World Hepatitis Day 2021
Hepatitis Can’t Wait
Concerted Effort Needed to Eliminate Hepatitis in Pakistan
More than half liver cancer patients have evidence of prior infection with hepatitis B or C
Observing World Hepatitis Day is mandated by the World Health Assembly as a public health issue of priority. It is marked on the 28th of July each year, to unite the global community around action against hepatitis. The theme this year is “Hepatitis Can’t Wait” – we need to act on viral hepatitis even during the ongoing coronavirus pandemic because, somewhere in the world, someone dies every 30 seconds from a hepatitis-related illness. The World Health Organization has set ambitious targets of eliminating viral hepatitis as a public health concern by 2030, which means a 90% reduction in incidence and a 65% reduction in mortality compared with a 2015 baseline. All stakeholders will need to make coordinated and sustained efforts to achieve these targets.
The word hepatitis refers to inflammation of the liver, resulting in variable degrees of impairment of the functions of the liver, which are vital for the body. While there are various causes of hepatitis, including drugs, alcohol and obesity, the commonest cause, worldwide, is infection with one or more of the hepatitis viruses – hepatitis A, B, C, D and E. While each of these can cause hepatitis and serious liver disease, it is important to understand that they have different modes of transmission, cause different patterns of disease and require different means of prevention. Hepatitis B, C and D are transmitted by infected blood and body fluids, and require special attention because they often lead to prolonged illness and severe progressive liver damage, known as chronic hepatitis. This can progress to an irreversible stage of advanced liver disease, known as liver cirrhosis, which can lead, in some, to liver cancer and/or liver failure and death. Unfortunately, over one million people are still dying annually from viral hepatitis each year, despite the availability of a vaccine for hepatitis B and a cure for hepatitis C. The reasons for this are several, chief amongst them, in Pakistan, being a lack of awareness, lack of screening programmes, paucity of treatment facilities, inability to afford treatment and an ongoing cycle of infection caused in large part by unsafe injection practices, transfusion of un-screened blood and unsafe surgical and dental practices.
Globally, as well as in Pakistan, a large number of people suffering from chronic hepatitis remain unaware of their diagnosis. Chronic hepatitis is often called a “silent-killer” because symptoms may develop decades after exposure, when significant damage to the liver has already occurred. By one estimate, only 10% of people with hepatitis B are aware of their diagnosis while only 21% of people with hepatitis C the world over are aware of their infection. Pakistan is part of the World Health Organization’s Eastern Mediterranean Region, where more than 15 million people are chronically infected with hepatitis C and 21 million with hepatitis B. Pakistan and Egypt together account for 80% of this disease burden, with almost 12 million people in Pakistan alone estimated to be suffering from hepatitis B or C.
Last year, liver cancer ranked as the third commonest cause of cancer deaths in the world. A study published in 2007 by the Shaukat Khanum Memorial Cancer Hospital and Research Centre analysed survival from hepatocellular carcinoma and found that 61% of liver cancer patients at the hospital in Lahore had evidence of prior infection with hepatitis B or C, while only 14% of patients were suitable for treatment due to the advanced stage of their disease and the absence, at that time, of a liver transplantation programme. Treatment of liver cancer is both clinically challenging and resource intensive, underscoring again the importance of prevention of liver cancer by addressing the root cause in Pakistan – infection by hepatitis B and C – and early diagnosis and treatment of those infected.
Prevention of hepatitis B and C involves avoiding high-risk behaviour such as unsafe injection practices involving re-use of needles for injection, using un-screened blood for transfusions, avoiding the use of unsterilized equipment for dental or surgical procedures, and engaging in unsafe sex. A vaccine is available for hepatitis B, which makes it an important tool in controlling new cases of hepatitis B. Screening of pregnant women for hepatitis B and ensuring that birth dose of vaccination is available for those who test positive can avoid mother to child transmission of the virus. Vaccination of children against hepatitis B, as part of national immunisation programmes, can effectively prevent future infection. Since no equivalent vaccine against hepatitis C exists currently, the best strategy is to reduce the risk of infection by avoiding the high-risk behaviours described above, and by ensuring access to treatment in a timely manner for those infected, since hepatitis C is now essentially a completely curable infection.
The Government of Pakistan has introduced steps such as vaccination for hepatitis B as part of the Expanded Programme on Immunisation (EPI) in 2009, but continued efforts need to be directed towards identifying the missing millions suffering from hepatitis without being aware of it, in order to fight this disease effectively. Screening is thus imperative for early detection. Organisations can ensure pre-employment screening of employees, educational institutions can promote screening of students, and the lay public can opt for voluntary annual screening to promote early detection, allowing for immediate treatment and thus disrupting the cycle of infection and transmission.