Hepatitis B virus on surrealistic space background.Credit: Dr_Microbe/ iStock/Getty Images Plus
An inexpensive, safe, and effective birth-dose vaccine against Hepatitis B has the potential to prevent tens of thousands of deaths in Africa every year if it is administered within 24 to 48 hours of the child’s delivery.
Logistics are just one of many complex challenges that combine to make viral hepatitis a serious and growing health burden on the African continent. Because the disease goes mostly undetected until it is too late for treatment, it causes significant preventable loss of life.
In Uganda, for example, as many as 40% of babies are born outside hospitals and clinics, limiting immediate access for health workers, explains Rachel Beyagira, a hepatitis technical officer in the country’s Ministry of Health. So while the rollout of universal vaccination against Hepatitis B for all infants is critical, it is only one part of the picture, she says.
A ‘silent epidemic’
Experts in the field refer to hepatitis as a silent epidemic. World Health Organization (WHO) statistics say more than 90 million people have the disease in the WHO African Region (47 of the continent’s 54 countries) – an estimated 82 million with Hepatitis B, and a further 8 million with Hepatitis C. Roughly a million new Hepatitis B infections occur in Africa each year, accounting for seven of every 10 globally. And at least 125,000 Africans die of hepatitis every year.
Wendy Spearman, head of the Division of Hepatology in the University of Cape Town’s Department of Medicine, and co-director of the Viral Hepatitis in sub-Saharan Africa ECHO clinic, explains: “With malaria, for example, when you have it, you know you have it. The signs and symptoms are there, in your face. If you have an HIV-positive mother who doesn’t get treatment, and her child contracts HIV, you are going to run into problems with that young baby.”
For Hepatitis B, the illness can take as long as 20 to 30 years to manifest, despite mother-to-child transmission of the virus at birth. “So we have men in their 20s presenting with liver cancer that has spread throughout the liver, to their lungs and bones. By that time, everyone’s forgotten that the mother had Hepatitis B, and these young men will have an average of only two and half months to live.
“The impact isn’t really felt, because they don’t stay in our health systems for long periods. They come in and they die shortly afterwards, Spearman adds.”
Burden of disease under-reported
Spearman says that the burden of liver disease due to Hepatitis B-related liver cancer is severely under-reported, because accurate figures depend on a combination of cancer registries, and notification of Hepatitis B.
Registries are dependent on a histo-pathological diagnosis of liver cancer, yet liver biopsies are seldom performed on affected patients in sub-Saharan Africa, with most diagnoses now done only with liver imaging. Hepatitis B surface antigen testing can be done at a primary level clinic, but ultrasound and CT scans would usually be performed at a hospital. This will depend on access to imaging.
As Spearman explains, “Hepatitis B infection is diagnosed by testing for the surface antigen in the blood. Hepatitis B-related liver cancer is now mainly diagnosed radiologically with ultrasound and CT scan and a histological diagnosis with a liver biopsy is seldom required or performed.
Even when a patient is admitted to hospital, the cancer is not necessarily reported, because liver cancer registries still rely on histological confirmation of hepatocellular carcinoma, rather than on diagnostic radiological imaging. Until this changes, the data on liver cancer will not be accurate. Addressing the challenge, the specialists agree, starts with political commitment.
In Uganda, recognising the enormous potential of birth-dose Hepatitis B vaccines to eliminate the disease prompted the recommendation for universal rollout last month by the National Immunisation Technical Advisory Group.
Beyagira says it is the latest in a long list of developments that started in 2015 when Uganda began a huge, free Hepatitis B screening programme, which leveraged support from political leaders and civil society. This led to widespread community mobilization and other initiatives to raise awareness.
By 2019, more than four million people had been screened, and more than 30% of the population infected with Hepatitis B were aware of their status, and could access comprehensive treatment services, including free medication.
Integrated approach is vital
The birth-dose Hepatitis B vaccine has been implemented in 14 African countries, according to the WHO, achieving an overall coverage of 10%.
Beyagira also concedes that despite the impressive progress, the battle is far from won. While screening of pregnant women is on the rise, she says a continuous integrated approach is critical to realise the goal of elimination. “The lesson for all resource-limited countries is to work with programmes that are already established. Maternal-child health is a very good starting point, especially in respect of the need to reach the mothers who don’t deliver their babies in hospitals,” she says.
Pauline Bakibinga, associate research scientist at the African Population and Health Research Center in Kenya, concurs. She warns that as many as 90% of children across the continent are still not receiving the birth-dose vaccine. The reasons include erratic vaccine supplies, and outdated vaccination schedules. “We are missing an opportunity when clients seek treatment for malaria or HIV, for example, but aren’t also screened for other conditions, such as hepatitis. The integration of HIV and tuberculosis is a success story that should be harnessed for viral hepatitis too.”
Possible elimination
Spearman asserts that “we really need to realise that Hepatitis B can be eliminated, purely by ensuring full birth-dose vaccine coverage, identifying those who are infected, and linking them to appropriate care.” Identifying pregnant women with Hepatitis B has the extra benefit of acting as an introduction to further screening of high-risk partners, children and siblings, she adds.
It’s a simple action, Spearman says, that would make a world of difference to the Hepatitis B burden of disease by breaking cycles of infection. “If we are able to identify and treat people with viral hepatitis, they have a lower risk of hepatocellular carcinoma (HCC).” HCC is the most common form of liver cancer, with about 80% associated with chronic Hepatitis B or Hepatitis C virus infections.
In his opening address at the World Hepatitis Summit in June 2022, WHO Director-General Tedros Adhanom Ghebreyesus called hepatitis “one of the most devastating diseases on earth”. But he added that it is also one of the most preventable and treatable, with services that can be delivered easily and cheaply at primary healthcare level.
Most countries globally are not on track for elimination by 2030, Tedros pointed out. This is despite expanded coverage of infant vaccination for Hepatitis B, and the development of new direct-acting antivirals that have transformed Hepatitis C from a chronic disease with limited treatment options to one that is curable in a matter of weeks.
Tedros described scaling up Hepatitis B birth dose in routine immunisation schedules as “low-hanging fruit”, that could be a game-changer. “The reasons people miss out on services for hepatitis are the same as the reasons they miss out on other health services — accessibility and affordability, because of who they are, where they live, or how much they earn.”
Resilient healthcare systems needed
The Framework for an Integrated Multisectoral Response to TB, HIV, STIs and Hepatitis in the WHO African Region 2021-2030 highlights the need for the revitalisation of primary health care, along with increased public financing for health.
Spearman suggests that the need for resilient healthcare systems in Africa, able to address the range of priority health threats on the continent, is one of the most important issues highlighted by the COVID-19 pandemic.
Both Beyagira and Bakibinga confirm that the longstanding challenges around viral hepatitis in Africa have been exacerbated by the response demanded by the pandemic, which diverted human, infrastructure and financial resources away from other essential health services.
However, the response to COVID-19 has also delivered many lessons for the response to viral hepatitis. “Africa’s largest-ever vaccination drive against COVID-19 has shown us what’s achievable. It entrenched the public health imperatives of test, treat and identify contacts in the early phases,” Bakibinga says.
