Researchers have found that cheaper and more accessible blood testing methods can improve the care of patients with chronic hepatitis B in Africa.
In a study published in Nature Communications, the researchers recommend revising the current World Health Organization (WHO) guidelines on managing the condition.
“Our data are important for informing clinical practice in [Sub-Saharan Africa] and should be considered in the next revision of the WHO hepatitis B guidelines,” say the researchers who make up the Hepatitis B in Africa Collaborative Network (HEPSANET).
Lead author of the study, Asgeir Johannessen, tells IPS that clinicians working in Africa have “repeatedly reported that very few patients in Africa” are eligible for treatment using the current WHO guidelines published in 2015.
“The lack of data from Africa is a major challenge, and 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.
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 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, early diagnosis and treatment are impacted because often only picked up when there is advanced liver damage.
The challenge in clinical practice in Africa has been to identify patients at risk of progressive liver disease who should start antiviral therapy in good time.
“In resource-limited settings, however, these fibrosis assessment tools are rarely available, and antiviral treatment is therefore often delayed until the patients have developed symptoms of advanced chronic liver disease,” the research paper says.
So, the 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.
In the study, the 23 researchers reviewed data for 3,548 chronic hepatitis B patients living in eight sub-Saharan African countries, namely Burkina Faso, Ethiopia, The Gambia, Malawi, Nigeria, Senegal, South Africa, and Zambia.
They evaluated the existing WHO treatment guidelines and a simple liver damage biomarker developed in West Africa.
They established that the conventional hepatitis B care standards are unsuitable for patient management in Africa. They found that the diagnosis level as set by the WHO “is inappropriately high in sub-Saharan Africa,” which is often constrained by a lack of resources.
The problem, the researchers say, is that the existing WHO guidelines are not adapted for the African population.
The study that informed these guidelines was performed among active chronic hepatitis C patients in the USA, much older than Africa’s hepatitis B virus population and on a very different patient population compared to African chronic hepatitis B patients.
“Our data are important for informing clinical practice in SSA [Sub-Saharan Africa] and should be considered in the next revision of the WHO hepatitis B guidelines,” says Johannessen.
He says they have shared their findings with the WHO and 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 IPS.
“Africa is now the epicenter of the hepatitis B epidemic. In fact, 2 of 3 new infections occur on the African continent. To combat the hepatitis B pandemic in Africa, we need African data to inform practice,” Johannessen says.
Initially, the researchers thought their main challenge would be to get people to share data.
“But in fact, everyone we reached out to were eager to participate. It is obvious that this is a topic that feels like a priority to colleagues working throughout Africa,” he says.
The study is the largest, most comprehensive, and geographically representative analysis ever conducted in Africa.
“We, therefore, believe our results are generalizable,” the researchers conclude.
However, they admit some limitations of their study. For example, the method used to assess liver damage has been associated with technical limitations, including unsuccessful measurements reported in patients with certain health conditions such as obesity. The researchers did not ascertain the rates of failure of these tests.
“This may affect the overall applicability of our findings to the entire population with HBV,” they say.
But Adamson Muula, Professor and Head of Community and Environmental Health at the Kamuzu University of Health Sciences (KUHES) in Malawi, says in terms of the methodology used in this study, the systematic review of data was relevant in answering the question at hand.
“In the hierarchy of evidence, systematic reviews and meta-analyses are high up with respect to the rigor of the findings,” says Muula, who was not part of the research.
He noted, however, that there are downsides to this approach, including the fact that in the interpretation of the findings, there is an implicit sense that Africa is one place. Muula argues that African health systems can be different even within the same country.
Within a country, you can find a health system comparable with developed countries; others are more closely aligned to developing countries. The studies applied more to those with less sophisticated health systems.
Regardless, the study is vital, he acknowledges.
Hepatitis B diagnosis on the continent has been a luxury. In Malawi, for example, where 5 percent of the adults are estimated to be infected, virtually no screening or diagnostic system exists.
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.
“However, research is one thing, health systems strengthening another. Studies like this one add to the impetus and arm the policymakers to make the right decisions,” he says.
But he urges communities to take charge of these findings instead of leaving action in the hands of “sometimes incapacitated policymakers’ hands.”
“The question should be, what is the community saying about findings such as these? If we wait for policymakers 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.
IPS UN Bureau Report