HCV eradication is now possible with proper selection of patients and appropriate treatment-Wasim Jafri


 PSSLD’s 11th Annual Conference at Islamabad

HCV eradication is now possible with
proper selection of patients and
appropriate treatment - Wasim Jafri

WHO envisages by 2030 90% of HCV patients will be diagnosed
and 80% will be on treatment - Massimo Colombo

To achieve WHO targets we need to adopt aggressive prevention,
and treatment strategies-Masood Siddiq

ISLAMABAD:  With the availability of oral medications, HCV eradication has now become possible with proper selection of patients and appropriate treatment. However, the cirrhotic will require lifelong monitoring. This was stated by Prof. Wasim Jafri an eminent Gastroenterologist, Hepatologist and founder President of Pakistan Society for Study of Liver Diseases while speaking at the PSSLD’s 11th annual meeting held here from December 8-10, 2017.  He also laid emphasis on micro elimination wherein everyone has access to safe medications, remove transmission, HBV vaccination at birth, safe injection practices, safe blood and blood products, safe sex. To achieve WHO targets of HCV diagnosis and treatment, we need to work on emergency basis and show commitment besides allocating adequate resources, he remarked. This session was chaired by Dr. Masood Siddiq along with Prof. Saeed Hamid while Prof. Zaigham Abbas acted as the moderator.

Pakistan Society for Study of Liver Diseases organized its 11th annual conference at Islamabad
from December 8-10, 2017. Photographed during the conference from (L to R) are Prof. Muzzafar
Latif Gill, Prof. Saeed Hamid, one of the foreign delegates, Prof. Masood Siddiq,
Zaigham Abbas and Prof. Wasim Jafri.

Speaking on “Hepatitis-C, Discovery, Elimination, Myth or Reality” Prof. Wasim Jafri first traced the history of hepatitis and said that HBV was first discovered in 1965 while HAV was discovered in 1973. It was Stephen who in 1975 named it Non-A Non-B wherein post transfusion patients were found to be suffering. In 1989 HCV was identified and diagnosed with the help of PCR. Its global prevalence is about 1-4%. There was a time that almost 45% of Egypt population was suffering from HCV. In Pakistan about 80% of liver cancer is due to HCV. His own study in 1989 showed the prevalence of HCV of 4.9%. Another local study showed that 1.6% of children suffer from HCV. Almost 90% of HCV in Pakistan is of Genotype 3. Pakistan comes at No.2 after China when we consider about the Viremic pool. He laid emphasis on early diagnosis before the complications set in. almost 25% of HCV will progress to develop HCC and now it is possible to eradicate HCV.

Prof. Wasim Jafary founder President of PSSLD photographed along with some of the
foreign delegates at the PSSLD annual conference held at Islamabad on December 8, 2017.

Speaking about treatment of HCV and the medications which became available, he referred to Interferon which was followed by Peg Interferon while a major breakthrough came in 2013 when FDA approved Sofosobuvir the first oral medication. In the next three years thirteen other oral medications for treatment of HCV were approved by FDA and it is hoped that by 2030 we will have numerous other safe and effective drugs for the treatment of HCV. No vaccination is available for HCV and we need to adopt preventive measures. HCV cure reduces all-cause mortality. Talking about WHO treatment cascade Prof. Wasim Jafri said that it envisages increased access to new medicines and simplified diagnosis.

Concept of Micro elimination

Dr. Massimo Colombo was the next speaker who talked about “Tackling the HCV Epidemic Bit by Bit: the concept of Micro Elimination”.  He discussed in detail the principles of infection elimination and eradication. WHO, he said, hopes that by 2030 there will be 65% reduction in mortality and 90% reduction in its prevalence. To achieve that we need to ensure 100% blood and injection safety.  It also calls for 90% achievement in providing three doses of HBV vaccine. As per the WHO Hepatitis strategy, HCV elimination, he opined, was feasible since there is no non-human reservoir. Achieving SVR is now possible in 95% of the patients. Difficult to treat patients are no more difficult however effective screening and linkage to cure is important. With effective therapies now increased treatment is also possible. We need to close gaps in diagnosis, treatment and infrastructure. At present according to reports there are about 71 Million infected persons globally. Achieving WHO goals will not be possible unless we remove barriers to diagnosis. China, India, Pakistan and Egypt have the largest population of HCV patients. Efforts need to be intensified to stop infection. It is possible with safe blood supply, therapeutic interventions, prevention of HCV transmission. Displaced people are most vulnerable. Better HCV treatment will allow simplified pathways. He also referred to micro elimination and pointed out that we need to set targets to cover children, drug abusers and prisoners who should be provided treatment. We can also have target areas and mandatory screening of all patients who visit hospitals for any complaint. It is extremely important that screening is linked to treatment, he added.

Simplifying Screening

Dr. Mario Mondelli from Italy spoke about Simplifying the Screening and linkage to Care for HCV. He pointed out that it is for the first time in history of medicine that a diseases can be eliminated without a vaccine. We have not yet fully eradicated Polio. However, he reminded the audience that we face the problems of lack of simple, low cost diagnostic tests, lack of laboratory tests and testing facilities. There is lack of national and international guidelines for hepatitis testing. In view of limited resources, it is important to decide who should be tested concentrating on high risk cases. Diagnosis and treatment of identified cases can interrupt transmission. 

We need high yield of case finding. He also talked about rationale of birth cohort testing and finding out the best strategy for each country. He was of the view that a mix testing approach will be required for each country. We are facing issues of limited awareness, knowledge about HCV infection, under diagnosis, inadequate screening and referral to care. Limited healthcare facilities have facilities for HCV testing. We need multiple preventive strategies to curb HCV epidemic. Providing access to treatment for all the patients as desired by WHO is not possible for all the countries. Hence, it will be advisable to opt for community based primary care services which are appropriate to test the patients. They are good for care of routine cases but complicated cases will need to be referred to specialized tertiary care facilities. We need to develop and practice triage and referral of advanced, difficult to treat cases to specialized centers. It will be much better to find target groups and treat them, he added.

Prof. Masood Siddiq Chairman of the organizing committee highlighted the most important risk factors which need to be tackled to reduce HCV transmission. Referring to the PMRC survey conducted in 2008, the prevalence of HCV was found to be 4.8% which means that we have about eight million patients suffering from HCV. This survey also showed that seven districts in Sindh and 23 districts in Punjab have HCV prevalence of more than 4.8% which was up to 13%. The risk factors identified included the large number of injections, reuse of syringes. Some villages had as high as 54% HCV infection. More blood transfusion means more HCV. Ear piercing, shave by barbers and nosocomial transmission were also highlighted.  Prime Minister’s scheme for Hepatitis control did provide treatment facilities to some and later it was transferred to provinces. Government of Punjab has taken certain important initiatives and according to reports 7,752 patients have completed six months treatment. We need to stop risk factors. At present just 15% of our population was being diagnosed. He laid emphasis on use of aggressive treatment strategies to reduce HCC by 80% and 85% reduction in cirrhosis, decompensated liver. To achieve WHO targets set for 2030 we need to adopt aggressive prevention, screening and treatment strategies. Contaminated medical equipment was yet another source of HCV transmission which needs to be looked into to curtail many preventable deaths, he remarked.

Treatment Options for HCV

Prof. Saeed Hamid from Aga Khan University discussed “What treatment options are available for HCV in Pakistan and what are the results”. He also talked about the impact of Generic DAAs on elimination of HCV infection. According to FDA there are certain pre-requisites for the Generic drugs which are it should use the same Active Pharmaceutical Ingredient (APIs), same dosage strength, same dosage form, same route of administration. Similar drugs should also ensure bioavailability. Now there is a wide spread use of DAAs which can make the elimination of HCV possible. However, there are certain problems because low income countries tend to spend very little of their resources on Public Health. These DAAs are still available in few countries despite voluntary licensing. The issues faced are related to production, registration and politics for which the patients continue to suffer. With the availability of generic Sofosobuvir and Decla, Egypt has reduced the prevalence of HCV considerably. With the availability of Generic DAAs the number of patients on treatment for HCV has increased manifold. In Pakistan we suspect about one hundred fifty to one hundred seventy thousand new infections every year hence availability of Generics DAAs may not make much difference. It is not known whether all the generics are as effective since there is no head to head trial. Treatment with SOF plus DECLA for twelve to twenty four weeks ensures 97-99% response rate. Generics has reduced drug prices. In Pakistan fourteen companies got their products registered and twenty five different brands are being marketed. Now it is possible to reduce the HCV disease burden and eliminate it as well. We can do it provided we have effective strategies. Generic competition is doing well but we need to ensure quality of generics. For that we need to have WHO pre-qualification, proper monitoring and bioequivalence data, batch testing by HPLC, clinical validation of results in patients. These drugs are effective and prices will continue to fall further. We must ensure that SVR are comparable to the originator and WHO should reduce the time required for pre-qualification of drug manufacturing facilities.

Some of the foreign delegates attending the Pakistan Society for Study of Liver Diseases 11th annual
conference at Islamabad being presented mementoes by Prof. Wasim Jafri, Prof. Zaigham Abbas,
Masood Siddiq along with Prof. Muzzafar Latif Gill.

Dr. Huma Qureshi gave Overview of National Hepatitis Strategic Framework (2017-2021). It aims at reducing infection, diagnosis of new patients, decrease in new infections, fast track registration of new drugs, reduction in diagnostics and treatment cost. Vaccination against HBV will also contribute to elimination of HCV, she added.

Dr. Asad Chaudhry gave highlights of a Project-ECHO Hep-C Elimination. It aims at 80-90% reduction   in infection, elimination of HCV through treatment. They had screened 5546 patients which showed the prevalence of HBV 2.7%, HCV 25.6%, 15.8% had received anti-viral treatment. We are busy in capacity building, training GPs, measure the outcome, involved in case based learning, educating doctors, nurses, patients, educators about HCV. We believe and practice low CME, our Mission is working and learning and we plan to have one hundred Model Hepatitis Clinics in the province of Punjab, Dr. Asad remarked.

Dr. Mark Thursz talked about “Elimination efforts of HBV from Africa and what can be adopted by Pakistan”? He pointed out that the efficacy of HBV birth dose vaccine was almost 75%. Infants of HBV positive mothers should be vaccinated within twenty four hours. There is a need for publically funded screening programme. We must cover infants of over 90% HBV positive mothers with HBV birth dose vaccine, ensure antenatal screening and treat HBV positive patients.

Mr. Osman Khalid Waheed from Ferozesons Laboratories highlighted the role played by the pharma industry in the elimination of HCV from Pakistan by making available oral anti-viral medications. He was of the view that we should not restrict our efforts to treatment only. Over ninety thousand patients in Punjab are going to be treated but we need to do a lot more. Healthcare professionals should engage themselves in CME, help start treatment networks, teachers, and students training, sessions with responsible employers to arrange screening and treatment of their infected patients, involvement of the corporate sector screening and treating their own employees will all go a long way in achieving elimination of HCV from Pakistan.

Inaugural Session

Prof. Wasim Jafri along with Dr. Masood Siddiq, Muzzafar Latif Gill and Masao Omata from Japan chaired the formal inaugural session. Prof. Muzzafar Latif Gill shared highlights of the scientific programme of the meeting. A special feature was participation of over hundred postgraduates in the Workshop at Quaid-e-Azam International Hospital. Prof. Masood Siddiq President of PSSLD in his speech said that this was for the first time that PSSLD had organized its meeting in the North. We have delegates from seven different countries the biggest delegation has come from China. We have participants from Turkey, UK, USA, Europe, and Japan. It provides us an opportunity for international collaboration. We have laid special emphasis on training of postgraduates by organizing advanced workshops. We have also supported their logistics and some have also been provided travel grants. This is our investment in the young doctors.

Some of the foreign delegates attending the PSSLD conference held at Islamabad recently photographed
with PSSLD office bearers and members of the organizing committee. Prominent among them are
Prof. Saeed Hamid, Prof. Zaigham Abbas, Prof. Muzzafar Latif Gill, Prof.
Masood Siddiq
and Prof. Wasim Jafri.

Prof. Wasim Jafri thanked the National and International faculty for their presence.  He also pointed out that some countries have dramatically reduced their morbidity and mortality due to viral diseases. In Taiwan now there is no newborn with HBV, Japan has reduced its disease burden of HCV. Egypt has made lot of progress. Each one of us is contributing to elimination or micro elimination of HCV. We need to create awareness among healthcare professionals, public, community at large to get themselves tested, ask every patient to get screened and those found positive should be referred to appropriate setting for treatment.

Prof. Masao Omata talked about the Forty Years History of APASL. Meeting held in Shanghai had 5,300 delegates. In all the APASL meetings the number of delegates so far from Pakistan have been 1264. From 2009 we also started holding Single Topic Meetings and the participation increased from 767 to 1183.  Japan has supported the developing countries by providing generic licensing. Treatment of HBV will prevent HCC. In China and Japan patients who have developed HCC are now dying. There are so many patients in Asia. We need to treat all HCC patients by adopting Spidor Plot which aims to see durable response. For advanced HCC, Sorafenib plus Lenva is cost effective. For renal cell cancer Penbro plus Lenvia is safe and effective. For endometrial cancer there is lot of competition even in generics, he added.