BY MINNIE KARANJA Hepatitis is not a commonplace disease. However, there have been rising cases of Hepatitis B and Hepatitis C infections and related deaths in Rwanda. The government, through Rwanda Biomedical Centre (RBC) is hence currently conducting awareness campaigns to sensitize the public about the infections – causes, prevention and treatment. What is Hepatitis? Hepatitis is an inflammation of the liver that can be caused by viruses or toxic substances (e.g. alcohol). Viral hepatitis is liver inflammation due to a viral infection. There are different hepatitis virus types: A, B, C, D, E, etc. Hepatitis B (HBV) and C (HCV) are most prone to cause chronic infection. For this reason, these 2 types have been the focus in national health strategic plans to combat viral hepatitis. Both types of viruses cause acute infection, which may progress to chronic infection in some cases. Many of those chronically infected with either virus manifest no obvious signs or symptoms for decades; however, if left untreated, chronic infection can lead to fibrosis (scaring of liver tissue), cirrhosis (extensive scarring of the liver, later stage of fibrosis) and hepatocellular carcinoma (HCC). Dr. Jean Damascene MAKUZA, Ag. Director of Viral Hepatitis and STI Unit in RBC says, “Because many people infected with the virus do not show obvious signs of infection, many people seek treatment at a later stage when the infection is at an advanced level. At this stage, treatment is complicated with low chances of success. Dr. Jean Damascene Makuza, Ag. Director of viral Hepatitis and STI unit Transmission & Prevention of Hepatitis B and Hepatitis C Hepatitis B and Hepatitis C are transmitted through contact with infected blood or bodily fluids. In resource-limited settings, transmission in healthcare settings is common through the reuse of needles, the use of unscreened blood, or through other medical and surgical procedures. Other transmission routes include mother to child transmission, sexual transmission, the reuse of needles among Injecting Drug Users (IDUs), transmission in traditional medicine settings, sharing sharp objects (razors, toothbrushes, ..) and the use of contaminated equipment in other facilities (e.g. tattooing or piercings). In high endemic areas, many Hepatitis B infections are acquired early in life during early childhood, highlighting the need for prevention and Hepatitis B vaccination campaigns aimed at new born. Transmission of Hepatitis C from mother-to-child is less common than for Hepatitis B. In adult people, Hepatitis B can be prevented through a vaccination that is given in 3 shots with 6 months intervals. Vaccination services are available in all health facilities including health centres at the cost of RwF. 5,000 per vaccine shot while Hepatitis B vaccine in new born is free of charge since 2002. Currently, there is no vaccine against hepatitis C. Treatment Hepatitis B Treatment In chronically infected Hepatitis Bpatients, lifelong antiviral treatment (Tenofovir) is available at all public health facilities offering HIV services and has been shown to suppress Hepatitis Bviral replication and prevent disease progression and subsequent mortality. Currently, Tenofovir is still available free of charge for those in need. As there is no cure for Hepatitis B, RBC is putting more efforts in prevention through sensitization of the public and increase access to vaccine. Hepatitis C Treatment Until recently, treatment for Hepatitis Chas been virtually inaccessible in resource-limited settings posing the major barrier to scale-up. Unlike Hepatitis B, Hepatitis C can be cured through treatment. RBC has been able to negotiate for the price reduction of Harvoni (the new oral effective and less toxic HCV medication) with the American manufacturer, Gilead Sciences, Inc. This drug is now locally available at a negotiated cost from RwF 76,000,000 ($95,000) to RwF. 960,000 ($1,200) per cure of 12 weeks. Currently, more than 850 people are on this medication nation-wide. Today, the Ministry of Health through RBC has successfully negotiated a donation of Daclatasvir from BMS for 2,000 patients. This new drug is to be combined with Sovaldi (a molecule from Gilead Sciences, Inc) for 12 weeks reducing the cost of hepatitis C cure at RwF 720,000 ($900). This should be available in Rwanda starting September 2016. Viral Hepatitis Services availability in Rwanda Rwanda Biomedical Centre Interventions In order to reduce the number of Hepatitis B and C infections and related deaths in the country, the Rwanda Biomedical Centre: * Is increasing awareness among the general population on how the viruses are transmitted, how they can be prevented and where people can access information and treatment within the country. * Has conducted capacity building for health care professionals including Medical Doctors, Nurses and Lab technicians to foster the prevention, early diagnosis of infections and early treatment at each health facility in Rwanda. In line with this it has developed the national guidelines for healthcare professionals dealing with infected persons. * Is increasing the capacity of labs nationwide so that all health care facilities; health care centres to referral hospitals, can diagnose hepatitis B and C. * Is planning to increase access to medication, as currently some drugs are still very costly, by negotiating with manufacturers. * Has negotiated with health insurance companies to cover cost of diagnosis and treatment both viruses and vaccination for Hepatitis B. Currently, RSSB and private insurers cover the diagnosis and treatment costs and negotiations are on going to include viral hepatitis services package in the community based insurance (Mutuelle) coverage * People living with HIV who are among high risk population to get hepatitis B and C and fast progress to their complications have been screened for hepatitis B and C. Most Asked Questions on Viral Hepatitis B and C Q1: How Likely Is Hepatitis B Infection to Become Chronic? The risk for chronic infection varies according to the age at infection and is greatest among young children. Approximately 90% of infants and 25%–50% of children aged 1–5 years and most of HIV-Infected people remain chronically infected with HBV. By contrast, approximately 95% of adults recover completely from HBV infection and do not become chronically infected. For Hepatitis C, approximately, 75-85% will develop into chronic infection Q2: How are Viral Hepatitis B&C Transmitted? HBV is transmitted through activities that involve percutaneous (i.e., puncture through the skin) or mucosal contact with infectious blood or body fluids including * Sex with an infected partner * Injection drug use that involves sharing needles, syringes, or drug-preparation equipment * Birth to an infected mother * Contact with blood or open sores of an infected person * Needle sticks or sharp instrument exposures * Sharing items such as razors or toothbrushes with an infected person HBV is not spread through food or water, sharing eating utensils, breastfeeding, and hugging, kissing, hand holding, coughing, or sneezing. Hepatitis C is usually spread when blood from a person infected with the Hepatitis C virus enters the body of someone who is not infected. Today, most people become infected with the Hepatitis C virus by sharing needles or other equipment to inject drugs. People can become infected with the Hepatitis C virus during activities such as; * Sharing needles, syringes, or other equipment to inject drugs. * Needle stick injuries in health care settings * Being born to a mother who has Hepatitis C Less commonly, a person can also get Hepatitis C virus infection through sharing personal care items that may have come in contact with another person’s blood, such as razors or toothbrushes, having sexual contact with a person infected with the Hepatitis C virus. Q3: How Long Do Viral Hepatitis B&C Survive outside the Body? HBV can survive outside the body at least 7 days and still be capable of causing infection, and the Hepatitis C virus can survive outside the body at room temperature, on environmental surfaces, for up to 3 weeks Q4: Who Is at Risk for Viral Hepatitis B&C Infections? The following populations are at increased risk of becoming infected with Viral Hepatitis B &C: * Infants born to infected mothers * Sex partners of infected persons * Sexually active persons who are not in a long-term, mutually monogamous relationship * Men who have sex with men * Injection drug users * Household contacts of persons with chronic HBV infection * Health care and public safety workers at risk for occupational exposure to blood or blood-contaminated body fluids * Hemodialysis patients * Travelers to countries with intermediate or high prevalence of HBV infection Q5: What Are the Signs and Symptoms of Viral Hepatitis B&C Infections? Symptoms of acute hepatitis B begin an average of 90 days after exposure and 45 days for hepatitis C. Most children under age 5 years and newly infected immunosuppressed adults are asymptomatic; whereas 30%–50% of persons aged ≥5 years have initial signs and symptoms lasting from a few weeks to several months. For Hepatits C, approximately 70%–80% of people with acute Hepatitis C do not have any symptoms. Fever, Fatigue, Loss of appetite, Nausea, Vomiting, Abdominal pain, Grey-colored stools, Dark urine, Joint pain, Jaundice are signs and symptoms of VH B&C viruses. Many people with chronic Hepatitis do not have symptoms and do not know that they are infected. However, even though a person has no symptoms, the virus can still be detected in the blood and continue to be transmitted. When symptoms do appear, they are similar to acute infection or can be a sign of advanced liver disease (liver cancer, cirrhosis, etc) Q6: Who Should Be Vaccinated? The following should be vaccinated: * All infants before 24 hours * Persons with HIV infection * Susceptible sex partners of HBsAg-positive persons * Health care and public safety workers at risk for exposure to blood or blood-contaminated body fluids * Susceptible household contacts of HBsAg-positive persons * Travelers to regions with intermediate or high rates of HBV infection * All other persons seeking protection from HBV infection Q7: Who Should Not Receive Hepatitis B Vaccine? Anyone who has had a serious allergic reaction to a prior dose of Hepatitis B vaccine, a component of the Hepatitis B vaccine, or yeast should not receive Hepatitis B vaccine. Q8: What to Do If there Was an Interruption of HBV Vaccine Doses? If there was an interruption between doses, the series does not need to be restarted. If the vaccine series was interrupted after the first dose, the second dose should be administered as soon as possible. The second and third doses should be separated by an interval of at least 8 weeks. If only the third dose is delayed, it should be administered as soon as possible. Q9: Is it Harmful to Administer an Extra Dose(s) of Hepatitis B Vaccine? If documentation of vaccination history is unavailable, it is not harmful to receive an extradose or to repeat the entire vaccine series. Q10: Can Hepatitis B Vaccine Be Administered Concurrently with other Vaccines? Yes. When Hepatitis B vaccine has been administered at the same time as other vaccines, no interference with the antibody response of the other vaccines has been demonstrated. Separate body sites and syringes should be used for simultaneous administration of injectable vaccines. Harvoni medication for Hepatitis C Sovaldi that is to be combined with Daclatasvir for the treatment of Hepatitis C
