Establishment of a Viral Hepatitis Surveillance System --- Pakistan, 2009--2011

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Morbidity and Mortality Weekly Report (MMWR)

Establishment of a Viral Hepatitis Surveillance System --- Pakistan, 2009--2011

Weekly

October 14, 2011 / 60(40);1385-1390

Hepatitis A is thought to infect almost all persons living in Pakistan by age 15

years (1), and hepatitis E is responsible for sporadic infections and outbreaks

(2). The prevalence of hepatitis B virus (HBV) infection is estimated at 2.5%

and the prevalence of hepatitis C virus (HCV) infection, estimated at 4.8%, is

one of the highest rates in the world (3). Hepatitis surveillance in Pakistan

has been syndromic, failing to confirm infection, distinguish among viruses, or

collect information on risk factors. To understand the epidemiology of viral

hepatitis in Pakistan more clearly, the Ministry of Health (MOH) asked the

Pakistan Field Epidemiology and Laboratory Training Program (FELTP) to establish

a hepatitis sentinel surveillance system in five large public hospitals in four

provinces and Islamabad Capital Territory. This report describes the

implementation of the viral hepatitis surveillance system in Pakistan and

summarizes major findings from June 2010 through March 2011. A total of 712

cases of viral hepatitis were reported; newly reported HCV infection accounted

for 53.2% of reported cases, followed by acute hepatitis A (19.8%), acute

hepatitis E (12.2%), and newly reported HBV infection (10.8%). A history of

health-care--related exposures, particularly receipt of therapeutic injections

and infusions, commonly were reported by persons infected with HBV and HCV, and

most patients reported drinking unboiled water. These findings point to the need

for improved provider and community education about risks associated with unsafe

injections, strengthening infection control practices in health facilities,

increasing hepatitis B vaccination coverage, and improving access to clean

drinking water in Pakistan.

Several studies have demonstrated the substantial burden of viral hepatitis in

Pakistan (1--4). In response, MOH launched a National Program for Hepatitis

Prevention and Control (NPHPC) in 2005. The program focused primarily on

screening and treatment for HCV infection and did not establish laboratory-based

viral hepatitis surveillance. At that time, hepatitis surveillance in Pakistan

was syndromic, failing to provide laboratory confirmation of infection or

information on the type of hepatitis virus, and failing to collect information

on risk factors.

In August 2009, to monitor the effectiveness of NPHPC's activities and guide

implementation of evidence-based prevention interventions, the Pakistan FELTP

launched a hepatitis sentinel site surveillance system in collaboration with

CDC's Division of Viral Hepatitis. Criteria for site selection were based on

geographic distribution, patient load, capacity for laboratory testing, ability

to conduct data entry, and capacity for transmitting viral hepatitis data to the

National Institute of Health in Islamabad, where FELTP is housed.

Five public sector tertiary-care hospitals,* located in four provincial

headquarters (Lahore, Peshawar, Karachi, and Quetta) and in Islamabad (the

federal capital), were selected as sentinel sites for viral hepatitis

surveillance. Staff members at each site were trained to identify cases of viral

hepatitis from the pediatric and adult outpatient and inpatient departments

using a range of criteria (e.g., specific symptoms and elevated liver enzymes in

the blood, as detected by hospital-based laboratories). For those suspected

cases, additional data were collected from consenting patients using a standard

investigation form. The case reporting form was comprehensive, allowing for

collection of information regarding patient demographics, symptoms, and

risk-factor exposures during the 6 months before illness onset. Enzyme-linked

immunoassay (ELISA) test kits were used to test serologic specimens for all

types of viral hepatitis. Laboratory data were interpreted and cases classified

based on preestablished case definitions† for each type of viral hepatitis.

Data were entered into a database and transmitted to the FELTP office for

analysis. Each month, viral hepatitis data were shared with NPHPC, sentinel

surveillance sites, and federal and provincial health authorities. The hepatitis

surveillance system was fully operational by June 2010.

During June 2010−March 2011, a total of 712 cases of viral hepatitis were

reported by the five sentinel sites. Newly reported hepatitis C was the most

common cause of viral hepatitis, accounting for 53.2% of cases, followed by

acute hepatitis A (19.8%), acute hepatitis E (12.2%), and newly reported

hepatitis B (10.8%). In addition, among patients, 28 (3.9%) had evidence of HBV

and HCV coinfection, and 11 (14.3%) of those with HBV infection had evidence of

coinfection with hepatitis D.

Most persons reported with viral hepatitis resided near the reporting hospital,

all of which were in large cities (Figure). For all types of viral hepatitis,

nearly twice as many cases were reported among males than females. Most reported

cases occurred among persons aged 20--39 years (365 cases; 53.3%), although some

variation occurred by type of hepatitis. Of 24 women with acute hepatitis E

infection, 75% were of childbearing age (15--49 years), but information

regarding pregnancy status was unavailable. Hospitalization rates ranged from

7.1% for acute hepatitis A infection to 10.4% for newly reported HBV infection

(Table 1). No deaths were reported among persons with any type of viral

hepatitis. Of the 25 persons with any type of hepatitis who reported being

vaccinated against HBV, two (8%) were aged ≤5 years, three (12%) were aged

6--19 years, and 20 (80%) were aged ≥20 years. Of the 13 hepatitis cases

reported among children aged ≤5 years, only two of the children previously

were vaccinated against HBV, including one child with newly reported HBV

infection.

Drinking unboiled water during the past 6 months was commonly reported by

persons with all types of viral hepatitis. HBV-infected case patients reported

having undergone surgery and dental procedures, and exposure to therapeutic

injections, intravenous infusions, and skin piercing more commonly than did

those with other types of viral hepatitis (Table 2).

Reported by

Rana M. Safdar, MBBS, Muhammad Salman, MBBS, Rana J. Asghar, MBBS, Abdullah K.

Soomro, MBBS, Field Epidemiology and Laboratory Training Program; Aftab Mohsin,

MBBS, National Program for the Prevention and Control of Hepatitis; Birjees M.

Kazi, MBBS, National Institute of Health, Ministry of Health, Pakistan. Henry

Walke, MD, Nabil Ahmed, MPH, Div of Public Health Systems and Workforce

Development, Center for Global Health; Francisco Averhoff, MD, Div of Viral

Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB

Prevention; Rania A. Tohme, MD, EIS Officer, CDC. Corresponding contributors:

Rania A. Tohme, rtohme@..., 404-718-8577; Muhammad Salman,

salman14m@..., +92-333-538-4248.

Editorial Note

This report describes the establishment of the first sentinel surveillance

system for viral hepatitis in Pakistan. Findings indicate that all types of

viral hepatitis are highly prevalent in Pakistan, with newly reported HCV

infection being the most frequently reported in this system. Continued

transmission of enteric viral hepatitis A and E in Pakistan, as revealed by

sentinel surveillance, can be attributed to lack of sanitation. Because most

drinking water in Pakistan is contaminated, persons are encouraged to boil their

drinking water. However, as revealed by sentinel surveillance, the majority of

persons infected with any type of viral hepatitis reported drinking unboiled

water, likely because of practicality and cost. Previous studies indicated that

almost all persons living in Pakistan have been infected with hepatitis A virus

by age 15 years (1). Although acute hepatitis A is usually a self-limited

asymptomatic or mild illness in children, it can cause severe symptoms in

adults. Reports of acute hepatitis A infections among persons aged >30 years

might demonstrate an epidemiologic shift in age of infection, likely resulting

from improved sanitation in some areas. Similar findings have been reported in a

recent systematic review, which suggested a decrease in hepatitis A endemicity

in the South Asia region that includes Pakistan (5). Furthermore, high

prevalence of acute hepatitis E infection among women of childbearing age is an

indicator of frequent exposure in a population at high risk for mortality from

infection. These data underscore the need for improved access to safe drinking

water in Pakistan to decrease hepatitis A and E transmission.

Surveillance data also revealed that despite initiation of childhood hepatitis B

vaccination in 2002, the majority of children with hepatitis reported to the

surveillance system were not vaccinated and cases of HBV infection were reported

among persons aged <10 years, including children aged ≤5 years. In Pakistan,

the first dose of hepatitis B vaccine is given at age 6 weeks as part of the

pentavalent vaccine, which provides immunization against diphtheria, tetanus,

pertussis, HBV, and Haemophilus influenzae type b infections. Three-dose vaccine

coverage in 2009 was reported to be >85% among children aged 12--23 months,

although the demographic and health survey conducted in 2005 reported a coverage

of 57% (6). Based on the findings in this report and the coverage survey data,

routine coverage needs to be improved, and implementation of the hepatitis B

birth dose to prevent infection among infants should be considered.

Data obtained through this system point to several potential opportunities to

improve viral hepatitis control and prevention, particularly in injection safety

and infection control. Consistent with previous studies, HBV and HCV infections

were associated with a history of medical injections and procedures, suggesting

that unsafe injection practices and health-care procedures contribute to

transmission of HBV and HCV in Pakistan (3,4,7), although these practices also

were commonly reported among hepatitis A and E patients. Use of therapeutic

injections is a common practice in Pakistan, with an estimated four to eight

injections per person per year, one of the highest rates in the world (4). These

injections frequently are unnecessary and are administered for common, minor

complaints such as fever and fatigue (4). The high demand for these injections

is driven by the popular but erroneous belief that medications administered by

injection are more effective than those given orally, and by economic incentives

for health-care providers, who can charge patients more for medicines

administered by injection (8). In Pakistan, injections often are given by

unqualified practitioners using unsterile syringes, which increases the risk for

transmission of bloodborne infections, including viral hepatitis (4,7).

Addressing unsafe injections is essential to curb the ongoing epidemic of HCV

infection in this country.

Since 2000, a significant increase in injection drug use also has been reported

in Pakistan (9), and high prevalence rates of HCV infection have been reported

among injection drug users (IDUs) (60%--93%) (4). However, only one case of

hepatitis C reported through the surveillance system involved a reported IDU.

This finding might be explained by the social stigma associated with admitting

to such a behavior.

This report is subject to at least four limitations. First, because sentinel

hospital sites are public hospitals located in large cities, the catchment

population for the surveillance sites mainly includes the urban poor. Persons

with acute hepatitis who seek care in the private sector and sites run by

nongovernmental organizations (NGOs), which account for 70% of health-care

services in Pakistan and provide services for high-risk groups (e.g., IDUs, men

who have sex with men, and persons with human immunodeficiency virus) (10) might

not be captured in this surveillance system. Second, surveillance data only

represent persons who came to a health-care facility and received viral

hepatitis testing; infected persons with mild disease not requiring medical

attention or lacking access to or failing to receive medical care were not

included, leading to a likely underreporting of the number of persons with

hepatitis infection. Third, because of resource constraints and lack of

diagnostic capabilities, immunoglobulin M antibody to hepatitis B core antigen

(IgM anti-HBc) testing was not available, which limited the ability to

distinguish acute from chronic HBV infection; identification of HBV infections

was therefore solely based on acute symptoms and elevation of liver enzymes,

along with positive hepatitis B surface antigen (HBsAg) and total anti-HBc.

Similarly, lack of confirmatory testing using high signal-to-cut-off ratios,

nucleic acid testing, or recombinant immunoblot assay for cases of HCV infection

reported to the surveillance system, based on positive ELISA test results, might

have led to an overestimation of the number of newly reported HCV infections.

Finally, the associations between risk factors and hepatitis infections might be

confounded by differences in the age distribution of persons with various types

of hepatitis infection.

Despite these challenges, the hepatitis sentinel surveillance system provided

Pakistan's health authorities with valuable information regarding the

epidemiology of viral hepatitis and could serve as a foundation for

strengthening hepatitis control in the country. Even in the United States,

availability of complete and accurate information on hepatitis risk factors is

difficult to achieve through a national surveillance system; most data on

hepatitis risk factors are now based on enhanced sentinel surveillance from the

Emerging Infections Program and previously were based on data from just six

sentinel counties (of the more than 3,000 counties in the United States).

However, representativeness of the Pakistan viral hepatitis surveillance system

would improve with the addition of surveillance sites in the private sector and

NGOs. Improving laboratory testing capacity and quality assurance of serologic

testing would improve data quality. Ultimately, addressing the actual burden of

viral hepatitis in Pakistan will require a national surveillance system with

adequate laboratory testing capacity and resources that could be incorporated

with the proposed Integrated Disease Surveillance and Response System in

Pakistan to provide long-term sustainability.

Data collected through Pakistan's sentinel surveillance system show that viral

hepatitis remains a major public health problem in Pakistan. The data support

the need for educating health-care providers and the public about the risk for

HBV and HCV transmission through unsafe and unnecessary injections, promoting

proper infection control practices and hepatitis B vaccination for infants, and

improving access to clean water to prevent further transmission of hepatitis A

and hepatitis E in Pakistan. Surveillance plays a key role in the identification

of gaps and weaknesses in prevention and control efforts, providing useful

information for decision makers and improving outbreak detection and response.

Acknowledgments

Jamshed Maqbool, MS, Jmail A. Ansari, MBBS, Zeeshan Hamid, MBBS; other Field

Epidemiology and Laboratory Training Program staff members; Muhammad Munir,

MBBS, King Medical Univ, Lahore; Ghulam Sarwar Pirkani, MBBS, Bolan

Medical Complex Hospital, Quetta; Fazle Raziq, MBBS, Hyatabad Medical Complex,

Peshawar; Shakeel Malick, MBBS, Civil Hospital Karachi; staff members at the

sentinel sites, Pakistan. Novak, PhD, ph Perz, DrPH, CDC.

References <CUT>

STATISTICS TABLES ON WEB SITE AT:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6040a3.htm?s_cid=mm6040a3_e & source=go\

vdelivery

[Guest guest]

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6040a3.htm?s_cid=mm6040a3_e & source=go\

vdelivery

Morbidity and Mortality Weekly Report (MMWR)

Establishment of a Viral Hepatitis Surveillance System --- Pakistan, 2009--2011

Weekly

October 14, 2011 / 60(40);1385-1390

Hepatitis A is thought to infect almost all persons living in Pakistan by age 15

years (1), and hepatitis E is responsible for sporadic infections and outbreaks

(2). The prevalence of hepatitis B virus (HBV) infection is estimated at 2.5%

and the prevalence of hepatitis C virus (HCV) infection, estimated at 4.8%, is

one of the highest rates in the world (3). Hepatitis surveillance in Pakistan

has been syndromic, failing to confirm infection, distinguish among viruses, or

collect information on risk factors. To understand the epidemiology of viral

hepatitis in Pakistan more clearly, the Ministry of Health (MOH) asked the

Pakistan Field Epidemiology and Laboratory Training Program (FELTP) to establish

a hepatitis sentinel surveillance system in five large public hospitals in four

provinces and Islamabad Capital Territory. This report describes the

implementation of the viral hepatitis surveillance system in Pakistan and

summarizes major findings from June 2010 through March 2011. A total of 712

cases of viral hepatitis were reported; newly reported HCV infection accounted

for 53.2% of reported cases, followed by acute hepatitis A (19.8%), acute

hepatitis E (12.2%), and newly reported HBV infection (10.8%). A history of

health-care--related exposures, particularly receipt of therapeutic injections

and infusions, commonly were reported by persons infected with HBV and HCV, and

most patients reported drinking unboiled water. These findings point to the need

for improved provider and community education about risks associated with unsafe

injections, strengthening infection control practices in health facilities,

increasing hepatitis B vaccination coverage, and improving access to clean

drinking water in Pakistan.

Several studies have demonstrated the substantial burden of viral hepatitis in

Pakistan (1--4). In response, MOH launched a National Program for Hepatitis

Prevention and Control (NPHPC) in 2005. The program focused primarily on

screening and treatment for HCV infection and did not establish laboratory-based

viral hepatitis surveillance. At that time, hepatitis surveillance in Pakistan

was syndromic, failing to provide laboratory confirmation of infection or

information on the type of hepatitis virus, and failing to collect information

on risk factors.

In August 2009, to monitor the effectiveness of NPHPC's activities and guide

implementation of evidence-based prevention interventions, the Pakistan FELTP

launched a hepatitis sentinel site surveillance system in collaboration with

CDC's Division of Viral Hepatitis. Criteria for site selection were based on

geographic distribution, patient load, capacity for laboratory testing, ability

to conduct data entry, and capacity for transmitting viral hepatitis data to the

National Institute of Health in Islamabad, where FELTP is housed.

Five public sector tertiary-care hospitals,* located in four provincial

headquarters (Lahore, Peshawar, Karachi, and Quetta) and in Islamabad (the

federal capital), were selected as sentinel sites for viral hepatitis

surveillance. Staff members at each site were trained to identify cases of viral

hepatitis from the pediatric and adult outpatient and inpatient departments

using a range of criteria (e.g., specific symptoms and elevated liver enzymes in

the blood, as detected by hospital-based laboratories). For those suspected

cases, additional data were collected from consenting patients using a standard

investigation form. The case reporting form was comprehensive, allowing for

collection of information regarding patient demographics, symptoms, and

risk-factor exposures during the 6 months before illness onset. Enzyme-linked

immunoassay (ELISA) test kits were used to test serologic specimens for all

types of viral hepatitis. Laboratory data were interpreted and cases classified

based on preestablished case definitions† for each type of viral hepatitis.

Data were entered into a database and transmitted to the FELTP office for

analysis. Each month, viral hepatitis data were shared with NPHPC, sentinel

surveillance sites, and federal and provincial health authorities. The hepatitis

surveillance system was fully operational by June 2010.

During June 2010−March 2011, a total of 712 cases of viral hepatitis were

reported by the five sentinel sites. Newly reported hepatitis C was the most

common cause of viral hepatitis, accounting for 53.2% of cases, followed by

acute hepatitis A (19.8%), acute hepatitis E (12.2%), and newly reported

hepatitis B (10.8%). In addition, among patients, 28 (3.9%) had evidence of HBV

and HCV coinfection, and 11 (14.3%) of those with HBV infection had evidence of

coinfection with hepatitis D.

Most persons reported with viral hepatitis resided near the reporting hospital,

all of which were in large cities (Figure). For all types of viral hepatitis,

nearly twice as many cases were reported among males than females. Most reported

cases occurred among persons aged 20--39 years (365 cases; 53.3%), although some

variation occurred by type of hepatitis. Of 24 women with acute hepatitis E

infection, 75% were of childbearing age (15--49 years), but information

regarding pregnancy status was unavailable. Hospitalization rates ranged from

7.1% for acute hepatitis A infection to 10.4% for newly reported HBV infection

(Table 1). No deaths were reported among persons with any type of viral

hepatitis. Of the 25 persons with any type of hepatitis who reported being

vaccinated against HBV, two (8%) were aged ≤5 years, three (12%) were aged

6--19 years, and 20 (80%) were aged ≥20 years. Of the 13 hepatitis cases

reported among children aged ≤5 years, only two of the children previously

were vaccinated against HBV, including one child with newly reported HBV

infection.

Drinking unboiled water during the past 6 months was commonly reported by

persons with all types of viral hepatitis. HBV-infected case patients reported

having undergone surgery and dental procedures, and exposure to therapeutic

injections, intravenous infusions, and skin piercing more commonly than did

those with other types of viral hepatitis (Table 2).

Reported by

Rana M. Safdar, MBBS, Muhammad Salman, MBBS, Rana J. Asghar, MBBS, Abdullah K.

Soomro, MBBS, Field Epidemiology and Laboratory Training Program; Aftab Mohsin,

MBBS, National Program for the Prevention and Control of Hepatitis; Birjees M.

Kazi, MBBS, National Institute of Health, Ministry of Health, Pakistan. Henry

Walke, MD, Nabil Ahmed, MPH, Div of Public Health Systems and Workforce

Development, Center for Global Health; Francisco Averhoff, MD, Div of Viral

Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB

Prevention; Rania A. Tohme, MD, EIS Officer, CDC. Corresponding contributors:

Rania A. Tohme, rtohme@..., 404-718-8577; Muhammad Salman,

salman14m@..., +92-333-538-4248.

Editorial Note

This report describes the establishment of the first sentinel surveillance

system for viral hepatitis in Pakistan. Findings indicate that all types of

viral hepatitis are highly prevalent in Pakistan, with newly reported HCV

infection being the most frequently reported in this system. Continued

transmission of enteric viral hepatitis A and E in Pakistan, as revealed by

sentinel surveillance, can be attributed to lack of sanitation. Because most

drinking water in Pakistan is contaminated, persons are encouraged to boil their

drinking water. However, as revealed by sentinel surveillance, the majority of

persons infected with any type of viral hepatitis reported drinking unboiled

water, likely because of practicality and cost. Previous studies indicated that

almost all persons living in Pakistan have been infected with hepatitis A virus

by age 15 years (1). Although acute hepatitis A is usually a self-limited

asymptomatic or mild illness in children, it can cause severe symptoms in

adults. Reports of acute hepatitis A infections among persons aged >30 years

might demonstrate an epidemiologic shift in age of infection, likely resulting

from improved sanitation in some areas. Similar findings have been reported in a

recent systematic review, which suggested a decrease in hepatitis A endemicity

in the South Asia region that includes Pakistan (5). Furthermore, high

prevalence of acute hepatitis E infection among women of childbearing age is an

indicator of frequent exposure in a population at high risk for mortality from

infection. These data underscore the need for improved access to safe drinking

water in Pakistan to decrease hepatitis A and E transmission.

Surveillance data also revealed that despite initiation of childhood hepatitis B

vaccination in 2002, the majority of children with hepatitis reported to the

surveillance system were not vaccinated and cases of HBV infection were reported

among persons aged <10 years, including children aged ≤5 years. In Pakistan,

the first dose of hepatitis B vaccine is given at age 6 weeks as part of the

pentavalent vaccine, which provides immunization against diphtheria, tetanus,

pertussis, HBV, and Haemophilus influenzae type b infections. Three-dose vaccine

coverage in 2009 was reported to be >85% among children aged 12--23 months,

although the demographic and health survey conducted in 2005 reported a coverage

of 57% (6). Based on the findings in this report and the coverage survey data,

routine coverage needs to be improved, and implementation of the hepatitis B

birth dose to prevent infection among infants should be considered.

Data obtained through this system point to several potential opportunities to

improve viral hepatitis control and prevention, particularly in injection safety

and infection control. Consistent with previous studies, HBV and HCV infections

were associated with a history of medical injections and procedures, suggesting

that unsafe injection practices and health-care procedures contribute to

transmission of HBV and HCV in Pakistan (3,4,7), although these practices also

were commonly reported among hepatitis A and E patients. Use of therapeutic

injections is a common practice in Pakistan, with an estimated four to eight

injections per person per year, one of the highest rates in the world (4). These

injections frequently are unnecessary and are administered for common, minor

complaints such as fever and fatigue (4). The high demand for these injections

is driven by the popular but erroneous belief that medications administered by

injection are more effective than those given orally, and by economic incentives

for health-care providers, who can charge patients more for medicines

administered by injection (8). In Pakistan, injections often are given by

unqualified practitioners using unsterile syringes, which increases the risk for

transmission of bloodborne infections, including viral hepatitis (4,7).

Addressing unsafe injections is essential to curb the ongoing epidemic of HCV

infection in this country.

Since 2000, a significant increase in injection drug use also has been reported

in Pakistan (9), and high prevalence rates of HCV infection have been reported

among injection drug users (IDUs) (60%--93%) (4). However, only one case of

hepatitis C reported through the surveillance system involved a reported IDU.

This finding might be explained by the social stigma associated with admitting

to such a behavior.

This report is subject to at least four limitations. First, because sentinel

hospital sites are public hospitals located in large cities, the catchment

population for the surveillance sites mainly includes the urban poor. Persons

with acute hepatitis who seek care in the private sector and sites run by

nongovernmental organizations (NGOs), which account for 70% of health-care

services in Pakistan and provide services for high-risk groups (e.g., IDUs, men

who have sex with men, and persons with human immunodeficiency virus) (10) might

not be captured in this surveillance system. Second, surveillance data only

represent persons who came to a health-care facility and received viral

hepatitis testing; infected persons with mild disease not requiring medical

attention or lacking access to or failing to receive medical care were not

included, leading to a likely underreporting of the number of persons with

hepatitis infection. Third, because of resource constraints and lack of

diagnostic capabilities, immunoglobulin M antibody to hepatitis B core antigen

(IgM anti-HBc) testing was not available, which limited the ability to

distinguish acute from chronic HBV infection; identification of HBV infections

was therefore solely based on acute symptoms and elevation of liver enzymes,

along with positive hepatitis B surface antigen (HBsAg) and total anti-HBc.

Similarly, lack of confirmatory testing using high signal-to-cut-off ratios,

nucleic acid testing, or recombinant immunoblot assay for cases of HCV infection

reported to the surveillance system, based on positive ELISA test results, might

have led to an overestimation of the number of newly reported HCV infections.

Finally, the associations between risk factors and hepatitis infections might be

confounded by differences in the age distribution of persons with various types

of hepatitis infection.

Despite these challenges, the hepatitis sentinel surveillance system provided

Pakistan's health authorities with valuable information regarding the

epidemiology of viral hepatitis and could serve as a foundation for

strengthening hepatitis control in the country. Even in the United States,

availability of complete and accurate information on hepatitis risk factors is

difficult to achieve through a national surveillance system; most data on

hepatitis risk factors are now based on enhanced sentinel surveillance from the

Emerging Infections Program and previously were based on data from just six

sentinel counties (of the more than 3,000 counties in the United States).

However, representativeness of the Pakistan viral hepatitis surveillance system

would improve with the addition of surveillance sites in the private sector and

NGOs. Improving laboratory testing capacity and quality assurance of serologic

testing would improve data quality. Ultimately, addressing the actual burden of

viral hepatitis in Pakistan will require a national surveillance system with

adequate laboratory testing capacity and resources that could be incorporated

with the proposed Integrated Disease Surveillance and Response System in

Pakistan to provide long-term sustainability.

Data collected through Pakistan's sentinel surveillance system show that viral

hepatitis remains a major public health problem in Pakistan. The data support

the need for educating health-care providers and the public about the risk for

HBV and HCV transmission through unsafe and unnecessary injections, promoting

proper infection control practices and hepatitis B vaccination for infants, and

improving access to clean water to prevent further transmission of hepatitis A

and hepatitis E in Pakistan. Surveillance plays a key role in the identification

of gaps and weaknesses in prevention and control efforts, providing useful

information for decision makers and improving outbreak detection and response.

Acknowledgments

Jamshed Maqbool, MS, Jmail A. Ansari, MBBS, Zeeshan Hamid, MBBS; other Field

Epidemiology and Laboratory Training Program staff members; Muhammad Munir,

MBBS, King Medical Univ, Lahore; Ghulam Sarwar Pirkani, MBBS, Bolan

Medical Complex Hospital, Quetta; Fazle Raziq, MBBS, Hyatabad Medical Complex,

Peshawar; Shakeel Malick, MBBS, Civil Hospital Karachi; staff members at the

sentinel sites, Pakistan. Novak, PhD, ph Perz, DrPH, CDC.

References <CUT>

STATISTICS TABLES ON WEB SITE AT:

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6040a3.htm?s_cid=mm6040a3_e & source=go\

vdelivery