‘Hepatitis is a silent killer’

“It’s silent, it’s there, and there are simple interventions to turn the tide; that is why we are here today,” said Professor Mark Sonderup of the University of Cape Town (UCT) at a media briefing held in Cape Town on Friday, 28 July, to mark World Hepatitis Day – and to raise awareness about a disease that is widely viewed among healthcare professionals as a “silent killer”.

Arranged by Professor Sonderup, a hepatologist based at Groote Schuur Hospital and UCT, in association with the Gastroenterology and Hepatology Association of Sub-Saharan Africa, the briefing featured a panel of medical experts who issued an urgent call to accelerate testing and treatment for viral hepatitis.

Among other concerns, they emphasised the need for more readily available screening to curb the high prevalence of hepatitis-related liver cancer, the need to raise the level of advocacy to that of other infectious diseases such as COVID-19, and the need for the hepatitis B vaccine to be administered more effectively.

“Africa cannot wait. We cannot wait as clinicians, and our patients cannot wait to find out their status and get access to care.”

Hepatitis B is spread through contact with an infected person’s blood or body fluids. It can be transmitted from mother to child at birth or in early childhood. This asymptomatic disease goes largely undetected until adulthood, when it often presents with advanced symptoms such as multifocal tumours in the liver, or cirrhosis of the liver.

Africa has one of the world’s highest incidences of liver cancer caused by hepatitis B: it is the second-most and third-most common cause of cancer-related death in men and women respectively in sub-Saharan Africa. In South Africa, about 2.8 million people have hepatitis B, though only 20% have been diagnosed and a mere 1% are being treated. These are devastating statistics considering that hepatitis C is curable in more than 95% of cases, while hepatitis B is a vaccine-preventable disease and treatable.

Elimination goals

In response to the public health threat that viral hepatitis poses, the World Health Organization (WHO) has promulgated guidelines to expand and ease treatment and has set elimination targets for 2030 to decrease new infections by 90% and deaths by 65%.

“This will require us to diagnose 90% and treat 80%; but we are lagging far behind in Africa, despite there being effective anti-viral therapy and a life-changing hepatitis B vaccine,” said Professor Wendy Spearman, the head of Hepatology at UCT and Groote Schuur Hospital, who co-chairs the WHO’s new guidelines.

Professor Spearman called for the same level of awareness, advocacy and healthcare policies that exist for HIV, tuberculosis (TB) and malaria to be extended to hepatitis.

“We need commitment from Department of Health policymakers and industry in terms of the pricing of drugs and diagnosis,” she said. “There’s a lot to be done, and a lot that we can do; but it requires us as a community – healthcare workers and policymakers, driven by advocacy groups – to ensure that we move towards the 2030 goals.”

Africa’s burden of disease

Liver transplant specialist Dr Bilal Bobat outlined the typical pattern of liver cancer in sub-Saharan Africa, which he said has not changed much in 40 years, with little improvement in therapies and survival. Young people in their thirties continue to present with advanced disease, and about half of patients diagnosed with hepatocellular carcinoma (the most common type of primary liver cancer) die within three to four months. He added that new treatments are expensive, and transplant options are not available to many.

“Africa cannot wait,” Dr Bobat said. “We cannot wait as clinicians, and our patients cannot wait to find out their status and get access to care. This is why hepatitis B and C awareness needs to be brought to the forefront.”

“Mortality from hepatitis B, C and D (Delta) has overtaken the combined mortality of HIV, TB and malaria.”

Emeritus Professor of Medicine Geoffrey Dusheiko, a consultant hepatologist at King’s College Hospital, London, pointed out that hepatitis B and C have not attracted the kind of advocacy and funding that emerged with the onset of HIV, deeming lukewarm efforts to address the spread of viral hepatitis as the “public health failing of the 20th century”.

“Mortality from hepatitis B, C and D (Delta) has overtaken the combined mortality of HIV, TB and malaria,” he said. “Yet the diagnosis is simple. Relatively inexpensive point-of-care tests are available, as well as tests for antibodies. We need to draw attention to the disease, encourage people to be tested, and encourage government to step up funding and efforts to link people to care.”

Africa-based research

Africa-specific research must also be scaled up. Dr Eduard Jonas, the head of Surgical Gastroenterology at UCT and Groote Schuur Hospital, said: “We’re probably dealing with a different disease in sub-Saharan Africa, with only 1% of research being done in Africa.” In addition, the data that does exist is probably the result of an underreporting of cases, meaning we don’t know what the actual burden of disease is in our societies.

“We have a unique clinical expression of the disease, which differs in the Western world,” explained Professor Mashiko Setshedi, the head of Medical Gastroenterology at UCT and Groote Schuur Hospital. “There’s a lot we don’t understand about the biology of the disease and how it presents. We need to do research in our populations, to answer the questions that will help us advance therapies, diagnostics and outcomes, and improve the lives of our patients.”

The way forward

Other than the pressing need for advocacy and awareness, all the experts called for routine screening to be carried out, and for the hepatitis B vaccine to be rolled out and scheduled more effectively.

“Treating the infection can treat the cancer,” urged Dr Jonas; while Dr Neliswa Gogela, a hepatologist at UCT and Groote Schuur Hospital, recommended that pregnant mothers be screened to prevent the possible transmission of hepatitis B to their children, and that newborns of women with the disease receive a birth-dose vaccine.

“In 2000 we were facing HIV, and we were saying the same things,” Sonderup said. “HIV showed us what can be done.”