Khalil Kreidieh

Distribution of hepatitis C virus genotypes among injecting drug users in Lebanon

BackgroundThe aim of this study is to determine the prevalence of anti-HCV among injecting drug users (IDUs) in Lebanon, to establish the current prevalence of HCV genotypes in this population and to determine whether demographic characteristics and behavioral variables differ between participants who were HCV-RNA positive and those who were HCV-RNA negative or between the different genotypes. Participants were recruited using respondent-driven sampling method. The blood samples were collected as dried blood spots and then eluted to be tested for HCV, HBV and HIV by ELISA. Anti-HCV positive samples were subjected to RNA extraction followed by qualitative detection and genotyping.ResultsAmong 106 IDUs, 56 (52.8%) were anti-HCV-positive. The two groups did not differ in terms of age, marital status, and nationality. As for the behavioral variable, there was a trend of increased risky behaviors among the HCV-RNA positive group as compared to the HCV-RNA negative group but none of the variables reached statistical significance. Half (50%) of the 56 anti-HCV-positive were HCV-RNA positive. Genotype 3 was the predominant one (57.1%) followed by genotype 1 (21%) and genotype 4 (18%).ConclusionsThe predominance of genotype 3 seems to be the predominant genotype among IDUs in Lebanon, a situation similar to that among IDUs in Western Europe. This study provides a base-line against possible future radical epidemiological variant that might occur in IDUs.

Hepatitis B Virus and Hepatitis C Virus Infections among Female Sex Workers and Men Who Have Sex with Men in Lebanon: Prevalence, Risk Behaviour and Immune Status

BACKGROUND The aim of our study was to study the prevalence of and the risk behaviours associated with the hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among two high-risk groups: female sex workers (FSW) and men who have sex with men (MSM). Furthermore, since vaccination is a key component of HBV prevention programs, the immune status of HBV infection in these two high-risk groups was evaluated. METHODS Participants included in this study were part of a bio-behavioural surveillance study done to assess HIV prevalence among four vulnerable groups in Lebanon. Participants were recruited using a respondent-driven sampling method. The total number of eligible participants were 101 MSM and 103 FSW. Blood samples were collected as dried blood spots and then eluted to be tested for HCV, HBV and HIV by enzyme-linked immunosorbent assay. RESULTS None of the 204 individuals tested has been exposed to HCV. In the 101 MSM, only one (0.99%) was an HBsAg carrier and one (0.99%) was confirmed as anti-HIV-positive. Among FSW, 30% showed they were immune to HBV compared with only ~10% among MSM. The distribution of socio-demographic characteristics and potential risk factors in both groups were shown. CONCLUSION Our results highlight the urgent need to raise awareness among FSW and MSM and their health care providers of the availability and benefits of HBV vaccination in Lebanon. In addition, and due to the absence of vaccines against HCV and HIV, education programs aiming at behavioural changes should be intensified.

Hepatitis C virus infection in the Middle East and North Africa "MENA" region: injecting drug users (IDUs) is an under-investigated population.

PurposeInvestigation of the injecting drug users (IDUs) population is becoming extremely critical and timely in light of the recent evidence that IDUs now act as the core of hepatitis C virus (HCV) epidemics in developed countries. The purpose of this article, therefore, is not only to review the epidemiology of HCV in the Middle East and North Africa (MENA) region, but also to see whether IDUs were adequately studied and whether harm reduction strategies to be applied for their protection have been set.MethodsA literature review was carried out of articles published within the last decade on HCV infection.ResultsThe gathered data showed that the population of IDUs is severely under-investigated throughout the whole region, possibly due to religious and cultural impediments.ConclusionIn order to reduce the risk of HCV infection in IDUs, a set of recommendations are advanced emphasizing the urgent need for bio-behavioral studies in this population in order to help identify the source and mode of transmission and the genotypes of HCV involved. These results may allow the development of effective and, yet, socially acceptable intervention strategies. We believe that the role which IDUs play in sustaining HCV infection is also an under-investigated topic in many developing countries. Similar reviews and, hence, interventions should be initiated in these regions.

Characterization of astrovirus-associated gastroenteritis in hospitalized children under five years of age

PURPOSE The aim of this study was to determine the incidence and genetic diversity of astrovirus (AstV) detected in children hospitalized for gastroenteritis (GE). METHODS A multi-center, hospital-based surveillance study was conducted across Lebanon to investigate the incidence of AstV among diarrheal hospitalizations. Viral RNA was extracted from stool samples collected between 2011 and 2013 from children, below the age of 5years, hospitalized for GE at six medical centers across Lebanon. Demographic and clinical data were collected and analyzed. RNA of eligible samples (n=739) was screened by two AstV-specific PCR assays followed by genotype-specific PCR. Sanger sequencing and phylogenetic analysis were performed for genotypic characterization. RESULTS Overall, 5.5% (41/739) of rotavirus-negative stool samples collected from hospitalized children <5years old tested positive for AstV infection. AstV infections were detected all year long. Diarrhea, dehydration, vomiting and fever were the most common symptoms associated with AstV infections. Children aged 48-59months had the highest incidence of AstV. Using the Vesikari Scoring System to assess clinical severity, 85.4% of children with AstV had a score>11, indicating severe GE. Genotype-specific PCR identified 22 classical and 4 MLB-like AstV specimens. Further sequencing and phylogenetic analysis of orf1b and orf2 genes revealed that AstV classical 1-3, 5, 6, and 8, MLB-1, VA-1 and -2 genotypes circulated in Lebanon. Recombination between classical AstV strains was detected in several cases as evident by the lack of congruency in the tree topologies of the orf1b and orf2. Two cases of mixed infections between classical and non-classical genotypic strains were recorded. CONCLUSION High genetic diversity was detected among AstVs in Lebanon. AstVs are associated with 5.5% of non-rotavirus GE-associated hospitalizations in children under five years in Lebanon.

The Syrian refugees crisis brings challenges to the health authorities in Europe: hepatitis A virus is a case in point

The ongoing 3-year Syrian Civil war has left hundreds of thousands killed or wounded in addition to the displacement of more than 6.5 million Syrians throughout the world [1]. According to the United Nations High Commission on Refugees (UNHCR), the bulk of those displaced are hosted by neighboring countries: Lebanon (approximately 1.2 million people), Jordan (approximately 650,000), Iraq (approximately 250,000) and Turkey (approximately 1.9 million) [1]. It has been reported that slightly more than 10 % of the displaced Syrian refugees are seeking safety in Europe. The majority of the Syrian refugees in Europe are concentrated in Serbia and Germany (57 %) compared to 31 % in Sweden, Hungary, Austria, Netherlands and Bulgaria, and 12 % in the remaining 37 European Countries [2]. These numbers are increasing daily along with the associated challenge of their adequate settlement [3]. The influx of refugees to Europe presents the health authorities with the potential of introducing infectious diseases that have had low rates of morbidity and mortality in the hosting countries across time. These diseases include measles, polio, hepatitis A virus (HAV), hepatitis B virus (HBV), tuberculosis, human immunodeficiency virus (HIV), hepatitis C virus (HCV), cutaneous leishmaniasis, schistosomiasis, MERS-CoV, Haemophilus influenzae type b (Hib), as well as many vaccine-preventable diseases (DTap, meningococcal, varicella) that have been reported to be on the rise among Syrian refugees in Lebanon, Turkey, Jordan and Iraq [4–7]. The breakdown in the Syrian health care infrastructure led to the discontinuation of vaccination programs in the country. The disruption of vaccination in addition to over crowdedness, the miserable living condition and the lack of basic health care facilities culminated in severe outbreaks of vaccine-preventable diseases such as polio [8] and measles [9] in refugee camps in Syria and neighboring countries [10]. While most of the European populations are immunized against vaccine-preventable diseases, an imminent challenge is introduced due to the Syrian settlement in Europe especially due to the lack of implementation of vaccination against expected re-emerging infections; hepatitis A virus infection is a case in point. HAV, a non-enveloped RNA virus belonging to the family picornaviridae, continues to cause significant morbidity in many parts of the world [11]. Recent estimates indicate a global incidence of 1.9 % with 119 million cases infected with HAV [12]. HAV virus is primarily transmitted via ingestion of contaminated food or water or through direct contact with an infected person. The severity of HAV infection increases with age [12]. The overwhelming majority of children \5 years of age show no sign of infection (asymptomatic) compared to more than 70 % of cases in older children and adults presenting with jaundice. Consequently, the proportion of cases requiring hospitalization increases with age ranging from 21 % in children\5 years to 53 % among adults aged C60 years [13]. The endemicity of HAV is ranked as high, intermediate or low in different geographic areas. The level of endemicity correlates with sanitary and hygienic conditions [14]. Consequently, the incidence of hepatitis A infection is strongly correlated with access to safe drinking water, to & Sami Ramia sramia@aub.edu.lb

Hepatitis E Virus in the Countries of the Middle East and North Africa Region:An Awareness of an Infectious Threat to Blood Safety

Introduction: Hepatitis E virus (HEV) is mainly transmitted through contaminated water supplies which make the virus endemic in developing countries including countries of the Middle East and North Africa (MENA) region. Recent reports suggest potential risk of HEV transmission via blood transfusion particularly in endemic areas. Materials and Methods: Related articles on HEV were collected by searching through the 25 countries of the MENA region using Pubmed and Medline within the past 14 years: January 2000-August 2014. Results: One hundred articles were extracted, of which 25 were not eligible. The articles discussed the seroprevalence of HEV and HEV markers in 12 countries. Eight articles provided data on HEV in blood donors. The seroprevalence of HEV in the general MENA population ranged from 2.0%-37.5% and was higher in males than in females. Prevalence increased with age, but exposure seems to be in early life. Discussion: In the MENA region the role of HEV as an infectious threat to blood safety is under-investigated. More data are needed to quantify the risk of transmission and to assess clinical outcomes. This requires, at least, surveillance screening of donors and recipients for HEV markers using sensitive and specific serological tests. At the present time, serious consideration should be given to selective screening for certain groups of patients (e.g. immunocompromised, pregnant women and others) who commonly require blood transfusion and are at high risk of hepatic failure or chronicity from HEV infection.

A review of the diverse genetic disorders in the Lebanese population: highlighting the urgency for community genetic services

The review lists the genetic diseases reported in Lebanese individuals, surveys genetic programs and services, and highlights the absence of basic genetic health services at the individual and community level. The incidence of individual diseases is not determined, yet the variety of genetic diseases reported is tremendous, most of which follow autosomal recessive inheritance reflecting the social norms in the population, including high rates of consanguinity, which favor the increase in incidence of these diseases. Genetic services including all activities for the diagnosis, care, and prevention of genetic diseases at community level are extremely inadequate. Services are limited to some clinical and laboratory diagnostic services with no genetic counseling. These services are localized within the capital thus preventing their accessibility to high-risk communities. Screening programs, which are at the core of public health prevention services, are minimal and not nationally mandated. The absence of adequate genetic services is attributed to many factors undermining the importance of genetic diseases and their burden on society, the most important of which is genetic illiteracy at all levels of the population, including high-risk families, the general public, and most importantly health care providers and public health officials. Thus, a country like Lebanon, where genetic diseases are expected to be highly prevalent, is in utmost need for community genetics services. Strategies need to be developed to familiarize public health officials and medical professionals with medical genetics leading to a public health infrastructure that delivers community genetics services for the prevention and care of genetic disorders at community level.

Update on the epidemiology of rotavirus in the Middle East and North Africa

Rotavirus (RV) is the leading cause of severe acute gastroenteritis (AGE) worldwide. Consequently, we conducted a systematic literature review on articles studying RV in the 25 countries of the MENA region during the past 15years (2000-2015). The methods and reporting were set according to the 2015 preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) and based on the elements from the international prospective register of systematic reviews (PROSPERO). Our literature search identified 169 studies meeting our predefined inclusion criteria. Studies reporting on RV were conducted in 19 out of the 24 countries of the MENA region. The largest number of studies was reported in Turkey (n=32), Iran (n=31), Saudi Arabia (n=19) and Egypt (n=17). The majority of studies reporting on RV gastroenteritis rates were clinical observational studies. In 115 studies out of 169, RV was reported among in-patients whereas 35 studies reported RV among outpatients. The predominantly reported RV genotype in the region was G1[P8] followed by G2[P4] and G9[P8]. The majority of studies (n=108) were conducted among children less than 5years of age whereas the remaining studies reported on AGE among other age groups and rarely adults. In MENA countries, RV infection was reported all year round with peaks described in cold as well as hot months. This systematic review provides a current update on the epidemiology of RV-associated gastroenteritis in countries of the MENA region and draws attention to the major gaps existing in the continuous monitoring of RV.

Clinical and epidemiological characteristics of norovirus gastroenteritis among hospitalized children in Lebanon

AIM To assess the burden of norovirus (NoV) and to determine the diversity of circulating strains among hospitalized children in Lebanon. METHODS Stool samples were collected from children presenting with acute gastroenteritis to six major hospitals in Lebanon. A total of 739 eligible stool samples, testing negative for diarrhea caused by rotavirus as a possible viral pathogen, were collected between January 2011 and June 2013. A standardized questionnaire including demographic, epidemiological and clinical observations was used at the time of hospitalization of children presenting with diarrhea. Viral RNA was extracted from stool samples followed by reverse transcription polymerase chain reaction and nucleotide sequencing of a fragment of the viral protein 1 capsid gene. Multiple sequence alignments were carried out and phylogenetic trees were constructed using the MEGA 6 software. RESULTS Overall, 11.2% of stool samples collected from children aged < 5 years tested positive for NoV genogroups I (GI) and II (GII). GII accounted for 10.6% of the gastroenteritis cases with only five samples being positive for GI (0.7%). The majority of hospitalized children showed symptoms of diarrhea, dehydration, vomiting and fever. Upon sequencing of positive samples and based on their clustering in the phylogenetic tree, 4/5 of GI gastroenteritis cases were designated GI.3 and one case as GI.4. GII.4 was predominantly detected in stool of our study participants (68%). We report a JB-15/KOR/2008 GII.4 Apeldoorn 2008-like variant strain circulating in 2011; this strain was replaced between 2012 and 2013 by a variant sharing homology with the Sydney/NSW0514/2012/AUS GII.4 Sydney 2012 and Sydney 2012/FRA GII.4 strains. We also report the co-circulation of non-GII.4 genotypes among hospitalized children. Our data show that NoV gastroenteritis can occur throughout the year with the highest number of cases detected during the hot months. CONCLUSION The majority of NoV-associated viral gastroenteritis cases among our participants are attributable to GII.4, which is compatible with results reported worldwide.

Potential role of killer immunoglobulin receptor genes among individuals vaccinated against hepatitis B virus in Lebanon.

AIM To explore the role of killer immunoglobulin receptor (KIR) genes in responsiveness or non-responsiveness to vaccination against hepatitis B virus. METHODS We recruited 101 voluntary participants between March 2010 and December 2011. Sera samples from vaccinated and non-vaccinated participants were tested for the presence of anti-HBs antibodies as a measure of protection against hepatitis B, hepatitis B surface antigen and hepatitis B core antibody as indicators of infection by enzyme-linked immunosorbent assay. KIR gene frequencies were determined by polymerase chain reaction. RESULTS Sera samples from 99 participants were tested for the levels of anti-HBs as an indicator of protection (≥ 10 mIU/mL) following vaccination as defined by the World Health Organization international reference standard. Among the vaccinated participants, 47% (35/74) had anti-HBs titers above 100 mIU/mL, 22% (16/74) had anti-HBs ranging between 10-100 mIU/mL, and 20% (15/74) had values of less than 10 mIU/mL. We report the lack of significant association between the number of vaccine dosages and the titer of antibodies among our vaccinated participants. The inhibitory KIR2DL1, KIR2DL4, KIR3DL1, KIR3DL2, and KIR3DL were detected in more than 95%, whereas KIR2DL2, KIR2DL3, KIR2DL5 (KR2DL5A and KIR2DL5B) were expressed in 56%, 84% and 42% (25% and 29%) of participants, respectively. The observed frequency of the activating KIR genes ranged between 35% and 55% except for KIR2DS4, detected in 95% of the study participants (40.6% 2DS4*001/002; 82.2% 2DS4*003/007). KIR2DP1 pseudogene was detected in 99% of our participants, whereas KIR3DP*001/02/04 and KIR3DP1*003 had frequencies of 17% and 100%, respectively. No association between the frequency of KIR genes and anti-HBs antibodies was detected. When we compared the frequency of KIR genes between vaccinated individuals with protective antibodies titers and those who lost their protective antibody levels, we did not detect a significant difference. KIR2DL5B was significantly different among different groups of vaccinated participants (group I > 100 mIU/mL, group II 10-100 mIU/mL, group III < 10 mIU/mL and group IV with undetectable levels of protective antibodies). CONCLUSION To our knowledge, this is the first study screening for the possible role of KIR genes among individuals vaccinated against hepatitis B virus (HBV). Our results can be used to design larger studies to better understand the role of KIR genes in protection against or susceptibility to HBV post vaccination.