Dr Kolawole Akande is a hepatitis expert and the principal investigator of the Hepatitis Registry at the University College Hospital (UCH), Ibadan. In this interview with SADE OGUNTOLA, he speaks on the prevalence of liver diseases in Nigeria and what should be done to stem it.
IT is said that there is a high incidence of liver-related diseases in Nigeria and hepatitis plays a big part in predisposing people to it. What can be done to curtail it?
Nigeria is indeed an endemic region for hepatitis B. Out of every 100 Nigerians, at least eight of them will have chronic hepatitis B infection; and chronic hepatitis B is the most common cause of liver diseases, including liver cirrhosis and liver cancer.
Liver cancer is about the most common cancer in our medical ward at the University College Hospital (UCH), Ibadan and this is the reason Nigeria must find everyone with hepatitis B that does not know about it because it will reduce the burden of liver disease, especially liver cancer. Liver cancer is a terrible cancer and most people that have it will die within six months of diagnosis, because they usually come very late.
What is hepatitis and how prevalent is it in Nigeria?
Hepatitis simply means inflammation of the liver – which means, in layman’s terms, the destruction of the liver or injury to the liver. There are many causes of hepatitis. There are various causes, including hepatitis A, B, C, D, E viruses. Apart from these viral causes, alcohol is also a cause of hepatitis, so also is non-alcoholic fatty liver disease, which is common in people who are obese and or diabetic or have abnormal lipids in their blood.
Certain drugs and herbs can also cause hepatitis. But out of all these, in Nigeria and, indeed, sub-Saharan Africa, the most common cause of hepatitis is viral hepatitis. Hepatitis B is the most common cause of hepatitis in sub-Saharan Africa. A national study to determine the prevalence of hepatitis, alongside HIV in Nigeria, gave a prevalence of eight percent – meaning that out of every 100 Nigerians, eight people will have chronic hepatitis B infection.
Is there any uniqueness about hepatitis in Nigeria compared to that in other countries?
Generally, most people that have hepatitis B in Nigeria don’t know. The reason is that hepatitis B is asymptomatic until the liver is almost destroyed. In fact, only one out of 10 people with chronic hepatitis B knows that they have it; and this is why the Society of Gastroenterology and Hepatology in Nigeria (SOGHIN) advises that every adult Nigerian should screen for hepatitis B virus infection.
In terms of the treatment, evaluation for people with hepatitis B is costly in Nigeria. For instance, there is a particular test called viral load; the cost ranges between N35,000 and N50,000, depending on the laboratory. Many people are not able to afford this test. The test is very important in determining who will need treatment and who will not. So, you have a lot of people who are getting to know about hepatitis because of awareness, medical screening, in-service screening and all others. But many of them are unable to afford the evaluation that will determine if they need treatment or not. And when they need to be treated also, the drugs might be out of the reach of some, though not expensive. It costs between N6,000 and N10,000 for a month pills. A study at UCH found that many of our patients are not taking the medication for various reasons. One of the common reasons was the fact that many of them could not afford those drugs. That is why the government should come in to subsidise the evaluation and treatment for hepatitis B infection.
For people interested in hepatitis screening, where can they get the test done?
Almost every laboratory and hospital can screen for hepatitis B and it is not expensive. It goes for as little as N2,000. The challenge is that after getting screened and it is positive for hepatitis B virus infection, the evaluation to determine who will need treatment and who will not need it is a bit expensive.
Hepatitis B is a viral infection, so why does it persist only in some people and not everybody?
When it comes to hepatitis, we talk about acute hepatitis; meaning that the hepatitis is less than six months in duration; and chronic hepatitis means that it is six months and above in duration. When it comes to hepatitis B, the most important determinant whether it will become chronic or not is the age of acquisition of the virus. If a new born baby acquires hepatitis, maybe from the mother or from others, the possibility of it becoming chronic is about 90 percent. If an older child, let’s say a five-year-old, gets hepatitis B, the possibility of it becoming chronic is between 40 and 50 percent; but if an adult gets hepatitis B, the possibility of it becoming chronic is less than 10 percent. So, the younger one is at the time of the infection, the more the chances of the infection persisting for a long time.
Unfortunately, in this environment, most infections occur in childhood. So, most people that are getting to know that they have hepatitis B in adulthood have had it, most times since childhood. But since it is asymptomatic, people will not know. That is why SOGHIN advises that every adult Nigerian should screen for hepatitis B at least once in their lifetime, to know whether it is there or not.
How is hepatitis B contracted?
Their routes of transmission are many, including from mother to child around the time of labour. This is why during the antenatal period; hepatitis B screening is one of the screenings that are done for mothers, because if a mother has it, there are things that can be done to reduce the chances of the baby having it. Apart from the mother-to-child transmission, there is also child-to-child transmission and that is why it tends to cluster in families. That is why when we have someone with hepatitis B, we advise the person to alert the siblings to also go and do the screening, because of child-to-child transmission. Other routes of transmission include indiscriminate use of sharp objects like conducting circumcision with unsterilised equipment; sharing of blades, clippers, needles and syringes etc.
How does child-to-child transmission of hepatitis B happen?
We are not very sure about how child-to-child transmission of hepatitis B occurs, but people have talked about exchange of wound exudates that contain a lot of the hepatitis B virus. When children are playing together, they tend to contract it. Again, its transmission in the same family may be from sharing sharp objects like blades, nail cutters and other sharp objects. There are cultural practices that promote the spread of hepatitis B virus. For instance, a local surgeon will use unsterilised equipment to circumcise three or four children at the same time. That same equipment he will later use to do tribal marking, tattooing and female genital mutilation. It is the same with ear piercing that is done by old women. All these things promote the spread of hepatitis.
One thing about hepatitis B is that the virus is 100 times more infectious than HIV. So, if there is blood that contains hepatitis B virus, it can survive outside the body for at least seven days. If you have maybe a clipper that has been contaminated with the blood from somebody yesterday, the virus is still alive for the next seven days. So, if this clipper is used on other people and then they also have cuts, it can be passed on. Also, it can be from reused needles and/or syringes.
There are hepatitis A, B, C, D and E. One can get hepatitis A and or E from faeces, contaminated foods or drinks but hepatitis B, C and D spread essentially through blood and body fluids. Unprotected sexual intercourse too can spread hepatitis B virus.
How serious is the need for treatment of hepatitis B in Nigeria?
The need for the treatment is huge and the government, non-governmental organisations and specialists in hepatitis need to sensitise people on the need to screen for hepatitis B virus infection. Government also should find a way of either bringing it into NHIS or subsidising its evaluation so that when people know that they have it, they can get evaluated and benefit from subsidised evaluation and treatment. Egypt has done this; it used to be the country with the highest prevalence of hepatitis C in the whole world. But Egypt rose to the problem; they screened their people massively; they manufactured the drugs and they treated them and now Egypt is no more the country with the highest burden of hepatitis C. So, government should do something about hepatitis B in Nigeria, because many of the people that have it are poor; they are not able to take proper care of the infection.
If a person does not need treatment today, it does not mean that they will not need treatment tomorrow. Whether they are on treatment or not, people with chronic hepatitis B need to be on periodic evaluation by experts. As we speak now, there is no cure for hepatitis B, but there is effective treatment that significantly reduces the chances of having a liver disease in future. There is a cure for hepatitis C, although it is not as common as hepatitis B in Nigeria. Government can help with awareness, evaluation and drugs as well as encourage pharmaceutical companies to manufacture these drugs locally.
In our clinics, for instance at the UCH, Ibadan, hepatitis B is the most common disease that we see. In fact, we book about 60 patients every week to see because if you don’t do that, many of them may not be seen until six months or more. These patients are usually very anxious because they must have heard a lot about the infection and most of the information is not true.
Are there effective vaccines against hepatitis?
We have vaccination against hepatitis; there are effective vaccines against hepatitis A and B. As a matter of fact, hepatitis B vaccination has been part of the routine national programme on immunisation for children since 2004. That is why we encourage women to make sure that they vaccinate their children. But for adults, they will have to be screened first. If they are negative, they can then go and get vaccinated. It is not that expensive. If they are positive, they should not take the vaccine because it is useless for those that are already infected. The vaccine is meant for people that are negative and it is to prevent the acquisition of the virus.
READ ALSO FROM NIGERIAN TRIBUNE
and then