Elimination of Hepatitis-C is going to be a medical miracle -Prof. Hamid Saeed

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 Liver Disorders Session during PSIM conference
Elimination of Hepatitis-C is going to be
a medical miracle -Prof. Hamid Saeed
We have established the first HCC clinic
in public sector hospital-Prof. Umar

SWAT: With the likely elimination of Hepatitis-C, there is a medical miracle in the making. This was stated by Prof. Hamid Saeed from Aga Khan University Karachi while making a presentation on Hepatitis-C Updates during the fourth scientific session at Pakistan Society of Internal Medicine Mid-Summer conference held here recently. This session was chaired by Prof. Javed Akram alongwith Prof. Asif Abbas Naqvi, Prof. Intikhab Alam and Dr. Bakht Buland. Prof. Hamid Saeed also advised his colleagues to look at Fatty Liver disease in Type-2 diabetes mellitus as it is going to be the next epidemic.

Fatty liver, Prof. Hamid Saeed said, is a big problem. At present the focus is on elimination of Hepatitis-C by 2030. Plans are afoot to combat viral hepatitis and it is included in Sustainable Development Goals (SDGs). At present almost 90% of children are getting Hepatitis-B vaccination at birth. Blood donors are being screened for HBV and HCV. Safe blood transfusion is being practiced. Almost 90% of hepatitis cases are being diagnosed and treated and they will be cured. Deaths from hepatitis, he said, are more than malaria, HIV and Tuberculosis. Elimination does not mean zero percent. After China, Pakistan is No. 2 as regard the number of HCV cases. Egypt has reduced the prevalence of HCV considerably.


Photographed during the PSIM Mid-Summer conference held at Swat recently prominent
from (L to R) are Prof. Tariq Waseem, Prof. Javed Akram CC UHS, Prof. Arshad Javed VC
KMU, Prof. Mohammad Umar VC RMU, Prof. Asif Abbas Naqvi, Prof. Intikhab Alam, Prof.
Hamid Saeed and othe
rs.

Prevalence of HCV in Pakistan was 5% as per the National survey done in 2008-9. Genotype-3 accounts for almost 90% of cases and it is difficult to treat. In some areas in Punjab the prevalence was 6.7% while another survey reported 9% but in some other areas it is reported to be even higher than this. HCV number is increasing rapidly and it is more in rural areas. A survey done in Malir in Karachi showed the prevalence of HCV as 40% in 2008 but now it has come down. Use of therapeutic injections is said to be the major cause of hepatitis infection. Our population has 5-10 injections per year as against WHO recommendation of one to two injections per year. We need to diagnose at least one million patients and treat them annually to meet the target by 2030. We also need fourfold increase in the number of cases being treated, 24% increase in diagnosis. It is a challenge. We have a good drug combination and 100% cure is now possible. Generic oral drugs are very cheap and they provide cure rate of almost 97%. However, we need to simplify the treatment, ensure early diagnosis and treatment. In another study they screened 9310 patients of which 1547 were found to be HCV positive and they are being treated in two Union Councils with an aim to eliminate HCV. He emphasized on training the community and healthcare professionals and link the GPs with Specialists. His conclusions were that it is high time that we educate the public, healthcare professionals, screen, diagnose and treat almost 90% of patients, improve treatment and prevent new infections. Government alone, he stated, cannot do it and they need partners in this field.

Dr. Noor Mohammad was the next speaker who spoke on Hepatitis-B Updates. He pointed out that we get HBV through unsterilized instruments, unscreened blood and blood products. He then referred to the diagnostic criteria for chronic HBV, indications for treatment in detail. It is important to ensure monitoring of the patients currently under treatment and they must be followed up every three to six months. Do their ALT assessment regularly. Goal of treatment, he said, is to improve quality of life and survival, prevent transmission from mothers to child. One should consider milder cases for treatment. Patients with decompensated liver should be referred for liver transplant. Pregnant and lactating women suffering from HBV can continue breast feeding. One can continue Peg Interferon if needed. ETC plus TDF and TAF are recommended for treatment of children. Healthcare workers suffering from HBV are not barred from working. ETV plus TAF should be used in recommended dose for treatment and the dose may have to be adjusted from patient to patient. When to start treatment is not easy but it is difficult. When to stop treatment we do not know as the risk of reactivation is there. What should be the viral load before starting treatment needs to be looked into.

HCC Updates and current
status in Pakistan

This was followed by an excellent presentation by Prof. Muhammad Umar Vice Chancellor of Rawalpindi Medical University on Hepatocellular Carcinoma and its present status in Pakistan. He gave details of the integrated healthcare model which he opined we need in Pakistan. We at our center, he said, have developed a database, all staff has to undergo mandatory training in infectious diseases. We have started Certificate Course in HIV, HCV. HCC can lead to death of the patient and the prognosis depends on general health of the patient and severity of the disease. We have BCLC tools to assess patients with HCC. Patients with less than 2 cm lesion are advised resection and those with more than three CM tumour are advised liver transplant. HCC treatment cost about five lac rupees. Chances of disease free survival are also dependent on size of the tumour. Those patients with single lesion are sent for resection if it is resectable.


Prof. Arshad Javed Vice Chancellor of Khyber Medical University presenting mementoes to
Prof. Hamid Saeed, Prof. Umar, Dr. Asif Abbas Naqvi, Prof. Intikhab Alam and others
during the PSIM Mid-Summer conference held at
Swat recently.

Continuing Prof. Umar said that one should screen the patients first. Do CT guided resection which is possible. In case of less than two cm lesion, alcohol injection is quite effective. Radio Frequency Ablation is another useful treatment modality. He also referred to another treatment modality TACE which offers 41% survival for two years. Treatment response is 35%. The number of sessions needed vary from one to five. There is a risk of infection and renal failure. Symptomatic chemotherapy is a failure. On the whole HCC outcome is poor. He was of the view that one must use the therapeutic doses of drugs to be effective. We have established the HCC clinic in public sector and so far we have registered 1249 HCC cases of which 40% were BCLC stage-C where not much can be done. Seven patients had resection, twenty two patients had liver transplant and another 24 had RFA. We have a one to two years follow up of twenty patients who are in a curative stage. His conclusions were that early diagnosis offers better chances of survival. One should identify these patients in early stage in the high risk group. Serious patients with cirrhosis with 2cm lesions can be resected and they can be cured.

During the discussion the likely increase in HCC after antiviral therapy was highlighted. Prof.Asif Abbas Naqvi in his concluding remarks said that there are chances for HCV elimination after effective treatment. However, it is a big challenge. We should try to meet it. HBV need to be controlled and for this surveillance is very important. When to start and when to stop treatment are important issues.

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