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Sero-prevalence of Hepatitis B and C Virus from rural areas of northern Punjab (Sargodha District), Pakistan

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Pakistan is endemic for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections with 10 and 11 million infections, respectively. The epidemiological studies of these virus showed that the information is only from few cities of the country and is relevant to high risk groups. It is of great importance to have an idea about the prevalence of infectious agents in general population to help in identification of hot spot for infections. Identification of hot spots will help in disease management for future. As the there is no report form district Sargodha (Punjab Province) so this study was designed to analyze the prevalence of HBV and HCV in general population. Blood samples of 2373 randomly selected individuals from six different tehsils were collected and were analyzed for HBV and HCV sero-positivity. An overall prevalence of both HBV and HCV in district Sargodha was 28.10% (667/2373). HCV prevalence was (20.01%) and HBV seropositivity was (8.09%). Males were more infected than females, and a significant difference was found in positive cases between male (58.77%) and female (41.22%). The most common routes of transmission of hepatitis virus in present study were shaving assisted by barbers in male patients 143 (21.43%), non sterile or used needles & syringes 127 (19.04%), dental surgical procedures 88 (13.19%), and sharing razors in males 49 (7.34%). In female patients a significant factor is labor and child birth process. Most cases of hepatitis were seen in mesons, farmers and house wives. The prevalence of HBV and HCV in general population of district Sargodha is very high. The study will help for better management of disease to contain the disease spread. The study highlighted that District Sargodha is endemic for these viral infections and it is highly warranted to carry out more studies to get better idea about the infection spread. Community education campaigns are also highly warranted to general population as well as high risk population to control future disease spread. © 2016, Malaysian Society for Parasitology. All rights reserved.
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Tropical Biomedicine 33(4): 599–607 (2016)
Sero-prevalence of Hepatitis B and C Virus from rural areas
of northern Punjab (Sargodha District), Pakistan
Bostan, N.1, Naeem, M.2, Afzal, M.S.3, Shah, Z.H.3, Mustafa, I.2, Arshad, M.2, Haider, W.1, Khan, A.A.1,
Asif, S.4, Khan, M.R.5, Ahmad, S.S.6, Ali, S.7, Naveed, M.8 and Ahmed, H.2*
1Department of Biosciences, COMSATS Institute of Information Technology (CIIT), Park Road, Chakh Shazad,
Islamabad, Pakistan
2Department of Zoology, University of Sargodha, Sargodha, Pakistan
3School of Science, University of Management and Technology (UMT), Lahore, Pakistan
4Department of Botany, PMAS-University of Arid Agriculture, Rawalpindi, Pakistan
5Department of Remote Sensing & GIS/ University Institute of Information Technology, PMAS-University of
Arid Agriculture, Rawalpindi, Pakistan
6Department of Remote Sensing & GIS, Fatima Jinnah Women University, Rawalpindi, Pakistan
8Department of Biotechnology, University of Gujrat, Sialkot Campus, Pakistan
*Corresponding author e-mail: haroonahmad12@yahoo.com
Received 22 November 2014; received in revised form 17 January 2015; accepted 28 February 2015
Abstract. Pakistan is endemic for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections
with 10 and 11 million infections, respectively. The epidemiological studies of these virus
showed that the information is only from few cities of the country and is relevant to high risk
groups. It is of great importance to have an idea about the prevalence of infectious agents in
general population to help in identification of hot spot for infections. Identification of hot
spots will help in disease management for future. As the there is no report form district
Sargodha (Punjab Province) so this study was designed to analyze the prevalence of HBV and
HCV in general population. Blood samples of 2373 randomly selected individuals from six
different tehsils were collected and were analyzed for HBV and HCV sero-positivity. An
overall prevalence of both HBV and HCV in district Sargodha was 28.10% (667/2373). HCV
prevalence was (20.01%) and HBV seropositivity was (8.09%). Males were more infected than
females, and a significant difference was found in positive cases between male (58.77%) and
female (41.22%). The most common routes of transmission of hepatitis virus in present study
were shaving assisted by barbers in male patients 143 (21.43%), non sterile or used needles &
syringes 127 (19.04%), dental surgical procedures 88 (13.19%), and sharing razors in males 49
(7.34%). In female patients a significant factor is labor and child birth process. Most cases of
hepatitis were seen in mesons, farmers and house wives. The prevalence of HBV and HCV in
general population of district Sargodha is very high. The study will help for better management
of disease to contain the disease spread. The study highlighted that District Sargodha is
endemic for these viral infections and it is highly warranted to carry out more studies to get
better idea about the infection spread. Community education campaigns are also highly
warranted to general population as well as high risk population to control future disease
spread.
INTRODUCTION
Infections caused by hepatitis B and C virus
are among leading public health dilemmas,
having wide clinical spectrum and natural
history of viral infection varies between
asymptomatic infections, symptomatic acute
infections to chronic infections leading to
cirrhosis and hepatocellular carcinomas
(Duddempudi & Bernstein, 2014; Villar
et al., 2014). According to World Health
Organization (WHO) prevalence of HBV
and HCV is approximately 240 million and
185 million respectively across the globe
(World Health Organization, 2014).
600
A comprehensive population based
epidemiological survey data on the
prevalence of HBV and HCV is lacking from
Pakistan. Only a few reports based on
convenient sampling methods and patients
attending hospital OPDs are available. Most
of the studies targeted a specific population
type like Hemodialysis patients, injection
drug users, jail prisoners, thalasemic patients
or co-infections with HIV, high risk
populations and children etc (Reviewed
in Umer and Iqbal, 2016; Afzal MS., 2016).
Changing global epidemiology of the
HBV and HCV infection requires the
comprehensive annual reports of viral
prevalence from all parts of the world to
estimate the morbidity and mortality as well
as future disease burden (Mohd et al., 2013;
Ditah et al., 2014; Esteban et al., 2008). One
such study was conducted by Pakistan
Medical Research Council in year 2007-2008
to estimate the prevalence of HBV and HCV
in Pakistan. It was estimated that the
prevalence of HBsAg was 2.5% and for anti
HCV it was 4.8%. Collectively the prevalence
of both infections was 7.6%. Moreover the
estimated chronic carriers for both the
infections were 13 million. Most significant
contributory factor in disease acquisition was
the reuse of syringes through therapeutic
injections. More than 30% of population had
10 injections/person/year. The prevalence of
HBV and HCV was not uniform in all districts.
There was a high prevalence of HBV and HCV
in 30 districts from all provinces (PMDC,
2009; WHO, 2015). The comprehensive data
in high risk population is not available with
reference to HBV and HCV prevalence. It is
reported that the prevalence of HCV in female
sex workers and eunuchs is between 4.3-38%
with an average of 19%. Likewise another high
risk population is multiple transfused patients
suffering from hemophilia, thalassemia and
other disorders where HBV prevalence was
5-8.4% (average 7.8%) and HCV prevalence
was alarmingly high ranged between 25-60%
(on an average 47.2%). Another high risk
studied population was chronic dialysis
patients with an average 14.6% (12.4-16.6%)
HBsAg seropositivity, the values for HCVAb
was very high 38% (23.7-68%). A relatively
high risk was observed in healthcare workers
0-10.3% HBV (weighed average 6%) and
HCVAb 4-5.9% with weighted average 5.5%.
Pregnant females showed higher risks of
HCV as compared to HBV, weighted average
5.3% and 2.9% respectively (Ali et al., 2009).
In Pakistan HCV disease burden is
increasing because of previously infected
Hepatitis cases and newly reported cases.
While partial control of HBV infection is the
consequence of availability of an efficacious
vaccine particularly in geographical areas
with high prevalence. In Pakistan the HBV
vaccine became the part of National
Expanded Program on Immunization (NEPI)
in year 2002 (Mangrio et al., 2008; Omer et
al., 2009; Siddiqi et al., 2007). As there is no
information about the prevalence of HBV and
HCV from District Sargodha; therefore this
study was designed not only to collect
information about the prevalence of these
viruses but to identify the risk factors for these
infections.
MATERIALS AND METHODS
Study area and population
The aforesaid study site for hepatitis strains
project was rural sites from district Sargodha
(N 32° 5’ 1", E 72° 40’ 16"), in Punjab province,
Pakistan. Sargodha district has a population
size of 26, 65,979 individuals according to
1998 census report. Administratively it has
been divided into six tehsils, viz Sargodha
(542761 individuals) (N 31° 50’ 11", E 72° 32’
51"), Bhalwal (population of 1056600
individuals) (N 32° 15’ 59", E 72° 54’ 00"), Kot
Moman (50,000 individuals) (N 32° 11’ 01",
E 73° 01’ 35"), Sahiwal (235,600 persons)
(N 31° 58’ 26", E 72° 19’ 56"), Shahpur (274,000
individuals) (N 32° 16’ 15", E 72° 28’ 23"),
Sillanwali (255,000) (N 31° 49’ 09", E 72° 32’
18") (Figure 1). A total of 2373 male and
female patients aged 11 to 60 and above were
the study participants. All of the study
participants were selected randomly from
the above mentioned six tehsils of district
Sargodha for screening of hepatitis B and C
viruses.
601
Sample size calculation
Sample size was calculated using following
formula
Risk: 3% HBV
10% for HCV
Sample size calculation formula
(za/2)2 p(1 – p)
n =
E2
z = qnorm (.975)
p = 0.5
d = 0.05
z^2*p*(1-p)/d^2
Door to door Survey
Random sampling was carried out from six
tehsils of the district Sargodha. A brief
questionnaire was designed regarding the
demographic and other information of the
participants. Informed written consent was
obtained from each participant. The study
was approved by Departmental ethical
committee, Zoology Department, University
of Sargodha,Sargodha, Pakistan For female
cases additional questions involved the
number of children, mode of birth etc as
other risk factors. Monthly income of the
household was noted in order to calculate
the poverty index (Ditah et al., 2014) and to
find any possible correlation between low
socioeconomic status and disease positivity.
Moreover it was emphasized that educational
years would have an impact in disease
management and can its occurrence be
related to educational level of the individual.
As we assume and suppose that a well
educated person having knowledge about
the disease can better handle it if he/she
acquires such infection. Moreover educated
person has a better understanding about the
mode of spread of blood borne viruses and
therefore can minimize the risk of disease
acquisition.
Laboratory Analysis
From sampled blood, the serum was drawn
for further analysis. Qualitative deter-
mination of HBsAg was made using third
generation ELISA kit (Diapro). For
determining seropositivity of HCV a third-
generation enzyme-linked immunosorbent
assay (ELISA) kit (Diapro) was used for the
detection of anti HCV antibody according to
manufacturer protocol.All the samples were
retested for the validation of results and if in
the retest values were less than the cutoff
values the samples were considered negative
for HBV and HCV.
Statistical analyses
Data from the epidemiological survey of
Sargodha district, Punjab, Pakistan was used
to describe the current epidemiology of
HCV infection in this area of Pakistan. All
analyses were performed using IBM
Statistical Package for Social Sciences
(SPSS) version 20 (IBM SPSS Statistics
Publisher’s). Prevalence of HCV was
presented by a variety of demographic
factors. Data fromsurvey were combined to
evaluate trends and riskfactors associated
with HCV infection. Only individuals 11 years
and older were included in the risk factor
analysis. Correlation of disease positivity
with age groups and genders was calculated
using the Chi-square Test. p values<0.05 were
considered significant in the model.
Standard deviation of prevalence
Standard deviation of prevalence was
calculated using following formula. It’s
calculated as sqr[p(1-p)/n] (Where P is
prevalence and n is that population’s size).
RESULTS
Characteristics’ of studied cohort
A total of 2373 representatives of
general population, from Sargodha
Punjab, participated in the current survey
conducted between January to December
2014. Participants belonged to all six
tehsils of Sargodha district (Figure 1).
Male study participants were 1321 (55.66%)
while 1052 (44.33%) were the females.
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Figure 1. Map showing study area of Sargodha district, Punjab, Pakistan.
Table 1. Seroprevalence of HBV and HCV
Coinfections in district Sargodha (n=2373),
Pakistan
Age Infected # (%)
Males Females
11-20 2 (0.084%) 0 (0%)
21-30 3 (0.126%) 0 (0%)
31-40 15 (0.632%) 4 (0.17%)
41-50 4 (0.17%) 0 (0%)
51-60 1 (0.042%) 0 (0%)
61 > 1 (0.042%) 0 (0%)
Total 26 4
Prevalence of HBV and HCV in studied
Cohort from Sargodha district as to 2014
Screening of blood revealed that 192 (8.0%)
were positive for HBV and 475 (20%) were
HCV ELISA positive.
Prevalence of HBV and HCV Co-infections
in studied Cohort from Sargodha district
as to 2014
There were 30 cases co-infected with both
hepatic viruses at the same time (i.e., HBV/
HCV Co-infection). It constituted 1.3% of
the studied population. Among co-infected
patients 26 (86.66%) were males and only
four (13.33%) were females (Table 1).
Tehsil wise prevalence of HBV and HCV
infections
Out of 667 positive patients, 198 (29.68%)
patients were from Bhalwal, 131 (19.64%)
were from Sahiwal, 119 (17.84%) were from
Sillanwali, 77 (11.54%) were from Sargodha,
70 (10.49%) were from Kotmoman, and 72
(10.79%) were from Shahpur. The statistical
analysis showed the significant difference
of positive cases among tehsils (p < 0.05).
Out of 667 patients, 475 (71.21%) patients
603
were positive (+ve) for HCV and 192 (28.78%)
patients were positive (+ve) for HBV. Among
475 hepatitis C positive, 156 (32.84%)
patients were from Bhalwal, 69 (14.52%)
were from Sahiwal, 85 (17.89%) were from
Sillanwali, 59 (12.42%) were from Sargodha,
51 (10.73%) were from Kotmoman, and 55
(11.57%) were from Shahpur. The statistical
analysis showed no significant difference
of HCV positive cases among six tehsils
(p > 0.05). Among 192 hepatitis B positive,
42 (21.87%) patients were from Bhalwal, 62
(32.29%) were from Sahiwal, 34 (17.70%)
were from Sillanwali, 18 (9.37%) were from
Sargodha, 19 (9.89%) were from Kotmoman,
and 17 (8.85%) were from Shahpur. The
statistical analysis revealed a significant
difference of HBV positive cases among six
tehsils (p < 0.05).
HCV and HBV infections in association
with different age groups
Prevalence of HBV and HCV infection was
maximum in the age range of 41-50 years,
342 patients (51.27%) (Figure 2). The
statistical analysis showed the significant
difference in age groups and hepatitis positive
cases (p < 0.05). Overall 110 (16.49%) patients
have hepatitis victims in their family
members. The statistical analysis showed
the difference in patients have family
members victim and hepatitis positive cases
(p < 0.05).
Modes of HBV and HCV Transmission in
studied subjects
The most common routes of transmission
of HCV & HBV in present study for males
were shaving assisted by barbers 143
(21.43%) and sharing razors 49 (7.34%).
Non-sterile or used needles & syringes 127
(19.04%), dental surgical procedures 88
(13.19%) were mutual risk factors while
important risk factor with reference to
females was child birth. The other routes of
viral transmission are also summarized in
Figure 3.
Occupational details of the HBV and HCV
Cases
In present study 174 (26.08%) of the positive
cases were laborers, 147 (22.03%) were
farmers, 119 (17.84%) were house wives, 60
(8.99%) were physicians and dentists, 53
(7.94%) were surgeon & theater staff, 34
(5.09%) were Government servant, 29 (4.34%)
were nurses & midwives, 23 (3.44%) were
drivers, 17 (2.54%) were students and 11
(1.64%) was miscellaneous group.
Figure 2. Age wise distribution of HCV and HBV in males and females.
604
DISCUSSION
Pakistan is world’s sixth most populous
country with estimated population in year
2015 over 191.71 million, with low living
standards, educational levels and poor
health conditions (Pakistan Economic
Survey, 2015). The united nation’s human
development index out of total 174
countries ranks Pakistan at 134th position.
The prevalence of HBV and HCV in
general Pakistani population is 3% and 5%
respectively. It is estimated that prevalence
of chronic carriers in HBV in high risk groups
varies between 6-12%. The figures are much
higher for HCV i.e., upto 66%. (Babanejad
et al., 2016; Umer and Iqbal, 2015). Because
of lack of international standard health care
facilities, awareness in general public and
implementation of basic health standards
(sterilization, screening, disinfection) for
procedures like dental, surgical, transfusion
of blood and its products, syringes and needle
reuse, injection drug abusing, tattooing,
visiting quacks, shaving from barbers using
the same shaving kits and towels, the
prevalence incidences and disease burden
is increasing (Afzal et al., 2013; Afzal et al.,
2014; Raza et al., 2015; Afzal et al., 2016).
The present study was designed to
estimate the seroprevalence of HBV and HCV
in general population of Sargodha District
Punjab, Pakistan. Primary observation of
the current study was consistently high
prevalence rate of HBV and HCV in studied
population. According to the results of the
study, Sargodha District is a hot spot for these
infectious viruses. There are also difficult to
treat cases of co-infection of HBV and HCV.
As previous findings about HBV and HCV
prevalence in general population is very
limited and is from few metropolitan cities.
HBV prevalence in general population is
ranged from 2-5% while prevalence of
HCV was higher i.e. 3-24% (Afzal et al., 2016;
Babanejad et al., 2016). The results of the
current study are in line with previous findings
about the prevalence of HCV but the infection
rate of HBV is higher as compared with
previous data from the country. The higher
sero-prevalence of HBV is alarming and
might showing the lack of vaccination against
HBV in local population of the district. The
knowledge about the infection rate is always
important to design the prevention strategies
to contain the future spread. The overall
prevalence of HBV and HCV is quite high in
general population of the District which
Figure 3. Routes of transmission and Risk factors of Hepatitis B and C collectively of
667 positive patients in district Sargodha Pakistan.
605
showed the immediate need of counter
strategies; not only for treatment of the
infected individuals but also to limit the
disease spread.
Current study demonstrates that the most
affected age group in hepatitis B and C was
41-50 years (1968-1976 birth cohort)
followed by 31-40 (1977-1986) and 51-60
years (1958-1967 birth cohort). One of the
obvious reasons might be the acquisition of
disease prior to the development of efficient
screening methods for blood and blood
products (Umar et al., 2010). Other identified
possible risk factors for viral spread in
general population are shaving assisted
by barbers, Non-sterile or used needles &
syringes, dental surgical procedures. The
results of the study are in accordance with
previous findings that barber assisted shaving
(male participants) followed by unsafe
therapeutic injections and dental procedures
are the major risk factors across the country
(Abbas et al., 2015; Ali et al., 2009; Bari et al.,
2001; Khattak et al., 2008; Quddus et al., 2006;
Raja & Janjua, 2008). Community education
campaigns are highly warranted regarding
safe use of barber’s equipment, syringes,
surgical procedures not only for general
population but also for health care providers.
The results of current study highlight the
future challenges for health care step-up of
Pakistan. Most of the infected individuals
are in age group 30-50 Years, it is an
anticipation that with growing age of this
cohort HBV and HCV related complications
i.e., liver cirrhosis, end stage liver disease
and hepatocellular carcinomas (HCC) will
increase as we suspect these cases to acquire
ailment several decades ago (Afzal et al.,
2016). Availability of an efficient vaccine
for HBV has markedly reduced the HBV
prevalence and individuals between 11-30
years are comparatively less effected age
cohorts, although hyper-endemicity of disease
(HBV) and vertical transmission still pose
threat to this age cohort. While in case of
HCV the in-availability of a successful viral
vaccine has resulted in a persistently high
viral prevalence in Pakistani population.
Only available strategy for HCV is control and
that requires the in time diagnosis and
efficient treatment using pangenomic HCV
regimens (Afdhal et al., 2014; Jacobson et al.,
2011; Lawitz et al., 2013; Pawlotsky et al.,
2015; Sulkowski et al., 2014). Awareness of
the HBV and HCV risk factors is crucial for
resource allocation in preventive measures.
Through electronic and print media Public
health division is creating awareness in
Pakistani population regarding these viral
infections but still a lot of more efforts are
required for an efficient control of these
infections.
CONCLUSION
Current study described the epidemiology
of HBV and HCV in general population of
Sargodha District, Punjab, Pakistan. Exact
figures of prevalence and incidence are
missing from Pakistan but it is estimated
that the prevalence of HBV and HCV is very
high in certain areas of the country. Most of
the infections are attributed to 1961-1973
birth cohorts. High prevalence of both the
infections will increase the disease burden
in terms of morbidity, hepatic and extra-
hepatic complications and mortality in
future. There is a need to use efficient
treatment strategies for the control of these
viral infections. A comprehensive screening
of whole population is required to get the
complete picture of disease incidence and
prevalence. Public awareness is the key to
control and prevent the future infections.
Acknowledgements. The authors are
thankful to Department of Biological
Sciences University of Sargodha for
providing facilities to conduct this research
activity.
REFRENCES
Afzal, M.S., Ahmad, T. & Ahmed, H. (2015).
Hepatitis C Virus Infection in Iran; Viral
Spread Routes in General Population
and Safety Measures Hepatitis Monthly,
15(10): e17343. doi: 10.5812/hepatmon.
17343.
606
Afzal, M.S., Sahb, H.S. & Ahmed, H. (2016).
Recent HCV genotype changing pattern
in the Khyber Pakhtunkhwa province of
Pakistan; is it pointing out a forthcoming
problem? Brazilian Journal Infect
Diseases, 20(03): 312-313. http://dx.doi.
org/10.1016/j.bjid.2015.12.011
Abbas, Z., Jeswani, N.L., Kakepoto, G.N.,
Islam, M., Mehdi, K. & Jafri, W. (2015).
Prevalence and mode of spread of
hepatitis B and C in rural Sindh, Pakistan.
Tropical Gastroenterology, 29(4): 210-
216.
Afzal, M.S., Ahmed, T. & Zaidi, N.U. (2014).
Comparison of HCV prevalence in
pakistan and iran; an insight into future.
Hepatitis Monthly, 12; 14(1):e11466. doi:
0.5812/hepatmon.11466.
Afzal, M.S., Anjum, S. & Zaidi, N.U. (2013).
Effect of Functional Interleukin-10
Polymorphism on Pegylated Interferon-
á Plus Ribavirin Therapy Response in
Chronic Hepatitis C Virus Patients
Infected With 3a Genotype in Pakistani
Population. Hepatitis Monthly, 08;
13(6):e10274. doi: 10.5812/hepatmon.
10274.
Afzal, M.S. (2016). Are efforts up to the mark?
A cirrhotic state and knowledge about
HCV prevalence in general population of
Pakistan. Asian Pacific Journal of
Tropical Medicine, 9(6): 616-618.
doi:10.1016/j.apjtm.2016.04.013
Babanejad, M., Izadi, N., Najafi, F. & Alavian,
S.M. (2016). The HBsAg Prevalence
Among Blood Donors From Eastern
Mediterranean and Middle Eastern
Countries: A Systematic Review and
Meta-Analysis. Hepatitis Monthly, 26;
16(3):e35664. doi: 10.5812/hepatmon.
35664
Afdhal, N., Zeuzem, S., Kwo, P., Chojkier, M.,
Gitlin, N., Puoti, M. & Marcellin, P. (2014).
Ledipasvir and Sofosbuvir for Untreated
HCV Genotype 1 Infection. The New
England Journal of Medicine, 370:
1889–1898. http://doi.org/10.1056/NEJ
Moa1402454
Ali, S.A., Donahue, R.M.J., Qureshi, H. &
Vermund, S.H. (2009). Hepatitis B and
hepatitis C in Pakistan: prevalence and
risk factors. International Journal of
Infectious Diseases/: IJID/: Official
Publication of the International Society
for Infectious Diseases, 13(1): 9-19.
http://doi.org/10.1016/j.ijid.2008.06.019
Bari, A., Akhtar, S., Rahbar, M.H. & Luby, S.P.
(2001). Risk factors for hepatitis C virus
infection in male adults in Rawalpindi–
Islamabad, Pakistan. Tropical Medicine
and International Health, 06(9): 732-738.
Babanejad, M., Izadi, N., Najafi, F. & Alavian,
S.M. (2016). The HBsAg Prevalence
Among Blood Donors From Eastern
Mediterranean and Middle Eastern
Countries: A Systematic Review and
Meta-Analysis. Hepatitis Monthly.
16(3):e35664. doi:10.5812/hepatmon.
35664
Ditah, I., Ditah, F., Devaki, P., Ewelukwa, O.,
Ditah, C., Njei, B. & Charlton, M. (2014).
The changing epidemiology of hepatitis
C virus infection in the United States:
National health and nutrition examina-
tion survey 2001 through 2010. Journal
of Hepatology, 60(4): 691-698. http://doi.
org/10.1016/j.jhep.2013.11.014
Duddempudi, A.T. & Bernstein, D.E. (2014).
Hepatitis B and C. Clinics in Geriatric
Medicine, 30: 149-167. http://doi.org/10.
1016/j.cger.2013.10.012
Esteban, J.I., Sauleda, S. & Quer, J. (2008).
The changing epidemiology of hepatitis
C virus infection in Europe. Journal of
Hepatology, 48(1): 148-162. http://doi.org/
10.1016/j.jhep.2007.07.033
Government of Pakistan. 2015. Pakistan
Economic Survey. (2015). Population,
Labour force and Employment 2014-15.
Chapter 12.
Jacobson, I.M., McHutchison, J.G., Dusheiko,
G., Di Bisceglie, A.M., Reddy, K.R.,
Bzowej, N.H. & Zeuzem, S. (2011).
Telaprevir for previously untreated
chronic hepatitis C virus infection.
The New England Journal of Medicine,
364(25): 2405-2416. http://doi.org/10.
1056/NEJMoa1012912
Khattak, M.N., Akhtar, S., Mahmud, S. &
Roshan, T.M. (2008). Factors influencing
Hepatitis C virus sero-prevalence among
blood donors in north west Pakistan.
Journal of Public Health Policy, 29: 207-
225. http://doi.org/10.1057/jphp.2008.7
607
Lawitz, E., Mangia, A., Wyles, D., Rodriguez-
Torres, M., Hassanein, T., Gordon, S.C.
& Gane, E.J. (2013). Sofosbuvir for
previously untreated chronic hepatitis C
infection. The New England Journal of
Medicine, 368(20): 1878-87. http://doi.
org/10.1056/NEJMoa1214853
Mangrio, N.K., Alam, M.M. & Shaikh, B.T.
(2008). Original Article Is Expanded
Programme on Immunization doing
enough/? Viewpoint of Health workers
and Managers in Sindh, Pakistan.
Journal of Pakistan Medical Associa-
tion, 58(2): 64-67.
Mohd Hanafiah, K., Groeger, J., Flaxman,
A.D. & Wiersma, S.T. (2013). Global
epidemiology of hepatitis C virus
infection: New estimates of age-specific
antibody to HCV seroprevalence. Hepa-
tology, 57(4): 1333-1342. http://doi.org/10.
1002/hep.26141
Omer, S.B., Salmon, D.A., Orenstein, W.A.,
deHart, M.P. & Halsey, N. (2009). Vaccine
refusal, mandatory immunization, and
the risks of vaccine-preventable
diseases. The New England Journal of
Medicine, 360(19): 1981–8. http://doi.org/
10.1056/NEJMsa0806477
Pawlotsky, J.-M., Feld, J.J., Zeuzem, S. &
Hoofnagle, J.H. (2015). From non-A,
non-B hepatitis to hepatitis C virus cure.
Journal of Hepatology, 62(1S): S87-S99.
http://doi.org/10.1016/j.jhep.2015.02.006
PMDC. (2009). Prevalence of Hepatitis B and
C in General Population of Pakistan.
Raza, H., Ahmad, T. & Afzal, M.S. HCV. (2015).
Interferon therapy response, direct
acting antiviral therapy revolution and
Pakistan: future perspectives. Asian
Pacific Journal of Cancer Prevention,
16(13): 5583-5584.
Umer, M. & Iqbal, M. (2016). Hepatitis C virus
prevalence and genotype distribution
in Pakistan: Comprehensive review of
recent data. World Journal of Gastro-
enterology, 22(4): 1684-700. doi: 10.3748/
wjg.v22.i4.1684.
Quddus, A., Luby, S.P., Jamal, Z. & Jafar, T.
(2006). Prevalence of hepatitis B among
Afghan refugees living in Balochistan,
Pakistan. International Journal of
Infectious Diseases, 10: 242–247. http://
doi.org/10.1016/j.ijid.2005.04.007
Raja, N.S. & Janjua, K.A. (2008). Epidemio-
logy of hepatitis C virus infection in
Pakistan. Journal of Microbiology,
Immunology, and Infection, 41(1): 4-8.
http://www.ncbi.nlm.nih.gov/pubmed/
18327420
Siddiqi, N., Khan, A., Nisar, N. & Siddiqi, A.E.
A. (2007). Assessment of EPI (expanded
program of immunization) vaccine
coverage in a peri-urban area. Journal
of the Pakistan Medical Association, 57:
391-395.
Sulkowski, M.S., Gardiner, D.F., Rodriguez-
Torres, M., Reddy, K.R., Hassanein, T.,
Jacobson, I. & Grasela, D.M. (2014).
Daclatasvir plus sofosbuvir for
previously treated or untreated chronic
HCV infection. The New England
Journal of Medicine, 370: 211-21. http://
doi.org/10.1056/NEJMoa1306218
Umar, M., Bushra, H.T., Ahmad, M., Data, A.,
Khurram, M., Usman, S. & Bilal, M. (2010).
Hepatitis C in Pakistan: a review of
available data. Hepatitis Monthly, 10(3):
205-14.
Villar, L.M., Amado, L.A., de Almeida, A.J., de
Paula, V.S., Lewis-Ximenez, L.L. & Lampe,
E. (2014). Low prevalence of hepatitis
B and C virus markers among children
and adolescents. Biomedicine Research
International, 324638. http://doi.org/
10.1155/2014/324638
WHO. (2015). Pakistan: Prevention and
control of hepatitis. Retrieved from
http://www.emro.who.int/pak/
programmes/prevention-a-control-of-
hepatitis.html
World Health Organization. (2014). World
Health Statistics 2014. In World Health
Statistics. pp.175. http://doi.org/10.2307/
3348165
... The result showed that adults (30-40 years) have high frequency of HCV that was 33%. Same results were showed in the study of Rehman (2017) and Bostan (2016) [38,39]. Ahmad et al in 2010 reported the same kind of results that frequency of HCV infection in people ≤ 40 years of age was higher than those people > 40 years of age in Lahore [40]. ...
... The result showed that adults (30-40 years) have high frequency of HCV that was 33%. Same results were showed in the study of Rehman (2017) and Bostan (2016) [38,39]. Ahmad et al in 2010 reported the same kind of results that frequency of HCV infection in people ≤ 40 years of age was higher than those people > 40 years of age in Lahore [40]. ...
... The prevalence of Hepatitis C is high in the diabetic patients as compared to the general population of Lahore, Pakistan. Diabetic patients of age group (30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40) years have the highest risk for HCV. In diabetic patients gender is also a risk factor for the Hepatitis C. Further studies are needed to find out the basics behind these high prevalence. ...
... The result showed that adults (30-40 years) have high frequency of HCV that was 33%. Same results were showed in the study of Rehman (2017) and Bostan (2016) [38,39]. Ahmad et al in 2010 reported the same kind of results that frequency of HCV infection in people ≤ 40 years of age was higher than those people > 40 years of age in Lahore [40]. ...
... The result showed that adults (30-40 years) have high frequency of HCV that was 33%. Same results were showed in the study of Rehman (2017) and Bostan (2016) [38,39]. Ahmad et al in 2010 reported the same kind of results that frequency of HCV infection in people ≤ 40 years of age was higher than those people > 40 years of age in Lahore [40]. ...
... The prevalence of Hepatitis C is high in the diabetic patients as compared to the general population of Lahore, Pakistan. Diabetic patients of age group (30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40) years have the highest risk for HCV. In diabetic patients gender is also a risk factor for the Hepatitis C. Further studies are needed to find out the basics behind these high prevalence. ...
... The result showed that adults (30-40 years) have high frequency of HCV that was 33%. Same results were showed in the study of Rehman (2017) and Bostan (2016) [38,39]. Ahmad et al in 2010 reported the same kind of results that frequency of HCV infection in people ≤ 40 years of age was higher than those people > 40 years of age in Lahore [40]. ...
... The result showed that adults (30-40 years) have high frequency of HCV that was 33%. Same results were showed in the study of Rehman (2017) and Bostan (2016) [38,39]. Ahmad et al in 2010 reported the same kind of results that frequency of HCV infection in people ≤ 40 years of age was higher than those people > 40 years of age in Lahore [40]. ...
... The prevalence of Hepatitis C is high in the diabetic patients as compared to the general population of Lahore, Pakistan. Diabetic patients of age group (30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40) years have the highest risk for HCV. In diabetic patients gender is also a risk factor for the Hepatitis C. Further studies are needed to find out the basics behind these high prevalence. ...
Article
ackground: Hepatitis C virus or HCV is a blood borne pathogen, transmitted primarily via blood, body secretions and by piercing through skin (percutaneous), veins and mucosal surfaces. Prevalence of HCV in Pakistan is 4.5-8%. The prevalence of HCV in diabetic patients is reported to be 14.9% in 2016. Different studies show different prevalence of Hepatitis C in local population of Pakistan. This study was designed to find out the prevalence of HCV in diabetic patients of different age groups and gender. Methods: Blood samples from 259 diabetic patients were collected at Diabetes Testing and Screening Camp arranged by Akhuwat Health Services (AHS) at Township, Lahore. People of all age groups and gender were invited. Results were entered in MS Excel and analyzed on SPSS 19. Results: Out of 259 patients, 53% were females while 47% were males. This study shows the prevalence of HCV in Diabetic Patients as 8%. It was observed in diabetic patients, that females and patients from age group 30-40 years had high prevalence of HCV. Conclusion: The prevalence of Hepatitis C is high in the diabetic patients as compared to general population. HCV has a greater incidence in diabetic females of age group (30-40 years). B Abstract www.als-journal.com/
... Although the country is endemic for these infections but data regarding the prevalence of HBV and HCV in general population is very low [14]. The major transmission factors in Pakistan are unsafe blood transmission, injection drug usage, unsafe medical and dental procedures, treatment by quacks, barber's shops, unsafe sex practices and lack of education in general community [15][16][17]. Pakistan is a country with more than 200 million inhabitants. A recent review article summarized the previous data regarding the HCV epidemiology and concluded that there are only 32 studies analyzing the HCV prevalence in Pakistan. ...
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Hepatitis C virus (HCV) is endemic in Pakistan and its burden is expected to increase in coming decades owing mainly to widespread use of unsafe medical procedures. The prevalence of HCV in Pakistan has previously been reviewed. However, the literature search conducted here revealed that at least 86 relevant studies have been produced since the publication of these systematic reviews. A revised updated analysis was therefore needed in order to integrate the fresh data. A systematic review of data published between 2010 and 2015 showed that HCV seroprevalence among the general adult Pakistani population is 6.8%, while active HCV infection was found in approximately 6% of the population. Studies included in this review have also shown extremely high HCV prevalence in rural and underdeveloped peri-urban areas (up to 25%), highlighting the need for an increased focus on this previously neglected socioeconomic stratum of the population. While a 2.45% seroprevalence among blood donors demands immediate measures to curtail the risk of transfusion transmitted HCV, a very high prevalence in patients attending hospitals with various non-liver disease related complaints (up to 30%) suggests a rise in the incidence of nosocomial HCV spread. HCV genotype 3a continues to be the most prevalent subtype infecting people in Pakistan (61.3%). However, recent years have witnessed an increase in the frequency of subtype 2a in certain geographical sub-regions within Pakistan. In Khyber Pakhtunkhwa and Sindh provinces, 2a was the second most prevalent genotype (17.3% and 11.3% respectively). While the changing frequency distribution of various genotypes demands an increased emphasis on research for novel therapeutic regimens, evidence of high nosocomial transmission calls for immediate measures aimed at ensuring safe medical practices.
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The hepatitis C virus (HCV) was discovered in the late 1980s. Interferon (IFN)-α was proposed as an antiviral treatment for chronic hepatitis C at about the same time. Successive improvements in IFN-α-based therapy (dose finding, pegylation, addition of ribavirin) increased the rates of sustained virologic response, i.e. the rates of curing HCV infection. These rates were further improved by adding the first available direct-acting antiviral (DAA) drugs to the combination of pegylated IFN-α and ribavirin. An IFN-free era finally started in 2014, yielding rates of sustained virologic response over 90% in patients treated for 8 to 24weeks with all-oral regimens. Major challenges however remain in implementation of these new treatment strategies, not only in low- to middle-income countries, but also in high-income countries where the price of these therapies is still prohibitive. Elimination of HCV infection through treatment in certain areas is possible but raises major public health issues. Copyright © 2015 European Association for the Study of the Liver. All rights reserved.
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This study aimed to determine the prevalence of HBV and HCV among children and adolescents attending schools and daycare centres in Rio de Janeiro State, located in southern Brazil. Serum samples from 1,217 individuals aged 0 to 18 years were collected from 1999 to 2012 and tested for HBsAg, total anti-HBc, anti-HBs, and anti-HCV by ELISA. Reactive HBsAg and anti-HBc samples were tested for HBV DNA. Reactive anti-HCV samples were tested for HCV RNA and genotyped by RFLP. HBsAg was detected in 1.8% of individuals, and total anti-HBc was detected among 3.6% of individuals. Anti-HBs reactivity was found among 25.3% (322/1,217) of the individuals and increased from 6.28% in the years 1999-2000 to 76.2% in the years 2001–2012 ( P < 0.0001 ) . HBV DNA was detected in 18 of 51 individuals who presented with HBsAg or isolated anti-HBc, and nine were considered occult hepatitis B cases. Three individuals were anti-HCV- and HCV RNA-positive: two of them were infected with genotype 1, and the other was infected with genotype 3. Low levels of HBV and HCV markers were observed in children and adolescents. HBV immunity increased during the period of study, indicating that childhood universal HBV vaccination has been effective for controlling HBV infection in Brazil.
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All-oral combination therapy is desirable for patients with chronic hepatitis C virus (HCV) infection. We evaluated daclatasvir (an HCV NS5A replication complex inhibitor) plus sofosbuvir (a nucleotide analogue HCV NS5B polymerase inhibitor) in patients infected with HCV genotype 1, 2, or 3. In this open-label study, we initially randomly assigned 44 previously untreated patients with HCV genotype 1 infection and 44 patients infected with HCV genotype 2 or 3 to daclatasvir at a dose of 60 mg orally once daily plus sofosbuvir at a dose of 400 mg orally once daily, with or without ribavirin, for 24 weeks. The study was expanded to include 123 additional patients with genotype 1 infection who were randomly assigned to daclatasvir plus sofosbuvir, with or without ribavirin, for 12 weeks (82 previously untreated patients) or 24 weeks (41 patients who had previous virologic failure with telaprevir or boceprevir plus peginterferon alfa-ribavirin). The primary end point was a sustained virologic response (an HCV RNA level of <25 IU per milliliter) at week 12 after the end of therapy. Overall, 211 patients received treatment. Among patients with genotype 1 infection, 98% of 126 previously untreated patients and 98% of 41 patients who did not have a sustained virologic response with HCV protease inhibitors had a sustained virologic response at week 12 after the end of therapy. A total of 92% of 26 patients with genotype 2 infection and 89% of 18 patients with genotype 3 infection had a sustained virologic response at week 12. High rates of sustained virologic response at week 12 were observed among patients with HCV subtypes 1a and 1b (98% and 100%, respectively) and those with CC and non-CC IL28B genotypes (93% and 98%, respectively), as well as among patients who received ribavirin and those who did not (94% and 98%, respectively). The most common adverse events were fatigue, headache, and nausea. Once-daily oral daclatasvir plus sofosbuvir was associated with high rates of sustained virologic response among patients infected with HCV genotype 1, 2, or 3, including patients with no response to prior therapy with telaprevir or boceprevir. (Funded by Bristol-Myers Squibb and Pharmasset (Gilead); A1444040 ClinicalTrials.gov number, NCT01359644.).
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Background: In phase 2 studies, treatment with the all-oral combination of the nucleotide polymerase inhibitor sofosbuvir and the NS5A inhibitor ledipasvir resulted in high rates of sustained virologic response among previously untreated patients with hepatitis C virus (HCV) genotype 1 infection. Methods: We conducted a phase 3, open-label study involving previously untreated patients with chronic HCV genotype 1 infection. Patients were randomly assigned in a 1:1:1:1 ratio to receive ledipasvir and sofosbuvir in a fixed-dose combination tablet once daily for 12 weeks, ledipasvir-sofosbuvir plus ribavirin for 12 weeks, ledipasvir-sofosbuvir for 24 weeks, or ledipasvir-sofosbuvir plus ribavirin for 24 weeks. The primary end point was a sustained virologic response at 12 weeks after the end of therapy. Results: Of the 865 patients who underwent randomization and were treated, 16% had cirrhosis, 12% were black, and 67% had HCV genotype 1a infection. The rates of sustained virologic response were 99% (95% confidence interval [CI], 96 to 100) in the group that received 12 weeks of ledipasvir-sofosbuvir; 97% (95% CI, 94 to 99) in the group that received 12 weeks of ledipasvir-sofosbuvir plus ribavirin; 98% (95% CI, 95 to 99) in the group that received 24 weeks of ledipasvir-sofosbuvir; and 99% (95% CI, 97 to 100) in the group that received 24 weeks of ledipasvir-sofosbuvir plus ribavirin. No patient in either 12-week group discontinued ledipasvir-sofosbuvir owing to an adverse event. The most common adverse events were fatigue, headache, insomnia, and nausea. Conclusions: Once-daily ledipasvir-sofosbuvir with or without ribavirin for 12 or 24 weeks was highly effective in previously untreated patients with HCV genotype 1 infection. (Funded by Gilead Sciences; ION-1 ClinicalTrials.gov number NCT01701401.).
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C4 Dense-Deposit Disease , N Engl J Med 2014;370:. The final sentence (page 786) should have read, The renal deposits were composed of C4d, with negative staining for C3 and immunoglobulins on immunofluorescence microscopy; evidence of alternative-pathway activation was strikingly absent, rather than The renal deposits were composed of C4d with C3; immunoglobulins and evidence of alternative-pathway activation were strikingly absent. The article is correct at NEJM.org.