In early October, the World Health Organization (WHO) made an announcement that Cairo could only have dreamed of a few years ago: it confirmed that, after an unprecedented national campaign against hepatitis C, Egypt is the first country in the world on track to end this epidemic before 2030 finish.
This achievement is all the more extraordinary considering that just a decade ago Egypt was the country with the highest hepatitis C prevalence in the world. But between 2014 and 2020, it launched one of the largest public health campaigns ever aimed at eradicating the disease from the map: it mobilized tens of thousands of its health workers, screened 50 million people and treated more than four million. Now that success is assured, the lesson has been learned and the global health community is recognized, Cairo has decided to go a step further and is supporting other low- and middle-income countries, particularly in Africa, to replicate its program to achieve the same
“Egypt’s journey from having one of the highest hepatitis C infection rates in the world to eliminating it in less than a decade is simply astonishing,” the WHO director-general said in October. Tedros Adhanom Ghebreyesus. “Egypt is an example to the world of what can be achieved with modern tools and the political commitment to use them to prevent infections and save lives,” he said. “Egypt’s success should give us all hope and motivation.”
an infected country
The hepatitis C epidemic in Egypt has its origins in a public health campaign to treat an earlier epidemic. Between the 1940s and 1970s, the country struggled, particularly in rural areas, with a disease caused by parasitic worms contracted through contact with contaminated Nile water, says Imam Waked, a professor in the department of hepatology at the National Liver Institute of Egypt.
Every family in Egypt had [de media] at least one member is infected with hepatitis C
Mohamed El-Kassas, Professor and Head of Endemic Medicine at Helwan University in Cairo
The only treatment available at the time to treat the disease was intravenous injections, but Waked points out that the hepatitis virus was not yet known and disposable syringes were not available. When the government launched a nationwide campaign to eliminate it in the 1950s, the hepatitis C virus was unintentionally spread. To treat groups of 500 to 600 young people, mainly infected with the disease, 15 or 20 syringes could be used, explains the expert. “This is the age group that was affected by hepatitis C. We made a big bag [demográfica] the disease, which then spread even further through blood transfusions, in health centers and through injections,” explains the professor.
By the early 2000s, West Nile disease had been virtually eradicated. But in 2008, a public health and population survey found that 15% of Egyptians had antibodies to hepatitis C, meaning they had been exposed to the virus, and that 10% of people aged 15 to 59 had it lived with a chronic infection. Seven years later, in 2015, another study found that the prevalence in adults was 7%. But the decline was only because hepatitis C was more common in older age groups – who had been treated for schistosomiasis decades earlier – than in young people, diluting the percentage but not changing the total.
“For many years, Egypt was considered the country with the highest hepatitis C prevalence in the world,” notes Mohamed El-Kassas, professor and head of the Department of Endemic Medicine at Helwan University in Cairo. “Every family in Egypt had [de media] “At least one member is infected with hepatitis C,” he explains.
In 2008, a survey found that 15% of Egyptians had antibodies to hepatitis C, meaning they had been exposed to the virus, and 10% of people aged 15 to 59 were living with a chronic infection.
The consequences for the country were equally painful: in 2015, hepatitis C caused around 40,000 deaths, accounting for 7.6% of all deaths, and was responsible for a decline in life expectancy of around 1.8 years in men and one year in women. In addition, it led to a decline in national GDP of 1.5% per year, which, according to World Bank estimates, is equivalent to about 5,000 million dollars (4,500 million euros) per year.
Faced with this challenge, Egypt established a national committee to combat hepatitis C in 2006 and launched its first national program two years later, primarily aimed at improving access to treatment. However, the hurdles were still very high: it was very expensive, it had serious side effects, the cure rate was low and it could not be offered to people with advanced liver disease. “It wasn’t very good treatment. We treated 50,000 patients a year and cured between 15,000 and 20,000,” recalls Waked. “It was an enormous health and economic burden.”
A nation mobilizes
The turning point came in late 2013, when the treatment of hepatitis C was revolutionized with a new oral antiviral drug that, together with other antiviral drugs, increased the cure rate to over 90% and almost completely ended the disease. The main obstacle then became the $84,000 (76,000 euros) per treatment set by Gilead, the pharmaceutical company that patented the drug. But Egypt forced the company to negotiate after it rejected its land license. First, he managed to reduce the price to 900 dollars (about 810 euros) per case, and then he managed to license it to local pharmaceutical companies, which reduced the cost to less than 84 dollars (76 euros), 99 .9% less, according to a 2021 study.
With the new drug, everyone who had been treated in the past but not cured would have started the process again, so that in 2017 almost all Egyptians who knew they were living with hepatitis C (about 2.3 million ), had been treated, woke up says. Still, health authorities knew that there were between two and three million more people with the disease who had not yet been diagnosed. Back in late 2018, Cairo opted for a much more ambitious strategy, shifting its focus from fighting hepatitis C to eliminating it. The goal of the “100 Million Healthy Lives” campaign was to test more than 60 million people and offer free treatment to those living with the disease. The majority of the funds came from state coffers, plus a loan from the World Bank worth around $250 million (€226 million).
One of the main keys to the campaign was speed. The state opened nearly 16,000 testing centers across the country, including 1,000 mobile units that could be visited without an appointment. Results were typically available within 20 minutes and those who tested positive were sent to another center for a confirmatory test. Those confirmed were notified within seven days of the treatment site, which lasted 12 weeks. And then those who received it were called back to an analysis center to check their status.
One of the main reasons for the campaign's success was the strong political will to combat the epidemic, including from the country's president, Abdel Fattah Al Sisi. The government also conducted an extensive publicity and awareness campaign through the media, social networks, text messages and at the community level. It was equally important to be able to rely on the neglected but extensive existing health infrastructure. “It became a national priority for everyone: government, civil society, industry,” says John Ward, director of the Global Hepatitis Elimination Coalition. “There was a real commitment to health equity: all Egyptians should benefit from the program.”
The state opened nearly 16,000 testing centers across the country, including 1,000 mobile units that could be visited without an appointment. Previously, results were available within 20 minutes
At the end of this campaign, around 50 million Egyptians had been tested. Of these, 2.2 million were positive and a confirmatory test was carried out that confirmed the infection of 1.6 million. A total of 900,000 cases were treated, with another 700,000 added after the campaign was completed. The cure rate was 98%. The campaign was later expanded to include minors. And between May 2019 and January 2020, tests were carried out on 3.8 million students, according to then-health spokesman Khaled Megahed.
“Thanks to the campaign we have achieved a prevalence of 10% [de hepatitis C] with a prevalence of 0.3 and 0.4%, respectively. “This is an incredible achievement,” says Ward. “It is one of the greatest achievements in global public health, at least this century,” he adds.
The jump to Africa
The success of Egypt's campaign and the lessons learned have become important assets that the WHO believes can be used to enable other low- and middle-income countries to develop plans to eliminate hepatitis C. 75% of people live with According to the health organization, this disease occurs worldwide in these two categories of countries.
In Africa the situation is significantly different than in Egypt in its worst moments, since hepatitis C is not such a widespread disease and its prevalence in the worst cases, such as the Democratic Republic of Congo and Nigeria, ranges from 3% to 4%, according to Waked.
Partly because this is an achievable achievement, then Egyptian Health Minister Hala Zayed announced at an African hepatitis summit in 2019 that Cairo, which then held the presidency of the African Union (AU), was ready to make offers to the continent's countries provide technical support, expertise and free treatment for hepatitis C, with the initial goal of reaching one million people. “When we found out that hepatitis C was easily curable and that medicines were very cheap in Egypt, we decided to help African countries in need of treatment with know-how, technology, advice and free medicines,” explains Waked.
“It is very commendable that Egypt is extending health diplomacy to these countries,” concludes Ward. One of the first countries to benefit was Ghana, where a survey conducted in 2021 found that the prevalence of hepatitis C in a sample of 100,000 people was 2.6%, with rates significantly higher in northern regions.
In March this year, Ghana received its first drug donation for the disease from Egypt, with the initial aim of providing it to people who had already been diagnosed but were unable to receive treatment due to cost. Currently, patients still have to undergo tests to determine the viral load of the virus, which cost between $37 and $80. “A cheaper price or alternative tests would significantly improve our capacity,” believes Waked.
With this in mind, Ward points out that giving free medicine is not enough. “You have to be able to stick to the other parts of the program [de Egipto] for the use of these medications. And this is where Egypt’s technical assistance comes into play, by selecting the right partners in each country and then providing them with free medicines,” he points out.
In addition to Ghana, the Egyptian Ministry of Health reported at the beginning of 2020 that just over 30,500 citizens in South Sudan, Chad and Eritrea had undergone a hepatitis C test and almost 400 had received free treatment. Waked points out that Egyptian health authorities are also in contact with Gambia. And Ward believes Kenya, Tanzania, Uganda, Sierra Leone, Zambia and, to some extent, South Africa could benefit from similar aid.
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