Effect of COVID-19 on viral hepatitis services in Pakistan
Authors: Zia Ul Mustafa, Chia Siang Kow, Syed Shahzad Hasan
Journal: The Lancet. Gastroenterology & hepatology (2021)

There are more than 15 million people infected with hepatitis B virus (HBV) and hepatitis C virus (HCV) in Pakistan.1WHO15 million people affected with hepatitis B and C in Pakistan: government announces ambitious plan to eliminate hepatitis.https://www.who.int/hepatitis/news-events/pakistan-hepatitis-elimination-plan/en/Date: July 28, 2019Date accessed: December 2, 2020Google Scholar Currently, the Hepatitis Prevention and Treatment Programme2Khan A Afzal S Yaqoob A et al.Epidemiology of viral hepatitis B and C in Punjab, Pakistan: a multicenter cross-sectional study, 2017-18.F1000Res. 2019; 82065Crossref Google Scholar and other government-funded initiatives are providing viral hepatitis care free of charge throughout the country. Encouraged by the Correspondence from Lemoine and colleagues,3Lemoine M Kim JU Ndow G et al.Effect of the COVID-19 pandemic on viral hepatitis services in sub-Saharan Africa.Lancet Gastroenterol Hepatol. 2020; 5: 966-967Summary Full Text Full Text PDF PubMed Scopus (19) Google Scholar which determined the effect of the COVID-19 pandemic on viral hepatitis services in sub-Saharan Africa, we aimed to quantify such effects in Pakistan. The total number of new and known cases of HBV and HCV in the province of Punjab were recorded from January to June, 2020, and the corresponding months in 2019, collected from 23 hepatitis care clinics involved in the Hepatitis Prevention and Treatment programme.2Khan A Afzal S Yaqoob A et al.Epidemiology of viral hepatitis B and C in Punjab, Pakistan: a multicenter cross-sectional study, 2017-18.F1000Res. 2019; 82065Crossref Google Scholar A representative from every clinic was also surveyed about the disruption of services in the respective clinic amid the COVID-19 pandemic. From January to June, 2020, the number of patients with HBV and HCV, seen monthly at the district hepatitis clinics, decreased substantially (appendix). In January, 2020, when no cases of COVID-19 had yet been reported, a mean of 45 new patients with HBV were seen at each district hepatitis clinic. By June, 2020, the figure had fallen by 84% to an mean of seven new patients with HBV at each district hepatitis clinic. Similarly, the mean number of patients with HBV attending follow-up at each district hepatitis clinic fell by 67% from January to June, 2020. A striking decline was also observed in the number of patients with HCV. A mean of 148 new patients with HCV were seen at each district hepatitis clinic during January, 2020, but the number declined by 66% to a mean of 51 new patients with HCV during June, 2020. A decline of 74% was reported in the mean number of patients with HCV attending follow-up at each district hepatitis clinic from January to June, 2020. We also observed a considerable reduction in the number of new or known patients with HBV or HCV in 2020, compared with 2019 (appendix). The introduction of telemedicine in these district hepatitis clinics amid the COVID-19 pandemic might have contributed to these declines, but its use was mainly to facilitate the dissemination of information about the availability of medicines and to inform dose adjustment for some patients. Importantly, all clinic representatives agreed that the care of patients with hepatitis was affected and disrupted during the COVID-19 pandemic, although none of these clinics experienced staffing shortages. In particular, the vaccination service was stopped in all hepatitis clinics in the province of Punjab because of an inadequate supply of vaccines. In addition, PCR tests for the diagnosis of viral hepatitis were halted because laboratories had reserved PCR tests for COVID-19. Routine monitoring of patients with viral hepatitis through laboratory tests such as measurement of liver enzyme concentration and complete blood count were also affected as laboratories prioritised patients with COVID-19. An estimated 325 people die due to viral hepatitis per day across Pakistan;4The Express TribuneHepatitis claims around 325 lives daily in Pakistan.https://tribune.com.pk/story/2255740/hepatitis-claims-around-325-lives-daily-in-pakistanDate: July 20, 2020Date accessed: November 29, 2020Google Scholar by contrast, there were 153 confirmed deaths due to COVID-19 during the peak of cases in June.5The MainichiPakistan reports 153 COVID-19 deaths, highest daily toll.https://mainichi.jp/english/articles/20200620/p2g/00m/0in/082000cDate: June 20, 2020Date accessed: November 29, 2020Google Scholar The province of Punjab had already received technical support from WHO to limit the increasing number of viral hepatitis cases before the emergence of COVID-19. Nevertheless, due to the need for strict lockdown, the country's borders were shut, which further reduced the availability of antiviral therapies. In April, 2020, Pakistan was reported to be facing a severe shortage of medicines, including viral hepatitis vaccines.6DawnMedicine shortage.https://www.dawn.com/news/1551772Date: April 24, 2020Date accessed: November 29, 2020Google Scholar A massive allocation of resources is needed to eliminate viral hepatitis in Pakistan, including doubling of screening capacity, rescreening of high-risk groups, and delivery of medicines and vaccines.7Lim AG Walker JG Mafirakureva N et al.Effects and cost of different strategies to eliminate hepatitis C virus transmission in Pakistan: a modelling analysis.Lancet Glob Health. 2020; 8: e440-e450Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar However, fulfilling these recommendations would require 9% of Pakistan's total health expenditure. The COVID-19 pandemic has led to more daunting challenges for viral hepatitis elimination in Pakistan. Rigorous and innovative efforts from health authorities are essential to ensure sustainability of hepatitis care services in the country. We declare no competing interests. Download .pdf (.1 MB) Help with pdf files Supplementary appendix