My last piece was titled “Hepatitis B virus infection-Keeping it in check”. I realized that there is the tendency for COVID-19 to eclipse all other health issues of the country. So I was intrigued by an article in the Lancet titled “Converging pandemics: implications of COVID-19 for the viral hepatitis response in sub-Saharan Africa”, www.thelancet.com/gastrohep Vol5 Jul 2020.I will be using a lot of materials from this article for this piece.
The Lancet article said sub-Saharan Africa is currently bracing itself as the next front in the fight against the coronavirus disease 2019 (COVID-19) pandemic. Despite younger age demographics and less travel than in other regions, and strong efforts for early containment, the potential for widespread community-based transmission in sub-Saharan Africa is high, but current modelled estimates vary widely.The current state in Ghana as captured from the Ghana Health Service website- Confirmed cases 41,212, Recoveries/Discharge 38,727, Deaths 215, Active cases 2,270, New cases 209.
Poor baseline heath status, overcrowded urban housing conditions, and limited health-care infrastructure for testing, contact tracing, and treatment could exacerbate the expected morbidity and mortality. There will be an accompanying loss of economic growth, and millions could be impoverished.
There has been speculation about the potential impact of COVID-19 on people living with well recognised, pre-existing conditions in sub-Saharan Africa (eg, HIV, tuberculosis, and malaria), as well as the potential implications for reproductive, maternal, child, and neonatal health and nutrition. At this point let me also add diseases such as hypertension and diabetes.
It appears the implications for people living with viral hepatitis have not yet been well considered. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are estimated to affect 71 million people in sub-Saharan Africa, more than three times the number infected with HIV in the region, and comprising more than a fifth of the global burden of viral hepatitis. Only 1% of these individuals have been diagnosed. People with viral hepatitis-related liver disease in sub-Saharan Africa are likely to remain undiagnosed or to present at very late stages of disease. This is evidenced by sub-Saharan Africa having the highest death rate from liver cirrhosis in the world (32·2 deaths per 100000 population).
Although the presence of viral hepatitis does not seem to increase susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, there is increasing evidence that the innate immune response to SARS-CoV-2 infection results in liver damage. SARS-CoV-2 infection might therefore be an important risk factor for critical disease and severe outcomes in this large and under-diagnosed population living with viral hepatitis in sub-Saharan Africa. Additionally, poorly controlled HIV co-infection and chronic diseases (eg, hypertension and diabetes) are highly prevalent among individuals living with viral hepatitis in sub-Saharan Africa.
There are already considerable pressures on the health system that will have direct implications for the core interventions needed for viral hepatitis elimination. The overall reduction in the availability and use of routine health services is likely to substantially reduce case finding of early stage and asymptomatic viral hepatitis infection among those at higher risk. Redeployment of laboratory equipment, infrastructure, and personnel for SARS-CoV-2 diagnosis is a crucial component of the pandemic response. However, such actions have been seen to affect the availability of the already limited PCR based testing for viral hepatitis in some countries within the sub-region.
Routine vaccination for HBV in sub-Saharan Africa which has shown steady progress over the past decade, is still lacking adequate coverage in many sub-regions. It is highly vulnerable to disruptions in core health system functioning and community perceptions of vaccine risks and benefits. Birth-dose HBV vaccine, still scarce in most parts of sub-Saharan Africa, is a central focus of elimination efforts but faces challenges such as an increase in the frequency of home deliveries, the breakdown of complicated cold-chain requirements, and shifting of government priorities and financing.
The collateral damage incurred by the emergence of COVID-19 in sub-Saharan Africa is not limited to individuals with viral hepatitis. There will be widespread epidemiological, clinical, and socioeconomic consequences of the COVID-19 pandemic for people already living with a broad range of conditions in sub-Saharan Africa. However, the extremely under-diagnosed, highly prevalent, and severely advanced nature of liver disease due to viral hepatitis in sub-Saharan Africa requires careful attention.
The momentum towards viral hepatitis elimination in sub-Saharan Africa will need a new and highly focused approach to ensure that early gains in the coverage of core viral hepatitis interventions are not lost. Innovative implementation strategies and novel financing mechanisms to maintain and strengthen health systems in low-income countries are urgently required to tackle not only emerging pandemics, but also pre-existing ones.
Viral Hepatitis has become a major public health problem in Ghana. Surveillance data on clinical viral hepatitis from the Disease Surveillance Department shows an increasing annual trend of reported clinical viral hepatitis cases from all the ten regions of Ghana.Ghana belongs to the areas where the prevalence of chronic HBV infection is high (more than 8%) and that of hepatitis C virus is also high (5-10%).
The risk of developing cirrhosis increased 8-fold in patients with HBV infections than those without-National Guidelines for the Prevention, Care and Treatment of Viral Hepatitis, 2016. The COVID-19 pandemic will also negatively affect viral hepatitis elimination programmes.
The World Health Organization has set the goal of eliminating viral hepatitis B and C as major public health threats by 2030. This aim includes reducing their incidence, prevalence, morbidity and mortality by means of prevention measures, including hepatitis B vaccination, extensive screening and improved access to care and antiviral treatments. During the COVID-19 crisis, attention has been diverted from chronic viral hepatitis, despite the fact that global viral hepatitis mortality of about 1.5 million per year. Lockdown, quarantine and social distancing, closing of harm reduction and treatment facilities, including primary care settings and general practitioners, will probably hamper the major efforts made to achieve the viral hepatitis elimination goals in many areas, further increasing indirectCOVID-19-linked mortality (Jean-Michel Pawlotsky, “COVID-19 and the liver-related deaths to come”, Nat Rev Gastroenterol. Hepatol 2020 Jun 11:1-3).
DR. EDWARD O. AMPORFUL
CHIEF PHARMACIST
COCOA CLINIC