Hepatitis in Cameroon

I. INTRODUCTION

Viral Hepatitis has become a public health challenge of global proportions. Although there are five distinct types of viral hepatitis (A, B, C, D, and E), chronic hepatitis B and C cause 95% of hepatitis-related sickness and untimely deaths [1]. In pregnant women, hepatitis E virus infection (HEV) has a higher case fatality rate[1].

The epidemic of viral hepatitis B and C affects 325 million people globally and is 10 times larger than the global HIV epidemic. Every day, more than 3600 people die of viral hepatitis-related liver disease, liver failure and liver cancer. In Africa, chronic viral hepatitis affects over 70 million Africans (60 million with hepatitis B and 10 million with hepatitis C)[1]. In Cameroon, the seroprevalence of hepatitis b infection is high, as it is estimated at 11.2%[2]. This prevalence vary from one area to another, from 5.08% to 6.4% in Dschang and Bamenda respectively[3,4]. Yet, despite the availability of diagnostic tools and effective treatment, over 90% of people living with hepatitis B and C in Africa lack much needed care. The situation is not different in Cameroon. The result is at least 200 000 deaths yearly in Africa[1].

II. OVERVIEW OF HEPATITIS

  • Definition

Hepatitis means inflammation of the liver[5]. Many illnesses and conditions such as drugs, alcohol, chemicals, autoimmune diseases and many viruses ( for instance, the virus causing mononucleosis and the cytomegalovirus) can inflame the liver. Most viruses, however, do not attack primarily the liver; the liver is just one of several organs that the viruses affect. When talking of viral hepatitis, we are using the definition that means hepatitis caused by a few specific viruses that primarily attack the liver and are responsible for about half of all human hepatitis. There are several hepatitis viruses; they have been named types A, B, C, D and E. The most common hepatitis viruses are types A, B, and C[5].

  • Risks Factors

People at risk of hepatitis are: health care professionals, sewage and water treatment workers, people with multiple sexual partners, intravenous drug users, HIV patients, people with hemophilia who receive blood clotting factors, people with lower socioeconomic status and low level of education[5].

  • Mode of transmission

The hepatitis B virus is transmitted through parenteral and percutaneous contact with the blood or other body fluids of an infected person. In highly endemic areas, hepatitis B is most commonly spread from mother to child at birth (perinatal transmission), or through horizontal transmission (exposure to infected blood), especially from an infected child to an uninfected child during the first 5 years of life. The development of chronic infection is very common in infants infected from their mothers or before the age of 5 years. Transmission of the virus may also occur through the reuse of contaminated or poorly sterilized needles and syringes either in health-care settings or among persons who inject drugs. In addition, infection can occur during medical, surgical and dental procedures, through tattooing, or through the use of razors and similar objects that are contaminated with infected blood. Sexual transmission of hepatitis B may occur, particularly in unvaccinated men who have sex with men and heterosexual persons with multiple sex partners or through contact with sex workers. The hepatitis B virus can survive outside the body for at least seven 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 [1].

The hepatitis C most common modes of infection are through parenteral exposure to blood, blood products and other body fluids. In Africa, the reuse or inadequate sterilization of medical equipment in health-care settings and the transfusion of unscreened blood and blood products  are the commonest routes of transmission. Sexual practices such as having multiple sexual partners and men who have sex with men are important routes of transmission especially in immunosuppressed populations like people living with HIV. Intravenous drug use has become an emerging concern for hepatitis C transmission in Africa. Mother to child transmission of HCV are less common except in pregnant women who are also injecting drug users [1].

Hepatitis C, like hepatitis B is not spread through breast milk, food, water or casual contact such as hugging, kissing and sharing food or drinks with an infected person [1].

  • Clinical presentation

The incubation period vary depending on the specific hepatitis virus. Hepatitis A virus has an incubation period of about 15 to 45 days; Hepatitis B virus from 45 to 160 days, and Hepatitis C virus from about 2 weeks to 6 months[5].

Many patients infected with HAV, HBV, and HCV have few or no symptoms of illness. For those who do develop symptoms of viral hepatitis, the most common are flu-like symptoms including: loss of appetite, nausea, vomiting, fever, weakness, tiredness and aching in the abdomen. Less common symptoms include: dark urine, light-colored stools and jaundice. In general, patient infected with hepatitis viruses will present with 2 forms of the disease:

ACUTE FULMINANT HEPATITIS

It is rare (less than 0.5% of adults) and usually affects patients infected with HAV and HBV. It presents with severe inflammation of the liver. These patients are extremely ill with the symptoms of acute hepatitis already described and the additional problems of confusion or coma, as well as bruising or bleeding. Up to 80% of people with acute fulminant hepatitis die within days to weeks[5].

CHRONIC HEPATITIS

Patients infected with HBV and HCV can develop chronic hepatitis which is defined as hepatitis that lasts longer than 6 months. In chronic hepatitis, the viruses live and multiply in the liver for years or decades causing chronic inflammation. For unknown reasons, these patients’ immune systems are unable to eradicate the viruses. Chronic hepatitis can lead to the development over time of liver cirrhosis (extensive liver scaring), liver failure and liver cancer[5].

  • Diagnosis

Hepatitis B: Laboratory diagnosis of hepatitis B infection focuses on the detection of the various hepatitis B antigens (hepatitis B surface antigen, HBsAg and hepatitis B e antigen, HBeAg) and antibodies (mainly antibodies to HBcAg). The presence of HBsAg identifies current infection (either acute or chronic) [5].

Hepatitis C: HCV infection is diagnosed by identification of HCV antibody (anti-HCV) developed by the body in response to HCV infection. This serological test identifies all persons who have been exposed to HCV infection and is unable to distinguish current infections from resolved infection. It becomes therefore important to test for a nucleic acid test for HCV ribonucleic acid (RNA) to confirm chronic infection given that about 30% of people infected with HCV spontaneously clear the infection by a strong immune response without the need for treatment. Although no longer infected, they will still test positive for anti-HCV antibodies [5].

  • Treatment

No treatment is needed for hepatitis A since the infection almost always resolves on its own. Nausea is common, though transient, and it is important to stay hydrated.

Treatment of acute viral hepatitis and chronic viral hepatitis are different. Treatment of acute viral hepatitis involves resting, relieving symptoms, and maintaining an adequate intake of fluids. Treatment of chronic viral hepatitis involves medications to eradicate the virus and taking measures to prevent further liver damage[5]. For instance, following the treatment of hepatitis C infection, 96% of patients can achieved a sustained virological response[6].

  • Prevention

Prevention of hepatitis involves measures to avoid exposure to the viruses, using immunoglobulin in the event of exposure, and vaccines. Administration of immunoglobulin is called passive protection because antibodies from patients who have had viral hepatitis are given to the patient. Vaccination is called active protection.

III. SITUATION OF HEPATITIS IN CAMEROON

In Cameroon, despite a high prevalence of hepatitis infection (10% for hepatitis B and 13% for hepatitis C)[7], there is no national program to fight against the infection. The major factors leading to the occurrence of hepatitis in the country are cost, insufficient medical supplies and personnel, as well as a lack of awareness.

Immunizations have been deployed by the Ministry of Public Health through the expanded program of immunization,  to help tackle the epidemic but ignorance, mostly in rural areas, continues to prevail [7]. And the vaccination coverage, even among the most expose population is not good (as about 1 out of 6 medical students had completed the HBV vaccination series [8]); this situation has worsen since the occurrence of the covid-19 pandemic.

Many NGO and community based organization are also involved in the fight against the disease by organising health promotion compaigns to raise awareness about the disease in the community. They obtained fair results as we noticed that knowledge of hepatitis b now vary from average to adequate[3,8].

In 2012, when hepatitis first began to encroach upon Cameroon, the government contacted a leading pharmaceutical company to negotiate a price reduction for medication to treat hepatitis in Cameroon. They successfully reached an agreement that decreased the cost of medication by 33 percent. In January 2016, more good news spread with the announcement of another reduction in price (one-third to as much as one-half of the cost). Still, the path to everyone with hepatitis in Cameroon receiving treatment is still a struggle. As of now, only 1.5 percent of those in need of hepatitis C medication are actually receiving drugs [7]. This tells us the long way we still have to go, to guaranty an adequate supply in drugs for patients infected by hepatitis viruses.

IV. CONCLUSION

The burden of hepatitis infection in Cameroon is high and need to be address. The Immunization program had help but is not as effective since the occurrence of the COVID-19 pandemic. As far as the management of hepatitis (treatment and prevention) is concerned, Cameroon still has a long way to go to reach an acceptable level of control of disease. The creation of a national program to fight against Hepatitis infections could be at the beginning of the solution.


Dr. Stanis FOWA TSANANG

REFERENCES

  1. Hepatitis [Internet]. WHO | Regional Office for Africa. [cited 2021 Jul 19]. Available from: https://www.afro.who.int/health-topics/hepatitis
  2. Bigna JJ, Amougou MA, Asangbeh SL, Kenne AM, Noumegni SRN, Ngo-Malabo ET, et al. Seroprevalence of hepatitis B virus infection in Cameroon: a systematic review and meta-analysis. BMJ Open. 2017 Jun 30;7(6):e015298.
  3. Samje M, Sop S, Tayou CT, Mbanya D. Knowledge, attitude and seropositivity of hepatitis B virus among blood donors in the Bamenda Regional Hospital Blood Bank, Cameroon. Pan Afr Med J [Internet]. 2021 May 12 [cited 2021 Jul 19];39(33). Available from: https://www.panafrican-med-journal.com/content/article/39/33/full
  4. Tadongfack TD, Keubo FRN, Bianke P. Hepatitis B infection in the rural area of Dschang, Cameroon: seroprevalence and associated factors. Pan Afr Med J. 2020 Aug 28;36:362.
  5. Viral Hepatitis A, B, C, D, E: Treatment, Symptoms, Causes & Types [Internet]. MedicineNet. [cited 2021 Jul 19]. Available from: https://www.medicinenet.com/viral_hepatitis/article.htm
  6. Coyer L, Njoya O, Njouom R, Mossus T, Kowo MP, Essomba F, et al. Achieving a high cure rate with direct‐acting antivirals for chronic Hepatitis C virus infection in Cameroon: a multi‐clinic demonstration project. Trop Med Int Health. 2020 Sep;25(9):1098–109.
  7. Reducing Medication Prices to Treat Hepatitis in Cameroon [Internet]. The Borgen Project. 2016 [cited 2021 Jul 19]. Available from: https://borgenproject.org/hepatitis-in-cameroon/

8. Aroke D, Kadia BM, Anutebeh EN, Belanquale CA, Misori GM, Awa A, et al. Awareness and Vaccine Coverage of Hepatitis B among Cameroonian Medical Students. BioMed Res Int. 2018;2018:3673289

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