Research Article, Jldt Vol: 9 Issue: 5
Prevalence of Viral Hepatitis B and C in TheDistrict Bannu, Khyber Pakhtunkhwa, Pakistan
Muhammad Ashraf Khan*
Department of Elementary & Secondary Education, Khyber Pakhtunkhwa, Pakistan
Received: October 15, 2020 Accepted: November 09, 2020 Published: November 16, 2020
Citation: Khan MA (2020) Prevalence of Viral Hepatitis B and C in TheDistrict Bannu, Khyber Pakhtunkhwa, Pakistan. J Liver Disease Transplant 9:5. doi: 10.37532/jldt.2020.9(5).181
Objective: Viral hepatitis B and C are the major threat to public health. A retrospective study to determine the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) in the Bannu during the study period was conducted. Methods: The data was collected from the official register maintained by the pathology laboratory in the district headquarter hospital, Bannu. Results: In contrast to the previous studies, HBV cases contributed ≥70% share of overall occurrence of both types of hepatitis in the study area. Similarly, males also showed ≥70% prevalence of the disease compared to females. HBV is more prevailed compared to HCV in males (except August) and in females (except August and November). HBV is dominant in all age groups. Age group 15-30 Y constituted > 50% share, while age group < 5 Y contributed < 5% of the overall prevalence of both type of viral infections. Conclusion: HBV was more prevailed than HCV, while male compared to females as well as age group (15-30 Y) among all age groups demonstrated higher prevalence of hepatitis.
Keywords: Viral hepatitis B;Viral hepatitis C;Male;Female;Age group
Hepatitis is one of the leading cause of death ranked 7th worldwide  and is growing concern in Asian countries.  According to world health organization (WHO), there are five main types of viral hepatitis including A, B, C, D, and E. However, these types spread through different ways: contaminated food and water play main role to spread both hepatitis A and E, while both hepatitis B and C are blood borne and are spread through unscreened blood, serum, vaginal and other body fluids including saliva, semen and can also be transmitted perinatally.  Immunization is carried out only for hepatitis A, B, and D. Patients already suffered with hepatitis B can be infected with hepatitis D.
Both hepatitis B and C are responsible for chronic liver disease including hepatocellular carcinoma, liver cirrhosis and other liver complications and the related morbidity and mortality worldwide. [3-5] Hepatitis B Virus (HBV) is highly endemic to Pakistan. [6,7] Hepatitis C Virus (HCV) lead to prominent health issue worldwide  including Pakistan. [9,10] High prevalence of both hepatitis B and C in Pakistan as described by Waheed and Sadiq  have major sources including unscreened blood transfusions, shaving from barbers, reuse of needles and syringes and reuse of the same dental and surgical instruments for different patients in Pakistan.
Both HBV and HCV are widely occurred in Pakistan and result in end-stage liver disease including hepatocellular carcinoma and cirrhosis in the country . The population affected with both types of hepatitis reached to twelve million people in Pakistan and the disease prevailed ranged 4.5–8% with second largest nation in the world regarding prevalence of HCV [13-16] with 5% of the population infected: 8 million people (OECD. OECD health statistics .
World health Organization (WHO) introduced first Global Health Sector Strategies on Viral Hepatitis (GHSS) 2016-2021 with goals to reduce hepatitis incidence by 90% and to reduce hepatitis mortality by 65% by 2030. [1,18] Pakistan developed National Hepatitis Strategic Framework (NHSF) 2017-2021 in 2017 with support of WHO (GHSS) to eliminate hepatitis by 2030 in the country  Pakistan accounted for 7.1 million out of total 71 million HCV patients Globally [1,19]. The factors responsible for higher rate of hepatitis C virus being prevailed in Pakistan are lack of patient knowledge of the disease, financial problems related to investigations and treatment of the disease and lack of experienced healthcare workers .
The present study is the first attempt to determine the prevalence of viral hepatitis B and C in the general population of Bannu and cover period July through December, 2018.
Materials and Methods
Hepatitis B and C tests and provision of data
Samples (blood/serum or plasma) from 213 individuals including 149 males and 64 females were collected and were tested to detect HBV surface antigen and antibodies produced against HCV or both using a strip-based method called the immunochromatographic test (ICT) in the pathology laboratory of district Headquarter (DHQ) hospital Bannu during the study period. Screening kits (ICT:ACON, ACON Laboratories Inc., San Diego, CA 92121, USA) were used for detection of anti HCV and HBsAg (hepatitis B surface antigen).
Three drops of suspected patient sample were placed on the kit device by means of the dropper and added no buffer solution for screening HBsAg, while similarly 1/2 drops of sample with added buffer solution were used to determine HCV. The sample showing two bands against C (control sample) and T (test sample) were considered positive for both HBsAg and anti-HCV antibody. The individuals appearing positive in the screening were not further subjected to PCR based detection of viral DNA/RNA as well as ELISA. The data were taken from the official register maintained by the Pathology laboratory in the DHQ hospital Bannu.
For testing the association between viral types and months (Table 1) Pearson chi-squared tests conducted on frequencies which showed significant association between viral type (VB,VC) and months (X-squared = 17.257, df = 5, p = 0.0040). Significance difference were determined using Post Hoc pairwise comparisons (p = 0.05) for the relation viral type by months (adjustment method: Benjamini and Hochbergm.  Gender by months not significant (Table 2): (X-squared = 2.4538, df = 5, p-value = 0.7834). Gender by viral type not significant (Table 1): X-squared = 0.030795, df = 1, p-value = 0.8607, Age by months’ relation not significant (Table 1): (Fisher’s Exact Test: p-value = 0.05547).
|Male||Female||Age groups (years)||Tot M||Tot F|
Table 1: Distribution of viral hepatitis B and C in Bannu during July through December 2018.
Table 2: Distribution of viral types (HBV + HCV) in Bannu by months during July-December (2020).PosthocTukey test. * rates with the same letter are not significant (p=.05).
The data indicated variable prevalence of the hepatitis regarding type of hepatitis, sex and age of individuals. Out of 213 positive cases of both HBV and HCV, 153 (71.8%) were found positive against HBsAg and 60 (28.2%) were HCV positive (Tables 1 and 2). Overall male accounted for 149 (70%) cases of both hepatitis B and C in the study period. HBV accounted for 71.1% and 73.4% among males and females respectively. Age group 15-30 Y contributed largest share of 54.3%, while age group < 5 Y yielded lowest share of 4.2% of both hepatitis. Furthermore, the major share 71 (33.3%) cases were reported in the month of December. In all age groups HBV was more prevalent compared to HCV (Table 3). Among males, HBV was more prevalent than HCV in all months except August (Figure 1). Similarly, percentage occurrence of HBV in females was high compared to HCV except in August and November.
|M||Pos cas||<5 Y||5-14 Y||15-30 Y||31-45 Y||46-60 Y||>60 Y||Tot
Table 3: Types and gender wise viral hepatitis occurrence in different age groups in Bannu during July through December 2018.Note: M for male, F for female and T for total. B for viral hepatitis B, and C for viral hepatitis C. Two males have both types of hepatitis in December.
In 2000, Pakistan introduced the monovalent hepatitis B vaccine in the national EPI and replaced it in 2008 with the pentavalent vaccine where hepatitis B vaccine is jointly administered with diphtheria, tetanus, pertussis and Haemophilus influenza . However large number of newborns don’t get vaccinated resulted in the many children are exposed to these diseases . The differences in hepatitis viruses that are most prevalent in a population are because of difference in age-, sex-, and race-specific rates among different regions. 
The current study demonstrated higher prevalence of hepatitis in males compared to females (Table 1) supported by Butt and Sharif  found males were infected with hepatitis more than females. In Pakistan, different studies demonstrated either males or females as dominant group in term of prevalence of hepatitis [23-25]. The higher frequency of males affected with hepatitis is because of the greater vulnerability of male to the hepatitis virus as they were more exposed : males share personal items more than females such as towels, comb and scissor. Number of individuals suffered from HBV was more compared to HCV in the present study. However  found 39 (7.5%) patients were suffering from HCV while 5 (0.96%) were found positive for HBV surface antigen in Azad Jammu and Kashmir. Similarly, Butt and Sharif  concluded overall prevalence of hepatitis C was higher than hepatitis B as prevalence of HBV and HCV were 2.4% and 4.8%, respectively, in Pakistan . Among males, HBV was more prevalent than HCV (Figure 1).
The higher prevalence of HBV than HCV in the present study was because these patients were mostly belong to rural area in Bannu, was supported by Alam  who concluded that HBV is mainly affecting poor people in rural areas. HBV accounted for more than 70% both in males and females compared to HCV. While, Rauf  found higher HBV in males and higher HCV in females in Pakistan. HBV being dominant in the 1980 and 1990s was replaced by HCV in Pakistan. The higher HCV in Pakistan now may be because of more use of psychoactive drugs by the people.
CDC&P  reported HCV patients were 53.2%, and HBV were 10.8% (majority of them were males, > 62%), and also found age group (20 to 29 years) was the most dominant group with highest prevalence of the disease (39% HBV), similar to the current finding of age group 15-30 Years as the most dominant group (54.3% both HBV and HCV). Although EPI was introduced in Pakistan in 1978,  nevertheless, the hepatitis B vaccine and pentavalent vaccine were introduced more than 20 years later on and the delay in the introduction of anti-hepatitis vaccine contributed to high prevalence of the disease occurred in the age group of 15-30 Y. While, the low incidence of chronic HBV infection in the age group <5 years in children in the current study is because of the widespread use of antihepatitis vaccine in Pakistan. Vaccination against HBV are focus on the age <5 years as HBV infections acquired before the age of 5 years contribute most of the share of disease.
Overall the both types of hepatitis were more than twice occurred in male compared to females. Overall HBV is dominant over HCV, moreover, all age groups and most months show HBV more prevailed compared to HCV. Age groups 15-30 Y share the largest while age group < 5 Y demonstrated lowest contribution to the overall prevalence of both type of hepatitis.
I suggest to the government to focus on HBV more compared to HCV and proper vaccination of individuals of age group (15-30 Y) should be conducted to lessen the burden of the disease in the study area.
- Waheed Y, Siddiq M (2018) Elimination of hepatitis from Pakistan by 2030: is it possible. Hepatoma Res 4:45.
- Butt A, Sharif F (2016) Viral Hepatitis in Pakistan: Past, Present, and Future. Euroasian J Hepato-Gastroenterol 6:70-81.
- Farhat M, Yasmeen A, Ahmad A (2014) An Overview of Hepatitis B and C in Pakistan. IJOMAS 1:98-102.
- Kokki I, Smith P, Simmonds (2016) Hepatitis E virus is the leading cause of acute viral hepatitis in Lothian, Scotland. New Microbes and New Infections 10: 6-12.
- Sharma S, Carballo M, Feld J, Janssen (2015) Immigration and viral hepatitis, J. of Hepatol 63: 515-522.
- Noorali, S, Hakim S, Mclean D, Kazmi, S (2008) Prevalence of Hepatitis B virus genotype D in females in Karachi, Pakistan. J. Infect. Develop Count 2: 373-378.
- Rauf A, Nadeem MS, Muhammad Arshad M, Riaz H, Latif MM, et.al. (2013) Prevalence of Hepatitis B and C Virus in the General Population of Hill Surang Area, Azad Jammu and Kashmir, Pakistan. Pakistan J. Zool 45: 543-548.
- Wedemeyer H, Duberg A, Buti M, Rosenberg W, Frankova S, et.al. (2014) Strategies to manage hepatitis C virus (HCV) disease burden. J Viral Hepat 21: 60-89.
- Averhoff FM, Glass N, Holtzman D (2012) Global burden of hepatitis C: considerations for healthcare providers in the United States.Clin Infect Dis 55: 5-10.
- Kumar T, Ahmad N, Hayat MK, Bo-Xuan Gao, Faisal S, et.al. (2017) Prevalence and Genotypic Distribution of Hepatitis C Virus in Peshawar KPK, Pakistan, HAYATIJ Biosci 24: 22-25.
- Waheed Y, Shafi T, Safi SZ, Qadri I (2009) Hepatitis C virus in Pakistan: A systematic review of prevalence, genotypes and risk factors. World J Gastroenterol. 15: 5647-5653.
- Ali S, Rafe M, Donahue, Huma Qureshi, Sten H, et.al. (2009) Hepatitis B and hepatitis C in Pakistan: prevalence and risk factors. Int J Infect Dis 13: 9-19.
- Gower E, Estes C, Hindman S, Razavi-Shearer K, Razavi H, et.al. (2014) Global epidemiology and genotype distribution of the hepatitis C virus. J Hepatology 61: 45-57.
- Sana R, Atia I (2016) A Review of Hepatitis C in the General Population in Pakistan Pakistan, Toplumunda Hepatit C ile İlgili Bir Gözden Geçirme. Viral Hepat J 22:74-81.
- National Hepatitis Strategic Framework for Pakistan (2018) NHSF 2017-2021.
- Mahmud S, Kanaani A, Laith J, Abu-Raddad L (2019) Characterization of the hepatitis C virus epidemic in Pakistan, BMC Infectious Diseases 19:809.
- OECD (2017) OECD health statistics.
- WHO (2018) Global Health Sector Strategy On Viral Hepatitis, 2016–2021.
- Polaris Observatory HCV collaborators (2017) Global prevalence and genotype distribution of hepatitis C infection in 2015: a modelling study. Lancet Gastroenterol Hepatol 2: 161-76.
- Benjamini Y,Hochberg Y (1995) Controlling the false discovery rate: a practical and powerful approach to multiple testing. Journal of the Royal Statistical Society Series B 57: 289-300.
- Qureshi H, Bile K, Jooma R, Alam S, Afridi H (2010). Prevalence of hepatitis B and C viral infections in Pakistan: findings of a national survey appealing for effective prevention and control measures. East Mediterr Health J 16: 15-23.
- El-Serag H (2012). Epidemiology of Viral Hepatitis and Hepatocellular Carcinoma, Gastroenterology 142: 1264-1273.
- Aslam M, Mumtaz N, Majid A, Tahir M, Obaidullah A, et.al. (2013) Magnitude of HCV burden in plastic surgery patients. Pak J Med Res 42: 112-115.
- Naeem S, Siddiqui U, Kazi N, Khan S, Abdullah E, et.al. (2012) Prevalence of Hepatitis ‘B’ and Hepatitis ‘C’ among preoperative cataract patients in Karachi. BMC Res Notes. 6: 492.
- Gastroenterology 142: 1264-1273
- Ashraf S, Aftab A (2015) Viral hepatitis in Pakistan: challenges and priorities. Asian Pac J Trop Biomed 5: 190-191.
- Choudhary I, Khan S (2015) Should we do hepatitis-B and C screening on each patient before surgery. Pak J Med Sci 21:278-280.
- Center for diseases control and prevention (2011) Establishment of a Viral Hepatitis Surveillance System Pakistan, Morbidity and Mortality Weekly Report, 60;1385-1390.
- Imran, H, Raja D, Grassly N, Wadood, M, Safdar M, et.al. (2018). Routine immunization in Pakistan: comparison of multiple data sources and identification of factors associated with vaccination. International Health, 10: 84-91.