Goals to improve global health are replete with ambition, hope, and inspiration. However, numerous challenges exist concerning the practical measures needed to achieve progress. In 2016, the World Health Assembly published a set of targets aiming to eliminate viral hepatitis. What healthcare strategies should national governments consider in attempts to achieve these targets?
The major considerations for a national program are screening, treatment, and cost. The target population needs to be identified and the timeframe for screening and treatment needs to be determined. In addition, optimal locations for screening, ranging from conventional healthcare settings to large population gatherings (e.g., sporting events and public holiday gatherings) need to be established. Effective communication is essential to promote public engagement and follow up and evaluation of patients during and after treatment is key to minimizing loss to follow up. Both overall and per unit costs need to be understood.
In 2018, the Egyptian government launched a national effort to achieve the elimination of hepatitis C virus (HCV) infection and the results were reported in a recent issue of NEJM. In a target population of 62.5 million people, 80% participated in screening. Overall seropositivity was 4.6% and 92% of those who were seropositive started treatment. The cost of identifying and curing one case was $US130.00. This successful national screening and treatment program provides a framework for future disease elimination projects.
The following NEJM Journal Watch summary explains the program and results in more detail.
Egypt Implements Successful Nationwide Program to Eliminate Hepatitis C
Mary E. Wilson, MD reviewing Waked I et al. N Engl J Med 2020 Mar 19
An integrated program screened almost 50 million residents and provided free antiviral treatment to more than 2 million HCV-infected individuals.
Egypt has a high prevalence of hepatitis C virus (HCV) infection, attributed to past schistosomiasis treatment with unsafe injections. In 2018, the Ministry of Health began a program to screen for and treat HCV. To reach a target population of 62.5 million, residents were screened at multiple healthcare and other sites using a WHO-approved rapid diagnostic test (RDT) that analyzed finger-prick samples for HCV antibodies. Participation was encouraged by a massive national campaign using television, radio, text messaging, and other media. The program was supported by the Egyptian president. Officials negotiated low prices for diagnostics and treatment drugs.
Those with positive RDT results had HCV RNA levels measured with quantitative polymerase chain reaction (PCR) assay and underwent abdominal ultrasound and liver function testing. Viremic persons received sofosbuvir (400 mg daily) plus daclatasvir (60 mg daily) with or without ribavirin for 12 or 24 weeks.
Almost 50 million people (80% of the target population) participated; two thirds were <45 years old. Overall seropositivity was 4.6% but was >8% in the Nile Delta. Seroprevalence was higher among men and rural residents, and it increased with age and was inversely related to mean household income by state. More than three quarters of those with positive RDT had viremia, 91.8% of whom started treatment. The cost of identifying and curing a patient was about $US130.00.
Comment: This impressive public health achievement required political support from the highest levels, commitment of sufficient resources, and an integrated program that involved multiple sectors. The potential economic benefit is enormous. The authors note that previous studies have shown the lifetime cost per person with chronic HCV infection in Egypt is >$US100,000. Major factors in the success of the program included social pressure on policymakers from large numbers of HCV-infected patients with complications, negotiation for mass procurement of diagnostics and treatment, information-technology support that allowed integration of national databases, rapid provision of results, and simplified management guidelines that shifted care to nonspecialists.
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Ken is a 2019-2020 NEJM Editorial Fellow and a paediatrician working in the National Health Service of the United Kingdom. He graduated from Imperial College School of Medicine and is training in general paediatrics in London.