By Doris Obinna
In 2021, the United Nations estimated Nigeria’s population to be 211.4 million. Applying the 9.5 per cent prevalence to this figure translates into 20.083 million Nigerians having Hepatitis B Viral (HBV).
Somehow, these millions are missing in the public health space. This is not only in Nigeria but also in the global public health agenda.
The World Health Organization (WHO) disclosed that every year more than 125,000 people in Africa are dying from complications of viral hepatitis B and C-related liver disease, including cirrhosis and liver cancer.
Sixty million people in the WHO Africa region were living with chronic hepatitis B infection in 2015. More than 4.8 million of them are children under five years old. A further 10 million are infected with hepatitis C, most likely due to unsafe injection practices within health facilities or by communities.
Every July 28, the globe marks the World Hepatitis Day to raise awareness of this “silent killer.” This year’s theme was “Bringing Hepatitis Care Closer to You.” WHO in the African Region launched the 2021 scorecard for hepatitis, with blood tests revealing high prevalence of hepatitis B in more than eight per cent of the total populations of 19 countries.
WHO said: “For hepatitis C, prevalence in 18 countries is more than one per cent. Transmission of hepatitis B from mother to child also remains high, with prevalence of 2.5 per cent among children younger than five in the region.”
Dr. Olusegun Ogboye, Permanent Secretary, Ministry of Health, Lagos State, said: “The state government is determined to bring this scourge of hepatitis to an end by providing free hepatitis awareness, screening and vaccination programme which aligns with the theme goal targeted at improving the prevention, control and management of diseases while reducing the incidence and impact of public health emergencies.
“This year’s theme connotes that hepatitis is a killer disease that waits for no one. It is a reminder of the urgency to end hepatitis by bringing hepatitis care closer to citizens through awareness, prevention, diagnosis and treatment.
“It is a charge to commitment to eliminate viral hepatitis as a public health menace by reducing its incidence and mortality rates by 95 per cent and 65 per cent respectively by 2030 which is achievable.”
WHO Regional Director for Africa, Dr. Matshidiso Moeti, stated: “More than 90 million people are living with hepatitis in Africa, accounting for 26 per cent of the global total. But because the disease goes mostly undetected due to an absence of symptoms until it is too late for treatment, preventable loss of life is the tragic result.
“For this, WHO in the African Region launched the 2021 scorecard for hepatitis with blood tests and only 14 African region countries have managed to reduce that number to the one per cent milestone, which has been achieved by all other WHO Regions.
“The 2021 global hepatitis report reminded us that only two per cent of people living with hepatitis B in Africa know their status and that less than one per cent are receiving treatment. For hepatitis C, only five per cent of patients know their status, with an alarming 0 per cent treatment rate.
“In addition, only six per cent of babies have received the hepatitis B birth-dose vaccine that prevents transmission of the virus from their mothers. This is a travesty considering the capacity of this available vaccine to save hundreds of thousands of lives. The main barriers include that hepatitis services are centralized in cities and major urban areas, being delivered primarily by specialists, along with the high cost of diagnosis and medicines, and an inadequate laboratory platform.”
HBV-HIV infection
Moeti continued: “About one per cent of persons living with HBV infection (2.7 million people) are also infected with HIV. Conversely, the global prevalence of HBV infection in HIV-infected persons is 7.4 per cent. Since 2015, WHO has recommended treatment for everyone diagnosed with HIV infection, regardless of the stage of disease.
“Tenofovir, which is included in the treatment most commonly spread from mother to child at birth (perinatal transmission) or through horizontal transmission (exposure to infected blood), especially from an infected child to an uninfected child during the first five years of life according to WHO. The development of chronic infection is common in infants infected from their mothers or before the age of five years.
“Hepatitis B is also spread by needle stick injury, tattooing, piercing and exposure to infected blood and body fluids, such as saliva and menstrual, vaginal and seminal fluids. Transmission of the virus may also occur through the reuse of contaminated needles and syringes or sharp objects either in health care settings, in the community or among persons who inject drugs. Sexual transmission is more prevalent in unvaccinated persons with multiple sexual partners.
“Hepatitis B infection acquired in adulthood leads to chronic hepatitis in less than five per cent of cases, whereas infection in infancy and early childhood leads to chronic hepatitis in about 95 per cent of cases. This is the basis for strengthening and prioritising infant and childhood vaccination.
“The hepatitis B virus can survive outside the body for at least seven days. During this time, the virus can still cause infection if it enters the body of a person who is not protected by the vaccine.
“The incubation period of the hepatitis B virus ranges from 30 to 180 days. The virus may be detected within 30 to 60 days after infection and can persist and develop into chronic hepatitis B, especially when transmitted in infancy or childhood.”
Symptoms
WHO report shows that most people do not experience any symptoms when newly infected. However, some people have acute illness with symptoms that last several weeks, including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.
The report added: “People with acute hepatitis can develop acute liver failure, which can lead to death. Among the long-term complications of HBV infections, a subset of persons develops advanced liver diseases such as cirrhosis and hepatocellular carcinoma, which cause high morbidity and mortality.
Diagnosis
“It is not possible on clinical grounds to differentiate hepatitis B from hepatitis caused by other viral agents; hence laboratory confirmation of the diagnosis is essential. Several blood tests are available to diagnose and monitor people with hepatitis B. They can be used to distinguish acute and chronic infections.
“WHO recommends all blood donations be tested for hepatitis B to ensure blood safety and avoid accidental transmission. As of 2019, 30.4 million people (10.5 per cent of all people estimated to be living with hepatitis B) were aware of their infection, while 6.6 million (22 per cent) of the people diagnosed were on treatment.
According to latest WHO estimates, “The proportion of children under five years of age chronically infected with HBV dropped to just under one per cent in 2019 down from around five per cent in the pre-vaccine era ranging from the 1980s to early 2000.
Treatment and
management
“There is no specific treatment for acute hepatitis B. Therefore, care is aimed at maintaining comfort and adequate nutritional balance, including replacement of fluids lost from vomiting and diarrhoea. Most important is the avoidance of unnecessary medications. Acetaminophen, paracetamol and medication against vomiting should be avoided.
“Chronic hepatitis B infection can be treated with medicines, including oral antiviral agents. Treatment can slow the progression of cirrhosis, reduce incidence of liver cancer and improve long-term survival. In 2021, WHO estimated that 12 per cent to 25 per cent of people with chronic hepatitis B infection will require treatment, depending on setting and eligibility criteria.
“WHO recommends the use of oral treatments (tenofovir or entecavir) as the most potent drugs to suppress hepatitis B virus. Most people who start hepatitis B treatment must continue it for life. In low-income settings, most people with liver cancer die within months of diagnosis.
“In high-income countries, patient present to hospital earlier in the course of the disease, and have access to surgery and chemotherapy which can prolong life for several months to a few years. Liver transplantation is sometimes used in people with cirrhosis or liver cancer in high-income countries with varying success.”
Prevention
WHO recommends that all infants receive the hepatitis B vaccine as soon as possible after birth, preferably within 24 hours, followed by 2 or 3 doses of hepatitis B vaccine at least four weeks apart to complete the vaccination series. Protection lasts at least 20 years and is probably lifelong. WHO does not recommend booster vaccinations for persons who have completed the 3-dose vaccination schedule.
In addition to infant vaccination, WHO recommends the use of antiviral prophylaxis for the prevention of hepatitis B transmission from mother-to-child. Implementation of blood safety strategies and safer sex practices, including minimizing the number of partners and using barrier protective measures (condoms), also protect against transmission.