•Dr Matthew Olumuyiwa Bojuwoye
A consultant gastroenterologist at the University of Ilorin Teaching Hospital and associate professor of medicine at the University of Ilorin, Dr Matthew Olumuyiwa Bojuwoye, in this interview speaks about viral hepatitis, a major cause of liver cancer, that many people are not aware of or how best, to stay protected from the virus that is prevalent in Nigeria, reports Nigerian Tribune.
Excerpts:
What is viral hepatitis and how rare or dangerous is the condition?
Viral hepatitis refers to the diffuse inflammation of the liver as a result of at least one of the viruses that have an affinity for the liver (the viral hepatitides). Inflammation is the body’s response to harmful agents such as pathogens, irritants or anything that appears to be harmful. When this occurs in the liver, it tends to be widespread, affecting the whole of the liver. In some, it may produce symptoms. However, in others, there may be an obvious symptom.
Basically, there are 5 major hepatitis viruses; these are hepatitis A, B, C, D and E. Three of these five viruses, that is, hepatitis B, C and D, tend to persist in the body for several years, causing chronic inflammation. However, hepatitis A and E only cause acute inflammation of the liver (that is, the inflammation does not last up to six months). Whenever the inflammation persists for at least 6 months, it has become chronic.
The different hepatitis viruses are not limited to Africa; they are actually worldwide. For instance, hepatitis B is more prevalent, especially in Sub-Saharan Africa. Worldwide estimates suggest that more than 2 billion people have been infected with HBV and that 248 million of these people are chronically infected.
In Nigeria, the prevalence of hepatitis B is between 10 and 14 per cent, meaning that more than 20 million Nigerians actually have hepatitis B infection.
Sadly, the majority of those who are infected are not aware of this because they have not been screened. Quite a sizable number of people have not even heard about the virus.
So, the priority is to create awareness so people know about the virus, know that there are screening tools and should go for screening.
Screening is not that expensive. Also, for those who are not infected, there is a potent vaccine that is capable of preventing hepatitis B infection.
There is a cure for hepatitis C. Egypt has the highest known hepatitis C virus (HCV) prevalence rate in the world, with over 14 per cent of its population affected. This high prevalence is primarily due to a history of unsterile injection equipment used for mass schistosomiasis treatment from the 1920s to 1980s. There is no cure for hepatitis B, but it can be managed in such a way that it does not cause significant damage to the liver or death that can result from such consequences.
Why is hepatitis B the leading cause of liver cancer globally even though it is a preventable disease?
It is still the leading cause of liver cancer because the level of awareness, especially in the developing countries, about hepatitis is low, screening rates are low and the practices that encourage its transmission are still prevalent. Transmission is through contact with infected blood and body fluids.
So, some cultural practices like administration of tribal marks, circumcision, female genital mutilation, traditional uvulectomy, and local manicure and pedicure encourage the transmission of the infection. Transmission can also be through sexual contact and from an infected mother to her baby during delivery (mother-to-child transmission or vertical transmission). Pregnant women are one of the target groups for hepatitis screening. Steps are taken to prevent those that are positive for hepatitis from transmitting the virus to their unborn child.
What are the risks the infection poses to the affected individual?
The liver, the largest internal organ in the body, is quite resilient and performs important functions in the body. The virus got its name from the fact that it has a predilection for the liver. When it enters the body, it tends to target the liver, where it causes inflammation. The extent of the inflammation depends on the age at which the person acquires the virus. When infection occurs before the age of 5 years, the immune system may not mount a sufficient response to produce symptoms.
However, the virus continues to multiply within the liver, posing significant risk to liver health in the future. Such individuals are at risk of developing liver cirrhosis and/or liver cancer.
However, if the infection is acquired in early adulthood or as an adult, they may develop acute viral hepatitis.
About 85 per cent of those who acquire it at this stage that develop viral hepatitis may actually go on to clear the virus and develop immunity. Another 10 to 15 per cent – even though they recover from the initial illness, the virus continues to persist in their body.
If the body is not able to get rid of the virus or the infection within 6 months, then we say it has become chronic viral hepatitis. Then, the patient needs to be on lifelong monitoring to ascertain when the best time is to institute treatment.
There are guidelines that specialists in liver care follow to determine who should be on treatment since there is no cure; it is all about preventing cirrhosis and liver cancer. Unlike hepatitis A, C, D, and E, which are RNA viruses, hepatitis B is a DNA virus. As such, it enters the nucleus of the liver cell and incorporates its DNA into that of the host. This makes it difficult for the body to get rid of the virus.
When people who are infected are identified, steps are taken to make sure that they don’t develop liver cirrhosis or liver cancer. Also, those who do not have the virus need to get vaccinated to protect them from getting infected. The vaccine is not useful for those who are already infected; they need to see a specialist for further evaluation and treatment when indicated.
What is the rule for health workers regarding hepatitis screening?
Hepatitis virus is endemic in Nigeria because its prevalence is high. While it may not be possible to screen the whole population, what can be done is to emphasise opportunities for screening, targeting groups that, by virtue of what they do, are particularly at risk, like health workers and emergency care workers, those with illnesses that require frequent blood transfusions, pregnant women, etc.
Screening can also be at the point of school entry, starting new jobs, travelling, before blood donation, pre-marriage screening or registering for antenatal care.
Screening of individuals about to get married is very important to ensure that if one of the couple is infected, the other partner who is not infected can be vaccinated.
A positive hepatitis test result comes with stigma, loss of job opportunities and travel restrictions from some countries. How can this be stopped?
That is the importance of health education; we still have many misconceptions about hepatitis that need to be dispelled in society. Some people still believe that hepatitis can be contracted by hugging, holding hands, sharing utensils and sleeping on the same bed. That is not the case. It boils down to a lack of knowledge about the virus and how it is transmitted.
For intending couples, all they need to do is to ascertain how much of that virus is in the infected individual. The higher the viral load, the greater the risk of the affected individual developing serious disease, and the higher the risk of transmission to other people.
So, the partner with the high viral load is placed on treatment. The fact that one of the intending couple is infected does not mean that they cannot go ahead and get married.
Can women positive for hepatitis B get pregnant and carry the baby to term? Are there precautions you need to take to ensure that you don’t pass it on to your child?
A woman who has hepatitis B can actually get pregnant; all she needs to do is to make sure that she is in contact with the doctor who is a specialist in managing hepatitis B (gastroenterologist) and then, of course, the obstetrician and gynaecologist. The recommendation is that all pregnant women are screened for hepatitis at antenatal booking, although this is still not widely practised in Nigeria.
Oftentimes, the woman is not ill from the virus. Our priority usually is to prevent mother-to-child transmission of the virus. Tests are done to know if her viral load is high or low. Antiviral therapy is given to those with high viral loads to lower the chances of the baby getting it during delivery. The antiviral medication usually prescribed is safe in pregnancy. At birth, the child is vaccinated.
There are two types of vaccines: the passive immunization and the active immunization. The hepatitis B vaccine that provides active immunization has been incorporated into the National Programme for Immunization. It is given to all babies irrespective of the status of their mothers. Babies born to hepatitis B-positive mothers may need passive immunization in addition to active immunization, and it should be given within 24 hours of birth, so the prevention of the virus from mother-to-child transmission is actually achievable.
Are these statements, “viral hepatitis can be transmitted through breastfeeding”, “viral hepatitis only affects a group of people”, “there is no treatment for viral hepatitis”, and “all cases of hepatitis have no symptoms”, true? If they are true, can you explain?
Well, the virus has been isolated in blood but also other body fluids, and breast milk is one of such. However, breast milk actually is very beneficial for the baby to fight infections and provide nourishment.
So mothers that are hepatitis B positive should actually breastfeed their babies. There shouldn’t be any fear once they have taken the steps to ensure the baby is prevented from getting the virus. The baby is also vaccinated. The vaccine is more than 95 per cent effective.
In your practice, what are the common things you encounter in your practice that you want to disabuse the minds of Nigerians of regarding viral hepatitis?
There are claims on the internet that the virus is curable; sometimes patients are being sold supplements at a high cost, claiming that the infection will be cured. It is wrong. As of now, once the infection has been established, it is not curable.
We don’t have any medications that provide a cure for hepatitis B. With adequate follow-up, evaluation and monitoring, liver cirrhosis and liver cancer from hepatitis B can be prevented.
Beliefs that someone can contract hepatitis through hugging, staying in the same room, or sleeping in the same bed with an infected person are false. This is not true.
However, people shouldn’t share sharps like manicure or pedicure sets, razor blades and clippers for cutting hair. And of course circumcision is better done in the hospital. Female genital mutilation should be discouraged totally; it carries a lot of risks, including transmission of hepatitis B.
