Effect of the COVID-19 pandemic on viral hepatitis services in sub-Saharan Africa

The global response to limit the spread of COVID-19 has diverted attention and resources from existing local health priorities, particularly in countries of low and middle income (LMICs).¹ As highlighted in a Comment in The Lancet Gastroenterology & Hepatology by Neil Gupta and colleagues,² the collateral damage on efforts to address the viral hepatitis epidemic in sub-Saharan Africa is of high concern. However, the potential effect of COVID-19 on viral hepatitis services has been poorly documented.²

We have recorded a striking decrease in use of outpatient services by patients with chronic hepatitis in three countries in sub-Saharan Africa. We retrospectively counted the number of new and known cases of chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection seen at the main referral hospitals in Burkina Faso (Yalgado-Ouédraogo Hospital and Bodogodo Hospital, Ouagadoudou; and Souro-Sanou Hospital, Bobo-Dioulasso), Tanzania (Muhimbili National Hospital, Dar es-Salam), and The Gambia (Medical Research Council Clinical Services, Fajara) from Jan 1 to April 30, 2020, a period covering the time before and during the COVID-19 pandemic. We also asked a doctor in charge of hepatitis services at each centre about the type of clinical and laboratory services that were disrupted, and plausible reasons for such disruption, using a standardised questionnaire (appendix pp 1–3).

The number of patients reviewed monthly at the hepatitis clinics fell substantially from January to April, 2020, by 71% in Burkina Faso, 95% in Tanzania, and 83% in The Gambia for new cases, and by 73% in Burkina Faso, 77% in Tanzania, and 89% in The Gambia for patients in follow-up (appendix p 4). To exclude any annual seasonal effects, we compared the number of viral hepatitis cases (new patients and patients in follow-up) in 2020 against those seen during the same period last year (Jan 1 to April 30, 2019) in The Gambia and found no significant fluctuation in cases (data not shown).

Across these countries, doctors consistently cited the patient's fear of contracting severe acute respiratory syndrome coronavirus 2 at clinics as a primary reason for the drop in patient numbers. The decrease in number of outpatient visits seems to have started in February, 2020, preceding confirmation of the first COVID-19 cases in these countries (from the second to third week of March, 2020) and implementation of public health measures limiting social contacts by the respective governments (in March and April, 2020). In Burkina Faso, the number of patients regularly monitored for chronic viral hepatitis steadily fell over this period, even though clinics were maintained and treating doctors encouraged patients to be retained in care. By contrast, in Tanzania and The Gambia, hepatitis clinics were temporarily closed at the end of March, 2020, to prepare for the COVID-19 epidemic, and staff at hepatitis services were relocated to support COVID-19 preparedness, to receive patients who were febrile with a suspicion of COVID-19, and to mitigate COVID-19 outbreaks. Of the essential diagnostic tests to manage chronic hepatitis, rapid tests for HBsAg, alanine aminotransferase, and haematology were available without any disruption throughout this period in these countries. However, there was a severe shortage of nucleic acid tests for HBV DNA or HCV RNA. Moreover, in Burkina Faso, direct-acting antivirals for HCV were temporarily unavailable because of disrupted supply secondary to suspension of international flights. Nevertheless, during this period, none of the doctors surveyed witnessed a health-care system collapse attributable to overwhelming demand for COVID-19 care.

The disrupted use of viral hepatitis services in sub-Saharan Africa might have a long-term clinical effect: people newly identified as having HBsAg or anti-HCV antibody could have lost their opportunity to be linked to care, assessed for viral load, and eventually treated, and those who had been receiving antiviral therapy might have had their treatment interrupted. Moreover, in the three countries we investigated, the relative reduction in outpatient visits was substantial (>70%) when comparing the period just before the COVID-19 pandemic (January, 2020) with a period during the pandemic (April, 2020). This decline was far more pronounced than was the reduction in use of routine health-care services recorded during the 2014 Ebola outbreak in west Africa (mean reduction 18·0%, 95% CI 9·5–26·5).³ An economic analysis showed that the indirect effect of the 2014 Ebola outbreak on deaths from non-Ebola causes was greater than its direct effect on Ebola-related deaths,⁴ indicating the importance of maintaining routine health services in LMICs.

Efforts to address viral hepatitis in sub-Saharan Africa have been remarkable in recent years. The growing availability of simple point-of-care tests and antiviral therapies at low cost make elimination of viral hepatitis a realistic goal in LMICs, as set out in a Lancet Gastroenterology & Hepatology Commission.⁵ Yet, these encouraging prospects also need to be balanced by the reminder that a large proportion of these viral hepatitis services are not supported by national programmes in most LMICs and, in the midst of further resource limitation, remain incredibly fragile. The COVID-19 pandemic vividly highlights this fragility and the urgent need for innovative and sustainable hepatitis programmes in sub-Saharan Africa. In the face of the COVID-19 pandemic, viral hepatitis services are at great risk of being neglected.