Risk Factors for HCV Transmission in Pakistan

Dr. Saeed Hamid

Professor & Chair

Department of Medicine

Aga Khan University

Karachi, Pakistan

President , PSSLD

Modes of transmission of HCV in Pakistan.

• Only 25% blood banks tested blood and blood product donations for HCV infection.

Luby S, Health Policy Plan 2000;15:217-22.

• Relationship between therapeutic injections using non-sterile needles and transmission of HCV.

Khan AJ, Bull World Health Organ 2000;78:956-63.

• Excessive use of barbers for shaving

• Ear piercing

• Non-sterile surgical and dental practices of unqualified health care workers.

Bari A, Trop Med Int Health. 2001;6:732-8. 2

Pakistan Hepatitis Survey 2007-8

Prevalence of HCV according to use of IM Injections

Use of IM

Injection

No. of

Subjects

Prevalence of HCV

No % 95% C.I.

None 10987 402 3.7 3.3 – 4.0

2- 4 22623 1007 4.5 4.2 – 4.7

5-10 10492 641 6.1 5.7 – 6.6

> 10 2941 244 8.3 7.3 – 9.3

Total 47043 2294 4.9 4.7 – 5.1

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Population- Attributable Risk Estimates for Hepatitis B in Pakistan

No of IM

injections

Prevalence OR PAR

None 1

<5 3.1 1.4 1.3

5 to 10 3.3 1.5 1.8

> 10 4.4 1.7 3.5

Types of syringes

None 1

Re used syringes 3.7 1.7 2.7

Shaving

None 1

Home 3.7 1.1 0.4

Barber 4.1 1.5 2.1 4

Population- Attributable Risk Estimates for Hepatitis C in Pakistan

No of IM

injections

None 1

<5 4.4 2.38 6.1

5 to 10 5.9 1.71 4.2

> 10 8.1 2.38 11.3

Types of syringes

None 1

Re used syringes 6.8 1.91 6.2

Shaving

None 1

Home 7.5 1.4 3.0

Barber 9.8 1.8 7.9 5

• A peri-urban community of Karachi, pop= 59,000.

• High rate of liver related deaths reported

• Cross sectional household survey using systematic sampling, including adults 18 yrs and older.

• Of the 1997 study participants, 476 (23.8%) were anti- HCV positive.

• Of these, 402 were also HCV PCR positive.

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Prevalence of HCV infection in Karachi, Pakistan according to age

Journal of Viral Hepatitis, 2010, 17, 317–326 7

Risk factors associated with HCV Infection in Karachi

Journal of Viral Hepatitis, 2010, 17, 317–326 8

Injection Practices in Karachi

• 203 Adult patients interviewed-- 81% received injections • 135 blood samples from these patients analysed • 59(44%) Anti HCV +ve • 26(19%) Anti HBc +ve • If equally effective oral medications were available, 44%

would still prefer injections. • 94% injections were given with used syringes. • None of the practitioners knew that HCV can be transmitted

by injections.

Khan et al 2000 9

Blood Bank Practices In Karachi

• Participated in Study 24

• Regularly utilized paid donors 12 (50%)

• Actively recruited volunteer donors 06 (25%)

• Asked donors about IV drug abuse 02 (8%)

• None about high risk behavior 24 (0%)

• Facilities for HBV screening 23 (96%)

• Facilities for HIV screening 03 (54%)

• Facilities for HCV screening 06 (25%)

Luby et al 2000

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• While 95% of blood banks had appropriate equipment and reagents to screen for hepatitis B, only 55% could screen for HIV and 23% for hepatitis C.

• Twenty-nine percent of the facilities were storing blood products outside the WHO recommended temperature limit.

HCV : Blood Bank Practises In Karachi

Evaluation of blood bank practices in Karachi, Pakistan and the government’s response Luby, S; Khanani, R; Zia, m; Vellani, Z; Ali, M; Qureshi, A H; khan, A J; Abdul-Mujeeb, S; Shah S A; Fisher-Hoch, S

(Health Policy Plan 2000 Jun) 11

HCV : Relationship to Therapeutic Injections and Barbers in Pakistan

Cases were more likely to have received therapeutic injections in the past 10 years

(>10 vs. 0 therapeutic injections; Odds Ratio = 3.1)

Were significantly more likely to have daily face ( Odds Ratio = 5.1) and

armpit shaves (Odds Ratio = 2.9) by a barber.

Bari, A; Trop Med Int Health 2001

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Primary Objective:

To determine the key behavioral and lifestyle factors for the transmission of HCV infection in high versus low prevalent clusters in Pakistan

Secondary Objective

To estimate the prevalence and factors associated with intrafamilial clustering of HBV/HCV infection in Pakistan

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Spatial and Intra-familial Transmission

Analysis Of HCV Infection in Pakistan

Spatial Analysis

• We compared districts of low (≤ 4.9%), high (4.9%-8%) and very high (> 8%) prevalence

• Ordinal logistic regression was run by keeping low prevalent cluster as a reference catagory

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Adjusted Multivariable Analysis

Cluster type Unadjusted

odds ratios

95% CI Adjusted Odds

ratios

95% CI

Very high

prevalent cluster

(> 8 %)

Source of

shaving

Home 1 1

Barber 1.3 1.2-2.2 2.35 1.63-2.89

Sharing tooth

brushes

No 1 1

Yes 4.2 1.6-5.1 3.12 1.8-3.5

Sharing smoking

utensils

No 1 1

Yes 2.3 1.36-3.3 1.5 1.1-2.9

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Adjusted Multivariable Analysis

Cluster type Unadjusted

odds ratios

95% CI Adjusted Odds

ratios

95% CI

High prevalent

Cluster (4.10-8

%)

Source of

shaving

Home 1 1

Barber 1.4 1.2-1.8 1.6 1.2-1.9

Sharing tooth

brushes

No 1 1

Yes 3.9 1.5-10.2 2.5 1.4-3.6

Sharing smoking

utensils

No 1 1

Yes 1.4 1.1-2.6 1.2 1.1-1.9

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Frequency of household clusters with Anti HCV

HCV

Total subjects screened 47043 percentage

Anti HCV +ve 2294 4.80

Total households screened 6749

total households with HCV positive 1729 25%

households with 2 HCV positives 315 18.22%

households with 3 HCV positives 73 4.22%

households with 4 HCV positives 17 0.98%

households with 5 HCV positives 4 0.23%

households with 6 HCV positives 4 0.23%

households with 9 HCV positives 1 0.06%

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Prevalence of factors associated intra-familial clustering of HCV infection in Pakistan

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Cluster

household with

1 individual

household with

2 individuals

household with

> 2 individuals

P value

Number of IM

injections

2-5 N 590 265 152

0.136

% 44.7% 42.4% 43.7%

5-10 N 350 185 106

% 26.5% 29.6% 30.5%

>10 N 149 54 41

% 11.3% 8.6% 11.8%

none N 232 121 49

% 17.6% 19.4% 14.1%

Type of Syringes Reused N 686 348 164

0.03 % 52% 55.7% 47.1%

None N 635 277 184

% 48% 44.3% 52.9%

Tattooing/

acupuncture

No N 1312 625 348 0.10

% 99.3% 98.6% 99.7%

Yes N 9 9 1

% 0.7% 1.4% 0.3%

Prevalence of factors associated intra-familial clustering of HCV infection in Pakistan

Cluster

household

with 1

individual

household

with 2

individuals

household

with > 2

individuals

P value

Ear/nose

piercing

No N 812 353 194

0.04 % 61.5% 56.5% 55.7%

Yes N 509 272 154

% 38.5% 43.5% 44.3%

Sharing tooth

brush/ miswak

No N 1292 614 347

0.05 % 97.8% 98.2% 99.7%

Yes N 29 11 1

% 2.2% 1.8% 0.3%

Sharing smoking

utensils

No N 1217 595 324

0.04 % 92.1% 95.2% 93.1%

Yes N 104 30 24

% 8% 4.8% 7%

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Proportions, Odds Ratios (ORs) for the Risk Factors for Hepatitis C in Pakistan

5.9

8.1 6.8

9.8

11.5

8.3

5.8

2.0 1.6

1.8

1.9 2.3 1.7

1.7

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Risk Factors for HBV and HCV in South Asia

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How much could the burden of HCV and HBV be decreased by eliminating following exposures?

Hepatology Int, 2013 22

Burden of HCV related chronic liver

disease

• More recent data shows nearly 60-70% patients with CLD to be positive for anti-HCV.

Khan AA, J Coll Physicians and Surg Pak 2002;12:105-7.

• The number of admissions to hospital related to chronic HCV infection also show a nearly linear

increase over time. Hamid S, Hepatology 1999;30:212A.

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Chronic liver disease admissions (AKUH) 1988 - 1998

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HCC at AKUH, Karachi 1988 to Oct 2008

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HCC with HBV and HCV 1988 to Oct 2008

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How do we explain such a high prevalence of HCV Infection in Pakistan?

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Phylogenetic tree constructed in NS5B region of Pakistan genotype 3a cluster used for Molecular Clock Analysis

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1964-1982 Smallpox

vaccination

First 5 years health action plan

Afghanistan unrest 1978 onward

The maximum-likelihood estimates of the effective number of infections with HCV-3a in Pakistan

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Conclusions

• There is high disease burden of chronic viral hepatitis in Pakistan.

• This is driving the high liver related mortality and incidence of HCC.

• Most risk factors for transmission are driven by faulty health care delivery systems.

• Appropriate preventive and treatment strategies are imminently necessary.

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Recommendation

• Government and stakeholders

– Should design low cost intervention programs

– Continue educating the general public, health care providers and people involved in high risk activities

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Aga Khan University, Karachi

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