Dying Unaware: Race to rescue “the missing millions” from hepatitis in Nigeria
Dying of viral hepatitis in Africa is becoming a bigger threat than dying of AIDS, malaria or tuberculosis, says the World Health Organisation (WHO). Yet hepatitis does not usually get the awareness and funding it deserves.
It’s time for this to change.
In 2016, the WHO set targets to eliminate viral hepatitis as a public health threat by 2030, and provided a global health sector strategy (GHHS) to run from 2016–2021. Since then, this strategy has been adopted and endorsed by 194 countries. The aim is to reduce new hepatitis infections by 90% and deaths by 65% between 2016 and 2030.
Currently, only 12 countries are on track to eliminate hepatitis by 2030. Viral hepatitis kills more than 1.34 million people each year, more than HIV/AIDs or Malaria, yet there is a cure for hepatitis C and a vaccine and effective treatment for hepatitis B. The 4,000 deaths each day caused by viral hepatitis are preventable. Currently, 290 million people live with viral hepatitis completely unaware, and one of the key reasons is a lack of knowledge about the disease.
World Hepatitis Day (WHD) takes places every year on 28 July, to bring the world together under a single theme to raise awareness of the global burden of viral hepatitis and to influence real change. This year, the emphasis is to take action and raise awareness to “find the missing millions.” Without finding the undiagnosed and linking them to care, millions will continue to suffer, and lives will be lost.
Nigeria joined the league of other nations to sign up to the GHSS and was among the few countries in Africa to develop firm goals towards the elimination of viral hepatitis. Nigeria’s Federal Ministry of Health, at a briefing on July 30, 2018, said the government was articulating strategies that would lead to a reduction in the number of more than 22 million Nigerians infected with hepatitis B and the more than 4 million with hepatitis C.
Hepatitis B, according to the Ministry of Health, has a national prevalence of 11% while hepatitis C has a prevalence of 2.2%. Both have become leading silent killers in the country; more than half of the nation’s population have never been tested and therefore do not know their infection status.
Bridging the gaps from screening to treatment
A major cause of the spread of the disease in Nigeria stems from lack of knowledge about the disease, and poor health-seeking behaviours, which makes screening for viral hepatitis difficult. When pregnant women do not attend antenatal care, it means they are not screened for the virus, and there is an increased chance they will pass the virus to their unborn baby if they are positive. Also, most Nigerians do not do annual medical checks, which reduces the chance of the diseased being spotted on time. Screening for those who work in places like restaurants, gyms, health facilities and schools needs to be better or made mandatory as these workers usually come in contact with sharp objects and serve large groups of people on a daily basis. Screening for those who work in places like restaurants, gyms, health facilities and schools needs to be better or made mandatory as these workers usually come in contact with sharp objects and serve large groups of people on a daily basis.
Awareness about the disease is also low because there are fewer non-governmental organisations (NGOs) focused solely on advocating for action to tackle hepatitis. Donor agencies as well have traditionally focused on HIV and TB rather than hepatitis, which means the disease been grossly underfunded.
Besides screening, there are also gaps in diagnosis and treatment of viral hepatitis in Nigeria. The cost of diagnosis and treatment is one challenge. Dr David Uzochukwu, a general practitioner who specialises in hepatitis diagnosis and treatment, said it costs about 30 million naira ($75,000) for a 12-week therapy to treat hepatitis C in the US. The high cost of treatment stems from the fact that there are only a few companies producing drugs that treat hepatitis C right now.
In Nigeria, the hepatitis B vaccine has been included as part of the immunisation schedule for children since 2004. This has helped reduce hepatitis B rates in children. However, rates in adults have gone up. Abraham Malu, former president of the Society of Gastroenterology and Hepatology in Nigeria (SOGHIN), said in 2018 that hepatitis is killing many Nigerians without them knowing. “On a nationwide scale there is a drop in the rate of hepatitis infection among children and this is attributed to the routine immunisation instituted in the country years back, but on the other hand there is a great upsurge among adults as a result of unguarded lifestyle and refusal to undertake periodic medical check-ups,” Malu noted.
Low coverage of testing and treatment is the most important gap to be addressed if Nigeria is to achieve the global elimination goals by 2030.
Are there solutions worth expanding?
In 2017, the Lagos State Ministry of Health developed the first time 2-year Operational Plan for the control of viral hepatitis in the State. This came on the heels of the adoption of the 2016 National Council on Health resolution that called for the establishment of state-specific Viral Hepatitis Control Programmes in the 36 states and Federal Capital Territory (FCT). The plan is meant to help the state make available viral hepatitis preventive and treatment services in all its health care facilities, in line with the National Viral Hepatitis Strategic Plan.
Nigeria’s former Minister of Health, Professor Isaac Adewole, launched the Nigerian Viral Hepatitis Health Facility Directory to commemorate the World Hepatitis Day in 2018. The directory provides information on existing health facilities where hepatitis services are being provided. Uzochukwu points out that the directory was necessary to point people to centres where they could receive care for hepatitis because of the shortage of specialists in Nigeria. He noted that there are only 5–7 gastroenterologists in Abuja, called for training of more doctors to be able to handle the diagnosis and management of non-complex cases of hepatitis.
For World Hepatitis Day, doctors like Uzochukwu are raising awareness through the media and some centres in Abuja, like Epiconsult Diagnostics, are providing free screening for hepatitis. Organisations such as Rotary International held Hepatitis Zero Week Awareness Campaigns to bring the issue to the forefront of public discuss. The Federal Ministry of Health held a symposium to address the issue on Tuesday, July 30th, 2019.
The case for Nigeria to invest in hepatitis treatment
A new study by WHO, published in Lancet Global Health, has found that investing US$6bn per year in eliminating hepatitis in 67 low-and middle-income countries would avert 4.5 million premature deaths by 2030, and more than 26 million deaths beyond that target date.
A total of US $58.7 billion is needed to eliminate viral hepatitis as a public health threat in these 67 countries by 2030. This means reducing new hepatitis infections by 90% and deaths by 65%, according to the study.
“Today 80% of people living with hepatitis can’t get the services they need to prevent, test for and treat the disease,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “On World Hepatitis Day, we’re calling for bold political leadership, with investments to match. We call on all countries to integrate services for hepatitis into benefit packages as part of their journey towards universal health coverage.”
The WHO calls on countries to take advantage of recent reductions in the costs of diagnosing and treating viral hepatitis and scale up investments in disease elimination. By investing in diagnostic tests and medicines for treating hepatitis B and C now, countries can save lives and reduce costs related to long-term care of cirrhosis and liver cancer that result from untreated hepatitis.
Some countries are already taking action. The Government of India has announced that it will offer free testing and treatment for both hepatitis B and C, as part of its universal health coverage plan. This has been facilitated through the reduction in prices of medicines. In India, a hepatitis C cure costs less than US$40 and a year of hepatitis B treatment costs less than US$30. At these prices, hepatitis C cure will result in healthcare cost savings within three years.
The Government of Pakistan has also procured hepatitis C curative treatment at similarly low prices. Providing curative treatment to all those currently diagnosed with hepatitis C could also reduce healthcare costs in Pakistan within three years. Meanwhile, Pakistan is faced with one of the highest new annual infection rates of hepatitis C virus and is launching a new infection control and injection safety plan on World Hepatitis Day to stop transmission.
While there has been broad support among WHO Member States in adopting the WHO hepatitis elimination strategy, with 124 out of 194 countries developing hepatitis plans, over 40% of country plans lack dedicated budget lines to support elimination efforts.
Does Nigeria have the political will and a robust budget line to support the elimination of this silent killer disease that infects more than 20 million people in our country every year? Former Minister of Health Adewole said in 2018 that the country has “inaugurated a national technical working group on the disease and launched the Directory for Viral Hepatitis Services. We have also signed a memorandum of understanding (MoU) with a pharmaceutical company to produce the drugs to treat hepatitis C, while testing for hepatitis has been included in the Nigeria AIDS Indicators and Impact Survey to be conducted by the federal government before the end of this quarter.”
These are laudable initiatives. But if Nigeria’s government is to reduce the burden of viral hepatitis by 2030 in line with global objectives, it must also find a way to reduce the cost of hepatitis treatment for Nigerians.
Have you been screened and tested for hepatitis B and C? Share your experience with us! What else should we be doing to reduce the prevalence of hepatitis in Nigeria?