Reducing hepatitis-related deaths
Today is World Hepatitis Day. It is a day set aside to address a disease that was recently confirmed by The Lancet journal to be ten times more deadly than malaria, Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) and Tuberculosis (TB). New estimates show that over 23 million Nigerians are living with the disease and five million die yearly from hepatitis-related complications such as liver cancer. Yet, today only one in 20 people with viral hepatitis know they have it. And just one in 100 with the disease is being treated. CHUKWUMA MUANYA (Assistant Editor) writes on efforts aimed to reduce the increasing hepatitis-related deaths.
Christy Bassey was treated for malaria and typhoid after laboratory tests. But one week after she was still feeling very tired. Christy noticed that her urine had turned straw yellow. Her eyes were not left out. Christy was rushed back to the hospital with chronic fatigue. Further tests showed that she had liver cancer. 32 year-old Christy died months later.
29 year-old Obinna Okwute was battling with feverish conditions, headaches and bodily pains for sometime. “I have taken the best of malaria drugs and I am not feeling better,” he told a friend. Obinna died two months later of liver damage caused by hepatitis infection. Christy and Obinna are some of the estimated 23 million Nigerians infected with hepatitis and part of the five million that die annually.
According to the World Health Organisation (WHO), viral hepatitis exists in five forms – A, B, C, D and E. It is transmitted via bodily fluids, or, in the case of A and E, through food or drink contaminated with faeces.
The WHO said hepatitis B and C infections are transmitted through contaminated blood as well as through contaminated needles and syringes in healthcare setting and among people who inject drugs. The viruses can also be transmitted through unsafe sex and from an infected mother to her newborn child.The symptoms include fatigue, jaundice and nausea but in many people the infection is symptom-less – and so an individual may not know they are infected until they develop serious complications.
The WHO in a statement ahead of the World Hepatitis Day (WHD), July 28, said: “Around the world 400 million people are infected with hepatitis B and C, more than 10 times the number of people living with HIV/AIDS. An estimated 1.45 million people died of the disease in 2013 – up from less than a million in 1990.”
The theme of WHD 2016 is “Know hepatitis. Act now.”According to the WHO, the WHD 2016 is an opportunity to step up national and international efforts on hepatitis and urge partners and Member States to support the rollout of the first Global Health Sector Strategy on viral hepatitis for 2016 to 2021, which was approved during the Sixty-ninth World Health Assembly in May 2016.
The new strategy introduces the first-ever global targets for viral hepatitis. These include a 30 per cent reduction in new cases of hepatitis B and C, and a 10 per cent reduction in mortality by 2020.
Key approaches will be to expand vaccination programmes for hepatitis B; focus on preventing mother-to-child transmission of hepatitis B; improve injection, blood and surgical safety; “harm reduction” services for people who inject drugs; and increase access to diagnosis and treatment for hepatitis B and C.
The WHO, however, urged countries to take rapid action to improve knowledge about the disease, and to increase access to testing and treatment services. Today, only one in 20 people with viral hepatitis know they have it. And just one in 100 with the disease is being treated.
WHO Director-General, Dr. Margaret Chan, said: “The world has ignored hepatitis at its peril. It is time to mobilize a global response to hepatitis on the scale similar to that generated to fight other communicable diseases like HIV/AIDS and tuberculosis.”
President, Society for Gastroenterology and Hematology in Nigeria (SOGHIN), Prof. Musa Borodo, said liver diseases is responsible for more than half of the major chronic diseases of the Gastro Intestinal Tract (GIT) and they post a lot of devastation and death on the people. Borodo said some of the emergencies conditions and cancers are related to the neglect of liver diseases especially hepatitis B and hepatitis C.
Borodo explained: “Studies done in Nigeria indicate an average prevalence of 11 per cent to 14 per cent for hepatitis B infection suggesting that about 17 to 22 million Nigerians may be affected by hepatitis B virus alone. The implication is that at least one of every 10 Nigerian is chronically infected by hepatitis B and not only at risk of liver diseases and death but also at risk of transmitting it to others. About five million die annually due to the consequences of this disease.
“Hepatitis is a disease of the liver resulting in injury to the liver. It is caused by many factors including germs notably viruses, alcohol, drugs. Hepatitis may start and get better quickly (acute hepatitis) or it may become a long lasting condition (chronic hepatitis). In some cases, chronic hepatitis may lead to liver damage, liver failure, or even liver cancer.
Hepatitis is described as a ‘silent epidemic’ because most persons do not realize that they are infected and, over decades, slowly progress to damage the liver resulting in such diseases as liver cirrhosis, liver failure, liver cancer and even death. Viral hepatitis has cut down many Nigerians in their prime and recent studies have shown that it kills as many people as HIV/AIDS. The virus is indeed a silent killer.”
A recurring question about viral hepatitis is why it receives so little funding and attention from global health policy makers and donors. For example, the Sustainable Development Goals (SDGs) have a goal to “end the epidemics of” HIV, tuberculosis, and malaria by 2030 while only “combating” hepatitis, despite the fact that hepatitis accounts for more deaths than each of those infections individually.
One reason for this is the difficulty in accurately quantifying and explaining the morbidity and mortality related to viral hepatitis. This difficulty stems from the fact that hepatitis deaths are caused by five distinct viruses (hepatitis A–E) with different routes of transmission, that death occurs decades after infection, and that when people die with hepatitis-related liver cancer and cirrhosis, these deaths are not always linked to the underlying infection.
Prof. Jeffrey Stanaway and colleagues in a study published in journal The Lancet have made a major advance in addressing these challenges. Using the Global Burden of Disease (GBD) Study approach, which estimates the causes of mortality and morbidity and their relative importance, they have assessed the burden of disease caused by viral hepatitis from 1990 to 2013 at the country, regional, and global levels.
The main conclusion from their analysis is that viral hepatitis accounted for 1.45 million deaths (95 per cent uncertainty interval [UI] 1.38 to 1.54) in 2013, a 63 per cent (95 per cent UI 52 to 75) increase compared with the 0.89 million deaths (0.86 to 0.94) in 1990. Morbidity also increased in terms of years lived with disability (from 0.65 million [0.45 to 0.89] to 0.87 million [0.61 to 1.18]) and disability-adjusted life-years (DALYs; from 31.7 million [30.2 to 33.3] to 42.5 million [39.9 to 45.6]).
The biggest increase was noted for hepatitis C infection, for which the rate of DALYs increased by 43 per cent. Most of the morbidity and mortality is caused by hepatitis B and C infections (96 per cent [95 per cent UI 94 to 97] of mortality and 91 per cent [88 to 93] of DALYs in 2013), because these two viruses cause chronic, life-long infections, resulting in progressive liver damage that leads to cirrhosis and hepatocellular carcinoma. Finally, the burden of disease was not equally distributed worldwide.
The study found high mortality rates in Oceania, Africa and Asia.Hepatitis-related mortality was highest (≥33.50 deaths per 100 000 population per year) in Oceania, western sub-Saharan Africa, and central Asia. However, in absolute numbers, East Asia and south Asia have the greatest number of hepatitis deaths (52 per cent of the total number of deaths). Unlike HIV, which primarily occurs in low-income countries (mostly in Africa), 58 per cent of hepatitis deaths occurred in upper-middle-income countries and high-income countries.
The Lancet study is an extension of an earlier global analysis of the GBD Study that for the first time combined deaths due to acute and chronic infection to provide an improved estimation of the true burden of viral hepatitis. Both Stanaway and colleagues’ study and the earlier analysis used complex statistical methods that rely on several assumptions and on estimations of the incidence and prevalence of hepatitis infection, as well as the number of deaths recorded by death certification. Unfortunately, these measures are particularly weak for hepatitis, with widely varying estimates for the number of people living with hepatitis infection and documented under-reporting of deaths due to hepatitis-related cirrhosis and liver cancer.
Stanaway and colleagues’ study has several important implications. It provides convincing evidence that viral hepatitis is a major contributor to the global disease burden and shows that this disease requires a stronger national and international response. Such an effective response needs to combine interventions that prevent new infections (for example, immunization, safe health care, and harm reduction) and scaling up of testing and treatment to reduce mortality among the estimated 400 million people with chronic hepatitis B and C infection.
Addressing the global burden of hepatitis infection will require substantial additional resources. Since most of the hepatitis burden is in high-income countries and upper-middle-income countries that do not receive development assistance, in many countries, these resources will probably need to come from national health budgets. For low-income countries and lower-middle-income countries, it is hoped that the improved understanding of the high burden of hepatitis will lead to an increase in international development assistance.
There are indications that the momentum is building to better address viral hepatitis. Several countries – such as Egypt, Georgia, and Mongolia – have adopted elimination goals, and in May 2016, WHO adopted the first-ever global hepatitis strategy with a goal to eliminate viral hepatitis as a public health threat by 2030, defined as a reduction in incidence by 90 per cent and mortality by 65 per cent. Global estimates documenting the high level of hepatitis-related mortality were key in advocating for the global strategy and are now further supported by Stanaway and colleagues’ findings. Improved national estimates are now needed to monitor the success of this strategy.
Meanwhile, Borodo urged the public to recognize the features of the diseases early enough. He also stressed on the need of going to hospital regularly for check up. He encouraged that children should be immunized and pregnant mothers to bring themselves for screening to prevent them from passing the diseases to their children. “Above all for the general population, those already infected, should go and get treated and avail themselves of screening at least once a year,” Borodo said.
The SOGHIN President appealed to the government to provide adequate gadget for diagnosis and make drug available at cheaper rate, so that the population infected can get treated. “If you get treated well, you will not get to the situation that you will die,” he said. Borodo added: “We work with the government to fashion out a strategic policy to treating hepatitis B. We are very grateful this happened. When the WHO declared emergency on hepatitis B, Nigeria signed to that declaration. The Federal Ministry of Health (FMoH) collaborated with SOGHIN to fashion out the policy.”
In May 2016, at the World Health Assembly, 194 governments adopted the first-ever Global Health Sector Strategy on viral hepatitis and agreed to the first-ever global targets. The strategy includes a target to treat eight million people for hepatitis B or C by 2020. The longer-term aim is to reduce new viral hepatitis infections by 90 per cent and to reduce the number of deaths due to viral hepatitis by 65 per cent by 2030 from 2016 figures.
The strategy is ambitious, but the tools to achieve the targets are already in hand. An effective vaccine and treatment for hepatitis B exists. There is no vaccine for hepatitis C but there has been dramatic progress on treatment for the disease in the past few years. The introduction of oral medicines, called direct-acting antivirals, has made it possible to potentially cure more than 90 per cent of patients within two to three months. But in many countries, current policies, regulations and medicine prices put the cure out of most people’s reach.
WHO’s Director of the HIV/AIDS Department and Global Hepatitis Programme, Dr. Gottfried Hirnschall, said: “We need to act now to stop people from dying needlessly from hepatitis. This requires a rapid acceleration of access to services and medicines for all people in need.”
Meanwhile, following the adoption of the National Strategic Plan on Viral Hepatitis in Nigeria in July 2015, Nigeria is poised to adopt and implement the guidelines for the management and care of people with viral hepatitis thereby keying into the global strategy for viral hepatitis elimination.
To help achieve the global goal of elimination, WHO has requested member nations are to increase awareness, increase diagnosis and key intervention strategies including universal vaccination especially in hyper-endemic regions, blood and injection safety, harm reduction for injection drug users and early diagnosis and treatment. According to WHO, every activity that addresses viral hepatitis is a positive step towards hepatitis elimination A global elimination movement will be launched to bring people together and provide a platform for people to speak up and speak out. It is hoped that with full implementation of the global goal of elimination, the five million Nigerians that lose their lives yearly including Christy and Obinna would be saved.