Johnstone Kayandabila

: Sub-Saharan Africa has a high burden of hepatitis B virus (HBV) and hepatocellular carcinoma (HCC). The lack of surveillance programs has led to low rates of diagnosis and treatment, particularly in rural areas. We conducted mobile HBV-HCC screening clinics in rural Tanzania between March 2021 and February 2023. After undergoing informed consent, patients completed a questionnaire about HBV. A rapid point-of-care (POC) assay measured HBV surface antigen (HBsAg), and HBsAg-positive patients underwent POC ultrasound to screen for HCC and POC hepatitis C (HCV) antibody testing. The primary outcome was number of HBV diagnoses, and the secondary outcome was prevalence of liver masses in HBsAg-positive individuals. Data were analyzed with descriptive statistics. Five hundred and one patients were screened for HBV; 63% (n = 303) were female with median (interquartile range [IQR]) age of 40 (28–55) years. Only 6% (n = 30) reported being vaccinated against HBV, 92% (n = 453) reported no vaccination, and 2% (n = 12) did not know their vaccination status. Seventy-six percent (n = 340) did not know they should get vaccinated, and 4% (n = 16) reported that vaccination was too expensive. Two percent (n = 11) of patients were positive for HBsAg, with 55% (n = 6) of those being female with median (IQR) age of 36 (34–43) years. None of the HBsAg-positive patients reported being vaccinated against HBV, and all were negative for HCV. On ultrasound, one patient had a liver mass, and another had ascites. We demonstrated that community-based HBV and HCC screening can be implemented in Africa with local partnerships, and this model could be used to promote awareness and improve early detection of disease.

: The WHO aims to detect 90% of global cases of hepatitis B virus (HBV) by 2030. Sub-Saharan Africa carries a disproportionate burden of HBV and hepatocellular carcinoma (HCC). In this study, we sought to assess the utility of a combined HBV and HCC screening program in Tanzania. We conducted a prospective, serial cross-sectional study of patients who participated in a combined HBV and HCC screening program at a regional referral hospital emergency department (ED) in Arusha, Tanzania, between April 19, 2022 and June 3, 2022. All patients completed a study questionnaire and were tested for HBV surface antigen. Patients who were HBV positive were screened for HCC via point-of-care ultrasound (POCUS). The primary outcome was the number of new HBV diagnoses. Data were analyzed with descriptive statistics. A total of 846 patients were tested for HBV (primary ED: 761, clinic referral: 85). The median age of patients was 44 ± 15 years, and 66% were female. Only 15% of patients reported having a primary care doctor. Thirteen percent of patients had been previously vaccinated for HBV. There were 17 new HBV diagnoses (primary ED: 16, clinic referral: 1), which corresponds to a seroprevalence of 2.0% (95% CI: 1.2%, 3.2%). No patients had liver masses detected on POCUS. An ED-based, combined HBV and HCC screening protocol can be feasibly implemented. This study could serve as a model for HBV/HCC screening in regions with high HBV endemicity and low rates of community screening.

In July 2022, the American Society of Tropical Medicine and Hygiene Green Task Force advocated to acknowledge the health impacts of climate change, particularly on those in low- and middle-income countries, and called on global health organizations to act. Simultaneously, academic medical centers are resuming Short-Term Electives in Global Health (STEGH) as travel restrictions imposed during the COVID-19 pandemic ease in most countries. International flights by trainees from academic medical centers in high-income countries (HIC) on these electives encapsulate the climate injustice of who generates carbon emissions and who bears the impacts of climate change. Using “decolonization” and “decarbonization” as guiding principles, we suggest several strategies that global medical education programs in HIC could implement. First, restructure rotations to halt STEGH with minimal benefit to host institutions, optimize trainee activities while abroad, and lengthen rotation duration. Second, programs can calculate the carbon impact of their STEGH and implement concrete measures to cut emissions. Finally, we urge academic medical centers to promote climate-resilient healthcare infrastructure in host countries and advocate for climate solutions on the global stage.

Hepatocellular carcinoma (HCC) represents a major cause of morbidity and mortality in the world, but this problem is especially significant in low-resource countries where HCC screening recommendations and strategies are limited. We describe a rare complication of newly diagnosed HCC in a patient with untreated hepatitis B virus (HBV) infection, underscoring the importance of improving screening strategies and promoting early diagnosis of HCC in Sub-Saharan Africa.

: As coronavirus disease 2019 (COVID-19) spreads across Africa, little is known about the impact of the pandemic on health-care workers (HCWs) in the region. We designed an anonymous survey distributed via e-mail and phone messaging to 13 countries through the African Hepatitis B Network. We obtained 489 analyzable responses. We used risk ratio analysis to quantify the relationship between binary variables and χ² testing to quantify the statistical significance of these relationships. Median age of respondents was 30 years (interquartile range, 26–36 years) and 63% were physicians. The top three sources of information used by HCWs for COVID-19 management included the Ministry of Health of each country, the WHO, and social media. Forty-nine percent reported a decrease in income since the start of the pandemic, with the majority experiencing between a 1% and a 25% salary reduction. Sixty-six percent reported some access to personal protective equipment; only 14% reported appropriate access. Moreover, one third of respondents reported no availability of ventilators at their facility. Strikingly, the percentage of HCWs reporting never feeling depressed changed from 61% before the pandemic to 31% during the pandemic, with a corresponding increase in daily depressive symptoms from 2% to 20%. Most respondents (> 97%) correctly answered survey questions about COVID-19 symptoms, virus transmission, and prevention. Our survey revealed African HCWs face a variety of personal and professional context-dependent challenges. Ongoing support of HCWs through and after the COVID-19 pandemic is essential.

COVID-19 is now impacting every country in Africa and healthcare workers (HCWs) across the continent remain susceptible to professional burnout. We designed a 43-question survey addressing multiple aspects of the COVID-19 pandemic. The survey was anonymous, distributed via email and phone messaging to 13 countries in Africa. We obtained 489 analyzable responses. 49% off HCWs reported a decrease in income, with the majority experiencing between 1–25% salary reduction. Sixty-six percent reported some access to personal protective equipment (PPE), 20% had no access to PPE and only 14% reported proper access. Strikingly, the percentage reporting never feeling depressed changed from 61% before the pandemic to 31% during the pandemic, with an increase in daily depression from 2% to 20%. We found no association between depression and change in income, household size, availability of PPE or lockdown. Safety concerns related to stigma from being HCWs affected 56% of respondents.

Hepatitis B virus (HBV) vaccination patterns and the understanding of its risks among healthcare workers (HCWs) is a critical step to decrease transmission. However, the depth of this understanding is understudied. We distributed surveys to HCWs in 12 countries in Africa. Surveys had nine multiple-choice questions that assessed HCWs’ awareness and understanding of HBV. Participants included consultants, medical trainees, nurses, students, laboratory personnel, and other hospital workers. Surveys were completed anonymously. Fisher’s exact test was used for analysis, with a P-value of < 0.05 considered significant; 1,044 surveys were collected from Kenya, Egypt, Sudan, Tanzania, Ethiopia, Uganda, Malawi, Madagascar, Nigeria, Cameroon, Ghana, and Sierra Leone. Hepatitis B virus serostatus awareness, vaccination rate, and vaccination of HCWs’ children were 65%, 61%, and 48%, respectively. Medical trainees had higher serostatus awareness, vaccination rate, and vaccination of their children than HCWs in other occupations (79% versus 62%, P < 0.001; 74% versus 58%, P < 0.001; and 62% versus 45%, P = 0.006, respectively). Cost was cited as the most frequent reason for non-vaccination. West African countries were more aware of their serostatus but less often vaccinated than East African countries (79% versus 59%, P < 0.0001 and 52% versus 60%, P = 0.03, respectively). West African countries cited cost as the reason for non-vaccination more than East African countries (59% versus 40%, P = 0.0003). Our study shows low HBV serostatus awareness and vaccination rate among HCWs in Africa, and reveals gaps in the perception and understanding of HBV prevention that should be addressed to protect HCWs and improve their capacity to control HBV infection.