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December 2010, Volume 60, Issue 12

Review Articles

A review of hepatitis viral infections in Pakistan

Altaf Bosan  ( National Institute of Health. )
Huma Qureshi  ( Pakistan Medical Research Council. )
Khalif Mohamud Bile  ( World Health Organization. )
Irtaza Ahmad  ( National Institute of Health. )
Rehan Hafiz  ( National Institute of Health. )

Abstract

A review of published literature on viral hepatitis infections in Pakistan is presented. A total of 220 abstracts available in the Pakmedinet and Medline have been searched. All relevant articles were reviewed to determine the prevalence of hepatitis viral infections in Pakistan. Two hundred and three (203) relevant articles/abstracts including twenty nine supporting references are included in this review. Of the articles on prevalence of hepatitis infection, seven were related to Hepatitis A, fifteen to Hepatitis E while the remaining articles were on frequency of hepatitis B and C in different disease and healthy population groups. These included eight studies on healthy children, three on vertical transmission, nineteen on pregnant women, fifteen on healthy individuals, six on army recruits, thirty one on blood donors, thirteen on health care workers, five on unsafe injections, seventeen on high risk groups, five on patients with provisional diagnosis of hepatitis, thirty three on patients with chronic liver disease, four on genotypes of HBV and five on genotypes of HCV. This review highlights the lack of community-based epidemiological work as the number of subjects studied were predominantly patients, high risk groups and healthy blood donors.
High level of Hepatitis A seroconversion was found in children and this viral infection accounts for almost 50%-60% of all cases of acute viral hepatitis in children in Pakistan. Hepatitis E is endemic in the country affecting mostly the adult population and epidemic situations have been reported from many parts of the country.
The mean results of HBsAg and Anti-HCV prevalence on the basis of data aggregated from several studies was calculated which shows 2.3% and 2.5% prevalence of HBsAg and Anti-HCV in children, 2.5% and 5.2% among pregnant women, 2.6% and 5.3% in general population, 3.5% and 3.1% in army recruits, 2.4% and 3.6% in blood donors, 6.0% and 5.4% in health care workers, 13.0% and 10.3% in high risk groups, 12.3% and 12.0% in patients with provisional diagnosis of hepatitis and 25.7% and 54% in patients with chronic liver disease respectively.
This review has illustrated the high endemicity of hepatitis viral infections in Pakistan where hepatitis B and C potentially account for a serious burden of the disease. This review has triggered the launching of a network intervention for the control of hepatitis viral infectious.
This review was used as the basis for the launch of hepatitis programme, but putting it into a formal review took time and the hepatitis program was initiated.
Correspondence: WHO Country Representative, World Health Organization, NIH premises, Chack Shahzad, Islamabad.

Introduction

Viral hepatitis is a serious global public health problem. At present, six distinct types of hepatitis virus have been identified and called as hepatitis A, B, C, D, E and G viruses. For Hepatitis A virus (HAV) and Hepatitis E virus (HEV), the primary source of infection is the faeces with fecal-oral route being the most predominant mode of transmission. Hepatitis B virus (HBV), Hepatitis C virus (HCV), and Hepatitis D virus (HDV) are blood borne viruses and are primarily transmitted through a breach in the skin (percutaneous) or mucosa (mucosal). All hepatitis viral infections are acute but hepatitis B, C and Delta can also result in chronic infections.
Acute viral Hepatitis A is a common infection among children in Pakistan and accounts for 50-60% of all cases of acute viral hepatitis in children. Almost 96% of the population is exposed to HAV by the age of 5 years and 98-100% at adulthood.1-3
Size and this is a review and what ever published data is available is compiled here so the question of small sample does not arise. The method of diagnosis, sample site of data is given in the tables.
Hepatitis E is a disease of mild to moderate severity (mortality rate of 0.4 - 4.0%) except in pregnancy, where the mortality rate may reach 20% in last trimester of pregnancy especially during epidemics.4 HEV is a major cause of acute viral hepatitis (AVH) in Pakistan particularly in adults from lower socioeconomic groups. Hepatitis E virus typically spreads by faecal contamination of water. The infection is endemic in developing countries and turns into mini epidemics in grave situations. Hepatitis E is endemic in Pakistan5 and occurs mostly during summers, rains and floods. Major epidemic outbreaks occur in areas where drinking water gets contaminated with sewage and where people have a communal living and drinking water from a common contaminated source.
Hepatitis B (HBV) and C (HCV) viral infections are transmitted through blood and body secretions which penetrate the human body through a breach in the skin, mucosa or vein. Both the viruses cause acute hepatitis which clears within 6 months in 80% cases of HBV and 20% cases of HCV. In 20% HBV and 80% HCV cases the virus becomes chronic and may progress to chronic liver disease.
The consequences of HBV infection depend on the age of its acquisition. There is an over 90% risk of a new born to get infected and become a long term carrier of HBV. This risk drops from about 90% in the first six months of life, to about 25% by the age of five years, and to 10% by the age of 15 years. It is unusual (2%- 5%) for adults who are infected later in life to become chronic carriers.6
The most common routes of transmission of HCV in developed countries include intravenous drug use, blood transfusions, haemodialysis, needle-stick injuries, tattooing, sexual intercourse and peri-natal infections. In developing countries, therapeutic injections from reused needles and syringes and improper sterilization of invasive medical devices is the major vehicle for transmission of blood borne organisms including hepatitis B virus (HBV), HCV and HIV.7 Overuse and unsafe injection practices cause an estimated 8 to 16 million Hepatitis B virus infections, 2 to 5 million Hepatitis C virus infections and 80,000 to 160,000 HIV infections globally.8 These infections lead to a high burden of chronic disease, disability and death.
This review shall serve as a valuable technical resource article for policy makers, planners and health professionals with the objective to generate sufficient evidence for policy and programmatic action. The analysis of the currently available literature will also help in reorganizing the endemicity level of these hepatitis viral infections and thus enable future national control interventions.

Methods

Pakmedinet and MEDLINE search was undertaken using the key words "Hepatitis, Hepatitis A, B, C, D and E prevalence, epidemiology, transmission, and carrier". All studies pertaining to prevalence of infections conducted in Pakistan were included in this review. A manual search was also carried out on many indexed Pakistani journals. In most instances full articles were reviewed but in cases where full article could not be traced, the abstract was used. The 95% confidence intervals for the prevalence studies were calculated by using the prevalence reported and the sample size of the study.
All studies where less sensitive methods like CIEP or chromatography was used for testing were excluded from the analysis and only studies using assays like ELISA, EIA, MEIA were included, as these assays are more sensitive and specific.

Results

A total of 220 abstracts were reviewed and of these only 208 articles were finally included in this review to determine the prevalence of hepatitis A to E viral infections in Pakistan.
Very few community based studies on the prevalence of Hepatitis viral infections are available in Pakistan. However, most published studies are hospital or clinics based and therefore show a variation in the reported frequencies/prevalence. Overall, the data suggests that these infections are endemic in Pakistan. The reported prevalence figures in the general population, blood donors and among pregnant women have placed Pakistan among the countries with intermediate endemicity.
The results of the meta analysis of the present review have been tabulated separately for waterborne infections and blood borne infections and the group-wise results are given below:
Hepatitis A and E
Hepatitis A infection:
Almost all studies on hepatitis A showed high prevalence of Hepatitis A (HAV) infection in children especially those who were admitted in hospitals with acute hepatitis. Most of the children were exposed to the virus during early life and remain immune for life as seen by the presence of IgG antibodies in adults in these studies (Table-1).


Hepatitis E infection:
Most studies on hepatitis E infection (Table-2)

were a part of the clinical work of acute hepatitis in patients who were admitted with jaundice. Four studies have reported mini epidemic outbreaks due to faecal contamination of water. Total HEV was checked in most studies while in few HEV IgM antibodies which are specific of acute infection were tested. Two studies on pregnant cases with jaundice showed HEV positivity of 57-61% while a 3rd study in non pregnant females showed mortality in 33% of the cases who went into fulminant hepatic failure.
Hepatitis B and C:
Hepatitis B and C infections cause significant morbidity and mortality in Pakistan. Many studies have been reported from medical screening camps, hospitals and clinics in different groups of individuals to see the magnitude of the problem. Prevalence of HBV and HCV infection in various groups is presented below:
Children:
Studies on HBs Ag and Anti-HCV in healthy children showed a prevalence of HBs Ag between 1.9%-3.6% and for Anti-HCV between 0.4%-4% (Table-3).


Mother to infant transmission:
The contribution of perinatal transmission to the overall burden of disease is related to the prevalence of HBe Ag in the pregnant woman. If a mother is HBs Ag positive and HBe Ag positive there is over 90% chance that she will transmit the infection to her infants.1
Maternal to child transmission of HBsAg and HBeAg was done in 3 studies. Kazmi etal35 screened 6225 mothers and found 249 HBs Ag positive. Out of 249 HBs Ag positive mothers 55 were HBeAg positive. In another study 50 infants born to HBsAg and HBeAg positive mothers were followed. The cord blood of these newborns was tested for HBeAg and the infants were followed for 18 months for the status of HBsAg. About 90% of HBeAg positive mothers transmitted HBV to their infants.
Aisha et al36 conducted a study in 245 pregnant women and found 8 cases positive for HBs Ag, of whom one was positive for HBe Ag. Eight babies born to sero-positive mothers were tested for HBs Ag and HBe Ag and all were found negative for these markers.
Iqbal33 screened 417 mothers and 538 children separately for HBs Ag and found 2.3% positive mothers and 3.3% positive children. Of these one mother and two children were HBe Ag positive.
Pregnant women:
Many studies are available on the status of HBs Ag and anti HCV in pregnant cases (Table-4).

HBs Ag was generally reported with low frequency in private sector patients39,41 and high in public sector patients.
General population:
Although there are no population studies on the prevalence of HBV and HCV infections in the country but the summation of available data on various healthy groups like voluntary blood donors, pregnant women, recruits and healthy individuals provide the infection status in the country (Tables-5,6,7).



The HBV prevalence in general population ranged from 1.1-11.9% and the figures for HCV ranged from 2-13.5%
Special groups:
Recruits:
The healthy individuals who were screened prior to their induction in the armed forces showed HBsAg range from 3- 7.3% and HCV from 2.2- 5.2% (Table-7).
Blood donors:
75 and 76 new references to be added. In Pakistan over 1.5 million pints of blood are collected each year.77 The main source of blood (65%) was replacement donors78 with another 10% from professional/paid donors. Only 25% donations came from volunteer non-remunerated blood donors.79 Most of the replacement donors are patient\'s relatives or friends.
The blood screening data showed higher prevalence of Anti-HCV as compared to HBs Ag in all years.
High risk groups:
Significant HBV and HCV transmission occurs in selected high risk groups including health care workers, injecting drug users and patients receiving blood products.

Table-8 shows the data of 13 studies in health care workers. The prevalence of HBsAg in this group ranged from 2.4-20%. Highest prevalence was seen in dentists (17%) and sweepers (20%). The anti-HCV prevalence ranged from4-10% with highest positivity of HCV (10%) in health care workers who reported needle stick injuries while working.
Trend of HBV & HCV infection in a community as per the use of injections:
Few studies have been published in Pakistan where the risk of unsafe injections for transmission of Hepatitis B and C infections has been highlighted (Table-9).


In a cross sectional study Khan et al124 identified injections as the major risk factor for Hepatitis C infection in patients seeking health care in a peri-urban community in Karachi. Luby125 found 16% HCV infection among households of HCV infected patients in Hafizabad. Khan et al126 studied the risk factors for the transmission of HBV or HCV in patients with chronic liver disease and found therapeutic injections, surgery, blood transfusion and dental extraction as the major risk factors for both these diseases.
Trend of HBV & HCV infection in other high risk groups:
Many studies have been done on the high risk groups like injecting drug users, commercial sex workers, transvestites and patients receiving blood products. All these studies also revealed high prevalence of HBs Ag and Anti-HCV in these groups. HBs Ag infection was found in 12% of the commercial sex workers (women) in Lahore while it was only 3.4% among transvestites in Karachi who acknowledged commercial sex with men. The mean prevalence of HBV and HCV in these groups was 15.5% and 12.3% respectively (Table-10).


The prevalence of these infections in individuals receiving multiple blood transfusions was high. For thalaessemia, the HBV figures ranged between 7.5-8.4% while for HCV they were between 36-56%. Figures in haemophilia were similarly high. In dialysis population HBV figures were 12.4% and HCV 20%.
Patients with provisional diagnosis of hepatitis:
Studies in patients who were admitted with a provisional diagnosis of hepatitis (Table-11)

showed a prevalence of HBs Ag ranging between 10% - 45% while only one study showed 12% HCV infection.
Chronic liver disease patients:
Many studies are reported on HBV/ HCV positivity in chronic liver disease cases (Table-12).

The HBsAg positivity in patients with chronic liver disease ranged from 10-46.6% and for HCV from 40-86% which is more than twice of that seen with HBV. Two studies are available in children and both show high prevalence of HBV but low of HCV.
Genotypes and serotypes of HBV and HCV:
Variable results are seen on genotypes of HBV (Table-13).

Majority of the studies from Sindh showed a high prevalence of genotype D while a study from Punjab showed high C.
Many studies on HCV serotypes have been carried out (Table-14)

and all showed that in over 80% the cases, genotype 3 was detected, followed by genotype 1, 2 and 4. Genotypes are important to determine the treatment response and disease transmission epidemiology. Better response to interferon and short term treatment (6 months) is reported in hepatitis C patients infected with serotype 3 while for all other genotypes a longer duration of therapy is suggested.
Sexual transmission of HCV was checked in few studies to see inter spousal transmission of the disease (Table-15).

Studies from Sindh192,195 show a higher frequency of disease in the spouses while those from Punjab show a low frequency.191,193,194
Hepatitis Delta (HDV):
Delta virus is dependant on presence of HBsAg for its transmission and survival. It can infect as co infection where both viruses are transmitted at the same time resulting in high mortality because of fulminant hepatitis. Super infection occurs in an already known HBV carrier who is exposed to delta virus, thus resulting in chronic liver disease. Zuberi196 reported 408 cases of chronic liver disease due to HBV infection of which 44% had delta super infection and 1.4% co infection. Riaz et al197 from Karachi studied 531 cases of HDV at a hepatology unit of a public sector hospital using EIA. Majority of their cases (68%) came from Northern Sindh, followed by Balochistan (17%) and death in most of these cases was due to complications of liver disease and failure. Mumtaz et al198 studied 8721 patients with chronic HBV disease and found HDV antibody in 1444(16.6%) cases and HDV infected cases has milder liver disease when compared with non delta infected HBV cases.

Discussion

Pakistan has a high disease burden of hepatitis A to E, with maximum morbidity in hepatitis A and E and maximum mortality in hepatitis B, C and D. The aim of this review was to determine the extent of hepatitis problem in the country and to provide road map for the policy makers in the development of national strategy on the prevention and control of hepatitis. This review provides sufficient evidence of infection in different groups.
Hepatitis A accounts for 50-60% of all cases of acute viral hepatitis in children. This infection is uncommon in adults but those who get infected have a longer convalescence and prolonged morbidity. Most of the children are exposed to this virus during their early age and remain immune for rest of their life. Vaccine is available for its prevention but its use is recommended for travelers coming from low endemicity areas and during epidemics and natural disasters.199 Two doses of hepatitis A vaccine are recommended which produce life long immunity
In Pakistan, Hepatitis E mainly affects the adult population. A number of mini epidemics have been reported in the country. Once infected recovery is a rule except in late trimester of pregnancy where a 30% maternal or foetal loss is reported especially during epidemics.200 Hepatitis E like hepatitis A infection is endemic in Pakistan due to faecal contamination of drinking water. In urban areas, the main water supply line gets contaminated from the nearby leaking sewage pipe while in rural areas water from wells, streams, canals, rivers and ponds gets contaminated by direct disposal of sewage in these sites. The immunity of hepatitis E lasts for 8-10 years and is lost thereafter making the individual susceptible to re-infection. A vaccine trial was done in Nepal with good results,201 but no vaccine is commercially available, therefore prevention of hepatitis E infection needs to be propagated.
Hepatitis B and C infections are blood borne and are transmitted through unscreened blood transfusions, inadequately sterilized invasive medical devices and re use of syringes.
Using WHO\'s criteria of endemicity of hepatitis B virus countries with a carrier rate of less than 3% fall in the low endemic region, those with rates between 3-5% fall in intermediate and those above 5% in high endemic region.202 The previous review showed that the prevalence of hepatitis B in Pakistan is around 4% in general population.196 With a sizable pool of delta positive cases in some parts of Sindh Punjab and Baluchistan,196-98 and a low EPI coverage of hepatitis B vaccine in some districts203 there is a high chance that this viral infection will continue to cause a major disease burden in our country. To contain the disease strategies have to be laid down to improve immunization coverage. Studies on vertical transmission of HBeAg are scarce; and some published studies are not so much supportive to decide for introducing the birth dose hepatitis B vaccine. There is need to study the HBsAg status in vaccinated children and see if vaccination at 6 weeks should be continued or an extra dose should be given at day zero.
For HCV, the global figures are that about 3% of the world\'s population is suffering from this viral infection. In Pakistan the prevalence of HCV infection is around 5%.196 Pakistan has the highest rate of therapeutic intramuscular injections per person per year.124,127,128 Apart from the known risk factors of blood transfusion, reuse of syringes and improper sterilization of invasive medical devices; shaving by barbers is coming up as another source of spread of this disease. As no vaccine is available for its prevention therefore adherence to best clinical practices and standard operating procedures for sterilization and disposal of hospital waste must be practiced along with legislation against non compliant blood banks and hospitals.
Clinical significance of HBV and HCV serotypes is important to see the disease response to treatment and progression. Of the HBV serotypes, type A and D are associated with cirrhosis of the liver and type C with liver cancer. Studies from Sindh show higher frequency of genotype D,183-85 while those from Punjab show more HBV genotype C182 which is associated with the development of cirrhosis and HCC as well as lower response rate to interferon or nucleoside analogue therapy as compared to genotype B.182
In hepatitis C six serotypes have been identified.1-6 Global studies have shown that serotype 3 is most easy to treat with a cure rate of around 80 percent.204 In Pakistan serotype 3 is most common. Most studies show about 50-70% sustained viral response with interferon therapy for 6 months.205-207
There is no national data on the leading causes of admissions to hospitals in Pakistan and the contribution of liver disease to overall mortality. One study from Peshawar showed 23% of total admissions of gastroenterology in a year were made for liver diseases.208 Khokhar et al181 reviewed twelve months admission data to see the cause of deaths in 283 cases out of 8529 admissions. There were 160 deaths related to medical causes, including 33 (20.6%) deaths from chronic liver disease.
Keeping in view the high disease burden of viral hepatitis infections and severity of its complications from hepatitis to cirrhosis and cancer, the Prime Minister of Pakistan launched a hepatitis prevention and control programme in collaboration with the ministry of health, the provincial health departments, to reduce the disease prevalence and incidence.

References

1.Shah U, Habib Z, Kleinman RE. Liver failure attributable to hepatitis-A virus infection in a developing country. Pediatrics 2000; 105: 436-8.
2.Mujeeb SA. Seroprevalence and pattern of viral hepatitis in Pakistan. Infect Dis J Pak 1998; 20-1.
3.Agboatwalla M, Isomura S, Miyake K, et al. Hepatitis A, B and C seroprevalence in Pakistan. Ind J Pediatr 1994; 61:545-9.
4.World Health Organization. Hepatitis E, WHO/CDS/CSR/EDC/2001.12.
5.Malik IA, Tariq WZ. The prevalence and pattern of viral hepatitis in Pakistan. J Coll Physicians Surg Pak 1995; 5: 2-3.
6.World Health Organization. Hepatitis B fact sheet. (Online) 2000. Available from URL: http://www.who.int/mediacentre/factsheets/fs204/en/.
7.Khan AJ, Luby SP, Fikree F, Karim A, Obaid S, Dellawala S,et al, Unsafe injections and the transmission of hepatitis B and C in a periurban community in Pakistan. Bull World Health Organ 2000; 78: 956-63.
8.Kane A, Lloyd J, Zaffran M, Simonsen L, Kane M. Transmission of hepatitis B, hepatitis C and HIV viruses through unsafe injections in the developing world: model based regional estimates. Bull World Health Organ 1999; 77: 801-7.
9.Qureshi H, Hafiz S. Exposure rate to Hepatitis A and E (IgG) in children. J Pak Med Assoc 2000; 40: 284-7.
10.Malik R, Ghafoor T, Sarfraz M, Hasan N. Hepatitis A - frequency in Children with non-specific abdominal symptoms. J Coll Physicians Surg Pak 2004; 14: 348-50.
11.Kiani IS, Shafi MS, Nasir J, Rehan M. Prevalence Of Hepatitis - A in healthy adult population of Rawalpindi / Islamabad, Pak J Gastroenterol 1999; 131 (1-2).
12.Jaffery G. Serodiagnosis of viral hepatitis E by exclusion of other acute viral hepatitis (AVH) markers. Pak J Pathol 1996; 7: 15-9.
13.Jaffery G. Hussain W. Serodiagnosis of acute viral hepatitis (AVH) in children. Pak Pediatr J 1996; 20: 17-20.
14.Lodhi TZ, Zuberi SJ. Cost effective approach for serological diagnosis of hepatitis. J Pak Med Assoc 1988; 38: 199-201.
15.Aziz S, Muzaffar R, Hafiz S, Abbas Z, Zafar MN, Naqvi SA, et al,.Helicobacter Pylori, hepatitis viruses A,C,E antibodies and HbsAg - prevalence and associated risk factors in pediatric communities of Karachi. J Coll Physicians Surg Pak 2007; 17: 195-8.
16.Saeedi MI, Mahmood K, Amanullah, Ziauddin M, Ilyas N, Zarif M., Frequency and clinical course of hepatitis E in tertiary care hospitals. J Coll Physicians Surg Pak 2004; 14: 527-9.
17.Tahir Z, Aslam M, Aman S, Kamal F, Hafeez R. Hepatitis E Super Infection, Ann King Edward Med Coll 2002; 8 :43-4.
18.Tahir Z, Aslam M, Aman S, Tahir ZN. Prevalence of hepatitis E Virus (HEV) - IgG Antibodies in Hospitalized Jaundiced Patients, Ann King Edward Med Coll 2001; 7: 258-9.
19.Shams R, Khero RB, Ahmed T, Hafiz A. Prevalence of hepatitis E virus (HEV) antibody in pregnant women of Karachi. J Ayub Med Coll Abbottabad 2001; 13: 31-5.
20.Qureshi H, Shahid A, Mujeeb SA. Exposer rate of hepatitis E (IgG) in a selected population of children and adults in Karachi. J Pak Med Assoc 2000; 50: 352-4.
21.Malik N, Farooq M, Karamat KA, Butt T, Hassan M, Qasim S. An Outbreak of Viral Hepatitis E. Pak Armed Forces Med J 2001; 51: 78-81.
22.Rab MA, Bile MK, Mubarik MM, Asghar H, Sami Z, Siddiqi S, etal, Water-borne hepatitis E virus epidemics in Islamabad, Pakistan: A common source of outbreak traced to the malfunction of a modern water treatment plant. Am J Trop Med Hyg 1997; 57: 151-7.
23.Malik IA, Tariq WZ. Hepatitis E in Pakistan. J Coll Physicians Surg Pak 1996; 6: 121-8.
24.Aziz AB, Hamid S, Iqbal S, Islam W, Karim SA et al, Prevalence and severity of viral hepatitis in Pakistani pregnant women: a five year hospital based study. J Pak Med Assoc 1997; 47: 198-201.
25.Bryan JP, Iqbal M, Tsarev S, Malik IA, Duncan JF, Ahmed A et al, Epidemic of Hepatitis E in Military unit in Abbottabad, Pakistan. Am J Trop Hyg 2002; 67: 662-8.
26.Quraishi MS, Ahmad M, Rashid H, Mushtaq S, Ahmed SA. Hepatitis non-A and non-B; report of a water borne outbreak. J Pak Med Assoc 1988; 38: 203-4.
27.Iqbal S. Umar M, Mumtaz S. Acute hepatitis E: experience at Holy Family Hospital, Rawalpindi. Pak J Gastroenterol 2006; 20: 32-6.
28.Hamid SS, Jafri SM, Khan H, et al. Fulminant hepatic failure in pregnant women: Acute fatty liver or acute viral hepatitis? J Hepatol 1996; 25: 20-7.
29.Hyder SN. Seroprevalence of anti-HCV in asymptomatic children. Pak J Pathol 2001; 25: 89-93.
30.Malik R, Ghafoor T, Sarfraz M, Hasan N. Hepatitis A - frequency in Children with non-specific abdominal symptoms, J Coll Physicians Surg Pak 2004; 14: 348-50.
31.Khan MA, Ali AS, Hassan Z, Mir F, Haque S. Seroprevalence of Hepatitis B in children. Pak Pediatr J 1998; 22: 75-7.
32.Abbass KA, Tanwani AK. Prevalence of hepatitis B surface antigenaemia in healthy children. J Pak Med Assoc 1997; 47: 93-4.
33.Khan HI. A study of seroprevalence of hepatitis B and C in mothers and children in Lahore. Pak Pediatr J 1996; 20: 163-6.
34.Agboatwalla M, Isomura S, Miyake K, Yamashita T, Morishita T, Akram DS. Hepatitis A, B and C seroprevalence in Pakistan. Indian J Pediatr 1994; 61: 545-9.
35.Kazmi K, Ghafoor A, Qureshi WA. Mother-infant transmission of hepatitis B in Pakistan, Pakistan J Med Res 2003; 42: 152-6.
36.Mehnaz A. Hepatitis B markers in mothers and its transmission in newborn. J Coll Physicians Surg Pak 2002; 12: 240-2.
37.Khokhar N, Raja KS, Javaid S. Seroprevalence of Hepatitis C virus infection and its risk factors in pregnant women. J Pak Med Assoc 2004; 54: 135.
38.Batool A, Bano KA, Khan MI, Hussain R. Antenatal screening of women for hepatitis B and C in an out-patient department. J Dow Uni Health Sci 2008; 2: 32-5.
39.Hussain A, Idris R, Manzoor B. HBs Antigenaemia pregnant women at Ziauddin Hospital, Karachi. Sarwar J Zuberi report on Hepatitis B in Pakistan.
40.Aziz AB, Hamid S, Iqbal S, Islam W, Karim S. Prevalence and severity of viral hepatitis in Pakistani pregnant women: a five years hospital based study. J Pak Med Assoc 1997; 47: 198-201.
41.Samad F, Lodi TZ, Zuberi SJ, Jafarey SN, Said M. Vertical transmission of Hepatitis B surface antigen. Asian Med J 1979; 22: 678-80.
42.Zuberi SJ, Lodi TZ, Kanji P. Pattern of HBs Ag/ Hbe antigenaemia in Pregnant women. J Pak Med Assoc 1989; 39: 160.
43.Nayab Bilal, Shahnaz Akhter, Mussarat Baber. Spectrum of HCV positive cases in a Gynae Unit. J Postgrad Med Inst 2002; 16: 68-71.
44.Fayyaz H, Latif Y, Sohail R. Screening for Hepatitis C in Gynecological population. Ann King Edward Med Coll 2004; 10: 287-8.
45.Zafar MF, Mohsin A, Husain I,Shah AA. Prevalence of Hepatitis C among Pregnant Women. J Surg Pak 2001; 6: 32-3.
46.Rana G, Akmal N, Akhtar N. Prevalence of hepatitis B in pregnant females. Ann King Edward Med Coll 2006; 12: 313-5.
47.Jaffery T, Tariq N, Ayub R, Yawar A. Frequency of Hepatitis C in pregnancy and pregnancy outcome. J Coll Physicians Surg Pak 2005; 15: 716-9.
48.Rizvi TJH, Fatima H. Frequency of Hepatitis C in obstetric cases. J Coll Physicians Surg Pak 2003; 13: 688-90.
49.Hakeem K, Khan S, Abdullah M. Prevalence of Hbs Ag & Anti HCV in pregnant ladies attending antenatal clinic at Sheikh Zayed Medical Complex, Rahim Yar Khan. Esculapio J Serv Inst Med Sci 2006; 2: 6-8.
50.Akhtar A, Talib W, Shami N, Anwar S. Frequency of Hepatitis C in admitted patients of Department of Obstetrics & Gynaecology, Ghurki Trust Teaching Hospital, Lahore. Ann King Edward Med Coll 2006; 12: 254-6.
51.Yousfani S, Mumtaz F, Memon A. Antenatal screening for Hepatitis B and C virus carrier state at a University Hospital. J Liaquat Uni Med Health Sci 2006; 5: 24-7.
52.Rana G, Akmal N, Akhtar N. Prevalence of hepatitis B in pregnant females. Ann King Edward Med Coll 2006; 12: 313-6.
53.Ali HS, Memon A. Prevalence of hepatitis B infection in pregnant women in a tertiary care hospital. Infect Dis J 2007; 16: 35-8.
54.Qasmi SA, Aqeel S, Ahmed M, Alam SI, Ahmad A. Detection of hepatitis B viruses in normal individuals of Karachi. J Coll Physicians Surg Pak 2000; 10: 467-9.
55.Ahmad M, Qureshi MS, Zuberi SJ. Hepatitis B surface antigenimia-role in the epidemiology of liver disease, J Pak Med Assoc 1979; 29: 23-7.
56.Anwar M, Bokhari SR. Prevalence of anti-HCV antibodies in patients with suspected liver disease. Biomedica 1999; 15: 80-4.
57.Gondal SH, Jawed S, Bhutta AR. Incidence of HBsAg patients in a general surgical ward. Pakistan Postgrad Med J 1999; 10: 33-4.
58.Luby SP, Qamruddin K, Shah AA, Omair A, Pahsa O, Khan AJ, et al, The relationship between therapeutic injections and high prevalence of hepatitis C infection in Hafizabad, Pakistan. Epidemiol Infect 1997; 119: 349-56.
59.Sultana N, Bari A, Qazalbash AA. Prevalence of anti-HCV antibodies in patients with liver disease and normal population, Pak J Med Res 1999; 38: 106-11.
60.Khokhar N, Gill ML, Malik GJ. General seroprevalence of hepatitis C and hepatitis B virus infections in population, J Coll Physicians Surg Pak 2004; 14: 534-6.
61.Abbass KA, Tanwani AK. Prevalence of hepatitis B surface antigenaemia in healthy children. J Pak Med Assoc 1997; 47: 93-4.
62.Farooqi JI, Farooqi RJ, Khan N, Mussarat. Frequency of hepatitis B and C in selected groups of population in NWFP. J Postgrad Med Inst 2007; 21: 165-8.
63.Amin J, Yousuf H, Mumtaz A, Iqbal M, Ahmed R, Adhami SZ, et al. Prevalence of Hepatitis B surface antigen and anti hepatitis C virus. Professional Med J 2004; 11: 334-7.
64.Kolachi HB, Rathi SL, Shaikh K, Khaskheli A, Shairani A, Nasreen. Hepatitis-B surface antigen (HBsAg) screening and vaccination experience in Tharparkar. Med Channel 2006; 12: 40-4.
65.Alam M, Tariq WZ, Akram S, Qureshi TZ. Frequency of hepatitis B and C in central Punjab. Pak J Pathol 2006; 17: 140-1.
66.Abbas Z, Shazi L, Jafri W. Prevalence of hepatitis B in individuals screened during a countrywide. J Coll Physicians Surg Pak 2006; 16: 495.
67.Mirza IA, Kazmi SMH, Janjua AN. Frequency of hepatitis B surface antigen and anti-HCV in young adults - experience in southern Punjab. J Coll Physicians Surg Pak 2007; 17: 114-5.
68.Bhatti S, Quraishi M, Mahmood Z, Javaid K. Seroprevalence of HBsAg and HCV antibodies in healthy individuals of high socioeconomics status. Biomedica 2007; 23: 131-3.
69.Zakaria M, Ali S, Tariq GR, Nadeem M. Prevalence of anti-hepatitis C antibodies and hepatitis B surface antigen in healthy male naval recruits. Pak Armed Forces Med J 2003; 53: 3-5.
70.Ali N, Khattak J, Anwar M, Tariq WZ, Nadeem M, Irfan M, et al. Prevalence of hepatitis B surface antigen and hepatitis C antibodies in young healthy adults, Pak J Pathol 2002; 13: 3-6.
71.Sherif TB, Tariq WZ. Seroprevalence of hepatitis B and C in healthy adult male recruits. Pak J Pathol 2006; 17: 147-50.
72.Hashim R, Hussain AB, Rehman K. Seroprevalence of hepatitis-C virus antibodies among healthy young men in Pakistan. Pak J Med Res 2005; 44: 140-2.
73.Farooq MA, Iqbal MA, Tariq WZ, Hussain AB, Ghani I. Prevalence of hepatitis B and C in a healthy cohort. Pak J Pathol 2005; 16: 42-6.
74.Altaf C, Akhtar S, Qadir A, Malik KZ, Ahmed P, Tariq WZ. Frequency of hepatitis B and C among healthy adult males from Central Sindh. Pak J Pathol 2007; 18: 113-5.
75.Mujeeb SA, Donation of blood in Pakistan; Risks and Resources, Blood Transfusion, A technical and Clinical Care, Mujeeb SA (ed) Karachi; pp 1-8, 1998.
76.Mujeeb SA, Single unit blood transfusion a bad clinical practice? Transfusion today 1997; 36: 5-7.
77.Mujeeb SA. Blood transfusion, a technical and clinical care. In: Mujeeb SA, editor. Donation of blood in Pakistan risks and resources. Karachi, 1998; pp 1-8.
78.Mujeeb SA. Single unit blood transfusion a bad clinical practice? Transfus Today 1997; 36: 5-7.
79.El-Nageh M. An overview of blood transfusion services in countries of the Eastern Mediterranean Region. Transfus Today 1998; 37: 12-9.
80.Asif N, Khokhar N, Ilahi F. Seroprevalence of HBV, HCV and HIV infection among voluntary non remunerated and replacement donors in Northern Pakistan. Pak J Med Sci 2004; 20: 24-8.
81.Rahman M, Akhtar GN, Lodhi Y. Transfusion transmitted HIV and HBV infections in Punjab, Pakistan. Pak J Med Sci 2002; 18: 18-25.
82.Mumtaz S, Rehman M, Muzaffar M, Hassan M, Iqbal W. Frequency of seropositive blood donors for hepatitis B, C and HIV viruses in railway hospital Rawalpindi, Pak J Med Res 2002; 41: 51-3.
83.Rahman M, Akhtar GN, Lodhi Y. Seroprevalence of hepatitis-C antibodies in blood donors, Pak J Med Sci 2002; 18: 193-6.
84.Ali N, Nadeem M, Qamar A, Qureshi AH, Ejaz A. Frequency of hepatitis C virus antibodies in blood donors in Combined Military Hospital, Quetta, Pak J Med Sci 2003; 19: 41-4.
85.Ahmad S, Gull J, Bano KA, Aftab M, Khokhar MS. Prevalence of anti hepatitis C antibodies in healthy blood donors at Services Hospital Lahore. Pak Postgrad Med J 2002; 13: 18-20.
86.Ahmed MU, Aziz M. Anti hepatitis C Antibodies study in professional and volunteer blood donors, Ann Abbasi Shaheed Hosp Karachi Med Dent Coll 2001; 6: 278-9.
87.Ahmad M. Hepatitis B surface antigen study in professional and volunteer blood donors. Ann Abbasi Shaheed Hosp Karachi 2001; 6: 304-6.
88.Mujeeb SA, Aamir K, Mehmood K. Seroprevalence of HBV, HCV and HIV infections among college going first time voluntary blood donors. J Pak Med Assoc 2000; 50: 269-70.
89.Alam M, Khan DA. Prevalence of antibodies to hepatitis C virus in blood donors in Sialkot. J Coll Physicians Surg Pak 2001; 11: 783-5.
90.Khattak M F, Salamat N, Bhatti F A, Qureshi T Z. Seroprevalence of hepatitis B, C and HIV in blood donors in northern Pak J Pak Med Assoc 2002; 52: 398-402.
91.Kakepoto GN, Bhally HS, Khaliq G, Kayani N, Burney IA, Siddiqui T, et al, Epidemiology of blood borne viruses, a study of healthy blood donors in Southern Pakistan. Southeast Asian J Trop Med Public Health 1996; 27: 703-6.
92.Zuberi SJ, Lodi TZ. Hepatitis B Antigen in blood donors in Karachi. J Pak Med Assoc 1974; 24: 126-7.
93.Ahmad J, Taj AS, Rahim A, Shah A, Rehman M. Frequency of hepatitis B and hepatitis C in healthy blood donors of NWFP: a single center experience. J Postgrad Med Inst 2004; 18: 343-52.
94.Asif N, Khokhar N, Ilahi F. Seroprevalence of HBV, HCV and HIV infection among voluntary non remunerated and replacement donors in Northern Pakistan. Pak J Med Sci 2004; 20: 24-8.
95.Zaidi A, Tariq WZ, Haider KA. Seroprevalence of hepatitis B, C and HIV in healthy blood donors in Northwest of Pakistan. Pak J Pathol 2004; 15: 11-6.
96.Nadeem M, Yousaf MA, Mansoor S, Mansoor S, Khan FA, Zakaria M, et al. Seroprevalence of HBsAg and HCV antibodies in hospital workers compared to aged matched healthy blood donors. Pak J Pathol 2004; 15: 17-20.
97.Ali N, Nadeem M, Qamar A, Qureshi AH, Ejaz A. Frequency of hepatitis C virus antibodies in blood donors in Combined Military Hospital, Quetta. Pak J Med Sci 2003; 19: 41-4.
98.Ahmad A. Frequency of HBV surface antigen and anti-HCV in healthy voluntary blood donors in Swat district. J Postgrad Med Inst 2006; 20: 187-90.
99.Aziz MS. Prevalence of anti Hepatitis C antibodies and hepatitis B surface antigen in healthy blood donors in Baltistan. Pak Armed Forces Med J 2006; 56: 189-91.
100.Ujjan ID., Memon RA., Butt AR. Seroprevalence of HbsAg and anti-HCV in healthy blood donors. Pak J Gastroenterol 2006; 20: 75-7.
101.Chaudry NT, Jameel W, Ihsan I, Nasreen S. Hepatitis C. Professional Med J 2005; 12: 364-7.
102.Sirhindi GA, Khan AA., Alam SS. Frequency of hepatitis B, C and human immunodeficiency virus in blood donors at Shaikh Zayed Hospital, Lahore. Proc Shaikh Zayed Postgrad Med Inst 2005; 19: 33-6.
103.Naqvi A, Khaskheli QA, Ansari SH. Hepatitis C virus; prevalence in blood donors in Karachi. Prof Med J 2006; 13: 604-7.
104.Khan MA, Chaudhary GM, Fayyaz M. Hepatitis B, C and HIV: seroprevalence of infection in blood donors. Prof Med J 2006; 13: 632-6.
105.Chaudhary IA, Samiullah, Khan SS, Masood R, Sardar MA, Mallhi AA. Seroprevalence of hepatitis B and C among the healthy blood donors at Fauji Foundation Hospital, Rawalpindi. Pak J Med Sci 2007; 23: 64-7.
106.Ijaz AU, Shafiq F, Toosi NA. Hepatitis B and hepatitis C in blood donors: analysis of 2-years data. Ann King Edward Med Coll 2007; 13: 59-61.
107.Alam M, Naeem MA. Frequency of hepatitis B surface antigen and anti-hepatitis C antibodies in apparently healthy blood donors in Northern Areas. Pak J Pathol 2007; 18: 11-4.
108.Ishaq M,  Ali SS, Karim N. Frequency of hepatitis B and C virus among the healthy volunteer blood donors at Taulka Hospital Sujjawal, District Thatta, Sindh. Ann Abbasi Shaheed Hosp Karachi Med Dent Coll 2007; 12: 97-101.
109.Azam M, Jamal N, Imtiaz F. Blood donor screening for hepatitis and HIV. J Dow Uni Health Sci 2007; 1: 82-3.
110.Mahmood MA, Khawar S, Anjum AH. Prevalence of hepatitis B, C and HIV infection in blood donors of Multan region. Ann King Edward Med Coll 2004; 10: 459-61.
111.Khurum M. Prevalence of anti-HCV antibodies among health care workers of Rawalpindi and Islamabad, Rawal Med J 2003; 28: 7-11.
112.Tariq WZ, Eijaz Ghani, Karamat AK. Hepatitis B in health care Personnel, Pak Armed Forces Med J 2000; 50: 56-7.
113.Aziz S, Memon A, Tily HI, Rasheed K, Jehangir K, Quraishy MS. Prevalence of HIV, hepatitis B and C amongst health workers of Civil Hospital Karachi. J Pak Med Assoc 2002; 52: 92-4.
114.Mujeeb SA, Zuberi SJ, Lodi TZ. Prevalence of hepatitis HBV infection in health care personnel. J Pak Med Assoc 1994; 44: 265-8
115.Zuberi SJ, Samad F, Lodi TZ, Ibrahim K, Maqsod R. Hepatitis and hepatitis B surface antigen in health care personnel. J Pak Med Assoc 1977; 27: 373-5.
116.Mujeeb SA, Khatri Y, Khanani R. Frequency of parenteral exposure and Seroprevalence of HBV, HCV and HIV among operation room personnel. J Hos Infect 1998; 38: 133-7.
117.Pirzado ZA, Malik R, Lal S, Shaikh SA. Prevalence of hepatitis B carriers in Chandka Medical College and Hospital staff, Larkana. Pak J Med Res 1996; 35: 183-4.
118.Shaikh MH, Shams K. Prevalence of HBV markers in health care personnel vs matched control. J Coll Physicians Surg Pak 1995; 5: 19-21.
119.Khan GM. Profile of hepatitis B surface antigen positivity in health care personnel. Mother Child 1996; 34: 135-8.
120.Shah SH, Khan JA, Khan MH, Khalik MA. Prevalence of hepatitis B carrier in hospital staff. Pak J Med Res 1991; 30: 96-7.
121.Zahid MA, Rehman K, Jangua IM, Haider Z. Prevalence of hepatitis B surface antigen among health care workers in hospital. Pak J Med Res 1991; 30: 98-100.
122.Shrestha SK, Bhattarai MD. Study of hepatitis B among different categories of health care workers. J Coll Physicians Surg Pak 2006; 16: 108-11.
123.Ahmed MU, Khatoon., Sabir M. Surveillance of needle stick injuries (NSI) and sharp injuries at two centers in Pakistan. Ann Abbasi Shaheed Hosp Karachi Med Dent Coll 2005; 10: 710-5.
124.Khan AJ, Luby SP, Fikree F, Karim A, Obaid S, Dellawala S, et al. Unsafe injections and the transmission of hepatitis B and C in periurban community in Pakistan. Bull World Health Organ 2000; 78: 956-63.
125.Luby SP, Qamruddin K, Shah AA, Omair A, Pasha O, Khan AJ, et al, The relationship between therapeutic C infection in Hafizabad, Pakistan. Epidemiol Infect 1997; 119: 349-56.
126.Khan OF, Saim M, Zuberi SJ. Risk factors of hepatitis B and C transmission in patients coming to a hepatology out patients clinic. Pak J Med Res 2008; 47: 44-7.
127.Usman HR, Akhtar S, Rahbar MH, Hamid S, Moattar T, Luby SP. Injections in health care settings: a risk factor for acute hepatitis B virus infection in Karachi, Pakistan. Epidemiol Infect. 2003; 130: 293-300.
128.Janjua NZ, Akhtar, S Hutin YJF. Injection practices in Sindh, Pakistan: A population survey. In "Pilot-testing the who tools to assess and evaluate injection practices. A summary of 10 assessments coordinated by WHO in Seven Countries (2000-2001)" WHO/BCT 03.10.
129.Rahman S, Hafiz A. Seroprevalence of HDV in hemodialysis and drug addicts in Karachi. J Coll Physicians Surg Pak 2000; 10: 470-2.
130.Anwar AS, Jaffery G, Rasheed SA. Serological screening of female prostitutes for anti-HIV and hepatitis B surface antigen. Pak J Health 1998; 35: 69-73.
131.Baqi S, Shah SA, Baig MA, Mujeeb SA, Memon A. Seroprevalence of HIV, HBV, and syphilis and associated risk behaviours in male transvestites (Hijras) in Karachi, Pakistan. Int J STD AIDS 1999; 10: 300-4.
132.Khokhar N, Alam AY, Naz F. Hepatitis B surface antigenemia in patients on hemodialysis. Rawal Med J 2004; 29: 18-21.
133.Shafiq F, Akram S, Hashmat N. Prevalance of hepatits C in patients with endstage renal disease before and during hemodialysis. Pak J Gastroenterol 2002; 16: 17-20.
134.Hussain M, Khan MA, Mohammad J, Jan A. Frequency of hepatitis B and C in hemophiliac children, Pak Pediatr J 2003; 27: 157-60.
135.Mohammad J, Hussain M, Khan MA. Frequency of hepatitis B and hepatitis C infection in thalassemic children. Pak Pediatr J 2003; 27: 161-4.
136.Rizvi TJH, Fatima H. Frequency of hepatitis C in obstetric cases. J Coll Physicians Surg Pak 2003; 13: 688-90.
137.Aslam M, Mumtaz N, Majid A,Tahir M, Obaidullah A. Magnitude of HCV burden in plastic surgery patients, Pak J Med Res 2003; 42: 112-5.
138.Abbas Hussain SM, Fatima T. Incidence of hepatitis B and C Surgical Patients, Ann Abbasi Shaheed Hosp Karachi Med Dent Coll 2000; 5: 188-91.
139.Hussain M, Khan MA, Mohammad J. Frequency of hepatitis B and C in hemophiliac children. Pak Paediatr J 2003; 27: 157-60.
140.Mohammad J, Hussain M,  Khan MA. Frequency of hepatitis B and hepatitis C infection in thalassemic children. Pak Paediatr J 2003; 27: 161-4.
141.Tarar MR, Malik NA, Chughtai A S. Markers of viral infection in hemophiliacs. Int J Pathol 2003; 1: 22-4.
142.Shah MA,  Khan MT., Zahoorullah, Ashfaq Y. Prevalence of hepatitis B and Hepatitis C virus infection in multi-transfused thalassemia major patients in North West Frontier Province. Pak J Med Sci 2005; 21: 281-3.
143.Burki MFK, Hassan M, Hussain H. Prevalence of anti-hepatitis C antibodies in multiply transfused beta thalassemia major patients. Ann Pak Inst Med Sci 2005; 1: 150-3.
144.Shall ST, Haq R, Shafi R. Prevalence and rate of seroconversion of hepatitis C in hemodialysis patients. Proc Shaikh Zayed Postgrad Med Inst 2003; 17: 19-22.
145.Khokhar N., Alam AY, Naz F. Hepatitis B surface antigenemia in patients on hemodialysis. Rawal Med J 2004; 29: 18-21.
146.Tayyab GN, Arfeen N, Ahmad U, Hafeez A. Seroprevalence of hepatitis B in patients suffering from hepatitis in Lahore, Pakistan. Pak J Gastroenterol 1999; 13.
147.Mahmood A. Hepatitis B virus: prevalence in Karachi. J Coll Physicians Surg Pak 2000; 10: 107-8.
148.Zuberi SJ, Lodi TZ, Alam SE. Spectrum of viral hepatitis. J Pak Med Assoc 1991; 41: 288-91.
149.Zuberi SJ, Lodhi TZ, Maqsood R, Ibrahim K, Khan SM. Acute viral hepatitis. J Pak Med Assoc 1979; 25: 107-12.
150.Iqbal S, Ruknuddin. Liver cirrhosis in North-West Frontier province of Pakistan. J Coll Physicians Surg Pak 2002; 12: 289-91.
151.Farooqi JI, Farooqi RJ. Predictors of the outcome after the first episode of acute variceal bleeding in liver cirrhosis patients, J Coll Physicians Surg Pak Jun 2001; 11: 379-82.
152.Farooqi JI, Farooqi RJ. Relative frequency of hepatitis B Virus and hepatitis C virus infections in patients of cirrhosis in NWFP. J Coll Physicians Surg Pak 2000; 10: 217-9.
153.Farooqi JI, Farooqi RJ. Relative frequency of hepatitis B and C virus infections in cases of hepatocellular carcinoma in North West Frontier Province, Pakistan. J Coll Physicians Surg Pak 2000; 10: 128-30.
154.Iqbal S, Ruknuddin. Liver cirrhosis in North West Frontier Province of Pakistan. J Coll Physicians Surg Pak 2002; 12: 289-91.
155.Mashud I, Khan H, Khattak AM. relative frequency of hepatitis b and c viruses in patients with hepatic cirrhosis at DHQ Teaching Hospital DI Khan. J Ayub Med Coll Abottabad 2004; 16: 32-4.
156.Farooqi JI, Khan PM. Viral aetiology of liver cirrhosis patients in Swat. Pak J Gastroenterol 2002; 16: 39-42.
157.Khan TS, Rizvi F, Rashid A. Hepatitis C seropositivity among chronic liver disease patients in Hazara, Pakistan. J Ayub Med Coll Abottabad 2003; 15: 53-5.
158.Khan TS, Rizvi F. Hepatitis B seropositivity among chronic liver disease patients in Hazara Division Pakistan. J Ayub Med Coll Abottabad 2003; 15: 54-5.
159.Hanif M, Raza J, Qureshi H, Issani Z. Etiology of chronic liver disease in children. J Pak Med Assoc 2004; 54: 119-22.
160.Sharieff S, Burney I, Salam A, Siddiqui T. Hepatocellular carcinoma. J Coll Physicians Surg Pak 2002; 12: 264-7.
161.Zuberi SJ, Lodi TZ, Maqsood R, Ibrahim K, Khan SM. Eastern view of hepatic cirrhosis and its etiology. J Pak Med Assoc 1979; 29: 71-5.
162.Shaikh MA, Shaikh WM, Solangi GA, Abro H. Frequency and transmission mode of hepatitis C virus in Northern Sindh. J Coll Physicians Surg Pak 2003; 13: 691-3.
163.Nadeem MA, Waseem T, Sheikh AM, Grumman N, Irfan K, Hasnain SS. Hepatitis C virus: an alarmingly increasing cause of liver cirrhosis in Pakistan. Pakistan J Gastroenterol 2002; 16: 3-8.
164.Khan AA, Rehman K, Haider Z, Shafqat F. Seromarkers of hepatitis B and C in patients with cirrhosis. J Coll Physicians Surg Pak 2002; 12: 105-7.
165.Naheed T, Nabeel, Naureen, Chaudhry NU, Malik MA. Oesophageal varices - what is the cause? Cirrhotic or non-cirrhotic portal hypertension, Pak J Med Sci 2001; 17: 133-42.
166.Kausar S, Shafqat F, Shafi F, Khan AA.The association of hepatocellular carcinoma with hepatitis B and C viruses. Pak J Gastroenterol 1998; 12.
167.Hussain I, Nasrullah M, Shah AA. Prevalence of hepatitis B and C viral infections in liver cirrhosis in Pakistan. Pak J Gastroenterol 1998; 12.
168.Shah F, Salih M, Malik IA, Hussain I.Increasing prevalence of chronic hepatitis and associated risk factors. Pak J Med Res 2002; 41: 46-50.
169.Khokhar N. Spectrum of chronic liver disease in a tertiary care hospital. J Pak Med Assoc 2002; 52: 56-8.
170.Masood A, Anwar F, Umar M, Khaar B, Hayat A, Rizwan A, et al. Sero-prevalence of liver disease in diabetes mellitus. J Rawal Med Coll 2001; 5: 76-7.
171.Mumtaz MS, Iqbal R, Umar M, Khar B, Mumtaz MO, Anwar F, et al. Sero-prevalence of hepatitis B and C viruses in hepatocellular carcinoma. J Rawal Med Coll 2001; 5: 78-80.
172.Chohan AR, Umar M, Khaar B, Khurram M, Zahid M, Shah SF, et al. Demographic features of hepatocellular carcinoma: a study of 30 cases. J Rawal Med Coll 2001; 5: 81-3.
173.Umar M, Bushra HT, Younis N, Bashir N. Clinical spectrum of chronic liver disease due to HBV, HCV and dual infection - a comparative study. Pak J Gastroenterol 1999; 13.
174.Khan AS, Rizvi F. Hepatitis B seropositivity among chronic liver disease patients in Hazara Division Pakistan. J Ayub Med Coll Abbottabad. 2003; 15: 54-5.
175.Sultana A, Usmani AQ, Hussain HM. Rashid H, Khan MA, Riaz O. Serological profile of patients with liver cirrhosis in northern Pakistan. Pak Armed Forces Med J 2006; 56: 73-9.
176.Bilal A, Qureshi FS, Omar Z,Khalid G. Frequency of hepatitis B and C virus in patients with decompensated cirrhosis of liver in Faisalabad. Pak J Gastroenterol 2006; 20: 43-8.
177.Mashud I, Khan H, Khattak AM. Relative frequency of hepatitis B and C viruses in patients with hepatic cirrhosis at DHQ Teaching Hospital DI Khan. J Ayub Med Coll Abbottabad 2004; 16: 32-4.
178.Murtaza G, Memon IA, Omer AK, Sardar MR, Memon R, Saeed W. Spectrum of liver disorders in children: a hospital based study. Pak Paediatr J 2006; 30: 124-6.
179.Mujeeb SA. Prevalence of HBs Ag and HCV antibodies in hepatocellular carcinoma in Karachi. Trop Doctor 1996; 27: 297.
180.Qureshi H, Zuberi JA, Jafari NA, Zaidi SHM. Hepatocelmular carceloma in Karachi. J Gastroenterol Hepatol 1990; 5: 1-6.
181.Khokhar N, Niazi SA. Chronic liver disease related mortality pattern in northern Pakistan. J Coll Physicians Surg Pak 2003; 13: 495-7.
182.Idrees M, Khan S, Riazuddin S. Common genotypes of hepatitis B virus. J Coll Physicians Surg Pak 2004; 14: 344-7.
183.Baig S, Siddiqui AA, Ahmed W, Qureshi H, Arif A. The association of complex liver disorders with HBV genotypes prevalent in Pakistan. Virol J 2007; 4: 128.
184.Hakim ST, Kazmi SU, Bagasra O. Seroprevalence of Hepatitis B and C Genotypes among Young Apparently Healthy Females of Karachi-Pakistan. Received for publication on 04 September 2007. Accepted in revised form 11 October 2007. Libyan J Med AOP: 071123. www.ljm.org.ly.
185.Alam MM, Zaidi SZ, Malik SA, Shaukat S, Naeem A, Sharif S, et al. Molecular epidemiology of hepatitis B virus genotypes in Pakistan. BMC Infect Dis 2007; 7: 115.
186.Zuberi SJ, Arif A. Serotyping of the hepatitis C in Pakistan. J Pak Med Assoc 2002; 52: 218-9.
187.Idrees M. Comparison of two typing systems for genotyping of hepatitis C virus isolates. J Coll Physicians Surg Pak 2001; 11: 679-83.
188.Ansari N, Ahmed A, Esmail J, Mujeeb SA. HCV serotyping in Karachi: a Liaquat National Hospital experience. J Pak Med Assoc 2002; 52: 219-20.
189.Sarwar S, Butt AK, Alain A. Value of quantitative HCV RNA in management of chronic hepatitis C patients with genotype 2 and 3. Proc Shaikh Zayed Postgrad Med Inst 2005; 19: 55-61.
190.Azhar MA, Bukhari MH, Ghanni U. Prevalence of hepatitis C virus and its serotypes in Bahawalpur Division. Biomedica 2003; 19: 18-22.
191.Umar M, Khar HB, Anwar F, Ahmed S, Chohan A, Siddique K, et al. Evaluation of anti-HCV antibodies among family contracts of HCV related chronic liver disease patients. Pak J Gastroenterol 2003; 17: 27-9.
192.Kumar N, Sattar RA, Ara J. Frequency of hepatitis-C virus in the spouses of HCV positive patients and risk factors of the two groups. J Surg Pak 2004; 9: 36-9.
193.Irfan A, Arfeen. Hepatitis C virus infection in spouses. Pak J Med Res 2004; 43: 113-6.
194.Khokhar N, Gill ML, Alam AY. Interspousal transmission of Hepatitis C virus. J Coll Physicians Surg Pak 2005; 15: 587-9.
195.Qureshi H, Arif A, Ahmed W, Alam E. HCV exposure in spouses of the index cases. J Pak Med Assoc 2007; 57: 175-7.
196.Zuberi SJ. An overview of HBV/HCV in Pakistan. Pak J Med Res 1998; 37(Suppl): 12.
197.Riaz A, Zuberi SJ, Qureshi H, Alam SE. Delta hepatitis in Pakistan. Trop Doct 2005; 35: 121.
198.Mumtaz K, Hamid SS, Adil S, Afaq A, Islam M, Abid S, et al. Epidemiology and clinical pattern hepatitis delta virus infection in Pakistan. J Gastroenterol Hepatol 2005; 20: 1503-7.
199.Hepatitis A vaccines [WHO position].Wkly Epidemiol Rec 2000; 75: 43.
200.Sherlock S, Dooley J. Viral hepatitis in diseases of the liver and biliary system. 9th ed. Oxford: Blackwell Scientific Publication, 1993; pp 287.
201.Shrestha MP, Scott RM, Joshi DM, Mammen MP Jr, Thapa GB, Thapa N, et al. Safety and efficacy of a recombinant hepatitis E vaccine. N Engl J Med 2007; 1356; 895-903.
202.Management of Co-infections in HIV positive injecting drug user. Participants manual 2007. WHO USAID Family Health International, 2007, pp 2-10.
203.NIPS. Pakistan demographic and health survey 2006-07. Islamabad: National Institute of Population Studies; 2008, pp 125.
204.Hepatitis C: an update. US Food and Drug Administration. FDA Consumer Magazine 2001.
205.Hussain AB, Hussain T, Anwar M, Hussain S, Kazmi Y, Tariq WU, et al. Treatment response in HCV related chronic hepatitis. J Coll Physicians Surg Pak 2004; 14: 466-9.
206.Muhammad N, Jan MA, Rahman N. Treatment response of hepatitis C patients to combination therapy of interferon plus ribavirin. J Postgrad Med Inst 2004; 18: 563-8.
207.Ahmed SI, Mahmud MR, Khan NY, Naseemullah M, Hanif M. Pegylated interferon and ribavirin in HCV genotype 3 detectable patients after 12 weeks of conventional interferon - ribavirin treatment. Pak J Gastroenterol 2006; 20: 58-62.
208.Ahmad N, Aamir A.H, Hussain I, Ghulam S. Annual prevalence of various diseases in hospitalized patients in a teriary level teaching hospital at Peshawar. Pak J Med Res 2004; 43: 166-71.

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