Evidence for widespread infection of wild rats with hepatitis E virus in the United States

Characterization of self-assembled virus-like particles of rat hepatitis E virus generated by recombinant baculoviruses

Hepatitis E virus (HEV) is a causative agent of hepatitis E. Recently, a novel hepatitis E-like virus was isolated from Norway rats in Germany. However, the antigenicity, pathogenicity and epidemiology of this virus are unclear because of the lack of a cell-culture system in which to grow it. In this study, an N-terminally truncated ORF2 protein was expressed in insect Tn5 cells using a recombinant baculovirus expression system and a large amount of 53 kDa protein was expressed and efficiently released into the supernatant. Electron microscopic analyses of the purified 53 kDa protein revealed that the protein self-assembled into two types of empty HEV-like particles (rat HEVLPs). The smaller rat HEVLPs were estimated to be 24 nm in diameter, which is similar to the size of genotype G1, G3 and G4 HEVLPs. The larger rat HEVLPs were estimated to measure 35 nm in diameter, which is similar to the size of native rat HEV particles. An ELISA to detect antibodies was established using rat HEVLPs as the antigens, which demonstrated that rat HEVLPs were cross-reactive with G1, G3 and G4 HEVs. Detection of IgG and IgM antibodies was performed by examination of 139 serum samples from wild rats trapped in Vietnam, and it was found that 20.9 % (29/139) and 3.6 % (5/139) of the samples were positive for IgG and IgM, respectively. In addition, rat HEV RNA was detected in one rat serum sample that was positive for IgM. These results indicated that rat HEV is widespread and is transmitted among wild rats.

Outbreak of Viral Hepatitis E in a Regimental Training Centre

BACKGROUND

An outbreak of viral hepatitis occurred in a regimental centre with 265 cases occurring during a 3 months period.

METHODS

190 serum samples were tested for IgM antibodies against viral hepatitis E by Enzyme Immuno Assay (EIA) and for antibodies against Hepatitis A and Hepatitis B viruses. Epidemiological investigation comprised review of surveillance data, filling up epidemiological case sheet, sanitary survey, inspection of water supplies and bacteriological examination of water for coliforms.

RESULT

97.4% of the serum samples were positive for IgM antibodies against Hepatitis E virus. Two leaks were detected in water pipelines, which were passing through contaminated areas around improperly functioning septic tanks and soak pits. The attack rate among recruits being supplied water through leaking pipelines was 11.1% whereas it was 2.89% in those not directly exposed. This difference was statistically significant (p<0.001). Bacteriological examination of water showed a high coliform count.

CONCLUSION

The outbreak of viral hepatitis E occurred due to sewage contamination of water pipelines.

Novel hepatitis E virus genotype in Norway rats, Germany

Human hepatitis E virus infections may be caused by zoonotic transmission of virus genotypes 3 and 4. To determine whether rodents are a reservoir, we analyzed the complete nucleotide sequence of a hepatitis E–like virus from 2 Norway rats in Germany. The sequence suggests a separate genotype for this hepatotropic virus.

Hepatitis E in high-income countries

PURPOSE OF REVIEW

To discuss recent advances in characterising viral Hepatitis E (HEV) in nonendemic regions, with a special focus on epidemiology in high-income countries, different clinical aspects of the disease, possible zoonotic origin of these cases and the improvement of Hepatitis E diagnosis.

RECENT FINDINGS

In high-income countries, most cases of Hepatitis E are acquired locally and not imported from endemic regions. Different genotypes are involved in indigenous cases than those in endemic regions. Particular population groups, such as transplant recipients, can be persistently infected by hepatitis E and develop chronic diseases. Viral hepatitis E is frequently observed in people in animal care occupations. Indeed, HEV has a large animal reservoir and this emerging disease in developed countries has probably a zoonotic origin.

SUMMARY

Recent studies on viral Hepatitis E have shown that the epidemiology of the disease differs between endemic and nonendemic regions. Several lines of evidence suggest that Hepatitis E is more frequent than was suspected and that it has a possible animal origin. Particular attention must be paid to the possible chronic evolution of various forms of the disease. Surveillance of human cases and animal reservoirs must be developed further.

Zoonotic hepatitis E: animal reservoirs and emerging risks

Hepatitis E virus (HEV) is responsible for enterically-transmitted acute hepatitis in humans with two distinct epidemiological patterns. In endemic regions, large waterborne epidemics with thousands of people affected have been observed, and, in contrast, in non-endemic regions, sporadic cases have been described. Although contaminated water has been well documented as the source of infection in endemic regions, the modes of transmission in non-endemic regions are much less known. HEV is a single-strand, positive-sense RNA virus which is classified in the Hepeviridae family with at least four known main genotypes (1–4) of mammalian HEV and one avian HEV. HEV is unique among the known hepatitis viruses, in which it has an animal reservoir. In contrast to humans, swine and other mammalian animal species infected by HEV generally remain asymptomatic, whereas chickens infected by avian HEV may develop a disease known as Hepatitis-Splenomegaly syndrome. HEV genotypes 1 and 2 are found exclusively in humans while genotypes 3 and 4 are found both in humans and other mammals. Several lines of evidence indicate that, in some cases involving HEV genotypes 3 and 4, animal to human transmissions occur. Furthermore, individuals with direct contact with animals are at higher risk of HEV infection. Cross-species infections with HEV genotypes 3 and 4 have been demonstrated experimentally. However, not all sources of human infections have been identified thus far and in many cases, the origin of HEV infection in humans remains unknown.

Hepatitis E virus: animal reservoirs and zoonotic risk

Hepatitis E virus (HEV) is a small, non-enveloped, single-strand, positive-sense RNA virus of approximately 7.2kb in size. HEV is classified in the family Hepeviridae consisting of four recognized major genotypes that infect humans and other animals. Genotypes 1 and 2 HEV are restricted to humans and often associated with large outbreaks and epidemics in developing countries with poor sanitation conditions, whereas genotypes 3 and 4 HEV infect humans, pigs and other animal species and are responsible for sporadic cases of hepatitis E in both developing and industrialized countries. The avian HEV associated with Hepatitis-Splenomegaly syndrome in chickens is genetically and antigenically related to mammalian HEV, and likely represents a new genus in the family. There exist three open reading frames in HEV genome: ORF1 encodes non-structural proteins, ORF2 encodes the capsid protein, and the ORF3 encodes a small phosphoprotein. ORF2 and ORF3 are translated from a single bicistronic mRNA, and overlap each other but neither overlaps ORF1. Due to the lack of an efficient cell culture system and a practical animal model for HEV, the mechanisms of HEV replication and pathogenesis are poorly understood. The recent identification and characterization of animal strains of HEV from pigs and chickens and the demonstrated ability of cross-species infection by these animal strains raise potential public health concerns for zoonotic HEV transmission. It has been shown that the genotypes 3 and 4 HEV strains from pigs can infect humans, and vice versa. Accumulating evidence indicated that hepatitis E is a zoonotic disease, and swine and perhaps other animal species are reservoirs for HEV. A vaccine against HEV is not yet available.

Experimental infection of Mongolian gerbils by a genotype 4 strain of swine hepatitis E virus

An ideal animal model for hepatitis E virus (HEV) research is still unavailable. To assess the possibility of using Mongolian gerbils as animal model, 28 gerbils were randomly assigned into two groups, 14 for each group. Gerbils in Group 1 were inoculated with a genotype 4 HEV recovered from swine via the intraperitoneal route. Group 2 was used as a negative control and inoculated with normal suspension of swine liver. Sera and feces samples were collected once a week for 7 weeks. Two gerbils from both groups were necropsied weekly, pathological changes were recorded and tissue samples collected for further investigation. Distribution of the virus antigens was determined by immunohistochemical staining. Nested RT-PCR and a commercial ELISA kit were used to confirm the infection. Research results demonstrated that Mongolian gerbils in Group 1 were successfully infected with HEV. Viremia and fecal virus shedding lasted nearly 4 weeks, while the virus could be detected constantly in the liver, and occasionally in the kidneys and spleen as well as the small intestine. Histopathological changes in the liver were present with slight, multifocal, lymphohistiocytic infiltrates in the portal tracts or distributed irregularly throughout the liver. HEV antigens could be detected in the liver and intestine, and were mainly distributed in the nuclei. The results indicate that Mongolian gerbils could be used as an ideal animal model for the study of HEV.

Epidemiology of hepatitis E virus in the United States: results from the Third National Health and Nutrition Examination Survey, 1988-1994

BACKGROUND

Hepatitis E virus (HEV) is prevalent and causes disease worldwide, but its epidemiological profile is only partially understood.

METHODS

We used an enzyme immunoassay to measure anti-HEV immunoglobulin G antibodies in 18,695 serum samples collected in the Third National Health and Nutrition Examination Survey. We calculated estimates of HEV seroprevalence and examined associations with putative risk factors.

RESULTS

The seroprevalence of HEV in the civilian noninstitutionalized United States (US) population during the period from 1988 through 1994 was 21.0% (95% confidence interval [CI], 19.0%-22.9%). Among US-born individuals, males, non-Hispanic whites, and individuals residing in the Midwest and/or in metropolitan areas had the highest seroprevalence estimates. Having a pet in the home (odds ratio [OR], 1.19 [95% CI, 1.01-1.40]) and consuming liver or other organ meats more than once per month (OR, 1.38 [95% CI, 1.01-1.88]) were significantly associated with increased odds of HEV seropositivity.

CONCLUSIONS

Exposure to HEV is common in the US population, although hepatitis E is rarely reported. Having pets and consuming organ meats may play a role in HEV transmission in the United States, but other mechanisms of transmission may also exist. HEV may be considered a possible etiologic agent of acute and chronic hepatitis in US patients reporting no travel history.

Experimental infection of Balb/c nude mice with Hepatitis E virus

BACKGROUND

Several animal species can reportedly act as reservoirs for Hepatitis E virus (HEV), a zoonotic pathogen. HEV and antibody to the virus have been detected in a variety of animals including rodents. Pig and rat models for HEV have been established for HEV, but a nude mouse has not yet been developed.

METHODS

Balb/c nude mice were inoculated with swine HEV, both orally and via intravenous injection to insure infection. Negative control and experimental contact-exposed groups of mice were also included in the study. The liver, spleen, kidney, jejunum, ileum, cecum and colon of each mouse from all three groups were collected for reverse transcription nested polymerase chain reaction (RT-nPCR) detection, indirect immunofluorescence observation and histopathologic examination. The sera from nude mice were tested for anti-HEV IgG by enzyme linked immunosorbent assay (ELISA). Activities of liver enzymes, including alanine aminotransferase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase (ALP), as well as total bilirubin (TBIL) were also measured in the sera of the nude mice.

RESULTS

HEV antigens and HEV RNA were detected in liver, spleen, kidney, jejunum, ileum and colon both by indirect immunofluorescence and by RT-nPCR in all of the inoculated and in one of the contact-exposed nude mice. Histopathological changes were observed in the liver and spleen of these mice. Infected mice showed increased levels of AST, ALP, and anti-HEV IgG in sera. The livers of contact-exposed mice showed obvious histopathological damage.

CONCLUSION

Nude mice could be readily infected by HEV isolated from pigs. The nude mouse may therefore be a useful animal model for studying the pathogenesis of HEV.

Molecular biology and pathogenesis of hepatitis E virus

The hepatitis E virus (HEV) is a small RNA virus and the etiological agent for hepatitis E, a form of acute viral hepatitis. The virus has a feco-oral transmission cycle and is transmitted through environmental contamination, mainly through drinking water. Recent studies on the isolation of HEV-like viruses from animal species also suggest zoonotic transfer of the virus. The absence of small animal models of infection and efficient cell culture systems has precluded virological studies on the replication cycle and pathogenesis of HEV. A vaccine against HEV has undergone successful clinical testing and diagnostic tests are available. This review describes HEV epidemiology, clinical presentation, pathogenesis, molecular virology and the host response to HEV infection. The focus is on published literature in the past decade.

Phylogenetic and case-control study on hepatitis E virus infection in Germany

BACKGROUND

Hepatitis E is a classic water-borne disease in developing countries. In Germany, hepatitis E virus (HEV) infections are notifiable. The number of non-travel-associated infections has increased in recent years, but the route of transmission in most is unknown. Our objective was to determine risk factors for autochthonous HEV infections in Germany.

METHODS

Cases of HEV met clinical definitions and were confirmed by laboratory analysis (defined as detection of HEV by polymerase chain reaction [PCR] or immunoglobulin M by serologic testing). PCR products from blood or stool samples were genotyped for phylogenetic analysis. A case-control study included case subjects with autochthonous HEV infection and matched control subjects who were randomly recruited from a population-based telephone list.

RESULTS

From May 2006 through August 2007, 76 of 96 persons for whom HEV infection had been reported to the routine surveillance system were interviewed. Sixty-six persons had disease that fulfilled the inclusion criteria: 45 (68%) had autochthonous infection, and 21 (32%) had travel-associated disease. Genotypes 3 or 4 were present in 15 of 15 persons with autochthonous infection, and genotype 1 was present in 8 of 9 persons with travel-associated infection. In conditional logistic regression involving 45 case subjects and 135 control subjects, consumption of offal (41% vs. 19%; odds ratio [OR], 2.7; 95% confidence interval [CI], 1.2-6.2) and wild-boar meat (20% vs. 7%; OR, 4.3; 95% CI, 1.2-15.9) were independently associated with autochthonous HEV infection.

CONCLUSION

Hepatitis E is endemic in Germany and likely exists as a food-borne zoonosis. Implicated meat products should be investigated to provide recommendations for preventive measures.

Excretion of hepatitis E virus by pigs of different ages and its presence in slurry stores in the United Kingdom

Five faecal samples were collected from four different stages of production at each of 10 pig farms in the Yorkshire Humberside area of the UK, and samples of slurry were collected from nine of the farms. All the samples were tested for hepatitis E virus (HEV) RNA by a nested reverse transcriptase PCR. At least one sample from the pigs on each of the farms tested positive for hev; its prevalence in the 10 herds varied from 5 per cent to 35 per cent and its mean prevalence was 21.5 per cent. The mean prevalence in pigs aged three to five weeks was 26.0 per cent, in pigs aged 10 to 12 weeks 44.0 per cent, in pigs aged 22 to 24 weeks 8.9 per cent, and in adult dry sows 6.0 per cent. Two of the nine slurry lagoons tested positive for HEV RNA. Phylogenetic analysis of the sequence data indicated that the strains of the virus were of genotype 3 and closely related to strains detected in other pigs and in human beings in the UK.

Hepatitis E: a complex and global disease

Thirty years after its discovery, the hepatitis E virus (HEV) continues to represent a major public health problem in developing countries. In developed countries, it has emerged as a significant cause of non-travel-associated acute hepatitis. HEV infects a wide range of mammalian species and a key reservoir worldwide appears to be swine. Genomic sequence similarity between some human HEV genotypes and swine HEV strains has been identified and we know that humans can acquire HEV infection from animals. Although for the most part the clinical course of HEV infection is asymptomatic or mild, significant risk of serious disease exists in pregnant women and those with chronic liver disease. In addition, there are data on the threat of chronic infections in immunocompromised patients. Beyond management of exposure by public health measures, recent data support that active immunisation can prevent hepatitis E, highlighting the need for vaccination programmes. Here we review the current knowledge on HEV, its epidemiology, and the management and prevention of human disease.

Deletions of the hypervariable region (HVR) in open reading frame 1 of hepatitis E virus do not abolish virus infectivity: evidence for attenuation of HVR deletion mutants in vivo

Hepatitis E virus (HEV) is an important human pathogen, although little is known about its biology and replication. Comparative sequence analysis revealed a hypervariable region (HVR) with extensive sequence variations in open reading frame 1 of HEV. To elucidate the role of the HVR in HEV replication, we first constructed two HVR deletion mutants, hHVRd1 and hHVRd2, with in-frame deletion of amino acids (aa) 711 to 777 and 747 to 761 in the HVR of a genotype 1 human HEV replicon. Evidence of HEV replication was detected in Huh7 cells transfected with RNA transcripts from mutant hHVRd2, as evidenced by expression of enhanced green fluorescent protein. To confirm the in vitro results, we constructed three avian HEV mutants with various HVR deletions: mutants aHVRd1, with deletion of aa 557 to 585 (Delta557-585); aHVRd2 (Delta612-641); and aHVRd3 (Delta557-641). Chickens intrahepatically inoculated with capped RNA transcripts from mutants aHVRd1 and aHVRd2 developed active viral infection, as evidenced by seroconversion, viremia, and fecal virus shedding, although mutant aHVRd3, with complete HVR deletion, was apparently attenuated in chickens. To further verify the results, we constructed four additional HVR deletion mutants using the genotype 3 swine HEV as the backbone. Mutants sHVRd2 (Delta722-781), sHVRd3 (Delta735-765), and sHVRd4 (Delta712-765) were shown to tolerate deletions and were infectious in pigs intrahepatically inoculated with capped RNA transcripts from the mutants, whereas mutant sHVRd1 (Delta712-790), with a nearly complete HVR deletion, exhibited an attenuation phenotype in infected pigs. The data from these studies indicate that deletions in HVR do not abolish HEV infectivity in vitro or in vivo, although evidence for attenuation was observed for HEV mutants with a larger or nearly complete HVR deletion.

Hepatitis e: a UK perspective

Hepatitis E is increasingly recognized as a cause of viral hepatitis within the UK and should be considered in any patient presenting with acute hepatitis. Mortality rates of around 4% have been described, but are even higher during pregnancy.

Serological evidence for hepatitis e virus infection in laboratory monkeys and pigs in animal facilities in Japan

In laboratory animal facilities, monkeys and pigs are used for animal experiments, but the details of hepatitis E virus (HEV) infection in these animals are unknown. The risk of infection from laboratory animals to humans has become a concern; therefore, much attention should be paid to the handling of these animals during their care and use, including surgical procedures performed on infected animals. In this connection, serum samples collected from 916 monkeys and 77 pigs kept in 23 animal facilities belonging to the Japanese Association of Laboratory Animal Facilities of National University Corporations (JALAN) and the Japanese Association of Laboratory Animal Facilities of Public and Private Universities (JALAP) in Japan were examined for the purpose of detecting antibodies to HEV and HEV RNA by using ELISA and RT-PCR, respectively. One hundred and seven serum samples of 916 (11.7%) monkeys were positive for anti-HEV IgG, and 7 and 17 serum samples of 916 (0.8% and 5.3%) monkeys were positive for anti-HEV IgM and IgA, respectively. Thirty-six samples from 62 (58.1%) farm pigs were positive for anti-HEV IgG, whereas all samples tested from miniature pigs were negative (0/15, 0%). Seven samples from 62 (9.1%) farm pigs and 7 samples from 916 (0.8%) monkeys were positive for IgM antibody, but these HEV-IgM antibody positive serum samples were HEV-RNA negative by RT-PCR. The IgM antibody positive rate (9.1%) of farm pigs was much higher than that of monkeys (0.8%). These results suggest the relative levels of risk of HEV infection from these animals to animal handlers and researchers who work with them in laboratory animal facilities.

Hepatitis E virus: molecular virology, clinical features, diagnosis, transmission, epidemiology, and prevention

Hepatitis E virus (HEV), the sole member of the genus Hepevirus in the family of Hepeviridae, is the major cause of several outbreaks of waterborne hepatitis in tropical and subtropical countries and of sporadic cases of viral hepatitis in endemic and industrialized countries. Transmission of HEV occurs predominantly by the fecal-oral route although parenteral and perinatal routes have been implicated. The overall death rate among young adults and pregnant women is 0.5-3% and 15-20%, respectively. HEV is a small non-enveloped particle that consists of a polyadenylated single-strand RNA molecule containing three discontinuous and partially overlapping open reading frames. There are four major genotypes of HEV and a single serotype. At present, there are approximately 1,600 sequences of HEV that are already available at INSDC of both human and animal isolates. Diagnostic and molecular assays have been described for the accurate differentiation of ongoing from remote infection of HEV. Identification and characterization of swine HEV in the United States, Japan, and many other countries and their close relationship to locally characterized human HEV found in the same geographic areas prove that HEV is indeed a zoonotic virus and that domestic swine, wild deer, and boars are reservoirs of HEV in nature. A cell culture system for the propagation of the virus has been described, and a very successful phase 2 vaccine trial has been completed. This review summarizes the current knowledge on the molecular biology, clinical features, transmission, diagnosis, epidemiology, and prevention of HEV.

Hepatitis E: an emerging awareness of an old disease

Although hepatitis E was recognized as a new disease in 1980, the virus was first visualized in 1983 and its genome was cloned and characterized in 1991, the disease is probably ancient but not recognized until modern times. Hepatitis E is the most important or the second most important cause of acute clinical hepatitis in adults throughout Asia, the Middle East and Africa. In contrast, hepatitis E is rare in industrialized countries, but antibody (anti-HEV) is found worldwide. HEV is a small round RNA-containing virus that is the only member of the genus Hepevirus in the family Hepeviridae. Although similar to hepatitis A virus in appearance, there are significant differences between the two viruses. Hepatitis E is principally the result of a water-borne infection in developing countries and is thought to be spread zoonotically (principally from swine) in industrialized countries. Because diagnostic tests vary greatly in specificity, sensitivity and availability, hepatitis E is probably underdiagnosed. At present, control depends upon improved hygiene; a highly efficacious vaccine has been developed and tested, but it is not presently available.

[Hepatitis E virus: zoonotic implications]

The Hepatitis E virus (HEV) is transmitted primarily by the feco-oral route throughout contaminated water and/or food, and is one of the main causes of acute hepatitis worldwide. Hepatitis E shows a high mobility but a low mortality rate, except in pregnant women, where it can be as high as 30%. HEV causes sporadic cases and epidemic outbreaks, mainly in Africa, Asia and Central America. In Europe, there is an increase in the number of reported autochthonous cases no related with travel to endemic areas. In addition, HEV also infects animals, including pigs, and its zoonotic potential has been recently demonstrated. In fact, porcine and human strains of the same area are genetically more closely related to each other than to strains of the same species but a different geographical region, and there are data suggesting that people in close contact with pigs presents a higher prevalence of specific anti-HEV antibodies. All together, these data have drove to an increase interest in determining the incidence of the disease in animals, its possible zoonotic risk, and its implications for human health. In the present article we revised the current knowledge about HEV, with special emphasis in the possible consequences of its zoonotic potential.

Evaluation of anti-hepatitis E virus (HEV) immunoglobulin A in a serological screening for HEV infection

BACKGROUND

Several formulations of serological diagnostic kits were developed recently in Japan for detecting hepatitis E virus (HEV) infection. The present study was conducted to evaluate a novel anti-HEV serological kit based on detection of class A immunoglobulin antibody (anti-HEV IgA).

METHODS

Serum samples from 81 acute hepatitis (AH) and 112 chronic hepatitis (CH) patients were tested for anti-HEV IgG, anti-HEV IgM, and anti-HEV IgA by enzyme immunoassay, and HEV RNA was detected by reverse transcription-polymerase chain reaction.

RESULTS

Eight of 81 (9.9%) AH patients were positive for anti-HEV IgG; 6/81 (7.4%) were positive for anti-HEV IgM; and 3/81 (3.7%) were positive for anti-HEV IgA. HEV RNA was detected only in two patients, and both were positive for anti-HEV IgA and negative for hepatitis A, B, and C virus markers. Of 112 CH patients, reactivity to anti-HEV IgM and anti-HEV IgG was found in two and four patients, respectively. None of these six patients was positive for anti-HEV IgA or HEV RNA. For these six CH patients, serial serum samples stored during the clinical follow-up (1994-2003) were further subjected to anti-HEV IgG, IgM, IgA, and HEV RNA examinations. None of the examined stored samples was reactive for anti-HEV IgA or HEV RNA despite reactivity to anti-HEV IgM and IgG.

CONCLUSIONS

Serological examination for anti-HEV IgA together with IgM and IgG allows sensitive and specific determination of acute or past infection with HEV. Although its prevalence is low, HEV infection must be investigated in acute hepatitis patients even in nonendemic HEV countries.

Analysis of the full-length genome of hepatitis E virus isolates obtained from farm pigs in Mongolia

Although no outbreaks of hepatitis E have been reported in Mongolia, a significant proportion of the general population had antibodies to hepatitis E virus (HEV). To investigate whether pigs are possible reservoirs of HEV in Mongolia, serum samples obtained from 243 2- or 3-month-old pigs on four swine farms surrounding Ulaanbaatar, the capital city of Mongolia, were tested for the presence of anti-HEV antibodies and HEV RNA. Overall, 223 pigs (91.8%) tested positive for anti-HEV, while 89 pigs (36.6%) had detectable HEV RNA. The 89 HEV isolates obtained from the viremic pigs were 78.7-100% identical to each other, and 80.9-85.9% similar to the prototype genotype 3 HEV isolate (US1) in the 412-nucleotide (nt) sequence within open reading frame 2. They were classified into two novel phylogenetic groups within genotype 3, differing by 16.4-21.3%. The swMN06-A1288 and swMN06-C1056 isolates, representing each of the two clusters within genotype 3, had a genomic length of nucleotides (nt) 7,222 nt and 7,223 nt, respectively, excluding the poly(A) tail, and shared only 81.6% over the entire genome. Upon comparison with the 25-reported genotype 3 HEV isolates over the entire genome, swMN06-A1288 had identities of merely up to 84.9%, while swMN06-C1056 of only up to 85.9%. Phylogenetic analysis confirmed the remote relatedness of the Mongolian swine isolates to the genotype 3 HEV isolates reported thus far. These results indicate that farm pigs in Mongolia are frequently infected with presumably indigenous HEV strains of genotype 3 and could be a source of HEV infections in humans in Mongolia.

Hepatitis E virus

Hepatitis E virus (HEV) is the aetiological agent of non-HAV enterically transmitted hepatitis. It is the major cause of sporadic as well as epidemic hepatitis, which is no longer confined to Asia and developing countries but has also become a concern of the developed nations. In the Indian subcontinent, it accounts for 30-60% of sporadic hepatitis. It is generally accepted that hepatitis E is mostly self-limited and never progresses to chronicity. It has a higher mortality in pregnant women where the disease condition is accentuated with the development of fulminant liver disease. Currently, no antiviral drug or vaccine is licensed for HEV, although a vaccine candidate is in clinical trials. HEV genome is 7.2kb in size with three open reading frames (ORFs) and 5' and 3' cis acting elements, which have important roles to play in HEV replication and transcription. ORF1 codes for methyl transferase, protease, helicase and replicase; ORF2 codes for the capsid protein and ORF3 for a protein of undefined function. HEV has recently been classified in the genus Hepevirus of the family Hepeviridae. There are four major recognised genotypes with a single known serotype. The absence of a reliable in vitro propagation system is an obstacle to deciphering HEV biology. The genome of HEV has been cloned, sequenced and the infectious nature of these replicons has been established. However, questions related to replication, transcription, virus-host interactions and pathogenesis remain to be answered. This comprehensive review summarises the progress made so far in HEV research, and addresses some of the unanswered questions.

Using improved technology for filter paper-based blood collection to survey wild Sika deer for antibodies to hepatitis E virus

Recent reports from Japan implicated wild Sika deer (Cervus nippon) in the zoonotic transmission of hepatitis E to humans. Seroprevalence studies were performed to determine if imported feral populations of Sika deer in Maryland and Virginia posed a similar risk of transmitting hepatitis E virus (HEV). Hunters collected blood on filter paper discs from freshly killed deer. The discs were desiccated and delivered to a collection point. The dried filters were weighed to estimate the amount of blood absorbed and were eluted and collected in one tube via a novel extraction system. The procedure was quantified and validated with negative and positive serum and blood samples obtained from domestic Sika deer before and after immunization with HEV recombinant capsid protein, respectively. None of the 155 tested samples contained antibody to HEV, suggesting that Sika deer in these populations, unlike those in Japan, do not pose a significant zoonotic threat for hepatitis E. However, the new method developed for collecting and eluting the samples should prove useful for field studies of many other pathogens.

Fulminant liver failure from acute autochthonous hepatitis E in France: description of seven patients with acute hepatitis E and encephalopathy

Fulminant hepatitis E has not been well characterized in industrialized countries. The aim of this study was to prospectively describe patients with acute hepatitis E presenting as fulminant hepatic failure, i.e. with encephalopathy and prothrombin index <50%. Between February 1997 and April 2005, seven patients with encephalopathy were diagnosed with acute hepatitis E using viral RNA detection. These patients were compared with 33 patients diagnosed with a mild form (absence of encephalopathy) of acute hepatitis E during the same time period. Patients were 65 +/- 11 years old. Five were active drinkers and six had chronic liver disease. All hepatitis E virus sequences evaluated (5/7) were of genotype 3. All patients but two died (71%). Four patients had no travel history. When compared with patients with a mild form of acute hepatitis E, active alcohol abuse and chronic liver disease were more frequent in patients with the severe form. Duration of hospitalization was longer. Aspartate transferase and bilirubin levels were significantly higher. Prothrombin index and accelerin levels were lower and death was more frequent. Acute nontravel-associated hepatitis E can appear as fulminant hepatitis with encephalopathy and coagulation disorders. Prognosis is severe and this may be due to the age at which it occurs and frequent underlying chronic liver disease.

Genetic variability and evolution of hepatitis E virus

Hepatitis E virus (HEV) is the sole member of the genus Hepevirus in the family Hepeviridae. HEV is transmitted primarily by the fecal-oral route, and water-borne epidemics are characteristic of hepatitis E in many developing countries in Asia, Africa and Latin America where sanitation conditions are suboptimal. Accumulating lines of evidence indicate that HEV-associated hepatitis also occurs domestically among individuals in industrialized countries, that there are animal reservoirs of HEV such as domestic pigs and wild boars, and that hepatitis E is a zoonosis. Based on the extensive genomic variability among HEV isolates, HEV sequences have been classified into four genotypes: genotype 1 consists of epidemic strains in developing countries in Asia and Africa; genotype 2 has been described in Mexico and several African countries; genotype 3 HEV is widely distributed and has been isolated from sporadic cases of acute hepatitis E and/or domestic pigs in many countries in the world, except for countries in Africa; and genotype 4 contains strains isolated from humans and/or domestic pigs exclusively in Asian countries. This paper reviews current knowledge on the genomic variability, geographic distribution and zoonotic aspects of HEV as well as the clinical significance of genotype and evolution of HEV.

Avian hepatitis E virus in an outbreak of hepatitis–splenomegaly syndrome and fatty liver haemorrhage syndrome in two flaxseed-fed layer flocks in Ontario

Two commercial layer chicken flocks that were fed a flax-based diet beginning at 28 weeks of age for the production of omega-3 fatty-acid-enriched eggs experienced increased mortality when the birds reached 37 weeks. The average weekly mortality was 0.34% over a 20-week period, with peak mortality of 0.9% for 1 week. Reduced feed consumption, reduced body weight gain and poor peak production were noticed prior to the onset of increased mortality. A total of 245 birds were necropsied and 78% of these had lesions in the liver and spleen, with 44% of those necropsied having changes consistent with hepatitis-splenomegaly syndrome, with lesions ranging from acute periportal lymphoplasmacytic hepatitis to chronic severe cholangiohepatitis with haemorrhage, vasculitis and amyloidosis. A total of 11% of the birds had lesions typical of fatty liver haemorrhagic syndrome, and 22% had lesions found in both hepatitis-splenomegaly syndrome and fatty liver haemorrhagic syndrome. No significant bacteria or viruses were recovered from samples of the liver/bile or spleen but 11 of 21 bile samples contained avian hepatitis E virus RNA detectable with a reverse transcriptase-polymerase chain reaction assay. Comparative sequence analysis found identities of 82 to 92% and 78 to 80% between the helicase and capsid protein genes, respectively, of the virus detected in this outbreak and those of other avian hepatitis E virus isolates, suggesting extensive genetic heterogeneity in avian hepatitis E viruses in Ontario flocks.

A survey of zoonotic pathogens carried by Norway rats in Baltimore, Maryland, USA

Norway rats (Rattus norvegicus) carry several zoonotic pathogens and because rats and humans live in close proximity in urban environments, there exists potential for transmission. To identify zoonotic agents carried by rats in Baltimore, Maryland, USA, we live-trapped 201 rats during 2005-2006 and screened them for a panel of viruses, bacteria, and parasites. Antibodies against Seoul virus (57.7%), hepatitis E virus (HEV, 73.5%), Leptospira interrogans (65.3%), Bartonella elizabethae (34.1%), and Rickettsia typhi (7.0%) were detected in Norway rats. Endoparasites, including Calodium hepatica (87.9%) and Hymenolepis sp. (34.4%), and ectoparasites (13.9%, primarily Laelaps echidninus) also were present. The risk of human exposure to these pathogens is a significant public health concern. Because these pathogens cause non-specific and often self-limiting symptoms in humans, infection in human populations is probably underdiagnosed.

Hepatitis E indigenous to economically developed countries: to what extent a zoonosis?

PURPOSE OF REVIEW

Hepatitis E, a disease transmitted by hepatitis E virus, is increasingly recognized as being indigenous to affluent, temperate-zone countries. Issues pertaining to disease acquisition and hepatitis E virus infection, particularly in Western countries, are reviewed and highlighted.

RECENT FINDINGS

Clinical hepatitis E in the West, as in Japan, manifests more commonly in older people (>60 years) and in men, but fulminant hepatitis appears less frequent than in Japan. There, specific gastronomic and culinary risk factors associated with disease are being identified, but in the West, data implicating hepatitis E as being foodborne have yet to emerge. While hepatitis E virus subgenomic sequences in Western case patients are found to be closely related to swine hepatitis E virus, a porcine linkage to their infection remains to be established. Weak associations between occupational contact with pigs and risk of infection have been noted. Findings from earlier studies implicating animals that cohabitate with humans as reservoirs, and sewage as vehicles of infection await confirmation.

SUMMARY

Hepatitis E indigenous to developed countries is a distinct clinico-epidemiological entity. Humans, animals, food and the environment contribute and interact to cause human disease, and to sustain hepatitis E virus endemicity and enzooticity.

Hepatitis E is an autochthonous disease in industrialized countries. Analysis of 23 patients in South-West France over a 13-month period and comparison with hepatitis A

OBJECTIVES

Hepatitis E virus (HEV) is responsible for acute hepatitis predominantly in developing countries. In Western Europe and in the US, cases of acute HEV infection are uncommon and occur primarily in travelers returning from endemic countries. The aim of this study was to describe patients with acute hepatitis E in South West France and compare them with patients with acute hepatitis A.

METHODS

23 consecutive patients over 13 months were analysed. Acute hepatitis E was diagnosed on the presence of specific serum antibodies or viral RNA detection in serum or stools. Real time PCR products from viraemic patients were sequenced.

RESULTS

All the HEV sequences belonged to genotype 3. Two patients (8%) died during their hospital stay, both suffered from severe underlying disease. Only 3 patients (13%) had travelled outside of Europe, within 3 months of the onset of disease. When compared to 23 patients with acute hepatitis A at the same hospital and during the same time frame, HEV-infected patients were older (54.4 +/- 16.6 vs 24.5 +/- 16.6, P<0.05), had lower ALT levels (55.4 X upper normal limit +/- 48.6 vs 107.8 X upper normal limit +/- 82.8, P<0.05) and had lower incidence of recent travel outside of Europe (13% in the hepatitis E group vs 60% in the hepatitis A group, P<0.05).

CONCLUSIONS

Hepatitis E can be considered an autochthonous infection in South West France. All strains sequenced were related to genotype III. When compared to hepatitis A, HEV-infected patients were older, had lower ALT levels and had a lower incidence of travel outside of Europe.

Locally acquired hepatitis E virus infection, El Paso, Texas

Hepatitis E virus (HEV) is an enterically transmitted RNA virus that causes both epidemic and sporadic cases of acute hepatitis. Despite sero-surveys showing antibody to HEV in up to 36% of the US population, acute hepatitis E has been reported among individuals with no history of international travel only three times in the United States. We report a case of apparently locally-acquired hepatitis E that occurred in El Paso, Texas that was 98% similar to a previously isolated HEV found in swine in the United States. Like the three previous cases, a thorough investigation found no conclusive sources of infection. Active case surveillance found no additional cases.

Seroprevalence for hepatitis E virus (HEV) infection among volunteer blood donors of the Regional Blood Bank of Londrina, State of Paraná , Brazil

A cross-sectional study was carried out among 996 volunteer blood donors enrolled from May 1999 to December 1999 to determine the seroprevalence of hepatitis E virus (HEV) infection among volunteer blood donors of the Regional Blood Bank of Londrina, State of Paraná, Brazil, and to evaluate whether the rate of seroprevalence of IgG anti-HEV antibodies is associated with sociodemographic variables and with seropositivity for hepatitis A virus (HAV) infection. All participants answered the questionnaire regarding the sociodemographic characteristics. Serum samples were tested for IgG antibodies to HEV (anti-HEV) by an enzyme linked immunoassay (ELISA). All serum samples positive for anti-HEV IgG and 237 serum samples negative for anti-HEV were also assayed for IgG anti-HAV antibodies by ELISA. Anti-HEV IgG was confirmed in 23/996 samples, resulting in a seroprevalence of 2.3% for HEV infection, similar to previous results obtained in developed countries. No significant association was found between the presence of anti-HEV IgG antibodies and the sociodemographic variables including gender, age, educational level, rural or urban areas, source of water, and sewer system (p > 0.05). Also, no association with seropositivity for anti-HAV IgG antibodies was observed (p > 0.05). Although this study revealed a low seroprevalence of HEV infection in the population evaluated, the results showed that this virus is circulating among the population from Londrina, South Brazil, and point out the need of further studies to define the clinical and epidemiological importance of HEV infection and to identify additional risk factors involved in the epidemiology and pathogenesis of this infection in this population.

Molecular tracing of Japan-indigenous hepatitis E viruses

The ancestor(s) of apparently Japan-indigenous strains of Hepatitis E virus (HEV) was probably of foreign origin, but it remains unclear when and from where it made inroads. In this study, 24 genotype 3 and 24 genotype 4 HEV strains recovered in Japan each showed a significant cluster, clearly distinct from those of foreign strains, in the phylogenetic tree constructed from an 821 nt RNA polymerase gene fragment. The evolutionary rate, approximately 0.8 x 10(-3) nucleotide substitutions per site per year, enabled tracing of the demographic history of HEV and suggested that the ancestors of Japan-indigenous HEV had made inroads around 1900, when several kinds of Yorkshire pig were imported from the UK to Japan. Interestingly, the evolutionary growth of genotype 3 in Japan has been slow since the 1920s, whereas genotype 4 has spread rapidly since the 1980s. In conclusion, these data suggest that the indigenization and spread of HEV in Japan were associated with the popularization of eating pork.

Identification of B-cell epitopes in the capsid protein of avian hepatitis E virus (avian HEV) that are common to human and swine HEVs or unique to avian HEV

Avian hepatitis E virus (avian HEV) was recently discovered in chickens from the USA that had hepatitis-splenomegaly (HS) syndrome. The complete genomic sequence of avian HEV shares about 50 % nucleotide sequence identity with those of human and swine HEVs. The open reading frame 2 (ORF2) protein of avian HEV has been shown to cross-react with human and swine HEV ORF2 proteins, but the B-cell epitopes in the avian HEV ORF2 protein have not been identified. Nine synthetic peptides from the predicted four antigenic domains of the avian HEV ORF2 protein were synthesized and corresponding rabbit anti-peptide antisera were generated. Using recombinant ORF2 proteins, convalescent pig and chicken antisera, peptides and anti-peptide rabbit sera, at least one epitope at the C terminus of domain II (possibly between aa 477-492) that is unique to avian HEV, one epitope in domain I (aa 389-410) that is common to avian, human and swine HEVs, and one or more epitopes in domain IV (aa 583-600) that are shared between avian and human HEVs were identified. Despite the sequence difference in ORF2 proteins between avian and mammalian HEVs and similar ORF2 sequence between human and swine HEV ORF2 proteins, rabbit antiserum against peptide 6 (aa 389-399) recognized only human HEV ORF2 protein, suggesting complexity of the ORF2 antigenicity. The identification of these B-cell epitopes in avian HEV ORF2 protein may be useful for vaccine design and may lead to future development of immunoassays for differential diagnosis of avian, swine and human HEV infections.

Unexpected high prevalence of IgG-antibodies to hepatitis E virus in Swedish pig farmers and controls

Hepatitis E virus (HEV) infections are responsible for large waterborne outbreaks in developing countries. Sporadic cases in the developed world are mainly imported via immigrants and travellers from endemic areas. HEV has been suggested to be a zoonotic infection where pigs may be an important reservoir for the disease and specific swine strains of HEV have been identified which can infect also humans. The aim of this study was to analyse if Swedish pig farmers are more exposed to HEV than persons with other occupations. A total of 115 male pig farmers aged 40-60 y and 108 age- and geographically- matched control subjects were tested for IgG anti-HEV antibodies. No statistical difference in anti-HEV prevalence was noted between pig farmers (13.0%) and control subjects (9.3%). The prevalence of anti-HEV antibodies in the pig farmers and controls was higher than that previously reported among other populations in Europe (<1-9%). Further studies are needed to elucidate the routes for infection of indigenous HEV and if sub-clinical infections with pig associated HEV strains occur in Sweden.

Phylogenetic analysis of global hepatitis E virus sequences: genetic diversity, subtypes and zoonosis

Nucleotide sequences from a total of 421 HEV isolates were retrieved from Genbank and analysed. Phylogenetically, HEV was classified into four major genotypes. Genotype 1 was more conserved and classified into five subtypes. The number of genotype 2 sequences was limited but can be classified into two subtypes. Genotypes 3 and 4 were extremely diverse and can be subdivided into ten and seven subtypes. Geographically, genotype 1 was isolated from tropical and several subtropical countries in Asia and Africa, and genotype 2 was from Mexico, Nigeria, and Chad; whereas genotype 3 was identified almost worldwide including Asia, Europe, Oceania, North and South America. In contrast, genotype 4 was found exclusively in Asia. It is speculated that genotype 3 originated in the western hemisphere and was imported to several Asian countries such as Japan, Korea and Taiwan, while genotype 4 has been indigenous and likely restricted to Asia. Genotypes 3 and 4 were not only identified in swine but also in wild animals such as boar and a deer. Furthermore, in most areas where genotypes 3 and 4 were characterised, sequences from both humans and animals were highly conserved, indicating they originated from the same infectious sources. Based upon nucleotide differences from five phylogenies, it is proposed that five, two, ten and seven subtypes for HEV genotypes 1, 2, 3 and 4 be designated alphabetised subtypes. Accordingly, a total of 24 subtypes (1a, 1b, 1c, 1d, 1e, 2a, 2b, 3a, 3b, 3c, 3d, 3e, 3f, 3g, 3h, 3i, 3j, 4a, 4b, 4c, 4d, 4e, 4f and 4g) were given.

Norway rat population in Baltimore, Maryland, 2004

Norway rats are reservoirs for several zoonotic agents, including hantaviruses, and are implicated in the transmission of pathogens to humans in urban environments. The rat population of Baltimore, Maryland was estimated from surveys in 1949 and again in 1952, but has not been evaluated for more than 50 years. Previously identified sociodemographic risk factors for rat infestation, including median income, human density, and percentage of rental properties, were used to categorize census block groups in Baltimore. Rat infestation risk factors, including median income and human density, have improved over the last 50 years in Baltimore. Rat infestation was determined both by observation and trapping of rats in alleys that were representative of the different strata of risk factors. Despite improvements in risk factors, the outdoor, residential rat population of Baltimore in 2004 was estimated to be approximately 48,420 +/- 14,883 rats, which is comparable to the 1949 and 1952 estimates. Approximately half of the rats trapped in Baltimore City had detectable antibody against Seoul virus. The failure to substantially impact rat population levels in the past 50 years indicate that alternative control strategies for rat infestation are needed to reduce the risk of rat-borne pathogen spillover to the human population.

Infectious swine hepatitis E virus is present in pig manure storage facilities on United States farms, but evidence of water contamination is lacking

Fresh feces, manure slurry (from earthen lagoons and/or concrete pits), and drinking and surface water samples were collected from 28 pig farms in the Midwestern United States. All samples were tested for hepatitis E virus (HEV) RNA by reverse transcription-PCR. Seven of 28 farms had fecal samples that contained HEV. Of 22 farms where pit samples were accessible, 15 contained HEV, and of 8 farms that had lagoons, 3 contained HEV. The highest virus titers were 10 and 10(3) genome equivalents per 60 ml of manure slurry in lagoon and pit samples, respectively. None of the water samples tested HEV positive. To determine the infectivity of the HEV found in the positive farm 19 lagoon (designated L19) or farm 12 pit (designated P12) samples, pigs were inoculated either intravenously (n = 3) or orally (n = 3) with the L19 or P12 manure slurry. Four pigs inoculated intravenously with prototype swine HEV served as positive controls. All positive-control pigs shed HEV in feces and 3 of 4 developed anti-HEV antibodies. Two pigs in the intravenously inoculated P12 group shed HEV in feces, and one of the pigs seroconverted to anti-HEV antibodies. None of the pigs in the negative-control, L19 oral, L19 intravenous, or P12 oral group shed HEV in feces. The findings indicate that HEV found in pig manure slurry was infectious when inoculated intravenously. Pit manure slurry is a potential source of HEV infection and for contamination of the environment. Contamination of drinking or surface water with HEV was not found on or near the pig farms.

Prevalence of and risk factors for hepatitis C in rural pregnant Egyptian women

Prevalence and risk factors for hepatitis C virus (HCV) infection were studied in 2,587 pregnant women from three rural Egyptian villages in the Nile Delta being admitted to a prospective cohort study of maternal-infant transmission; 408 (15.8%) had antibodies to HCV (anti-HCV) and 279 (10.8%) also had HCV-RNA. Fewer than 1% gave a history of jaundice or liver disease. Risk factors for anti-HCV included increasing age, low socioeconomic status and a history of blood transfusion or injection therapy for schistosomiasis. Sub-analyses after stratification of subjects by village revealed risks associated with specific venues for medical care, having a previous delivery attended by a traditional birth assistant (TBA), receiving medical care in a temporary clinic located in a mosque, overnight admission to a private doctor's clinic, and circumcision by a TBA or a 'health barber'. Our results suggest HCV causes very little detected illness in young adult Egyptian women and some sources of HCV transmission in rural Egypt in the past were associated with the provision of medical care and varied by location. Prevention should be focused on providing appropriate resources and health education should be given to formal and informal health care providers and should be sufficiently broad to adjust for local variations in exposures.

Serological evidence of hepatitis E virus infection in different animal species from the Southeast of Brazil

Serological evidence of hepatitis E virus infection (HEV) has been observed in both humans and different animal species living in non-endemic areas, suggesting that animals could be important reservoir for virus transmission to man. Antibodies to HEV have been detected in some Brazilian population groups. Nevertheless, sporadic cases of acute HEV infection have never been reported. We collected 271 serum samples from several domestic animals and also from pig handlers from Southeast of Brazil in order to investigate the seroprevalence of HEV infection. Anti-HEV IgG was detected in cows (1.42%), dogs (6.97%), chickens (20%), swines (24.3%), and rodents (50%), as well as in pig handlers (6.3%). The recognition of swine HEV infections in pigs in many countries of the world led us to investigate a larger sample of pigs (n = 357) from the same Brazilian region with ages ranging from 1 to > 25 weeks. IgG anti-HEV was detected in 100% of 7-day old pigs. Following a gradual decline between weeks 2 and 8 (probably due to loss of maternal IgG), the prevalence then steady increased until it reached 97.3% of animals older than 25 weeks. Besides the detection of anti-HEV antibodies in different animal species, the results showed that swine HEV infection seems to be almost universal within this Brazilian pig population. This is the first report that shows evidences of HEV circulation in Brazilian animal species and pig handlers.

Construction and characterization of infectious cDNA clones of a chicken strain of hepatitis E virus (HEV), avian HEV

Hepatitis E virus (HEV), the causative agent of hepatitis E, is an important human pathogen. Increasing evidence indicates that hepatitis E is a zoonosis. Avian HEV was recently discovered in chickens with hepatitis-splenomegaly syndrome in the USA. Like swine HEV from pigs, avian HEV is also genetically and antigenically related to human HEV. The objective of this study was to construct and characterize an infectious cDNA clone of avian HEV for future studies of HEV replication and pathogenesis. Three full-length cDNA clones of avian HEV, pT7-aHEV-5, pT7G-aHEV-10 and pT7G-aHEV-6, were constructed and their infectivity was tested by in vitro transfection of leghorn male hepatoma (LMH) chicken liver cells and by direct intrahepatic inoculation of specific-pathogen-free (SPF) chickens with capped RNA transcripts from the three clones. The results showed that the capped RNA transcripts from each of the three clones were replication competent when transfected into LMH cells as demonstrated by detection of viral antigens with avian HEV-specific antibodies. SPF chickens intrahepatically inoculated with the capped RNA transcripts from each of the three clones developed active avian HEV infections as evidenced by seroconversion to avian HEV antibodies, viraemia and faecal virus shedding. The infectivity was further confirmed by successful infection of naïve chickens with the viruses recovered from chickens inoculated with the RNA transcripts. The results indicated that all three cDNA clones of avian HEV are infectious both in vitro and in vivo. The availability of these infectious clones for a chicken strain of HEV now affords an opportunity to study the mechanisms of HEV cross-species infection and tissue tropism by constructing chimeric viruses among human, swine and avian HEVs.

Hepatitis E viruses in humans and animals

Hepatitis E virus (HEV) is an emerging pathogen belonging to a newly recognized family of RNA viruses (Hepeviridae). HEV is an important enterically transmitted human pathogen with a worldwide distribution. It can cause sporadic cases as well as large epidemics of acute hepatitis. Epidemics are primarily waterborne in areas where water supplies are contaminated with HEV of human origin. There is increasing evidence, however, that many animal species are infected with an antigenically similar virus. A recently isolated swine virus is the best candidate for causing a zoonotic form of hepatitis E. The virus is serologically cross-reactive with human HEV and genetically very similar, and the human and swine strains seem to be cross-infective. Very recent evidence has also shown that swine HEV, and possibly a deer strain of HEV, can be transmitted to humans by consumption of contaminated meat. In this review, we discuss the prevalence, pathogenicity, diagnosis and control of human HEV, swine HEV, the related avian HEV and HEV in other hosts and potential reservoirs.

Acute hepatitis E infection in a visitor to Louisiana

A man from Africa had been visiting Mississippi and Louisiana when he had development of acute hepatitis. Although hepatitis E is endemic to many parts of the world and has been associated with large outbreaks, it has remained relatively uncommon in this country. With growing foreign travel and an ever-increasing number of cases reported nationally, hepatitis E infection should be considered more frequently in the differential diagnosis of acute hepatitis.