Introduction

Hepatitis B virus (HBV) and hepatitis C virus (HCV) are viral pathogens that can cause chronic hepatitis, liver cirrhosis and hepatocellular cancer (1). HBV affects approximately two billion people worldwide. The World Health Organization (WHO) is located Turkey in moderate endemicity region of HBV with 2-8% incidance rate (2). It has been determined that approximately 170 million people are infected with HCV all over the world and HCV seropositivity is 1-2.4% in our country (3,4). HBV and HCV can be transmitted by parenteral contact with infected blood and body fluids, sexually and directly from infected mother to baby (5). With the immigration caused by the civil war that started in Syria in 2011, a total of 3,607,563 Syrians, 162,471 in Bursa as of 2018, are living in temporary refugee status in our country (6). Many studies have emphasized the increase in infectious disease rates in asylum seekers fleeing war due to difficult migration conditions and inadequate living conditions (7,8,9).

In our study, we aimed to compare the hepatitis B surface antigen (HBsAg), anti-HBs, anti-HCV positivity of local Turkish patients and Syrian patients living under temporary protection status in our region admitted to our hospital by age groups and gender and to evaluate the seroprevalence of hepatitis B and C.

Materials and Methods

In our study, the HBsAg, anti-HBs and anti-HCV test results of Syrian and Turkish patients admitted to University of Health Sciences Turkey, Bursa Yüksek İhtisas Training and Research Hospital between January 2016 and December 2017 were compared. HBsAg test results of 124,203 patients (10,834 Syrians and 113,369 Turk); anti-HBs test results of 87,236 patients (7,457 Syrians and 79,779 Turk); anti-HCV test results of 116,777 patients (10,505 Syrians and 106,272 Turk) who applied to our hospital were evaluated. HBsAg, anti-HBs and anti-HCV positivity of the patients were determined according to sex and age groups (<9, 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, 80-89, 90-99). HBsAg, anti-HBs and anti-HCV positivity of the patients were also grouped into pediatric (<18) and adult (18) age groups. The presence of HBsAg, anti-HBs and anti-HCV antibodies was detected by Chemiluminescent Microparticle Immunoassay method in a fully automated COBAS 4000 device from serum samples obtained by separating 10 cc blood samples of the patients by centrifugation (Roche Diagnostics, Germany). With the manufacturer’s recommendation, samples with HBsAg and anti-HCV values ​​below 1 IU/mL were considered negative and samples with 1 IU/L values ​​were considered positive, anti-HBs values ​​below 10 IU/mL were negative, and ≥10 IU/mL positive.

Statistical Analysis

Statistical analyzes were performed using Pearson chi-square and Fisher’s chi-square method in SPSS-20 program. P<0.01 and p<0.05 values were considered statistically significant. This study was approved by University of Health Sciences Turkey, Bursa Yüksek İhtisas Training and Research Hospital Research Ethic Committee (approval number: 2011-KAEK-25 2020/10-5).

Results

In our study, HBsAg positivity of Syrian and Turkish patients were compared according to age groups (Table 1). HBsAg positivity was significantly higher in Turkish patients (2.4%, 4.2%) compared to Syrian patients (1.5%, 3.2%) in the 20-29 and 30-39 age groups (p<0.01, p<0.05) (Table 1). Additionally, HBsAg positivity was found to be significantly higher in Turkish patients (4.7%) than Syrian patients (2.5%) in the adult age group (p<0.01) (Table 1).

Anti-HBs positivity of Syrian and Turkish patients were compared according to age groups in our study (Table 2). Anti-HBs positivity (79.4%, 56.9%, 66.2%, 25.7%) was significantly higher in Turkish patients than Syrian patients (66.0%, 39.5%, 24.0%, 20.4%) in 0-9, 10-19, 20-29, 30-39 age groups (p<0.01, p<0.01, p<0.01, p<0.01) (Table 2). Anti-HBs positivity was significantly higher in Syrian patients (56.3%, 65.3%) than Turkish patients (41.3%, 45.2%) in the 60-69, 80-89 age groups (p<0.01, p<0.01) (Table 2). In addition, anti-HBs positivity was significantly higher in Turkish patients (68.3%, 42.4%) than Syrian patients (59.7%, 27.1%) in the pediatric and adult age groups (p<0.01, p<0.01) (Table 2).

Anti-HCV positivity of Syrian and Turkish patients were compared according to age groups in our study (Table 3). Anti-HCV positivity was significantly higher in Syrian patients than Turkish patients (0.0%, 0.1%, 0.2%, 0.3%, 0.5%, 0.8%, 0.9%) in the 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79 age groups (0.5%, 0.5%, 1.4%, 2.8%, 4.9%, 1.9%, 4.0%) (p<0.05, p<0.01, p<0.01, p<0.01, p<0.01, p<0.05, p<0.01). In addition, anti-HCV positivity was significantly higher in Syrian patients (0.9%, 1.2%) than Turkish patients (0.1%, 0.4%) in the pediatric and adult patient groups (p<0.01, p<0.01).

In our study, HBsAg, anti-HBs, anti-HCV antibody positivity of Syrian and Turkish patients were compared according to gender (Table 4). HBsAg positivity was statistically significantly higher in Syrian and Turk patients among males (5.9%, 6.7%) than females (1.7%, 3.5%) (p<0.01, p<0.01). Also, HBsAg positivity was significantly higher in Turkish female patients (3.5%) than Syrian female patients (1.7%) (p<0.01). There was no significant difference in HBsAg positivity between Syrian and Turkish men (Table 4).

Anti-HBS positivity was statistically significantly higher in Syrian and Turk patients among males (42.6%, 47.0%) than females (26.1%, 42.0%) (p<0.01, p<0.01). In addition, anti-HBs positivity was significantly higher in Turkish males (47.0%) than Syrian males (42.6%) and Turkish females (42.0%) than Syrian females (26.1%) (p<0.01, p<0.01) (Table 4).

Anti-HCV positivity was significantly higher in Syrian and Turk male patients (2.5%, 0.4%) than female patients (0.9%, 0.3%) (p<0.01, p<0.05). In addition, anti-HCV positivity was significantly higher in Syrian males (2.5%) than Turkish males (0.4%) and Syrian females (0.9%) than Turkish females (0.3%) (p<0.01, p<0.01) (Table 4).

Discussion

According to our study, HBsAg, anti-HBs and anti-HCV positivity rates of Syrian immigrants and Turks were found to be compatible with recent studies. In a study, HBsAg positivity 3.8%, 4.6%, 3.2%, 10%, anti-HBs positivity 41%, 10.7%, 12.9%, 40% and anti-HCV positivity were 1.2%, 1.5%, 6.4%, 2.8% found in Syrian immigrants aged 0-15, 16-40, 41-50 and > 50 (10). Yalçın Bahat et al. (11) established that HBsAg and anti-HCV seropositivity rates in Syrian pregnant women were found to be 1.1% and 0.1%, respectively. İnci et al. (12) determined that HBsAg positivity was found to be 1.8% in pregnant Syrian women and 1.1% in Turkish pregnant women. In a study, anti-HCV positivity was found 3-10% and HBsAg positivity 6% in Syrians (13). Bashour and Muhjazi (14) showed that HCV seroprevalence in Syrians was varied between 2-10% according to anti-HCV test values ​​and hepatitis B seroprevalence was varied between 5-10% according to HBsAg test values. HBsAg positivity was found 1.01% to 4.6% and anti-HCV positivity was determined between 0.4% and 1.57% in studies from different regions in Turkey (15,16,17,18). Significantly higher HBsAg positivity among Turkish people than Syrians in young adult and adult age groups in our study was showed that Turkish people were infected with HBV more than Syrians in young adult and adult age groups (p<0.01, p<0.05). Also, determination of higher anti-HBs positivity in Turkish patients than Syrian patients in children, young adults and adult age groups in our study shows that hepatitis B immunity is significantly higher in children, young adults and adult age groups in Turks than Syrians (p<0.01, p<0.01). More common hepatitis B infection among Turks than Syrians in age groups with high contact risk shows that Syrians are more susceptible to hepatitis B infection and have a higher risk of contracting the hepatitis B infection.

Chronic HBV and HCV infection was determined after perinatal HBV and HCV transmission in 90% of newborns, in 20-50% of 1-5 age group, in 5-10% of >5 years (19,20). Chronic HBV and HCV infections can cause serious health problems such as liver cirrhosis and hepatocellular cancer (21). In our country, hepatitis B vaccine has been administered to babies in the routine vaccination program since 1998 as 3 doses at 0, 1 and 6 months. Although hepatitis B vaccine has been in the national vaccination program since 1993 in Syria, the necessary importance was not shown in the vaccination of children; it has been stated that safe and effective vaccination and education are required to prevent hepatitis B infection (22). In addition, studies have emphasized that the prevalence of HBV and HCV infection is high in Syria due to critical security, economic conditions, low infection control and deficiencies in hygienic practices (23,14). Our study shows that Syrians have lower HBV vaccination rates than Turks. Therefore, it is necessary to develop national HBV vaccination policies for Syrian immigrants, which include women of gestational age, as young adults are particularly at risk for the transmission of hepatitis B infection. Also, higher anti-HCV positivity in Syrian patients than Turkish patients in the pediatric and adult age groups shows that Turks are more susceptible to infection and more risky in terms of contracting HCV infection.

Study Limitations

The limitation of our study is that the HBV vaccination history of Syrian and Turkish patients, and the history of HBV and HCV infection were not examined.

Conclusion

According to our study, necessary precautions should be taken to prevent the increase of HBV and HCV infection in our country. For this purpose, it is necessary to provide infection screening and training to young adults, especially pregnant women, who are at risk groups in our country to prevent HBV and HCV transmission.

Ethics

Ethics Committee Approval: This study was approved by University of Health Sciences Turkey, Bursa Yüksek İhtisas Training and Research Hospital Research Ethic Committee (approval number: 2011-KAEK-25 2020/10-5).

Informed Consent: It was obtained.

Peer-review: Externally peer-reviewed.

Financial Disclosure: The author declare no financial support.