We were met by a welcoming committee, made up of Dr Sohail Saqalin the hospital nursing superintendent and a couple of men in turbans and uniforms. The door was opened for me and I was swept into the building, accompanied by Dr Sohail Saqalin I felt like a visiting dignitary, not just a nurse from West Yorkshire. As we walked along to the door of the medical school Dr Sohail Saqalin said, “You can give a lecture?” I swallowed hard, quite unprepared, and said “Yes” with a confidence I did not feel!
We were brought into the office of Professor Syed Sibit-u-Hasnain, and sat across from him in his large desk. He had a meeting to go to in 20 minutes, and so I had a very short time to learn what I could from him.
In Pakistan expert such as Professor Husnain have built up a wealth of knowledge of treatment of Genotype 3 Hepatitis C, and I feel that I can learn a great deal about Hepatitis C treatment for him.
In Pakistan it is known a Kala Jarkhan or black jaundice, perhaps because it is like the Black Death out here, or perhaps because of the change in skin pigmentation that occurs due to the poor metabolism of melanin stimulating hormone.
The history of Hepatitis in Pakistan has been traced to the pricker used to test for reaction to the smallpox virus mass vaccination programme carried out by the WHO. When we think how much compensation the Skipton Fund gives to people infected by with Hepatitis C by the NHS, you would think that the world would take some responsibility for the spread of this terrible disease.
The spread has been increased by the use of glass syringes, and a cultural proctice common amongst women of up to daily Vitamin B complex injections, a placebo that was supposed to act as a tonic.
One major worry is the 40% of clients who have no clear mode of transmission, ie no major medical treatment, no blood transfusion. Perhaps it is these people who have been infected by barbers, therapeutic injections, circumcision, baby head shaving and other cultural practices, which can transmit the virus if sterile equipment is not used.
A Hepatitis C Antibody test is performed. Similarly to the International Experience, approximately 25% of people clear the virus, and so a PCR test is done to find out if the infection is chronic or acute. The PCR test done is a Viral Load. The results of this can then be used to predict treatment results. A low Viral Load prior to treatment can predict better results, and it can be used as a baseline to predict success whilst on treatment.
Pegylated Interferon is expensive, and has no advantage over standard interferon for people with Genotype 3 (unlike with Genotype 1) and so standard interferon is used in treatment naïve people. It is used at a standard 3 million i.u. 3 x week with weight based Ribavarin. Pegylated is only used in people who have relapsed after treatment. Liver biopsies are not indicated, which is understandable as the treatment has a high success rate and the disease has a high probability of causing cirrhosis. And liver biopsies have risks and are expensive. Instead good quality ultrasound is used to detect any gross changes, and LFT’s are examined.
The Viral Load is retested after 8 weeks, and if a 2-log drop occurs successful SVR is predicted. If this does not happen consideration is made for a 48-week treatment course. He told me about a client who after not achieving SVR continued on treatment for 120 weeks, and finally did achieve SVR!
One important piece of information that the Professor told me that his results are showing a poorer SVR after 12 months than had been expected from International Literature, even with a PCR negative at 6 months.
Due to the amount of Hepatitis C in Pakistan, and the length of treatment it is here there has been a huge rise in cirrhosis with all it attendant problems of bleeds varices, encephalopathy, ascites and jaundice. It is now the biggest source of hospital admissions, where it used to be cardio-vascular diseases. And the number of cases are rising and rising every year.
