Prevalence and Risk Factors for Transmission and Genotype of HCV in Iraqi Patients

Abstract

BACKGROUND: Hepatitis C virus (HCV) infection is a serious public health problem in the world, and about 170 million patients are chronically infected with HCV. Worldwide; different epidemiologic patterns of HCV infection have been identified. AIM OF THE STUDY: By this study, we try to know the prevalence and risk factors for HCV transmission in Iraqi patients and genotype distribution of the disease. PATIENTS & METHODS: In a cross sectional study of 355898 persons, 232645 males & 123253 females; had been enrolled for the study in Baghdad teaching hospital, Iraqi blood bank, Al-Yarmouk teaching hospital, Al-Nu'man teaching Hospital and Al-Basrah teaching hospital from February 2017 to February 2019. Positive patients for hepatitis C antibody were further studied for way of transmission and viral load and genotype. History had been taken about the possible risk factor for HCV transmission which included (15) risk factors. RESULTS: A total of 355898 persons, 232645 males & 123253 females their Mean age at diagnosis was 47.3 (± 15.6) years, Ranged (19–78) years. The mean body mass index (BMI) of the study sample was 22.9 (± 3) kg/m2, studied all screen for hepatitis C antibody 1155 discovered to be positive 650 were males and 505 were females, further study done for viral load in 746 patients and genotype in 633 patients: 356 (48%) with high viral load, 390 (52%)with low viral load and 345 (52.8%) with genotype V and 301 (46.2%) with genotype IV, while genotype II was 2 (0.3%) and III 7 (0.5%), The most common possible ways of transmission of the disease by history in this study was blood transfusion 53%, dental procedure 42%, hemodialysis 36%, caesarean section 34.5%, while injured male during shaving 33%, patient who have surgical operation 24%, Tattooing in 8%, cupping in 6.6%, IV injection in 4% heterosexual seen in 2%, renal transplant in 2%, and only 1% in needle stick injury. while the more frequent genotype is 1 then 4. Hemodialysis and improper use of IV medication had been found to be more significant in HCV male patients .The relation between possible risk factor for transmission of HCV and residence, viral load were not significant. CONCLUSION: The most common probable risk factors as single risk factor for the male was blood transfusion, and for female was caesarean section. While for two risk factors for male were Blood transfusion and Hemodialysis and for female were Caesarean section & Dental procedure and for both gender were hemodialysis & dental procedure. While for three risk factors for both gender were surgery, barbers, and dental procedure. In our study we had found the prevalence of HCV in our Iraqi big sample was relatively low. The most common genotype was genotype I then genotype IV with rarity of genotype III 0 and genotype II.

Full text

Global Journal of Health Science; Vol. 11, No. 12; 2019
ISSN 1916-9736 E-ISSN 1916-9744
Published by Canadian Center of Science and Education
185
Prevalence and Risk Factors for Transmission and Genotype of HCV in
Iraqi Patients
Khalid Abdulla Al-Khazraji1, Wissam Khudhair Abbas2 & Safiya Khalid Abdullah1
1 Professor of Gastroenterology, College of Medicine, Baghdad University, Iraq
2 Al-Mustansiriya University, College of Medicine, Iraq
Correspondence: Khalid Abdulla Al-Khazraji, MBCHB, MD, CAMB, FRCP, FACP, Professor of
Gastroenterology, College of Medicine, Baghdad University, Iraq.
Received: September 2, 2019 Accepted: October 8, 2019 Online Published: October 24, 2019
doi:10.5539/gjhs.v11n12p185 URL: https://doi.org/10.5539/gjhs.v11n12p185
Abstract
Background: Hepatitis C virus (HCV) infection is a serious public health problem in the world, and about 170
million patients are chronically infected with HCV. Worldwide; different epidemiologic patterns of HCV infection
have been identified.
Aim of the Study: By this study, we try to know the prevalence and risk factors for HCV transmission in Iraqi
patients and genotype distribution of the disease.
Patients and Methods: In a cross sectional study of 355898 persons, 232645 males & 123253 females; had been
enrolled for the study in Baghdad teaching hospital, Iraqi blood bank, Al-Yarmouk teaching hospital, Al-Nu'man
teaching Hospital and Al-Basrah teaching hospital from February 2017 to February 2019. Positive patients for
hepatitis C antibody were further studied for way of transmission and viral load and genotype. History had been
taken about the possible risk factor for HCV transmission which included (15) risk factors.
Results: A total of 355898 persons, 232645 males & 123253 females their Mean age at diagnosis was 47.3 (± 15.6)
years, Ranged (19–78) years. The mean body mass index (BMI) of the study sample was 22.9 (± 3) kg/m2, studied
all screen for hepatitis C antibody 1155 discovered to be positive 650 were males and 505 were females, further
study done for viral load in 746 patients and genotype in 633 patients: 356 (48%) with high viral load, 390
(52%)with low viral load and 345 (52.8%) with genotype V and 301 (46.2%) with genotype IV, while genotype II
was 2 (0.3%) and III 7 (0.5%), The most common possible ways of transmission of the disease by history in this
study was blood transfusion 53%, dental procedure 42%, hemodialysis 36%, caesarean section 34.5%, while
injured male during shaving 33%, patient who have surgical operation 24%, Tattooing in 8%, cupping in 6.6%, IV
injection in 4% heterosexual seen in 2%, renal transplant in 2%, and only 1% in needle stick injury. while the more
frequent genotype is 1 then 4. Hemodialysis and improper use of IV medication had been found to be more
significant in HCV male patients .The relation between possible risk factor for transmission of HCV and residence,
viral load were not significant.
Conclusion: The most common probable risk factors as single risk factor for the male was blood transfusion, and
for female was caesarean section. While for two risk factors for male were Blood transfusion and Hemodialysis
and for female were Caesarean section & Dental procedure and for both gender were hemodialysis & dental
procedure.
While for three risk factors for both gender were surgery, barbers, and dental procedure. In our study we had found
the prevalence of HCV in our Iraqi big sample was relatively low. The most common genotype was genotype I then
genotype IV with rarity of genotype III 0 and genotype II.
Keywords: hepatitis C, genotype, prevalence, transmission
1. Introduction
HCV present in all continents, and about 170 million patients are chronically infected with HCV. In industrialized
countries, the incidence of HCV infection has decreased considerably due to blood screening and measures that
prevent HCV infections in intravenous drug users (Goldman & Schafer, 2015; Moradpour & Penin, 2013).

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
186
However, according to the Centers for Disease Control and Prevention about 17,000 new cases of acute HCV still
occur annually in the United States. In France, about 2500 new infections occur yearly. In developing areas of the
world; HCV incidence and prevalence are higher in which the main route for HCV infection is unsafe medical or
surgical procedures, only about 50% of blood products are screened for Anti-HCV antibodies in these countries,
and about 40% of all injections are assumed to be given with reused equipment (Moradpour & Penin, 2013;
Feldman, Friedman, & Brandt, 2015).
Worldwide; three different epidemiologic patterns of HCV infection have been identified. They are (1) previous
exposure through health care with peak prevalence in older patients; (2) exposure due to IV drug using; the major
risk factor since about 1960. When data first became available with peak prevalence among middle-aged persons;
and (3) ongoing high levels of HCV infection in areas in which high rates infection occur in all age groups
(Cheifetz, Brown, Curry, & Moss, 2011).
All over the world; Subtypes {1a} and {1b} predominate. In the United States; the most common genotypes are
{1a} and {1b} about75%, {2a} and {2b} about 15%, and {3a} about 7%. Genotype {3a} is more prevalent in
Western Europe where it accounts approximately 35% of cases, specifically among intravenous drug users.
Genotype {4} is highly prevalent in Middle East and Africa. Its incidence and prevalence had been found to be
increase in IV drug users in industrialized countries. Genotype {5} is rare outside South Africa, and genotype {6}
is rare outside Southeast Asia, Genotype VII has been reported in Canada from central African immigrants
(Goldman & Schafer, 2015; Cheifetz et al., 2011).
Figure 1. Common ways of transmission of hepatitis C
2. Patients and Methods
In this cross sectional retrospective study; from February 2017 to February 2019 we studied all people who attend
four big hospitals, three of them in Baghdad: (Baghdad medical city, Al- Yarmouk teaching hospital, Al-Nu'man
teaching Hospital) and one hospital in Basrah (Al-Basrah teaching hospital).
Those people attended hospitals before surgery or pregnant or marriage, or seeking for medical treatment for
advice for their complaint, all were screen for hepatitis C, any positive result was recorded in the lab file or sent by
the patient to GIT and medical consultation department where it also recorded in specific file. So all people had
been documented in one or these two places, their total number were 165273 and we studied all looking healthy
people and who attending main Baghdad blood bank for donation who were screen for hepatitis C, the total number
was 190625 persons, so by collection of both samples from the hospital and blood bank the total number was
355898, 232645 were males, and 123253 were females, total persons who were positive for hepatitis C were 1155,
males were 650 (56%) and females 505 (44%).
Further evaluation of positive patients were done looking for their viral load by PCR and genotype for hepatitis C,
both of these lab tests were done in private lab because they were not available in those hospitals, positive persons

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
187
were recorded in special file and signed for that in order not to donate again and we took documentation form these
files.
The questionnaire in this study for multiple risk factors for HCV transmission included;
1). History of blood transfusion
2). Hemodialysis
3). Caesarean section for female.
4). Injured male during shaving by barber.
5). Patients who had dental procedure.
6). Surgical operation.
7). Tattooing.
8). Cupping.
9). Improper use of IV medication (by intravenous route without medical prescription).
10). Body piercing.
11). Sexual or household.
12). Organ transplant.
13). Needle stick.
14). Perinatal.
15). Drug abuse (intravenous drug abuse IVDU).
We did evaluate the prevalence of the genotype and the viral load and it’s relationship to the root of transmission so
we consider:
1). High viral load (>800000 IU/ml).
2). Low viral load (<800000 IU/ml). (Koziel, 1997; Franciscus et al., 2011; Carey, 2003)
2.1 Statistical Analysis
Each patient assigned a serial identification number. The data were analyzed using the Statistical Package for
Social Sciences (SPSS) version 20. The categorical data presented as frequency and percentage tables.
The continuous data were represented by mean, standard deviation and range. The Chi-square was used to assess
the association between categorical variables. P – Value less than 0.05 was used as the alpha level of significance.
Finally all findings and results were presented in tables and figures with an explanatory paragraphs for each table
and figure.
3. Results
Patients who had been confirmed to have hepatitis C positive (1155) patients of these, (505) patients were female
and (650) patients were male. Their ages were ranging from (19) to (78) years with mean age at presentation = 48.1
(standard deviation [SD] ± 15.8) years. Also their mean age at diagnosis = 47.3 (SD ± 15.6) years.
BMI normal value are:
Underweight = <18.5
Normal weight = 18.5–24.9
Overweight = 25–29.9
Obesity = BMI of 30 or greater
Their body mass index (BMI) was divided into:
1) Below normal weight; <18.5 kg/m2 were 9%
2) Normal weight; 18.5 - 25 kg/m2 were 62%
3) Over weight; ≥25 kg/m2 were 29%. (WHO, 2014)
The mean body mass index = 22.9 (SD ± 3) kg/m2, Their BMI range (17 – 29) kg/m2.

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
188
Table 1. Socio-demographic characteristics of cases with HCV infection
Variables Number %
Gender
Male 650 56
Female 505 44
Residence
Urban 914
Rural 241
Body mass index categories
< 18.5 Kg/m2 96 9
18.5 – 25 Kg/m2 684 62
>= 25 Kg/m2 375 29
No. of partners
Single 117 10
Married 1038 89.9
Occupation
Housewife 490 52
Constructor 309 20
Retired 101 9
Student 18 4
Teacher 17 4
Healthcare worker 60 1
Others 140 10
Total 1155 100%
Mean age at presentation = 48.1 (standard deviation [SD] ± 15.8) years.
Mean Age at diagnosis = 47.3 (± 15.6) years, Range (19 – 78) years.
Body mass index = 22.9 (± 3) kg/m2, Range (17 – 29) kg/m2.
3.1 Prevalence of HCV in Studied Sample
Prevalence of HCV in studied sample
Point prevalence Female Male All
Per 100% 0.41% 0.28% 0.32%
Per 100,000 (95%CI) 409.7
(406.2 – 413.3)
279.4
(277.3 – 281.5)
324.5
(322.7 – 326.4)
95%CI: 95 percent confidence interval.

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
189
Figure 2. Prevalence of HCV
3.2 HCV Characters Among the Studied Cases
From the (1155) patients, viral load was done in (746) patients which range (5200 – 10500000 IU/ml) and their
Median is 688000 IU/m. (356 patients had high viral load (>800000 IU/ml) to comprise (48%), while (390)
patients had low viral load (<800000 IU/ml) and comprise (52%).
Also from the (746) patients, only (653) patients had done their genotype.
Genotype I is found in (345) patients to comprise (52.8%) genotype Ia 152 and Ib 193, and genotype 4 is found in
(301) patients to comprise (46.2%), while genotype III is found only in 7 case to comprise (0.5%) and genotype II
in 2 cases 0.3%.As shown in Table 2.
Table 2. Characteristics of HCV among the studied cases
Variables Number %
Viral load
High viral load (>800000 IU/mL) 356 48
Low viral load (<800000 IU/mL) 390 52
Total 746 100
Median (Range) IU / mL 688000 (5200-10500000)
Genotype
I 345 52.8
Ia 152 -
Ib 193 -
IV 301 46.2
III 7 0.5
II 2 0.3
V 0 0
VI 0 0

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
190
3.3 Number and Percentage of Cases, According to Possible Risk Factors for HCV Transmission
Patients with blood transfusion history were (536) to comprise (53%), those with dental procedures surgery are
(425) to comprise (42%). Those who underwent hemodialysis whom were negative for hepatitis C before starting
hemodialysis and then got positive result hemodialysis their number is (364) to comprise (36%).
Female sustained Caesarean section (C.S) were (193) from total number of 505 of female to comprise (34.5%),
while injured male patients during shaving by barbers are (216) from total 650 to comprise (33%).
Patients who have history of surgical operation were 243 to comprise (24%). while only (84) patients had done
tattooing comprising (8%). patients with history of cupping are (67) to comprise (6%), and number of patients who
took intravenous injections by their own without medical prescription (improper use of IV medication) is (45) to
comprise (4%).and (43) patients had done body piercing comprising (4%).
21 patients had Sexual history (heterosexual) i.e.; 2% of total. Also 22 patients had organ(Renal) transplantation
who were negative before that, and comprise (2%),while only 11 patient had needle stick injury(nurse) to comprise
(1%),and no case with history of perinatal,intravenous drug abuse(IVDU) or idiopathic.
These data are presenting in Table 3:
Table 3. Number and percentage of cases, according to possible risk factors for HCV transmission
Risk factor No (1155) %
History of blood transfusion 536 53
Dental procedure 425 42
Hemodialysis 364 36
Caesarean section (total=55) 191 34.5
Injured males by barbers (total=45) 216 33
Surgical operation 243 24
Tattooing 84 8
Cupping 67 6
Improper use of IV medication 48 4
Body piercing 46 4
Sexual or household 21 2
Organ transplant 22 2
Needle stick 11 1
Perinatal 0 0
Drug abuse 0 0
Idiopathic 0 0
*no. of females with history of caesarian section per total 505 females.
**no. of males with history of injury by barbers per total 650 males.

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
191
3.4 Average Age at Diagnosis, According to Patients ‘Gender’
Table 4. Average age at diagnosis, according to patients’ gender
Age (year)
Male
N = 650
Mean ± SD
Female
N = 505
Mean ± SD
P value
At diagnosis 50 ± 15.7 45.1 ± 15.4 0.119
Student’s t-test, SD= Standard deviation.
3.5 Average Age at Diagnosis, According to Possible Risk Factor for Transmission
By this we found that mean age at diagnosis for patients with history of body piercing and history of organ
transplantation was younger than other risk factors which their mean age at diagnosis was at middle age. As shown
in Table 5:
Table 5. Average age at diagnosis, according to possible risk factors of transmission
Risk factor Age at diagnosis
Mean±SD (Range)
Improper use of IV medication 60.75±12.74 (44-75)
History of blood transfusion 50.87±15.13 (19-75)
Hemodialysis 48.58±14.98 (20-75)
Sexual or household 52.5±17.68 (40-65)
Surgical operation 55.12±14.52 (27-78)
Body piercing 25.75±4.57 (20-31)
Needle stick 41
Organ transplant 27.5±10.6 (20-35)
Cupping 54.7±9 (44-64)
Tattooing 48.1±16.4 (31-75)
Female C/S 42±14.6 (22-75)
Shaving among males 48.6±11.8 (23-62)
Dental procedure 48.9±15 (20-75)
3.6 Relation Between Number of Possible Risk Factors for HCV Transmission and Number of Patients for That
Number
By this relation we find that there are (398) patients have history of single risk factor of transmission, (380)
patients have history of two risk factors of transmission, (248) patients have history of three risk factors of
transmission while (124) patients have history of four risk factors of transmission.
For the single risk factor, (178) patients have history of blood transfusion due to anemia, peptic ulcer, menorrhagia,
pregnancy and hemorrhoids .Also we have (56) patients for dental procedure and 52 for caesarian section(c/s), (38)
for surgical operation and injured male by barbers during shaving was 35while (13) patient for each hemodialysis,
body piercing was 14 and tattooing was 13 as shown below in Table 6.

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
192
Table 6. Number of possible risk factors of transmission and patients Number
Risk factors Number of patients
Single risk factor N = 398
Hemodialysis 13
Piercing 14
Tattooing 18
barbers 35
Surgery 37
Dental procedure 56
Caesarean section 252
Blood transfusion 178
Two risk factors N = 380
Hemodialysis, Cupping 17
barbers, Dental procedure 16
Blood transfusion, Cupping 17
Cupping, Dental procedure 18
Piercing, Dental procedure 19
Cupping, Tattooing 14
Hemodialysis, Transplant 13
Blood transfusion, Dental procedure 15
Hemodialysis, Caesarean section 25
Blood transfusion, Caesarean section 23
Surgery, Dental procedure 24
Blood transfusion, Surgery 33
Hemodialysis, Dental procedure 41
Caesarean section, Dental procedure 47
Blood transfusion, Hemodialysis 58
Three risk factors N = 248
Hemodialysis, Surgery, barbers 16
Blood transfusion, Hemodialysis, Caesarean section 17
Blood transfusion, Hemodialysis, Surgery 15
Hemodialysis, Sex household, Dental procedure 12
Blood transfusion, Hemodialysis, barbers 13
Blood transfusion, Hemodialysis, Caesarean section 11
Blood transfusion, Hemodialysis, Transplant 14
Blood transfusion, Surgery, barbers 13
Blood transfusion, Caesarean section, Dental procedure 12
Cupping, Caesarean section, Dental procedure 13
Blood transfusion, Surgery, Dental procedure 13
Sex household, barbers, Dental procedure 12
Blood transfusion, Hemodialysis, Surgery 22
Blood transfusion, Hemodialysis, Dental procedure 31

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
193
Surgery, barbers, Dental procedure 32
Four risk factors
Improper use of IV medication, Hemodialysis, Surgery,
Dentists
16
Blood transfusion, Hemodialysis, Needle stick, Tattooing 17
Blood transfusion, Hemodialysis, Caesarean section, Dentists 18
Hemodialysis, Tattooing, barbers, Dentists 12
Blood transfusion, Surgery, Tattooing, Caesarean section 11
3.7 Relation of Cases’ Gender With Possible Risk Factors of Transmission
Table 7. Relation of cases’ gender with possible risk factors of transmission
Risk factor
Gender
p-value
Male Female
No. (N=650) % No. (N=505) %
History of blood transfusion 232 51.1 300 54.5 0.732
Dental procedure 194 42.2 23 41.8 0.968
Hemodialysis 211 46.7 157 27.3 0.044
Surgical operation 132 28.9% 119 20.0% 0.3
Tattooing 24 4.4% 67 10.9% 0.236
Cupping 41 8.9% 23 3.6% 0.271
Improper use of IV medication 41 8.9% 0 0% 0.024*
Body piercing 0 0% 40 7.3% 0.065
Sexual or household 22 4.4% 0 0% 0.114
Organ transplant 21 4.4% 0 0% 0.114
Needle stick 0 0.0 19 1.8 0.363
Chi-square test, * Significant at 0.05 level.
3.8 Relation of Cases’ Residence With Possible Risk Factors of Transmission
According to the residence wither urban or rural areas,there are (90) patients from urban area and (10) patients
from rural area .The risk factors with high percentages in urban area are dental procedure, hemodialysis, surgical
operation, cupping, sexual contact, organ transplantation and needle stick injury .
While in rural area the risk factors of high percentages are blood transfusion, tattooing, improper use of IV
medication and body piercing.
Significant p-value have not been found as shown in Table 8.

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
194
Table 8. Relation of cases’ residence with possible risk factors of transmission
Risk factor
Residence
p-value Urban Rural
No. (N=1029) % No. (N=126) %
History of blood transfusion 380 42 63 50 0.640
Dental procedure 340 33 40 31.7 0.892
Hemodialysis 204 24% 28 22% 0.267
Surgical operation 122 12% 29 22% 0.755
Tattooing 70 7% 11 0.8% 0.806
Cupping 63 6% 0 0% 0.4
Improper use of IV medication 30 3% 11 0.8% 0.306
Body piercing 30 2% 9 0.7% 0.306
Sexual or household 22 2% 0 0% 0.634
Organ transplant 21 2% 0 0% 0.634
Needle stick 19 1.2 0 0.0 0.738
Chi-square test.
3.9 Relation of Viral Load Categories With Possible Risk Factor for Transmission
From the total (1155) patients; only (746) patients had done their viral load. From the (350) patients; (390) patients
with low viral load (<800000 IU/ml), and (350) patients with High viral load (>800000 IU/ml).
For patients who have history of tattooing, body piercing, sexual contact, organ transplantation and needle stick
injury have been found to have high percentage of low viral load compared with other patients who have same risk
factor but with high viral load.
For patients who have history of blood transfusion, hemodialysis, dental procedure, surgical operation, cupping
and improper use of IV medication have been found to have high percentage of high viral load compared with
other patients who have same risk factor but with low viral load .
P-value regarding this relation was not significant. As shown in Table 9.
Table 9. Relation of viral load categories with possible risk factor for transmission
Risk factor
Low viral load High viral load
p-value
No. (N=390) % No. (N=356) %
History of blood transfusion 182 46.0 181 50.0 0.469
Dental procedure 148 37.0 175 49.0 0.263
Hemodialysis 143 36% 132 37% 0.912
Surgical operation 72 18% 98 25% 0.278
Tattooing 28 7% 22 6% 0.735
Cupping 29 7.4% 4 2.5% 0.358
Improper use of IV medication 17 4.3% 24 8% 0.493
Body piercing 0 0% 28 8% 0.13
Sexual or household 22 5.6% 0 0% 0.174
Organ transplant 21 5% 0 0% 0.174
Needle stick 12 3.0 0 0.0 0.34
Chi-square test.

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
195
4. Discussion
In our study we had found the prevalence of HCV in our Iraqi big sample was 0.41% in female, 0.28% in male and
0.32% in all, and most common genotype was genotype I 52.8% then genotype IV 46.2% with rarity of genotype
III 0.5 % and genotype II 0.2%, while the most common occupation for HCV patients is housewife (52%) and
constructor (20%) which resemble other study done in Egypt at 2014 by Adinolfi et al. (2001).
while health care worker (nurse) comprise (1%) only. while in the world the occupation which consider a risk
factor for HCV acquisition is health care worker where significant prevalence had been found in USA, North
Africa, Middle East and South Asia with low prevalence in Europe and no increase prevalence in Japan by study
done by Claudia Westermann et al. at 2015 (Westermann et al., 2015).
By our study;the more frequent genotype is 1 then 4.while the genotype 4 is the more frequent in Arabian
peninsula region (Saudi Arabia, Yemen, Oman,Bahrain, Qatar, UAE, Kuwait), Sham region (Iraq,Syria, Lebanon,
Gaza Strip except Jordan), also in Egypt,Sudan and Libya. While genotype 1 is the more frequent in Jordan and
Morocco by study done at 2012 by Mohamed A. Daw et al which mention the more frequent genotype in Arabian
world (Daw & Dau, 2012).
While in a study done by Farahnaz Fallahian et al at 2011; the genotype 1 is the more frequent in Iraq, Bahrain,
Jordan, Iran and Turkey.
While genotype 4 was more frequent in Saudi Arabia, Syria, Lebanon, Egypt and Sudan, while genotype 3 was the
more in Pakistan.
In Europe, the more prevalent genotype is 1 followed by 3 and 2 (European Association for Study of Liver, 2014).
While In the United States; genotype 1 is the more prevalent of HCV infections followed by genotype 2 then 3
while genotype 4, 5, or 6 is the less frequent types (Blatt et al., 2000).
In retrospective study had done by Ekram ABD EL-WAHAB et al in Egypt at 2014 for factors associated with
HCV transmission (El-Wahab, Mikheal, Sidkey, & Shatat, 2014), the results were as follow(percentages of
patients reported history of risk factor for transmission); Barbers(sharing manicure set) 72.7%, Parenteral
treatment range from once time 14.4% to more than once 72.2%, Body piercing 52.8% while blood transfusion
51%, Injection anti bilharzial drug 32.3%, Tattooing 30.8% while cupping 28.3%, Surgical operation range from
minor 16.9% to major 30.1%.
By comparism these results to our study; there are somewhat similarity with blood transfusion, dentists, surgical
operation and needle stick injury. While tattooing, cupping, body piercing, drug abuse and barbers are higher than
our percentages results.
By study done at 2005 in Turkey by Beytullah Yildirim et al; the main risk factors for HCV infection in Turkish
community are surgical operation, multipartner sex, frequent dental therapy, dental extraction and blood
transfusion (Yildirim et al., 2005), which favour our study that blood transfusion, dentists and surgical operation
are from the main routes of HCV transmission (Yildirim et al., 2005).
In the developed world (United States, Russia and China); the primary risk factor for HCV transmission is
intravenous drug use (Nelson et al., 2011).
In the united states the percentages of risk factors for HCV transmission are : Injection drug use 60%, sexual
contact 15%, blood transfusion (before screening) 10%, unknown 10% and other (health care work, hemodialysis,
Perinatal) 5% (Nelson et al., 2011; Xia, Luo, Bai, & Yu, 2008).
As we notice, there are different percentages for risk factor for HCV transmission in comparism between our study
and other studies in different regions in the world and this probably due to different in social, cultural, behavioral
and environmental factors.
By our study; there is relation between male gender and infection with HCV by hemodialysis and this similar to
other studies had done in united states (Kalautar-Zadeh et al., 2007; Charles et al., 2005) and Europe (Italy) (by
Natov et al., 2005) while there was no relation between gender and infection with HCV by hemodialysis by study
done in Iraq at 2010 (Al-Rubiaei, 2010).
By our study there are no relations between risk factor for HCV transmission and patients residence, while by other
studies done in Egypt (by Mohamed et al., 1996; Guerra et al., 2012) and Australia (Roberts & Algert, 2000) had
shown that HCV infection increase in rural areas (Pallás et al., 1999).
5. Conclusions
By our study we found there are multiple risk factor for infection by HCV in Iraqi patients, and the most probable

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
196
common risk factors are hemodialysis, dental extraction, surgical operation, blood transfusion, caesarean
section,injured male by barbers and. Most probable risk factor for patients with HCV infection who had history of
single route of transmission is blood transfusion. While the most common two result was dental procedure and
caesarean section.
Also there are significant transmission of HCV by hemodialysis and improper use of IV medication with male
patient.
There are difference in prevalence of risk factors for HCV transmission in HCV Iraqi patients and other regions in
the world which belong to differences in social, cultural, behavioral and environmental factors.
The incidence of genotype I is 52% is more than genotype IV is 465 in our study. While genotype III was 0.5% and
II only 0.3%.
-from total 355899 persons; 1155 were positive for HCV (0.32), male = 232645 and 650 of them were positive
(0.28) and female = 123253 and 505 of them were positive (0.41).
Competing Interests Statement
The authors declare that there are no competing or potential conflicts of interest.
References
Adinolfi, L. E., Gambardella, M., Andreana, A., Tripodi, M. F., Utili, R., & Ruggiero, G. (2001). Steatosis
accelerates the progression of liver damage of chronic hepatitis C patients and correlates with specific HCV
genotype and visceral obesity. Hepatology, 33(6), 1358-1364. https://doi.org/10.1053/jhep.2001.24432
Al-Rubiaei, H. M. (2010). Seroconversion Rate of Hepatitis C Virus Infection in Haemodialysis Patients in
AL-Kadhymia Teaching Hospital. 2010
Blatt, L. M., Mutchnick, M. G., Tong, M. J., Klion, F. M., Lebovics, E., Freilich, B., ... & Conrad, A. (2000).
Assessment of hepatitis C virus RNA and genotype from 6807 patients with chronic hepatitis C in the United
States. Journal of viral hepatitis, 7(3), 196-202. https://doi.org/10.1046/j.1365-2893.2000.00221.x
Carey, W. (2003). Tests and screening strategies for the diagnosis of hepatitis C. Cleveland Clinic journal of
medicine, 70(4), S7. https://doi.org/10.3949/ccjm.70.Suppl_4.S7
Cheifetz, A. S., Brown, A., Curry, M., & Moss, A. C. (2011). Oxford American handbook of gastroenterology and
hepatology (p. 183). Oxford University Press.
Daw, M. A., & Dau, A. A. (2012). Hepatitis C virus in Arab world: a state of concern. The Scientific World Journal,
2012. https://doi.org/10.1100/2012/719494
El-Wahab, E. W. A., Mikheal, A., Sidkey, F., & Shatat, H. Z. (2014). Factors associated with hepatitis C infection
among chronic HCV Egyptian patients. Iranian journal of public health, 43(11), 1510.
European Association for Study of Liver. (2014). EASL Clinical Practice Guidelines: management of hepatitis C
virus infection. Journal of hepatology, 60(2), 392. https://doi.org/10.1016/j.jhep.2011.02.023
Feldman, M., Friedman, L. S., & Brandt, L. J. (Eds.). (2015). Sleisenger and Fordtran's Gastrointestinal and Liver
Disease E-Book (10th ed., Vol. 1, Chapter 80, p. 1336). Elsevier Health Sciences.
Franciscus, A., Lusk, H., Hoex, L., & Design, B. K. (2011). Hepatitis C Support Project. Guía Para Comprender la
Hepatitis B. Versión, 4.
Goldman, L., & Schafer, A. I. (2015). Goldman-Cecil Medicine E-Book. Elsevier Health Sciences.
Guerra, J., Garenne, M., Mohamed, M. K., & Fontanet, A. (2012). HCV burden of infection in Egypt: result from a
nationwide survey. Journal of viral hepatitis, 19(8), 566-567.
https://doi.org/10.1111/j.1365-2893.2011.01576.x
Kalantar-Zadeh, K., Kilpatrick, R. D., McAllister, C. J., Miller, L. G., Daar, E. S., Gjertson, D. W., ... & Greenland,
S. (2007). Hepatitis C virus and death risk in hemodialysis patients. Journal of the American Society of
Nephrology, 18(5), 1584-1593. https://doi.org/10.1681/ASN.2006070736
Kalantar-Zadeh, K., McAllister, C. J., & Miller, L. G. (2005). Clinical characteristics and mortality in hepatitis
C-positive haemodialysis patients: a population based study. Nephrology Dialysis Transplantation, 20(8),
1662-1669. https://doi.org/10.1093/ndt/gfh895
Koziel, M. J. (1997). The role of immune responses in the pathogenesis of hepatitis C virus infection. Journal of
Viral Hepatitis, 4, 31-41. https://doi.org/10.1111/j.1365-2893.1997.tb00178.x

gjhs.ccsenet.org Global Journal of Health Science Vol. 11, No. 12; 2019
197
Mohamed, M. K., Hussein, M. H., Massoud, A. A., Rakhaa, M. M., Shoeir, S., Aoun, A. A., & Aboul, M. N.
(1996). Study of the risk factors for viral hepatitis C infection among Egyptians applying for work abroad.
The Journal of the Egyptian Public Health Association, 71(1-2), 113-147.
Moradpour, D., & Penin, F. (2013). Hepatitis C virus proteins: from structure to function. In Hepatitis C virus:
from molecular virology to antiviral therapy (pp. 113-142). Springer, Berlin, Heidelberg.
https://doi.org/10.1007/978-3-642-27340-7_5
Natov, S. N., & Pereira, B. J. (2005). Hepatitis C virus in chronic dialysis patient. The Italian Journal of Urology
and Nephroctomy, 57(3), 175-197.
Nelson, P. K., Mathers, B. M., Cowie, B., Hagan, H., Des Jarlais, D., Horyniak, D., & Degenhardt, L. (2011).
Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews.
The Lancet, 378(9791), 571-583. https://doi.org/10.1016/S0140-6736 (11)61097-0
Pallás, J. R., Fariñas-Álvarez, C., Prieto, D., & Delgado-Rodríguez, M. (1999). Coinfections by HIV, hepatitis B
and hepatitis C in imprisoned injecting drug users. European journal of epidemiology, 15(8), 699-704.
https://doi.org/10.1023/A:1007619614350
Pawlotsky, J. M. (2003). Hepatitis C virus genetic variability: pathogenic and clinical implications. Clinics in liver
disease, 7(1), 45-66. https://doi.org/10.1016/S1089-3261(02)00065-X
Roberts, C. L., & Algert, C. S. (2000). The urban and rural divide for women giving birth in NSW, 1990–1997.
Australian and New Zealand journal of public health, 24(3), 291-297.
https://doi.org/10.1111/j.1467-842X.2000.tb01571.x
Westermann, C., Peters, C., Lisiak, B., Lamberti, M., & Nienhaus, A. (2015). The prevalence of hepatitis C among
healthcare workers: a systematic review and meta-analysis. Occup Environ Med, 72(12), 880-888.
https://doi.org/10.1136/oemed-2015-102879
World Health Organization [WHO]. (2014). Obesity and overweight. Fact sheet number 311. World Health
Organisation, 5-1.
Xia, X., Luo, J., Bai, J., & Yu, R. (2008). Epidemiology of hepatitis C virus infection among injection drug users in
China: systematic review and meta-analysis. Public health, 122(10), 990-1003.
https://doi.org/10.1016/j.puhe.2008.01.014
Yildirim, B., Tahan, V., Ozaras, R., Aytekin, H., Mert, A., Tabak, F., & Senturk, H. (2005). Hepatitis C virus risk
factors in the Turkish community. Digestive diseases and sciences, 50(12), 2352-2355.
https://doi.org/10.1007/s10620-005-3061-3
Copyrights
Copyright for this article is retained by the author(s), with first publication rights granted to the journal.
This is an open-access article distributed under the terms and conditions of the Creative Commons Attribution
license (http://creativecommons.org/licenses/by/4.0/).