More than two million people in Senegal, or some 15 percent of the population, including 350,000 chronic carriers, have hepatitis B as a result of untimely vaccinations, prohibitive treatment costs and lack of universal screening to curb transmissions.
“It’s quite an urgent public health concern,” said Mamadou Mourtalla Ka, dean of the Thies School of Medicine in Senegal and a viral hepatitis and liver cancer researcher. “Hepatitis B is much more common than people think and causes many illnesses, many deaths here each year.”
Hepatitis B virus (HBV), which can lead to scarring of the liver (cirrhosis) and liver cancer, affects an estimated 350 million people worldwide. It is one of the most prevalent and serious viral infections in the world, affecting more people than HIV/AIDS and tuberculosis, yet it remains a low priority in many countries, according to the World Hepatitis Alliance. The prevalence is particularly high in West Africa, where 10-15 percent of the population is believed to be infected with HBV.
Despite the existence of a cheap, safe and effective vaccine, the World Health Organization (WHO) says hepatitis B is responsible for around 600,000 deaths each year. HBV causes around 80 percent of all liver cancers. In Senegal, liver cancer is the number one cancer killer among men and third among women, but health authorities do not have specific figures.
Ibrahima Gueye, founder and president of the Association Saafara Hépatite Sénégalaise, which works to raise awareness about hepatitis and offer support to patients, said people with chronic hepatitis face many difficulties, notably lack of affordable treatment.
“Hepatitis B is very difficult to manage here,” he said. “If you want to stop the virus from advancing into cirrhosis or liver cancer, you must get treatment. But the medication is very expensive.”
In Senegal, a year’s supply of HBV antiretroviral drugs, costs around US$4,000, which is too expensive for many in a country where more than half the population lives on less than two dollars a day. The generic brand, which costs less than $100 a year, has not yet been made available in Senegal and the government does not subsidize the cost.
“When the pharmacist handed me the bill for the first time, I thought he had made a mistake. How do you expect someone in this country to pay that much? It just isn’t possible,” said Gueye, who was diagnosed with chronic hepatitis B in 2010.
Gueye says he, like many Senegalese who suffer from chronic hepatitis B, go to great lengths to afford treatment. He was forced to take out multiple loans and sell his car. Too sick to continue working, he fell into a cycle of debt, unable to pay back what he owed, and is now without a salary to pay for more treatment.
Free treatment only for HIV patients
There is no cure for hepatitis B, but symptoms and the virus’s progression can be managed with proper treatment, doctors say. Chronic hepatitis B patients can receive antiretroviral treatment in Senegal for free, or in some cases for around $100 per year, if they are also HIV-positive.
Mark Thursz, a professor of hepatology at Imperial College London who is working to improve HBV treatment programmes in resource-poor countries, including Senegal, said he recalls meeting one particularly desperate hepatitis B patient who was told by his doctor that “if you had HIV, you could have this drug. But since you don't, you can’t.”
“Thereafter, the man kept getting tested for HIV… [He] subsequently died because he didn’t have HIV,” Thursz said. “It seems quite perverse, but that’s the way the system works currently.”
In 1999, Senegal’s Ministry of Health created a National Programme Against Hepatitis (PNLH), pledging to reduce the HBV infection rate, and improve treatment and care of patients. Fifteen years later, doctors, patients and hepatitis B activists say that while improvements in HBV vaccination campaigns have reduced the prevalence among young people, little has been done to help chronic carriers of the virus.
Most people do not know they have HBV because few experience any symptoms. Ninety percent of HBV cases are asymptomatic although fever, tiredness and abdominal pain can be signs of infection, but they are vague, according to PNLH.
“Some people may think that if you prevent new children from being infected [with hepatitis B], that that will solve the problem,” said Shevanthi Nayagam, a hepatology specialist at Imperial College London, who has been researching hepatitis B in Senegal. “But there’s actually a whole generation of people who are already infected and who are already going to die of consequences of hepatitis B.”
PNLH says around 85 percent of Senegalese have been exposed to the hepatitis B virus, which is spread through contact with blood and bodily fluids, such as saliva and semen. While many of the cases disappear on their own, around 11 percent will develop chronic hepatitis B, symptoms of which include a bloated stomach, extreme fatigue, jaundice and nausea.
Lack of screening
A lack of universal screening in the country means the majority do not know they are positive.
“Sometimes you don’t realize it until you get liver cancer or liver cirrhosis, and by that time, it’s often too late,” Nayagam said. “And so in Senegal, for example, once you develop cancer due to hepatitis B, often the prognosis is only a couple of months: you get the disease and then you die.”
Knowing one’s HBV status can help stop the virus from silently destroying the liver and prevent the spread of infection.
“Persuading people to get tested and setting up screening facilities is well within the capabilities of doctors in Senegal,” Thursz said. “And it’s important this be done, because you can’t get on top of this infection unless you screen and pick people up before they develop end-stage liver disease.”
Screening is particularly important for pregnant mothers, who can pass HBV to their child during birth. WHO says all babies should be vaccinated within 24 hours of birth to prevent transmission. In Senegal, most children do not receive the HBV vaccine until at least six weeks, when they get other routine vaccinations. HBV vaccination coverage is now around 70 percent, close to sub-Saharan average of 72 percent.
“There is no logic to this,” said Aminata Sall Diallo, coordinator for both the Pan African Initiative in the Fight against Hepatitis and Senegal’s PNLH, and a professor in the department of medicine at Cheikh Anta Diop University in Dakar. “We keep recommending that the HBV vaccine be given immediately after birth. That’s the best strategy to stop children from growing up to become chronic carriers. But Senegal still continues to vaccinate at six weeks.”
Doctors say it is often difficult to vaccinate within the first 24 hours, especially if a child is not born in a hospital. Birth-dose vaccines are also not usually funded by international health organizations.
Vaccinations and better screening must go hand-in-hand, experts say. “There’s no point diagnosing someone with hepatitis B if you aren’t able to give them treatment to prevent their progression,” Nayagam said.