Converging pandemics: implications of COVID-19 for the viral hepatitis response in sub-Saharan Africa

Sub-Saharan Africa is currently bracing itself as the next front in the fight against the coronavirus disease 2019 (COVID-19) pandemic. Despite low testing capacity, 61 991 cases and 1778 deaths had been reported in the WHO Africa Region as of May 18, 2020, with a recent increase in reported daily cases and deaths. Despite younger age demographics and less travel than in other regions, and strong efforts for early containment, the potential for widespread community-based transmission in sub-Saharan Africa is high, but current modelled estimates vary widely. Poor baseline heath status, overcrowded urban housing conditions, and limited health-care infrastructure for testing, contact tracing, and treatment could exacerbate the expected morbidity and mortality. Certainly, there will be an accompanying loss of economic growth, and millions could be impoverished.¹

There has been speculation about the potential impact of COVID-19 on people living with well recognised, pre-existing conditions in sub-Saharan Africa (eg, HIV, tuberculosis, and malaria), as well as the potential implications for reproductive, maternal, child, and neonatal health and nutrition.² However, the implications for people living with viral hepatitis have not yet been well considered. Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections are estimated to affect 71 million people in sub-Saharan Africa, more than three times the number infected with HIV in the region, and comprising more than a fifth of the global burden of viral hepatitis.³ Only 1% of these individuals have been diagnosed. As clinicians, researchers, and programme implementers in sub-Saharan Africa, our concerns regarding the impact of the COVID-19 pandemic on people living with viral hepatitis in sub-Saharan Africa can be described in three major areas.

First, people with viral hepatitis-related liver disease in sub-Saharan Africa are likely to remain undiagnosed or to present at very late stages of disease. This is evidenced by sub-Saharan Africa having the highest death rate from liver cirrhosis in the world (32·2 deaths per 100 000 population).⁴ Guidelines from the US Centers for Disease Control and Prevention have included patients with chronic liver disease as a vulnerable population with increased risk for severe manifestations of COVID-19.⁵ Although the presence of viral hepatitis does not seem to increase susceptibility to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, there is increasing evidence that the innate immune response to SARS-CoV-2 infection results in liver damage.6, 7 SARS-CoV-2 infection might therefore be an important risk factor for critical disease and severe outcomes in this large and underdiagnosed population living with viral hepatitis in sub-Saharan Africa. Additionally, poorly controlled HIV co-infection and chronic diseases (eg, hypertension and diabetes) are highly prevalent among individuals living with viral hepatitis in sub-Saharan Africa. The additional risks posed by the interaction of such comorbidities are not yet known.

Second, for patients already diagnosed with HBV or HCV, substantial disruptions to ongoing monitoring and treatment are now occurring. In most settings where we work, travel restrictions have been strictly enforced, severely reducing access to critical health services. Professional societies in high-income settings have strongly encouraged remote consultation via telemedicine and other virtual platforms to maintain continuity of care.8, 9 However, in sub-Saharan Africa, many patients and providers do not have mobile phones or internet-enabled devices, broadband networks or connectivity, or payment mechanisms to enable such telemedicine solutions. Remote laboratory monitoring is complicated by the absence of diagnostic services outside major centres. We have witnessed marked reductions in the already precarious supply of both tenofovir-based and direct-acting antiviral drugs in both public sector treatment programmes and private pharmacies. Many patients in this context typically access medications through out-of-pocket payments, and current pressures on economic livelihoods will markedly reduce the numbers able to initiate or maintain antiviral treatments. Undertreated infection, disease flares, and loss to follow-up due to treatment interruption are inevitable. The critically low detection and management of severe outcomes, such as liver decompensation and hepatocellular carcinoma, are likely to worsen further in this context.

Third, there are considerable pressures on the health system that will have direct implications for the core interventions needed for viral hepatitis elimination. The overall reduction in the availability and use of routine health services is likely to substantially reduce case finding of early stage and asymptomatic viral hepatitis infection among those at higher risk. Redeployment of laboratory equipment, infrastructure, and personnel for SARS-CoV-2 diagnosis is a crucial component of the pandemic response. However, such actions have further decreased the availability of the already limited PCR-based testing for viral hepatitis. Routine vaccination for HBV in sub-Saharan Africa had shown steady progress over the past decade but is still lacking adequate coverage in many subregions and is highly vulnerable to disruptions in core health system functioning and community perceptions of vaccine risks and benefits. Birth-dose HBV vaccine, which is still scarce in most parts of sub-Saharan Africa but is a central focus of elimination efforts, faces challenges such as an increase in the frequency of home deliveries, the breakdown of complicated cold-chain requirements, and shifting of government priorities and financing. Finally, further reductions in scarce services for harm reduction and opioid substitution therapy have already exacerbated outcomes among key populations, particularly in urban settings.¹⁰

The collateral damage incurred by the emergence of COVID-19 in sub-Saharan Africa is by no means unique to individuals with viral hepatitis. There will be widespread epidemiological, clinical, and socioeconomic consequences of the COVID-19 pandemic for people already living with a broad range of conditions in sub-Saharan Africa. However, the extremely underdiagnosed, highly prevalent, and severely advanced nature of liver disease due to viral hepatitis in sub-Saharan Africa requires careful attention to, and awareness of, this vulnerable population by policy makers and clinical providers and a pragmatic, clear strategy to mitigate risks during the growing pandemic. The momentum towards viral hepatitis elimination in sub-Saharan Africa will need a new and highly focused approach to ensure that early gains in the coverage of core viral hepatitis interventions are not lost. Innovative implementation strategies and novel financing mechanisms to maintain and strengthen health systems in low-income countries are urgently required to tackle not only emerging pandemics, but also pre-existing ones.