Hepatitis C: The deadly drill

Published: April 9, 2012
The use of unsterilised dental instrument is the second largest cause of the spread of hepatitis in Pakistan.

The use of unsterilised dental instrument is the second largest cause of the spread of hepatitis in Pakistan.


Imran Ali got the shock of his life when his blood samples tested positive for Hepatitis C. He had gone to a private clinic to donate blood to one of his friends, but instead found out that has own blood was tainted with the deadly virus. What was even more mystifying was the fact that he had tested negative for Hepatitis C when he had donated blood four months ago. It was easy for the health-conscious 22-year-old to put two and two together.

“The only thing that I could figure out which could have caused hepatitis was a dental examination I underwent,” pinpoints Ali.

“I had gone to a small clinic near my home in Iqbal Town and I was told the equipment was clinically sterilised but later I found out that using an autoclave [a steam-heated vessel where dental instruments are kept and boiled at certain heat and pressure levels to kill all viruses] is the proper way to get sterilisation done and the clinic didn’t have that procedure.”

Ali subsequently filed an application with the Health Department to take action against the private clinic, but his plea did not bear any fruit. His friends and lawyers then advised him to file a complaint with the Ombudsman’s office or file a case against the clinic in court.

“But I didn’t have any proof to substantiate my case so I didn’t consider it a viable option. Had the Health Department taken the matter seriously and seized the equipment of the clinic, it could easily have established that the equipment wasn’t sterilized properly,” he says in dismay.

Unfortunately Ali’s case is not an isolated one. According to the statistics available with the Hepatitis Prevention and Control Programme (HPCP), which gives guidelines and drafts policy for controlling hepatitis, every ninth person in Pakistan is a hepatitis patient. There are no proper figures available, but health officials say that the second largest transmission source for hepatitis in Pakistan is non-sterilised dental equipment. The number one cause is reused blades and razors at barber shops.

What puts those undergoing dental work particularly at risk is that in many dental procedures, blood will necessarily contaminate instruments. “In orthodontics (the alignment of teeth), maxillofacial surgery or root-canal treatments, instruments will definitely come in contact with blood,” explains dental surgeon Dr Anwar. “There is a small pin called the reamer which is inserted into the gums and, in many cases, it isn’t sterilised properly if it’s not put in autoclaves.”

Thus, the proper sterilisation of dental equipment is of utmost importance for preventing the spread of blood-related infection. Yet, this basic safety precaution is neglected at several dental clinics.

“There are above 30,000 unregistered so-called dental surgeons and quacks in Punjab alone, and they are the second largest source of spreading hepatitis in country,” says Pakistan Medical Association (PMA) Joint Secretary Dr Salman Kazmi. “Other than some teaching public hospitals there isn’t any Central Sterilisation Services Department (CSSD) where all surgical instruments, especially dental instruments could be properly sterilised.”

One of the reasons that autoclaves, while being of utmost importance, are severely underused, is simply because of the cost. A good autoclave costs around Rs 250,000 and runs on gas or electricity. This means that even those small clinics that actually consider sterilisation important may not be able to afford an autoclave.

In the absence of proper equipment, they use other methods which are not as effective.

“What happens here that in many small clinics dental surgeons use ovens to sterilise the instrument which isn’t at all effective in killing bacteria. Only an autoclave can do it properly and safely,” says Abid.

And even where autoclaves are available, there’s the usual problem of poor maintenance and apathy.

“There are autoclaves in all government hospitals at district headquarters, however in several cases they are not working properly,” reveals Kazmi.

Another way to disinfect instruments is by chemical sterilisation which is conducted by dipping instruments in a solution which has chemicals like gludraldehyde.

While Dr Anwar and Dr Kazmi lay the blame on the quacks, others allege that even reputed hospitals don’t have proper means of cleaning dental gear. “There are some departments at the Punjab Dental Hospital, where there isn’t any proper mechanism of sterilisation. In the scaling department, there isn’t any proper procedure for sterilization and even autoclaves are out of order,” claims a dental surgeon at the PDH. “The surgery department system is very nice, but inside every department, instruments and mouth mirrors are dipped in the same solution for the whole day for sterilisation. The same instruments go in every patient’s mouth and are likely to spread hepatitis from one person to the other.” Given that over 550 patients frequent the PDH every day, the chances for transmission are thus extremely high.

However, the Medical Superintendent (MS) of the Punjab Dental Hospital refuted the claims that dental equipment is not properly disinfected at public hospitals. “We properly steriliseequipment at public hospitals, however the problem lies with quacks and some small clinics,” she says.

A dentist surgeon at Mayo Hospital, however, claims that it’s not as simple as that. “Most of the time the sterilization of dental equipment in public hospitals depends on lower level employees, who do it during the evening or night. If they don’t do their job honestly the risk factor goes above manifold,” he explains. “There should be some training sessions to create awareness and responsibility among lower staffers who sterilisedental equipment in order to prevent hepatitis from spreading.”

However, any oversights or ommissions in this regard often go unpunished. Dr Altaf Hussain, the head of health department’s Hepatitis Preventive Control Programme (HPCP) says, “We give a policy line to control hepatitis, but we don’t have any mechanism to check or punish those who use non-sterilized instruments. The EDOs (Health) in their districts are responsible for this.”

The Punjab Government had in fact launched an anti-quackery campaign to prevent the spread of hepatitis, but it failed to show results.  An official in the health department claims the problem persists because government officials have no proper mechanism to inspect instruments at private clinics and drug inspectors are only sent out to check on these clinics once in a blue moon.

According to Dr Altaf Hussain, applications regarding unsterilised instruments can be filed with the area’s EDO Health, after which the health department has to take appropriate action.

Sadly, this procedure is not really followed. “The drug inspectors mostly settle issue with quacks or small clinics on their own and the show goes on and these people keep playing with lives of innocent people,” reveals another official.

In this situation, victims like Imran really have nowhere to turn to have their complaints heard. And every day that this situation persists, more and more people fall victim to this criminal neglect.

Published in The Express Tribune, March 21st, 2012.

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