==== Front Ann Saudi MedAnn Saudi MedAnnals of Saudi Medicine0256-49470975-4466King Faisal Specialist Hospital and Research Centre 2345893110.5144/0256-4947.2013.1asm-1-1Systematic ReviewPrevailing genotypes of hepatitis C virus in Saudi Arabia: a systematic analysis of evidence Abozaid Suhair M. aShoukri Mohamed bcAl-Qahtani Ahmad adAl-Ahdal Mohammed N. ae a Department of Infection and Immunity, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia b Biotechnology Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia c Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada d Liver Disease Research Centre, King Saud University, Riyadh, Saudi Arabia e Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi ArabiaCorrespondence: Prof. Mohammed N. Al-Ahdal, Department of Infection and Immunity, King Faisal Specialist Hospital and Research Center, PO Box 3354 (MBC-03) Riyadh, 11211 Saudi Arabia, T: +966 1 442 4581, F: 966 1 442 4519, ahdal@kfshrc.edu.saJan-Feb 2013 33 1 1 5 Copyright © 2013, Annals of Saudi Medicine2013This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.BACKGROUND AND OBJECTIVES Although hepatitis C virus (HCV) genotype 4 has been reported to be prevalent in some countries of the Middle East, the genotype distribution in some geographical areas is not conclusive. We aimed to perform a meta-analysis on available literature on this issue in an attempt to identify or confirm the prevailing HCV genotypes in Saudi Arabia. METHODS We searched for reports describing genotypes in Saudi Arabia. A meta-analysis was performed on the samples in 18 studies, published between 1995 and 2011, in which HCV genotypes were identified. RESULTS A total of 2277 specimens from 18 studies showed that 617, 82, 119 and 1198 subjects were HCV-positive for genotypes 1, 2, 3 and 4, respectively. The meta-analyses showed that there is a great deal of heterogeneity in estimated prevalence among the studies. The highest prevalence was found in genotype HCV-4, followed by HCV-1, HCV-3, and HCV-2. CONCLUSION Our meta-analysei emphasizes that HCV genotype 4 is the most prevalent, followed by genotype 1. Further studies on genotype determination and subtype distribution are warranted. ==== Body Hepatitis C virus (HCV) infection is a global disease, with 2% to 3% infected people worldwide. 1 It can progress to a chronic and persistent infection, possibly leading to liver cirrhosis and hepatocellular carcinoma.2,3 HCV belongs to the genus Hepacivirus from the Flaviviridae family. It is a small, enveloped virus, with about a 10-kb single-stranded RNA molecule as its genome.4 The virus mutates frequently leading to changes in the envelope proteins which may help the virus to evade the immune system. Significant genomic variations have been reported, with six major genotypes and more than fifteen subtypes.5 The six major genotypes may differ from one another in relation to response to treatment, rate of mutation, and seriousness of liver injury.6,7 The widely-known combination therapy of pegylated interferon-alpha (2a or 2b) and ribavirin was beneficial in reducing the morbidity of the virus infection, albeit with limited success and high costs.8 Predictors of sustained virologic response (virus eradication) with this therapy are many, including virus genotypes and quasispecies, with plenty of amino acid sequence variations.9–11 Therefore, the determination of HCV genotypes is beneficial not only for predicting the response to treatment (type, duration, and dose) and for vaccine investigation, but for epidemiological purposes as well. Although the data are limited, information has been published in relation to the HCV genotypes described in Saudi Arabia. Most reports showed that HCV genotype 4 is the most prevalent, while others contest this conclusion.12–29 In this paper, we aimed to apply a meta-analysis on the current information, regardless of the purpose of the study, to pinpoint the most prevalent HCV genotypes in this part of the world. The lack of sufficient information on HCV genotypes in Saudi Arabia may reduce the effectiveness of this study. However, such an analysis is timely and needed for the community. METHODS MEDLINE, PubMed, and the Cochrane Clinical Trials were searched by two investigators (SMA and MNA) independently. English language restriction was applied. All reports of clinical trials that identified HCV genotypes have been searched. The Medical Subject Heading (MesH) terms used in the MEDLINE search were hepatitis C virus, hepatitis C virus genotypes distribution, hepatitis C virus genotype prevalence, hepatitis C virus genotypes and treatment with pegylated interferon alpha (2a or 2b) and ribavirin, and hepatitis C virus genotypes in Saudi Arabia. Searching the Cochrane databases of randomized, controlled trials was used to complete the MEDLINE exploration. Two investigators reviewed the abstracts and the articles (MMS, and AAA) independently. Prior to commencing this study, the inclusion criteria decided upon were to involve studies written only in English, on males or females, of a sample number containing 20 subjects or more, with any method of HCV genotyping, and at different risks of different chronic diseases of patients. Eighteen articles were found to meet these criteria, and were published between 1995 and 2011. Previous to 1995, no information on HCV genotypes in Saudi Arabia was found. We assessed the heterogeneity among the studies, separately, for each genotype with the chi-square test (with a P value <.05 indicating the presence of significant heterogeneity). The presence of significant heterogeneity was the reason for using the random effects model to construct an overall estimate of prevalence and confidence intervals for each HCV genotype. The methodological approach described in Sidek and Jankman30 for testing heterogeneity, constructing weighted averages for the overall prevalence, taking into account the effect of heterogeneity, and constructing confidence intervals was used. RESULTS The outcome measures for each study included in the meta-analysis were the point estimates of prevalence together with their estimated standard errors. After an extensive search for HCV genotypes in Saudi Arabia, only 18 citations comprising 2277 specimens were found to include HCV genotyping, although the purpose of each study may be different. Our search did not reveal any study before 1995. Table 1 is a summary of these studies, most of them from the two major cities (Riyadh and Jeddah) in Saudi Arabia. HCV genotypes 5 and 6 were not analyzed since their prevalence is negligible (11 and 0, respectively, out of a total of 2277 samples from those studies) compared to the other four genotypes. The prevalence of the other, more common, four genotypes was analyzed for each genotype using information in each study and in all studies. The upper and lower limits of the 95% confidence intervals on the population prevalence are shown on each study and to the far right for all studies showing HCV-1, HCV-2, HCV-3, and HCV-4 in Figure 1, Figure 2, Figure 3, and Figure 4, respectively. In Table 2, the P values indicate that the hypothesis of homogeneity among the studies is not supported by the data for all genotypes. The P value for testing heterogeneity was less than .0001. Therefore, the constructed confidence interval on the common prevalence is based on the random effects model which assumes non-zero variations among the studies. The random effect model based on 95% confidence intervals is shown in Table 2. DISCUSSION The major aim of our review was to establish baseline information about the most prevalent HCV genotypes in Saudi Arabia. Since the estimates varied from one study to another, we used meta-analysis—an approach that combines information from a variety of studies. Such baseline information is essential prior to planning any intervention strategy. None of the studies referenced here reported information on age, gender, ethnicity, or other co-morbidities. A meta-regression test would have been performed if the information were available from all the studies used in this report. HCV infection is a worldwide problem, with a prevalence of 0.9% in the general population of Saudi Arabia.31 Genotypes of HCV result from the mutation of the virus during replication and there are six major genotypes, 1–6. Determination of the genotype of HCV in a given patient is important, since it can affect the success of the treatment and the length of time the medication will need to be taken.32 Moreover, the identification of HCV genotypes in different geographical areas of the world and knowing the prevailing genotype will assist scholars in their quest for better diagnosis and for obtaining an effective, universal vaccine.33 HCV-1 is the most common around the world, and prevails in the Americas, Europe and Japan.33 In Saudi Arabia, the generally accepted conclusion is that HCV-4 is the main genotype. 31 However, with advanced technologies, such as HCV gene sequencing, more genotypes became evident. 16 Our electronic search revealed that the number of published studies and the amount of data are not sufficient to allow solid conclusions. The strength of data used in our study may not be concrete, although a random effects model for meta-analysis was assumed to account for the heterogeneity among the studies. We believe, however, that pooling the available data for meta-analysis would release important information despite the heterogeneity of the cited studies. A few deficiencies exist in this study; some are inherent with the method of meta-analysis. First, the size of many individual studies may not be sufficient to produce a reliable estimate. Second, the strong heterogeneity among the studies can be another limitation. The presence of unobserved sources of heterogeneity (such as many migrant workers living in Saudi Arabia, particularly from Asia and North Africa) may interfere with the validity of this work. Third, it is possible that the popular conclusion of HCV-4 being the major HCV genotype in Saudi Arabia may change if there were studies that involve specimens representing the true population of Saudi Arabia and taken from every part of this vast country. Basing our analysis on 4-nomial joint distributions would produce the same results. The multinomial distribution can be utilized only if we were interested in comparing the prevalence of genotypes (eg, testing the hypothesis that genotype 1 is less prevalent than genotype 4), and that would be the only advantage of it. In this case one needs to use the covariance between the estimated prevalence, which is obtained from the 4-nomial distribution. Such a comparison is trivial and is not of any particular interest. In conclusion, the meta-analysis we performed shows that HCV genotype 4 is the most prevalent, followed by genotype 1. Further studies on genotype determination and, more importantly, on subtype distribution are merited. The overall estimated prevalence of HCV genotypes may be used as a benchmark to evaluate the likely size of the problem and deciding on the course of intervention. Our study will provide a baseline for further investigations that may involve larger specimen numbers, better diagnostic techniques, and involvement of HCV subtype identification. Figure 1 Prevalence of HCV-1 by study reference (17 studies). Upper limits and the lower limits of the 95% confidence intervals on the population prevalence are shown. The last line (far right, all studies) shows the confidence limits of the combined estimated prevalence. Figure 2 Prevalence of HCV-2 by study reference (12 studies). Upper limits and the lower limits of the 95% confidence intervals on the population prevalence are shown. The last line (far right, all studies) shows the confidence limits of the combined estimated prevalence. Figure 3 Prevalence of HCV-3 by study reference (10 studies). Upper limits and the lower limits of the 95% confidence intervals on the population prevalence are shown. The last line (far right, all studies) shows the confidence limits of the combined estimated prevalence. Figure 4 Prevalence of HCV-4 by study reference (18 studies). Upper limits and the lower limits of the 95% confidence intervals on the population prevalence are shown. The last line (far right, all studies) shows the confidence limits of the combined estimated prevalence. Table 1 Summary of the studies included in the meta-analysis of HCV genotypes in Saudi Arabia. Study no. City HCV patients Sample no. HCV -1 HCV-2 HCV-3 HCV-4 HCV-5 HCV-6 Reference no. 1 Riyadh CH, HD 60 25 2 - 33 - - 12 2 Riyadh CH 119 32 3 2 57 - - 13 3 Jeddah Various 61 21 1 0 39 0 0 14 4 Jeddah CH, HD, DU 154 44 - - 92 - - 15 5 All Unknown 80 6 - 44 30 - - 16 6 Riyadh CH 76 17 3 2 42 - - 17 7 Jeddah CH, Cirrhosis 140 34 2 0 97 2 0 18 8 Jeddah CH 107 32 5 6 59 - - 19 9 South CH 22 11 - - 11 - - 20 10 All CH 492 119 36 29 305 2 - 21 11 Riyadh CH 62 19 - - 40 - - 22 12 Riyadh CH 48 10 2 28 - - 23 13 Riyadh CH 272 60 30 148 - - 24 14 Jeddah CH 240 46 9 15 82 1 - 25 15 Dammam IVDU 131 97 1 15 13 5 0 26 16 Riyadh OLT 46 - - - 29 - - 27 17 Qatif SCA 51 13 20 6 8 1 NT 28 18 Riyadh CH 116 31 - - 85 - - 29 Total 2277 617 82 119 1198 11 - CH: chronic hepatitis, HD: hemodialysis, DU: drug users, OLT: orthotopic liver transplantation, SCA: sickle cell anemia, NT: not tested Table 2 Confidence limits (95%) on combined estimates of prevalence based on the random effects model. Limits HCV-1 HCV-2 HCV-3 HCV-4 Lower 0.22 0.01 0.02 0.43 Upper 0.36 0.11 0.20 0.59 P<.0001 for each genotype. ==== Refs REFERENCES 1 Lavanchy D The global burden of hepatitis C Liver Int 2009 29 74 81 2 Hoofnagle JH Natural history of hepatitis C Hepatology 1997 26 Suppl 1 S21 8 3 Seeff LB Natural history of hepatitis C Hepatology 2002 36 Suppl 1 S35 46 12407575 4 Suzuki T Aizaki H Murakami K Shoji I Wakita T Molecular biology of hepatitis C virus J Gastroenterol 2007 42 411 23 17671755 5 Smith DB Simmonds P Hepatitis C Virus: Types, Subtypes, and Beyond Methods Mol Med 2008 19 133 46 6 Kobayashi M Tanaka E Sodeyama T Urushihara A Matsumoto A Kiyosawa K The natural course of chronic hepatitis C: A comparison between patients with genotypes 1 and 2 hepatitis C viruses Hepatology 1996 23 695 9 8666319 7 Yu M-L Chuang WL Treatment of chronic hepatitis C in Asia: when East meets West J Gastroenterol Hepatol 2009 24 336 45 19335784 8 Shepherd J Brodin H Cave C Waugh N Price A Gabbay J Pegylated interferon alpha-2a and -2b in combination with ribavirin in the treatment of chronic hepatitis C: a systematic review and economic evaluation Health Technol Assess 2004 8 1 125 9 Hnatyszyn HJ Chronic hepatitis C and genotyping: the clinical significance of determining HCV genotypes Antivir Ther 2005 10 1 11 15751759 10 Al-Qahtani AA Kessie G Dela Cruz D Al-Faleh FZ Al-Ahdal MN Quasispecies of genotype 4 of hepatitis C virus genomes in Saudi patients managed with interferon alpha and ribavirin therapy Ann Saudi Med 2010 30 109 14 20220259 11 Aurora R Donlin MJ Cannon NA Tavis JE Genome-wide hepatitis C virus amino acid covariance networks can predict response to antiviral therapy in humans J Clin Invest 2009 119 225 36 19104147 12 al-Faleh FZ Huraib S Sbeih F al-Karawi M al-Rashed R al-Mofleh IA Hepatitis C virus genotypes in patients with chronic liver disease and haemodialysis patients from Saudi Arabia J Viral Hepat 1995 2 293 6 8732175 13 Al-Ahdal MN Rezeig MA Kessie G Genotyping of hepatitis C virus isolates from Saudi patients by analysis of sequences from PCR-amplified core region of the virus genome Ann Saudi Med 1997 17 601 4 17338004 14 Fakeeh M Zaki AM Hepatitis C: prevalence and common genotypes among ethnic groups in Jeddah, Saudi Arabia Am J Trop Med Hyg 1999 61 889 92 10674665 15 Shobokshi OA Serebour FE Skakni L Al-Saffy YH Ahdal MN Hepatitis C genotypes and subtypes in Saudi Arabia J Med Virol 1999 58 44 8 10223544 16 Boriskin YS Bakir TM al-Aska AI Booth JC Is hepatitis C virus genotype 4 predominant in Saudi Arabia? New Microbiol 1999 22 173 80 10423734 17 Al-Faleh FZ Aljumah A Rezeig M Al-Kanawi Al-Otaibi M Alahdal M Treatment of chronic hepatitis C genotype IV with interferon-ribavirin combination in Saudi Arabia: a multicentre study J Viral Hepat 2000 7 287 91 10886538 18 Osoba AO Ibrahim M Abdelaal MA Al-Mowallad A Al Shareef B Hussein BA Hepatitis C virus genotyping by polymerase chain reaction and DNA enzyme immunoassay among Saudi patients in the Western Province, Saudi Arabia Ann Saudi Med 2000 20 394 7 17264630 19 Akbar HO Effect of induction therapy on Hepatitis C Saudi Med J 2002 23 773 6 12174222 20 Al-Knawy B Okamoto H Ahmed El-Mekki A Elbagir Khalafalla M Al Wabel A Qazi F Distribution of hepatitis C genotype and co-infection rate with hepatitis G in Saudi Arabia Hepatol Res 2002 24 95 8 12270737 21 Shobokshi OA Serebour FE Skakni LI Hepatitis C genotypes/subtypes among chronic hepatitis patients in Saudi Arabia Saudi Med J 2003 24 Suppl 2 S87 91 12897908 22 Al-Traif I Handoo FA Al-Jumah A Al-Nasser M Chronic hepatitis C. Genotypes and response to anti-viral therapy among Saudi patients Saudi Med J 2004 25 1935 8 15711670 23 Alfaleh FZ Hadad Q Khuroo MS Aljumah A Alghamedi A Alashgar H Peginterferon alpha-2b plus ribavirin compared with interferon alpha-2b plus ribavirin for initial treatment of chronic hepatitis C in Saudi patients commonly infected with genotype 4 Liver Int 2004 24 568 74 15566506 24 Al Ashgar H Khan MQ Helmy A Al Swat K Al Shehri A Al Kalbani A Sustained virologic response to peginterferon alpha-2a and ribavirin in 335 patients with chronic hepatitis C: a tertiary care center experience Saudi J Gastroenterol 2008 14 58 65 19568501 25 Dahlan Y Ather HM Al-Ahmadi M Batwa F Al-Hamoudi W Sustained virological response in a predominantly hepatitis C virus genotype 4 infected population World J Gastroenterol 2009 15 4429 33 19764095 26 Alzahrani AJ Dela Cruz DM Obeid OE Bukhari HA Al-Qahtani AA Al-Ahdal MN Molecular detection of hepatitis B, hepatitis C, and torque teno viruses in drug users in Saudi Arabia J Med Virol 2009 81 1343 7 19551834 27 Mudawi H Helmy A Kamel Y Al Saghier M Al Sofayan M Al Sebayel M Recurrence of hepatitis C virus genotype-4 infection following orthotopic liver transplantation: natural history and predictors of outcome Ann Saudi Med 2009 29 91 7 19318754 28 Issa H Safety of pegylated interferon and ribavirin therapy for chronic hepatitis C in patients with sickle cell anemia World J Hepatol 2010 2 180 4 21160993 29 Alqaraawi AM Sanai FM Al-Husseini H Albenmousa A AlSheikh A Ahmed LR Prevalence and impact of hepatic steatosis on the response to antiviral therapy in Saudi patients with genotypes 1 and 4 chronic hepatitis C Dig Dis Sci 2011 56 1222 8 20931285 30 Sidik K Jonkman JN A note on variance estimation in random effects meta-regression J Biopharm Stat 2005 15 823 38 16078388 31 Al-Faleh FZ Ramia S Hepatitis C virus (HCV) infection in Saudi Arabia Ann Saudi Med 1997 17 77 82 32 Le Guillou-Guillemette HL Vallet S Gaudy-Graffin C Payan C Pivert A Goudeau A Genetic diversity of the hepatitis C virus: Impact and issues in the antiviral therapy World J Gastroenterol 2007 13 2416 26 17552024 33 Zein NN Clinical significance of hepatitis C virus genotypes Clin Microbiol Rev 2000 13 223 235 10755999