HEPATITIS c Virus prevention IN eGYPT                               Reducing Transmission by Reducing Exposure
Prevention Iatrogenic Infection Incidence
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New Section: Review of Epidemiologic Investigations in Egypt on HCV
Since the discovery of the HCV epidmeic in Egypt first published by Dr. Moamena Kamel, Dr. F DeWolfe Miller and other coauthors in 1992 there has
been many epidemoilogic studies published in the scientific literature. Some of these studies were well done and made important contributions. Other studies
were not well done and had little impact. However, there have been some high profile studies published which have lead to wide spread 
misconceptions and poor public health policy.

I hope this review will shed light on the current status of HCV epidemiology in Egypt. The review is presented historically starting from the first report of HCV in Egypt.


High HCV Prevalence in Egyptian Blood donors.

Kamel, M.A., Ghaffar, Y.A., Wasef, M.A., Wright, M., Clark, L.C., Miller, F.D., 1992. Lancet. 340 (8816): p. 427.

This was the FIRST report in the scientific literture that HCV was an epidemic in Egypt. This report was a ground breaking discovery of the HCV epidemic in Egypt.Over 2,000 first time apparently healthy volunteer blood donor were tested for HCV in a sample of their blood sera. 10.9% of these donors were found positive for HCV antibody. This is much higher than any other country in the world. Lancet is a prestigious scientific medical journal published in England. The sample size of this study was large, that is over 2,000 persons were tested.  After the publication in Lancet more than an additional 13,000 blood donors were tested. The results were similar. That is about 10% were confirmed positive for HCV antibody. Because blood donors who are considered to be healthy are not the same as the general population, the 10% has to be considered as biased. If a representative sample of the general population had been possible at the time, which would include people who were not healthy, the results would show that the percentage of persons positive for HCV would be higher. More importantly we already knew that most people who were positive for HCV antibody were also positive for HCV RNA. That is these people would have antibody and virus and be infectious to other people.

Dr. F. DeWolfe Miller, Professor of Epidemiology at the University of Hawaii, designed the study, conducted the analysis of data, and drafted the report.

The epidemiology of Schistosoma mansoni, hepatitis B and hepatitis C infection in Egypt.

Kamel, M.A., Miller, F.D. and others. 1994. Annals of Tropical Medicine and Parasitology. 88 (5): 501-509.

This was the first population community based study of HCV in Egypt. The study from the urban Cairo blood donors was from blood donors and not a representative sample of a community population. Working with Dr. Rashida Barakat from the University of Alexandria, we established a study of the entire population of a remote rural village in northern Nile Delta. This would be a population based study and it would be in a rural area rather than urban Cairo and it would be remote from all major cities of Egypt.  15.9% of the village population was found positive for HCV antibody. This study was also the first to publish an age specific prevalence of HCV as shown in the figure below. The y axis on the left is the prevalence of HCV antibody and the x axis on the bottom is age.For example, people who are 40 to 44 years old, the prevalence of HCV was 36.8%. This was a remarkable discovery. We noted that the prevalence of HCV increased with age in the blood donors in the same way but only lower overall. 

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

Christina Frank, Mostafa K Mohamed, G Thomas Strickland, Daniel Lavanchy, Ray R Arthur, Laurence S Magder, Taha El Khoby, Yehia Abdel-Wahab, El Said Aly Ohn, Wagida Anwar, Ismail Sallam. 2000.   Lancet 2000; 355: 887–891

This study suggested that the epidemic of HCV in Egypt was started by the injections given for bilharzia in Egypt started more that 60 years ago and ending with the development of a safer oral drug more than 25 years ago. This study has serious flaws and limitations. Nevertheless, this explaination for the HCV epidemic has become widely accepted. Because this treatment program with injections ended 25 years ago, many believe that the TRANSMISSION of HCV ended. This is not the case. This and other studies have had a negative public health impact in Egypt. Programs to reduce transmission have been delayed.  See the page on new cases of HCV.

M. Karmochkine, F Carrat, O Dos Santos, and others. A case-control study of risk factors for hepatitis C infection in patients with unexplained routes of infection. Journal of Viral Hepatitis 13(11): 775-782. November 2006.

 see: http://www.hivandhepatitis.com/hep_c/news/2007/121206_c.html 

This study suggests that Iatrogenic Infections which are very important in Egypt also play a role in the transmission of HCV in other developed countries as well. In fact there was a recent iatrogenic exposure to over 40,000 patients in Las Vagas, NV. U.S.A.

Summarized Results from this report are:

Among the 66 items considered, multivariate analysis identified 15 independent risk factors for HCV infection: 

Iatrogenic inpatient exposures
admission to a medical facility (OR 2.1);
digestive endoscopy (OR 1.9);
admission to a surgical ward (OR 1.7);
surgical abortion (OR 1.7).>

Out-patient treatments:
Cutaneous ulcer or wound care (OR 10.1);
diathermy (OR 3.0);
gamma globulin administration (OR 1.7);
intravenous injections (OR = 1.7);

varicose vein sclerotherapy (OR 1.6);
acupuncture (OR 1.5);
intramuscular injections (OR 1.4).http://www2.hawaii.edu/%7Edewolfe/Iatrogenic.html

Lifestyle factors:
intranasal cocaine use (OR 4.5);
engaging in contact sports (OR 2.3);
beauty treatments (OR 2.0);
professional pedicure or manicure (OR 1.7). 

These factors explained 73% of community-acquired HCV infections. 


In conclusion, the authors wrote, "for patients with unexplained routes of HCV infection, our data incriminate previously unidentified risk factors (abortions, some dermatological procedures, outpatient injections, contact sports, beauty treatments, professional pedicure/manicure) and confirm those already recognized (hospitalization, digestive endoscopy, acupuncture and intra-nasal cocaine use)."

These results suggest that prevention education materials and programs should include a broader range of exposures and activities that may put individuals at risk for contracting HCV. They also emphasize the need for universal precautions and sterile procedures in medical settings.

Mohamed, M. K.et al. Intrafamilial transmission of hepatitis C in Egypt. Hepatology. 42: 683-7. 2000.

This publication was an important contribution to understanding HCV transmission in Egypt. Many, including those in the medical profession, considered that since the PAT campaigns had been stopped more than 25 years ago, then the transmission of HCV had also stopped (see reference 2 above). This report shows that in areas of Egypt with high HCV prevalence, incidence (the number of new cases per year) was also high (6.8/1000 per year).


The conclusion is that HCV transmission is ongoing in Egypt and has not ended as many in the medical profession believe.

This report also suggests that there is transmission of HCV within household or family members. This is an unexpected and unlikely finding. The transmission of HCV virus is low even when exposed directly to for example a needle contaminated with blood from a person known to have HCV viremia. We know this from studies of accidental needle stick injury.

This report did not demonstrate exactly how HCV transmission occurred within the family. Only indirect evidence was given. Also the absolute numbers of new incident cases in the study was small, 28 cases in one village and 5 in the other village. Therefore the analysis was based on small numbers. It is not possible to rule out that exposure and infection of family members did not occur outside the household and confounded by health care provider.

The results from this single prospective study have not been confirmed by other prospective studies. Even if there were household transmission, the attributable risk of this exposure to the total exposure of HCV infection in Egypt was not given. The results consequently in Egypt have been blown out of proportion relative to the more substantial data on transmission of HCV by iatrogenic exposures both in Egypt and elsewhere in the world. This has had a negative impact on focusing prevention messages and measures on the more widely spread iatrogenic exposures and efforts to reduce these exposures. Reducing iatrogenic exposures is essential even if there is household transmission.

Finally, this report potentially stigmatizes family members who may find themselves tested positive for HCV. This is unnecessary and unfortunate. 

Saleh, DA et al. Incidence and risk factors for hepatitis C infection in a cohort of women in rural Egypt. Transactions of the Royal Society of Tropical Medicine and Hygiene (2008)

This very recent report estimates incidence of HCV in rural women at 0.5% per year.

El-Zanaty F, Way A. Egypt Demographic and Health Survey 2008. Egyptian: Ministry of Health. El-Zanaty and Associates, and Macro International. Cairo. p 431, 2009.  Egypt Demographic Health Survey: Final Report - June 2009.

This study completed the first representative national sample of HCV antibody and HCV RNA.  The final estimated prevalence of HCV antibody was 14.7%. See  Figure 1