Abstract
Aim
Hepatitis C virus (HCV) infects 10 million people in Pakistan with a prevalence rate of 4.9 %. Methods commonly used to diagnose HCV include anti-HCV and HCV RNA testing. However, HCV RNA is a molecular test that aims to identify active infection and is a test indicated for monitoring disease progression during therapy, while anti-HCV is a screening tool for detecting the presence of a virus in the body. Furthermore, liver function tests are part of routine testing in cases to assess the extent of liver damage. However, many clinicians in Pakistan are utilizing molecular tests to screen and diagnose HCV. Furthermore, elevated liver function test values are being justified for direct utilization of molecular tests instead of opting for anti-HCV tests. As HCV RNA tests detect only active infection and LFT values can be elevated or decreased because of other infections, using the HCV RNA test as a screening tool may have implications for patient management. Therefore, the main objective of this study was to evaluate clinicians’ perspectives for HCV test-based diagnostic management and identify the quality gap with respect to the utility of molecular tests.
Subjects and Methods
A retrospective, cross-sectional study was conducted analyzing medical records of patients coming to the gastroenterology outpatient department (OPD) of The Indus Hospital Laboratory, Karachi, Pakistan, during January 2014–2015. The study included patients in whom HCV RNA testing was performed. Both positive and negative HCV RNA groups were further analyzed to determine whether HCV antibody and liver function testing had been performed for the respective patients. The diagnostic management quality gap was identified on the basis of clinicians’ perspectives with respect to the International Centers for Disease Control and Prevention (CDC) diagnostic guidelines.
Results
A total of 1758 patients with HCV RNA testing were included in the study. Of these, 17.5 % of the patients had been tested for LFT only with direct testing for HCV RNA. In both the HCV RNA-positive (56 %) and -negative groups (44 %), the following discrepancies in diagnostic management were observed—the anti-HCV test was not performed in 51 and 62 % of the patients in the positive and negative HCV RNA group, respectively. Furthermore, 9.6 and 36 % of the HCV RNA-negative and -positive groups had not been evaluated for liver function tests and anti-HCV prior to molecular testing.
Conclusion
Diagnostic management of HCV in Pakistan is compromised as clinicians utilize molecular testing as a screening tool rather than using the international guideline for utilizing anti-HCV for the diagnosis of HCV. Furthermore, the results of the liver function tests are being used to justify the generation of molecular tests. This practice is an important parameter in the diagnostic and disease management of HCV in Pakistan and requires robust clinician awareness at the national level.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Ahmad K, Janjua NZ, Bin Hamza H, Khan MI (2004) Novel means of spread of bloodborne infections in Pakistan. Lancet 363(9425):2002
Arif A, Ahmed W, Alam SE, Qureshi H (2012) Active disease in chronic hepatitis C patients with normal alanine aminotransferase. J Coll Physicians Surg Pak 22(8):488–491
Averhoff FM, Glass N, Holtzman D (2012) Global burden of hepatitis C: considerations for healthcare providers in the United States. Clin Infect Dis 55(Suppl 1):S10–S15
Bernstein D (2002) The importance of laboratory test results in hepatitis C infection. Accessed 22 Jan 2016
Bibi S, Dars S, Ashfaq S, Ara Qazi R, Akhund S (2013) Seroprevalence and risk factors for hepatitis C virus (HCV) infection in pregnant women attending public sector tertiary care hospital in Hyderabad Sindh. Pak J Med Sci 29(2):505–508
CDC (2009–2011) Establishment of a viral hepatitis surveillance system. Morb Mortal Wkly Rep 60:1385. Accessed 22 Jan 2016
CDC (2013) Testing for HCV infection: an update of guidance for clinicians and laboratorians. Morb Mortal Wkly Rep 62. Accessed 22 Jan 2016
Giboney PT (2005) Mildly elevated liver transaminase levels in the asymptomatic patient. Am Fam Physician 71(6):1105–1110
Gupta E, Bajpai M, Choudhary A (2014) Hepatitis C virus: screening, diagnosis, and interpretation of laboratory assays. Asian J Transfus Sci 8(1):19–25
Hamid S, Umar M, Alam A, Siddiqui A, Qureshi H, Butt J, G. Pakistan Society of (2004) PSG consensus statement on management of hepatitis C virus infection-2003. J Pak Med Assoc 54(3):146–150
Helsper C, van Essen G, Frijling BD, de Wit NJ (2012) Follow-up of mild alanine aminotransferase elevation identifies hidden hepatitis C in primary care. Br J Gen Pract 62(596):e212–e216
Higuchi M, Tanaka E, Kiyosawa K (2002) Epidemiology and clinical aspects on hepatitis C. Jpn J Infect Dis 55(3):69–77
Ijaz B, Ahmad W, Javed FT, Gull S, Sarwar MT, Kausar H, Asad S, Jahan S, Khaliq S, Shahid I, Sumrin A, Hassan S (2011) Association of laboratory parameters with viral factors in patients with hepatitis C. Virol J 8:361
Jamal MM, Soni A, Quinn PG, Wheeler DE, Arora S, Johnston DE (1999) Clinical features of hepatitis C-infected patients with persistently normal alanine transaminase levels in the Southwestern United States. Hepatology 30(5):1307–1311
Kang KS (2013) Abnormality on liver function test. Pediatr Gastroenterol Hepatol Nutr 16(4):225–232
Lee CH, Shin HP, Lee JI, Joo KR, Cha JM, Jeon JW, Lim JU, Min JK, Kim DH, Kang SW, Joung HJ (2013) Predicting factors of present hepatitis C virus infection among patients positive for the hepatitis C virus antibody. Clin Mol Hepatol 19(4):376–381
Limdi JK, Hyde GM (2003) Evaluation of abnormal liver function tests. Postgrad Med J79(932):307–312
Liu Y, Lawrence RH, Falck-Ytter Y, Watts B, Hirsch AA (2014) Evaluating a hepatitis C quality gap: missed opportunities for HCV-related cares. Am J Manag Care 20(7):e257–e264
Nelson PK, Mathers BM, Cowie B, Hagan H, Des Jarlais D, Horyniak D, Degenhardt L (2011) Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet 378(9791):571–583
Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP (2006) The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol 45(4):529–538
Qureshi H, Bile KM, Jooma R, Alam SE, Afridi HU (2010) Prevalence of hepatitis B and C viral infections in Pakistan: findings of a national survey appealing for effective prevention and control measures. East Mediterr Health J16(Suppl):S15–S23
Raja NS, Janjua KA (2008) Epidemiology of hepatitis C virus infection in Pakistan. J Microbiol Immunol Infect 41(1):4–8
Zeisel MB, Crouchet E, Baumert TF, Schuster C (2015) Host-targeting agents to prevent and cure hepatitis C virus infection. Viruses 7(11):5659–5685
Acknowledgments
We would like to thank all the clinicians and medical providers who shared their clinical experiences with us.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declared that they have no conflict of interest for this study.
Financial support
This study was not funded by any granting agency.
Informed consent
For this type of study, formal consent was not required as it was a retrospective study.
Additional information
Contribution
FN conducted the study, analyzed the data and wrote the manuscript; AM conducted the study; AR analyzed the data and reviewed the final draft of the manuscript; AA designed the study and made revisions of the final manuscript.
Rights and permissions
About this article
Cite this article
Naseer, F., Mukhtar, A., Ahmed, A. et al. Hepatitis C diagnostic management gap in Pakistan—Clinicians’ knowledge impacting public health. J Public Health 24, 299–305 (2016). https://doi.org/10.1007/s10389-016-0725-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10389-016-0725-8