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The eradication of hepatitis C in Egypt
Published in Ahram Online on 13 - 04 - 2019

Egypt has the unfortunate distinction of ranking first in the world for infection with the hepatitis C virus, with seven million people, or around 10 percent of the population, being infected in 2007. Infection rates in India and China stood at around one percent of their populations at the same time.
In reaction to these alarming figures, the government has launched several programmes to combat and treat hepatitis C, most recently the National Campaign to Eradicate the Hepatitis C Virus and Detect Chronic Diseases launched by President Abdel-Fattah Al-Sisi under the slogan “Good health for 100 million” which targets citizens over the age of 18.
The campaign began in October 2018 and aims to eradicate the virus by 2020 and slash death rates from chronic diseases that cause 70 percent of deaths in Egypt.
World Health Organisation (WHO) Representative in Egypt John Paul Eissa has praised the campaign, telling a news conference before its launch that although Egypt topped the list of countries with the most people infected with the hepatitis C virus, it also had the greatest capacity to combat it. The campaign was the first of its kind in the region and the world as a whole, he said.

The WHO defines the hepatitis C virus as a liver infection that can cause both acute and chronic hepatitis, ranging in severity from a mild illness lasting a few weeks to a serious life-long condition. The hepatitis C virus is bloodborne, and the most common modes of infection are through unsafe injection practices, inadequate sterilisation of medical equipment, and the transfusion of unscreened blood and blood products. Hepatitis C is not spread through breast milk, food, water, or by casual contact such as hugging, kissing, or sharing food or drink with an infected person.

According to the WHO, 185 million people across the globe are infected with the disease, of whom 350,000 die annually. An estimated one-third of patients with chronic hepatitis C will develop cirrhosis and hepatocellular carcinoma. Although hepatitis C infection is a common disease, most carriers are unaware of their illness, and treatment is still unavailable for many who are diagnosed. Treatment, when available, has been successful for most patients, and recovery rates for patients in low- and middle-income countries are similar to those in high-income countries.

The WHO states that hepatitis C is found worldwide. The most affected regions are Africa and Central and East Asia. Depending on the country, the disease can be concentrated in certain populations, for example, among people who inject drugs, and/or in the general population. There are multiple strains (or genotypes) of the virus, and their distribution varies by region.

Hepatitis C is unlike other chronic viral infections, among them the human immunodeficiency virus (HIV), because recovery is possible, and there are several effective treatments. Recovery rates have improved with the introduction of new medicines, and treatment continues to change.

There are several new treatments in the pipeline, and these can treat more than 90 percent of those infected with hepatitis C and are effective for serotypes that were once difficult to treat. So far, licensed treatments include extended-effect interferon, pegylated interferon (IFN), ribvirin (RBV), protease inhibitors such as boceprevir, telaprevir, simeprevir, and sofosbuvir and nucleotide polymer inhibitors like NS5B. More anti-viral compounds are expected to be licensed in the next few years.

SCREENING 30 MILLION: During the hepatitis C campaign in October 2014, new treatments were employed to eradicate the disease using drugs imported from overseas at the expense of the Ministry of Health, said Imam Waked, professor of hepatology at the National Liver Institute at the University of Menoufiya and a member of the National Committee for the Control of Viral Hepatitis.

“In 2015, we treated 250,000 patients, and in 2016 we treated more than 600,000, which was the largest number in the world,” Waked told Al-Ahram Weekly. He said five million people had been diagnosed with the virus and needed treatment, but by 2008 this figure had dropped, meaning “that there are still 1.5 million to two million people who were not treated and don't know they have the disease because there are no symptoms. Symptoms are detected in later stages of the disease when they become severe,” he explained.

“It is necessary to screen everyone, so we can reach all those who need treatment. We need to make sure that those infected do not develop liver disease and to prevent transmission of the infection. That's why the 100 million campaign was launched.”

Before the campaign began last year, the price of screening, testing and treatment was negotiated with the drug companies making the treatments. Egypt was divided into three parts, with treatment being divided into phases, nine governorates between October and December 2018, 11 governorates between December 2018 and February 2019, and seven governorates between March and April 2019.

“The campaign targets those over the age of 18, which amounts to even more than the officially announced 50 million people and about 59 million divided into three stages,” Waked said. “There are 17 million in the first phase, 22 million in the second, and 20 million in the final phase.”

After training medical teams to carry out the tests, screenings for the virus as well as hypertension and obesity are conducted in each governorate under the campaign. Hypertension patients are given free medication, obese patients are given guidelines and advice, and hepatitis C patients are referred to the Ministry of Health clinics for more testing and free treatment.

So far, more than 30 million people have been screened, according to Waked. Four percent had antibodies for the virus and were sent to clinics for more tests, where 3.25 percent or 800,000 to 900,000 people were found to be infected with the virus. “We expect to find between 300,000 to 400,000 more, which would mean that virus infections have dropped from seven percent to less than 0.5 percent of the population,” he added.

“I discovered I had the virus three months after I left the hospital,” said Hajja Magda, a woman in her late 50s, who has benefited from the campaign. She went to one of the major university hospitals in Cairo for hernia surgery three years ago, previously carrying out tests to show she was free of any disease. After she left the hospital, however, she found she had contracted the hepatitis C virus while having the operation.

“I went in for a hernia operation, and they asked for many tests, which I did, and they were all negative. After surgery, they kept the cannula at the site of the operation for one month so it could dry up and heal,” she said. “They sent me home, but one month later my leg began to swell, and the incision was not dry. I went back, but I was told not to worry and sent home. One week later, I went back because my foot was more swollen. Then I went to a private doctor, who said there was an infection and I would need to carry out tests. I found out I had the hepatitis C virus even though I was healthy before surgery and my tests attest to that.”

Magda is one of the thousands who were infected in the hospital due to medical negligence. Former minister of health Adel Adawi said four years ago that such infections could take place in the hospital during surgery due to negligence in sterilisation procedures. He said that hospitals, dental clinics, blood transfusions, dialysis clinics and even hairdressers or barbers could spread hepatitis C if they did not follow proper procedures.

Figures at the time revealed that eight to 10 million people were infected with the hepatitis C virus, with 150,000 new infections every year, according to the Ministry of Health.

The ministry launched a national campaign to combat such hospital-acquired infections (HAIs) as a result, especially after the Faqous Public Hospital scandal where there was severe negligence in sterilising dialysis equipment because of a lack of supplies, the breakdown of a viral-infection detection machine, negligence in applying anti-infection measures, and problems in virus testing at a joint laboratory in Zagazig.

As a result, eight doctors and 36 nurses faced criminal charges for negligence in spreading infection among patients being treated for renal failure.
Hisham Al-Khayat, professor of hepatology at the Theodor Bilharz Research Institute in Cairo, told the Weekly that many patients had been infected with hepatitis C and B, a different type of the hepatitis virus, in hospitals. “I'm not talking about some small hospital in a village or suburb. I'm talking about leading public, private and university hospitals in the capital that are well known,” he said.

Many diseases could be contracted in hospitals, most notably hepatitis, he said, with 150,000-200,000 people infected with the hepatitis virus C every year, of which five to 10 percent were infected in hospitals, dental clinics or due to medical negligence. Al-Khayat explained that the incubation period for the infection was between two to six weeks and those complications could come from stays in intensive-care units since these could incubate pneumonia and fungal infections.

Hospital patients could be infected with a variety of illnesses from a variety of sources, including medical equipment intended for one use that was used repeatedly among different patients, he said. “There are global standards for sterilisation, but unfortunately these are not always observed in Egypt,” he said.

Maha Talaat, head of infection control at the US Naval Medical Research Unit 3 (NAMRU-3) in Egypt, said in an address four years ago at a conference for Monitoring and Preventing the Infection of Health Facilities and the Containment of Antibiotic-Resistant Microbes that 100,000 people out of 2.5 million patients treated in the US each year die at healthcare facilities. She said that a study on the scope of infection at healthcare facilities in Egypt had revealed that 29 percent of infections were through the bloodstream, 28 percent through prior weakening with pneumonia, and 25 percent in intensive-care units.

Minister of Health and Population Hala Zayed has told the press that there is a need to ensure that anti-infection standards are properly applied in Egypt. She said that patients in the hospital were more prone to infection due to their often already weakened immune systems.

MINISTRY PLANS: Egypt plans to eradicate infection with the hepatitis C virus by 2020 and to reach global standards of less than one percent infections by providing effective and safe treatment for all patients.

This means eradicating the disease and preventing its transmission to others. Gamal Esmat, a member of the National Committee for the Control of Viral Hepatitis, told the Weekly that those infected were the only source of transmission of the virus and could transmit the disease to four other people during their lifetimes.
“Every case we discover not only saves that person but also their community because we are preventing four others from being infected,” Esmat explained. “This is treatment for prevention, as we also saw in the anti-bilharzia campaign.”

In the early 1980s, the rate of bilharzia, a parasitic disease, in Egypt was more than 40 percent of the population, but with new oral-tablet treatments levels dropped to less than 0.5 percent. Esmat said that similar treatment for prevention methods for hepatitis spearheaded the ministry's plan to combat the virus by supporting changes to prevent the transmission of the disease and updating databases at blood banks at ministry and university hospitals.

“We all know that the virus is transmitted through blood transfusions and blood products,” he said. “So, we are striving for safe blood transfusions: every blood bag leaving a university hospital or blood bank is now 100 percent safe and does not carry the hepatitis B or C viruses or the HIV virus,” he added.
Esmat said the third focus of the plan was to apply performance protocols at the government, university and private hospitals “to prevent infection in general, and not just with the C virus”. Another area of focus was raising people's awareness through the media and advertising because “the media's role is to raise awareness that the disease can spread through many means, including even personal grooming tools such as scissors, toothbrushes, and razors, especially since an infected person has no symptoms.”

The last focus to prevent the spread of the disease was ending “bad habits”, Esmat said, such as tattoos, body piercings, and pedicures using unsterilised equipment.

Other than the medical strides that Egypt has taken in eradicating the virus, there is also an economic impact of the campaign. “A virus patient costs the state LE50,000 due to absences from work, renal medicine, and possible liver tumours, which make the treatment more expensive,” Esmat explained. “Add to that the cost of the four others who could be infected, this means LE250,000. The cost of treatment for patients discovered in the campaign is no more than LE1,500, however, which saves about LE48,500 in terms of cost of treatment per person.”

“The two to three million people targeted in the president's campaign to eradicate the hepatitis C virus and detect chronic disease will save the country millions of pounds. Egypt will stamp out the virus by 2020 and reach global standards of less than one percent of the population infected,” he concluded.

*A version of this article appears in print in the 7 April 2019 edition of Al-Ahram Weekly under the headline: The eradication of hepatitis C

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