Systematic overview of hepatitis C infection in the Middle East and North Africa

ARTICLE HIGHLIGHTS

Research background

The Middle East and North Africa (MENA) has been identified as the region most affected by hepatitis C virus (HCV) infection worldwide predominantly due to the high HCV infection burden in Egypt and Pakistan. Since 2013, chronic infections with HCV genotypes 1, 2, 3, and 4 are curable, making elimination of HCV infection achievable for the first time. However, access and availability of the new direct-acting antiviral drug (DAA) regimens remains a challenge owing to country-level economic matters.

Research motivation

Developing and prioritizing evidence-based strategies for prevention programs and treatment scale-up require up-to-date information generated from rigorously designed studies and reported outcomes. A substantial number of systematic reviews of HCV infection in the MENA region have been published. What is the quality of these systematic reviews and what is the quality of the studies included in these systematic reviews? Researchers can be influenced by financial relationships while making judgments and decisions at a subconscious level such that they are not aware of the influence. The use and interpretation of the outcomes in the systematic reviews need to be viewed keeping in mind the reported conflict of interests by the authors of the systematic reviews. Our overview was also motivated because of the following questions: what do we know about hepatitis C epidemiology in the MENA region? High country-level anti-HCV prevalence has been identified in Egypt and Pakistan. What is the status of the other 18 MENA countries? What are the identified potential modes of transmission and populations at higher risk of acquiring hepatitis C infection?

Research objectives

The primary objective of our overview is to assess the quality of the data reported by the published systematic reviews of HCV epidemiology in the MENA countries taking into account conflict of interest disclosed by the authors of these systematic reviews. Our secondary objective is to produce a comprehensive picture of HCV infection epidemiology in the 20 countries of the MENA region.

Research methods

An a priori protocol of our overview is registered with the International Prospective Register of Systematic Reviews (PROSPERO registration number CRD42017076736). We conducted an overview of systematic reviews based on the Cochrane Handbook for Systematic Reviews of Interventions. We used broad search criteria to include all systematic reviews on HCV infection in the MENA region published after 2008 - the publication year of the first version of the Cochrane Handbook for Systematic Reviews of Interventions. We extracted all relevant outcomes related to HCV infection epidemiology. The nine primary outcomes of interest were HCV antibody (anti-) prevalences and incidences in different at-risk populations; the HCV viremic (RNA positive) rate in HCV-positive individuals; HCV viremic prevalence in the general population; the prevalence of HCV co-infection with the hepatitis B virus, human immunodeficiency virus, or schistosomiasis; the HCV genotype/subtype distribution; and the risk factors for HCV transmission. Thereafter, we critically analyzed and synthesized the extracted data by assessing their quality - using PICOTS framework, by evaluating conflict of interests disclosed by the authors of the systematic reviews, and by mapping the evidence and the gaps. Our overview is reported following PRISMA guidelines and assessed using AMSTAR tool.

Research results

Data reporting in a substantial proportion of systematic reviews on HCV infection in MENA may mislead the interpretation of these data. Our overview identified that a substantial proportion of the systematic reviews failed to report their outcomes following the PICOTS framework. Additionally, a substantial proportion of the systematic reviews lacked the key identified features of transparency and pragmatism. Our overview emphasizes the significance of considering the disclosure of financial relationships while assessing research and its reported outcomes. In the era of DAA treatment, the only published systematic reviews providing the number of chronically HCV-infected individuals in the MENA region - number of candidates for DAA treatment, have a large number of authors who disclosed financial relationships with HCV DAA pharmaceutical companies. We identified low prevalence of anti-HCV (< 1.5%) in Djibouti, Kuwait, Oman, Qatar, and UAE; moderate prevalence (1.5%-3.5%) in Algeria, Iraq, Lebanon, Libya, Morocco, Saudi Arabia, Sudan, Syria, and Tunisia; and high prevalence (> 3.5%) in Egypt, Pakistan, and Yemen. In Pakistan, anti-HCV prevalence may have increased from 5.4% in 1996-2007 to 6.7% in 2007-2008. No reported data in the general population was identified for Bahrain, Jordan, or Palestine. Intravenous drug use appears to drive HCV infection in Egypt, Lebanon, Libya, Morocco, Oman, Pakistan, Palestine, Saudi Arabia, Syria, and Tunisia. Relatively up-to-date data with good reporting quality were identified for these countries. However, missing data for the other ten MENA countries affect the evaluation of role of intravenous drug use in HCV transmission in a substantial part of the region. Furthermore, we identified that HCV transmission most likely occurs in healthcare settings due to iatrogenic and/or occupational exposures. Community-acquired HCV infection may also occur in the MENA countries; however, we identified evidence gaps in the region. Often, anti-HCV prevalence measures were not identified for key populations such as prisoners, men who have sex with men, and sex workers. Anti-HCV prevalence data were predominantly missing for the countries of the Gulf Cooperation Council and Yemen.

Research conclusions

Correct measures of anti-HCV prevalence, viremia, and genotype distribution are essential for developing strategies to manage and eliminate HCV infection. Evidence gap mapping and quality assessment, along with reviewing reported authors conflict of interest, revealed MENA countries and specific populations where data are scarce and/or lacking in quality. Our overview comprehensively characterizes hepatitis C epidemiology in the 20 countries of the MENA region and emphasizes their needs in terms of treatment and prevention. This will help policy makers of these countries to develop and prioritize evidence-based strategies for prevention programs and treatment scale-up in the region. This overview will contribute to the improvement of population health research practices in order to build research capacity in the MENA region

Research perspectives

Future systematic reviews on HCV epidemiology in the MENA region should strive to provide accurate information on HCV epidemiology demonstrating practical and clinical significance and relevance. To facilitate the development of precise prevention strategies and treatment programs, we recommend when estimating and reporting HCV prevalence and incidence, to avoid mixing populations at differing risk of acquiring HCV. Furthermore, up-to-date and good quality data are required in order to nowcast HCV epidemiology in the region. When data is available for long time periods, reporting should reflect changes in prevalence or incidence over time, which will allow to accurately describe the past and current HCV epidemiology in a population.