By Manal Ghazzawi, BPharm (Hons), PharmD, FPCP, MPH
Hepatitis B is claiming lives of Sierra Leoneans, it is becoming a public health problem. Already it is a global health concern. Globally 350-400 million people are chronically infected with hepatitis B virus (defined as hepatitis B surface antigen positive for at least 6 months). Worldwide, more than 686,000 people die every year due to complications of hepatitis B, including cirrhosis and liver cancer.
Though data does not exist to verify this, Sierra Leone has a higher prevalence of hepatitis B than C. Due to the paucity of research in Sierra Leone, we do not know the current prevalence of hepatitis B in the country. However few statistics exist for different population groups; for children affected with hepatitis B ranges between 1.3% – 1.6%, health care workers 8.7%, pregnant females 11.3% and blood donors at Connaught hospital 15.2%.
During my training as a clinical pharmacist, I came across many patients infected with the virus at the Joint Medical Unit within the military hospital. To make matters worse most of these patients are co- infected with HIV. Adding more burden to the disease, because they will have to deal with the side effects of their drugs, and debilitating symptoms of both diseases. Statistics in Sierra Leone has confirmed, that up to 22% of those infected with hepatitis B are also living with HIV/AIDs.
Hepatitis B is a viral infection that is transmitted through blood and body fluids such as vaginal fluids and semen. Hence, it is transmitted through sex, sharing of contaminated sharp object (needles, razors e.t.c), blood transfusion, and mother to child during birth. There is not much evidence to show whether it is transmitted by sweat or sharing of kitchen utensils or even by kissing. The hepatitis B virus can survive outside the body for at least 7 days. During this time, the virus can still cause infection if it enters the body of a person who is not protected by the vaccine.
The incubation period of the hepatitis B virus is 75 days on average but can vary from 30 to 180 days. Due to the long incubation period, it is possible for an infected individual to be spreading the disease because he/she is asymptomatic. This is how the virus might be spreading at a faster rate, among many other factors. The virus may be detected within 30 to 60 days after infection and can persist and develop into chronic hepatitis B after 6 months.
People at risk of developing hepatitis B are:
- Infants born to infected mothers
- Sex partners of infected persons
- Persons with multiple sex partners
- Persons with a sexually transmitted disease (STD)
- Men who have sex with men
- Injection drug users
- Household contacts of infected persons
- Healthcare and public safety workers exposed to blood on the job
- Hemodialysis patients
- Residents and staff of facilities for developmentally disabled persons
- Travelers to regions with intermediate or high rates of Hepatitis B (HBsAg prevalence of ≥2%)
Signs and Symptoms:
- Loss of appetite
- Muscle pain and joint pain
- Upper right abdominal pain
- Dark urine
- Clay colored stool
Complications of chronic active hepatitis include chronic liver disease, cirrhosis of the liver and liver cancer.
Hepatitis B infection continues to rise among Sierra Leoneans and will continue to rise if precautionary measures are not taken among already infected patients and uninfected individuals. Also, some health facilities misdiagnose the infection on clinical grounds for malaria and typhoid since these infections manifest mimicking symptoms like fever, malaise, joint pain, loss of appetite etc. This translates into infected patients being treated wrongly with antimalarial agents, IV fluids and antibiotics leading to antimicrobial resistance, increased cost for patient, and reduced quality of life.
Consistent misdiagnosis of this infection will lead to increased viral load, causing chronic infective hepatitis B with symptoms showing early or late signs of liver damage. The national hepatitis task force, has formulated a treatment guideline in the management of viral Hepatitis (VH). Until that guideline is released to all health care facilities in the country, it is important that most health care workers educate themselves about prevention and proper management of VH, instead of over prescribing antiviral drugs when it is not needed and when they are not authorized to do so.
I cannot overemphasize the fact that not all those infected with the virus need an antiviral medication. I advise the public to seek the right health care advice, from specialists before accepting treatment not only for hepatitis but for any other disease.
For clinicians to decide whether to commence therapy or not, certain diagnostic criteria according to international guidelines must be met. Diagnostic tests such as liver function tests and identification of stage of the hepatitis B infection are available in Sierra Leone (but not easily accessible at all public hospitals nationwide).
More sophisticated tests like viral load determination, which is a diagnostic criterion in the management of hepatitis B is provided by a private facility, which costs about $160. This is nerve wrecking for people who cannot afford it and might need more than 3 months of their salary to pay for that. Thanks to Partners in Health at the Koidu Government hospital which is offering tremendous support in diagnosis and management for free.
Hepatitis B can only be managed but not curable. Those that are lucky with a strong immune system, can get infected and clear the virus completely and recover. Supportive treatment is only required for managing acute hepatitis B infection. Less than 4% of those infected become chronic, within this 4% some will become immune tolerant or have inactive chronic infection without evidence of active disease, hence asymptomatic and can be non-infectious. Those with chronic active infection can have symptoms of liver disease which is treated with antiviral medications to suppress viral load and disease progression. Patients infected with this virus should continue to eat a healthy balanced diet, avoid drinking alcohol and drugs that are toxic to the liver.
The best way to prevent hepatitis is to get vaccinated. The vaccine is not widely available and affordable, but can be accessible at some facilities, especially in Freetown. For those that cannot afford buying the vaccine, the best they could do, to stay out of trouble is sticking with one partner, use of condoms during sex, avoid sharing of sharp objects and blood transfusion from unscreened blood.
Introduction of the birth dose of hepatitis B vaccine for all babies have been introduced in many countries including Africa. China CDC in collaboration with the Ministry of Health and Sanitation (MOHS) is to implement that in Sierra Leone. However, the MOHS already provides HBV vaccine which is included in the pentavalent vaccine given at 6th, 10th and 14th week of a baby’s life.
Adoption of the birth dose is part of the global elimination strategy, to prevent mother-to-child transmission where a baby needs to be vaccinated within 12-24 hrs. This strategy is particularly important in prevention of new infections, because 90% of babies born from infected mothers will develop chronic hepatitis B which eventually could lead to liver cancer at their adult age.
The Ministry of Health and Sanitation (MOHS) needs to have a Viral Hepatitis (VH) elimination action plan where its focus is on 4 main goals:
Goal 1: To prevent new viral hepatitis infections, through awareness raising, capacity building of HCWs, address data gaps through surveillance, preventive for vulnerable groups,
Goal 2: Reduce deaths and improve the health of people living with VH by swift identification of those infected with VH. Improved access to quality care and treatment among those infected with VH, those coinfected with HIV/AIDS and intravenous drug users,
Goal 3: Reduce VH health disparities by partnering with and educating priority populations and their communities about viral hepatitis and the benefits of available prevention, care, and treatment.
Goal 4: Coordinate, monitor, and report on implementation of VH activities by strengthening timely availability and use of data.
Government and private health facilities should be able to provide more sophisticated laboratory investigations, which will aid in the proper management of Hepatitis B in Sierra Leone. Moreover, all health professionals should be dedicated to educating the public by increasing awareness about the disease and its prevention.
This is not only Government’s fight, but all of us, it takes the support and commitment of a broad mix of stakeholders i.e. the scientific community, community leaders, policy makers and the private sector. It is amazing how our national collective effort can create a massive impact towards elimination of VH by 2030.