Archives of Virology

, Volume 159, Issue 8, pp 1901–1907 | Cite as

Determinants of poor outcome in patients with hepatitis A infection: a four-year retrospective study in Shiraz, Southern Iran

  • Kamran B. Lankarani
  • Mojtaba Mahmoodi
  • Behnam Honarvar
  • Parastoo Nematollahi
  • Nima Zamiri
  • Fariborz Ghaffarpasand
Original Article


There are 1.4 million estimated cases of hepatitis A every year worldwide. We aimed to detect the correlates of poor outcome in patients with hepatitis A virus (HAV) infection. In this four-year retrospective study, which was conducted in Shiraz, Southern Iran, data of all hospitalized HAV patients were analyzed by SPSS and STATA. Out of 110 HAV patients, 8 (7.3 %) developed hepatic encephalopathy, and 7 (6.4 %) died. The results show that 19 years of age is a cutoff level for predicting mortality, with a sensitivity of 42.9 % and specificity of 91.3 %, and with an area under the curve (AUC) of 0.595 (95 % CI, 0.309–0.881). Every one-year increase in age adds 3 % to the mortality rate from severe hepatitis A. The cutoff level of alanine aminotransferase (ALT) for predicting death is 1819.5 IU/L, with a sensitivity of 100 %, specificity of 68 %, and AUC 0.877 (95 % CI, 0.777–0.977). Every 100 IU/L increase in ALT is associated with a 0.1 % increase in the risk of death. Patients from large families (OR, 0.583, 95 % CI, 0.46–0.74) and those who are not the firstborn child of their family (OR, 0.287, 95 % CI, 0.146–0.564) have better outcome. Adult patients with hepatitis A who are first children, are from a small family, or have a very high level of ALT are more prone to a poor outcome of this infection. Public education and establishment of a national surveillance system for HAV and an HAV vaccination program for high-risk populations should be regarded among the priorities of the health system of Iran.



Hepatitis A virus


Acute liver failure


World Health Organization


International Classification of Disease Version 10


Intensive care unit


Statistical Package for the Social Sciences


Standard deviation


Receiver operating characteristics


Area under the curve


Acute liver failure



The authors wish to thank all the staff of the central archive offices of Namazi and Shahid Faghihi hospitals, Shiraz University of Medical Sciences, Shiraz, Iran, for their kind cooperation.

This project was financially supported by the Health Policy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran, through grant no. HP-90-2314.

Conflict of interest

Authors’ declaration of personal interests: All authors declare that they have no conflict of interest and also no financial interests relevant to the subject of the manuscript.


  1. 1.
    Jacobsen KH, Koopman JS (2004) Declining hepatitis A seroprevalence: a global review and analysis. Epidemiol Infect 132(6):1005–1022 Epub 2005/01/08PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Kim YJ, Lee HS (2010) Increasing incidence of hepatitis A in Korean adults. Intervirology 53(1):10–14 Epub 2010/01/14PubMedCrossRefGoogle Scholar
  3. 3.
    Faber MS, Stark K, Behnke SC, Schreier E, Frank C (2009) Epidemiology of hepatitis A virus infections, Germany, 2007–2008. Emerg Infect Dis 15(11):1760–1768 Epub 2009/11/07PubMedCentralPubMedCrossRefGoogle Scholar
  4. 4.
    Jeong SH, Lee HS (2010) Hepatitis A: clinical manifestations and management. Intervirology 53(1):15–19 Epub 2010/01/14PubMedCrossRefGoogle Scholar
  5. 5.
    Anastassopoulou CG, Kafatos G, Nardone A, Andrews N, Pebody RG, Mossong J et al (2009) The European Sero-Epidemiology Network 2 (ESEN2): standardization of assay results for hepatitis A virus (HAV) to enable comparisons of seroprevalence data across 15 countries. Epidemiol Infect 137(4):485–494 Epub 2008/08/13PubMedCrossRefGoogle Scholar
  6. 6.
    Arteaga A, Carrasco-Garrido P, de Andres AL, de Miguel AG, Jimenez-Garcia R (2009) Trends of hepatitis A hospitalizations and costs associated with the hospitalization in Spain (2000–2005). J Viral Hepat 16(4):286–291 Epub 2009/02/10PubMedCrossRefGoogle Scholar
  7. 7.
    MacIntyre CR, Burgess M, Isaacs D, McIntyre PB, Menzies R, Hull B (2007) Epidemiology of severe hepatitis A in indigenous Australian children. J Paediatr Child Health 43(5):383–387PubMedCrossRefGoogle Scholar
  8. 8.
    Gharbi-Khelifi H, Sdiri K, Ferre V, Harrath R, Berthome M, Billaudel S et al (2007) A 1-year study of the epidemiology of hepatitis A virus in Tunisia. Clin Microbiol Infect 13(1):25–32PubMedCrossRefGoogle Scholar
  9. 9.
    Sofian M, Aghakhani A, Farazi AA, Banifazl M, Etemadi G, Azad-Armaki S et al (2010) Seroepidemiology of hepatitis A virus in children of different age groups in Tehran, Iran: implications for health policy. Travel Med Infect Dis 8(3):176–179 Epub 2010/06/15PubMedCrossRefGoogle Scholar
  10. 10.
    Marcello Campagna AS, Meloni Angelo, Basciu Claudia, Ferrai Luigi, Pettinau Alessandro, Cardia Cristiana, Masia Giuseppina, Coppola Rosa Cristina (2012) Changing pattern of Hepatitis A virus epidemiology in an area of high endemicity. Hepat Mon 12(6):382–385PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Rajan E, O’Farrell B, Shattock AG, Fielding JF (1998) Hepatitis A in urban Ireland. Ir J Med Sci 167(4):231–233 Epub 1998/12/30PubMedCrossRefGoogle Scholar
  12. 12.
    Tapia-Conyer R, Santos JI, Cavalcanti AM, Urdaneta E, Rivera L, Manterola A et al (1999) Hepatitis A in Latin America: a changing epidemiologic pattern. Am J Trop Med Hyg 61(5):825–829 Epub 1999/12/10PubMedGoogle Scholar
  13. 13.
    Husain E, Al-Tawfiq JA, Husain K (2006) Epidemiology and outcome of severe hepatitis a infection in children in Kuwait. Med Principles Pract 15(4):266–269CrossRefGoogle Scholar
  14. 14.
    Taylor RM, Davern T, Munoz S, Han SH, McGuire B, Larson AM et al (2006) Fulminant hepatitis A virus infection in the United States: Incidence, prognosis, and outcomes. Hepatology 44(6):1589–1597 Epub 2006/11/30PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Rezende G, Roque-Afonso AM, Samuel D, Gigou M, Nicand E, Ferre V et al (2003) Viral and clinical factors associated with the fulminant course of hepatitis A infection. Hepatology 38(3):613–618 Epub 2003/08/27PubMedCrossRefGoogle Scholar
  16. 16.
    Vento S, Garofano T, Renzini C, Cainelli F, Casali F, Ghironzi G et al (1998) Fulminant hepatitis associated with hepatitis A virus superinfection in patients with chronic hepatitis C. N Engl J Med 338(5):286–290 Epub 1998/01/29PubMedCrossRefGoogle Scholar
  17. 17.
    Fujiwara K, Kojima H, Yasui S, Okitsu K, Yonemitsu Y, Omata M et al (2011) Hepatitis A viral load in relation to severity of the infection. J Med Virol 83(2):201–207 Epub 2010/12/25PubMedCrossRefGoogle Scholar
  18. 18.
    Fujiwara K, Yokosuka O (2004) Association between severity of hepatitis A and variations in hepatitis A viral RNA. Nihon Rinsho 62(Suppl 8):458–461 Epub 2004/09/30PubMedGoogle Scholar
  19. 19.
    Ajmera V, Xia G, Vaughan G, Forbi JC, Ganova-Raeva LM, Khudyakov Y et al (2011) What factors determine the severity of hepatitis A-related acute liver failure? J Viral Hepat 18(7):e167–e174 Epub 2010/12/15PubMedCrossRefGoogle Scholar
  20. 20.
    Berthelot P (1992) Viral hepatitis A: a changing epidemiology leading to a change in concepts. Gastroenterologie Clinique Et Biologique. 16(8–9):669–670PubMedGoogle Scholar
  21. 21.
    World Health Organization (2012) Available from Accessed Jan 09, 2012
  22. 22.
    Merat S, Rezvan H, Nouraie M, Abolghasemi H, Jamali R, Amini-Kafiabad S et al (2010) Seroprevalence and risk factors of hepatitis A virus infection in Iran: a population based study. Arch Iran Med 13(2):99–104 Epub 2010/03/02PubMedGoogle Scholar
  23. 23.
    Vitral CL, Souto FJ, Gaspar AM (2008) Changing epidemiology of hepatitis A in Brazil: reassessing immunization policy. J Viral hepat 15(Suppl 2):22–25 Epub 2008/10/22PubMedCrossRefGoogle Scholar
  24. 24.
    Pollock SL, Sheikholeslami A, Edgar B, David ST, Buxton JA 2006 The changing epidemiology of hepatitis A in British Columbia: using health authority follow-up data to inform policy and practice. Canada Communicable Disease Report = Relevé Des Maladies Transmissibles Au Canada. 32(20):239–44Google Scholar
  25. 25.
    Yap I, Guan R (1993) Hepatitis A sero-epidemiology in Singapore: a changing pattern. Trans Royal Soc Trop Med Hyg 87(1):22–23CrossRefGoogle Scholar
  26. 26.
    Mohebbi SR, Nejad MR, Tahaei SM, Pourhoseingholi MA, Habibi M, Azimzadeh P, et al. (2012) Seroepidemiology of hepatitis A and E virus infections in Tehran, Iran: a population based study. Trans Royal Soc Trop Med Hyg 106(9):528–531 Epub 2012/07/24CrossRefGoogle Scholar
  27. 27.
    Taghavi SA, Hosseini Asl MK, Talebzadeh M, Eshraghian A (2011) Seroprevalence study of hepatitis A virus in Fars province, southern Iran. Hepat Mon 11(4):285–288 Epub 2011/04/01PubMedCentralPubMedGoogle Scholar
  28. 28.
    Ceran N, Yuksel Kocdogan F, Mert D, Erdem I, Dede B, Adaleti R et al (2012) Hepatitis A seroprevalence in children and young adults in Istanbul, Turkey: seroprevalence change and associated factors. J Viral Hepat 19(1):72–76 Epub 2011/12/23PubMedCrossRefGoogle Scholar
  29. 29.
    Buisson Y, Joussemet M, Schill H, Martet G (1994) Epidemiology and prevention of hepatitis A. Médecine Tropicale Revue Du Corps De Santé Colonial 54(3 Suppl):9–13PubMedGoogle Scholar
  30. 30.
    Hendrickx G, Van Herck K, Vorsters A, Wiersma S, Shapiro C, Andrus JK et al (2008) Has the time come to control hepatitis A globally? Matching prevention to the changing epidemiology. J Viral Hepat 15:1–15PubMedCrossRefGoogle Scholar
  31. 31.
    Abdolvahab M, Behnaz K, Sima B, Teimoorian M (2010) Hepatitis a in young adults in the golestan province, northeast of iran. J Global Inf Dis. 2(2):198–199 Epub 2010/07/08CrossRefGoogle Scholar
  32. 32.
    Saberifiroozi M, Serati AR, Taghvaee T, Marooofi GR, Shirazi KM (2005) Prevalence of hepatitis A virus antibodies in patients with chronic liver disease in Shiraz, Iran. Indian J Gastroenterol off J Indian Soc Gastroenterol 24(1):33–34 Epub 2005/03/22Google Scholar
  33. 33.
    World Health Organization.Water, sanitation and hygiene: Exposure by country. Available from Accessed on 25 Dec 2013

Copyright information

© Springer-Verlag Wien 2014

Authors and Affiliations

  • Kamran B. Lankarani
    • 1
  • Mojtaba Mahmoodi
    • 1
  • Behnam Honarvar
    • 1
  • Parastoo Nematollahi
    • 1
    • 2
  • Nima Zamiri
    • 1
  • Fariborz Ghaffarpasand
    • 1
  1. 1.Community and Preventive Medicine, Health Policy Research CentreShiraz University of Medical Sciences, School of MedicineShirazIran
  2. 2.Student Research CommitteeShiraz University of Medical SciencesShirazIran

Personalised recommendations