S. Ramia

Hepatitis C Virus Antibodies in High-Risk Saudi Groups

Abstract. The recombinant‐based enzyme immunoassay developed by Ortho Diagnostic System for the detection of antibodies of hepatitis C virus (HCV) was used to determine the extent of exposure to HCV in healthy Saudi subjects (500 males; 260 females) without liver disease and with no history of percutaneous exposure to blood and in Saudis who are considered at high risk for contracting the disease: hemophiliacs (28), thalassemics (78), hemodialysis patients with renal failure (65) and patients with sexually transmitted diseases (STD) (220). The results show that HCV is endemic in the Saudi population with an overall frequency of 5.3% in healthy Saudi adults which is at least 5 times higher than what has been reported from Western Europe and the United States. Seropositivity rate in the high‐risk groups ranges from 15.9% in patients with STD to 78.6% in hemophiliacs. These data underscore the urgent need for routine anti‐HCV screening of blood donations in order to reduce the frequency of postransfusion non‐A, non‐B hepatitis and its sequelae in the Saudi population.

Hepatitis C virus genotypes in patients with chronic liver disease and haemodialysis patients from Saudi Arabia

Summary. The genotypes of hepatitis C virus (HCV) were investigated in 28 Saudi patients (21 males, seven females; age range 23–68 years; mean 45.0 years) with histologically proven chronic hepatitis (13 chronic active hepatitis and 15 liver cirrhosis) and in 32 Saudi patients with chronic renal failure maintained on haemodialysis (22 males, 10 females; age range 18–60 years; mean 40.0 years) who also had liver disease due to HCV. Among the 28 patients with chronic liver disease genotype 4 was the predominant one (60.7%), followed by types 1b (21.4%), 1a (14.3%) and 2a (3.6%). The distribution of genotypes was similar in patients with chronic active hepatitis to those with liver cirrhosis. Among the 32 patients with chronic renal failure and maintained on haemodialysis, genotype 4 was also the dominant type (55.0%), followed by 1a (25.0%), 1b (21.9%) and 2a (3.1%). In all categories studied the prevalence of genotypes between males and females was the same. As our patients were selected from various regions of Saudi Arabia, we believe that genotype 4 is the predominant one throughout the whole kingdom.

Integration of hepatitis B vaccine into the expanded program on immunization: The Saudi Arabian experience.

Hepatitis B virus (HBV) is endemic in the Kingdom of Saudi Arabia. To prevent the chronic carriage of HBV in Saudi children, hepatitis B vaccine was added as the seventh immunogen in the expanded program on immunization (EPI). In the first year, the coverage of the first dose and third dose of HB vaccine was 90% and 73%, respectively. In a survey of 637 children, 603 (95%) were positive for antibody to hepatitis surface antigen (anti-HBs) without concomintant antibody to hepatitis B core antigen (anti-HBc) or hepatitis B surface antigen (HBsAg). A total of 592 (93%) with anti-HBs titer of > 10 IU/L were considered as responders to the vaccine. The majority (60%) of these responders had titers > 100 IU/L. Only one (0.3%) non-responder was positive for anti-HBc alone. Using historical control, the protective efficacy was estimated as 99%. Neither the gender of the recipient, schedule of the vaccination, nor the sourve of vaccine influenced the response to the vaccine. The successful integration of the HB vaccine into the EPI was due to the effectiveness of the EPI and the efficient primary health care system in Saudi Arabia.

Seropositivity to Hepatitis C Virus in Saudi Haemodialysis Patients

Seropositivity to hepatitis B, C and D viruses was studied in 66 Saudi haemodialysis patients from Al Baha region, south of Saudi Arabia, and was compared to that in 380 healthy Saudis from the same region. The results showed that HCV is endemic in this region (3.6%) and the prevalence of anti‐HCV in the haemodialysis patients was 45.5%, which is the highest reported so far in this group of patients. Anti‐HCV was related to the amount of blood transfused (> 5 units) and the duration of dialysis (> 3 years). The region is also hyperendemic for hepatitis B virus (67.4% overall exposure rate in controls compared to 75.7% in haemodialysis patients) and hepatitis D virus (HDV; 11.4% in controls compared to 12.5% in haemodialysis patients). The similarity in profile of HBV markers and HDV between haemodialysis patients and controls indicates that the current strategy regarding HBV is quite effective, in preventing the transmission of HBV and hence HDV but not HCV in haemodialysis patients. A strategy for preventing HCV is recommended.

Hepatitis C virus (HCV) infection in Saudi Arabia: A review.

It is well established now that HCV is the major etiological agent of parenterally transmitted non-A, non-B hepatitis (PT-NANBH), and that it has a worldwide distribution. Studies on HCV infection have led to three striking observations. First, there is a high frequency of chronic infection in a significant number of infected individuals. It is estimated that at least 50% of HCV infections lead to chronic liver disease, including chronic active hepatitis with or without concurrent cirrhosis. 4-6 Second, HCV has been implicated as one of the major causative agents of primary hepatocellular carcinoma (HCC) in Japan, 7 Saudi Arabia, and other parts of the world. 9-10 Third, approximately 45% of HCV cases have no obvious risk factors, including parenteral exposure, 4-6 leaving unanswered the question of virus transmission via as yet unidentified routes of exposure. The aim of this article is to review the literature about the extent of HCV infection in Saudi Arabia and see what can be concluded from the studies conducted so far. However, since there have been dramatic advances in the serologic diagnosis of HCV during the past six to seven years, we would first like to briefly review those serologic tests used and their reliability in diagnosing HCV infection.

Antibody against hepatitis A in Saudi Arabians and in expatriates from various parts of the world working in Saudi Arabia.

The age-specific rate of exposure to hepatitis A virus (HAV) was studied in 1015 native Saudi Arabians (504 males, 511 females) from the Riyadh area. The relatively high prevalence of antibody to HAV (anti-HAV) (38.6%) in children between 1 and 4 years of age indicates that infection is acquired early in life in the Saudi Arabian population. The prevalence of anti-HAV was found to increase steadily so that by the age of 30 years 91.0% of Saudi Arabians have anti-HAV. The prevalence in adult Saudi Arabians was compared with that in expatriates from various parts of the world working in Saudi Arabia. It was lowest among Swedish (10.7-12.3%) and highest among Yemeni (94.5%) blood donors while British blood donors were intermediate same among Saudi Arabian, Yemeni, Egyptian and Filipino blood donors (91.0-94.5%). All the donors tested were of the same age group (20-35 years).

Bacterial, parasitic and viral enteropathogens associated with diarrhoea in Saudi children

In a 2-year study of stools from Saudi children with gastro-enteritis and from controls, rotavirus was the pathogen most frequently detected, either alone (44.3%) or in combination with other enteropathogens (7%). There were two peaks for rotavirus isolates, one during the cold months and the other during the dry, hot season. Salmonella spp. and Campylobacter jejuni were the second and third most frequently isolated enteropathogens. Enteropathogenic Escherichia coli did not contribute significantly to diarrhoea. Detection of enterotoxigenic E. coli was not attempted and its role in diarrhoea remains obscure. Giardia lamblia was detected more frequently in controls than in cases of diarrhoea. Neither Entamoeba histolytica nor Schistosoma mansoni was detected in any of the children studied.

Delta agent infection in Riyadh, Saudi Arabia

Blood samples from 186 HBsAg-positive Saudis and 42 HBsAg-positive Philippino blood donors were tested for anti-delta using the radioimmunoassay technique. The high prevalence of anti-delta in Saudis with liver disease (32%) contrasted sharply with that in Saudis with illness other than liver disease (13%) and in apparently healthy Saudis (5.4%). Together with the high prevalence of anti-delta in Philippino blood donors (9.5%), these results suggest that foci of endemic delta infection other than Italy probably exist.

Epidemiology of hepatitis E virus (HEV) infection in Saudi Arabia.

A newly developed assay for antibody to hepatitis E virus (anti-HEV) was used to study the rate of exposure to HEV infection in two Saudi areas: Riyadh (Central Province-788 people) and Gizan (Southern Province-630 people). These two regions were chosen for the study because the Riyadh area is an urban area and Gizan is considered rural, based on sewage disposal and water sanitation systems in each area. In both areas, HEV is endemic and acquisition of infection to the virus starts early in life and increases with age. In both areas, males are also at higher risk of acquiring the infection than females and this is probably because of social habits rather than genetic factors. The observation of higher anti-HEV prevalence in Gizan (14.9%) than in Riyadh (8.4%) (P < 0.0002) confirms earlier observations that the level of exposure to HEV is related to the hygienic conditions in the community and that improvement in sanitation is an effective measure in lowering the spread of infection.

Seroprevalence of human T-lymphotropic virus type I (HTLV-I) in Saudi Arabia

During the past 6 years, blood donors at various hospitals and blood banks in Saudi Arabia have been screened by enzyme immuno-assay for antibodies to human T-lymphotropic virus type I (anti-HTLV-I). Seropositivity for anti-HTLV-I, clearly confirmed by western blot, was only demonstrable in three out of the 34,541 subjects (including at least 21,000 Saudi nationals). The three positives were all expatriates: two Indians and one Syrian. Another six subjects, who gave ambiguous reactions on western blots and may also have been positive, were also all expatriates. Saudi Arabia therefore appears to be a non-endemic area for HTLV-I and hence the current practice of screening all blood donors for anti-HTLV-I does not seem to be cost-effective. An alternative strategy, in which only expatriate blood donors are screened, should perhaps be considered by the Saudi Ministry of Health.