The aim of our study was to evaluate the steps of the CoC of CHB patients at the Douala General Hospital, which comprised enrolment in care, basic work up done, treatment uptake, and viral load suppression. This is done in order to provide a useful framework, to establish effective interventions at each step and for improvement in CHB care.
In this study, 1033 participants with a confirmed diagnosis of CHB (HBsAg positive for at least 6 months) were enrolled in care, 492 (47.6 %) had completed the minimal but crucial work up, which was made up of transaminases + quantification of HBV DNA, 149 (14.2%) were eligible for antiviral treatment, of which 121 (11.7%) were effectively initiated on treatment. Following treatment uptake, 53 (5.2%) had their viral load suppressed. Older age (>34 years), male gender, having a medical insurance were factors associated with treatment uptake.
Safe and effective vaccines against hepatitis B have been available since 1982 [14]. Hepatitis B vaccine has been introduced in the expanded programme of immunization in Cameroon in 2005 in order to reduce childhood HBV transmission and for eradication of the disease [15].
It is strongly recommended that HBV serological testing be offered to individuals who are part of a population with a high prevalence or who are at risk of HBV infection. Circumstances of diagnosis in our setting are mainly during blood donation [16], screening prior to vaccination, as a routine medical check-up, as a work up for infertility. There is no systematic screening for HBV as for HIV, even in people known to be at high risk, like family contacts of HBV infected patients, patients on haemodialysis, patients who underwent a surgery, previously transfused individuals, despite the fact that we are in a highly prevalent country [17]. Promotion of HBV screening especially in the at risk population, should be prioritized by health care givers to improve the CoC as early screening is cost effective and has benefits in the quality of life. The use of rapid diagnostic tests, is recommended to ease access to diagnosis especially in our setting, considering its low cost, and the fact that it can be done by any trained person, but laboratory based immuno assays, remain the preferred technique for diagnosis [18]. Following HBV diagnosis, patients are referred for further management by a specialist. The fact that patients are being referred causes a great number of loss to follow up [19]. The Consultation of the specialist, was considered as the enrolment in care. The Patients we reviewed in our study were already tested and enrolled in care, corresponding to step 1.
Following enrolment, clinical evaluation and a proper counselling are done followed by a pretherapeutic work up. For pretherapeutic evaluation during clinical assessment of CHB patients, it is recommended that they should be screened for HDV antibodies, as it is an additive cause of severe liver disease and is common in CHB patients. It helps in the decision making of treatment eligibility and the type of treatment to initiate. HDV screening is systematically requested for all CHB patients in DGH but Only 535(52%) patients were effectively assessed for HDV coinfection. Our results demonstrate how HDV screening remains poor in our context, though essential in CHB patients, and this may be worse in health facilities where it is not yet a systematic practice. Of the 535 patients assessed, 40 (7.5%) were positive. This prevalence found is similar to the one found by Stockdale et al. in central Africa (8.3%), the 10.5% obtained by Luma et al. in Cameroon, and to the 5.9% of Celen et al. in Turkey [20–22]. The result is divergent to the one of Seetlani et al. in Pakistan who had a prevalence of 58.6% [21]. Such a big difference can be explained by the known epidemiology of HDV infection that shows a high prevalence of HDV infection found in the western regions of Asia Eastern Europe, South America, Mediterranean countries than in the rest of world. The basic work up (transaminases +HBV DNA) which is crucial to identify people in need of antiviral therapy, was done by only 47.6% (492) of those enrolled in care. Our result is divergent to the finding of Spradling et al. in US, where only 0.6% did not have ALT assessment, and 18% HBV DNA assessment at least once [23]. The difference observed may be due to the fact that the work up is very costly for our setting (about USD 550 for the complete baseline work up and about USD 182 for only transaminases + viral load), with just a small proportion having a medical insurance; also the HBV DNA quantification can be done only in few reference laboratories. We hope that new low cost methods for identification of viral replication will be developed in order to facilitate the clinical evaluation of patients. HCC surveillance is recommended in all cirrhotic (F4) patients, with a 6 monthly US (±AFP) [24].
The actual regimen for treatment of CHB are generic oral direct acting antiviral drugs which are available only in 2 towns in Cameroon, and the prescriptions must be made only by gastroenterologists. The regimen of treatment provided by the public health system are tenofovir + emtricitabine combination, tenofovir and lamivudine. For those coinfected with HDV, peg IFN is the treatment regimen. In our study, 14.2% of the study population was found to be eligible for treatment and 11.7% effectively commenced on treatment. Our results concurs with the study of Shankar et al. in US, Jung et al. in US who obtained a treatment uptake of 10% [26, 27]. Our finding was higher than that of Allard et al. in Australia (5%)[28]; this difference may be due to the fact that we considered only those enrolled in care not the entire CHB population ever diagnosed of the country, and also lower than the result of Eloumou et al., in Cameroon, 4.8% [9]; the study period may explain this difference since our study was conducted when oral direct acting antiviral medications were made available in Cameroon. Our result was far much lower than that obtained by Celen et al. in Turkey who had a treatment uptake of 61.3% [22,28], this difference can be due to the fact that, a great proportion of patients in our study do not do the baseline investigations to identify those in need of antivirals and also, the need of antiviral therapy, may be observed during follow up with continuous monitoring of disease activity as CHB is a dynamic disease but here in our setting follow up remains less effective and decision to initiate therapy relies mostly on the baseline evaluation following enrolment. In 2015, it was estimated that less than 1% of people with CHB were receiving treatment, and the targets are to have 5 million patients receiving treatment by 2020 and 80% of the eligible patients treated by 2030 [29]. This low treatment rate in our context may be a reflection of the fact that, not all treatment eligible patients can be identified as a great number of patient are not properly evaluated, and though consistent subsidization has been made on antiviral medications, it remains not affordable for many patients. Also many patients don’t want to bear a lifelong treatment as far as they are asymptomatic.
Viral load suppression is the outcome of a successful antiviral therapy within 12 months of treatment. In our study, only 53 (5.1%) patients had an undetectable viral load within 12 months following treatment. This low percentage can be due to the fact that many patients did not have quantification of HBV DNA following treatment, also treatment adherence is the most identified cause of the inability to reach viral load suppression following antiviral therapy [30], some patients completely drop out of care as they are asymptomatic, whereas CHB treatment is a lifelong therapy [31]. Another crucial problem CHB patients face in their care are the multiple ruptures of stocks, that occur and may impair the antiviral medications treatment process thus the inability to achieve viral load suppression.
Some Sociodemographic characteristics were associated with treatment initiation, people with older age were more likely to receive treatment, as old people in our setting tend to be more financially stable to afford investigations which are crucial to identify the need of antiviral therapy, and also, in CHB there is a progression of liver disease with time making old people more susceptible to treatment. Having a medical insurance contribute as a major element to CHB care, this concurs to the finding of Liou et al. is US [30] and may be explained by the fact that health insurance allows continuous patient’s monitoring, and covers the financial aspects of CHB therapy.
Through concerted collaboration, CHB care providers and public health professionals, are able to improve the outcomes at each step of the CHB CoC. Though patients enter in the continuum following different pathways, and dynamically progress differently, the ultimate goal remains achievement of a suppressed viral load. This goal can only be reached, by strengthening the outcomes at each step, of the CoC through improvement on both care providers and population education, disease surveillance, integration and enhancement of viral hepatitis services in order to move closer, to achieve, the goal of WHO of eliminating HBV infection as a major public health treat by 2030.
This study was conducted in a retrospective design, with review of records which are susceptible to missing data and misclassification errors. In order to stratify steps of continuum of care, the questionnaire was adapted to medical records as the files were not conceived to serve the purpose of the research; DGH being one the biggest health facilities in Cameroon, patients attending consultations there may have different characteristics therefore they may not be representative of the whole CHB population. Our study did not evaluate screening, linkage to care, and treatment adherence as data on these steps were scares.
Despite these limitations, this is the first study that demonstrates a clear profile of the gaps, in the continuum of CHB care in a major CHB treatment centre in Cameroon, and we strongly believe our findings would serve as a call for concern in the management of CHB in Cameroon, and provide the basis to establish new strategies for interventions at each step of the CHB care, and to improve the health practice related to HBV.