As a disease that suddenly creeps up on its victims, experts say Hepatitis appears to be having a free run on millions of unsuspecting Nigerians while government appears yet to have a clear plan for dealing with it
At 19, Niran Ajayi (not his real name) had the natural street talent and physique needed for professional football. Often, he would promise Awele, his mother, that he would join the big league soon after his university education. But as things turned out, that never happened. On Monday, July 10, Ajayi’s dreams became frozen in the morgue of the Lagos University Teaching Hospital, LUTH, Idi-Araba, Lagos. He, alongside his dreams, had succumbed to hepatitis C, a viral disease that was never part of his plan.
When news of Ajayi’s demise filtered in on Monday, July 10, shock and bewilderment literally ran through his Ilupeju, Lagos community. The young man was only ill for three days. It started with complaints of dizziness. And then things progressed at a pace many around him found rather disturbing. On the second day of his illness, he was promptly taken to LUTH where he was placed on bed rest. He died the next day.
“It was like a big joke when I heard the news”, said Bambo Okemuyiwa, who has been Ajayi’s friend on and off the football pitch for some years now. As far as Okemuyiwa is concerned, only a spiritual attack could have claimed the life of a bubbling young man like Ajayi with little or no notice. Convinced about his line of thought, Okemuyiwa assured the magazine that God will soon expose whoever took the life of his friend.
When Sani Abu (not real name), a tomato seller at Oko-Oba, Agege, Lagos had a similar experience, he was dead before his fellow traders and customers could fathom what was happening. For six months, Abu tolerated the intense stomach pains and extreme weakness that clutched his frail body. But some of his customers noted his silent pain. By the time Funmi Lesi, a consultant gastroenterologist with LUTH and one of his customers advised him to come for a medical check, it was a little too late for Abu who left Maiduguri, his home town for Lagos 15 years ago.
Lesi said Abu lost the battle to hepatitis B, an acute infection of the liver. Perhaps, if Abu had managed to go for hepatitis test, he would have survived and still be able to attend to his customers and add value to the lives of his children. “Most hepatitis patients who present with liver cancer or who developed cirrhosis (hardening of the liver) showed up late. They came when they noticed the symptoms of chronic hepatitis and at that point we can only do little or nothing”, Lesi said.
Lesi worries that there are millions of Nigerians like Abu with various degrees of liver infections. If the infection is not treated on time, the doctor fears that the virus would eventually kill such persons. The World Hepatitis Alliance and the Society for Gastroenterology and Hepatology, SOGHIN, have disclosed that about 20 million Nigerians are already infected with hepatitis.
Hepatitis is a family of seven viruses (hepatitis A–G) and they all attack the liver. Now this is why it is a dangerous disease. The human liver is the largest internal organ in the body and helps in the digestion of food and the regulation of excess sugar in the body. Most of the time, the liver plays a big role in removing poisonous substances from the blood. When it is infected by hepatitis, the liver swells and functions below its capacity and if left untreated, the liver can get scarred or hardened leading to what doctors describe as liver cirrhosis. This condition leaves a lot of poisonous substances in the blood and eventually leads to death.
The World Health Organisation, WHO, has declared hepatitis B endemic in sub-Saharan Africa and South-east Asia. It is also regarded as a major global health threat. Many people are infected with viral hepatitis without knowing it. Acute hepatitis is short-lived and the body gets rid of it on its own. However, chronic hepatitis lasts for six months and could hibernate in the body for decades without symptoms.
This is why Gabriel Ogunyemi, another consultant gastroenterologist, First Foundation Medical Centre, Lagos, describes hepatitis as a dangerous smokescreen. “Hepatitis B and C can stay in the body for many years. Majority of the people who are diagnosed with hepatitis have no complain. They walk into the hospital for other things and we discover they have hepatitis,’’ he said.
Both Lesi and Ogunyemi agree that hepatitis is usually at the end stage when symptoms start showing. And symptoms include loss of appetite, nausea, weakness and fatigue. Other signs are abdominal pain, passage of dark-coloured urine, jaundice and joint pains.
For SOGHIN, it is imperative for the government to declare viral hepatitis as a public health disease in the country. Members of the society are alarmed that aside from the free hepatitis B virus, HBV immunisation for young children, there is no national plan to contain a disease, which has infected more Nigerians than the Human Immuno-deficiency Virus and the Acquired Immune Deficiency Syndrome, HIV/AIDS. While HIV/AIDS prevalence still hovers at 4.7 per cent, hepatitis B has a prevalence rate of 13.7 per cent.
As far as WHO is concerned, hepatitis B is one of the most common viral infections in the world. The organisation says about two billion people across the world are infected. For health care analysts, this is a time bomb set against the world’s seven billion population. Closer home, the WHO declares that 20 million Nigerians are infected with the virus and about five million die of liver complications each year.
Hameed Oladipo, a consultant gastroenterologist and hepatologist, says the figure may even be higher. He is of the opinion that hepatitis might be the number one killer disease in the country. “I have lost a lot of patients to hepatitis. I have lost young people who were 16 or 19 years of age and they die of hepatitis. Unfortunately, we don’t keep records of causes of deaths in our environment. Hepatitis B and C are very deadly”, Oladipo said.
What makes it particularly dangerous is the fact that it is easily spread in a family. “The fact that one person in a family is having the infection puts every one else in that family at risk. A father may pass it to the son, the wife and so on. If the father died at 47 years of age, the son might die at 46 years and when family members start to analyse the deaths, they conclude that it is a spiritual attack”, he said.
But why is hepatitis B on what may appear like a silent genocide mission in sub-Saharan Africa? Medical experts say the virus derives strength from its presence in all body fluids of infected individuals. Unlike the HIV, which can be contracted through infected blood, vaginal fluid and semen, abundant presence of the HBV can be found in the blood, vaginal fluid, semen as well as the sweat, tears, urine and saliva of infected people.
With Oladipo’s explanations it is perhaps clear why the disease spreads at such an alarming rate. If hepatitis B swims in the sweat, breast milk and urine as confirmed by scientific studies, then, it is a viper on the loose. For instance, the endemic nature of the virus in Nigeria might have some things to do with chronic housing problems and sharing of public facilities. A recent report alleged that about 6,000 pupils of Lagos State public schools share unhygienic toilet facilities. Add this to the number of times children share sweets and drinks in school and at home and the reality of the danger ahead would naturally stare one in the face. Lesi’s experience at LUTH speaks volume. She admits that about 20 people are diagnosed with liver disease every week. “We see no less than 10 cases every week and these are cases you really can’t do much about. HBV is highly contagious - between 50 and 100 times more infectious than HIV and can survive outside the body for at least seven days. During this time, the virus can still cause infection if it enters the body of a person who is not infected,’’ she said.
Majority of those who pick hepatitis B do so during childhood period and it is mainly from mother to child. If such a child is not vaccinated, or got a partial immunisation, then he or she is not likely to live to adulthood.
Though the National Immunisation Programme in Nigeria provides that babies be immunised against vaccine preventable diseases, VPD, like hepatitis B, various factors ranging from religious sentiments to undue suspicion, poverty and use of expired vaccines have contributed to the poor coverage.
In a recent research, Saliu Abdulraheem of the Department of Epidemiology and Community Health, College of Medicine, University of Ilorin, Kwara State, discovered reasons why Nigerian children are prone to incomplete vaccination and why some of them are not vaccinated at all.
Targeting mothers with children who are less than a year old, the researchers analysed their immunisation cards to check for completeness and correctness of immunisation schedule. The research was done at Awe Local Government area, Nasarawa State.
The research showed that “about two-thirds (62.8 per cent) of the children were not fully immunised by age one, 33.4 per cent had experienced a missed opportunity for immunisation and 36.4 per cent were partially and incorrectly immunised.” Accounting for why this is so, the research showed that “parents’ objection, disagreement or concern about immunisation safety accounts for 38.8 per cent while long distance walking accounts for 17.5 per cent and long waiting time at the health facility accounts for 15.2 per cent”. This position is reinforced by the 2003 Nigeria Demographic and Health Survey, which puts the national average of immunisation coverage at 12 per cent.
Investigations have also indicated reasons why the HBV lives in the bloodstream of more than 20 million Nigerians. First, it was not until 2004 that the federal government included the hepatitis B and yellow fever vaccines in the national immunisation schedule. This has not only effectively excluded children born before then it has also sidelined adults who already have the disease.
Even after government had included Hepatitis in the schedule, there is still a snag. This is because immunisation exercises in the country are often targeted at polio and measles vaccine. This means that young children and adults need a deliberate visit to hospitals and other health care facilities for hepatitis B vaccination at an exorbitant cost.
In many hospitals across the country, a shot of hepatitis B vaccination costs N1,500 ($10). It could even be higher. For instance, checks in Osogbo, Osun State where public health workers have been on strike for more than five months showed that a shot of hepatitis B immunisation costs about N3,000 ($20). This is a sizeable chunk off the monthly income of the average Nigerian worker whose minimum wage had just been pegged at N18,000 ($120) amidst strikes. In the opinion of Oladipo, only a deliberate government intervention involving nationwide mass testing and immunisation at little or no cost could signal the way out of the hepatitis B scourge in the country.
Hepatitis C is no less endemic in Nigeria. Although some mother to child transmission cases have been documented, the WHO has said that this route is extremely rare and the major route of transmission remains blood contact and exposure. Like its sister virus, hepatitis C usually does not exhibit obvious symptoms until it is almost too late. Oladipo says that the symptoms of hepatitis C include, “nausea, fatigue, aching muscles and joints, anxiety and depression, poor concentration, stomach ache and loss of appetite.’’ A symptom that usually differentiates between hepatitis B and C is that patients with end stage hepatitis C presents with bulging stomachs lined with spider like veins. The doctor says it is also possible for an individual to be infected with two or more different types of hepatitis.
Unlike hepatitis B, which has a vaccine, hepatitis C has no known cure at present. In spite of this, medical experts are convinced that early treatment for healthy hepatitis carriers would not only demystify the disease but also reduce the mortality rate significantly.
Oladipo shares this view. He insists that the federal government can learn how Egypt managed to tame hepatitis. From the WHO statistics, Egypt is home to the world’s largest number of hepatitis C patients. About 15 per cent of the country’s 64 million people are currently living with the disease.
A joint study of the University of Maryland School of Medicine, United States and the Egyptian Ministry of Health has suggested that the endemic hepatitis C virus was transmitted through the contamination of reusable needles and syringes used in the treatment of schistosomiasis, a parasitic infection. The researchers declared that the treatment might well be the world’s largest transmission of blood borne infections resulting from medical intervention.
The Egyptian government however rose to the occasion with a national policy that declared war on hepatitis. Liver treatment centres were established in every nook and cranny of the country and services were rendered free of charge. In addition, liver transplant centres – a rare surgical procedure in developing countries – were established across the country and the cost drastically subsidised to $25,000 (about N3.8million) for Egyptians while foreigners have to cough up $100,000 (about N15million).
For Oladipo, the way to start is for the Nigerian government to collate records on the cause of deaths in public hospitals. He is of the opinion that this will guide the national action plan. He also suggests a nationwide free screening and treatment for all types of hepatitis.
As a medical practitioner, Lesi has a burning wish. “I wish we could see hepatitis patients early and treat them before the disease develops into liver cancer or liver cirrhosis; I wish patients would present early for us to give them hope and treat them and not bother about the issue of liver transplant which is still a dream in Nigeria”, she said.