Egypt: Viral time bomb set to explode

It is a health crisis of alarming proportions. Up to nine million Egyptians have been exposed to hepatitis C, and tens of thousands will die each year unless they receive a liver transplant. Health authorities are taking steps to stop the spread of the blood-borne virus, but must also contend with higher liver failure mortality rates as the disease advances in those infected decades ago. "The prevalence of hepatitis C is not growing, but the impact of an outbreak in the 1960s and 70s is appearing now as a clinical outcome," says Dr. Mostafa Kamal Mohamed, professor of community medicine at Ain Shams University in Cairo. "Liver disease has become the number one healthcare priority for the country and will continue to be so for the next decade. About 70 percent of all liver deaths here are due to hepatitis C." Egypt has the highest prevalence of hepatitis C in the world, the legacy of a well-intended health campaign that went horribly wrong. In the 1960s, the government turned to modern medicine in the hope of eradicating bilharzia, a water-borne parasite that has plagued Egyptian farmers since the dawn of time. In a tragic irony, the tartar-emetic injections given to Egyptians living in rural areas cured their bilharzia, but spread another deadly disease among the population, the hepatitis C virus (HCV). "At that time, bilharzia treatment was administered intravenously," recalls Dr. Refaat Kamel, a prominent surgeon and specialist in tropical diseases. "There were no disposable syringes, so once the needle got infected, the disease spread quickly from one person to another." Millions of Egyptians were inadvertently infected with HCV before the World Health Organisation (WHO) sponsored anti-bilharzia campaign was shut down in 1982. Scientists only discovered the hepatitis C virus in 1987, and it was another decade before they proved that its high prevalence in Egypt was a consequence of the mass treatment campaign. While Egyptian healthcare workers adopted disposable needles in the 1980s, HCV continued to spread due to improper blood screening and poor hygiene practices. "There is a laxity in precautions in Egypt," says Kamel. "People are careless or ignorant where blood is involved, and this has facilitated the transmission of HCV." The results of a national survey released last month show that eight to nine million Egyptians, more than 10 percent of the population, have been exposed to hepatitis C, of which approximately 5.5 million are chronic carriers. In some rural areas over half the adult population carries HCV antibodies. About 30 percent of people infected with HCV spontaneously clear the virus from their system within six months, according to studies done in Egypt. The rest develop chronic hepatitis, which in about a quarter of cases leads to cirrhosis and liver failure in 20 to 30 years. Egypt's viral time bomb is about to go off. Doctors estimate that some 30,000 Egyptians die each year of HCV-related liver failure - a figure that is projected to climb as the disease progresses in those who contracted it during the 1964-82 anti-bilharzia campaign. "We expect the number of mortalities will peak in 2012," says Dr. Wahid Doss, head of the National Committee for the Control of Viral Hepatitis (NCCVH), a government body formed to fight the disease. NCCVH is implementing an infection control programme in hospitals and blood banks as part of a national strategy to reduce new HCV infections, estimated at 70,000-140,000 cases a year. It is also spearheading a media campaign to educate the public on the various routes of blood-to-blood transmission. "Prevention is a big problem in Egypt - people are still being infected with hepatitis C (due to risky behaviour)," says Doss. "For example, if you go to a festival you will find people doing circumcisions or tattooing - the same tool for 50 people." Treatment options are limited for HCV carriers with end-stage liver disease. Egypt's prohibition on cadaveric organ transplants and the strict criteria for living donors limit the number of livers available for transplant. "A few hundred donor transplants are carried out each year; tens of thousands are needed," says Kamel. "Without transplants, all these people will die." Limited organ availability is only one problem. A partial liver transplant can cost up to 60,000 dollars plus another 10,000 dollars for immunosuppression therapy - a sum far beyond the reach of most Egyptians. The government has in some cases subsidised the cost of transplant operations, but it cannot afford to foot the total bill. "No government on earth could afford to cover the costs of all liver transplants," asserts Kamel. Instead, the priority is to treat HCV infections where the disease has not yet caused severe liver impairment. The standard therapy is a combination of interferon and the antiviral drug ribavirin. A 48-week course costs 3,500 dollars, but is effective in only 30-50 percent of cases, and can have severe side effects. NCCVH has established 16 treatment centres around the country, which have provided free interferon shots for 47,000 HCV patients since the programme began two years ago. The government is spending more than 50 million dollars a year on the subsidy package, but Doss argues that it is the most sensible and cost-effective strategy. "You pay per patient now and you save on a liver transplant 10 years later."