Epidemiological data for hepatitis D in Africa
Authors: Jose D Debes, Shemal Shah
Journal: The Lancet Global Health (2017)

Alexander Stockdale and colleagues (October, 2017)1Stockdale AJ Chaponda M Beloukas A et al.Prevalence of hepatitis D virus infection in sub-Saharan Africa: a systematic review and meta-analysis.Lancet Glob Health. 2017; 5: e992-e1003Summary Full Text Full Text PDF PubMed Scopus (76) Google Scholar describe the epidemiology of hepatitis D virus in Africa, and conclude that the infection is more common in west Africa than in other regions, particularly east Africa. This epidemiological statement is generally known among practising hepatologists and has important implications when screening for hepatitis D virus. However, a few points should be highlighted from the study. First, depending on which definition of east Africa is used (UN or East Africa Community), the only countries addressed in the study are Tanzania, Malawi, and Mozambique (the latter is usually considered southern Africa). Stockdale and colleagues report that the prevalence of hepatitis D virus in Tanzania is 5%. However, the quoted study found 0% prevalence of hepatitis D virus on retesting the same patients with the same test (the conclusion of that article is that initial hepatitis D virus results were false positives).2Winter A Letang E Vedastus Kalinjuma A et al.Absence of hepatitis delta infection in a large rural HIV cohort in Tanzania.Int J Infect Dis. 2016; 46: 8-10Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar In Malawi, the authors apparently retested old samples, since hepatitis D virus was not addressed in the referenced article, and found 1·5% seroprevalence of hepatitis D virus with no positivity for hepatitis D virus RNA in an HIV-positive population.3Aoudjane S Chaponda M González Del Castillo AA et al.Hepatitis B virus sub-genotype A1 infection is characterized by high replication levels and rapid emergence of drug resistance in HIV-positive adults receiving first-line antiretroviral therapy in Malawi.Clin Infect Dis. 2014; 59: 1618-1626Crossref PubMed Scopus (28) Google Scholar Mozambique is therefore left as the only country in east Africa with some hepatitis D virus assessment for individuals with and without HIV infection.1Stockdale AJ Chaponda M Beloukas A et al.Prevalence of hepatitis D virus infection in sub-Saharan Africa: a systematic review and meta-analysis.Lancet Glob Health. 2017; 5: e992-e1003Summary Full Text Full Text PDF PubMed Scopus (76) Google Scholar Second, all patients in Tanzania and Malawi, and most of the patients included in the meta-analysis, were infected with HIV. According to international recommendations, fully applied in Africa by the US Agency for International Development, the US President's Emergency Plan For AIDS Relief, and others, patients with HIV infection who also have hepatitis B should be treated for HIV on diagnosis, and the treatment should include a drug that targets hepatitis B virus.4Vitoria M Vella S Ford N Scaling up antiretroviral therapy in resource-limited settings: adapting guidance to meet the challenges.Curr Opin HIV AIDS. 2013; 8: 12-18Crossref PubMed Scopus (35) Google Scholar Because hepatitis D virus relies on active hepatitis B virus to replicate, patients with HIV infection and controlled hepatitis B are less likely to show positivity for hepatitis D virus. This crucial point should be taken into account in African studies. Third, as mentioned previously, all patients with hepatitis D are positive for hepatitis B virus; the authors appropriately mention issues with the reliability of hepatitis D virus tests but not that of hepatitis B virus tests. The reliability of hepatitis B virus tests in Africa is variable, since many studies and centres use non-conventional tests or ones only approved for research.5Lemoine M Thursz MR Battlefield against hepatitis B infection and HCC in Africa.J Hepatol. 2017; 66: 645-654Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar We commend Stockdale and colleagues for taking the lead in attempting to understand the epidemiology of a forgotten disease, and agree with them that further studies are needed. More research is particularly important in east Africa, because there is little to no information from this region. Emphasis, however, should be on the reliability of hepatitis B virus testing in Africa, as well as a clear distinction between individuals with HIV infection and those without, to properly address this problem. We declare no competing interests. Prevalence of hepatitis D virus infection in sub-Saharan Africa: a systematic review and meta-analysisFindings suggest localised clusters of hepatitis D virus endemicity across sub-Saharan Africa. Epidemiological data are needed from southern and east Africa, and from patients with established liver disease. Further studies should aim to define the reliability of hepatitis D virus testing methods, identify risk factors for transmission, and characterise the natural history of the infection in the region. Full-Text PDF Open AccessEpidemiological data for hepatitis D in Africa – Authors' replyJose Debes and Shemal Shah highlight the paucity of data from east Africa, one of our major findings. The authors draw attention to a study from Tanzania, where samples that initially tested positive for antibodies against hepatitis D virus by a commercial assay did not test positive on retesting with a second assay.1 The performance of the second assay relative to the first was unknown. Given that the first assay was used widely in the studies included in our analysis without confirmation by a second assay, we elected not to take retesting into account for the study from Tanzania and to maintain consistency with data available from the other studies. Full-Text PDF Open AccessEpidemiological data for hepatitis D in AfricaThe systematic review on the seroprevalence of hepatitis D virus in sub-Saharan Africa by Alexander Stockdale and colleagues1 is a key contribution to the epidemiology of hepatitis D virus infection, and highlights the scarcity of reliable data from the African continent. Most of the studies included in this meta-analysis were based on convenience sampling, and less than half of these studies include a confirmation of hepatitis D virus infection by a molecular test. The Article concludes that there is a need for reliable epidemiological data that are representative of the general population, that there are localised clusters of hepatitis D virus endemicity, and that there is a need for reliable hepatitis D virus testing methods. Full-Text PDF Open Access