On one front at least, Egypt had plenty of reason to celebrate. On Tuesday 4 October 2016, Egypt marked Egyptian Liver Day. Those attending included Margaret Chan, Director-General of the World Health Organisation (WHO) and a number of Egyptian and international public figures. The Ministry of Health had every reason to be proud, given that since the establishment in 2014 of its Plan of Action to cure hepatitis C, a disease caused by hepatitis C virus (HCV), the number of Egyptians cured amounted to more than 913,000.
Before 2014, Egyptian statistics revealed that prevalence of hepatitis C among Egypt’s 85 million-strong population was 9.8 per cent, thought to be the highest in the world. Back then HCV was treated with Interferon, a protein which triggers the defences of the immune system and interferes with viral replication. It was administered to hepatitis C patients with a mild form of the disease, but the cure rates never exceeded 50 per cent with a risk of recurrence years later.
Hepatitis-free by 2025
During the 2016 event, Health Minister Ahmed Emad announced that Egypt was working to be hepatitis C-free by 2025. Egypt’s Demographic and Health Survey of 2016 placed the prevalence of hepatitis C in Egypt at less than 8 per cent.
Dr Chan praised Egypt’s efforts to control the disease and its commitment to provide a highly-efficient, low-cost medication for patients. The Egyptian government had worked very hard and received full support from WHO to guarantee that the locally-made, affordable equivalent matched in quality and effectiveness the original drug, Sovaldi, used to cure HCV, she said. Egyptians were showing the world the brilliant results that could be accomplished when political will, resources and proper planning work hand in hand. The Egyptian model was now being followed by other countries such as Pakistan, she added.
While international health organisations announced a global strategy to eliminate hepatitis [B and] C by 2030, the Egyptian Health Ministry announced that Egypt’s Action Plan aimed to eradicate the C virus by 2025 by adoptinga strategy revolving around three main axes. These centred on applying prevention procedures in hospitals and healthcare facilities; providing proper sterilisation and maintenance of medical equipment used in public and private medical centres and clinics; and adopting safe blood transfusion and injection practices.
Acute, chronic hepatitis
Hepatitis C is a liver disease caused by the hepatitis C virus (HCV). According to information provided by WHO, it can cause both acute and chronic hepatitis infection ranging in severity from a mild illness lasting a few weeks to a serious, lifelong illness.
The hepatitis C virus is blood-borne with the most common modes of infection being through unsafe injection practices, inadequate sterilisation of medical equipment and the transfusion of unscreened blood and blood products.
WHO states that the number of people infected with the HCV worldwide ranges between 130 and 150 million, most of whom will eventually develop liver cirrhosis or liver cancer. The most affected regions are Africa and Central and East Asia.
“Antiviral medicines can cure approximately 90 per cent of persons with hepatitis C infection, thereby reducing the risk of death from liver cancer and cirrhosis, but access to diagnosis and treatment is low. There is currently no vaccine for hepatitis C; however, research in this area is ongoing,” WHO states.
WHO statistics show that almost 17 million people are infected with the HCV in the Eastern Mediterranean region of which Egypt is part. People infected with hepatitis C usually discover their illness by coincidence while undertaking routine blood tests or medical exams.
Back in July 2015, the WHO Regional Office for the Eastern Mediterranean (EMRO) hosted an event to mark World Hepatitis Day in Cairo. The event, which included a marathon, was held in Egypt in recognition of its “pioneering role in combating viral hepatitis” and for demonstrating “a high level of commitment by tackling hepatitis comprehensively in their plan of action for prevention, care and treatment 2014–2018”. The WHO media centre declared that Egypt, the country with the highest prevalence rate of hepatitis C in the world, had set a national action plan to control HCV. A year earlier the Ministry of Health had set up 32 specialised centres and introduced a new hepatitis C drug, the first highly-effective and approved direct-acting antiviral drug, for nationwide treatment of hepatitis C infection. This medication was safer than previous medications and, used in combination with other drugs, could cure more than 90 per cent of those completing treatment. In a global first, the WHO declaration said, the drug Sovaldi, the generic name of which is Sofosbuvir, was made available to Egyptian patients for USD900, 1 per cent of its international price.
Charles Gore, Head of the World Hepatitis Alliance, presented an honorary award to the then Health Minister Adel Adawi for his role in preventing and controlling HCV in Egypt and for launching the national injection safety project to “reinforce infection control measures and transition to the exclusive use of safety syringes”. Egypt was chosen, along with India and Uganda, to participate in the WHO Global Initiative for Injection Safety; the Egyptian national project is part of this global initiative.
Consultant epidemiologist Dr Nasr Tantawi said that because the reuse of syringes and needles was among the main causes of spreading infection, an agreement was reached to help Egypt build a factory for self-destructing syringes [syringes that were specifically engineered with a metal clip to prevent the plunger from being pulled back after use, or which had a weak spot in the plunger that made it break if an attempt were made to reuse it], Dr Tantawi said. A specialised team from the NAMRU-3 (Naval Medical Research Unit 3) would be responsible for training Egyptian medical and nursing staff on the use of the new syringes as well as their production, he added.
Setting a plan
Egypt started to set a plan for the prevention and treatment of HCV in 2006 with the establishment of the National Committee for Control of Viral Hepatitis (NCCVH) headed by liver specialist Dr Wahid Doss and a panel of distinguished Egyptian professors of hepatic diseases/hepatology including Dr Gamal Esmat, Former President of the International Liver Congress.
The NCCVH started to set the Egyptian National HCV Control Programme in line with the international regulations for disease prevention and control set by WHO.The programme goals included establishing a database for HCV patients and their geographical distribution within Egypt, and stressing the importance of early detection of the disease to prevent it from reaching the stage of chronic infection where complete cure is almost impossible. The outcome of the programme also included determining the categories of people at increased risk of contracting HCV. These include drug abusers who share the same needles; patients with medical conditions (especially haemophilia or leukaemia patients) that require the transfusion of blood which might be contaminated; or those being treated inside healthcare facilities with “inadequate infection control practices”. High risk persons also include couples where one partner has hepatitis C; in this case the other partner must follow routine check-ups to make sure he or she is not infected with the virus, People with HIV (AIDS), current or ex-prisoners, people who undergo tattoos or body piercings, and finally healthcare personnel who have frequent contact with HCV patients are also at risk. The NCCVH recommended that prevention was an integral part of combatting the spread of HCV in Egypt.
In 2012, the Plan of Action for the Prevention, Care and Treatment of Viral Hepatitis (2014 — 2018) was set in motion by the Ministry of Health and Population under the supervision of the then Health Minister Adel Adawi in collaboration with NCCVH, WHO and other international healthcare institutions. The plan focused on the seven main components of viral hepatitis prevention and control: surveillance, infection control, blood safety, hepatitis B virus (HBV) vaccination, care and treatment, communication, and research. It also focused on introducing low-cost but highly effective medication for the treatment of hepatitis C.
A media awareness campaign was launched in 2014 under the slogan “It’s either us or virus C” on radio and TV. The campaign was prepared by mass communication professor Farag al-Kamel, who had previously coordinated several successful campaigns to raise awareness on social issues and endemic diseases. The televised spots were broadcast in the form of cartoons chiefly addressing the illiterate and explaining the different methods of infection, such as the use of unsterilised syringes, the transfusion of contaminated blood, and the use of unsterilised shaving razors and unsterilised dental tools.
The cartoon campaign was voiced by comedian Muhammad Heneidi. The title of the campaign suggested that society was at war with the disease and that only one of the two would prevail.
Serious efforts are ongoing on various fronts to battle the disease. Given that HVC is usually discovered by chance and that when its detrimental symptoms emerge the diseases is too far advanced, early discovery of the virus is of prime importance.
Health Minister Ahmed Emad on 14 January launched a nationwide campaign of testing Egyptians above 18 years of age for HVC, with the aim of creating a national database on hepatitis C. The campaign started in the village of al-Barageel in south Minya, some 300km south of Cairo. Testing is done through 20 medical teams each composed of a doctor, a public awareness officer, an administrator, 10 laboratory technicians and a data entry technician. According to Dr Doss, Upper Egypt has the highest prevalence of HVC in Egypt. Hence the campaign started in Minya and is expected to cover the south of Egypt then move up north.
Dr Gamal Esmat, professor of hepatology and endemic medicine and a member of NCCVH, says Cairo University has set up a programme to test all first-year students and residents of university dorms for HCV and treat those who test positive free of charge.
Everyone drafted for military service is also tested for HCV, Dr Esmat says, and those who are infected are treated at the expense of the government. Civil servants and all government employees are also tested and their treatment is provided by the public medical insurance system.
The Ministry of Health now issues certificates to persons who have followed the hepatitis C treatment plan and are completely cured. These certificates are issued when the patient has taken several tests such as the internationally accredited PCR test. The first 15 certificates were issued last week to individuals from the southern governorate of Qena.
25 January 2017