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• W2613692562 abstract "Clinical ReviewHepatitis B Infection in Saudi Arabia Faleh Z. Al-FalehFacharzt Faleh Z. Al-Faleh Address reprint requests and correspondence to Dr. Al-Faleh: Department of Medicine, College of Medicine, King Saud University, P.O. Box2925, Riyadh 11461, Saudi Arabia. From the Department of Medicine, College of Medicine, King Saud University, Riyadh Search for more papers by this author Published Online:1 Nov 1988https://doi.org/10.5144/0256-4947.1988.474SectionsPDF ToolsAdd to favoritesDownload citationTrack citations ShareShare onFacebookTwitterLinked InRedditEmail AboutABSTRACTABSTRACTThis article on the hepatitis B virus (HBV) in Saudi Arabia reviews 24 articles on HBV which have been published in national and international journals. The data of 49,312 Saudi individuals have been analyzed. Some conclusions have been drawn about the prevalence of HBsAg and HBeAg, overall exposure of the population, and control of HBV infection.IntroductionHepatitis B virus (HBV) infection is one of the most common viral diseases in the world. Thanks to the serologic and immunologic tests which were developed following the discovery of HBsAg in 1964 by Blumberg et al,1 a significant amount of data has accumulated in the world literature regarding the prevalence, the carrier state, the mode of transmission, and the mode of infection by HBV. Most of these data are related to the epidemiologic aspects of this infection and have highlighted several interesting differences in different populations.In Saudi Arabia, for the last 10 years, various studies of the hepatitis B surface antigen (HBsAg) prevalence have been conducted, and the results have been published both in national and international journals2–14 (and M Al-Moagel, personal communication). A large amount of these data have been collected by analysis of blood drawn from blood donors and outpatient populations.2–20 Recently, hepatitis B marker studies have also been published,4,5,9,11 and comparison has been made in the HBsAg prevalence in different regions of Saudi Arabia.8 This article is an attempt to review the data reported regarding the HBV infection in the Saudi population with the following objectives: (1) to present the current epidemiologic status of HBV in Saudi Arabia based on the already reported data; (2) to try to determine clues in the reported data regarding the routes of transmission of HBV in this part of the world and to try to compare local findings with the results reported from other countries; (3) to discuss the question of control strategy of HBV infection; and (4) to discuss recommendations for future studies.CURRENT EPIDEMIOLOGIC STATUS OF HBV IN SAUDI ARABIATable 1 shows the studies in the different areas which have been conducted and reported from Saudi Arabia. For simplicity, I have divided the studies according to three main geographic areas, namely, Central Province, Southwestern Province, and Eastern Province. To compare the three regions, the overall prevalence of HBsAg obtained by pooling samples from all reported studies is presented in Table 2. With the expected difference between males and females, studies giving no sex breakdown were not included in this table.Table 1. HBsAg prevalence in different areas of Saudi Arabia.Table 1. HBsAg prevalence in different areas of Saudi Arabia.Table 2. Estimated prevalence of HBsAg in Saudi Arabia.Table 2. Estimated prevalence of HBsAg in Saudi Arabia.A total of 49,312 Saudi individuals have so far been screened for the HBV marker HBsAg. Most of these individuals (33,632) belong to Riyadh in the Central Province of the country. The average overall prevalence of HBsAg in Saudi Arabia is estimated to be 8.3% (see Table 2), a figure which puts Saudi Arabia among the most highly endemic areas of HBV infection in the world.23Table 2 shows also the prevalence rate in the two sexes in different areas of Saudi Arabia. The available data confirm the male preponderance,6,7,13 which agrees with the results reported from other parts of the world. The only exception is the study of El-Hazmi8 in Gizan, where the prevalence of affected females is more than that of males. However, a more recent study in the same area by the same team (MAF El-Hazmi, personal communication) shows similar results to the study of Arya et al in Gizan.7 If the results of only the male subjects are considered, it becomes obvious that the Southwestern Province and Eastern Province of Saudi Arabia can be classified as hyperendemic areas of the world.The HBV markers in addition to HBsAg, i.e., HBeAg, anti-HBs, and anti-HBc, have also been investigated in a few studies on Saudis. Table 3 shows the overall marker positivity rate in different areas of Saudi Arabia. These results demonstrate very interesting and important findings. It is clear from these results that the exposure ate of HBV infection ranges from 30% to 80% in different regions of Saudi Arabia, with an average of 50%. The highest exposure rate (i.e., 80%) is encountered in the Khaiber population. This exposure rate is very high and has significant implications to the transmission and the prevalence of hepatitis due to HBV infection.Table 3. Overall marker positivity rate in different areas on different subjects.Table 3. Overall marker positivity rate in different areas on different subjects.The antigen HBeAg is closely related to the concentration of Dane particles in serum and is considered as an important marker of infectivity in a given population. The prevalence of HBeAg has been determined in several studies conducted in Saudi Arabia. Table 4 presents the HBeAg prevalence in different areas of Saudi Arabia. A slight difference is encountered in the population from different regions, and in patients with viral or bacterial serology the prevalence is as high as 26%. These results differ markedly from the findings reported from Taiwan and Korea where HBeAg in HBsAg-positive population ranges between 30% and 80%.24 In addition, if we exclude the study of Waller et al,25 which represents a very selected population (i.e., positive viral or bacterial serology), in all the other studies the HBeAg prevalence does not exceed 9%.26Table 4. Prevalence of HBsAg in different areas at different subjects.Table 4. Prevalence of HBsAg in different areas at different subjects.Certain populations, such as those receiving regular blood transfusions, patients on hemodialysis, patients with liver diseases and chronic active hepatitis, patients undergoing cholecystotomy, and preschool children born to HBsAg-positive mothers, are considered as the high-risk groups since they have a greater chance of acquiring HBsAg. In Saudi Arabia, several studies have reported the prevalence of HBsAg in high-risk populations. In Table 5 the HBsAg prevalence in the high-risk populations is summarized. The most interesting figures are those of the association of HBV infection and liver diseases.Table 5. HBsAg prevalence in different areas of Saudi Arabia in a high-risk population.Table 5. HBsAg prevalence in different areas of Saudi Arabia in a high-risk population.TRANSMISSION ROUTE OF HBV INFECTION IN SAUDI ARABIASeveral studies in Saudi Arabia have tried to study the transmission route of HBV infection.2,4,7,16 They have all demonstrated that perinatal transmission is unlikely, or at least its role is minimal.It has now been proved, beyond any doubt, that HBV is transmitted by several routes in both the developed and less developed world. Infection acquired through close personal contact is far more common than that acquired through needles or transfusions.29 In animal experiments, it has been shown that, besides blood and blood products, saliva, semen, and urine can transmit the infection.26,30 Francis et al29 reviewed the literature about the epidemiologic pattern of HBV transmission. They concluded that in countries of Asia and sub-Sahara Africa, HBV infection occurs commonly early in life, but the mode of transmission is different. While in Taiwan, Korea, and Japan, perinatal transmission is the most common route following the high rate of HBeAg positivity, in Africa, horizontal transmission seems to be the dominant route. The low HBeAg positivity of HBsAg-positive mothers here in Saudi Arabia, the low HBsAg positivity of infants under 1 year of age, and the rapid increase of HBV infection between 1 and 12 years old4,5 speak more for horizontal transmission of HBV infection. Al-Admawy et al4 showed in their study of HBsAg acquisition in Riyadh that it was significantly greater in children up to 5 years old than in older children and adults. Fathalla et al5 showed in their study of 168 preschool Saudi children born to HBsAg-positive mothers that acquisition of infection increased rapidly between the ages of 10 weeks and 5 years from 3.6% to 14.6%. The question arises as to what happens to these age groups to make them more susceptible to HBV infection. Francis et al29 have suggested that serum-sharing associated with close personal contact and oozing from dermatologic lesions occurring during early childhood are the most common modes of HBV transmission in hyperendemic settings. However, in addition to this factor, I think in Saudi Arabia the folk medicine practices, the large families and joint family system, low standards of hygiene among the population, and the common habit to have infants and children kissed by everyone are factors which have contributed to increased prevalence of HBV infection. Saliva, urine, and blood could be involved in this transmission. On the other hand, Talukder et al3 and Arya et al7 have produced evidence that in Saudi Arabia there are two peaks for HBV exposure. One is in infancy and early childhood and the other is around 30 years of age. The second peak could be attributed to heterosexual transmission (marriage age in Saudi Arabia begins normally around the age of 17 years) in addition to the above-mentioned factors.STRATEGY FOR HBV INFECTION CONTROLIt is very alarming to have a nationwide carrier rate of 8.3% which reaches almost 10% in the Southwestern Province. In a population of 10 million persons, this means that about 800,000 are affected by HBV. The correlation between hepatocellular carcinoma and HBV is well documented.25 In high incidence areas (such as China and Japan), 35% to 40% of patients with hepatocellular carcinoma have evidence of HBV infection. The relative risk to develop hepatocellular carcinoma has been calculated for 22,707 male government employees of Taiwan and found be 223 times greater in HBsAg carriers. However, an updated study has calculated the risk to 104 times.31,32 We now increasingly see in hospital settings cases of cirrhosis and hepatocellular carcinoma in advanced stages. The relation of the early HBV infection and development of hepatocellular carcinoma has been stressed.33 Therefore, the only hope to decrease this morbidity and mortality for the new generation is the vaccine. Its efficacy has been established worldwide. The question is when should the vaccine be administered and to whom? As we have seen in reviewing the reported data, it seems that in Saudi Arabia we are dealing mostly with the horizontal transmission route. The infection, as we have mentioned before, seems to occur here in two peaks. The first is early childhood starting from the first year. A large-scale program for HBV vaccination should be integrated with other vaccination programs which usually start at the age of 3 months. All children should be given the vaccine so that at the age of 1 to 1½ years, the program is completed; a booster dose should be given after 5 years.23,34–36 For the adult peak, the control program should include mandatory screening of blood donors and promoting good hygiene by more public education. Selected risk groups should be identified and vaccinated and so should their close contacts.RECOMMENDATIONS FOR FUTURE STUDIESAfter reviewing all these data, I think there is no need for further large-scale studies of the prevalence of HBsAg in most areas of Saudi Arabia. However, one should still evaluate data coming from areas of Saudi Arabia which have not yet been screened. The screening of blood donors, a procedure already practiced in all of the hospitals in Saudi Arabia, will fulfill this objective. Further studies should concentrate on the high-risk population and children to determine further evidence for the mode of transmission of HBV and eventually to identify the risk factors leading to increased infection. In addition, there should be studies to determine efficacy of the vaccine in the Saudi population, especially in infants and the high-risk population.ARTICLE REFERENCES:1. Blumberg GS, Alter HJ, Visnich S. A “new” antigen in leukemia sera . JAMA. 1965; 191;541–6. Google Scholar2. Ramia S, Abdul-Jabbar F, Bakir TM, Hossain A. Vertical transmission of hepatitis B surface antigen in Saudi Arabia . Ann Trop Paediatr. 1984; 4(4):213–6. Google Scholar3. Talukder MA, Gilmore R, Bacchus RA. 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Hepatitis B infection and immunization: a review . Saudi Med J. 1984; 5(4):369–76. Google Scholar21. Laajam MA, Al-Mofleh IA, Al-Faleh FZ, et al.. Upper gastrointestinal endoscopy in Saudi Arabia: analysis of 6386 procedures . Q J Med. 1988; 66(249):21–5. Google Scholar22. Shobokshi O, Serebour F. Hepatitis B: a Saudi Arabian problem . Abstracts of the 5th Saudi medical meeting, Riyadh, 1980. Google Scholar23. Chopra S. Acute viral hepatitis . American Gastroenterology Association meet the professor annual meeting, 19 May 1986, San Francisco. Google Scholar24. Arthur MJ, Hall AJ, Wright R. Hepatitis B, hepatocellular carcinoma, and strategies for prevention . Lancet. 1984; 1(8377):607–10. Google Scholar25. Waller DK, Nixon P, Talukder MAS, Al-Admawy AMO. A survey of the prevalence of “e” antigen infectivity marker in HBsAg positive hospital patients . Saudi Med J. 1984; 5(2):227–8. Google Scholar26. Karayiannis P, Novick DM, Lok AS, et al.. 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Google Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byAlbadran A, Hibshi A, Saeed B, Sedar C and Awartani K (2019) Hepatitis B and C virus prevalence in couples attending an in vitro fertilization clinic in a tertiary care hospital in Saudi Arabia: comparison with ten years earlier, Annals of Saudi Medicine , 37:4, (272-275), Online publication date: 1-Jul-2017.Al-Faleh F (2019) Changing Pattern of Hepatitis Viral Infection in Saudi Arabia in the Last Two Decades, Annals of Saudi Medicine , 23:6, (367-371), Online publication date: 1-Nov-2003.Shobokshi O, Serebour F and Skakni L (2019) Hepatitis B Surface Gene Mutants and their Emerging Role in the Efficacy of HBV Vaccination Programs, Annals of Saudi Medicine , 19:2, (87-92), Online publication date: 1-Mar-1999.Okonkwo T, Aderoju A, Ene D, Ignatius A and Aboh I (2019) Pattern of Referrals from a General Hospital to a Regional Tertiary Health Institution: Samtah Experience, Annals of Saudi Medicine , 18:6, (565-566), Online publication date: 1-Nov-1998.Al-Knawy B, El-Mekki A and Yarbough P (2019) The Role of Hepatitis E Virus Infection among Patients with Acute Viral Hepatitis in Southern Saudi Arabia, Annals of Saudi Medicine , 17:1, (32-34), Online publication date: 1-Jan-1997.Ajarim D (2019) Pattern of Primary Gastrointestinal Cancer: King Khalid University Hospital Experience and Review of Published National Data, Annals of Saudi Medicine , 16:4, (386-391), Online publication date: 1-Jul-1996.Tandon P, Pathak V, Zaheer A, Chatterjee A and Walford N (1995) Cancer in the Gizan Province of Saudi Arabia: An Eleven Year Study, Annals of Saudi Medicine , 15:1, (14-20), Online publication date: 1-Jan-1995.Al Saigh A, Allam M, Khan K and Al Hawsawi Z (2019) Pattern of Cancer in Madina Al-Munawara Region, Annals of Saudi Medicine , 15:4, (350-353), Online publication date: 1-Jul-1995.Al-Dhahry S, Aghanashinikar P, Al-Marhuby H, Buhl M, Daar A and Al-Hasani M (1994) Hepatitis B, Delta and Human Immunodeficiency Virus Infections among Omani Patients with Renal Diseases: A Seroprevalence Study, Annals of Saudi Medicine , 14:4, (312-315), Online publication date: 1-Jul-1994.Al-Freihi H (2019) Prevalence of Hepatitis B Surface Antigenemia among Patients with Schistosoma Mansoni, Annals of Saudi Medicine , 13:2, (121-125), Online publication date: 1-Mar-1993.Al-Faleh F, Ayobanji Ayoola E, Al-Jeffry M, Arif M, Al-Rashed R and Ramia S (2019) Integration of Hepatitis B Vaccine into the Expanded Program on Immunization: The Saudi Arabian Experience, Annals of Saudi Medicine , 13:3, (231-236), Online publication date: 1-May-1993.Saeed A, Ahmed A, Al-Karawi M, Mohamed A, Al-Saud A and Shariq S (2019) The Association between Hepatitis C Virus Antibody and Hepatocellular Carcinoma in Relation to Hepatitis B Viral Infection (Rafh Experience), Annals of Saudi Medicine , 12:3, (283-285), Online publication date: 1-May-1992.Ajarim D (2019) Cancer at King Khalid University Hospital, Riyadh, Annals of Saudi Medicine , 12:1, (76-82), Online publication date: 1-Jan-1992.Khan A, Hussain N, Al-Saigh A, Malatani T and Sheikha A (2019) Pattern of Cancer at Asir Central Hospital, Abha, Saudi Arabia, Annals of Saudi Medicine , 11:3, (285-288), Online publication date: 1-May-1991.Fakunle Y, Al-Mofarreh M, Al-Ghreimil M, Idrees Y, El-Drees A, Al-Karamany W and Ezzat H (2019) Prevalence of Antibodies to Hepatitis C Virus in Saudi and Expatriate Women in Riyadh, Saudi Arabia, Annals of Saudi Medicine , 11:5, (494-496), Online publication date: 1-Sep-1991.Fakunle Y, Al-Mofarreh M, El-Drees A, El-Karamany W, Ezzat H, Ballesteros M and Khawaji M (2019) Prevalence of Antibodies to Hepatitis C Virus in Saudi Patients with Chronic Liver Disease, Annals of Saudi Medicine , 11:5, (497-500), Online publication date: 1-Sep-1991.Fakunle Y, Al-Mofarreh M, El-Karamany W, Ezzat H, Al-Shora B and El-Drees A (2019) Prevalence of Antibodies to Hepatitis C Virus in Hemodialysis Patients in Riyadh, Annals of Saudi Medicine , 11:5, (504-506), Online publication date: 1-Sep-1991.Jamjoom G, Quli S, Shenoy A, Nqer Y, Al-Basha M, Buluk O, Kafi M and Al-Zughaibi O (2019) Hepatitis A and Hepatitis B in the ASIR Region, Southwestern Saudi Arabia, Annals of Saudi Medicine , 10:4, (429-433), Online publication date: 1-Jul-1990. Volume 8, Issue 6November 1988 Metrics History Accepted2 May 1988Published online1 November 1988 KeywordsHepatitis B infectionInformationCopyright © 1988, Annals of Saudi MedicinePDF download" @default.
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