Prevalence of celiac disease in Saudi children: Is it underestimated?

Sir,

I refer to the interesting study by Al Hatlani published in this Journal.[1] However, there are some aspects that are worth commenting upon. First, I presume that the actual prevalence of celiac disease (CD) among symptom-free children is higher than the 1% reported by Al Hatlani.[1] Apart from the limitation addressed by the author, namely, the conduction of the study in a single center, I believe that the following points might be additionally relevant. (1) The methodology employed in the study consisted of screening for CD by testing for antitissue transglutaminase IgA (IgA-tTG) and IgG antibodies (IgG-tTG). Small intestinal biopsy was offered to those who tested positive for IgA-tTG [IgA-tTG > 20 relative units (RU)/mL].[1] Since a proportion of children with CD have been shown to have a spontaneous disappearance of antibodies over time,[2] I presume that significant percentage of potentially silent CD were missed from Al Hatlani's study. (2) The consumption of wheat containing gluten as a major staple food is still a common custom in the Kingdom of Saudi Arabia (KSA). (3) Consanguinity is a well-known risk factor contributing to the development of CD. The practice of consanguineous marriage is still the culturally preferred form of marriage in KSA.[3] (4) It is obvious that the presence of HLA-DQ2 and/or DQ8 is an important determinant of CD prevalence. Although recent studies are not available on the distribution of HLA phenotypes in the Saudi population, the available data have pointed out that CD prevalence is expected to increase over the next few years or decades in many Asian countries.[4] (5) There is limited alertness of the primary health care physicians and pediatricians on the uncommon manifestations of CD, particularly those that are silent cases.

Second, based on the study data, Al Hatlani recommends mass screening for CD in other provinces of KSA. I do agree with that recommendation.[1] However, I presume that the aforementioned methodology to be employed for the mass screening would be not suitable due to the aforementioned methodological limitation. I presume that the following screening protocol might be a better alternative. It is obvious that individuals carrying the HLA-risk haplotypes DQ2 and/or DQ8 are more susceptible to have CD. As HLA-DQ genotyping has been suggested as a screening method for CD among asymptomatic children,[5] the implementation of this screening strategy in different provinces of KSA could yield better estimation on the actual nationwide CD prevalence in asymptomatic pediatric population in KSA.

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