Hepatitis on the prowl in Nigeria
TWENTY NINE year-old Obinna Okwute was battling with feverish conditions, headaches and bodily pains for sometime. “I have taken the best of malaria drugs and I am not feeling better,” he told a friend. Obinna died two months later of liver damage caused by hepatitis infection. Obinna was one of the estimated 20 million Nigerians infected with hepatitis and one of the five million that die annually.
Hepatitis, is an inflammation of the liver due to the presence of toxic substances or infections caused by a protozoan parasite or viruses. People affected by viral hepatitis usually recover, but some continue to carry the virus for many years and can spread the infection to others.
These are chronic carriers. Chronic hepatitis may persist for years and lead eventually to cirrhosis (destruction and replacement of liver cells by fibrous tissue).
A substantial number of cirrhotic end up with liver cancer. Chronic carriers serve as an important source of new infections; most have no signs or symptoms and an estimated two-thirds are unaware of their status. It can be contracted from unsafe blood, unsafe injections, and sharing drug-injection equipment. Children born to mothers with hepatitis and sex partners of people with hepatitis are also at risk of becoming infected.
According to the Society for Gastroenterology and Hepatology in Nigeria (SOGHIN), Hepatitis B virus (HBV) is 50 to100 times more infectious than Human Immuno-deficiency Virus (HIV) and it is estimated that over two billion people are infected worldwide and approximately one million deaths occur annually from HBV related illnesses.
Formed in September 2007, SOGHIN is a professional body made up of Nigerian physicians, surgeons, pathologists and allied health professionals dedicated to the advancement of knowledge on the recognition, prevention, investigation and treatment of liver diseases.
Publicity Secretary of SOGHIN, Dr. Uchenna Ijemo, said: “There are 300 to 400 million carriers of HBV in the world. Several studies have demonstrated that HBV is endemic in Nigeria and have also shown the sero-prevalence among various groups. About 170 million people are infected with hepatitis C virus. “Studies carried out in Nigeria have put the burden of Hepatitis B in most Nigerian cities to an average of 13 per cent translating to an estimated 20 million people infected. This means that at least one of every 10 Nigerian is a chronic carrier of hepatitis B and not only at risk of liver diseases and death but also at risk of transmitting it to others.
It is estimated that about five million die annually due to the consequences of this disease “Viral hepatitis is described as a ‘silent killer’ because most persons do not realize that they are infected and usually are without any clinical symptoms.
Over decades, the disease slowly progress to damage the liver. Symptoms of disease appear in advanced stages of disease when the effect of medical care will be limited.” In addition to hepatitis B and C, hepatitis A and E viruses also cause viral hepatitis.
These two viruses are primarily transmitted through contact with contaminated food and water and are responsible for less than one per cent of all hepatitis-related deaths.
Nigeria on Tuesday, July 28, 2015, on the occasion of the World Hepatitis Day, joined the rest of the world to draw global attention to the plights of over 400 million patients living with Hepatitis B or C worldwide and the over 1.4 million people that would be lost to the virus this year.
The theme of the 2015 World Hepatitis is Prevent Hepatitis: Act Now. By the adoption of a resolution during the 63rd World Health Assembly in May 2010, the World Hepatitis Day was endorsed to be globally celebrated on July 28 in honour of the 1976 Nobel Laureate Baruch Samuel Blumberg for his outstanding work on the discovery and effective test for Hepatitis B.
The World Hepatitis day is currently recognized in over 100 WHO member countries with millions of people across the world taking part.
Medical experts including those from the World Health Organisation (WHO), SOGHIN, World Hepatitis Alliance, Nigerian Institute for Medical Research (NIMR), and the Federal Ministry of Health say these needless, preventable deaths are often unreported or misclassified as deaths after a “brief illness” since Hepatitis B and C symptoms only become obvious few days or weeks to the death of the patient.
They say there is need to educate the population about Hepatitis B and C especially on the need to prevent infection since unlike HIV, tuberculosis (TB) and malaria, which are backed by donor funds, control is not yet subsidised and patients have to bear the cost of their testing, vaccine and of course treatment for those who must be on treatment.
The experts say the infection can also be innocuous in many patients and may even be eradicated in some cases by the body’s immune system without treatment. “But you need to be armed with the right information about this disease,” they say.
So, how do you know when the virus has become acute or chronic and to the point of becoming a terminal disease? How do you know your body is fighting the disease and there is no cause for alarm? How do you know when you are at risk of being infected or passing on the Hepatitis virus? What treatment options are available to a patient infected with Hepatitis B or C and what are the chances of treatment success? At what point can you say, “This patient cannot be helped?” Education and public enlightenment makes all the difference.
And that is what this year’s World Hepatitis Day is all about. But this time with a little slant on improving access to quality treatment and prevention services. Growing burden Researchers have long known that patients with hepatitis C are at increased risk of liver cancer. But a new study recently presented at the European Association for the Study of the Liver’s 50th International Liver Congress in Vienna, Austria, finds hepatitis C virus (HCV) may also raise the risk of developing other cancers.
The researchers calculated that patients with HCV were 2.5 times more likely than non-HCV patients to be diagnosed with cancer, including liver cancer, and at two times higher risk of cancer when liver cancer was excluded.
According to the Centers for Disease Control and Prevention (CDC), most people become infected with HCV by sharing needles or other drug-injecting equipment.
Though less common, HCV can also be spread through having sexual contact with an infected person, sharing personal care items – such as toothbrushes and razors – that may have come into contact with the blood of an infected individual, or being born to a mother with hepatitis C. It is well established that infection with HCV can increase a person’s risk of liver cancer.
The CDC state that one to five in every 100 people with HCV die from liver cirrhosis (scarring of the liver tissue) or liver cancer. Meanwhile, the WHO has highlighted the urgent need for countries to enhance action to prevent viral hepatitis infection and to ensure that people who have been infected are diagnosed and offered treatment.
The WHO, in a press statement said it is focusing particularly on hepatitis B and C, which together cause approximately 80 per cent of all liver cancer deaths and kill close to 1.4 million people every year.
To curb the rising cases of the viral infection, the WHO recommends among other things that people should: Know their risks; demand safe injections; get vaccinated; get tested and seek treatment.
WHO is alerting people to the risks of contracting hepatitis from unsafe blood, unsafe injections, and sharing drug-injection equipment.
Some 11 million people who inject drugs have hepatitis B or C infection. Children born to mothers with hepatitis B or C and sex partners of people with hepatitis are also at risk of becoming infected.
The organisation emphasises the need for all health services to reduce risks by using only sterile equipment for injections and other medical procedures, to test all donated blood and blood components for hepatitis B and C (as well as HIV and syphilis) and to promote the use of the hepatitis B vaccine. Safer sex practices, including minimising the number of partners and using barrier protective measures (condoms), also protect against transmission.
Demand safe injections According to the WHO, approximately, two million people, a year, contract hepatitis from unsafe injections. These infections can be averted through the use of sterile syringes that are specifically designed to prevent reuse. The WHO noted that eliminating unnecessary injections is also an effective strategy to protect against hepatitis transmission. There are 16 billion injections administered every year.
Around five per cent of these injections are for immunisation, a further five per cent for procedures like blood transfusions and injectable contraceptives, and the remaining 90 per cent to administer medicines. For many diseases, injections are not the first recommended course of treatment and oral medications could be used.
Recommendations SOGHIN urges all Nigerians to pay attention to the following key preventive messages: •Knowing the risks: Unsafe blood, unsafe injections, sharing of sharps including drug injection equipment can all result in hepatitis •Demand safe injections: About two million people contact hepatitis from unsafe injections.
Using sterile single use disposable syringes can prevent these infections. Approximately 8 billion injections are given unnecessarily globally and unnecessary injections increase the risks.
•Vaccinate children as well as adults: A safe and effective vaccine can be given and this protects from hepatitis B for life.
•Get tested, seek treatment. Effective treatment options exist for hepatitis B and cure for hepatitis C It is important to: Talk to your doctor about testing you for hepatitis virus infection, irrespective of your health status and about receiving a vaccine to prevent hepatitis B if you test negative for the virus. All pregnant women should be screened for hepatitis with a view to protecting the yet-unborn baby To prevent being infected by hepatitis viruses, paying attention to the following will be helpful
•Avoid sharing personal items such as razors or toothbrushes. •Do not share needles or other drug equipment (such as straws for snorting drugs). •Clean blood spills with dilute household bleach.
•Avoid getting tattoos, body piercings and circumcision with poorly sterilized instruments. •Avoid unsafe and unnecessary injections. •Avoid transfusion of unscreened blood and other blood products.
•Avoid casual and unprotected sexual intercourse SOGHIN wants Nigerians to be aware that viral hepatitis is eminently preventable and by embracing the preventive strategies outlined above. “We can control this disease in our country and reduce its burden on our society.
This way also we can prevent the personal misery and suffering that chronic hepatitis, cirrhosis and liver cancer bestow on affected individuals,” Ijemo said. WHO recommends vaccinating all children against hepatitis B infection, from which approximately 780, 000 people die each year.
A safe and effective vaccine can protect from hepatitis B infection for life. Ideally, the vaccine should be given as soon as possible after birth, preferably within 24 hours. The birth dose should be followed by two or three doses to complete the vaccine series. WHO also recommends vaccinating adults who are at increased risk of acquiring hepatitis B.
These include people who frequently require blood or blood products (for example dialysis patients), health-care workers, people who inject drugs, household and sexual contacts of people with chronic hepatitis B, and people with multiple sexual partners.
According to the WHO, since 1982, over one billion doses of hepatitis B vaccine have been used worldwide and millions of future deaths from liver cancer and cirrhosis have been prevented. In a number of countries where around one in 10 children used to become chronically infected with the hepatitis B virus, vaccination has reduced the rate of chronic infection to less than 1 in 100 among immunised children.
To date, there is no available vaccine against hepatitis C. Medicines are now available that can cure most people with hepatitis C and control hepatitis B infection. People who receive these medicines are much less likely to die from liver cancer and cirrhosis and much less likely to transmit the virus to others.
WHO, therefore, urged people who think they might have been exposed to hepatitis to get tested so they can find out whether they need treatment to improve their own health and reduce the risk of transmission. Earlier this year, WHO issued new guidelines for treatment of hepatitis B infection.
These recommend using simple non-invasive tests to assess the stage of liver disease to help identify who needs treatment. WHO also calls for prioritising treatment for those with cirrhosis – the most advanced stage of liver disease and for the use of two safe and highly effective medicines, tenofovir or entecavir.
Continued monitoring using simple tests is important to assess whether treatment is working, and if it can be stopped. In 2014, WHO issued guidance for testing and treatment of hepatitis C infection.
WHO recommends providing testing for people considered at high risk of infection and ensuring treatment for those who have the virus with several effective medicines, including new regimens that use only oral medicines.
WHO will update recommendations on drug treatments periodically as new antiviral medicines become available and as new evidence emerges.
Weight loss for a healthy liver Weight loss through both lifestyle modification and bariatric surgery can significantly reduce features of nonalcoholic steatohepatitis (NASH), a disease characterized by fat in the liver, according to two new studies published in Gastroenterology, the official journal of the American Gastroenterological Association.
Lifestyle modifications: Eduardo Vilar-Gomez and colleagues from Cuba report in Gastroenterology that a weight reduction of 10 percent or more, induced by a comprehensive lifestyle program, is necessary to bring about NASH resolution and reverse scarring of the liver in overweight and obese patients.
To a lesser degree, modest weight loss (seven to 10 percent) reduced disease severity in certain subsets of patients, including male patients and those without diabetes. Conversely, 93 percent of the patients with little or no weight reduction (less than five percent) experienced worsening of liver scarring.
This is the first large prospective study conducted in real-world clinical practice that explores the potential benefit of a 12-month lifestyle intervention on NASH-related features, as well as the cut off points for positive outcomes. While promising, less than 50 percent of patients achieved the necessary weight loss goal of seven to 10 percent, providing a stark reminder of the sustainability of weight loss interventions.
Going forward Stem cell therapy for liver failure could replace liver transplants For the first time, scientists have restored organ function in a severely damaged liver in a live animal by transplanting lab-grown stem cells. The achievement brings closer the day when cell-based therapies that regenerate the organ replace the need for liver transplants.
The study brings closer the day when cell therapies that regenerate liver tissue replace the need for liver transplants. In the journal Nature Cell Biology, the researchers describe what happened when they transplanted liver stem cells into mice with severely damaged livers.
Over the ensuing months, the cells spurred major areas of the liver to regrow, improving the structure and function of the animals’ organs.
The liver is generally very good at healing itself. This is because it contains cells called hepatocytes that are capable of self-renewal following injury. However, these cells are less capable of self-renewal following severe injury, such as that caused by conditions like cirrhosis and acute liver failure.
Also, hepatocytes are not easy to grow under lab conditions, which limits their potential for transplant. That is why the team decided to find out whether liver stem cells – called hepatic progenitor cells (HPCs) – can regenerate liver tissue.
HPCs are much easier to grow in the lab, and they have the flexibility to transform into hepatocytes and other types of liver cells. Investing in hepatitis C drugs could save the economy billions, researchers suggest Researchers who examined the effect of treating hepatitis C patients with the newer generation of oral drugs suggest while these medications may cost tens of thousands of dollars for a 12-week course, they could avert billions in lost productivity.
The drugs interfere with enzymes that help hepatitis C multiply. They conclude that the higher cure rate and reduced side effects of treating hepatitis C patients with an all-oral combination of ledipasvir and sofosbuvir (LDV/SOF) led to substantially less absenteeism and better work productivity that could save economies of the US and five European countries more than $3.2 billion a year.
The study featured at Digestive Disease Week 2015, an international gathering being held May 17-19 in Washington DC of clinicians and researchers from gastroenterology, hepatology, endoscopy and gastrointestinal surgery. Drugs produce high hepatitis C eradication rates, even in liver-diseased patients A course of new antiviral drugs in a clinical trial has resulted in almost all the patients with chronic hepatitis C infection becoming virus-free, even those whose disease meant they had scarring of the liver and so were at transplant or cancer risk.
Hepatitis C virus was eliminated for most patients whose chronic infection had led to liver scarring. The direct-acting medicines, designed against the genotype 1 virus, the most common hepatitis C (HCV) infection in the US, also worked in people with chronic infection but no liver cirrhosis.
The results of the two trials of the drugs used in combination – daclatasvir, asunaprevir and beclabuvir – are published online by JAMA.
The trials, one including people with liver disease, the other without, both saw eradication rates of around 90 per cent and more against a measure of aviremia called sustained virologic response (SVR). Malaria’s key to the liver uncovered Scientists uncover a port of liver entry for malaria parasites in a report published in The Journal of Experimental Medicine.
If these results hold up in humans, drugs that target this entry protein might help prevent the spread of disease. The first stop for malaria parasites in humans is the liver, where a few organisms multiply into tens of thousands, which are then released into the bloodstream.
Passage through the liver is essential for the parasite to establish a productive infection and cause disease, and the bug’s entry route has been traced to specialized liver cells called Kupffer cells. But exactly how the parasite traverses these cells is not clear.
A team of scientists at Johns Hopkins Bloomberg School of Public Health now find that a Kupffer cell protein called CD68 is needed for parasite passage and efficient liver infection, as mice lacking CD68 had 70 per cent fewer parasites in their livers compared to intact animals.
If this reduction is sufficient to substantially limit blood infections (and thus disease), CD68 may represent a potential new drug target in the fight against malaria.