Hepatitis C: Egypt vs. United States

An Overview of Hepatitis C
It is known that the liver is one of the most important organs in the body, and it is considered one of the body’s powerhouses. It helps process the nutrients, metabolize medications, and it also helps clear the body of toxic waste products. We know that unprotected sex, drugs, tattoos, and alcohol have something in common, and avoiding them is something individuals have heard all their life. However, there is also another connection for them, and it’s the fact that they all can lead to a liver condition called hepatitis. Hepatitis is an inflammation of the liver, the different types of hepatitis are caused by different things, but they all result in inflammation of the liver. These specifically include bacterial infection, liver injury, and it can also be caused by an attack from the body’s own immune system. Hepatitis is most often caused by a virus. The three most common types of hepatitis viruses are hepatitis A, hepatitis B, or hepatitis C. The other two types of hepatitis, virus D and E, are a rare disease in the United States.

Hepatitis C is a type of hepatitis that is caused by an RNA virus; it’s referred to as non-A, non-B hepatitis. This viral disease leads to inflammation of the liver. There are many ways in which the virus can be spread between people. This virus is primarily found in the liver and in various components of the blood and not in most other parts of the body. It is usually spread by direct contact with the blood of an infected person. People who may be at risk for hepatitis C are those who have unprotected sexual contacts with a person who has hepatitis C, have been on long term kidney dialysis, as well as, through blood transfusions, sharing drug injections with people who have the disease, and by sharing personal items such as toothbrushes and razors with someone who has the disease.
Clinical Manifestations of Acute Viral Hepatitis
Patients who are infected with hepatitis C are usually asymptomatic, or do not have specific symptoms such as mild nausea and fatigue. After incubation period of 60 days, acutely affected indivuals develop elevated serum alanine aminotransferase (ALT) enzyme levels with peak levels typically averaging 600 U/L. Up to 25% of infected patients experience an icteric or symptomatic illness including jaundice. Symptoms and signs are similar to other acute viral hepatitis forms when they occur, but at the same they are milder than Hepatitis B infection symptoms.
Clinical Manifestations of Chronic Viral Hepatitis

A significant number of hepatitis C infections (greater that 70%) lead to a chronic state, and they are asymptomatic in most cases. Symptoms may be non-specific when they are present and include mild to severe fatigue and right upper quadrant abdominal pain or discomfort. Jaundice, fever, chills or night sweats, malaise, concentration problems, headaches and nausea may also occur. In addition that liver enzymes (ALT, AST) reach high levels, which are common and they may last for years as acute infection enters chronic phase. Enzyme levels may fluctuate and be at normal range. Based on data, most people who contract HCV become chronic carriers. Many people who are HCV antibody positive will be asymptomatic, and chronic carriers are at a higher risk of developing liver damage.
Statistics
Hepatitis C is a worldwide problem. The hepatitis C virus is a major cause of both acute and chronic hepatitis. The World Health Organization estimates that 170 million individuals worldwide are infected with hepatitis C virus, but statistics around the world vary. It was reported that Egypt had the highest number of reported infections, and the reason for that was attributed to the use of contaminated parenteral antischistosomal therapy, which resulted to a mean prevalence of HCV antibodies in persons in Egypt of 22%. The HCV epidemic in Egypt is unique in the world and well-documented in international medical scientific literature. The incidence of acute HCV infection has greatly decreased in the United States during the last decade. Its prevalence remains high (approximately 2.7 million Americans). According to the US Centers for Disease Control and Prevention, an estimated 1.8% of the US population is positive for HCV antibodies.
Prevalence & Risks
The World Health Organization has declared hepatitis C a global health problem, with approximately 3% of the world’s population (roughly 170-200 million people) infected with HCV. In the US, approximately 3 million people are chronically infected, many of whom are still undiagnosed. In Egypt, the situation is significantly worse. Egypt has a population of 62 million and contains the highest prevalence of hepatitis C in the world. The national prevalence rate of HCV antibody positivity has been estimated to be between 10-13%. Only one third of these individuals (1.75 million) are estimated to have chronic liver disease (elevated ALT) and, furthermore, among these one third (577,000 people) are suffering from advanced liver disease.
Chronic HCV is the main cause of liver cirrhosis and liver cancer in Egypt and is one of the top five leading causes of death. In Egypt, the major route of exposure appears to be due to injection therapy and inadequate infection control practices. In addition to blood transfusions prior to 1994, the major risk factor associated with HCV infection is a history of antischistosomal injection treatment before 1986. Schistosomiasis used to be a common parasitic disease in Egypt acquired through swimming or wading in contaminated irrigation channels or standing water. Thus, farmers and rural populations were at greatest risk, and this is supported by the higher prevalence rate of HCV in the Nile delta and rural areas. Schistosomiasis can lead to urinary tract or liver damage over many years. Prior to 1986, the mainstay of treatment was intravenous tartar emetic.
Widespread treatment campaigns were carried out in the countryside of Egypt in the 1960s-1970’s and early 80’s. At the time of availability of only glass syringes, needles were routinely and inadequately sterilized by boiling due to time restraints and limited resources. Overall, despite improvement in schistosomiasis-related morbidity from 1980-1990, these treatment campaigns set the stage for the current large hepatitis disease burden in Egypt. Further, with such a high background in prevalence rate, transmission of hepatitis C through other non-medical routes has become more significant. For example, tattooing, circumcision or other medical procedures performed by non-medical personnel are more frequent routes of infection in Egypt than elsewhere. In addition, household transmission, vertical transmission and sexual transmission are routes that are also under investigation. As expected, the availability and cost of treatment for hepatitis C in Egypt is quite prohibitive. Although the most common methods of previous hepatitis C transmission (injection-based treatment for schistosomiasis and blood transfusions) have been addressed, the prevalence in those under the age 20 is still approximately 5-8%, demonstrating the continued presence of significant hepatitis C transmission in modern-day Egypt.
Prevention
One disparity for Hepatitis C is that there are currently not any vaccines available. Prevention measures include infection control measures. This would include hand washing and the use of gloves when expecting contact with blood. Modification of high risk sexual behavior is also a preventative measure that is imperative. A condom is advised for sexual intercourse. Razors, toothbrushes and other personal items should not be shared. To prevent transmission to another individual, blood, organ and tissue donors must be screened.
Nursing Interventions
The nursing priority for a client diagnosed with Hepatitis C is to reduce demands on that individual’s liver, while promoting his/her well-being. Comfort measures are used to relieve pruritus, headache and arthralgia's. The patient should receive adequate nutrition. Small, frequent meals are preferable due to the fact this will prevent nausea. Although there is no special diet required, a diet high in carbohydrates and proteins with a low fat content is usually recommended. Since the client will be anorexic, measures to stimulate appetite such as mouth care, antiemetics, and meals that are attractive to the patient in a pleasant environment are essential.
It is very important that the client gets rest and that measures to prevent skin, respiratory and circulatory complications are prevented. Most patients can be managed at home and rest helps promote healing and liver regeneration. Alternating rest with activity is a good way to maintain a balance to meet every day needs for clients. Drug therapy is focused on eradicating the virus, reducing the viral load, and decreasing the progression of the disease. despite remarkable decline in HCV infections in Egypt since the end of the PAT campaign, a campaign that sought to increase awareness and prevention of Hep C in Egypt, mortality related to existing cases will likely continue to increase over the next ten to twenty years. Government funding for hepatitis education in Egypt has been greatly beneficial. However, the journal continues to explain that more research regarding cost-effectiveness of screening for HCV infection and indication for treatment are needed to guide public health policy in this matter. World Health Organization<ref name="WHO" /> donations to Egypt have been helpful in the education and treatment of this illness. WHO’s official World Hepatitis day, July 28, 2011, was initiated to raise awareness and understanding of viral hepatitis and the diseases it causes. It provided an opportunity for governments, health professionals and the general public to focus on specific actions such as strengthening prevention, screening and control of viral hepatitis and its related diseases within the context of health systems, increasing coverage of hepatitis-B vaccine and integrating it into national immunization programs, and coordinating a global response to hepatitis.
Primary teaching for prevention in Egypt and the United States include educating patients to avoid: unnecessary and unsafe injections or unsafe blood and blood products, unsafe disposal of sharps, and unprotected sex with infected people Secondary and tertiary prevention include education and counseling on options for care and treatment. Educating patients in both the United States and Egypt the importance of being immunized for Hep A&B to prevent co-infection and to be monitored early so that liver disease is diagnosed early is essential. These teachings can take place in healthcare facilities, colleges, schools, health-fairs, in churches and hemodialysis centers. According to the journal of viral Hepatitis,<ref name="Lehman" /> continued research on the natural history of HCV and the development of new treatments should remain top priorities, not only for Egypt, but for global health as well.
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