Egypt is the number-one country in the world afflicted with hepatitis C. This translates into thousands of deaths among its 15 million patients every year, as well as a high incidence of new cases. Experts say that after heart attacks, hepatitis C is the top killer of Egyptians. Scientific discoveries have brought new drugs onto the scene, some of which may significantly reduce the size of Egypt's health problem. But the cost of these drugs remains out of reach for most patients. Unless Egypt is allowed to manufacture the drugs locally it is unlikely that the new treatments can be used on a scale that would slow the spread of the disease, now at epidemic proportions. On the stairs of the National Hepatology and Tropical Medicine Research Institute (NHTMRI) in Cairo, Sabah Abdel-Fattah, a 40-year-old mother of two, waits for her husband to take her home. She is too weak to cross the street on her own, she says. Sabah started taking weekly shots for the treatment of her hepatitis C last summer. But the shots, for the moment her only hope of recovery, have weakened her further. Loss of energy is a common side effect of current treatments for this debilitating disease. Before being diagnosed with hepatitis C, Sabah thought she was anaemic. She was weak and lethargic and had recurrent bouts of dizziness. But blood tests showed abnormalities in her liver functions, and the doctors decided that hepatitis C was the culprit. They explained to her that she must have contracted the disease from unsterilised medical tools or blood transfusions. Her symptoms started after she received treatment at a dental facility, which she believes was the cause of her affliction. “When I checked the date of contracting the disease, I discovered that it coincided with a visit to a dental clinic around the same time, a year and a half before I was told I had hepatitis C,” she says. Sabah lives in the Cairo southern suburb of Helwan. Every week she travels to the NHTMRI for her shot, a combo of two drugs known as interferon and ribavirin. Her course of treatment runs for 38 weeks. The shots are free, as they are paid for by the government. But Sabah has to foot a bill of LE70 to LE150 ($10 to $21) per week for tests that doctors need to evaluate her progress. And she's always in pain. “If I tell you the extent of the pain I feel, you'll find it hard to believe,” she says. Immediately after taking the shots, she suffers from exhaustion and fatigue. She also has pain that shoots throughout her body for half the week, or even until the time of the next injection. She cannot leave the house alone, cannot finish her housework, and is unable take care of her two children, aged seven and nine. Sabah is one of up to 15 million Egyptians who have contracted the disease, almost one out of every five people. About 200,000 Egyptians contract the disease every year, says Mohamed Ezz Al-Arab, head of the NHTMRI Tumour Unit and adviser to the Right to Medicine Centre, an NGO. The lowest incidence is among children, while the highest is among those aged 45 and above, according to Ezz Al-Arab. The Delta is more affected than Upper Egypt, and the remotest governorates are the least affected of all. In 2002, the government set up a specialised body, the Egyptian National Committee for the Combat of Hepatic Viruses (NCCHV), to assess the problem and find the best prevention and treatment measures. Since then, the NCCHV has produced guidebooks on treatment of the disease, organised training programmes for healthcare workers, and devised a national programme for vaccination. It is now compiling clinical data about hepatitis C for the use of researchers and medical practitioners. The bilharzia connection: Experts attribute the epidemic status of ehpatitis C in Egypt to an aggressive national campaign to eliminate bilharzia, or schistosomiasis, in the 1960s. Tartar emetic, the substance used to treat the bilharzia, was sometimes injected with needles that were not properly sterilised. Experts thus link the spread of hepatitis C, which became evident in the 1980s, to the anti-bilharzia campaign of 20 years earlier. Alaa Awad is a professor of hepatic diseases and ailments of the digestive tract. He says that people can also contract hepatitis C through a lack of hygiene in barbershops and tattooing and circumcising during public festivals known as mouleds, or saints' days. But this is not the only, or even the primary, cause of infection. Hospitals have become a main suspect in the spread of the disease, according to Awad. “The revolutionary changes that have happened in medical technology, with the introduction of endoscopy and catheterisation, have also taken their toll. Because of the high cost of the tools involved, they can be reused dozens of times, instead of once as intended.” Blood transfusions also carry the risk of spreading the hepatitis C virus. In 2008, the NCCHV designed an $80 million plan to treat hepatitis C patients with a combination of interferon and ribavirin. The campaign failed to achieve its declared goal of treating 20 per cent of the country's patients by 2012, according to a paper by researcher Heba Wanis that was published by the Egyptian Initiative for Personal Rights (EIPR), an NGO. Only two per cent of Egyptian patients received the treatment, and the paper criticises the plan for focusing on patients who have a high chance of recovery and neglecting those in advanced stages of the disease. According to Wanis, the money spent on the plan could have helped more people had it focused more on prevention than on treatment. “The key to resolving this situation is not treatment alone,” Awad said. Monitoring hygiene and sterilisation in the healthcare industry is the more urgent task. According to Awad, the government has for too long turned a blind eye to the erroneous practices of hospitals and clinics, though recently the NCCVP started focusing on preventing infection in health facilities. It has urged closer monitoring of medical procedures to ensure that one-time use equipment is not used repeatedly to cut costs, that sterilisation is carried out with methodical rigour, and that the recycling of hospital refuse is done properly. The NCCVP has also called for the government to pass stringent laws criminalising lax hygiene in hospitals. Ezz Al-Arab says that these points cannot be overstated. Dental clinics, he notes, need on average ten sterilising devices to make sure that infection is not transmitted from one patient to another. He wants to see more inspectors checking on sterilisation and hygienic practices in independent clinics and says that the inspectors should be given legal powers to investigate cases of malpractice. Hope for patients: According to Ezz Al-Arab, four out of five hepatitis C cases turn chronic, in the sense of the disease lasting more than six months. Of the chronic cases, one out of five will develop liver cirrhosis within 20 years. Up to four per cent of all chronic patients may develop cancer. Some cases of liver cirrhosis are silent, with the patient feeling normal although liver enzymes are elevated. But in some cases acute health problems may occur, including stomach bleeding, ascites (excess fluid in the peritoneal cavity), and the brain disease known as hepatic encephalopathy. Patients like Sabah who receive injections of interferon and ribavirin often suffer from excessive fatigue. But a new drug called Sovaldi was approved by the US Food and Drug Administration (FDA) in late 2013 and has milder side effects. According to Awad, Sovaldi is revolutionary in its approach to the disease, as it represses an enzyme the virus needs to multiply. Its success rate so far is said to be 90 per cent or more, and the treatment period is only six to 24 weeks, almost half the length of current drugs. Another advantage is that the drug can be taken by mouth, obviating the need for repeated trips to the hospital, and it needs less monitoring and fewer tests, further reducing the inconvenience for patients. Gilead Sciences, the company that developed Sovaldi, has negotiated a deal with the NCCVH in Egypt. According to the deal, Egyptians can buy a one-month supply of the drug for $300, a fraction of the cost in the US. But this price is still so high by Egyptian standards that many patients are likely to be left out. According to the EIPR research paper written by Wanis, the US company is still selling the drug to Egypt at an excessively high price. Wanis wants to see the Egyptian government produce the drug locally, something that may have legal implications. As the developer of the drug, Gilead has property rights that may prevent local production, except under licence from the US-based company. Gilead has sought to register its product under Egyptian intellectual property rights laws, but its application has been turned down on the grounds that the drug does not meet the conditions for novelty demanded by local regulators. Wanis says that Gilead's chances of obtaining Egyptian recognition of its intellectual property rights remain slim, and as a result other companies may feel free to duplicate the drug locally without fear of litigation. Wanis's paper notes that in September 2014 Gilead signed licencing agreements with seven Indian companies to produce duplicates of the drug. These Indian companies have the right to produce the active ingredients, called Sofosbuvir and Ledipasvir. It is likely that the price of their products will be affordable by developing world standards. Accordingly, Egyptian companies may be able to import the active ingredients from India and use them to produce Solvadi at locally affordable prices, thus ending the suffering of millions of Egyptian patients, says Wanis. Alternatively, Egyptian companies may be able to seek a deal that allows them to produce the active ingredients locally. Such a solution may be more likely in the long term, as it calls for a lot of training and technology transfers, but it may prove cheaper than the other alternatives. Two Egyptian companies will start marketing Sovaldi next month, Ezz Al-Arab said. According to current arrangements, Egyptians will have access to 225,000 bottles of Sovaldi pills, each containing a one-month supply. However, these will only be enough to treat about 50,000 patients, leaving millions of patients without access to the drug. An Egyptian initiative, of which Ezz Al-Arab is a part, calls for the production of five million bottles of Sovaldi. “The initiative brings together civil society organisations, pharmaceutical companies and professional syndicates” in an effort “to treat 20 per cent of the total patients, or nearly three million Egyptians within five years,” he said. A new medicine called Harvoni, also from Gilead Sciences (approved by the FDA on 10 October 2014), is also attracting the attention of Egypt's health administrators. Ezz Al-Arab calls it a “quantum leap forward in curing the virus without interferon,” and the Ministry of Health is about to start an experiment on 200 patients to ascertain the safety and effectiveness of Harvoni for use in the country. Economic fallout: The most recent plan to treat hepatitis C in Egypt cost nearly $80 million annually and failed to make a dent in the problem. Experts say that the treatment cost is only part of the problem, however. “There is also the economic burden that hepatitis C creates because of the lethargy and exhaustion the disease brings on patients and the concomitant reduction of their productivity,” said economist Elhami Al-Marghani, an advisor to the government on prevention programmes. With anywhere between 12 and 20 million people infected with hepatitis C in Egypt, the impact on the economy “runs into billions of pounds,” Al-Marghani added. Alaa Ghannam, director of the EIPR health programme, agrees. Ghannam also warned that hepatitis C patients are often discriminated against, as companies are hesitant to hire them, even when they are healthy enough to work. In order to ensure early detection of the virus, the government should carry out periodic examinations of people between the ages of 12 and 30, Ghannam said.
