CANCER

Cancer is major public health problem for Pakistan where annually about 148,000 new cancer cases are diagnosed and almost 100,000 die due to cancer. The most common cancers in Pakistan are oral, lung, liver, breast, cervical and blood/bone-marrow cancer.

The major risk factors for cancer include smoking, physical inactivity, unhealthy diet, infections (hepatitis B/C, Human Papilloma virus) and exposure to toxins. All these can be prevented by adopting health life style and appropriate vaccinations. Therefore there is a need to educate the people especially the younger age group about risk factors of cancer and their preventive measures.

Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. Not all tumors are cancerous; benign tumors do not spread to other parts of the body.

Dog Bite Rabies

Rabies is endemic in Pakistan, with human infections being mostly due to the dog bite and cases are mostly diagnosed on clinical grounds only. Although no data on human rabies cases is available at the national level but it was estimated that 2,000 to 5,000 people die of rabies every year. Human rabies is not a notifiable disease in Pakistan and there is also no nationally coordinated response to the diseases and its surveillance.

In the past, globally all stress was being given on the management of dog bite and rabies with introduction newer and cost-effective vaccines. Despite all this, the overall treatment cost of dog bite cases is high and beyond the reach of many countries. However, now there has been a shift in the rabies elimination and now there is more focus on dog vaccination (both Pet and stray dogs). It is estimated that this cost is many folds less than the treatment of dog bite cases.  Dr Huma Qureshi, ED. PHRC has been nominated as National Focal person for Zoonosis and she is working on Rabies prevention and control in Pakistan.

World Rabies Day:

The World Rabies Day is celebrated in the world on 28th of September 2016. The Global Alliance for Rabies Control this year proposed the theme "Educate, vaccinate, eliminate". PHRC being the focal point for zoonosis in Pakistan is celebrating 28th September as "World Rabies Day".  Information brochure on rabies (preventive measures and what to do in case of dog bite) has been developed and these will be disseminated to general public in Public parks of Islamabad (Daman-e-Koh, Fatima Jinnah Park F9, Shakar Parian and Lake View Park).

Hepatitis

Pakistan has 12 million cases of hepatitis B and C (HBV/HCV) and is therefore highest country in the world to have such a high disease occurrence. Viral hepatitis B and C cause chronic liver disease and its complications and death and is a major concern for Pakistan.

Federal government recognized the importance of disease prevention and took steps towards disease prevention and strategizing its control. Following steps are being undertaken along with some achievements.

1. SOVALDI, the new oral drug for hepatitis C treatment has been registered in Pakistan on fast track and through special negotiations; its cost has been reduced by 99% as compared to that in USA. The drug is being given on special prescription to date but shall be available freely in a week.
2. Birth dose of hepatitis B vaccine has been sorted by making the Provincial program and the Federal EPI sit together and share the resources. The Provincial programs shall procure the vaccine and hand it over to Provincial EPI which shall store it in their cold rooms and give to new born children at health facility through their own EPI worker who also gives BCG and polio on day of delivery. There is no added cost and compliance report shall be sent to hepatitis program.
3. Infection control. Reuse of injections and improper sterilization of medical devices in health care is the major reason for hepatitis spread in Pakistan. These issues come under infection control, therefore WHO in collaboration with Pakistan Health Research Council (PHRC) has developed infection control guidelines, posters, small pocket book in Urdu for each health care provider and also supplied heavy duty WHO approved needle cutters and sharp containers to all BHUs, RHCs, DHQ and THQ of 25 high hepatitis districts of Pakistan. Materials have been sent, trainings done and now monitoring is being done.
4. Hepatitis B and C survey was supported by the federal ministry of health in 2006 to see the exact situation of the disease. The figures of this survey are used on the world maps by WHO, CDC and all partners while referring to hepatitis situation in the world. The survey is widely referred by researchers.
5. Technical Advisory Group (TAG) on hepatitis has been gazette notified by the federal government. It has experts from all Provinces and from WHO and CDC. This group of hepatitis experts’ advice the Federal and Provincial governments on issues related to hepatitis using scientific authentic references and not wishes.

Future strategies

1. Develop viral hepatitis strategy. TAG requested WHO and CDC USA to assist Pakistan in developing viral hepatitis strategy. Both partners agreed and the strategy is being developed in consultation with Provincial hepatitis experts and program.
2. Create awareness about disease. The disease can be tackled once behaviors are changed. Very aggressive media campaigns are being planned to create awareness about risk factors of disease and how to prevent them.
3. Hepatitis C treatment guidelines. Guidelines are being developed through technical support of WHO and CDC to ease diagnosis and treatment of disease.
4. Working together. All related programs like National blood transfusion authority, HIV AIDS, EPI, MNCH etc are being taken on board so that each program handles its component on hepatitis and reports back to program. This will reduce duplication.
5. Creation of Provincial infection control program. Provinces are being sensitized to have infection control program which shall cater for needs of all programs. All hospitals should have active infection control committees with regular monthly meetings with the hospital administration to check compliance to infection control by hospital staff. A cadre of infection control nurse needs to be created to make this functional.

co-amplified renal cell carcinoma: a distinct entity with potential implications for clinical management

A subset of renal cell carcinomas shows TFEB overexpression secondary to MALAT1-TFEB gene fusion. As alternate mechanisms of TFEB overexpression are likely to have the same effect, we sought to determine the frequency of amplification of TFEB and the adjacent VEGFA gene at 6p21.1. As patients with metastatic renal cell carcinomas are managed with anti-VEGF therapies, we retrospectively assessed therapeutic response in patients with amplified tumors. Amplification status was analyzed for 875 renal cell carcinomas from our institution, a consultative case and 794 cases from The Cancer Genome Atlas. Cases were classified as having low level (5–10 copies), and high-level amplification (>10 copies), and were further analyzed for adjacent oncogene copy number status (n=6; 3 single-nucleotide polymorphism genomic microarray, 3 The Cancer Genome Atlas) and structural rearrangements (n=1; mate-pair sequencing). These were then reviewed for histopathology, immunophenotype, and response to VEGF-targeted therapy on follow-up. In all, 10/875 (1.1%) institutional cases, 1 consultative case, and 3/794 (0.4%) of The Cancer Genome Atlas cases showed TFEB high-level amplification, while 14/875 (1.6%) cases showed TFEB low-level amplification. All cases had associated VEGFA amplification. This was confirmed with evaluation for copy number changes (n=6). The 6p21.1 high and low-level amplified tumors occurred in adults (mean age: 66), with over half being ≥pT3 (13/25, 52%), and most showed oncocytic, tubulopapillary features and high grade (≥grade 3: 20/22, 91%). These were aggressive tumors with metastasis and death from renal cell carcinoma in 11 (of 24, 46%) cases. Four patients received targeted therapy and had a mean survival of 31 months (range: 17–50) post nephrectomy. In summary, a group of aggressive renal cell carcinomas show genomic amplification of the 6p21.1 region including TFEB and VEGFA genes and share morphologic features. Additional studies are warranted to determine whether these patients respond to anti-VEGF therapy.