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Contrary to the widely-held perception
that this rate of occurrence reflects merely the limited safety measures during anti-bilharzia campaigns, HCV incidence likely continues at alarming levels due to limitations in the implementation and enforcement of stringent standard precautions in public and private medical and dental facilities.

Highest Rates of Hepatitis C Virus Transmission Found in Egypt
© 2010 Al Bawaba

The Arab Republic of Egypt has the highest rates of new hepatitis C virus (HCV) infection in the world, according to a new study published today in the prestigious Proceedings of the National Academy of Sciences.  The study also estimates more than 500,000 new HCV infections occur in Egypt every year, likely signaling an epidemic in a country of more than 77 million people. This high rate of HCV transmission may be due to the lack of sufficient standard safety precautions in medical and dental facilities, the authors suggest.

“Nearly 7 out of every 1,000 Egyptians acquire HCV infections every year, suggesting intense ongoing transmission. This is the highest level of HCV transmission ever recorded at a national level for a blood borne infectious disease transmitted parenterally, that is, by use of non-sterile medical instruments,” said Dr. F. DeWolfe Miller, lead author of this study and professor of epidemiology at the Department of Tropical Medicine and Medical Microbiology and Pharmacology at the University of Hawaii.

Although the high prevalence of hepatitis C in Egypt has been well established for many years, and linked in part to limited safety measures during anti-bilharzia campaigns, published estimates of prevalence from different Egyptian communities failed to provide a nationwide picture of the magnitude of ongoing HCV infection transmission. To estimate the rate of new HCV cases of infection in Egypt, the authors of the study performed epidemiologic modeling of data from a range of studies, including a 2008 national HCV survey with a representative sample and well-documented study design.

“The study opened our eyes to a disease burden similar in scale and challenge to the HIV problem in sub-Saharan Africa: Millions of cases of an infection for which there is no vaccine, no effective treatment, and where case management is so expensive that it is beyond the reach of most patients,” said Dr. Laith J. Abu-Raddad, co-author of the study and assistant professor of public health at the Infectious Disease Epidemiology Group at the Weill Cornell Medical College–Qatar.

The study necessitates not only further analysis of HCV transmission in Egypt but also justifies the immediate increase of resources to strengthen public health measures aimed at reducing the transmission of HCV in clinical and non-clinical settings, according to the authors. Failure to address this problem will result in a massive disease burden in the nation in terms of HCV infection complications, including active liver disease, liver failure, or liver cancer.

“There is only one way to deal with the HCV challenge in this country: HCV prevention,” warned Dr. Miller. “Effective and stronger HCV prevention programs are urgently needed in Egypt. Failure to act could swamp the public health system over the coming decades with millions of cases of HCV disease complications with an economic and social cost that this nation does not have the means to confront.”

Key scientific findings of the study
• Nearly 7 out of each 1,000 Egyptians acquire HCV infection every year for a total of 537,000 new HCV infections every year. This is by far the largest ever recorded rate of occurrence of HCV at a national level of all countries in the world.

• One in every 10 Egyptians is a carrier of the HCV infection, which means that there are at least 4,459,000 persons infected with HCV who are infectious to others. This is the largest reservoir of HCV infection in the world. 

• Contrary to the widely-held perception that this rate of occurrence reflects merely the limited safety measures during anti-bilharzia campaigns, HCV incidence likely continues at alarming levels due to limitations in the implementation and enforcement of stringent standard precautions in public and private medical and dental facilities.




Mar 12, 2008 Researchers at the University of Maryland School of Medicine have concluded that a high prevalence of hepatitis C infection in Egypt can be traced to mass treatment campaigns to fight a common illness in that country decades ago. The study, conducted in cooperation with the World Health Organization and the Egyptian Ministry of Health and Population, is published in this week's issue of The Lancet.

The study suggests that the hepatitis C virus was transmitted through the contamination of reusable needles and syringes used in the treatment of schistosomiasis, a condition caused by a parasite in the blood.

Researchers say the treatment campaigns may account for the world's largest transmission of blood-borne pathogens resulting from medical intervention.

Hundreds of thousands of Egyptians received the treatment, called parenteral antischistosomal therapy (PAT), from the 1950's to the 1980's. Today, drugs for schistosomiasis are administered in pill form.

"They were given the only available form of treatment for a serious disease, but the treatment was administered with reusable injection equipment, as was the standard in those times," says Christina Frank, a doctoral candidate at the University of Maryland School of Medicine and author of the study. "Doctors meant well, but they were unaware of the dangers associated with inadequate sterilization procedures."

Frank and her colleagues reviewed historical public health records and statistics to determine whether there was a connection between the PAT injections and the hepatitis C rate in different age groups. Researchers found a significant association between exposure to PAT and Hepatitis C infection. A drop in the hepatitis C rate coincided with the gradual replacement of PAT injections with oral medications in the mid-1970's and early 1980's.

The investigators concluded that PAT played a major role in the spread of hepatitis C throughout Egypt. In part because of the high number of people who were infected, the risk of transmission remains high in the Egyptian population today. It is believed that at least 15% of the Egyptian population has been infected with hepatitis C. Liver disease caused by chronic hepatitis C infection is a significant health problem in Egypt today.

"The treatment campaigns were conducted with the best of intentions, using accepted sterilization techniques of the time," says Frank. "Testing for hepatitis C only became available in the early 1990's, years after PAT injection campaigns had ended."

"This situation is somewhat paradoxical," says Thomas Strickland M.D., Ph.D., professor of Epidemiology at the University of Maryland School of Medicine, and the director of the USAID-supported Hepatitis C Prevention Project that coordinated the study.

"Egypt's extensive and dedicated nationwide control program for schistosomiasis was the cause of the current high prevalence of hepatitis C in the country," says Dr. Strickland. "The practice of mass treatment with PAT before the danger of exposure to blood was so well known, and before the availability of disposable syringes and needles, provided a very potent means for transmission of blood-borne infections."


The role of parenteral antischistosomal therapy in the spread of hepatitis C virus in Egypt. 

Lancet 2000 Mar 11;355(9207):887-91 

Frank C, Mohamed MK, Strickland GT, Lavanchy D, Arthur RR, Magder LS, El Khoby T, Abdel-Wahab Y, Aly Ohn ES, Anwar W, Sallam I

University of Maryland, School of Medicine, Department of Epidemiology and

Preventive Medicine, Baltimore, USA. 

BACKGROUND: The population of Egypt has a heavy burden of liver disease, mostly due to chronic infection with hepatitis C virus (HCV). Overall prevalence of antibody to HCV in the general population is around 15-20%.The risk factor for HCV transmission that specifically sets Egypt apart from other countries is a personal history of parenteral antischistosomal therapy (PAT). A review of the Egyptian PAT mass-treatment campaigns, discontinued only in the 1980s, show a very high potential for transmission of blood-borne pathogens. We examine the relative importance of PAT in the spread of HCV in Egypt. METHODS: The degree of exposure to PAT by cohort was estimated from 1961-86 Ministry of Health data. A cohort-specific exposure index for PAT was calculated and compared with cohort-specific HCV prevalence rates in four regions.

 FINDINGS: HCV prevalence was calculated for 8499 Egyptians aged 10-50 years. A significant association between seroprevalence of antibodies to HCV and the exposure index (1.31 [95% CI 1.08-1.59]; p=0.007) was identified across four different regions. In all regions cohort-specific HCV prevalence was lowest in children and young adults than in older cohorts. These lower prevalence rates coincided with the gradual and final replacement of PAT with oral  antischistosomal drugs at different points in time in the four regions.

INTERPRETATION: The data suggest that PAT had a major role in the spread of HCV throughout Egypt. This intensive transmission established a large reservoir of chronic HCV infection, responsible for the high prevalence of HCV infection and current high rates of transmission. Egypt's mass campaigns of PAT may represent the world's largest iatrogenic transmission of blood-borne pathogens.

PMID: 10752705, UI: 20214379