FRANCE; HEPATITIS E.

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HEPATITIS E - FRANCE: (SOUTHEAST), AUTOCHTHONOUS AND FOOD-BORNE
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A ProMED-mail post
<http://www.promedmail.org/>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org/>
Date: Tue 12 Apr 2011
From: Philippe Colson [edited]
<philippe.colson@univmed.fr>

Autochthonous hepatitis E -- Marseille, southeastern France
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We report on 11 hepatitis E virus (HEV) infections diagnosed from
January through March 2011 by PCR and serology in our microbiology lab
at University hospitals of Marseille, southeastern France. The 11
cases were 10 men and a woman. Their age was 57 plus or minus 11
years. One patient died 2 months after the onset of hepatitis. None of
the cases traveled abroad during the three months before the disease
onset. Consumption of pig liver sausage was documented in 6 of 9
patients that could be interviewed. Noteworthy, anti-HEV IgM could be
detected in the serum from the wife of 2 of the cases that ate
uncooked pig liver sausage. Both women ate the same sausage as their
husbands. In one of the women, ALT level was 165 UI/l; no clinical
symptom was noted.
Eight of these 11 hepatitis E cases occurred from 24 Feb 2011. From
this date, the number of hepatitis E cases diagnosed in our lab
significantly increased. This was detected by EPIMIC, a home-made
alert and surveillance epidemiologic tool that analyses in real-time
the number of clinical samples and positive diagnosis in our
microbiology lab. The alert threshold is the mean value of historical
data plus 2 standard deviations (SD). Starting from 24 Feb 2011, the
number of serum samples tested and of those testing positive for
anti-HEV IgM were above the threshold. Indeed, 54 sera were tested
(mean value, 22; 2 SD, 30), and at least 5 of them tested positive for
anti-HEV IgM (Adaltis assay) (mean value, 1; 2 SD, 3). Concurrently,
the number of PCR-documented hepatitis E was between 1 and 3 per week,
whereas the mean value is 0.4 based on historical data.
In developed industrialized countries, it was thought until recently
that hepatitis E was related to travel in tropical or sub-tropical
countries, where HEV infection is hyper-endemic. Nevertheless, it
turns out that most cases are autochthonous, occurring in patients who
have not traveled abroad over the last 2-9 weeks (incubation period of
the disease). In France, more than 200 indigenous cases are reported
each year. Most of them were diagnosed in the southern region, where
the prevalence of anti-HEV IgG in blood donors is higher than in the
North (8-16.6 percent versus 3.4 percent).
It has been clearly shown in developed industrialized countries that
pigs (and boars) are reservoirs of the virus. Acute hepatitis E has
been diagnosed in our lab in persons who consumed uncooked pig liver
sausages, which are widely eaten in southeastern France. These
sausages are good candidates for the transmission of hepatitis E
because they are made with pig liver (the site of viral
multiplication), are not cooked during the manufacturing process, and
are often eaten uncooked. We reported in 2009 on 8 hepatitis E among
patients who ate pig liver sausage [see: ProMED-mail post archived as:
Hepatitis E - France: (Marseille) pig liver sausage 20090917.3267]. A
case-control study conducted in 3 different families revealed that
acute or recent hepatitis E were significantly associated with
consumption of uncooked pig liver sausage. In addition, genetic links
were found between viral sequences recovered from sausages and those
recovered from patients.
Subsequently to the notification of these cases, French health
authorities compelled producers of pig liver sausages to indicate on
the label of the products that they need to be cooked thoroughly.
Indeed, it was shown that cooking pieces of liver containing HEV
limits their infectivity.
The mortality of symptomatic cases of hepatitis E is 1 to 4 percent;
fatal outcome occurs mostly among people who already have chronic
liver disease. Moreover, it appears that the infection can progress
towards chronic hepatitis among severely immunocompromized persons, as
observed in kidney or liver transplant recipients and in persons
infected with HIV. The proportion of asymptomatic HEV infections
remains unknown to date.
--
Philippe Colson PharmD PhD
Pôle des Maladies Infectieuses et Tropicales Clinique et
Biologique,
Federation de Bacteriologie-Hygiene-Virologie,
Centre Hospitalo-Universitaire Timone, AP-HM,
URMITE CNRS UMR 6236 IRD 198
Facultes de Medecine et de Pharmacie
Universite de la Mediterranee
<philippe.colson@ap-hm.fr>
and
Rene Gerolami MD PhD
Service d'Hepato-Gastro-Enterologie
Centre Hospitalo-Universitaire Conception
147 boulevard Baille, 13385 Marseille CEDEX 05, France
<rene.gerolami@ap-hm.fr>
[ProMED-mail thanks Drs Philippe Colson and Rene Gerolami for sharing
with us and our readers this account of their current investigations
of hepatitis E virus infection in southeastern France.
To put the clinical investigation of of Drs Colson and Gerolami in
context, the following are some extracts from the WHO Fact sheet
(<http://www.who.int/mediacentre/factsheets/fs280/en/index.html>):
"Hepatitis E was not recognized as a distinct human disease until
1980. Hepatitis E is caused by infection with hepatitis E virus (HEV),
a non-enveloped, positive-sense, single-stranded RNA virus. HEV is
transmitted via the faecal-oral route.
"Hepatitis E has been considered a waterborne disease, and
contaminated water or food supplies have been implicated in major
outbreaks. Consumption of faecally contaminated drinking water has
given rise to epidemics, and the ingestion of raw or uncooked
shellfish has been the source of sporadic cases in endemic areas.
There is a possibility of zoonotic spread of the virus, since several
non-human primates, pigs, cows, sheep, goats and rodents are
susceptible to infection. The risk factors for HEV infection are
related poor sanitation in large areas of the world, and HEV shedding
in faeces. Person-to-person transmission is uncommon. There has been
no evidence for sexual transmission or for transmission by
transfusion. The highest rates of infection occur in regions where low
standards of sanitation promote the transmission of the virus.
Epidemics of hepatitis E have been reported in Central and South-East
Asia, North and West Africa, and in Mexico, especially where faecal
contamination of drinking water is common. However, sporadic cases of
hepatitis E have also been reported elsewhere and serological surveys
suggest a global distribution of strains of hepatitis E of low
pathogenicity. In general, hepatitis E is a self-limiting viral
infection followed by recovery. Prolonged viraemia or faecal shedding
are unusual and chronic infection does not occur.
"The incubation period following exposure to HEV ranges from 3 to 8
weeks, with a mean of 40 days. The period of communicability is
unknown. There are no chronic infections reported.
"Hepatitis E virus causes acute sporadic and epidemic viral
hepatitis. Symptomatic HEV infection is most common in young adults
aged 15-40 years. Although HEV infection is frequent in children, it
is mostly asymptomatic or causes a very mild illness without jaundice
(anicteric) that goes undiagnosed.
"Typical signs and symptoms of hepatitis include jaundice (yellow
discoloration of the skin and sclera of the eyes, dark urine and pale
stools), anorexia (loss of appetite), an enlarged, tender liver
(hepatomegaly), abdominal pain and tenderness, nausea and vomiting,
and fever, although the disease may range in severity from subclinical
to fulminant.
"Since cases of hepatitis E are not clinically distinguishable from
other types of acute viral hepatitis, diagnosis is made by blood tests
which detect elevated antibody levels of specific antibodies to
hepatitis E in the body or by or by reverse transcriptase polymerase
chain reaction (RT-PCR). Unfortunately, such tests are not widely
available.
"Hepatitis E should be suspected in outbreaks of waterborne hepatitis
occurring in developing countries, especially if the disease is more
severe in pregnant women, or if hepatitis A has been excluded. If
laboratory tests are not available, epidemiologic evidence can help in
establishing a diagnosis. (As is demonstrated by Drs Colson and
Gerolami above).
"As no specific therapy is capable of altering the course of acute
hepatitis E infection, prevention is the most effective approach
against the disease. Hospitalization is required for fulminant
hepatitis and should be considered for infected pregnant women."