis
C treatment in Pakistan, many pharmaceutical companies are currently vying
for market
share here. Interferon products made in Argentina, the European Union, and
the United
States are in competition with products made in China, which are
relatively cheaper but
where there are concerns about quality control standards. Furthermore,
there are no head
to head comparison studies of these different interferon preparations to
determine if there
is equivalence of efficacy. The timing and rapidity of hepatitis C viral
clearance predicts
the likelihood of achieving a SVR. Such determinations, called rapid
virologic response
(RVR) and early virologic response (EVR), require PCR testing which costs
approximately Rupees 15,000 ($188). This test is so expensive here that
some health
practitioners initiate interferon treatment in patients with a positive
hepatitis C antibody,
without doing a PCR to confirm the presence of chronic infection.

Many patients, wary of side effects from allopathic medications, find
their way to
homeopathic and ayurvedic and spiritual health practitioners who promise
cures without
adverse effects. The country’s premier English language daily newspaper,
the Dawn,
recently published an article promising an herbal cure for hepatitis C
free of any side
effects, based on two anecdotal and poorly documented cases. Finally, the
country lacks
a liver transplant program and patients who need and can afford such a
procedure must
travel abroad to get it done.

While reading about major advances in the field of hepatitis C
treatment, like the two
articles on Telaprevir published in April, one can’t help but think how
little
relevance such breakthroughs have to the current state of viral hepatitis
in Pakistan and
probably other third world countries as well. Research that would be
relevant to Pakistan
would focus on reducing the cost of therapy (studies on shortening the
duration of
interferon treatment to less than 24 weeks in genotype 3 patients have
produced
conflicting results) and prevention of new infections (perhaps by the
introduction of autodestructible,
disposable needles that can not be reused).

There is currently much discussion and debate about terrorism in
Pakistan and about
whether this country is going to become a “failed state”. There is no
question, however,
that successive (civilian and military) Pakistani governments have failed
their population
in the realm of health care and education. It is not possible to treat the
ever growing
number of hepatitis C infections in this country. The only way to control
this epidemic is
through prevention, in particular public education by an active and
engaged medical
community, no heroes in this story thus far, about how this virus is
spread and how to
avoid infection.

References

1. www.pmrc.org.pk/hepatitisbc.html.

2. Luby SP, Qamruddin K, Shah AA. The relationship between therapeutic
injection and
high prevalence of hepatitis C infection in Hafizabad, Pakistan. Epidemiol
Infec
1997;119:349-56.

3. Luby S, Khanani R, Zia M, et al. Evaluation of blood bank practices in
Karachi,
Pakistan, and the government’s response. Health Policy Plan 2000;15(2):217
-222.

4. Manns MP, McHutchison JG, Gordon SC, et al. Peginterferon alfa-2b plus
ribavirin
compared with interferon alfa-2b ribavirin for initial treatment of
chronic hepatitis C: a
randomised trial. Lance 2001;358:958-65.

5. Hamid S, Umar m, Alam A, et al. PSG Consensus Statement on management
of
Hepatitis C virus infection- 2003. J Pak Med Assoc 2004;54(3):146-150.

Competing interests:
None declared

Competing interests: No competing interests

04 December 2009
Furqaan Ahmed
Consultant Gastroenterologist
South City Hospital, Karachi, Pakistan