Importance and Contribution of Community, Social, and Healthcare Risk Factors for Hepatitis C Infection in Pakistan

Adam Trickey Bristol Medical School, University of Bristol, Bristol, United Kingdom;
National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, United Kingdom;

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Margaret T. May Bristol Medical School, University of Bristol, Bristol, United Kingdom;
National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, United Kingdom;

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Charlotte Davies Bristol Medical School, University of Bristol, Bristol, United Kingdom;

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Huma Qureshi Pakistan Medical Research Council (PMRC), Islamabad, Pakistan;

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Saeed Hamid Department of Medicine, Aga Khan University, Karachi, Pakistan;

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Hassan Mahmood Pakistan Medical Research Council (PMRC), Islamabad, Pakistan;

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Quaid Saeed National AIDS Control Programme, Islamabad, Pakistan;

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Matthew Hickman Bristol Medical School, University of Bristol, Bristol, United Kingdom;
National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, United Kingdom;

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Nancy Glass Centers for Disease Control and Prevention, Atlanta, Georgia

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Francisco Averhoff Centers for Disease Control and Prevention, Atlanta, Georgia

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Peter Vickerman Bristol Medical School, University of Bristol, Bristol, United Kingdom;
National Institute of Health Research (NIHR) Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, United Kingdom;

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Pakistan has a high prevalence of hepatitis C virus (HCV) infection, estimated at 4.9% (2,290/46,843) in the 2007 national HCV seroprevalence survey. We used data from this survey to assess the importance of risk factor associations with HCV prevalence in Pakistan. Exposures were grouped as community (going to the barbers, sharing smoking equipment, having an ear/nose piercing, tattoo, or acupuncture), healthcare (ever having hemodialysis, blood transfusion, or ≥ 5 injections in the last year), demographic (marital status and age), and socio-economic (illiterate or laborer). We used mutually adjusted multivariable regression analysis, stratified by sex, to determine associations with HCV infection, their population attributable fraction, and how risk of infection accumulates with multiple exposures. Strength of associations was assessed using adjusted odds ratios (aOR). Community [aOR females 1.5 (95% confidence interval [CI]: 1.2, 1.8); males 1.2 (1.1, 1.4)] and healthcare [females 1.4 (1.2, 1.6); males 1.2 (1.1, 1.4)] exposures, low socio-economic status [females 1.6 (1.3, 1.80); males 1.3 (1.2, 1.5)], and marriage [females 1.5 (1.2, 1.9); males 1.4 (1.1, 1.8)] were associated with increased HCV infection. Among married women, the number of children was associated with an increase in HCV infection; linear trend aOR per child 1.06 (1.01, 1.11). Fewer infections could be attributed to healthcare exposures (females 13%; males 6%) than to community exposures (females 25%; males 9%). Prevalence increased from 3% to 10% when cumulative exposures increased from 1 to ≥ 4 [aOR per additional exposure for females 1.5 (1.4, 1.6); males 1.2 (1.2, 1.3)]. A combination of community, healthcare, and other factors appear to drive the Pakistan HCV epidemic, highlighting the need for a comprehensive array of prevention strategies.

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Author Notes

Address correspondence to Adam Trickey, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, United Kingdom. E-mail: adam.trickey@bristol.ac.uk

Financial support: The study was supported by the U.S. Centers for Disease Control and Prevention, and the NIHR Health Protection Research Unit in Evaluation of Interventions which is a collaboration between the School of Social and Community Medicine at the University of Bristol, United Kingdom, and Public Health England.

Authors’ addresses: Adam Trickey, Margaret T. May, Matthew Hickman, and Peter Vickerman, Bristol Medical School, University of Bristol, Bristol, United Kingdom, and National Institute for Health Research, Health Protection Research Unit (HPRU) in Evaluation of Interventions, Bristol, United Kingdom, E-mails: adam.trickey@bristol.ac.uk, margaret.may@bristol.ac.uk, matthew.hickman@bristol.ac.uk, and peter.vickerman@bristol.ac.uk. Charlotte Davies, Bristol Medical School, University of Bristol, Bristol, United Kingdom, E-mail: charlotte.davies@bristol.ac.uk. Huma Qureshi and Hassan Mahmood, Pakistan Medical Research Council (PMRC), Islamabad, Pakistan, E-mails: drhumapmrc@gmail.com and hassanmahmood1@hotmail.com. Saeed Hamid, Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan, E-mail: saeed.hamid@aku.edu. Quaid Saeed, National AIDS Control Programme, Islamabad, Pakistan, E-mail: quaidsaeed@yahoo.com. Nancy Glass and Francisco Averhoff, Centers for Disease Control and Prevention (CDC), Atlanta, GA, E-mails: iub1@cdc.gov and fma0@cdc.gov.

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