Egypt has established large HCV treatment programs for those with symptomatic disease18. We show with data from a unique real-life mass screening program in Southern Egypt that a large number of local individuals clearly desired an opportunity for HCV testing and on being invited to participate, turned out at a high rate (between 5,000 to 6,000 persons per month). Knowledge of the HCV epidemic in the national and local Egyptian population is well known to be high2,3,12.
That and the opportunity to be treated at no cost by the new highly efficacious DAAs was no doubt a strong motivating factor in the very large turnout from the local community experienced by the project. This well designed and implemented program with strong community support bodes well for a potential goal of treating the entire country in the near future as an achievable reality based on the ultimate objectives of the Tahya Misr project19.
The screening results showed a high prevalence of anti-HCV (14.5%) in Southern Egypt. This is consistent with the overall prevalence of anti-HCV antibodies in the most recent EHIS 201513 study, which was 9.9%. All screened participants who were positive for anti-HCV were tested for HCV RNA at the Luxor center and if positive received treatment without prioritization20.
From both national studies, DHS 20082 and EHIS 201513, among those who were positive for anti-HCV, an estimated mean of 67.3% tested positive for HCV RNA regardless of age or gender. There were 9,701 persons positive for anti-HCV, which approximates 6,529 person positive for HCV RNA (9701 x .673 the estimated proportion with HCV RNA; see Table 1). Persons who screened positive for anti-HCV were subsequently referred for treatment at the Luxor center. In our recent study, we showed that treatment with generic DAAs in asymptomatic patients at the Luxor center had greater than 96% sustained viral response21.
Anti-HCV prevalence was significantly higher in males and in those older than 40 years which is consistent with results of the previous national surveys. The results strongly suggest that screening focused on those over 40 years old will be a productive strategy for ongoing HCV screening and treatment campaigns in Egypt, or at least in Southern Egypt. This is an important finding. Data from the EHIS 2015 study would have suggested screening starting from a younger age group (Figure 3). Our observation is reinforced by the data shown in (Figure 1), in which the absolute largest number of persons who tested positive for anti-HCV, peaked at age 55. In comparison with the two previous national surveys, the peak prevalence of anti-HCV was 44.3%, 95%CI 35.9 – 52.9, at 56 years old in the DHS 2008 study, 36.4%, 95%CI 30.2 – 43.0, at 59 years old in the EIHS 2015 study, and 41.6%, 95%CI 38.7 – 44.5, at 59 years old in this screening study in Luxor.
Also notable was the high HBsAg prevalence of 4.4% overall and 6.2% in males relative to the overall national 1.4% prevalence reported by the EHIS 201513 study. This suggests that HBsAg screening should be recommended for other large screening projects in Egypt, as HBsAg positive patients can develop complications from HCV treatment with DAAs11. This finding also suggests a need to improve HBV immunization coverage in this area.
Although the number screened in this study was very large, it was not a representative sample of the local population in Southern Egypt or the city of Luxor. This must be borne in mind when comparing results with nationally representative samples. There was a clear difference in the age specific patterns of anti-HCV antibodies and HBsAg as seen in (Figure 3). As a footnote, the national studies may have a bias towards more healthy individuals (ill individuals tend to be unavailable or less likely to participate). Nevertheless, our recommendation to recruit older adults, 40 years of age or older, is based on the results of screening for HCV and will likely be more productive and efficient for designing larger national screening programs.
Table (1) showed significant differences in anti-HCV and HBsAg prevalence between genders. This was not seen in the two national studies2,13 where the differences between genders were much smaller. The OR is greater than two for both viruses and greater than three for those positive for both anti-HCV and HBsAg. The latter was remarkably more common in those 50 years old and older. Further inquiry may shed light on the association of HBsAg with males.
There are no Egyptian population-based data for anti-HCV in those 60 years old and older. This is not an insignificant group of the population22. The level of HCV infection in this older age group was essentially unknown. The overall anti-HCV prevalence in this older age group was greater than the overall prevalence; 33.8% compared to 14.7% respectively. As seen in (Figures 2 and 3), there is a dramatic decline in anti-HCV prevalence after the age of 60. This precipitous decline generates questions about the epidemiologic history of HCV in Egypt and the natural history of HCV in general. In Egypt, HCV has been iatrogenically transmitted throughout the health care system for decades3,6,7. Conjecture suggests that over 60 years ago, the Egyptian health care system was much smaller, and percutaneous exposures were less common. There is evidence that the global introduction of glass syringes and re-usable needles iatrogenically spread bloodborne infections globally and was an impetus for the introduction of use only once needles and syringes seen today23. Those over 60 years old may have had a much-reduced percutaneous exposure in the past. This remains to be shown.
Another contribution to the anti-HCV prevalence decline in those 60 years old and older may, in part, be attributable to a selection bias known as survival bias24 that would be more apparent in older age groups. However, additional investigation is needed to address this issue.
We are in the process of investigating possible explanations for the unusual gender difference of prevalence for both viruses, the unanticipated higher prevalence of HBsAg in the Luxor area relative to national data, the odd gender/age distribution of those positive for both anti-HCV and HBsAg, and why both viruses precipitously decline in the older adult age groups.
As progress in screening, treatment, and cure moves towards ridding HCV from Egypt, all efforts must continue to prevent HCV transmission through strict infection control measures in healthcare settings throughout the country3.