Is Uganda Africa's role model when it comes to tackling hepatitis B?

KAMPALA, Uganda — At 9 a.m., the inside of the Mulago National Referral Hospital on the outskirts of Kampala, Uganda, sees patients sitting shoulder to shoulder in the waiting room. No chair is left vacant and no wall left un-leaned upon. Many of the patients arrived overnight, traveling great distances in the hope of guaranteeing a place in line and being seen by a doctor today. 

Egalimaka is one of them. A businessman in Nakataka village, 120km (75 miles) north of Kampala, he’s suffering from chest pain — which he described as feeling like fire in his lungs — that may or may not be related to his hepatitis B diagnosis.

A viral infection that can go on to cause a chronic infection, cirrhosis, and liver cancer if not managed, hepatitis B is caused by the hepatitis B infection, or HBV, and can be fatal. Egalimaka is just one of the estimated 257 million people living with HBV worldwide. In Uganda, the prevalence stands at 4.3%, yet 52% endure a lifetime of exposure to the disease. This figure excludes children, yet HBV is predominantly contracted under the age of 5.

Unlike hepatitis C, there is no cure for hepatitis B, but the effects can be suppressed with nutritional balance and oral antiviral medicines — such as tenofovir — should the disease reach a chronic stage. 

Egalimaka was diagnosed with hepatitis B in 2018, and while he was referred to Mulago National Referral Hospital some time ago, this is his first trip to the hospital that specializes in hepatitis diagnosis and treatment. After a consultation in a busy side room filled with nurses, the doctor will test his viral load levels — a measurement of how much HBV is in the blood — to determine whether he needs further treatment. 

“They told me I should take greens, mangoes, I should not take cooking oil, I should not take alcohol … They counseled me that if I followed what the doctor said I should survive for some good years,” Egalimaka said, who lives with his wife and six children.

So far, Egalimaka says he has very few of the common symptoms — malaise, yellowing of the eyes, dark urine, sickness, and abdominal pain — and can’t be certain of how he contracted the disease. Like HIV/AIDS, the virus is transmitted via exposure to blood or other bodily fluids. Yet in Africa, dying of viral hepatitis is becoming a bigger threat than that of HIV/AIDS, malaria, or tuberculosis.

Dr. Opeto Moses, a medical officer and general practitioner in the gastroenterology clinic at the hospital, said that 80% of the patients he sees have hepatitis B. Most of them have been referred from different facilities, yet the diagnosis takes many by surprise, he said. 

Despite the high prevalence at this hospital, in general, diagnosis rates remain low worldwide at 9%, making Egalimaka one of the lucky ones. The World Health Organization has set a target, as part of the first “Global Health Sector Strategy on Viral Hepatitis, 2016-2020,” for 30% of HBV-infected individuals to be diagnosed by 2020 and 90% by 2030. 

“The government of Uganda took a bold decision to vaccinate all the adults who have tested negative to protect them against hepatitis B, even if they may not need the vaccine,” Kabagambe said. 

However, ensuring people receive all three doses of the vaccine is proving a challenge, according to Aceng. Coverage for the first dose can be as high as 91%, but that decreases to 68% for the second dose and 33% for the third, she explained. 

“The majority of the people we talk to mention forgetting as one of the highest causes [of missing a vaccine appointment], because there is a six-month gap in between and the majority of the people forget,” Aceng said, adding that another challenge is a lack of transport to a health facility. “I want to appeal to the population, please come back and get your third dose so you are certain you are 100% protected from viral hepatitis B.”

Kabagambe argued that Uganda needs to invest more in community mobilization and awareness raising so that people will actively seek a diagnosis and return for their vaccination doses. Stigma and misinformation about hepatitis can lead to a lack of willingness to be tested. “The government really needs to revisit its strategies and fund more of the awareness activities and community mobilization in order to create demand for scaling up the testing.”

Public information campaigns for other diseases such as measles and polio have cost the country over $30 million, Aceng said. “It’s not easy to run a campaign when we have very limited partners supporting us in this initiative.”

While that may be the case, one partner the country is working with to improve diagnosis of hepatitis B is Abbott. Together they piloted Abbott’s new point-of-care rapid test — the Determine HBsAg 2 — which aims to enable faster identification of those with the virus. The thin strip of plastic encases a tiny test that collects a blood sample from a finger and reveals a result in 15 minutes. 

“We’re able to provide an affordable and accessible solution once [governments] have decided to undertake screening programs for their populations,” Appiah said, highlighting new technologies as critical to the fight against hepatitis B. “It’s the only way that you can get high-level, laboratory comparable tests to people in the most remote sites.”

The trial showed the test’s high sensitivity, ability to diagnose, and ease of use. The next step is for Uganda and other countries to register and procure the test so that health care workers in more remote settings can instantly diagnose a patient, therefore speeding up treatment plans and reducing transmission rates.

It’s critical this screening process runs as part of bigger campaigns to screen, identify and treat people, Appiah said. “We’re encouraging countries to put that holistic program in place.”

She called upon other organizations also working to bring down the cost of hepatitis B testing and treatment, to ensure any innovations are accessible in individual countries down to the local level. 

For someone like Egalimaka, that would mean a doctor’s visit without hours of travel time, an overnight stay, and a potential loss of a day’s earnings. 

“My plans for the future are to take care of my children so they can go to school and to care for my family,” he said.