Hepatitis E virus infection of transplanted kidneys

Immunocompromised patients are at risk of chronic hepatitis E (HEV) infection. Recurrent T cell and borderline rejections in a pediatric patient with high HEV copy numbers led us to study HEV infection within renal transplants. To investigate the frequency of renal HEV infection in transplanted patients, 15 samples from patients with contemporaneous diagnoses of HEV infection were identified at our center. Ten samples had sufficient residual paraffin tissue for immunofluorescence (IF) and RNA-fluorescence-in-situ-hybridization (RNA-FISH). The biopsy of the pediatric index patient was additionally sufficient for tissue polymerase chain reaction and electron microscopy. HEV RNA was detected in paraffin tissue of the index patient by tissue polymerase chain reaction. Subsequently, HEV infection was localized in tubular epithelial cells by IF, RNA-FISH, and electron microscopy. One additional biopsy from an adult was positive for HEV by RNA-FISH and IF. Focal IF positivity for HEV peptide was observed in 7 additional allografts. Ribavirin therapy was not successful in the pediatric index patient; after relapse, ribavirin is still administered. In the second patient, successful elimination of HEV was achieved after short-course ribavirin therapy. HEV infection is an important differential diagnosis for T cell rejection within transplanted kidneys. Immunostaining of HEV peptide does not necessarily prove acute infection. RNA-FISH seems to be a reliable method to localize HEV.

Acute Hepatitis E Infection during Chemotherapy for Lung Cancer: A Case Report

Acute hepatitis E, one of the causes of acute liver injury, has been increasingly diagnosed in developed countries in recent years. Misdiagnosis of acute hepatitis E virus (HEV) infection as drug-induced liver injury (DILI) may lead to discontinuation of effective chemotherapy. Thus, viral hepatitis, including hepatitis E, must be ruled out in the diagnosis of DILI. A 78-year-old woman with lung adenocarcinoma and multiple bone metastases received maintenance therapy with pemetrexed + pembrolizumab for a year. Increased aspartate aminotransferase and alanine aminotransferase levels, indicating acute liver injury, were observed. Initially, DILI was suspected, and she was given medications to lower the levels of hepatic enzymes. She was later admitted to the hospital with the chief complaint of general malaise and anorexia. Serum aspartate aminotransferase and alanine aminotransferase levels were markedly elevated (381 and 854 U/L, respectively). Acute HEV infection was diagnosed based on the detection of serum HEV immunoglobulin A antibodies. The patient received liver support therapy, and the serum hepatic enzymes recovered to normal levels. Chemotherapy was resumed without any subsequent relapse of hepatic enzyme elevation. When DILI is suspected during chemotherapy, exclusion of viral hepatitis is mandatory, which can be achieved by measuring markers of hepatitis viruses, including HEV, and examining the patient's detailed medical history.

Rat Hepatitis E Virus as Cause of Persistent Hepatitis after Liver Transplant

All hepatitis E virus (HEV) variants reported to infect humans belong to the species OrthohepevirusA (HEV-A). The zoonotic potential of the species OrthohepevirusC (HEV-C), which circulates in rats and is highly divergent from HEV-A, is unknown. We report a liver transplant recipient with hepatitis caused by HEV-C infection. We detected HEV-C RNA in multiple clinical samples and HEV-C antigen in the liver. The complete genome of the HEV-C isolate had 93.7% nt similarity to an HEV-C strain from Vietnam. The patient had preexisting HEV antibodies, which were not protective against HEV-C infection. Ribavirin was an effective treatment, resulting in resolution of hepatitis and clearance of HEV-C viremia. Testing for this zoonotic virus should be performed for immunocompromised and immunocompetent patients with unexplained hepatitis because routine hepatitis E diagnostic tests may miss HEV-C infection. HEV-C is also a potential threat to the blood product supply.

Hepatitis E in the State of Sikkim (North East India)-A report on an outbreak

Background Hepatitis E virus is a significant public health menace in developing countries and is being reported from newer geographical regions. It is enterically transmitted and causes acute hepatitis. Objective The objective of this study is to correlate the patient details from outbreak of Hepatitis E in 2012 with the water culture done during that period. Method Records of the patients with Hepatitis E virus (HEV) infection in 2012 were analysed. Their serum samples were tested for Immunoglobulin M (IgM) Hepatitis E virus by rapid immunochormatography (ICT) and further confirmed by Immunoglobulin M Enzyme linked immunosorbent assay (IgM ELISA) in National Centre for Disease Control, New Delhi. Water was tested by the Multiple Tube test method using double strength Mc Conkey broth with neutral red and H2 S test method. Result Patients with febrile jaundice (n-62) were screened for Hepatitis E virus and 32 were positive by rapid Immunochromatography test and Enzyme linked immunosorbent assay. The overall attack rate was 0.03%. Drinking water from ten different localities in Gangtok were tested and 83% of the water were found to be unsatisfactory for drinking during that period. Conclusion Regular testing of water quality and public education and awareness is important to curb such outbreaks in future.

Hepatitis E Virus Infection in Solid Organ Transplant Recipients, France

The rate of transfusion-transmitted hepatitis E virus (HEV) in transplant recipients is unknown. We identified 60 HEV-positive solid organ transplant patients and retrospectively assessed their blood transfusions for HEV. Seven of 60 patients received transfusions; 3 received HEV-positive blood products. Transfusion is not the major route of infection in this population.

Hepatitis E Virus Infection after Platelet Transfusion in an Immunocompetent Trauma Patient

Hepatitis E virus (HEV) infection causes acute liver disease, but severe infections are rare in immunocompetent patients. We describe a case of HEV infection in a previously healthy male trauma patient in France who received massive transfusions. Genotyping confirmed HEV in a transfused platelet pool and the donor.

Familial Hepatitis E Outbreak Linked to Wild Boar Meat Consumption

An HIV-infected patient was diagnosed with acute hepatitis E infection in our hospital. An epidemiological inquiry was performed to collect demographic, food and animal exposure variables in order to identify the potential route of transmission. The patient reported that his family traditionally hunted wild boar for food. All family members were analysed for hepatitis E virus infection. Additionally, route of transmission by wild boar meat consumption and prevalence of HEV infection among wild boar from the same hunting area were investigated. In all-family members (n = 8), HEV-RNA was amplified. Two wild boar meat slices consumed was analysed, showing the presence of HEV. The virus isolated was consistent with genotype 3, revealing 100% homology between family members and meat. Additionally, we tested nine wild boar hunted in the same hunting area. All of them were RNA-HEV positive, isolating the same HEV genotype 3 viral strain. We demonstrated by phylogenetic analysis zoonotic transmission of HEV by wild boar meat consumption. The prevalence of HEV infection among wild boar found in our study suggests that this species is an important route of transmission to human.

Red blood cell transfusion-transmitted acute hepatitis E in an immunocompetent subject in Europe: a case report

BACKGROUND

Acute hepatitis E in industrialized countries is usually related to intake or manipulation of undercooked or raw meat. Cases of transfusion-transmitted hepatitis E have rarely been documented in immunosuppressed patients, mainly after receiving frozen plasma.

STUDY DESIGN AND METHODS

A 61-year-old man was admitted to hospital for jaundice. His personal history included disseminated bacillus Calmette-Guerin infection treated with antituberculous drugs. He had received red blood cell (RBC) transfusion 2 months previously, during admission for mycotic aneurysm surgery. Since liver function tests worsened despite stopping antituberculous drugs, other causes of acute hepatitis were explored.

RESULTS

Acute hepatitis E was diagnosed by the presence of both immunoglobulin M and hepatitis E virus (HEV) RNA. Traceback procedure for the 8 RBC units was carried out, and one of the eight archive plasma samples tested positive for HEV RNA, with an estimated viral load of 75,000 IU/mL. Phylogenetic analysis revealed the same HEV strain Genotype 3 in one of the transfused RBC products and in the patient's serum sample.

CONCLUSION

Transfusion of RBCs with detectable HEV RNA is a risk factor for acute hepatitis E in immunocompetent patients in Europe.

A Nationwide Survey of Hepatitis E Virus Infection and Chronic Hepatitis E in Liver Transplant Recipients in Japan

Background

Recently, chronic hepatitis E has been increasingly reported in organ transplant recipients in European countries. In Japan, the prevalence of hepatitis E virus (HEV) infection after transplantation remains unclear, so we conducted a nationwide cross-sectional study to clarify the prevalence of chronic HEV infection in Japanese liver transplant recipients.

Methods

A total of 1893 liver transplant recipients in 17 university hospitals in Japan were examined for the presence of immunoglobulin G (IgG), IgM and IgA classes of anti-HEV antibodies, and HEV RNA in serum.

Findings

The prevalence of anti-HEV IgG, IgM and IgA class antibodies was 2.9% (54/1893), 0.05% (1/1893) and 0% (0/1893), respectively. Of 1651 patients tested for HEV RNA, two patients (0.12%) were found to be positive and developed chronic infection after liver transplantation. In both cases, HEV RNA was also detected in one of the blood products transfused at the perioperative period. Analysis of the HEV genomes revealed that the HEV isolates obtained from the recipients and the transfused blood products were identical in both cases, indicating transfusion-transmitted HEV infection.

Interpretation

The prevalence of HEV antibodies in liver transplant recipients was 2.9%, which is low compared with the healthy population in Japan and with organ transplant recipients in European countries; however, the present study found, for the first time, two Japanese patients with chronic HEV infection that was acquired via blood transfusion during or after liver transplantation.

•

We conducted the multicenter survey for HEV infection in liver transplant recipients.

•

Though the chronic HEV infection is rare, transfusion-transmitted cases were detected.

•

Blood products can be a risk of chronic HEV infection in transplant recipients.

Hepatitis E Virus Mutations: Functional and Clinical Relevance

Hepatitis E virus (HEV) infection is a major cause of acute hepatitis and affects more than 20 million individuals, with three million symptomatic cases and 56,000 recognized HEV-related deaths worldwide. HEV is endemic in developing countries and is gaining importance in developed countries, due to increased number of autochthone cases. Although HEV replication is controlled by the host immune system, viral factors (especially specific viral genotypes and mutants) can modulate HEV replication, infection and pathogenesis. Limited knowledge exists on the contribution of HEV genome variants towards pathogenesis, susceptibility and to therapeutic response. Nonsynonymous substitutions can modulate viral proteins structurally and thus dysregulate virus-host interactions. This review aims to compile knowledge and discuss recent advances on the casual role of HEV heterogeneity and its variants on viral morphogenesis, pathogenesis, clinical outcome and antiviral resistance.

•

HEV causes acute hepatitis and recently comes into focus because of persistent infection in immunocompromised patients.

•

HEV variability can be associated with clinical pathogenesis and transmission dynamics.

•

Mutations in the HEV genome can influence HEV physiology and virus-host interaction.

•

HEV mutations and variability are likely associated with fulminant hepatic failure and chronic hepatitis E.

•

The Y1320H and G1634R/K mutations in the RdRp domain contribute to antiviral resistance through enhancing HEV replication.

We searched MEDLINE database and PubMed for articles from 1980 through June 30, 2016. Search terms used in various combinations were “hepatitis E”, “hepatitis E virus”, “hepatitis E virus infection”, “hepatitis E virus mutation”, “HEV variability”, “HEV genotype”, “HEV drug resistance”, “HEV replication” and “ribavirin”. Articles resulting from these searches and relevant references cited in those articles were selected based on their related topics and were reviewed. Abstracts and reports from meetings were also included. Articles published in English were included.

[Hepatitidis E virus]

The number of detected cases of hepatitis E (HE) shows an increasing trend in the Czech Republic, probably due the introduction of new diagnostic methods and greater awareness of HE. In most cases, the source of infection has remained unconfirmed or entirely unclear. The causative agent, the hepatitis E virus (HEV), belongs to the Hepeviridae family. Recently, many isolates from mammals, birds, and fish have been identified. HEV is widespread among farm pigs and wild boar populations all over the word. Both species serve as HEV reservoirs. Consumption of undercooked meat or offal from the reservoir animals is considered to be unsafe due to zoonotic transmission of HEV. The aim of the present article is to summarize recent findings regarding HEV.

KEY WORDS

hepatitis E - zoonosis - food-borne infection.

Variability of hepatitis E serologic assays in a pediatric liver transplant recipient: challenges to diagnosing hepatitis E virus infection in the United States

Hepatitis E virus (HEV) is an emerging cause of viral hepatitis among immunocompromised individuals in developed countries. Yet the diagnosis of HEV infection in the United States remains challenging, because of the variable sensitivity and specificity of currently available tests, and the lack of a US Food and Drug Administration-approved test. We report a case of multiple discordant HEV serology results in a pediatric liver transplant recipient with idiopathic hepatitis, and review the challenges to diagnosis of HEV infection in the United States.

Late onset post-transfusion hepatitis E developing during chemotherapy for acute promyelocytic leukemia

We herein report the case of a leukemia patient who developed hepatitis E seven months after undergoing a transfusion with contaminated blood products. The latency period in this case was significantly longer than that of typical hepatitis E. Recently, chronic infection with hepatitis E virus (HEV) genotype 3 has been reported in immunocompromised patients. There is a possibility that our patient was unable to eliminate the virus due to immunosuppression following chemotherapy and the administration of steroids. The prevalence of HEV in healthy Japanese individuals is relatively high and constitutes a critical source of infection via transfusion. Hepatitis E is an important post-transfusion infection, and immunocompromised patients may exhibit a long latency period before developing the disease.

[Analysis of epidemiologic and etiology of hepatitis E in Hangzhou, 2004-2011]

OBJECTIVE

To comprehend the epidemiologic of hepatitis E and genetic characteristics of hepatitis E virus (HEV) in Hangzhou from 2004 to 2011.

METHODS

Using China information system for disease control and prevention, the incidence of hepatitis E from 2004 to 2011 in Hangzhou city, and the basic information of patients were collected. In 2011, 65 hepatitis E laboratory confirmed cases were selected by random number table sampling method from the hospitals designated infectious diseases in Hangzhou city, and acquisition of the 60 blood specimens and stool specimens of 18 copies. One city and two surrounding counties were selected by cluster random sampling method in the context of Hangzhou city, and the pig slaughters and farmers were selected as the sampling point, and acquisition of pig gallbladder specimens of 52 copies, and 30 stool samples of scatter-feed pigs, 15 stool specimens of scatter-feed rabbits. HEV was tested in samples, gene extraction and analysis of gene sequence were conducted which were compared with gene bank HEV gene sequence, and a phylogenetic tree was formed. The epidemic characteristics of hepatitis E of Hangzhou city from 2004 to 2011 were described. The difference of incidence of hepatitis E was analyzed between years and sexes in Hangzhou city.

RESULTS

There were reported a total of 3 490 cases of hepatitis E in Hangzhou from 2004 to 2011, and 3 cases of death; The average annual incidence rate was 5.79/100 000 (3 490/60 276 338). There was the overall upward trend in incidence between different years (χ² = 52.38, P < 0.01) , which the highest was 8.10/100 000 (705/8 700 373) in 2011, and the lowest incidence rate was 4.19/100 000 in 2005. The incidence of males (8.12/100 000 (2 474/30 450 990) ) was significantly higher than that of the females (3.46/100 000 (1 016/29 384 491) ) (χ² = 558.45, P < 0.05). 78 specimens of blood and stool were collected, including 16 positive samples, with positive rate 21%. There were a total of 97 specimens of pig gallbladder, pig manure and rabbit stool, including 2 positive rabbit stool samples, with positive rate of 2%. HEV genes isolated from Hangzhou were mainly type IV, with homology of 91.8% to 100%; compared with human type IV strains, the homology of nucleotide was 84.6%-96.7%; compared with type IV strain of pig genome sequence alignment, homology was 82.6%-95.2%.

CONCLUSION

Hepatitis E's incidence showed an increasing trend year by year in Hangzhou. HEV of type IV was dominant, and HEV strains in the human and swine were highly homologous.

Effect of pregnancy on anti-HEV antibody titres, plasma cytokines and the corresponding gene expression levels in the PBMCs of patients presenting with self-recovering clinical and subclinical hepatitis E

High mortality in pregnant women (PR) is a characteristic of hepatitis E in developing countries. To understand the pathogenesis of HEV infection in self-limiting disease during pregnancy, we compared clinical (PR-patients) and subclinical-HEV-infections in pregnant women in the first (SC-PR-1) and later (2nd and 3rd, SC-PR-2+3) trimesters with the respective healthy controls and acute non-PR patients. The SC-PR-2+3 exhibited lower ALT, bilirubin levels, anti-HEV-IgM/IgG titres than the acute-PR/non-PR-patients (p<0.05-0.0001). IFNγ/IL4ratios indicated Th2/Th1 bias in non-PR and PR-patients respectively. Raised levels of 10/20 plasma cytokines in the non-PR-patients reflect predominant inflammatory response, unaltered- IFNγ/reduced-IFNα responses and a robust chemokine secretion. On contrary, the acute-PR-patients exhibited drastic reduction in majority of the cytokines relative to in the non-PR-patients. Importantly, diminished or unaltered response was noted in the acute-PR-group when compared to the corresponding controls. The only exception was sIL2RA, increasing in both patient categories. Of the 14 genes evaluated, the expression of IFNγ/IL10/IL1A/IL7/CCL2/CCL3/CXCL8/CXCL10 was higher in the non-PR patients. Of these, the expression of IFNγ/IL10/IL1A/CCL2/CCL3/CXCL8 and, additionally, IL2/IL6/TNF genes was higher in the clinical-PRs. Almost identical pattern was noted in the control-PR-2+3 category indicating no influence of HEV infection. Comparison of patient-categories identified significant elevation of IFNγ(P<0.001), CCL2(p<0.01), CXCL8(P<0.05), IL1B(p<0.05) and IL10(P<0.0001) and decrease in CXCL10(<0.05) in the PR-patients. The results suggest antibody-dependent disease severity and impaired immune response in the PR patients. Higher expression of cytokine-genes in the PBMCs did not correlate with the plasma-cytokine levels in the PR-patients.

Cirrhosis, liver transplantation and HIV infection are risk factors associated with hepatitis E virus infection

BACKGROUND

Acute and chronic hepatitis E have been associated with high mortality and development of cirrhosis, particularly in solid-organ recipients and patients infected by human immunodeficiency virus. However, data regarding the epidemiology of hepatitis E in special populations is still limited.

AIMS

Investigate seroprevalence and possible factors associated with HEV infection in a large cohort of immunosuppressed patients.

METHODS

Cross-sectional study testing IgG anti-HEV in serum samples from 1373 consecutive individuals: 332 liver-transplant, 296 kidney-transplant, 6 dual organ recipients, 301 non-transplanted patients with chronic liver disease, 238 HIV-infected patients and 200 healthy controls.

RESULTS

IgG anti-HEV was detected in 3.5% controls, 3.7% kidney recipients, 7.4% liver transplant without cirrhosis and 32.1% patients who developed post-transplant cirrhosis (p<0.01). In patients with chronic liver disease, IgG anti-HEV was also statistically higher in those with liver cirrhosis (2% vs 17.5%, p<0.01). HIV-infected patients showed an IgG anti-HEV rate of 9.2%, higher than those patients without HIV infection (p<0.03). Multivariate analysis showed that the factors independently associated with anti-HEV detection were liver cirrhosis, liver transplantation and HIV infection (OR: 7.6, 3.1 and 2.4). HCV infection was a protective factor for HEV infection (OR: 0.4).

CONCLUSIONS

HEV seroprevalence was high in liver transplant recipients, particularly those with liver cirrhosis. The difference in anti-HEV prevalence between Liver and Kidney transplanted cases suggests an association with advanced liver disease. Further research is needed to ascertain whether cirrhosis is a predisposing factor for HEV infection or whether HEV infection may play a role in the pathogeneses of cirrhosis.

Locally acquired hepatitis E in the Netherlands: Associated with the consumption of raw pig meat?

We here present 2 patients who developed hepatitis E, without having been abroad or in contact with anyone who did, indicating locally acquired hepatitis E. We point out that the consumption of raw pig meat could be of relevance in HEV-associated hepatitides in the Netherlands.

[Hepatitis E virus seropositivity in hemodialysis patients in Hatay province, Turkey]

Hepatitis E virus (HEV) which is mainly transmitted through faecal-oral route, can also be transmitted via parenteral and vertical route. Recent studies suggest zoonotic nature of the virus. The last studies done in Turkey indicate increasing frequency of HEV infection. This study was conducted to determine the rate of anti-HEV seropositivity among patients with terminal stage renal failure undergoing hemodialysis. A total of 92 patients (54 male, 38 female; age range: 22-71 years, mean age: 55 +/- 11 years) who had undergone hemodialysis for a mean period of 66 +/- 18 months, were included to the study. HEV antibodies were analyzed using anti-HEV IgG enzyme immunoassay (ELISA, Dia.Pro Diagnostic Bioprobes, Italy). In order to study the relationship of anti-HEV positivity between hepatitis C virus and hepatitis B virus infections, anti-HCV antibody and HBsAg were also considered. Mean age, duration of hemodialysis, platelet, serum albumin, alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels, blood transfusion history were the other evaluated parameters. Anti-HEV IgG positivity was detected in 19 (20.6%) patients, while 7 (7.6%) had anti-HCV positivity and 4 (4.3%) had HBsAg positivity. No statistically significant relation was determined between anti-HEV IgG positive and negative patients in terms of hemodialysis duration, blood transfusion, other laboratory findings and anti-HCV and HBsAg positivity (p > 0.05). While the anti-HEV seropositivity rate (20.6%) determined in this study was higher than the rates determined in the same group of patients in the western part of the country (10-16%), the rate was similar to the rates reported from the southeastern part (23%) of Turkey. It can be concluded that screening of patients before or during hemodialysis in terms of anti-HEV antibodies, seems to be of crucial importance in order to establish necessary precautions to prevent parenteral and/or nosocomial transmission of HEV.

[New aspects of HEV infection]

The hepatitis E virus (HEV), known for being the cause of major outbreaks of waterborne hepatitis in Asia and Africa, is an emerging pathogen in industrialized countries. Virologic analyses of sporadic cases in Europe, Japan and the United States have shown that the origin of the infection was through autochthonous viral strains suggesting that the virus is present locally. In addition, transmission is not only enterically through contaminated water but also through ingestion of undercooked infected meat (swine or wild animals) or through infected blood products. Recently, a persistent HEV infection with chronic hepatitis and cirrhosis has been reported in patients with reduced immune surveillance as induced by chemotherapy or post-transplant immunesuppression.

The histology of acute autochthonous hepatitis E virus infection

AIM

To document the histological appearances of liver biopsies in autochthonous hepatitis E virus (HEV) infection.

METHODS AND RESULTS

Four patients were serologically positive for HEV; three had no traditional risk factors, the fourth had recently returned from China. All four consumed meat products. Liver histology of the three autochthonous (locally acquired) cases showed portal tracts expanded by a severe mixed polymorph and lymphocytic inflammatory infiltrate, with a geographical distribution of polymorphs at the interface and lymphocytes centrally. Moderate to severe interface hepatitis and cholangiolitis were present. There was a striking acinar mixed inflammatory infiltrate made up of polymorphs, lymphocytes and macrophages; frequent apoptotic hepatocytes, focal necrosis, cholestatic rosettes and zone 3 canalicular and cytoplasmic bilirubinostasis were noted. Significant steatosis, megamitochondria and Mallory bodies were not present. There was no evidence of iron, copper or alpha(1)-antitrypsin accumulation. By contrast, the histology of the imported case of HEV infection showed less intense portal and acinar inflammation, no cholangiolitis and no geographical distribution of the portal inflammatory infiltrate.

CONCLUSION

The histological appearances of autochthonous HEV infection are sufficiently distinctive to consider the diagnosis in an acute setting and possibly to differentiate it from the endemic form of the disease.

Serological evidence of hepatitis E virus infection in an indigenous North American population

BACKGROUND

Hepatitis E virus (HEV) infections are thought to be uncommon in North America. Recently, HEV transmission has been reported following the consumption of deer meat. Because deer are closely related to caribou and caribou meat is a staple of the Canadian Inuit and the American Eskimo diet, the present study explored the seroprevalence of HEV infection in an isolated Canadian Inuit community.

METHODS

Stored sera were thawed and tested for immunoglobulin (Ig) G and IgM anti-HEV by ELISA, and tested for HEV-RNA by reverse transcriptase polymerase chain reaction.

RESULTS

The study consisted of 393 sera (representing approximately 50% of the community's inhabitants). Eleven samples (3%) were IgG anti-HEV-positive. Their mean age was 29+/-8 years and three were male. Two of 11 (18%) were also IgM anti-HEV-positive. All IgG anti-HEV-positive individuals were HEV-RNA-negative. Liver biochemistry was normal in all. Seven of 11 (64%) were also positive for anti-hepatitis A virus, five (46%) were hepatitis B virus seropositive and none (0%) were positive for anti-hepatitis C virus. There were no associations between infections with HEV and other hepatropic viruses. Serological testing was negative for HEV infection in 25 caribou from an adjacent region.

CONCLUSION

The results of the present study showed that serological evidence of HEV infection was present in 3% of the observed Canadian Inuit population; the presence of IgM anti-HEV suggested recent infection and HEV did not appear to coinfect with other common hepatotropic viruses. The source of HEV infection in the population remains unclear. These findings are interesting but preliminary. Additional data are required to determine whether HEV infections are responsible for otherwise unexplained acute hepatitis in the Canadian Inuit population and visitors returning from northern North American communities.

Bayesian estimation of hepatitis E virus seroprevalence for populations with different exposure levels to swine in The Netherlands

Hepatitis E virus (HEV) is ubiquitous in pigs worldwide and may be zoonotic. Previous HEV seroprevalence estimates for groups of people working with swine were higher than for control groups. However, discordance among results of anti-HEV assays means that true seroprevalence estimates, i.e. seroprevalence due to previous exposure to HEV, depends on choice of seroassay. We tested blood samples from three subpopulations (49 swine veterinarians, 153 non-swine veterinarians and 644 randomly selected individuals from the general population) with one IgM and two IgG ELISAs, and subsets with IgG and/or IgM Western blots. A Bayesian stochastical model was used to combine results of all assays. The model accounted for imperfection of each assay by estimating sensitivity and specificity, and accounted for dependence between serological assays. As expected, discordance among assay results occurred. Applying the model yielded seroprevalence estimates of approximately 11% for swine veterinarians,approximately 6% for non-swine veterinarians and approximately 2% for the general population. By combining the results of five serological assays in a Bayesian stochastical model we confirmed that exposure to swine or their environment was associated with elevated HEV seroprevalence.

Autochthonous hepatitis E in southwest England

Although autochthonous hepatitis E has been reported in developed countries, its extent and nature in the United Kingdom are unclear. The aim of the present study was to report the natural history, lifestyle risk factors and molecular epidemiology of autochthonous hepatitis E infection in southwest England. Three hundred and thirty-three patients with unexplained hepatitis were tested for markers of hepatitis E virus (HEV) infection over a 7-year period. HEV RNA isolated from the cases was amplified and characterized. Of the 333 patients, 21 had autochthonous hepatitis E. Patients were middle-aged or elderly and males were more commonly affected. Clinical manifestations ranged from asymptomatic infection to severe hepatitis. Of the 21 patients, 20 recovered within 6 weeks. None of the cases had travelled to an area endemic for HEV. None of the patients were vegetarian and all ate pork. Of the 21 cases, 20 occurred in the spring, summer and autumn months. All polymerase-chain-reaction-confirmed cases carried HEV genotype 3, which bore close sequence homology to HEV circulating in UK pigs. In the United Kingdom, autochthonous hepatitis E may be more common than previously recognized. Although the mode of transmission remains to be determined, it may be a zoonosis with pigs as a reservoir. Hepatitis E should be considered a public health issue in the United Kingdom.

Hepatitis E virus (HEV) infection in patients with cirrhosis is associated with rapid decompensation and death

BACKGROUND/AIMS

India is hyper-endemic for hepatitis E virus (HEV). HEV infection in cirrhosis may cause high mortality. Prospective study evaluating HEV infection in cirrhotics is scarce.

METHODS

Consecutive patients with cirrhosis and healthy controls were included. Cirrhotics were categorized to 3 groups, (Group I - rapid decompensation, Group II - chronically decompensated, Group III - cirrhotics without decompensation). Sera from cirrhotics and controls were tested for HEV-RNA (RT-PCR). HEV-RNA positivity among cirrhotics and controls was compared. Natural course and mortality rate between HEV infected and non-infected cirrhotics were assessed during a 12-month follow-up.

RESULTS

107 cirrhotics and 200 controls were included. 30 (28%) cirrhotics and 9 (4.5%) controls had detectable HEV-RNA (p<0.001). HEV- RNA positivity among Group I (n=42), II (n=32) and III (n=33) cirrhotics was 21 (50%), 6 (19%) and 3 (10%), respectively (p=0.002). 70% (21/30) with HEV infection and 27% (21/77) without it had rapid decompensation (p=0.001). Mortality between HEV infected and non-infected cirrhotics at 4 weeks (43% vs. 22%, p=0.001) and 12 month (70% vs. 30%, p=0.001) was different. Multivariate analysis identified HEV infection, Child-Pugh's score, renal failure, and sepsis as independent factors for mortality.

CONCLUSIONS

In India, cirrhotics were prone to HEV infection, which was associated with rapid decompensation and death.

Transfusion-transmitted hepatitis E in a 'nonhyperendemic' country

Indigenous hepatitis E is increasingly recognized in developed countries, where it may be a zoonosis. We describe the first case of transfusion-transmitted hepatitis E in the UK from a blood donor who had no history of recent travel abroad. Follow-up of the donor and recipients of the blood products was carried out using serological and molecular techniques. Acute hepatitis E was transmitted to one of two recipients. The infected patient would have received a larger volume of the donor's plasma. HEV subgenomic sequences carried by the donor and recipient were identical. This is the first case of post-transfusion hepatitis E in the UK. Secondary transmission of hepatitis E indigenous to a nonhyperendemic country may occur by blood transfusion. It is important that blood donors inform the transfusion service of all post-donation illnesses so that appropriate interventions can take place.

[Study on risk factors of sporadic hepatitis E virus cases in some districts of Shanghai]

OBJECTIVE

To study the risk factors of acute sporadic hepatitis E virus (HEV) cases and to analyze its partial sequence in some districts of Shanghai.

METHODS

30 blood samples were collected from the acute sporadic HEV cases in 2003-2004 and the RT-nPCR method was applied to obtain the sequence of HEV in these cases. Meanwhile, a 1:2 case-control study was used to identify risk factors in the process of sporadic HEV infection in these regions of Shanghai.

RESULTS

Data from the sequential analysis showed that HEV of the sporadic cases belonged to HEV genotype IV. Finding from the case-control study implicated that the housing condition, outside eating history, especially seafoods (OR = 7.048) played an important role in the infection of HEV. Results from multiple logistic regression showed that eating raw seafoods appeared to be one of the risk factors of HEV infection.

CONCLUSION

HEV sequences isolated from the sporadic cases of HEV in some districts of Shanghai belonged to HEV genotype IV. Foods, especially seafood, were the risk factors in the infection of HEV.

Hepatitis E virus infection as a marker for contaminated community drinking water sources in Tibetan villages

In April-May 2001, a study was conducted to determine the prevalence of antibodies against hepatitis E virus (HEV) among 426 persons 8-49 years of age randomly selected from two groups of rural villages in central Tibet. Group 1 villages were assessed in 1998 as having poor quality water sources; new water systems were then constructed prior to this study. Group 2 villages had higher quality water and were not designated as priority villages for new systems prior to the study. No participants tested positive for IgM; only IgG was detected in the analyzed samples. Overall, 31% of the participants had ever been infected with HEV (95% confidence interval [CI] = 26.7-35.7%). The rate was higher in men (36.6%) than women (26.3%) and highest in those 30-39 years of age (49.1%). The rate of past infection was higher in group 1; the risk ratio was 2.77 (95% CI = 1.98-3.88). This difference is most likely the result of the poor quality of the original water sources in these villages. In resource-poor countries, HEV may be a useful health indicator reflecting the degree of contamination in village water sources. This may be especially important in rural areas (such as Tibet) where maternal mortality ratios are high because HEV may be an important cause of deaths during pregnancy in disease-endemic areas.

Prevalence of Antibody to Hepatitis E Virus among Haemodialysis Patients in Taiwan: Possible Infection by Blood Transfusion

BACKGROUND/AIMS

A higher prevalence of anti-hepatitis E virus (HEV) in non-endemic viral hepatitis such as in Germany has been reported in our previous study. The aim of this study was to assess the seroepidemiology of HEV among haemodialysis (HD) patients in Shin-Kong Hospital, Taiwan, and to evaluate whether there was an increased risk of infection and exposure to HEV even in an area of endemic viral hepatitis.

METHODS

Serum samples obtained from 400 Taiwanese patients on chronic HD (group 1), 400 sex- and age-matched healthy subjects (group 2) and hospital patients (group 3) were tested for the IgG anti-HEV.

RESULTS

The prevalence of anti-HEV among the HD patients and the healthy controls were 31 and 8.9%, respectively. The difference (22%) was statistically significant (p < 0.01). In comparison, the anti-HEV in hospital patients was 16%.

CONCLUSION

The study indicated a significantly higher risk of HEV infection among patients on chronic HD in endemic regions of viral hepatitis such as Taiwan. Mostly because of anaemia, HD patients usually received packed transfusion (red blood cells) if their haemoglobin was low. It is possible that HEV infection may be transmitted through blood transfusions in an endemic area. In such areas, appropriate strategies should be adopted to prevent the risk of HEV among HD patients.

Age-wise exposure rates to hepatitis e virus in a southern Indian patient population without liver disease

To determine the age-stratified exposure to hepatitis E virus (HEV) in patients attending a tertiary care hospital in southern India, serum samples from 600 individuals were tested using a commercial HEV IgG enzyme-linked immunosorbent assay. Subjects were composed of blood donors, antenatal women, and pre-operative individuals who were negative for hepatitis B surface antigen and antibody to hepatitis C virus with no evidence of liver disease; 200 each were 1-5 and 6-15 years old and 100 each were 16-40 and > or = 41 years old. One (0.5%) sample was positive in those 1-5 years old, two (1.0%) in those 6-15 years old, eight (8%) in those 16-40 years old, and 13 (13%) in those > or = 41 years old. The overall seropositivity rate was 4%. However, there was an age-related increase in exposure to HEV that was statistically significant (P < 0.001), with a higher HEV seropositivity in urban individuals.

Prevalence of hepatitis E virus infection among hemodialysis patients in Japan: Evidence for infection with a genotype 3 HEV by blood transfusion

To investigate the prevalence of hepatitis E virus (HEV) infection among patients on maintenance hemodialysis, serum samples collected in January 2003 from 416 patients who had been undergoing hemodialysis for 7.6 +/- 6.3 (mean +/- standard deviation) (range, 0.3-26.0) years in a dialysis unit in Japan and serum samples that had been collected from these patients at the start of hemodialysis were tested for IgG antibodies to HEV (anti-HEV IgG) by an "in-house" enzyme-linked immunosorbent assay (ELISA). Overall, 39 patients (9.4%) had anti-HEV IgG in January 2003, and included 35 patients (8.4%) who had already been positive for anti-HEV IgG at the start of hemodialysis and 4 patients (1%) who seroconverted after initiation of hemodialysis. Periodic serum samples that had been collected from the four seroconverted patients were tested for HEV antibodies and HEV RNA. The four patients became positive for anti-HEV IgG in 1979, 1980, 1988, or 2003, and continued to be seropositive until the end of the observation period. Although anti-HEV IgM was not detectable in the four patients, three were infected transiently with apparently Japanese indigenous HEV strains of genotype 3. The patient who contracted HEV infection in 1979 had been transfused with 2 U of blood 21 days before the transient viremia: one of the two stored pilot serum samples had detectable HEV RNA with 100% identity to that recovered from the patient. Our study provides evidence of transfusion-transmitted HEV infection in Japan in 1979, and that the prevalence of de novo HEV infection during hemodialysis was low (1.1% or 4/374).

Increased Risk of Hepatitis E in Sewage Workers from India

Considering feco-oral transmission of hepatitis E virus (HEV), the risk of the infection was assessed among sewage workers. On the basis of the close contact with sewage, the participants (n = 147) were divided into sewage workers (n = 92) and others (n = 55); none used personal protective equipment (eg, coveralls, boots, gloves) Age-matched individuals from lower socioeconomic status and without any exposure to sewage were used as controls. IgG-anti-HEV positivity in enzyme-linked immunosorbent assay was significantly higher (P < 0.01) among staff members (83/147, 56.5%) than the controls (19%). A significant rise in anti-HEV positivity (P < 0.05) was recorded in sewage workers working for >5 years. Multivariate regression analysis identified contact with sewage as the independent variable associated with anti-HEV positivity. Strict adherence to good working practices must take top priority for protection of these workers from sewage pathogens.

Swine hepatitis E virus: cross-species infection and risk in xenotransplantation

Swine hepatitis E Virus (swine HEV), a ubiquitous agent recently discovered in pigs, is antigenically and genetically closely related to the human HEV. Swine HEV infection in pigs generally occurs at about 2-3 months of age, and about 80%-100% of the pigs in commercial farms in the USA were infected. Swine HEV infections have now been recognized in pigs in many other countries of the world. Interspecies transmission has been documented, as swine HEV infects non-human primates and some strains of human HEV infect pigs. Recent seroepidemiological studies showed that swine veterinarians and other pig handlers are at higher risk of HEV infection compared to normal blood donors. In addition, novel strains of human HEV recovered from hepatitis patients in the USA, Japan and Taiwan are genetically more closely related to strains of swine HEV from respective countries than to other strains of human HEV. The ubiquitous nature of the virus in pigs and the demonstrated ability of cross-species infection raise a potential concern for swine HEV infection in xenotransplantation with pig organs. This chapter discusses the recent advances in HEV research with emphases on potential zoonosis and xenozoonosis.

Viral hepatitis in international travellers: risks and prevention

Viral hepatitis is caused by a number of unrelated hepatotrophic viruses, known and unknown. Five hepatitis viruses namely HAV, HBV, HCV, HDV and HEV have been well characterized and the epidemiology and disease pattern of each agent has been defined. In the West, HAV, HBV and HCV are major causes of viral hepatitis. In the East, HEV is the most common cause of viral hepatitis. HAV is ubiquitous in childhood in such countries and accounts for less than 4% of disease in adults. Viral hepatitis becomes a problem to an international traveller when he envisages a journey from low endemic to high endemic area and is susceptible to the infection endemic at his destination. Millions of such potentially susceptible travellers from Europe, the USA, Canada, Japan, Australia, and New Zealand visit endemic areas every year for various reasons. Viral hepatitis is the most common reported immunization-preventable disease among travellers to developing countries. Imported viral hepatitis incapacitates the incumbents for an average of 4-10 weeks. Considering the magnitude of the travel, the number of cases of viral hepatitis and case fatality of around 2%, the disease causes significant morbidity and mortality in such communities. It has been estimated that viral hepatitis occurs 100 times more frequently than typhoid fever and 1,000 times more often than cholera in travellers to developing countries. Hepatitis A is the most common form of viral hepatitis in travellers and cumulative data have shown a risk of 3-6 cases/1,000 persons/month of stay whereas the risk of acquiring hepatitis B is 10 times lower.

Aetiology, clinical course and outcome of sporadic acute viral hepatitis in pregnancy

Hepatitis E causes large-scale epidemics in endemic areas. The disease, during epidemics, has increased incidence and severity in pregnant women. Sporadic acute viral hepatitis (AVH) is common in endemic areas. The relationship of sporadic AVH and pregnancy has not been well studied. Over a 3-year period we prospectively studied 76 pregnant women and 337 non-pregnant women of childbearing age with sporadic acute viral hepatitis for aetiology, clinical course and outcome of disease. The aetiology in sporadic AVH was hepatitis A virus (HAV) in six (1.5%), hepatitis B virus (HBV) in 62 (15%), hepatitis C virus (HCV) in seven (1.7%), hepatitis D virus (HDV) co-infection in six (1.5%), hepatitis E virus (HEV) in 205 (49.6%), and hepatitis non-A-to-E (HNAE) in 127 (30.7%). Sixty-five (85.5%) pregnant women and 140 (41.5%) nonpregnant women had hepatitis E. The proportion of pregnant women was 31.7% in HEV group and 5.3% in non-HEV group [P < 0.001; OR=8.3 (95%C1 4.2-16.3)]. The prevalence of HEV in pregnant women in first trimester (76.9%), second trimester (88.9%), third trimester (83.8%) and puerperium (100%) did not differ significantly (P=0.09). Forty-seven (61.8%) of the 76 pregnant women developed fulminant hepatic failure (FHF), 69.2% in HEV group and 10% in non-HEV group (P < 0.001). Thirty-four (10.1%) nonpregnant women developed fulminant hepatic failure, 10% in HEV group and 9.7% in non-HEV group (P=0.86). FHF had occurred in four (40%) of 10 patients with HE in first trimester as against 41 (74.5%) of 55 patients in second trimester and beyond (P=0.015). Amongst the major complications of fulminant hepatic failure, cerebral oedema (53.2%) and disseminated intravascular coagulation (21.3%) occurred more often in pregnant women than in nonpregnant women (29.4% and 2.8%; P=0.03 and 0.016, respectively) while infections occurred more often in nonpregnant women (36.1%) than in pregnant women (10.6%; P=0.003). Fifty (61.7%) patients with FHF died [25 (53.2%) pregnant women and 25 (69.5%) nonpregnant women (P=0.06)]. Cerebral oedema and HEV aetiology were independent variables of survival in patients with FHF. Patients with cerebral oedema had worse prognosis and patients with HEV aetiology had best chances of survival. Hence HEV was the most common cause of sporadic AVH in this endemic area. High proportion of pregnant women and increased severity of disease in pregnancy were limited to patients with hepatitis E. Sporadic AVH caused by agents other than HEV did not show any special predilection to or increased severity in pregnancy. FHF in pregnant women caused by HEV was an explosive disease with short pre- encephalopathy period, rapid development of cerebral oedema and high occurrence of disseminated intravascular coagulation and may represent a severe manifestation of a Schwartzmann-like phenomenon.

Hepatitis agents with enteric transmission--an epidemiological analysis

BACKGROUND

Viral hepatitis is characterized by special clinical, biochemical and serological findings. This study was planned to determine the seroprevalence, epidemiological characteristics and clinical and biochemical findings of hepatitis A virus (HAV) and hepatitis E virus (HEV) infections during an outbreak of jaundice.

MATERIALS AND METHODS

340 children aged 5-16 years were included. Clinical findings and alanine aminotransferase (ALT) levels were documented. Anti-HAV IgG and IgM in addition to anti-HEV IgG and IgM were determined by microELISA.

RESULTS

Clinical findings, high levels of ALT, anti-HAV IgM and IgG, anti-HEV IgM and IgG were present in 6%, 23%, 17%, 100%, 7% and 9% of cases, respectively. The relationship between ALT levels and anti-HAV or anti-HEV IgM seropositivity was significant (p </= 0.0001).

CONCLUSION

HAV and HEV infection were both caused by a contaminated water supply.

Hepatitis E: review of a disease endemic in Pakistan

Hepatitis E is enterically transmitted causing a self-limiting illness similar to hepatitis A. However, unlike hepatitis A, immunity to hepatitis E is not life long, hepatitis E is a disease of developing nations with improper sewage disposal and unclean water supplies. It is thought to be the most common cause of acute sporadic hepatitis in Pakistan, where it has also caused major epidemics. Hepatitis E causes a mild self-limiting illness with no long-term sequelae. However, it is especially severe in pregnant females in the second and third trimesters, in whom it results in a high mortality rate (up to 20%) and an increased incidence of stillbirths. Diagnosis depends on clinical findings and elevated hepatic enzymes. Protection from this disease in endemic areas lies mainly in prevention, as the vaccine for hepatitis E is still in the experimental stage. Provision of clean drinking water, hand washing before eating and proper disposal of sewage has been shown to decrease the incidence of this disease.

[Hepatitis E virus infection in Albania]

Acute HEV in Albania make up 35.7% of acute non A-non B hepatitis and 2.4% of all acute viral hepatitis cases, affecting women more with a 2:1 ratio, and are described more frequently in adults (73.3%) older than 35 years. In the general population (control group), the prevalence of anti-HEV antibodies increases progressively with age, from 1.2% in the younger than 9 years, to 17.7% among the over 60, in general the average is of 9.7%. A statistical comparison of anti-HEV antibodies in healthy persons younger than 20, and those 20 years old and over is significant (p < 0.0001). HEV transmission by blood transfusion, mentioned by some authors, could be related to the infection of blood donors. We have not found any positive cases in thalassemic children who received between 24 and 169 transfusions. The prevalence of anti-HEV antibodies in pregnant women is lower than in the general population (p < 0.0001). In patients with chronic liver disease, in comparison with the general population (control group), there is no statistical significant difference (p = NS).

Hepatitis E

Hepatitis E, previously known as enterically transmitted non-A, non-B hepatitis, is an infectious viral disease with clinical and morphologic features of acute hepatitis. Its causative agent, hepatitis E virus, consists of small, 32- to 34-nm diameter, icosahedral, nonenveloped particles with a single-stranded, positive-sense, 7.5-kb RNA. The virus has two main geographically distinct strains, Asian and Mexican; recently, novel isolates from nonendemic areas and a genetically related swine HEV have been described. HEV is responsible for large epidemics of acute hepatitis and a proportion of sporadic hepatitis cases in the Indian subcontinent, southeast and central Asia, the Middle East, parts of Africa, and Mexico. The virus is excreted in feces and is transmitted predominantly by fecal-oral route, usually through contaminated water. Person-to-person transmission is uncommon. Clinical attack rates are the highest among young adults. Recent evidence suggests that humans with subclinical HEV infection and animals may represent reservoirs of HEV; however, further data are needed. Diagnosis of hepatitis E is usually made by detection of specific IgM antibody, which disappears rapidly over a few months; IgG anti-HEV persists for at least a few years. Clinical illness is similar to other forms of acute viral hepatitis except in pregnant women, in whom illness is particularly severe with a high mortality rate. Subclinical and unapparent infections may occur; however, chronic infection is unknown. No specific treatment is yet available. Use of clean drinking water and proper sanitation is currently the most effective method of prevention. Passive immunization has not been proved to be effective, and recombinant vaccines for travelers to disease-endemic areas and for pregnant women currently are being developed.

Sporadic acute hepatitis E in the united kingdom: an underdiagnosed phenomenon?

BACKGROUND

Hepatitis E (HEV) is the primary cause of enterically transmitted non-A non-B hepatitis worldwide. Case reports of HEV in individuals in the United Kingdom relate to travel to endemic areas or contact with individuals who have visited these areas.

CASE REPORTS

Four individuals presented with acute hepatitis to a hepatology clinic in a teaching hospital. Serology confirmed acute hepatitis E in all four. Investigation by the Communicable Disease Control Department established no links between the cases, no travel to an endemic area, and no contacts.

CONCLUSION

Contrary to current belief, community acquired hepatitis E virus infection occurs sporadically in the United Kingdom and should be considered as a cause of seronegative hepatitis.

Short report: phylogenetically distinct hepatitis E viruses in Pakistan

Hepatitis E, which is enterically transmitted, is the most common cause of acute hepatitis in much of Asia. Phylogenetic analysis of several isolates of hepatitis E virus (HEV) from Asia suggests that transmission of this virus is geographically restricted. In Sarghoda, Pakistan, HEV Sar-55 was isolated from a 1987 outbreak. It belongs to the Central-Asian cluster of the Asian sub-genotype. We now report the complete sequence of a second Pakistan HEV from a 1988 outbreak in Abbottabad. The Abbottabad nucleotide sequence was compared with 15 other complete HEV sequences using statistical methods of phylogenetic analysis. The analysis showed that Abbottabad HEV belongs to the South Asia cluster of the Asian sub-genotype. The sequence differences of the 2 Pakistan isolates recovered only one year apart suggest that HEV of 2 distinct origins circulate in Pakistan.

Hepatitis E: an overview and recent advances in clinical and laboratory research

Hepatitis E virus (HEV) is a non-enveloped RNA (7.5 kb) virus that is responsible for large epidemics of acute hepatitis and a proportion of sporadic hepatitis cases in southeast and central Asia, the Middle East, parts of Africa and Mexico. Hepatitis E virus infection spreads by the faecal-oral route (usually through contaminated water) and presents after an incubation period of 8-10 weeks with a clinical illness resembling other forms of acute viral hepatitis. Clinical attack rates are the highest among young adults. Asymptomatic and anicteric infections are known to occur. Chronic HEV infection is not observed. Although the mortality rate is usually low (0.07-0.6%), the illness may be particularly severe among pregnant women, with mortality rates reaching as high as 25%. Recent isolation of a swine virus resembling human HEV has opened the possibility of zoonotic HEV infection. Studies of pathogenetic events in humans and experimental animals reveal that viral excretion begins approximately 1 week prior to the onset of illness and persists for nearly 2 weks; viraemia can be detected during the late phase of the incubation period. Immunoglobulin M antibody to HEV (anti-HEV) appears early during clinical illness but disappears rapidly over a few months. Immunoglobulin G anti-HEV appears a few days later and persists for at least a few years. There is no specific treatment available for hepatitis E virus infection. Ensuring a clean drinking water supply remains the best preventive strategy. Recombinant vaccines are being developed that may be particularly useful for travellers to disease-endemic areas and for pregnant women.