With a staggering 8.1% and 1.1% of Nigerians living with Hepatitis B and C respectively, there is an urgent need to invest in Eliminating Viral Hepatitis in Nigeria. This article objectively discusses the burden, mortality and impact of viral hepatitis as well as strategies to eliminating this global killer in Nigeria.
What is Viral Hepatitis?
Viral Hepatitis is the inflammation of the Liver which is caused by a set of viruses collectively known as Hepatitis viruses. While Hepatitis A and E are self-limiting and would go within the first six months of infection, Hepatitis B and C can progress into chronic condition which if left untreated can result in severe liver damage with complications such as Cirrhosis, Failure or Cancer and ultimately, death.
Global Data on Viral Hepatitis Burden
Globally, over 2 billion are affected by viral hepatitis which currently infects over 325 million people across the world. Of this number, over 60% of the global burden is in developing countries. Nigeria ranks among the highest in viral hepatitis burden in the world. Every year, over 1.34 million people die because of viral hepatitis.
This mortality is higher than that associated with HIV, Malaria or Tuberculosis. Viral hepatitis account for over 90% of all deaths resulting from Liver diseases and is a major contributor to cancer burden in the world. Across the world, less than 10% of people living with viral hepatitis have access to diagnosis and treatment. Less than 9% of the global population are aware of viral hepatitis. These shortcomings have accounted for a perpetual increase in new infections yearly across the world.
The Burden of Viral Hepatitis in Nigerian
In Nigeria, available statistics reveals that an estimated 24.5 million people are living with viral hepatitis B and C. According to studies carried out in recent years, about 11.3% and 2.2% of Nigerians are living with Hepatitis B and C respectively. Based on the most recent population estimate of Nigeria, we can say that 1 in every 9 Nigerians is living with viral hepatitis. Unfortunately, research in recent years has revealed that less than 5% of the over 24.5 million Nigerians living with viral hepatitis have access to treatment and care.
In fact, a recent study carried out in Lagos and Cross River State has shown that over 90% of people living with viral hepatitis in Nigeria are not aware that they have the virus. This is largely due to poor access to diagnosis for viral hepatitis. Most worrisome is the fact that a research carried out by Trinity Healthcare Foundation in 2017 revealed that a good number of health workers in Nigeria have not been tested for viral hepatitis let alone be vaccinated even though they constitute some of the at-risk group of individuals by virtue of their profession.
Furthermore, a study carried out by THF and published at the 2017 World Hepatitis Summit revealed that the high level of ignorance on viral hepatitis among pregnant women might be directly responsible for the perpetual increase in perinatal transmission of Hepatitis B in some parts of the country particularly the northern region.
According to the Multi-Indicator Cluster Survey carried out by UNICEF in 2017, less than 23% of infants born in Nigeria are fully immunized against vaccine-preventable diseases such as Hepatitis B. This is due to the high level of ignorance about this global killer disease. In fact, experts have estimated that only about 5% of the entire Nigerian population are aware of viral hepatitis.
A combination of extremely low awareness level, poor access to diagnosis and treatment as well as prevention of viral hepatitis is responsible for the perpetual increase in the burden of viral hepatitis in Nigeria. According to recent estimates, Nigeria has the highest burden of Hepatitis B in Africa and contributes 13% of the global burden of the disease.
Experts have projected that if nothing urgent is done, a third of the Nigerian population may be living with viral hepatitis by the year 2030.
In response to the global burden of viral hepatitis, at the 2016 World Health Assembly, the United Nations drew up a Global Health Sector Strategy on viral hepatitis which called on every country to develop National Action Plans to eliminate viral hepatitis as a public health threat by the year 2030.
This global compact stipulated that by the year 2030, there should be a 90% decrease in new infections and 65% of people living with viral hepatitis must be treated while at least 80% of people living with the disease must have access to diagnosis. This compact also demanded the commitment of member countries to invest in eliminating viral hepatitis by improving access to diagnosis, prevention and treatment of viral hepatitis. The Elimination goal was therefore expected to be achieved by all member countries by the year 2030.
Sequel to this global compact, the Federal Ministry of Health in Nigeria developed a National Guideline for the Prevention, Diagnosis, Treatment and Care for Viral Hepatitis which served as a template for healthcare providers in managing cases of viral hepatitis. Unfortunately, little or no tangible investment has been made in addressing the challenges facing the prevention, diagnosis and treatment of viral hepatitis in Nigeria. In fact, despite the efforts of some donor Organizations like the Clinton Health Access Initiative, Gilead Sciences, etc., many people living with viral hepatitis in Nigeria do not have access to affordable diagnosis and treatment of Hepatitis B and C.
Hitherto, despite the commitment of the Global Vaccine Alliance GAVI, no more than 27.1% of infants born in Nigeria have access to the universal birth dose Hepatitis vaccine. This is far below the benchmark stipulated by the World Health Organization. This means that over 70% of newborns are at risk of contracting the deadly Hepatitis B virus. Till date, the National Health Insurance Scheme does not cover viral hepatitis services which means that patients still pay out of pocket for these services which are very unaffordable.
The high level of ignorance and erroneous perception about viral hepatitis occasioned by poor patient and public education has accounted for an unprecedented high level of stigmatization; a situation that has prevented several hepatitis patients from seeking treatment. The latter has been responsible for the high mortality and transmission rate of the virus in Nigeria.
In September 2019, the United Nations General Assembly adopted viral hepatitis as a critical component of the Universal Health Coverage (UHC) political declaration during the United Nations High Level Meeting on UHC. This compact call on all member countries to ensure that everyone everywhere has unhindered access to affordable diagnosis prevention and treatment of viral hepatitis at every time. This can only be achieved through deliberate and strategic investment in viral hepatitis services.
Moreover, now that it is a well-known fact that viral hepatitis kills more people than HIV, Malaria or Tuberculosis, it is even more important that priority be given to the provision of high quality healthcare services to people living with viral hepatitis. Experts have projected that with the current investment portfolio dedicated to viral hepatitis in Nigeria, elimination is not possible even in the coming decades.
For us to be on track towards eliminating Viral Hepatitis in Nigeria, we must not only invest meaningfully in scaling up the current level of care but equally design and implement a national action plan to improve Awareness, Prevention, Diagnosis, Treatment and Care for people living with viral hepatitis. We must increase budgetary allocation for the procurement of life-saving vaccines for both infants and at-risk adults; drugs; diagnostic apparatuses; surgical facilities for patients who may require transplant; training of health professionals as well as provision of job aids and commensurable remuneration package for healthcare providers.
To ensure affordability, accessibility and equity, we must incorporate viral hepatitis services into the National Health Insurance Scheme and integrate it with other services such as HIV, Tuberculosis to ensure optimization of resources.
Examples of Milestones Achieved by other UN Member Countries
While Nigeria has the highest burden of Hepatitis B in Africa, Egypt has the highest number of people living with Hepatitis C in Africa. In line with the Global Health Sector Strategy on viral hepatitis elimination, the Egyptian government launched a national action plan to eliminate the epidemic which culminated in the implementation of a nationwide campaign against Hepatitis C. In less than 3 years, the Egyptian government screened over 20 million people and treated over 2 million Egyptians infected with Hepatitis C. This ambitious project was successfully carried out through sustainable public-private partnership with a deliberate attempt to tackle a public health menace that affected over a third of the country’s population. With this effort, Egypt is on track to eliminating viral hepatitis by 2030 in accordance with the United Nations Health Sector Strategy on viral hepatitis elimination.
Scotland despite the low burden of Hepatitis C has commenced a national action plan to eliminate the virus. With less than 35,000 Scottish living with chronic Hepatitis C, the government ensures that over 50% of those living with the virus are screened and no less than 1750 people receive treatment each year with a target of eliminating the scourge by the year 2024 which is 6 years ahead of the United Nations target. The achievement so far has been made possible through strong and purpose-driven political will of the government and the determination to save lives and improve the overall quality of life of its citizenry.
Pakistan which has one of the highest burden of Hepatitis B in the South Asia has developed a robust national action plan towards eliminating the public health threat. The Pakistani government has initiated the plan to screen over 20 million people and treat no less than 65% of those diagnosed with the virus as well as strengthen the provision of birth dose Hepatitis B vaccine. By the end of the next decade, the Pakistani government hopes to reduce the rate of new Hepatitis B infection by as high as 85% which is in line with the United Nations GHSS targets. Like Egypt, Pakistan hope to achieve elimination goals through effective public-private partnership to ensure that everyone everywhere at every time has unhindered access to affordable Hepatitis B diagnosis, prevention and treatment.
Strategies for improving Healthcare Financing for Eliminating Viral Hepatitis in Nigeria
The urgent need for a strategic investment in the elimination of viral hepatitis in Nigeria cannot be overemphasized given the damming statistics of disease burden and mortality in Nigeria. Like experts have projected, Nigeria might much likely lose a third of her population to viral hepatitis in a couple of decades if meaningful investment is not made towards improving healthcare services for people living with viral hepatitis and making it affordable and accessible. Considering the aforementioned, there is an urgent need for a robust, strategic and integrated action plan towards strengthening the delivery of viral hepatitis services through investment. Recommended components of such an action plan include:
Increased budgetary allocation for viral hepatitis services. This will ensure that Hepatitis B and C medications are made available at very affordable rates for patients at all times and in all healthcare centers. In 2017 up to 15% of people living with Hepatitis C in Nigeria were diagnosed but less than 3% of them could afford the medications which currently goes for about US$1,000. A national action plan should attract reasonable investment as well as considerable budgetary allocation to ensure these medications are much more affordable.
Cirrhosis and Hepatocellular carcinoma resulting from untreated Hepatitis B and C accounts for over 95% of Liver related deaths in Nigeria. With the advent of the Clinton Health Access Initiative, diagnosis of viral hepatitis has been more affordable in a few states where they operate nonetheless, there is need to scale up this investment so that more people living with viral hepatitis can access high quality diagnosis and treatment; this requires the appropriation of more funds and efficient management of resources in delivering viral hepatitis services in the country.
Effective engagement of the private sector in the provision of affordable services to people living with the viral hepatitis. Like it was done in Egypt, Mongolia, Rwanda, Pakistan, Australia and Scotland there is an urgent need to foster a robust public-private partnership (PPP) in the provision of health services for people living with viral hepatitis. Key players in the organized private sector like multinational companies, international non-governmental organizations, donor agencies, philanthropists, multinational development partners as well as other relevant stakeholders can make substantial investment in viral hepatitis elimination if adequately engaged.
Some of these players have been major contributors to the global fund for HIV, Malaria and Tuberculosis. Therefore, by developing a robust relationship and providing data-driven portfolio on viral hepatitis, we can make a good case and thus convince them to expand their investment scope to accommodate viral hepatitis services.
Engagement with Pharmaceutical companies to ensure the manufacture and distribution of life-saving vaccines, drugs, diagnostic apparatuses, to healthcare centers at very affordable rates. Pharmaceutical business is driven by turnovers. Pricing for commodities like Directly Acting Antivirals for Hepatitis B and C, live-saving vaccines as well as diagnostic kits can be negotiated based on volume of consumption. Moreover, with the emergence of more generic manufacturers, the price of DAAs is expected to drop in the coming years. For example, in Egypt, the government collaborated with Gilead Sciences and so far over 20 million people have been tested and 2 million people infected with Hepatitis C are undergoing treatment.
Strengthening and investing in the National Health Insurance Scheme to ensure that it can cater for the healthcare needs of everyone everywhere living with viral hepatitis. In line with the principles of Universal Health Coverage, there’s is an urgent need for viral hepatitis services to be enlisted in the National Health Insurance Scheme. This will make diagnosis and treatment of viral hepatitis to be accessible and affordable for the poorest of the poor.
In 2017, less than 5% of the total number of people diagnosed with Hepatitis B received treatment. In fact, of the total number of diagnosed persons, less than 1% could afford a viral load count. For Nigeria to achieve elimination goals, we need to ensure that everyone everywhere has unhindered access to affordable diagnosis treatment and care of viral hepatitis through a strengthened NHIS. A good example is Australia where the government has incorporated viral hepatitis services in the country’s health insurance scheme making the services available and affordable to everyone.
Integration of viral hepatitis services into existing services like HIV, Tuberculosis etc. to ensure resource optimization. Unlike Viral hepatitis, HIV, Tuberculosis and Malaria have experienced huge investments in the past two decades, As a result, significant milestones have been achieved including lower mortality and reduced rate of transmission. Viral hepatitis on the other hand has grown exponentially in terms of mortality (1,34 million), rate of transmission and burden – currently infecting almost half a billion people globally (325 million).
Interestingly, the mode of managing viral hepatitis and HIV are similar thus providing an opportunity for integration of both services. Experts believe that integrating viral hepatitis services with HIV and TB services can help strengthen the system and optimize the use of resources. Commodities like Directly Acting Antivirals, diagnostic apparatuses like the GeneXpert machines sometimes remain underutilized. These could be better used to served people living with viral hepatitis in an integrated system.
Benefits of Investing in Eliminating Viral Hepatitis in Nigeria
Investing in eliminating viral hepatitis in Nigeria has great long-term return on investment (ROI). According to the World Health Organization, investing $6bn yearly in eliminating viral hepatitis in 67 low and middle-income countries will save over 4.5 million premature deaths by 2030 and more than 26 million deaths beyond the target date while preventing tens of millions of new infections.
Over 2.5 million live years would have also been saved. In fact, investing in viral hepatitis elimination will reduce the incidence of Liver cancer by over 90% thus nearly eliminating the need for Liver transplant. According to WHO, every $1 spent in treating viral hepatitis will produce a return of $16 by 2030 in terms of manhours and life years.
In Nigeria, investing in eliminating viral hepatitis will not only reduce the mortality and transmission of the virus but will also reduce the burden on health facilities and providers. Eliminating viral hepatitis as a public health threat in Nigeria by the year 2030 would mean less people will need to be diagnosed and treated, patients will live healthier lives and be productive while the overall life expectancy of people living with viral hepatitis will increase. The occurrence of liver failure or cancer will be almost non-existent thus the need for liver transplant will be rare.
Also, Experts believe that the elimination of viral hepatitis in Nigeria would save the country over USD$12bn by the year 2050 by averting over 600,000 deaths, 12,000 Liver transplants, and 1.2 million manhour loss. Eliminating viral hepatitis will help reduce the mortality rate among people who have co-morbidities like HIV, Tuberculosis, Non-Alcoholic Fatty Liver Disease, Cancer or patients on Haemodialysis.
For Nigeria to achieve the viral hepatitis elimination goals by 2030, we must be ready to make meaningful commitments towards ensuring the provision of affordable healthcare services for all Nigerians living with viral hepatitis while ensuring that those at risk of the disease are aware and have access to life-saving vaccines.
With the adoption of viral hepatitis in the Universal Health Coverage political declaration at the just concluded United Nations High Level Meeting on Universal Health Coverage, Nigeria must be ready at this time to tackle the scourge of viral hepatitis which has claimed the lives of over 85,000 Nigerians yearly and leaves over 24 million people battling for survival.
We must bring every stakeholder to the table and implement a national action plan to ensuring that by the year 2030, viral hepatitis is eliminated as a public health threat which means that at least 80% of people living with viral hepatitis are diagnosed, 65% of infected persons are treated and 90% of new cases are averted. Learning from the successes recorded so far in Egypt, Mongolia, Australia, China, Scotland and others, we must demonstrate strong political will and financial commitment towards eliminating the scourge of viral hepatitis.
This can only be made possible by fostering a robust public-private partnership, and demonstrating genuine commitment to save lives and improve the overall wellbeing of Nigerians. It is very certain as experts believe, that Nigeria like Mongolia will have the highest burden of Hepatocellular Carcinoma HCC by the year 2030 if no action is taken urgently to reverse the current trend in viral hepatitis services in the country.
According to WHO, a total of US$58.7 billion is needed in order to eliminate viral hepatitis from the 67 Low and Middle-income countries which includes Nigeria. If Nigeria is indeed hoping to achieve viral hepatitis elimination goals by the target date 2030, then every stakeholder must be ready to invest in improving access to diagnosis, treatment and prevention of Hepatitis B and C in line with the principles of Universal Health Coverage.