Risk Factors for HCV Transmission in Pakistan

Transcription

1 Risk Factors for HCV Transmission in Pakistan Dr. Saeed Hamid Professor & Chair Department of Medicine Aga Khan University Karachi, Pakistan President, PSSLD

2 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: Relationship between therapeutic injections using non-sterile needles and transmission of HCV. Khan AJ, Bull World Health Organ 2000;78: 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:

3 Pakistan Hepatitis Survey Prevalence of HCV according to use of IM Injections Use of IM No. of Prevalence of HCV Injection Subjects No % 95% C.I. None > Total

4 Population- Attributable Risk Estimates for Hepatitis B in Pakistan No of IM Prevalence OR PAR injections None 1 < to > Types of syringes None 1 Re used syringes Shaving None 1 Home Barber

5 Population- Attributable Risk Estimates for Hepatitis C in Pakistan No of IM injections None 1 < to > Types of syringes None 1 Re used syringes Shaving None 1 Home Barber

6 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. 6

7 Prevalence of HCV infection in Karachi, Pakistan according to age 7 Journal of Viral Hepatitis, 2010, 17,

8 Risk factors associated with HCV Infection in Karachi 8 Journal of Viral Hepatitis, 2010, 17,

9 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

10 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

11 HCV : Blood Bank Practises In Karachi 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. 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

12 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

13 Spatial and Intra-familial Transmission Analysis Of HCV Infection in Pakistan 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 13

14 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 14

15 Adjusted Multivariable Analysis Cluster type Very high prevalent cluster (> 8 %) Source of shaving Unadjusted odds ratios 95% CI Adjusted Odds ratios 95% CI Home 1 1 Barber Sharing tooth brushes No 1 1 Yes Sharing smoking utensils No 1 1 Yes

16 Adjusted Multivariable Analysis Cluster type High prevalent Cluster ( %) Source of shaving Unadjusted odds ratios 95% CI Adjusted Odds ratios 95% CI Home 1 1 Barber Sharing tooth brushes No 1 1 Yes Sharing smoking utensils No 1 1 Yes

17 Frequency of household clusters with Anti HCV HCV Total subjects screened percentage Anti HCV +ve Total households screened 6749 total households with HCV positive % households with 2 HCV positives % households with 3 HCV positives % households with 4 HCV positives % households with 5 HCV positives % households with 6 HCV positives % households with 9 HCV positives % 17

18 Prevalence of factors associated intra-familial clustering of HCV infection in Pakistan household with 1 individual Cluster household with 2 individuals household with > 2 individuals P value Number of IM 2-5 N injections % 44.7% 42.4% 43.7% 5-10 N % 26.5% 29.6% 30.5% >10 N % 11.3% 8.6% 11.8% none N % 17.6% 19.4% 14.1% Type of Syringes Reused N % 52% 55.7% 47.1% 0.03 None N % 48% 44.3% 52.9% Tattooing/ No N acupuncture % 99.3% 98.6% 99.7% Yes N % 0.7% 1.4% 0.3% 18

19 Prevalence of factors associated intra-familial clustering of HCV infection in Pakistan Ear/nose piercing Sharing tooth brush/ miswak Sharing smoking utensils Cluster household with 1 individual household with 2 individuals household with > 2 individuals No N % 61.5% 56.5% 55.7% Yes N % 38.5% 43.5% 44.3% No N % 97.8% 98.2% 99.7% Yes N % 2.2% 1.8% 0.3% No N % 92.1% 95.2% 93.1% Yes N % 8% 4.8% 7% P value

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

21 Risk Factors for HBV and HCV in South Asia 21

22 How much could the burden of HCV and HBV be decreased by eliminating following exposures? 22 Hepatology Int, 2013

23 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: 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. 23

24 Chronic liver disease admissions (AKUH)

25 HCC at AKUH, Karachi 1988 to Oct

26 HCC with HBV and HCV 1988 to Oct

27 How do we explain such a high prevalence of HCV Infection in Pakistan? 27

28 Phylogenetic tree constructed in NS5B region of Pakistan genotype 3a cluster used for Molecular Clock Analysis 28

29 The maximum-likelihood estimates of the effective number of infections with HCV-3a in Pakistan Afghanistan unrest 1978 onward First 5 years health action plan Smallpox vaccination 29

30 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. 30

31 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 31

32 Aga Khan University, Karachi 32

33 33