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2020 WORLD HEPATITIS DAY: Finding the missing millions and planning for a Hepatitis-free future

By Dr Paul Johnt
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The main aim of July 28, World Hepatitis Day, is to sensitize and encourage people on how to prevent, diagnose, and treat viral hepatitis infections.

It pains me when patients who received blood transfusion in the past later come down with hepatitis B or C infection and the cause is traceable to no other source except the past blood transfusion.

In view of this, our hospitals should upgrade to the use of Polymerase Chain Reaction (PCR) in screening blood samples ( especially those units of blood from donors with questionable lifestyles) .This is because the current tests used in detecting the viral infections in many hospitals in developing countries are targeted at detecting the antigen or antibody to the infecting viral particles in the serum hence it takes some time ( the incubation period etc ) before the current tests in many developing countries can detect the antigen/antibody in a newly infected individual .PCR can detect the infection at each stage of the disease .

We cannot forget in a hurry the 2006 incident at Lagos University Teaching Hospital (LUTH) where baby Oyinkansola Eniola was transfused with a HIV positive blood in a tertiary hospital where the highest form of medical treatment was expected in line with international best practices . It is crime and unethical to transfuse a unit of blood without first screening it for HIV 1 & 2, Hepatitis B and C and VDRL among other preliminary tests.

The question in that case in LUTH is ,was the blood screened before the ill-fated transfusion? Believe you me ,the answer will be in the affirmative ,then why didn't the screening pick up the HIV in the donor's blood? The Window period of HIV infection cannot easily be ruled out at the time of screening that blood hence screening with PCR remains the only trusted test at all stages of the infection .If that was possible with HIV ,it is still possible with some of the viral hepatitis, especially hepatitis B and C .

THEME FOR 2020 CELEBRATION : There are two themes for this year’s World Hepatitis day.

The theme recognized by World Health Organization is Hepatitis-free future while World Hepatitis Alliance believes that the theme for this year’s celebration is Finding the missing millions

BRIEF HISTORY
Initially, the World Hepatitis Day was celebrated on May 19th of each year but in 2010 the World Health Assembly changed the date to July 28th in honour of the birthday of the noble laureate Professor Baruch Samuel Blumberg, who discovered Hepatitis B.

INTRODUCTION:
More than 23 million Nigerians are infected with Hepatitis B, making Nigeria one of the countries with the highest Hepatitis infection in the world since more than 500 million people in the world are living with either Hepatitis B or C while about 325 million people are living with both B and C globally . It is pathetic that many people worry more about contracting AIDS and Corona virus than Viral Hepatitis, even when in reality in each year about 1.4 million people worldwide die due to these viral hepatitis infections and more become infected. Hepatitis B contributes about 900,000 out of the 1.4 million deaths annually .

At times ,infected people die faster with viral hepatitis than they would with AIDS. Remember that globally, HIV-AIDS currently kills about 1.6 million people yearly. And more unfortunate is the fact that just only Hepatitis B virus is about 50 to 100 times more infectious than HIV. Despite this mind-boggling data, viral hepatitis has attracted very little attention from both the governments and the people.

WHO believes that the number of deaths due to HIV/AIDS has really changed and expanded access to antiretroviral therapy (ART) and a declining incidence of HIV infections have led to a steep fall globally in the number of adults and children dying from HIV-related causes. The estimated 770 000 [570 000−1 100 000] people dying from HIV globally in 2018 were 56% fewer than in 2004 (the peak) and 33% fewer than in 2010 in spite of a period of substantial population growth in many high burden countries.

Nevertheless, there is no room for complacency. Countries need to live up to their commitment to end the AIDS epidemic as a public health threat by 2030 -- a target included in the 2030 Agenda for Sustainable Development adopted by the United Nations General Assembly in September 2015. The immediate challenge is to reach the Fast-Track targets for 2020, as HIV-related deaths are still unacceptably high.

The 2020 targets include reducing the number of people dying from HIV-related causes to fewer than 500 000. Based on current estimates, this provides an opportunity to prevent almost 300 000 deaths per year.

The drop in HIV-related mortality is especially evident in the regions with the greatest burden of HIV infection, including the WHO African Region, home to over 61% of people dying from HIV-related causes in 2018. An estimated 470 000 [340 000−630 000] people died in the African Region from HIV-related causes in 2018, which indicates that mortality has dropped by almost 40% since 2010.

World Hepatitis Alliance (WHA) maintains that globally there are about 290 million people living with viral hepatitis unaware and without finding the undiagnosed and linking them to care, millions will continue to suffer, and lives will be lost. This is why the theme recognized by WHA for this year’s celebration is Finding the missing millions.

However, World Health Organization (WHO) currently maintains that 325 million people are living with viral hepatitis B and C; 900,000 deaths per year are caused by hepatitis B virus infection ; 10% of people are living with hepatitis B and 19% of the people who are living with hepatitis C know their hepatitis status; 42% of children, globally, have access to the birth dose of the hepatitis B vaccine

Coming to data available in Nigeria, Dr Chukwuma Anyaike,a Community Health physician , few years ago argued that about 20 million Nigerians are infected with Hepatitis B and C .The said physician who was then the Head, Prevention, Department of Public Health at the Federal Ministry of Health stated this at a one-day stakeholders’ advocacy workshop on Viral Hepatitis awareness organised by the Yakubu Gowon Foundation in Abuja.He further pointed out that ,''Viral Hepatitis is a very big public health issue in Nigeria. By the work Federal Ministry of Health has done, we have 20 million Nigerians living with Hepatitis B and C and they are at the risk of developing cirrhosis of the liver and cancer of the liver. Most importantly, these ones are living in the communities and they are not aware of it and in the same process, they are transferring the infection to other people in the community.”

In the occasion, it was further revealed that approximately 20 million of Nigeria’s 170 million population that are infected by the virus, 25 percent of them go on to develop chronic liver disease and between 500,000 to 700,000 result in deaths annually.

From the survey (2000-2013), Kano had the highest number of people infected with the B variant of the virus while Kwara state had the highest number of people with Hepatitis C.

However , Nigeria HIV/AIDS Indicator and Impact Survey(NAIIS) report currently shows that Nigeria, with an estimated population of 190 million people, has a Hepatitis B prevalence of 8.1% and Hepatitis C at 1.1%

DEFINITION AND CLASSIFICATION:
Hepatitis is a health condition characterized by the presence of inflammatory cells in the tissues of the liver.It can be self-limiting(healing on its own) or can simply progress to fibrosis(scarring),Cirrhosis, liver failure or liver cancer. Hepatitis can be acute when it lasts for less than six months or chronic when it lasts for more than six months.

Viral hepatitis is mainly classified into five groups: Hepatitis A, B, C, D and E. There are other classifications of hepatitis such as autoimmune, alcoholic hepatitis etc., but the main aim of the World Hepatitis Day is to sensitize and encourage people on how to prevent, diagnose and treat these five VIRAL hepatitis infections.

Hepatitis A:
Caused by Hepatitis A virus and it occurs when an uninfected person ingests food or water contaminated with the faeces of an infected person. It can also be contracted through close physical contact with an infectious person, although casual contact among people does not spread the virus. There are about 1.4 million cases each year worldwide. Unlike Hepatitis B & C, it does not run a chronic course but can lead to debilitating symptoms and fulminant hepatitis(acute liver failure), which has a very high mortality rate.

WHO maintains that that :
Hepatitis A is a viral liver disease that can cause mild to severe illness.

Hepatitis B:
It is a potentially life threatening disease of the liver caused by Hepatitis B virus and it is contracted by contact with the blood or body fluids of an infected person. It is commonly spread from mother to child at birth,or from person to person in early childhood. In the rural settings, it can be contracted by sexual transmission (when no barrier protective measure is used) and the use of contaminated sharp objects like needles, razor blades etc., and inadequately sterilized hospital equipment. It runs both acute and chronic courses and about 240 million individuals globally have chronic Hepatitis B infection whereas in each year, about 780,000 people die globally from acute and chronic Hepatitis B infections. It is an important occupational hazards for health care professionals, members of the Federal Road Safety Corps,commercial sex workers,long distance drivers etc.

WHO still believes that : Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic disease.

  • The hepatitis A virus (HAV) is transmitted through ingestion of contaminated food and water or through direct contact with an infectious person.
  • Almost everyone recovers fully from hepatitis A with a lifelong immunity. However, a very small proportion of people infected with hepatitis A could die from fulminant hepatitis.
  • WHO estimates that hepatitis A caused approximately 7 134 deaths in 2016 (accounting for 0.5% of the mortality due to viral hepatitis).
  • The risk of hepatitis A infection is associated with a lack of safe water, and poor sanitation and hygiene (such as dirty hands).
  • In countries where the risk of infection from food or water is low, there are outbreaks among men who have sex with men (MSM) and persons who inject drugs (PWIDs).
  • Epidemics can be prolonged and cause substantial economic loss.
  • A safe and effective vaccine is available to prevent hepatitis A.
  • Safe water supply, food safety, improved sanitation, hand washing and the hepatitis A vaccine are the most effective ways to combat the disease. Persons at high risk, such as travelers to countries with high levels of infection, MSM and PWIDs can get vaccinated.

    Hepatitis C:
    Caused by Hepatitis C virus and it is contracted the same way Hepatitis B infection is contracted through unsafe injection practices;inadequate sterilization of medical equipment in healthcare settings;and unscreened blood and blood products. Like Hepatitis B,it runs both acute and chronic courses but it has more propensity of running chronic course than Hepatitis B.A significant number of the chronic carriers of the disease will come down with Cirrhosis or Liver cancer. It is estimated globally that about 130-150 million people are chronic carriers of the infection while about 350,000-500,000 people die annually from Hepatitis C related infections.

    WHO maintains that : Hepatitis C is a liver disease caused by the hepatitis C virus (HCV): the virus can cause both acute and chronic hepatitis, ranging in severity from a mild illness lasting a few weeks to a serious, lifelong illness.

    • The virus is most commonly transmitted from mother to child during birth and delivery, as well as through contact with blood or other body fluids, including sex with an infected partner, injection-drug use that involves sharing needles, syringes, or drug-preparation equipment and needle sticks or exposures to sharp instruments.
    • WHO estimates that in 2015, 257 million people were living with chronic hepatitis B infection (defined as hepatitis B surface antigen positive).
    • In 2015, hepatitis B resulted in an estimated 887 000 deaths, mostly from cirrhosis and hepatocellular carcinoma (i.e. primary liver cancer).
    • As of 2016, 27 million people (10.5% of all people estimated to be living with hepatitis B) were aware of their infection, while 4.5 million (16.7%) 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 1% in 2019 down from around 5% in the pre-vaccine era ranging from the 1980s to the early 2000s.
    • Hepatitis B can be prevented by vaccines that are safe, available and effective.

      Hepatitis D:
      Caused by Hepatitis D virus, which is called an incomplete virus or subviral satellite because it can propagate only in the presence of Hepatitis B virus,hence the transmission of Hepatitis D can only occur either via simultaneous infection with hepatitis B virus(co-infection) or superimposed on chronic Hepatitis B carrier state (superinfection). Regrettably, in combination with Hepatitis B virus, Hepatitis D infection has the highest mortality rate of all the Hepatitis infections.

      WHO is of the opinion that : Hepatitis D virus (HDV) is a virus that requires hepatitis B virus (HBV) for its replication. HDV infection occurs only simultaneously or as super-infection with HBV.

      • Hepatitis C is a major cause of liver cancer.
      • The hepatitis C virus is a bloodborne virus: the most common modes of infection are through exposure to small quantities of blood. This may happen through injection drug use, unsafe injection practices, unsafe health care, transfusion of unscreened blood and blood products, and sexual practices that lead to exposure to blood.
      • Globally, an estimated 71 million people have chronic hepatitis C virus infection.
      • A significant number of those who are chronically infected will develop cirrhosis or liver cancer.
      • WHO estimated that in 2016, approximately 399 000 people died from hepatitis C, mostly from cirrhosis and hepatocellular carcinoma (primary liver cancer).
      • Antiviral medicines can cure more than 95% of persons with hepatitis C infection, thereby reducing the risk of death from cirrhosis and liver cancer, but access to diagnosis and treatment is low.
      • There is currently no effective vaccine against hepatitis C; however, research in this area is ongoing.

        Hepatitis E:
        Caused by Hepatitis E virus and mainly transmitted through contaminated drinking water. Less commonly,it can also be transmitted by transfusion of infected blood products and vertical transmission from a pregnant woman to her fetus. It is self-limiting,resolving within four to six weeks,though it may at times run a fulminant course(acute liver failure) leading to death. Globally, there are approximately 20 million incidents of Hepatitis E infections every year; three million acute cases; 56,600 hepatitis E-related deaths. Hepatitis E can also induce a mortality of about 20% among pregnant women in their third trimester.

        Finally , WHO opines that Hepatitis E is a liver disease caused by infection with a virus known as hepatitis E virus (HEV).

        • The virus is most commonly transmitted from mother to child during birth and delivery, as well as through contact with blood or other body fluids, including sex with an infected partner, injection-drug use that involves sharing needles, syringes, or drug-preparation equipment and needle sticks or exposures to sharp instruments.
        • Vertical transmission from mother to child is rare.
        • Hepatitis D virus (HDV) affects globally nearly 5% of people who have a chronic infection with hepatitis B virus (HBV).
        • Several geographical hotspots of high prevalence of HDV infection exist, including Mongolia, the Republic of Moldova, and countries in Western and Middle Africa.
        • Populations that are more likely to have HBV and HDV co-infection include people who inject drugs, indigenous populations and recipients of hemodialysis.
        • Worldwide, the overall number of HDV infection has decreased since 1980s. This trend is mainly due to a successful global HBV vaccination programme.
        • HDV-HBV co-infection is considered the most severe form of chronic viral hepatitis due to more rapid progression towards liver-related death and hepatocellular carcinoma.
        • Currently, treatment success rates are generally low.
        • Hepatitis D infection can be prevented by hepatitis B immunization.

          CLINICAL FEATURES:
          The viral hepatitis infections have almost common features which can be asymptomatic (no symptoms) but often lead to jaundice, loss of appetite, and malaise. As noted earlier on, some of them can run either acute or chronic courses.

          The acute features:
          In children, the features are usually asymptomatic while in older individuals, there may be nonspecific flu-like symptoms,common to almost all acute viral infections which include: malaise; muscle and joint aches; fever; nausea or vomiting; diarrhoea; headache. The more specific acute features include: loss of appetite; aversion to smoking (among smokers); dark urine; yellowing of the eyes and the skin; enlargement of the liver; enlarged lymph nodes in about 5%; enlargement of the spleen.

          Meanwhile, a small proportion of the people with acute infections can develop liver failure with associated hepatic encephalopathy (confusion and coma due to inability of the liver to perform its functions); peripheral edema and bleeding.

          The chronic features: Although they may present with malaise; tiredness; weakness; jaundice, individuals with chronic infections usually run asymptomatic courses until complicated with cirrhosis, liver cancer, and liver failure.

          PREVENTION:
          This is the theme for this year's World Hepatitis day. It is generally believed that ,'prevention is better than cure.' The transmission of the virus can be prevented through better awareness and services that improve vaccinations ,blood and injection safety,and reduce harm. This annual campaign aims not only to raise awareness among the general public and infected patients,but also to urgently promote improved access to hepatitis services ,particularly prevention interventions by policymakers.

          Hepatitis A can be prevented by adequate supplies of safe drinking water; proper disposal of sewage within the communities; personal hygiene such as regular hand washing with safe water and soap; getting immunized with Hepatitis A vaccine.

          Hepatitis B can be prevented by quality-assured screening of all donated blood and blood components used for transfusion;safe injection practices; safe sex practices,including minimizing the number of partners and using barrier protective measures (condom). Moreover, Hepatitis B vaccine is the mainstay of prevention, no wonder it is part of our National Programme On Immunization. However, adults who were not immunized at childhood and who are among the high risk groups should meet their doctors to ascertain if they are eligible for the vaccination.

          Hepatitis C and D infections have almost the same preventive measures as Hepatitis B except that Hepatitis C vaccine is currently unavailable globally though research is still ongoing.

          Hepatitis E can be prevented by maintaining quality standards for public water suppliers;establishing proper disposal systems to eliminate sanitary wastes; maintaining hygienic practices such as hand washing with safe water, particularly before handling food; avoiding water/or ice of unknown purity; adhering to WHO safe food practices. Hepatitis E vaccine is still not available in the global market, though it has been produced and licensed in China.

          DIAGNOSES AND TREATMENTS:
          Consult the nearest medical doctor who is professionally trained to make the diagnosis from clinical history,physical examination and interpretation of laboratory investigation results . The doctor knows when to refer you to a specialist (Gastroenterologist) who is also professionally trained to use simple non-invasive tests to assess the stage of the disease,prioritise treatment for those at advanced stages of the disease,make use of safe and highly effective medications in the treatment and to further monitor the progress of the treatment or disease using simple tests. The managing medical doctor can as well advise you on the need to get vaccinated especially if you tested negative to the virus(s) in order to prevent occupational hazards for those whose occupations involve handling of human blood and other bodily fluids.

          In view of the above, our government should map out comprehensive national plans to tackle this silent killer called viral hepatitis especially in our rural communities since many women get to know their statuses during antenatal period where many government hospitals make it compulsory that all pregnant women must be tested for HIV 1 & 2, Hepatitis B and C , VDRL( for syphilis) among other relevant tests.

          REFERENCES:
          (1) Kumar and Clark's Clinical Medicine,8th edition

          (2) Davidson's Principles And Practice Of Medicine,21st edition

          (3) Oxford Handbook Of Clinical Medicine,9th edition

          (4) www.who.int/en/
          (5) http://en.m.wikipedia.org/wiki/Hepatitis
          (6) http://www.who.int/hiv/mediacentre/news/whd2015_preventhepatitis/en/

          (7) http://www.dailytrust.com.ng/daily/index.php/news-menu/news/59986-20m-nigerians-infected-with-hepatitis-virus-fg

          (8) http://www.who.int/hiv/topics/hepatitis/hepatitisinfo/en/

          (9) http://www.google.com/m?q=baby+hiv+positive+parents+negative+lagos+luth+cmd&client=ms-opera-mini-android&channel=new

          (10) https://www.worldhepatitisday.org/

          Dr Paul John,Port Harcourt,08083658038,[email protected]

          • Every year, there are an estimated 20 million HEV infections worldwide, leading to an estimated 3.3 million symptomatic cases of hepatitis E (1).
          • WHO estimates that hepatitis E caused approximately 44 000 deaths in 2015 (accounting for 3.3% of the mortality due to viral hepatitis).
          • The virus is transmitted via the fecal-oral route, principally via contaminated water.
          • Hepatitis E is found worldwide, but the disease is most common in East and South Asia.
          • A vaccine to prevent hepatitis E virus infection has been developed and is licensed in China, but is not yet available elsewhere.