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ObjectiveTo characterise the environmental presence of hepatitis A virus (HAV) in low- and middle-income countries (LMICs).DesignSystematic review and meta-analysis.Data sourcesEBSCOhost, PubMed, Scopus, ScienceDirect, Clinical Key and Web of Science were searched. Grey literature was sourced by searching the following electronic databases: Open Grey, National Health Research Database and Mednar.Eligibility criteria for including studiesCross-sectional and ecological studies reporting HAV environmental presence and conducted in LMICs between January 2005 and May 2019, irrespective of language of publication.Data extraction and data synthesisRelevant data were extracted from articles meeting the inclusion criteria, and two reviewers independently assessed the studies for risk of bias. High heterogeneity of the extracted data led to the results being reported narratively.ResultsA total of 2092 records were retrieved, of which 33 met the inclusion criteria. 21 studies were conducted in Tunisia, India and South Africa, and the rest were from Philippines, Pakistan, Morocco, Chad, Mozambique, Kenya and Uganda. In Tunisian raw sewage samples, the prevalence of HAV ranged from 12% to 68%, with an estimated average detection rate of 50% (95% CI 25 to 75), whereas HAV detection in treated sewage in Tunisia ranged from 23% to 65%, with an estimated average detection rate of 38% (95% CI 20 to 57). The prevalence of HAV detection in South African treated sewage and surface water samples ranged from 4% to 37% and from 16% to 76%, with an estimated average detection rates of 15% (95% CI 1 to 29) and 51% (95% CI 21 to 80), respectively. Over the review period, the estimated average detection rate of environmental HAV presence appeared to have declined by 10%.ConclusionThe quality of included studies was fair, but sampling issues and paucity of data limited the strength of the review findings.Prospero registration numberCRD42019119592.

Original publication




Journal article


BMJ open

Publication Date





Faculty of Health Sciences, Department of Public Health, Lira University, Lira, Uganda


Humans, Hepatitis A virus, Cross-Sectional Studies, Developing Countries, Morocco, Tunisia, Kenya, Uganda, Mozambique, South Africa, Philippines, India, Pakistan