Ten different studies showed that the percent prevalence of HCV in the general adult population was 4.95% ± 0.53%[10-19], while six studies showed a percent prevalence of 1.72% ± 0.24% in the pediatric population[20-25]. In Pakistan, military recruits are screened for HCV before induction; six different studies showed a percent prevalence of 3.64% ± 0.31% in candidates for military recruitment[26-31]. About 5% of infants obtained HCV infection transmitted from a mother carrying both HCV antibody and HCV RNA[32]; four studies in pregnant women showed the percent prevalence to be 4.54% ± 3.5%[33-36]. Volunteer blood donors are the healthiest population in a community and HCV prevalence in these individuals is a true reflector of a general population’s health[9]; twelve different studies showed the percent prevalence to be 3.78% ± 0.41% in blood donors[17,37-47].

It was estimated that there were about 5 million drug users in Pakistan, out of which 15% were regular IDUs[48]. There has been an increased shift among addicts from inhalatory to injectable drugs due to decrease in quality and availability of heroin (common inhalatory drug used in Afghanistan and Pakistan)[49]. The effect of injecting drugs is more intense and satisfying, and young drug users who switch over to injectables usually adopt it as the main route of their drug administration[50]. Approximately 50% of IDUs reported by Altaf et al[51] in 2007 were in a treatment program; the majority of them wanted to get rid of their addiction but could not do so due to non availability or high charges by rehabilitation centers. The main reason for relapse was the economic crisis which most addicts suffer because the rehabilitation centers are not involved in the development of vocational skills among addicts. Four different reports showed a high 57% ± 17.7% prevalence of HCV among the IDUs[52-55].

Thalassemic and hemophilic patients require life-long blood transfusions, so it is necessary to obtain screened blood from a reputable source, because the multi-transfused population is more prone to blood-borne pathogens. Arif et al[56] reported that only 15.8% of parents of thalassemic children knew the importance of blood screening. Six different reports showed an HCV percent prevalence of 48.67% ± 1.75% among the thalassemic and hemophilic population[56-62].

Health care workers are at high risk of HCV infection because they are dealing with blood, blood-related products and instruments which may carry transmittable pathogens. Hamid et al[63] reported that recapping of syringes is the key factor for receiving needle stick injuries in health care workers and that transmission of HCV by needle stick injury ranges from 2% to 10%. Two different reports showed an HCV percent prevalence of 5.2% ± 0.63% in health care workers[64,65].

It has been reported from the US that up to 20% of new HCV infections are due to sexual activity[66]. Two different reports from the USA and Congo indicate low HCV prevalence among commercial sex workers[67,68]. The main problems in Pakistan are illiteracy, lack of awareness about sexually transmitted diseases and low use of condoms among the sex workers. Saleem et al[69] reported in 2005 that 17% of female sex workers, 3% of male sex workers and 4% of hijras (transgender men) consistently used condoms during the previous month; 67% of female sex workers were illiterate, 34% of female sex workers were suffering from sexually transmitted infections. Homosexual activities were very high among street children who are sexually victimized or indulge in such activities; later on they adopt commercial sex in order to raise their income. Condom usage among the male homosexual population was very low. Four different studies showed an interspousal percent prevalence of 17.24% ± 7.98%[70-73].

The reuse of syringes and needles was a major factor contributing towards increased HCV prevalence[74,75]. It was reported that there are several small groups involved in recycling and repacking of used unsterilized syringes, which were available in various drug stores. It was difficult for the public to differentiate between new sterilized syringes and recycled unsterilized syringes[76]. Janjua et al[77] reported that 68% of individuals received injections during the previous three months in Digri and Mirpur khas, two districts of Pakistan, out of which only 54% were from freshly opened syringes. The incidence of sharing of injection equipment for the last injection was 8.5% in Hyderabad and 33.6% in Sukkur[54].

In Pakistan, the number of estimated injections per person per year ranged from 8.2 to 13.6, which was the highest among developing countries, out of which 94.2% were unnecessary[51]. Household members who received four injections per year were 11.4% more prone to HCV infection than who did not receive injection[78]. Khan et al[74] reported that if both oral and injectable medicine were equally effective, 44% of the Pakistani population preferred injectable medicine.

In 2000, the WHO recommended that countries should implement strategies to change the behavior of health care workers and patients in order to decrease the over-use of injections, to ensure the practice of sterile syringes and needles, and to properly destroy sharp waste after use[79]. It was reported that 59% of syringes were dumped into the general waste and not properly disposed of in the healthcare waste. Scavengers seeking valuable things from the waste are at high risk of receiving needle stick injuries from contaminated needles[76].

People in developing countries are mostly anemic, and are more prone to traumatic injuries and obstetric complications. Blood transfusion in these situations is life-saving. If blood is not properly stored or is carrying blood-borne pathogens, then the situation becomes more complicated. According to the WHO office in Pakistan about 1.2 to 1.5 million transfusions are carried out annually in Pakistan[80]. In 2000, Luby et al[81] reported that 50% of blood banks in Karachi recruited paid donors, 25% of donations were from volunteer donors and only 23% of the blood banks screened for HCV while 29% of them were storing blood outside the WHO recommended temperature.

In developing countries, blood transfusion is still a problem due to lack of organized infrastructure, continuous supply of electricity, and properly trained and educated staff. In Pakistan the main source of blood donations are replacement donors and the majority of these are friends and relatives of the patient. These donors donate blood due to fear of death of a relative, chance of further complication of disease or under family pressure. These donors mostly hide their health conditions from their relatives. Selection of donor and their proper screening are key factors to ensure safe transfusion. Safe blood donors are those whose donations are repeatedly negative on screening[17]. Sixty-six percent of Pakistanis are residents of rural areas where there is less access to blood transfusion services. To provide proper transfusion facilities to underdeveloped areas requires economic growth. Efforts are required to eliminate the transfusions from paid donors, to improve the safety of the blood supply[81]. These conditions can be overcome by development of a fair and organized system of blood screening and transfusion.

In third world countries like Pakistan, most of the barbers are illiterate and unaware of transmission of infectious agents through the repeated use of razors and scissors for different customers without sterilizing them first[82]. Janjua and Nizamy reported that only 13% of the barber community knew that hepatitis is a liver disease and that it could be transmitted by contaminated razors; 11.4% of them were cleaning razors with antiseptic solution while 46% of them were re-using razors[83]. Recent reports suggested that only 42% knew about hepatitis, 90% did not wash hands, 80% were not changing aprons and 66% were not changing towels after each customer. Circumcision is a very important religious procedure performed during early infancy both in rural and urban areas, and the barber community performing this procedure are mostly unaware of transmission of hepatitis by contaminated instruments[84]. Bari et al[85] identified the risk factors involved in transmission of HCV and reported that 70% and 48% of HCV patients had histories of facial and armpit shaving from barbers respectively.

In the Pakistani population there was moderate knowledge about HCV infection whereas awareness about various HCV risk factors was very low[31,86,87]. In a survey conducted at a family medicine clinic in Karachi, most of the participants had some educational background and were living in Karachi city. It was reported that 61% of participants believed that HCV was a viral disease, 49% believed that it could be transferred by needles and injections, 5.3% believed that it could be transmitted by ear and nose piercing, and 20.6% knew that it can cause cancer[86]. Kuo et al[52] reported in 2006 that HCV awareness was only 19% in the IDU population of Lahore and Quetta. Zuberi et al[88] reported that knowledge about HCV infection was related to the educational background of the participants. Public awareness programs are required to decrease the future burden of HCV infection in the Pakistani population.