Vaccine “Unaffordable” in Hepatitis B Endemic Liberia

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 This reporting was supported by the International Women’s Media Foundation’s Global Health Reporting Initiative: Vaccines and Immunization in Africa.

MONROVIA – Twenty-one-year-old Satta Kollie (not her real name), a high school senior student, never thought her dream of becoming a Registered Nurse would be shattered when she contracted Hepatitis B that landed her in the hospital.  

Satta looks as if she is nine months pregnant — her belly protruding from her emaciated body.  Initially, her mother mistook the illness for another, so she took her to a herbalist.

“My daughter was attending school in Monrovia, and when she fell sick, my brother called me to get her to seek treatment. So, I brought her to a country doctor in Bong County. He said my daughter was bewitched, so he promised to flush it out of her system with his herbs.”

Journalist Mae Azango interviewing Satta and her mother

Satta stayed with the herbalist for three months, ingesting big cups of herbs three times a day and appeared to have recovered. “She went to her boyfriend’s house and after a few weeks, her mother-in-law called me to come get my sick daughter. This was how I met her, looking like a big belly woman,” her mother explained.

Satta is among thousands of Liberians suffering from Hepatitis B; a disease caused by a viral infection that leads to inflammation (swelling and reddening) and can result in liver damage. The Hepatitis B virus is spread when blood, semen, or other bodily fluids from a person infected with the virus enters the body of someone who is not infected. This can happen through sexual contact, sharing needles, syringes, or other drug-injection equipment, or from mother to baby at birth.

Dr. James Kervieh, an Internist at Phebe Hospital in Bong County

Hepatitis B is widespread in Liberia. It affects more people than HIV.  According to Dr. James Kervieh, an Internist at Phebe Hospital, seven out of every 10 Liberians are carriers of the virus. But it is difficult to get official estimates of the disease in Liberia. For example, the 2019 global hepatitis B virus report estimates the prevalence rate of chronic HBV in the country to be at 10% and 519 HBV-related deaths are recorded annually.  A recent study by Shobayo et al. reported the prevalence to be as high as 45.2% among adult patients attending the Seventh Day Adventist Cooper Hospital, Montserrado County.

Viral hepatitis is a leading cause of death worldwide. Viral hepatitis accounts for 1.46 million deaths each year – higher than deaths from HIV, TB, or malaria. The World Health Organization (WHO) projects that there will be 19 million hepatitis-related deaths between 2015 and 2030, with more than 90% of deaths attributable to complications of hepatitis B (HBV) and C (HCV).

According to the latest WHO data published in 2018, Hepatitis B accounted for 69 or 0.21% of total deaths in the country. The age adjusted death rate is 2.28 per 100,000 of population ranks Liberia #41 in the world.

Viral hepatitis is a leading cause of death worldwide, with a higher mortality rate than that from human immunodeficiency virus (HIV), tuberculosis (TB) or malaria.

Objective:

To establish baseline rates of hepatitis B and C among healthcare workers at the national medical center of Liberia.

Dr. Kervieh described the damage the virus does to the body, including ascites — people with enlarge stomach. Most people experience abdominal swelling or bloating at some point, due to various causes. It feels as though the stomach has expanded and stretched, which can be uncomfortable.

“For women, you will think they are pregnant. For men, most times, people will think they have been bewitched. Initially, when one is infected, some of the presentations are yellow eyes, which we call jaundice,” he said.

“I have practiced in four counties in Liberia; Hepatitis B is a major problem leading to many deaths, because it causes a complication that damages the liver, which we call liver cirrhosis,” Dr. Kervieh stated.

Phebe Hospital in Bong County, central Liberia, where Satta has been receiving care for the past several months is the biggest referral medical facility in the county. The disease is vaccine preventable, but the vaccines are expensive and not part of the routine vaccine program funded by the government. Many Liberians like Satta and her mother live below US$1 a day and cannot afford the vaccine.  

 “I think it is available; a complete dose would be offered for US$60 in the public sector and for some private clinics, US$100,” Dr. Kervieh said.

On May 10, 2019, the Government of Liberia through the National Public Health Institute (NPHIL) launched the Hepatitis B Vaccination Project. This was one of the biggest initiatives taken by NPHIL, through UNICEF and two international organizations, PROBITAS FOUNDATION and GRIFOLS, which donated 54,000 doses of the Hepatitis B vaccine. But the head of the Ministry of Health Expanded Program on Immunization, Adolphus Clarke, said the Hepatitis B Vaccines are not to be sold anywhere in Liberia. 

“Vaccines should be free and no government institutions should sell vaccines. Since 2009 we have been giving Hepatitis B, vaccines but only for children,” said Clarke.  

He said the Hepatitis B vaccines are expensive and the government is only able to get vaccines from their donors to give to health workers and the National Army who are at high risk.

“Only UNICEF is supposed to bring vaccines into Liberia, so if private institutions are bringing the HBV vaccine into the country, we are not aware. Because anybody bringing the vaccine into the country, the Ministry of Health should be aware so that the vaccines can be tested by the health regulatory Board of Liberia, because if anything goes wrong, who do we hold responsible?” said Mr. Clarke.

Dr. Jonathan Flomo, who was the Bong County Health Officer at the time, said much attention hasn’t been placed on the fight against Hepatitis B

Dr. Flomo, said the disease affects 50 to 75 percent of the liver and it leads to cirrhosis, a form of cancer called hepatocellular carcinoma. But sadly, not much concern has been directed towards the fight against this endemic silent killer.

“Over the past time, the concerns have been HIV, TB, but we need to make this a priority because of the number of deaths that have occurred due to Hepatitis B and it’s like we are actually taking it lightly,” he said.

Dr. Flomo presented grim statistics from two of the public medical facilities in the region — Charles B. Dunbar and Phebe Hospitals. These are the two biggest hospitals in the central region, which is very populated. Even people from neighboring Guinea cross over to seek medical attention here. At CB Dunbar “for 2020 & 2021, we had 56 cases reported and for Phebe we had 59 cases reported, just for those two facilities. Other health facilities are reporting higher numbers.”

The then Bong County Health Officer said the government had provided doses of the vaccine free of charge for healthcare workers. But journalist discovered that not every healthcare worker in the country is vaccinated against the virus. At Phebe Hospital, at least two junior level health workers – a nurse and a nurse aid – who are directly assigned on the wards are yet to be vaccinated. The vaccines carried for health workers were not enough to cover all the healthcare workers.

Nurse Anetha Paigar provides direct care for those on the Hepatitis B wards. She said some of the previous patients were treated and discharged, but later died after they were rushed back to the hospital. She thinks one thing that is lacking is awareness.

“Our people believe in taking country herbs to cure them. I am not saying herbs are bad; but it is dangerous because they do not know the proper measurement to ingest. Too much can put burdens on the liver,” she said. 

Dr. Moses Jeuronlon, World Health Organization Liberia Office’s Infectious Disease Advisor, confirmed that the vaccine is available in Liberia. However, couldn’t say how affordable it is.

“At WHO, we only provide technical assistance, and we don’t go into implementation, only the home country does,” said Dr. Jeuronlon.

Dr. Ahmad Jo’s Syrianna Medical Clinic in Sinkor, Monrovia

Some private and public institutions and individuals have been lucky to receive some doses of the Hepatitis B vaccine from a philanthropist, Dr. Ahmad Jo, who imports the vaccines for his clinic but donates some to them.

Dr. Jo, who has been donating doses of vaccines since 2016, said because of the very high prevalence of the disease in Liberia, he decided to help any medical facility or organization that asks him since he administers the vaccines at his own clinic.

Ms. Layal Kazouh, is an Epidemiologist and head of the Liberia National Hepatitis Foundation, which administers Hep B vaccine in collaboration with Dr. Jo.  Kazouh, works with affected communities and individuals. In addition to her foundation administering the vaccines, she also provides references or points people to where they can get tested.

“Being a small foundation, we don’t have outside funding. So we are limited in a way we can provide vaccines, because we do vaccinate people who are really at risk like health workers,” she said.

While Satta believes she will get well and go home and one day to pursue her dreams of becoming a nurse, Nurse Paigar on the other hand, believes it might not happen, because patients with such big stomachs like Satta’s, do not normally survive. Their condition is the sign of their last moment on earth.  

 This reporting was supported by the International Women’s Media Foundation’s Global Health Reporting Initiative: Vaccines and Immunization in Africa.

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