A clinical epidemiological study on end-stage liver disease in Ghana

End-stage liver disease (ESLD), including advanced liver cirrhosis and hepatocellular carcinoma (HCC), is the final stage of long-standing injury to the liver due to risk factors such as chronic viral hepatitis and alcoholic liver disease. There is a high disease burden and mortality globally, especially in sub-Saharan African (SSA) countries such as Ghana, where the primary cause of HCC and cirrhosis is infection with hepatitis B virus (HBV). To overcome the problem of ESLD in Ghana and SSA, epidemiological data on patient characteristics, challenges with diagnosis and management and mortality estimates are necessary so that well-directed and appropriate policies can be developed. This thesis, therefore, aimed to determine the clinical epidemiological profile of liver cirrhosis and HCC patients in Ghana and to explore diagnostic and management practices associated with the care of patients. In Study I, we described the clinical characteristics of ESLD from liver cirrhosis and HCC in Ghana and evaluated the performance of the aspartate aminotransferase (AST) - platelet ratio index (APRI) score and alpha fetoprotein (AFP) in a cross-sectional study involving 141 HCC, 216 cirrhosis and 218 chronic HBV patients. We found a median age at diagnosis of 44 years, with most patients presenting at an advanced stage of disease. APRI cut-off of 2 had sensitivity of 45.4% and specificity of 95% in the diagnosis of cirrhosis, whilst a cut-off of 1 had sensitivity of 75.9% and specificity of 89%. The AUC of AFP of 0.88 indicated the utility of this test in the surveillance of HCC in Ghana. Study II evaluated the in-hospital testing of HBV infection and burden of disease in Ghana by reviewing hospital-based data from 136,068 laboratory register entries, 165,213 blood bank register entries, and 83,920 delivery register entries in 22 healthcare institutions. We found that HBsAg RDT testing was widely available in government hospitals, however, HBV serological profile and DNA testing were mostly limited to teaching hospitals. The crude national seroprevalence was 8.40% ((95% CI 8.25-8.57%), whilst the pooled estimate was 11.39% (95% CI 10.43-12.35). Seroprevalence in children <5 years was 1.87% (95% CI 1.07-3.27). Our study indicated that Ghana remains a country with high endemicity and limitations in the full complement of testing for HBV infection. In Study III, we explored the opinions and practices of cirrhosis patients and health workers on the nutritional management of cirrhosis through a qualitative study. We found that patients and health workers felt dietary recommendations for patients were frequently addressed but could be significantly improved. Additionally, we found that local guidelines were not available for nutritional assessment and management in the opinion of study participants. Participants believed these to be important and necessary in managing cirrhosis patients in Ghana. Study IV assessed the proportion of liver-related deaths from liver cirrhosis and HCC, and their known risk factors in Ghana, and determined clinical factors associated with mortality. We found that 8.8% of deaths between 2018 -2020 in adults aged 18 years and above were due to liver-related causes. The proportion of liver-related deaths associated with HBV infection was 48.76%, HCV infection was 10.0%, and alcohol was 7.01%. Predictors of in-patient mortality in cirrhotic patients were elevated WBC (OR = 1.14 95% CI: 1.00 -1.30) and the revised model for end-stage liver disease with incorporation of sodium (MELD-Na) score (OR = 1.24 95% CI: 1.01-1.54). For HCC patients, female sex (OR=3.74 95% CI: 1.09-12.81) and hepatic encephalopathy (grade 1) were associated with higher mortality (OR = 5.66 95% CI: 1.10-29.2). In conclusion, this thesis presented the current landscape of end-stage liver disease, clinical epidemiology, diagnosis, and management in Ghana. It enhanced knowledge of the burden of viral hepatitis-related to liver cirrhosis and liver cancer. Finally, it shed light on factors associated with in-hospital mortality in Ghana

Global change in hepatitis C virus prevalence and cascade of care between 2015 and 2020: a modelling study

Background Since the release of the first global hepatitis elimination targets in 2016, and until the COVID-19 pandemic started in early 2020, many countries and territories were making progress toward hepatitis C virus (HCV) elimination. This study aims to evaluate HCV burden in 2020, and forecast HCV burden by 2030 given current trends. Methods This analysis includes a literature review, Delphi process, and mathematical modelling to estimate HCV prevalence (viraemic infection, defined as HCV RNA-positive cases) and the cascade of care among people of all ages (age ≥0 years from birth) for the period between Jan 1, 2015, and Dec 31, 2030. Epidemiological data were collected from published sources and grey literature (including government reports and personal communications) and were validated among country and territory experts. A Markov model was used to forecast disease burden and cascade of care from 1950 to 2050 for countries and territories with data. Model outcomes were extracted from 2015 to 2030 to calculate population-weighted regional averages, which were used for countries or territories without data. Regional and global estimates of HCV prevalence, cascade of care, and disease burden were calculated based on 235 countries and territories. Findings Models were built for 110 countries or territories: 83 were approved by local experts and 27 were based on published data alone. Using data from these models, plus population-weighted regional averages for countries and territories without models (n=125), we estimated a global prevalence of viraemic HCV infection of 0·7% (95% UI 0·7–0·9), corresponding to 56·8 million (95% UI 55·2–67·8) infections, on Jan 1, 2020. This number represents a decrease of 6·8 million viraemic infections from a 2015 (beginning of year) prevalence estimate of 63·6 million (61·8–75·8) infections (0·9% [0·8–1·0] prevalence). By the end of 2020, an estimated 12·9 million (12·5–15·4) people were living with a diagnosed viraemic infection. In 2020, an estimated 641000 (623000–765000) patients initiated treatment. Interpretation At the beginning of 2020, there were an estimated 56·8 million viraemic HCV infections globally. Although this number represents a decrease from 2015, our forecasts suggest we are not currently on track to achieve global elimination targets by 2030. As countries recover from COVID-19, these findings can help refocus efforts aimed at HCV elimination