How to optimize hepatitis C virus treatment impact on life years saved in resource-constrained countries.

UNLABELLED: In resource-constrained countries where the prevalence of hepatitis C virus (HCV) disease is usually high, it is important to know which population should be treated first in order to increase treatment effectiveness. The aim was to estimate the effectiveness of different HCV treatment eligibility scenarios in three different countries. Using a Markov model, we estimated the number of life-years saved (LYS) with different treatment eligibility scenarios according to fibrosis stage (F1-F4 or F3-4), compared to base case (F2-F4), at a constant treatment rate, of patients between 18 and 60 years of age, at stages F0/F1 to F4, without liver complications or coinfections, chronically infected by HCV, and treated with pegylated interferon (IFN)/ribavirin or more-efficacious therapies (i.e. IFN free). We conducted the analysis in Egypt (prevalence = 14.7%; 45,000 patients treated/year), Thailand (prevalence = 2.2%; 1,000 patients treated/year), and Côte d'Ivoire (prevalence = 3%; 150 patients treated/year). In Egypt, treating F1 patients in addition to ≥F2 patients (SE1 vs. SE0) decreased LYS by 3.9%. Focusing treatment only on F3-F4 patients increased LYS by 6.7% (SE2 vs. SE0). In Thailand and Côte d'Ivoire, focusing treatment only on F3-F4 patients increased LYS by 15.3% and 11.0%, respectively, compared to treating patients ≥F2 (ST0 and SC0, respectively). Treatment only for patients at stages F3-F4 with IFN-free therapies would increase LYS by 16.7% versus SE0 in Egypt, 22.0% versus ST0 in Thailand, and 13.1% versus SC0 in Côte d'Ivoire. In this study, we did not take into account the yearly new infections and the impact of treatment on HCV transmission. CONCLUSION: Our model-based analysis demonstrates that prioritizing treatment in F3-F4 patients in resource-constrained countries is the most effective scenario in terms of LYS, regardless of treatment considered.

Screening for hypertension among adults: community outreach in Cairo, Egypt.

BACKGROUND: Studies have shown alarming levels of hypertension among adults in the Middle East. The aim of our study is to measure the prevalence rate of hypertension among adults in Cairo (Egypt), identify possible risk factors for the development of hypertension and assess the rates of undiagnosed and uncontrolled hypertension. METHODS: Cluster sampling was utilized and the fieldwork was conducted by 12 teams; each team consisted of a house officer, community worker and senior epidemiologist. A formulated questionnaire that addresses risk factors for hypertension was filled by all participants. Also, weight and height measurements were done to calculate the body mass index. Blood pressure measurement was done by calibrated sphygmomanometers. Blood pressure measurement was done twice, and a mean recording was calculated. A case which recorded both systolic blood pressure of ≥140 and diastolic blood pressure of ≥90 was considered hypertensive. RESULTS: The study included 774 adult residents of Al-Waily District (Western Zone of Cairo) in late 2011 and early 2012. The mean age of the study participants was 46.5 (SD 17.9) years. Female subjects constituted 67.1% of the studied sample. The prevalence rate of hypertension in our study was 16.5% (95% confidence interval (CI): 13.9-19.3). The rate of hypertension was higher among females and three times higher among obese compared with normal or overweight adults. The prevalence of undiagnosed hypertension was 11% (95% CI: 8.4-13.9), and uncontrolled hypertension was 30% (95% CI: 24.2-37). CONCLUSIONS: Community outreach campaigns should be conducted regularly in the future for early detection of hypertension cases and proper health education about hypertension and its dangerous consequences.

Effectiveness and cost-effectiveness of immediate versus delayed treatment of hepatitis C virus-infected patients in a country with limited resources: the case of Egypt.

BACKGROUND: Because of logistical and economic issues, in Egypt, as in other resource-limited settings, decision makers should determine for which patients hepatitis C virus (HCV) treatment should be prioritized. We assessed the effectiveness and cost-effectiveness of different treatment initiation strategies. METHODS: Using a Markov model, we simulated HCV disease in chronically infected patients in Egypt, to compare lifetime costs, quality-adjusted life expectancy (QALE), and the incremental cost-effectiveness ratio (ICER) of different treatment initiation strategies. RESULTS: Immediate treatment of patients at stages F1/F2/F3 was less expensive and more effective than delaying treatment until more severe stages or not providing treatment (in patients diagnosed at F1: QALE = 18.32 years if treatment at F1 vs 18.22 if treatment at F2). Treatment of F4 patients was more effective than no treatment at all (QALE = 10.33 years vs 8.77 years) and was cost-effective (ICER = $1915/quality-adjusted life-year [QALY]). When considering that affordable triple therapies, including new direct-acting antivirals, will be available starting in 2016, delaying treatment until stage F2, then treating all patients regardless of their disease stage after 2016, was found to be cost-effective (ICER = $33/QALY). CONCLUSIONS: In Egypt, immediate treatment of patients with fibrosis stage F1-F3 who present to care is less expensive and more effective than delaying treatment. However, immediate treatment at stage F1 is only slightly more effective than waiting for disease to progress to stage F2 before starting treatment and is sensitive to the forthcoming availability of new treatments. Treating patients at stage F4 is highly effective and cost-effective. In Egypt, decision makers should prioritize treatment for F4 patients and delay treatment for F1 patients who present to care.

Seroprevalence of rubella antibodies among adult Egyptian females aged 20-30 years. Is there a need for rubella vaccination?

INTRODUCTION: Egypt adopted a comprehensive strategy to eliminate measles and rubella by conducting a catch up campaign (in 2008) targeting children and young adults in the age group 10-19 years. This study aimed to explore the seroprevalence of rubella among females aged 20 to 30 years in order to provide the Ministry of Health with information to develop future strategies for rubella supplemental immunization activities among women of childbearing age before marriage and conception. METHODS: A total of 339 females in the age group 20 to 30 were selected. The study group comprised women who attended the central laboratory of the Ministry of Health for checking up before travelling abroad as pre-travel requirements for visa application. The collected serum samples were tested for rubella-specific IgG antibodies. RESULTS: The overall prevalence of rubella antibodies in the study group was 88.2%. Around 5.0% of females, who reported that they had been vaccinated, were susceptible to rubella. Age, history of measles, mumps and rubella (MMR) vaccination and past history of rubella infection were considered factors associated with seropositivity for rubella. CONCLUSION: The seroprevalence rate of rubella antibodies among our female study group was considered low.

Risk perception and priority setting for intervention among hepatitis C virus and environmental risks: a cross-sectional survey in the Cairo community.

BACKGROUND: Hepatitis C virus (HCV) recently emerged as a major public health hazard in Egypt. However, dramatic healthcare budget constraints limit access to the costly treatment. We assessed risk perception and priority setting for intervention among HCV, unsafe water, and outdoor air pollution in Cairo city. METHODS: A survey was conducted in the homes of a representative sample of household heads in Cairo city. Risk perception was assessed using the "psychometric paradigm" where health hazards are evaluated according to several attributes and then summarized by principal component analysis. Priority setting was assessed by individual ranking of interventions reducing health hazards by 50% over five years. The Condorcet method was used to aggregate individual rankings of the three interventions (main study) or two of three interventions (validation study). Explanatory factors of priority setting were explored in multivariate generalized logistic models. RESULTS: HCV was perceived as having the most severe consequences in terms of illness and out-of-pocket costs, while outdoor air pollution was perceived as the most uncontrollable risk. In the main study (n = 2,603), improved water supply received higher priority than both improved outdoor air quality (60.1%, P < .0001) and screening and treatment of chronic hepatitis C (66.3%, P < .0001), as confirmed in the validation study (n = 1,019). Higher education, report of HCV-related diseases in the household, and perception of HCV as the most severe risk were significantly associated to setting HCV treatment as the first priority. CONCLUSIONS: The Cairo community prefers to further improving water supply as compared to improved outdoor air quality and screening and treatment of chronic hepatitis C.

Knowledge, attitudes, and practices of family physicians and nurses regarding unintentional injuries among children under 15 years in Cairo, Egypt.

Unintentional injuries are a leading cause of death among children, especially in developing countries. Lack of reliable data regarding primary health care professionals' role in childhood unintentional injury prevention hinders the development of effective prevention strategies. A survey of 99 family physicians and nurses from 10 family health centres sought to develop insight into their knowledge, attitudes, and practices regarding unintentional injury prevention for children <15 in Cairo, Egypt. Approximately, 60% were familiar with the terms unintentional injuries and injury prevention. Falls and road traffic crashes were identified as primary causes of childhood injuries by 54.5%. While >90% agreed injury prevention counselling (IPC) could be effective, only 50.5% provided IPC. Lack of time and educational materials were the leading barriers to provision of IPC (91.9% and 85.9%, respectively), while thinking counselling is not part of their clinical duties was the least perceived barrier (9.1%). There is a large disconnect between providers' knowledge, attitudes and practices regarding IPC, more training and provision of counselling tools are essential for improving IPC by Egyptian medical providers.

Assessment of rheumatoid arthritis patients' adherence to treatment.

BACKGROUND: Reports on adherence among patients with rheumatoid arthritis (RA) in Egypt and the Middle East region are lacking. This study aimed to measure adherence to treatment among a sample of patients with RA at Ain Shams University Rheumatology outpatient clinic and to assess factors affecting it. METHODS: A cross-sectional descriptive study was carried out at the rheumatology outpatient clinic on a sample of 140 patients with RA. An interview questionnaire was used to measure adherence using the 8-item Morisky's scale, factors affecting adherence to treatment like patients satisfaction were assessed using the short form patient satisfaction questionnaire, also patients' knowledge, beliefs and rate of prescription refilling were assessed. Disease Activity Score-28 was used as an objective method to assess RA disease activity. RESULTS: According to Morisky's scale, 90.6% and 9.4% were classified as low and moderately adherent, respectively, none was classified as highly adherent to treatment. Important barriers to adherence reported were fear of side effects, nonavailability of free drugs in hospital pharmacy and cost of medications. Younger patients (P=0.002) and those reporting greater general satisfaction (P=0.02) were more likely to be adherent. In addition, on-time refill rates of medication (P=0.001) and disease activity (P=0.02) were associated with higher adherence scores and thus further validated the results of the adherence questionnaire. CONCLUSIONS: Higher adherence was associated with more positive beliefs on medication, greater satisfaction with health care and less disease activity.

A measles and rubella (MR) catch-up vaccination campaign in an Egyptian University: vaccine uptake and knowledge and attitudes of students.

INTRODUCTION: In 2008, following a rubella epidemic, the Egyptian Ministry of Health implemented a Measles Rubella (MR) catch-up campaign, based on WHO recommendations for supplementary immunization activities to eliminate measles by 2010. The age group targeted was 10-20 years. This campaign was unique in Egypt as it was the first national vaccination campaign which included university students. AIM: To report uptake of MR vaccine and reasons for declining the vaccine among medical and non-medical students in the campaign and to assess the knowledge about the vaccine and the diseases. METHODS: The study was conducted in two stages. In the first stage during the vaccination sessions, medical and other students (N=310) were given a questionnaire to assess their knowledge of the campaign and the vaccine. The second stage (N=341) was carried out when the campaign was completed to assess vaccine uptake among medical students. RESULTS: Posters displayed inside the university were reported to be the main source of information about the campaign. Students were generally poorly informed about both vaccine adverse effects, and contraindications although medical students tended to be better informed than other students. Overall 64.8% medical students accepted the vaccine with higher uptake among females than males (85.9 and 58.3% respectively). Non-compliant students had a significantly higher mean age. Almost half of students who did not accept the vaccine gave their reason as having little information about the vaccine (43.3%). CONCLUSION: The MR campaign in Ain Shams University may have been more successful with better use of health education messages.

Chronic hepatitis C virus infection: does it really impact health-related quality of life? A study in rural Egypt.

Previous Western studies showed a consistent and marked reduction in health-related quality of life (HRQOL) in patients chronically infected with hepatitis C virus (HCV). However, these studies were conducted on patients whose knowledge of their serological status may have affected their HRQOL. This HRQOL survey conducted in the Egyptian rural population provides a unique opportunity to clarify this issue among a population whose serological status is unknown. HRQOL was assessed by an Arabic translation of the Short-Form 12, and a visual analog scale of the relative severity of one's health status. HCV chronic infection was defined by positive tests for anti-HCV antibody and HCV-RNA. HRQOL was compared according to HCV chronic infection status in linear mixed models adjusted for potential confounding factors, such as age, sex, education, and health care-related risk factors, and adjusted for interviewer as a random effect. One hundred forty-six Egyptians chronically infected with HCV had similar Short-Form 12 and visual analog scale scores, compared with 1,140 uninfected controls from the same rural community. In individuals chronically infected with HCV, serum aminotransferase levels did not correlate with HRQOL. In conclusion, this study did not find a significant reduction of HRQOL in patients chronically infected with HCV compared with uninfected, contemporaneous controls. This may be explained in part by a lower morbidity amongst patients chronically infected with HCV in rural Egypt and a higher morbidity amongst uninfected controls as compared with those of Western studies, as well as a lack of awareness of hepatitis C serological status.