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• W4384207492 abstract "Introduction Globally, hepatitis B virus (HBV) and hepatitis C virus (HCV) are leading causes of liver disease and pose a significant burden on health care and the economy, especially in developing countries such as Pakistan1. HBV is responsible for 1.4 million deaths per year, with more than 2 billion exposed, of whom an estimated 296 million have a chronic infection2. It is the seventh leading cause of death around the globe3, highest rates being prevalent in sub-Saharan Africa and East Asia4. In Pakistan, there are an estimated 7–9 million carriers of HBV, with a carrier rate of 3%–5%. According to a study by Zahoor et al,5 estimates show that by 2030 3.25% of patients in Pakistan will be positive for HBV, and 6.36% will be positive for HCV. Considered a “silent” infection, HBV can be considered fatal, as usually, people affected are unaware that they have contracted or passed it on. Infection with HBV leads to a broad spectrum of clinical presentations, ranging from asymptomatic carrier state to acute self-limiting infection or fulminant hepatic failure, chronic hepatitis with progression to cirrhosis, and hepatocellular carcinoma6. Chronic HBV (lasting more than 6 mo) victims are at greater risk of developing liver failure, cancer, or cirrhosis. One in 4 people with chronic HBV infection are at a risk of premature death from cirrhosis or liver cancer7. Most patients have no symptoms because HBV develops slowly over decades. Signs and symptoms of liver failure include a fluid buildup in the abdominal cavity (ascites), confusion, tremors (due to encephalopathy), and bloody vomit or blood in the stool. Similarly, most patients with HCV report no symptoms; however, some patients may have nonspecific symptoms related to fatigue and discomfort on the right side of the abdomen. Often, symptoms that lead to a diagnosis of HCV are noticeable only at the end stage of liver disease, when the patient has developed liver cirrhosis and liver failure. This study highlights the need to devise a new therapy for patients suffering from HBV and HCV and aims to provide recommendations for further decreasing the incidence of hepatitis in Pakistan. Challenges Various factors add up to hinder the control of hepatitis B/C cases in Pakistan. Many of these cases are due to unnecessary therapeutic injection use and prolonged hospital stay, along with reusing syringes and using unsterilized equipment for dental or surgical procedures8. The cases keep rising due to unscreened blood transfusions, sharing of personal objects, such as razors and shaving machines, contact with contaminated blood and body fluids, getting a tattoo or piercing, and trips to unhygienic salons or barbershops along with having intimate relations with someone who has hepatitis. A mildly high prevalence of HCV in Hindu participants was also reported; this could be attributed to tattooing practice8. Moreover, a study conducted among pregnant women showed a higher prevalence of HBV in pregnant mothers with sociodemographic characteristics, including low educational level and residency in the urban area, being significantly associated with HBV seropositivity9. A major contributing factor to rising hepatitis B/C cases is the lack of vaccination in Pakistan. Chronic hepatitis B infections occur during or after birth, which can mostly be prevented by at-birth vaccination10. According to the American Academy of Pediatrics, if a baby receives the first dose within 24 hours of delivery, the efficacy of the vaccine in preventing hepatitis B transmission from parent to infant is 75%–95%11. Hepatitis B and C have been spreading rapidly across all provinces of Pakistan, mainly due to a lack of awareness about ways of transmission and the reluctance of people to seek medical advice on time, imposing a huge burden on the health care system12. The main issue faced by health care workers and health organizations is the lack of effort to reduce exposure to HBV and HCV, especially in high-risk populations. The unavailability of vaccines in case of HCV, and a lack of skilled personnel to administer the existing vaccines for HBV, are some pivotal reasons why these diseases are still widespread, especially in places that have zero access to any secondary health care, such as Interior Sindh. Lastly, diagnosis is a major practical challenge around the globe. Only 10% of those infected with chronic hepatitis B know their diagnosis, and just 21% of those with chronic hepatitis C know that they are currently infected10. Development of point-of-care testing and self-testing is desperately required. Although the drugs used in HBV and HCV treatments have been made available in Pakistan, it is important to note that the cost incurred by the regimens is beyond affordability in high-risk rural areas. Despite Pakistan tackling this serious health issue from many angles, all the stated reasons continue to pose a hindrance in eliminating hepatitis. Ongoing efforts and current treatment Acute hepatitis B or C infections do not require specific treatment, with the only management being symptomatic treatment. The treatment of hepatitis B infection revolves around viral suppression and, therefore, relies on the consistent use of drugs for life after diagnosis13. Currently, there are 2 types of interferons (IFNs) available: conventional and pegylated, and 5 nucleos(t)ides: telbivudine, entecavir, tenofovir disoproxil fumarate, tenofovir alafenamide fumarate, and besifovir dipivoxil14. Nucleos(t)ides are preferred over IFN therapy due to better patient compliance and fewer adverse effects15. In addition, the use of immunotherapy has been tested to assess the impact of boosting the body’s antiviral system against HBV. Despite insignificant effectiveness on its own, it is promising as a part of combination therapy with other drugs16. A functional cure is, however, yet to be discovered. As opposed to HBV, hepatitis B core treatment is focused on cures17. Groundbreaking findings from research on the virus’ structure and replication mechanism in 2015 enabled the shift from the former treatment, of using a combination of pegylated IFN and ribavirin, to the newly developed pan-genotypic direct-acting antivirals, which have shown viral eradication in 98% HCV patients without significant side effects that were encountered with used IFN regimens18,19. Sofosbuvir, a common direct-acting antiviral, alongside NS5A inhibitor velpatasvir, showed 99% sustained virologic response (SVR) in patients with compensated liver disease for genotypes 1, 2, 4, 5, and 6, whereas the lower SVR for genotype 3, the most prevalent strain in Pakistan, showed improvement with the addition of ribavirin (94% SVR) even in patients with cirrhosis or decompensated liver disease18. This will also prove beneficial in removing a significant burden on the economy of Pakistan, as estimated by the fact that HCV elimination by 2030 alone can save a net cost of 9.1 billion USD by 205020. The World Health Organization has developed a global health sector strategy to achieve hepatitis elimination by 2030 in collaboration with different countries’ authorities, and among them, some countries, like Iceland, Qatar, Australia, Japan, etc, are on track to achieving hepatitis elimination by 203021. It is a sign of progress that viral hepatitis is included in the Sustainable Developmental Goals22. Egypt received 530 million USD from the World Bank in 2018 for its campaign to eliminate hepatitis C and is now one of the first few countries to have eradicated this disease23. A decrease in the infections of HBV in some areas of khyber pakhtunkhwa shows development in health care facilities and accurate diagnostic systems9. The gradual decrease in disease burden may be due to awareness campaigns against viral infections by local government/other authorities, which played an important role in educating the population of the study area9. However, there is still a need to provide updated health care facilities in developing countries like Pakistan. Recommendations To curtail the transmission and thus reduce the prevalence of hepatitis B and C in Pakistan, it is essential to begin by educating people about high-risk behavior. An effective method of raising awareness can be workshops aimed at providing basic information regarding the disease and prevention strategies. Special attention should be given to local barbers, tattoo artists, and syringe-using individuals, whether drug abusers or those requiring regular transfusions, such as thalassemia patients and local dentists, as the main mode of transmission for these viruses is through introduction into the blood24. The promotion of the already introduced single-use syringes can play a pivotal role in preventing not only hepatitis but also human immunodeficiency virus and other communicable diseases25. The importance of vaccination against hepatitis B, given its 90%–95% effectiveness against the virus26, needs to be reiterated through regular information sessions and vaccination campaigns. Its inclusion in the extended program of immunization for infants can be fully utilized by addressing vaccine hesitancy among individuals, especially parents27. Adults, especially pregnant women, can be encouraged to also get vaccinated with the help of local religious and social leaders. Strengthening screening can also play an important role in the prevention of viral hepatitis by helping direct those with positive status to treatment at early stages as well as plan out localized measures to confine outbreaks28. Screening of pregnant women can help prevent maternal and fetal complications through the immediate provision of vaccines17. In addition, this can increase preparedness to act once the child is born, as the administration of the hepatitis B immune globulin and HBV vaccine within a narrow window of 12 hours of birth brings down the likelihood of mother-to-child transmission to 10%29. Finally, enhancing research projects focused on epidemiology, developing better diagnostic and screening methods, and effective treatment options can be useful30. The required investment can be funded through welfare activities hosted by non-governmental organizations, global hepatitis networks, and the government of Pakistan. Effective implementation of such measures through the cooperation of the public can pave the way to a hepatitis-free future for the country. Conclusion A huge percentage of the global hepatitis B and C burden is contributed by Pakistan, with many individuals progressing to decompensated liver disease and even hepatocellular carcinoma. The inability to reduce prevalence is attributed to various factors that promote transmissions, such as the use of infected syringes, low vaccination rates, lack of screening, and low patient compliance to treatment due to financial constraints or otherwise. Despite the availability of recommended regimens for both hepatitis B and C infections, adequate distribution and follow-up are required to ensure maximal effectiveness in treatment. The government, the health care sector, as well as the public must work together to promote strategies focused on prevention rather than cure through awareness and action to relieve the country from impending economic and medical crises due to the current alarming rates of infection. Ethical approval Not needed. Sources of funding Not applicable. Author contributions All authors contributed equally. Conflict of interest disclosures The authors declare that they have no financial conflict of interest with regard to the content of this report. Research registration unique identifying number (UIN) Not applicable. Guarantor Not applicable." @default.
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• W4384207492 title "Hepatitis B and C in Pakistan: is there hope for a better treatment?" @default.
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