Evolution of infection control in Egypt: achievements and challenges

Evidence for the elimination of viral hepatitis B and C in Egypt: Results of a nationwide survey in 2022

INTRODUCTION

Viral hepatitis C (HCV) and B (HBV) were at the top of Egypt's most significant public health challenges, with an estimated 14.7% of its population having antibodies to HCV in 2008. Egypt issued an ambitious action plan in 2014 to eliminate viral hepatitis through strengthening infection control and improving patient care. In 2018, an extensive HCV mass screening campaign was conducted for the entire country's population with treating more than 4 million patients with antivirals. This study aimed to evaluate the current prevalence of viral hepatitis in Egypt after all these efforts.

METHODS

A cross-sectional household cluster survey was conducted in all 27 Egyptian governorates to obtain a representative sample of Egypt's population. Subjects aged 1-70 years were interviewed using a standardised questionnaire that included demographics, viral hepatitis knowledge, previous infection and risk factors data. Laboratory testing was performed for all subjects for anti-HCV and HBsAg using chemiluminescence. Subjects positive for anti-HCV were further tested for HCV-RNA by RT-PCR. Prevalence rates were calculated by demographic groups and compared to the demographic health survey 2015 results.

RESULTS

Of 20 881 subjects interviewed, 48.8% were males, 20.2% were children <15 years of age, and 53.7% were residents of rural areas. Of all subjects, 92 (0.4%) were HCV-infected, 1577 (7.6%) were anti-HCV positive and 177 (0.8%) were HBV-chronically infected, including one patient who had mixed HBV and HCV current infection. The prevalence of HCV-current and HBV chronic infections decreased by 93% and 20%, respectively, compared to 2015.

CONCLUSIONS

Egypt achieved the elimination of the viral hepatitis goal. To maintain low rates of viral hepatitis, community health education, in addition to maintaining infection control and blood safety programs, is essential.

Coverage and methods of surveillance of healthcare-associated infections in Middle Eastern and North African countries

BACKGROUND

Surveillance of healthcare-associated infections (HAIs) is a cornerstone for effective infection prevention and control (IPC) programs. The objective was to evaluate the coverage and methods of HAI surveillance in Middle Eastern and North African (MENA) countries.

METHODS

A cross-sectional study targeted IPC staff working in MENA countries using the Infection Control Network electronic database of the Arab countries. The study focused on self-reported surveillance-related characteristics of IPC staff, facilities, and the IPC program.

RESULTS

A total of 269 IPC staff were included. They were mainly females (68%), nurses (63%), and working in GCC countries (83%). Approximately 69% of covered facilities had surveillance activities. Hand hygiene, multidrug-resistant organisms, central line-associated bloodstream infections, and catheter-associated urinary tract infections were the most common surveillance activities (>90%). The surveillance workload consumed 27% of the average weekly working time. The scores of performing multiple surveillance, with appropriate methods and tools, were 83%, 67%, and 61% (respectively). Appropriate surveillance methods and/or tools were linked to GCC region, CBIC qualifications, surveillance training, specific setting (acute care and long term), staff-to-bed ratio, presence and active function of IPC committee, presence of IPC annual plan, communications with health care workers, and leadership support.

CONCLUSIONS

While most health care facilities in the MENA region perform multiple surveillance, surveillance methods and tools are still suboptimal and their optimization should be a priority.

A self-reported survey on the implementation of infection prevention and control elements in Indian hospitals, part of a HAI surveillance network: Results from 23 hospitals conducting a standardized IPC assessment

BACKGROUND

Healthcare-associated infections (HAIs) are one of the most common adverse events in patient care that account for substantial morbidity and mortality. We evaluate the existing Infection Prevention and Control (IPC) practices in hospitals participating in the nationally representative HAI Surveillance network.

METHODS

This cross-sectional survey was conducted in 23 hospitals across 22 states of India from October-2015 to September-2018 in the HAI surveillance network. The World Health Organization (WHO) IPC core components assessment tool for health-care facility level (IPCAT-H) was adapted from IPC assessment tool developed by US Centers for Disease Control and Prevention (US CDC) under the Epidemiology and Laboratory Capacity (ELC) Infection Control Assessment and Response (ICAR) Program. Mann-Whitney U test was used to calculate the significant difference between scores (P < .05).

RESULTS

Amongst the participating hospitals, 7 were private sectors and 16 were public health care facilities. Infection IPCAT-H average score per multimodal strategy was less than 50% for programmed IPC activities (45.7); implementation of health care workers (HCWs) immunization programme (43.5%); monitoring and evaluation component (38.30%).

CONCLUSIONS

There is potential for improvement in Human Resources, Surveillance of HAIs as well as Monitoring and Evaluation components.

Current situation of viral hepatitis in Egypt

An estimated 8-10 million people suffer from viral hepatitis in Egypt. Hepatitis A virus (HAV) and hepatitis E virus (HEV) are the major causes of viral hepatitis in Egypt as 50% or more of the Egyptian population are already exposed to HAV infection by the age of 15. In addition, over 60% of the Egyptian population test seropositive for anti-HEV in the first decade of life. HEV mainly causes self-limiting hepatitis; however, cases of fulminant hepatitis and liver failure were reported in Egypt. Hepatitis B virus (HBV), hepatitis C virus (HCV), and hepatitis D virus (HDV) are the main causes of chronic hepatitis, liver cirrhosis, and liver cancer (hepatocellular carcinoma [HCC]) in Egypt. Globally, Egypt had the highest age-standardized death rate due to cirrhosis from 1990 to 2017. The prevalence rate of HBV (1.3%-1.5%) has declined after national infantile immunization. Coinfection of HBV patients with HDV is common in Egypt because HDV antibodies (IgG) vary in range from 8.3% to 43% among total HBV patients. After the conduction of multiple national programs to control HCV infection, a lower rate of HCV prevalence (4.6%) was recently reported. Data about the incidence of HCV after treatment with direct antiviral agents (DAAs) are lacking. An HCC incidence of 29/1000/year in cirrhotic patients after DAA treatment is reported. A higher rate of infiltrative pattern among HCC patients after DAA treatment is also recognized. Viral hepatitis is one of the major public health concerns in Egypt that needs more attention and funding from health policymakers.

Landscape of Multidrug-Resistant Gram-Negative Infections in Egypt: Survey and Literature Review

Purpose

This article is the first to review published reports on the prevalence of multidrug-resistant (MDR) gram-negative infections in Egypt and gain insights into antimicrobial resistance (AMR) surveillance and susceptibility testing capabilities of Egyptian medical centers.

Materials and Methods

A literature review and online survey were conducted.

Results

The online survey and literature review reported high prevalence of extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae (19–85.24% of E. coli, and 10–87% of K. pneumoniae), carbapenem-resistant Enterobacteriaceae (35–100% of K. pneumoniae and 13.8–100% of E. coli), carbapenem-resistant Acinetobacter baumannii (10–100%), and carbapenem-resistant Pseudomonas aeruginosa (15–70%) in Egypt. Risk factors for MDR Gram-negative infections were ventilated patients (67.4%), prolonged hospitalization (53.5%) and chronic disease (34.9%). Although antimicrobial surveillance capabilities were deemed at least moderate in most centers, lack of access to rapid AMR diagnostics, lack of use of local epidemiological data in treatment decision-making, lack of antimicrobial stewardship (AMS) programs, and lack of risk prediction tools were commonly reported by respondents.

Conclusion

This survey has highlighted the presence of knowledge gaps as well as limitations in the surveillance and monitoring capabilities of AMR in Egypt, with most laboratories lacking rapid diagnostics and molecular testing. Future efforts in Egypt should focus on tackling these issues via nationwide initiatives, including understanding the AMR trends in the country, capacity building of laboratories and their staff to correctly and timely identify AMR, and introducing newer antimicrobials for targeting emerging resistance mechanisms in Gram-negative species.

Characterizing the historical role of parenteral antischistosomal therapy in hepatitis C virus transmission in Egypt

Background

Egypt is the nation most affected by hepatitis C virus (HCV) infection, following an epidemic of historic proportions. We aimed to characterize the epidemic’s historical evolution and to delineate the role of parenteral antischistosomal therapy (PAT) campaigns in transmission.

Methods

A mathematical model was constructed and analysed in order to understand HCV-transmission dynamics. The model was fitted to Egypt’s Demographic and Health Survey data and to a systematic database of HCV-prevalence data.

Results

The incidence rate peaked in 1966 at 15.7 infections per 1000 person-years—a period of time that coincides with the PAT campaigns—and rapidly declined thereafter, beginning the mid-1990s. The annual number of new infections peaked in 1993 at 581 200 (with rapid demographic growth), leading to a high-incidence-cohort effect, and declined to 67 800 by 2018. The number of individuals ever infected (1950–2018) was 16.4 million, with HCV prevalence peaking in 1979. The number of individuals ever exposed to PAT was 8.3 million; however, of these individuals, 7.3 million were alive in 1980 and only 3.5 million alive in 2018. The number of individuals ever infected due to PAT exposure was 963 900, with 850 200 individuals alive in 1980 and only 389 800 alive in 2018. The proportion of PAT-attributed prevalent infections peaked at 19.9% in 1972, declining to 5.5% by 2018.

Conclusions

PAT campaigns played an important role in HCV transmission, yet explain only 6% of infections—they appear to be a manifestation, rather than a cause, of the epidemic. A possible driver of the epidemic could be the mass expansion of inadequate-quality healthcare during PAT campaigns and subsequent decades. Despite a historic toll, the epidemic has been rapidly diminishing since the mid-1990s.

Reduced incidence of hepatitis C in 9 villages in rural Egypt: Progress towards national elimination goals

BACKGROUND & AIMS

Egypt has a major HCV burden and a well established treatment programme, with an ambitious goal of HCV elimination. Our aim was to assess the impact of a comprehensive HCV prevention, test and treat programme on the incidence of new HCV infections in 9 villages in rural Egypt.

METHODS

An HCV "educate, test and treat" project was implemented in 73 villages across 7 governorates in Egypt between 06/2015 and 06/2018. In 2018, in 9 of the villages we re-tested individuals who originally tested HCV antibody (HCV-Ab) and HBsAg negative using rapid diagnostic tests (RDTs); confirmatory HCV RNA testing was performed for positive cases. The incidence rate per 1,000 person-years (py) was calculated, and risk factors for incident HCV infections assessed through an interviewer-administered questionnaire in 1:3 age- and gender-matched cases and controls.

RESULTS

Out of 20,490 individuals who originally tested HCV-Ab negative in the 9 villages during the 2015-2016 implementation of the "educate, test and treat" programme, 19,816 (96.7%) were re-tested in 2018. Over a median of 2.4 years (IQR 2.1-2.7), there were 19 new HCV infections all of which were HCV RNA positive (incidence rate 0.37/1,000 py) (95% CI 0.24-0.59). Compared to a previous estimate of incidence in the Nile Delta region (2.4/1,000 py) from 2006, there was a substantial reduction in overall incidence of new HCV infections. Exposures through surgery (odds ratio 51; 95% CI 3.5-740.1) and dental procedures (odds ratio 23.8; 95% CI 2.9-194.9) were significant independent predictors of incident infections.

CONCLUSIONS

This is the first study to show a substantial reduction in incidence of new HCV infections in a sample of the general population in Egypt following attainment of high testing and treatment coverage. New infections were significantly associated with healthcare-associated exposures.

LAY SUMMARY

Egypt has a major national HCV testing and treatment programme with the goal of eliminating HCV infection. We assessed the impact of a comprehensive HCV prevention, test and treat programme in 73 villages that achieved high coverage of testing and treatment on the subsequent incidence of new HCV infections in nine of the villages. We re-tested people who were previously HCV antibody negative and found that the rate of new HCV infections was greatly reduced compared to previous estimates. We also found that exposure through surgery and dental procedures were associated with these new infections. This highlights the importance of continued strengthening of infection control and prevention measures, alongside treatment scale-up.

Characteristics and predicting factors of Corona Virus Disease-2019 (COVID-19) among healthcare providers in a developing country

A limited number of publications have identified risk factors for Corona Virus Disease 2019 (COVID-19) among Healthcare Providers (HCPs). We aimed to assess the clinical and epidemiological characteristics and the predicting factors related to COVID-19 among HCPs in Egypt. A comparative cross-sectional study was conducted among HCPs via an online questionnaire. Out of 440 responses, a total of 385 complete responses were analyzed. The responders’ mean age was 37.5±9.4 years, 215 (55.8%) of the participants were males. They included 77 (20%) confirmed COVID-19 cases; most of them had mild (58.6%) or moderate symptoms (30%), and (9.1%) were asymptomatic. Almost all sustained infection while on duty (97.4%). The sources of infection were either infected patients (39%), colleagues (22.1%), household contacts (5.2%) or uncertain (33.8%). The sources were symptomatic in only 62.3% of cases. Asymptomatic or pre-symptomatic sources accounted for 37.7% of the cases. Exposure occurred during healthcare provision in 66.3% of the cases. The presence of co-morbidities (OR = 2.53, CI 1.47–4.38, P = 0.001), working more than 8 hours per day in isolation hospital (OR = 3.09, CI 1.02–9.35, P = 0.046), training on hand hygiene (OR = 2.31, CI 1.05–5.08, P = 0.038) and adherence to IPC measures (OR = 2.11, CI 1.16–3.81, P = 0.014) were the significant predictors of COVID-19. In conclusion, COVID-19 occurred in 20% of responders. Silent spread from asymptomatic or presymptomatic patients, and infected colleagues in hospital settings is an alarming sign. Proactive infection prevention and control measures are highly encouraged on both strategic and operational levels. Reconsideration of surveillance strategy and work-related regulations in healthcare settings are warranted.

Mass screening for hepatitis B and C in Southern Upper Egypt

Background

It is well documented that Egypt has the highest prevalence of hepatitis C virus (HCV) infection in the world. The recent development of highly effective direct acting antiviral drugs (DAAs), has opened the possibility of treating and curing HCV infection in the Egyptian population on a large scale.

Methods

A screening demonstration project was implemented in southern Egypt in and around the city of Luxor. Free screening and if indicated, treatment, was offered to those 16 years or older for anti-HCV antibodies (anti-HCV) and hepatitis B surface antigen (HBsAg) using third generation enzyme immunoassays (Enzygnost® Anti-HCV and HbsAg). Statistical methods included estimation of odds ratios (OR) and 95% confidence intervals (95% CI).

Results

There was a large turnout of 67,042 persons who were screened in a 12-month period starting in June 2016. Thirty-one thousand nine hundred sixty-four males (47.7%) and 35,074 females (52.3%) were screened with a mean age of 43.6 ± 14.3 years. Nine thousand seven hundred one patients (14.5%) were positive for anti-HCV and 2950 (4.4%) for HBsAg. Prevalence of anti-HCV was significantly higher in males than females (19.67% vs.9.73% OR = 2.27; CI 2.2 to 2.4; p < 0.001) and the same for HBsAg (6.2% vs. 2.8% OR = 2.3; CI 2.2 to 2.5; p < 0.001). The prevalence of anti-HCV was significantly associated with age (p < 0.001), ranging from between 1 and 4% in individuals below the age of 40 years, then increased steadily to 42% at age 60 followed by a precipitous decline in age specific prevalence.

Conclusions

The results showed unanticipated patterns in the Luxor area of anti-HCV and HBsAg by age and gender in contrast to previous reports on this unique HCV epidemic in Egypt. Moreover, the level and rate of turnout, cost, and other logistical issues, provided essential information for effective planning, design, and evaluation methods for larger national mass screening and treatment programs.

National survey of infection control programmes in South Asian association for Regional Cooperation countries in the era of patient safety

Background

The implementation of hospital infection prevention and control (IPC) in south Asia is not well described. We aimed to assess IPC programmes in hospitals in this region and explore opportunities for improvement.

Methods

Attendees from hospitals in the South Asian Association for Regional Cooperation (SAARC) region who were at one of four National Initiative for Patient Safety workshops organised by All India Institute of Medical Sciences (New Delhi) from 2009 to 2012 were invited to complete a semi-structured questionnaire. The survey addressed six main components of IPC programmes.

Results

We received responses from 306 participants from 82 hospitals. Five key opportunities for improvement emerged: (1) lack of healthcare epidemiologists, (2) relative infrequency of antibiotic guidelines (53%) and prescribing audits (33%) (3) lack of awareness of needle stick injury rates (84%) (4) only 47% of hospitals were prepared for surge capacity for patients with infectious diseases, and (5) limited coordination of hospital infection control personnel with other support services (55%-66%).

Conclusion

These results outline IPC challenges in the SAARC region and may be useful to guide future quality improvement initiatives.

Evidence of sustained reductions in the relative risk of acute hepatitis B and C virus infections, and the increasing burden of hepatitis a virus infection in Egypt: comparison of sentinel acute viral hepatitis surveillance results, 2001-17

BACKGROUND

Egypt ranks fifth for the burden of viral hepatitis worldwide. As part of Egypt's renewed national strategy for the elimination of viral hepatitis, surveillance for acute viral hepatitis (AVH) was re-established during 2014-2017 to describe the current epidemiology and associated risk factors, and changes from surveillance conducted during 2001-2004.

METHODS

Patients with suspected AVH were enrolled, completed a questionnaire, and provided blood for testing for hepatitis viruses A (HAV), B (HBV), C (HCV), D, and E (HEV) infections by enzyme-linked immunosorbent assay. Odds ratios and Chi2 were used to detect differences between hepatitis types by patient characteristics and exposures. Newcombe-Wilson method was used to compare results between surveillance periods 2001-2004 and 2014-2017.

RESULTS

Between 2014 and 2017, among 9321 patients enrolled, 8362 (89.7%) had one or more markers of AVH including 7806 (93.4%) HAV, 252 (3.0%) HCV, 238 (2.8%) HBV, and 31 (0.4%) HEV infection. HAV infection occurred most commonly among children < 16 years age, while HBV infection occurred among ages 16-35 years and HCV infection in ages greater than 45 years. Healthcare-associated exposures were significantly associated with HBV and HCV infections compared to HAV infection including receiving therapeutic injections, surgery, wound suture, or urinary catheter and IV line insertions, while significant lifestyle exposures included exposure to blood outside the healthcare system, IV drug use, or incarceration. Exposures significantly associated with HAV infection were attending nursery or pre-school, contact with person attending nursery or pre-school, having meals outside the home, or contact with HAV case. Compared with AVH surveillance during 2001-2004, there was a significant increase in the proportion of HAV infections from 40.2 to 89.7% (RR = 2.3) with corresponding reductions in the proportions of HBV and HCV infections from 30.0 to 2.8% (RR = 0.1) and 29.8 to 3.0% (RR = 0.1), respectively.

CONCLUSIONS

Healthcare-associated exposures were significantly association with and remain the greatest risk for HBV and HCV infections in Egypt. Additional studies to evaluate factors associated with the reductions in HBV and HCV infections, and cost effectiveness of routine HAV immunization might help Egypt guide and evaluate control measures.

Hepatitis C Virus Exposure Rate among Health-care Workers in Rural Lower Egypt Governorates

BACKGROUND AND OBJECTIVES

Studies on hepatitis C virus (HCV) in Egypt supported a strong role for various exposures in the health-care setting. In this study, we attempted to estimate the frequency of HCV exposure among Egyptian health-care workers (HCWs).

METHODS

Five hundred and sixty-four (564) HCWs were included in this study. Two hundred and fifty-eight (45.74%) were health-care providers and 306 (54.25%) were non-health-care providers. All HCWs completed both the study questionnaire and provided a blood sample for anti-HCV testing by third-generation enzyme-linked immunosorbent assay. Subsequently, anti-HCV-positive samples were tested for HCV RNA using nested polymerase chain reaction (PCR).

RESULTS

The mean age of included HCWs was 33.0 ± 9.8 years; of them, 319 (56.56%) were males and 245 (43.44%) were females. The mean duration of health-care work was 9.3 ± 6.7 years. The frequency of antibody against hepatitis C virus (anti-HCV) among included HCWs was 8.7% (n = 49). Old age and prolonged duration of health-care work were significantly associated with anti-HCV seropositivity. Forty (81.63%) of 49 with anti-HCV-positive HCWs had positive hepatitis C viremia. The frequency of HCV RNA positivity increased with age. The frequency of eradicated past infection among nurses (36.85%) was markedly higher than that (6.7%) detected in non-health-care providers.

CONCLUSION

High rate of HCV infection is detected in Egyptian HCWs in rural Lower Egypt governorates. Health-care providers seem to eradicate HCV infection more frequently than non-health-care providers. National screening and treatment of infected HCWs are recommended.

Health care providers' perspectives for providing quality infection control measures at the neonatal intensive care unit, Cairo University Hospital

BACKGROUND

Health care-associated infections are one of the major causes of morbidity and mortality in neonatal intensive care units (NICUs). This study identified health care providers' perspectives for providing quality infection control measures at a NICU.

METHODS

A qualitative approach was adopted. Participants were selected via a purposive sampling technique. The study group was composed of 3 medical staff who held leadership positions and 10 nurses working in the NICU at Cairo University Hospital. Data were collected using semi-structured interviews.

RESULTS

Responses were analyzed using a thematic content analysis. The priorities identified by thematic analysis were suggestions and barriers for providing quality infection control measures, from the perspectives of health care providers. All interviewees cited shortage in staffing, especially nurses, lack of time to apply infection control standards, limited opportunities for infection control training, and work overload as the main barriers. All interviewees recommended on-going training and the introduction of audiovisual aids and case study approaches.

CONCLUSIONS

Lack of time to apply infection control standards, limited opportunities for infection control training, and work overload are the most commonly perceived barriers. The current infection control system in the NICU is likely to remain ineffective unless these underlying barriers are adequately addressed.

Real-world challenges for hepatitis C virus medications: a critical overview

From 2010, the landscape of hepatitis C therapeutics has been changed rapidly, and today we are standing at a cusp of a pharmacological revolution where highly effective and interferon (IFN)-free direct acting antivirals (DAAs) are already on the market. Such treatment paradigms attain 90-95% sustained virologic response (SVR; undetectable viral load at week 12 or 24 at the end of therapy) rates in treated individuals compared to 50-70% with treatment completion of dual-therapy-pegylated interferon (PEG-IFN) and ribavirin (RBV). As the major goal now for the hepatologists, clinicians, physicians, and health care workers is likely to eradicate hepatitis C infection in parallel to treatment, the demand is for a one-size-fits-all pill that could be prescribed beyond the limitations of hepatitis C genotype, viral load, previous treatment history, advanced hepatic manifestations (fibrosis, cirrhosis) and antiviral drug resistance. Although the new treatment strategies have shown high cure rates in clinical trials, such treatment paradigms are posing dilemmas too in real-world clinical practice. Therapy cost, treatment access to low and middle-income countries, treatment-emergent adverse events, lack of effective viral screening and disease progression simulation models are potential challenges in this prospect. This review article deeply overviews the challenges encountered while surmounting the burden of hepatitis C around the world.

The 17th International Congress on Infectious Diseases workshop on developing infection prevention and control resources for low- and middle-income countries

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Hospital-acquired infections (HAIs) are associated with significant morbidity and mortality across the globe.

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Resources outlining infection prevention and control (IPC) practices are in existence, but there are many barriers to IPC implementation in low- and middle-income countries (LMICs).

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Further studies are required to evaluate simplified approaches adapted to the needs of LMICs in order to guide IPC in practice.

Hospital-acquired infections (HAIs) are a major concern to healthcare systems around the world. They are associated with significant morbidity and mortality, in addition to increased hospitalization costs. Recent outbreaks, including those caused by the Middle East respiratory syndrome coronavirus and Ebola virus, have highlighted the importance of infection control. Moreover, HAIs, especially those caused by multidrug-resistant Gram-negative rods, have become a top global priority. Although adequate approaches and guidelines have been in existence for many years and have often proven effective in some countries, the implementation of such approaches in low- and middle-income countries (LMICs) is often restricted due to limited resources and underdeveloped infrastructure. While evidence-based infection prevention and control (IPC) principles and practices are universal, studies are needed to evaluate simplified approaches that can be better adapted to LMIC needs, in order to guide IPC in practice. A group of experts from around the world attended a workshop held at the 17th International Congress on Infectious Diseases in Hyderabad, India in March 2016, to discuss the existing IPC practices in LMICs, and how best these can be improved within the local context.

Health professionals' knowledge about relative prevalence of hospital-acquired infections in Delta State of Nigeria

INTRODUCTION

Hospital-acquired infections (HAIs) constitute a serious global public health challenge, causing great suffering to many people across the globe at any given time. This study ascertains the knowledge of health professionals on the challenge and their compliance with infection control measures.

METHODS

Validated questionnaires were administered to 660 health professionals and supported with face-to-face interview. Data were analyzed using Statistical Package for Social Sciences (SPSS) version 16.0 (SPSS Inc, USA). Chi-square was used to test association between the independent and the outcome variables. Cut-off point for statistical significance was 5% (p value<0.05).

RESULTS

UTIs (61.4%) followed by Hospital-acquired Pneumonia (55.6%) were known to be the most prevalent HAIs in government hospitals while Staphylococcus aureus (54.4%) was reported the most microbial agent. In private health facilities, Hospital-acquired Pneumonia was known to be the most common (66.1%) while Pseudomonas aeruginosa was the most reported culprit. HAIs were reported to have occurred more in government hospitals and catheterization was the commonest modes of transmission in both health facilities.

CONCLUSION

The prevalence of HAIs in this state was reported to be high. Although health-care professionals have good knowledge of HAIs, active effort is not always made to identify and resolve them. Standardized surveillance of HAIs is urgently needed.

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.

Milestones along the road of infection prevention in Egypt

Sequela of infectious diseases include not only morbidity and mortality, but are also associated with chronic illnesses that has long constituted public health problems and huge economic burdens. This review gives a brief idea about important infectious diseases (ID) in Egypt, the main lines taken to combat them, the challenges still existing, and the possible barriers keeping IDs still forming threats to the community. Egypt has the highest prevalence rates of HCV infection worldwide. Significant evidence points towards that the HCV epidemic was initiated and propagated by the anti-schistosomal mass campaigns during the last century. Though the rates of HCV infection are declining, still the decline has not yet met the full expectations. Therefore, infection control programs are gaining more ground all over the country, especially with the growing problem of antimicrobial resistance complicating healthcare-associated infections (HAI) worldwide. Also, mass immnunization of childhood, mycobacterial tuberculosis infections, and avian influenza will be discussed.

Identification, molecular cloning, and analysis of full-length hepatitis C virus transmitted/founder genotypes 1, 3, and 4

Hepatitis C virus (HCV) infection is characterized by persistent replication of a complex mixture of viruses termed a “quasispecies.” Transmission is generally associated with a stringent population bottleneck characterized by infection by limited numbers of “transmitted/founder” (T/F) viruses. Characterization of T/F genomes of human immunodeficiency virus type 1 (HIV-1) has been integral to studies of transmission, immunopathogenesis, and vaccine development. Here, we describe the identification of complete T/F genomes of HCV by single-genome sequencing of plasma viral RNA from acutely infected subjects. A total of 2,739 single-genome-derived amplicons comprising 10,966,507 bp from 18 acute-phase and 11 chronically infected subjects were analyzed. Acute-phase sequences diversified essentially randomly, except for the poly(U/UC) tract, which was subject to polymerase slippage. Fourteen acute-phase subjects were productively infected by more than one genetically distinct virus, permitting assessment of recombination between replicating genomes. No evidence of recombination was found among 1,589 sequences analyzed. Envelope sequences of T/F genomes lacked transmission signatures that could distinguish them from chronic infection viruses. Among chronically infected subjects, higher nucleotide substitution rates were observed in the poly(U/UC) tract than in envelope hypervariable region 1. Fourteen full-length molecular clones with variable poly(U/UC) sequences corresponding to seven genotype 1a, 1b, 3a, and 4a T/F viruses were generated. Like most unadapted HCV clones, T/F genomes did not replicate efficiently in Huh 7.5 cells, indicating that additional cellular factors or viral adaptations are necessary for in vitro replication. Full-length T/F HCV genomes and their progeny provide unique insights into virus transmission, virus evolution, and virus-host interactions associated with immunopathogenesis.

Hepatitis C virus (HCV) infects 2% to 3% of the world’s population and exhibits extraordinary genetic diversity. This diversity is mirrored by HIV-1, where characterization of transmitted/founder (T/F) genomes has been instrumental in studies of virus transmission, immunopathogenesis, and vaccine development. Here, we show that despite major differences in genome organization, replication strategy, and natural history, HCV (like HIV-1) diversifies essentially randomly early in infection, and as a consequence, sequences of actual T/F viruses can be identified. This allowed us to capture by molecular cloning the full-length HCV genomes that are responsible for infecting the first hepatocytes and eliciting the initial immune responses, weeks before these events could be directly analyzed in human subjects. These findings represent an enabling experimental strategy, not only for HCV and HIV-1 research, but also for other RNA viruses of medical importance, including West Nile, chikungunya, dengue, Venezuelan encephalitis, and Ebola viruses.

Assessing Hand Hygiene Resources and Practices at a Large African Teaching Hospital

Objective.

To gather baseline data on hand hygiene (HH) practices in an African hospital with a newly established infection prevention and control team.

Design.

Cross-sectional, observational study.

Setting.

Komfo Anokye Teaching Hospital, a large teaching hospital in Ghana with approximately 1,000 beds.

Participants.

All hospital staff with patient contact were eligible for assessment of HH practices.

Interventions.

HH observations were conducted using a standardized data collection tool and method based on the World Health Organization's “5 Moments of Hand Hygiene.” Small-group interviews were conducted to gather additional information on perceptions of HH and barriers to its use. HH resource needs were also assessed using a standardized tool.

Results.

HH was attempted in 12% of the opportunities and was performed appropriately in 4% of the opportunities. Most main wards (89%) had at least 1 functional HH station. The most commonly identified barriers to HH were limited resources and lack of knowledge on appropriate times to perform HH.

Conclusion.

We developed and applied tools to evaluate HH resources and practices in a large African hospital. These assessments were undertaken to guide future efforts to improve HH at this hospital but can also serve as a model of the way to perform a systematic assessment at acute care hospitals in developing countries.

Hepatitis C virus infection treatment: An era of game changer direct acting antivirals and novel treatment strategies

Chronic hepatitis C virus infection and associated liver diseases represent a major health care burden all over the world. The current standard of care, i.e. peginterferon-alfa (PEG-IFNα) plus ribavirin (RBV) are associated with frequent and sometimes serious adverse effects and contraindications, which further limit their therapeutic efficacy. The approval of first and second generation HCV protease inhibitors represents a major breakthrough in the development of novel direct acting antivirals (DAAs) against different HCV genotypes and establishes a new standard of care for chronically infected HCV genotypes 1 patients. Similarly, next generation protease inhibitors and HCV RNA polymerase inhibitors have shown better pharmacokinetics and pharmacodynamics in terms of broader HCV genotypes coverage, better safety profile, fewer drug interactions and possible once daily administration than first generation direct acting antivirals. The testing of adenovirus-based vector vaccines, which escalates the innate and acquired immune responses against the most conserved regions of the HCV genome in chimpanzees and humans, may be a promising therapeutic approach against HCV infection in coming future. This review article presents up-to-date knowledge and recent developments in HCV therapeutics, insights the shortcomings of current HCV therapies and key lessons from the therapeutic potential of improved anti-HCV treatment strategies.

Potential for human immunodeficiency virus parenteral transmission in the Middle East and North Africa: An analysis using hepatitis C virus as a proxy biomarker

The Middle East and North Africa (MENA) region has endured several major events of infection parenteral transmission. Recent work has established the utility of using hepatitis C virus (HCV) as a proxy biomarker for assessing the epidemic potential for human immunodeficiency virus (HIV) parenteral transmission. In this review, we use data on the prevalence of HCV infection antibody (seroprevalence) among general population and high risk population groups to assess the potential for HIV parenteral transmission in MENA. Relatively low prevalence of HCV infection in the general population groups was reported in most MENA countries indicating that parenteral HIV transmission at endemic levels does not appear to be a cause for concern. Nonetheless, there could be opportunities for localized HIV outbreaks and transmission of other blood-borne infections in some settings such as healthcare facilities. Though there have been steady improvements in safety measures related to parenteral modes of transmission in the region, these improvements have not been uniform across all countries. More precautions, including infection control training programs, surveillance systems for nosocomial infections and wider coverage and evaluation of hepatitis B virus immunization programs need to be implemented to avoid the unnecessary spread of HIV, HCV, and other blood-borne pathogens along the parenteral modes of transmission.

Hepatitis C screening beyond CDC guidelines in an Egyptian immigrant community

BACKGROUND & AIMS

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.

METHODS

A unique partnership, the Hepatitis Outreach Network (HONE), combines the expertise and resources of the Mount Sinai School of Medicine, the NYC Department of Health and Mental Hygiene and community-based organizations, to provide education, screening and link to care in communities with high prevalence of chronic viral hepatitis.

RESULTS

Through four community-based screening events, 192 Egyptian-born persons were screened for HCV. Thirty (15.6%) persons were HCV positive. HCV antibody prevalence in those, whose national origin was Egypt, increased strongly with age and was associated with increasing number of years resident in Egypt and rural residents. Of the 30 Egyptian persons with HCV infection, 18 (60%) received a medical evaluation (2 with local providers and 16 at Mount Sinai). Of the HCV-infected persons evaluated, treatment was recommended in four and begun in three (75%).

CONCLUSION

Egyptian-born persons living in the New York City area have a high burden of HCV disease. HONE has successfully established targeted HCV screening in Egyptian-born persons through use of several unique elements that effectively link them to care.

Determining the status quo of infection prevention and control standards in the hospitals of iran: a case study in 23 hospitals

BACKGROUND

Applying Prevention and Control of Infection (PCI) standards in hospitals reduces probable risks to patients, staff and visitors; it also increases efficiency, and ultimately improves productivity of hospitals.

OBJECTIVE

The current study aimed to determine the status quo of international standards of PCI in hospitals located in the north of Iran.

MATERIALS AND METHODS

This cross-sectional study was conducted in 23 hospitals. Data collection tool was a questionnaire with confirmed validity and reliability. . In this regard, 260 managers, section supervisors and infection control nurses participated in the study according to census basis. SPSS software version 16 was employed to analyze the data through descriptive and analytical statistics.

RESULTS

Among the studied hospitals, 18 hospitals were public. Hospitals enjoyed 77.2% of leadership and programming, 80.8% of focus of programs, 67.4% of isolating methods, 88.2% of hand health and protection techniques, 78.8% of improving patient's safety and quality, 90.3% of training personnel, and 78.7% of the average status quo of PCI standards.

CONCLUSIONS

This study revealed that PCI standards were significantly observed in the studied hospitals and that there were necessary conditions for full deployment of nosocomial infection surveillance.

The Association between Female Genital Cutting and Spousal HCV Infection in Egypt

Objective. To identify the risk factors for HCV infection within married couples in Egypt. Methods. In 2008 Egypt conducted its first nationally representative survey of HCV prevalence. 11126 of the 12780 individuals aged 15-59 year who were sampled agreed to participate and provided information via a questionnaire about demographic and behavioural characteristics and blood for HCV antibody and RNA analysis. We assessed the risk factors for HCV infection in a subsample of 5182 married individuals via multivariate logistic regression. Results. Overall HCV antibody prevalence in the married couples was 18.2% (95% CI, 16.8-19.6). HCV antibody prevalence was higher in the husbands (23.7%) than the wives (12.1%; P < 0.001). Having a spouse who was infected with HCV was an independent risk factor for HCV infection with odds ratios of 2.1 (95% CI, 1.6-2.9) and 2.2 (95% CI, 1.6-3.1) for women and men, respectively. Husbands whose wives had experienced female genital cutting (FGC) had a higher prevalence of HCV and this relationship was driven by a strong association in urban areas. Amongst the women there was no association between FGC and HCV overall but in urban areas only women who had experienced FGC were HCV infected. Conclusions. This study provides additional evidence of the importance of intrafamilial transmission of HCV in Egypt.

Incidence and pathogen distribution of healthcare-associated infections in pilot hospitals in Egypt

OBJECTIVE

To report type and rates of healthcare-associated infections (HAIs) as well as pathogen distribution and antimicrobial resistance patterns from a pilot HAI surveillance system in Egypt.

METHODS

Prospective surveillance was conducted from April 2011 through March 2012 in 46 intensive care units (ICUs) in Egypt. Definitions were adapted from the Centers for Disease Control and Prevention's National Healthcare Safety Network. Trained healthcare workers identified HAIs and recorded data on clinical symptoms and up to 4 pathogens. A convenience sample of clinical isolates was tested for antimicrobial resistance at a central reference laboratory. Multidrug resistance was defined by international consensus criteria.

RESULTS

ICUs from 11 hospitals collected 90,515 patient-days of surveillance data. Of 472 HAIs identified, 47% were pneumonia, 22% were bloodstream infections, and 15% were urinary tract infections; case fatality among HAI case patients was 43%. The highest rate of device-associated infections was reported for ventilator-associated pneumonia (pooled mean rate, 7.47 cases per 1,000 ventilator-days). The most common pathogens reported were Acinetobacter species (21.8%) and Klebsiella species (18.4%). All Acinetobacter isolates tested (31/31) were multidrug resistant, and 71% (17/24) of Klebsiella pneumoniae isolates were extended-spectrum β-lactamase producers.

CONCLUSIONS

Infection control priorities in Egypt should include preventing pneumonia and preventing infections due to antimicrobial-resistant pathogens.

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.

Current progress in development of hepatitis C virus vaccines

Despite major advances in the understanding and treatment of hepatitis C, a preventive vaccine remains elusive. The marked genetic diversity and multiple mechanisms of persistence of hepatitis C virus, combined with the relatively poor immune response of the infected host against the virus, are major barriers. The lack of robust and convenient model systems further hampers the effort to develop an effective vaccine. Advances in our understanding of virus-host interactions and protective immunity in hepatitis C virus infection provide an important roadmap to develop potent and broadly directed vaccine candidates targeting both humoral and cellular immune responses. Multiple approaches to generating and testing viral immunogens have met with variable success. Several candidates have advanced to clinical trials based on promising results in chimpanzees. The ultimate path to a successful preventive vaccine requires comprehensive evaluations of all aspects of protective immunity, innovative application of state-of-the-art vaccine technology and properly designed vaccine trials that can affirm definitive endpoints of efficacy.

The epidemiology of hepatitis C virus in Egypt: a systematic review and data synthesis

BACKGROUND

Egypt has the highest prevalence of hepatitis C virus (HCV) in the world, estimated nationally at 14.7%. Our study's objective was to delineate the evidence on the epidemiology of HCV infection among the different population groups in Egypt, and to draw analytical inferences about the nature of HCV transmission in this country.

METHODS

We conducted a systematic review of all data on HCV prevalence and incidence in Egypt following PRISMA guidelines. The main sources of data included PubMed and Embase databases. We also used a multivariate regression model to infer the temporal trend of HCV prevalence among the general population and high risk population in Egypt.

RESULTS

We identified 150 relevant records, four of which were incidence studies. HCV incidence ranged from 0.8 to 6.8 per 1,000 person-years. Overall, HCV prevalence among pregnant women ranged between 5-15%, among blood donors between 5-25%, and among other general population groups between 0-40%. HCV prevalence among multi-transfused patients ranged between 10-55%, among dialysis patients between 50-90%, and among other high risk populations between 10% and 85%. HCV prevalence varied widely among other clinical populations and populations at intermediate risk. Risk factors appear to be parenteral anti-schistosomal therapy, injections, transfusions, and surgical procedures, among others. Results of our time trend analysis suggest that there is no evidence of a statistically significant decline in HCV prevalence over time in both the general population (p-value: 0.215) and high risk population (p-value: 0.426).

CONCLUSIONS

Egypt is confronted with an HCV disease burden of historical proportions that distinguishes this nation from others. A massive HCV epidemic at the national level must have occurred with substantial transmission still ongoing today. HCV prevention in Egypt must become a national priority. Policymakers, and public health and medical care stakeholders need to introduce and implement further prevention measures targeting the routes of HCV transmission.

Incidence of hepatitis C virus infection among Egyptian healthcare workers at high risk of infection

BACKGROUND

Hepatitis C virus (HCV) is a global health threat with Egypt having the highest worldwide prevalence. Evaluation of the efficacy of a preventive HCV vaccine, such as those currently in Phase I/II trials, requires a cohort with a high-risk exposure to HCV.

OBJECTIVE

To identify a reliable cohort for evaluating preventive HCV vaccines, we studied HCV incidence among HCW in a hospital where almost 85% of patients are HCV-infected.

STUDY DESIGN

Of 717 HCW negative for HCV-antibodies (anti-HCV) at baseline, 651 were followed up and tested for seroconversion twice annually for an average of 504 ± 154 days. Those reporting a needle-stick injury were additionally tested for both HCV antibodies and RNA monthly for a total of four months.

RESULTS

Two subjects (0.31%) had anti-HCV and HCV-RNA seroconversion with an overall incidence of 2.04/1000 person-years and a 4.8% incidence among the 21 subjects who reported a needle-stick injury. Two additional subjects had viremia without detectable anti-HCV. Two of the four subjects were among 21 with reported needle-stick injuries (9.5%) and another had surgery. All four were nurses providing direct patient care.

CONCLUSIONS

Our results show that both transient and persistent viremia were detectable in this high-risk cohort of HCW and suggest that absence of anti-HCV in two of the subjects may be due to low-dose viral exposures. These data indicate that HCV infections acquired from documented injuries during direct patient care are frequent in Egypt and can guide selection of eligible HCW suitable for preventive HCV vaccine trials.

Frequent transient hepatitis C viremia without seroconversion among healthcare workers in Cairo, Egypt

Backgrounds

With 10% of the general population aged 15–59 years chronically infected with hepatitis C virus (HCV), Egypt is the country with the highest HCV prevalence worldwide. Healthcare workers (HCWs) are therefore at particularly high risk of HCV infection. Our aim was to study HCV infection risk after occupational blood exposure among HCWs in Cairo.

Methodology/Principal Findings

The study was conducted in 2008–2010 at Ain Shams University Hospital, Cairo. HCWs reporting an occupational blood exposure at screening, having neither anti-HCV antibodies (anti-HCV) nor HCV RNA, and exposed to a HCV RNA positive patient, were enrolled in a 6-month prospective cohort with follow-up visits at weeks 2, 4, 8, 12 and 24. During follow-up, anti-HCV, HCV RNA and ALT were tested. Among 597 HCWs who reported a blood exposure, anti-HCV prevalence at screening was 7.2%, not different from that of the general population of Cairo after age-standardization (11.6% and 10.4% respectively, p = 0.62). The proportion of HCV viremia among index patients was 37%. Of 73 HCWs exposed to HCV RNA from index patients, nine (12.3%; 95%CI, 5.8–22.1%) presented transient viremia, the majority of which occurred within the first two weeks after exposure. None of the workers presented seroconversion or elevation of ALT.

Conclusions/Significance

HCWs of a general University hospital in Cairo were exposed to a highly viremic patient population. They experienced frequent occupational blood exposures, particularly in early stages of training. These exposures resulted in transient viremic episodes without established infection. These findings call for further investigation of potential immune protection against HCV persistence in this high risk group.

Case control study to identify risk factors for acute hepatitis C virus infection in Egypt

BACKGROUND

Identification of risk factors of acute hepatitis C virus (HCV) infection in Egypt is crucial to develop appropriate prevention strategies.

METHODS

We conducted a case-control study, June 2007-September 2008, to investigate risk factors for acute HCV infection in Egypt among 86 patients and 287 age and gender matched controls identified in two infectious disease hospitals in Cairo and Alexandria. Case-patients were defined as: any patient with symptoms of acute hepatitis; lab tested positive for HCV antibodies and negative for HBsAg, HBc IgM, HAV IgM; and 7-fold increase in the upper limit of transaminase levels. Controls were selected from patients' visitors with negative viral hepatitis markers. Subjects were interviewed about previous exposures within six months, including community-acquired and health-care associated practices.

RESULTS

Case-patients were more likely than controls to have received injection with a reused syringe (OR=23.1, CI 4.7-153), to have been in prison (OR=21.5, CI 2.5-479.6), to have received IV fluids in a hospital (OR=13.8, CI 5.3-37.2), to have been an IV drug user (OR=12.1, CI 4.6-33.1), to have had minimal surgical procedures (OR=9.7, CI 4.2-22.4), to have received IV fluid as an outpatient (OR=8, CI 4-16.2), or to have been admitted to hospital (OR=7.9, CI 4.2-15) within the last 6 months. Multivariate analysis indicated that unsafe health facility practices are the main risk factors associated with transmission of HCV infection in Egypt.

CONCLUSION

In Egypt, focusing acute HCV prevention measures on health-care settings would have a beneficial impact.

Device-associated nosocomial infection rates in intensive care units at Cairo University hospitals: first step toward initiating surveillance programs in a resource-limited country

BACKGROUND

Device associated infections (DAIs) have major impact on patient morbidity and mortality.

METHODS

This study involved active prospective surveillance to measure the incidence of DAIs, evaluate microbiological profiles, and investigate excessive mortality in intensive care units (ICUs) in 3 hospitals of Cairo University applying the US Centers for Disease Control and Prevention's National Healthcare Safety Network case definitions for ventilator-associated pneumonia (VAP), catheter-associated urinary tract infection (CAUTI), and central-line associated bloodstream infection (CLABSI). Data were collected between March 2009 and May 2010.

RESULTS

A total of 1,101 patients were hospitalized for a total of 10,869 days, had 4,734 device-days, and acquired 97 DAIs, with an overall rate of 20.5/1,000 ICU days. VAP was the most commonly identified infection (88.7%); followed by CLABSI (8.2%) and CAUTI (3.1%). Excess mortality was 48% (relative risk, 1.9; P < .001) for CAUTI, 12.9% (relative risk, 1.2; 95% confidence interval, 1.1-1.4; P < .05) for VAP, and 45.7% for CLABSI. Acinetobacter baumannii was the most frequently isolated pathogen (36.1%), followed by Klebsiella pneumoniae (29.2%) and Pseudomonas aeruginosa (22.2%). High antimicrobial resistance was identified, with 85% of A baumannii isolates resistant to ciprofloxacin and imipenem, 76% of K pneumoniae isolates were extended-spectrum β-lactamase producers, and 56.3% P aeruginosa isolates resistant to imipenem (56.3%).

CONCLUSION

High rates of DAI and antimicrobial resistance require strengthening infection control, instituting surveillance systems, and implementing evidence-based preventive strategies.

Evaluation of blood supply operation and infectious disease markers in blood donors during the Egyptian revolution

BACKGROUND

The Egyptian revolution took place on January 25, 2011. Millions of protesters demanded the overthrow of the Egyptian president's regime. Many people suffered from life-threatening injuries after violent clashes between police and protesters.

STUDY DESIGN AND METHODS

The overall management of the blood bank operation at Cairo University Hospital was described, in an attempt to evaluate blood safety and establish a standard effective plan to manage blood supply during crisis.

RESULTS

Three days after the uprising, thousands of Egyptians rushed to the hospital to alleviate the blood shortage. A total of 3425 units were collected in 3 days and thousands of donors were turned away. An error delayed processing of 1000 units and they were used as stored whole blood. Apheresis platelets were donated by protesters who were particularly motivated to donate for two victims with liver injury. The usual positive rate of hepatitis C virus (HCV) antibody in Egyptian donors is 3.8%. However, the positive rate of HCV markers in the collected units was only 1.6%. The mean age of donors during the revolution was 31.7±10.4 years while the usual mean age of donors is 39.2±8.5 years. Operating theaters were used only for emergencies. A blood surplus developed that met the hospital needs for 1 month.

CONCLUSION

Revolution resulted in an influx of first-time donors with a relatively low positive rate of HCV antibody. To be prepared for disasters, a systematic approach to spread donors evenly on a daily basis is needed.

Risk factors for hepatitis C virus acquisition and predictors of persistence among Egyptian children

BACKGROUND

Hepatitis C virus (HCV) has a lower prevalence in children and knowledge is limited regarding the natural outcome of HCV infection in children.

AIM

To study the risk factors of HCV acquisition and predictors of persistence in Egyptian children.

METHODS

Children, 1-9 years of age, were evaluated for acquisition of HCV (anti-HCV positive regardless of viraemia) and persistence of HCV (anti-HCV and HCV-RNA positive) at two paediatric hepatology clinics in Cairo at enrollment and at 3 monthly intervals. Spontaneous clearance of HCV was defined as ≥ two positive anti-HCV antibody tests with negative HCV-RNA at least 6 months apart.

RESULTS

Over a 33-month-period a total of 226 children <9 years of age were screened for HCV antibodies. Of those, 146 (65%) were anti-HCV positive of which 87 (60%) were HCV-RNA positive. The HCV acquisition was more likely to occur in older children (P = 0.003) with comorbid conditions (P < 0.01) compared to anti-HCV negative children. In a multivariate logistic regression analysis, the highest risk factors for HCV acquisition were surgical interventions [odds ratio (OR): 4.7] and blood transfusions (OR: 2.3). The highest risk factor for HCV persistence was dental treatment (OR: 16.9) and male gender (OR: 7.5). HCV persistence was also strongly associated with elevated baseline alanine aminotransaminase (ALT) levels (OR: 4.9) and fluctuating aspartate aminotransferase (AST) levels (OR: 8.1).

CONCLUSION

Although surgical interventions and blood transfusion are significant risk factors for HCV acquisition in Egyptian children, dental treatment remains the highest risk factor for HCV chronic persistence in children.

A review of health system infection control measures in developing countries: what can be learned to reduce maternal mortality

A functional health system is a necessary part of efforts to achieve maternal mortality reduction in developing countries. Puerperal sepsis is an infection contracted during childbirth and one of the commonest causes of maternal mortality in developing countries, despite the discovery of antibiotics over eighty years ago. Infections can be contracted during childbirth either in the community or in health facilities. Some developing countries have recently experienced increased use of health facilities for labour and delivery care and there is a possibility that this trend could lead to rising rates of puerperal sepsis. Drug and technological developments need to be combined with effective health system interventions to reduce infections, including puerperal sepsis. This article reviews health system infection control measures pertinent to labour and delivery units in developing country health facilities. Organisational improvements, training, surveillance and continuous quality improvement initiatives, used alone or in combination have been shown to decrease infection rates in some clinical settings. There is limited evidence available on effective infection control measures during labour and delivery and from low resource settings. A health systems approach is necessary to reduce maternal mortality and the occurrence of infections resulting from childbirth. Organisational and behavioural change underpins the success of infection control interventions. A global, targeted initiative could raise awareness of the need for improved infection control measures during childbirth.

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.

Surveillance of catheter-associated urinary tract infection in 4 intensive care units at Alexandria university hospitals in Egypt

BACKGROUND

We sought to measure the incidence rate of catheter-associated urinary tract infections (CAUTIs), identify risk factors associated with acquiring the infections; and identify the etiologic and antibiotic resistant patterns associated with CAUTIs in the intensive care units (ICUs) of a large University Hospital in Alexandria, Egypt.

METHODS

Prospective active surveillance of CAUTIs was conducted in 4 ICUs during a 13-month period from January 1, 2007 through January 31, 2008 in Alexandria University Hospital using the standard Centers for Disease Control National Nosocomial Infection Surveillance (NNIS) case definitions. Rates were expressed as the number of infections per 1000 catheter days.

RESULTS

During the study period, 757 patients were monitored after ICU admission, with either existing indwelling urinary catheters (239), or got catheters inserted after ICU admission (518), for a total duration of 16301 patient days, and 10260 patient catheter days. A total of 161 episodes of infection were diagnosed, for an overall rate of 15.7 CAUTIs per 1000 catheter days. Important risk factors associated with acquiring CAUTI were female gender (Relative risk (RR), 1.7; 95% confidence interval (CI); 1.7-4.3), and previous catheterization within the same hospital admission (RR, 1.6; 95% CI; 1.3-1.96). Patients admitted to the chest unit, patients =40 years, patients with prolonged duration of catheterization, prolonged hospital and ICU stay had a significantly higher risk of acquiring CAUTIs. Out of 195 patients who had their urine cultured, 188 pathogens were identified for 161 infected patients; 96 (51%) were Candida, 63 (33.5%) gram negatives, 29 (15.4%) gram positives. The prevalence of ESBL producers among K. pneumoniae and E. coli isolates was 56% (14/25) and 78.6% (11/14), respectively.

CONCLUSION

Despite infection control policies and procedures, CAUTI rates remain a significant problem in Alexandria University hospital. Using the identified risk factors, tailored intervention strategies are now being implemented to reduce the rates of CAUTIs in these 4 ICUs.

Injection drug use is a risk factor for HCV infection in urban Egypt

Objective

To identify current risk factors for hepatitis C virus (HCV) transmission in Greater Cairo.

Design and Setting

A 1∶1 matched case-control study was conducted comparing incident acute symptomatic hepatitis C patients in two “fever” hospitals of Greater Cairo with two control groups: household members of the cases and acute hepatitis A patients diagnosed at the same hospitals. Controls were matched on the same age and sex to cases and were all anti-HCV antibody negative. Iatrogenic, community and household exposures to HCV in the one to six months before symptoms onset for cases, and date of interview for controls, were exhaustively assessed.

Results

From 2002 to 2007, 94 definite acute symptomatic HCV cases and 188 controls were enrolled in the study. In multivariate analysis, intravenous injections (OR = 5.0; 95% CI = 1.2–20.2), medical stitches (OR = 4.2; 95% CI = 1.6–11.3), injection drug use (IDU) (OR = 7.9; 95% CI = 1.4–43.5), recent marriage (OR = 3.3; 95% CI = 1.1–9.9) and illiteracy (OR = 3.9; 95% CI = 1.8–8.5) were independently associated with an increased HCV risk.

Conclusion

In urban Cairo, invasive health care procedures remain a source of HCV transmission and IDU is an emerging risk factor. Strict application of standard precautions during health care is a priority. Implementation of comprehensive infection prevention programs for IDU should be considered.

Decline of viral hepatitis prevalence among asymptomatic Egyptian blood donors: a glimmer of hope

BACKGROUND

Viral hepatitis is an important etiological agent of chronic hepatitis and liver disease and is a major cause of morbidity and mortality especially in Egypt since it has the highest prevalence of hepatitis C virus (HCV) infection. We aimed to assess if there is any change in the annual seroprevalence of both HCV and hepatitis B virus (HBV) infection in Egypt in the current era.

METHODS

Our study included 55,922 potentially healthy asymptomatic blood donors; 52,280 males and 3642 females with mean age of 30.98+/-8.6 years. All of them were volunteers for the first time and 70% were from rural areas. We applied our own questionnaire that included past medical history, surgical history, and history of blood donation. We screened their sera for the presence or absence of anti-HCV antibodies with the 3rd generation enzyme-linked immunosorbent assay (ELISA) and the presence or absence of hepatitis B surface antigen (HBsAg) with ELISA.

RESULTS

The cumulative seroprevalence of HCV and HBV infection was 11.95% and 1.3% respectively. The annual seroprevalence of both viruses showed a declining pattern throughout the study period from 17.7% to 7.4% regarding HCV and HBV infection from 2.3% to 0.9%. The decline trends for both viral infections were observed for both genders.

CONCLUSION

This study carries a glimmer of hope because of a decline in seroprevalence of viral hepatitis in Egypt. However stringent implementation of infection control programs in Egypt is mandatory to face this furious health problem.

Incidence and risk factors for hepatitis C infection in a cohort of women in rural Egypt

A prospective cohort study of the incidence and risk factors for hepatitis C virus (HCV) infection was performed in 2171 pregnant women in three rural Egyptian villages who were HCV antibody (anti-HCV) and RNA (HCV-RNA) negative at baseline. During an average of 2.2 years follow up, 25 incident cases were observed, giving an estimated HCV incidence of 5.2/1000 person-years (PY). The infection rate correlated with community anti-HCV prevalence in pregnant women, while the perinatal incidence rate of 11.2/1000 PY was almost five times that of the non-perinatal rate (2.3/1000 PY). The data suggested iatrogenic perinatal risk factors were associated with infection in one village, while health education reduced infections in another. Among the 25 incident cases, eight were HCV-RNA negative when they were first found to be anti-HCV positive and one-third of the 15 viraemic cases with follow-up data available cleared their HCV-RNA after an average of 1.3 years. None of the 25 incident cases were jaundiced or had symptoms of hepatitis but elevated serum alanine aminotransferase levels confirmed hepatitis in nine. Our data suggest that asymptomatic HCV infections frequently occurred during the perinatal period but often cleared and that educating medical personnel on safe practices possibly reduced HCV transmission.

Establishment of hybrid cell lines producing monoclonal antibodies to a synthetic peptide from the E1 region of the hepatitis C virus

We aimed at establishing hybridoma cells secreting monoclonal antibodies (mAbs) against E1 synthetic peptide of HCV. BALB/c mice were immunized with HCV E1-synthetic peptide (GHRMAWDMM) and its spleenocytes were fused with the P3NS1 myeloma cell line. Two highly reactive and specific mAbs (10C7 IgG2b mAb, and 10B2 IgG1 mAb) were generated. The target HCV E1 antigen was identified at approximately 38 kDa in serum of infected individuals. A newly developed ELISA detected the target antigen in 90% of sera from HCV RNA infected individuals with a specificity of 84%. So, the generated mAbs may provide promising probes for serodiagnosis of HCV infection.

Changing Patterns of Acute Viral Hepatitis at a Major Urban Referral Center in Egypt

BACKGROUND

Changes in the viral etiology of hospitalized patients can inform us of changes in the overall epidemiology of acute viral hepatitis infections. We hypothesized that improvements in health care and sanitation in the past 2 decades in Egypt have significantly impacted the viral causes of acute viral hepatitis in hospitalized patients. We compared the viral causes of acute viral hepatitis at a major urban referral center with results reported from the same center 20 years earlier.

METHODS

Over a period of 10 months, 200 consecutive inpatients with clinical acute viral hepatitis were enrolled in the study, and serum samples were tested for hepatitis A through E, cytomegalovirus, and Epstein-Barr virus.

RESULTS

The frequency of acute hepatitis B virus infection as a cause of symptomatic hepatitis decreased from 43.4% in 1983 to 28.5% in 2002 (P<.01), and acute hepatitis A virus infection increased from 2.1% in 1983 to 34% in 2002 (P<.01), and occurred at older ages. In 1983, non-A, non-B hepatitis virus infection caused acute viral hepatitis in 38.7% of cases, compared with 31% in the present study (P=.12). The mean alanine aminotransferase level was highest in patients with combined infections, and clinical presentation did not distinguish between different viral etiologies of hepatitis.

CONCLUSIONS

A significant decrease in hepatitis B virus infection and an increase in hepatitis A virus infection have occurred since the earlier study was performed in 1983. The decrease in hepatitis B virus infection is attributable to the steep decrease in hepatitis B virus infection among children that resulted from the universal hepatitis B virus immunization of infants that was initiated in 1991. The increase in clinical hepatitis A virus infection occurred in older patients and could be attributed to improved sanitation that delayed individuals' initial exposures to the virus.