Viral hepatitis remains a massive challenge in Africa where around 100 million people are estimated to have either hepatitis C or B infection, writes Richard Ofori-Asenso for The Conversation. The prevalence of hepatitis viruses in Africa is more than four times the 23 million infected across resource-rich nations.
And of the almost 1.4 million people who die from complications related to these infections each year, the majority are in resource constrained areas like Africa.
To tackle this problem, the World Health Organisation has set an ambitious target to eliminate viral hepatitis in Africa by 2030.
As part of the plan in the next five years the organisation aspires to reduce chronic hepatitis B and C infection by one third and reduce hepatitis associated deaths by 10% on the continent.
For countries in the region the next 14 years will be a race against time to action these commitments. But for Africa to be successful, countries need to overcome three main hurdles.
Firstly, they must develop stronger data systems to understand the burden of the diseases. Secondly, they must plan to prevent the spread of these infections. And thirdly, they need to roll out effective treatment programmes.
In our research which highlights Ghana’s high viral hepatitis burden, we found that countries can have challenges in all three areas. New and extraordinary measures are needed on the continent if the 2030 goal is to become a reality.
Data is one of the main challenges. Most countries in Africa do not have strong data systems to efficiently track temporal changes in disease burdens. As a result reliable national estimates are often lacking or outdated. What this means, for instance with viral hepatitis, is that the burden could be significantly higher than previously thought or reported.
Ghana is a case in point. According to Ghana’s Health Service, there 2.5 million people in the country who live with viral hepatitis.
But our research estimated the prevalence of chronic hepatitis B infection in Ghana to be 12.3%. This means that there could be as many as three million Ghanaians living with hepatitis B alone if recent population estimates are used.
The level of hepatitis B infection in the country is far higher than the global prevalence of 3.61% and the reported prevalence in the Africa region of of 8.83%.
Our analysis also showed that pregnant women and Ghanaians aged 16 to 39 face the highest levels of infection. And among HIV patients in Ghana, we estimated that almost one in seven people suffer from chronic hepatitis B infection while 3% of Ghana’s population also suffer from chronic hepatitis C infection.
Our hepatitis C prevalence figure is far higher than the previously reported estimate of 1.7%. Our preliminary assessments also indicate that around one in eight Ghanaians show evidence of past hepatitis E infection (unpublished data).
The socio-economic implications of a high viral hepatitis burden in Ghana while not thoroughly documented could be far reaching. Two of every three pregnant women in Ghana who develop sudden and severe hepatitis E infection are likely to die.
And research also suggests that chronic hepatitis B infection is implicated in over 40% of liver cirrhosis cases in Ghana. Additionally, one in 14 liver cirrhosis patients in in the country has being found to be chronically infected with hepatitis C.
The challenge is that cost of treating the complications such as liver cirrhosis and cancer that arise from chronic viral hepatitis could run into thousands of dollars. Many Ghanaians cannot afford such treatment and this could significantly deplete national health resources even if it were to be publicly funded.
The economic consequences due to loss of life and absenteeism from work could all come at a significant cost to a country still struggling to address its economic problems. These all support economic arguments for intensified prevention efforts to curb the spread of viral hepatitis in the country.
Lapses in control
Historically, efforts to control viral hepatitis in Ghana have been too slow and inconsistent. Several practises are hampering effective control of these infectious diseases.
A vaccine for hepatitis B has been available for more than three decades. It has been shown to be safe and 95% effective in preventing infection and chronic disease developing.
Administering the vaccine is an integral part of the Ghanaian government’s viral hepatitis policy, which was launched in 2015.
While children born after 2003 are routinely screened and vaccinated against hepatitis B as part of the Expanded Programme on Immunisation, no publicly funded population-wide vaccination is currently offered outside the programme. Even pregnant women and HIV patients among whom infection risks remain very high are excluded.
In addition, Hepatitis B immunoglobulin G and vaccines for babies born to mothers with hepatitis B has not been covered under the country’s National Health Insurance Scheme. As a result this has to be financed out-of-pocket.
Ghana’s blood policy also mandates that donated blood is screened for blood-borne infections. This focuses mainly on HIV 1 and 2, syphilis, hepatitis B and hepatitis C but neglects other important viral hepatitis such as hepatitis E. This is despite growing evidence that shows possible hepatitis E transmission through blood transfusion, especially in endemic regions like Africa.
In addition, hepatitis C screening for high risk groups such as injection drug users is not done. And comprehensive harm-reduction services including offering sterile injecting equipment is not standard.
The way forward
The major gaps in hepatitis prevention and care services need to be addressed to tackle these viruses.
But in addition, programmes that help people understand how these viruses are transmitted are a necessity. Many Ghanaians do not know how these diseases are transmitted and there are still a lot of misconceptions.
Both the government and public health institutions should engage in extensive efforts to address unhealthy population practices and low living standards that contribute to spread of these infectious diseases.
The World Health Organisation has set a good path. The Ghanaian government, health professionals and all non-state actors must now rally together and intensify efforts towards bringing the burden of viral hepatitis under control.
Richard Ofori-Asenso is a PhD student in the Department of Epidemiology and Preventive Medicine at Monash University.
Hepatitis B in Ghana: A systematic review and meta-analysis of prevalence studies (1995-2015).
RI Ofori-Asenso and AA Agyeman
Although, chronic hepatitis B (HBV) is considered to be of significant public health importance in Ghana, not many reviews detailing the burden (prevalence) of the disease have been conducted. This study was aimed at summarizing the available information and to make an accurate estimate of HBV infection prevalence in Ghana over the last two decades (1995-2015).
A systematic search was conducted in PubMed, ScienceDirect, Google Scholar and Africa Journals Online (AJOL) databases to retrieve primary studies published between 1st January 1995 and 4th October 2015, assessing the prevalence of HBV among populations in Ghana. This was supplemented by a manual search of retrieved references.
Thirty (30) studies across all the ten (10) regions of Ghana and involving an overall population size of 105,435 were analyzed. The national prevalence of HBV as determined by HBsAg seropositivity was 12.3%.
HBV prevalence among voluntary blood donors (VBDs), replacement blood donors (RBDs) and pregnant women were 10.8, 12.7 and 13.1% respectively. HBV infection prevalence was highest among studies published within the period 1995-2002 (17.3%), followed by those published within 2003-2009 (14.7%) and the lowest prevalence rate being recorded across studies published in the period 2010-2015 (10.2%).
Regional prevalence were determined for Ashanti, Greater Accra, Eastern, Northern, central and Brong-Ahafo regions as 13.1, 10.6, 13.6, 13.1, 11.5 and 13.7% respectively. No aggregate data were derived for Volta, Western, Upper East and Upper West regions. Higher prevalence of HBV infection was attained for rural (13.3%) compared to urban settings (12.2%). Across the country, highest HBV infection prevalence rates were recorded in persons within the age group 16-39 years.
Hepatitis B infection is clearly an important public health problem in Ghana. The burden of the disease as dictated by a high prevalence rate calls for urgent public health interventions and strategic policy directions to controlling the disease to avert any potential future explosion.
WHO HEPATITIS ANNOUNCEMENT
By 2030, the African Region wants to eliminate viral hepatitis as a major public health threat. With the launch of the document “Prevention, Care and Treatment of viral hepatitis in the African Region: Framework for action 2016–2020”, WHO provides guidance to Member States in the Region on how to implement the first-ever Global Health Sector Strategy on viral hepatitis, which was adopted last May at the World Health Assembly.
“Over the next five years, the African Region should have one third less chronic viral hepatitis B and C infections,” says Dr Matshidiso Moeti, WHO Regional Director for Africa. “In addition, we also want to bring down the number of viral hepatitis B and C related deaths by 10%,” Dr Moeti continues.
Viral hepatitis is an infection of the liver caused by five distinct hepatitis viruses (A, B, C, D, and E) and is a highly widespread public health problem in the African Region. All five hepatitis viruses can cause severe disease, but the highest numbers of deaths result from liver cancer and cirrhosis –a condition in which there is irreversible scarring of the liver following chronic infection with hepatitis B and C.
Around the world 400 million people are infected with hepatitis B and C, more than 10 times the number of people living with HIV. Viral hepatitis was the seventh highest cause of mortality in the world in 2013, with an estimated 1.4 million deaths per year – up from less than a million in 1990. Today, only 1 in 20 people with viral hepatitis know they have it, and just 1 in 100 with the disease is being treated.
In the African Region, hepatitis B is highly endemic and affects an estimated 100 million people, mainly in West and Central Africa, while an estimated 19 million adults are chronically infected with hepatitis C. An effective vaccine is available for preventing viral hepatitis B.
New oral, well tolerated medicines for people with chronic hepatitis C virus infection can achieve cure rates of over 90%. Effective treatment is also available for people with chronic hepatitis B infection, although for most people such treatment needs to be lifelong.
Viral hepatitis is also becoming more and more a growing cause of mortality among people living with HIV. About 2.3 million people living with HIV are co-infected with the hepatitis C virus, and another 2.6 million are co-infected with the hepatitis B virus.
With the newly adopted framework at the WHO Regional Committee for Africa, the Region aims at stopping viral hepatitis transmission, strengthening public awareness and prevention as well as ensuring that everyone living with viral hepatitis has access to safe, affordable and effective care and treatment services.The Conversation article Hepatitis B in Ghana journal article World Health Organisation press release, 21 August 2016