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 Table of Contents  
Year : 2012  |  Volume : 2  |  Issue : 3  |  Page : 77-78

Hepatitis A vaccination in developing countries: Is Syria next?

1 Department of Neurosurgery, Cleveland Clinic, Cleveland, Ohio, USA
2 Yale School of Public Health, Yale University, New Haven, CT, USA
3 Damascus University Faculty of Medicine, Damascus, Syria

Date of Web Publication12-Oct-2012

Correspondence Address:
Shadi M Alhalabi
Yale School of Public Health, Yale University, New Haven, CT
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2231-0770.102284

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How to cite this article:
Habboub G, Alhalabi SM, Mousabasha G, AL-Faham Z. Hepatitis A vaccination in developing countries: Is Syria next?. Avicenna J Med 2012;2:77-8

How to cite this URL:
Habboub G, Alhalabi SM, Mousabasha G, AL-Faham Z. Hepatitis A vaccination in developing countries: Is Syria next?. Avicenna J Med [serial online] 2012 [cited 2020 Sep 28];2:77-8. Available from: http://www.avicennajmed.com/text.asp?2012/2/3/77/102284

   Introduction Top

Hepatitis A is a disease caused by a RNA virus that is classified as a member of the picornavirus family. Hepatitis A virus (HAV) is usually transmitted by the fecal-oral route, most frequently via contaminated food or water or close contact. The virus is also associated with poor sanitary conditions and low socioeconomic status. [1]

HAV causes an acute benign disease that is generally self-limited, rarely fatal and normally limited to the liver. Seventy percent of infected children less than 6 years old are asymptomatic and even when illness occurs, it is usually subclinical. [2] On the other hand, in children above the age of 6, infection is usually symptomatic and accompanied by jaundice in more than 70% of cases. [3] Typical symptoms last less than 2 months, yet prolonged or relapsing disease accounts for 10-15% of cases. [4]

The case fatality ratio of Hepatitis A is estimated to be 0.3-0.6% and reaches up to 1.8% in adults older than 50 years of age. [5] Patients with chronic liver disease who acquire hepatitis A are at an increased risk of acute liver failure disease. [6],[7]

At this point there is no specific treatment for HAV infection. The Centers for Disease Control and Prevention (CDC) recommends the vaccination of all children at age 1 year as it is the most effective method to prevent hepatitis A infection. [8]


Previous vaccination attempts to reduce the incidence of HAV infection were very successful. Universal vaccination programs had a positive impact not only on the vaccinated groups but also on nonvaccinated groups mainly due to a herd immunity effect. [9] In the USA, Hepatits A vaccine was implemented in 17 states, decreasing the Hepatitis A rate by 88% to a historic low. [10] Vaccination has proven to be safe with no increases in serious adverse events compared with baseline. [11]

In Syria, vaccination against HAV is not included in the Extended and Routine Program on Immunization, and currently there is no recommended HAV vaccination strategy in Syria.

The status of Hepatitis A in Syria

In 2000, a study conducted in Syria on over 800 patients noted serologically that 89% were previously infected, with 95% of cases occurring in patients under the age of 15 years. [12]

In different parts of the world, there has been a gradual shift in the age of acquiring HAV to older age groups. [13] This shift has also been documented in most of Syria's neighboring countries. [14],[15] This is mainly due to enhancing sanitation of the drinking water, increased promotion of personal hygiene measures reflecting an improvement in the socioeconomic conditions. The same applies for Syria; with the current development of better sanitation and living conditions, a shift in the age of infection to an older age group would be expected in the near future.

   Discussion Top

Despite the advances of modern medicine, most diseases are not vaccine-preventable. In the case of Hepatitis A, we are fortunate that a vaccine exists and that its administration can prevent future infection. Syria's current situation is best described as having high seroprevalance of Hepatitis A in children. [12] Considering the improvements in personal hygiene standards, international support of Syria's water network and sanitation, and the epidemiologic shift documented in several neighboring countries, an epidemiological shift in prevalence of Hepatitis A in Syria is likely to occur. This expected epidemiological shift to adult population would increase the symptomatic infection rate as well as the morbidity and mortality. A decision in Syria on when and how the vaccine should be used needs to be made.

We recommend Hepatitis A vaccine in Syria for the following reasons:
  • Hepatitis A vaccine has been commercially available for more than a decade and it has proved to be both effective and immunogenic. [16]
  • The safety of HAV has been well studied concluding that it is a well tolerated vaccine with low side-effect profile. In addition, although the vaccine is a two shot series, a protective response has been illustrated with a single shot. [17],[18],[18]
  • Considering the high prevalence of infections in Syria, the great morbidity associated with hepatitis A and the successful western experience in dealing with hepatitis A, [10] it is reasonable to include the Hepatitis A as part of the routine vaccination for the children.
  • The vaccine appears to be cost-effective in countries where it has been implemented. [19],[20],[21]
  • Taking into consideration the fact that a high percentage of the Syrian population is seropostive for Hepatitis A and that most patients reported asymptomatic disease, this may seem like a reason to avoid the expenditures and hard work associated with implementing a new vaccine nationwide. On the other hand with the development of better health promotion in Syria, the effect of reducing the early infection/late infection ratio would favor a trend in increasing symptomatic versus asymptomatic cases. The increase in morbidity from symptomatic cases and mortality of fulminant cases necessitates serious consideration of adding the vaccination to the national immunization program.

Future studies should document the anticipated, and probably already existing, epidemiological shift to the adult population. It could be only a matter of time before a much-anticipated improvement in Syria's water system and food hygiene standards prove to have a deleterious health effect from Hepatitis A.

   Acknowledgement Top

We would like to thank Dr. Steven D. Mawhorter, Cleveland Clinic Department of Infectious Disease, for his contribution in revising and editing this article.

   References Top

1.Jacobsen KH, Koopman JS. The effects of socioeconomic development on worldwide hepatitis A virus seroprevalence patterns. Int J Epidemiol 2005;34:600-9.  Back to cited text no. 1
2.Hadler SC, Webster HM, Erben JJ, Swanson JE, Maynard JE. Hepatitis A in day-care centers. A community-wide assessment. N Engl J Med 1980;302:1222-7.  Back to cited text no. 2
3.Lednar WM, Lemon SM, Kirkpatrick JW, Redfield RR, Fields ML, Kelley PW. Frequency of illness associated with epidemic hepatitis A virus infection in adults. Am J Epidemiol 1985;122:226-33.  Back to cited text no. 3
4.Glikson M, Galun E, Oren R, Tur-Kaspa R, Shouval D. Relapsing hepatitis A. Review of 14 cases and literature survey. Medicine (Baltimore) 1992;71:14-23.  Back to cited text no. 4
5.Novotny TE. US Department of Health and Human Services: A need for global health leadership in preparedness and health diplomacy. Am J Public Health 2006;96:11-3.  Back to cited text no. 5
6.Tandon BN. Ninth Triennial International Symposium on Viral Hepatitis and Liver Diseases. Rome 21 st -25 th April 1996. Trop Gastroenterol 1996;17:77-83.  Back to cited text no. 6
7.Bell BP. Hepatitis A and hepatitis B vaccination of patients with chronic liver disease. Acta Gastroenterol Belg 2000;63:359-63.  Back to cited text no. 7
8.Centers for Disease Control and Prevention. Hepatitis A Information for Health Professionals. Available from: http://www.cdc.gov/hepatitis/HAV/index.htm. [Last accessed on 2012 Jun 05].  Back to cited text no. 8
9.Domínguez A, Oviedo M, Carmona G, Batalla J, Bruguera M, Salleras L, et al. Impact and effectiveness of amass hepatitis A vaccination programme of preadolescents seven years after introduction. Vaccine 2008;26:1737-41.  Back to cited text no. 9
10.Wasley A, Samandari T, Bell BP. Incidence of hepatitis A in the United States in the era of vaccination. JAMA 2005;294:194-201.  Back to cited text no. 10
11.Westblom TU, Gudipati S, DeRousse C, Midkiff BR, Belshe RB. Safety and immunogenicity of an inactivated hepatitis A vaccine: Effect of dose and vaccination schedule. J Infect Dis 1994;169:996-1001.  Back to cited text no. 11
12.Antaki N, Kebbewar MK. Hepatitis A seroprevalence rate in Syria. Trop Doct 2000;30:99-101.  Back to cited text no. 12
13.Barzaqua BN. Hepatitis A shifting epidemiology in South-East and China. Vaccine 2000;18 (Suppl):S61-4.  Back to cited text no. 13
14.Sacy RG, Haddad M, Baasiri G, Khoriati A, Gerbaka BJ, Abu-Elyazeed R. Hepatitis A in Lebanon: A changing epidemiological patent. Am J Trop Med Hyg 2005;73:453-6.  Back to cited text no. 14
15.Battikhi MN, Battikhi EG. The seroepidemiology of Hepatitis A virus in Amman, Jordan. New Microbial 2004;27:215-20.  Back to cited text no. 15
16.Werzberger A, Mensch B, Kuter B, Brown L, Lewis J, Sitrin R, et al. A controlled trial of formalin-inactivated hepatitis A vaccine in healthy children. N Engl J Med 1992;327:453-7.  Back to cited text no. 16
17.Niu MT, Salive M, Krueger C, Ellenberg SS. Two-year review of hepatitis A vaccine safety: Data from the Vaccine Adverse Event Reporting System (VAERS). Clinical Infectious Diseases 1998;26:1475-6.  Back to cited text no. 17
18.Mawhorter SD. Who should receive hepatitis A vaccine? Cleve Clin J Med 2001;68:825-7.  Back to cited text no. 18
19.Rein DB, Hicks KA, Wirth KE, Billah K, Finelli L, Fiore AE, et al. Cost-effectiveness of routine childhood vaccination for hepatitis A in the United States. Pediatrics 2007;119:e12-21.  Back to cited text no. 19
20.Domínguez A, Salleras L, Carmona G, Batalla J. Effectiveness of a mass hepatitis A vaccination programme in preadolescents. Vaccine 2003;21:698-701.  Back to cited text no. 20
21.Lopaclo PL, Salleras L, Barbuti S, Germinario C, Bruguera M, Buti M, et al. Hepatitis A and B in children and adolescents--what can we learn from Puglia (Italy) and Catalonia (Spain)? Vaccine 2000;19:470-4.  Back to cited text no. 21

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