Liver disease: Study makes case for cheaper hepatitis B diagnosis

By Charles Mpaka:

Hepatitis B isn’t a popular language in Malawi’s disease profile.

Rarely does it pop up in disease burden discourse in the country. It is one of the neglected tropical diseases.

But, in its silence, the disease is inflicting misery, far more than can be imagined. Five percent of the adult population in Malawi is estimated to be infected by viral hepatitis.

And according to the World Health Organisation (WHO), dying from viral hepatitis in Africa is becoming a bigger threat than dying from HIV and Aids, malaria and tuberculosis.

Across the continent, fewer than one in 10 people have access to testing and treatment for hepatitis B, WHO says.

“So the disease often progresses to advanced liver disease with its associated catastrophic financial burden as well as emotional distress and stigmatisation,” says the WHO.

Now researchers have found that cheaper and more accessible blood testing methods – than those based on current WHO guidelines — can improve care of patients with chronic hepatitis B in Africa.

In a study, published in Nature Communications journal on January 3, 2023, the researchers reviewed data for 3,548 chronic hepatitis B patients living in eight sub- Saharan African countries namely Malawi, Burkina Faso, Ethiopia, The Gambia, Nigeria, Senegal, South Africa and Zambia.

Lead author of the study, Asgeir Johannessen, tells Malawi News in an email that clinicians working in Africa have “repeatedly reported that very few patients” are eligible for treatment using the current WHO guidelines published in 2015.

According to the study, Africa represents one of the high burden regions for chronic hepatitis B virus: Of the estimated 316 million people that live with chronic hepatitis B virus infection worldwide, 82 million of them are in Africa.

The research further says that antiviral therapy effectively reduces the risk of complications resulting from hepatitis B virus infection.

But with current WHO-recommended guidelines, treatment is delayed because it is only subject to evidence of advanced liver damage usually shown by elevated hepatitis B virus in the blood.

The challenge in clinical practice in Africa, however, has been to identify patients at risk of progressive liver disease who should start antiviral therapy in good time.

“In resource-limited settings, these fibrosis assessment tools [developed on the basis of current WHO guidelines] are rarely available, and antiviral treatment is therefore often delayed until the patients have developed symptoms of advanced chronic liver disease,” it says.

So 23 researchers set out to deal with this question: “Can we diagnose advanced liver fibrosis in the Africa region, using routinely available and low-cost blood tests for patients with hepatitis B?” Says Alexander Stockdale, a member of the team and senior clinical lecturer at the University of Liverpool and Malawi Liverpool Wellcome Programme.

They evaluated the existing WHO treatment guidelines and examined data for over 3,000 hepatitis B patients.

They also reviewed a simple liver damage testing method developed in West Africa.

They found that the diagnosis level as set by the WHO “is inappropriately high in sub-Saharan Africa” which is often constrained by lack of resources.

The problem, the researchers say, is that the study that informed these WHO guidelines of 2015 was conducted among active chronic hepatitis C patients in the USA and on a very different patient population compared to African chronic hepatitis B patients.

Johannessen says lack of data from Africa to inform new methods has been a major challenge all along.

“We wanted to use African data from African patients to inform African treatment guidelines,” says Johannessen, a specialist in internal medicine and infectious diseases at the Institute of Clinical Medicine, University of Oslo in Norway.

The researchers who make up the Hepatitis B in Africa Collaborative Network (Hepsanet) believe that their findings are important in informing clinical practice in Sub-Saharan Africa and should be considered in the next revision of the WHO hepatitis B guidelines.

Johannessen says they have already shared their findings with the WHO and also the Centre for Disease Control (CDC) in Africa.

“We believe our findings will inspire the first ever African hepatitis B treatment guidelines, and even the WHO is now changing their guidelines because of our work,” he tells Malawi News in an email.

He says Africa is now the epicentre of the hepatitis B epidemic such that 2 of 3 new infections in the world occur on the African continent.

“To combat the hepatitis B pandemic in Africa we need African data to inform practice,” Johannessen says.

The study is the largest, most comprehensive and geographically representative analysis ever conducted in Africa.

Adamson Muula, Professor and Head of Community & Environmental Health at the Kamuzu University of Health Sciences (KUHES), says the study is vital in the fight against hepatitis B in Malawi and Africa in general.

Diagnosis of the disease on the continent has been a luxury, he says. In Malawi, for example, where an estimated five percent of the adults are said to be infected, virtually no screening or diagnostic system exists.

Muula who was not part of the research says individual patients may interact with the health system but more so when things are already out of hand when irreversible liver damage has already happened.

“Efforts to reduce the time at which diagnosis can happen are therefore commendable. This study adds guidance as to when such earlier diagnosis may be attained,” he says.

He says studies like this add to the impetus and arms the policy makers to make the right decisions in strengthening health systems to respond to their findings.

But he also throws the gauntlet on communities to take charge of such findings, instead of leaving action in the hands of “sometimes incapacitated policy makers’ hands”.

“The question should be what is the community saying about findings such as these? If we wait for policy makers to decide when they are going to invest in hepatitis B interventions, we will wait for the rest of our lifetimes.

“Time has come for community groups to work with the duty-bearers to the extent that hepatitis B is not a neglected tropical disease anymore,” he says.

The WHO’s goal is to have hepatitis eliminated by 2030.