Karima Chaabna

The Epidemiology of Hepatitis C Virus in the Fertile Crescent: Systematic Review and Meta-Analysis.

Objective To characterize hepatitis C virus (HCV) epidemiology in countries of the Fertile Crescent region of the Middle East and North Africa (MENA), namely Iraq, Jordan, Lebanon, Palestine, and Syria. Methods We systematically reviewed and synthesized available records of HCV incidence and prevalence following PRISMA guidelines. Meta-analyses were implemented using a DerSimonian-Laird random effects model with inverse weighting to estimate the country-specific HCV prevalence among the various at risk population groups. Results We identified eight HCV incidence and 240 HCV prevalence measures in the Fertile Crescent. HCV sero-conversion risk among hemodialysis patients was 9.2% in Jordan and 40.3% in Iraq, and ranged between 0% and 3.5% among other populations in Iraq over different follow-up times. Our meta-analyses estimated HCV prevalence among the general population at 0.2% in Iraq (range: 0–7.2%; 95% CI: 0.1–0.3%), 0.3% in Jordan (range: 0–2.0%; 95% CI: 0.1–0.5%), 0.2% in Lebanon (range: 0–3.4%; 95% CI: 0.1–0.3%), 0.2% in Palestine (range: 0–9.0%; 95% CI: 0.2–0.3%), and 0.4% in Syria (range: 0.3–0.9%; 95% CI: 0.4–0.5%). Among populations at high risk, HCV prevalence was estimated at 19.5% in Iraq (range: 0–67.3%; 95% CI: 14.9–24.5%), 37.0% in Jordan (range: 21–59.5%; 95% CI: 29.3–45.0%), 14.5% in Lebanon (range: 0–52.8%; 95% CI: 5.6–26.5%), and 47.4% in Syria (range: 21.0–75.0%; 95% CI: 32.5–62.5%). Genotypes 4 and 1 appear to be the dominant circulating strains. Conclusions HCV prevalence in the population at large appears to be below 1%, lower than that in other MENA sub-regions, and tending towards the lower end of the global range. However, there is evidence for ongoing HCV transmission within medical facilities and among people who inject drugs (PWID). Migration dynamics appear to have played a role in determining the circulating genotypes. HCV prevention efforts should be targeted, and focus on infection control in clinical settings and harm reduction among PWID.

Hepatitis C Virus Epidemiology in Djibouti, Somalia, Sudan, and Yemen: Systematic Review and Meta-Analysis

Objectives To characterize hepatitis C virus (HCV) epidemiology and assess country-specific population-level HCV prevalence in four countries in the Middle East and North Africa (MENA) region: Djibouti, Somalia, Sudan, and Yemen. Methods Reports of HCV prevalence were systematically reviewed as per PRISMA guidelines. Pooled HCV prevalence estimates in different risk populations were conducted when the number of measures per risk category was at least five. Results We identified 101 prevalence estimates. Pooled HCV antibody prevalence in the general population in Somalia, Sudan and Yemen was 0.9% (95% confidence interval [95%CI]: 0.3%–1.9%), 1.0% (95%CI: 0.3%–1.9%) and 1.9% (95%CI: 1.4%–2.6%), respectively. The only general population study from Djibouti reported a prevalence of 0.3% (CI: 0.2%–0.4%) in blood donors. In high-risk populations (e.g., haemodialysis and haemophilia patients), pooled HCV prevalence was 17.3% (95%CI: 8.6%–28.2%) in Sudan. In Yemen, three studies of haemodialysis patients reported HCV prevalence between 40.0%-62.7%. In intermediate-risk populations (e.g.. healthcare workers, in patients and men who have sex with men), pooled HCV prevalence was 1.7% (95%CI: 0.0%–4.9%) in Somalia and 0.6% (95%CI: 0.4%–0.8%) in Sudan. Conclusion National HCV prevalence in Yemen appears to be higher than in Djibouti, Somalia, and Sudan as well as most other MENA countries; but otherwise prevalence levels in this subregion are comparable to global levels. The high HCV prevalence in patients who have undergone clinical care appears to reflect ongoing transmission in clinical settings. HCV prevalence in people who inject drugs remains unknown.

Protocol for a systematic review and meta-analysis of hepatitis C virus (HCV) prevalence and incidence in the Horn of Africa sub-region of the Middle East and North Africa

BackgroundIn the Middle East and North Africa (MENA), hepatitis C virus (HCV) distribution appears to present a wide range of prevalence. The scale and nature of HCV disease burden is poorly known in the Horn of Africa sub-region of MENA including Djibouti, Somalia, and Sudan in addition to Yemen at the southwest corner of the Arabian Peninsula. The aim of this review is to provide a systematic review and synthesis of all epidemiological data on HCV prevalence and incidence among the different population groups in this sub-region of MENA. A second aim of the study is to estimate the national population-level HCV prevalence for each of these four countries.Methods/designThe systematic review will be conducted based on the items outlined in the PRISMA statement. PubMed, Embase, and the World Health organization (WHO) regional databases will be searched for eligible studies without language or date restrictions. Observational and intervention studies reporting data on the prevalence or incidence of HCV in any population group in Djibouti, Somalia, Sudan, or Yemen will be included. Additional sources will be obtained through the database of the MENA HIV/AIDS Epidemiology Synthesis Project, including international organizations’ reports and country-level reports, and abstracts of international conferences. Study and population characteristics will be extracted from eligible publications, with previously agreed pro formas; and entered into a computerized database. We will pool prevalence using DerSimonian and Laird random-effects models after a Freeman-Tukey transformation to stabilize variances. We will conduct meta-regression analysis to explore the effect of study-level characteristics as potential sources of heterogeneity.DiscussionThis proposed systematic review and meta-analysis aims to better describe HCV infection distribution across countries in the Horn of Africa sub-region of MENA; and between sub-population groups within each country. The study will provide empirical evidence necessary for researchers, policy-makers, and public health stakeholders to set research, policy, and programming priorities for HCV prevention, control, and treatment.Systematic review registrationPROSPERO CRD42014010318

Hepatitis C virus genotypes in the Middle East and North Africa: Distribution, diversity, and patterns

Our objective was to characterize the distribution, diversity and patterns of hepatitis C virus (HCV) genotypes in the Middle East and North Africa (MENA). Source of data was a database of HCV genotype studies in MENA populated using a series of systematic literature searches. Pooled mean proportions were estimated for each genotype and by country using DerSimonian‐Laird random‐effects meta‐analyses. Genotype diversity within countries was assessed using Shannon Diversity Index. Number of chronic infections by genotype and country was calculated using the pooled proportions and country‐specific numbers of chronic infection. Analyses were conducted on 338 genotype studies including 82 257 genotyped individuals. Genotype 1 was dominant (≥50%) in Algeria, Iran, Morocco, Oman, Tunisia, and UAE, and was overall ubiquitous across the region. Genotype 2 was common (10‐50%) in Algeria, Bahrain, Libya, and Morocco. Genotype 3 was dominant in Afghanistan and Pakistan. Genotype 4 was dominant in Egypt, Iraq, Jordan, Palestine, Qatar, Saudi Arabia, and Syria. Genotypes 5, 6, and 7 had limited or no presence across countries. Genotype diversity varied immensely throughout MENA. Weighted by population size, MENAs chronic infections were highest among genotype 3, followed by genotype 4, genotype 1, genotype 2, genotype 5, and genotype 6. Despite ubiquitous presence of genotype 1, the vast majority of chronic infections were of genotypes 3 or 4, because of the sizable epidemics in Pakistan and Egypt. Three sub‐regional patterns were identified: genotype 3 pattern centered in Pakistan, genotype 4 pattern centered in Egypt, and genotype 1 pattern ubiquitous in most MENA countries.

Migrants, healthy worker effect, and mortality trends in the Gulf Cooperation Council countries

The Gulf Cooperation Council (GCC) countries namely, Bahrain, Kuwait, Oman, Qatar, United Arab Emirates (UAE), and Saudi Arabia, have experienced unique demographic changes. The major population growth contributor in these countries is young migrants, which has led to a shift in the population age pyramid. Migrants constitute the vast proportion of GCC countries’ population reaching >80% in Qatar and UAE. Using Global Burden of Disease Study 2015 (GBD 2015) and United Nations data, for the GCC countries, we assessed the association between age-standardized mortality and population size trends with linear and polynomial regressions. In 1990–2015, all-cause age-standardized mortality was inversely proportional to national population size (p-values: 0.0001–0.0457). In Bahrain, Qatar, Oman, and Saudi Arabia, the highest annual decrease in mortality was observed when the annual population growth was the highest. In Qatar, all-cause age-specific mortality was inversely proportional to age-specific population size. This association was statistically significant among the 5–14 and 15–49 age groups, which have the largest population size. Cause-specific age-standardized mortality was also inversely proportional to population size. This association was statistically significant for half of the GBD 2015-defined causes of death such as “cirrhosis and other chronic liver diseases” and “HIV/AIDS and tuberculosis”. Remarkably, incoming migrants to Qatar have to be negative for HIV, hepatitis B and C, and tuberculosis. These results show that decline in mortality can be partly attributed to the increase in GCC countries’ population suggesting a healthy migrant effect that influences mortality rates. Consequently, benefits of health interventions and healthcare improvement are likely to be exaggerated in such countries hosting a substantial proportion of migrants compared with countries where migration is low. Researchers and policymakers should be cautious to not exclusively attribute decline in mortality within the GCC countries as a result of the positive effects of health interventions or healthcare improvement.

Hepatitis C virus viremic rate in the Middle East and North Africa: Systematic synthesis, meta-analyses, and meta-regressions

Objectives To estimate hepatitis C virus (HCV) viremic rate, defined as the proportion of HCV chronically infected individuals out of all ever infected individuals, in the Middle East and North Africa (MENA). Methods Sources of data were systematically-gathered and standardized databases of the MENA HCV Epidemiology Synthesis Project. Meta-analyses were conducted using DerSimonian-Laird random-effects models to determine pooled HCV viremic rate by risk population or subpopulation, country/subregion, sex, and study sampling method. Random-effects meta-regressions were conducted to identify predictors of higher viremic rate. Results Analyses were conducted on 178 measures for HCV viremic rate among 19,593 HCV antibody positive individuals. In the MENA region, the overall pooled mean viremic rate was 67.6% (95% CI: 64.9–70.3%). Across risk populations, the pooled mean rate ranged between 57.4% (95% CI: 49.4–65.2%) in people who inject drugs, and 75.5% (95% CI: 61.0–87.6%) in populations with liver-related conditions. Across countries/subregions, the pooled mean rate ranged between 62.1% (95% CI: 50.0–72.7%) and 70.4% (95% CI: 65.5–75.1%). Similar pooled estimates were further observed by risk subpopulation, sex, and sampling method. None of the hypothesized population-level predictors of higher viremic rate were statistically significant. Conclusions Two-thirds of HCV antibody positive individuals in MENA are chronically infected. Though there is extensive variation in study-specific measures of HCV viremic rate, pooled mean estimates are similar regardless of risk population or subpopulation, country/subregion, HCV antibody prevalence in the background population, or sex. HCV viremic rate is a useful indicator to track the progress in (and coverage of) HCV treatment programs towards the set target of HCV elimination by 2030.

Gray literature in systematic reviews on population health in the Middle East and North Africa: protocol of an overview of systematic reviews and evidence mapping

BackgroundSystematic review (SR) guidelines recommend extending literature search to gray literature in order to identify all available data related to the review topic. We aim to conduct an overview of SRs on population health in the Middle East and North Africa (MENA), to assess the methodology of these SRs, to produce an evidence map highlighting methodological gaps in SRs regarding gray literature searching, and to aid in developing future SRs by listing gray literature sources related to population health in MENA.Methods/designWe will conduct an overview of SRs based on the Cochrane Handbook for Systematic Reviews of Interventions. This overview will be reported following PRISMA 2009 guidelines. Using comprehensive search criteria, we will search the PubMed database to identify relevant SRs published since 2008. Our primary outcomes are gray literature sources and study-level quality in the gray literature. We will include MENA countries with Arabic, English, French, and/or Urdu as primary official languages and/or media of instruction in universities. Two reviewers will independently conduct a multilevel screening on Rayyan software. Extraction of relevant data will be done on Statistical Package for the Social Sciences (SPSS) software. The methodological quality of included SRs will be assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) tool. Any disagreements will be resolved by discussion and consensus.We will estimate the overall proportion of SRs that used gray literature as one of their data sources. Subgroup analyses will be conducted to identify characteristics of these gray literature sources. Chi-squared and t tests will be used to determine whether the differences between subgroups are statistically significant. Additionally, an evidence gap map will be constructed to highlight characteristics and quality of the gray literature used in SRs on population health in MENA and emphasize existing gaps in gray literature searching. We will also list gray literature sources identified in the included SRs stratified by country and research topic.DiscussionThis overview will comprehensively assess the overall quality of the SRs on population health issues in MENA. Our findings will contribute to the improvement of population health research practices in MENA.Systematic review registrationThe systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 26 October 2018 (registration number CRD42017076736 (Syst Rev 2:4, 2013).

Enteric Salmonella in humans and food in the Middle East and North Africa: protocol of a systematic review

Introduction Non-typhoidal Salmonella is considered one of the leading causes of foodborne disease worldwide. This protocol provides methods that will be used to synthesise available epidemiological data on non-typhoidal enteric Salmonella in humans and food in Middle East and North Africa (MENA) region and to characterise the morbidity of human salmonellosis in this region. Methods and analysis A systematic review will be conducted based on the Cochrane Collaboration handbook and will be reported following the items outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We will search PubMed, Embase, CAB Direct and Global Health Library (WHO) databases in order to identify relevant reports. Additionally, the literature search will be supplemented by checking references of the included reports and the identified reviews. Furthermore, we will hand-search conference proceedings and Ministry of Healths website of each country of the MENA region. We will use comprehensive search criteria with no time and no language restrictions. We will extract data on report and study characteristics, biological assay characteristics, individuals’ demographic characteristics and on primary and secondary outcomes of interest. If appropriate, meta-analysis will be conducted in order to estimate pooled prevalence measures using DerSimonian and Laird random-effects models. We will conduct meta-regression analysis to explore the effect of study-level characteristics as potential sources of heterogeneity. Ethics and dissemination The results of the systematic review will be disseminated in a peer-reviewed journal and presented at relevant conferences. Trial registration number The trial registration number is CRD42016046360.

Systematic overview of hepatitis C infection in the Middle East and North Africa

AIM To assess the quality of and to critically synthesize the available data on hepatitis C infections in the Middle East and North Africa (MENA) region to map evidence gaps. METHODS We conducted an overview of systematic reviews (SRs) following an a priori developed protocol (CRD42017076736). Our overview followed the preferred reporting items for systematic reviews and meta-analyses guidelines for reporting SRs and abstracts and did not receive any funding. Two independent reviewers systematically searched MEDLINE and conducted a multistage screening of the identified articles. Out of 5758 identified articles, 37 SRs of hepatitis C virus (HCV) infection in populations living in 20 countries in the MENA region published between 2008 and 2016 were included in our overview. The nine primary outcomes of interest were HCV antibody (anti-) prevalences and incidences in different at-risk populations; the HCV viremic (RNA positive) rate in HCV-positive individuals; HCV viremic prevalence in the general population (GP); the prevalence of HCV co-infection with the hepatitis B virus, human immunodeficiency virus, or schistosomiasis; the HCV genotype/subtype distribution; and the risk factors for HCV transmission. The conflicts of interest declared by the authors of the SRs were also extracted. Good quality outcomes reported by the SRs were defined as having the population, outcome, study time and setting defined as recommended by the PICOTS framework and a sample size > 100. RESULTS We included SRs reporting HCV outcomes with different levels of quality and precision. A substantial proportion of them synthesized data from mixed populations at differing levels of risk for acquiring HCV or at different HCV infection stages (recent and prior HCV transmissions). They also synthesized the data over long periods of time (e.g., two decades). Anti-HCV prevalence in the GP varied widely in the MENA region from 0.1% (study dates not reported) in the United Arab Emirates to 2.1%-13.5% (2003-2006) in Pakistan and 14.7% (2008) in Egypt. Data were not identified for Bahrain, Jordan, or Palestine. Good quality estimates of anti-HCV prevalence in the GP were reported for Algeria, Djibouti, Egypt, Iraq, Morocco, Pakistan, Syria, Sudan, Tunisia, and Yemen. Anti-HCV incidence estimates in the GP were reported only for Egypt (0.8-6.8 per 1000 person-year, 1997-2003). In Egypt, Morocco, and the United Arab Emirates, viremic rates in anti-HCV-positive individuals from the GP were approximately 70%. In the GP, the viremic prevalence varied from 0.7% (2011) in Saudi Arabia to 5.8% (2007-2008) in Pakistan and 10.0% (2008) in Egypt. Anti-HCV prevalence was lower in blood donors than in the GP, ranging from 0.2% (1992-1993) in Algeria to 1.7% (2005) in Yemen. The reporting quality of the outcomes in blood donors was good in the MENA countries, except in Qatar where no time framework was reported for the outcome. Some countries had anti-HCV prevalence estimates for children, transfused patients, contacts of HCV-infected patients, prisoners, sex workers, and men who have sex with men. CONCLUSION A substantial proportion of the reported outcomes may not help policymakers to develop micro-elimination strategies with precise HCV infection prevention and treatment programs in the region, as nowcasting HCV epidemiology using these data is potentially difficult. In addition to providing accurate information on HCV epidemiology, outcomes should also demonstrate practical and clinical significance and relevance. Based on the available data, most countries in the region have low to moderate anti-HCV prevalence. To achieve HCV elimination by 2030, up-to-date, good quality data on HCV epidemiology are required for the GP and key populations such as people who inject drugs and men who have sex with men.

Adult mortality trends in Qatar, 1989-2015: national population versus migrants

Introduction With the increase of Qatar’s total population, primarily due to the influx of healthy male migrant labor, worldwide attention has been focused on deaths among these migrant workers. Objective To describe adult mortality trends in Qataris (nationals) and non-Qataris (migrants) from all causes, cardiovascular and circulatory disease, neoplasms, and injuries, 1989–2015. Methods We retrieved Qatar’s vital registration data by nationality, sex, age group, year, and codes of the World Health Organization’s International Classification of Diseases, Ninth and Tenth Revisions. We assessed age-standardized mortality rate (ASMR) trends in Qatar’s total population, in Qataris and non-Qataris using Joinpoint regression. Findings During the study period, 26,673 deaths were recorded. In 2015, we estimated 60,716 years of life lost (82% in males) in the overall population. In Qataris (both sexes) and in non-Qatari females, all-cause rate decreased significantly and steadily between 1989–2015. In non-Qatari males, it decreased significantly between 1998–2010 probably attributed to a massive influx of healthy migrants. Yearly rates were significantly lower in non-Qataris over 27 years. Reduction in Qatar’s total population rates for all causes and for neoplasms can be partially attributed to the healthy migrant effect. For injuries in males, it was lower in non-Qatari. Remarkably, for falls, cause-specific ASMR in non-Qatari males decreased significantly reaching 2.6/100,000 in 2014, suggesting improved safety in the work environment. However, while young adult males in Qatar die predominantly from injuries, young adult females die from neoplasms. Conclusion Our study demonstrates that premature death in young adult males and females in Qatar is predominantly due to injuries and neoplasms respectively. These identified causes of death are for a large part preventable and should be addressed appropriately to lower premature mortality among young adults in Qatar.