A hepatitis E outbreak caused by a temporary interruption in a municipal water treatment system, Baripada, Orissa, India, 2004

Methodology for a Comprehensive Health Impact Assessment in Water Supply and Sanitation Programmes for Brazil

Based on the broader concept of health proposed by the Pan-American Health Organization/World Health Organization (PAHO/ WHO), 2018, and the absence in the literature of indices that translate the causal relationship between sanitation and health, a methodology for assessing the health impact of a water and sanitation programmes, known as a Health Impact Assessment (HIA), was developed, specifically in the Brazilian context, and focused on a school in the northeast of the country. Through exploratory and descriptive evidence, and using documentary research as a method, a retrospective survey was carried out from 2000 to 2022 using documents proposing evaluation methodologies. A single document was found to fit the research objective, which was used to develop the proposed HIA methodology. Development of the methodology consisted of two stages: definition of the health dimensions and selection of the indicators making up each dimension. The HIA methodology was then applied to a school in northeast Brazil to test its use, before a water-efficient management intervention was going to be used. The overall score of 46% indicated that there was room for improvement, which the new management approach could facilitate. This methodology is therefore proposed to be an instrument for the evaluation of public water and sanitation policies, thus assisting managers in the decision-making process and in guiding sanitation programs and plans.

Setting a Course for Preventing Hepatitis E in Low and Lower-Middle-Income Countries: A Systematic Review of Burden and Risk Factors

BACKGROUND

Hepatitis E virus (HEV) is responsible for outbreaks of acute jaundice in Africa and Asia, many of which occur among displaced people or in crisis settings. Although an efficacious vaccine for HEV has been developed, we lack key epidemiologic data needed to understand how best to use the vaccine for hepatitis E control in endemic countries.

METHODS

We conducted a systematic review of articles published on hepatitis E in low-income and lower-middle-income countries in Africa and Asia. We searched PubMed, Scopus, and Embase databases to identify articles with data on anti-HEV immunoglobulin (Ig)G seroprevalence, outbreaks of HEV, or risk factors for HEV infection, disease, or death, and all relevant data were extracted. Using these data we describe the evidence around temporal and geographical distribution of HEV transmission and burden. We estimated pooled age-specific seroprevalence and assessed the consistency in risk factor estimates.

RESULTS

We extracted data from 148 studies. Studies assessing anti-HEV IgG antibodies used 18 different commercial assays. Most cases of hepatitis E during outbreaks were not confirmed. Risk factor data suggested an increased likelihood of current or recent HEV infection and disease associated with fecal-oral transmission of HEV, as well as exposures to blood and animals.

CONCLUSIONS

Heterogeneity in diagnostic assays used and exposure and outcome assessment methods hinder public health efforts to quantify burden of disease and evaluate interventions over time and space. Prevention tools such as vaccines are available, but they require a unified global strategy for hepatitis E control to justify widespread use.

Hepatitis E Virus Infection: Circulation, Molecular Epidemiology, and Impact on Global Health

Infection with hepatitis E virus (HEV) represents the most common source of viral hepatitis globally. Although infecting over 20 million people annually in endemic regions, with major outbreaks described since the 1950s, hepatitis E remains an underestimated disease. This review gives a current view of the global circulation and epidemiology of this emerging virus. The history of HEV, from the first reported enteric non-A non-B hepatitis outbreaks, to the discovery of the viral agent and the molecular characterization of the different human pathogenic genotypes, is discussed. Furthermore, the current state of research regarding the virology of HEV is critically assessed, and the challenges towards prevention and diagnosis, as well as clinical risks of the disease described. Together, these points aim to underline the significant impact of hepatitis E on global health and the need for further in-depth research to better understand the pathophysiology and its role in the complex disease manifestations of HEV infection.

Hepatitis E Genotype 1 Outbreak in Jharkhand, India: A Descriptive Analysis

INTRODUCTION

A waterborne outbreak of hepatitis E virus occurred in the Jamshedpur city of Jharkhand from March 2018 to October 2018. The aim of the present study is to study the hepatitis E virus outbreak clinically, serologically and etiologically.

METHODS

Five hundred and eighty-four clinically and biochemically documented cases were screened for the hepatotropic viral markers (HepatitisA, B, C, and E) by the ELISA. Demographic data such as gender, age, clinical diagnosis, location, outcome and time of admission were extracted from the online hospital management system. Water samples from the affected area were tested for HEV RNA detection. Genotyping of HEV virus was carried out by sequencing and phylogenetic analysis.

RESULTS

Hepatitis E genotype 1 was confirmed as the major etiological agent in this outbreak due to the faecal contamination of drinking water supply while establishing illegal water connections. Mixed infection of HEV-HAV (5.31%) or HEV-HBV (0.91%) was also detected in the present series of acute viral hepatitis.

CONCLUSION

The study highlights the importance of screening for both enterically transmitted hepatotropic viral markers as well as the parenterally transmitted hepatotropic viral markers during the outbreaks of acute viral hepatitis.

Hepatitis E virus genotype 3 strains and a plethora of other viruses detected in raw and still in tap water

In this study, next generation sequencing was used to explore the virome in 20L up to 10,000L water from different purification steps at two Swedish drinking water treatment plants (DWTPs), and in tap water. One DWTP used ultrafiltration (UF) with 20 nm pores, the other UV light treatment after conventional treatment of the water. Viruses belonging to 26 different families were detected in raw water, in which 6-9 times more sequence reads were found for phages than for known environmental, plant or vertebrate viruses. The total number of viral reads was reduced more than 4-log10 after UF and 3-log10 over UV treatment. However, for some viruses the reduction was 3.5-log10 after UF, as for hepatitis E virus (HEV), which was also detected in tap water, with sequences similar to those in raw water and after treatment. This indicates that HEV had passed through the treatment and entered into the supply network. However, the viability of the viruses is unknown. In tap water 10-130 International Units of HEV RNA/mL were identified, which is a comparable low amount of virus. The risk of getting infected through consumption of tap water is probably negligible, but needs to be investigated. The HEV strains in the waters belonged to subtypes HEV3a and HEV3c/i, which is associated with unknown source of infection in humans infected in Sweden. None of these subtypes are common among pigs or wild boar, the major reservoirs for HEV, indicating that water may play a role in transmitting this virus. The results indicate that monitoring small fecal/oral transmitted viruses in DWTPs may be considered, especially during community outbreaks, to prevent potential transmission by tap water.

The global burden of hepatitis E outbreaks: a systematic review

Hepatitis E virus (HEV) is responsible for repeated water-borne outbreaks since the past century, representing an emerging issue in public health. However, the global burden of HEV outbreak has not been comprehensively described. We performed a systematic review of confirmed HEV outbreaks based on published literatures. HEV outbreaks have mainly been reported from Asian and African countries, and only a few from European and American countries. India represents a country with the highest number of reported HEV outbreaks. HEV genotypes 1 and 2 were responsible for most of the large outbreaks in developing countries. During the outbreaks in developing countries, a significantly higher case fatality rate was observed in pregnant women. In fact, outbreaks have occurred both in open and closed populations. The control measures mainly depend upon improvement of sanitation and hygiene. This study highlights that HEV outbreak is not new, yet it is a continuous global health problem.

Surveillance at Private Laboratories Identifies Small Outbreaks of Hepatitis E in Urban Bangladesh

Although large outbreaks of hepatitis E are regularly identified in south Asia, the majority of south Asian countries lack surveillance systems for this disease, which has hindered burden of disease estimates and prioritization of resources for prevention. Our study aimed to identify small hepatitis E outbreaks through a sentinel private laboratory in Dhaka, Bangladesh. We identified patients with detectable IgM antibody against hepatitis E virus. We defined a small outbreak as at least two laboratory-confirmed cases or ≥ 2 acute jaundice cases from the sentinel cases' family, neighborhood, or workplace. From November 2008 to November 2009, we identified 29 small outbreaks of hepatitis E from one private laboratory. The median number of cases in each outbreak was three. Cases were identified every month. Eighteen outbreaks occurred among families or neighbors, and 11 in the workplace. Among 103 cases identified as part of outbreaks, 31 (30%) sought care for diagnosis. In Bangladesh, collaboration between government public health surveillance and private laboratories can strengthen capacity for outbreak detection and improve estimates of disease burden.

Removal of Rotavirus and Bacteriophages by Membrane Bioreactor Technology from Sewage

Human enteric viruses constitute a public health concern due to their low infectious dose and their resistance to environmental factors and to inactivation processes. We aimed at assessing the performance of a laboratory scale Submerged membrane bioreactor (SMBR) treating abattoir wastewaters for Rotavirus (RV) and total coliphages removal. We also aimed at evaluating removal efficiency of enteric viruses through conventional activated sludge treatment by measuring concentrations of total coliphages, considered as fecal and viral contamination indicators, with double-layer agar technique. The Log10 reduction values of bacteriophages ranged from 1.06 to 1.47. Effluents were analyzed to investigate and quantify RV, hepatitis A virus (HAV), Hepatitis E virus (HEV), Noroviruses genogroup I (NoV GI) and genogroup II (NoVGII), and Enterovirus (EV) by real-time PCR, using standardized detection kits (ceeramTools detection kits(®)). All effluent samples were positive for RV; concentrations ranged from 5.2 × 10(5) to 1.3 × 10(7) genome copies/L. These results highlight the inefficiency of conventional biological process for viral removal. A complete removal of RV during Membrane Bioreactor treatment was obtained. To the best of our knowledge, this is the first study providing an evidence of removal of RV simultaneously with total coliphages by SMBR.

Molecular detection of hepatitis E virus in feces and slurry from swine farms, Rio Grande do Sul, Southern Brazil

Hepatitis E virus (HEV) is highly disseminated among swine herds worldwide. HEV is also a threat to public health, since particularly genotypes 3 and 4 may cause acute hepatitis in human beings. No previous studies were done on the occurrence of HEV in environmental samples in Rio Grande do Sul, Brazil. In the present study, reverse transcriptase-polymerase chain reaction (RT-PCR) was employed to detect the presence of HEV in swine feces and in effluents from slurry lagoons in farms located in the municipality of Teutônia, inside the area of swine husbandry in the state. Pooled fecal samples from the floor of pig barns from 9 wean-to-finish farms and liquid manure samples were collected from the slurry lagoons from 8 of these farms. From the pooled fecal samples, 8/9 were positive for the HEV ORF1 gene by RT-PCR; all the slurry lagoon samples were positive for HEV RNA (100%). The identity of the HEV ORF1 amplicons was confirmed by sequencing belonging to HEV genotype 3, which was previously shown to be circulating in South America.

Outbreak of hepatitis E in urban Bangladesh resulting in maternal and perinatal mortality

BACKGROUND

Hepatitis E virus (HEV) causes outbreaks of jaundice associated with maternal mortality. Four deaths among pregnant women with jaundice occurred in an urban community near Dhaka, Bangladesh, in late 2008 and were reported to authorities in January 2009. We investigated the etiology and risk factors for jaundice and death.

METHODS

Field workers identified suspected cases, defined as acute onset of yellow eyes or skin, through house-to-house visits. A subset of persons with suspected HEV was tested for immunoglobulin M (IgM) antibodies to HEV to confirm infection. We used logistic regression analysis to identify risk factors for HEV disease and for death. We estimated the increased risk of perinatal mortality associated with jaundice during pregnancy.

RESULTS

We identified 4751 suspected HEV cases during August 2008-January 2009, including 17 deaths. IgM antibodies to HEV were identified in 56 of 73 (77%) case-patients tested who were neighbors of the case-patients who died. HEV disease was significantly associated with drinking municipally supplied water. Death among persons with HEV disease was significantly associated with being female and taking paracetamol (acetaminophen). Among women who were pregnant, miscarriage and perinatal mortality was 2.7 times higher (95% confidence interval, 1.2-6.1) in pregnancies complicated by jaundice.

CONCLUSIONS

This outbreak of HEV was likely caused by sewage contamination of the municipal water system. Longer-term efforts to improve access to safe water and license HEV vaccines are needed. However, securing resources and support for intervention will rely on convincing data about the endemic burden of HEV disease, particularly its role in maternal and perinatal mortality.

Investigating a community-wide outbreak of hepatitis a in India

Background:

There was an outbreak of acute hepatitis in Mylapore village, Kollam district, Kerala, southern India during February to June 2013. An outbreak investigation was initiated with the objective of describing the epidemiological features of the hepatitis outbreak.

Materials and Methods:

House-to-house visits were undertaken to identify symptomatic cases. The outbreak was described in terms of person, place and time. Hypothesis was generated based on findings from descriptive study, laboratory investigation of water samples, and environmental observations. A case-control study was designed to test the hypothesis. Chi-square test, univariate analysis, and logistic regression to identify the risk factors associated with hepatitis A infection were done.

Results:

Line list generated consisted of 45 cases. Attack rate was the highest among the age group 15-24 years (4.6%) followed by 5-14 years (3.1%). The geographical distribution of the cases suggested a clustering around the water supply through the pipeline and epidemic curve showed a sharp rise in cases suggestive of a common source outbreak. Water samples collected form pipeline showed evidence of fecal contamination and absence of residual chlorine. In the case-control study, having consumed water from the pipeline (odds ratio: 9.01 [95% confidence interval: 2.16-37.61]) was associated with the hepatitis A cases.

Conclusion:

The time frame of disease occurrence, environmental observations, anecdotal evidences, laboratory results and results of the analytical study indicated the possibility of occurrence of hepatitis A outbreak as a result of pipe water contamination supplied from a bore well. The study warrants establishment of an efficient water quality surveillance system.

Why "improved" water sources are not always safe

Existing and proposed metrics for household drinking-water services are intended to measure the availability, safety and accessibility of water sources. However, these attributes can be highly variable over time and space and this variation complicates the task of creating and implementing simple and scalable metrics. In this paper, we highlight those factors - especially those that relate to so-called improved water sources - that contribute to variability in water safety but may not be generally recognized as important by non-experts. Problems in the provision of water in adequate quantities and of adequate quality - interrelated problems that are often influenced by human behaviour - may contribute to an increased risk of poor health. Such risk may be masked by global water metrics that indicate that we are on the way to meeting the world's drinking-water needs. Given the complexity of the topic and current knowledge gaps, international metrics for access to drinking water should be interpreted with great caution. We need further targeted research on the health impacts associated with improvements in drinking-water supplies.

Environmental indicators of intra-urban hetererogeneity

A large number of human diseases are related to poor access to water and sewer systems, inadequate solid waste management and deficient storm water drainage. The goal of this study was to formulate environmental sanitation indicators and classify sanitation conditions in specific sewer basins and their respective neighborhoods. The database used contains information on the following sanitation components in these areas: water supply, sewer systems, urban drainage, road pavement, building typology and public cleaning. Data was analyzed using cluster analysis. The key variable of each component was identified, and eight sewer basins and twenty-three neighborhoods were classified into the following categories: good, regular, and poor. The use of environmental sanitation indicators allows decision makers to identify critical areas and define priorities for improving environmental sanitation conditions.

Epidemiology of mammalian hepatitis E virus infection

Mammalian hepatitis E virus (HEV), the etiological agent of hepatitis E in humans, is a recently discovered infectious agent. It was identified for the first time in 1983 using electron microscopy on a faecal specimen of a person infected with non-A, non-B enterically-transmitted hepatitis. Based on retrospective and prospective studies, HEV was long described as one of the leading causes of acute viral hepatitis in tropical and subtropical countries, whereas in developed countries hepatitis E was considered an imported disease from HEV hyperendemic countries. Data from studies conducted during the past decade have greatly shifted our knowledge on the epidemiology and clinical spectrum of HEV. Recently, it has been shown that contrary to previous beliefs, hepatitis E is also an endemic disease in several developed countries, particularly in Japan and in Europe, as evidenced by reports of high anti-HEV immunoglobulin G prevalence in healthy individuals and an increasing number of non-travel-related acute hepatitis E cases. Moreover, a porcine reservoir and growing evidence of zoonotic transmission have been reported in these countries. This review summarizes the current knowledge on the epidemiology and prevention of transmission of mammalian HEV.

The global burden of hepatitis E virus genotypes 1 and 2 in 2005

We estimated the global burden of hepatitis E virus (HEV) genotypes 1 and 2 in 2005. HEV is an emergent waterborne infection that causes source-originated epidemics of acute disease with a case fatality rate thought to vary by age and pregnancy status. To create our estimates, we modeled the annual disease burden of HEV genotypes 1 and 2 for 9 of 21 regions defined for the Global Burden of Diseases, Injuries, and Risk Factors Study (the GBD 2010 Study), which represent 71% of the world's population. We estimated the seroprevalence of anti-HEV antibody and annual incidence of infection for each region using data from 37 published national studies and the DISMOD 3, a generic disease model designed for the GBD Study. We converted incident infections into three mutually exclusive results of infection: (1) asymptomatic episodes, (2) symptomatic disease, and (3) death from HEV. We also estimated incremental cases of stillbirths among infected pregnant women. For 2005, we estimated 20.1 (95% credible interval [Cr.I.]: 2.8-37.0) million incident HEV infections across the nine GBD Regions, resulting in 3.4 (95% Cr.I.: 0.5-6.5) million symptomatic cases, 70,000 (95% Cr.I.: 12,400-132,732) deaths, and 3,000 (95% Cr.I.: 1,892-4,424) stillbirths. We estimated a probability of symptomatic illness given infection of 0.198 (95% Cr.I.: 0.167-0.229) and a probability of death given symptomatic illness of 0.019 (95% Cr.I.: 0.017-0.021) for nonpregnant cases and 0.198 (95% Cr.I.: 0.169-0.227) for pregnant cases.

CONCLUSION

The model was most sensitive to estimates of age-specific incidence of HEV disease.

Fatal outbreaks of jaundice in pregnancy and the epidemic history of hepatitis E

Space-time clustering of people who fall acutely ill with jaundice, then slip into coma and death, is an alarming phenomenon, more markedly so when the victims are mostly or exclusively pregnant. Documentation of the peculiar, fatal predisposition of pregnant women during outbreaks of jaundice identifies hepatitis E and enables construction of its epidemic history. Between the last decade of the 18th century and the early decades of the 20th century, hepatitis E-like outbreaks were reported mainly from Western Europe and several of its colonies. During the latter half of the 20th century, reports of these epidemics, including those that became serologically confirmed as hepatitis E, emanated from, first, the eastern and southern Mediterranean littoral and, thereafter, Southern and Central Asia, Eastern Europe, and the rest of Africa. The dispersal has been accompanied by a trend towards more frequent and larger-scale occurrences. Epidemic and endemic hepatitis E still beset people inhabiting Asia and Africa, especially pregnant women and their fetuses and infants. Their relief necessitates not only accelerated access to potable water and sanitation but also vaccination against hepatitis E.

Clinical characteristics and risk factors of sporadic Hepatitis E in central China

Background

Epidemiological investigations, detections and vaccines of hepatitis E (HE) have been paid a focus of attention in prior studies, while studies on clinical features and risk factors with a large number of sporadic HE patients are scarce.

Results

Sporadic HE can occur throughout the year, with the highest incidence rate in the first quarter of a year, in central of China. Of the 210 patients, 85.2% were male, and the most common clinical symptoms were jaundice (85.7%), fatigue (70.5%) and anorexia (64.8%). Total bilirubin (TBil), blood urea nitrogen (BUN), and international normalized ratio (INR) were found as major risk factors for death of HE patients. There was an overall mortality of 10%, and the mortality in the cirrhotic and non-cirrhotic group was 25% and 6.47%, respectively. Moreover, hepatitis E virus (HEV) infected patients with liver cirrhosis had a higher mortality and incidence of complications.

Conclusions

TBil, BUN, and INR are major risk factors of mortality for HE. Liver cirrhosis can aggravate HE, and lead to a higher mortality. HEV infection can cause decompensation in patients with cirrhosis, as evidenced by a worsening Child-Pugh score.