This is the sixth installment in my series on progress toward the elimination of Hepatitis C infection and disease. Read more about Hepatitis C in part one, part two , part three, part four, and part five.
TRANSLATION: “IT IS EITHER US, OR HEPATITIS VIRUS C: (1) DON’T USE PERSONAL ITEMS THAT ARE NOT … [+]
Both the World Bank and the World Health Organization declare Egypt to have eliminated hepatitis C from its entire population. How was this done, and why hasn’t it been done in the United States or any other country regardless of income? Our analysis of the Egyptian program suggests there are three main barriers to eliminating hepatitis C. Most important of these is political will. The second is the organization of public health systems to implement the program and finally, the third barrier is the cost of the diagnostic tests and treatment. Here we provide some details of Egypt’s 100 Million Healthy Lives campaign which, with a modest loan from the World Bank, resulted in the elimination of hepatitis C.
FIGURE 1. 2009 COMPARISON OF HCV PREVALENCE IN EGYPT AS COMPARED TO SEVERAL OTHER COUNTRIES AND … [+]
How Did Egypt Become the Country with the Highest Incidence of Hepatitis C?
Many people in Egypt were infected with hepatitis C as children. During a mass vaccination program against schistosomiasis, children were inoculated with anti-schistosomiasis drugs using cross contaminated needles. After nearly thirty years of the campaign, Egypt realized that sharing used needles was rapidly transmitting the hepatitis C virus and ended the campaign. By that time, almost 15% of the population had been infected. The long term consequences of this were a high incidence of serious liver disease and one of the highest incidences of liver cancer in the world.
In response to the high prevalence of hepatitis C, the Egyptian government designed the 100 Million Healthy Lives program. The campaign was enabled by a loan of approximately $250 million which was around half of a $530 million loan from the World Bank. The seven month program was formed under the leadership of President Abdel Fattah al Sisi, managed by Egypt’s Ministry of Health, and the detailed plans were designed and implemented by Dr. Wahid Doss. Its ambitious objective was to screen and treat Egypt’s entire population over the age of 12, including those in prison and in the army, for hepatitis C.
FIGURE 2. EGYPT’S FLOW OF INDIVIDUALS FROM SCREENING TO TREATMENT TO FOLLOW UP DURING THE 100 … [+]
Design of the Program
The 100 Million Healthy Lives campaign was a universal program established throughout the country and illustrated the president’s commitment to eliminating hepatitis C. Egypt’s ability to organize its efforts across the country made the 100 Million Healthy Lives program the largest medical screening campaign to date. The program followed a simple, yet highly effective cascade of 6 steps. (Figure 2).
The first step was to organize the screening groups. For the first phase of the program, the government targeted citizens 18 years and older but later expanded the program to include those over the age of 12.
The second step was to recruit people for screening. The Egyptian government employed several promotional avenues, including a mass media campaign and print media, to spread the word about the program and encourage people to get tested.
The third step was to screen the 50 million citizens who opted for hepatitis C testing for seropositivity. Citizens were able to register for appointments on the centralized campaign website, www.stophcv.eg, and get tested at one of thousands of testing centers and mobile units stationed around the country. The fingerstick antibody tests produced results in as little as twenty minutes and were immediately uploaded to the central website.
Step four was to determine how many of those who tested positive for hepatitis C antibodies had active infections. Those with positive antibody results were referred to specialized testing centers for confirmation PCR testing. The Egyptian government established several PCR testing centers throughout the country, some of which were able to conduct an estimated 36,000 tests each day.
Step five was to provide those with active infections with three months of free treatment. On average, approval for treatment took place within a week of PCR confirmation and was dispensed on site at specialized hepatitis C centers. Of the 1.6 million adults with active hepatitis C infections, 1.47 million accepted government provided treatment for no cost, or opted for private treatment for $70.
The final step was to retest those who received treatment for clearance of the disease. After three months of treatment, individuals were reevaluated for disease clearance with an additional PCR test. Those who tested negative were then provided with a certificate of cure. At the end of the campaign, an estimated 1.23 million Egyptian citizens with active hepatitis C infections were cured.
FIGURE 3. A 100 MILLION HEALTHY LIVES ADVERTISEMENT BANNER FEATURING PRESIDENT EL-SISI.
FIGURE 4. A 100 MILLION HEALTHY LIVES MOBILE TESTING VAN.
Overcoming the Barriers
One of the major contributors to the success of Egypt’s program was the country’s political will to eliminate hepatitis C. With the strong support of both President El-Sisi and the Health Ministry, Egypt’s dedication to eliminating hepatitis C made the country an ideal recipient for a collaborative partnership between the Egyptian government and the World Bank. To illustrate the country’s commitment to elimination, the government made a great effort to ensure everyone knew the program had the full support of both the President El-Sisi and the Ministry of Health. The country was flooded with advertisements for the campaign. Banners and billboards were installed everywhere from the smallest to the largest cities (Figure 3). In addition to word of mouth and print promotion, the government also used television commercials, SMS text messaging, and social media platforms like Facebook to advertise the campaign. The demonstrated will of Egypt’s government encouraged millions of its citizens to participate in the program and made the 100 Million Healthy Lives campaign one of the largest health screening programs in the world.
FIGURE 5. TOTAL NUMBER OF THOSE SCREENED AND FOUND TO BE SEROPOSITIVE FOR HEPATITIS C ANTIBODIES … [+]
The second barrier most countries face in eliminating hepatitis C is the need for coordinated organization. The Million Healthy Lives program was made possible by creating a heavily resourced flow of individuals from screening to treatment. In addition to establishing over 5,000 testing centers throughout the country, the government also created over 1,000 mobile testing vehicles and trained over 60,000 enthusiastic staff. Many of those trained to perform testing at the specialized centers were people from local communities with no medical background (Figure 4). The amount of personnel and wide distribution of hepatitis C centers enabled them to reach all its targeted 50 million citizens, including the 57% that lived in rural areas. The government also used a virtual private network within its national healthcare service to report all the results of the campaign in real time. Program officials were able to track how many people were screened, what the age distribution was, and the percent of the population covered (Figure 5). The central organization system also allowed for the screening of other public health diseases in Egypt including hypertension, diabetes, and obesity. Egypt’s organizational efforts provide an excellent model for screening and treating public health issues across entire populations.
For most countries, the cost barrier to eliminating hepatitis C is substantial. The success of Egypt’s program relied on the ability of its government to control the costs of implementation, diagnostics, and drugs. To control the organizational costs, Egypt was able to deploy much of its existing infrastructure within its centralized healthcare service system. The government was also able to establish testing centers, train its staff, and establish its specialized hepatitis C website all for a low cost.
Egypt’s program included several points of testing including the seropositivity rapid test, the active infection PCR test, and the secondary PCR test to verify disease clearance. While those tests are 10 to 100 times more expensive in the United States, the Egyptian government was able to bring the costs of diagnostics down to a considerably lower price. During the program, Egypt was able to provide antibody tests for 56 cents and PCR tests for just $5 USD. These same tests in the United States can cost around $20 for an antibody rapid test, and up to $300 for a PCR test.
FIGURE 6. A COMPARISON OF THE COST OF SOME DIRECT ACTING ANTIVIRAL MEDICATIONS IN THE UNITED STATES … [+]
Internationally, many hepatitis C drugs are available at lower costs through pharmaceutical tier systems. Direct acting antivirals are available for between $22,000 to $87,000 for high income countries, $6000 for middle income countries, and $900 for low income countries. For the success of Egypt’s program, however, the Egyptian government needed an even greater reduction in cost. The Egyptian government declared the burden of hepatitis c drug costs as a contributor to its endemic status. This exempted the country from drug patent protection in accordance with the Trade-Related Aspects of Intellectual Property Rights agreement. Egypt was then able to purchase active pharmaceutical ingredients for seven different direct acting antivirals from India where treatment can cost anywhere from $25 to $35 USD. These materials were then formulated by Egyptian pharmaceutical companies. This allowed the program to provide free treatment for all its citizens at a cost of $45 to the Egyptian government. These efforts also allowed those who opted for private treatment to pay just $70. For comparison, those same treatment regimens can cost a United States citizen anywhere from $24,000 to $84,000 (Figure 6). According to Hassanin et al (2021), the testing and treatment portion of the 100 Million Healthy Lives program cost the Egyptian government around $207 million USD.
What Made the 100 Million Healthy Lives Program So Effective?
According to the World Health Organization’s verification report, the success of the 100 Million Healthy Lives campaign was achieved through six key factors. The first was its establishment of a specialized committee to support national public health initiatives. In 2018, the Ministry of Health formed such a committee for the sole purpose of designing and overseeing the program and awarding proper allocation of resources.
The second was its commitment to updating national health strategies based on its national priorities. In conjunction with the World Health Organization and the World Bank, Egypt’s government developed a plan of action for eliminating hepatitis C and effectively outlined its objectives and methods to achieve those goals. Third, Egypt reviewed and updated its national hepatitis C relevant legislation and regulations which enabled the government to sustain its achievements.
Another key factor was the program’s ability to finance and provide resources for sustainability. Egypt’s ability to mobilize its human resources by conducting widespread training and developing standard operating procedures for screening and treatment enabled the program to equally serve citizens across all regions of the country.
Additionally, by ensuring the existence of a national medication use and procurement policy, Egypt was able to dramatically reduce the costs of treatment drugs and now has the largest share of the pharmaceutical industry in the Middle East and North Africa region. Lastly, the government created mechanisms like its patient input hotline which allowed proper, prompt, and continuous adjustment and improvement of the program.
The specifications of the Egyptian program are no secret and have been described in detail by medical and scientific literature including the New England Journal of Medicine. Its success was also recently verified by the World Health Organization in their report detailing its creation, implementation, and success. In any country, Egypt’s 100 Million Healthy Lives program has the feasibility to eliminate hepatitis C as well as identify other serious health issues including hypertension, diabetes, and obesity.
The remaining question is why aren’t similar programs being established in other high, middle, and even low income countries? In the next story, we describe the United States’ first steps toward achieving the elimination of hepatitis C by 2030.