The Scientific World Journal
Volume 2012, Article ID 719494, 12 pages
Hepatitis C VirusinArabWorld: AState of Concern
1Department of Medical Microbiology & Immunology, Tripoli Medical Centre, Faculty of Medicine Tripoli,
P.O. Box 82668, Tripoli, Libya
2Department of Vascular Surgery, Tripoli Medical Centre, Faculty of Medicine Tripoli,
P.O. Box 82664, Tripoli, Libya
Correspondence should be addressed to Mohamed A. Daw, email@example.com
Received 1 January 2012; Accepted 18 January 2012
Academic Editors: L. A. Videla and T. Weiss
Copyright © 2012 M. A. Daw and A. A. Dau. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cellular carcinoma. The prevalence of such virus varies greatly over the world. Arab world has a unique geography and consists
over nineteen countries who share the same heritage and customs and do speak the same language. In this area, the epidemiology
of hepatitis C is not well understandable. Hepatitis C virus was found to be endemic in Arabia. The serostatus of such virus was
found to be variable among these countries with uniform patterns of genotypes. Such prevalence varies tremendously according to
the risk factors involved. Blood and blood products, haemodialysis, intravenous, and percutaneous drug users, and occupational,
habitual, and social behavior were found to be the important factors involved. Hepatitis C will have major social, economic, and
even political burdens on such young and dynamic societies. Thus, strategies and clear policy of intervention are urgently needed
to combat the consequences of HCV both regionally and at state level of each country.
Hepatitis C virus has been considered to be one of the most
potential pathogens that have hindered the medical commu-
nity all over the world. Indeed, since its discovery in 1989,
of chronic liver disease worldwide and due to the surpassing
hepatitis B virus . The data reported by WHO estimated
that the prevalence of HCV infection is 2.2%, and more than
one million new cases were reported annually. Furthermore,
an estimated 27% of cirrhosis and 25% of hepato-cellular
. Such infection increases tremendously among the devel-
oping countries particularly at those categories that were
considered to be at a potential risk of acquiring hepatitis C
Arabian compound states are composed of unique ge-
ography being the central and transcross of the world. It is
composed of more than nineteen countries with more than
350 million; they all speak the same language and mostly
they have the same heritage and customs. Indeed it is the
whole site of east and south of the Mediterranean basin
up to the Atlantic cost in the west and Persian gulf and
Indian Ocean south east. The African region is composed
of the whole north African countries which are composed
of approximately 23% of Africa, though the Asian region
composed most of the north west of Asia and composed
around 10% of Asia. Such area has over 30% of the world
oil revenue, and most of them enjoy great wealth and pros-
The global epidemiology of HCV varies greatly allover
the world, and different studies have shown such variations.
Hepatitis C virus was found to be endemic in certain coun-
tries, and different studies have confirmed such endemicity
. It is important to consider the shortcoming of regional
studies are in Arab world. Most of the epidemiological
studies carried out individually based upon seroprevalence
of HCV among specific groups. These include blood donors,
heath care workers, or patients undergoing haemodialysis.
Such studies were not representative of the community, they
were usually carried out by independent scientists. Even
though, some countries lack such studies.
2 The Scientific World Journal
Table 1: Prevalence of hepatitis C virus and its common genotypes among Arab countries.
Prevalence (%) of HCV among
HaemodialysisMore frequent Less frequent
Arabian peninsula region
Saudi Arabia [Sa]
Nile river region
North African region
NA: no data available,∗less frequent type.
1a 1b 3a
2, 3, 4
1a, 1b, 3a
1b, 1a, 3a, 5∗
1a, 1b, 2, 3
1a 1b 2a
4e, 4c, 4d
2a, 2b, 2c, 3a
2a 2c 1a
2a 2c 1a
Nowadays, HCV is responsible for infecting over 20
million in Arab countries, and without immediate and ef-
fective intervention, that number is predicted to increase
tremendously in the next two decades. The objectives of
this paper were to analyze the status of HCV epidemiology
among the Arab countries and its variation accordingly and
to highlight the future consequences and how to overcome
the implications of such infection.
2.Epidemiology of HepatitisCVirusin
The Arab world consists of heterogeneous countries with
various levels of developments and different approaches of
concepts and priorities. Infrastructure of health services is
variable among these countries; some of them succeeded
in adapting the modern routes of infection prevention;
others fail and rarely adapt such recommendations .
However, most of them share the concept of bureaucracy
and hierarchal among their health services and education
[4, 5]. This will make the implementation of international
standards indeed difficult to follow or adapt by their
institution and health services personnel. HCV infection is a
of infected individuals in the Arab world by such virus
reached 25 million with an average prevalence rate of 3.5%.
Table 1 shows the universal epidemiology of HCV among
general population and patients undergoing haemodialysis
and genotypes reported in each country. Such prevalence
varies greatly from one region to another and even among
the countries of the same region.
2.1. Hepatitis C Virus in Arabian Peninsula Region. Arabian
peninsula is unique geographical area a composed 35% of
Arab world that it is composed of Saudi Arabia, Yemen,
Oman, Qatar, Bahrain, UAE, and Kuwait. Saudi Arabia
is the largest country not only in the Arabian peninsula
but in the Arab world, and considered to be the richest.
Hepatitis C virus is well studied in Saudi Arabia, and its
serostatus is known among the different population .
The universal prevalence of HCV in the general population
ranged from 1.1 to 1.7% . Such prevalence was found
to be high among the risk groups such as haemodialysis
patients where it ranged from 18.6 to 56%, 40% among the
genotype isolates were genotype 4 followed by rare ones
1a, 1b, and 3a [8–10]. Yemen is the second largest heavily
populated and the poorest country in Arabian peninsula;
the prevalence of HCV in Yemenis was found to be 1.7%
among healthy volunteers though it reached 2.7% among
blood donors [11, 12]. Such prevalence reached up to 60%
in haemodialysis patients . In the less populated Gulf
states, HCV was found to be 0.9 to 1.5% in blood donors
The Scientific World Journal3
Table 2: Categorization of Arab countries according to the prevalence hepatitis C virus.
Libya, Tunis, Oman, Saudi Arabia, Kuwait, Bahrain, Syria, Lebanon
Algeria, Mauritania, Yemen, Gaza Strip
UAE, Iraq, Sudan
Egypt, Morocco, Qatar, Jordan
of Oman and 26% in haemodialysis patients , though it
was found to be 40% among haemolytic Bahraini patients
with HCV genotypes 4, and 1a and 1b as the commonly
prevalent genotypes . In Qatar, the prevalence rate
among the general population reached 6.3% and 44.6% in
dialysis patients [16–18], though in UAE, the prevalence was
found to be 23% among haemodialysis patients, and the
predominantly genotypes were 4, 3, and 1 . In Kuwait,
HCV is better known, and different studies were carried
out to determine the prevalence of HCV as it was found to
be 0.8% among the general populations and 71% among
haemodialysis patients [20, 21]. The commonest genotypes
were genotype 4 followed by genotype 1 . However, it is
clear that in the less populated states of Gulf area, detailed
studies on HCV are lacking, and the magnitude of such
problem is not well documented. Furthermore, the impact
of foreign workers on the prevalence of HCV is not known,
particularly as most of these workers are coming from
it is evident that the prevalence of HCV in Arabian peninsula
ranges from to 0.8% to 2.1% among these countries apart
from Qatar which reached 6% and that is difficult to explain
(such data has to be taken with caution). Over one and
half million were infected with HCV as HCV genotype 4 is
more prevalent. This makes such region classified within an
intermediate range worldwide as shown in Table 2.
2.2. Hepatitis C Virus in Sham Region. This region is com-
posed of Syria, Iraq, Lebanon, Jordan, and the existing Gaza
Syria on the prevalence of HCV among different categories
. The prevalence of HCV among Syrian was found to
be 1% among the general population, though its remarkably
high in the risk groups. Among haemodialysis patients it
ranged from 24.4 to 88.6%, though it is 3% among health
care workers and 60.5% among IDUs, and 1.96% among
prostitutes . The commonly isolated genotypes among
Syrian people were genotype 4/1b followed by rare ones as
1a, 3a, and unusual genotype 5 was also reported .
In Iraq, the prevalence of HCV ranged from 3.21 to
7.1% among the pregnant women and general population
of four HCV genotypes, 1a, 1b, and 3a [26, 27]. A study
carried out on Iraqi refuges showed further discrepancy in
this regard; Chironna et al.; using HCV-RNA analysis found
that the prevalence among these refuges was 0.1%, and
HCV genotype 4c, d was the commonest . Hence then
further studies were needed to clarify the Iraqi serostatus.
However, such prevalence was remarkably increased among
haemophilia patients as it reached 66.0% .
HCV is less frequent among Lebanese; it ranged from
0.16 to 1.22% among healthy volunteers, blood donors, and
patients . Genotype 4 was the commonest isolated
genotype among the various groups studied followed by
genotypes 1a and 1b .
The collected data form Jordanian studies was found to
be variable and even contradicting. The overall prevalence
of HCV among Jordanian people varied from 0.65 to 6.25%
depending on the population studied . It was found to
be 28% among haemodialysis patients and 40.5% in he-
mophiliac patients. The predominant genotype was found
to be genotype 1a followed by 1b and 4 . However, few
studies were coming out from Gaza Strip concerning the
prevalence of HCV where it was found to be 2.2%, though
the most prevalent genotype was found to be genotype 4
followed by 1 and 3a [34, 35].
Hence then, over two million with 0.7–6% of prevalence
were infected in Sham region; the lowest prevalence was
reported in Lebanon followed by Syria, Gaza strip, and then
Jordan and Iraq, though the HCV genotype 4 was the
commonest among all the regions a part from Jordan which
do need further elucidation.
2.3. Hepatitis C Virus in Arabian Nile River Region. Sudan
and Egypt are the main countries to be considered in this
from the Ethiopian mountains to cross Sudan and pass via
Egypt to the Mediterranean basin and indeed its one of the
oldest ancient civilizations in the world. Hepatitis C virus
has been intensively studied in Egypt, and great efforts have
been shown in this important area . The prevalence of
such virus is reported to be higher in Egypt than in any
other country. Indeed, it is a phenomenon that attracted the
attention of many researches and scientists not only in Egypt
but allover the world . Despite the different speculation
which has been postulated, the argument is still going on,
and no obvious reason was proofed. The prevalence of HCV
among the general populations was variable according to the
studies conducted, as it varied from 13 to 22% accordingly
[38, 39]. The prevalence of HCV among various groups and
categories was intensively studied. It was found to be 14.5%
among blood donors, 7.7% among health care workers,
12.1% of rural primary school children, 18.1% of rural
villages residents, and 22.1% among army recruitments. It
was even higher among risk groups, 70.4% in haemodialysis
patients, 54.9% in multitransfused children, and 47.2% in
chronic liver disease patients [40, 41]. The predominant
HCV genotype among Egyptians was found to be genotype
4 The Scientific World Journal
4, particularly subtype 4a . However, recent studies re-
vealed that other genotypes and subtypes as 1a, 1b, 2a are
also present indicating that HCV genotypes are extremely
The status of HCV among Sudanese is also obvious as
it is reported to be (2.2–3%) among the general population
[44, 45]. High-risk population showed a higher prevalence
of HCV, and it was found to be 23.7% in haemodialysis
patients . The major genotype isolated was genotype 4
with subtypes 4e, 4c, and 4d . This was found to be
similar to those genotypes isolated from Egypt.
Hence then, the Nile River region was considered to be
the highest endemic area in prevalence of HCV with 15 mil-
lion infected persons particularly genotype 4 as shown in
Table 2. Further studies are needed to explore new methods
for prevention and treatment.
The Arabian North African countries include Libya,Tunis,
Algeria, Morocco, and Mauritania, (Mauretania). The preva-
lence of HCV and its genotypes among different populations
at Maghreb countries is variable. In Libya, HCV has been
intensively studied by Daw and his collaborators over the
last ten years; the prevalence of HCV among Libyans was
1.2% though among hemodialysis was 20.2% . Recently,
a comprehensive study consisted of 1240 Libyan patients was
carried out . Different genotypes were reported in the
study; genotype 4 was the commonest (35.7%), followed
by genotype 1 (32.6%). According to subtypes, 28% were
unclassified as genotype 4, 14.6% were genotype 1b, and
some patients were infected with more than one subtype
commonest among males, while genotype 4 among females.
Despite the obvious role of prevention and control of such
virus and data available by Libyan researchers, the national
authority failed to adapt these regulations at a national
level, though every centre has its own way of adapting such
Different studies were also carried out in Tunis [50, 51];
the prevalence of HCV reported among Tunisians was 0.4 to
0.7%; the lowest among was the Maghreb countries, though
such prevalence was high in haemodialysis patients as it
reached 51% . The commonly isolated HCV genotypes
by genotypes 1a(5%), 2a(7%), 2b and 3a(3%), and 4a (1%),
respectively . In Algeria, a national seroprevalence study
was carried out covering healthy blood donors and pregnant
women. Prevalence of HCV among these two groups was
0.18 and 0.19%, respectively, though it was 2.5% among
the general population [54–56]. However, further studies
on genotype and analyzing the serostatus on other risk
population as haemodialysis and haemophilia are needed.
In Morocco, the prevalence of HCV was reported to be
to be 1.93% in a study carried out by Beghdadli et al. ,
Such prevalence was high among haemodialysis as it reached
42.4%, though it was 35.1% within the haemophiliacs
patients . The most prevalent genotypes reported among
the Moroccans are 1b (47.6%), 2a/2c (37.1%), and 1a (2.8%)
. Furthermore, the prevalence of such genotypes varies
according to age; genotype 1b is more prevalent among old-
er patients, whereas subtype 2a/2c is mainly found among
Despite the clear picture of HCV epidemiology in Libya,
Tunis, and to a certain instant in Algeria and Morocco, such
among blood donors . It has been assumed it will be the
same pattern as the rest of other Maghreb countries though
no reported studies in this subject, and hence then, further
studies are needed to clarify such assumption.
The epidemiology HCV among the Maghreb countries
was found to be variable, and around one million and half
population, followed by Libya with low prevalence, then
Algeria and Mauritania which are classified as moderate
and later Morocco with a higher prevalence; furthermore
HCV genotype 4 is the predominant one among Libyans,
though genotype 1 is more common in the rest of Maghreb
countries. However, it was difficult to explain such variation
as the people in these countries are very interacted and
sometimes difficult to differentiate between. This may be
related to the nature of the studies we referred to, and hence
then, further detailed studies are needed.
The epidemiology of HCV among Arabs is unique in its
nature, and varieties of risk factors have been found to
be associated with its high prevalence rate. However, the
emphasis on these factors may vary from one country to
another as shown in Table 3.
3.1. Blood and Blood Products. HCV has been known to
be the most common blood-borne virus over the world
particularly among the developing countries. Blood and
blood products remain a major cause of spread of HCV
among Arab countries, and most of them fail to fulfill the
criterions of modern blood transfusion system. Different
studies have shown the impact of blood transfusion on
the status of HCV in these countries. Studies from Jordan
showed that HCV infection was detected in 34% of patients
who had received blood transfusion, compared to only 16%
of those who received no transfusion . The picture in
have previous history of blood transfusion. In Yemen,
80% received blood transfusion were infected with HCV
compared with 20% who received no blood . In Libya,
a history of blood transfusion was reported in 22.7% of
those with HCV . HCV was found to be remarkably high
among thalassemia patients who received repeated blood
transfusion; it was found to be 67.3% in Iraq, 42.4% in
Morocco, 40.7% in Jordan, and 40% in Saudi Arabia .
In Arab countries, blood transfusion is still a problem
and qualified staff. The main sources, of blood donation are
The Scientific World Journal5
Table 3: Factors associated with the Transmission of HCV among Arab countries.
Extent of Exposure among each country
[All in this range]
[All in this range]
[All in this range]
[Lb, Ly, Tu, Sa, UAE, Om, Bh, Qr, Jr, Kt]
[Lb, Tu, Ly, Jr, Sy, Sa, Bh, Kt, Qr, Om, UAE]
[Lb, UAE, Sa, Ly, Lb, Bh, Qr, Om, Tu, Jr, Sy, Kt] [Alg, Mo, Sud, Eg, Ye, Irq, Mu]
[Alg, Irq, UAE, Qr, Bh, Kt, Om]
[Ly, Sa, Ye, Sud, Mu, Om, Kt][Alg, Tu, Eg, Jr, Sy, Lb]
Health care workers
Invasive Medical procedures
Hospital Waste Handling
High risk behavior
[All in this range]
[All in this range]
[Eg, Ye, Sud, Mo, Mu, Alg, Irq, Sy]
[Mu, Mo, Alg, Sud, Irq, Ye, Eg]
[All in this range]
[Eg, Mr, Mo, Ye, Sud]
[Mo, Bh, Irq, UAE, Qr,]
[Ly, Tu, Lb, Sa, Jr, Sy]
Low: <5%, Moderate: 5–20%, High: > 20%, NO: No country in this category.
usually relatives and friends of the patients who come on
social pressure and due to the fear of the death of a patient
(i.e. relative). Donors usually come in emergency time, and
questions about high-risk behaviors are seldom asked .
Therefore, resources and organization should be available to
recruit altruistic volunteers.
The current data indicate that all the Arab countries
undertake anti-HCV screening mandatory in all blood
banks, though in some countries, patients may have to pay
for such tests. The main concern is the reliability of such
tests, and some data indicated that antibody tests for HCV
genotypes/subtypes common in Europe and North America
are not well applicable on the sera tested from developing
countries though most of Arab countries import such tests
. Furthermore, rapid tests and some lots of ELISA failed
to detect HCV-reactive sera and up to 1% of seronegative
blood units tests positive for HCV-RNA using RT-PCR
technology . Therefore, even when HCV screening test
is performed the risk of becoming infected is still visible.
This however makes it necessary to add new molecular tests
such as the determination of HCV RNA by nucleic acid
technology (HCV-NAT) to the already performed tests in
blood donation which should be coupled with meticulous
The recent uprising in Arab countries which may
brought inspiration to Arab citizens left some of health care
services in a chaotic situation. In Libya, such crises left an
estimated 50.000 killed and over 120.000 injured; screening
of blood in war field was mainly limited quick screening
. This will have great impact on the prevalence of HCV
and the consequence among the infected victims in such
Blood transfusion and hospital-associated practice were
found to be important risk factors for HCV among Arabian
countries. These conditions can be overcome by develop-
ment of a fair and organized system of blood screening and
transfusion. National and international standards should
be implemented, and firm revision for such standards
and its implantation should be regularly revised. Further,
independent or even legal bodies should observe that such
implantation and legal action should be taken.
3.2. Haemodialysis Practice. The prevalence of HCV among
haemodialysis patients varies greatly from one region to
another, and it has been reduced drastically over the years
in developed countries. In Japan and UK, it was found to
be (1.2%) and (4%), respectively, though in certain African
countries, it reached up to 80% as in Senegal . Among
Arab countries the picture of serostatus of HCV among HD
patient is peculiar. Such prevalence is higher than that in the
general population, blood donors, and even among those
with other risk factors. Furthermore, it is more complex
and varies greatly from one country to another and even
among different dialysis centres in the same country .
Indeed, the prevalence of HCV among the haemodialysis
patients in any Arabic state per se surpasses any other
international centres in the developed countries, who follow
the strict regulations of HCV prevention in such setting.
The prevalence of HCV varies from 20.2% to 76% in such
countries, the highest prevalence was reported in Morocco
(76%), Kuwait (71%), and Yemen (61%), though the lowest
was reported in Libya (21%) as shown in Table 1.
In Arab countries, blood transfusion has played an im-
portant role in transmission of HCV in HD patients. Fur-
thermore, dialysis centres are usually overloaded with pa-
tients, and there is a shortage of material support (filters),
which leads to multiple use of the filter without proper
per machine is twice that in developed countries. Clusters
of HCV infection have been noticed in many haemodialysis
centres as in Syria, Sudan, Morocco, Yemen, Kuwait, and
Bahrain which may suggest large outbreaks in such centres
due to patient-to-patient transmission via HCWs’ hands
. Further evidence from CDC’s investigators raises one
possible way in which inappropriate use of medication vials
in haemodialysis units. This is however to be confirmed by
phylogenetic analysis of subgenomic regions of HCV .
6 The Scientific World Journal
after drying and environmental exposure to room temper-
ature for at least 16 hours; therefore, blood-contaminated
surfaces and objects can serve as sources for HCV trans-
mission. Generally, such transmission among haemodialysis
units is considered to be nosocomial with possible factors
being failure to disinfect devices between patients; sharing
of a single-use vials of infusions; poor sterile technique; poor
cleaning of dialysis machines; poor distance between chairs
in addition to dialyser reuse, duration, and frequency of
dialysis . HCV can hardly be transmitted during dialysis
procedures when state-of-the-art machines are used, where
most of these countries offered to have. The prevention
of HCV among HD is visible and such risk could be
drastically reduced. Erythropoietin should be used to reduce
the need of blood in HD patients, and proper nosocomial
prevention program should be implemented. This could be
advanced and supplemented by training, proper staffing and
a sufficient supply of materials and disposables according to
the actual need.
3.3. Intravenous Drug Users (IDUs) and Prisoners. Trans-
mission of HCV was strongly associated with intravenous
and percutaneous drug users (IDUs). The hepatitis C
European network for cooperative research group reported
a prevalence of HC of 80% among intravenous drug users
(IVDU), 40% in Thailand and up to 74% in Australia .
In injecting drug users (IDUs) population there has been
increased shifts among addicts from inhalatory to injectable
drugs due decrease in quality and availability of heroin.
Further, the effect of injecting drugs is more intense and
satisfying as HCV is found in a high concentration in spoons
and rinsing liquids that could be used in association with
needle drug use.
Injecting illegal drugs, sex behavior, and imprisonment
are considered to be shameful and unrespectable misconduct
among Arabian society. Individuals usually hide and deny
such act even if they did it, a state to be taken with caution
when taking history of risk factors particularly among blood
donors. More than a third of all prisoners and more than
80% of injecting drug users, were positive for antibodies
to hepatitis C virus . Alcohol consumption was also
found to accelerate the course of chronic hepatitis C. In Arab
countries, alcohol is licensed for sale except in Libya and
Saudi Arabia. Such important risk factors rarely are covered
by Arab researchers; very little data exist regarding the prev-
alence of injection drug use combined with Alcoholism and
imprisonment and its contribution to HCV infection in the
Arab world . In Lebanon HCV among IDU was found
to be 52.8%, with no difference in marital status, and in
prisoners, it was found to be (3.4%); tattooing was also
associated with HCV . In Syria, the prevalence of HCV
among Syrian prisoners was found to be 60.5 among IDUs
and 1.96 among prostitutes . A study in Saudi Arabia
showed that intravenous drug addicts have 14% of exposure
rate ; another study in Libya found that HCV was 15%
among IDUs .
Such behaviors are significant factors for HCV infection,
and this may become one of the prison system major health
to minimize the spread of hepatitis within these groups
are essential and education programs seem to be most
appropriate way to minimize such risk . This emphasizes
that the time has come for national and regional policy
makers, researchers, and clinicians among Arab countries
to take prisons as important health risks and never to be
considered as disadvantaged population.
3.4. Occupational Transmission of HCV. Hepatitis C virus
has been known to be an important nosocomial pathogen,
and several outbreaks have been linked to breaches in stan-
dard precautions for blood-borne infections during nursing
procedures or interventions such as colonoscopy surgery
and dialysis . In Arab countries where HCV infection
is endemic in the general population, hospitalization and
invasive procedures do appear to be significant risk factors
for HCV infection. Different studies have shown that the
prevalence of HCV among HCW was reported to be 3% in
Syria, 0.4% in Lebanon. In Egypt, health-care-related risk
factors contributed immensely in HCV infection particularly
those aged over 20 years old. Surgical practice such as suture
was associated with (32.3%), IV catheters (11.7%), though
urinary catheter (5.2%), and it was much higher in dental
practice as it reached (62.2%) .
The occupational transmission was better studied and
the picture was more obvious in the North African region.
In Libya, the commonest predisposing factor reported was
mainly medical-related transmission of HCV, such as hos-
pitalization and/or surgical procedure risk which accounted
for 33%, and history of dental procedure for 15.5%, when
compared with other risk factors . The prevalence of
HCV among Libyan children has an immense increase in
HCV and HIV in a short period of time with no evidence
of vertical transmission ; this unusual increase in the
prevalence of HCV among Libyan children was associated
with Bulgarian nurses saga. However, such scrutiny is still
under a major scientific dispute among scientists .
In Tunis, 51% of HCV cases were reported to be nosoco-
mial rather than transfusion related. In Algeria, occupational
mission . Needle stick injuries represented 81% among
the health care personnel in Algerian hospitals mainly due
the mismanagement of health care waste produced in the
hospital environment . Hence then, strict adherence to
the international standard precaution should be adapted on
a national level allover Algeria.
The assessment of sharps use in Arab countries indicates
that injections sometimes were given in a way that may
harm the patient. Determinants of these unsafe injection
practices include the lack of single-use injecting devices, the
lack of awareness of the risk of HCV and HIV infection
associated with unsafe injections, and the absence of sharps
waste management . Infection control practices in health
care settings needs to be reviewed and improved to prevent
nosocomial and iatrogenic transmission of HCV (and other
blood-borne pathogens). All health care workers should
The Scientific World Journal7
regard patients as infected with a transmissible blood-borne
3.5. Habitual and Community-Associated Factors. Commu-
nity has been considered to be an important source for
hepatitis C, and up to 50% of individuals deny exposure
to any of these known risk factors where, infection is often
designated as community acquired. Different habitual and
biosocial behaviors have reflected on the endemicity of HCV
among Arab countries. Indeed children and young adults
in Arab countries have a relatively high HCV prevalence,
although it is less than in the older population, which sug-
. A variety of contributing factors may be involved, and
it becomes imminent that strategies should be implemented
to overcome such potential risks. Unsafe use of unsterilized
injection is a major risk factor of HCV in Arab communities.
It is likely that injections given in rural communities by
both traditional and nontraditional health care providers are
an important cause of HCV transmission, particularly in
countries like Egypt, Sudan, Mauritania, Morocco, Algeria,
Iraq, and Yemen. The importance of combating this ubiq-
uitous risk in prevention programs cannot be overstated.
A study carried out by World Health Organization (WHO)
on the global use of injection has shown that most of the
Arab countries have serious problems in using injection in
their communities. Eastern Mediterranean region D which
mainly includes Egypt, Iraq, Morocco, Yemen, and Sudan
has the highest injection per person associated with lack
of sterilization. Interestingly, injection practices are safer
in sub-Saharan African than in these countries . The
same study have also shown that African region which
included among the states studied Algeria and Mauritania
has also shown a high incidence of unsafe use of injection
both health care settings and among community .
Furthermore, there is an ongoing speculation that the use of
parenteral antischistosomal therapy campaigns contributed
to the establishment of a large reservoir of HCV infection in
Nile River region .
Habitual and social behaviors have been found to influ-
ence HCV infection in Arab countries. Circumcision, one
of the potential culturally influenced exposures to HCV in
the community, occurred too frequently. Males over the age
of 20 had been circumcised either by informal health care
providers or by community physicians or nurses who were
more likely to be infected with HCV than those circumcised
by surgeons [83, 90]. Interestingly, marriage was found to be
another strong risk for HCV. In UAE, increased prevalence
of HCV among spouses was detected with longer duration of
marriage being an important risk factor, such infection was
passed to children at an early stage . A major logistic-
regression model study carried out in Egypt found that
the association of HCV in spouses could be the result of
sexual transmission or common exposures. Furthermore,
they have reported that spouses of patients with HCV have
an increased risk for acquiring HCV, and this risk increases
with age and is proportional to the duration of marriage
. However, unique community-acquired exposures such
as smoking goza pipes, shaving by a community barber, ears
piercing which common practice among Arab communities
were never reported as a cause HCV infections [83, 93].
Elucidating the relative contribution of various modes of
transmission of blood-borne viruses could help to direct our
achieve viral hepatitis prevention and control. Community
centres and counseling institutions should be established in
order to understand and facilitate to overcome such existing
risk factors. This will help persons in need by modifying
the patient is identified and could be referred to such a
convenient community centers.
Indeed, the status of HCV among Arabic countries should
be a worrying issue to all sectors involved in public health,
particularly those who are in close contact with patients
and strategists who should plan for new healthy look of
the Arabic societies , despite that there is clear difference
among the Arab countries regarding the prevalence and
the problematic issues of HCV, which should be eventually
taken in consideration regarding the prevention of HCV
at each country. Major measures should be implemented
as illustrated in Table 4. These include immediate primary
intervention (short-run) strategies and long-run prevention
strategies. Such prevention strategies should target reduction
of transmission of HCV, particularly among those at risk
of acquiring the virus. Risk-reduction counseling and HCV
screening program were directed to specific population as
suggested by Centre for Disease Control (CDC) which may
include persons at long-term dialysis, chronic liver diseases
patients, health care workers after needle stick injury, and
children of HCV-positive mothers . Preventive measures
should be directed towards individuals or populations at
specific settings such IDUs/STD and prisoners. Hospitals
and health care centers should adapt universal and specific
infection control programs targeting not only the status of
nosocomial infection per se but also particularly those units
or persons who were more prone to HCV infection.
ing better cleansing and standard sterilization methods to
stop nosocomial and iatrogenic transmission of HCV.
Patient-care practices associated with higher HCV preva-
and recommendations and precautions in these settings
should be adapted. This includes routinely wearing gloves;
restricting the use of common supplies, instruments, and
medications for multiple patients; prohibiting the use of
mobile carts within treatment areas to store or distribute
medications and clean supplies [95, 96].
Further programs should include obligatory advanced
laboratory screening methods for blood and blood products
and reduction of number of transfusion-related trans-
missions and promote judicious injection and parenteral
medications among doctors and patients. Once patients are
found to have hepatitis C, they need to be counseled and
8 The Scientific World Journal
Table 4: Preventive and combat strategy programs for hepatitis C virus in Arab countries.
(1) Immediate continuous prevention strategies
(A) Universal prevention planning
(i) Well-planned educational programs regarding the risk of HCV both at the community and health institutions levels
(ii) Implementation of international and national guidelines regarding the prevention of HCV particularly at special hospital
settings as blood banks and haemodialysis units and high risk groups at the community
(iii) Strict adherence to such guidelines and regular assessment to its applications
(iv) Introducing specific patient-care practices
(B) Special settings prevention programs
(i) Blood and blood products, HCV screening program and using thioproprin, haemovigilance
(ii) Haemodialysis; strict adherence to nosocomial prevention program; review practices to ensure they are consistent with
recommendations and applied routinely,
(iii) Laboratory and health care; improving laboratory testing, better sterilization, safer injection, and less exposure to blood
(2) Long-run preventive strategies
(A) Universal preventive planning
(i) Vigilance and health alert programs which should report any problem and allow to interfere at any time
(ii) Elucidation is needed for better prevention, screening, and updating HCV treatment
(iii) Prevention of HCV infection progress
(iv) Eradicate the massive use of unsafe medical procedures
(B) Special settings preventive planning
(i) Injecting drug users
(ii) HIV-HCV coinfected patients
(iii) Prisoners inmates
(3) Research planning and priorities
Well-designed research programs should be established both at country level and regional levels which may include
(i) Population-based surveillance studies
(ii) Evaluation of safety and efficacy of antiviral therapy for HCV alone and with other coinfected viruses particularly HIV
(iii) Further evaluation of iatrogenic causes of HCV transmission
clinically evaluated, to reduce the risk of transmission and
stop the progression of the disease, respectively. Patients with
chronic HCV are susceptible to HAV, or HBV infections
should be vaccinated particularly among the Arab countries
as the prevalence of these two viruses is high . Further
HCV is considered to be an opportunistic disease in persons
with HIV infection . Hence then, the safety and efficacy
of antiviral therapy INF-& and/or INF-& plus ribavirin for
HCV coinfected patients must be evaluated scientifically
through clinic trial in Arab world . The implementation
of new antiviral treatment and the role of genotyping also
have be assessed and appropriate strategies for management
of end-stage liver diseases have to be rigorously investigated
4.1. Implications for the Future Challenges. Hepatitis C virus
is a serious ongrowing problem in Arab countries, and it has
great social-economic impacts which may touch the future
of the young generation and influence the infrastructure of
such dynamic states. Despite the great capital and natural
resources that this nation has, none of these countries have
shown meticulous and clear national or regional scientific
plans to combat the future damage that HCV may cause.
Prevalence of HCV is destined to increase further among
Arabcountrieswhichshould beanalarming issueforfurther
measures. A recent forecast modeling study for prediction
of hepatitis C seropositivity among Libyans has shown
that in 2020 the HCV will increase by threefold .
Another modeled incidence study from Egypt showed that
the prevalence of HCV is expected to be continuing at a rate
hyperepidemic transmission in this region . This will
have an immense effect on the Arab society with great social
clinical and economic implications. Hence then, radical
improvement in local infection control measures capable
of limiting viral spread among general population should
be implemented. Further prospective studies in various
population groups are needed in most of the Arabia to
generate reliable data on the clinical significance of HCV and
its genotypes to hamper such rigorous implications.
Conflict of Interests
The authors declare that they have no conflict of interests.
All the authors have read and approved the final paper
and contributed immensely in the study. M. A. Daw is a
The Scientific World Journal9
Professor of Clinical Microbiology and Acting Physician of
Internal Medicine, a leading expert in nosocomial infection
and epidemiology, and Editor-in-Chief of Libyan Journal
of Medicine—PubMed indexed. A. A. Dau is a Consultant
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