Why Nigeria must find everyone who has hepatitis and doesn't know it
World Hepatitis Day—28 July—is an opportunity to raise awareness of hepatitis and encourage commitments of governments, policy makers and the public towards eradication of this dangerous disease.
The World Health Organization has chosen "hepatitis free future" as its theme this year and is focusing on prevention of hepatitis B among mothers and newborns. The World Hepatitis Alliance has chosen the theme "find the missing millions" – the millions of people who have hepatitis B but are not aware of it.
In Nigeria alone, there could be about 15 million people who are unaware that they are infected. The danger of this is that some of them could go on to develop liver disease, including cancer. They could also continue to infect others around them, especially family members and sexual partners. This is why it is important to screen family members and sexual contacts of anyone diagnosed with hepatitis B virus infection.
Hepatitis means inflammation of the liver and viral causes are the most common.
There are five types of hepatitis virus, named A, B, C, D and E. Hepatitis B (HBV) and C (HCV) are the most common cause of long-term liver damage, accounting for about 90% of deaths from viral hepatitis. Hepatitis D virus is not a complete virus and can only affect those who already had hepatitis B.
Hepatitis A & E viruses are transmitted by feco-oral routes. Feco-oral routes means pathogens in fecal particles pass from one person to the mouth of another person. This is usually as a result of poor hygiene and lack of adequate sanitation.
Hepatitis B, C, and D are transmitted through vertical transmission, child to child transmission, transfusion of unscreened blood, use of unsterilised equipment for surgical procedures, indiscriminate use of sharp objects such as local circumcision, tribal marking, ear piercing, tattoos, reuse of needles and syringes and unprotected sexual intercourse. Vertical transmission refers to passage of a pathogen from mother to baby immediately before and after birth. It might occur through direct contact during or after birth.
HBV and HCV are international public health problems, chronically infecting 292 million and 71 million people respectively worldwide. The two viruses cause about 1 million deaths annually. But the burden of hepatitis is not evenly spread. The sub-Saharan African and Western Pacific regions account for about 68% of all chronic hepatitis B infections. The reason for this discrepancy is the delay in the availability of vaccines and frequency of risky behaviors in these regions.
A recent study in Nigeria found the prevalence of hepatitis B and C in the country to be 8.1% and 1.1% of the population respectively. This means that about 19 million Nigerians have hepatitis B or C. We found in our research that about 11% of Nigerian patients with hepatitis B also had hepatitis D. The co-existence of hepatitis B and D is a greater threat to liver health than hepatitis B virus alone.
Unfortunately, most patients with hepatitis B and hepatitis C infections are asymptomatic and can remain so until the liver is significantly damaged. The World Health Organization has estimated that only about 10% and 19% of patients with chronic HBV and HCV are aware of their infections. Hepatitis B and C viruses could lead to liver cancer if not properly treated. The median survival of patients with hepatocellular carcinoma (liver cancer) in sub-Saharan Africa is less than three months.
The Society of Gastroenterology and Hepatology in Nigeria advocates in its HBV guideline that all unimmunised adults in Nigeria should be screened for hepatitis B infection, especially when they visit a hospital for whatever reason. This is to ensure that the millions of people with asymptomatic infection are diagnosed and treated, if need be.
It's not known whether all healthcare workers are following this advice.
Prevention and treatment
The World Health Organization aims to reduce new HBV infections by 90% and deaths by 65% by 2030. The United Nations also placed combating hepatitis as the third target of goal 3 of its sustainable development goals.
Though HBV has no cure, it is preventable through vaccination and avoidance of risky behaviors that promote its transmission. There is no effective vaccine that can prevent hepatitis C but it is curable with the available medications.
Prevention of mother to child transmission is the most important intervention to reduce the incidence of chronic hepatitis B. This is because, unlike adults who acquire the infection, 90%-95% of children who acquire the infection from their mothers will have persistent infection until adulthood. All pregnant mothers should be screened for HBV but screening and treatment are unaffordable for many of these women.
HBV vaccination has been incorporated into the routine immunization program for children in Nigeria since the late 1990s and it is free. Two things that stand in the way of prevention efforts in Nigeria are the cost of the investigations of HBV and HCV, which are not covered by the national health insurance scheme, and the knowledge of health workers.
In another study we conducted, only 44% of health workers were aware of the mother to child route of transmission of HBV.
Though hepatitis B has no cure, there are effective medications that reduce the possibility of liver damage and cancer. Because they are imported to Nigeria, though, these medications are not necessarily affordable or available. This reduces the compliance of patients on this drug.
As we mark the 2020 World Hepatitis Day, government and nongovernmental organizations should create greater awareness of screening. Those found positive should then be linked with treatment centers. There should be continuous education of all health workers on hepatitis routes of transmission and treatment.
In addition to measures which are free according to national policy, screening for HBV and HCV should be free. Large procurement of treatment drugs or encouragement of their local production should also be encouraged so that they are affordable and available. This will help to ensure a hepatitis free Nigeria.