In this exclusive interview with Prof Olufunmilayo Lesi, Regional Medical Officer for Viral Hepatitis from the World Health Organization (WHO) Office for the Africa Region, discusses tackling viral hepatitis in Africa
Today, viral hepatitis has become a public health challenge of global proportion. While there are five distinct types of viral hepatitis (A, B, C, D, E), chronic hepatitis B and C cause 95% of hepatitis-related sickness and untimely deaths. Hepatitis D, however, is less common and occurs only in association with hepatitis B. The other viruses (namely hepatitis A & E) are spread via contaminated water and food and result in acute infections and outbreak in areas of inadequate waste disposal and poor sanitation. Having said this, acute infections are often short-lived and are resolved within the space of a few weeks.
In this exclusive interview with Prof Olufunmilayo Lesi, Regional Medical Officer for Viral Hepatitis from the World Health Organization (WHO) Office for the Africa Region, she speaks to us about the priorities for tackling viral hepatitis in Africa. Amongst the many insights given here, we learn how the epidemic of viral hepatitis B and C affects people globally compared to the global HIV epidemic. Also, we find out about the distinct types of viral hepatitis (A, B, C, D, E) and how the virus is picked up and which groups of people it affects the most. We also find out how it is treated.
How does the epidemic of viral hepatitis B and C affect people globally compared to the global HIV epidemic?
The epidemic of viral hepatitis B and C affects 328 million people globally and is nearly 10 times the magnitude of the global HIV epidemic. The epidemic caused by hepatitis B (257 million) mostly affects the WHO African Region and the Western Pacific Region. The epidemic caused by hepatitis C (71 million) affects all regions, with major differences between and within countries. The WHO Eastern Mediterranean Region and the European Region have the highest reported prevalence of hepatitis C (1).
Everyday liver, more than 3,600 people die of viral hepatitis-related liver disease, failure and liver cancer. Data from the 2017 WHO hepatitis report showed that the number of deaths from hepatitis B and C has increased by 22% from the baseline in 2000 (2). In contrast, the death rate from HIV has been rapidly declining due to universal and sustained access to care.
In response to the growing threat of viral hepatitis, the World Health Assembly endorsed the Global Hepatitis Strategy for the elimination of viral hepatitis as a public health threat by the year 2030 with two impact targets relating to incidence (decreased incidence of new infections by 90%) and deaths (reduction in mortality by 65%) (2). To accomplish these targets, modelling studies have identified five key interventions in prevention, testing and treatment that will reach these targets only if taken to scale.
Tell us about the distinct types of viral hepatitis (A, B, C, D, E)
Although there are mainly five distinct types of viral hepatitis (A, B, C, D, E), 96% of morbidity and mortality are due to chronic hepatitis B and hepatitis C infections. Hepatitis D occurs only in people who have hepatitis B, has a variable global distribution, but is less common in the Africa region.
Acute infection is associated with all types of viral hepatitis A-E, is often short-lived, may be associated with jaundice, low mortality rate and complete resolution within a few weeks. Hepatitis A and E are spread via contaminated food and water and cause disease outbreaks in areas of poor sanitation and inadequate waste disposal with a mortality rate as low as 0.8% in HAV and 3.5% in HEV (3). Ensuring high levels of sanitation and access to clean water are the most effective intervention for hepatitis A and E.
Progression to chronic infection and chronic liver disease is a defining feature of both hepatitis B and C infection. Most viral hepatitis deaths in 2015 were due to chronic liver disease (720,000 deaths due to cirrhosis) and primary liver cancer (470,000 deaths due to hepatocellular carcinoma). In Africa, liver cancer occurs at a younger age, causing catastrophic expenditures and impacting negatively the economic productivity. The disease is rapidly fatal and the opportunity for surgery and transplantation is limited.
How is the virus picked up and which groups of people does it affect the most?
The epidemic of chronic viral hepatitis in sub-Saharan Africa affects over 71 million people. There is a high rate of hepatitis B infection with a general population prevalence of 6.1% with over 60 million people estimated to be chronic carriers. Chronic hepatitis B infects approximately one in every 15 people (1:15), 4.8 million are children under the age of five years and over 2 million with HIV/Hepatitis B co-infections. The hepatitis C infection affects 10 million people with higher occurrence in older age and some key populations including PWID- Persons who inject drugs.
In Africa, hepatitis B is mostly acquired in the perinatal period (including mother to child transmission) and in childhood with 50% to 90% going on to develop a chronic infection with a high risk of liver cirrhosis or cancer over two to three decades. For these reasons, WHO recommends hepatitis B vaccination at birth (within 24 hours) and early childhood as a high impact intervention and an important pillar of the global hepatitis response. In contrast, hepatitis B infection acquired in adulthood leads to the development of chronic infection in less than 5% of adults.
Unsafe injection practices both in health facilities and in the community account for the majority of hepatitis C infection in Africa, with several investigators suggesting large-scale transmission in the 1990s due to unsafe injections and blood transfusion (4,5). Intravenous drug use is an emerging concern for hepatitis C transmission in Africa and is recognised as the most prominent route of hepatitis C transmission in Europe and the U.S. Although low rates of infection occur in the general population with one in 100 (1:100) people infected, most may ultimately need treatment.
The available evidence suggests that over 1.5 million infected Africans may develop progressive liver disease in the next few decades in the absence of large-scale testing and treatment programmes for both hepatitis B and C. This is unacceptable for a disease that can be prevented with childhood vaccination and hepatitis B birth dose and effectively managed with affordable and cost-effective suppressive hepatitis B or curative hepatitis C antiviral therapy.
Despite these compelling statistics, less than 5% of infected persons in Africa know their hepatitis status. This is a sharp contrast to the HIV response where over 80% of PLWHA are aware of their status. A recent study conducted by the World Hepatitis Alliance suggests that lack of awareness among the population and policymakers and even healthcare workers is a significant barrier to prevention and testing of viral hepatitis (6).
This low level of hepatitis awareness has significant implications for ongoing transmission, especially high mother to child transmission and household transmission in children and siblings and unsafe injection practices.
How is it treated?
Testing is the gateway to treatment. In most of the sub-Saharan countries, blood testing for viral hepatitis is not routinely provided except in blood banking services, specialist centres and in the private sector. In 2015, approximately 1.3 million people with hepatitis B infection and nearly 500,000 people with hepatitis C were detected in the blood transfusion services in Africa (7). In the absence of counselling and linkage to care, this represents a huge missed opportunity for intervention.
All persons with chronic hepatitis B or C require further assessments. In adults, anti-viral therapy with tenofovir is effective and rapidly causes viral suppression in chronic hepatitis B, thus, limiting disease progression. Treatment is recommended in all patients with HIV- hepatitis B co-infection and in people with hepatitis B mono infections who have evidence of liver disease or are at a higher risk of disease progression (3). Treatment is recommended for all hepatitis C infected persons with evidence of viremia. The development of curative antiviral therapy (DAA) has revolutionised treatment with cure rates exceeding 95% when treated for 12 weeks.
Identification of people with hepatitis (case finding) is a significant step in the global response and provides the opportunity for disease assessment and treatment to halt disease progression and maintain and improve the quality of life. People need to take steps to know their status and receive counselling for other co-risk factors, such as alcohol and cigarette consumption, aflatoxin ingestion and obesity that may accelerate the development of liver disease.
The priorities for tackling viral hepatitis in Africa
Although viral hepatitis has become a disease that can be eliminated, progress in scaling up the hepatitis response to prevent premature death from complications of liver cirrhosis or the development of liver cancer remains inadequate.
Implementing the global hepatitis response in Africa will require investments in hepatitis-specific activities and strengthening health systems, as well as ensuring the availability of adequate, sustained financial resources; affordable good quality diagnostics, medicines and Hep B birth dose vaccines; and trained human resources. Some of the challenges to scale up include poor political and community awareness and stigma, high cost of diagnostics and drugs and lack of surveillance data. Government leadership is critical to the establishment of a sustained public health response and has the potential to be cost-effective, reach millions of the infected populations and save lives.
The role of the community and patient groups cannot be understated. Civil-society interventions promoted by World Hepatitis Alliance has commenced a widespread testing campaign tagged “finding the missing million”. Their collaboration with civil-society groups in Africa has increasingly enhanced awareness and demand for hepatitis services. A strategy of decentralisation of care and integration of specific hepatitis activities into existing healthcare services or disease programmes such as HIV/TB appear feasible and can facilitate cross programmatic efficiencies and promote universal healthcare. Investment in healthcare financing, mobilisation of domestic financing and partnerships, community commitment are required to launch a successful and sustainable programme.
The development of affordable multi-platform laboratory tests, efficient supply chain and pooled procurements, implementation research into efficient service delivery models and other innovations may accelerate the response towards the vision of a “Region where hepatitis transmission is halted and everyone living with viral hepatitis has access to safe, affordable and effective care and treatment.”
References
1. Global Hepatitis Report, 2017.
2. Global Health Sector Strategy for viral hepatitis.
3. Guidelines for the prevention, care and treatment of persons with chronic hepatitis B infection, March 2015.
4. Progress report on HIV, viral hepatitis and sexually transmitted infections, 2019 Accountability for the global health sector strategies, 2016–2021.
5. Combating hepatitis b and C to reach elimination by 2030.
6. World Hepatitis Alliance.
7. Current status on blood safety and availability in the WHO African Region- report of the 2013 survey.
