Dr. Nzubechukwu Ogamba MBBS (Nig) is a medical doctor and social entrepreneur who is committed to healthcare advancement in Africa and bridging the health equity gap through youth empowerment and health innovation.

In this interview with Business Hallmark’s Tumininu Ojelabi Hassan, he highlighted the factors contributing to the prevalence rate of Hepatitis in Nigeria while giving a broad overview of the infection.

He further suggested preventive measures as well as the role of the government, civil society groups and international organizations towards ensuring a decline in the rate of hepatitis cases in the country. He is the founder of Youth Health Action Network and Co-founder of Mymedicare Healthcare.

Excerpts:

Based on your experience as a doctor, how high is the rate of hepatitis in Nigeria, and what are the factors contributing to its prevalence?

Hepatitis, as we call it, is a silent pandemic, why it is called the silent pandemic is because it is more common than many diseases we are conversant with but it is not getting the same attention as those diseases. Because I am a scientist, I will go with the available scientific data and avoid speculations.

According to the Nigeria HIV/AIDS Indicator and Impact Survey, 2018 (NAIIS 2018), Nigeria has a prevalence rate of 8.1% and 1.1% for Hepatitis B (HBV) and Hepatitis C (HCV) respectively, among adults aged 15-64 years. Usually when HIV is studied, hepatitis is studied alongside because there is a 1.1% co-infection rate of HIV & Hepatitis.

Based on some estimates, the country has more than 20 million people living with hepatitis B, C, or both; yet more than 80% of the people, who have the disease do not know their status. Many patients get diagnosed accidentally, in the most random settings, for instance during an attempt at blood donation, or a medical certification for employment.

From the surveys done by Youth Health Action Network in Enugu, Anambra, Edo, Rivers, and Lagos, the prevalence stands at 1.4 per cent in a sample size of 2504 and 1.7 per cent in a sample size of 857 for hepatitis B and C respectively over 30 months.

Depending on the focus of study, there might be differences in the prevalence rate that are reported, however the important thing is that it is endemic in Nigeria and there are millions of people walking around everyday with Hepatitis.

Talking about factors contributing to the prevalence, the first factor contributing to the prevalence of hepatitis is ignorance. Many people do not know their status and will likely keep transmitting the virus (es) to other people, especially those with viral infection. Due to their ignorance about their health status, they go around having unprotected sex, sharing sharp objects and engaging in other risk factors that can lead to transmission of the infection to other people.

Another factor is the cost of treatment , for a complete diagnosis of the nature of the chronic condition, a series of investigations are required, which can range from N200,000 to 300,000, now this is in a country with a minimum wage of N30,000 and more than 80 million living with $1/day. How can people afford this?

These investigations are important because not everyone will require antiviral medications. After diagnosis, people don’t come back, especially the ones with the asymptomatic infection which doesn’t show symptoms until later, however they come back after the damages are done. The three major damages include liver failure, liver cirrhosis which means the scarring of the liver tissues, the third complication that is very common in people with chronic hepatitis is Liver Cancer. So these are the issues.

Can you give a brief overview of what Hepatitis is, the causes, symptoms, and how it is transmitted?

Hepatitis is an inflammation of the liver that is caused by a variety of infectious viruses and noninfectious agents leading to a range of health problems, some of which can lead to death. There are five main strains of the hepatitis virus, referred to as types A, B, C, D and E. While they all cause liver disease, they differ in important ways including modes of transmission, severity of the illness, geographical distribution and prevention methods. Types A and E are faecal-oral viruses associated with poor hygiene in terms of coming in contact with the faeces of someone with hepatitis and in some cases through Cunnilingus. Types B and C lead to chronic disease in hundreds of millions of people and together are the most common cause of liver cirrhosis, liver cancer and viral hepatitis-related deaths. Type D only occurs in the presence of type B as a co-infection or super-infection.

The symptoms depend on the type of hepatitis. It could be asymptomatic meaning there are no obvious symptoms or signs to show that one has it. This is, especially seen in chronic hepatitis. Most adults with hepatitis B recover fully, even if their symptoms are severe. Infants and children are more likely to develop a long-lasting hepatitis B infection. This is known as a chronic infection.

The symptoms range from mild to severe and can include abdominal pain, dark urine, fever, joint pain, loss of appetite, nausea and vomiting, weakness and fatigue, Yellowing of the skin and the whites of the eyes, also called jaundice

In highly endemic areas like Nigeria, hepatitis B is most commonly spread from mother to child at birth (perinatal transmission) or through horizontal transmission (exposure to infected blood), especially from an infected child to an uninfected child during the first five years of life. The development of chronic infection is common in infants infected from their mothers or before the age of five years.

The major risk factors for both hepatitis B and C include, having unprotected sex with multiple sexual partners, or with someone who’s infected with HBV, exposure to body fluids like semen, heavy amounts of saliva, and vaginal fluids. Sharing needles during IV drug use, infants born to an infected mother, having a job that exposes you to human blood like being a health worker and receiving poorly screened or unscreened blood or blood products.

It is important to contact your healthcare provider immediately if you know you have been exposed to hepatitis B. Post-exposure preventive treatment may reduce your risk of infection if you receive the treatment within 24 hours of exposure to the virus. Also, If you suspect symptoms of hepatitis B, contact your healthcare provider.

Can you give a brief explanation of the treatment process, duration of treatment, recovery, and cost of treatment?

Treatment process starts with screening, this is how we know that someone has hepatitis, be it acute or chronic. After screening, proper diagnosis will commence. This process helps establish the nature of the disease for each individual and guides decision-making for the treatment and its duration.

For acute hepatitis B, the treatment is mostly supportive with no specific antiviral medications administered. Chronic hepatitis B infection can be treated with oral medicines, including tenofovir or entecavir. Treatment can slow down the advancement of cirrhosis, reduce the risk of developing liver cancer and improve long-term survival.

It is important to note that most people, who start hepatitis B treatment must continue it for life. It is estimated that 12–25% of people with chronic hepatitis B infection will require treatment, depending on setting and eligibility criteria, usually the viral load levels and the presence of certain antibodies or antigens in the blood.

Hepatitis treatment is still very costly, hepatitis medications, for example, depending on the combination can go as high as N200,000 for just one month’s supply of hepatitis C medications.

According to WHO, more than 20 million Nigerians are living with Hepatitis B, C, or both, but more than 80% of them do not know their status. What are the factors contributing to this?

The figure is as high as 85 per cent of the affected persons not even being aware, according to some reports.The main factor is the asymptomatic nature of chronic hepatitis at the initial stages. Many chronic carriers go about every day without knowing their status and can go ahead to infect others. This also increases their risk of dying from the disease because those, who may need medications to halt ongoing damage to the liver, don’t get them. Also, they may indulge in harmful practices that further damage the liver, like alcohol consumption and smoking, which increases their risk of developing liver cirrhosis, liver failure and hepatocellular carcinoma (liver cancer)

Another factor is the “Not my portion syndrome”, when it comes to health conditions, many Nigerians will always believe it is not their portion and will respond to information about their diagnosis with ‘God forbid, it is not my portion’

Also, many still choose to live in disbelief and may refuse testing because they don’t believe it can affect them.

One of the factors is lack of knowledge of the disease’s existence. A survey conducted by Youth Health Action Network in 2021 revealed that a shocking 52 per cent of students in three tertiary institutions, where the survey was done did not know about the disease. You can’t prevent what you don’t know about.

Less focus on hepatitis awareness compared to other communicable diseases like HIV is contributing to the ignorance level. Today, almost everyone knows about HIV, old and young, educated or not and that is because of the emphasis that has been laid on the pandemic over the years. Information on HIV is readily available in primary and secondary schools health education curriculum on radio and TV, print media etc. The same cannot be said about hepatitis.

There are speculations that Hepatitis B is 100 times more contagious than HIV, while Hepatitis C is 1000 times more contagious than HIV. How true is this?

For Hepatitis C, I don’t know about being 1000 times more infectious, but it has been documented to be 10 times more infectious than HIV and hepatitis B is up to 100 times more infectious than HIV. Hepatitis B is also noted to survive longer on surfaces. The important thing is to know that they are highly infectious and take necessary precautions.

How many doses of Hepatitis vaccine does a child need to receive to have full immunity against the infection?

All babies should receive the hepatitis B vaccine as soon as possible after birth (within 24 hours). This is followed by two or three doses of hepatitis B vaccine at least four weeks apart.

Booster vaccines are not usually required for people, who have completed the three-dose vaccination series. The vaccine protects against hepatitis B for at least 20 years and probably for life. So for people in endemic areas like Nigeria, especially those, who are most at risk, it may be advisable to repeat the vaccination as adults. Three doses are advocated for adults, taken at 0, one month and six months. The second dose should be received after one month of receiving the first dose, the third dose should be taken after six months of taking the second dose.

Despite the Expanded Programme on Immunization (EPI), why are we still struggling with Hepatitis in 2023?

According to the 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.

In settings with high Hepatitis B surface antigen seroprevalence in the general population (defined as >2% or >5% HBsAg seroprevalence), an example being Nigeria, WHO recommends that all adults have access to and be offered HBsAg testing with linkage to prevention and care and treatment services as needed.

WHO also recommends blood donor screening, and routine testing for hepatitis B for all pregnant women to provide the opportunity to institute measures for the prevention of mother-to-child transmission as well as focused or targeted testing of specific high-risk groups including migrants from endemic regions, partners or family members of infected persons, and health-care workers, persons, who inject drugs, people in prisons and other closed settings, sex workers and HIV-infected persons.

We are still struggling because we are yet to make much progress in terms of adult screening and vaccination. The side effects of the vaccine include mild pain, where the vaccine was administered, mild flu-like symptoms within 24 hours, which can be treated with paracetamol.

How can it be prevented, also what role can the society/government play in ensuring a decline in the rate of hepatitis in the country?

The WHO recommends five major intervention areas of focus towards eliminating hepatitis. The five core intervention areas include vaccination, prevention of mother-to-child transmission, blood and injection safety, harm reduction, hepatitis B and C testing and treatment.

Organizations, civil society groups, government agencies and the international community must begin to look at how to integrate measures towards hepatitis elimination that consider these five core areas.

The Advocacy for Healthy Liver and Sexual Health Program of Youth Health Action Network (YOHAN Africa) has successfully implemented some of these approaches towards curbing the effects of disease.

For example, the program focuses on mass screening programs, which gives access to free screening for all age groups. In the same setting, there is the provision of free or subsidized vaccines focused on solving the major challenges of access, cost and completion, when it comes to the hepatitis B vaccine as the vaccines are brought to the beneficiaries who are followed up to ensure completion of the three doses. In the last 30 months, 381 people have been enrolled into the vaccination program and 261 completed their three doses.

The program also has a blood donor registry, and as young people are encouraged to become donors, they are also screened, thereby using blood donation to screen more people. The fight against hepatitis is a tough one and all stakeholders must make the necessary commitment towards elimination efforts.

Funding by the government and international health organizations must increase towards making hepatitis screening, vaccination and treatment free or as affordable as possible. We need to invest more in research, intervention, including health education.

We must re-evaluate our approach and focus if we are to achieve the WHO goal 2030 of reducing hepatitis incidence from 6-10 million cases to 0.9 million cases and to reduce annual hepatitis deaths from 1.4 million to 0.5 million, by 2030. All hands must be on deck, it is real and we must make efforts to curb the pandemic

JOIN THE FIGHT! HEPATITIS CAN’T WAIT