On July 28, 2022, Nigeria joined the rest of the world to mark the “World Hepatitis Day’’, a day set aside to create awareness about the disease. Globally, about 325 million people are estimated to have been infected with the virus while in Nigeria the number of infected people is estimated to be 20million In this interview with TheFact Daily, Dr. Nimzing Ladep, Consultant Hepatologist, Norfolk and Norwich University Hospital, United Kingdom tells us about the disease, its prevention and self-help tools for patients. Excerpts:
TheFact Daily: What is Hepatitis?
Dr. Ladep: According to the World Health Organisation (WHO), Hepatitis is simply
referred to as an inflammatory condition of the liver.
TheFact Daily: How big is the Hepatitis problem?
Dr. Ladep: Globally, about 2billion people are estimated to have been affected
in one way or the other by hepatitis, of that amount, about 350million, sometimes approaching 400million people are chronically infected, meaning that they have some evidence of the virus circulating in their blood stream. The countries that are most afflicted in high amounts are Sub-Saharan Africa, South East Asia and areas of Mongolia. Going down Sub-Saharan Africa, there is a huge population of hepatitis B patients in West Africa. Narrow that down to Nigeria, the National surveillance from the Nigerian Health Ministry estimated that about 20 million people are carriers of hepatitis in Nigeria. If you take the population of Nigeria of about 180 million, if you count 10 people, 1 person has the disease. It will shock you to
know that not many people know their status and so they go about it and people are getting infected and may not even have been protected at all, whereas there are systems in place to help support patients.
TheFact Daily: How is it transmitted?
Dr. Ladep: In a developing country such as Nigeria, the most prevalent way by which hepatitis is transmitted has been from mother to child, a mother who was infected may have passed it over to the child without the child knowing anything and may not have done anything but in utero,
the child was given the disease before he/she was born. Also, children playing with each other and cutting themselves with some sharp objects may get the transmission of this virus.
These children can also share things like household equipment, cutting their nails with razors that are shared or brushing their teeth with a shared toothbrush in a family sense and so get the infection from each other because it is a blood product-based virus.
The other part is the sexual route which is not really common but does occur especially in the era of HIV/AIDS. In the developed world, the sexual route is very likely.
TheFact Daily: Can you tell us the history of the Virus?
Dr. Ladep: It was discovered in 1965 by an Australian scientist, Dr. Baruch Blumberg. It was first called the Australian antigen. From that period, not much was known about it, so people were getting transfusions of blood. If you went to hospital and you needed blood transfusion, you were given blood but it was not being screened. A lot of people who got blood transfusion before 1992 may have actually been transmitted Hepatitis without knowing. It was from 1992 that mandatory screening for Hepatitis from blood before transfusion was implemented in health delivery systems, that was when its transmission became a bit lower. Hepatitis is not an innocent disease, a lot of people may not even realize the side effect or the long term damage, but in a particular proportion of patients about twenty to thirty years from the time they were infected, have the tendency to develop cirrhosis; cirrhosis is when the liver has become replaced by a fibrotic tissue, in other words, a scar of the liver that no longer produces the benefit that it should to the body and that way the system shuts down and that is when swelling of the belly comes, swelling of the legs, eyes becoming yellow, pain and wasting and people die. Or if after long term they then develop cancer as well. It kills by the process of developing cirrhosis and cancer.
TheFact Daily: How do you prevent the transmission of Hepatitis?
Dr. Ladep: 1) The most potent way to prevent hepatitis is by vaccination. If you
know that you are living in an African setting, you are at risk of infection. That is, if a family member of yours has the infection, then it would be relevant to go ahead and get vaccinated, that way you
are protected. The vaccination protects in almost 100% of everyone who receives it.
2) Do not share sharp objects or intimate objects that have a tendency to expose blood that would be exposed to a wound surface. That would expose that virus into the body of an uninfected person.
3) If you have to get a blood transfusion ensure it has been screened.
If you are vaccinated, you are protected, the vaccine produces cells and antibodies that will attack the virus when it gets into your system and annuls it, so that the infection does not get established at all. If you are vaccinated and you get exposed to these things, you are not at risk of being infected by hepatitis B. Not only is the
vaccine important in protecting against the infection, it also has been shown to reduce the incidence of liver cancer.
For partners who are married and if the partner is not yet on treatment and the other partner is not yet vaccinated, the use of barrier methods such as condom would be important in preventing the transmission of hepatitis to the uninfected person.
But if you are cohabiting as a partner to each other and the other partner who is uninfected has been vaccinated, you are safe to go ahead and consummate your marriage and they would be no issues about that.
TheFact Daily: Can a father pass the infection to an uninfected child?
Dr. Ladep: Research was done in Taiwan and it has demonstrated that that is possible, not because of a transmission from the spermatozoa but from the use of household items like blades or some kind of sharp objects that the child played with. That is if the child did not receive vaccination. First dose vaccination is very important, pregnant mothers who may have been infected, need to be seen by a doctor when they go to antenatal care. The doctor will screen them and determine whether they need to take some antiviral agents prior to delivery and at delivery to make sure that the baby also gets vaccinated.
TheFact Daily: What is the clinical approach to monitoring, at what stage do you monitor and how do you effectively monitor a patient for the hepatitis
virus?
Dr. Ladep: There are established guidelines the World Health Organisation has a simplified way by which patients with hepatitis would be followed up. Most people will be diagnosed incidentally, perhaps they’ve just gone for blood test or they went to donate blood and it was discovered at the point that they were positive, at that point, what the patient need is to be seen by specialist who looks after liver diseases, they will carry out additional tests, if for example, at the time of diagnosis it has been shown that the liver has become cirrhotic, in other words it has become replaced by fibrous tissue. Then you don’t even need to do more tests all you can do is to look for complications
of the cirrhosis and start treatment without doing viral load. The specialist will also follow up for those who do not meet the criteria to start treatment at the time of diagnosis need to be followed up ideally every four months although in developing countries it can be done every six months which is much easier because of distance to hospital, transportation costs and also investigation cost for patients.
TheFact Daily: Do you think that Nigerian Government has done enough in the area of awareness? And what will you suggest to the government of the day?
Dr. Ladep: There was a storm gathering just before covid-19 came on board. The
Ministry of Health was trying to establish a system to quantify the number of cases and also to look at the importance of this disease so that they can bring out a national a mechanism to control it. However, covid-19 took away a lot of the resources that the government had and
so not much has happened in that regard, but it is hoped that with the slight improvement in health resources and the lessons learned from covid, a lot more people will be doing this.
That is the reason why there has been a proliferation of traditional drug vendors; people who claim they have cures for hepatitis B and they will come to someone especially when they hear me for example
saying there is no cure but it can be treated. They will come and say “these are all bollocks, you’re lying, we can cure it”, “you come to us, we will give you treatment and you’ll be cured” but it is based on no sound scientific evidence at all and a gullible patient who has no idea what is ongoing will go and lose their resources.
Of course, a few of them may survive to come and say the stories but a lot may die. Those who have gone there in the sense of being cured may have even died in the process. So, we don’t even know the stories ongoing and there has been no evidence that these people have undergone a robust system registered with the drug regulatory system to make sure that they are tested or their products are validated. A lot of these things have flourished because of this poor and/ or low
level of national engagement in this area.
A disease that affects at least ten percent i.e 1 in every 10 persons is definitely an endemic disease that is worth the time of anyone.
TheFact Daily: Why is it taking long to provide cure?
Dr. Ladep: Clearly, the concept of cure that is understood by the community is different from the concept of cure that we as physicians define. Many people would wish that hepatitis was like malaria, where you go, have a test then if positive, you go for treatment, after treatment you are
tested and you are told negative, but that’s not the case. However, there are a few cases that may test negative, when you have given them treatment but that is not the rule and that is not the target of treatment.
There is still some research work ongoing, with the hope that we can have a breakthrough on how to tackle the virus. If we compare the speed with which the vaccine for covid-19 was found, with what should be done for hepatitis B, I know it’s going to be a challenge because covid-19 came at a time when there has been a significant advance in science, the human genome had been found and people can manipulate the DNA, RNA and so on to develop proteins and so on at the time that
hepatitis B was found, none of this had happened.
If for example hepatitis B was found at this time, perhaps we may have had such, it is hoped that scientists might look backwards and have some gains from what has been discovered and then be able to use this rapid discovery of the twenty first century in identifying drug and drug targets so that we would be able to at least in our generation find a cure for hepatitis B.
TheFact Daily: Can you tell us about the self-help apps you developed for hepatitis patients?
Dr. Ladep: The frustration I had when I was looking after patients with hepatitis in Nigeria and elsewhere has been the lack of manpower and I also think about the journey patients make from remote villages into cities and then when you see them, they have to source for money again to go
and look for where to buy drugs and then do investigations, and that was what led me to thinking about virtual consultation. I have my virtual doctor app which interestingly I built by myself, using simple
platforms already existing on Google and with that app, I’ve been able to reach out to many people and had consultations via zoom and also made suggestions which they will then take back to their physicians or even their general practitioners with the advice that is given to these patients.
Unfortunately, people are still limited because they don’t know how to use the technology to access these things and also when they do, you send them letters and some find it difficult to download and also go and interact with their doctors, there is that uncertain fear about it. Again, the payment platform was a challenge for patients as well. That was what led me to develop self help apps, where you go into the app, you discover for yourself the results of tests you have done, you’re able to interpret what that test tells you and gives you a better idea of your status so that you are able to go ahead and say ‘I have got this combo test, it is hepatitis B combo 2 which is on google playstore’, you look at that and compare and find whether you have an active or inactive disease, then that tells you whether to see a doctor or go and do a test.
Recently, I released the LIVSTA app which is the Liver Stiffness Assessment App, the app will even tell you if you are supposed to start treatment right away or delay and if you are on treatment, is it getting better? Those are the kinds of products that I have in my quest to support the care of patients who do not have access to doctors easily to use and then be able to advise themselves on what quickly they can do and engage with doctors meaningfully.
TheFact Daily: What sort of drinks are hepatitis patients supposed to avoid?
Dr. Ladep: If a patient with hepatitis is drinking alcohol, it is like you are pouring gas or petrol on a burning flame. The liver is already inflamed and you’re drinking on top of it, that will quickly damage the liver. Alcohol is a no-go but adequate amount of fluid intake is a very good thing for any person, so avoid alcohol even in its minutest forms. It is not something that we can say take in small amounts because once it is inflamed anything that would be taken to burden the liver would worsen the outcome for the patient.
Particularly alcohol that is produced in iron pots; Burukutu and so on can release iron into the pots and distort products and these are quickly absorbed and they go into the liver to damage the liver farther. So not only is alcohol causing direct damage but even the contents and the broken-down products within the local buru is of worse outcomes in patients who have hepatitis.
