Egypt's hepatitis C success: 'The most remarkable accomplishment in global health' in the past 50 years

In 1992, a Sudanese doctor working in a blood blank in Saudi Arabia made a disturbing discovery. While screening blood donations for the newly discovered hepatitis C virus, they found that blood donors from Egypt were 10 times more likely than donors from almost any other country to have the virus.

When this data was published in The Lancet later that year, Ministry of Health officials in Egypt launched a nationally representative survey that confirmed the alarming results. It appeared that Egypt had the highest burden of hepatitis C in the world.

"Hepatitis C is a silent disease," said Dr. John Ward, director of the Coalition for Global Hepatitis Elimination. "The virus attacks the liver and liver functions. Those infected may not have symptoms for decades, until they have liver cancer or liver failure, at which time there is little hope."

The virus was silently killing tens of thousands of Egyptians each year.

Egyptian health leaders responded by launching a program that achieved what Dr. Ward has called, "the most remarkable accomplishment in the history of global health over the last 50 years."

Their efforts helped Egypt make an unlikely journey: from the worst afflicted country for hepatitis C – with more than 6 million people infected – to a hepatitis C success story and leader in the global effort to eliminate the disease.

Later this year, the World Health Organization (WHO) is expected to declare the country free of hepatitis C as a public health concern. It is a historic turnaround and remarkable accomplishment that Egypt now aims to replicate by donating drugs and providing technical support for similar efforts in South Sudan, Chad, Ghana, and other countries across Africa. Egypt's goal, with support from the Coalition for Global Hepatitis Elimination, is to facilitate the treatment of 1 million Africans for hepatitis C.

Egypt's hepatitis C crisis can be traced back, like so much of Egypt's history, to the Nile River. For centuries, the river had infected those who used its waters for farming or lived along its banks with schistosomiasis, also known as bilharzia. It is a disease of the liver caused by parasitic worms that live in the Nile. In the 1950s, health campaigns across the country began offering Egyptians a cure for the debilitating disease. That cure came in the form of an intravenous injection. This was before the advent of disposable needles, so, a single needle might be used for half a village. Those reused and improperly cleaned needles helped spread hepatitis C to as many as half the population of some regions of Egypt.

When the news came from Saudi Arabia, health leaders in Egypt despaired. "We thought the problem was too big to solve," said Dr. Imam Waked, who was appointed to a special national planning committee to address the crisis.

Nonetheless, Egypt's leaders marshaled the country's health leaders, including Dr. Waked, and formed a planning committee to do what it could.

Any Egyptian who tested positive for hepatitis C was offered free treatment. But, at that time, treatment options were limited to weekly shots of interferon. The side effects were so serious, as many as half of all those who tested positive weren't eligible for treatment, recalled Dr. Waked. And even those who were eligible had a less than 40% cure rate.

With these limited tools, the government managed to offer treatment to only about 50,000 Egyptians each year.

In 2012, new oral treatments were developed that had a cure rate of about 95%. The government of Egypt seized on this pharmaceutical breakthrough. Led by the planning committee, it negotiated access to the new treatment at a steeply discounted price from the manufacturer, Gilead Sciences, and launched a new program in 2014 to reach even more patients.

"We knew we needed to cure 350,000 people each year to meet our goal of eliminating hepatitis C," said Dr. Waked. "But by 2017, after treating almost all patients who knew their diagnosis, we realized that most of the people with hepatitis C in Egypt were undiagnosed. There were about 2.5 million undiagnosed patients at that time. To reach them, we knew we had to reach out to them."

So, Egypt launched an ambitious year-long national screening program – considered among the largest screening campaigns in history – with the goal of screening 60 million adults and 12 million children for hepatitis C and referring all who tested positive for free treatment at government health facilities. More than 60,000 health care personnel including doctors, nurses, pharmacists, lab technicians, and data entry employees participated in the campaign at more than 5,000 health facilities and testing and screening sites across the country, including military and university hospitals. Screenings were even conducted at mosques before Friday prayers, at churches before Sunday masses, at soccer stadiums before big matches, at bus and train stations, and at shopping malls on holidays. Screening sites were kept open 12 hours each day, seven days a week. And in areas without health facilities, the government sent mobile health teams in specially outfitted vehicles. Officials made sure that no Egyptian was further than 40 kilometers from a screening and treatment site. Citizens were able to register for appointments on a centralized campaign website or could just show up without an appointment.

A massive national advertisement campaign encouraged participation. The campaign included movie, music, and sports stars featured in television and radio ads and billboards. Millions of text messages were sent to cellphones.

The screening involved a rapid finger-prick test that provided results in 20 minutes and allowed health workers to immediately identify those exposed to the virus and to schedule follow-up tests within two weeks to confirm infection and begin treatment. A national call center contacted patients who missed any of their appointments.

"It was a bold initiative, and it required a huge commitment," said Dr. Waked. "Over a period of just seven months, we screened 50 million adults and 7 million teenagers, and identified 2.2 million people who were infected but hadn't known it. We referred them all to treatment and we had a 98.5% cure rate."

Today, an estimated 0.5% of Egypt's population has hepatitis C, among the lowest rate in the world. The WHO estimates that 58 million people around the world are living with hepatitis C. Four out of five people don't know they have it. The virus kills over 400,000 people every year.

Dr. Waked and Dr. Ward say the key drivers of Egypt's success have been: a national planning committee with the authority and budget to negotiate for supplies from international partners, purchase drugs and testing supplies, and lead domestic efforts; a robust data system that provided health leaders and the president of the country with real-time daily and weekly updates; a free and accessible screening and treatment program; and the remarkable political and societal commitment that made all of the above possible.

"In Egypt, everyone has a family member who was impacted by hepatitis C," said Dr. Waked. "This gave us the national will to address this problem. We've now demonstrated that any health problem can be solved if there is an effective and affordable treatment available."

The program was also highly cost effective. Dr. Waked and his colleagues recently published a paper estimating that identifying and curing an adult in Egypt cost about US$120 and identifying and curing a teenager cost about US$300. Both are a fraction of the direct medical costs and indirect costs of disability and early death for a patient with untreated hepatitis C, which is estimated at more than US$100,000.

"The country is already seeing measurable drops in liver cancer and mortality from hepatitis C," said Dr. Ward. "If Egypt can do it, every country can. No country should be hesitant."