Prevalence of Hepatitis B & C in Cataract Patients (A socio-demographic and economic profile with nationwide hepatitis control plan and guide-lines, a community-based Study in most affected regions.)


Purpose: This study was conducted to find out the prevalence of Hepatitis B and C in pre-operative cataract patient. It is a descriptive cross-sectional study conducted at Tandlianwala District Faisalabad from March to August 2017.
Material and Methods: A total of 573 pre-operative cataract patients were invited for participation in the study. After taking the informed consent, these patients were screened for HbsAg and Anti HCV by Immuno-chromatographic test.
Results: Out of 573 subjects, 325 (57%) were found positive for either HBsAg or anti-HCV while among them anti-HCV shared 90% (293 patients) of the disease burden. Gender wise, 59% of male and 47% of female were sero-positive for anti-HCV while male (12%) and female (2%) positive for HBsAg. Patient with age >40 years were the mostly affected (59%) by either HBV or HCV.
Conclusion: This study found that Faisalabad region could be earmarked as one of most affected regions in Pakistan by viral infection of HCV and HBV. So, there is an immediate need to lay out nationwide hepatitis control plan as well as implementation of guidelines to reduce the risk of exposure to the healthcare professionals involved in these free eye camps.
Key words: Hepatitis C, Hepatitis B, Faisalabad, Cataract, Eye Camps

INTRODUCTION 

Among all types of viral hepatitis, Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections pose a severe threat to the public health especially in developing countries1. The latest evidence estimates that around on third of the global population is infected by HBV where as 71 million people have chronic hepatitis C infection. The annual mortality  due to HBV is around 780000 and HCV accounts for 399000 deaths2. It is worth mentioning that the developed countries have managed to curtail the disease transmission through proper vaccination for HBV and public awareness about the gravity of these viral infections3such as liver cirrhosis, hepatocellular carcinoma, hepatic fibrosis and steatosis. A literature review was conducted on hepatitis B virus (HBV. In contrast, the lack of preventive measures and health literacy among the general population are the major reasons to restrict the problem in developing countries4. Pakistan is facing a serious challenge of these viral infections as both HBV and HCV are endemic representing the intermediate prevalence zone1. The available data of Pakistan describes that around 4 to 5% of the population is the sufferer of HCV which represents one of the highest global infection rates5. However the first national survey which was conducted in the year of 2007-2008 concluded the overall prevalence of HBV as 2.4% and of HCV was 4.8%5.


There is an immediate need to layout a nationwide hepatitis control plan as well as the implementation of guidelines to reduce the risk of exposure to the health care professionals involved in eye camps.


Diverse studies conclude that not only the remote areas, but the industrialized regions like Faisalabad are equally affected. A relevant study in this area concluded the cumulative prevalence of HBV and HCV as 48.81% in a community based free eye camp. It indicates a higher prevalence rate of hepatitis B & C than the projected national figures6. The major way of transmission is parentral, peri-natal and sexual route and the health care workers, intravenous drug addicts and child born to positive mothers are the high risk group7. Poor  socio-economic conditions of the exposed population is considered as the main risk factor. Similarly lack of awareness, jobs at healthcare facilities, shaving with shared razors, and practice of non-sterilized equipment for surgeries, unchecked quackery and absence of safe blood transfusion services are the few other risk factors The socio demographic and economic profile Pakistani population represents that a significant portion of the society is ignorant about the epidemiology and risk factors of viral hepatitis. Although, secondary prevention modes in the form of early diagnosis and prompt treatment are highly recommended. But majority of the patients of these viral infections approach the hospitals at a stage of complication and advanced liver damage8. Although HBV vaccination is highly effective to prevent the infection but its proper availability and affordability is another issue9. It is evident that about 10% of Pakistani population is at verge of getting either HCV or HBV viral infection which is around 20 million of the total population. These asymptomatic patients pose a great threat not only to the the general population but national health care system and economy as well. An efficient vaccination plan combined with a public education campaign may lead to an effective control over the transmission of HBV. On the otherhand, the absence of any vaccination for HCV limits our effortsto the identification of high risk population and a mass drive against unsafe practices. Traditionally, provision of community based free eye care services is a regular feature of the medical professionals, charity organizations and philanthropists in Pakistan. These services mainly focus the screening and extraction of cataract with intraocular lens implantation. A study by Jadoon et al shows that as cataract causes bilateral blindness, estimated 570 000 individuals are effected from cataract in Pakistan, which has been estimated to increase up to 3 560 000 by the year 202010.Most of these patients get their cataract surgeries done in free eye camps. As a result, health care workers and ophthalmic surgeons exposed to HCV and HBV transmission via contaminated instruments or accidental needle-stick or sharp injuries4, 11.As large number of patients approach these free activities which may increase the risk of accidental transmission to health care professionals and patients. Keeping in view this scenario, the current study was conducted to quantify the magnitude of HBV and HCV prevalence in free eye camps at Tandlianwala region of Faisalabad.

MATERIAL AND METHODS

This descriptive cross-sectional study was conducted during the month of March to November 2017. The ethical approval was obtained and a semi structured questionnaire was prepared for data collection. The study was conducted in a community based free eye camp at Tandlianwala district Faisalabad. The camps continued for a period of three days both in March and November 2017. These camps were primarily arranged for the screening of Cataract and surgery for Intra ocular lens Implantations. A well-planned public campaign was launched at least one month before the camp date. The relevant channels of communication effective in the local area were used. The patients were screened by the qualified ophthalmologists. A total of 573 patients were selected for cataract surgery in both the camps. These patients were invited for participation in the study. After taking the informed consent, these patients were screened for HbsAg and Anti HCV by Immuno-chromatographic test. The serum obtained was tested for HBsAg and HCV antibodies using Immuno-chromatographic test kit. The test were performed according to the manufacturer’s instructions. The sampling process was observed and performed under the supervision of a qualified virologist. Around three ml of venous blood was drawn strict aseptic conditions. The blood was centrifuged for 5 minutes at 4500 rpm to obtain the serum and 20μl obtained serum was used for each of the test on immuno-chromatographic kits. The serum was let to run on the ICT kit for HBsAg while 20μl of binding buffer was added to the serum on the ICT kit for anti-HCV test. The sample sera were allowed to migrate chromatographically by capillary action to react with the dye conjugate immunogenic protein on the pre-coated membrane for 10 minutes. The reaction had generated colored band on the membrane. The number of bands were observed. A single band indicated the absence of the immunogenic protein and referred as a negative result while in positive samples, two bands were observed. The presence of a single band is the verification of sufficient serum and proper flow of it as a control. It was assured that during analysis the background of immune-chromatographic membrane was clear and no result was entertained after 20 min of sample run.

RESULTS

Among all the 573 subjects of this study 199 (34%) were males and 374 (66%) were females. The study subjects were divided into two age groups. Group A consisted of 171 (30%) subjects, with age ≤ 40 years. Group B comprised of 402 (70%) subjects with age > 40 years. Further distribution is presented in Table 1 and 2 respectively. The results represent that 248 (43%) subjects were found negative for HBsAg and Anti- HCV while 325 (57%) were found positive for either HBV or HCV. These findings are presented in Figure I. Prevalence of HCV shared the most of the disease burden as out of 325 subjects that found positive for either HCV or HBV, 293 (90%) subjects were found positive for anti-HCV. However,32 (10%) were found positive for HBsAg (Table-1). The result shows that out of 171 subjects with age ≤40 years, 13 (8%) and 75 (44%) were found positive for HBsAg and anti- HCV respectively. Similarly, out of 402 subjects with age >40 years, 19 (5%) and 218 (54%) were respectively found reactive for HBsAg and anti-HCV ICT tests. AP-value of < 0.05 (0.02) reflects that prevalence of hepatitis C viral infection is significantly associated with the older age (Table-1). These results conclude that 51% of the study subjects could be HCV carrier and pose a great threat to the general population. Similarly, the gender wise analysis of the data shows that 59% of male were screened out as positive for anti-HCV while 12% were also positive for HBsAg. The gravity of the situation is not different for female subjects as 47% were found positive  for anti-HCV and two percent were positive when subjected to ICT testing for HBsAg. The calculated P-Values for males and females of < 0.05 (0.00, 0.00) demonstrate that both HBV and HCV are significantly associated with gender (Table 2). Tables & figures







DISCUSSION

During the past decade, hepatic cirrhosis has emerged as a major source of mortality in Pakistan. Viral hepatitis stayed at the top among the major reasons for a widespread CLD (chronic liver disease). Different surveys have estimated that 7.6% of Pakistani population is infected with the viral infections of Hepatitis B and Hepatitis C while 2.82% and 4.8% respectively for HBV and HCV.1,16,24But a latest study accomplished that about 5% of Pakistani population is infected with HCV while these 5% could be translated into 10 million of the population. These numbers reflect the threat of these viral infection for the world population.1 Worldwide there are more than 175 million HCV carrier patients that accounts for 3% of world population1. If we assume that the figures given in recent surveys is accurate than Pakistan is burdened by at least 2% of world hepatitis C patients.25 But the situation could even be worse if an integrated nationwide extensive campaign is not launched with a focus to the highrisk regions of Pakistan specifically Faisalabad 21. The present study was conducted in Faisalabad region keeping in mind the results of some previous studies that suspected this region on the verge of a situation that could be called epidemic of hepatitis viral infections specially HCV.22 The result of this study could only aggravate the current situation regarding the prevalence of HBV and HCV as it shows that 57% of the subjected population was found positive  for either HBsAg or anti-HCV. More alarming situation is that among all the positive patients 90% were found positive for anti-HCV by immune-chromatographic test. These results are not only contrary to the already established facts but also enough for declaring socio-medical emergency. These results again ask for the requirement of a nationwide extensive integrated study and the need to lay out a national action plan by public healthcare system to counter this widespread menace of HBV and HCV. According to a previous study that was conducted in two regions Layyah and Rajanpur of southern Punjab in medical camps20, it was found that the cumulative sero-positivity rate for HBsAg and anti-HCV was 13% which also higher than the established numbers but the situation in Faisalabad region is getting worse.21,22 Other studies, done in Kashmir17, northern areas Pakistan18and Sargodha19, also reported that of prevalence of these viral infection is higher than the national estimations. The sero-positivity rate of HBsAg and anti- HCV antibodies did not significantly differ across gender. However, it greatly differs among the subjects  of age group of >40 years as compare to those with age ≤40 years. In group B (>40 years), prevalence of HBsAg and anti- HCV is respectively 5% and 54% as compare to group A results of 8% and 44%. The possible reasons for a higher prevalence of Hepatitis B and Hepatitis C among population of ages older than 40 years could be due to increased exposure to the risk factors for a longer time as compare the younger ones.23,24 Another reason is selection of study subjects from the pre-operative cataract patients which is an age-related problem. This study found that 71% of all male participants were found positive for either HBsAg or anti-HCV while 49% of all female subjects were found positive for either HBsAg or anti-HCV. So, the prevalence rate of these two viral infections is found significantly higher (P-value <0.005) in males as compare to the female participants. These findings are consistent to the results of a similar previous study where male subjects were more susceptible than the female ones. One of the possible reasons could that the males in our socio-economic setup has to stay outside home for earnings and to fulfill other responsibilities. Hence their exposure to the risk factors is far greater as compare to females.25 The silent or unknown carriers of hepatitis B and C pose a great risk to the staff involved in the management of a patient with a cataract surgery. The eye camps arranged in different communities do not have standard operative procedures. Thus, a higher prevalence of HCV or HBV in pre-operative cataract patient may potentially expose the healthcare professional to these menaces. 26 The application of the standard precautionary measures during such free medical camps may be the key in reducing the risk of Hepatitis B and Hepatitis C viral transmission that in turn may result in reduction of infection-related cancers. As an affordable and convenient screening method, the immuno-chromatographic test kits are preferably used for HBsAg and anti-HCV antibodies testing in most of the clinical or diagnostic facilities. For large scale studies in remote areas with insufficient diagnostic facilities, The ICT kits are again the most preferable choice in developing countries like Pakistan despite of all its error prone results.27 Thus, PCR test are to be used to confirm any positive result for HBsAg and  anti-HCV antibodies.

CONCLUSION

As some recent studies are in consistence with the findings of this studies that Faisalabad region may be one of most affected regions in Pakistan by viral infection of HCV and HBV. This study also hints about the probability that there could be some other high-risk regions in Pakistan still not surveyed. So, this study is a way forward in the right direction to counter this national calamity with the priority to educate the healthy ones about precautionary measures and the risk factors while treatment and disease management of the ill-fated infected ones. On other hand, free eye camps are one of the most sought-after community services that may be helpful in restoring the eye-sight of the under privileged communities. So, the application of the standard guidelines may be the key in reducing the risk of Hepatitis B and Hepatitis C viral transmission to the healthcare workers involved in these activities. The government should develop and implement legal protocols for these camps as well as launch a sustainable nationwide mass drive of an awareness and hepatitis control strategy.
The Nationwide Action Plan:
The Nationwide Action Plan against Hepatitis in Pakistan aims to improve the prevention, management and surveillance of hepatitis prevalence in the country. The action plan will serve as a focus for the health sector and proposes multi-sectarian strategies to achieve the set goals. The approach is based on respect for human rights, prohibiting stigma, discrimination or exclusion. Coordination among all concerned authorities will be put in place to monitor the implementation of the action plan. This coordination will work in close collaboration with all the health sectors involved in the implementation of the action plan and will be responsible for giving feedback twice a year on its different indicators as well as the possible solutions to be made. The action plan has set and prioritized few goals that will be implemented as the guidelines towards the awareness, management, prevention and eradication of hepatitis B & C. These goals are:
• Early detection of infected people on larger scale.
• Adequate healthcare access for people infected with hepatitis by diagnoses, follow-up and treatment according tonational and international recommendations
• Long-term reduction in the incidence of the hepatitis B & C epidemic
• Enhanced hepatitis precautionary measures for both the general public and those at-risk populations
• Better prevention from re-infection and recurrence of HBV and HCV
• Collection of the epidemiological data of HBV and HCV infections in the context of the national health.
• Improvement in diagnostic and laboratory facilities at the doorstep.
Conflict of interests. All authors declare that they have no conflict of interests.

1. Asad M, Ahmed F, Zafar H, Farman S. Frequency and
determinants of hepatitis B and C virus in general population of Farash Town,Islamabad.Pakistan J Med Sci. 2015;31(6)1394–8.
2. Jefferies M, Rauff B, Rashid H, Lam T, Rafiq S. Update on global epidemiology of viral hepatitis and preventive strategies. World J Clin Cases. 2018;6(13):589–99.
3. Saeed U, Waheed Y, Ashraf M. Hepatitis B and hepatitis C viruses: A review of viral genomes, viral induced host immune responses, genotypic distributions and worldwide epidemiology. Asian Pacific J Trop Dis. 2014;4(2):88–96.
4. Badawi MM, Atif MS, Mustafa YY. Systematic review and metaanalysis of HIV, HBV and HCV infection prevalence in Sudan. Virol J. 2018;15(1):1–16.
5. Butt AS, Sharif F. Viral Hepatitis in Pakistan: Past, Present, and Future1.Euroasian J Hepato-Gastroenterology. 2016;6(1)70–81.
6. Latif MZ, Hussain I, Nizami R, Dar U. Prevalence of Hepatitis B & C in Patients Visiting a Free Eye Camp for Cataract Surgery at Jarranwala District Faisalabad. Pakistan J Med Heal Sci. 2013;7(2):436–8.
7. Nepal A. Evidence of Hepatitis C Virus Infection and Associated Treatment in Nepal. J Mol Biomark Diagn [Internet]. 2016;07(02). Available from: https://www.omicsonline.org/openaccess/ evidence-of-hepatitis-c-virus-infection-and-associatedtreatment- in-nepal-2155-9929-1000270.php?aid=67123
8. Area HS, Jammu A, Rauf A, Nadeem MS, Arshad M, Riaz H, et al. Prevalence of Hepatitis B and C Virus in the General Population of. Pak J Zool. 2013;45(2):543–8.
9. Binka M, Butt ZA, Wong S, Chong M, Buxton JA, Chapinal N, et al. Differing profiles of people diagnosed with acute and chronic hepatitis B virus infection in British Columbia, Canada. World J Gastroenterol. 2018;24(11):1216–27.
10. Jadoon Z, Shah SP, Bourne R, Dineen B, Khan MA, Gilbert CE, Foster A, Khan MD. Cataract prevalence, cataract surgical coverage and barriers to uptake of cataract surgical services in Pakistan: the Pakistan National Blindness and Visual Impairment Survey. Br J Ophthalmol. 2007;91:1269–1273.
11. Tahir MA, Cheema A, Tareen S. Frequency of Hepatitis-B and C in patients undergoing cataract surgery in a tertiary care centre. Pakistan J Med Sci. 2015;31(4):895–8.
12. Lim AG, Qureshi H, Mahmood H, Hamid S, Davies CF, Trickey A, Glass N, Saeed Q, Fraser H, Walker JG, Mukandavire C. Curbing the hepatitis C virus epidemic in Pakistan: the impact of scaling up treatment and prevention for achieving elimination. International journal of epidemiology. 2018 Jan 3;47(2):550-60.
13. Shahid M, Idrees M, Butt AM, Raza SM, Amin I, Rasul A, Afzal S, Zahid S, Nawaz R. Short article: Hepatitis C and G virus coinfection in Punjab, Pakistan: incidence and its correlation analysis with clinical data. European journal of gastroenterology & hepatology. 2019 Mar 1;31(3):389-92.
14. Parkash O, Hamid S. Next big threat for Pakistan hepatocellular carcinoma (HCC). J Pak Med Assoc. 2016 Jun 1;66(6):735-9.
15. Lin YJ, Lee MH, Yang HI, Jen CL, You SL, Wang LY, Lu SN, Liu J, Chen CJ. Predictability of liver-related seromarkers for the risk of hepatocellular carcinoma in chronic hepatitis B patients. PLoS
One. 2013 Apr 17;8(4):e61448.
16. Miyamura T. Global Control of Hepatitis C Virus Infection. InHepatitis C Virus II 2016 (pp. 347-368). Springer, Tokyo.
17. A Rauf, MS Nadeem, M Arshad, H Riaz, MM Latif, M Iqbal, MZ Latif, N Ahmed, AR Shakoori: Prevalence of Hepatitis B and C Virus in the General Population of Hill Surang Area, Azad Jammu and Kashmir, Pakistan. Pak J Zool 2013, 45 (2), 543-548.
18. Rauf A, Nadeem MS, Riaz H, Latif MM, Latif MZ, Ahmed N, Shakoori AR: Tuberculosis and Hepatitis Infections among the Underprivileged Orphan Children of Northern Pakistan. Pak J Zool 2013, 45 (6), 1765-1770.
19. Riaz H, Latif MZ, Qureshi MA, Rauf A, Nizami R: HCV Prevalence and its Predominant Genotypes in Sargodha Region of Pakistan. Pak J Med Health Sc 2016, 10 (1), 6-10.
20. Riaz H, Latif MZ, Mujtaba SWA, Nizami R, Qureshi MA: Hepatitis B and C; an immuno-chromatographic study of hepatitis b and c prevalence in Southern Punjab. Professional Med J 2017, 24 (2), 244-248
21. Khalid A, Zahid M, Aslam Z, Bilal M, Haider A: Sero-Epidemiology of Hepatitis B and C Virus in Rural Population of Tehsil Samundri, District Faisalabad, Pakistan. Int J Virol Mol Bio 2015, 4(2): 19- 22.
22. Khalid A, Zahid M, Aslam Z, Bilal M, Haider A. Sero-Epidemiology of Hepatitis B and C Virus in Rural Population of Tehsil Samundri, District Faisalabad, Pakistan. International Journal of Virology and Molecular Biology. 2015;4:19-22.
23. Trickey A, May MT, Davies C, Qureshi H, Hamid S, Mahmood H, Saeed Q, Hickman M, Glass N, Averhoff F, Vickerman P. Importance and contribution of community, social, and healthcare risk factors for hepatitis C infection in Pakistan. The American journal of tropical medicine and hygiene. 2017 Dec 6;97(6):1920-8.
24. Afridi SQ, Ali MM, Awan F, Zahid MN, Afridi IQ, Afridi SQ, Yaqub T. Molecular epidemiology and viral load of HCV in different regions of Punjab, Pakistan. Virology journal. 2014 Dec;11(1):24.
25. Ali M, Idrees M, Ali L, Hussain A, Rehman IU, Saleem S, Afzal S, Butt S. Hepatitis B virus in Pakistan: a systematic review of prevalence, risk factors, awareness status and genotypes. Virology journal. 2011 Dec;8(1):102.
26. Garozzo A, Falzone L, Rapisarda V, Marconi A, Cinà D, Fenga C, Spandidos DA, Libra M. The risk of HCV infection among health-care workers and its association with extrahepatic manifestations. Molecular medicine reports. 2017 May1;15(5):3336-9.
27. Umer M, Iqbal M. Hepatitis C virus prevalence and genotype distribution in Pakistan: Comprehensive review of recent data. World journal of gastroenterology. 2016 Jan 28;22(4):1684.