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Yapali et al. Hepatoma Res 2018;4:24 I http://dx.doi.org/10.20517/2394-5079.2018.57 Page 7 of 10

infection. Up to 80% of HBV and HDV co-infected patients progress to cirrhosis [73,74] . It has been estimated
that almost 5% of HBV infected patients have HDV co-infection [73,74] .

The epidemiologic distribution of HDV infection is variable throughout the world. HDV is highly endemic in
the Eastern Mediterranean countries . Two studies from Turkey show prevalence of anti-HDV in 18.8% to
[75]
23.0% of HBsAg positive HCC [37,76] . A Jordanian study reported the prevalence of anti-HDV in a small group of
HBsAg positive HCC patients was 67%, but the sample size was very small . The risk of HCC is increased in
[77]
HDV infection compared to HBV monoinfection. HDV infection increases the risk for HCC threefold and for
mortality two fold in patients with hepatitis B cirrhosis [78,79] . However, the pathogenetic mechanism of HDV in
HCC development has not been clarified yet. Oxidative stress as a result of severe necroinflammation, epigenetic
mechanisms like DNA methylation and histone modification are the proposed mechanisms .
[80]
The only available treatment for HDV is interferon with a very low efficacy . Therefore, the spread of
[81]
HDV can be prevented by effective HBV vaccination programs leading to a decrease in the incidence of
HCC . Health-care providers should be educated to check for HDV infection in chronic HBV carriers. In
[82]
addition, patients should be informed about the risk of superinfection from carriers co-infected with HDV
and educated about preventive practices.

SUMMARY
HBV and HCV infections are the most important etiologies for HCC in Eastern Mediterranean and Middle
Eastern countries. Implementation of screening programs for individuals at high risk, maintaining HBV
suppression in chronic hepatitis B and sustained viral response in CHC, surveillance of patients at high
risk for developing HCC are recommended to prevent progression to cirrhosis and HCC development. The
lack of data registry systems in the region resulted in limited understanding of the exact epidemiology of
disease. Furthermore, the political and social unrest in the region and the immigrations after the wars may
restrict the application of preventive programs and may lead to increased incidence of hepatitis. Public
health policies should consider the future impact of the current situations.

DECLARATIONS
Authors’ contributions
Literature research, drafting and revision of the manuscript: Yapali S
Idea of the review, critical revision of the manuscript: Tozun N

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
The authors declare that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.