Hepatitis E virus infection is highly prevalent among pregnant women in Accra, Ghana

Hepatitis E virus infection during pregnancy: Advances in animal models

Hepatitis E virus (HEV) is one of the major pathogens causing acute viral hepatitis worldwide, which usually causes acute self-limited diseases in general individuals. However, it can lead to high mortality and adverse pregnancy outcomes in pregnant women. Due to the lack of effective and stable cell culture models for HEV, the establishment of suitable animal models for HEV infection during pregnancy is necessary. An electronic search of the relevant database was conducted to identify eligible articles. Main animal models for the study of HEV infection during pregnancy include rabbits, swine, nonhuman primates and Mongolian gerbils. These animal models have been used to study the prevention, treatment and possible mechanisms of HEV infection during pregnancy. Studies using these animal models have investigated the potential pathogenesis of HEV infection during pregnancy. It has been found that immune mechanism (changes in the CD4/CD8 ratio and cytokines), hormonal changes (increase in pregnancy-related hormones) and viral factors (different genotypes and genome structures) can lead to HEV-related adverse pregnancy outcomes in animal models. In this review, we aimed to comprehensively present the characteristics of different animal models and the pathogenesis of HEV-related adverse pregnancy outcomes.

Clinical Manifestations of Hepatitis E

The clinical manifestations of hepatitis E are similar to those of other types of viral hepatitis. While acute hepatitis E is usually self-limited, pregnant women and chronic liver disease patients suffering from acute hepatitis E usually present with severe clinical manifestations that may develop into fulminant hepatic failure. Chronic HEV infection is typically seen in organ transplant patients; most HEV cases are asymptomatic and rarely display jaundice, fatigue, abdominal pain, fever, fatigue, or ascites. The clinical manifestations of HEV infection in neonates are diverse and have varied clinical signs, biochemistry, and virus-biomarkers. Lastly, the extrahepatic manifestations and complications of hepatitis E are in need of further study.

Epidemiology of Hepatitis E

Hepatitis E virus (HEV) is globally prevalent with relatively high percentages of anti-HEV immunoglobulin G-positive individuals in the populations of developing and developed countries. There are two distinct epidemiological patterns of hepatitis E. In areas with high disease endemicity, primarily developing countries in Asia and Africa, this disease is caused mainly by genotypes HEV-1 or HEV-2; both genotypes transmit predominantly through contaminated water and occur as either outbreaks or sporadic cases of acute hepatitis. The acute hepatitis has the highest attack rate in young adults and is particularly severe among pregnant women. In developed countries, sporadic cases of locally acquired HEV-3 or HEV-4 infection are observed. The reservoir of HEV-3 and HEV-4 is believed to be animals, such as pigs, with zoonotic transmission to humans. The affected persons are often elderly, and persistent infection has been well documented among immunosuppressed persons. A subunit vaccine has been shown to be effective in preventing clinical disease and has been licensed in China.

Hepatitis E Virus Seroprevalence and Associated Risk Factors in Pregnant Women Attending Antenatal Consultations in Senegal

In West Africa, research on the hepatitis E virus (HEV) is barely covered, despite the recorded outbreaks. The low level of access to safe water and adequate sanitation is still one of the main factors of HEV spread in developing countries. HEV infection induces acute or sub-clinical liver diseases with a mortality rate ranging from 0.5 to 4%. The mortality rate is more alarming (15 to 25%) among pregnant women, especially in the last trimester of pregnancy. Herein, we conducted a multicentric socio-demographic and seroepidemiological survey of HEV in Senegal among pregnant women. A consecutive and non-redundant recruitment of participants was carried out over the period of 5 months, from March to July 2021. A total of 1227 consenting participants attending antenatal clinics responded to a standard questionnaire. Plasma samples were collected and tested for anti-HEV IgM and IgG by using the WANTAI HEV-IgM and IgG ELISA assay. The overall HEV seroprevalence was 7.8% (n = 96), with 0.5% (n = 6) and 7.4% (n = 91) for HEV IgM and HEV IgG, respectively. One of the participant samples was IgM/IgG-positive, while four were declared indeterminate to anti-HEV IgM as per the manufacturer’s instructions. From one locality to another, the seroprevalence of HEV antibodies varied from 0 to 1% for HEV IgM and from 1.5 to 10.5% for HEV IgG. The data also showed that seroprevalence varied significantly by marital status (p < 0.0001), by the regularity of income (p = 0.0043), and by access to sanitation services (p = 0.0006). These data could serve as a basis to setup national prevention strategies focused on socio-cultural, environmental, and behavioral aspects for a better management of HEV infection in Senegal.

Seroprevalence and Potential Risk Factors of Hepatitis E Virus among Pregnant Women in Khartoum, Sudan

Although hepatitis E virus (HEV) infection has been widely understood as a public health concern in pregnant females, it is sometimes overlooked because of unusual observations of hepatitis E-induced complications during pregnancy. The objective of this descriptive cross-sectional study was to find out how frequent Hepatitis E virus infection is in pregnant women in Sudan. Blood samples were collected from pregnant women (n = 90) attending Khartoum North Hospital from February to December 2019. The specimens were investigated for Hepatitis E virus IgG and IgM antibodies using the commercial kits based on the enzyme immunosorbent assay (ELISA) technique. Out of ninety pregnant women, 36 (40%) were found positive for IgG antibodies, and 5 (6%) were tested positive for IgM antibodies. In addition, 13 (14.5%) of the positive cases are women in their third trimester. These data showed a significant association between previous Hepatitis E virus infection and miscarriage (p <0.001). This study did not find a significant association between maternal and gestation age, education, water sources, and hepatitis E virus infection. In conclusion, there was a high percentage of HEV infections among pregnant women attending Khartoum North Hospital. This study estimates the Hepatitis E virus burden in Khartoum state, but more extensive studies are required to confirm the burden in Sudan.

Hepatitis E seroprevalence and risk factors in humans and pig in Ghana

Background

Although Hepatitis E virus (HEV) infection has significant negative impact on the health and wellbeing of underprivileged populations, the burden of HEV in Ghana is still unclear, despite widespread water, sanitation, and hygiene (WASH) related conditions that predispose people to the risk of infection.

Methods

A cross-sectional study was conducted to explore rates of HEV seroprevalence and HEV prevalence, as well as risk factors in humans and domestic pigs in Ghana. These were determined using ELISAs manufactured by Wantai Beijing Biopharmaceuticals, China. The study involved 1365 community members, 105 pig farmers and 474 domestic pigs from four administrative regions of Ghana.

Results

Results showed overall seroprevalence and prevalence of 12.4% and 0.7% in community members and 15.2% and 2.9% in pig farmers respectively. There was no significant difference in the seroprevalence between the two groups (Z = 0.851; p = 0.3953). However, the prevalence in pig farmers was significantly higher than in community members (Z = 2.412; p = 0.016). Age (OR = 1.369, CI = 1.243 – 1.508; p = 0.0000), gender (OR = 1.419, CI = 1.101 – 1.991; p = 0.043), and the region of residence (OR = 1.569, CI = 1.348 – 1.827; p = 0.0000) were significant risk factors for HEV seroprevalence in a multivariate regression model.

In pigs, overall seroprevalence and prevalence of 62.4% and 5.5% were recorded respectively. A significant difference in seroprevalence was found between confined (6.7%) and free-range pigs (88.3%), (Z = 7.492; p < 0.00001) in the Volta Region. Multivariate logistic regression showed a significant association between seroprevalence and husbandry (OR = 7.051, CI = 3.558– 13.972; p = 0.0000) and region (OR = 4.602, CI = 2.300 – 9.205; p = 0.0000) in pigs in the Volta and Greater Accra Region.

Conclusion

From this study, HEV is endemic in Ghana with high seroprevalence in humans and pig populations. This underscores the need for awareness creation and action for prevention and control.

Hepatitis E virus genotyping in Pakistan: a regional study to explore the implications for pregnant females

Aim: Hepatitis E virus (HEV) has different genotypes 1–4, which is generally associated with mild to severe complications among immunocompromised patients and pregnant women. Materials & methods: Immunoglobulin M (IgM) HEV-positive samples were collected from the diagnostic center. HEV infection was further confirmed by RT-based PCR and genotyping was done to affirm the prevailing genotype. Results: This study identified 28 patients from Islamabad who were confirmed to have immunoglobulins type M against HEV showing acute infection, of which 17 were pregnant and 11 were non-pregnant women. All pregnant women were in their third trimester of pregnancy. Conclusion: Genotype-1 is commonly associated with pregnant females presenting with HEV infections in Islamabad. There is a need to further identify both the sources & route of infections.

Prevalence and clinical correlation of hepatitis E virus antibody in the patients' serum samples from a tertiary care hospital in Thailand during 2015-2018

Background

Prevalence and incidence of hepatitis caused by HEV infection are usually higher in developing countries. This study demonstrated the HEV seroprevalence and incidence of HEV infection in patients with clinical hepatitis in a tertiary hospital in Thailand.

Methods

A laboratory-based cross-sectional study was conducted using 1106 serum samples from patients suspected of HEV infection sent to the Serology laboratory, Siriraj Hospital, for detecting HEV antibodies during 2015–2018. Prevalence of anti-HEV IgG and IgM antibodies in general patients, including organ transplant recipients and pregnant women in a hospital setting, were determined using indirect enzyme-linked immunosorbent assay (ELISA) kits. Comparison of laboratory data between groups with different HEV serological statuses was performed.

Results

HEV IgG antibodies were detected in 40.82% of 904 serum samples, while HEV IgM antibodies were detected in 11.75% of 1081 serum samples. Similar IgG and IgM antibody detection rates were found in pregnant women. Interestingly, anti-HEV IgM antibodies were detected in 38.5% of patients who underwent organ transplantation. Patients who tested positive for anti-HEV IgM antibodies had higher alanine aminotransferase levels than those who had not. In contrast, patients who tested positive for anti-HEV IgG had more elevated levels of total bilirubin than those who tested negative.

Conclusions

HEV seroprevalence and incidence in patients with clinical hepatitis were relatively high in the Thai population, including the pregnancy and organ transplant subgroups. The results potentially benefit the clinicians in decision-making to investigate HEV antibodies and facilitating proper management for patients.

Sero-molecular epidemiology of hepatitis E virus in pigs and human contacts in Ghana

BACKGROUND

Hepatitis E virus (HEV) is among the leading causes of viral hepatitis in most developing countries. Zoonotic acquisition of HEV genotype 3 from swine has come into focus more recently. Available studies on HEV in Ghana and other countries in the region do not provide enough information towards understanding the epidemiology of HEV in human and animal populations. Towards this end, we conducted a comparative cross-sectional study to determine the seroprevalence and risk factors associated with HEV exposure, both in swine and humans working on pig farms in typical local settings. The presence of viral RNA in human and swine samples was also evaluated, along with classification of viral sequences from HEV-positive samples.

METHODS

Structured questionnaires soliciting information on pigs reared, as well as socio-demographic information including age, sex and educational background of humans was collected. A total of 10 ml and 5 ml of whole blood was collected from pigs and human participants respectively. ELISA and real-time RT-PCR were performed on the sera for the qualitative detection of IgG antibodies to hepatitis E virus and viral RNA, respectively.

RESULTS

Five hundred and forty-four (544) human participants including 264 swine contacts and 280 swine non-contacts were enrolled in the study. Although the proportion of HEV IgG antibodies was higher in contact groups (114; 54.3%) than non-contact groups (96; 45.7%), a multivariate analysis did not show any significant difference. No HEV RNA was detected in human samples. Similarly, 720 pigs were sampled from 18 farms located in five regions in Ghana. Twenty-three (23) of the pigs (3.2, 95%CI = 2.0-4.8) were positive for HEV RNA by real-time RT-PCR testing. Sequences obtained from HEV-positive samples were found to share high sequence identities with each other and clustered with other genotype 3 viruses indicating the existence of circulating zoonotic genotype 3 viruses on farms. Although we did not find evidence of pig to human transmission of HEV genotype 3, the presence of this genotype in pigs shows the potential for possible zoonotic transmission in African farm settings and buttresses the importance of active surveillance for the infection among at risk populations.

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 in Sub Saharan Africa - A significant emerging disease

Hepatitis E is an emerging endemic disease found across the African continent, but there are clear differences in epidemiology between North Africa and countries south of the Sahara. In this systematic review, Google scholar and PubMed databases were searched for peer-reviewed articles on HEV epidemiology. Publications meeting our inclusion criteria were critically reviewed to extract consistent findings and identify knowledge gaps. Hepatitis E has been reported in 25 of the 49 countries in Sub Saharan Africa.

Mortality rates of 1–2% in the general population and ~ 20% in pregnant women. Outbreaks were closely linked to refugees and Internally Displaced Persons in camps which accounted for 50% of reported outbreaks. There was very little research and concrete evidence for sources of contamination and transmission routes. There are indications of zoonotic transmission of Hepatitis E Virus infection but further research in these fields is required.

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No data from 50% of African countries

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Outbreaks closely linked to refugee and IDP camps

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Little data on sources of HEV contamination

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Indications but little evidence of zoonotic transmission

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Low awareness amongst health professionals and general public

Burden of hepatitis E virus infection in pregnancy and maternofoetal outcomes: a systematic review and meta-analysis

Background

There is still a dearth of knowledge on the burden of HEV infection in the global population of pregnant women. Therefore, we conducted a systematic review and meta-analysis to estimate the global burden of HEV infection in pregnancy.

Methods

We searched PubMed, Embase, Web of Knowledge, and Global Index Medicus to identify articles published until January 26, 2020. We considered cross-sectional, case-control, and cohort studies reporting the immunoglobulins M HEV seroprevalence in asymptomatic and symptomatic (jaundice or elevated transaminases) pregnant women or investigating the association between HEV infection and maternofoetal outcomes. We used a random-effects model to pool studies. This review was registered with PROSPERO, CRD42018093820.

Results

For HEV prevalence estimates, we included 52 studies (11,663 pregnant women). The seroprevalence was 3.5% (95% confidence interval: 1.4–6.4) in asymptomatic women (most of whom from high endemic areas). The prevalence in symptomatic women was 49.6% (42.6–56.7) with data only from HEV high endemic countries. In the multivariable meta-regression model, the prevalence was higher in symptomatic women compared to asymptomatic (adjusted prevalence odds ratio [aPOR]: 1.76; 95%CI: 1.61–1.91) and decreased with increasing year of publication (by 10-year) (aPOR: 0.90; 95%CI: 0.84–0.96). The proportion of HEV vertical transmission was 36.9% (13.3–64.2). Risk of bias was low, moderate and high respectively in 12 (23%), 37 (70%), and 4 studies (7%) addressing HEV prevalence estimation. HEV infection was associated with maternal deaths (pooled OR 7.17; 3.32–15.47), low birth weight (OR: 3.23; 1.71–6.10), small for gestational age (OR: 3.63; 1.25–10.49), preterm < 32 weeks (OR: 4.18; 1.23–14.20), and preterm < 37 weeks (OR: 3.45; 2.32–5.13), stillbirth (OR: 2.61; 1.64–4.14), intrauterine deaths (OR: 3.07; 2.13–4.43), and not with miscarriage (OR: 1.74; 0.77–3.90). All studies which assessed the association between HEV infection and maternofoetal outcomes had a moderate risk of bias.

Conclusions

Findings from this study are suggestive of a high burden of HEV infection in pregnancy in high endemic countries, its association with poor maternofoetal outcomes, and a high rate of vertical transmission. This study supports the need for specific strategies to prevent exposure of pregnant women to HEV infection, especially in high endemic areas.

Serological and molecular investigation of hepatitis E virus in pigs reservoirs from Cameroon reveals elevated seroprevalence and presence of genotype 3

Background

Hepatitis E virus (HEV) is a zoonotic pathogen of which pigs have been established as reservoirs. In the present study, we investigated the presence of HEV among pigs in the Center and Littoral regions of Cameroon and performed the molecular characterization of positive strains.

Methodology

A total of 453 serum and stool samples were randomly collected from pigs in slaughterhouses in Obala, Douala and Yaounde. All samples were examined for the presence of anti-HEV IgG and IgM antibodies using ELISA assays. IgM positive stool samples were tested for HEV RNA using an RT-PCR assay, followed by a nested PCR assay for sequencing and phylogenetic analysis.

Results

Overall, 216 samples (47.7%, 95% CI: 43.1%-52.3%) were positive for at least one of the serological markers of HEV infection. Amongst these, 21.0% were positives for anti-HEV IgM, 17.7% for anti-HEV IgG, and 9.1% for both. A total of eight stool samples (5.9%) were positive for HEV RNA by nested RT-PCR. Phylogenetic analysis showed that the retrieved sequences clustered within HEV genotype 3.

Conclusion

This study shows a high prevalence of anti-HEV antibodies and the circulation of genotype 3 in the swine population in Cameroon. Subsequent studies will be needed to elucidate the zoonotic transmission of HEV from pigs to humans in Cameroon.

Detection and genomic characterization of hepatitis E virus genotype 3 from pigs in Ghana, Africa

BACKGROUND

Hepatitis E virus (HEV) is a major cause of human hepatitis worldwide. Zoonotic genotypes of the virus have been found in diverse animal species with pigs playing a major role. Putative risk of zoonotic infection from livestock particularly swine in Sub-Saharan Africa including Ghana is poorly understood due to scarcity of available data, especially HEV sequence information.

METHODS

Serum samples were collected from cattle, sheep, goats and pigs from Kumasi in the Ashanti region of Ghana. Samples were subjected to nested RT-PCR screening and quantification of HEV RNA-positive samples using real-time RT-PCR and the World Health Organization International Standard for HEV. Testing of all pig samples for antibodies was done by ELISA. Sanger sequencing and genotyping was performed and one representative complete genome was generated to facilitate genome-wide comparison to other available African HEV sequences by phylogenetic analysis.

RESULTS

A total of 420 samples were available from cattle (n = 105), goats (n = 124), pigs (n = 89) and sheep (n = 102). HEV Viral RNA was detected only in pig samples (10.1%). The antibody detection rate in pigs was 77.5%, with positive samples from all sampling sites. Average viral load was 1 × 10⁵ (range 1.02 × 10³ to 3.17 × 10⁵) International Units per mL of serum with no statistically significant differences between age groups (≤ 6 month, > 6 months) by a T-test comparison of means (t = 1.4272, df = 7, p = 0.1966). Sequences obtained in this study form a monophyletic group within HEV genotype 3. Sequences from Cameroon, Ghana, Burkina Faso and Madagascar were found to share a most recent common ancestor; however this was not the case for other African HEV sequences.

CONCLUSION

HEV genotype 3 is highly endemic in pigs in Ghana and likely poses a zoonotic risk to people exposed to pigs. HEV genotype 3 in Ghana shares a common origin with other virus strains from Sub-Saharan Africa.

Seroprevalence of hepatitis E virus antibodies in different human populations of Cameroon

Hepatitis E virus (HEV) is a major cause of acute hepatitis worldwide. HEV infection is self-limiting, but fulminant hepatitis may occur with higher mortality rates. The aim of this study was to determine the seroprevalence of the HEV in three different populations in Cameroon and to assess alimentary risk factors of infection. A total of 903 individuals including 450 elderly people, 183 pregnant women, and 270 HIV-infected patients were enrolled during 2009-2015. All sera obtained were tested for the presence of anti-HEV antibodies with commercial enzyme-linked immunosorbent assay kits. The association between initial anti-HEV status and potential risk factors was assessed. Out of the 903 samples, 22.0% (199/903) were positives for anti-HEV immunoglobulin M (IgM), 5.8% (52/903) for anti-HEV IgG, and 3.5% (32/903) for both. The seropositivity for IgM was 7.0%, 13.1%, and 34.7%; meanwhile, the seropositivity for immunoglobulin G was 8.5%, 3.3%, and 5.1%, in HIV-infected patients, pregnant women, and the elderly population, respectively. Both antibodies were detected simultaneously in 2.2%, 1.6%, and 5.1% in HIV-infected patients, pregnant women, and the elderly population, respectively. No risk factors were significantly associated with HEV infection in these populations. This study showed a high prevalence of anti-HEV antibodies in three different populations in Cameroon.

Hepatitis E virus infection among pregnant women in Africa: systematic review and meta-analysis

BACKGROUND

There have been a number of studies about seroprevalence of HEV among pregnant women in Africa. However, the finding of seroprevalence of HEV infection among pregnant women is variable and inconsistent. Therefore; this systematic review intended to provide the pooled seroprevalence of HEV among pregnant women in Africa.

METHODS

We searched, Pub Med, Science direct, African online journals and Google scholar electronic data bases and all available references until August 30, 2018. We included cross sectional studies and cohort studies. The search was further limited studies done in African pregnant women. Statistical analysis done by using Stata (version 11) software. The overall pooled prevalence of HEV presented by using the forest plot with 95% CI. The methodological qualities of included studies were assessed using Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instruments.

RESULT

The pooled seroprevalence of HEV among pregnant women in Africa was 29.13% (95% CI 14.63-43.63). The highest seroprevalence was 84.3% in Egypt and the lowest 6.6% reported in Gabon. There was highest heterogeneity level where I2 = 99.7%; P < 0.0001.The observed heterogeneity attributed to geographic location/ region, country, assay method used in each study and year of study published. Moreover, HEV seroprevalence varies between countries and within countries. The HEV infection among African pregnant women seems to have a decreasing trend over time.

CONCLUSION

The seroprevalence of HEV among pregnant women in Africa is high. The seroprevalence of HEV among pregnant women differ with geographic location and assay method. Therefore, it is recommended to conduct further research on commercial ELISA kit sensitivity and specificity, molecular tests, incidence, morbidity and mortality and vertical transmission of HEV from mother to infant in Africa.

TRIAL REGISTRATION

CRD42018084963 .

Aetiology of viral hepatitis among jaundiced patients presenting to a tertiary hospital in Ghana

BACKGROUND

Viral hepatitis continues to play significant role in causing morbidity and mortality in sub-Saharan Africa. Apart from the few population based studies available, not many have investigated the burden of these viruses in jaundiced patients. Among the few studies, hepatitis E is the least studied among jaundiced patients. This study was aimed at describing the frequency, distribution and risk of the different hepatitis viruses among jaundiced patients reporting to the second largest teaching hospital in Ghana.

METHODS

From November, 2015 to April, 2016, a cross-sectional study was conducted among jaundiced patients attending the Komfo Anokye Teaching Hospital. Between 3-5 ml of blood was collected from each patient and screened for viral hepatitis agents using both serologic and molecular-based assays.

RESULTS

In the 155 patients recruited, hepatitis B was the most prevalent [54.2% (95% CI = 46.0%-62.2%)] followed by hepatitis E [32.9% (95% CI = 25.6-40.9%)]. Most cases of hepatitis E occurred as co-infections with hepatitis B (18%), with the predominant clinical feature being hepatocellular carcinoma. Risk factor variable analysis showed middle and older aged individuals were more at risk of hepatitis B exposure whereas younger age groups (<18 years) were more at risk of hepatitis E virus infection.

CONCLUSION

Hepatitis viruses are still important in the viral aetiology of jaundice in Ghana. Hepatitis B and hepatitis E co-infections could play significant roles in causing severe disease. A more aggressive approach needs to be adopted in order to reduce the morbidity and mortality associated with hepatitis causing viruses in Ghana and other developing countries.

Seroprevalence and risk factors of Hepatitis E virus infection among pregnant women attending antenatal care in health facilities of Tigray, Northern Ethiopia

Existing literatures from developing countries show an increased mortality and morbidity related to hepatitis E virus during pregnancy as compared to the general population. Studies focusing on pregnant women are required for policy makers to improve maternal and child health. Therefore this study is aimed at determining the prevalence and associated risk factors of hepatitis E virus infection among pregnant women attending the health facilities of Tigray region, Northern Ethiopia. In this cross sectional study 846 pregnant women were included consecutively from April 2014 to February 2016. Clinical and sociodemographic were collected using structured questionnaire and blood was collected for laboratory analysis of Hepatitis E virus using IgG and IgM HEV ELISA. The data were analyzed using SPSS software version 21.0. Association with variables with the risk factors was determined using bivariate and multivariate analysis. The overall sero-prevalence of hepatitis E virus using anti-HEV IgG and anti-HEV IgM antibody among pregnant women were 367 (43.4%). From this 359 (42.4%) and 8 (0.9%) were tested positive for anti-HEV IgG and anti-HEV IgM antibody, respectively. Then finally age, rural residence, not washing after toilet use and lack of prevention aspects to minimize contamination were associated with HEV infection. This study shows the significant public health impact of HEV during pregnancy in low income countries.

Sero-prevalence and risk factors for hepatitis E virus infection among pregnant women in the Cape Coast Metropolis, Ghana

BACKGROUND

Hepatitis E virus is an emerging infection in Africa with poor maternal and foetal outcomes. There is scanty data on the sero-prevalence of HEV infection among pregnant women in Ghana. This study highlighted the prevalence and risk factors associated with HEV infection among pregnant women in Cape Coast Metropolis, Central Region of Ghana.

METHODS

A multicenter (3 selected sites) analytical cross sectional study involving 398 pregnant women in the Cape Coast metropolis was conducted. HEV (Anti-HEV IgG and Anti-HEV IgM) ELISA was performed. Sero-positive women had liver chemistries done and data collected on maternal and neonatal outcomes. Data analyses were performed using Stata version 13 software (STATA Corp, Texas USA).

RESULTS

Mean age was 28.01 (± 5.93) years. HEV sero-prevalence was 12.2% (n = 48) for IgG and 0.2% (n = 1) for IgM with overall of 12.3%. The odds of being HEV sero-positive for women aged 26-35 years was 3.1 (95% CI: 1.1-8.1), p = 0.02 and ≥36 years it was 10.7 (95% CI; 3.4-33.5), p = 0.0001. Living in urban settlement was associated with lowest odds of HEV infection {OR 0.4 (95% CI; 0.2-0.8), p = 0.01}. Factors with no statistical evidence of association include main source of drinking water and history of blood transfusion. The sero-prevalence of HEV IgG increased progressively across trimesters with the highest among women in their third trimester (55.3%). None of the 49 HEV sero-positive women had elevated ALT level. Ten (N = 41) of the neonates born to sero-positive women developed jaundice in the neonatal period. The mean birth weight was 3.1kg (SD 0.4).

CONCLUSION

HEV sero-prevalence among pregnant women in the Cape Coast Metropolis is high enough to deserve more attention than it has received so far. It is therefore important to conduct further research on the potential impact on maternal and neonatal mortality and morbidity in Ghana.

Prevalence, risk factors and molecular evaluation of hepatitis E virus infection among pregnant women resident in the northern shores of Persian Gulf, Iran

BACKGROUND

Although Iran is reported to be an endemic country for hepatitis E virus (HEV), data on the prevalence of HEV infection among pregnant women are scarce and the epidemiology of HEV is unknown in most parts of the country. Therefore, this study was conducted to elucidate the prevalence, risk factors and genotypic pattern of HEV infection among pregnant women resident in the northern shores of Persian Gulf. This is the first report on the epidemiology of HEV infection among pregnant women in this territory.

METHODS

From October 2016 to May 2017, 1331 pregnant women participated in this study. The mean age ± SD of participants was 27.93±5.7 years with a range of 14-45 years. Serum samples of pregnant women were screened for the presence of anti-HEV total antibodies, anti-HEV IgG and anti-HEV IgM using commercially available ELISA kits (DIA.PRO, Milan, Italy). All anti-HEV IgG and anti-HEV IgM positive samples were tested for HEV RNA using two independent reverse transcriptase polymerase chain reaction (RT-PCR) assays, targeting ORF2 and ORF3 of HEV genome. In addition, 92 anti-HEV seronegative samples as well as 50 pooled seronegative samples were evaluated by two independent RT-PCR assays for validation of results.

RESULTS

Of the 1331 pregnant women, 84 women (6.3%, 95% CI: 5.1%-7.7%) were positive for anti-HEV antibodies, of which 83 women had anti-HEV IgG, and 11 women (0.83%, 95% CI: 0.47%-1.47%) had anti-HEV IgM. The highest rate of HEV seroprevalence was observed among Afghan immigrants (68.0%), uneducated pregnant women (46.51%) and those residents in Bushehr city (8.75%). All anti-HEV IgG and/or IgM positive samples were found to be negative for HEV RNA. In addition, all of the evaluated anti-HEV seronegative samples were negative for HEV RNA. HEV seropositivity among pregnant women was statistically associated with age, ethnicity, place of residence, number of pregnancies, and level of education. So that, low education levels, Afghan, residence in Bushehr city, age group >34 years, and more parities were risk factors for exposure to HEV. In contrast, HEV seropositivity was not associated with stage of gestation, history of abortion, and time of sampling.

CONCLUSION

The northern shores of Persian Gulf in Iran, with HEV seroprevalence of 6.3%, can be classified as an endemic geographical region for hepatitis E, and residents of Bushehr city, Afghan immigrants and uneducated women are the main at-risk populations in this territory.

Acute Hepatitis E Virus Infection in Two Geographical Regions of Nigeria

Hepatitis E virus (HEV) remains a major public health concern in resource limited regions of the world. Yet data reporting is suboptimal and surveillance system is inadequate. In Nigeria, there is dearth of information on prevalence of acute HEV infection. This study was therefore designed to describe acute HEV infection among antenatal clinic attendees and community dwellers from two geographical regions in Nigeria. Seven hundred and fifty plasma samples were tested for HEV IgM by Enzyme Linked Immunosorbent Assay (ELISA) technique. The tested samples were randomly selected from a pool of 1,115 blood specimens previously collected for viral hepatitis studies among selected populations (pregnant women, 272; Oyo community dwellers, 438; Anambra community dwellers, 405) between September 2012 and August 2013. One (0.4%) pregnant woman in her 3rd trimester had detectable HEV IgM, while community dwellers from the two study locations had zero prevalence rates of HEV IgM. Detection of HEV IgM in a pregnant woman, especially in her 3rd trimester, is of clinical and epidemiological significance. The need therefore exists for establishment of a robust HEV surveillance system in Nigeria and especially amidst the pregnant population in a bid to improve maternal and child health.

Clinical Manifestations of Hepatitis E

The clinical manifestations of hepatitis E are similar to those of other types of viral hepatitis. While acute hepatitis E is usually self-limited, pregnant women and chronic liver disease patients suffering from acute hepatitis E usually present with severe clinical manifestations that may develop into fulminant hepatic failure. Chronic HEV infection is typically only seen in organ transplant patients; most HEV cases are asymptomatic and rarely display jaundice, fatigue, abdominal pain, fever, fatigue, or ascites. The clinical manifestations of HEV infection in neonates are diverse and have varied clinical signs, biochemistry, and virus biomarkers. Lastly, the extrahepatic manifestations and complications of hepatitis E are in need of further study.

Epidemiology of Hepatitis E

Hepatitis E virus (HEV) is globally prevalent with relatively high percentages of anti-HEV immunoglobulin G-positive individuals in the populations of developing and developed countries. There are two distinct epidemiologic patterns of hepatitis E. In areas with high disease endemicity, primarily developing countries in Asia and Africa, this disease is caused mainly by genotype 1 or 2 HEV, both of which transmit predominantly through contaminated water and occur as either outbreaks or as sporadic cases of acute hepatitis. The acute hepatitis caused by either of these two genotypes has the highest attack rate in young adults, and the disease is particularly severe among pregnant women. In developed countries, sporadic cases of locally acquired genotype 3 or 4 HEV infection are observed. The reservoir of genotype 3 and 4 HEV is believed to be animals, such as pigs, with zoonotic transmission to humans. The affected persons are often elderly, and persistent infection has been well documented among immunosuppressed persons. A subunit vaccine has been shown to be effective in preventing clinical disease and has been licensed in China.

Seroprevalence and risk factors associated with hepatitis E virus infections among people and pigs in Tibet, China

Hepatitis E virus (HEV), the causative agent of hepatitis E, is an important public health problem throughout the world. There is little information available on the autochthonous HEV infection in highland inhabitants (Tibet, average elevation >3000m) of China. Therefore, we conducted a cross-sectional survey to determine the sero-prevalence of Hepatitis E and association of different risk factors in local people and pigs in Tibet, China. For this purpose, serum samples were collected from 600 local volunteers and 453 Tibetan pigs from July 2014 to August 2015. All the samples were examined for the presence of anti-HEV IgG antibodies by using enzyme-linked immunosorbent assay (ELISA). While socio-demographic and behavioral characteristics were also obtained through questionnaire. The present survey found a close relationship among the HEV of Tibetan people and pigs. The prevalence of anti-HEV IgG was detected 39.33% (236/600) and 42.38% (192/453) in local people and pigs, respectively. There was a significance association of different age groups, ethnic groups, people having contact with pigs or consuming uncooked meat, and gender of Tibetan pigs. Our findings confirmed the presence of autochthonous HEV among people and pigs in Tibet, China. Therefore, effective measures should be taken to prevent and control HEV infection in Tibet, China.

Seroprevalence and risk factors of Hepatitis E Virus infection among pregnant women in Addis Ababa, Ethiopia

Background

Hepatitis E virus (HEV) is highly endemic in several African countries with high mortality rate among pregnant women. The prevalence of antibodies to HEV in Ethiopian pregnant women is not known. The study was conducted to investigate the prevalence of anti-HEV IgG and anti-HEV IgM among pregnant women.

Material and methods

A total of 386 serum samples were collected from pregnant women between April 2014 to January 2015 in Gandhi Memorial Hospital and four selected Health centers in Addis Ababa, Ethiopia. Data were collected for socio demographic characteristics using a structured questionnaire. Serum samples were examined for anti-HEV IgG and anti- HEV IgM using ELISA. The association of anti-HEV status with risk factors was assessed. Factors demonstrating significant association in bivariate analysis were included in multivariate logistic regression models. Analyses were performed using SPSS version 21.

Results

Anti- HEV IgG antibody was detected in 122 (31.6%) women and two women (0.5%) were positive for anti-HEV IgM from the total 386 women. Age and educational status had statistically significant association with HEV infection. There was no significant association between anti-HEV antibody seroprevalence rate with trimester, parity, HIV status and other risk factors.

Conclusion

In this study we found a high seroprevalence rate of anti-HEV IgG among pregnant women in Addis Ababa Ethiopia. Preventive measures like improvement of education and creating awareness may reduce the risk in pregnant women. Moreover nationwide surveillance of HEV especially in rural setting should be conducted to establish a national estimate and validate our findings.

Hepatitis E infection among Ghanaians: a systematic review

Background

Hepatitis E virus (HEV) infection is considered to be of significant public health importance in many developing countries. In this review, we aim to summarise studies on HEV with the aim of providing a further understanding of the epidemiology of the disease in Ghana.

Methods

A systematic review was conducted by following the recommendations outlined in the PRISMA statement. Studies on HEV infection among Ghanaians were identified by searching for articles (published up until 4th August 2016) in the PubMed, ISI Web of Science, African Journals Online, Google Scholar and the WHO African Index Medicus databases. We also searched the websites of the Ministry of Health and the Ghana Health Service to identify any related non-indexed studies. References of all retrieved studies were screened to identify additional publications.

Results

Ten studies involving a total of 2 894 participants from six regions of Ghana were identified. The proportion of Ghanaians showing positive serological markers for HEV infection was within the range of 5.8–71.55%. In addition, 0.7–45.9% tested positive for IgM antibodies while the proportion of Ghanaians testing positive for IgG antibodies was within the range of 0–45.3%. One study reporting a case fatality rate of 66.7% among pregnant women was identified. No information on HEV genotypes was retrieved.

Conclusions

Although based on a limited number of studies, this review does highlight that there is a high level of HEV infection among Ghanaians. Preventive measures including educational interventions as well as general improvements to sanitary and living conditions are needed to reduce the burden of the disease. Additionally, further research regarding the contribution of the various HEV genotypes is urgently needed to fully understand the burden of this disease in Ghana.

Electronic supplementary material

The online version of this article (doi:10.1186/s40249-017-0239-9) contains supplementary material, which is available to authorized users.

Epidemiology of Hepatitis E in Pregnant Women and Children in Iran: A General Overview

From an epidemiological point of view, hepatitis E is an old infection in Iran, but only recently has its importance as a public health concern been considered from research and public health standpoints. As such, there is still a long road ahead to clarify the real burden of hepatitis E virus (HEV) infection in Iran. According to the available epidemiological studies, the seroprevalence of HEV infection among pregnant women is between 3.6% and 7.4%, and among Iranian children is between 0.9% to 8.5%, varying by geographic regions within the country and directly dependent upon the sanitary status of each. In addition to evaluating the sanitation level of a society, community-based seroprevalence studies of HEV infection demonstrate the most prevalent risk factors, the major routes of transmission, and the epidemiological patterns of HEV among that country's population. In this review, the current knowledge about the pathogenesis and epidemiology of HEV infection in pregnant women and children in Iran, as well as the recent advances in diagnosis, prevention and treatment of HEV infection have been summarized.

Use of Pathogen-Specific Antibody Biomarkers to Estimate Waterborne Infections in Population-Based Settings

PURPOSE OF REVIEW

This review discusses the utility of pathogen-specific antibody biomarkers for improving estimates of the population burden of waterborne infections, assessing the fraction of infections that can be prevented by specific water treatments, and understanding transmission routes and the natural history and ecology of disease in different populations (including asymptomatic infection rates).

RECENT FINDINGS

We review recent literature on the application of pathogen-specific antibody response data to estimate incidence and prevalence of acute infections and their utility to assess the contributions of waterborne transmission pathways. Advantages and technical challenges associated with the use of serum versus minimally invasive salivary antibody biomarkers in cross-sectional and prospective surveys are discussed. We highlight recent advances and challenges and outline future directions for research, development, and application of antibody-based and other immunological biomarkers of waterborne infections.

A preliminary cost-effectiveness analysis of hepatitis E vaccination among pregnant women in epidemic regions

Objective To estimate the cost-effectiveness of hepatitis E vaccination among pregnant women in epidemic regions. Methods A decision tree model was constructed to evaluate the cost-effectiveness of 3 hepatitis E virus vaccination strategies from societal perspectives. The model parameters were estimated on the basis of published studies and experts' experience. Sensitivity analysis was used to evaluate the uncertainties of the model. Results Vaccination was more economically effective on the basis of the incremental cost-effectiveness ratio (ICER< 3 times China's per capital gross domestic product/quality-adjusted life years); moreover, screening and vaccination had higher QALYs and lower costs compared with universal vaccination. No parameters significantly impacted ICER in one-way sensitivity analysis, and probabilistic sensitivity analysis also showed screening and vaccination to be the dominant strategy. Conclusion Screening and vaccination is the most economical strategy for pregnant women in epidemic regions; however, further studies are necessary to confirm the efficacy and safety of the hepatitis E vaccines.

Hepatitis E virus seroprevalence in pregnant women in Jiangsu, China, and postpartum evolution during six years

Background

China is an endemic area for hepatitis E virus (HEV). The previous surveys of anti-HEV seroprevalence are cross-sectional. This study aimed to investigate the prevalence of infection among pregnant women and their children in Jiangsu, China, and to observe postpartum anti-HEV evolution.

Methods

Sera from 497 women collected during pregnancy and 6-year postpartum and from their 497 children were screened for anti-HEV by ELISA and confirmed by Western blotting. HEV RNA was detected by reverse transcription-nested PCR.

Results

Of the pregnant women, 3 (0.6 %) were anti-HEV IgM positive and 55 (11.1 %) were IgG positive. At 6-year postpartum, 18 anti-HEV IgG positive samples became negative and 18 others became IgG positive; the accumulated prevalence in this cohort of women was at least 14.7 % (73/497). Of the 497 children, the positive rates of anti-HEV IgM and IgG were 0.2 % and 0.4 %, respectively. None of the 18 children from mothers with anti-HEV IgG seroconversion was anti-HEV IgG positive.

Conclusions

Our data indicate that the constant seroprevalence of anti-HEV IgG in adults may be resulted from the balance of negative seroconversion due to waning immunity and positive seroconversion due to novel infections, and the risk of intra-family transmission of HEV was low. The data also imply that cross-sectional seroepidemiological survey may underestimate the prevalence of HEV infection, due to the natural decay of pathogen-specific IgG.

Epidemiology of hepatitis E virus infection during pregnancy in Benin

OBJECTIVES

Hepatitis E virus (HEV) is the cause of enterically transmitted non-A, non-C hepatitis (an infection that is particularly severe during pregnancy) in tropical and subtropical countries. As there are no published data concerning the prevalence of HEV antibodies in Benin, their presence was investigated in pregnant women undergoing routine HIV screening in a rural area in northern Benin and in pregnant women with acute non-A, non-C hepatitis.

METHODS

A total of 278 serum samples were collected from asymptomatic pregnant women in 2011 were tested for HEV and hepatitis A virus (HAV) antibodies, and the HEV IgM-positive samples were further tested for HEV-RNA. A further seven samples of pregnant women with acute non-A, non-C hepatitis collected during episodes of acute hepatitis in 2005 were also analysed.

RESULTS

Of the 278 samples collected in 2011, 16.19% were positive for HEV IgG and 1.44% for HEV IgM (none positive for HEV-RNA), and 99.64% were positive for total HAV antibodies (none positive for HAV IgM). Six of the seven samples collected in 2005 were positive for HEV IgG and IgM, and two were also positive for HEV-RNA.

CONCLUSIONS

The circulation of HEV infection is significant among pregnant women in Benin, in whom the consequences may be fatal.

A systematic review of the epidemiology of hepatitis E virus in Africa

BACKGROUND

Hepatitis E Virus (HEV) infection is a newly recognized serious threat to global public health and Africa is suspected to be among the most severely affected regions in the world. Understanding HEV epidemiology in Africa will expedite the implementation of evidence-based control policies aimed at preventing the spread of HEV including policies for the use of available resources such as HEV vaccines.

METHODS

Here we present a comprehensive review of HEV epidemiology in Africa based on published data. We searched for articles on HEV epidemiology in Africa from online databases such as PubMed, Scopus, and ISI Web of Science and critically reviewed appropriate publications to extract consistent findings, identify knowledge gaps, and suggest future studies.

RESULTS

Taking a particularly high toll in pregnant women and their fetuses, HEV has infected human populations in 28 of 56 African countries. Since 1979, 17 HEV outbreaks have been reported about once every other year from Africa causing a reported 35,300 cases with 650 deaths.

CONCLUSIONS

In Africa, HEV infection is not new, is widespread, and the number of reported outbreaks are likely a significant underestimate. The authors suggest that this is a continent-wide public health problem that deserves the attention of local, regional and international agencies to implement control policies that can save numerous lives, especially those of pregnant women and their fetuses.

Epidemiology and associated risk factors of hepatitis e virus infection in plateau state, Nigeria

A cross-sectional study in Nigeria was undertaken to determine the epidemiology, seroprevalence, and associated risk factors, of hepatitis E virus (HEV). A total of 462 subjects were used for the study, categorized into four groups: apparently healthy persons, pregnant women, HIV positive subjects, and animal handlers. Information was obtained from subjects using interviewer-administered questionnaire. Blood samples were collected and analyzed for HEV antibodies (IgG and IgM) using enzyme-linked immunosorbent assay (ELISA) technique. Results obtained were analyzed using Statistical Package for Social Sciences (SPSS) version 17.0 statistical software. The overall seroprevalence of IgG and IgM was 42.7 and 0.9%, respectively. Animal handlers had the highest seroprevalence (66.7%). The associated risk factors for IgM seroprevalence were rural dwelling (P = 0.039, odds ratio (OR) 3.3, 95% confidence interval (CI) 0.7–15.4), blood transfusion (P < 0.001, OR 9.6, 95% CI 2.6–35.6), attending to animals (P = 0.032, OR 4.9, 95% CI 0.9–26.6), and waste disposal (P < 0.001). Factors associated with IgG were age (P = 0.044), location (P < 0.001), marital status (P < 0.001), formal education (P < 0.001), farming as occupation (P < 0.001), rural dwelling (P = 0.001), waste disposal (P < 0.001), alcohol consumption (P = 0.001, OR 2.4, 95% CI 1.4–4.0), open defecation (P < 0.001, OR 2.9, 95% CI 1.4–5.7), attending to animals (P < 0.001, OR 2.3, 95% CI 1.6–3.4), consuming unwashed fruits/vegetables (P < 0.001, OR 4.2, 95% CI 0.3–54.1), and stream/river as a source of drinking water (P < 0.001, OR 3.6, 95% CI 1.6–7.8). Preventive public health measures should be reinforced among all communities, particularly domestic animal handlers and pregnant women. Potable water should be provided for all communities. Data suggest that HEV remains an under-recognized and significant public health problem, warranting further attention and research.

An outbreak of hepatitis E and high maternal mortality at Port Sudan, Eastern Sudan

During 4 months (November 2010-March 2011) of an outbreak of hepatitis E virus (HEV), 39 pregnant women presented at Port Sudan Hospital, Sudan, with various symptoms of viral hepatitis. The diagnosis of viral hepatitis was confirmed by serology using ELISA anti-HEV IgG and IgM. The mean (SD) maternal age and gestational age were 24·0 (4·2) years and 33·6 (3·7) weeks, respectively. Eight (20·5%) women were primigravidae. There were 11 (28·2%) maternal deaths, 14 (36·0%) intrauterine fetal deaths, and eight (20·5%) cases of postpartum haemorrhage. There were nine (23·0%) cases of preterm (<37 weeks of gestation) deliveries. Fulminant hepatitis with hepatic encephalopathy was the most common cause of death among these patients. Nine of these women died before delivery and the other two died immediately following the delivery due to severe haemorrhage. There were no significant differences in clinical and biochemical data between the women who died (11) and those who survived.

Clinicolaboratory study of mother-to-neonate transmission of hepatitis E virus in Egypt

OBJECTIVES

To study the presence of hepatitis E viremia in neonates with congenital infections.

METHODS

We included 29 neonates with clinical signs and symptoms suggesting congenital infections, along with their mothers. The control group comprised 29 healthy neonates and their mothers. Laboratory evaluations were performed for each sample for liver function profiles and virological studies for hepatitis viruses B, C, and E.

RESULTS

The most common viral markers in mothers were for hepatitis C immunoglobulin G (IgG) (41%), followed by hepatitis B surface antigen (34%) and hepatitis E virus (HEV) IgG (31%). The most common presentations in neonates were respiratory distress syndrome, followed by preterm birth and signs of sepsis (both 41%) and hepatosplenomegaly (13%).

CONCLUSIONS

This study highlights the occurrence of HEV infection among other etiological conditions causing congenital infections. Vertical transmission from mothers was common in our patients. Although HEV ran a milder course, more studies are needed.

Hepatitis e and acute liver failure in pregnancy

Hepatitis E virus is a positive strand RNA virus with three open reading frames which is transmitted predominantly through the fecal contamination of water and food. It is the most common cause of acute liver failure in endemic areas. Pregnant women especially from the Indian subcontinent and Africa are at increased risk of contracting acute HEV infection as well as developing severe complications including ALF. Transmission of HEV occurs from mother to unborn child. Both maternal and fetal complications may occur, including abortion, fetal demise, preterm labor and maternal or neonatal death. The precise reasons for increased susceptibility to HEV infection during pregnancy and associated severe disease are still an enigma. Management is supportive and termination of pregnancy is not recommended as a general rule. Prevention of infection is of vital importance, as availability of clean drinking water can reduce the burden of this disease in the community. There is a need for future research to focus on prevention of ALF in pregnancy and to study the disease pathogenesis, which is not explicitly understood at present. The availability of a vaccine may alter the natural course of the disease in this select population which is at risk.

Hepatitis E virus infections in HIV-infected patients in Ghana and Cameroon

BACKGROUND

Chronic hepatitis E virus (HEV) infections have recently been described in HIV-infected patients. Only few data are available for sub-Saharan Africa, where HIV and HEV are highly co-endemic, and where liver pathology is common in HIV-infected individuals.

OBJECTIVES

To assess the prevalence of HEV viremia, anti-HEV antibodies, and serum aminotransferase levels in HIV patients in Ghana and Cameroon.

STUDY DESIGN

We retrospectively surveyed a cross-section of patients who were enrolled in cohort studies in Ghana (West Africa), and Cameroon (Central Africa). Plasma samples from 1029 HIV patients from Ghana and 515 patients from Cameroon including 214 children were analyzed for HEV-RNA by two reverse transcription PCR methods. In a subset of 791 patients, anti-HEV IgG and IgM antibodies were analyzed.

RESULTS

No HEV-RNA was detected in any of the plasma samples of 1544 patients. HEV seroprevalence was high in adult HIV patients from Ghana (45.3%, n=402) and Cameroon (14.2%, n=289), but low in pediatric HIV patients from Cameroon (2.0%, n=100). Elevations of alanine aminotransferase and aspartate aminotransferase levels were common in adult patients from Ghana (20.8% and 25.4%) and Cameroon (38.9% and 69.8%). The prevalence of hepatitis B virus surface antigen was 11.8% and of hepatitis C virus antibodies 2.5% in our adult Cameroonian study population.

CONCLUSIONS

Acute or chronic HEV infections did not play a role in liver pathology in two HIV cohorts in Ghana and Cameroon. A better understanding of the epidemiology and genotype-specific characteristics of HEV infections in HIV patients in sub-Saharan Africa is needed.

Socio-demographic determinants of aflatoxin B1-lysine adduct levels among pregnant women in Kumasi, Ghana

OBJECTIVES

Aflatoxins are fungal metabolites that contaminate staple food crops in many developing countries. Although studies have linked these toxins to adverse birth outcomes and poor infant development, no study has investigated the socio-demographic and economic determinants of aflatoxin levels among pregnant women living in sub-Saharan Africa.

DESIGN

A cross-sectional study was conducted among 785 pregnant women in Kumasi. Aflatoxin B1 lysine adduct levels (AF-ALB) were determined by High Performance Liquid Chromatography. Analysis of variance was used to determine mean log AF-ALB levels and significance of differences in these levels according to socio-demographic variables. Logistic regression was used to identify independent associations of socio-demographics with having AF-ALB levels (≥ 11.34 pg/mg; upper quartile).

RESULTS

AF-ALB levels ranged from 0.44 pg/mg to 268.73 pg/mg albumin with a median level of 5.0 pg/mg. Bivariate analyses indicates that mean ln AF-ALB as well as the percent of women having high AF-ALB levels (≥ 11.34 pg/mg; upper quartile) were inversely associated with indices of higher socioeconomic status: higher education and income, being employed and having a flush toilet. Higher income, being employed, having one child (verses no children) and having a flush toilet (verses no toilet facilities) were each independently associated with a 30-40% reduced odds of high AF-ALB levels.

CONCLUSIONS

Additional research is needed to investigate how socio-demographic and economic factors interact to influence aflatoxin ingestion by individuals in regions with high aflatoxin crop contamination. This knowledge can be used to formulate and implement policies that will reduce exposure of women and their unborn children to these toxins.

Complete genome sequence of the genotype 4 hepatitis E virus strain prevalent in swine in Jiangsu Province, China, reveals a close relationship with that from the human population in this area

Hepatitis E virus (HEV) is a zoonotic pathogen of which several species of animal were reported as reservoirs. Swine stands out as the major reservoir for HEV infection in humans, as suggested by the close genetic relationship of swine and human viruses. In a previous study, we sequenced the complete genome of a human genotype 4 HEV strain (HM439284) that is prevalent in Jiangsu Province, China. Here we report the complete genome of one genotype 4 HEV strain which is prevalent in swine herds in Jiangsu Province. Phylogenetic analysis indicated that the swine HEV strain in the present study has high sequence homology (>92%) with the genotype 4 HEV strains prevalent in the human population of Jiangsu Province. These results suggested that the genotype 4 HEV strain in the present study is involved in cross-species transmission between swine and humans in this area.

Seroprevalence of fecal-oral transmitted hepatitis A and E virus antibodies in Burkina Faso

Hepatitis A virus (HAV) and hepatitis E virus (HEV) infections occur chiefly as a result of unhygienic conditions. The purpose of this study was to assess the seroprevalence of antibodies to both viruses in central Burkina Faso in the absence of a recorded hepatitis epidemic. Serum samples from 178 blood donors (131 males and 47 females) and from 189 pregnant women were collected from November 2010 to March 2012, at blood banks and medical centers in Burkina Faso. An immunochromatography test was used to screen for Anti-HAV IgM and IgG in a subgroup of 91 blood donors and 100 pregnant women. The seroprevalence of anti-HAV IgG was 14.3% [CI95, 7.1-21.4%] for all blood donors and 23% [CI95, 14.8-31.2%] for pregnant women. Anti-HEV IgG were detected using the ELISA kits Dia.pro and Wantai and were found in 19.1% [CI95, 13.3-24.9%] of the blood donors and 11.6% [CI95, 7.1-16.2%] of the pregnant women. The seroprevalences of anti-HAV and anti-HEV IgGs did not differ significantly between men and women blood donors. Anti-HAV IgM was detected in 3.3% of the blood donors and in 2% of the pregnant women. These findings for asymptomatic individuals indicate that the HAV and HEV circulate at low but significant levels. This is the first evaluation of the acute hepatitis virus burden in Burkina Faso and the underlying epidemiologic status of the population.

Fatal hepatitis E viral infection in pregnant women in Ghana: a case series

BACKGROUND

Viral infections during pregnancy can pose serious threats to mother and fetus from the time of conception to the time of delivery. These lead to congenital defects, spontaneous abortion and even death. The definitive diagnosis and management of pregnancy-related viral infections may be challenging especially in less resourced countries.

CASE PRESENTATION

We present clinical and laboratory responses to the diagnosis and management of three cases of fulminant hepatitis secondary to Hepatitis E viral infection in pregnancy.Case 1 was a 31-year-old Ghanaian woman who presented with a week's history of passing dark urine as well as yellowish discoloration of the eyes. She subsequently developed fulminant hepatitis secondary to Hepatitis E viral infection, spontaneously aborted at 24 weeks of gestation and later died.Case 2 was also a 31-year-old Ghanaian woman who was admitted with a four-day history of jaundice. She had low grade fever, but no history of abdominal pain, haematuria, pale stool or pruritus. She next developed fulminant hepatitis secondary to Hepatitis E viral infection. However, she did not miscarry but died at 28 weeks of gestation.Case 3 was a 17-year-old Ghanaian woman who was referred to the tertiary health facility on account of jaundice and anaemia. She had delivered a live male infant at maturity of 32 weeks but noticed she was jaundiced and had a presentation of active disease 3 days prior to delivery. The baby was icteric at birth and on evaluation, had elevated bilirubin (mixed type) with normal liver enzymes. Hepatitis E virus infection was confirmed in both mother and baby. However, the jaundice and the hepatomegaly resolved in mother and baby after 5 and 12 days respectively.

CONCLUSION

To the best of our knowledge, these are the first documented cases of fatal fulminant hepatic failures resulting from HEV infection in Ghana.

Bats worldwide carry hepatitis E virus-related viruses that form a putative novel genus within the family Hepeviridae

Hepatitis E virus (HEV) is one of the most common causes of acute hepatitis in tropical and temperate climates. Tropical genotypes 1 and 2 are associated with food-borne and waterborne transmission. Zoonotic reservoirs (mainly pigs, wild boar, and deer) are considered for genotypes 3 and 4, which exist in temperate climates. In view of the association of several zoonotic viruses with bats, we analyzed 3,869 bat specimens from 85 different species and from five continents for hepevirus RNA. HEVs were detected in African, Central American, and European bats, forming a novel phylogenetic clade in the family Hepeviridae. Bat hepeviruses were highly diversified and comparable to human HEV in sequence variation. No evidence for the transmission of bat hepeviruses to humans was found in over 90,000 human blood donations and individual patient sera. Full-genome analysis of one representative virus confirmed formal classification within the family Hepeviridae. Sequence- and distance-based taxonomic evaluations suggested that bat hepeviruses constitute a distinct genus within the family Hepeviridae and that at least three other genera comprising human, rodent, and avian hepeviruses can be designated. This may imply that hepeviruses invaded mammalian hosts nonrecently and underwent speciation according to their host restrictions. Human HEV-related viruses in farmed and peridomestic animals might represent secondary acquisitions of human viruses, rather than animal precursors causally involved in the evolution of human HEV.

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.

Differences in capabilities of different enzyme immunoassays to detect anti-hepatitis E virus immunoglobulin G in pigs infected experimentally with hepatitis E virus genotype 3 or 4 and in pigs with unknown exposure

Hepatitis E virus (HEV), a major cause of acute viral hepatitis in humans in many developing countries, is highly prevalent in the pig population worldwide. The objective of this study was to assess the capability of three porcine prototypes of a human enzyme-linked immunosorbent assay (ELISA), an in-house ELISA and a line-immunoassay (LIA) to detect anti-HEV antibodies in pigs infected experimentally with HEV (n = 57), known to be negative for HEV infection (n = 27), or with unknown exposure to HEV infection (field samples, n = 90). All 27 samples from non-infected pigs were negative with all five assays. The earliest detection of anti-HEV antibodies occurred at 14 days post-inoculation (dpi) with four of five assays. From 42 dpi, all samples from infected pigs were detected correctly as anti-HEV positive. Kappa analysis demonstrated substantial agreement among tests (0.62-1.00) at 14 dpi and complete agreement (1.00) at 56 dpi. The overall area under the curve for all quantitative tests as determined by receiver operator characteristic analysis ranged from 0.794 to 0.831 indicating moderate accuracy. The results showed that all five assays can detect anti-HEV IgG antibodies accurately in pigs infected experimentally with HEV. In field samples, a higher prevalence of anti-HEV IgG was found in breeding herds than in growing pigs (100% versus 66.7-93.9%). These serological assays should be very useful in veterinary diagnostic labs for HEV diagnosis in swine.

Recombination analysis reveals a double recombination event in hepatitis E virus

Recombination of Hepatitis E Virus (HEV) has rarely been reported. In the present study, phylogenetic and recombination analyses were performed on 134 complete HEV genomes. Three potentially significant recombination events, including both intra-genotype and one inter-genotype, were identified by recombination detection analysis. Recombination events I and II occurred intra-genotype and inter-genotype, respectively, among three isolates, including the lineage represented by CHN-XJ-SW13 (GU119961, swine isolate), E067-SIJ05C (AB369690, human isolate), and JJT-Kan (AB091394, human isolate), and lead to the recombinant swine isolate swCH31 (DQ450072). Recombination event III occurred between the lineage represented by the NA1 (M73218) and K52-87 (L25595), which resulted in the recombinant Xingjiang-1 (D11092). Our analyses proved that that recombination could occur between human and swine HEV strains, double recombination events existed in HEV, and recombination event could happen within ORF2 region of HEV. These results will provide valuable hints for future research on HEV diversity.