Regional Mortality From Chronic Liver Diseases in African Countries Attributable to Hepatitis B Virus and Hepatitis C Virus Infections From 1990 to 2021 and Projections to 2030

Abstract

Background

This study aims to explore the magnitude and temporal trend of the chronic liver disease (CLD) burden in Africa and examine the progress toward the global goal of eliminating CLD attributable to HBV and HCV by 2030.

Methods

Data from the Global Burden of Disease database were used to extract the mortality burden across 47 African countries between 1990 and 2021. The CLD burden from 2022 to 2030 was projected using the Bayesian age cohort model.

Results

In 2021, the number of CLD-related deaths and age-standardized death rates (ASDR) due to HBV were higher (81 074 deaths and 14.2 per 100 000) compared to HCV (60 717 and 11.2 per 100 000). Western Africa had the highest number of deaths from CLD caused by HBV (33 603) and HCV (19 583), whereas Central Africa experienced the highest ASDR for both HCV (12.7) and HBV (16.1). An increase in CLD deaths is predicted to continue through 2030 across all regions, with the largest increases anticipated for CLD due to HBV (42.5%) in Eastern Africa and CLD due to HCV in Central Africa (45.5%).

Conclusions

Despite a significant decline in ASDR for CLD, the mortality burden of CLD still increased considerably in Africa between 1990 and 2021. By 2030, most African regions are less likely to achieve the global target of CLD elimination, emphasizing the need for international support to reduce the burden of CLD caused by HBV and HCV in Africa.

Chronic liver disease (CLD) is defined as the progressive deterioration of liver function over an extended period of time. It is characterized by long-term inflammation, which can lead to fibrosis, and eventually to severe and permanent scarring called cirrhosis [1]. CLD poses a significant health burden, contributing to considerable morbidity and mortality. Globally, CLD accounted for over 1.4 million deaths in 2019 [2]. Remarkably, the highest age-standardized death rate (ASDR) for CLD is observed in eastern sub-Saharan Africa, where the death rate reaches 44.2 per 100 000 individuals, more than twice the global average [3, 4]. While alcohol-associated liver disease contributes predominantly to the development of CLD worldwide [5]. Viral hepatitis remains one of the most common causes of CLD in Africa [6]. In 2020, ∼100 million individuals in Africa were estimated to be infected with either the hepatitis B virus (HBV) or the hepatitis C virus (HCV), accounting for 26% of the total global burden of viral hepatitis in 2020 [7].

Chronic infections with HBV and HCV can progress to hepatocellular carcinoma (HCC) due to persistent inflammation and damage to liver cells. Typically, the prognosis for HCC is poor, with median survival times postdiagnosis ranging between 6 and 20 months [8]. While vaccination prior to HBV exposure and antiviral medications for HBV infection are utilized in the prevention and management of the virus, respectively, no cure yet exists. Conversely, HCV is treatable and highly curable, though there is no vaccine.

In Africa, sociodemographic factors have significantly influenced the burden of CLD. Prior research has shown that regions with lower income levels tend to have higher incidence rates of viral hepatitis compared to economically developed regions [9]. Limited access to healthcare due to delayed diagnosis and treatment of liver disease is an important contributor to the burden of CLD in lower income regions [10].

The battle against viral hepatitis has become more challenging since the outbreak of the COVID-19 pandemic, which diverted significant resources toward combating its high incidence and mortality rates. As a result, other infectious diseases, including viral hepatitis, were impacted on a large scale [11]. Given this shift in resources and subsequent impacts, a thorough review of the burden of CLD attributable to viral hepatitis is necessary.

Aligning with the World Health Organization's goal to eradicate viral hepatitis by 2030, assessing whether countries in Africa are making progress toward that objective is crucial. Unfortunately, as of 2019, no Global Burden of Disease (GBD) region is projected to achieve a 65% reduction in mortality from viral hepatitis infection by 2030 [12]. By updating our data of GBD 2021 and focusing on African regions, our study aims:

1. To describe the impact of HBV and HCV on CLD mortality in Africa from 1990 to 2021.

2. To detail the progress made by WHO African countries in reducing mortality related to CLD associated with HBV and HCV during the same period.

METHODS

We extracted data from the GBD database (http://ghdx.healthdata.org/gbd-results-tool), updated through 2021, to analyze the number of liver cancers, cirrhosis deaths, and mortality rates due to HBV and HCV across 47 African countries. The approach to estimate the burden of liver diseases related to HBV and HCV was described elsewhere [13]. In the study, the CLD burden attributable to HBV and HCV was calculated from 4 categories defined by GBD: liver cancer due to hepatitis B, liver cancer due to hepatitis C, chronic hepatitis B including cirrhosis, and chronic hepatitis C including cirrhosis.

CLD burden data were analyzed and compared across age groups, sex, geographic regions, and socio-demographic index (SDI) levels. Age was classified into five groups: 0–14, 15–24, 25–44, 45–64, and 65 + . Based on the classification of WHO subregions in Africa, we analyzed 4 African subregions: Central Africa, Western Africa, Eastern Africa, and Southern Africa [14]. In terms of socio-economic status, we used the SDI to further categorize regions into three groups: high-middle and middle SDI, low-middle SDI, and low SDI groups.

The burden of CLD attributable to HBV and HCV was measured by total deaths, age-specific mortality rate (ASMR), and ASDR over the period from 1990 to 2021. Total deaths represent the magnitude of the burden in a specific country and period. However, the measure is highly influenced by population size, the structure of age and sex across countries over a time period. To address the limitation, we used ASMR per 100 000 individuals to identify which age group has the highest burden of CLD and how it varies by age groups and over time. To compare the overall mortality between countries over time and adjust it for different population size, structure of age and sex, we used the ASDR estimated by direct standardization based on the GBD standard population structure [15, 16]. The detailed approach of direct standardization has been described elsewhere [16, 17].

ASDR trends were modeled using a linear regression equation:

$$\ln (\mathrm{ASDR})=\alpha +\beta x+\epsilon$$ (1)

Where, α is the intercept, β is the annual change per 100 000 in rates, x is the calendar year, and ε is the error term.

Estimated annual percentage change (EAPC) was calculated as 100 * (exp(β) − 1), and its 95% confidence interval (CI) was determined based on the regression model. A positive EAPC and CI indicate an increasing ASDR, suggesting a growing burden of disease in that period, while a negative EAPC and CI suggest a decreasing burden.

For mortality predictions from 2021 to 2030, we utilized a Bayesian age-period-cohort (BAPC) model to assess the contributions of age, period, and birth cohort effects on CLD burdens. BAPC generates age-specific and age-standardized projected rates to predict the death rate of CLD attributable to hepatitis B and C. The BAPC model was demonstrated as follows:

$$n_{ij}=\log ({\lambda }_{ij})=\mu +{\alpha }_i+{\beta }_j+{\gamma }_k+\epsilon$$ (2)

Where, λ_ij denotes the number of deaths, μ denotes the intercept,α_i, β_j, and γ_k represents age, period, and cohort effects, respectively.i (1 ≤ i ≤ I) denotes age group at time j (1 ≤ j ≤ J).

We utilized the BAPC and INLA (integrated nested Laplace approximations) in the R program to project the mortality burden of CLD related to HBV and HCV from 2022 to 2030. We assume the inverse the gamma prior distribution of age, period, and cohort effects and adopt the second-order random walk to account for excessive dispersion.

Using the predicted results, we calculated the WHO core 10 indicators regarding the CLD mortality based on the following formula:

$$(D_{i,2030}-D_{i,2015})/D_{i,2015}\times 100$$ (3)

Where,D_i,2030 denotes the predicted number of CLD deaths in a specific country or African region by 2030.D_i,2015 denotes the number of CLD deaths in a specific country or African region by 2015.

According to Global Health Sector Strategy (GHSS), WHO selected 2015 as the baseline year to measure the progress of CLD mortality reduction toward the GHSS goal of 65% reduction in HBV and HCV-related CLD deaths by 2030 [18].

RESULTS

Table 1 shows the mortality burden and the ASDR of CLD HBV and the EAPC of ASDR in WHO African regions from 1990 to 2021. In 2021, the total number of HBV-related CLD deaths was 81 074 people, mostly in low-middle and low-SDI communities (75 972 deaths). Deaths from cirrhosis and other CLDs caused by HBV (66 708 deaths) were higher than those from HBV-related liver cancer deaths (14 366 deaths). From 1990 to 2021, the number of deaths increased by 31 087 cases, while the ASDR dropped from 21.0 to 14.2 per 100,000, following a decline in the EAPC of 1.3% per year. Regarding gender, the total burden was significantly higher among males than females. In 2021, there were 54 501 deaths in males, approximately twice the number of female deaths (26 573 deaths). Regarding GBD regions, there was a decline in the burden of CLD due to HBV in all regions. The highest burden of CLD diseases caused by HBV was observed in central Africa with an ASDR of 16.1 per 100 000 and an EAPC of −1.1% per year. In 2021, Western Africa was the region with the highest number of deaths, at 33,603, increasing by 11 053 deaths between 1990 and 2021. However, the region observed the most significant decline in CLD burden due to HBV, with a decrease in ASDR of 8.79 per 100 000 and EAPC of −1.5%. Additionally, the middle SDI and high-middle SDI region is the only group in which the EAPC of liver cancer due to HBV was positive (0.2%). The total burden of CLD observed a consistent downtrend with a significant drop in the EAPC in low-middle SDI and low-SDI regions at 7.5% and 7.6% during the study period.

Table 1.

The Total Burden of CLD Attributable to Hepatitis B in WHO African Regions

Location	Liver Cancer Due To Hepatitis B					Cirrhosis and Other CLD Due to Hepatitis B					Total Burden of Chronic Liver Disease Due to Hepatitis B
	1990		2021		EAPC 1990–2021	1990		2021		EAPC 1990–2021	1990		2021		EAPC 1990–2021
	Deaths	ASDR	Deaths	ASDR		Deaths	ASDR	Deaths	ASDR		Deaths	ASDR	Deaths	ASDR
African Region	8554	3.5	14 366	2.4	−1.4	41 433	17.5	66 708	11.8	−1.3	49 987	21.0	81 074	14.2	−1.3
African Region (Female)	2335	1.9	4166	1.4	−1.2	13 748	12.1	22 407	8.0	−1.2	16 083	13.9	26 573	9.4	−1.2
African Region (Male)	6219	5.1	10 200	3.6	−1.5	27 685	23.0	44 301	16.0	−1.2	33 904	28.2	54 501	19.6	−1.3
Central Africa	1218	3.4	2017	2.1	−1.9	6789	19.1	13 159	14.0	−1.0	8007	22.5	15 175	16.1	−1.1
Eastern Africa	896	1.3	1574	1.0	−1.4	12 972	21.0	20 568	14.0	−1.5	13 869	22.3	22 142	15.0	−1.5
Southern Africa	1217	2.8	2898	3.1	−0.2	4344	10.0	7256	7.7	−0.9	5561	12.7	10 154	10.8	−0.7
Western Africa	5223	5.1	7878	3.2	−1.7	17 328	18.0	25 725	11.1	−1.5	22 550	23.1	33 603	14.3	−1.5
Middle SDI and High-middle SDI	473	1.1	1393	1.4	0.2	2405	6.3	3709	4.1	−1.5	2878	7.4	5102	5.6	−1.2
Low-middle SDI	2695	3.3	4385	2.3	−1.6	15 046	19.5	23 454	13.0	−1.2	17 741	22.8	27 839	15.3	−1.3
Low SDI	5386	4.4	8588	2.9	−1.5	23 982	19.7	39 545	13.6	−1.3	29 368	24.1	48 133	16.5	−1.3

ASDR, age-standardized death rate (per 100 000 person-years); EAPC, estimated annual percentage change.

Table 2 presents the total burden of CLD due to HCV, including the number of deaths, ASDR, and the EAPC between 1990 and 2021 among African countries. In 2021, the number of deaths from CLD due to HCV in African regions was 60 717, with an increase in the number of CLD deaths caused by HCV at 25 511 compared to the number in 1990. In contrast, the ASDR for HCV observed a decrease from 15.2 per 100 000 to 11.2 per 100 000 in 2021. Total deaths from cirrhosis and other CLDs caused by HCV (30 506 deaths) exceeded those from liver cancer due to HCV (8895 deaths). While the number of liver cancer deaths in females was higher than in males during this period (5655 female deaths compared to 3239 male deaths in 2021), the total number of deaths from cirrhosis and other CLD due to HCV was higher in males (34 385 male deaths compared to 17 437 female deaths). There was an increase in the ASDR of liver cancer due to HCV in middle and in middle-high SDI regions by 0.3 per 100 000 and an EAPC of 0.3% per year from 1990 to 2021. The disease burden was observed predominantly in the low SDI countries, with 36 669 deaths in 2021 following an ASDR at 13.1 per 100 000 and an EAPC drop by 1.1%. In terms of WHO African regions in 2021, Western Africa had the highest number of deaths from CLD caused by HCV at 19 583 deaths, primarily driven by cirrhosis and other CLD, followed by Eastern Africa with 18 534 deaths. While most regions observed a decrease in ASDR of liver cancer caused by HCV from 1990 to 2021, the ASDR increased in Southern Africa by 0.5 with the EAPC increasing by 0.4%. Central Africa held the highest ASDR in 2021, at 15.5 per 100 000, primarily driven by cirrhosis and other CLD (12.7 per 100 000).

Table 2.

The Total Burden of CLD Attributable to Hepatitis C in WHO African Regions

Location	Liver Cancer Due To Hepatitis C					Cirrhosis And Other Chronic Liver Diseases Due To Hepatitis C					Total Burden Of Chronic Liver Disease Due To Hepatitis C
	1990		2021		EAPC 1990–2021	1990		2021		EAPC 1990–2021	1990		2021		EAPC 1990 – 2021
	Deaths	ASDR	Deaths	ASDR		Deaths	ASDR	Deaths	ASDR		Deaths	ASDR	Deaths	ASDR
African Region	4701	2.4	8895	2.0	−0.8	30 506	12.8	51 823	9.1	−1.1	35 207	15.2	60 717	11.2	−1.1
African Region (Female)	2852	2.8	5655	2.4	−0.6	9959	8.7	17 437	6.3	−1.0	12 811	11.5	23 093	8.7	−0.9
African Region (Male)	1848	1.9	3239	1.6	−1.1	20 547	17.0	34 385	12.3	−1.1	22 395	18.9	37 625	13.9	−1.1
Central Africa	1148	3.9	1898	2.8	−1.4	6076	16.9	12 047	12.7	−0.9	7224	20.8	13 945	15.5	−1.0
Eastern Africa	883	1.7	1728	1.5	−0.8	10 020	16.1	16 806	11.3	−1.3	10 903	17.8	18 534	12.8	−1.3
Southern Africa	785	2.2	1965	2.8	0.4	3765	8.6	6691	7.2	−0.6	4550	10.8	8655	9.9	−0.4
Western Africa	1884	2.3	3304	1.8	−1.0	10 645	11.2	16 279	7.2	−1.4	12 529	13.4	19 583	9.0	−1.3
Middle SDI and High-middle SDI	352	1.1	1089	1.4	0.3	2552	6.7	4281	4.9	−1.2	2903	7.9	5371	6.3	−0.9
Low-middle SDI	1369	2.0	2511	1.8	−0.8	9705	12.5	16 167	8.9	−1.0	11 075	14.6	18 678	10.7	−1.0
Low SDI	2980	3.0	5295	2.4	−1.0	18 249	14.8	31 374	10.7	−1.2	21 229	17.8	36 669	13.1	−1.1

ASDR, age-standardized death rate (per 100 000 person-years); EAPC, estimated annual percentage change.

Figure 1 shows the total number of deaths from CLD due to HBV and HCV gradually increased between 1990 and 2021. Regarding the mortality rate (per 100 000 person-years), there was a similar trend for both HBV and HCV, characterized by a steady increase until 2000, followed by a sharp decline until 2020. Those aged 45 to 64 years old had the highest death rates from both HBV and HCV. Among the five age groups, those 65 years and older had the highest ASDR for both HBV and HCV, while the 0–14 and 15–24 age groups had the lowest ASDR, at nearly zero. Regarding liver cancer caused by hepatitis B and C, there was a slight increase in the age group 65 years and older between 1990 and 2000, followed by a decrease in the 20 years following.

Figure 1.

The burden of CLDs attributable to hepatitis B and hepatitis C for both genders by age groups from 1990 to 2021.

Figure 2 shows the burden and the EAPC of ASDR for CLD attributed to HBV and HCV in African countries or regions. The burden of CLD caused by HBV was primarily concentrated in Western Africa and in South Sudan between 1990 and 2021, while the burden of CLD due to HBV was highest in Central African regions. The Central African Republic was the country with the highest disease burden attributed to HBV and HCV during this period, with the ASDR exceeding 20.0%. Furthermore, Mauritania (western Africa), Ethiopia (Eastern Africa), Angola and Botswana (southern Africa), and Congo (central Africa) observed the most reduction in disease burden, with the EAPC for both HBV and HCV falling below −3.0% per year during this time.

Figure 2.

The burden and EAPC of ASDR for CLD attributable to hepatitis B and C in African countries or territories.

Figure 3 describes the overall death rate of CLD attributed to HBV and HCV in 2021, categorized by gender among different SDI regions and GBD regions. In 2021, the disease burden of both hepatitis B and C was predominantly among men. The highest mortality rate for hepatitis B and Hepatitis C in males of all ages was observed in central Africa. A low SDI correlated with the highest death rates in men of all age groups. The death rates due to CLD caused by HCV of women aged 65 and older was high and nearly equal to the rate of death among men in the same age group in low-middle and low SDI communities. Regarding the burden due to HBV, the death rate attributable to liver cancer was observed to be highest in the Southern and Western African regions (Supplementary Figure 1), whereas the chronic liver burden due to HCV was highest in Central Africa (Supplementary Figure 2).

Figure 3.

The death rate of CLDs attributable to hepatitis B and C in WHO African regions by genders in 2021.

Figure 4 indicates the predicted ASDR of CLD due to hepatitis B in WHO African regions from 1990 to 2021. Most regions experienced a similar trend, remaining steady from 1990 to 2000 and then declining significantly between 2000 and 2020. It is predicted that the ASDR in these regions will continue to drop in the following 10 years. In contrast, southern Africa exhibited a different trend, with a significant increase in ASDR from 1990 to 2000, followed by a decline over the next 20 years. This downtrend is expected to continue until 2030.

Figure 4.

The predicted age standardized death rate of CLDs attributable to hepatitis B in WHO African regions from 1990 to 2021.

Figure 5 demonstrates the predicted ASDR of CLD caused by HCV among WHO African regions in the 30-year period between 1990 and 2021. Like the trend observed for CLD caused by HBV, the predicted ASDR of CLD caused by HCV in eastern, western, and central Africa remained steady from 1990 to 2000 and then declined significantly over the next 20 years. This downtrend is expected to continue until 2030. Southern Africa also experienced a similar trend for predicted ASDR attributed to CLD due to HCV compared to HBV, with an increase between 1990 and 2000, followed by a decline over the next 10 years, and a predicted continued downtrend until 2030.

Figure 5.

The predicted age standardized death rate of CLDs attributable to hepatitis C in the WHO African regions from 1990 to 2021.

Table 3 indicates the changes in the deaths attributable to CLD caused by HBV and HCV between 2015 and 2030. The number of deaths caused by either HBV or HCV-related CLD is predicted to increase across African regions by 2030. The largest increase in CLD deaths due to HBV is expected to be in Eastern Africa, with the highest increase of 42.5%. In contrast, Central Africa is predicted to observe the highest increase in CLD-related deaths caused by HCV by 2030 (45.51%).

Table 3.

The Changes in Deaths Due to Chronic HBV and HCV Infection Between 2015 and 2030

Location	Number Of Deaths Caused By Chronic HBV				Number Of Deaths Caused By Chronic HCV
	2015	2030	Change	% Change	2015	2030	Change	% Change
African Region	74 946	92 389	17 443	23.3	54 738	71 989	17 251	31.5
Eastern Africa	19 444	27 709	8265	42.5	16 141	22 661	6520	40.4
Western Africa	32 364	35 711	3347	10.3	18 324	22 013	3689	20.1
Central Africa	13 549	18 319	4770	35.2	12 121	17 637	5516	45.5
Southern Africa	9581	11 010	1429	14.9	8115	9466	1351	16.7
Low SDI	43 554	57 502	13 948	32.0	32 201	46 041	13 840	43.0
Low-middle SDI	26 760	29 676	2916	10.9	17 630	20 223	2593	14.7
Middle SDI and High-middle SDI	4636	5833	1197	25.8	4890	6226	1336	27.3

DISCUSSION

Our study analyzed the latest data of the GBD 2021 to explore the current burden and temporal trends in the mortality burden of CLD attributable to hepatitis B and hepatitis C from 1990 to 2021 and predictions by 2030 in African regions. Although the number of deaths caused by HBV and HCV increased in all African regions, the ASDR observed a declining trend over the period from 2021 to 2030. The ASDR also witnessed the largest decrease in the low SDI countries, whereas the middle SDI populations experienced the opposite trend. The hepatitis-related mortality burden among men was greater than among women. Using the BAPC model, the number of deaths and the ASDR is expected to increase across sub-African regions where no countries are expected to meet the WHO goal of a 65% reduction in CLD deaths.

These results demonstrate the impact of HBV as an ongoing significant factor in CLD-related deaths in African countries (CLD-HBV deaths: 81 000; CLD-HCV deaths: 60 717). Our findings are consistent with previous findings from the GBD 2021 study on liver cancer [19] and estimates from the WHO [20, 21].We found that the number of deaths from cirrhosis and other CLDs due to hepatitis C or B exceeds those from liver cancer due to HBV or HCV in 2021. Our finding is consistent with previous studies and the WHO reports [22, 23]. The predominant burden of cirrhosis may be explained by its etiology and limited access to health care treatment in many African countries. Fibrosis typically progresses over 10–20 years to cirrhosis [24]. Approximately 90% of HCC patients develop more than a decade after the onset of cirrhosis, regardless of its cause [25, 26]. In Africa, where the median age of just 19 years versus 31 years globally, hepatitis cohorts are less likely to survive into the decade-long window when HCC risk peaks. The burden of CLDs may be more severe in a limited health care resources setting, particularly in African countries. Prior studies reported low HBV vaccination coverage [27–29] and poor access to nucleos(t)ide analogues for HBV and direct acting antiviral agents for HCV [30, 31] in Africa, posing significant challenges in reducing incidences and mortality related to chronic hepatitis infection.

We observed the contrasting trend for total deaths and ASMR of CLD burden over the period from 1990 to 2021. The increase in total deaths over time may be explained by the increase in population size in African countries. Prior reports indicate that Africa had the highest rate of population growth [32]. However, we found an opposite trend for ASMR, which declined among individuals aged 45 and over, and remained stable over time among those aged 15–44. The divergence in direction of the total deaths and ASMR emphasizes the importance of adjusting for demographic structure when interpreting disease trends. The decline in ASDR among individuals aged 45 and older implies the potential progress in CLD management and prevention in African countries. However, the plateau trend for ASDR among the younger population aged 15–44 indicates the need for additional efforts to reduce the CLD burden.

Among the African subregions, Western Africa witnessed the largest growth of CLD deaths caused by either HBV or HCV. This finding is supported by previous studies which found the overall age-standardized prevalence of cirrhosis being highest in western sub-Sahara Africa [33]. Nigeria, which accounts for 50% of the West African population [34], is among the top 3 countries in the world for HBV-related liver disease [35]. The treatment rate for HBV in Nigeria was among the lowest of all African countries at 58% [36], increasing the overall risk of developing CLD.

Our study also found that the highest ASDR of CLD attributable to HBV and HCV is in the Central African region. The finding aligns with previous results indicating Central Africa among the lowest vaccination rates (74%) and the highest prevalence of HBsAg and HBV infection in children under 5 compared with other African subregions [36]. Furthermore, most Central African countries observed low hepatitis vaccination rates of less than 80%, especially in the Central African Republic, Democratic Republic of Congo, and Equatorial Guinea where vaccination rates are less than 60% [36]. These findings highlight the urgent need to develop timely new initiatives and substantial implementation of early dose vaccine coverage for individuals in the region. Expanding vaccination coverage plays a significant role in reducing the prevalence of chronic hepatitis infections and results in the decrease of advanced liver diseases such as cirrhosis and liver cancer. Unfortunately, the recent COVID-19 pandemic imposed many challenges to expanding immunization campaigns in many countries. Previous studies predicted that a 1-year disruption in the at-birth and childhood immunization schedules might lead to over 5 million new HBV-infections in children born between 2020 and 2030; potentially contributing to an additional 1 million deaths of these individuals a decade later [37].

Apart from vaccines, the coinfection of HBV and others contributes to the larger burden of disease in West and Central Africa. The high prevalence of coinfection of HBV and HDV among HbsAg-positive individuals reported in Western and Central Africa is one example [38]. Coinfection is considered the most severe form of chronic hepatitis due to the rapid progression toward liver cancer and even death [21]. Miao et al. estimate that individuals with HBV and HDV coinfection have the potential to progress to cirrhosis within 5 years [39]. Additionally, coinfection between HIV and HBV or HIV and HCV, particularly among those [39, 40]. Untreated HIV–HBV or HIV–HCV patients were at a higher risk of liver disease progression and cirrhosis than those with a single infection [39, 40].

Another barrier to controlling the pandemic in the African regions is low implementation and treatment accessibility. The majority of African patients seek treatment at late stages of CLDs (eg, cirrhosis and liver cancer), leading to a higher disease burden and associated treatment costs [21]. The low rates of diagnosis and treatment coverage were considered factors associated with these. The WHO progress report indicated the rate of hepatitis B diagnosis and treatment coverage was <5% in African populations [21]. Of those diagnosed with cirrhosis, ∼50% were lost to follow-up [41]. In spite of the availability of HCV treatments in 2013, the percentage of African patients receiving HCV treatment is limited due to high medical costs. A recent WHO report reveals that only 3% have received treatment, and 13% of all HCV infections were diagnosed [21]. At the country level, most African countries did not list the hepatitis medications and treatments in the national essential medicine lists or made it available in the primary health care setting [21]. Additionally, treatment expenditure is a key barrier for many patients in African regions. A large percentage of the population paid for the treatment out of pocket since only 33% of countries provide free hepatitis-related services [21]. Since advanced liver disease is linked to more cost in healthcare, the high prevalence of patients with a late diagnosis will have financial risk and create a greater burden on their families. The shortage of healthcare providers might be another factor contributing to low rates of treatment. The African region has only 2.9 physicians and 19 nurses per 10 000 population compared to the global mean of 16.7 physicians and 38.8 nurses [42]. Therefore, a strategic plan is essential to improve resource allocation in these countries.

Recently, the WHO has worked with the African Union to advocate for an increased awareness of viral hepatitis and its harms, as witnessed by the Cairo Declaration on viral hepatitis in Africa adopted by the African Union in 2020. Therefore, further collaboration on developing a strategic plan and allocating resources more effectively has the potential to reduce the burden of CLD for many individuals.

Our study recognizes certain limitations. First, the accuracy and robustness of the GBD 2021 estimates largely depend on the quality and quantity of data used in the modeling. This issue could be exacerbated in African countries where the patient report outcome system (PRO) is limited, and the accuracy rate varies between different diseases across countries. For example, previous studies found that those with HBV report less PRO impairment than those with HCV [43]. Therefore, strengthening data reports and registration systems is crucial for improved accuracy of data and timely responses in planning. The impact of COVID-19 on the CLD burden might be underreported in African countries. With a shortage of healthcare providers and inadequate healthcare infrastructure, most African countries are facing the great challenge of collecting data in response to the COVID-19 pandemic [44]. Despite these limitations, our study used the latest and most comprehensive estimates of the CLD burden in Africa using rigorous methods developed by the GBD team, providing further insights into the current burden and temporal trends of GBD over the long study period.

CONCLUSIONS

In summary, our analysis highlights an escalating mortality burden of CLD attributable to HBV and HCV at the African regional and subregional levels. Although the number of deaths increased in all sub-African regions, the ASDR decreased within those regions. Central Africa and Western Africa were hot spots of pandemic-period infections and witnessed the largest increase in CLD burden from 1990 to 2021. Using the BAPC model, the CLD burden of all countries is projected to increase, with no country expected to meet the WHO target of HBV or HCV reduction. These findings highlight the importance of initiatives and globally targeted efforts toward combatting the burden of CLD imposed by HBV and HCV infections throughout African regions.

Supplementary Data

Supplementary materials are available at Open Forum Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.