7 July 2018

Lesotho: Urgent Need for Data for Hepatitis Treatment

interview

Viral hepatitis is an international public health challenge, comparable to other major communicable diseases including HIV, tuberculosis and malaria. Despite the significant burden it places on communities across the globe, hepatitis has been largely ignored as a health and development priority until recently. 28 June 2018 marked the World Hepatitis Day with the theme "Eliminate Hepatitis".

In this wide-ranging interview, WHO Country Representative Dr Cornelia Atsyor (CA) speaks to Lesotho Times (LT) reporter, Pascalinah Kabi. She talks about how the disease can no longer remain hidden with the adoption of the resolution on the 2030 Agenda for Sustainable Development Goals (SDGs) whose target 3 particularly calls for specific action to combat viral hepatitis.

LT: It appears so little is known about this disease in the communities, what exactly is hepatitis?

CA: Hepatitis is an inflammation of the liver. The condition can be self-limiting or can progress to fibrosis (scarring), cirrhosis or liver cancer. Hepatitis viruses are the most common cause of hepatitis in the world but other infections, toxic substances like alcohol and certain drugs and autoimmune diseases can also cause hepatitis.

Hepatitis A and E are typically caused by eating contaminated food or drinking contaminated water. Hepatitis B, C and D usually occur as a result of contact with infected body fluids. Common modes of transmission for these viruses include transfusion of blood or blood products contaminated with the virus, invasive medical procedures using equipment that are not properly sterilised and contaminated with the virus such as during dental procedures, surgery, injections and also though transmission from mother to baby at birth, and also by sexual contact.

Acute infection may occur with limited or no symptoms or may include symptoms such as jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting and abdominal pain.

LT: You mentioned the various types of hepatitis; how do they vary and can they be treated?

CA: Scientists have identified five unique hepatitis viruses, identified by the letters A, B, C, D and E. While they all cause liver disease, they vary in important ways. These five types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread. In particular, types B and C lead to chronic disease in hundreds of millions of people and together, are the most common cause of liver cirrhosis and cancer. In 2015 325 million people were living with chronic hepatitis infections worldwide and 1,34 million people died of hepatitis globally that year.

Hepatitis A virus (HAV) is present in the faeces of infected persons and is most often transmitted through consumption of contaminated water or food. Certain sex practices can also spread HAV. Infections are in many cases mild, with most people making a full recovery and remaining immune from further HAV infections. However, HAV infections can also be severe and life threatening. Most people in areas of the world with poor sanitation have been infected with this virus. Safe and effective vaccines are available to prevent HAV.

Hepatitis B virus (HBV) is transmitted through exposure to infective blood, semen, and other body fluids. HBV can be transmitted from infected mothers to infants at the time of birth or from family member to infant in early childhood. Transmission may also occur through transfusions of HBV-contaminated blood and blood products, contaminated injections during medical procedures, and through injection drug use. HBV also poses a risk to healthcare workers who sustain accidental needle stick injuries while caring for infected-HBV patients. Safe and effective vaccines are available to prevent HBV. Sexual transmission is also another means of infection.

Hepatitis C virus (HCV) is mostly transmitted through exposure to infective blood. This may happen through transfusions of HCV-contaminated blood and blood products, contaminated injections during medical procedures and through injection drug use. Sexual transmission is also possible but is much less common. There is no vaccine for HCV.

Hepatitis D virus (HDV) infections occur only in those who are infected with HBV. The dual infection of HDV and HBV can result in a more serious disease and worse outcome. HBV vaccines provide protection from HDV infection.

Hepatitis E virus (HEV) is mostly transmitted through consumption of contaminated water or food. HEV is a common cause of hepatitis outbreaks in developing parts of the world and is increasingly recognised as an important cause of disease in developed countries. Safe and effective vaccines to prevent HEV infection have been developed but are not widely available.

LT: Do we have any reported cases in Lesotho and if yes, please provide us with statistics?

CA: In Lesotho, the severity of the hepatitis burden is not known as routine data collection of those afflicted by the viruses is not collected. There is an urgent need for data to determine the burden of the disease in the country to develop a comprehensive programme for addressing the problem. This programme will address the issue of mass screening and availability of antiviral molecules for those in need.

LT: What is the cost of treating the various types of hepatitis?

CA: Prevention is always better than cure. The HBV vaccine is the mainstay of HBV prevention. WHO recommends that all infants receive the HBV vaccine as soon as possible after birth, preferably within 24 hours. A vaccine against HBV has been available since 1982. The vaccine is 95 percent effective in preventing infection and the development of chronic disease and liver cancer due to HBV.

Lesotho introduced the vaccine into the routine immunisation programme for children since 2008. Coverage of the third dose of DPT-Hib-Hep B Vaccine in Lesotho in children under one year of age is 87 percent. In many countries where between 8-15 percent of children used to become chronically infected with the HBV virus, vaccination has reduced the rate of chronic infection to less than 1% among immunised children. Routine vaccination for health workers who are one of the high occupational risk populations is not available in Lesotho.

WHO recommends that all blood donations be tested for HBV to ensure blood safety and avoid accidental transmission to people who receive blood products. In Lesotho all blood to be transfused are screened for HBV and HCV and blood found to be positive are discarded. There is no specific treatment for those who are newly infected with HBV.

Most cases of HBV who are infected will completely discard the infection from their body but few (about 6-10 percent) will still have the virus in their body after six months and are referred to as chronic carriers. In the case of those who are infected with HCV the rate of developing chronic infection is higher (60-80 percent) six months after infection. These chronic carriers are at risk of developing liver scarring or liver cancer in future.

For HCV, the majority of those infected are not aware of the disease since this is not as severe as HBV and those infected get to know only during routine screening. Chronic carriers of HCV are also prone to liver scarring and liver cancers.

There is no treatment as such for acute onset of hepatitis but only with supportive symptomatic treatment such as bed rest etc. Chronic hepatitis can be treated with antiviral agents some of which are also used for HIV treatment and may be lifelong as in the case of HBV. Treatment in most upper middle and high-income countries range from US$400 to US$1500 while the Global Price Reporting Mechanism (GPRM) indicates a range of from US$48 to US$ 50 in February 2017 for generic drugs. The medication is not yet available in the essential drug list of Lesotho.

In the case of HCV, treatment is shorter of 12 weeks and success rate for complete cure is 95 percent. High risk groups who will require HCV vaccination include: people who frequently require blood or blood products, dialysis patients, recipients of solid organ transplantations; people interned in prisons; persons who inject drugs; household and sexual contacts of people with chronic HBV infection; people with multiple sexual partners; healthcare workers and others who may be exposed to blood and blood products through their work and travelers who have not completed their HBV vaccination series, who should be offered the vaccine before leaving for endemic areas.

The rate of those living with HBV disease is highest in the WHO Western Pacific Region and the WHO African Region, where 6.2 percent and 6.1 percent respectively of the adult population is infected. In Lesotho the prevalence of HBV vaccine is not known but there is plan to conduct a population prevalence study.

LT: Is there any specific age groups prone to the various types of hepatitis?

CA: HBV and HCV can affect all age groups but disease is most severe in children under five years and can lead to chronic infection. This is the reason that globally, WHO recommends incorporating HBV vaccination into the childhood immunisation programme. There is not yet a vaccination against HCV. About 1% and 6 percent of people living with HIV are also infected with HBV and HCV respectively.

Mother to child transmission, unprotected sexual contact, unsafe injections using nonsterile injection materials in health facilities, communities and among those who inject drugs, unsafe surgical procedures using unsterilised equipment such as in dental procedures, operation theatres, tattooing using unsterilised equipment, circumcision especially the traditional circumcision using unsterilised sharp instruments, blood transfusion using unscreened blood. This is rare now as blood is screened for hepatitis viruses.

LT: What do you advice people should do to limit their chances of contracting this disease?

CA: HBV vaccination and vaccination with other hepatitis vaccine like HAV vaccination are safe and appropriate use of health care injections. Safe handling and disposal of sharp needles and waste; provision of comprehensive harm-reduction services to people who inject drugs including sterile injecting equipment; screening of donated blood for HBV and HCV as well as HIV and syphilis.

We also need to embark on a training of health personnel in preparation and use of sterile equipment, management of patients with Hepatitis; advocacy and awareness programmes on the dangers on use of unsterilised sharp instruments in the community like tattooing and traditional circumcision and promotion of safe sexual practices such as promotion of correct and consistent use of condoms.

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