Iraq: A Hot Zone for HAV Infection?

Case Presentation:A 25 year-old man referred to our center with symptoms compatible with acute hepatitis for the past two weeks. He was a government employee and had married two months before. We evaluated his lab test and while we were waiting for his lab test result, he called us to say that his wife had the same symptoms. We visited her and found that the clinical picture was compatible with the acute hepatitis, too. It was really interesting for us to see acute presentation in a husband and his wife simultaneously. We asked them about important risk factors like history of transfusion, recent surgery, tattooing, and addiction, all of which were negative. They mentioned that they had a trip to Karbala in Iraq one month before. Afterwards, we received their lab data showing: ALT and AST more than 10 times of upper limit of normal range, elevation in direct bilirubin, HBsAg negative, HBcAb IgM negative, HCV Ab by Eliza test negative and HAV Ab IgM positive. During follow up, fortunately, the symptoms and signs improved and they lived happily ever after! The question is: "should we consider the trip to Iraq a risk factor for acquiring acute HAV infection?"