In Egypt, Viral Hepatitis Elimination Starts With a Village: An Interview With Dr. Ammal Metwally

Dr. Ammal Metwally. Photo by World Hepatitis Alliance.

Since being commissioned by the European Liver Patients’ Association (ELPA) in 2016, the Hep-CORE study has engaged patient groups on an annual basis in monitoring national and subnational viral hepatitis policy across Europe and the Mediterranean Basin.

In this new series, an update of the 2016 Hep-CORE interview series,  the Principal Investigator (PI) Jeffrey Lazarus conducts interviews with new members of the Hep-CORE study group to understand the perspectives that they bring to bear on this patient-led study. Here, he interviews Dr. Ammal Metwally, research professor of public health and preventative and community medicine at the Egyptian National Research Centre (NRC) and representative of the Eastern Mediterranean Region for the World Hepatitis Alliance Regional Board.

Can you describe your experience in the viral hepatitis field and what brought you to be a part of the Hep-CORE Study Group?

Firstly, some might be surprised to learn that Egypt has achieved so much in the field of viral hepatitis. My country is one of only 12 countries around the world on track to reach the WHO goal of eliminating hepatitis C as a public health threat by 2030.

"Some might be surprised to learn that Egypt has achieved so much in the field of viral hepatitis. My country is one of only 12 countries around the world on track to reach the WHO goal of eliminating hepatitis C as a public health threat by 2030"

My own involvement in advocating for the elimination of viral hepatitis began in 2010. As a public health and community medicine specialist in the National Research Centre (NRC) of Egypt, I worked in close collaboration with the key officials of the hepatitis department of the Ministry of Health, serving as a member of various taskforces, to set the communication strategy and action plan for hepatitis C in Egypt 2014-2018. Throughout my work, I emphasize the importance of working to connect officials and policymakers to the community and in different projects have developed materials that educate, reduce stigma, convey optimistic messages, and move from just awareness to action.

In May 2015, a collaboration between the Association of Liver Patient Care (ALPC) and the epidemiology unit of the Egyptian Liver Research Institute and the Community Medicine Research Dept. of the National Research Centre launched an innovative project called “Towards a village free from viral hepatitis”. This project is aimed at working with ‘prototype’ villages in Egypt to eliminate viral hepatitis locally, implementing community-based outreach interventions and provision of accessible and comprehensive treatment and care services. We offered free screening for nearly half a million people and free treatment and care for all diagnosed cases. We declared 63 villages free from viral hepatitis in 2018.

"We offered free screening for nearly half a million people and free treatment and care for all diagnosed cases. We declared 63 villages free from viral hepatitis in 2018"

It is with the backdrop of this research and community engagement at many different levels here in Egypt, and as a longstanding ELPA member, that I became involved with the Hep-CORE Study Group this year.

Dr. Ammal Metwally speaks to a community about risk behaviors and emerging practices in the Egyptian context that lead to increased HCV transmission. El Othmanyia, Egypt.

What makes Hep-CORE unique in the viral hepatitis research realm?

Hep-CORE is unique as it provides data on policy progress and achievements in pursuit of viral hepatitis elimination from the patient group perspective. It has always highlighted topics that are otherwise neglected somehow in research and provides comparative policy monitoring figures that should help policy officials plan for the next steps.

"Hep-CORE is unique as it provides data on policy progress and achievements in pursuit of viral hepatitis elimination from the patient group perspective"

Hep-CORE enhanced the collaboration between all ELPA members. It enabled positive information exchange between its members and, in particular, Hep-CORE inspired me to direct my current research to focus on micro-elimination for hep C and to build more links with WHO staff in Egypt. 

What do you see as the role for viral hepatitis patient groups in research and advocacy?

Patient groups can, and should, advocate for actions and initiatives according to their country’s situation. They can also anticipate future challenges for fighting liver diseases and identify areas where action is needed. Patient groups have the potential to highlight the real size of the hepatitis problem, to work with professional bodies such as the European Association for the Study of the Liver (EASL) and with the EU to ensure that treatment and care are harmonised to the highest standards.

"Patient groups can, and should, advocate for actions and initiatives according to their country’s situation. They can also anticipate future challenges for fighting liver diseases and identify areas where action is needed"

Hepatitis patient groups by combating stigma and discrimination, improving public awareness in order to “find the missing millions” – 9 out of 10 people with viral hepatitis are unaware – and helping other patients to improve their quality of life.

Dr. Ammal Metwally displays her commitment to the “NOhep” campaign in Egypt.

What would you like to see happen after this years’ Hep-CORE 2018 study results come in?

I am hoping that policies will improve for all neglected and marginalized groups and that micro-elimination projects will target them. Hoping that patient groups could work with researchers and policymakers to adopt improved policy, scientific approaches, and actions to counteract gaps identified in Hep-CORE.

Based on your experience in the viral hepatitis field, what is the most urgent/crucial area to be addressed in future research?

Behaviour change, care and surveillance are crucial areas to be addressed in future research. I believe that hepatitis patient groups specifically can make a difference and accelerate the hepatitis elimination process by combating stigma.

More information

Hep-CORE Study Group

Scientific References

• Metwally A, Mohsen A, Saleh R, Foaud W, Ibrahim N, Rabaah T, El-Sayed M. (2014). Prioritizing High-Risk Practices and Exploring New Emerging Ones Associated With Hepatitis C Virus Infection in Egypt. Iranian J Publ Health, Vol. 43, No.10, Oct 2014, pp.1385-1394.
• Metwally A, Elmosalami D, Fouad W, Khalifa A, Etreby L, AbdelRahman M. (2013). 'Assessing Psycho-Social Stressors for Chronically Infected Hepatitis C virus Patients in Egypt', World Academy of Science, Engineering and Technology, International Science Index 84, International Journal of Medical Science and Engineering, 7(12), 819 – 828.

Further Hep-CORE Reading

• Bielen R, Stumo S, Halford R, Werling K, Reic T, Stöver H, Robaeys G, Lazarus JV, Harm reduction and hepatitis in European prisons: Results from the 2016 Hep-CORE Study. Harm Reduction Journal (2018) 5:25. doi.org/10.1186/s12954-018-0230-1.
• Lazarus JV, Stumo SR, Maticic M, Harris M, Hetherington KL, Jauffret-Roustide M, Tallada J, Simojoki K, Reic T, Safreed-Harmon K, on behalf of the Hep-CORE Study Group. HEP-CORE: a cross-sectional study of the viral hepatitis policy environment reported by patient groups in 25 European countries in 2016 and 2017. J Int AIDS Soc. 2018, 21(S2):e25052. doi.org/10.1002/jia2.25052.
• Lazarus JV, Safreed-Harmon K, Stumo SR, Jauffret-Roustide M, Maticic M, Reic T, Schatz E, Tallada J, Harris M, on behalf of the Hep-CORE Study Group. Restrictions on access to direct-acting antivirals for people who inject drugs: The European Hep-CORE study and the role of patient groups in monitoring national HCV responses, Int J Drug Policy 2017 Jul 6. doi: 10.1016/j.drugpo.2017.05.054.