Fighting Hepatitis C in Egypt

It seemed like an ordinary demonstration. Clusters of banner-waving youths marched along the sun-drenched main street of Damanhour, in the heart of Egypt’s Nile Delta, on March 6. But the banners they held, featuring a large cartoonish drop of red blood beside an emphatic “No!,” were directed not at political figures but at Hepatitis C (HCV), a blood-transmitted virus attacking the liver that counts nearly 12 million Egyptians as its victims. HCV is especially prevalent in the Delta region.[1] The march was organized by Damanhour University Professor Ashraf el-Sharaby, director of the HCV Media Unit, a public awareness-raising effort funded by the Egyptian Ministry for Scientific Research, one of many state, private sector, and civil society programs attempting to combat an epidemic that for the moment is winning.

“The public needs HCV awareness, but health care providers—doctors, nurses, dentists, anyone dealing with blood—need it a lot more,” says epidemiologist F. DeWolfe Miller, referring to the fact that HCV is often spread through unsanitary practices in medical facilities. Miller participated in the study that sounded Egypt’s HCV alarm in 1992; its results showed that 10 percent of 2,164 blood donors carried the virus[2] and compelled Egypt’s parliament to mandate HCV screening of blood bank donors in 1994.

In 2008, the Ministry of Health and Population (MoHP) launched a program for HCV care and treatment. As of 2011, 23 treatment centers had been established nationwide, with 190,000 patients treated with interferon and ribavirin (generic antiviral drugs). Sixty percent of those patients—112,000—had successfully completed the 48 week-long treatment. However significant this achievement, at least 100,000 new infections occur annually, a figure that may be considerably higher.[3]  Meanwhile, HCV treatment consumes 20 percent ($80 million) of Egypt’s annual health budget, with the state covering 40 percent of the costs and insurance companies and patients paying the balance.[4]

Unhygienic practices while administering injections is the most common way the virus is transmitted. Medical providers will sometimes change the needle but not the syringe when administering successive injections, and backwash from the syringe can carry infection. They may also use multi-dose vials for more than one patient, again changing the needle but not the syringe.

In addition, because the virus is transmitted by blood, if a worker has trace amounts of blood on his or her hands when preparing an injection, he or she can spread the infection. Good Egypt (Masr Kher), one of several NGOs attempting to contribute solutions, recently purchased and distributed latex gloves to undersupplied hospitals and clinics to assist with prevention. “They forgot to mention [that] you need to keep changing the gloves between patients,” says Miller. “And all you really need is soap and water to kill this virus. Infection rates would drop if [health care providers] were just trained to be more careful about washing their hands.”   

Yet only one percent of MoHP’s HCV budget ($800,000) is devoted to prevention, through awareness-raising and improved infection control practices.[5]  Though MoHP scored a success in the early 2000s by cleaning up Egypt’s kidney dialysis treatment centers, a major source of infection, the bulk of the nation’s overburdened, underfunded hospitals, over 4,500 of which are MoHP-operated, continue to spread the virus.[6]  Considering that the HCV epidemic was fueled in its early stages by the use of poorly sterilized glass syringes during a 1962-1982 nationwide campaign to eradicate another liver pathogen, schistosomiasis, or bilharzia, prevention should be a top priority.

The experience of Mahmoud Zalabany, a 28-year-old internal medicine resident at Cairo’s Ahmed Maher Teaching Hospital, illustrates the situation from the perspective of both health care providers and patients.  In 2008, while attending medical school at the University of Mansoura in the Nile Delta, Zalabany’s father suffered what appeared to be sudden liver failure and died 40 days later, having unsuccessfully sought the appropriate diagnosis and treatment in several hospitals for what turned out to be HCV. Since those infected rarely exhibit symptoms, HCV may not be identified until irreparable liver damage is done. Of every 100 people infected, one to five will die of cancer or cirrhosis of the liver. 

During his posting at a family clinic near his university, Zalabany spoke to doctors and nurses. “They knew almost nothing about HCV and were not only caring for people, but were under high risk of infection themselves,” he says. Determined to launch a prevention campaign targeting medical professionals, Zalabany started a website in 2011 after he found little Arabic language HCV infection control information online.[7] Instead, he came across Miller’s website, which outlines prevention measures in English.[8] With Miller, Zalabany planned to run a pilot study to demonstrate the high risks of HCV exposure in small health facilities. Although a private Egyptian company offered to fund the project through a charity organization it sponsors, permissions were stalled by the MoHP, whose activities have been disrupted, along with those of other administrative authorities, by six cabinet changes in the last three years.

Through his website, Zalabany attracted an Egyptian NGO called Terous (Arabic for “gears”) aimed at linking public, private, and civil sector efforts by creating a database of concerned parties in regard to select issues, including HCV. With terous.org contacts, Zalabany proposed to create a video library of instructive prevention clips to post online and eventually show in health facilities, a project that is getting underway. Targeting the right audience will be a logistics challenge, since Egypt counts some 376,700 doctors, nurses, dentists, and pharmacists.[9] “The problem is big and needs a political decision,” says Zalabany, citing low salaries for doctors and nurses—$300 per month on average—as a key issue. “How do you make people commit to better practices,” he asks, “when they are not concentrated on their work because they need to keep a second job?”

HCV is currently high on the public agenda owing to the televised February 23, 2014 presentation by an army spokesperson of a device called C-Fast that uses the body’s  “electromagnetic pulse” to detect HCV, and another invention, the Complete Cure Device (CCD), which purportedly eliminates the virus altogether. Members of the international scientific community have greeted both C-Fast, a spin-off of bomb detection technology, and CCD with skepticism.[10] Major General Dr. Ibrahim Abdul Atti, the head of the research team that invented CCD, has yet to publish the research leading to the alleged cure.[11] The promise of C-Fast and CCD’s availability in military hospitals nationwide as of June 30 (the first anniversary of the army-backed ouster of President Mohamed Morsi) has nonetheless raised the hopes of many underprivileged Egyptians.

Late last year, a promising new HCV drug called Sovaldi was approved in the United States, coincidentally patented by Alexandria-born Raymond Schinazi, whose Jewish family was exiled during the Nasserist 1960s. Although a full 12-week course of treatment costs $84,000, Gilead, the California pharmaceutical company producing the drug, will make it available in Egypt at a 99 percent reduction ($900). [12]

In the wake of these developments, Egypt’s HCV epidemic is acquiring an increasingly political dimension, owing to media highlighting the public’s risk of infection while arguing the virtues of one treatment over another. The Egyptian Initiative for Personal Rights (EIPR), a research, advocacy, and litigation NGO that met with Gilead officials to discuss reducing Sovaldi’s cost, has called on the state to provide all Egyptians with affordable and effective HCV treatment as per their constitutional right to health which, according to EIPR researcher Dina Iskander, extends to infection control through upgraded health facilities and practices.[13]

The time seems ripe for a state-facilitated HCV awareness-raising campaign targeting health care providers and involving civil society and private sector resources. The life-saving tools—soap, water, and sterile instruments and practices—are readily available.  All that is needed is the political will. As Egypt prepares for its next presidential elections with more shuffling of ministerial and administrative positions, the question is who will be prepared and empowered to deliver it.