F. DeWolfe Miller

Evidence of intense ongoing endemic transmission of hepatitis C virus in Egypt

Egypt has the highest prevalence of antibodies to hepatitis C virus (HCV) in the world, estimated nationally at 14.7%. An estimated 9.8% are chronically infected. Numerous HCV prevalence studies in Egypt have published various estimates from different Egyptian communities, suggesting that Egypt, relative to the other nations of the world, might be experiencing intense ongoing HCV transmission. More importantly, a new national study provided an opportunity to apply established epidemiologic models to estimate incidence. Validated mathematical models for estimating incidence from age-specific prevalence were used. All previous prevalence studies of HCV in Egypt were reviewed and used to estimate incidence provided that there was sufficient age-specific data required by the models. All reports of anti-HCV antibody prevalence were much higher than any single other national estimate. Age was the strongest and most consistently associated factor to HCV prevalence and HCV RNA positivity. It was not possible to establish a prior reference point for HCV prevalence or incidence to compare with the 2009 incidence estimates. The modeled incidence from the national study and collectively from the modeled incidence from the previous community studies was 6.9/1,000 [95% confidence interval (CI), 5.5–7.4] per person per year and 6.6/1,000 (95% CI, 5.1–7.0) per person per year, respectively. Projected to the age structure of the Egyptian population, more than 500,000 new HCV infections per year were estimated. Iatrogenic transmission is the most likely, underlining exposure to the ongoing transmission. The study demonstrates the urgency to reduce HCV transmission in Egypt.

Spatial epidemiology of hepatitis C virus infection in Egypt: analyses and implications.

Egypt has the highest hepatitis C virus (HCV) prevalence in the world (14.7%). The drivers of the HCV epidemic in Egypt are not well understood, but the mass parenteral antischistosomal therapy (PAT) campaigns in the second half of the 20th century are believed to be the determinant of the high prevalence. We studied HCV exposure in Egypt at a microscale through spatial mapping and epidemiological description of HCV clustering. The source of data was the 2008 Egypt Demographic and Health Survey. We identified clusters with high and low HCV prevalence and high and low PAT exposure using Kulldorff spatial scan statistics. Correlations across clusters were estimated, and each cluster age‐specific HCV prevalence was described. We identified six clusters of high HCV prevalence, three clusters of low HCV prevalence, five clusters of high PAT exposure, and four clusters of low PAT exposure. HCV prevalence and PAT exposure were not significantly associated across clusters (Pearson correlation coefficient [PCC] = 0.36; 95% confidence interval [CI] −0.12 to 0.71). Meanwhile, there was a strong association between HCV prevalence in individuals older than 30 years of age (who could have been exposed to PAT) and HCV prevalence in individuals 30 years of age or younger (who could not have been exposed to PAT) (PCC = 0.81; 95% CI 0.55‐0.93). Conclusion: The findings illustrate a spatial variation in HCV exposure in Egypt. The observed clustering was suggestive of an array of iatrogenic risk factors, besides past PAT exposure, and ongoing transmission. The role of PAT exposure in the HCV epidemic could have been overstated. Our findings support the rationale for spatially prioritized interventions. (Hepatology 2014;60:1150–1159)

Estimation of hepatitis C virus infections resulting from vertical transmission in Egypt

Despite having the highest hepatitis C virus (HCV) prevalence in the world, the ongoing level of HCV incidence in Egypt and its drivers are poorly understood. Whereas HCV mother‐to‐child infection is a well‐established transmission route, there are no estimates of HCV infections resulting from vertical transmission for any country, including Egypt. The aim of this study was to estimate the absolute number of new HCV infections resulting from vertical transmission in Egypt. We developed a conceptual framework of HCV vertical transmission, expressed in terms of a mathematical model and based on maternal HCV antibody and viremia. The mathematical model estimated the number of HCV vertical infections nationally and for six subnational areas. Applying two vertical transmission risk estimates to the 2008 Egyptian birth cohort, we estimated that between 3,080 and 5,167 HCV infections resulted from vertical transmission among children born in 2008. HCV vertical transmission may account for half of incident cases in the <5‐year age group. Disproportionately higher proportions of vertical infections were estimated in Lower Rural and Upper Rural subnational areas. This geographical clustering was a result of higher‐area‐level HCV prevalence among women and higher fertility rates. Conclusion: Vertical transmission is one of the primary HCV infection routes among children <5 years in Egypt. The absolute number of vertical transmissions and the young age at infection highlight a public health concern. These findings also emphasize the need to quantify the relative contributions of other transmission routes to HCV incidence in Egypt. (Hepatology 2015;61:834–842)

Solid Waste Scavenger Community: An Investigation in Bangkok, Thailand

A solid waste scavenger community at On-Nooch dump site in Bangkok was investigated. The purpose was to identify the dimensions of the public health risk to this group of people and their community due to exposure to hazardous conditions from waste materials. A cross-sectional descriptive study utilizing field surveys and measurements was performed. The demographic, socioeconomic, health related and environmental characteristics of this community were examined. Health complaints and injuries were inventoried among scavengers. Prevalence of childhood respiratory illness was high especially in those households where smoking was present. Intestinal helminthic and protozoan infection in children were detected. Six individuals with possible HIV infection and a number of Hepatitis B antigenemia were found among male respondents. An appreciable proportion of respondents fell below normal when tested for lung function. Air pollution measurements showed acceptable ambient air levels except for particulate matters. Water quality was low for both potable and nonpotable water.

An Apparent Lack of Epidemiologic Association between Hepatitis C Virus Knowledge and the Prevalence of Hepatitis C Infection in a National Survey in Egypt

Background Egypt has by far the largest hepatitis C virus (HCV) prevalence in the world with 14.7% of the population being antibody positive for HCV. The aim of this study was to examine the association between knowledge of HCV and HCV antibody positivity among the Egyptian population. Methods We characterized different measures of HCV knowledge and examined their associations with HCV prevalence, by analyzing a nationally representative database using standard epidemiologic methods. The database, the 2008 Egyptian Demographic and Health Survey, included demographic, health, and HCV biomarker information for a sample of over 12,000 individuals. Results Basic knowledge of HCV was found to be high, but multiple gaps were identified in the specific knowledge of HCV and its modes of transmission. There was no statistically significant difference in HCV prevalence between those who have heard of HCV infection and those who have not (14.4% vs. 15.9%, p>.05). Similar results were found for the other HCV knowledge measures including those specific to HCV modes of transmission and to the sources of information for HCV awareness. Logistic regression analyses did not demonstrate an association between HCV knowledge and HCV prevalence. Conclusions Our results do not provide support for an effect of awareness on reducing the risk of HCV infection in Egypt. Public health messages directed at the lay public may not provide sufficient empowerment for individuals to avoid HCV infection, and should be complemented with prevention programs to promote and strengthen infection control in the settings of exposure, particularly in health care facilities.

Hepatitis C screening beyond CDC guidelines in an Egyptian immigrant community

Many Egyptian‐born persons in the U.S. are at high risk of chronic hepatitis C virus (HCV) infection, yet are not aware of their infection and lack healthcare coverage or linkage to care. In this study, we target Egyptian‐born persons living in the New York City area for screening and link to care.

Epidemiology of hepatitis C virus exposure in Egypt: Opportunities for prevention and evaluation.

AIM To critically evaluate the current epidemiology data on exposures, rather than infection, to hepatitis C virus (HCV) transmission and recommend epidemiologic strategies to fill gaps. METHODS Standard methods for identifying and evaluating relevant epidemiologic literature and available data were used. RESULTS There is a large body of literature on the epidemiology of HCV transmission in Egypt that collectively identifies ongoing iatrogenic exposures as the major driver for HCV transmission due to short comings in infection control and standard procedures. Additional epidemiologic studies on HCV transmission that requires the participation of human subject is unwarranted. Alternatively, very little literature was found on the epidemiology of exposure to HCV, infection control, and safe injection practices. The information that is available on patterns of HCV exposure shows high frequencies of inadequate infection control, problems in sterilization in health care facilities, low rates of hand washing, untrained personnel, lack of stated policies in facilities, HCV contamination of instruments and very large injection frequencies with low but very significant syringe and needle reuse. There is an important need to increase the number, size, and diversity of epidemiologic studies on HCV exposures, patterns of risk factors for infection, infection control, and safe injection practices. In addition to health care facilities evaluation, relevant knowledge attitude and practice studies are recommended. CONCLUSION Epidemiologic methods on HCV exposure can be used to characterize the magnitude of exposures to HCV infection, target interventions to reduce exposures, and provide the best method for evaluating interventions by demonstrating the reduction of exposure to HCV infection.

Are Geographical “Cold Spots” of Male Circumcision Driving Differential HIV Dynamics in Tanzania?

Background Growing evidence suggests significant geographic clustering of male circumcision (MC) in Tanzania. The impact of spatial heterogeneity of MC prevalence on HIV transmission dynamics in this country is not well documented. The aim of this study was to assess the spatial association between MC and HIV infection in Tanzania. Methods Data from three Demographic and Health Survey rounds conducted in Tanzania were analyzed to identify spatial associations between MC and HIV using bivariate local indicators of spatial association (LISA). Spatial clusters with low MC prevalence (MC cold spots) were identified using scan statistics. HIV incidence rates for males and females within and outside the MC cold spots were calculated. Results Local indicators of spatial association analysis indicated a significant association between MC and HIV in the northern and southwestern regions of Tanzania. Scan statistics identified two MC cold spots in the same locations. Males located outside the MC cold spots had the lowest HIV incidence rate at 0.28 per 100 person-years at risk (pyar). HIV incidence in females located outside the MC cold spots increased from 0.40/100 pyar during 2004–2008 to 0.68/100 pyar in 2008–2012. Conclusion Our study provides evidence for a geographic association between MC and HIV in Tanzania. MC could be one of the key factors driving the geographical distribution of the HIV epidemic in the country. Furthermore, in areas where most males are circumcised, the HIV infection burden could be concentrating in the female population. Therefore, along with the voluntary medical MC program, efforts targeting the female population should also be considered.

Environmental Health Education in Micronesia

Water supply and sanitation programmes in Micronesia require substantial capital investments. In the past, many of these projects have failed to achieve their maximum impact on preventing water-related diseases. Cases of cholera and the continuation of frequently occurring gastro-intestinal diseases undermine the expectations that new and planned water and sanitation systems will result in disease prevention. This report indicates that knowledge of water-related diseases and the understanding of the benefits of safe water supply and sanitation are limited as programmes in Micronesia that would educate the different sectors of the community have never been institutionalised. We have developed the first comprehensive system for teaching about water supply, sanitation and health in a Micronesian environment. The educational materials will be used as curricula in public education and as information resources for appropriate individuals in these remote and scattered communities of the Pacific.

An Initial Investigation of Do Not Resuscitate Acceptance in Egypt

Background: The aim of this work was to obtain objective data on the extent of knowledge and attitudes of the do not resuscitate (DNR) concept in an Egyptian urban setting. Methods: This survey was conducted in Cairo, Egypt, using a structured questionnaire including 23 questions. Questions and questionnaire were developed from literature on DNR in the region and from pilot testing. Results: A total of 461 persons participated. In all, 48 participants (10.4%, 95% confidence interval [CI]: 7.8-13.7) agreed on the concept of DNR, 226 (49%, 95% CI: 36.1-45.2) stated that it depends on the patient condition, and 187 (40.5%, 95% CI: 44.4-53.7) rejected DNR. Combining the first 2 categories, agree and depends on patient condition, over 60% of the respondents in effect supported DNR. Family members (35.6%, 95% CI: 31.4-40.3) and attending physicians (43.3%, 95% CI: 30.1-39.0) were selected over religious leaders (21%, 95% CI: 17.5-25.2) and representatives from state institutions (4.6%, 95% CI: 2.9-7.0) as to who should have authority for making a DNR decisions. Discussion: These and additional results provide objective evidence that DNR will not be rejected outright in Egypt. More formal surveys are justified and will provide needed guidance for implementing DNR and related end-of-life medical care in Egypt.