The world is facing an unprecedented displacement crisis. Recently, over 1.1 million asylum seekers have been granted protection status in the European Union (EU). The majority of these asylum seekers were from countries of the Middle East and North Africa (MENA) region.This influx carries with it a potential introduction of infectious diseases that have been eliminated in the EU, which poses a challenge for EU health authorities. Compared to MENA region countries where Hepatitis A Virus (HAV) endemicity is high to intermediate, member states of the EU show very low (Western Europe) to low (Eastern Europe) levels of HAV endemicity. Because of this situation, there is an ongoing public health concern in high-income countries, like members of the EU, that many adults remain susceptible to HAV outbreaks. The overwhelming majority of the EU members’ states do not include HAV vaccine in their immunization calendars. Hence, this paper urgently calls for the implementation of new policies regarding HAV in EU members’ states. Keywords—European Union, Hepatitis A, MENA Region Refugees, Vaccine preventable diseases.

Objective: A shift in the age of hepatitis A virus (HAV) infection from early childhood to adulthood has been observed in many developing countries. This epidemiological shift has been attributed to improved socioeconomic status and sanitary conditions resulting in growing cohorts of susceptible young people and hence an increased risk of HAV outbreaks. The aim of this study was to investigate the evolutionary trend of anti-HAV seroprevalence in Lebanon in a cohort of Lebanese adults. Methods: This was a cross-sectional study employing a convenience sample (voluntary blood donors) along with secondary data analysis. Sera from 283 healthy blood donors were tested for anti-HAV IgG antibodies. Moreover, we analyzed the national reports of HAV cases published by the Lebanese Ministry of Public Health since 2001. Results: Anti-HAV seropositivity increased steadily from 60% in the younger age group (19–29 years) to 91% in the older age group (50–59 years), leaving the younger group at higher risk of acquiring HAV. The national data show that the number of acute hepatitis A infections is higher in the age groups 5–9 and 10–19 years. Conclusion: Our seroprevalence data reveal that young adults are becoming more at risk of acquiring HAV infection. Thus the introduction of hepatitis A vaccine is highly recommended.

Introduction: Hepatitis E virus (HEV) is mainly transmitted through contaminated water supplies which make the virus endemic in developing countries including countries of the Middle East and North Africa (MENA) region. Recent reports suggest potential risk of HEV transmission via blood transfusion particularly in endemic areas. Materials and Methods: Related articles on HEV were collected by searching through the 25 countries of the MENA region using Pubmed and Medline within the past 14 years: January 2000-August 2014. Results: One hundred articles were extracted, of which 25 were not eligible. The articles discussed the seroprevalence of HEV and HEV markers in 12 countries. Eight articles provided data on HEV in blood donors. The seroprevalence of HEV in the general MENA population ranged from 2.0%-37.5% and was higher in males than in females. Prevalence increased with age, but exposure seems to be in early life. Discussion: In the MENA region the role of HEV as an infectious threat to blood safety is under-investigated. More data are needed to quantify the risk of transmission and to assess clinical outcomes. This requires, at least, surveillance screening of donors and recipients for HEV markers using sensitive and specific serological tests. At the present time, serious consideration should be given to selective screening for certain groups of patients (e.g. immunocompromised, pregnant women and others) who commonly require blood transfusion and are at high risk of hepatic failure or chronicity from HEV infection.

Hepatitis E virus (HEV) is mainly transmitted through contaminated water supplies which make the virus endemic in developing countries including countries of the Middle East and North Africa (MENA) region. Recent reports suggest potential risk of HEV transmission via blood transfusion.Related articles on HEV were collected by searching through the 25 countries of the MENA region using Pubmed and Medline within the past 14 years: January 2000-August 2014.One hundred articles were extracted, of which 25 were not eligible. The articles discussed the seroprevalence of HEV and HEV markers in 12 countries. Eight articles provided data on HEV in blood donors. The seroprevalence of HEV in the general MENA population ranged from 2.0 to 37.5% and was higher in males than in females. Prevalence increased with age, but exposure seems to be in early life.In the MENA region, the role of HEV as an infectious threat to blood safety is under-investigated. More data are needed to quantify the risk of transmission and to assess clinical outcomes. This requires, at least, surveillance screening of donors and recipients for HEV markers using sensitive and specific serological tests. At the present time, serious consideration should be given to selective screening for certain groups of patients (e.g., immunocompromised, pregnant women and others) who commonly require blood transfusion and are at high risk of hepatic failure or chronicity from HEV infection.

During the past three decades, a gradual shift in the age of infection with hepatitis A virus (HAV) from early childhood to adulthood has been observed. There is a general lack of updated data on HAV burden of disease, incidence and age-specific seroprevalence in countries of the Middle East and North Africa (MENA) region. The aim of this article is to review the published data on anti-HAV seroprevalence, an important tool to monitor infections rates, in countries of the MENA region and associated risk factors including water and socioeconomic data when available. Data on anti-HAV seroprevalence were found for 12 of 25 MENA countries. We show that MENA countries, similar to other areas in the world, have a clear shift in HAV incidence with a decline among young age groups and an increase among adults and older individuals. This would likely be associated with increased morbidity and increased risks of outbreaks among younger age groups. Consequently, the continuous surveillance of hepatitis A cases and the inclusion of hepatitis A vaccine in the expanded immunization programmes are needed in countries of the MENA.

Background Symptoms such as medically unexplained vaginal discharge (MUVD) are common and bothersome, leading to potentially unnecessary use of resources. Methods A community-based individually randomized controlled trial to assess the effectiveness of a relatively simple, culturally appropriate multi-component intervention on reducing reported MUVD, among women suffering from low-moderate levels of common mental distress. The setting was a socio-economically deprived, informal settlement in the southern suburbs of Beirut, Lebanon. The intervention comprised up to 12 group sessions implemented over a six-week period, each divided into a psychosocial and a relaxation exercise component. The primary outcome was self-reported MUVD, which was defined as a complaint of vaginal discharge upon ruling out reproductive tract infections (RTIs), through lab analysis. Anxiety and/or depression symptoms were the secondary outcomes for this trial. These were assessed using an Arabic validated version of the Hopkins Symptoms Checklist-25 (HSCL-25). Assessments were done at baseline and six months using face-to face interviews, pelvic examinations and laboratory tests. Women were randomized into either intervention or control group. Blinding on the intervention status was not possible for both logistic and ethical reasons, especially as knowledge of involvement in the intervention was integral to its delivery. Intent to treat analysis was used. Results Of 75 women randomized to the intervention, 48% reported MUVD at 6 months compared with 63% of 73 in the control group (difference of -15%, 95% confidence interval (CI) -31%, 0%, p=0.067). Adjustments for baseline imbalances and any factors relating to consent had no appreciable effect on these results. The risk of MUVD was reduced in absolute terms by 2.4% for each intervention session attended (95% CI -4.9%, 0.0%, p=0.049). While there was also marginal evidence of a beneficial effect on anxiety, there was no evidence of mediation of the effect on MUVD through measures of common mental disorders. Conclusion This study confirms that MUVD is an important public health problem. While the benefits of this intervention may appear modest, the intervention offers an opportunity for women to enhance their problem-solving skills as well as use physical relaxation techniques that can help them deal with stressful in their lives. Further research is needed in a variety of contexts, for different populations and preferably involving larger randomized trials of such an intervention. Trial registration * Title of trial: The Relaxation Exercise and Social Support Trial ISRCTN assigned: ISRCTN98441241 Date of assignation: 10/09/2010 Link: http://www.controlled-trials.com/ISRCTN98441241 * Also registered at the Wellcome Trust register: http://www.controlled-trials.com/mrct/trial/469943/98441241

INTRODUCTION:This study aimed to identify reproductive tract infections (RTIs) in married, non-pregnant women, aged 18 to 49 years, living in a low-income suburb of Beirut, and to investigate the relationship between demographic and socioeconomic factors and these infections.METHODOLOGY:Among 1,015 women recruited for the study, 502 were found eligible and 441 were medically examined. Appropriate specimens were collected for Nisseria gonorrhea, Chlamydia trachomatis, Trichomonas vaginalis, candidiasis, and bacterial vaginosis.RESULTS:The results showed a relatively high prevalence of RTIs (28.2%). The prevalence rates of different agents were as follows: 22.9% of the women were positive for T. vaginalis, 8.8% for candidiasis, 4.5% for bacterial vaginosis, and 1% for N. gonorrhea; none of the women were positive for C. trachomatis. Regression analysis showed that women between the ages of 30 and 39 were twice more likely to have T. vaginalis as compared to younger women. Furthermore, women whose husbands were taxi drivers were at higher risk of acquiring T. vaginalis (OR = 2.2) as compared with women whose husbands occupation was listed as skilled/unskilled. This conclusion can be drawn for the odds of developing any RTI (OR = 2.15). Moreover, those participants with the lowest income were twice as likely to have any RTI compared to those with higher incomes.CONCLUSIONS:This study shows a relatively high prevalence of RTIs (T. vaginalis mainly). It urges further in-depth research on cultural practices and economic factors to understand the pattern of sexual behavior in this community.

PURPOSE:Investigation of the injecting drug users (IDUs) population is becoming extremely critical and timely in light of the recent evidence that IDUs now act as the core of hepatitis C virus (HCV) epidemics in developed countries. The purpose of this article, therefore, is not only to review the epidemiology of HCV in the Middle East and North Africa (MENA) region, but also to see whether IDUs were adequately studied and whether harm reduction strategies to be applied for their protection have been set.METHODS:A literature review was carried out of articles published within the last decade on HCV infection.RESULTS:The gathered data showed that the population of IDUs is severely under-investigated throughout the whole region, possibly due to religious and cultural impediments.CONCLUSION:In order to reduce the risk of HCV infection in IDUs, a set of recommendations are advanced emphasizing the urgent need for bio-behavioral studies in this population in order to help identify the source and mode of transmission and the genotypes of HCV involved. These results may allow the development of effective and, yet, socially acceptable intervention strategies. We believe that the role which IDUs play in sustaining HCV infection is also an under-investigated topic in many developing countries. Similar reviews and, hence, interventions should be initiated in these regions.

Hepatitis D virus (HDV) is a defective RNA virus and its life cycle is dependent on hepatitis B virus (HBV). Worldwide, it is estimated that 15 to 20 million individuals are HDV- infected representing approximately 5 % of the 350 million cases of HBV chronically- infected individuals. The belief that HDV is under control is far from true. Studies from Europe have clearly shown that HDV reservoirs have been maintained via import from Southern or Eastern Europe, and from endemic areas such as countries of the Middle East and North Africa (MENA region). The current review highlights the underestimated disease burden caused by HDV in the MENA region. A series of recommendations are advanced which will contribute to the control of HBV/HDV in the MENA region and consequently in neighboring Europe. The lack of conclusive evidence on the best treatment strategy of HDV, necessitates continued research on HDV infection.

BACKGROUND:Studies suggests a possible link between vaginal discharge and common mental distress, as well as highlight the implications of the subjective burden of disease and its link with mental health.METHODS/DESIGN:This is a community-based intervention trial that aims to evaluate the impact of a psycho-social intervention on medically unexplained vaginal discharge (MUVD) in a group of married, low-income Lebanese women, aged 18-49, and suffering from low to moderate levels of anxiety and/or depression. The intervention consisted of 12 sessions of structured social support, problem solving techniques, group discussions and trainer-supervised relaxation exercises (twice per week over six weeks). Women were recruited from Hey el Selloum, a southern disadvantaged suburb of Beirut, Lebanon, during an open recruitment campaign. The primary outcome was self-reported MUVD, upon ruling out reproductive tract infections (RTIs), through lab analysis. Anxiety and/or depression symptoms were the secondary outcomes for this trial. These were assessed using an Arabic validated version of the Hopkins Symptoms Checklist-25 (HSCL-25). Assessments were done at baseline and six months using face-to face interviews, pelvic examinations and laboratory tests. Women were randomized into either intervention or control group. Intent to treat analysis will be used.DISCUSSION:The results will indicate whether the proposed psychosocial intervention was effective in reducing MUVD (possibly mediated by common mental distress).TRIAL REGISTRATION:The trial is registered at the Wellcome Trust Registry, ISRCTN assigned: ISRCTN: ISRCTN98441241.

BACKGROUND:The aim of our study was to study the prevalence of and the risk behaviours associated with the hepatitis B virus (HBV) and hepatitis C virus (HCV) infections among two high-risk groups: female sex workers (FSW) and men who have sex with men (MSM). Furthermore, since vaccination is a key component of HBV prevention programs, the immune status of HBV infection in these two high-risk groups was evaluated.METHODS:Participants included in this study were part of a bio-behavioural surveillance study done to assess HIV prevalence among four vulnerable groups in Lebanon. Participants were recruited using a respondent-driven sampling method. The total number of eligible participants were 101 MSM and 103 FSW. Blood samples were collected as dried blood spots and then eluted to be tested for HCV, HBV and HIV by enzyme-linked immunosorbent assay.RESULTS:None of the 204 individuals tested has been exposed to HCV. In the 101 MSM, only one (0.99%) was an HBsAg carrier and one (0.99%) was confirmed as anti-HIV-positive. Among FSW, 30% showed they were immune to HBV compared with only ~10% among MSM. The distribution of socio-demographic characteristics and potential risk factors in both groups were shown.CONCLUSION:Our results highlight the urgent need to raise awareness among FSW and MSM and their health care providers of the availability and benefits of HBV vaccination in Lebanon. In addition, and due to the absence of vaccines against HCV and HIV, education programs aiming at behavioural changes should be intensified.

Objectives:To measure HIV prevalence and associated risk factors among female sex workers, injecting drug users (IDUs) and men who have sex with men (MSM) in Lebanon and the prevalence of hepatitis B virus and hepatitis C virus among IDUs. Methods and design:A cross-sectional survey of 135 female sex workers, 81 IDUs and 101 MSM was recruited using respondent-driven sampling. A structured interview was conducted by members of nongovernmental organizations working with these populations and blood was collected for serological testing. Results:HIV prevalence was 3.7% among MSM but no HIV cases were detected among female sex workers or IDUs. Among IDUs, prevalence of hepatitis C virus antibody was 51% and prevalence of hepatitis B virus surface antigen was 5%. Three-quarters of MSM had nonregular male sexual partners during the last year but only 39% reported using a condom every time. There was evidence of overlapping HIV risk: 36% of MSM and 12% of IDUs reported that they had sold sex. Previous testing for HIV was lowest among MSM (at 22%) despite their having the highest level both of knowledge about HIV and of perception of being at risk of HIV infection (67%). Conclusion:Prevention efforts at greater scale are needed to reach these at-risk populations in Lebanon. These should target MSM in particular, including access to HIV testing, but will need to address and overcome stigma. For IDUs, surveillance and prevention efforts should integrate both hepatitis C virus and HIV.

Background: People admitted to correctional facilities often have a history of risky behaviours which frequently lead to transmission of blood-borne viruses, such as human immunodeficiency virus (HIV), hepatitis B virus (HBV) and hepatitis C virus (HCV). Our aim was to determine the prevalence of HIV, HBV and HCV infections among prisoners in Lebanon.Methodology: Conducted between August 2007 and February 2008 in Roumieh Prison, Lebanon, the study included a total of 580 male prisoners aged 16 and above who were randomly selected from four prison blocks. Peripheral blood was collected by a finger prick, blotted onto high-quality filter paper, dried and later eluted to be tested for markers of HIV, HBV and HCV infections.Results: A significantly higher seroprevalence of HBV (2.4%) and HCV (3.4%) was found among prisoners compared to the seroprevalence of these virus infections reported in the general Lebanese population (< 1% for HBV and HCV). Only one of the 580 prisoners tested (0.17%) was confirmed as anti-HIV-positive. The majority (89%) of anti-HCV-positive prisoners had a history of previous imprisonment and were injecting drug users (IDUs). Tattooing was also associated with HCV transmission: all nine anti-HCV-positive prisoners had tattoos compared to only 60% who were anti-HCV-negative. Only HCV genotypes 1 and 3 were detected.Conclusions: We provide evidence for an outbreak of HCV and HBV occurring in Roumieh prison. In addition to vaccinating prisoners against HBV, collaborations should develop between the prison's administration, academic institutions, and community-based organizations to provide HCV prevention services within the prisons.

Background The aim of this study is to determine the prevalence of anti-HCV among injecting drug users (IDUs) in Lebanon, to establish the current prevalence of HCV genotypes in this population and to determine whether demographic characteristics and behavioral variables differ between participants who were HCV-RNA positive and those who were HCV-RNA negative or between the different genotypes. Participants were recruited using respondent-driven sampling method. The blood samples were collected as dried blood spots and then eluted to be tested for HCV, HBV and HIV by ELISA. Anti-HCV positive samples were subjected to RNA extraction followed by qualitative detection and genotyping. Results Among 106 IDUs, 56 (52.8%) were anti-HCV-positive. The two groups did not differ in terms of age, marital status, and nationality. As for the behavioral variable, there was a trend of increased risky behaviors among the HCV-RNA positive group as compared to the HCV-RNA negative group but none of the variables reached statistical significance. Half (50%) of the 56 anti-HCV-positive were HCV-RNA positive. Genotype 3 was the predominant one (57.1%) followed by genotype 1 (21%) and genotype 4 (18%). Conclusions The predominance of genotype 3 seems to be the predominant genotype among IDUs in Lebanon, a situation similar to that among IDUs in Western Europe. This study provides a base-line against possible future radical epidemiological variant that might occur in IDUs.

The presence of hepatitis B virus (HBV) serological markers have been investigated in 101 Lebanese patients (69 men, 32 women; mean age 32.7 +/- 1.7 years) infected with human immunodeficiency virus type 1 (HIV-1). Seven patients (6.9%) were HBsAg carriers compared with 54 patients (53.5%) who had no evidence of exposure to HBV infection. Twenty-four patients (23.8%) had anti-HBc alone as a serological marker compared with four patients who were positive for anti-HBs alone and 12 patients (11.9%) who were anti-HBc and anti-HBs-positive. Occult HBV infection (presence of HBV DNA in the absence of HBsAg) is found to be relatively high (28.7%) in HIV-infected Lebanese patients and the overwhelming majority (83.3%) of those who were positive for anti-HBc alone had a detectable HBV DNA in their serum. However, none of our HIV-positive patients with occult HBV infection had abnormal alanine aminotransferase level, which also raises the question as to whether occult HBV plays a role in the aetiology of liver disease in HIV-infected patients. Further, studies on the association between HBV DNA levels and markers of liver function in addition to data on liver biopsy would help in answering this question.

This report has grown out of the implementation of an Integrated Bio Behavioral Surveillance (IBBS) study among most at-risk populations in Lebanon. AIDS-related policies and programs in the Middle East and North Africa region are highly constrained by the lack of accurate information about the full scale of the epidemic. This is for a number of reasons, including limitations of existing surveillance, and intense stigma associated with the disease. Lebanon urgently requires greater understanding of its epidemic and high quality integrated bio-behavioral surveys of vulnerable populations are a prerequisite for greater understanding of low prevalence epidemics, such as Lebanon's. The costs of continuing to respond without adequate data or insight greatly outweigh the cost and complexities of such a survey. A Lebanese survey will also contribute to a greater regional understanding of the magnitude and dynamics of the Middle East's epidemics. The study aims to provide an estimate of HIV prevalence among four major vulnerable groups in Lebanon, namely men who have sex with men (MSM), prisoners, commercial sex workers (FSWs) and intravenous drug users (IDUs); provide an estimate of co-infection with Hepatitis B and C among HIV positive participants in the MSM population, FSW population, IVUDs, and the prisoners; provide an estimate of level of infection of Hepatitis C among the entire intravenous drug user population; foster research collaboration for the project between NGOs involved with the vulnerable groups, the National AIDS Program and the American University of Beirut and contribute to building the research capacity of the NGOs involved; estimate the population size of the four vulnerable groups using the multiplier method based on NGO sources and estimates; and gain greater insight into major HIV transmission dynamics among the four vulnerable groups in Lebanon.

Occult hepatitis B virus (HBV) infection, characterised by the presence of HBV infection with undetectable hepatitis B surface antigen (HBsAg), was investigated in 98 Lebanese patients with chronic hepatitis C liver disease and 85 control subjects recruited from eight institutions in different parts of the country. The prevalence of occult HBV infection ranged from 11.9% to 44.4% in hepatitis C virus (HCV)-infected patients and it increased with increasing severity of the liver disease. The overall rate of HBV DNA in our 98 HCV-infected patients was 16.3%. On the other hand, the rate of HBV DNA was 41.0% in anti-HBc alone positive patients compared to only 7.1% in healthy controls who were also anti-HBc alone positive (p < 0.001). Moreover, the prevalence HBV DNA increased with increasing severity of the liver disease, but this increase was only marginally significant and, perhaps, could have been significant if more patients were involved in the study. Although Lebanon is an area of low endemicity for both HBV and HCV, occult HBV infection is common in HCV-infected patients. The presence of HBV DNA, therefore, presents a challenge for the effective laboratory diagnosis of hepatitis B, particularly if polymerase chain reaction (PCR)-based HBV detection methods are not used.

Recently we identified hepatitis C virus (HCV) genotype 4 as the principle genotype among Lebanese thalassaemics. In an attempt to confirm the predominance of genotype 4 in Lebanon and perhaps in the Middle East, genotyping was attempted on 142 HCV-infected Lebanese patients from five different hospitals in the country. These included 38 HCV-positive patients with symptomatic liver disease who were referred to gastroenterologists and 104 HCV-positive patients with no symptoms of liver disease: 27 patients with thalassaemia, 30 patients on haemodialysis, 32 multi-transfused and 15 intravenous drug users. HCV genotyping was performed on PCR HCV RNA-positive samples using a commercial line probe assay (LiPA; Innogenetics, Ghent, Belgium). HCV genotype 4 is found to be the predominant genotype among HCV-infected Lebanese patients (ranging from 34·2% to 53·3%) followed by 1a (ranging from 12·5% to 43·3%) and 1b (ranging from 8·0% to 34·4%). In patients with symptomatic liver disease, however, genotype 4 (34·2%) was preceded by genotype 1a (39·5%). The predominance of HCV genotype 4 in our population (45·7%) confirms the predominance of HCV genotype 4 in Lebanon and most of the Arab countries in the Middle East but contrasts with data reported from non-Arab Middle Eastern Countries as can be seen from the literature review. Implications of genotyping for clinical outcome of HCV infection, response to treatment as well as for vaccine development are discussed.