Egypt: A Beacon of Hope on World Hepatitis Day
Will Chukra
M.D. Candidate: Schulich School of Medicine & Dentistry
In the United States, hepatitis C was once projected to become a rare disease by 2036, and while this may seem like a rapid demise of such a prevalent disease, these projections are now suggested to be even sooner due to improvements in screening and medical interventions, such as direct-acting antiviral agents (DAAs; Dennis et al., 2021). However, while the United States and other first-world counties have benefited from these advancements in medicine, countries of low and middle income are expected to continue to have a high prevalence of hepatitis C and its associated health complications until changes to their healthcare services are made possible (Dennis et al., 2021).
Hepatitis C is a liver infection caused by the hepatitis C virus (HCV), which is a blood-borne RNA virus that the World Health Organization (WHO) recognizes as a global health concern due to estimates of 58 million people having a chronic HCV infection (HCV infection for 6+ months), and 1.5 million new infections occurring per year (WHO, 2021). These concerns are heightened by the downstream complications that chronic HCV infection has on the liver, such as liver cirrhosis, hepatocellular carcinoma (HCC), and eventually, end-stage liver disease (Dennis et al., 2021). It is also approximated that once end-stage liver disease is met, the risk of death in the following year is 15-20%, increasing with each year after (Thomas & Seeff, 2005). To make matters more concerning, unlike other hepatitis infections that have vaccines (i.e., hepatitis A and B), major barriers such as the vast genetic variability between HCV strains, limited models for testing HCV vaccines, and our incomplete understanding of protective immune responses against HCV all significantly hinder the development of an HCV vaccine coming anytime soon (Bailey et al., 2019; Dennis et al., 2021). As a result, the current treatment for HCV consists of direct-acting antiviral agents (DAAs). However, once end-stage liver disease is met, liver transplantation is the best option to save the patient’s life (Dennis et al., 2021).
As you can probably imagine by now, chronic HCV infection is a devastating disease with a significant burden on one’s life. But who is most at risk of obtaining this blood-borne virus? One of the most common means of transmission of HCV is through the high-risk use of drug injection via shared or non-sterile needles, which is recognized to be the primary cause of spread in low-to middle-income countries (WHO 2021; Alter, 2003). From an epidemiology standpoint, the prevalence of chronic HCV is highest in Africa compared to other continents, with the Western Africa sub-region being the most prevalent of all, accounting for an estimated 20 million active chronic HCV infections (Petruzziello et al., 2016). This prevalence in low-to middle-income countries of Africa and other continents is suggested to be underestimated as well due to inadequate infrastructure for population-wide testing (Dennis et al., 2021). More specifically, the global inequity of disproportionately higher HCV prevalence in these low and middle-income countries is directly impacted by the lack of public health funding that limits screening and prevention measures for HCV infections (Dennis et al., 2021). Furthermore, existing therapeutics discussed earlier, such as DAAs or liver transplantation, are both very expensive therapeutic options, and require highly specialized clinicians that are often in shortage within these countries (Dennis et al., 2021).
Despite the barriers that several countries continue to face in reducing the HCV rates of infection, there have been innovative strategies put forth as possible solutions, even in a resource-limited setting. Arguably the most ambitious of them all has begun in Egypt, a low-to middle-income country that had one of the highest HCV prevalence rates in the world. Over the past decade and a half, Egypt has implemented an immensely successful strategy that is a community-based HCV care model focusing on educating, testing, and treating (Dennis et al., 2021). From 2014 to 2018, this model focused on five axes which are identified in table 1, and all played a role in advancing their strategy to where it is today. Additionally, the Egyptian government procured a license to locally manufacture DAAs, rather than purchase them from outside pharmaceutical companies, reducing the cost of DAAs significantly (Hassanin et al., 2021). Egypt’s National Committee for Control of Viral Hepatitis even went as far as setting a national strategy to make treatment paid for by the Egyptian government for all (Waked et al., 2020).
Table 1
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Axis 1: Strengthening surveillance to detect viral hepatitis transmission and disease. |
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Axis 2: Improving blood products safety to reduce transmission of viral hepatitis. |
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Axis 3: Promoting infection control practices to reduce transmission of viral hepatitis. |
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Axis 4: Educating providers and communities to increase awareness about viral hepatitis and its prevention. |
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Axis 5: Improving care and treatment to prevent liver disease and cancer. |
With both of these advancements in place, more than 2 million patients with HCV were treated in 2018, with cure rates of over 90%. However, due to the lack of testing on most of the general population, the majority of infected people remained unidentified (Waked et al., 2020). Recognizing this gap, the Egyptian government has responded by launching the 100 Million Seha (100 Million Healthy Lives) Campaign, which offers free voluntary HCV screening via finger prick rapid diagnostic tests to all residents of Egypt aged 18 and older, and maintains the free treatment for those with confirmed cases (Hassanin et al., 2021; Schwander et al., 2022). When launched, the vast amount of people eligible for screening required implementing 5820 testing sites, 1079 of which are mobile units reaching out to remote regions that would have otherwise not had access to the HCV screening and treatment. In the end, Egypt’s campaign led to successful HCV screening of over 50 million residents, as well as treatment of 4 million people for HCV (Hassanin et al., 2021).
While an effort such as Egypt’s may seem costly, especially for countries of lower income, estimations suggest that Egypt’s total healthcare costs were reduced effectively due to the decrease in costs for HCV-related mortality and complications, consequently saving more money than if they had not implemented the plan (Schwander et al., 2022). Therefore, Egypt’s approach proved to be beneficial from both a healthcare and economic standpoint. Today, Egypt is poised to be one of the first countries in the world where HCV will become a rare disease. Hopefully, others can learn from Egypt’s success, paving the way for low-to middle-income countries to follow this now evidence-based strategy (Hassanin et al., 2021).
With consideration of Egypt’s strategy to eliminate HCV, the current global health inequity surrounding HCV prevention and treatment should be an issue of the past. We need the WHO to prioritize HCV elimination efforts by assisting and guiding countries of low and middle income to come up with strategies similar to Egypt’s. For one, countries must have the opportunity to expand HCV testing on a mass scale, and the WHO should allocate testing kits to countries in need at a discounted cost similar to the cost that Egypt had purchased them. Furthermore, countries must prioritize access to DAAs at an affordable cost. This could be done through local manufacturing of DAAs similarly to Egypt. If this is not possible given a country’s resources, the WHO needs to ensure there are standards in place that require pharmaceutical companies to lower the costs of DAAs to a price that is more accessible for low-income countries. Lastly, educating providers and community members about HCV and how to reduce transmission will always be a key component of any strategy for eliminating HCV. For example, Shah and Abu-Amara (2013) conducted a systematic review of studies on educational interventions for HCV infections. In general, they found that these educational interventions significantly increase patients' knowledge about HCV and that this leads to behavioural changes in patients and other within their social circle, increasing the rates of testing and treatment for HCV infections. If these key aspects of HCV elimination can be met, then the overall global inequity of HCV will be reduced significantly. With it being World Hepatitis Day, this is an occasion where we should come together and spread awareness of the inequities surround hepatitis C, advocating for changes to be made, especially when these changes have been proven possible by Egypt.
References
Alter, M. J. (2003). Epidemilogy of hepatitis C. Hepatology, 26(S3), 62S-65S. https://doi.org/10.1002/hep.510260711
Bailey, J. R., Barnes, E., & Cox, A. L. (2019). Approaches, progress, and challenges to hepatitis C vaccine development. Gastroenterology, 156(2), 418-430. https://doi.org/10.1053/j.gastro.2018.08.060
Dennis, B. B., Naji, L., Jajarmi, Y., Ahmed, A., & Kim, D. (2021). New hope for hepatitis C virus: Summary of global epidemiologic changes and innovations over 20 years. World J Gastroenterol, 27(29), 4818-4830. https://doi.org/10.3748/wjg.v27.i29.4818
Hassanin, A., Kamel, S., Waked, I., & Fort, M. (2021). Egypt’s ambitious strategy to eliminate hepatitis C virus: A case study. Global Health: Science and Practice, 9(1), 187-200. https://doi.org/10.9745/GHSP-D-20-00234
Petruzziello, A., Marigliano, S., Loquercio, G., Cozzolino, A., & Cacciapuoti, C. (2016). Global epidemiology of hepatitis C virus infection: An up-date of the distribution and circulation of hepatitis C virus genotypes. World journal of gastroenterology, 22(34), 7824–7840. https://doi.org/10.3748/wjg.v22.i34.7824
Schwander, B., Feldstein, J., Sulo, S., Gonzalez, L., ElShishiney, G., & Hassany, M. (2022). Pursuing elimination of hepatitis C in Egypt: Cost-effectiveness and economic evaluation of a country-wide program. Infectious Diseases and Therapy, 11, 1193-1203. https://doi.org/10.1007/s40121-022-00631-x
Shah, H. A., & Abu-Amara, M. (2013). Education provides significant benefits to patients with hepatitis B virus or hepatitis C virus infection: A systematic review. Clinical Gastroenterology and Hepatoology, 11(8), 922-933. https://doi.org/10.1016/j.cgh.2013.04.024
Thomas, D. L., Seeff, L. B. (2005). Natural history of hepatitis C. Clin Liver Dis, 9(3), 383-398. https://doi.org/10.1016/j.cld.2005.05.003
World Health Organization. (2021, July). Hepatitis C. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c
Image retrieved from: https://egyptindependent.com/who-hails-egypts-experiment-of-treating-the-hepatitis-c-virus-making-it-role-model-in-africa/
