The clinical and economic burden of varicella in the Middle East: a systematic literature review

Figures & data

Figure 1. PRISMA flow chart for the global search with regional-level outcomes.

Table 1. Universal varicella vaccination programs in the Middle East.

Country	Dose	Schedule	Implementation date/approval date
Bahrain^*Citation4	2 doses	12 months; 3 y	2015
Kuwait^*Citation4	2 doses	12 and 24 months	2017
Oman^*Citation4	1 dose	12 months	2010
Qatar^*Citation4	2 doses	12 months; 4–6 y	2010
Turkey^Citation14,Citation15	1 dose	12 months	2013
Saudi Arabia^Citation11	2 doses	12 months; 4–6 y	Childhood varicella vaccine introduced in 1998; made mandatory in 2008
UAE^Citation16	2 doses	12 months; 5–6 y	2009

UAE, the United Arab Emirates.

*Identified via gray data review.

Table 2. Incidence of varicella across the Middle East.

				Incidence
Country	Study	Design and vaccine availability status	Age group	Minimum	Maximum
Iraq	Khaleel 2013^Citation19	Retrospective study investigating trend of registered clinical cases 2007–2011 (pre-UVV era)	All ages	73.4 per 100,000 population in 2007	222.6 per 100,000 population in 2011
Jordan	World Health Association^Citation20	Surveillance report. Pre-vaccine incidence rate, 1991 (no UVV program)	All ages	458 per 100,000 population
Lebanon	World Health Association^Citation20	Surveillance report. Pre-vaccine incidence rate, 1991 (no UVV program)	All ages	454 per 100,000 population
Saudi Arabia	Almuneef 2006^Citation21	Retrospective study in an outpatient setting 2001–2003 (pre-UVV era)	All ages	4,121 patients reported with varicella, 60% of cases in age group 5–14 y
	Jahan 2007^Citation22	Retrospective study, 1999 and 2003 (pre-UVV era)	All ages	207 per 100,000 population in 1999	759 per 100,000 population in 2003
	Al-Tawfiq 2013^Citation11	Retrospective study of 19,577 patients 1994–2011	All ages	88.1 per 100,000 population in 2011 (post-UVV era)	739.8 per 100,000 population in 1994 (pre-vaccine availability)
	Saleh 2014^Citation23	Retrospective review of surveillance records and book registries from the Armed Forces Hospital of the Southern Region of Saudi Arabia 2007–2012.	All ages	227 cases in 2012 (post-UVV era)	754 cases in 2007 (pre-UVV era)
Syria	World Health Association^*Citation20	Surveillance report. Pre-vaccine incidence rate, 1991 (no UVV program)	All ages	1,435 per 100,000 population
Turkey	Dinleyici 2012, 2015^Citation10,Citation15	Retrospective study of 824 patients hospitalized due to varicella between October 2008 and September 2010 (pre-UVV era)	Ages < 1–15 y	Incidence of varicella-related hospitalization: 5.3 per 100,000 children (overall) 3.9 per 100,000 children aged 5–10 y	Incidence of varicella-related hospitalization: 6.9 per 100,000 children (overall) 13.8 per 100,000 children aged < 5 y
	Kurugol 2011^Citation14	Cross-sectional study of 2,802 children from April 2008 to March 2009 (pre-UVV era)	Ages 2–15.5 y	4,550 per 100,000 person-years for vaccinated (breakthrough) children	12,020 per 100,000 person-year for unvaccinated (wild-type varicella) children
UAE	Uduman 2009^Citation24	Retrospective study conducted between 2000–2004 (pre-UVV era)	All ages	373 per 100,000 population	790 per 100,000 population

UVV, universal varicella vaccine.

*No gray data on incidence rates were identified.

Table 3. Seroprevalence data.

Country/Study	Population	Seroprevalence
Iran
Allami 2014^Citation27	Overall, n = 270 Aged 18–49 y	74.5%
Bayani 2013^Citation28	Overall n = 459 Mean age 32.2 ± 1.1 y	94.6%
	History of varicella	95.5%
Ardakani 2013^Citation29	Overall population of patients aged Aged 1–15 y, n = 558	27.6%
Talebi-Taher 2010^Citation30	Pregnant women, according to age, Aged 16–43 y n = 400; min–max values presented	77.8% at ≤ 20 y 94.7% at ≥ 30 y
Vojgani 2013^Citation31	Children, by age, n = not available Aged 7 months to 6 y Min–max values presented	6.6% at 7 months 21.3% at 6 y
Hoseini 2016^Citation32	Patients aged 10–18 y, n = 2,753	87.4%
Motamedifar 2006^Citation33	Children aged 0–10 y, n = 270	35.2%
Pourahmad 2010^Citation34	Women aged 11–45 y, n = 334	72.7%
Pourakbari 2012^Citation35	Individuals aged between 10–25 y, n = 412	65.3%
Majidy 2016^Citation36	Young women aged 13–40 y for pre-marital medical checkup, n = 250	71.2%
Sharif 2005^Citation37	Overall, n = 635, aged 1–60 y	83.6%
Amjadi 2017^*Citation38	Overall (meta-analysis), n = 7,867, aged ≤7–88 y	78.5%
Iraq
Yassien 2012^Citation39	Overall, children aged <1–15 y, n = 92	53.3%
Saudi Arabia
Almuneef 2006^Citation40	Overall, adults, n = 4,006	86.0%
Hossain 1989^Citation41	Children aged 1–15 y, n = 224	68.0%
	Adults – healthy male blood donors and pregnant women, n = 452	90.0%
Memish 2001^Citation42	Saudi Arabian National Guard soldiers, aged 15–40+ y, n = 1,350	88.5%
Ghazi 2002^Citation43	Pregnant Saudi Arabian women, ages unspecified, n = 926	74.4%
Almuneef 2003^Citation44	Healthcare workers, ages unspecified, n = 2,047	64.0%
Abbas 2007^Citation45	Healthcare workers, ages unspecified	68.4%
Turkey
Alp 2005^Citation46	Subjects aged < 30 y, n = 568	78.0%
Alp 2012^Citation47	Healthcare-worker population (pre-vaccination era), aged 19–60 y, n = 1,255	98.0%
Celikbas 2006^Citation48	Healthcare-worker population, mean age 29 y, n = 363	98%
Gürgöze 2006^Citation49	Unvaccinated children aged 1–16 y, n = 803	26.8% for 1–4 y 90.3% for 13–16 y
Karasahin 2014^Citation50	Healthcare-worker population, ages unspecified, n = 811	95.2%
Kanra 2002^Citation51	Subjects aged < 30 y, n = 4,387	77.8%
Kose 2013^Citation52	Subjects aged > 15 y, n = 2,136	94.3%
Aypak 2012^Citation53	Healthcare workers, mean age 33.5 ± 11 y, n = 284	98.2%
Ozkan 2005^Citation54	Children aged 9–60 months, n = 292	22.3%
Kurugol 2007^Citation55	Overall (ages 1–30 y), n = 600	84.1%
Savas 2004^Citation56	Children aged 0–15 y, n = 885	41.2% for 4–5 y 80% for 10–11 y 85% for 13–15 y
Syria
Barah 2012^Citation57	Females of childbearing age, n = 316	91.0%
UAE
Sheek-Hussein 2012^Citation58	Medical students, aged 16–33 y, post-vaccination era, n = 261	88.0%
Uduman 2001^Citation59	Overall, aged <10–>41 y, n = 648	80.6%
Qatar
Guanche Garcell, 2016^Citation60	Healthcare workers, 84% aged 30–49 y, n = 705	92.2%

UAE, the United Arab Emirates.

*Denotes identified gray data.

Figure 2. Seroprevalence by age in Iran (a), Turkey (b), and the UAE (c). References: Alp 2005,⁴⁶ Kurugol 2007,¹⁴ Motemedifar 2006,³³ Pourahmad 2010,³⁴ Uduman 2001,⁵⁹ Vojgani 2013³¹ UAE, the United Arab Emirates.

Figure 3. Common complications of varicella reported in hospitalized patients in Turkey. References: Koturoglu 2005,⁶³ Turel 2013,⁶⁴ Dinleyici 2012,¹⁵ Dinleyici 2015¹⁰.

Table 4. Hospitalization rate and duration of stay due to varicella.

Study	Study description/Population	Hospitalization rate	Average duration of stay
Turkey
Dinleyici 2012^Citation15	VARICOMP: Children between age 0–15 y hospitalized due to varicella, October 2008 to September 2010	Overall estimated incidence of varicella-related hospitalization: 5.3–6.9 per 100,000 children per year	6 d (median) 11 d in ICU (median)
Dinleyici 2015^Citation10	VARICOMP: Children between age 0–15 y hospitalized due to breakthrough varicella, October 2008 to September 2013	NR	8 d (median)
Dinleyici 2016^*Citation67	VARICOMP: Varicella-related hospitalization among children aged 1–5 y Pre-UVV era Post-UVV era	6.1–9.1 per 100,000 children per year 3.1–4.3 per 100,000 children per year	NR
Turel 2013^Citation64	Study of 186 patients hospitalized with varicella, November 2006 to June 2011	74.2% of patients were aged < 3 y, of which 64.2% were ≤ 1 y	5 d (median)
Kurugol 2011^Citation14	Study of 466 cases of breakthrough varicella in vaccinated children, and 723 cases of varicella in unvaccinated children	0.2% of children in the vaccinated group and 0.6% in the unvaccinated group	NR
Koturoglu 2005^Citation63	Study of 178 cases in children between 2007 and 2011	NR	6.2 d (mean)
UAE
Uduman^Citation24	187 hospitalized during 2000–2004 (pre-UVV era)	NR	7.5 d (mean)
Abro 2009^Citation62	Study period March 2005 to February 2008 (pre-UVV era)	NR	7.45 d (mean)
Saudi Arabia
Almuneef 2006^Citation21	Data collection period June 1, 2001, to December 30, 2003 (Pre-UVV era)	Hospitalization rate due to varicella: 2,050 per 100,000 reported cases	NR

ICU, intensive care unit; NR, not reported; UVV, universal varicella vaccine.

*Denotes gray data.

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