Systematic Mini-Review on Hepatitis C Virus Infection in Quetta and Balochistan, A Public Health Concern

1 This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). Systematic Mini-Review on Hepatitis C Virus Infection in Quetta and Balochistan, A Public Health Concern Aqsa Farooq1*, Muhammad Ayub Kakar 1, Noor Hassan1 1Institute of Biochemistry, University of Balochistan, Quetta 87300-Pakistan A R T I C L E I N F O A B S T R A C T KEYWORDS: Hepatitis C virus , Quetta, Risk factors, Epidemiology, Public health, Biomarkers HISTORY: Received 13 October 2025 Revised 20 October 2025 Accepted 23 October 2025 Hepatitis C virus (HCV) is one of the most common and significant global public health concern, affecting an estimated 58 million people worldwide, with 1.5 million new cases of infection reported each year. Chronic HCV infection is a leading cause of liver fibrosis, cirrhosis and hepatocellular carcinoma, contributing substantially to morbidity, mortality with an immense economic burden. Despite advances in screening methods and highly effective direct-acting antivirals (DAAs) treatment, the global disease burden remains unequally distributed. Pakistan has one of the highest HCV burdens in the world, with a national prevalence of approximately 5–6% with an another ≈ 16 million individuals living with chronic infection. However striking regional disparities persist with in Pakistan. Balochistan being the largest province of Pakistan by area is the least developed, remains underrepresented in epidemiological surveys and data. The provincial capital Quetta indicates higher HCV prevalence in certain subpopulations than the national average. Higher prevelance is primarily the result of limited surveillance, unregulated blood transfusion practices, poor infection control stratagies and reduced public awareness is complicating the timely diagnosis and treatment of infection. All stated factors are contributing to progression from acute to chronic infection, in 25% of the affected individuals. The review includes studies published between 2000-2025 encompassing both early epidemiological data, recent HCV surveillance and treatment strategies from hospital and community-based studies in Quetta Balochistan, describing HCV prevalence, associated risk factors and key biomarker trends. Particular emphasis is placed on inconsistencies in risk factor reporting, underdiagnosis of asymptomatic carriers and poor access to DAAs, which collectively hampers HCV elimination. The review also highlights critical gaps in surveillance, screening, prevention strategies and proposes evidence-based policy priorities aligned with the World Health Organization’s 2030 HCV elimination targets. Introduction Hepatitis C virus (HCV) infection is a major and common global public health challenge. HCV infects approximately 58 million people chronically worldwide, with an estimated 1.5 million new cases reported annually, underscoring ongoing transmission and underdiagnosis (WHO, 2023). ___________________ Corresponding author. E-mail address: [email protected] ( Aqsa Farooq). Institute of Biochemistry, University of Balochistan, Quetta 87300-Pakistan DOI: https://doi.org/10.5281/zenodo.17454017 Materion Journal Home Page: https://www.mjoes.com/ Vol. 2. Issue No. 2 Pp 01 – 06 - 2025 2 This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). Morphologically HCV is an enveloped, genetically positivesense, single-stranded RNA virus (≈9.6 kb) belonging to the family Flaviviridae and genus Hepacivirus (Kato et al., 2000; Simmonds et al., 2017). HCV is hepatotropic, causing a persistent inflammation of the liver, which can progress to fibrosis, cirrhosis and hepatocellular carcinoma (HCC) if left untreated (WHO, 2023). HCV infection is often asymptomatic having only mild, nonspecific symptoms such as jaundice or flu-like illness, leading to delayed diagnosis and treatment (CDC, 2023). Chronic infection develops in 55–85% of untreated cases and 15–30% leads to cause hepato-cellular cirrhosis (HCC) within two decades (Smith et al., 2012; Alter et al., 1999). HCV exhibits remarkable genetic diversity, with at least eight genotypes and over 90 subtypes identified (Smith et al., 2014; Petruzziello et al., 2016). HCV genotype 3 is predominant in South Asia, where as subtype 3a accounts for 75–90% of infections in Pakistan along with other serotypes (Hamid et al., 2003; Waheed et al., 2009; Attaullah et al., 2011) Several studies have highlighted HCV transmission which mainly occurs through percutaneous exposure to contaminated blood, including unscreened transfusions, reuse of syringes, inadequately sterilized surgical, dental instruments and unsafe medical practices (Shepard et al., 2005; Khan et al., 2011). Non-medical exposures such as tattooing, body piercing and barbering with unsterilized equipment are commone traditional HCV transmitting factors (Ali et al., 2009). The most vulnerable groups at the risk of HCV infection includes, hemodialysis patients, individuals requiring frequent transfusions, and healthcare workers , especially in low-resource settings with poor infection control system (Ali et al., 2009; Afridi et al., 2014; Khan et al., 2018). Pakistan bears one of the highest national HCV prevalence rates 5–6% compared to the global prevalence of 1–2%. Over 10 million individuals chronically infected, resulting in substantial liver-related morbidity and mortality (Umer & Iqbal, 2016; Polaris Observatory HCV Collaborators, 2017; WHO, 2023). The most common cause, contributing to spread of infection is the use of unsafe injections, reuse of syringes, weak infection control system and unregulated medical or dental care are major drivers of HCV transmission (Qureshi et al., 2010). Within Pakistan, Balochistan is the largest province by area but least populated province marked by geographic remoteness, underdevelopment, low literacy rates and poor healthcare infrastructure (Pakistan Bureau of Statistics, 2022). Quetta despite being the provincial capital has limited screening facilities, weak surveillance and inadequate infection control practices leading to persistently high HCV prevalence in some groups. The issue is confounded by underfunding and overburdened health care system by the high influx of Afghan refugees. (Mehmood et al., 2021). Limited region-specific data is hampering effective policymaking and resource allocation to address the challenge of HCV elimination. Against the backdrop, this review synthesizes the epidemiology, transmission dynamics and genotypic distribution of HCV in Quetta and Balochistan, identifying local risk factors, highlighting gaps in infection control and discusses policy priorities aligned with the WHO’s goal of HCV eliminating by 2030. By consolidating hospital and community-based data, it aims to inform researchers, clinicians and public health authorities to control HCV burden in the region. HCV in Global and National Context HCV epidemiology has shifted dramatically worldwide. High-income countries through effective infection control strategies, blood safety protocols and DAAs have not only curtailed HCV transmission but also made cure achievable for most patients. In contrast, low-income countries with limited resources, poor healthcare settings, limited screening facilities, reuse of unsterilized medical equipment and poor infection control system perpetuate HCV transmission (Hajarizadeh et al. 2013). Pakistan is considered a high-endemic country for HCV, with pockets of very high prevalence. Large-scale meta-analyses have shown considerable regional heterogeneity, with some 3 This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). rural and marginalized communities reaching prevalence rates exceeding 10% (Al Kanaani et al., 2018). HCV Epidemiology in Balochistan The review identified 12 relevant studies on HCV infection from Balochistan published between 2000-2025. Five studies were specifically from Quetta, primarily hospital or laboratory-based investigations involving outpatients, blood donors, and healthcare workers. The remaining studies were from districts including, Khuzdar, Turbat, Sibi, Gwadar and Loralai. Most of the studies provided only limited or subpopulation data and region specific evidences remains sparse and limited. Reports available show an alarming signs where blood donor studies have reported prevalence rates of as high as 20.8% and an overall frequency of up to 26% in young male donors (Khan,A et al. 2013). Such figures far exceed the national average, indicating a critical need for region-specific surveillance and interventions. Hospital-based HCV prevalence involving out patients suspected of infection were reported to have frequency of 31.9% (males 30%, females 33.9%) with a higher but not statistically significant proportion among younger adults (40.4%) (unpublished hospital-based study, 2025). Tariq et al, (2024) reported prevalence of HCV variant, Hepatitis D virus with hospital based prevalence of 20%. Since hospital-based prevalence cannot be directly generalized to the community, these findings underscore the need for systematic data collection with adequate regional representation. Risk Factors for HCV in Quetta and Balochistan Global traditional HCV risk factors include unscreened blood transfusions, contaminated medical equipment, injectable drug use, tattooing and unsafe dental or surgical procedures (Pomper et al. 2003). While in Pakistan in addition to global traditional risk factors unregulated blood banks and poor infection control have historically been major contributors to HCV infection (Idrees & Riazuddin 2008). Biomarker Trends and Clinical Presentation Clinical biomarkers for HCV infection diagnosis includes, liver enzymes, particularly alanine aminotransferase (ALT) and aspartate aminotransferase (AST). High ALT and AST levels are found as a result of hepatic injury caused by HCV and inflammation. AST level are more specific to hepatocellular injury than ALT. Higher ALT levels may also be found in patients with HCV-negative comparable to HCVpositive patients, whereas AST levels were significantly elevated in HCV-positive cases (p = 0.027). This pattern may indicate more persistent hepatocellular injury in chronic HCV infection or other comorbid liver diseases among HCVsuspected patients (Nadeem et al., 2010). Common clinical symptoms reported included abdominal pain, jaundice, nausea, and weight loss. However, these symptoms are not exclusive to HCV-positive individuals, reinforcing the need for laboratory confirmation of suspected cases (Akhtar, S., & Moatter, T. (2007). Gaps, Challenges and Recommendations Factors along with limited evidence and sparce clinical data, several challenges persist, threatening the progress toward HCV elimination. Stated below are common challenges hampering HCV elimination. I. Limited community-level data: Most studies are hospital-based, which overestimates prevalence and underrepresents asymptomatic individuals. II. Inconsistent risk factor reporting: Lack of standardized questionnaires involving infected individuals to study the etiology of infection hampers meta-analysis. III. Underdiagnosis and undertreatment: DAAs remain costly and less accessible to low income population in Balochistan. IV. Weak infection control and blood safety infrastructure: Unregulated blood transfusions and unsafe medical practices persist in many settings, resulting the spread of infection. V. Policy and Public Health Implications: To achieve WHO’s HCV elimination targets by 2030, Pakistan must accelerate efforts at both national and provincial levels. Based on the evidence from limited number of region specific studies, priority measures shall include, 4 This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). i. Expanding community-based screening programs to capture asymptomatic carriers. ii. Strengthening blood safety and infection control protocols across public and private facilities. iii. Scaling up access to DAAs with subsidies or publicprivate partnerships. iv. Enhancing public awareness campaigns tailored to local cultural contexts. v. Establishing a provincial HCV registry to monitor prevalence trends and treatment outcomes. Results and Discussions Hepatitis C Virus (HCV) continues to pose a significant and persistent public health challenge in Quetta and across Balochistan. The available evidence, though limited, consistently reveals prevalence rates exceeding the national average. This indicates not only a high disease burden but also the likelihood of substantial underdiagnosis in rural and underserved population. While traditional risk factors, such as unsafe injections, blood transfusions and reuse of medical equipment remain dominant factors of transmission. The apparent variability in risk profiles among different communities may reflect sampling biases, inconsistent surveillance systems and inadequate reporting rather than true epidemiological changes. Cross boarder HCV transmission in Balochistan requires integrated refugee health management into provincial disease control programs. Infection control training for informal healthcare providers could mitigate transmission risks arising from the movement of displaced populations. Collaborative initiatives with international organizations, such as WHO UNHCR and local NGOs are essential to ensure inclusion of refugee and migrant populations in screening and awareness programs. Addressing these challenges requires an integrated and province-specific approach, which may include, expanded community-based screening programs, standardized laboratory diagnostics and improved infection control in both public and private healthcare settings, accurate mapping and contain HCV transmission through microelimination approaches targeting high-risk groups, such as dialysis patients, blood donors, prisoners, refugees and migrant populations. Furthermore, the inclusion of marginalized populations, such as nomadic and border communities, in surveillance efforts is crucial to capture the full epidemiological picture. Public awareness campaigns targeting unsafe medical practices and stigma reduction can complement clinical interventions. Several successful pilot programs and interventions from other provinces have achieved high cure rates (SVR>90%) through both micro and macro-elimination pilot intervention programs. To align with the World Health Organization’s 2030 HCV elimination targets, Balochistan must strengthen its health infrastructure, ensure equitable access to direct-acting antivirals (DAAs) and invest in micro-elimination pilots programs in high risk groups and high yield setting (dialysis units, prisons, district hospitals, refugee settlements along with data collection systems. Pakistan can only through coordinated provincial and national action move forward to effective HCV control and eventual elimination. Conclusion Hepatitis C virus (HCV) remains a significant public health concern in Balochistan, where prevalence rates continue to exceed national averages. Despite advances in antiviral therapy, limited surveillance, weak infection control and poor healthcare access hinder progress toward HCV elimination. Strengthening community-based screening, ensuring blood safety and expanding access to direct-acting antivirals are essential to reduce disease burden. 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