Scientific study: recommendations and solutions to Prevalence risk factors of Hepatitis A in children in Najaf Governorate 

Prepared by the researche : Assist. Prof.Dr.Eman Hassani AL-Salami ¹Assist. Prof. Dr.Shaimaa Rahim Hussein²; Assist. Lec.Dr. Muntadhar Jasim Mohammed Houm Al-Arbawi ³ Assist. Prof. Dr. Sahira Ayed A. Al-Musawi ⁴;

• -Department of Microbiology, College of Medicine, Kufa University, Iraq¹
• -The General Directorate of Education Al-Najaf ^2,3
• – Department of Vocational Education in the General Directorate of Education of Najaf Al-Ashraf.⁴

Democratic Arabic Center

Journal of Progressive Medical Sciences : First issue – May 2025

A Periodical International Journal published by the “Democratic Arab Center” Germany – Berlin

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Abstract

The name problem: suggestions and solutions to a social problem (the prevalence of the risk factors of Hepatitis A in children in Najaf Governorate).

Type of Study: Scientific Study for Treatment of Scientific-Social Problem (spread of Hepatitis A in children in Najaf Governorate

Aim of Scientific Study: Finding solutions of spread of Hepatitis A in children in Najaf Governorate

Methods: A total of 369 serum samples from clinically infection cases of AVH were received from September 2023 to August 2024. Of the specimens, 369 (22.33%) were positive for IgM anti-HAV antibodies.

Results : Distribution of HAV infection in children according to gender demonstrating that percentage in males 55.28% more than in females 44.72 % and The rate showed high frequency among age group (6 -10 years) 167(45,2%),while . Regarding the seasonal variation the rate was more common during – March and August compared to January and July 2,9% , 5,6%  respectively .

Introduction

Hepatitis A virus (HAV) is the most common cause of viral hepatitis. HAV is a small, nonenveloped, single-stranded RNA virus from the Picornaviridae family. The risk of infection is universally distributed. The incidence of infection has a strong relation with sanitary and environmental conditions and the level of socioeconomic development. Hepatitis A has a high rate of endemicity in underdeveloped countries with poor sanitation. Hepatitis A virus (HAV) infection is a common health issue throughout the world, especially in areas with high prevalence rate of HAV. HAV infection is generally acquired through the facal-oral route by either person-to-person contact or ingestion of contaminated food or water.1, 2 Geographical areas can be classified as high, intermediate, low and very low prevalence of HAV infection.3 Although HAV infection has a mild course in under 6 years old children and it is mostly asymptomatic or shows nonspecific symptoms in these ages,4, 5 it may cause significant morbidity and mortality among both adolescents and adults.6 Fulminant hepatitis may also develop among individuals with underlying liver disease.6 Significant epidemiologic changes of HAV infection have been observed during the past few decades. The prevalence of hepatitis A infection is influenced by hygiene, sanitation conditions and age groups of communities.7 In several developing countries, the decline in the seroprevalence rates of anti-HAV is attributed mainly to the improvement of socioeconomic conditions and enhanced access to sanitary water sources.2, 8, 9 In highly endemic countries, exposure to HAV is almost universal before the age of 10 years, and large-scale immunization is not needed. In intermediate endemicity areas, where transmission occurs primarily from person to person in the general community (often with periodic outbreaks), control of hepatitis A may be achieved through widespread vaccination programs.10, 11

Epidemiology

First discovered in 1973 by Feinstone, a spherical 27 nanometer particle was seen on immune electron microscopy in the fecal sample of hepatitis A pa   tients[12]. A member of the picornavirus family, the hepatitis A virus (HAV) is an RNA virus responsible for 1.4 million cases per year globally[13], with an estimated 7134 deaths in 2016; almost half of these cases were reported in Asia[14]. In the United States, the annual incidence rate was reported to be 2 cases per 100000 people, in 2006. Recent outbreaks of the disease have shown a 294% increase in infections between 2016-2018 compared to 2013-2015[15].

 Pathogenesis

The transmission of HAV occurs via fecal-oral route, which includes consumption of contaminated food or water and person to person contact. Polymerase chain reaction testing for blood donors is performed as transmission through blood transfusion is noted on rare occasions[16]. The dissemination of the HAV into the liver occurs via the portal vein after the virus traverses the mucosa of the small intestinal wall. The virus particles subsequently replicate and are secreted into the biliary canaliculi, reaching back to the small intestine through the bile ducts and being re-excreted in the feces. Until the body responds with appropriate immune reaction in antibodies, the HAV enterohepatic cycle continues. Human leukocyte antigen-restricted, HAV-specific CD8+ T lymphocytes and natural killer cells have been implicated in the damage and destruction of infected hepatocytes[17].

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Clinical presentation

The usual HAV incubation period is about 2-4 wk[17]. Fever, malaise, jaundice have been described as the most common presenting symptoms for HAV infection[18]. Other common symptoms include weakness, fatigue, nausea, vomiting, abdominal pain, arthralgias, myalgias, diarrhea and anorexia[17]. Patients rarely enter a prolonged cholestatic phase through recovery, while relapsing infections have been described as well[19].

About 10%-15% of patients present with a relapsing course within a 6-mo period of the initial infection[20]. The symptoms during the relapse are usually less severe than the initial infection. Notably, on extremely rare occasions a type 1 autoimmune hepatitis has been observed in genetically predisposed patients[21]. The spectrum of infections can range from asymptomatic patients without jaundice, symptomatic patients with jaundice, cholestasis with prolonged jaundice, to relapsing infections or acute liver failure[19].

Serum aminotransferases above 1000 U/dL are usually noted, with total bilirubin typically ≤ 10 mg/dL, and alkaline phosphatase below 400 U/L. Usually the serum alanine aminotransferase (ALT) is higher than the aspartate aminotransferase (AST)[22,23]. In general, older patients are more likely to have severe hepatocellular derangements, hospital admissions and higher mortality[24]. These findings can be attributed to an impaired regeneration capacity of the liver and a relatively weaker immune system in the older population[25]. In addition to old age, higher mortality has been reported in males[26]. Old age, underlying liver pathology and chronic viral hepatitis are reported risk factors for acute liver failure. In patients who develop acute liver failure, higher mortality has been associated with creatinine > 2 mg/dL (strongest predictor) total bilirubin > 9.6 mg/dL and albumin < 2.5 g/L[18].

Figer (2)

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Diagnosis

Specific antibodies against HAV (anti-HAV) in the serum can be detected. The diagnosis is confirmed by the presence of immunoglobulin (Ig) M anti-HAV. The antibodies can be detected at the time of onset of symptoms. Serum IgM levels peak during the acute infection and remain positive for up to 4 mo on an average from the onset of symptoms[27]. Immunity is usually tested with HAV total antibody to determine HAV natural exposure or secondary to vaccination[28]. The presence of IgM antibodies without any clinical symptoms is indicative of HAV infection in the past with persistent antibodies, asymptomatic infection or false positive test [29].

Liver biopsy or imaging studies are not required to make a diagnosis. If performed, a liver biopsy may show marked portal inflammation with typically a lesser degree of necrosis, Kupffer cell proliferation, acidophil bodies, or ballooning when compared to non-HAV viral hepatitis[30].

Figer (4)

1. Study Design:

A cross-sectional study design will be used to assess the prevalence of Hepatitis A and identify associated risk factors among children in Najaf Governorate.

2. Study Population:

• Target Group: Children aged 1-15 years residing in Najaf Governorate.
• Sample Size Calculation: Use prevalence estimates from previous studies or pilot data to calculate the required sample size with a 95% confidence level and a margin of error of 5%.
• Sampling Method: Stratified random sampling to ensure representation from different districts and varying socioeconomic backgrounds within Najaf Governorate.

3. Inclusion and Exclusion Criteria:

• Inclusion Criteria:
  • Children aged 1-15 years.
  • Residents of Najaf Governorate for at least one year.
  • Parental/guardian consent for participation.
• Exclusion Criteria:
  • Children with chronic liver diseases unrelated to Hepatitis A.
  • Recent travelers (within the past month) to regions with known Hepatitis A outbreaks.

4. Data Collection:

• Data Collection Period: Over a 1year period to account for seasonal variations.
• Tools and Techniques:
  • Questionnaires: Structured interviews with parents/guardians to gather data on demographics, socioeconomic status, access to clean water, sanitation facilities, hygiene practices, dietary habits, and vaccination history.
  • Clinical and Laboratory Assessment:
    • Collection of blood samples from children to test for Hepatitis A antibodies (IgM for acute infection and IgG for past exposure).
    • Conduct physical examinations to assess overall health status.

5. Variables:

• Dependent Variable: Hepatitis A infection status (positive or negative).
• Independent Variables:
  • Demographic Variables: Age, gender, educational level of parents, family size.
  • Socioeconomic Variables: Income level, employment status of parents, housing conditions.
  • Environmental Variables: Access to clean water, type of sanitation facilities, living area (urban vs. rural).
  • Behavioral Variables: Handwashing practices, food hygiene, and outdoor activities.
  • Health-related Variables: Vaccination status, history of previous infections, healthcare access.

6. Data Analysis:

• Descriptive Statistics: To summarize demographic and risk factor data (e.g., mean, median, frequency).
• Prevalence Estimation: Calculate the prevalence of Hepatitis A in the study population.
• Bivariate Analysis: Assess the relationship between each risk factor and Hepatitis A infection using chi-square tests or t-tests as appropriate.
• Multivariate Analysis: Use logistic regression to identify independent risk factors associated with Hepatitis A after adjusting for potential confounders.

7. Ethical Considerations:

The College of Medicine’s ethical council of the University of Kufa gave its approval to this investigation. Additionally, prior to the beginning of the research project, permission was obtained from AL-Najaf health directorate, and the public health laboratory, and verbal consent was obtained from all participants in the study. All patients had been Ab out the study and they permitted the researcher to give them a questionnaire and to have the blood sample.

Results :

      Distribution of HAV infection in children according to gender demonstrating that percentage in males 55.28% more than in females 44.72 % as shown in (Table 1).

Table 1: Gender distribution among study population

A total of 369 serum samples from clinically infection cases of AVH were received from September 2023 to August 2024. Of the specimens, 369 (22.33%) were positive for IgM anti-HAV antibodies. Regarding the seasonal variation the rate was more common during – March and August compared to January and July 2,9% , 5,6%  respectively as shown in (Table 2).

Table 2: Distribution of HAV among study population during 2023.

According to age distribution, their age of positive HAV cases ranged between 1-15 years. The rate showed high frequency among age group (6 -10 years) 167(45,2%), while the remaining in age group (1-5) and (11-15) years30,4%, 24,4 % respectively as shown in (Table 3).

Discussion

      According to world Health Organization, about more four million people infected with HAV are in the milled east region. The aim of the present study is to estimate the sero-prevalence of HAV in AL-Najaf  Governorate among specific age group. Hepatitis A is an acute, typically self-limiting liver disease and one of the most common infectious diseases in the world” 7. HAV was highly prevalent during the 10 years when this research was performed. Poor personal hygiene and health education might be the main reason for the increasing number of HAV cases. Most of migrants’ families lived in camps far away from the city center where poor sanitations and limited access to safe drinking water. This may contribute to the incidence of HAV ( 3, 7.) Few community-based studies have been conducted to estimate the incidence and prevalence of HAV and HEV in Iraq. Our study confirmed that HAV most commonly affected the children, and more than 60% of HAV cases were patients younger than 14 years (2425–)

Role of liver transplant

Acute liver failure occurs in less than 1% of acute HAV infections[6]. From these patients, only 31% require emergent liver transplant for treatment of fulminant disease, while the remaining patients recover spontaneously with symptomatic management[37]. In a study comparing liver transplant outcomes in patients with HAV vs hepatitis B infection, the patients with HAV were found to have lower 1- and 5-year survival rates. Presence of acute pancreatitis and HAV recurrence in this population was identified as risk factors for shorter graft and patient survival. Following transplant, patients should be carefully monitored for HAV recurrence as it is common and is associated with poor outcomes[38].

Risk for Infection?

• Persons experiencing homelessness
• Persons living in the same household with an infected person
• Sex partner(s) of an infected person
• Persons traveling to countries where hepatitis A is common
• Men who have sex with men
• People who use injection drugs
• Children in day care
• People who eat raw or under-cooked shellfish

How is Hepatitis A Infection Prevented?

Vaccination

• The hepatitis A vaccine offers excellent protection against HAV. The vaccine is safe and highly effective. Vaccination consists of 2 doses of vaccine (shots) spaced 6-12 months apart. Protection starts 1-2 weeks after the first dose of vaccine, and lasts for 20 years to life after 2 doses.
• The American Academy of Pediatrics recommends that all children should receive hepatitis A vaccine starting at 1 year of age (2007 AAP Statement).
• The CDC recommends hepatitis A vaccine for all persons traveling to countries where HAV is common (CDC Yellow Book).  For infants that will be traveling internationally, an early dose of Hepatitis A vaccine can be given at age 6-11 months.

Figer (5)

Natural Immunity

• People who have hepatitis A infection become immune to HAV for the rest of their lives once they recover. They cannot get hepatitis A twice.
• The blood test for immunity to hepatitis A is called the “Hepatitis A Total Antibody test.” People who have had hepatitis A and those who have received hepatitis A vaccine show positive antibodies to hepatitis A on this test for the rest of their life.

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Solutions of Infection Problem

1- Good personal hygiene and proper sanitation help prevent the spread of the HAV virus.

2-  Always wash your hands with soap and water after using the bathroom, changing a diaper, and before preparing, serving, or eating food.

3- Alcohol-based hand sanitizers do not kill the hepatitis A virus

4- People who have hepatitis A should not be preparing or serving food, or caring for the elderly or for young children, until at least 2 weeks have passed since the first sign of hepatitis A illness.

5- Boiling or cooking food and drinks for at least 1 minute to 185°F (85°C) inactivates HAV.

6- Foods and drinks heated to this temperature and for this length of time do not transmit HAV infection unless they become contaminated after heating.

7- Travelers can lower their risk of hepatitis A (and other food-borne illnesses) in developing countries by drinking only water that has been boiled or chemically purified, by eating only foods that have been properly heated, and by avoiding fruits or vegetables that are not peeled or prepared by the traveler personally.

8- Adequate chlorination of water as recommended in the United States does inactivate HAV.

The following suggestions may contribute forward to recover solutions the infection:

• Only drink bottled water with an unbroken seal.
• Avoid unpackaged drinks or ice.
• Avoid eating raw food such as fruit or salad that has been (or may have been) cleaned or prepared with contaminated water.
• Avoid uncooked foods, particularly vegetables and fruit that you have not peeled, prepared or boiled yourself.
• Avoid raw or undercooked meat and fish.
• Make sure cooked food is hot and eat it right away.
• Avoid shellfish and unpasteurised dairy products.
• Avoid eating food from street vendors.

Conclusion

    Although hepatitis A virus infection has a benign, self-limited course without chronicity, recognition of atypical cases which carry mortality risk is important.Hepatitis A virus is still a major cause of infection and disease in the world and heterogeneous pockets of susceptible and exposed individuals may co-exist in rapidly developing societies. Thereafter, small localized or large outbreaks of HAV infection will remain a threat in such areas. The situation demands that conclusive guidelines be produced for HAV vaccination in these communities after characterizing them appropriately. WHO is in the process of revising its position paper on hepatitis A, issued in 2000, with a view to: update and evaluate the data on disease burden, epidemiology, vaccine products and availability and immunization protection; review the use of the vaccine in outbreaks and for contacts of cases; and issue guidance to countries where the prevalence rates are declining from high levels. In determining national policies, the results of appropriate epidemiological and cost-benefit studies need to be carefully considered and the public health impact weighed[18,25].

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