Sierra Leone: High Rates of Hepatitis B Infection

Administering a Hepatitis B test

Recent studies have revealed alarming rates of Hepatitis B infection among adults in Sierra Leone, with upwards of 18 to 20 percent testing positive. The following paper describes a recent study carried out at a mining camp in Moyamba District. The paper includes background on Hepatitis B, summaries and comparison of Hepatitis B studies done in the country, reasons why the virus may be spreading in Sierra Leone, and recommendations for future work.

The study was conducted by Bernard S. Moigula, medical clinician and co-author of the book “Sierra Leone: Inside the War”.

High Incidence of Hepatitis B Infection at a Sierra Leone Mining Company

Author and Affiliation

Bernard S. Moigula, Occupational Health Officer

BSc. Public Health and Higher Diploma in Community Health and Clinical Sciences, Njala University

Abstract

Voluntary testing for hepatitis B virus of employees at an international mining company in Sierra Leone resulted in 18% of employees testing positive. The result is consistent with results from previous studies initiated in Sierra Leone at Masanga (Tonkolili District) and in the Bo urban area. Possible reasons for the high prevalence are discussed and an annex includes recommendations for further work.

Introduction

Hepatitis B is considered a major global health problem. According to the World Health Organization (WHO), hepatitis B caused around 887,000 deaths in 2015, and it was estimated that 257 million people were living with hepatitis B virus (HBV) infection that year (defined as hepatitis B surface antigen positive). WHO estimates that 6.1% of adults in the Africa Region are infected with HBV. The hepatitis B virus is detected by a rapid test kit to detect the hepatitis B antigen (HBsAg). In Sierra Leone, clinics and hospitals do not generally test patients for HBV, instead concentrating on HIV for pre-operation screening, pregnant women, and blood donations. Tests for hepatitis B antigen can be taken at large hospitals, but patients must pay for the test. There is no information available from the Sierra Leone government on HBV prevalence in the country.

Three recent papers have discussed the prevalence of the hepatitis B virus in different parts of Sierra Leone. A 2005 paper found that 6.2% of middle and upper class women in Freetown tested positive for HBV when given prenatal tests. Higher rates were found in studies in 2017 in Masanga (Tonkolili District) where 15% of 214 male and 13% of 112 female candidate blood donors tested positive, and in the Bo urban area where 21.4% of 308 asymptomatic patients at Bo Government Hospital tested positive (with no differentiation by sex).

This paper describes a similarly high prevalence of HBV among employees of an international mining company in Moyamba District. The name of the mining company will remain anonymous to protect the identity of the study group.

“Hepatitis” refers to inflammation of the liver and exists in five types: A, B C, D, and E. Types A and E are spread by the oral-fecal route, while types B, C, and D are spread when blood, semen, or other body fluids from an infected person enter the body of an uninfected person. Though the hepatitis B virus is spread in the same way as HIV, the Center for Disease Control (CDC) estimates that hepatitis B is 50 to 100 times more infectious than HIV. Hepatitis B infection may become chronic with cirrhosis of the liver and other complications leading to death.

According to the CDC the main modes of transmission of hepatitis by body fluids are as follows:

1. from an infected mother passing the virus to her child during birth
2. from sexual activity: the virus can be contracted from both male and female sex partners who are infected
3. by sharing needles, syringes and other medical equipment with infected persons: this includes intravenous drug use, infection from re-use of syringes and other equipment in clinics and hospitals, and accidental exposure to blood from needle sticks or other instruments
4. sharing items such as razor blades and toothbrushes with an infected person
5. having direct contact with the blood or open sores of an infected person

Among the general population of Sierra Leone there is little knowledge of the signs and symptoms, means of transmission, diagnosis, and prognosis of hepatitis B. Local people may interpret the symptoms as chronic malaria because eyes may be jaundiced, or as poisoning because the abdomen may be distended. This lack of knowledge is mainly due to the absence of public health information on hepatitis, from the lack or high cost of testing kits, and from inadequate health and science instruction in local schools. In Sierra Leone, tests for HBV are normally done only after chronic symptoms have been detected.

Mining is a major industry in Sierra Leone with bauxite, rutile, diamond, iron, and gold mines being major employers and contributors to the country’s economy. The companies draw large numbers of workers from around the country and from overseas. The majority of workers are males who may leave their families to work and live in mining communities. In 2016 the mining company in this study had 473 employees of which over 30 were from countries outside Sierra Leone. The company has its own health facilities that provide outpatient services for employees and dependents.

Methods

At the mining company there were no records of previous cases of hepatitis B among employees, but in 2015 a clinician discovered a case of chronic hepatitis B in an employee of one of the company departments. Following this discovery, the clinician presented an orientation on hepatitis B to the employees of the department on the importance of testing for HBV, and 28 individuals (all male) volunteered for tests. Results found that six individuals tested positive for the hepatitis B antigen (21% of the total). Because of the high percentage, the company’s senior management decided to offer voluntary tests to all employees.

Prior to testing, all workers received an expanded orientation on hepatitis B including means of transmission, signs and symptoms, diagnosis, treatment, risks, and prevention. Staff then underwent voluntary testing for hepatitis B with consent forms signed by staff who agreed to undergo testing and results kept confidential.

Results

Out of the 473 total company employees, 328 (69%) including 297 males and 31 females consented to be tested. Out of the number tested, 59 (18%) tested positive for hepatitis B antigen.

18.5 percent of those who tested positive were males, and 13 percent were females, revealing a significantly higher infection rate for males, though the rates for both males and females were high by international standards.

The results confirmed that there was a serious problem with hepatitis B infection among employees, and company management agreed to purchase hepatitis B vaccine so that employees who tested negative could be vaccinated (also voluntarily). By international standards, a test for hepatitis B antigen must be administered within 24 hours of receiving a vaccination, so a rapid antigen test was administered before vaccination. Clinic staff also educated workers and management on the high level of positive cases and ways mitigate the risk of contracting hepatitis B. A total of 269 employees were vaccinated.

Discussion

The percentage of positive cases in the current study was comparable to the studies done in Masanga and the Bo urban area, and higher than the investigation of middle and high socioeconomic women in Freetown. The results from Masanga, Bo, and the current study reveal a seriously high percentages of positive cases. Following are comparisons of the current study with the other three studies.

• Freetown study: The mining company had a much higher percentage of women who tested positive than the middle and upper socioeconomic women in Freetown (13% vs 6.2%).
• Masanga study: The mining company had a higher percentage of men who tested positive than in Masanga (18.5% vs 15%), while it had the same percentage for women (13%).
• Bo study: The mining company had a lower overall percentage than the Bo urban area, though the results in both studies were high (18% vs 21%).

Though there is no verified evidence, it is possible through observation to hypothesize common means of transmission of hepatitis B in Sierra Leone. Discounting infection at birth, for which there are no statistics, it is probable that hepatitis B is largely spread through 1) sexual contact and 2) infection in clinics and hospitals through the re-use of needles and other equipment.

Following is evidence observed by the author for these conclusions:

1. In countries with high intravenous drug use, hepatitis B is commonly spread through the sharing of needles. Sierra Leone has a low number of intravenous drug users. Sierra Leoneans who use recreational drugs generally use cannabis and pills which include Tramadol, an opioid, and diazepam (Valium).
2. The mining company clinic reported a high incidence of sexually transmitted infections (STIs) including gonorrhea, syphilis, and Trichomoniasis indicating that employees may be engaging in sex with multiple partners without the protection of condoms.
3. There is a relaxed attitude toward sex with multiple partners in Sierra Leone, and sex workers are present in urban areas and areas of high employment such as mining towns.
4. There is little checking of the status of sex partners. It is not common to ask partners to reveal their status of HIV and other STIs.
5. There is little knowledge of hepatitis B among the population. Public health education concentrates on HIV.
6. Through public health campaigns, most Sierra Loneans are aware of the ways that HIV is spread, but even then, many people don’t practise safe sex.
7. It has been observed that staff in some clinics and hospitals re-use needles and other equipment because of improper training, lack of equipment, or disinterest.

Incorporating these observed reasons for the transmission of HBV with the study data, it is possible to hypothesize reasons for the prevalence of HBV found in the four studies. The discussion is limited to infection from sexual contact because it is not possible to know if study subjects were infected at birth, through improper procedures at clinics and hospitals, from intravenous drug use, or from contact with blood or open sores of infected persons.

• Freetown study: Middle and upper socio-economic women in Freetown, who had a lower infection rate, generally work or stay at home, are more highly educated, aren’t generally involved in social activities at bars and nightclubs, and don’t mingle with community people as frequently as other socio-economic groups. In a typical lower/middle class environment people move around the community, live and work in a more informal environment, and have many social contacts with a greater possibility of sexual contact with multiple partners.
• Masanga study: Masanga Hospital is located in a rural area near the towns of Magburaka and Makeni. While there are few sex workers in rural villages, members of the community may travel to larger towns and contract HBV from sex workers and through casual sex from where it can spread through rural areas, yielding the high infection rates for both men and women found in the study.
• Bo study: Bo is a large urban area that is rapidly developing. It is probable that HBV is largely spread through sex with multiple partners. The city has many schools, police and army barracks, and entertainment centers, with a relaxed attitude toward casual sex.
• Mining Company (current) study: Factors for the high HBV prevalence in the current study include the prevalence of sex workers in a community of wage earners, male employees living away from their families, jobs that include travel to different local communities, and a high number of employees from different parts of the country who may bring HBV and other STIs from outside the area. In addition, in a mining community in a rural area, there is a large population that is relatively isolated from other urban areas which can lead to the spread of HBV and other STIs among the local population.

Continuing the discussion of possible reasons for the high prevalence of HBV at the mining company, six company departments had significantly high numbers of workers who tested positive.

Following are possible reasons why these departments may have higher infection rates of HBV, by department:

1. Management and senior staff have resources to engage in more frequent contact with sex workers and other sex partners, including private vehicles and resources to bring sex partners from other areas.
2. Vehicle and Caterpillar mechanics travel frequently within local communities including overnight stays.
3. Laboratory laborers are local residents, mostly uneducated, who may engage in casual sex within their communities and when transporting samples.
4. Washing plant workers have higher pay so they have more resources for entertainment.
5. Mining and technical service workers stay in local communities and work in bush areas so there are opportunities for sex with multiple partners.
6. Transport drivers move from place to place with a high possibility of sexual encounters.

ANNEX: Recommendations

Following are recommendations for further work on hepatitis B in Sierra Leone:

1. Within the mining company, test and vaccinate families of workers who tested positive.
2. Expand testing to the local communities. Educate communities on the disease including risks, complications, and prevention, and why hepatitis B is a serious problem.
3. Use women’s organizations to educate women on hepatitis B including the importance of vaccinations.
4. Educate both men and women on the importance of using condoms to prevent not only hepatitis B, but HIV and other STIs.
5. Encourage the Ministry of Health to initiate a mass immunization program for hepatitis B for both children and adults.
6. The Ministry of Health should also be encouraged to initiate an extensive public health campaign on hepatitis B including radio and television programs.
7. Non-Governmental Organizations (NGOs) should institute programs focusing on hepatitis B education, testing, and vaccination.
8. Studies of hepatitis B should be carried out in a variety of locations to pinpoint problem areas.
9. Because little is known about hepatitis C prevalence in Sierra Leone, studies should also be carried out on hepatitis C.

Literature Cited

World Health Organization, Hepatitis Overview, www.afro.who.int/health-topics/hepatitis

World Health Organization, Hepatitis B Factsheet, Reviewed July 2017, www.who.int/mediacentre/factsheets/fs204/en/

Centers for Disease Control and Prevention, Hepatitis B FAQs for the Public www.cdc.gov/hepatitis/hbv/bsaq.htm#transmission

Sero-prevalence of hepatitis B virus among middle to high socio-economic antenatal population in Sierra Leone. Wurie I.M., Wurie A.T., Gevao S.M., West African Journal of Medicine,  2005 Jan-Mar; 24(1):18-20

Hepatitis B and C in Tonkolili Province, Sierra Leone, Noemi García-Tardón, Tom M Gresnigt, Abu B. Fofanah, Martin P. Grobusch, The Lancet, 23 September 2017

Seroprevalence of hepatitis B surface antigen in urban Bo, Sierra Leone, Exton M Zoker, Abu J Sundufu, Kathryn H Jacobsen,^, Tropical Journal of Medical Research, 2017, vol. 20, issue, pp. 41-44