A new centre for treating hepatitis C is offering new hope to patients, but ways of combating the threat effectively have still to be found, writes Ahmed Abu Ghazala Finding a person infected by the hepatitis C virus (HCV) is not difficult. Simply ask a friend, or a colleague, or even the doorman, and they will eventually tell you they have either heard about someone who is infected by the disease, or that they know of someone, whether a relative or a friend. According to Minister of Health Hatem El-Gabali, demographic studies have shown that some 9.8 per cent of the Egyptian population is infected with the hepatitis C virus, and the number of infected citizens may have reached nine million. Mohamed Hamdi, a successful journalist in his 40s, is one of the millions infected by the disease. Hamdi remembers how in 1995 he had an endoscopy. "While it was supposed to be a simple surgery, I came out with other complications," he said. After surgery, he suffered from abdominal pain, diarrhea and other symptoms. Concerned by these, he hurried to the doctor and had tests, which turned out to be negative for any specific disease. However, many years later in 2007, Hamdi was diagnosed with high blood pressure, and he had tests which showed unusually high liver enzymes. After further checkups, to his dismay Hamdi discovered that he was infected with HCV. "Almost a quarter of the Egyptian population is infected by different hepatic diseases, including schistosomiasis, cirrhosis, hepatitis A, B or C, or liver cancer. We should be treating hepatic diseases as a national threat," said Hassan El-Shenawi, professor of hepatology at the National Liver Institute at Menofiya University, at a recent training session on HCV at the Al-Qasr Al-Aini Medical School of Cairo University. The numbers of Egyptians infected by HCV and other hepatic diseases now exceeds the populations of many other countries in the world. Moreover, many infected people do not know that they have been infected. However, hope may now be on its way. In order to deal with the threat of such diseases, the Al-Qasr Al-Aini Medical School has established a new centre for treating hepatic patients. "It is anticipated that the number of HCV patients will increase during the 2012 to 2020 period, and that's why it was important to think practically of how to face the spread of the disease," said Gamal Esmat, professor of hepatology and tropical medicine at the Al-Qasr Al-Aini Medical School, president of the International Association for the Study of the Liver (IASL), and director of the new centre. The first goal of the new centre, the Al-Qasr Al-Aini Centre for Hepatic Diseases, is to open its doors to all patients who need its services. "The centre can treat 180 patients daily. We have 25 doctors, apart from those conducting laboratory tests," Esmat said, adding that the centre has agreed special prices with drug companies to ensure that drugs are available at reduced prices. The centre provides patients and their families with vaccinations and prophylactic procedures. It does not only serve patients, and aims instead to become a training centre for doctors in dealing with different kinds of hepatic disease, becoming a centre for research into the development of new treatments for hepatitis B and C. Statements made at the opening of the new centre were optimistic about its potential. "We lack informed scientific research to back up our work, so the opening of this centre makes me feel more confident," said Abdel-Hamid Abaza, head of the political bureau at the Ministry of Health. "We are offering all kinds of help as a public institution responsible for public health in Egypt, and we will support all the efforts of the Al-Qasr Al-Aini Medical School," Abaza said. Dean of the Al-Qasr Al-Aini Medical School Ahmed Farid said that the school is working in collaboration with other Egyptian and international centres and that the establishment of the centre, the first in Egypt specialising in hepatology, was part of the school's larger public-health efforts. According to Hani Hilal, minister of higher education and scientific research, it is also time for the private sector and NGOs to participate in financing similar projects, in order to help find solutions to such endemic diseases. Hossam Kamel, president of Cairo University, said HCV had been at the top of the university's research agenda for the 2006 to 2011 period, and that the centre would bolster efforts to combat the disease. Yet, despite these hopeful developments, HCV presents other predicaments. According to Esmat, some 70 per cent of HCV infections come from medical sources through the use of infected instruments during various hospital procedures. "It is a huge problem that when a patient enters a hospital to treat a certain disease, he or she then comes out with a more dangerous one," Esmat said. The other 30 per cent of infections are thought to come from instruments used by multiple users, such as shaving razors or toothbrushes. "The problem is that infection is taking place randomly," Hamdi said in an interview with Al-Ahram Weekly. "HCV is spread among poorer people in Egypt, who use each other's personal items and are treated in public hospitals. Such people often do not know that they have been infected. They don't have medical insurance and can't afford treatment." Esmat said that the only way to prevent risks of HCV infection was to use medical instruments once and then dispose of them. Normal high-temperature cleaning procedures were not sufficient to eradicate all risk of passing on the disease. However, using instruments only once was too expensive for the public hospitals, and "that is why the public hospitals aren't safe enough. If they used instruments only once, they would have to reduce the services they offer," he said. A way should be found of providing instruments to public hospitals at cheaper prices, he said. In order to avoid infection by HCV, people should avoid tattoos or using the same needles, and if possible they should only use their own medical instruments. "The problem occurs when a young person uses a friend's equipment, thinking that he looks healthy enough and without realising that HCV doesn't have clear symptoms and anyone can be infected without knowing it." While knowledge of one's serological status, especially in the early stages of the disease, can massively improve prognosis, many people only find out about their infection after many years of leading normal lives. Hamdi, for example, explains that, "I had many checkups prior to the last one, but no one told me I was infected with HCV, although I must have been infected since the original surgery." Treatment for HCV consists of interferon and ribavirin therapy, interferon as an injection taken once a week and ribavirin as tablets taken three times a day. The therapy is very expensive and has many side effects, but it is the only one at present that is internationally recognised. Side effects of treatment for HCV vary from one patient to the next, being sometimes mild but sometimes more severe, and including depression, coughing, loss of weight, dizziness, aching joints, abdominal and back pain, nausea, vomiting, diarrhea, skin problems, mild hair loss, reduced white and red blood cell count, anorexia, congestion and elevated liver enzymes. The price of one shot of interferon is LE1,390, with the therapy as a whole costing some LE6,000 a month. Fortunately for many patients, the Ministry of Health is able to provide interferon shots at LE480, but this is still not cheap for the average citizen. "It's a huge problem. If you can't afford therapy, and you don't have medical insurance, you will remain infected and without treatment until you die," Hamdi said. Successful treatment takes place in between 50 and 60 per cent of cases. For Hamdi, the treatment consisted of his taking interferon shots weekly and ribavirin tablets for one year, but he decided to stop treatment after six months, feeling that it was not effective. "Successful treatment takes place in only 40 per cent of cases," Hamdi explained. "I may try something else if a new treatment comes along. Research has shown that new treatments may become available that will raise success rates to 80 per cent," he said. In cases where a patient is not undergoing therapy, treatment consists of taking anti- oxidants, vitamins, and liver-enhancing supplements, which cost LE300-500 a month. An Egyptian-manufactured interferon shot is also on the market, manufactured in collaboration with a German company, and this is available from the Ministry of Health at LE220. According to Esmat, "the Egyptian medication achieves similar results to the American-Swiss one, which is the internationally recognised treatment. Many Egyptians prefer to use the Egyptian product because it is much cheaper." Esmat told the Weekly that the Egyptian product was undergoing improvements in order to increase its effectiveness and decrease side effects. The reason the Egyptian medication was not internationally recognised was because the American-Swiss product held the international patent rights. "When this patent ends, our medication will also be recognised," he said. As a person living with HCV and also a journalist, Hamdi is in a good position to promote awareness about the disease. Sometimes he writes out of anger at people selling false hope to patients with HCV by promoting herbal medications or other non-recognised forms of treatment. "These treatments are not based on scientific research. One person tries something on two or three patients and then claims to have discovered a new therapy. I try to raise people's awareness of this problem." El-Shenawi is also concerned at the promotion of herbal treatments for HCV on satellite television channels. "These so-called treatments are a swindle," he says. "There are no therapies for HCV apart from those based on scientific research. If people listen to the fraudulent claims made for herbal treatments, this could lead to further complications later." For his part, Esmat prefers to leave the matter to people to decide. "If I had really found a perfect therapy for HCV, as they claim on TV, I would be awarded the Nobel Prize in medicine and journalists would be running after me. I wouldn't have to pay a TV station to promote my therapy," he said. However, he also laments the fact that the disease is not treated as a serious problem in the media. "The most important topic in Egypt as far as the media is concerned is swine flu, which barely killed more than 100 people, while many more people are dying every year from complications from HCV. Much more is spent every year on interferon therapy and liver surgery than is ever spent on swine flu." It is this lack of public awareness that is the main reason behind the spread of HCV in Egypt. The peak of the virus's spread was in the 1960s and 1970s, when needles used to treat schistosomiasis patients were used for several patients at a time. For Esmat, television would be the best way of raising public awareness, though Hamdi cautions that the authorities also have a role to play. "A main problem is the lack of information. If the Ministry of Health sent awareness convoys to all Egypt's governorates, it could conduct tests that would also provide us with information about the extent of the disease in the country and effectively raise people's awareness." Before the opening of the new Al-Qasr Al-Aini centre, a training session was conducted for journalists about HCV. Those present were asked questions about the disease, and almost 20 per cent of the answers were incorrect. Many Egyptians do not know anything about the disease. "What is HCV? No, I don't know anything about it," said Ali Ragheb, 46, a janitor at a building in Nasr City. When Ragheb was told that HCV was a disease that could infect the liver, he commented that "many people suffer from liver infections. In my hometown of Minya I know a woman who is suffering from something similar and is being treated at the expense of the state." Although Ragheb doesn't know anything about HCV, he said that he asks the barber to change his razor before shaving his beard, and he is aware that he must use clean needles if injected. "I know that these are important requirements and that many diseases come from infected blood," he said. For Nehmedo Orabi, 39, a maid, the difference between hepatitis A, B, or C is slim, since for her they are only letters of the alphabet. "HCV is a disease that infects the liver. I think it infects those who eat unhygienic food or drinks," she said. Although the disease Orabi is referring to is hepatitis A, she also said that her brother had been infected by HCV, though this turned out to be hepatitis A, not hepatitis C. Like many poorer people in Egypt, Orabi's attitude was that "everything is in God's hands." For Hamdi El-Sayed, head of the Doctors' Syndicate and head of the medical committee of the People's Assembly, the media is not making sufficient efforts to combat the disease, though the Ministry of Health is running campaigns in schools and universities to raise students' awareness of HCV and inoculate them against hepatitis B. El-Sayed added that the government had spent LE250 million in 2009 to help treat HCV patients, and that 15 further centres had been established in various governorates to treat HCV, along with the formation of a national association to collect donations to fund liver surgery and other forms of treatment. The government was trying to decrease infections in public hospitals, though this should be accompanied by greater awareness of hygiene among the public as a whole. "The public should be aware of such issues when going to the barber, or the dentist," El-Sayed said. "The government cannot inspect everyone. However, if people are aware of the disease, they will force practitioners to sterilise their tools." Yet, even though Egypt has made many achievements in fighting HCV and hepatic diseases in general, the danger these diseases present is escalating. According to El-Shenawi, "we can only deal with HCV through a powerful nationwide campaign. If things get worse, we will face a very serious situation." Infection by HCV HCV can be transmitted in four main ways: - By blood transfusion or blood products, or by organ transplant from an infected person; - By instruments carrying the blood of an infected person, including instruments used for piercings and tattoos, dental instruments, shaving instruments, toothbrushes, needles, or other instruments that may cause wounds or blood-to-blood contact; - By infection from the mother to her child, though this is true of only three to five per cent of total infections; - By sexual relations, though these are rarely the cause of infection with HCV. Did you know? HEPATITIS C is an infectious disease that was discovered in 1989 and is transmitted through infected blood. It affects patients' livers, and without adequate treatment can develop to cause cirrhosis, or liver cancer. If this happens, a patient is required to have a liver transplant, though the virus may recur even after transplantation. HCV has six genotypes and 52 subtypes. The fourth genotype is the one infecting 90- 95 per cent of Egyptian patients. Unlike for hepatitis B, there is no vaccine against hepatitis C. Early discovery of HCV infection considerably improves prognosis, with successful treatment being possible in up to 98 per cent of cases. This rate falls the later the infection is discovered.
