Liver cirrhosis in sub-Saharan Africa: neglected, yet important
Authors: Sandro Vento, Bartholomew Dzudzor, Francesca Cainelli, Kenneth Tachi
Journal: The Lancet Global Health (2018)

Clinical efforts and research on liver diseases have been scarce in sub-Saharan Africa. The first Conference on Liver Disease in Africa (Nairobi, Sept 13–15, 2018), gathering all stakeholders from the continent, is a welcome step towards greater attention to the problem, and the important issue of liver cirrhosis. Cirrhosis-related deaths doubled in sub-Saharan Africa between 1980 and 2010, and the Central African Republic, Gabon, Malawi, Uganda, and Cote d'Ivoire were among the highest 10% of countries for these deaths in 2010.1Mokdad AA Lopez AD Shahraz S et al.Liver cirrhosis mortality in 187 countries between 1980 and 2010: a systematic analysis.BMC Med. 2014; 12: 145Crossref PubMed Scopus (655) Google Scholar Most cases of cirrhosis were attributed to hepatitis B virus (HBV), alcohol misuse, and hepatitis C virus (HCV), but around 30% were unrelated to these causes.1Mokdad AA Lopez AD Shahraz S et al.Liver cirrhosis mortality in 187 countries between 1980 and 2010: a systematic analysis.BMC Med. 2014; 12: 145Crossref PubMed Scopus (655) Google Scholar The understudied non-alcoholic fatty liver disease probably has a role in these latter cases, considering the increase in obesity in sub-Saharan Africa, and traditional herbal medicine could also contribute, because its use is associated with a substantial increase in liver fibrosis.2Auerbach BJ Reynolds SJ Lamorde M et al.Traditional herbal medicine use associated with liver fibrosis in rural Rakai, Uganda.PLoS One. 2012; 7: e41737Crossref PubMed Scopus (42) Google Scholar, 3Orlien SMS Ismael NY Ahmed TA et al.Unexplained chronic liver disease in Ethiopia: a cross-sectional study.BMC Gastroenterol. 2018; 18: 27Crossref PubMed Scopus (13) Google Scholar Treatment of liver cirrhosis is inaccessible in most parts of sub-Saharan Africa, given the huge shortage of hepatologists and gastroenterologists, interventional radiologists, hepatobiliary surgeons, and pathologists. Liver transplants are uncommon and done only in South Africa, and the costs are prohibitive for the governments of almost all sub-Saharan countries. How should we tackle the high burden of cirrhosis in sub-Saharan Africa, where more than 50% of patients are admitted to hospital with end-stage disease (due to poverty, limited confidence in Western medicine, trust in traditional medicine, or distance from suitable hospitals) and mortality is high at initial hospitalisation?4Myer L Smith E Mayosi BM Medical inpatient mortality at Groote Schuur hospital, Cape Town, 2002–2009.S Afr Med J. 2013; 103: 28-35Crossref Scopus (19) Google Scholar Public awareness and high-level government commitment are needed. Preventive measures must involve reliable screening of transfused blood for viral hepatitis; improved hygiene in health facilities; training or retraining of health-care workers on safe injection practices; vaccination of relatives, cohabitants, and long-term sexual partners of HBV carriers; and health promotion and education programmes to reduce alcohol consumption, excessive weight, and diabetes. Appropriate lifestyle messages should be spread by local opinion leaders, through radio programmes and at meetings of community and faith-based organisations. Nurses in rural and underserved area clinics could also play an important role. Diagnostic services must be decentralised to the provinces of countries and include use of point-of-care rapid diagnostic tests, including nucleic acid tests,5Llibre A Shimakawa Y Mottez E et al.Development and clinical validation of the Genedrive point-of-care test for qualitative detection of hepatitis C virus.Gut. 2018; (published online April 3.)DOI:10.1136/gutjnl-2017-315783Crossref PubMed Scopus (48) Google Scholar the prices of which will probably decrease with extended use. Earlier diagnosis of liver fibrosis is essential. Transient elastography should be made available in referral hospitals, and screening campaigns should be organised in areas where the prevalence of HBV or HCV infection is high.6Ginès P Graupera I Lammert F et al.Screening for liver fibrosis in the general population: a call for action.Lancet Gastroenterol Hepatol. 2016; 1: 256-260Summary Full Text Full Text PDF PubMed Scopus (104) Google Scholar Treatment of chronic liver disease must be improved and extended. Oral antiviral drugs for hepatitis B are easier to administer, and tenofovir and entecavir have excellent resistance profiles. However, treatment is lifelong and, therefore, costly, so generic formulations should be made available at low prices. Mass treatment for HBV infection with generic entecavir could be achieved at a low cost.7Hill A Gotham D Cooke G et al.Analysis of minimum target prices for production of entecavir to treat hepatitis B in high- and low-income countries.J Virus Erad. 2015; 1: 103-110Crossref PubMed Google Scholar Although progress has been made in lowering the prices and increasing the availability of oral, direct-acting antivirals for chronic hepatitis C, much remains to be done for the HCV epidemic to be tackled in sub-Saharan Africa.8Hill AM Nath S Simmons B The road to elimination of hepatitis C: analysis of cures versus new infections in 91 countries.J Virus Erad. 2017; 3: 117-123Crossref PubMed Google Scholar The availability of affordable point-of-care diagnostics and oral drugs could also facilitate shifting of treatment to the primary care level. African governments must invest in hepatology services. The main referral hospitals in each country should have efficient liver units and clinics, possibly established with help from private institutions; proper equipment and instrument maintenance should be ensured. The high fatality rate of complications, such as oesophageal variceal bleeding, must be reduced by solving problems in resuscitation and blood supply, increasing the availability of Sengstaken-Blakemore tubes, and facilitating referrals and access to therapeutic endoscopy.9Archampong TNA Tachi K Agyei AA Nkrumah KN The significance of variceal haemorrhage in Ghana: a retrospective review.Ghana Med J. 2015; 49: 142-146Crossref PubMed Scopus (3) Google Scholar Liver biopsy should be done more often in referral hospitals, in which well equipped pathology departments are essential to improvement of diagnostics for autoimmune liver diseases, Wilson's disease, and haemochromatosis, for example. Governments should find the resources to guarantee free treatment for poor patients. Medical schools in sub-Saharan Africa should train more hepatologists and gastroenterologists, interventional radiologists, hepatobiliary surgeons, and pathologists. Salaries should be sufficiently attractive in referral hospitals to retain these specialists and not lose them to private hospitals and clinics. When decompensated cirrhosis (end-stage liver disease) develops, palliative care services are needed, but they are present almost exclusively in South Africa and should be made more available. Prevention, early diagnosis, and treatment of liver cirrhosis deserve serious attention from the governments of sub-Saharan African countries and civil society, as well as by the medical and nursing communities. It is a growing issue that must be properly confronted to reduce considerable morbidity and mortality. We declare no competing interests. Khat-related liver disease in sub-Saharan Africa: neglected, yet importantIn their Comment, Sandro Vento and colleagues (October, 2018)1 highlight cirrhosis as an important but neglected health issue in sub-Saharan Africa. We endorse their call for greater public awareness of this emerging health issue, for governmental commitment to facilitate pertinent preventative efforts in public health, and for better diagnostic and treatment options. However, we were surprised that they did not mention what is, without a doubt, one of the most important emerging causes of chronic liver disease in this region, namely the recreational use of khat (Catha edulis). Full-Text PDF Open AccessKhat-related liver disease in sub-Saharan Africa: neglected, yet important – Authors' replyWe thank Stian Orlien and colleagues for raising attention to the issue of khat use as a recreational drug in sub-Saharan Africa in response to our Comment.1 Although we mentioned the fact that traditional herbal medicine could contribute to the burden of cirrhosis in this region, as the use of khat is associated with a substantial increase in liver fibrosis,2 we do not think that the available evidence shows that khat is a major contributor to chronic liver disease. Khat is used in parts of east Africa, including Djibouti, Ethiopia, Somalia, Somaliland, Kenya, Sudan, Uganda, and Madagascar. Full-Text PDF Open Access