Hepatitis and blood transfusion safety

Globally, hepatitis is a major public health challenge that requires urgent attention and response. The disease caused 1.34 million deaths in 2015, a number comparable to annual deaths caused by tuberculosis worldwide and higher than that caused by HIV. But while the tuberculosis and HIV epidemics are being managed successfully and their mortalities reducing, the viral hepatitis epidemic is still on the rise. To address this alarming scenario, the UN General Assembly in 2015 adopted the 2030 Agenda for Sustainable Development which called on the international community to eliminate hepatitis and followed it up by presenting the ‘Global Health Sector Strategy on Viral Hepatitis’ in the World Health Assembly in 2016. To implement this strategy, a global plan was outlined in the ‘Global Health Report 2017’ to contain and reverse the hepatitis epidemic through a number of key interventions and scaled up interventions. To highlight the scale of the hepatitis epidemic and raise awareness about its prevention, the World Health Organislation has designated July 28 as the World Hepatitis Day.

Viral hepatitis is inflammation of the liver caused by five main hepatitis viruses commonly referred to as types A, B, C, D and E. While all hepatitis viruses can cause acute hepatitis, Hepatitis B, C and D frequently cause chronic hepatitis, which can lead to progressive scarring of the liver (cirrhosis) and to primary liver cancer (hepatocellular carcinoma). HBV and HCV cause 96% of the mortality from viral hepatitis and usually occur as a result of parenteral contact with infected body fluids. Common modes of transmission include transfusion of contaminated blood or blood products, invasive medical procedures using contaminated equipment and for hepatitis B transmission from mother to baby at birth, from family member to child, and also by sexual contact. Hepatitis A and E infections are usually self-limiting and are typically caused by ingestion of contaminated food or water. Acute infection may occur with limited or no symptoms, or may include symptoms such as jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain. Hepatitis can also be caused by other infections, toxic substances (eg, alcohol, certain drugs), and autoimmune diseases.

Credible epidemiological evidence clearly demonstrates that elimination of viral hepatitis is possible. Universal coverage of Hepatitis B vaccine has established excellent results in containing the spread of Hepatitis B epidemic. The introduction of recent antiviral drugs treatment for chronic Hepatitis C infections has recorded cure rates exceeding 95%.

In Pakistan, all the five main types of viral hepatitis (A, B, C, D, and E) are epidemic. Most of the population is affected by Hepatitis A (Childhood) or E (Adulthood) with maximum morbidity. At the same time, Pakistan is also facing the epidemic of Hepatitis B and C. The last national survey conducted in 2008 showed 2.5% prevalence of HBV and 4.9% prevalence of HCV. HBV was more prevalent in males (2.9%) as compared to females (2.0%). But there was no gender difference in the HCV prevalence and overall Pakistan has the highest HCV prevalence after Egypt. The common causes of transmission identified in the Report and other research publications include contaminated blood transfusions, therapeutic injections, reuse of syringes and medical devices, injecting drug use, dental procedures, renal dialysis, shaving by barbers and commercial sex work.

The health care systems of developing countries continuously face challenges of inadequate supply of safe blood and an increase in the prevalence of transfusion associated infections, including hepatitis. Until 2010, the situation in Pakistan was also no different and the quality of blood transfusion services was adversely affected due to the imbalance in the supply and demand. According to national estimates, 3.5 million donations are made annually in Pakistan and the huge amount of blood collected used to be a potential key vector for transmitting infectious diseases, affecting about 7.4 per cent of the population. Screening for transfusion-transmissible infections is a critical part of the process of ensuring that transfusion is as safe and infection-free as possible. In a fragmented blood transfusion system and with an only incipient culture of voluntary donations, a strong reliance on family replacement donors, and the lack of systematic screening strategy, the infection risks were at the upper end. A large community of thalassaemic patients in the country (6% carrier rate) faced an imminent risk of acquiring infection through blood transfusion since they receive multiple transfusions every year.

To reduce the risk of transmission of infections through blood transfusions and improve the blood transfusion services, the Government of Pakistan with the support from the Government of Germany initiated the blood safety systems reforms in Pakistan in 2010. The reforms included the formulation of a national blood policy and strategic framework and the establishment of a national blood transfusion programme. At the federal level, the government’s Safe Blood Transfusion Programme (SBTP) performs the role of a central coordinating body to oversee policy planning, provide strategic guidelines, set standards, monitor and evaluate programmes, liaise with development partners and report on international commitments. The Programme is developing a nationwide blood transfusion infrastructure which consists of constructing and equipping a network of regional blood centres and renovation and refurbishment of the existing hospital blood banks. The model is consistent with international recommendations of separation of blood production and blood utilisation and regulated through a functioning oversight mechanism. The Programme also covers the associated technical work to prepare the system to function according to the international guidelines and directives.

The overall objective of the Programme is to provide safe, efficacious and quality assured blood to the people of Pakistan which is free from infections, particularly hepatitis, as much as possible. The infrastructure developed so far has started to provide service delivery and the people are thus deriving direct benefit of the blood sector reforms in the shape of better and safer blood transfusion services. In the current second phase of the project the size and scope of the project is being expanded exponentially to cover the hitherto uncovered regions.

The establishment of systems to ensure that all donated blood is screened for transfusion-transmitted infections, including hepatitis, is a core component of the SBTP. Through this Programme training activities and research studies have been conducted with the aim to improve the standard of screening in the blood centres and preventing the spread of infections through transfusions. National screening strategies and algorithms have been developed after extensive consultations. The adoption of these technical initiatives has contributed significantly to improvements in blood safety in the country. The regulatory oversight has been strengthened through the operationalisation of the largely dormant provincial and regional blood transfusion authorities. Despite all these milestone achievements by the flagship national blood programme gaps still remain. But with the gradual expansion in the coverage of services through the new system managed by the SBTP with continued support by the German partners strengthening of the credible partners and the regulatory authorities and phasing out of the smaller but numerous unsafe service providers the risk of hepatitis transmission through blood transfusions is likely to be successfully contained in Pakistan in the near future.

Published in The Express Tribune, July 31^st, 2018.

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