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Year : 2011  |  Volume : 22  |  Issue : 1  |  Page : 1-9
Epidemiology of hepatitis C in the middle east

Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran

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Date of Web Publication30-Dec-2010


The epidemiology of hepatitis C virus (HCV) infection is not well defined in the Middle East region. A review of the epidemiology and modes of transmission and spread of HCV infection in regions located in the Middle East, including Iran, Bahrain, Iraq, Oman, Qatar, Jordan, Kuwait, Saudi Arabia, United Arab Emirates, Cyprus, Sudan, Egypt, Pakistan, Syria, Turkey, Lebanon, Gaza Strip and West Bank, and Yemen, was undertaken. Public health strategies, well­programmed, population-based and certain HCV infection at-risk surveys, and transmission risk factors' settings detection are insufficient in some countries of this region. Since significant diffe­rences in prevalence and epidemiology of HCV exist among the Middle East countries or even inside the countries, control strategies should take these differences into account.

How to cite this article:
Fallahian F, Najafi A. Epidemiology of hepatitis C in the middle east. Saudi J Kidney Dis Transpl 2011;22:1-9

How to cite this URL:
Fallahian F, Najafi A. Epidemiology of hepatitis C in the middle east. Saudi J Kidney Dis Transpl [serial online] 2011 [cited 2023 Feb 6];22:1-9. Available from: https://www.sjkdt.org/text.asp?2011/22/1/1/74334

   Introduction Top

The Middle East is a geographical region of Africa-Eurasia with no clear definition; it tra­ditionally includes regions in Southwest Asia and parts of North Africa, consisting of Bahrain, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Leba­non, Oman, Qatar, Saudi Arabia, Syria, Turkey, United Arab Emirates, Yemen, Palestinian Territories and western parts of Pakistan. The inclusion of countries Azerbaijan, Armenia and Georgia, Greece, Cyprus, North Africa and the Maghreb is controversial because they are lo­cated outside the arbitrary geographical boun­daries of the Middle East.

Infections with the hepatitis C virus (HCV) are pandemic, and the World Health Organi­zation (WHO) estimates a world-wide preva­lence of 3%. In Middle Europe, approximately 1% of the population is infected, mostly with genotype 1 (85% in Austria). In developing countries, chronic hepatitis C is the most pro­minent cause for liver cirrhosis, hepatocellular carcinoma and liver transplantation. Transmi­ssion of HCV was predominantly iatrogenic, e.g. by blood transfusions before 1990, by blood products such as coagulation factors in hemophiliacs or anti-D-globulin in rhesus in­compatibility, parenteral anti-schistosomal treat­ment in Egypt, contaminated endoscopes or cardiac surgery. Today, sporadic transmission is more prevalent, mostly in drug addicts via needle sharing, and seldom by needle-stick in­juries in medical personnel, vertical transmi­ssion from mother to baby, tattooing, piercing, or razor sharing. [1]

The World Health Organization (WHO) estimates that there are at least 21.3 million HCV carriers in the Eastern Mediterranean countries, which is close to the number of carriers esti­mated in the Americas and Europe combined. Accumulated data show that there are two main patterns for the distribution of HCV geno­types in the Middle East: in the first pattern, genotype 4 is prevalent in most of the Arab countries, and in the second pattern, genotype 1a or 1b predominates in the non-Arab countries. [2],[3]

Reference sequences for accurate HCV geno­typing are required for optimized treatment, and a better knowledge of the global viral se­quence diversity is necessary to guide vaccines or new drugs effective in the worldwide epi­demic. [4] The epidemiology and modes of trans­mission and spread of HCV infection in the Middle East are reviewed in this article through the published literature about the subject.

   Prevalence and Risk Factors for HCV Infection in the Middle East Top


The prevalence of HCV infections per 100,000 Iranian blood donations was 0.13% for HCV, and the trends of infection prevalence in blood donations suggest the improvement of the safety measures employed in recent years in Iran. [5],[6] However, in 298 hemodialysis (HD) patients in Guilan province, overall HCV prevalence was 24.8%. Length of time on dialysis and history of rejected kidney transplant were statistically significantly associated with HCV infection. [7] Moreover, in another study, there was no sig­nificant correlation between the number of trans­fusions and HCV seropositivity. [8] Nevertheless, the prevalence of positive HCV antibodies (Ab) in the HD patients decreased over time. [9],[10],[11],[12],[13]

The prevalence of positive HCV Ab among household contacts (1.33%) was not signifi­cantly higher than that in the controls (1%). Intrafamilial transmission of HCV is not the significant transmission route and sexual trans­mission does not seem to play a role in the intrafamilial spread of HCV infection. [14]

The prevalence of HCV infection among the IV drug abusers was elevated [15] and associated with the length of intravenous drug injection habit, length of lifetime incarcerations and a history of being tattooed. [16] Moreover, the rate of HCV infection among HIV-positive cases was significantly higher than in the HIV negative patients. [17],[18],[19] The expansion of services for drug users in Iran such as needle and syringe programs and pharmacotherapy would be effec­tive in reducing the harms associated with opium use and heroin injection. [20]

The highest frequency was for HCV geno­type 1a, followed by genotype 3a and 1b in addition to mixed genotypes, [21],[22],[23] and subtype 1a was frequent in South Iran (70%), while 3a was more prevalent in North-west region (83%). Additionally, genotype 4 was over-represented among HD patients in Tehran. [24]


Among the multi-transfused patients with he­molytic anemia, 40% were seropositive for HCV antibody. [25] Among Bahraini HD patients, the prevalence of HCV was 9.24% and the geno­types were HCV 1a/1b plus HCV 4. [26]


The prevalence of anti-HCV antibodies is 7.1% in the general population [27] and 66.0% in HIV-infected hemophilia patients. Four HCV genotypes, 1a, 1b, 4 and 4, mixed with 3a were detected, and HCV-1b was the most frequent genotype. [28],[29]

The anti-HCV seroprevalence in pregnant women was 3.21% and correlated with the number of miscarriages and HCV-1b genotype. [30]

In 1005 samples of refugee Kurds from Iraq and Turkey, one subject was confirmed as po­sitive for anti-HCV (0.1%) and HCV-RNA and analysis showed a 4c/4d genotype. [31]


In a study, 26.5% of 102 sera from Omani patients on HD, 13.4% of 82 sera from kidney transplant patients and 1% of 103 sera from non-dialyzed, non-transplanted patients with various renal diseases had antibodies to HCV. Among the healthy subjects, none of 134 me­dical students and 0.9% of 564 blood donors were anti-HCV positive. [32]

HCV antibody detection was carried out on 600 seronegative blood donors and 9 (1.5%) were positive; only three antibody-positive samples had detectable HCV RNA. [33]


A 6.3 incidence rate of HCV infection was reported in the general population [34] and 44.6% incidence was reported in dialysis patients, significantly correlating with an increased pe­riod on dialysis. [35] Indian workers contributed significantly to HCV and contracted it before traveling to Qatar. [36]


HCV is prevalent among regular HD in the south of Jordan (28%) and risk factors include history of blood transfusion, history of kidney transplantation, history of other surgeries, and duration on HD. [37] Similar results were ob­tained in another study and the pre-dominant genotype was HCV la. [38] The prevalence of HCV in the general population was from 0.65 to 6.25%, depending on the sub population studied, [39] and was 40.5% in the multi-trans­fused patients presenting with hereditary hemo­lytic anemia. [40] Furthermore, the incidence den­sity due to incidental needle sticks was highest for the interns followed by staff nurses and environmental workers. [41]


The prevalence of anti-HCV among Kuwaiti national and non-Kuwaiti Arab first-time donors was 0.8 and 5.4%, respectively. [42]

Saudi Arabia

The prevalence of HCV infections is low in the general population, less in children than in adults, and unscreened blood transfusion be­fore 1990 and intravenous drug use are the main modes of infection. [43],[44],[45] The most prevalent genotypes in Saudi Arabia are genotype 4 followed by genotypes 1a and 1b, whereas genotypes 2a/2b, 3, 5 and 6 are rare. HCV core Ag was detected in 94.8% of the Saudi drug abusers. [46],[47]

The prevalence of HCV was between 18-46% in the regular HD patients. [48] However, the application of the universal precautions and de­signated dialysis machines decreased the pre­valence of HCV infection significantly. Fur­thermore, the prevalence of hepatitis C, as well as hepatitis B, is more frequent in HD (29%) than peritoneal dialysis (5%) units. [49] Patients in the groups with the relatively higher patient­to-nurse (P/N) ratio had a significantly higher HCV prevalence and seroconversion rates per year. [50] Among the renal transplant recipients screened for HCV antibodies, 41% were po­sitive and a higher incidence of chronic liver disease (37.5%) was found in this group. [51]

Blood transfusion was found more among HCV positive HD patients had never received blood transfusion. [52],[53]

United Arab Emirates

The prevalence of anti-HCV antibodies was 23%. [54] Increased prevalence of anti-HCV among spouses was detected, with longer duration of marriage being an important risk factor, [55] and infection was passed to children at an early stage of life from infected mothers. [56]


In a study among soldiers from Turkey, blood donors from Northern Cyprus, and soldiers from Northern Cyprus, prevalence of anti-HCV was 0.46%. Prevalence of HCV infection in Nor­thern Cyprus population was similar to that of Turkish population. [57] A study demonstrated a genetic heterogeneity of HCV infection in Cyprus, with five of the six known HCV geno­types on the island, including unclassified iso­lates in genotypes 1 and 4, and also the appa­rent introduction of the 2k/1b recombinant strain in intravenous drug users. [58]


The overall prevalence of anti-HCV among HD patients was 48.9% with a significant co­rrelation between prevalence of anti-HCV and duration of HD. [59] Genotype 4 was the most frequent genotype followed by genotypes 1 and 5, with no obvious epidemiological reason for prevalence of G5. [60] In another study, the HCV genotype distribution showed 1a, 1b, and 6 4a as the most prevalent genotypes. [61]

The prevalence of HCV antibodies was 60.5% among intravenous drug abusers, 1.96% among the prostitutes group, and 0.95% among blood donors group. [62] Furthermore, the prevalence of HCV antibodies among health care workers was 3%, and in the general population was 1%. [63]


Anti-HCV prevalence rate of 0.6% was re­vealed in blood donors [64] and it was 0.4% among health workers. [65] Cross-contamination unrelated to machines may also occur in HD patients, [66] with seropositivity of 27%. [67] Al­though Lebanon is an area of low endemicity for both HBV and HCV, occult HBV infection is common in HCV-infected patients (16.3%). [68] HCV geno-type 4 was found to be the predo­minant genotype, followed by genotypes 1a and 1b. [69]

Gaza Strip and West Bank

The Gaza Strip borders the southern part of Israel and Egypt. There is a remarkable dif­ference in the prevalence of antibodies to HCV between Israel (0.5%) and Egypt (10%). HCV prevalence in the Gaza Strip was found to be 2.2%, relatively higher than in Israel but lower than in Egypt. The most common genotypes found were type 1b in southern Israel and type 4 in the Gaza Strip, corresponding to the most prevalent genotype in Egypt. [70] Moreover, the incidence of HCV antigen (by PCR) in donors in Gaza was 0 . 1%. [71]


The prevalence of antibodies to HCV was 1.7% in healthy volunteers, 2.7% in blood donors, 33.8% in patients on regular HD, and 33.75% in patients with chronic liver diseases. [72] Similar patterns were found in other studies. [73],[74],[75],[76],[77]


Anti-HCV were detected in 1.0-2.1% of healthy individuals [78],[79] and 4.5% of multi-trans­fused patients with hemolytic anemia. [80] The most common risk factors among index cases were dental procedures, history of surgery, and blood transfusions. Anti-HCV positivity was established in family contacts, sexual partners, and offsprings of infected patients. [81] HCV ge­notypes other than genotype 1 are quite rare; these are possibly acquired in other coun­tries. [82] Both HBV and HCV infections may constitute occupational hazards for certain pro­fessions such as barbers. [83]


Hospitalization, dental treatment from unqua­lified providers, a large number of therapeutic injections, and re-usable glass syringes were identified as risk factors for HBV and HCV infections and remained unchanged in health­ care facilities. [84]

Hepatitis C infection was detected in 1.8% of pregnant women and in 16% of gynecological patients; unsafe surgery, injections and inade­quately screened blood transfusions were the main underlying causes of infection. [85] More­over, the prevalence of HCV in injecting drug users was 17%. [86] Genotype 3 is the most com­mon genotype in Pakistan. [87]


The prevalence of anti-HCV is 2.2-3%. [88],[89] No correlation was found between HCV infec­tion and Schistosoma mansoni infection or pa­renteral antischistosomal therapy. [90] The preva­lence of HCV seropositivity among HD pa­tients was 23.7%, and 17.1% seroconverted to positive in one year. [91] HCV genotype 4 was the major genotype isolated with subtypes 4, 4e and 4c/4d. [92]


Seroprevalence of hepatitis C virus in the urban blood donor population was 14.5%, while the seroprevalence was 70.4% in HD patients, 7.7% in health care workers, and 75.6% in tha­lassemic children. Schistomiasis does not seem to play a role in the seroprevalence of this di­sease in Egypt. [93] Moreover, HCV was found in 12.1% of rural primary school children, 18.1% of residents in rural villages, 22.1% of army re­cruits, 16.4% of children with hepatospleno­megaly, 54.9% of hospitalized multi-transfused children, 46.2% of adults on HD, and 47.2% of adults with chronic liver disease or hepatoma. [94]

A consistent increase of seropositivity for HCV antibodies with age was observed, with a peak level of 54.9% in all individuals for the age group 45-49 years. Analysis revealed that age, male sex, marriage, rural residence, living in upper and lower Egypt, injections for bilhar­ziasis and urography were significant in the final equation for the whole group. Blood trans­fusion was significant in the final regression analysis among females in urban living, and hospitalization was significant among males in urban living and females in rural living. [95] HCV genotype 4a was prevalent. [96],[97]


Anti-HCV was detected in 0.18% of blood donors and 0.19% of pregnant women. [98]

   Comments Top

There are insufficient data about HCV pre­valence and prevention methods in some areas of the Middle East. Although there are signi­ficant differences in prevalence and epidemio­logy of HCV among the Middle East countries or even different societies within the same country, control strategies should take these specific differences into account.

To establish public health strategies, more well-programmed, population-based and cer­tain HCV infection at-risk surveys are needed in the Middle East countries in addition to edu­cation of people about the risk of HCV infec­tion from contaminated instruments and certain traditional habits. Furthermore, efforts should be continued for HCV screening in intrave­nous drug users (IVDU), those who received transfusions, dialysis patients, those with inci­dental exposures in addition to expatriate wor­kers, gypsies, and occupations such as barbers, fire fighters, health care workers. Finally, better laboratory facilities and investigations should be provided for detection of HCV RNA in high-risk groups negative for HCV antibodies.

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