The myths and realities of Hepatitis diagnosis and treatment in Nigeria

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By Dr ANUMA ULU KALU

I had to scramble to do this article after I was inundated with requests to bring this topic forward due to its primacy of importance, having had to jettison my originally-planned article for the week.


To prod me towards doing this first, people told me that statistics has shown that about 20 million Nigerians have hepatitis and because of the increasing incidence and the fact that it is easily preventable, i was implored to do this article soonest. My first response to this was to ask, says who? You are talking about a country that is yet to get its actual population right and with no national database for anything now spewing out statistics with careless abandon and which I am quite confident are outlandish and incorrect to say the least, but, whilst not trying to throw away the baby with the bath water, I will tackle this topic as best as i can, correcting myths along the way, hoping to be didactic enough as to impart life-saving interventional choices in dire situations.

What is hepatitis? It can simply be defined as inflammation (irritation) of the liver. When we talk of hepatitis in Nigeria, we mostly mean that caused by viruses a k.a. viral hepatitis, and which will be the main bulk of my article today. We also have other less frequent causes in Nigeria like alcohol (alcoholic hepatitis), the latter being more rampant in the Western world than Nigeria, as well hepatitis caused by drugs like isoniazid used to treat tuberculosis, other drugs lije paraceramol/panadol in toxic doses as well as heavy metals like copper. Hepatitis cannot be treated with levity because the liver occupies a central role in almost all body functions especially the digestive system and any insult to it could have a reverberating effect to the entire body homeostasis.

The diagnosis of hepatitis is done with a simple blood test, which shows elevated liver enzymes. Further tests can determine the type of viral hepatitis we are dealing with, if viral in origin. The unfathomable malpractice of diagnosing hepatitis in Nigeria with a urine test showing urobilinogen or proteins could have been laughable had it not been egregiously criminal. I have personally had interactions with several victims of this practice that my knee-jerk reaction to any diagnosis of hepatitis in Nigeria is to debunk that until proved otherwise, as people who have interacted with me can testify. Infact just last week, a Miss Jane Obasi from Ohomja Ututu in Abia state, a microbiologist by training, recounted how she confronted a medical personnel that diagnosed a friend of hers with hepatitis, just because of urobilinogen found in her urine test!!! I am quite sure other examples of this criminal act abound. Do you now see why I question the veracity of the statistic being bandied about on the occurrence of hepatitis in Nigeria!!

Lest I digress, these liver enzymes are substances produced by the liver to aid digestion and other functions and which are minimally detected in the blood at normal times but in hepatitis are spilled into the blood at astronomical levels. The particular enzymes that are elevated more can further differentiate between viral hepatitis and alcoholic hepatitis, although a history of habitual alcohol consumption must be there for alcoholic hepatitis to be diagnosed. In alcoholic hepatitis, there will be physical symptom like yellowness of the eyes and frequently the skin (called jaundice) but no other acute findings per se because it is a slow-accumulating process. We shall not dwell more on this because stopping alcohol abuse here is therapeutic, otherwise it can progress to liver cirrhosis and its various sequelae including liver failure and death. Let us now discuss viral hepatitis, which is what we actually refer to in Nigeria, when we talk of hepatitis generally.

Viral hepatitis is broadly grouped into types A, B and C chiefly and to a lesser extent non-A non-B and the E types but for practical and clinical purposes we shall concentrate on types A, B and C as the others are mostly inconsequential. Unlike alcoholic hepatitis, they are usually acute infections that come with fever, jaundice, abdominal pain, loss of appetite, dark urine, joint pains, nausea, vomiting and at times diarrhea as well as other constitutional symptoms. Unlike the other viral hepatitis cases, hepatitis C can run a more chronic course whereby one contracts it for years without symptons then suddenly above symptoms ensue.

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Hepatitis A is usually benign, self-limiting though could last up to 2weeks, is contracted through contaminated food and drinks ( called feco-oral transmission), is treated symptomatically like medications for nausea and vomiting like avomine and medication for fever and pain like ibuprofen, etc. It does not leave a sequelae and most people do not even know that they had contracted it as the acute phase could be mistakenly treated for malaria or typhoid as it invariably would resolve by itself. It is when blood test is done showing IgG antibodies to Hepatitis A that most people realize they contracted it in the past. Like I said earlier, nothing to worry about here with hepatitis A.

Proceeding to Hepatitis B and C, the archetype of what we know as hepatitis whenever hepatitis is discussed in Nigeria. I shall take both of them together because of the similarities in contraction and progression but i shall not fail to point out a few points of divergence. Both are contracted the same way as HIV comprising sexual route, contaminated needles as in intravenous drug abuse, blood transfusions and vertical transmission from infected mom to fetus. Somebody from Nigeria asked me if they can be contracted through contact with somebody’s sweat as he heard and I promptly disabused his mind of this. In as much as you have these viruses in sweat, saliva and other body fluids, it is not possible to get them from these unless they are sufficiently bloody (mixed with infected blood of the host which then comes in contact with the blood of the person to be infected. Even semen (erroneously called sperm in Nigeria) which has a high concentration of these viruses still has to be in contact with the blood of the person to be infected to transmit it. This ends the debate about casual transmission through touch or rubbing on sweaty skin, etc.

The good thing here is that hepatitis B is preventable with simple vaccination, total of 3 doses with one each at day 1, then 1 month later and then 6months after the first dose. This is supposed to protect one from contracting it for about 10years so a booster dose every 10years is needed. Many are suggesting that everybody should be thus vaccinated in Nigeria because the vaccination is cheap and simple and due to the undue prevalence attached hepatitis B. Whilst I am not going to shoot this down, I must still say that in the USA, only people at risk of this disease get mandatory vaccination, after the childhood immunizations which include the hepatitis series. Such at risk people include health workers like us who are at risk for accidental needlesticks, then intravenous drug abusers, chronic disease patients, etc. But on the other hand there are other resources available to us in the USA to combat such an infection that a case can be made for a more widespread vaccination in Nigeria, devoid of other ancillary services. Just saying!!

Like i said earlier, hepatitis A is benign and inconsequential. Hepatitis B has 4 possible courses: It can be overcome by the body immunity of the infected just like hepatitis A and one develops antibodies to it conferring immunity from the disease. It can overcome the body in a mild chronic fashion to make the antigen (virus) continue to be present in the body, a chronic carrier state that does not really make the carrier sick but just being able infect others at will. It can also go the way of a fulminant acute infection leading to debilitating illness and death in a short time. Finally, it can lead to chronic disease resulting in cirrhosis of the liver (replacement of the liver tissue with fibrous tissue and nodules thus reducing its functions) and death over a long time if liver failure occurs or it may subsequently lead to liver cancer from the cirrhosis and then death. Some costly medications are in the market to cure hepatitis B and whilst they have greatly reduced the viral load ( just like in the case of HIV), they have not really provided cure.

For hepatitis C, the last course for hepatitis B above comprising chronicity, cirrhosis and death or possible liver cancer from cirrhosis and subsequent death is the only option available to the infected. The only silver lining is that it has a cure that eradicates it within 3 months but how many people in Nigeria can cough out 100, 000 US dollars for this treatment. With these statistics, it is obvious that prevention here is definitely better than cure. To buttress the importance of this prevention, I am going to blow your mind with some comparisons.

Do not get me wrong and go to town with wrong information, but I want you to know that hepatitis B and C are contracted similarly like HIV but are much more easily contracted than HIV. Either because HIV sounds so ominous due to the multiorgan system involved or just plain ignorance or stigma, people in Nigeria do not pay as much attention to hepatitis B and C like they do with HIV. Whilst one cannot get HIV from say a barber because HIV cannot survive in vitro ( outside the human body) for any length of time and needs a high inoculum from the host as well as low immunity of the recipient, same cannot be said of hepatitis B and C which can so easily contracted as above. This is why one cannot get HIV from a mosquito even if it fed on the blood of an HIV-POSITIVE patient (or even an AIDS patient) and came to bite an uninfected person, because the virus cannot survive outside the human body as in a mosquito.

I am bringing up this point because of things circulating in Nigerian social media at times about somebody running away from mosquito just coming out from an HIV ward in a hospital, which could be laughable if not that people actually believe this fallacy, or even some infected person spitefully spicing someone’s drink with HIV-positive blood so they can contract it, a ridiculous absurdity too. Finally, if a splash of blood is left to dry out on a wall and after 3 months an uninfected person leans on it accidentally with his back so that it is in contact with an open wound on the back of this person, if the blood splash was from someone with hepatitis B or C, the person leaning on it will contract the disease because there is blood to blood contact here and the virus can survive for this long and still be infectious.

If however the original blood splash was from an HIV-positive or even an AIDS patient, there will not be any infection because in as much as there is still blood to blood contact, the virus can only survive some minutes outside the human body, so it will be long dead in the blood splash. For more comparisons, you can inbox me. I almost refrained from writing above but since this is a teaching column, then i would not be doing my job of teaching if i withheld information just on misplaced moral grounds, would I?

Bottomline is this, whilst all the hysteria is going on about HIV in Nigeria, the more easily conbtractable but similar mode of transmission hepatitis B and C are being ignored, and are causing more disease and dare i say death daily. I am not scoffing at the virulence of HIV, just saying that we should not ignore these other two. In all, please do all you can to protect yourself from being infected with the above three, hepatitis B, C and HIV.


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