HCV screening in Egypt: key elements of a successful national screening programme

This article is part of a series on hepatitis C (HCV) elimination in Pakistan and other high-risk countries around the world. Forthcoming articles in this series will cover the Pakistani provinces of Sindh and Punjab. Scroll to the bottom of the article for the full list.

Hepatitis C virus (HCV) infection is one of the world’s leading threats to public health. A major challenge in tackling HCV is that most patients are asymptomatic and unaware they are infected. National HCV screening programmes can help to ensure that carriers of the virus are identified and enrolled into patient education and treatment regimens, thus preventing further transmission in the community.

National HCV screening programmes require close collaboration between clinics, hospitals, laboratories, governments and other key stakeholders. If deployed successfully, they not only save lives and reduce human suffering from HCV-related diseases, but also decrease costs and improve overall sustainability of healthcare systems [1].

Overview of Egypt’s HCV screening programme
In 2018, the world’s largest HCV screening campaign was initiated in Egypt. Its goal was to screen everyone aged 18 years or above within 1 year and provide treatment to all those who were infected. The screening was implemented in three phases, each including 5800-8000 screening teams across both urban and rural areas in the country.

Following initial screening for HCV antibodies, seropositive patients were referred for confirmatory testing at specialised treatment centres to determine the presence of active HCV infection. Patients also received liver function tests with serum biomarker panels to detect fibrosis progression and assess whether additional management of cirrhosis is needed. After receiving antiviral treatment, patients were followed up at 12 weeks and assessed for sustained virological response by absence of detectable HCV RNA.

Diagnostic protocols in Egypt’s HCV screening programme

To help manage these diagnostic protocols and drive patient engagement, Egypt deployed innovative digital solutions. Patients could register to the programme using their mobile phones via a web-based system that assigned them to the nearest screening site. They could then access testing results directly on their phones instead of having to wait to receive results at clinics. Personalised treatment and appointment reminders were also sent throughout the process to improve compliance.

Results and key success factors
In just 7 months, 49.6 million people had participated in screening and 2.2 million HCV-seropositive individuals had been referred for evaluation and treatment with high levels of adherence. The success of the programme has been widely acknowledged. In a March 2020 special report for The New England Journal of Medicine [2], a group of leading Egyptian medical and public health professionals attributed this success to five key factors:

Governmental support – the high prevalence of HCV in Egypt led the president and key policymakers to set up a national programme that was fully subsidised by the government and extended to the entire country, including both urban and rural areas.
Patient engagement and advocacy – public awareness of HCV and its negative socioeconomic impacts drove widespread patient support for government screening programmes and contributed to the high participation rates.
Streamlined procurement processes – a single negotiating body made the procurement process smooth and predictable, ensuring availability of immunoassays for screening and molecular assays for confirmatory testing.
Sufficient human and financial resources – a large multidisciplinary taskforce—including healthcare professionals, laboratory technicians, trainers, data-entry clerks, and transportation personnel—was involved at each stage of the programme.
Efficient IT support with a user-friendly application – a central database system was digitally connected to all treatment centres across the country to facilitate planning and patient flow during screening, evaluation and treatment.

While not deployed in Egypt, some countries are also incorporating reflex testing into their diagnostic protocols. This involves immediate confirmatory testing on the same sample if seropositivity is confirmed. It potentially reduces the loss of follow-up by avoiding the need to bring patients back to the clinic for confirmatory testing.

Reflex testing is possible through the use of previously collected samples that are then processed again in a central laboratory. Depending on the programme protocols, the samples used include serum or plasma. For remote areas that are difficult to reach, it may be advantageous to consider sample types that are easy to collect and stable during transportation.

Foundation for future HCV screening programmes
Due to the success of its national screening campaign, Egypt is among the few countries in the world considered to be ‘on-track’ for the HCV elimination target of 2030 set by the World Health Organisation. Strengths in their elimination strategy can be used to inform policy and decision makers for similar initiatives in the Asia Pacific region, where HCV infection remains a serious challenge.

References:[1] Scott N, Wilson D, Kuschel C, Aufegger L, Hellard M. Eliminating Viral. Hepatitis: The Investment Case. Doha, Qatar: World Innovation Summit for Health, 2018.[2] Waked, I. et al., 2020. Screening and Treatment Program to Elimitate Hepatitis C in Egypt. The New England Journal of Medicine, 382(12), pp.1166-1174.