Exposure to Infectious Healthcare Waste, Homosexuality, Unhygienic Dental Surgery and Circumcision Found Responsible for Alarmingly High Prevalence of Hepatitis B and C Among Vulnerable Children in Pakistan: A Multifaceted Countrywide Study

Background: Hepatitis B and C infections are major health concerns in Pakistan which is sixth largest country population wise with an estimated disease burden of over 20 million patients in the country. This multi-faceted country-wide study aimed at determining the prevalence status, treatment and preventive interventions of deadly hepatitis B and C among the most vulnerable underprivileged orphan children in Pakistan. Methodology: After a detailed survey, a total of 3980 male and female vulnerable orphan (fatherless) children and adolescents of 5-17 years of age with low socioeconomic status were included in the study. Rapid screening kits were used for the primary screening of anti-HCV antibody and anti-HBsAg. The positive samples in initial screening were confirmed by quantitative PCR of Hepatitis B Virus (HBV) DNA and Hepatitis C Virus (HCV) RNA after which the HCV genotyping was performed using multiplex genotyping PCR. Assessment of risk factors of HBV and HCV transmission was performed on a pretested structured questionnaire. Preventive education regarding hepatitis B and C was disseminated to participants and their guardians by Information, Education and Communication (IEC) material in local languages and interactive sessions. Results: A total of 353 (8.9%) children were found infected with either hepatitis B or C. Of these, 58 individuals (16.4%) were positive for HBV surface antigen while 295 (83.6%) were found positive for HCV antibodies. Nineteen out of 58 HBV DNA positive samples exhibited high viral load (over 2.0 million IU/ ml) in quantitative PCR. Of the 295 HCV antibody positive children, 87 were found positive for HCV RNA in their blood serum after PCR. During genotype analysis, an untypable HCV strain was found in highest frequency (33.3%) followed by genotype 2a (27.6%), 3a (20.6%), 1a (6.9%), 3b (5.7%), 1b (3.4%) and 2b (2.3%) of the positive cases of HCV. Genotypes were not correlated with the gender or geographic variation of the population. During the geographic distribution, Upper Sindh region, exhibited highest disease prevalence; Jacobabad was found to be the worst affected area by both hepatitis B (7.3%) and C (27.3%). In Khyber Pakhtunkhwa (KPK), Swat Valley exhibited HBV and HCV prevalence of 1.8% and 25.5%, Ghauspur 3.2% and 22.3%, Lower Dir 0.7% and 18.4%, Kandhkot 3% and 16.6%, Dera Murad Jamali 4.4% and 13.3% respectively. None of these infections were reported from Gilgit region in the Northern Areas. Dental surgery/procedure was the most common risk factor regarding the spread of hepatitis B and C in all provinces of Pakistan. Sexual exposure and male homosexuality were found significant only in KPK while exposure to infectious hospital waste was a significant risk factor in Sindh. Male circumcision by barbers with unsterilized razors was found a common risk factor in both KPK and Punjab. Awareness dissemination activities have raised the preventive knowledge of participants significantly. Conclusion: The current study reports a fairly high prevalence of hepatitis B and C in a vulnerable juvenile population of Pakistan. An untypable genotype of HCV found in high numbers opens new research dimensions for HCV control in Pakistan. Upper Sindh region and Swat Valley are the most disease prone areas. There is an urgent need to work on the screening, treatment and preventive education of all stake holders to eradicate Hepatitis B and C in order to minimize public sufferings. This study sets a disease eradication model for the countries with high endemicity, low HDI and fragile law and order situation. Funding Statement: This study was supported by Higher Education Commission (HEC), Pakistan; Helping Hand for Relief and Development (HHRD). Declaration of Interests: The authors hereby declare that they have no competing interests with any other author or reviewer. Ethics Approval Statement: The study was approved from the Directorate of Advance Studies and Research (DASR), University of Azad Jammu and Kashmir, Muzaffarabad, Pakistan. All the information of the participants was kept confidential and laboratory testing and results provision was free of cost.