A Q&A with Dr Isabelle A Nakhla on Hepatitis C infection in garbage collectors

To recognize World Hepatitis Day, Stefanie Howard interviews Dr Isabelle A Nakhla of Naval Medical Research Unit # 3 (Egypt) on a recent Hepatitis C Virus study published in Tropical Diseases, Travel Medicine and Vaccines.

Hepatitis C (HCV) is a major epidemic in Egypt.  According to the World Health Organization, HCV is responsible for an estimated 40,000 deaths per year in Egypt, and at least 1 in 10 of Egyptians ages 15 to 59 is infected.

The article “A cross-sectional household cluster serosurvey of hepatitis C virus antibodies in an urban slum of Cairo, Egypt in 2004” published in Tropical Diseases, Travel Medicine and Vaccines  by Dr. Isabelle A. Nakhla of Naval Medical Research Unit # 3 (Egypt) and co-authors discusses the potential risk factors for HCV infection in a study focused on garbage collectors in Manshiet Nasser, a slum in Cairo often referred to as Mokattem Hills where garbage collection and sorting is a common occupation.

In recognition of World Hepatitis Day, we caught up with Dr. Nakhla to discuss this important study.

How did the idea for this study develop? Why did you choose to focus on garbage collectors for this study?

Garbage collection in Egypt comprises a variety of jobs, including collection of the waste from homes, industry, hospitals and any other entity in addition to sorting and recycling. The characteristics of the garbage collectors’ population drew our interest to study the HCV prevalence especially in relation to age and among the younger generations.

Collected material is brought into the garbage collectors’ residential area where the people share the same home with the garbage and their domestic animals, like donkeys. Here is where the unprotected garbage sorting takes place. The sorters go through the garbage separating plastic, paper, metal and even contaminated medical waste and syringes. Sorting without gloves makes the sorters, who might be of any age and gender, vulnerable to become infected by sharp contaminated objects. A further step after sorting is recycling of the material, certainly without proper disinfection.

Another interesting characteristic of this population is the Upper Egyptian origin of many of them, where the injectable schistosomiasis treatment campaigns took place more than 30 years ago. This treatment was given using the same needles interchangeably among patients.

Why does Egypt have such a high prevalence of Hepatitis C Virus (HCV)?  What have been the effects on public health and economic consequences of this epidemic?

The use of the injectable treatment campaigns for schistosomiasis, a wide spread disease in Egypt before the launching of praziquantel tablets, is thought to be the main cause of HCV infection in Egypt.

Large reusable syringes were used at that time, which were filled with the medication enough for several individuals. As the drug was injected intravenously, blood was drawn in the needle then the drug injected. This was repeated with the same syringe, for several patients in a row, without changing the needle or the syringe.

Other causes, identified in the literature and also in our study are the high rate of injectable antibiotics, blood transfusion and dental work. The risk factors are expected to be changing now, and need more in-depth studies.

Were there any unexpected findings from this study?

In addition to the expected finding of infection among the middle aged participants, a trend of continuous transmission of the HCV infection was noticed, as younger age groups were infected as well. Going to barbershops was not associated with the infection as expected.

We also found an association between infection and the type of housing and toilets used, which we were very cautious to interpret.

What are you main recommendations as a result of this study?

Our recommendation is to continue follow up of incidence and prevalence of the disease in Egypt and to study further the risk factors and behaviors of importance in Egypt. Treatment availability for all patients, including those who cannot afford its high cost on their own, and studies of new treatment options is also recommended.

Do you have any follow up studies planned as a result of this research?

We were planning to have an incidence study to follow on for this study, by testing the negative participants after one year, but this could not be managed for lack of funding.

Also, the government was planning to launch the wide-scale free treatment campaign with the new available drugs. We are sequencing the virus from positive family members, trying to study intra-familial transmission. Some staff from our institution are members of the HCV committee at the Ministry of Health, though, and help in the Ministry of Health sentinel hepatitis surveillance in Egypt.

Isabelle Nakhla

Research Scientist at NAMRU-3
After medical school and a Master’s degree in Pediatrics, Isabelle Nakhla, has enjoyed an immensely successful career at the US Naval Medical Research Unit #3 (NAMRU-3) serving as a Principal or Associate Investigator on a broad range of studies.Her field of expertise extended to a wide range of infectious diseases research, including clinical trials, surveillance, and applied epidemiology. She pursued a PhD in pediatrics, with an emphasis on infectious diseases, after a few years at NAMRU-3.

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