FROM SCHISTOSOMIASIS TO HEPATITIS C: THE SPREAD OF HCV IN EGYPT

Hepatitis C is caused by a virus (HCV) and is trans- mitted by infected blood. It has no epidemiological relationship with schistosomiasis, which is a parasitic disease that is widespread in Egypt. From the 1950s to the 1980s, Egypt tried to control a schistosomia- sis epidemic with a program of mass injections of tartar emetic. Largely because of poor sterilization techniques, this program spread hepatitis C to Egyptians in what is believed to be the largest iatro- genic transmission of blood-borne disease in history. Hepatitis C is a widespread viral disease that is the most common cause of chronic hepatitis, cirrhosis, and hepatocellular cancer. (1,2) The story of the spread of HCV in Egypt in the last several decades begins with schistosomiasis, sometimes known as bilharziasis or bilharzia, an unrelated parasitic infec- tion. Schistosomiasis has existed for millennia and has even been detected in mummies. (3) In Africa and the Middle East, the 2 main schistosome species infecting humans are Schistosoma mansoni and S haematobium. (4) The parasite schistosome infects humans in contact with fresh water containing spe- cific snails that serve as intermediate hosts, and humans continue the life cycle by eliminating eggs with feces and urine. Historically, schistosomiasis has been the most important public health problem in Egypt, and S. mansoni has been the principal cause of liver dis- ease in this country. (5) Lower Egypt, with its farm- ing villages along the Nile River delta, has always had high rates of this parasitic infection, but with the spread of irrigation for agriculture, the prevalence in Middle and Upper Egypt increased as well. (6) The symptoms of the acute form of the disease, known as Katayama's fever, include fever, cough, abdominal pain, diarrhea, hepatosplenomegaly (abnormal enlargement of both the liver and the spleen), and eosinophilia (a large number of eosinophils in the blood). (4) Sometimes central nervous system lesions occur. Granulomatous lesions around ectopic eggs from S mansoni in the spinal cord may result in a transverse myelitis (inflammation of a transverse portion of the spinal cord) with severe loss of motor function in the lower extremities and lower portions of the trunk. Continuing infection may cause granulomatous reac- tions and fibrosis in the affected organs, which in turn may result in polyps in the colon, bloody diar- rhea, portal hypertension, vomiting of blood, and enlargement of the spleen (splenomegaly). It can progress to pulmonary hypertension, inflammation of capillaries in the kidneys (glomerulonephritis), and central nervous system lesions. Parenteral Antischistosomal Therapy Schistosomiasis was not treatable until 1918. (6) In that year, JB Christopherson discovered that injec- tions with the antimony salt tartar emetic could induce a cure. Because Egypt had the world's great- est schistosomiasis problem, parenteral antischisto- somal therapy was extensively adopted starting in the 1920s. The treatment became available in dif- ferent areas of the country at different times. In rural areas, health centers and traveling clinics prac- ticed parenteral antischistosomal therapy in the form of mass treatment. Although a few antischistosomal drugs could be injected intramuscularly, tartar emet- ic was injected intravenously, and tartar emetic was the most widely used in Egypt. Beginning in the 1950s and continuing until the 1980s, the Egyptian Ministry of Health conducted large campaigns using the standard treatment at that time, tartar emetic, as community-wide thera- py. (5) Between 1964 and 1982, more than 2 million injections were given annually to an average of