A major global disease causing most of the chronic liver disease. Hepatitis B is a problem facing the populations in Asia, Africa and Latin America. The World Health Organization approximates that about 2 billion human beings are suffering from hepatitis B infection with right over a half billion people suffering from the chronic form of the disease. In the countries endemic for the hepatitis b infection, Pakistani ranks high because of the poor health facilities, low socioeconomic status of the population and less awareness among the public concerning most communicable diseases Hepatitis B included.
In the studies conducted by the Pakistani Medical Research Council in determining the prevalence for HBV infections, the study approximated the prevalence at 3.2% and incidence rate representing new transmissions at 4.8%. According to the studies, approximately 15 million Pakistanis were suffering from an active form of Hepatitis B infection, which was highly attributed to the rampant use of injectable drugs in the population using syringes. The clinical presentation of HBV infection varies among the different individuals however, the range of clinical signs and symptoms tend to overlap among the same individuals. The infection following hepatitis B virus follows three different clinical courses depending on several factors in the environment or the infected person, which are:
- A carrier state that remains asymptomatic with the ability to transmit the infection horizontally or vertically to other individuals.
- An acute infection that is self-limited over a period of a few days to weeks, with the infected individuals able to transmit the virus through their body fluids.
- Chronic hepatitis B infection with a fulminant liver failure clinical sequel that can progress to liver cirrhosis or hepatocellular carcinoma.
Considering the size and population of Pakistani as a country, the information at national level concerning the prevalence and incidence rates of hepatitis B remain very scanty. However, studies into the field have provided for a lot of data and information concerning the risk factors and systems in place already to curb the spread of the Hepatitis B virus in the country and how the health policies and structures put in place increase or decrease the awareness levels and prevalence of hepatitis B. The current systematic review of peer-reviewed literatures therefore provides the information on the risk factors, current health structures and policies and the lifestyle of the Pakistani population. In addition, it gives account of how these factors together increase the spread of the infection and lastly will provide the mitigations and solutions to intervene effectively the spread of HBV considering the socioeconomic, political, development and financial situation of the country.
Using the PRISMA guidelines, the peer-reviewed literatures were collected for the systematic review of the strategies and interventions that would be effective in the prevention of the spread of hepatitis B virus in Pakistani. Using the key terms developed from the research question(see appendix 1) and the informal pilot searches, the search design was created and used to identify the most relevant publications. The search terms used to develop the content of the systematic review from the online peer-reviewed literature in the databases were hepatitis, hepatitis B, hepatitis B prevalence, hepatitis B in Pakistani and prevention of Hepatitis B in Pakistani.
Four databases containing information on science were used in the search for the peer-reviewed literature. The databases were;
- Scopus, a database that offers comprehensive information and knowledge through articles from the fields of science, sociology and literature.
- PubMed, is a free database containing full texts articles of biomedical and life sciences.
- Web of science, providing multiple databases through a subscription based system concerning topics in the fields of science, sociology, arts and literature.
- Google scholar, a free search engine providing full texts of academic articles in every field such as medicine, technology, law and humanities.
Publications between the years of 1968 to 2017 on the topics of Hepatitis B, Hepatitis B risk factors, Hepatitis B in Pakistani and Intervention and prevention of Hepatitis B in Pakistani. All these factors were reviewed as the primary peer-reviewed articles to analyse the data and provide a discussion for the strategies and interventions effective for the prevention of hepatitis B virus infections in the Pakistani population.
All publications available in English were systematically reviewed in this paper. I considered and therefore analysed all the papers provided from the databases that provided information and knowledge on the health status of the Pakistani population in regards to socioeconomic conditions and practices. Articles on the other sub types such as hepatitis A, C and D were excluded however, some interventions are applicable across the same. In the systematic review, I excluded articles and studies providing information on the clinical progression, symptomatology and prognosis of hepatitis B infections in the general or specific for the Pakistani population. Studies that determined the prevalence and incidence rates among the medical professionals in Pakistani as occupational health hazards were included in the systematic review as the focus of this article was the interventions effective in prevention of spread of HBV. Grey literature was not searched for nor reviewed in the systematic review however, data sources regarding the prevalence, incidence rates and mortality rates on hepatitis B in Pakistani from the World Health Organization and the Centre for Disease Control were included and discussed.
Selection of the study papers
A three-layer screening process was applied in the identification of the papers to be used in this systematic review. Using the relevance criteria, the titles to the articles were vetted then the selected papers were screened after reading the abstract for relevance to the study question. Lastly, the quality and quantity of information provided in the remaining papers was analysed to determine the 11 publications used in this systematic review.
Quality assessment and bias analysis
Bias was assessed using the checklist provided by the formal Critical Appraisal Skills Programme tool and therefore due to the nature of the infections and spread, deliberately caused infections, infections due to randomized trails and intervention studies regarding the issues were not found as expected.
The final selected publications and articles were noted in Endnote and a table of information containing study design, study population, methodology, key findings and key discussion points was created.
The study designs and findings in the selected papers are reviewed and compared. The study design approaches are discussed and compared with other studies used in different populations to assess the quality and quality of data obtained and used as evidence in the review of the effective strategies and interventions in the prevention of the spread of HBV in Pakistani. The studies are compared in validity to the general global studies with strengths and limitations of the selected papers determined for future researches.
In the systematic search, 438 publications were identified. After a selection criteria process was conducted on the identified papers, only 11 fulfilled and were selected for this systematic review. The details of the publications are summarized and are as follows, google scholar 181 papers, PubMed 126 papers, Scopus 67 papers and Web of Science provided 64 articles. The articles were summarized using endnote program and the 311 duplicated publications were removed. From the remaining 127 publications, 56 papers were selected to be subjected to the criteria on eligibility through reading the Abstracts where 31 articles were shortlisted with articles now written in English language excluded. Most of the publications discussing the prevalence, incidence and intervention strategies were conducted in the Lahore, Karachi and Bahawalpur regions of Pakistani. In the reviews, articles that provided information on researches outside Pakistani were not included however, they were set aside to support the effectiveness of the interventions and strategies. The findings obtained were categorized into risk factors, health policies and practices and interventions, however only the interventions will be discussed in this systematic review.
The studies were conducted in the regions of Lahore, Karachi and Bahawalpur in Pakistani. Most of the relevant and current information are provided from publications of studies done after 2005.
The research conducted in the different studies were cross-sectional studies. The studies compared the socioeconomic practices, policies, lifestyles and health outcomes between the counties, regions and populations with low and high prevalence’s and incidences of Hepatitis B. however, the approaches, models of research and statistical analyses were different in each studies.
Effective intervention strategies.
Strategy and intervention axis 1.
Creating and raising public awareness on Hepatitis B.
The Pakistani population do not have sufficient information regarding hepatitis B virus in terms what the disease is, what organisms cause the disease, the source of the organisms, mode of transmission and the clinical symptoms. In a study conducted in Karachi among college girls, only 57% of the participants had information concerning the transmission of hepatitis B virus (Nasim et al, 2009). In another study, Ali et al,2004 determined that in rural Faisalabad, only a mere 22.2% of the rural population were aware of viral hepatitis.
An aggressive public awareness campaign should be conducted across the country to sensitize the Pakistani population and create a full awareness on the information regarding viral hepatitis, predominantly Hepatitis B. The awareness program should be extensively carried out equipping the Pakistani population on;
- The knowledge on Hepatitis B as a viral infection that is transmissible from person to person. Affects the liver and the complications such as liver failure and carcinoma.
- The modes of transmission of Hepatitis B and the possible axis of transmission as vertical or horizontal transmissions. The modes of horizontal transmission include sexual intercourse, kissing, sharing of sharp objects such as needles used for injecting intravenous substances and drugs, blades and through body contact and vertical transmission such as mother to child during child birth and breast feeding.
- The Pakistani citizens should be educated on the Hepatitis B symptomatology such as jaundice, abdominal pains, general body malaise and hepatic encephalopathy neurological deficits such as confusion and coma. This would enable early detection and treatment of the infection to reduce transmission and curb outbreaks.
- The Pakistani population should be encouraged to seek vaccination for the Hepatitis B virus to help boost their immune system.
- Medical principles, policies and practises.
Therapeutic processes in the hospital setting such as injections, blood transfusions, surgical procedures and chronic patient procedures such as catheterization are responsible for the transmission of up to 9% incidence rates in Pakistani. A large percentage of the Pakistanis prefer injections as a mode of drug delivery. In a research conducted in Karachi, a large number of serum samples were found to be positive samples of Hepatitis B containing HBV antigen and antibodies in their serum samples (Khan et al, 2000). In Pakistani health setting, unsterile injections were given and the HBV patients were found to have received five or more injections in the last 10 years (Luby et al, 1997).
A robust system should be implemented with a proper way of enforcing the WHO principles, practices and procedures on reducing transmission of diseases to compliment the national policies of safe medical practice to protect the patients and the medical professionals. The following are the recommendation ions by the different studies regarding reducing hospital setting transmissions;
- Non-injectable methods of drug delivery should be encouraged among the patients and the medical professionals. The myth and delusions held by the patients that injections are the definite treatment (Janjua et al,2006) should be broken through public awareness campaigns.
- Use of single-usage sterilized hospital tools such as scalpels, blades, catheters and needles for injection to reduce transmission across patients or as occupational exposures.
- Thorough screening of blood and other body products that act as conduits for transmission of the Hepatitis B virus such as before transfusion of donated blood and blood products.
- Universal immunization of the general public with the HBV vaccine to reduce infections and transmissions. This should be adopted to compliment the immunization of the medical professionals and other high-risk workers in accordance with the Expanded Program for Immunization.
- Government policies in reducing substance and drug abuse.
According to the report by UNESCAP presented by Nai Zindagi, 2010 “taking it to the streets”, Pakistani has an approximately 4.0 to 4.8million drug users who use injectable forms of the drugs. Complimented by Strathdee et al, 2003, the number of the drug users has been increasing remarkably since 2001. According to two different studies, the reports describe a remarkable large prevalence percentage of HBV at 14.95% among the injectable drug users (Altaf et al, 2007; Alam et al, 2007).
As an effective strategy and intervention to prevent the transmission of HBV among the IDUs in the Pakistani population, the government should crack the whip on all the drug users and drug traffickers through federal authorities such as the police and the Inter-Service Intelligence agency. Additionally, the government through the relevant organizations should create awareness among the IDUs their safety measure to reduce the transmission rates during injections.
Screening, care and treatment.
Pakistan is still an endemic region when considering the prevalence of HBV infections with very high carrier rates. Stringent treatment of the diagnosed and reported cases followed by a strict follow up program to ensure drug adherence and dose completion. Complete cure should be attained to reduce chronic carriers of the virus who can transmit new infections as they act as the natural reservoirs. The following should be implemented in the Pakistani population;
- Persistent and regular screening for Hepatitis B in the serum samples of the people of Pakistan through measurement of the Alanine Transaminase levels, HBV DNA, hepatitis virus antigens and antibodies formed.
- Strict care and management of Hepatitis B patients should be implemented and integrated into the usual procedures and practices of medicine in Pakistani. Every patient should be approached with a policy that “they are all positive until proven otherwise” and the necessary measures put in place to ensure prevention of transmission.
- A thorough patient follow-up program should be initiated and enforced to ensure patient’s drug compliance, dose completion and dose modification in cases of resistance to the drug regime started as first line therapy until seroconversion is achieved with complete disappearance of hepatitis B antigens and formation of antibodies against the hepatitis B’s nuclear material or antigens, measured at least at every 6 months apart (Abbas et al, 2010).
The Pakistani population remains to be a population with a high prevalence for hepatitis B infections resulting in a high HBV chronic carrier burden with complications such as fulminant liver failure and hepatocellular carcinoma increasing the morbidity and mortality rates in Pakistan. Unlike other transmissible infections, HBV have transmissions occurring sporadically and in micro-epidemics (Syed Asad et al, 2009). This systematic review of peer-reviewed literatures reveals a high prevalence of HBV in different regions settled by the entire Pakistani population. However, some sub-groups such as the injection drug users are a special population with a higher prevalence and therefore require special attention to mitigate and prevent transmission through sharing of the sharp objects. Due to the high prevalence, especially in regions such as Lahore, there needs to be implemented programs that would ensure efficient public awareness, vaccination, screening and treatment to ensure prevention and eradication of hepatitis B virus.
Different sampling methods in the different studies may have resulted in different prevalence and incidence rates within similar regions or populations of Pakistani. For example, one researcher opted for cluster random sampling, Jafri et al 2006 while in another different study, the sample used was randomly generated from a newspaper advertisement, Aslam 2001. Additionally, most of the studies use donated blood to determine the prevalence of Hepatitis B virus in the population and therefore may not accurately represent the true value of the population because of reasons such as most donators are drug users who donate for money and incentives.
The present systematic review gives the strategies and interventions that would be effective in the prevention of the spread of Hepatitis B in the Pakistani population. The strategies divided into awareness programs, hospital setting principles and practices, government policies and screening and management are targeted towards eliminating the natural reservoirs and reducing vertical or horizontal transmissions in the population. However, additional studies need be carried out in the population exploring the molecular and biological mechanisms at cellular levels that affect the transmission and spread of HBV. Although a small population, injection drug users have a very prevalence of HBV and therefore need to be studied more for their large disease burdens to control the infections.
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