Hepatitis A virus in Middle East countries: More evidence needed

Received 10 September 2009; accepted 3 January 2010. published online 08 March 2010.

Article Outline

Hepatitis A virus (HAV) infection accounts for 75% of all cases of hepatitis in the world [1] and approximately about 1.5 million symptomatic cases of hepatitis A occur annually in the world [2]. This infection can easily spread by close contact with infected persons, by contaminated food, water and blood products [3]. Prevalence of HAV infection differs greatly in various parts of the world according to the geographic area, sanitary conditions and socioeconomic levels [4], [5], [6], [7]. There are several reports about a shifting epidemiological pattern of HAV from high prevalence to lower endemicity as a result of improved living conditions from all over the world, even in underdeveloped and developing countries [1], [8], [9], [10], [11], [12], [13]. Although this seems to be desirable, reports exist on higher risk of outbreaks among the adult population who have not been exposed to HAV in their life before and are, therefore, not immune [9]. An effective strategy to protect non-immune populations against this disease is necessary. To achieve this, or at least, to evaluate the necessity of protecting susceptible populations, estimating the global prevalence of HAV, especially the epidemiological features in areas like the Middle East in which HAV is known to be endemic is mandatory. In spite of HAV endemicity in Middle East countries, there are not enough up to date data on the current situation of the disease. In this respect, there are great variations between different Middle East countries and even between various parts of the same country in some regions due to difference in sanitary and socioeconomic levels [14], [15]. The prevalence rates of anti-HAV antibodies has been demonstrated to vary in different parts and among different populations of the same country [15], [16], [17]. For instance, the prevalence rate in Children less than 15years of age was 20.1%, 29%, 30.2%, 22.3% and 50% in United Arab Emirates [18], in Turkey [19], in Saudi Arabia [19], in Iran [20] and in Egypt [21], respectively but it was higher in Lebanon [22] and Syria [23] according to published reports. Although this variation can be attributed to differences in design of various studies, yet an important factor remains different sanitary conditions and hygienic improvements in various parts of the studied countries. Hepatitis A virus is mainly transmitted via the faecal-oral route by a person to person spread, contaminated food products, contaminated water supplies, shellfish, oysters, fresh fruits and vegetables like green onions, tomatoes, strawberries, raspberries and even their frozen products [24], [25], [26]. Water sources contaminated by sewage has been reported as the most likely identified responsible factor in some outbreaks, especially in developing countries [27]. Travelling from low prevalence countries to those with higher prevalence has been reported as a causative factor [28], [29], [30]. The booming tourism industry in the Middle East recommends efficient protective ways against hepatitis A.

The necessity for a higher universal attention on hepatitis A prevention is an extremely important point which has been emphasized in the first global meeting on HAV infection as the most common vaccine preventable disease in 2007 [31]. In addition to raising hygienic conditions of life, immunoprophylaxis such as vaccination and immunoglobulin administration, play important roles as promising preventive measures [32]. Vaccination has been indicated for travelers from low endemic areas to regions with higher prevalence of HAV [7], [33]. Passive immunization with immunoglobulin is another management policy [34]. Some studies illustrate, that post exposure prophylaxis is wiser when HAV prevalence is not high [33]. Therefore, making decision about prevention strategies in Middle East countries necessitates a comprehensive study of the current prevalence of HAV. Such information will help in designing vaccination guidelines customized according to HAV prevalence in different countries, various parts of the same country and different populations. Getting more accurate data on prevalence of HAV will be invaluable in revising prevention protocols for travelers to HAV intermediate and high endemic areas.

The serious threat for HAV outbreaks in the Middle East can be realized when considering the number of non-immune travelers (tourists, businessmen) coming to the region and the militarily unrest with its consequences related to hygiene and mobilization of army forces that may be also non-immune. These factors together with the above mentioned heterogeneity may pose question regarding the most suitable prevention method. Things can get more complicated if other factors as the annual incidence of fulminant hepatitis A cases as well as the costs of hospitalization and treatment, costs of HAV vaccine purchase and the gross national income are considered. Cost effectiveness studies will make it possible to analyze all the above mentioned factors together and conclude whether or not to implement HAV mass vaccination. Unfortunately, and till now it is not possible to categorize Middle East countries, even those with considerable numbers of prevalence studies, to HAV high, intermediate and low endemic areas accurately.

In conclusion, to be able to define more effective prevention strategies against HAV, more accurate prevalence data from all over the world, especially from areas like the Middle East should be obtained.

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Tehran University of Medical Sciences, Tehran, Iran

Department of Internal Medicine, Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences & Tehran Hepatitis Center, Vanaq Square, Mola Sadra St., Tehran, Iran Tel./fax: +98 21 8894186 8

PII: S1687-1979(10)00003-1

doi:10.1016/j.ajg.2010.01.002

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