The scourge of liver cancer and cervical cancer in Nigeria has become worrisome. Liver cancer is caused by Hepatitis B virus which is rated the No.2 killer in Nigeria after malaria. Despite the availability of effective preventive vaccines, liver cancer, and cervical cancer continue to kill Nigerians. In this interview, Dr. Lai Ogunbiyi, the Managing Director, Signal Health Nigeria Ltd., calls for urgent and sustainable action to check the menace. Excerpts:
By Sola Ogundipe
Why do we need to worry about Hepatitis B virus and Human Papillomavirus infections?
These viruses rank among the most dangerous in the world in terms of infectivity and the diseases they bring about. The viruses are not unique to Nigeria. They are present all over the world. The problem is that while the developed world and developing countries of the world are marshaling their resources to tackle these viruses, a similar undertaking is absent in Nigeria. These viral infections are quietly wreaking havoc to the population at large and no one seems to be noticing. The viruses are called “silent killers” for a reason. Once infected, carriers of these viruses are largely asymptomatic for months and in some cases years. Eventually, chronic carriers fall prey to these viruses and the consequences are dire. In chronic carriers of these viruses, the HBV invariably causes liver cancer while the HPV inevitably results in cervical cancer.
On the 16th of July 2015, the Federal Ministry of Health announced that about 20 million Nigerians are infected with the HBV. This stunning figure was followed by another announcement by the House of Representatives in October of the same year that 23 million Nigerians are infected with HBV and are at risk of developing liver cancer. On average, about 28 Nigerians die every day from liver cancer caused by the HBV.
This virus is one of the most infective viruses known to man. It is reported to be 100 times more infectious than the Human Immunodeficiency Virus (HIV) and is known to have an uncharacteristic property of surviving under rather harsh conditions. Isolates of the virus have been known to survive for days on dry inanimate objects.
Upon infection, the virus is known to be present in ALL bodily fluids. While this virus is predominantly sexually transmitted, it can also be transmitted via casual contact such as kissing, coughing and in crowded living quarters. Perinatal transmission is also prevalent. On average, it is estimated that in Nigeria, 13 percent – 17 percent of the population is literally walking around with this virus in their system. While this figure is completely unacceptable given the population of Nigeria, it is worth noting that there are pockets of the population where the infection rates far exceed the national average. The Human Papillomavirus (HPV) presents a similar problem as the HBV. It is also a” silent killer”.
In the 2010 World Health Organisation (WHO) report on cancer in Nigeria declared that 40.3 million women in Nigeria above the age of 15 are at risk of developing cervical cancer due to the HPV infection.
Presently, it is reported the 23.7 percent of women between the ages of 15 – 44 years are chronic carriers of the HPV. It is projected that left unchecked, the figure will balloon to 62.0 percent in 10-15 years. This is not far-fetched given the projected population growth. Like the HBV, the HPV is predominantly sexually transmitted with just about 1 percent due to perinatal transmission. Nigeria ranks first in mortality to the HPV infection in sub-Saharan Africa. Conservatively, 30 women die of cervical cancer every day in Nigeria.
The fact that cancer from these infections can be completely prevented by proven vaccines and that not much is being done to tackle this problem, I believe, suffices in explaining why we need to worry about the HBV and the HPV infections.
You stated there are vaccines that can effectively prevent liver cancer and cervical cancer. When were they introduced?
The first HBV vaccine was
introduced in 1998. That is about 21 years ago! It has been studied thoroughly and has successfully undergone the obligatory regulation-mandated 10-year retrospective examination and analysis (post-marketing analysis). Therefore its efficacy and safety are not in doubt.
The same thing can be said about the HPV vaccine as well. The first vaccine in this category was introduced in 2006. Based on data that has been accumulated to date, it is safe and effective in the prevention of cervical cancer caused by the HPV. I will even venture to suggest that the right question to ask is “why has much not been done to combat these scourges that are obviously ravaging Nigeria given the long availability of these vaccines in the marketplace”?
How bad are these conditions in Nigeria and how aware are stakeholders about them?
When one takes a very close look at the infection rates on a state-by-state basis, the enormity of the problem becomes quite glaring. In the case of HBV, it was originally thought to be largely a phenomenon of the waterlogged riverine states of the south-south. Recent figures clearly show that infectivity has spread far beyond the south-south. The spread of the virus cuts across all 36 states of the Federation with some of the northern states recording some of the highest rates of infection. In some of these states, while the average rate of infection is twice or three times higher than the national average, pockets of the population within these states have indeed exhibited alarmingly higher rates than the state average!
Similar infectivity trends have also been replicated in the case of HPV infections. The HPV infections have not had a history of regional predisposition in Nigeria. Nevertheless, the rates of infection are equally increasing and affect all the states of the Federation.
As far as the awareness of the stakeholders go, I believe that most Governors, Commissioners of Health and the Federal Ministry of Health are quite aware of these issues. Last year, the Federal Ministry of Health at the urging of the President embarked on a Presidential Initiative (The Nigerian HIV/AIDS Indicator and Impact Survey – NAIIS) designed to ascertain the infection level of HIV/AIDS, as well as Hepatitis is B and C in Nigeria with a view to re-strategising toward the eradication of HIV/AIDS and Hepatitis B and C.
The extensive survey involved 16 States and while the results on HIV/AIDS showed a decreasing trend, results of the survey on Hepatitis B and C are still pending. Furthermore, in the past four years, several states have conducted surveys to assess the extent of HPV infection in their respective states. I believe the core of the issue we are presently faced with is that of transitioning from the screening to the prevention stage.
Is Nigeria going through epidemics of liver cancer and cervical cancer? Should an emergency be declared?
An epidemic is classically defined as a condition that exists when an infection disproportionately affects a large segment of a population at a given time. Based on this definition, yes, I believe we are facing an epidemic of large proportions for both viruses – albeit a rather “silent” epidemic.
How else does one explain the persistent prevalence of these viruses in millions of Nigerians? When the Federal Ministry of Health, the National Assembly and the WHO are all in agreement that millions of Nigerians are infected by these viruses, it is preposterous not to call what we are facing an epidemic.
This is undoubtedly an emergency that requires prioritising the inclusion of vaccines for HPV and HBV in annual immunization schemes. It will require having all hands on deck. States and Federal government, separately or in a coordinated effort have to agree that tackling these viruses is a priority. No one arm of the government can do it alone. The good news is that there are proven tools for preventing cancers caused by these viruses.
Vaccination reduces liver and cervical cancers. How can Nigeria maximise the potentials of available vaccination initiatives?
Nigeria is a member state to the Global Alliance for Vaccines and Immunisations (GAVI). This is the foremost organization with a well-defined initiative to work with vaccine manufacturers to ensure that vaccines are available for purchase by the developing world for their immunization programmes.
To the extent that Nigeria gains access to these vaccines for immunization, somewhere along the way, Nigeria would have to have taken advantage of its membership in this global alliance. That is how Nigeria can benefit from its membership in the GAVI initiative. Membership in this alliance is important, as there is a limited worldwide shortage of some vaccines in the marketplace. The vaccine manufacturers’ arrangements with GAVI ensures that member states get preferential treatment with respect to access to vaccines in their (GAVI ’s) portfolio. It should, however, be pointed out that not all vaccines are in the GAVI portfolio. As an example, the HBV vaccine is not part of the GAVI initiative. The WHO has also awarded grants to Nigeria to assist in immunisation campaigns over the years.
What is the mortality rate in Nigeria for these viruses?
Conservatively, 28 Nigerians die daily from liver cancer caused by the HBV while for the HPV, the figure is about 30 Nigerians daily.
I say conservatively because these figures are based on mortalities for which death certificates (or some records) were issued. In other words, these are deaths that occurred in a medically supervised setting with reference data of mortality. I am sure you are aware that not all Nigerians who are sick go to medical practitioners or hospitals. Many Nigerians do not have access to hospitals or doctors nor can they afford to see medical practitioners. Some Nigerians would rather go to their traditional healers or pastors/imams while others will just stay at home rather than go to the Hospital. In fact, it is reported that about 17 percent of Nigerians do not go to medical settings when they are sick. Secondly, these mortality figures are based on reports that are about 10 years old. For viral infections that spread exponentially, it is reasonable to expect that the mortality figures will be much higher today. Hence, the term “conservative” does not really seem out of place.
Could you comment on the demography of infection in Lagos and other States that currently pose a challenge?
Lagos with a teeming population of about 23 million (by definition a megacity) inherently presents a unique opportunity for the viruses to thrive. Take the case of HBV for instance. It has been reported that the average infection rate is about 20 percent in the state while the infection rate among surgeons is about 25.7 percent.
What this means is that because of the high infection rate of this virus, and its presence in all bodily fluids, surgeons and emergency room personnel are unwittingly serving as chronic carriers and reservoirs for spreading the virus.
It is not farfetched to expect this phenomenon to be replicated in other population centers in the country. This explains why it is highly recommended that any HBV immunization programme starts with the vaccination of first-line responders such as hospital personnel, police, soldiers, ambulance personnel and related public servants.
Another state worth mentioning with respect to the HBV is Edo State. The average rate of infection for this virus in Edo State is about 29.3 percent. However, the infection rate in the Akoko Edo area is about 66.4 percent. This pocket of high infection rates may not be unique to Edo State.
The case of the HPV, infection rate in the two states are examples of why immunisation programmes for these viruses warrant urgent consideration. In 2014, Olabisi Onabanjo University (OOU) conducted a retrospective study of women who died of gynecological diseases between 2003 and 2014 in the Ijebu Ode/Shagamu axis.
Dr. Ogunbiyi is a graduate of the University of California San Francisco whose focus is on Clinical Pharmacy and drug development. He holds several United States patents in the field of clinical ophthalmology.