Seroprevalence of Hepatitis C Virus among Blood Donors in Middle Eastern Countries: A Systematic Review and Meta-Analysis

AUTHORS

Hossein Ghaderi-Zefrehi 1 , 2 , Heidar Sharafi ORCID 1 , 3 , Farzin Sadeghi 4 , Mohammad Gholami-Fesharaki 5 , Alireza Farasat 6 , Fatemeh Jahanpeyma 7 , Seyed Moayed Alavian 1 , 3 , *

1 Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, IR Iran

2 Department of Clinical Biochemistry, Faculty of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, IR Iran

3 Middle East Liver Diseases (MELD) Center, Tehran, IR Iran

4 Cellular and Molecular Biology Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, IR Iran

5 Department of Biostatistics, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran

6 Young Researchers and Elite Club, Pharmaceutical Sciences Branch, Islamic Azad University, Tehran, IR Iran

7 Department of Medical Biotechnology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, IR Iran

How to Cite: Ghaderi-Zefrehi H, Sharafi H, Sadeghi F, Gholami-Fesharaki M, Farasat A, et al. Seroprevalence of Hepatitis C Virus among Blood Donors in Middle Eastern Countries: A Systematic Review and Meta-Analysis, Iran Red Crescent Med J. 2017 ; 19(12):e58045. doi: 10.5812/ircmj.58045.

ARTICLE INFORMATION

Iranian Red Crescent Medical Journal: 19 (12); e58045
Published Online: November 28, 2017
Article Type: Review Article
Received: July 13, 2017
Revised: October 14, 2017
Accepted: November 1, 2017
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Abstract

Context: Hepatitis C virus (HCV) has been the main cause of post transfusion hepatitis. Long-term hepatitis can ultimately result in cirrhosis and hepatocellular carcinoma. Viral hepatitis, especially HCV infection, is a major health concern in the Middle East. The current study carried out a systematic search concerning HCV seroprevalence among blood donors in Middle Eastern countries.

Evidence Acquisition: Articles were identified through searching databases including PubMed, Scopus, and Web of Science. We reviewed systematically all studies reporting HCV seroprevalence among blood donors in Middle Eastern countries.

Results: A total of 5662 relevant records were identified by the electronic search, of which a total of 47 studies were identified as eligible papers that were meta-analyzed for the pooled seroprevalence of HCV among blood donors. Overall, HCV seroprevalence among blood donors in Middle Eastern countries was estimated 0.88% (95%CI = 0.79% - 0.97%). The highest pooled HCV seroprevalence rate was related to Egypt (5.76% [95%CI = 3.30% - 8.22%]), Libya (1.56% [95%CI = 0.99% - 2.13%]), and Yemen (1.09% [95%CI = 0.69% - 1.50%]) while the lowest pooled seroprevalence rate was in Iran and Israel with the rates of 0.14% (95%CI = 0.12% - 0.17%) and 0.16% (95%CI = 0.06% - 0.25%), respectively. Results of annual HCV seroprevalence suggest that there is a decrease in seroprevalence rate of HCV over time among blood donors in Egypt, Iran, Oman, Lebanon, Libya, and Saudi Arabia.

Conclusions: Our results showed that the trend of HCV seroprevalence over time among Middle Eastern blood donors was decreasing. It suggests that recent safety measures implemented in Middle Eastern countries have been effective.

Keywords

Blood safety Epidemiology Hepatitis C Middle East Systematic review

Copyright © 2017, Iranian Red Crescent Medical Journal. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

1. Context

First found in 1989, hepatitis C is caused by hepatitis C virus (HCV) (1) from the Flaviviridae family and it is the main reason of post transfusion hepatitis (2). HCV is most commonly transmitted through direct contact with blood as in blood transfusion (3). Screening of donated bloods for hepatitis C has been implemented in blood transfusion services since 1990s in most Middle Eastern countries (4). The post-transfusion hepatitis C has been a main cause of mortality and morbidity in poly-transfused patients such as patients with thalassemia and hemophilia in Middle Eastern countries (5). Viral hepatitis, especially HCV, is a major health concern in the Middle East, which is a geographical region with diverse ethnic groups including Arabs, Turks, Persians, etc. With an over 3.5% prevalence of HCV infection, Middle East is considered a hotspot for this disease (6, 7). There has been inadequate research on HCV prevalence and prevention methods in the Middle East (8). Moreover, prevalence of HCV infection among blood donors has not been discussed in some countries of this region. Therefore, this paper reviews the conducted studies in order to provide the current estimate of HCV seroprevalence among blood donors in Middle Eastern countries.

2. Evidence Acquisition

2.1. Data Resources and Search Strategies

Literatures on HCV prevalence among blood donors in Middle Eastern countries, such as Bahrain, Cyprus, Egypt, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Oman, Palestine, Qatar, Saudi Arabia, Syria, Turkey, UAE, and Yemen, were acquired through searching PubMed, Scopus, and Web of Science in the time span of 1996 to 2016. Our last search was conducted on October 05, 2016. In order to search and include related studies as many as possible, we used the following terms: “Hepatitis C virus”, “HCV”, “prevalence”, “blood donor”, and name of the Middle Eastern countries.

2.2. Eligibility Criteria

Published studies were regarded qualified for analysis if they met the following criteria: 1- Studies with full text of the paper available in English language; 2- Studies with a sample size more than 100; and 3- Studies that reported anti-HCV antibody (HCV Ab) prevalence among blood donors in the Middle Eastern countries. Conversely, the followings were exclusion criteria: 1- Non-English reports on the seroprevalence of HCV; 2- Studies that reported seroprevalence of HCV among paid blood donors; 3-Studies which all of the participants were first-time blood donors; 4- Studies with overlapped time or place of donation; 5- Studies that used first-generation or second-generation HCV enzyme-linked immunoassay (ELISA) without supplemental or confirmatory assay, and 6- Studies failing to present evident data.

2.3. Study Selection and Data Extraction

All articles categorized as potentially relevant were reviewed separately by two of the authors (H. G-Z. and H. S.) In addition, blinding and task separation were applied in selection of articles and data extraction. For each eligible study, the following information was extracted: first author’s name, year of publication, study period, study location, the method for the screening of HCV Ab, the method used for confirmation of HCV Ab, sample size, number of positive cases for HCV Ab, and the type of donors. Analysis was conducted according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) (9).

2.4. Data Analysis

In the current meta-analysis, the seroprevalence rate of HCV among blood donors from each country was computed by metan command. Statistical tests of heterogeneity among the studies were carried out using the Q test (P < 0.10 indicates statistically significant heterogeneity) and I-squared statistics. According to the results of heterogeneity test, we used fixed- or random-effect models for determining the prevalence of HCV Ab among blood donors. We also used funnel plot to investigate publication bias. All data analyses were performed using STATA 10.

3. Results

3.1. Study Screening and Characteristics of the Included Studies

The study selection process is depicted in Figure 1. A total of 5662 studies potentially associated with the seroprevalence of HCV infection among blood donors in the Middle Eastern countries were identified through web search, of which 2,291 duplicates were excluded. After reviewing the abstracts and titles, 3,181 studies were eliminated based on the stated inclusion and exclusion criteria. After full-text screening, a total of 47 records were deemed as eligible papers published between 1995 and 2016. These 47 records were composed of 13 studies from Iran (4, 10-21), 8 studies from Turkey (22-29), 8 studies from Saudi Arabia (30-37), and 6 studies from Egypt (38-43). Two studies were available from each of the following countries: Syria (44, 45), Libya (46, 47), Yemen (48, 49), and Israel (50, 51). Only one study was available from each of the following countries: Lebanon (52), Oman (53), Cyprus (54), and UAE (55). The characteristics of included studies are summarized in Table 1.

Flowchart of Article Selection Based on PRISMA Statement
Figure 1. Flowchart of Article Selection Based on PRISMA Statement
Table 1. Characteristics of Included Studies from Middle Eastern Countries
CountryCity, Province or RegionReference NumberScreening TestConfirmatory TestYear of PublishYear of StudySample Size, nHCV Ab Rate, %Donor Type
CyprusNicosa and Kyrenia(54)EIA ≥ 3NA2006200050570.45NA
Totala0.45% (0.30% - 0.68%)
EgyptCairo(38)EIA ≥ 3EIA ≥ 320071999 - 200021468.90Replacement donor
Cairo(39)EIA ≥ 3EIA ≥ 3200820057605.00Voluntary donor
Minya governorate(40)EIA ≥ 3NA20102000 - 20082117729.03Voluntary donor
Alexandria(41)EIA ≥ 3EIA ≥ 320112007 - 200834203.48Voluntary donor
Cairo(42)EIA ≥ 3NA20142006 - 20123087624.34Voluntary or replacement donor
Cairo(43)EIA ≥ 3NA20142010 - 2011171183.84Voluntary or replacement donor
Totala5.76% (3.30% - 8.22%)
IranShiraz(10)EIA < 3RIBA2000199878790.60Voluntary donor
Tehran(11)EIA ≥ 3RIBA20021996 - 19983193750.09Voluntary donor
Kashan(12)EIA ≥ 3NA20042001 - 20026000.50Voluntary donor
Tehran(13)EIA < 3RIBA20052001 - 200219590.46Voluntary donor
Guilan(14)EIA ≥ 3RIBA20071998 - 20032215080.32Voluntary donor
Tehran(15)EIA ≥ 3RIBA20092003 - 2005 (2003)b3295160.14Voluntary donor
Iran(16)EIA ≥ 3RIBA20092004 - 200764998510.13Voluntary donor
Shiraz(17)EIA ≥ 3RIBA2010200319330.52Voluntary donor
Arak(18)EIA ≥ 3NA201020085310.19Voluntary donor
Qazvin(19)EIA ≥ 3RIBA20122009205910.17NA
Tehran(4)EIA ≥ 3RIBA20152008 - 201317960900.10Voluntary donor
Bushehr, Borazjan and other cities(20)EIA ≥ 3RIBA20162004 - 2014 (2008 - 2014)b2195520.06Voluntary donor
Shiraz(21)EIA ≥ 3RIBA20162012 - 20131012450.05NA
Totala0.14% (0.12% - 0.17%)
IsraelTel HaShomer(50)EIA < 3RIBA19981994 - 19961938060.20Voluntary donor
Tel HaShomer(51)EIA ≥ 3RIBA200720032254520.11Voluntary donor
Totala0.16% (0.06% - 0.25%)
LebanonBeirut(52)EIA ≥ 3EIA ≥ 320061997 - 2003160840.40NA
Totala0.4% (0.31% - 0.51%)
LibyaTripoli(46)EIA ≥ 3NA20021999 - 200112001.17NA
Tripoli(47)EIA ≥ 3NA20162008 - 201310082141.78Voluntary donor
Totala1.56% (0.99% - 2.13%)
OmanMuscat(53)EIA2&3RIBA20031991 - 2001 (1995 – 2001)b211310.75NA
Totala0.75% (0.64% - 0.88%)
SaudiRiyadh(37)EIA ≥ 3NA19911991106461.01NA
Riyadh(30)EIA < 3RIBA19941992 - 1993185400.44NA
Bisha, El-Baha, Najran, Jizan, Aseer, Hafer El-Baten, Al-Hessa and El-Sharkia, Al-Qassim, Riyadh, Jeddah, Makkah, Medinah, Taif, El-Qunfuda, Tabuk, Al-Goofe, El-Quriate, Hail, El-Shamalia(31)EIA ≥ 3RIBA20031998 - 20025578131.13NA
Eastern Saudi Arabia(32)EIA ≥ 3NA20041998 - 2001134431.44Voluntary, replacement or employment/licensing donor
Jazan(33)EIA ≥ 3EIA ≥ 320132004 - 2009299490.42Voluntary or replacement donor
Aseer Region(34)EIA ≥ 3EIA ≥ 320152012 - 201372670.07Voluntary donor
Makkah(35)EIA ≥ 3NA20152011 - 2014229630.44Voluntary or replacement donor
Al-Baha(36)EIA ≥ 3RIBA20162009 - 201128070.04NA
Totala0.62% (0.23% - 1.01%)
SyriaDamascus(44)EIA ≥ 3EIA ≥ 32002200221000.95NA
Damascus(45)EIA ≥ 3NA2013201119390.41NA
Totala0.66% (0.13% - 1.19%)
TurkeyAydin(22)EIARIBA20041993 - 2002378660.19Voluntary donor
Denizli, Istanbul, Izmir, Adana, Bursa, Samsun, Eskisehir, Erzurum, Diyarbakir, Gaziantep, Sivas, Zonguldak, Trabzon, Antalya, Konya, Duzce, Balikesir, Sanliurfa, Kayseri, Isparta and Zeynep Kamil(23)EIA ≥ 3RIBA20061989-200462401300.38Voluntary or family donor or military personnel
Van(24)EIA ≥ 3NA20071995 - 2003390020.17NA
Istanbul(25)EIA ≥ 3RIBA20102007726950.07NA
Southeastern Anatolia(26)EIA ≥ 3NA20132000 - 2010 (2005 - 2010)b1556900.67Voluntary donor
Ankara(27)EIA ≥ 3RIBA20132004 - 2010155400.22Voluntary donor
Izmir(28)EIA ≥ 3EIA ≥ 320132004 - 2010 (2005 - 2010)b732130.41Voluntary or replacement donor
Adana(29)EIA ≥ 3RIBA20152007 - 2009624610.05Voluntary or replacement donor
Totala0.27% (0.13% - 0.41%)
YemenHajjah(48)EIA ≥ 3NA2002199924341.07Replacement donor
Aden(49)EIA ≥ 3NA201220074691.28Replacement donor
Totala1.09% (0.69% - 1.50%)
UAEDubai(55)ELFARIBA20122004 - 20091697810.11NA
Totala0.11% (0.10% - 0.13%)
Pooledc0.88% (0.79% - 0.97%)

Abbreviations: EIA, enzyme immunoassay; ELFA, enzyme-linked fluorescence assay; NA, not available; RIBA, recombinant immunoblot assay.

aTotal HCV seroprevalence in the country and its 95% confidence interval.

bIn the studies with temporal and spatial overlap, the time span of study with the included data in this meta-analysis.

cPooled HCV seroprevalence in the Middle Eastern countries and its 95% confidence interval.

3.2. Seroprevalence of HCV among Blood Donors in Middle Eastern Countries

Data on HCV seroprevalence as well as other indicators were abstracted from the 47 records as presented in Table 1. Information on HCV seroprevalence among blood donors was available from twelve countries.

As shown in Table 1, using random-effect model, the pooled seroprevalence of HCV among blood donors in the Middle Eastern countries from 1989 to 2014 was estimated 0.88% (95%CI = 0.79% - 0.97%). In addition, we used random-effect model to estimate pooled HCV seroprevalence rate for each of the Middle Eastern countries. The highest pooled HCV seroprevalence rate was related to Egypt (5.76% [95%CI = 3.30% - 8.22%]), Libya (1.56% [95%CI = 0.99% - 2.13%]), and Yemen (1.09% [95%CI = 0.69% - 1.50%]) while the lowest pooled seroprevalence rate was in Iran and Israel with the rates of 0.14% (95%CI = 0.12% - 0.17%) and 0.16% (95%CI = 0.06% - 0.25%), respectively. HCV seroprevalence among blood donors in countries with one study including Lebanon, Oman, Cyprus, and UAE was 0.40% (95%CI = 0.31% - 0.51%), 0.75% (95%CI = 0.64% - 0.88%), 0.45% (95%CI = 0.30% - 0.68%), and 0.11% (95%CI = 0.10% - 0.13%), respectively. Seroprevalence of HCV among blood donors by different countries is depicted in Figure 2.

Seroprevalence of HCV among Blood Donors in Middle Eastern Countries
Figure 2. Seroprevalence of HCV among Blood Donors in Middle Eastern Countries

For evaluating annual HCV seroprevalence rates and their trends, we only considered studies that reported HCV seroprevalence rate among blood donors annually. By exploring the trends of HCV seroprevalence rate in 6 countries, including Egypt (2007 - 2012), Iran (2003 - 2014), Lebanon (1997 - 2003), Libya (2008 - 2013), Oman (1995 - 2001), and Saudi Arabia (1998 - 2014), a decline in HCV seroprevalence rate among blood donors over time was observed (Figure 3). Detailed information on trends is shown in Figure 3.

Figure 3. Annual HCV Seroprevalence Rates and Their Trends among Blood Donors
Annual HCV Seroprevalence Rates and Their Trends among Blood Donors

A. Oman; B. Libya; C. Lebanon; D. Turkey; E. Iran; F. Egypt; G. Saudi Arabia.

4. Discussion

Blood transfusion and blood donation continue to play significant roles in the transmission of HCV in Middle Eastern countries (56). Several recent studies have provided good evidence on genotype distribution and epidemiology of HCV in the Middle East region (57-59). However, determination of HCV seroprevalence rates among blood donors in the Middle East region could be helpful to develop prevention and control strategies more effectively. The current systematic review was conducted to shed more light on the seroprevalence of HCV among blood donors in the Middle East region; a transcontinental region with diverse ethnic groups including Arabs, Turks, Persians, Azeris, Kurds, etc. To determine HCV seroprevalence rate among blood donors, the estimated pooled seroprevalence rate was calculated for each of the Middle Eastern countries. The results of our study indicated that HCV seroprevalence rates among blood donors in the Middle East region is 0.88% that is higher than the seroprevalence rates in North-European blood donors (0.01% - 0.02%) (60). In addition, a recently published meta-analysis reported 0.65% HCV seroprevalence rate among blood donors in African countries, which is also lower than the rate found in our study (61). Based on our statistical analysis, there is a dramatic geographical difference between Middle Eastern countries in terms of HCV seroprevalence rate in blood donors. The highest seroprevalence was found in Egypt with the rate of 5.7% and the lowest seroprevalence was found in UAE and Iran with the rates of 0.11% and 0.14%, respectively. Our results are in good agreement with some studies from Egypt, including two investigations with large sample sizes among Egyptian blood donors conducted by Eita et al. (62) and Rushdy et al. (63). In addition, based on a newly published systematic review from Egypt, HCV seroprevalence rates among blood donors ranged 5% - 25% (64). It should be noted that data from the aforementioned systematic review has to be treated with caution due to employing ELISA as a detection index and lack of confirmatory RIBA test. Moreover, the low sample size in some of the studies included in the aforementioned systematic review may affect the obtained results. The results of the present study are consistent with a number of reports from Iranian blood donors (16, 65). Interestingly, a comprehensive study by Kafi abad et al. among Iranian blood donors revealed 0.13% HCV seroprevalence rate that is in good agreement with our results (16). According to our results, Libya and Yemen have the second and third highest HCV seroprevalence rates in blood donors in the Middle East region. These findings are broadly consistent with other comprehensive epidemiologic studies on general populations in Libya and Yemen (66, 67). Seroprevalence of HCV in Libya and Yemen may increase in the next few years due to ongoing military conflicts and destruction of health-care infrastructures. The results of the present study demonstrated almost similar HCV seroprevalence rates in Saudi and Syrian blood donors. These findings are also consistent with the findings of more recent studies among blood donors in Saudi Arabia and Syria (68). However, our results are not supported by Shobokshi et al. who found 1.1% HCV seroprevalence rate among Saudi blood donor (31). Moreover, military conflicts and refugee crisis in Syria may increase HCV seroprevalence rate in the next few years. In the present study, seroprevalence of HCV in blood donors from Turkey and Israel was low (0.27% and 0.16%, respectively) that might be explained by good infection control practices and organized system of blood screening and transfusion. Our results showed a fluctuating trend in annual HCV seroprevalence rate in the Middle East region. With the exception of Turkey, other countries included in this investigation had a decreasing HCV seroprevalence trend.

Recently, with introduction of HCV direct-acting antiviral agents, the treatment of hepatitis C has transformed greatly (69, 70). These new therapies resulting in more than 95% treatment success have made hepatitis C a curable infectious disease (71-73). With availability of efficient treatments for hepatitis C, there is great hope to eliminate this disease by 2030; however, prevention of hepatitis C transmission through blood and blood products has a key role in elimination programs, as well (69).

A number of limitations exist in the present investigation that should be noted. First, the sample size in some of the Middle Eastern countries was not adequate and the quantity of data varied between countries. Second, different types of kits were utilized for detection of HCV Ab, which would have affected the obtained results of the current systematic review. Third, HCV seroprevalence rates in blood donor populations of some countries might be underestimated due to selection bias. In addition, data deficiencies existed in some studies did not allow us to include them in the final analysis.

Taken together, the present systematic review provides detailed and reliable data on the HCV seroprevalence rates among blood donors in Middle Eastern countries. The available data showed a dramatic geographical difference in the seroprevalence of HCV among Middle Eastern blood donors. The lowest seroprevalence rates were seen in Iranian and UAE blood donors, while the highest rate was observed in Egyptian blood donors. The trend of HCV infection among Middle Eastern blood donors was decreasing in recent years. It is suggesting recent safety measures implemented in Middle Eastern countries have been effective.

Footnote

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