Seroepidemiology of a recent outbreak of Hepatitis E in urban Shimla, Himachal Pradesh, India

Abstract

Hepatitis E, a major public health problem, continues to cause epidemics in different geographic areas in India and poses multi-sectoral challenges. The aim of the study was to determine the seroepidemiology of the hepatitis outbreak in the urban areas of district Shimla, Himachal Pradesh. Patients presenting with clinical features of acute viral hepatitis during and after the epidemic period were tested for seromarkers; IgM anti-HEV and IgM anti-HAV by enzyme linked immunosorbant assay. The weekly reporting under Integrated Disease and Surveillance Programme (IDSP) for cases of jaundice from Shimla from December 2015 to April 2016 was reviewed. The outbreak of hepatitis due to contamination of drinking water supply in urban Shimla beginning December 12, 2015 was confirmed by IDSP. A total of 425 serum samples (males: 292; females: 133) were tested for IgM anti-HAV and IgM anti-HEV by ELISA. Liver enzymes where deranged in all cases. Serological evidence of infection with HAV and/or HEV was seen in 64%. HEV infection alone was detected in 62.13%. All ages were affected, with one case of HEV infection below ten years. HEV infection alone was 5 times more common than HAV infection and co-infection was detected in 69 cases (m: 47; f:22). Six antenatal mothers were anti-HEV positive and the maternal mortality of 50% (n=3) due to fulminant hepatitis. Since HAV and HEV have a similar faecal-oral route of transmission, this study highlights periodic surveillance of HAV/HEV exposure pattern to improve levels of personal and food hygiene and inter-sectoral collaboration for provision of safe water supply and safe sewage disposal.

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

“…We identified 51 outbreak reports [ 30 , 50 , 78 , 82 , 85 , 93 , 104–148 ] describing 49 completed or ongoing outbreaks occurring in 18 countries between 1988 and 2017. Among outbreaks with reported locations (48 of 49), outbreaks were identified in Africa (43%) and Asia (57%), with over half of outbreaks reported from 3 countries: India (35%) [ 30 , 106 , 107 , 109 , 110 , 114 , 117 , 121 , 125 , 128 , 136–138 , 141 , 145 , 147 , 148 ], Sudan (10%) [ 119 , 133 , 140 , 143 , 144 ], and Uganda (8%) [ 78 , 85 , 108 , 126 , 129 ]. Reported outbreak durations ranged from 28 days (Yangon, Myanmar) [ 142 ] to 3.2 years (Karamoja region, Uganda) [ 126 ] (median, 166 days; interquartile range [IQR], 91–303).…”

“…Among studies reporting data on deaths (34 of 49), the CFR ranged from 0% to 28% among suspected cases (mean = 2, standard deviation [SD] = 6) and 0%–28% among confirmed cases (mean = 3, SD = 7). Fewer outbreak reports had available data on deaths among pregnant women (20 of 48), and the CFR among pregnant women ranged from 0% to 33% among suspected cases (mean = 11, SD = 10) and 0%–65% among confirmed cases (mean = 28, SD = 24) [ 50 , 78 , 82 , 104 , 106 , 108 , 112–114 , 117 , 119 , 120 , 123 , 124 , 126–129 , 140 , 146 ]. The highest CFR (65%; 15 fatalities among 23 confirmed pregnant cases) was reported among pregnant women in an outbreak in Napak district, Uganda, which had over 1300 confirmed cases of HEV in the overall population in 2013–2014 [ 108 ].…”

Setting a course for preventing hepatitis E in low and lower-middle-income countries: A systematic review of burden and risk factors

“…We identified 51 outbreak reports (30,50,78,82,85,93,104–107,107–148) describing 49 completed or on-going outbreaks occurring in 18 countries between 1988 and 2017. Among outbreaks with reported locations (48/49), outbreaks were identified in Africa (43%) and Asia (57%), with over half of outbreaks reported from 3 countries: India (35%) (30,106,107,109,110,114,117,121,125,128,136–138,141,145,147,148), Sudan (10%) (119,133,140,143,144), and Uganda (8%) (78,85,108,126,129). Reported outbreak durations ranged from 28 days (Yangon, Myanmar) (142) to 3.2 years (Karamoja region, Uganda) (126) (Median: 166 days; IQR: 91-303).…”

“…Among studies reporting data on deaths (34/49), the CFR ranged from 0-28% among suspected cases (mean: 2; SD: 6) and 0-28% among confirmed cases (mean: 3; SD: 7). Fewer outbreak reports had available data on deaths among pregnant women (20/48), and the CFR among pregnant women ranged from 0-33% among suspected cases (mean: 11; SD: 10) and 0-65% among confirmed cases (mean: 28; SD: 24) (50,78,82,104,106,108,112–114,117,119,120,123,124,126–129,140,146). The highest CFR (65%; 15 fatalities among 23 confirmed pregnant cases) was reported among pregnant women in an outbreak in Napak district, Uganda which had over 1,300 confirmed cases of HEV in the overall population in 2013-2014 (108).…”

“…Population types include general population, blood donors, patients attending a hospital or clinic for non-liver related, non-pregnancy related issues (hospital), pregnant women, occupational groups exposed to animals (occupational), outbreak residents, or other. Black line represents the best fit linear trend between age and seropositivity.Age-specific seroprevalence estimates, excluding occupational groups and outbreak residents, increased by age with all assays used, except Abbott (SupplementalFigure 1).OutbreaksWe identified 51 outbreak reports(30,50,78,82,85,93,104-107,107-148) describing 49 completed or on-going outbreaks occurring in 18 countries between 1988 and 2017.Among outbreaks with reported locations (48/49), outbreaks were identified in Africa (43%) and Asia (57%), with over half of outbreaks reported from 3 countries: India (35%)(30,106,107,109,110,114,117,121,125,128,(136)(137)(138)141,145,147,148), Sudan (10%)(119,133,140,143,144), and Uganda (8%)(78,85,108,126,129).Reported outbreak durations ranged from 28 days (Yangon, Myanmar) (142) to 3.2 years (Karamoja region, Uganda) (126) (Median: 166 days; IQR: 91-303). At least one largescale outbreak with over 5,000 suspected cases occurred in every decade since 1988, and outbreaks in the last 15 years (2004-2017) had a median of 1152 suspected cases reported (IQR: 252-2362).…”