The scale of infection with the hepatitis C virus (HCV) in Egypt was unlike any other country in the world—in 2015 an estimated 6.3% of the population was living with the virus. With a population of 93m at the time, that amounted to close to 6m people. In comparison, the prevalence of hepatitis B virus (HBV) was much lower, estimated at 1% of the total population.

The high prevalence of HCV in Egypt can be traced back to a programme that ran between the 1950s and 1980s to combat schistosomiasis, a water-borne parasitic disease that was endemic in the Nile Delta. Executed by the Egyptian Ministry of Health and Population with the advice and support of the World Health Organisation (WHO), 36m injections were administered to more than 6m people. Undertaken almost entirely with unsterilised and pre-used syringes and needles, the programme inadvertently transmitted HCV, which was not well known at the time. This, combined with weak infection control measures (such as quality controls for blood donations), led to high transmission rates and high prevalence.

Despite high HCV prevalence, the HBV-HCV co-infection rate was found to be just 0.06%, and the geographical distribution of the two infections differed markedly. Exposure to household members who are HBV positive has been found to be the main mode of transmission.

US$3.82bn Estimated economic burden of HCV in Egypt in 2015

The impact of HCV and HBV can be assessed on two fronts: the personal effects of the disease and its impact on economies in terms of employee productivity and direct medical costs. Chronic hepatitis is detrimental to a person’s quality of life, as they can experience fatigue and depression. There is a risk of developing progressive liver damage, which can lead to liver cancer or failure. HCV can increase the risk of type 2 diabetes and other health issues too. Both adversely impact employee productivity through disability and mortality. Specifically for HCV in Egypt, the economic burden was estimated at US$3.82bn in 2015. In terms of direct costs, HCV testing and treatment amounted to some 4% of total health expenditure in 2015 (over US$700m). The same study shows that treating over 300,000 individuals with HCV each year with antivirals could reduce its prevalence by 94% and liver-related deaths by 75% by 2030. Under this scenario, direct costs would be incurred, especially in the short-term to test and treat. But when indirect costs are taken into account, the intervention can be cost saving. Between 2015 and 2030, the estimated savings stand at US$4.6bn for direct costs and US$26.9bn for indirect costs.

Given the scale of the health issue, the response from the Egyptian government has been to craft and implement a national screening programme for chronic hepatitis, focusing on HCV, as well as treating those infected. The programme reached a milestone in May 2019, having screened 50m people across the country in six months. These efforts have been supplemented with infection prevention and control, ongoing surveillance and continued public education to sustain the positive health impact. As many countries in Africa and beyond battle against hepatitis B and C, there are vital lessons to learn from Egypt’s experience.

Reaching millions

As part of the Egyptian government’s commitment to address this health issue, they formed the National Committee for Control of Viral Hepatitis (NCCVH) in 2006, comprising representatives from the Ministry of Health and Population as well as liver and viral hepatitis experts.

The initial challenge was the state of public awareness. Three national studies had concluded that there were serious knowledge gaps in people’s understanding of hepatitis C. The response was to roll out a multi-channel mass education campaign, with clear messages for the public on risk factors (for those who have had surgery, blood transfusions or schistosomiasis injections), transmission modes (including reused syringes and shaving razors) and registering for testing.

In addition to other government initiatives to reach those in rural areas, Gamal Shiha, chairman of the board of trustees at the Egyptian Liver Research Institute and Hospital, and his colleagues at Mansoura University, launched the “Educate, Test and Treat” programme. Implemented across 73 villages, it was designed to educate people about viral hepatitis and start treatment rapidly. Education needs to be the first step, advises Dr Shiha. “If you go to a village without talking to the people and say ‘please come and be tested’, 50% will not come. But after we provide some information, people in the villages were welcoming.”

“When you cure everybody, there will be no transmission. We consider the massive treatment programme one of the pillars of prevention in addition to infection control.”

Dr Imam Waked, professor of hepatology, National Liver Institute

“We spent a lot on the media campaign but it was important to encourage people to come for testing,” says Wahid Doss, chairman of the NCCVH. The ambitious screening programme called “100 million healthy lives” cost between US$250m and US$300m and was partly funded from a loan by the World Bank. Of the 5m people estimated to have been living with HCV in 2014, 2.5m were treated between 2014 and early 2019, and 1.8m are expected to be treated by the end of 2019. As a result, the prevalence of HCV in Egypt is expected to decline from 7% to less than 1%. “When you cure everybody, there will be no transmission,” explains Imam Waked, professor of hepatology at the National Liver Institute at the University of Menoufiya and a member of the NCCVH. “We consider the massive treatment programme one of the pillars of prevention in addition to infection control.”

The 2-3% treatment failures would translate to about 50,000 patients who will need more specialised treatment that is not readily available in Egypt.

The last mile

At each stage from initial screening, there is a risk of drop-off as people fail to come back for further tests or complete treatment. The problem is most acute in rural areas, given long distances from testing and treatment centres and high levels of poverty. Layer this with cultural impediments (particularly among women, who are reluctant to leave behind their obligations at home to travel large distances) and it is easy to see why drop-off-rates can be high. To reduce the number of visits required, the “Educate, Test and Treat” programme led by Dr Shiha found a way to offer all the tests required to initiate treatment on a single day.

Going forward, a key challenge will be dealing with treatment failures. Even in the best scenarios, cure rates are between 97-98%. The 2-3% treatment failures would translate to about 50,000 patients who will need more specialised treatment that is not readily available in Egypt. To protect against transmissions from treatment failures, adoption of infection prevention and control measures can be effective.

A holistic approach

To eliminate HCV as a public health threat by 2023 requires a well-rounded approach beyond the current mass-screening and treatment campaign. These include a range of infection prevention and control policies, funded through a combination of government resources and a loan from the World Bank given to upgrade Egypt’s health system, explains Dr Waked.

To incentivise patients to report on treatment outcomes, the Ministry of Health and Population offered a certificate of cure, which was required to secure employment abroad. This improved reporting rates dramatically to 67%, from 25%

Injection safety, which addresses an important mode of transmission for viral hepatitis, has improved over the years. A recent assessment by the WHO found that all public-sector hospitals and 98% of private-sector hospitals used needles and syringes taken from a sterile packet or fitted with caps. To enhance this, healthcare facilities across Egypt will be required to use only auto-disabled syringes by July 2020. Greater adoption of best practice around preparing injections in a dedicated area and cleaning of needles are required.

To further strengthen infection prevention and control, blood banks will be conducting more stringent analysis of blood donations. In addition, the WHO’s national standards for blood transfusion services are being disseminated across Egypt to ensure that protocols for safe transfusion of blood are followed, complemented by efforts to improve regulatory oversight. This entails the formation of a national blood authority and revising the blood safety law.

Prevention measures for HBV have been in place for decades. Egypt began vaccinating infants in 1992, although testing of pregnant women has not been consistent. One study concludes that the existing vaccination programme provides adequate protection. From early 2019, hospitals have been administering the “birth dose”, delivering the first dose of the vaccine within 24 hours after birth (previously the first dose was given two months after birth). As part of the screening and treatment programme for HCV, vaccinations for HBV were also provided.

For further analysis of progress on eliminating HBV and HCV, the government needs to close the reporting gap. To incentivise patients to report on treatment outcomes, the Ministry of Health and Population offered a certificate of cure, which was required to secure employment abroad. This improved reporting rates dramatically to 67%, from 25%; follow-ups over the phone pushed the rate higher, to 75%. Experts we interviewed suggest that all public and private facilities should be reporting into the same database, with a clear link to individual patient IDs.

Sustaining the positive health impact

Looking ahead, health workers and people themselves must remain vigilant for symptoms of viral hepatitis and risk factors for transmission. But the government in Egypt must continue to provide the tools necessary, including frequent training for health workers as conditions evolve and an extended public education programme.

The screening programme accelerated the efforts to reach the millions who were infected, justified by the scale of the health issue. “It required estimating the magnitude of the problem, establishing treatment centres around the country and securing the political will and financing to provide affordable treatment to the people,” describes Dr Doss. But this must be complemented with effective infection prevention and control policies, including injection and blood safety, to reduce transmission. Dr Shiha concludes, “The government’s direction is very good and the commitment makes me happy. My dream is an Egypt, and a whole world, free of hepatitis C and B.”

“What you don’t know can’t hurt you” doesn’t apply to Uganda’s health challenges with hepatitis B and C. Data on prevalence are sparse, particularly for the hepatitis C virus (HCV). Based on small-scale studies, prevalence of HCV is estimated at 1-2% of the total population, says Ponsiano Ocama, chair of the department of medicine and academic hepatologist at Makerere University College of Health Sciences. Estimates for the hepatitis B virus (HBV) are better but based on an HIV impact assessment survey conducted in 2016. It places prevalence at 4.3% of the population aged between 15 and 49 years, with the highest prevalence in the northern region of the country.

There is evidence, albeit limited, that viral hepatitis is a growing health challenge in Uganda. Screening of blood donations for HBV and HCV has thus far been the primary source for identifying infections. According to a government-issued press release, Uganda Blood Transfusion Services has reported an increase in HBV found in blood donations from 1.9% in fiscal year 2012/13 (July-June) to 2.3% in 2016/17, confirming the higher prevalence in the northern and eastern parts. In addition, researchers have recently discovered three new strains of HCV in Uganda.

Importantly though, these figures exclude prevalence in children. In Uganda, HBV is mainly acquired before the age of five, explains Dr Ocama, believed to largely be the result of mother-to-child transmission. Among adults, modes of transmission are thought to include pre-used needles or shared blades, arising from skin scarification practices prevalent in some parts of the country.

At the Uganda Cancer Institute, the largest public-sector cancer institute in East Africa, “out of 280 liver cancer patients in 2018, 80-90% were attributable to viral hepatitis”.

Dr Olaro Charles, director curative services, Ministry of Health, Uganda

The health and financial burden of hepatitis B and C on patients and the government can be high, but with no robust estimates of the economic burden, the severity in Uganda is difficult to assess. One outcome that experts we interviewed emphasise is that chronic hepatitis can progress to liver cancer. At the Uganda Cancer Institute, the largest public sector cancer institute in East Africa, “out of 280 liver cancer patients in 2018, 80-90% were attributable to viral hepatitis,” explains Dr Olaro Charles, director curative services at the Ministry of Health. Addressing chronic hepatitis, he argues, is a way to address the cancer challenge too. Policymakers should assess the short-term costs to test and treat viral hepatitis against the future savings in healthcare expenditure if fewer people require cancer care.

In 2014 the government acknowledged that hepatitis is a serious health concern, making a public declaration to address it. The policies, however, focus almost exclusively on HBV with little or no mention of HCV. In this article, we examine the state of the policy response and priority areas for the future, as Uganda aims to meet this health challenge.

US$3m Amount earmarked in the annual government budget to tackle HBV in Uganda. 

Closing the information gap: Reporting and public awareness

An estimated US$3m of the annual government budget has been earmarked to tackle HBV in Uganda. In 2015 they launched a screening and treatment programme exclusively for HBV, targeting those above the age of 15. Those who test negative are given vaccinations, as a preventative measure. This effort started in the north, where the prevalence is very high, followed by east Uganda, with the aim of covering the whole country.

Information gathered as part of the programme will be valuable, providing more data on the prevalence of HBV than what is currently available. This will be important for completing the government’s strategic plan to tackle hepatitis, which is currently under development, and measuring progress in subsequent years. To strengthen its reporting system, in early 2019 the Ugandan government was given access to the Global Hepatitis Reporting System, which was created by the World Health Organisation (WHO). As part of this, various stakeholders in the healthcare system received two days of training by the WHO. Lessons on best practice learned over the course of the African Hepatitis Summit in Kampala in June 2019 may inform the strategy as well.

“Some people think that hepatitis is transmitted like the Ebola virus. So, whenever someone is identified in the community as having hepatitis, the whole community may exclude this person, even in families.”

Kenneth Kabagambe, executive director, National Organisation for People Living with Hepatitis B

In the absence of a formal framework, nongovernmental organisations (NGOs) such as the National Organisation for People Living with Hepatitis B (NOPLHB) have been very active in Uganda. They advocate for the rights of hepatitis patients and improving diagnostic and clinical services for patients. Importantly, they help to raise public awareness about HBV prevention, care and support services.

Resistance to testing for hepatitis stems from stigma and misinformation. Kenneth Kabagambe, the executive director of NOPLHB, says, “Some people think that hepatitis is transmitted like the Ebola virus. So, whenever someone is identified in the community as having hepatitis, the whole community may exclude this person, even in families.” A wider public awareness programme can help to correct misinformation, strengthen prevention practices and encourage people to get tested and treated. Adopting a multi-channel approach—through television, radio and billboards—could help reach the masses.

The building blocks to prevent, test and treat

Experts we interviewed point to health worker training as a priority going forward. Health workers have received training as part of the government’s wider efforts to improve injection safety, but more specific training on viral hepatitis is needed. “At the moment, we still have some health workers who don’t understand what hepatitis B and C is,” states Mr Kabagame. Dr Ocama concurs, explaining that there are challenges with the quality of training programmes. These need to be structured around an approved curriculum, enabling health workers to better identify at-risk patients and effectively treat those infected. To this end, the government is developing treatment guidelines. Broader protections include policies announced in 2014 requiring all health workers to be vaccinated for hepatitis B.

“We are now trying to see the feasibility of having HBV services integrated to the HIV setting. And then, if it is feasible, we are trying to assess what kind of additional funding will be required.”

Dr Ponsiano Ocama, chair of the department of medicine and academic hepatologist, Makerere University College of Health Sciences

To tackle the prevalence of HBV among children, the government introduced a vaccination programme for infants at six weeks after birth. Based on one study in Uganda, the programme seems to be effective: among 73 children who had been vaccinated, none were infected with HBV. To strengthen this, Mr Kabagambe advocates for the “birth dose”, under which infants receive the first dose within 24 hours after birth, in line with WHO recommendations. To safeguard against mother-to-child transmission, hepatitis testing should be made mandatory for pregnant women, asserts Mr Kabagambe.

Another gap in the system in Uganda is the completion rate of the vaccination programme among those who test negative. At present, 92% of those eligible for the hepatitis B vaccine receive the first dose, 68% receive the second dose and only 33% receive the third dose. Educating patients on the importance of vaccinations and completing treatment is part of the solution, and should be a core pillar of the country’s strategy for preventing and reducing transmission. Another part of the solution will be driving operational efficiency, making these subsequent doses more accessible to patients living in remote areas in particular.

The finance function

Across the system, improving access to testing and treatment has two components, both rooted in financial constraints. The first is that patients are required to pay for some tests before starting treatment. This is resulting in delayed diagnosis, explains Mr Kabagambe: “We are seeing that most of the patients who are infected are going to hospitals when they are at the end stage of the disease, when it is very advanced.”

The second impediment to testing and treating is that diagnostic equipment, especially in rural areas, is often made available through donor funds, which do not take into consideration maintenance and other recurrent costs.

To tackle the financing challenge, opportunities to integrate hepatitis services with HIV programmes could be leveraged. There are many similarities between HIV and hepatitis in terms of transmission, disease progression, diagnostic and monitoring equipment required, and in some cases the treatment too. Globally, between 5% and 20% of people living with HIV are also infected with HBV. “We are now trying to see the feasibility of having HBV services integrated to the HIV setting,” says Dr Ocama. “And then, if it is feasible, we are trying to assess what kind of additional funding will be required.”

The Global Fund to Fight AIDS, TB and Malaria now allows applicants to include work to address HIV comorbidities such as hepatitis in their funding requests. However, such requests would need to come from the country’s allocated funding for HIV, which already falls short of what is required in the case of Uganda. That may explain why funding for hepatitis has so far relied entirely on domestic sources, but this does not preclude opportunities for funding integration in the future.

Looking ahead

The Ministry of Health is taking some positive steps to address hepatitis in Uganda, with a dedicated budget and staff as well as the development of a strategic plan. But the plan must take into consideration various facets of the health issue.

Enhancing reporting from the screening programme under way as well as a planned nationwide survey will provide much-needed data on HBV and HCV prevalence. This will enable the government to craft evidence-based policies and plans with specific targets. Without plans and targets, it will be difficult to assess progress and the degree of alignment with WHO recommendations.

Emphasis on health worker training and providing treatment guidelines will be critical for the successful implementation of the strategy. In addition, the government can leverage the expertise of active NGOs in the country and build on their efforts to raise public awareness and advocate for patients’ rights and services. Broader education efforts to erase the stigma attached to these curable and preventable diseases will be an important driver of success as Uganda works towards the WHO goal of eliminating hepatitis B and C by 2030. 

Vast oil wealth in the Gulf has led to lifestyle changes which, in turn, have given rise to increased incidence of non-communicable diseases (NCDs). Healthy traditional diets have been almost entirely replaced by a high-sugar, low-nutrient diet. Tobacco smoking has been taken up by men, women and children. An active lifestyle, which came naturally to the self-sufficient nomadic forebears of Gulf Arabs, has largely been replaced by desk-bound jobs. This has led to an evolution in the disease profile of the region from a preponderance of infectious diseases to chronic diseases spanning obesity, diabetes, heart disease and cancer.

The growing prevalence of these lifestyle-related diseases also has wider economicimplications. It is therefore essential that these health issues are diagnosed and tackled before they progress and become chronic if the region is to develop a well-educated, skilled and diversified workforce and thereby achieve its economic potential. To do this, healthcare systems in the region need to adapt to changes in the disease profile. This paper examines the current state of healthcare delivery in the Gulf Co-operation Council (GCC), with a focus on the diagnostic process, and identifies strategies for the way forward.