- Time is of the essence
The word hepatitis is derived from ancient Greek word hepar, meaning liver and Latin itis, meaning inflammation. Hepatitis is a health state defined by inflammation or injury of the liver. It is caused by a variety of agents. Viruses are the most common cause of liver disease in Pakistan. In the west, alcohol is the most common cause of liver disease. According to national and World Health Organisation (WHO) reports, it is estimated that Pakistan, a country with a population of 200 million, has five million (2.5pc) hepatitis B and 10 million (5pc) hepatitis C patients, 15 million (7.5pc) in total or seven out of every 100 Pakistanis. Pakistan needs 10,000 liver transplants yearly. It may be worse than estimated because data may not have been monitored in the right places.
Pakistan has second highest prevalence of hepatitis C in the world. Overall, hepatitis B and C infect approximately 6pc (350-400 million) and 3pc world population (180-200 million) respectively. Both result in 70pc cases of all liver transplants, liver cancer and 1.5 million deaths every year around the globe. According to WHO, about 50,000 people die from hepatitis B and C related liver disease annually in Pakistan, almost equal to total deaths in terrorism related incidents since 9/11. This rate is quite alarming and new infections are constantly appearing. Punjab has more cases followed by Sindh, Khyber Pakhtunkhwa and Balochistan.
Viral hepatitis is caused by five main types of viruses known as A, B, C, D and E and theses are called hepatitis viruses because they exclusively attack the same organ — liver. They may cause acute or chronic infections. Symptoms may include fever, loss of appetite, nausea, fatigue, and yellowing of skin and eyes (jaundice), or a few of these or not at all. Hepatitis is also caused by alcohol, autoimmune disorders, genetic diseases, toxins and drugs. Paracetamole is the most common drug induced hepatitis. There are sporadic cases of home brewed alcohol in Pakistan causing acute liver failure and sometimes blindness due to high amount of toxins and methanol.
We need to understand the A B C of hepatitis to curb this menace in Pakistan. People often confuse it. Here is a rule of thumb. Hepatitis A and E virus infections are waterborne, short lived and not life threatening. Hepatitis B and C, D are blood borne viruses causing chronic lifelong infections. Hepatitis D virus is a small part of B, we can call it a baby of hepatitis B and occurs in its company only. Thus hepatitis B and C are two most dangerous viruses and can occur together. Both infections have same pattern. They progress slowly, silently and over time (10-20 years) damage to the liver results in liver cirrhosis (scarring-dead cells) which can lead to liver failure and liver cancer. Due to their asymptomatic nature, they are known as silent killers, giving life sentence, liver failures, liver cancer and ultimately death.
The risk factors are very well established in Pakistan. These are unsafe health care practices including unscreened blood and blood products transfusion, organ donation, reuse of needles and syringes, use of unhygienic or unsterilised or inadequately sterilised surgical and dental instruments, sharing of needles by drug addicts, barber shops with unhygienic towels and instruments, barbers moving door to door using straight razors, body piercing and tattooing particularly by hawkers at lok mela (folk festivals), infected partners, mother to child, household exposure by sharing personal items of use. In addition, healthcare wastes are an important risk, especially in villages and remote areas, where these are disposed of directly into water supply or open places. Despite national and provincial hepatitis prevention and control programmes these risk factors are still at large in Pakistan. This is mainly due to the failure of Pakistan to meet the standards and guidelines set by WHO and their implementation in letter and spirit.
According to national and World Health Organisation (WHO) reports, it is estimated that Pakistan, a country with a population of 200 million, has five million (2.5pc) hepatitis B and 10 million (5pc) hepatitis C patients
The direct cost associated with these infections and their sequelae in the Pakistan is worth millions of dollars per year. For example in PIMS Hospital, Islamabad around 2000-3000 patients of hepatitis B and 3000-5000 hepatitis C patients are diagnosed and treated annually. Suppose the cost of treatment to be a half of the standard market rates, for hepatitis B, the cost of one tablet daily is Rs20. It would be Rs600/month and Rs7200/year per patient. When multiplied by the number of treated cases (2000), the cost comes to Rs15 million.
New oral HCV drugs cheapest price is Rs20000/patient for three months. When multiplied by the number of patients (3000) who received treatment, it comes to Rs75 million. Adding both costs, the money spent on treatment cost comes to Rs90 million for one hospital. With a few more millions for the diagnostic tests, the cost would escalate to approximately Rs100 million. The government thus spent about Rs100 million on the treatment of about 5000 cases in one tertiary care hospital with an ultimate response in only 50pc cases in hepatitis B and now a days 90pc with hepatitis C. Let’s multiply this with 10 such hospitals in Pakistan and it would be Rs1000 million in total.
According to a UNDP report launched in May 2018, Pakistan is the youngest country in the world whose 64 percent population is below the age of 30. The lives of many of them are at a risk of contacting these viruses. These infections are not only the number one health problem of Pakistan but they are also certificates of permanent unfitness for all government offices and employment abroad. The plight of very bright and talented youngsters declared medically unfit for whole life, careers ruined and dreams shattered, is unspeakable. It seems that the only exceptions to this are our law makers who would join the parliament without any medical fitness test.
PM IK’s government has already vowed to introduce reforms in the health sector. The country is in dire need of an urgent and effective infection control programme with implementation in letter and spirit. PM Imran Khan should declare war on hepatitis in Pakistan to save the millions just as he declared war on cancer by building SKMCH & RC. The new government should also set up a task force for the control of all infectious disease including hepatitis viruses, HIV, dengue, polio, etc. The team should comprise of policy makers, healthcare professionals and bio-medical scientists. More Pakistanis are dying of liver disease than terrorism. Prevention is better than cure particularly in the young; it is completely preventable otherwise millions will continuously suffer in Pakistan.