Prevalence of celiac disease in healthy Iranian school children.

To the Editor: I have two comments on the interesting study by Dehghani et al.1

First, Dehghani et al1 stated in their study that the prevalence of celiac disease (CD) based on anti-tissue transglutaminase antibodies (tTGA) screening test was 1:50, whereas the prevalence of biopsyproven CD (silent celiac) was 1:167. I presume that the actual prevalence is higher. This is based on the following contributory factors: (1) The consumption of wheat as a major dietary staple is still a major custom in Iran. (2) Consanguineous marriage is a prevailing practice in Iran with the first cousin marriage being the most common type of consanguinity (69%).2 (3) Iran is a multiethnic country and, therefore, genetic variance does exist in the Iranian population. (4) There is inadequate awareness of the referring pediatricians with regard to the uncommon manifestations of CD. (5) Underdiagnosis of CD in the primary care setting is often compounded by disease mismanagement. (6) CD is strongly associated with HLA-DQ2 in developing countries. Though recent studies are not yet present on HLA phenotypes in Iranians, the available data has pertained to the potential role of HLA-DQ2 in increasing the propensity of certain populations in Asia like Iran to have CD.3 (7) Iranians might follow the general trend of overall worldwide increase in the CD prevalence, including silent cases.

Second, to meet the principles of screening, a disease must be common, and a significant health burden must be detectable and treatable. I presume that screening for CD in Iranian children seems justifiable. This is based on the following points: (1) There is substantial prevalence of CD, in particular, silent cases in Iran.1,4 (2) Undiagnosed CD patients have long-term serious health consequences, including malignancy, anemia, short stature, osteopenia, and infertility. Moreover, the medical costs and utilization of selected health care services over time for symptomatic CD patients during the delay between symptoms onset and diagnosis are substantial. (3) There is the presence of effective screening tool for CD in terms of measuring the serum tTGA supplemented whenever necessary by small intestinal biopsy. (4) There is the presence of effective therapy for CD in terms of gluten-free diet. The children’s age range supposed to undergo screening for CD ought to be determined in Iran. However, the available evidence has advocated the age 2 to 3 years as the best time for measuring the serum tTGA due to the high detection rate.5