The risk of hepatitis A spread in Syria—A call for awareness and prevention

This article sheds light on the concerning issue of hepatitis A in Syria, particularly in the aftermath of a devastating earthquake that struck on February 6. Hepatitis A is an acute inflammation of the liver caused by the hepatitis A virus (HAV), and is a global concern, especially in developing and impoverished regions. Annually, ≈1.5 million people worldwide are infected with this virus.¹ HAV is a non-enveloped single-stranded RNA virus, measuring between 27 and 32 nm in diameter.² HAV is steady in the environment for at least 1 month, it has been found that this virus is more resilient against heat and chlorine compared to other viruses, such as the poliovirus.² This characteristic, coupled with its hepatotropic nature, allows it to replicate in the liver, leading to viremia, and ultimately, it is excreted in bile and discharged in the stools of infected individuals.² Transmission primarily occurs through the fecal–oral route, enabling self-infection and the potential for epidemics.³ It is important to note that the family circle and close contacts of infected individuals often serve as the primary source of infection.² Additionally, travel to infested areas and infrequent cases of blood transfusion can also contribute to the spread of HAV. This article sheds light on the concerning correlation between the recent upswing in hepatitis A cases in Syria and water contamination stemming from the earthquake. Specifically, in the Hama region of central Syria, the confirmed cases have surpassed 106, with 70 infections reported among students from three schools in the town of Hayalin.⁴ The earthquake's aftermath has caused sewage to mix with water, creating a breeding ground for the virus and contributing significantly to its spread in the affected areas. Furthermore, the already fragile water infrastructure in the region has been severely damaged, exacerbating the situation. There is a pressing need to raise awareness about the importance of sterilizing groundwater to prevent contaminated water sources, whether due to insufficient chlorination or poor irrigation infrastructure, from causing both localized and epidemic infections. Typically, prodromal symptoms of hepatitis A, which manifest about 1 month after exposure and tend to be quite mild, include nausea, anorexia, vomiting, abdominal pain, body weakness, myalgia, loss of appetite, restlessness, and fever.¹ It is worth noting that infections in children often go unnoticed due to their asymptomatic nature or minimal symptoms. Serological evidence, particularly the presence of IgM and IgG, antibodies at the onset of symptoms (Figure 1), is commonly used for confirming and diagnosing hepatitis A.² Although serological detection of HAV RNA is possible, it is rarely employed in the diagnosis of acute hepatitis A infection.³ The molecular properties of HAV do not play a significant role in its diagnosis.³ Fortunately, it is rare for hepatitis A to cause liver failure, and supportive care remains the standard treatment for acute hepatitis A.³ Recent studies have explored the potential of interferon and direct-acting antivirals in inhibiting HAV replication, offering hope for improved treatment options.^{2, 3} Direct-acting antivirals (DAAs) are designed to specifically address the HAV by incorporating protease inhibitors, a polymerase inhibitor, and IRES inhibitors into their mechanism of action. Unlike interferon, DAAs do not induce adverse effects commonly associated with interferon treatment, such as flu-like syndrome, hematologic effects, or depression. Nonetheless, research on human immunodeficiency virus (HIV) and hepatitis C virus (HCV) indicates that certain DAAs demonstrate genotype-specific antiviral activities and exhibit a low genetic barrier to resistance.⁵ Preventing HAV infection necessitates robust sanitation measures, particularly in areas affected by disasters like the earthquake. It is imperative to emphasize the importance of maintaining high standards of hygiene, especially in the food service sector. Hospitalized patients with HAV should observe enteric precautions for 1 week after the onset of jaundice when the virus is most actively shed in the stool. Vaccination stands as the most widely accepted method for preventing HAV infections globally. The efficacy of both live-attenuated and inactivated vaccines has been firmly established in large-scale trials, covering nearly 750 000 patients. These vaccines provide robust protection against hepatitis A if administered before exposure.³ In conclusion, the surge of hepatitis A cases in Syria following the recent earthquake is a matter of grave concern. The contamination of water sources, coupled with a lack of awareness about sterilizing groundwater, has created a fertile environment for the virus to thrive. Timely intervention through public health measures, hygiene awareness, and vaccination campaigns is crucial to curbing the spread of this preventable disease. We urge authorities, healthcare professionals, and the international community to take swift action to mitigate this pressing public health issue.

The authors declare no conflicts of interest.