Epidemiology , Prevention and Control programs of Hepatitis C in Egypt

1. Epidemiology , Prevention and Control programs of Hepatitis C in Egypt Mostafa K. Mohamed and El-Said A. Aoun Egyptian Ministry of Health and Population WHO informal Consultation with VHPB Geneva, Swittzerland 13-14 May 2002

2. Prevalence of HCV infection Incidence of new Infections or Seroconversions Notification Systems Prevenetion Programs Laboratory /Clinical Networks Role of Authorities Cost and Burden of disease WHO informal Consultation with VHPB Geneva, Swittzerland 13-14 May 2002

3. Rural life 1996 62 Mil. Population 60 % in Rural Areas 2002 Population 70 Mil. Population Life expectancy 66 y

4. The Role of Parenteral Antischistosomal Therapy in the Spread of Hepatitis C Virus in Egypt Christina Frank1, Mostafa K. Mohamed1, G. Thomas Strickland1, Daniel Lavanchy2, Ray R. Arthur2, Laurence S. Magder1, Taha El Khoby3, Yehia Abdel-Wahab3, El-Said A. Ohn3, Wagida Anwar3, Ismail Sallam3 1 = HCP Project 2 = World Health Organization 3 = Egyptian Ministry of Health and Population THE LANCET  Vol 355  March 11, 2000

5. Lower Egypt Alexandria Upper Egypt Middle Egypt Comparison of Exposure Index and Prevalence

6. Seroprevalence of Hepatitis C Among Egyptian Workers 1996 and in the National Survey 1997-1998 60 55 50 47 47 46 41 38 40 36 35 35 35 34 34 32 30 27 27 23 18 20 13 13 10 10 9 8 10 6 0 <05 10 15 20 25 30 35 40 45 50 55 60 >60 National Survey > 10000 Workers > 5000

8. Prevalence of HCV HBV and HBsAg in Egypt 1996 *Adjusted for +ve predictive value of ELISA 98% specificity and 98% sensitivity).

9. HCV 16 % 21 % HBV Median Age 26 Median Age 46 25 % HAV Median Age 12 Median Age 34 All -ve Median Age 44 13 % 1 % Mixed HEV 24 % Etiology of Acute Viral Hepatitis in Egypt 1997-2000 Analysis of 1860 Acute hepatitis cases

10. Hepatitis C Virus Infection in a Community in the Nile DeltaSeroincidence and Risk FactorsCenter for Field and Applied Research Mostafa K. Mohamed, Fatma Abdel-Aziz, Mohamed Abdel-Hamid, Nabiel N. Mikhail, Mostafa Habib , Wagida Anwar , G. Thomas Strickland, Laurence S. Magder, Alan D. Fix, Ismail Sallam

12. ALT among Village Residents and HCV 1999 %

13. S1 IMX S2 PCR S3 EIA S2 IMX S1 EIA Negative S2 EIA Positive 87 Exclude 28 +ve +ve -ve Exclude 24 Seroconverter 5 None 30 +ve Seroconverter 11 -ve +ve Exclude 10 -ve Seroconverter 9

14. Over 2 years of follow-up, 2502/ 3394 seronegative (73.7%) followed-up 25 had valid anti-HCV seroconversion 11 had HCV RNA seroconversions RNA Seroconversion Rate 2.7/1000 P.Y. 95% C.L. 1.1-4.3 /1000 P.Y. Anti-HCV seroconversion Rate 6.2 /1000 P.Y. 95% C.L. 3.8 - 8.6 /1000 P.Y.

15. 95% CI for OR Variable OR Lower CI Upper CI Significance Kids Seroconversion MOTHER HCV 6.8 1.4 32.8 .0171 FATHER HCV .64 .20 2.0 .4503 INVASIVE Procedures 3.94 1.02 15.1 .0468 Frequent INJECTNS 1.44 .17 12.4 .7431 RAZOR Sharing 1.8 .28 11.4 .5424 AGE .96 .87 1.1 .4334 SEX .72 .26 2.0 .5225

16. Notification Systems Notification for Acute Jaundice : National Surveillance in 110 Fever hospitals and referral hospitals A National Cancer Registry with HCC notification in 8 MOHP cancer centers and University Centers Research on use of sentinel surveillance based on blood banks for monitoring changes in community prevalenceby comparing ratios blood banks prevalence with the surrounding communities in 6 geographical locations over 2 years.

17. Prevenetion Programs 1- Blood Banks : Screening of blood/blood products Central management , Reporting Provision of Lab Equipment Training, supplies, Monitoring 2- Central and Peripheral Infection Control Comittees 3- Development of Guidelines for Infection Control

18. Prevenetion Programs Cont. • Training of Health Care personnel on : • 1- Safe Injection Practices • 2- Destruction of disposable needles • 3- Proper Disposal of contaminated invasive materials • 4- Proper sterilization of reusable material • 5- Universal precautions and barrier techniques • 6- Proper Counseling of Patients and their families • Public Education :Use of Contaminated materials • Reduce public use of injections Unsafe practices shaving/circumcision

19. Laboratory /Clinical Networks NO Current Laboratory or Clinical Networks Blood Bank Serology reporting is The only network available Several Liver Disease Societies now collaborate for exchange of experiences but no common network Role of Authorities Cost and Burden of disease

20. Role of Authorities There are many public calls on authorities including Peoples Assembly to Develop guidelines for patient management Act for control of transmission Provide Public support for provision of treatment of infected individuals Cost and Burden of disease

21. Role of Authorities cont. MOHP Authorities are Supporting Research projects lead by the Ministry of Health and Universities in collaboration with International Agencies NIH CDC and WHO Physicians Syndicate authorities Organize meetings with national insurance authorities for developing guidelines for patient management News and Media Authorities Raising Awareness for prevention of infection

22. Cost and Burden of Liver Disease

25. Changes of Liver Disease Spectrum in Egypt over 70 Years 1930-1980 Schistosomiasis 30 % Hepato-Splenomegaly 1990 HCV 13% 1990-2000 HCV 14% HCC Liver Cirrhosis Death At Age 30-40’s At Age 50-60’s At Age 60-70’s Liver Cell damage Portal Fibrosis, Portal Hypertension Variceal bleeding occurs in ~ 20% of HCV-infected individuals After 20 of Infection Fatal in < 2 years In chronic HCV infection Patients Occurs annually in 4% of Cirrhotic patients Periportal Fibrosis, Portal Hypertension , variceal bleeding occurs in ~ 80% of individuals After 15-20 of Infection

28. Predicted Chronic Liver Disease in Egypt 1996

29. Predicted Hepatocellular carcinoma in Egypt 1996

31. Cost of STD. TTT = ALL ALT 1.5N X 30000 Cost of complication = Annually 10/100 ALT1.5N X 5000 Lost Productivity = Annually 20/100 ALT1.5N X 1500 Cost of YLL = Annually 3/100 ALT1.5N X 20000 Cost of Alternative TTT = Annually All ALT > N X 1000 TTT of All Cases with Viraemia will prevent infection of new cases