Identification of a novel variant of hepatitis E virus in Austria: sequence, phylogenetic and serological analysis

Vaccine Development against Zoonotic Hepatitis E Virus: Open Questions and Remaining Challenges

Hepatitis E virus (HEV) is a fecal-orally transmitted foodborne viral pathogen that causes acute hepatitis in humans and is responsible for hepatitis E outbreaks worldwide. Since the discovery of HEV as a zoonotic agent, this virus has been isolated from a variety of hosts with an ever-expanding host range. Recently, a subunit HEV vaccine developed for the prevention of human disease was approved in China, but is not yet available to the rest of the world. Meanwhile, notable progress and knowledge has been made and revealed in recent years to better understand HEV biology and infection, including discoveries of quasi-enveloped HEV virions and of a new function of the HEV-ORF3 product. However, the impact of these new findings on the development of a protective vaccine against zoonotic HEV infection requires further discussion. In this review, hallmark characteristics of HEV zoonosis, the history of HEV vaccine development, and recent discoveries in HEV virology are described. Moreover, special attention is focused on quasi-enveloped HEV virions and the potential role of the HEV-ORF3 product as antibody-neutralization target on the surface of quasi-enveloped HEV virions to provide new insights for the future development of improved vaccines against zoonotic HEV infection.

Public health risks associated with hepatitis E virus (HEV) as a food-borne pathogen

Hepatitis E virus (HEV) is an important infection in humans in EU/EEA countries, and over the last 10 years more than 21,000 acute clinical cases with 28 fatalities have been notified with an overall 10-fold increase in reported HEV cases; the majority (80%) of cases were reported from France, Germany and the UK. However, as infection in humans is not notifiable in all Member States, and surveillance differs between countries, the number of reported cases is not comparable and the true number of cases would probably be higher. Food-borne transmission of HEV appears to be a major route in Europe; pigs and wild boars are the main source of HEV. Outbreaks and sporadic cases have been identified in immune-competent persons as well as in recognised risk groups such as those with pre-existing liver damage, immunosuppressive illness or receiving immunosuppressive treatments. The opinion reviews current methods for the detection, identification, characterisation and tracing of HEV in food-producing animals and foods, reviews literature on HEV reservoirs and food-borne pathways, examines information on the epidemiology of HEV and its occurrence and persistence in foods, and investigates possible control measures along the food chain. Presently, the only efficient control option for HEV infection from consumption of meat, liver and products derived from animal reservoirs is sufficient heat treatment. The development of validated quantitative and qualitative detection methods, including infectivity assays and consensus molecular typing protocols, is required for the development of quantitative microbial risk assessments and efficient control measures. More research on the epidemiology and control of HEV in pig herds is required in order to minimise the proportion of pigs that remain viraemic or carry high levels of virus in intestinal contents at the time of slaughter. Consumption of raw pig, wild boar and deer meat products should be avoided.

Hepatitis E Virus in Industrialized Countries: The Silent Threat

Hepatitis E virus (HEV) is the main cause of acute viral hepatitis worldwide. Its presence in developing countries has been documented for decades. Developed countries were supposed to be virus-free and initially only imported cases were detected in those areas. However, sporadic and autochthonous cases of HEV infection have been identified and studies reveal that the virus is worldwide spread. Chronic hepatitis and multiple extrahepatic manifestations have also been associated with HEV. We review the data from European countries, where human, animal, and environmental data have been collected since the 90s. In Europe, autochthonous HEV strains were first detected in the late 90s and early 2000s. Since then, serological data have shown that the virus infects quite frequently the European population and that some species, such as pigs, wild boars, and deer, are reservoirs. HEV strains can be isolated from environmental samples and reach the food chain, as shown by the detection of the virus in mussels and in contaminated pork products as sausages or meat. All these data highlight the need of studies directed to control the sources of HEV to protect immunocompromised individuals that seem the weakest link of the HEV epidemiology in industrialized regions.

Molecular Biology and Infection of Hepatitis E Virus

Hepatitis E virus (HEV) is a viral pathogen transmitted primarily via fecal-oral route. In humans, HEV mainly causes acute hepatitis and is responsible for large outbreaks of hepatitis across the world. The case fatality rate of HEV-induced hepatitis ranges from 0.5 to 3% in young adults and up to 30% in infected pregnant women. HEV strains infecting humans are classified into four genotypes. HEV strains from genotypes 3 and 4 are zoonotic, whereas those from genotypes 1 and 2 have no known animal reservoirs. Recently, notable progress has been accomplished for better understanding of HEV biology and infection, such as chronic HEV infection, in vitro cell culture system, quasi-enveloped HEV virions, functions of the HEV proteins, mechanism of HEV antagonizing host innate immunity, HEV pathogenesis and vaccine development. However, further investigation on the cross-species HEV infection, host tropism, vaccine efficacy, and HEV-specific antiviral strategy is still needed. This review mainly focuses on molecular biology and infection of HEV and offers perspective new insight of this enigmatic virus.

Epidemiology of Hepatitis E Virus in European Countries

Over the last decade the seroprevalence of immunoglobulin (IgG) anti hepatitis E virus (HEV) has been increasing in European countries and shows significant variability among different geographical areas. In this review, we describe the serological data concerning the general population and risk groups in different European countries. Anti-HEV antibody prevalence ranged from 1.3% (blood donors in Italy) to 52% (blood donors in France). Various studies performed on risk groups in Denmark, Moldova and Sweden revealed that swine farmers have a high seroprevalence of HEV IgG (range 13%-51.1%), confirming that pigs represent an important risk factor in HEV infection in humans. Subtypes 3e,f are the main genotypes detected in the European population. Sporadic cases of autochthonous genotype 4 have been described in Spain, France, and Italy. Although most HEV infections are subclinical, in immune-suppressed and transplant patients they could provoke chronic infection. Fulminant hepatitis has rarely been observed and it was related to genotype 3. Interferon and ribavirin treatment was seen to represent the most promising therapy.

Current Knowledge on Hepatitis E

Although only a single serotype of hepatitis E virus (HEV), the causative agent of hepatitis E, has been identified, there is great genetic variation among the different HEV isolates reported. There are at least four major recognized genotypes of HEV: genotypes 1 and 2 are mainly restricted to humans and linked to epidemic outbreaks in nonindustrialized countries, whereas genotypes 3 and 4 are zoonotic in both developing and industrialized countries. Besides human strains, genotype 3 and 4 strains of HEV have been genetically characterized from swine, sika deer, mongooses, sheep, and rabbits. Currently, there are approximately 11,000 human and animal sequences of HEV available at the International Nucleotide Sequence Database Collaboration. HEV is the major cause of waterborne outbreaks of hepatitis in areas of poor sanitation. Additionally, it is responsible for sporadic cases of viral hepatitis in not only endemic but industrialized countries as well. Transmission of HEV occurs predominantly by the fecal-oral route, although parenteral and perinatal routes have been reported. HEV infection develops in most individuals as a self-limiting, acute, icteric hepatitis; with mortality rates around 1%. However, some affected individuals will develop fulminant hepatic failure, a serious condition that is frequently fatal without a liver transplant. This complication is particularly common when the infection occurs in pregnant women, where mortality rates rise dramatically to up to 25%. Among the preventive measures available to avoid HEV infection, two separate subunit vaccines containing recombinant truncated capsid proteins of HEV have been shown to be highly effective in the prevention of disease. One of them, HEV 239, was approved in China, and its commercialization by Innovax began in November 2012 under the name Hecolin(®).

New insights into hepatitis E virus virus–host interaction: interplay with host interferon induction

ABSTRACT 

Hepatitis E virus (HEV) is a fecal–oral-transmitted viral pathogen causing several large outbreaks of hepatitis across the world. HEV-mediated hepatitis has a mortality rate from 0.5 to 3% in young adults but is up to 30% in pregnant women. HEV is also a zoonotic pathogen as it has been isolated from different mammalian hosts including the pig, rabbit, rat, ferret, bat and deer. As an invading pathogen, HEV needs to overcome the host innate immune response to establish infection. Notable progress has been recently made in HEV mechanisms of antagonizing the host innate immune responses. In this review, we elaborate on the HEV interplay with host interferon induction while briefly summarizing the major aspects of HEV biology and host interferon induction to assist the understanding of the virus–host interaction.

Hepatitis E: an emerging disease

Currently, the infection with the hepatitis E virus represents the most frequent cause for acute hepatitis and jaundice in the world. According to WHO estimations, around two billion people, representing one third of the world's population, live in endemic areas for HEV and, therefore, are at risk of infection. In developed countries, the circulation of the virus in both human and animal (swine, boar, deer) sewage has been confirmed; however, the incidence rate is low compared to that of developing countries where outbreaks of acute hepatitis transmitted via the fecal-oral route are originated, more frequently in the flooding season or after natural disasters, combined with deficient sanitary conditions. There are currently 4 known genotypes of HEV. Genotypes 1 and 2 are isolated in all human epidemic outbreaks in developing countries, while genotypes 3 and 4 are isolated not only in humans but also in animals, in both developing and industrialized countries. These data support genotypes 3 and 4 having zoonotic nature. The diagnosis of this disease is based in the detection of anti-HEV IgG and IgM in blood serum using enzyme-linked immunosorbent methods. However, the method that best confirms the diagnosis is the RT-PCR, which detects HEV RNA in blood serum and also provides the genotype. The clinical course is generally that of an acute hepatitis which in some cases may require hospitalization and that, in transplant patients or HIV infected individuals can become a chronic hepatitis. Furthermore, the virus constitutes an important risk for pregnant women. The hepatitis E can present a wide range of symptoms, from a subclinical case to chronic liver disease with extrahepatic manifestations. For this reason, the diagnostic is challenging if no differential diagnosis is included. There is no specific antiviral drug for hepatitis E, but satisfactory results have been observed in some patients treated with pegylated interferon alfa2a and/or ribavirin. This revision is an update of all the molecular, epidemiological, clinic and preventive knowledge on this emergent disease up to date.

Hepatitis E: current status

Acute hepatitis E is a very common disease in developing countries, to the point that, according to World Health Organization estimates, one third of the world's population has been exposed to HEV. It also causes outbreaks in refugee camps or after natural disasters such as floods or earthquakes. Sporadic cases of acute hepatitis have been observed in practically all European countries and other developed geographical areas, not only in travelers from endemic countries but also in people with no risk factors. But, lately, new aspects of this infection are appearing in industrialized countries such as the possibility of the disease becoming chronic in transplant patients, the immunocompromised in general, and even in patients with previous liver disease who are immunocompetent. In this comprehensive review, we summarize the current knowledge on HEV infection.

Phylogenetic analysis of hepatitis e virus in northwest India

Genotyping and subtyping are important to understand epidemiology of the hepatitis E virus so as to improve control measures to prevent transmission of virus in the community. Hence, the aim of the current study was to identify the prevalent HEV genotypes in Rajasthan in acute sporadic hepatitis E cases with varying degree of liver failure. We studied hepatitis E virus (HEV) isolates from hospitalized patients in Rajasthan, western India. In a total of seventeen HEV sequences, six acute viral hepatitis, seven acute liver failure, and 4 acute- on-chronic cases were analyzed. Subtypes 1a and 1c of HEV are prevalent in Northwest India.

Transmission routes and risk factors for autochthonous hepatitis E virus infection in Europe: a systematic review

Increasing numbers of non-travel-associated hepatitis E virus (HEV) infections have been reported in Europe in recent years. Our objective was to review the evidence on risk factors and transmission routes of autochthonous HEV infection and hepatitis E in Europe in order to develop recommendations for future research, prevention and control. A systematic literature review was performed to identify all primary reports and studies published during 1998-2008 on hepatitis E in humans and animals in Europe by searching Pubmed, reference lists of major articles and international conference proceedings. Each of the 106 included studies was categorized into one of three evidence levels (EL) based on study design and diagnostic methodology. The evidence was generally weak (73 were assigned to EL1, two to both EL1 and EL2, and 30 to EL2), further compounded by the use of poorly validated serological assays in some studies. Only one case-control study was assigned to EL3. Persons with autochthonous hepatitis E infection were on average older than the general population and predominantly male. There was no evidence for one main transmission route of HEV infection or risk factor for hepatitis E. However, zoonotic transmission seemed likely and person-to-person transmission too inefficient to cause clinical disease. Multiple routes of transmission probably exist and should be further investigated through analytical studies and reliable diagnostic kits. Based on current evidence that points to zoonotic transmission from pigs, thorough cooking of all porcine products, prevention of cross-contamination in the kitchen and improved education for occupationally exposed people (e.g. pig farmers, veterinarians and sewage workers) may help prevent HEV infection. Although evidence for parenteral transmission is limited, it is recommended that a risk assessment is undertaken.

Full-genome nucleotide sequence and analysis of a Chinese swine hepatitis E virus isolate of genotype 4 identified in the Guangxi Zhuang autonomous region: evidence of zoonotic risk from swine to human in South China

BACKGROUND

Hepatitis E virus (HEV) is one of the leading causes of the enteric-transmitted acute hepatitis. Many studies have found high identities between human and animal HEV isolates using partial sequence comparison analysis.

AIMS

To determine and phylogenetically analyse the complete genome of the swGX40 isolate from the Guangxi Zhuang autonomous region.

METHODS

The overlapping fragments of HEV isolate swGX40 were amplified with reverse transcription-nested polymerase chain reaction (PCR) and the 5' and 3' ends of viral genome were amplified with rapid amplification of cDNA ends. The PCR products were cloned and sequenced. The sequence and phylogenetic analysis of swGX40 were performed.

RESULTS

The full genome of the swGX40 strain consisted of 7233 nucleotides, excluding the poly (A) tail of 36 residues. There are three open reading frames (ORFs), encoding 1705, 674 and 114 amino acids (aa) respectively. The full-genomic sequencing showed that the swGX40 strain shared similarity with all known HEV genotype 1, 2 and 3 isolates by 73.4-76.5% and with an identity of 83.1-91.2% among genotype 4 HEV isolates. The partial ORF2 sequencing (249 nt) showed that swGX40 shared a high nucleotide identity of 94 and 97% with the Chinese human strain LZ-105 and the Vietnamese human strain HE-JVN-1 respectively.

CONCLUSIONS

The swine isolate swGX40 was closely related to the human isolate LZ-105, both of which were collected from Liuzhou, the same district in the Guangxi Zhuang autonomous region. This molecular biological evidence strongly supported the zoonosis hypothesis of hepatitis E.

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.

Characterization of monoclonal antibodies to hepatitis E virus (HEV) capsid protein and identification of binding activity

Twenty-seven monoclonal antibodies (Mabs) recognizing the open reading frame 2 structural protein of the Pakistan strain of hepatitis E virus (HEV) were generated by conventional hybridoma technique. These Mabs were characterized by ELISA, affinity-capture reverse transcriptase-polymerase chain reaction (AC/RT-PCR), immune electron microscopy (IEM), and a RT-PCR based seroneutralization assay. Twenty-seven Mabs were positive by ELISA. By AC/RT-PCR, 24 Mabs bound to Pakistan and Namibia HEV strains. Thirteen Mabs were examined by IEM. Nine Mabs, positive by ELISA and AC/RT-PCR, bound and aggregated to Mexican HEV strain. We tested five Mabs that were positive by ELISA, AC/RT/PCR, and IEM by a RT-PCR based seroneutralization assay. Only one Mab (Mab 7) showed activity that inhibited the ability of HEV to attach to Alexander hepatoma cells (PLC-PRF-5). When Mab 7 was diluted to 1: 160, its inhibition activity persisted suggesting that Mab 7 might be a potential candidate for further evaluation in primates (passive protection experiments).

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.

Prevalence of hepatitis E virus among wild boar in the Ehime area of western Japan

AIMS

Transmission of hepatitis E virus (HEV) from wild boar to humans has been reported, particularly from Japan. We attempted to clarify this issue.

METHODS

We assessed the IgG class antibodies against HEV (anti-HEV) in serum samples taken from 406 boar living in the Ehime area of western Japan from 2001 to 2004, of which 392 were captured in the wild (wild-caught boar) and 14 had been kept in a breeding farm (bred boar).

RESULTS

Anti-HEV positive rate in the bred boar (10/14, 71.4%) was significantly higher than in the wild-caught boar (100/392, 25.5%) (P < 0.001). Of the 392 wild-caught boar, 12 (3.1%) were positive for HEV-RNA, 10 of which were then subjected to phylogenetic analyses by sequencing an 821-nt fragment within ORF1. All the 10 isolates segregated to genotype 3, and eight of them were mutually related to form a cluster. All the eight HEV isolates in this cluster were from the wild-caught boar living in one and the same habitat within the studied area, while the other two independent isolates were from different regions.

CONCLUSION

HEV infection is endemic in wild boar in the Ehime area, and we should regard the wild boar as an important reservoir of HEV.

Identification of the first strain of swine hepatitis E virus in South America and prevalence of anti-HEV antibodies in swine in Argentina

In Argentina, a country considered non-endemic for hepatitis E virus (HEV) infection, serologic evidence of HEV infection has been observed in different human population groups. In other countries, a high degree of genetic relatedness has been observed between human and swine HEV genotype 3 sequences, suggesting zoonosis as one probable route of infection. This is the first identification of swine HEV in South America. HEV RNA was detected and sequenced in the ORF 1 and ORF 2 regions from swine fecal samples from a herd located in Pergamino, in the province of Buenos Aires. These strains all group into genotype 3 and exhibit a close relationship to two novel HEV variants previously identified in Argentina from sporadic acute cases of non-A to -C hepatitis in humans. In addition, using a modified commercial ELISA, the presence of anti-HEV antibodies was surveyed in five provinces across the country and all five showed a prevalence of HEV antibodies, ranging from 4% to 58%. The results suggest that swine could be an important reservoir for virus transmission in Argentina as has been suggested for other non-endemic areas. The Argentine human strains and swine strain described in this article seem to be closely related to a human Austrian strain, suggesting a potential European origin of HEV infection in these cases.

Molecular detection and sequence analysis of a new hepatitis E virus isolate from Pakistan

Sporadic and epidemic acute viral hepatitis E in many developing countries is caused by hepatitis E virus (HEV). The HEV genome has been classified into three major genotypes. However, extensive diversity has been noted among HEV isolates from patients with acute hepatitis in China and Taiwan. Some reports indicated that multiple genotypes of HEV could cocirculate in the same area; even distinct genotypes of HEV could exist in the same patient. Pakistan is a highly endemic area for hepatitis E. So far only two Pakistan HEV isolates Sar-55 (87-Pakistan-A) and Abb-2B (88-Pakistan-2B) have been characterized, and the nucleotide sequences of these two HEV isolates show only 90% homology. In this study, a third HEV isolate from Pakistan (87-Pakistan-B) is reported. The sequences of a 438-bp fragment from ORF-2 and a 259-bp fragment from the ORF-1-3 region of this new HEV isolate were obtained and sequenced. The sequence analysis showed that this new HEV isolate was very closely related to the Sar-55 but different from the Abb-2B HEV isolate. These results indicated that the Sar-55 (87-Pakistan-A) genotype is the main endemic HEV strain in the Sargodha area. These data will be useful for HEV epidemiological studies, diagnosis and vaccine development.

[Acute hepatitis E in Madrid: description of 18 cases]

INTRODUCTION

Hepatitis E virus (HEV) is the main cause of non-A non-B enterically transmitted hepatitis in underdeveloped countries but is rare in industrialized areas. However, in the last few years, several sporadic autochthonous hepatitis E cases have been reported in Europe and no risk factors, such as visiting to endemic areas, could be found in these patients.

OBJECTIVE AND PATIENTS

Twelve patients with sporadic autochthonous hepatitis E (no risk factors such as traveling to endemic areas) and six imported cases (travel to Nepal, Santo Domingo, China, Brazil and Ecuador) were studied between June 1999 and December 2005.

RESULTS

HEV infection was diagnosed in patients with symptoms of acute hepatitis and the presence of IgG and IgM antibodies in serum with no other markers of hepatitis. HEV infection is probably overlooked in industrialized countries.

CONCLUSIONS

This diagnosis should be suspected in patients with acute hepatitis and anti-HEV antibodies in serum without known risk factors such as traveling to endemic areas.

Detection of hepatitis E virus shedding in feces of pigs at different stages of production using reverse transcription-polymerase chain reaction

The aim of this study was to determine at which production stages hepatitis E virus (HEV) is shed by the highest number of pigs and to estimate the relative risk associated with each stage. For this purpose, 146 fecal samples of pigs from 21 farms were studied. In addition, 1 sample from the manure ditch and another sample of drinking water, collected directly from the trough located in the pen, were taken from 16 farms. HEV RNA was detected in fecal samples from 34 pigs (23.29%). The production stages in which most pigs excreted HEV were weaners (41.7%) and pigs in the first month of feeding (60%). The results of the statistical analysis showed that the principal significant risk stage in HEV shedding was the first month of feeding (odds ratio [OR] 19.5, 95% CI 3.59-106.07, P = 0.001) followed by the weaners stage (OR 9.3, 95% CI .78-48.42, P = 0.008). In 8 out of 16 farms tested (50%) HEV RNA was detected in raw manure and in the water trough of only 1. Detection of HEV in manure ditches raises the concern of how to deal with manure of swine origin, because it is used as soil fertilizer.

Significance of serum IgA in patients with acute hepatitis E virus infection

AIM: To study the significance of serum anti-hepatitis E virus (HEV) IgA in patients with hepatitis E.

METHODS: A new method was established to assay anti-HEV IgA, which could be detected in the middle phase of the infection. We compared anti-HEV IgA assay with anti-HEV IgM and anti-HEV IgG assay in sera from 60 patients with positive HEV-RNA.

RESULTS: The 60 patients with positive HEV-RNA had both anti-HEV IgA and anti-HEV IgM and 410 patients with negative HEV-RNA were used as control. Periodic serum samples obtained from 60 patients with hepatitis E were tested for HEV RNA, anti-HEV IgM, anti-HEV IgA and anti-HEV IgG. Their HEV-RNA was detectable in the serum until 20 ± 11 d. We used anti-HEV IgM and anti-HEV IgA assay to detect HEV infection and positive results were found in 90 ± 15 d and 120 ± 23 d respectively, the positive rate of anti-HEV IgA was higher than that of anti-HEV IgM and HEV-RNA (P <0.05).

CONCLUSION: The duration of anti-HEV IgA in serum is longer than that of anti-HEV IgM, and anti-HEV IgA assay is a good method to detect HEV infection.

Phylogenetic analysis of hepatitis E virus isolates in southern China (1994-1998)

BACKGROUND

We have previously reported the identification of divergent hepatitis E virus (HEV) isolated (G9, G20 and 93G) in Guangzhou, a city in southern China. They are now recognised as a new HEV subgenotype in the world. However, the relatedness and significance of these novel isolates in sporadic HEV infection in southern China is still unclear.

OBJECTIVES

To perform phylogenetic analysis of nucleotide sequences from 41 HEV isolates in southern China from 1994 to 1998.

STUDY DESIGN

The partial nucleotide sequence of the HEV isolates were determined and compared with reported sequences in the GenBank. Their relatedness was analysed using computer software.

RESULTS

The majority of the HEV isolates, 39 out of 41, were found to belong to the Burmese-like isolates (genotype 1). The other two belonged to the Guangzhou-like isolates. The latter were only found in the samples collected in 1994. They, together with the G9 isolate, form a unique tree located between genotype 1 and genotype 4 (divergent HEV strains from northern China and Taiwan) on the phylogenetic tree.

CONCLUSION

Our results suggest that the Burmese-like isolates are the main causative agents of sporadic HEV infection in southern China. The Guangzhou-like isolates, which appeared transiently in 1994, did not seem to adapt to the environment and have caused no sporadic infection since.

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.

Hepatitis E virus genotyping based on full-length genome and partial genomic regions

Some genomic regions for hepatitis E virus (HEV) genotyping have been reported to correlate well with the results from the phylogenetic analyses on the basis of the complete genome. However, few studies have systemically investigated the genomic regions for HEV genotyping using a combined phylogenetic and statistical approach. A consensus region for HEV genotyping has not been determined. In this study the nucleotide identities and genetic distances of 24 partial genomic regions and the complete genome sequences of 37 HEV strains were compared statistically. It was demonstrated with both one-way ANOVA and two-way ANOVA that only one genomic region in RNA-dependent RNA polymerase domain (4254-4560nt) for which there were no significant differences when compared with the full-length genome (P>0.05). The same four genotypes were identified by phylogenetic analysis based on this statistically predicted region identified as for the complete genome. RT-PCR amplification of HEV strains from all four genotypes confirmed conservation of the flanking primer sites of this region. Serum samples from 20 patients with a clinical diagnosis of hepatitis E were further analyzed by PCR using the same primers, 13 were positive and could be classified into genotype 4. These data strongly suggested that this newly identified region could be used for future HEV genotyping.

Analysis of hepatitis E virus neutralization sites using monoclonal antibodies directed against a virus capsid protein

The dimeric form of the recombinant peptide (E2), comprising amino acid 394-606 of the capsid protein of hepatitis E virus (HEV), is strongly recognized by HEV reactive human serum, and when used as a vaccine, it protects rhesus monkeys against experimental HEV infection. In this work, the relationship of E2 to HEV has been probed using three murine monoclonal antibodies, 8C11, 13D8 and 8H3, all of which react predominantly against the E2 dimer, and can effect immune capture of the virus as well. 8C11 and 8H3 were further found to neutralize HEV infectivity in animals. Cross-blocking patterns between these antibodies discerned two spatially separate antigenic domains, one identified by 8C11 and 13D8, and the other, by 8H3. Kinetic studies using BIAcore biosensor suggest that the epitope to which 8H3 is directed is partially masked, and thus has limited access by the native antibody. However, this is not the case with the smaller Fab. Access to the 8H3 epitope was enhanced by the binding of 8C11, and inhibited by the binding of 13D8 to a distal site on the peptide. Similar to the effects of binding 8H3 to E2, 8C11 was found to enhance immune capture by 8H3, while 13D8 was inhibitory. Moreover, 8C11 and 8H3 act synergistically to neutralize HEV infectivity. The parallel cross-reaction patterns that these antibodies exhibit against the peptide and the virus, respectively, implicate two interacting conformationally dependent neutralization sites on the HEV particle. These sites might cooperate in the adsorption and penetration of the HEV virus.

Consumption of uncooked deer meat as a risk factor for hepatitis E virus infection: an age- and sex-matched case-control study

It was reported previously food-borne transmission of hepatitis E virus (HEV) to humans from deer meat. The present study attempted to clarify whether eating uncooked deer meat is a major epidemiological risk factor for HEV infection in Kasai, a city in western Japan. In total, 45 volunteer subjects with experience of eating raw deer meat were enrolled. An equivalent number of people from the same area who had never eaten raw deer meat served as controls. The subjects and controls had comparable age and sex distributions. Serum anti-HEV IgG and anti-hepatitis A virus (HAV) IgG levels were measured in all 90 volunteers. There was no significant difference in age, overseas travel history, or rate of anti-HAV antibody positivity between the subjects and controls. Eight (17.7%) of the subjects but only one (2.2%) of the controls had measurable serum anti-HEV IgG levels (P = 0.014). Anti-HAV prevalence did not differ between the anti-HEV-positive and negative groups. The results suggest that eating uncooked deer meat is an epidemiological risk factor for HEV infection in the studied area. In countries such as Japan where deer meat is sometimes eaten raw, attention must be paid to this route of HEV infection.

Complete sequence of a Kyrgyzstan swine hepatitis E virus (HEV) isolated from a piglet thought to be experimentally infected with human HEV

Hepatitis E virus (HEV) was identified by RT-PCR amplification with degenerate ORF2 primers in the stool of a piglet experimentally inoculated with a stool suspension from a patient with acute hepatitis during an outbreak of non-A, non-B hepatitis in Kyrgyzstan. Further characterization by sequencing of the complete genome and phylogenetic analysis showed that the piglet isolate was most closely related to HEV genotype 3. Because the original human stool specimen used to inoculate the piglet was no longer available, stool samples from three patients obtained during the same outbreak were sequenced and found to be HEV genotype 1. These findings suggest that the HEV isolated from the swine stool was probably an HEV enzootic in Kyrgyzstan and not the virus inoculated from the human stool.

Hepatitis E is a cause of unexplained hepatitis in The Netherlands

BACKGROUND

Hepatitis E virus (HEV) is the major etiologic agent of enterically transmitted viral hepatitis in much of the developing world. Evidence provided in recent years shows that HEV is also prevalent in very low numbers in non-endemic countries. Recently, a cluster of three patients with acute hepatitis E but no history of travel to endemic countries was discovered in the geographical area provided with service by the Public Health Laboratory Groningen and Drenthe, The Netherlands.

OBJECTIVE

This lead to the question whether hepatitis E is a cause of unexplained hepatitis in this district.

STUDY DESIGN

The prevalence of anti-HEV IgG and IgM among 209 patients with clinical signs of hepatitis, negative test for hepatitis A-C, no history of foreign travel and no other cause of hepatocellular damage was compared with a matched control group of 209 individuals.

RESULTS

We found a significant difference in seroprevalence between the two groups for IgG anti-HEV as determined with the Abbot HEV EIA (6.2% versus 0.5%); however this difference could not be confirmed with the Genelabs Diagnostics HEV IgG ELISA (6.7% versus 3.8%). For confirmed cases of IgM anti-HEV we also detected a significant difference between the two groups (3.3% versus 0.5%). Remarkably, the combination of IgG and IgM anti-HEV was only found among hepatitis patients.

CONCLUSION

This study provides evidence of locally acquired hepatitis E in The Netherlands. Therefore, in cases of unexplained acute hepatitis, the diagnosis of hepatitis E should be considered even in the absence of foreign travel.

Hepatitis E in the south west of France in individuals who have never visited an endemic area

A total of 431 consecutive patients from the Midi Pyrenees area with acute hepatitis with unknown etiology in 2001-2002 were tested for the presence of immunoglobulin G-class (IgG) anti-hepatitis E virus (HEV) antibodies. Forty-six (10.7%) had anti-HEV IgG, and the results were questionable for a further 17 (3.9%). Real time PCR based on TaqMan detection was used to identify HEV genome fragments in the serum of patients with positive or questionable anti-HEV serology. HEV RNA was found in 25.4% of cases. All amplification products were sequenced and analyzed. Phylogenetic analysis revealed that all the strains were genotype 3. In conclusion, virological and epidemiological data indicate that genotype 3 viruses are circulating in the south west part of France (Midi-Pyrenees) in patients with acute hepatitis and who have not visited recently areas in which HEV is endemic.

Routes of transmission of swine hepatitis E virus in pigs

Hepatitis E virus (HEV) is believed to be transmitted by the fecal-oral route in pigs. To date, in experiments, HEV has been transmitted successfully only by the intravenous or intrahepatic route. To assess the route of HEV transmission, 27 pigs were separated into nine groups of three pigs. Positive-control pigs were inoculated intravenously with swine HEV and served as the source of HEV for the other groups. Uninoculated contact pigs were placed in the positive-control group. On three consecutive days, naive pigs were inoculated using samples collected from the positive-control pigs at 9, 10, and 11 days postinoculation. The tonsils and nasal mucosa of each positive-control pig were swabbed and that swab was used to rub the tonsils and nasal and ocular mucosa of naive pigs. The positive-control pigs were also injected with bacterin, and the same needle was used to immediately inject naive pigs. Feces were collected from positive controls and fed by oral gavage to naive pigs. Weekly fecal and serum samples from each pig were tested for anti-HEV antibodies and HEV RNA. All positive-control pigs shed the virus in feces; two pigs were viremic and seroconverted to anti-HEV. All contact control pigs shed the virus in feces; two seroconverted and one became viremic. One of three pigs in the fecal-oral exposure group shed the virus in feces and seroconverted. Pigs exposed to the contaminated needles or the tonsil and nasal secretion swabs remained negative. This is the first report of experimental fecal-oral transmission of HEV in swine.

Transfusion-transmitted hepatitis E caused by apparently indigenous hepatitis E virus strain in Hokkaido, Japan

BACKGROUND

In industrialized countries, sporadic cases of hepatitis E have been reported in individuals who have never been in an endemic area. Hepatitis E virus (HEV) infection commonly occurs via the fecal-oral route but a potential risk of transfusion transmission route has been suggested.

STUDY DESIGN AND METHODS

A 67-year-old Japanese male patient who had never been abroad received a transfusion of blood from 23 voluntary donors and developed acute hepatitis with unknown etiology after transfusion. His blood samples were tested for viral markers of hepatitis viruses.

RESULTS

HAV, HBV, HCV, CMV, and EBV were ruled out as causative agents in this case. The patient's blood sample in the acute phase contained HEV RNA as well as IgM and IgG anti-HEV. HEV RNA was also detected in one of the FFP units transfused. The donor had no history of traveling abroad and had a normal ALT level at the time of donation. The PCR products from the patient and the donor showed complete identity for two distinct regions of HEV within open reading frame 1.

CONCLUSION

The patient was infected with HEV via transfused blood from a volunteer donor. A potential risk of posttransfusion hepatitis E should be considered even in nonendemic countries.

Identification of a new strain of hepatitis E virus from an outbreak in Namibia in 1995

Endemic circulation of hepatitis E virus (HEV) in Namibia was suspected from serological data during an outbreak of non-A, non-B hepatitis in Rundu in 1995. The source of the outbreak was suspected to be the water supply, which had been compromised approximately 6 months earlier. Four HEV isolates from four different persons in this outbreak were successfully amplified, sequenced and analysed over a 451 bp region of a subgenomic fragment from the 3' end of the genome in ORF2. Phylogenetic analysis showed that the four Namibian HEV isolates clustered with a Mexican isolate in genotype II and shared 85.8-86.3 % nucleotide identity with the 1987 Mexican isolate, but were only 77.6-79.6 % similar to other African isolates. HEV isolated from the same region of Namibia in 1983 was reported to cluster in genotype I. However, virus isolates from sporadic cases of HEV isolated in 1997/8 in Nigeria were also from genotype II.

Hepatitis E Vaccines

Hepatitis E accounts for the major part of enterally transmitted non-A, non-B hepatitis worldwide. Its agent, the hepatitis E virus (HEV), is a small, single-stranded RNA virus. Only one serotype of HEV is recognised. Infection results in protective immunity with long-lived neutralising antibodies. In developing countries with poor sanitary conditions and high population density, hepatitis E causes water-borne epidemics with substantial mortality rates in pregnant women. In addition, more than 50% of cases of acute hepatic failure and sporadic acute hepatitis are due to hepatitis E. The overall prevalence rates of antibodies to the HEV in populations native to these areas rarely exceed 25%. Hence, many individuals remain susceptible to hepatitis E infection, making hepatitis E an important public health concern. In this context, the development of an HEV vaccine is warranted. Because HEV does not grow adequately in cell cultures the development of a vaccine based on inactivated or attenuated whole-virus particles is not feasible. HEV vaccines currently under study are based on recombinant proteins derived from immunogenic parts of the HEV capsid gene. Other approaches such as DNA-based vaccines or transgenic tomatoes have also been developed. Several recombinant protein-based vaccines elicited neutralising antibodies and protective immunity in vaccinated non-human primates. One such vaccine has passed phase I trial and is currently under further evaluation in field trials. Even so, several questions remain to be answered before vaccination programmes could be implemented.

Sporadic acute or fulminant hepatitis E in Hokkaido, Japan, may be food-borne, as suggested by the presence of hepatitis E virus in pig liver as food

Among ten patients who contracted sporadic acute or fulminant hepatitis E between 2001 and 2002 in Hokkaido, Japan, nine (90 %) had a history of consuming grilled or undercooked pig liver 2-8 weeks before the disease onset. We tested packages of raw pig liver sold in grocery stores as food in Hokkaido for the presence of hepatitis E virus (HEV) RNA by RT-PCR. Pig liver specimens from seven (1.9 %) of 363 packages had detectable HEV RNA. Partial sequence analyses revealed that the seven swine HEV isolates belonged to genotype III or IV. One swine HEV isolate (swJL145) from a packaged pig liver had 100 % identity with the HE-JA18 isolate recovered from an 86-year-old patient in Hokkaido. Two swine HEV isolates (swJL234 and swJL325) had 98.5-100 % identity with the HE-JA4 isolate obtained from a 44-year-old patient in Hokkaido. These results indicate that inadequately cooked pig liver may transmit HEV to humans.

Identification of swine hepatitis E virus (HEV) and prevalence of anti-HEV antibodies in swine and human populations in Korea

The swine hepatitis E virus (HEV) is considered to be a new zoonotic agent due to its close genomic resemblance to the human HEV and its ability to infect nonhuman primates. Hepatitis caused by HEV infection has been a serious public health problem in developing countries. However, recent seroprevalence studies indicate that the HEV also circulates in industrialized countries. In this study, a nested reverse transcription (RT)-PCR was developed to detect a part of the swine HEV open reading frame 2. Three Korean isolates of swine HEV were identified in 128 swine sera (2.3% prevalence) by the nested RT-PCR method. They were isolated from 2- to 3-month old pigs showing an age-specific prevalence of the HEV viremia. A phylogenetic tree analysis with a number of swine and human HEV isolates indicated that all Korean isolates of the swine HEV belong to genotype III. They were closely related to the swine and human HEV isolates that were identified in the United States and Japan. In addition, they formed a distinct branch in genotype III, showing a 92.7 to 99.8% identity at their nucleotide sequences. The overall prevalence of anti-swine HEV antibodies in swine was 15%. Antibodies to the swine HEV were not detected in 1-month-old pigs. However, the anti-swine HEV antibodies appeared in pigs older than 1 month and also showed an age-specific prevalence. The antibody prevalence rates to the swine HEV were 6.0, 10.0, 36.0, and 25.0%, in 2-, 3-, 4-, and 5-to-7-month-old pigs, respectively. In addition, the seroprevalence in sows to the swine HEV was 8.8%. On the other hand, 18% of blood donors in Korea were found to be positive for anti-HEV antibodies. Overall, this study indicates that subclinical HEV infections may prevail in swine and human populations in Korea.

Characterization of Japanese swine and human hepatitis E virus isolates of genotype IV with 99 % identity over the entire genome

The full-length genomic sequences were determined of Japanese swine and human hepatitis E virus (HEV) isolates (swJ13-1 and HE-JA1, respectively) with 100 % identity in the partial sequence of open reading frame (ORF) 2 (ORF2, 412 nt). swJ13-1 was isolated from a 4-month-old farm pig born in Hokkaido, Japan, in 2002 and HE-JA1 was recovered from a 55-year-old patient who lived in Hokkaido and who had contracted sporadic acute hepatitis E in 1997. Both isolates consisted of 7240 nt, excluding the poly(A) tail, and contained three ORFs (ORFs 1-3) that encoded proteins of 1707, 674 and 114 aa. The overall nucleotide sequence identity between them was 99.0 % and the deduced amino acid sequence identities of ORFs 1-3 were 99.8, 100 and 100 %, respectively. The high degree of genomic similarity observed between swine and human HEV isolates in a restricted area of Japan further supports the finding that sporadic hepatitis E in Japan is a zoonosis.

Swine hepatitis E virus strains in Japan form four phylogenetic clusters comparable with those of Japanese isolates of human hepatitis E virus

Japanese patients with sporadic acute hepatitis E are infected with polyphyletic strains of hepatitis E virus (HEV). Hepatitis E is considered a zoonotic disease. Thus far in Japan, only three strains of swine HEV have been identified and an antibody study for HEV antibodies has not been done on Japanese pigs. To determine the prevalence of swine HEV infection in Japan and the extent of genetic variation among Japanese swine HEV strains, we tested serum samples obtained from 2500 pigs from 2 to 6 months of age at 25 commercial swine farms in Japan for the presence of IgG antibodies to HEV and swine HEV RNA. Anti-HEV antibodies were detected in 1448 pigs (58 %). One-hundred-and-thirteen (15 %) of the 750 3-month-old pigs and 24 (13 %) of the 180 4-month-old pigs were positive for swine HEV RNA. The nucleotide sequence of a 412 bp region within open reading frame 2 of the 137 swine HEV isolates was determined. Sequence analyses revealed that the 137 isolates shared 76.6-100 % nucleotide sequence identities and were classifiable into genotype III (93 %) or IV (7 %) and that the isolates from the same farm were > or = 97.1 % similar to each other. Phylogenetic analysis showed that the Japanese swine and human HEV isolates segregated into four clusters, with the highest nucleotide identity being 94.4-100 % between swine and human isolates in each cluster. These results indicate that swine HEV is widespread in the Japanese swine population and further support the hypothesis that swine serve as reservoirs for HEV infection.

Molecular investigation of hepatitis E virus infection in patients with acute hepatitis in Kathmandu, Nepal

One hundred fifty-four consecutive patients with sporadic acute hepatitis, who were seen at a city hospital in the Kathmandu valley of Nepal in 1997, were studied. IgM antibodies to hepatitis A virus were detected in four patients (3%), IgM antibodies to hepatitis B core in four patients (3%), hepatitis B surface antigen in 20 (13%), and hepatitis C virus RNA in four patients (3%). IgM antibodies to hepatitis E virus (HEV) (anti-HEV IgM) and HEV RNA were detected in 77 (50%) and 48 (31%), respectively. Consequently, 86 patients (56%) including nine HEV-viremic patients without anti-HEV IgM, were diagnosed with hepatitis E. The cause of hepatitis was not known in 53 patients (34%). All 48 HEV RNA-positive samples were genotyped as 1, and subtyped further as 1a in 17 (35%), 1c in 29 (60%), and mixed infection of 1a and 1c in 2 (4%). A seasonal difference in the prevalence of HEV subtypes was recognized. Before the rainy season (January to July), both 1a and 1c isolates were found: the intrasubtypic difference was up to 9.0% and 1.7%, respectively, in the 412-nucleotide sequence of open reading frame 2. During the rainy season (August), only 1c isolates (n = 17) with 99.5-100% identity were found; 13 of 17 isolates had the same sequence, being identical to the 3 isolates that emerged at the end of July. These results suggest that a particular HEV 1c strain spread widely during the rainy season and was implicated in a small epidemic in the Kathmandu valley in August 1997.

Molecular and serological characterization of sporadic acute hepatitis E in a Japanese patient infected with a genotype III hepatitis E virus in 1993

Serum samples collected periodically from a 40-year-old Japanese woman who had not travelled abroad and who had contracted sporadic acute hepatitis E in 1993 were semi-quantitatively tested by enzyme immunoassay for IgM, IgA and IgG antibodies to hepatitis E virus (HEV). Anti-HEV IgM and IgA antibody levels were the highest (1 : 2400 dilution and 1 : 3400 dilution, respectively) on day 9 after the onset of hepatitis and then decreased rapidly in a parallel manner. Anti-HEV IgG antibody levels were the highest (1 : 17000 dilution) on day 145 and then decreased gradually but remained at high titres (1 : 2200 dilution) even 8.7 years after the onset of hepatitis. An HEV isolate, HE-JA10, recovered from the patient's serum at admission was closely related to a genotype III strain isolated in the United States (US1), with 92.2% identity over the full-length genome, and was most closely related to the JMY-Haw isolate of Japanese origin (95.4% identity).

Cluster of cases of acute hepatitis associated with hepatitis E virus infection acquired in the Netherlands

Increasing evidence suggests that hepatitis E virus (HEV) infection may occur in developed countries and that swine may act as a reservoir. We report a cluster of 2 confirmed cases and 1 presumptive case of hepatitis associated with HEV. The typed strain from 1 case was related to HEV strains found in North America and Europe, and it was also related to a cluster of swine HEV strains found in The Netherlands. Our findings indicate that locally acquired HEV infections in industrialized countries may be overlooked. Routine testing for HEV infection in patients with acute hepatitis in The Netherlands should be considered before a diagnosis of autoimmune hepatitis is reached and steroid therapy is initiated.

A new enzyme immunoassay for the detection of antibody to hepatitis E virus

BACKGROUND AND AIM

The purpose of the present study was to develop enzyme immunoassay (EIA) for the detection of IgG anti-hepatitis E virus (HEV) activity using two new recombinant proteins as antigenic targets, and to evaluate these EIA with the aid of statistical methods.

METHODS

Two proteins, a mosaic protein and pB166 containing region 452-617 aa of the ORF2 of the HEV Burma strain, were used to develop the new HEV EIA. This EIA was evaluated using several panels of serum specimens obtained from: (i) acutely HEV-infected patients; (ii) patients with non-A, non-C hepatitis; (iii) normal blood donors (NBD) from non-endemic countries; and (iv) experimentally infected chimpanzees.

RESULTS

A new HEV EIA was developed using two new recombinant proteins. This assay was able to detect anti-HEV activity in all specimens from acutely HEV-infected patients. When NBD were tested, more than 15% of specimens were found to be IgG anti-HEV positive. All NBD anti-HEV-positive specimens were tested with overlapping synthetic peptides spanning the entire HEV ORF2-encoded protein. More than 90% of the anti-HEV-positive NBD specimens immunoreacted with an average of 15 synthetic peptides derived from different regions of the HEV ORF2 protein. These data suggest that the HEV EIA is at least 90% specific in detecting remote HEV infections.

CONCLUSION

The new HEV EIA developed in the present study is a highly specific diagnostic assay for the detection of anti-HEV activity in serum specimens obtained from different epidemiologic settings.

Genetic characterization and sequence heterogeneity of a canadian isolate of Swine hepatitis E virus

Swine hepatitis E virus (HEV) is a newly identified potentially zoonotic agent that is possibly transmitted to humans from pigs. Swine HEV is prevalent in pig populations and does not cause abnormal clinical symptoms in infected pigs, further implicating a likelihood of a risk of transmission to humans by normal contact. To date in North America, only one strain of swine HEV (strain US swine) has been fully sequenced. In the present study, we identified a swine HEV isolate from pigs in Canada, designated the Arkell strain, and determined the full length of the genomic sequence. The genome of Canadian strain Arkell consisted of 7,242 nucleotides, excluding the poly(A) tail of at least 15 A residues. The genome contained three open reading frames (ORFs), ORF1, ORF2, and ORF3, which had coding capacities for proteins of 1,708, 660, and 122 amino acids, respectively. Comparative analysis of the full-length genomic sequence indicated that the sequence of strain Arkell was distinct from those of all other known HEV isolates by 13 to 27% and shared the highest degrees of identity with human HEV isolates US-1 and US-2, HEV isolate US swine, and the human and swine HEV isolates recently isolated in Japan. On the basis of sequence similarities and phylogenetic analyses, HEV strain Arkell was grouped into genotype 3. The sequence of the Arkell swine HEV isolate differed from those of HEV isolate US swine and HEV isolate Japan swine by 13 and 14%, respectively. To date, two isolates of swine HEV (isolates Arkell and SK3 [D. Yoo et al., Clin. Diagn. Lab. Immunol. 8:1213-1219, 2001]) have been identified in Canadian pigs, and their sequences also differ from each other by 11.8%. Our studies indicate that, as with human HEV strains, swine HEV isolates exhibit extensive genetic heterogeneity.

Polyphyletic strains of hepatitis E virus are responsible for sporadic cases of acute hepatitis in Japan

Among 87 patients who were previously treated for acute hepatitis of unknown etiology between 1992 and 2001 at five hospitals in Japan, 11 (13%) patients were positive for immunoglobulin M-class antibodies to hepatitis E virus (HEV) by enzyme immunoassay and had detectable HEV RNA by reverse transcription-PCR with two independent sets of primers derived from well-conserved genomic areas in open reading frames 1 and 2. Clinical HEV infection was significantly associated with male sex (9 of 11 versus 29 of 76 patients [P < 0.01]) and older age (52 +/- 11 [mean +/- standard deviation] versus 41 +/- 17 years [P < 0.05]), and its prevalence differed by geographic region (6 to 25%), with a higher rate in the northern part of Japan. At admission, the 11 patients with HEV-associated hepatitis had elevated alanine aminotransferase levels of 914 to 4,850 IU/liter, and all but 1 had elevated bilirubin levels of 1.5 to 24.0 mg/dl. The 11 HEV isolates were of genotype III or IV and were segregated into three groups with intergroup nucleotide differences of 9.5 to 22.0%. Phylogenetic analysis revealed that four isolates of genotype III were closely related to a Japanese isolate, while the other four isolates of the same genotype were nearest those from the United States. The remaining three isolates were close to known isolates of genotype IV in China and Taiwan but shared less than 88% identity with them. These results indicate that multiple genotypes of HEV cocirculate in Japan and contribute to the development of sporadic acute hepatitis, with the prevalence differing by age, sex, and geographic region.

Identification of two distinct genotypes of hepatitis E virus in a Japanese patient with acute hepatitis who had not travelled abroad

Two distinct hepatitis E virus (HEV) isolates, designated HE-JI3 and HE-JI4, were identified in a single patient with acute hepatitis in Japan, who had not travelled abroad. The HEV load of HE-JI3 at admission was 10(2) copies/ml, but that of HE-JI4 was tenfold higher at 10(3) copies/ml. The viraemia of HE-JI4 persisted for up to 16 days from admission, whereas HE-JI3 disappeared at 9 days after admission. The entire nucleotide sequence of the HE-JI4 isolate and partial nucleotide sequences of open reading frames (ORFs) 1 and 2 of the HE-JI3 isolate were determined. The full-length nucleotide sequence of HE-JI4 consisted of 7171 nucleotides excluding the poly(A) tail and contained ORF1 encoding 1684 amino acids, ORF2 encoding 671 amino acids and ORF3 encoding 114 amino acids. Sequence and phylogenetic analyses of the HEV genomes indicated that HE-JI4 was most closely related to an HEV isolate (T1) of genotype IV with the same strategy for translation of ORF2 and ORF3, but which differed from it by 16.5% over the entire genome. The HE-JI3 isolate showed the highest nucleotide identity (88.6-95.1%) to the genotype III HEVs, having higher identity to human and swine HEV isolates from the United States (US1, US2 and swUS1) than to those reported thus far from Japan (JRA1 and swJ570). The two co-infecting strains of HE-JI3 and HE-JI4 identified from the single patient shared only 80.1% nucleotide identity. These results indicate that multiple genotypes of HEV co-circulate in Japan, and that genotype IV comprises a remarkably heterogeneous group of HEVs.

Hepatitis E: an overview

The hepatitis E virus (HEV) is a non-enveloped, positive-sense, single-stranded RNA virus with icosahedral symmetry. Although it is related to the alpha-virus superfamily, the HEV is classified as a separate Hepatitis E-like viruses genus. Infection in humans occurs in sporadic and epidemic forms and can cause an acute, self-limited, icteric hepatitis. Recent studies indicate the existence of a reservoir in animals.

Use of a swine bioassay and a RT-PCR assay to assess the risk of transmission of swine hepatitis E virus in pigs

The objective of this study was to assess the risk of transmission of swine hepatitis E virus (swine HEV) to naïve pigs by inoculation with tissues or feces collected from pigs infected experimentally with swine HEV. Seventy-five, 3-week-old pigs were assigned randomly to 24 groups of 3-4 pigs and inoculated with homogenates of tissues (liver, heart, pancreas, or skeletal muscle) or a suspension of feces from swine HEV-infected pigs collected at 3, 7, 14, 20, 27, or 55 days post inoculation (DPI). Each inoculum was prepared as a 10% suspension (w/v) in PBS buffer and tested by a semi-quantitative RT-PCR for swine HEV RNA and by the swine bioassay. The inoculation route was intravenous for liver, heart and pancreas, and via stomach tube for skeletal muscle and fecal suspension. The liver homogenate inocula and feces collected at 3-7 and 14-20 DPI were positive for swine HEV RNA by RT-PCR. The pigs inoculated with liver homogenates collected at 3-7 and 14-20 DPI developed anti-HEV antibodies and swine HEV RNA was detected in their sera. Pigs inoculated with heart, pancreas, skeletal muscle homogenates or fecal suspensions failed to develop anti-HEV antibodies. These findings suggest that there is a potential risk of transmission of swine HEV via liver tissue from infected pigs in the early stages (3-20 DPI) of infection and the in vitro RT-PCR assay correlates well with the swine bioassay.

Analysis of the complete genome of indigenous swine hepatitis E virus isolated in Japan

Using reverse transcription-polymerase chain reaction with primers derived from well-conserved genomic areas among all four hepatitis E virus (HEV) genotypes (I-IV), the HEV sequence was identified in serum samples obtained from 3 (3%) out of 95 60- to 90-day-old pigs in Japan and characterized molecularly. In the partial sequence of open reading frame (ORF) 2 of 421 nucleotides, the three swine isolates (swJ570, swJ681, and swJ791) showed the highest similarity of 83-87% to genotype III HEV representing human and swine strains (US1, US2, and swUS1) in the United States. The full-length nucleotide sequence of swJ570 consisted of 7225 nucleotides excluding the poly(A) tail and contained ORF 1 encoding 1703 amino acids (aa), ORF2 encoding 660 aa, and ORF3 encoding 122 aa. The swJ570 strain was most closely related to a Japanese strain (JRA1), which had been obtained from a hepatitis patient who had not traveled outside Japan. The overall nucleotide sequence identity between them was 89% and the deduced amino acid sequence identities of ORF1, ORF2, and ORF3 were 96, 99, and 98%, respectively. These results indicate that a certain proportion of pigs in Japan are HEV-viremic and may act as reservoirs of HEV infection, and that the presence of an indigenous strain(s) of HEV should be taken into consideration for the diagnosis of acute hepatitis in Japan.