Prevalence of Hepatitis B and C in District Dir Upper, Khyber Pakhtunkhwa, Pakistan

The current study was performed on the dominance of hepatitis B and C in three tehsils of District Dir upper namely Dir, Wari and Sheringal. The data were collected from three tehsils in which 11 were positive cases and 339 were found negative cases during my research work. The higher incidence of hepatitis was found in tehsil Dir which was 6 i.e. (3.52%) and lowest rate of hepatitis was showed in Tehsil Wari which was 4 i.e. (2.75%). And in Gender wise prevalence out of 350 positive cases were 8 i.e. (4.0%) were male and 3 i.e. (2%) were female. This shows that the prevalence of hepatitis is higher in males than females. The higher prevalence of hepatitis were found in the middle age people from 13-40 which was (4.76%) and lowest infection are establish in people having age greater than 41 which was (1.21%). Research Article Prevalence of Hepatitis B and C in District Dir Upper, Khyber Pakhtunkhwa, Pakistan Shahzeb Khan Shaz1*, Noor Ullah1 and Iqra Rafi que2 1Faculty of Health Sciences, Department of Microbiology, Hazara University Mansehra, 21300, KPK, Pakistan 2Department of Genetics, Hazara University Mansehra, 21300, KPK, Pakistan Received: 18 October, 2019 Accepted: 28 November, 2019 Published: 29 November, 2019 *Corresponding author: Shahzeb Khan Shaz, Faculty of Health Sciences, Department of Microbiology, Hazara University Mansehra, 21300, KPK, Pakistan, Tel: +923489100228; E-mail: https://www.peertechz.com


Introduction
Hepatitis word is derived from Greek "hepar'' means "liver" and "itis'' means ''infl ammation". Hepatitis is an infection which causes infl ammation and enlargement of the liver. Viral hepatitis have fi ve main type A,B,C,D and E. Hepatitis A and E are largely transmitted through contaminated food and water, while hepatitis B is largely increases through infected blood, sex, or childbirth. Hepatitis C and D are mainly transmitted through blood. Transmission of hepatitis B happens by blood and blood items, sexual contact. The intra familial Transmission is likewise reported sometimes. 350 million individual have Hepatitis B infection (HBV) contamination around the world [1]. Pakistan is a stand out amongst the most awful impacted countries of the world having hepatitis B. Different surveys have been performed to look into the transcendence of HCV and HBV in various areas of Pakistan [2,3]. There is next to no populace which is study to gauge the correct event of hepatitis in different regions [4]. The vast majority of the epidemiological reviews with respect to the typicality of HBV and HCV are compelled to the hospitalized patients [5,6]. From July 2007 to May 2008 a study of the entire nation was directed by Pakistan Medical Research Council [3], exhibits that prevalence of hepatitis B is 2.5% in like way people of Pakistan. Examination on sexual orientation astute demonstrates that it is somewhat more normal in guys all over Pakistan [3]. On the premise of territories hepatitis B was astoundingly typical in Baluchistan (4.3%) while in Sindh it was 2.5%, in Punjab it was 2.4% and 1.3% in Khyber Pakhtunkhwa. The total HBsAg consistency in region Punjab was 2.4%. For the most the HBV and HCV are fundamental in Vehari, Okara, Jhang, Islamabad, Attock, Rahim Yar Khan, Mandi Bhauddin, Gujranwala and Mianwali regions of Punjab district. People who are living in sullied ranges have high extent of viral hepatitis [7,8]. Viral hepatitis is the liver disease which is created by hepatotropic contaminations (hepatitis A, B, C, D, E and G) and is a signifi cant explanation for behind terribleness and mortality. Disease of HBV and HCV are imperative for bringing about constant hepatitis and being one of the signifi cant reasons for the cirrhosis and hepatocellular carcinoma. 33% (2 billion individuals) of the total populace has been spoiled with HBV and 400 million individual have interminable ailment out of these 75% people are living in Asia and Western Pacifi c edge. All around the hepatitis B normality is different which is more (>8%) in Africa, Asia and Western Pacifi c to low (<2%) in Western Europe, North America and Australia. It is assessed that 180 million individuals is tainted with HCV incorporating 400 million individual in USA. The most widely recognized perpetual blood bone contamination is brought on by HCV and records for half of all US patients with endless liver malady. However there is every year decrease in the frequency of diseases since (1980s) pinnacle of more than 230,000 new cases per each year to ebb and fl ow 19,000 cases per each year. This decline is principally comes about because of diminishing in transfusion related cases which is the consequence of screening techniques. In Asia and Africa the Citation: Shaz  dominance of HCV is on the top (up to 13%) while utmost (over 15%) in Egypt. Among healthy adults the sero-commonness of HBsAg has been accounted for to be 3.0%-9.9% and hostile to HCV 2.2-3.69 in various reviews led in Pakistan. The sero-prevalence of HCV has been accounted for from Faisalabad to be as high as 17.7%. The elevated pervasiveness of HCV contamination in Punjab was researched in Faisalabad. Contaminations of both HBV and HCV are of genuine worry in Pakistan since they cause serious or incessant liver ailment with impressive decrease in work, constrain and utilize an extensive part of the wellbeing spending plan. People experiencing HCV disease, there impressive rate are asymptomatic and are recognized just on arbitrary registration for different purposes. Distinctive parental ways of transmission of HBV and HCV have been guaranteed which joins: sharing of needles, razors, tooth brushes, implantations, unscreened blood transfusions, coincidental needle-stick wounds in human administrations providers and organs of transplantation from positive for HBsAg and 440(3.13%) were found positive for against HCV. Inescapability of HBsAg on nearby keen base is changed, for example, 1.17% in Mianwali and 7.58% in Rahimyar khan (n=211) and that of antagonistic to HCV from 0.0% in Layyah (n=113) to 8.9% in Chiniot (n=101). High power of against; HCV in various district were Faisalabad (7.2%), Vehari (7.03%), Shekhpura (5.83%), Rahimyar Khan (5.69%), Okara (5.39) and Muzaffargarh (5.95). All attempted constructive individuals did not give any clinical clue and signs of whiteness, jaundice or hepato splenomegaly. Presently a day overall medical issue is viral hepatitis and hepatocellular carcinoma. The transmission of hepatitis is possible through blood and other body fl uids are known since long time [9,10]. One of the major health problems is hepatitis B virus (HBV) [13], the condition is intense in Asia, Southren Africa, Latin America and Europe. It is assessed that more than 2 billion individuals are contaminated with HBV around the wide [14,15]. Out of these 2 billion patients around a 400 million are experience the ill effects of unending HBV [16]. Pakistan is highly endemic for HBV [17]. Up to date investigation show that 9 million people are infected from the disease and there is a fast enhancement in the rate of infection [18]. The other viral infection of liver is HCV which is concerned with highest mortality [19,20], because the hepatocellular carcinoma and liver cirrhosis are more familiar among anti-HCV positive patients [21]. World Health Organization (WHO) recently estimated that HCV infection has contaminated about 170 million people (up to 3% of the world's population) [22,23]. There are many genotypes of HCV with nine well studied genotypes are reported in the literature [24]. A huge ratio of Pakistani population is ignorant from the epidemiology and risk factors of viral hepatitis. Although the showing and investigative recommendations support early detection of HBV and HCV [25], but in Pakistan most of the sufferers of viral infection are bring when they are at the fi nal stage of liver damage. The risk of hepatocellular carcinoma increases by the delay analysis and decrease the effect of antiviral therapies [26]. The recent study was thus designed to fi nd the common population for the viral hepatitis infections. Pakistan is common for HBV having infected people round about nine million and its rate of infection is on a steady rise. The major reasons of HBV infection are: absence of legitimate wellbeing offi ces, poor prudent status and less open mindfulness from the conduction of major contagious maladies like HBV, HCV and HIV. Among people the medicals course and continuation of delight hepatitis is distinctive. HBV contamination produce a broad scale of medical appearance ranging from asymptomatic transporter state to serious auto-prohibitive disease or fl uminant hepatic stoppage, consistent hepatitis and improvement of cirrhosis and additionally hepatocellular carcinoma. The national level particularly among generally solid people studies are confi ned and don't give unmistakable photo of the regularity of HBV. Healthy individuals studies are restricted and do not give a clear picture of the commonness of HBV. Most earlier led review under assault different little gatherings of people. Infection of Hepatitis C Virus (HCV) is one of the mainly important Flaviviridae infections. HCV is in charge of the second most well known reason for viral hepatitis and deliver critical medical issue in the entire world. Studies to research the regularity of HCV disease in widespread populaces of various nations were directed when serological assay are available. The commonness of HCV are vary in the entire world and is more basic in Egypt (around 28% of the populace tainted being recorded). In Egypt this high predominance of HCV contamination is because of the utilization of parenteral antischistosomal treatment. About 2% of USA populace and 3% that is an expected 170 million individuals are HCV bearer around the world. It was seen in (1999) that HCV contamination was found in those people who got blood items or gave organs. The way of dispersion stayed obscure in around 30%-40% of HCV cases. Hepatitis C introduced a considerable measure of danger and no nation on the planet has the way to overview its entire populace for the occurrence of the infection. In some parts of the Pakistan a few of the sero-epidemiological survey is conducted which shows 8%-10% rate of prevalence. These surveys were conducted from volunteer blood donors and on the basis of these samples collection serological tests have been carried out. To accurately guess commonness all the more precisely we gather test from evidently solid people living in different parts of the District Dir upper and performed both serological and sub-atomic measures on these specimens since tests from volunteer blood benefactor do not demonstrate the genuine pervasiveness of HCV contamination as a rule populace.

Review of Literature
Kane A, et al., [27]. The Afghan evacuees living in the camps of Baluchistan region having the seroprevalence of HBsAg was 8.3% while the predominance among husband, wife and kids were 12.3%, 7.0% and 5.6% respectively. In a populace the commonness of HbsAg predominantly relies on upon vaccination reporting against hepatitis B and pervasiveness of hazardous infusion practices. Hepatitis B in the evacuee's camps is because of absence of vaccination administrations and the inclination for infusion for regular ailments are the fundamental obvious elements prompting to abnormal state (>8%) of HBsAg in this Afghan displaced person populace.  Tanaka T, et al. [28], among older age people the higher prevalence is due to constantly contact with the risk factors of HBV infection. Amid the earlier year accepting more than ten infusions was a key danger calculates in this review (OR 3.5, 95% CI 1.8-6.7). It was observed that those people who Dore G, et al. [34], from the last decade as crucial to treat HCV is being treated, the study and literature of HCV and intravenous drug users (IVDU) has extended quickly. Most of the research conducted previously shows the prevalence in the community of IVDU, carrying out tests mixing of services to alcohol and drug centers, the rural community has been under represented unfortunately in these studies with the huge majority of studies focused on metropolitan areas. The above review clears that there is a huge gap in research pertaining to the familiarities of hepatitis in rural areas of Australia.
Dore G, Temple-Smith M, et al. [35], for the treatment of HCV important changes are held over the years has lead to detection of different reason for not seeking treatment. It will take little bit time for changing apparent knowledge of people for hepatitis C treatment due to less value of past treatment and high rates of side effects. Jafri W, Jafri N, et al. [36], in various studies conducted in same population shows greatly different seroprevalence estimate both for HBV and HCV in same province. Transmission of HIV and hepatitis takes place sporadically or in micro-epidemics.
The great variation in commonness found in a country, in a region, or even in a group is due to these micro-epidemics.
When causes of these micro-epidemics are determined then it gives a chance to constrain the communication of these ailments.
Morb Mortal Wkly Rep [37], the distinctions in seroprevalence inside a like district or populace are due to methodological differences in sampling strategies. For example one study is conducted in a general population give a dramatic group of irregular testing of the whole city's review populations, while a moment study is performed in an accepted irregular samples in a alternate city enrolled people with the assistance of advertisement in news paper that may have bent the hazards synopsis of respondents when contrasted with the primary review.
Hutin YJ, et al. [38]. In Pakistan unnecessary injections are given which increase the prevalence and it is observed that infused pharmaceutical are more powerful than orally eaten drugs.
Janjua NZ, et al. [39], the causes and prevalence of hepatitis are intramuscular infusions that are oftentimes utilized for weariness, fever and basic ailment, while for the treatment of This survey is constructing for the most part with respect to rehashed.
HCC cases distinguishing proof in a particular healing centre. On the premise of the strictness of sickness the greater part of the cases require therapeutic care up at a few phases and therefore in the general population hospital-based series are expected to be representative of HCC cases. We are attempting to take out reviews which are known to be utilized as a part of an original examination for against HCV anti-microbial, which was lessened in both affectability and specifi city. Every one of those articles that don't recognize the technique for research facility for hostile to HCV test were accessible after 2009 as were dicey to have utilized an original investigation and after that we coordinated second-era on the grounds that the principle advantage of the third-era examination in crisply tainted people is expanded.
Gower E, et al. [47], top notch data for some nations is rare or missing which is the principle confi nement of our late metaexamination. For instance, a progression of cases accessible from Oceania is utilized as an original test for HCV and did not assemble our incorporation Criteria, an all the more as of now linkage think about has demonstrated similar extents of HBV and HCV Infection of HCC cases in Australia, however in this review marker-negative HCC cases are excluded. In some hyper endemic ranges the commitment of HBV disease is thought little of especially in China where HCC cases are went with mysterious of HBV.
Shi Y, et al. [48], we assembled information from numerous hotspots for methodical audit. It is hard to evaluate the effect of heterogeneity of investigative criteria and research center strategies. At last we didn't discover sex particular data (HBV, yet not HCV, is more predominant in men when contrasted with ladies) and different relates of HCC hazard (e.g., liquor and tobacco use and in addition a fl atoxin exposure).Apart from these confi nements our methodical audit has crucial intensity of permitting the joint evaluation of the two most essential reasons for HCC.
Qureshi, et al. [49], transmission of hepatitis B takes place by poor health facilities which are the result of improper screening as well as unsterilized dental instrument. A survey performed in mohmand agency KPK in 2010 and it was discovered that health sectors totally deprived of health facilities of modern screening, dental services and identifi cation and management of sexually transmitted diseases.
Ali, et al. [50], in the general population of Pakistan used needles are the most important factors in the increase of hepatitis B and C. In case of hepatitis B high re-use of needles produce prostration while excessive use of unprofessional practitioners and lack of awareness among the patients seems to be the basic cause of hepatitis C and both these causes are present in Mardan.
Norman, et al. [51], a major group of danger issues is due to unsafe sexual practices found in those people stay mostly away from home which is common in refugees of Mardan and can result to acquisition of high risk activities such as inject able Citation: Shaz

Language and religion
The main language of people inhibiting in dir is Pashto but there are few people who speak other languages. Urdu being national language is also spoken and understood by these people. The inhabitants of dir are totally Muslims. There are some Hindu and Christians which come here from other provinces of Pakistan.  technology than any other technologies mentioned above and highly expensive.

Statistical analysis
Data was statistically analyzed and tabulated by using Microsoft excel.

Aims and objectives
• To investigate the commonness of Hepatitis in Dir upper.
• To revise the prevalence of Hepatitis among individuals of various age groups.

Results
The late review was performed on the pervasiveness of Hepatitis B and C in District Dir upper. This study is conducted on the basis of laboratory reports and voluntarily blood donors in Dir upper. The reports were prepared from different hospitals and Basic Health Units (BHUs). A Performa in which name, sex, age, locality, socio-economic status, home state and previous history of hepatitis is mentioned was shaped. The blood samples of those people were gathered who have sign and symptoms of hepatitis. The route of transmission of hepatitis includes: Food contact with infective persons, contaminated razors in the barber shop, sexual contact with infected individual. Common symptoms are: Fatigue, Fever, Headaches. Jaundice (yellowish skin and eyes),Loss of weight, Decreased craving, Nausea and retching, Bad breath and astringent taste in the mouth, Dark cocoa pee, Pale hued gut movements, Pain in the correct side of the belly, just beneath the ribs (Table 1       conducted research work I reported that the higher hepatitis prevalence occur in middle age people as compared to adult and children.

Discussion
As a consequence of HCV interminable liver sickness it is evaluated that one fourth of a million passing's for each year happens [52]. A present group based review was led in which the estimated estimation of HCV was 6.3% in San Juan and amongst Central and South America in 2001-2002 [53]. In Europe the general prevalence of HCV was about 1%, but it was various amongst different countries [54]. The approximate prevalence of HCV infection in industrial countries during dialysis patients was about 8% to 20% [55] and greater in those countries which are not well industrialized. In Saudi Arabia during 2001 the anti HCV prevalence in dialysis patient was 34.9% [56]. HCV prevalence ratio was 5.31% in Islamabad through the study which carried out in the hospital [57]. To revise the prevalence of active HCV and molecular viewing of HCV in district Bannu a highly pattern protocol was required. In the recent study highly sensitized method of detection is used. Among the adults of the district Bannu the study was conducted which show that infection is about 2.70% in the age 15-17. Due to less contact to transfusion factors like contact to barber, blood transfusion and body piercing etc HCV was found in slightest ratio in this age.
In the age group from 23-26 the HCV recorded was 5.55% which is greater among all age group. Homosexual behaviour was too much among street children who are suffered sexually; later on they adopted commercial sex to raise their income. The prevalence ratio of 17.24±7.98% was observed among the male homosexual population because they use very slight condom [58]. Different route of HCV transmissions are showed by the histories of these young adults. Among these adults the probable route of transfusion were dental surgery, blood transmission, homosexuality and heterosexuality in both males and females, among the adults of these age prostitution in female were the peak hazard issue [2]. Concentrated the commonness of HCV in different age aggregates in which the predominance in males was more noteworthy than females as same to our review in which pervasiveness is more prominent in male when contrasted with females. The young male adults were more affected as compared to young females. Young female adults were fewer stained with HCV because route issue responsible like barber as well as estrogens hormones assume an essential part in the diminishing of HCV ailment in females [59]. The safe arrangement of the body assumes a crucial part in the freedom of infection from the body. At the point when reaction of the body cells are solid to HCV disease then it will evacuate the infection or devastate it and when reaction is frail then with the progression of time HCV contamination get to be develop and create perpetual contamination become build up and produce chronic infection [60]. Immunologic disorder leads to chronic hepatitis C which is about 38% [61]. The greater prevalence of hepatitis and other diseases is greater in males than females because they travel to other cities and provinces in search for improved jobs; hence they receive various infectivity in this process. In these industrial cities they acquire analysis during their stay and treated early for their infectivity and may not calculate in the infected population, but when they go to their local land, they transmitted these illnesses to their partners and other female inhabitants. These females is not identifi ed and treated due to poor health facilities because they are usually confi ned to their homes and city and hence may calculate in the infected population. In males the ratio of HBV infection is much high as compared to females because males are working outside their native lands and visiting to barber shops as well as their engagement in blood donation and transmission practices. Countries such as Pakistan, Iran, India, Bangladesh, Israel and Italy the HBV transmission takes place by blade sharing and equipments related to barber [62]. Hepatitis C and B virus disease occurs through blood transmission and it is a potential risk factors [63]. Examined normality of positive cases as for as HBsAg in the sera of 428 assembly line labours in beach front city of Yantasi (China) and recognized pinnacle pervasiveness in China. Another review demonstrated the contamination rate of hepatitis B in processing plant work which was lower than Beijing populaces values reported right on time in 980s [64][65][66][67][68][69][70][71][72][73]. The late review depends on the commonness of HBV among those male working in industrial facilities of Gujranwala. This review has a few confi nements as well. At fi rst the review is directed on the premise of good example measure however there is still need to lead consider on bigger level including socio statistic information of the subjects. Also for the examination the example size ought to be much extensive as per nature of the business. This review points that to research that there is require a fundamental need to accept such reviews in different populaces to such an extent that populaces having more noteworthy commonness can be known and techniques can be created for the shirking and treatment of these viral diseases.

Conclusion and Recommendation
Generally the commonness of HBsAg and hostile to HCV is diminishing. The gathered examples of high pervasiveness zone presented a genuine medical issue which require adjustment of separate preventive courses in the restorative and social ways and open cognizance operations for training of masses for anticipation. HBV infection prevalence is different with population which live in various regions of Dir upper. In Dir upper peak HBV prevalence is present in Afghan refugees, IDUs, health care professionals, skilled blood donors, prisoners and several transmission patients with HCC, psychiatric patients, common population of some specifi c areas such as Darora, Dir and Usheri. Barawal, Kohistan, Wari, Gandiger. Both host and viral issues are involved in molecular and cellular mechanism of HBV infection.
Some of the evidences recognized the viruses in saliva as a useful source of set ups disease and results of therapy or vaccination. In oral fl uid the viral hepatitis sign are present which show that they can easily be used for identifi cation purposes with less sensitivity. The illness by hepatitis virus is more general in native people as compared to foreigner people. Preventing the distance between native and non-native ratio it will be necessary to focus on tries to amplify HAV and HBV vaccination among affected indigenous population and Citation: Shaz

Recommendation
• The recent study shows that local community is unaware about the causes of Hepatitis.
• Government needs to teach people through media, workshops etc.
• The Hepatitis awareness programmes should be beginning so as mindful the people about its signs and symptoms, transmission, treatment etc.