Every day, as health care workers stand on the front lines of care, they put themselves at risk of contracting diseases due to occupational exposure to blood, needlestick injuries, and hazardous drugs. In fact, each year, needlestick injuries alone cause 66,000 cases of hepatitis B virus and 16,000 of hepatitis C virus among health care workers.
In Egypt, the prevalence of hepatitis C — a liver disease caused by the bloodborne hepatitis C virus, or HCV — is especially high, killing some 40,000 people each year. In 2018, prevalence stood at between 5% and 7% of the population, including health care workers yet excluding children.
A national vaccination campaign run between the 1950s and 1980s to tackle schistosomiasis — a potentially fatal waterborne disease — is to blame. As medical staff administered over 36 million vaccinations, poorly sterilized needles and the re-use of syringes contributed to the spread of hepatitis C, leading to an epidemic the country still battles today.
The prevalence of hepatitis B — a viral infection that can be fatal — is also high in Egypt, yet more ambiguous, currently standing at an estimated 2%-8% of the population.
Hepatitis: A major public health threat
Egypt is not alone in its fight against viral hepatitis; other countries have high prevalence rates too, making this a global issue.
In Uzbekistan, for example, the incidence rate sits at 8% for HBV and 7% for HCV, according to the Center for Disease Analysis Foundation, while in Pakistan, 5% of the population is infected with HCV and the same amount is thought to have contracted HBV.
Hepatitis has long received less attention than other diseases despite being an international public health challenge that, according to WHO, kills more people than HIV or tuberculosis. However, in recent years, combatting hepatitis has become a priority given Sustainable Development Goal target 3.3 on ending epidemics. Through the first “Global Health Sector Strategy on Viral Hepatitis, 2016-2020,” WHO has also set targets to eliminate viral hepatitis as a major public health threat by 2030 and reduce its incidence from the current 6-10 million cases of chronic infection to 0.9 million by 2030.
With the incidence of these diseases so high, Egypt’s health care workers are at an even higher risk of contracting hepatitis themselves, especially given the lack of compliance and awareness of infection prevention and control practices in some of the country’s hospitals.
Michael Ninburg, president of the World Hepatitis Alliance — a global, patient-led organization dedicated to eliminating viral hepatitis — noted that it sees many hepatitis C patients who are health care workers, often from Egypt or Georgia where there have been epidemics. “There are still a lot of people getting infected through unsterile medical equipment,” he told Devex at the Africa Hepatitis Summit in Kampala, Uganda.
How Egypt is tackling hepatitis C
Egypt, through a national policy, aims to eliminate HCV as a public health threat by 2023, as well as contribute to SDG target 3.3 and WHO goals. To do this, the government formed the National Committee for Control of Viral Hepatitis in 2006 to determine the disease burden and create a national treatment strategy for controlling HCV infection. Viral hepatitis centers were established, surveillance programs were implemented country-wide, health care workers were trained, and prevention measures rolled out.
One of the biggest challenges was to educate the public about hepatitis C, including how to avoid contracting the virus and a call to encourage people to come forward for testing.
Mass public awareness campaigns acted as a building block for the launch of the government’s unprecedented campaign, to test the entire adult population for hepatitis C — the population as a whole sits at 101 million — by encouraging people to get tested. Those who present with HCV, including health care workers, will receive antiviral treatment free of charge. Health care workers are leading this process and have been trained to go into communities, find patients, diagnose them, and link them to care.
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“Just knowing that one in five or one in six Egyptians was infected by hepatitis C [going back many years], there was an appetite that didn’t really exist in most of the rest of the world,” said Ninburg, explaining why Egypt is keen to lead the way in hepatitis C response.
Research shows that by treating 300,000 people in Egypt, the prevalence rate could decrease by 94% and reduce deaths related to liver disease by 75% by 2020.
There are also potential financial benefits. In 2015, the economic burden of HCV in the country totaled an estimated $3.8 billion. If the intervention proves successful, Egypt could save an estimated $31.5 billion in direct and indirect costs by 2030.
Launched in October 2018, the effort to screen the population within a year had already seen 50 million screened by May 2019.
In addition to screening, the government is also taking other steps to ensure hepatitis elimination. To prevent bloodborne transmission, more vigilance around testing blood donations is being implemented alongside the rollout of WHO’s national standards for blood transfusion services.
Efforts are also being undertaken to protect health care workers and patients from accidental needlestick injuries. To tackle the reporting gap on HCV, the government rolled out a surveillance system via an online register that encourages those who have hepatitis C to sign up and receive free treatment.
One of the challenges has been in encouraging people to complete treatment if they are found to have the virus. Limited access to testing and treatment centers are the main barriers. Should people not be treated there is a risk more people will be infected. To tackle this, the Ministry of Health and Population offers a certificate for those who have completed treatment — necessary should they want to work overseas, for example.
Despite a cure for hepatitis C being available, it is only effective in 97% of cases, meaning many will continue to live with the active disease and have the potential to transmit it.
“So many Western European countries and the U.S. have really focused on treatment, whereas Egyptians are looking at the total system, which is screening, linkage to care, and treatment,” said Homie Razavi, founder and managing director, Center for Disease Analysis Foundation, a nonprofit organization that studies complex diseases in order to provide countries with the information to roll out elimination strategies.
How the screening is likely to impact health care workers
As the people working to diagnose and treat people with hepatitis, what do these efforts mean for health care workers operating in Egypt?
“The Egyptian program does include screening and treatment of health care workers. As more individuals are tested and treated in Egypt, it reduces the chances of health care workers getting infected, for example, by accidental contaminated needle contact,” Razavi said. “Thus, the strategy of screening and treating health care workers is very important.”
While the screening of HCV could mean less exposure to hepatitis C patients, Dr. Ghada Ismail, professor of clinical pathology at Ain Shams University, Egypt, said risk still remains for health care workers. The screening means nothing if patients go on to visit unsafe clinics where they may catch hepatitis C because of poor infection control measures or the poor processing of hospital equipment, she advised.
How hepatitis spreads
Hepatitis B and C are viral infections that can cause chronic infection, cirrhosis, and liver cancer if not managed.
According to WHO, HCV is most commonly transmitted through contaminated blood either via transfusions, contaminated injections during medical procedures, or drug use. It can also be transmitted via semen, though this is not as common.
HBV is also transmitted by bodily fluids such as blood and semen and can be transmitted from mothers to babies at the time of birth or from family member to infant in early childhood. A vaccine is available.
“Infection control, budget to have personal protective equipment, and indicators of sensitization [are needed] but are not implemented 100% in all health care facilities. Places related to nongovernmental areas are not supervised or inspected,” Ismail said, adding that double gloving and the implementation of single-use items are other safety measures that could safeguard health care workers from needlestick injury and the risk of contracting diseases including hepatitis.
In 2001, the Egyptian Ministry of Health and Population launched an infection prevention and control program to improve practices and develop the national infection control guidelines and in 2014, it launched the Plan of Action for the Prevention, Care & Treatment of Viral Hepatitis. This outlines the main ways to prevent viral hepatitis.
To help reduce transmission via needlesticks, the government, as part of their initiative to tackle hepatitis C specifically, is already working to ensure that by 2020 all health facilities use only reuse prevention syringes, which ensure one-time use. Given that 37% of hepatitis B among health workers is the result of a sharps injury, such measures are critical in reducing disease prevalence among health care workers.
Egypt is also taking part in an ongoing WHO pilot intervention campaign on injection safety alongside India and Uganda. This initiative aims to provide more data on unsafe injections, assess injection practices, procurement, and continuous availability of products, and consider health care waste management, among other issues.
“We have high rates of needlestick injuries here [in Egypt],” Ismail said, adding that often the incidents are completely ignored by staff and health personnel. This means they may continue working without diagnosis or treatment and transmit the disease.
According to research, 40% of health workers in Egypt endured at least one sharps injury in 2010, while 90% did not report their injury. As reported by International News, the Egyptian Ministry of Health and Population and WHO say 8% of injections in Egypt are unsafe, totaling 23 million syringes per year.
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The rollout of a medical education program on injection safety for undergraduate students is also currently being discussed between WHO, the Ministry of Health and Population, and Egypt’s Supreme Council of universities. Egypt is also offering health care workers the opportunity to complete an online module on WHO's patient safety curriculum.
BD — a medical technology company — is working in Egypt with a local manufacturing partner to locally produce re-use prevention syringes that will help to protect health care workers by reducing the risk of accidental needlestick injuries.
“We came together to say this is to help the country improve the infrastructure locally and bring the right product to the clinicians, which can help drive improvement in clinical practices and prevent this transmission from taking place,” said Amardeep Singh, vice president of injection systems at BD.
One of the biggest challenges in doing this, he said, has been making sure the syringes were priced appropriately for the market and providing education and training for medical staff, as well as the public, on the use of auto-disabled syringes in preventing disease transmission.
While reuse prevention syringes are still in the process of being rolled out in the country, Egypt has put an emphasis on ensuring the safe use of needles in general. As a result, all public hospitals and almost all private hospitals use only needles and syringes taken from a sterile packet and/or fitted with safety caps.
Other measures needed to safeguard HCWs
While the screening campaign is making great strides in addressing the health care needs of the population, Razavi noted that health care workers should also be vaccinated against hepatitis B.
“If they don’t have it and the government is not providing it, they should be getting it on their own,” he said.
Razavi also believes more training for health care workers in LMICs on how to treat hepatitis — so they do not unnecessarily further expose themselves — is vital, given the many misconceptions among the medical community.
“I just came from a meeting where primary care physicians still go out and say ‘there’s no treatment available,’ or ‘you have hepatitis, don’t worry, you don’t need to be treated,’” he said, explaining that hepatitis used to be treated as a liver disease, but now should be treated as a viral infection.
While there is no cure for hepatitis B, there is a cure available for hepatitis C. Hepatitis B can also be managed with nutritional balance and oral antiviral medicines should the case become chronic.
An example for other countries
Egypt is a leader in terms of its political will to eliminate hepatitis and safeguard its health care workers, according to Razavi, adding that there are lessons other countries can learn from its experience.
“The call for action is really a call to drive and create political will to eliminate. Once the political will is there, then everything else starts falling in line. The training programs, access to treatment, and testing all becomes available,” Razavi said. “Once that’s there, all the other barriers are removed.”
Update, Dec. 2, 2019: This article has been amended to clarify that there is no vaccine for hepatitis C.