|Year : 2015 | Volume
| Issue : 5 | Page : 102-105
Prevalence of Hepatitis A virus (HAV) and Hepatitis E virus (HEV) in the patients presenting with acute viral hepatitis
A Joon1, P Rao2, SM Shenoy2, S Baliga2
1 Department of Ophthalmology, Mahadevappa Rampure Medical College, Gulbarga, Karnataka, India
2 Department of Microbiology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
|Date of Submission||18-Dec-2013|
|Date of Acceptance||05-Jun-2014|
|Date of Web Publication||6-Feb-2015|
S M Shenoy
Department of Microbiology, Kasturba Medical College, Manipal University, Mangalore, Karnataka
Source of Support: Pilot study was ICMR, STS project, Conflict of Interest: None
Background: Hepatitis A virus (HAV) and Hepatitis E virus (HEV) are both enterically transmitted, resulting in acute viral hepatitis (AVH) in developing countries. They pose major health problems in our country. This study was done to determine prevalence of HAV and HEV in patients presenting with AVH and the co-infection of HAV and HEV in these patients. Materials and Methods: A cross-sectional study of 2-years duration was conducted in the Department of Microbiology, KMC, Mangalore. A non-random sampling of 958 patients presenting with AVH was considered in the study. On the basis of history, serum samples were analysed for IgM anti-HAV and IgM anti-HEV for the detection of HAV and HEV, respectively using commercially available ELISA kits. Data collected was analysed by using Statistical Package for the Social Sciences (SPSS) version 11.5. Results: The seroprevalence of HAV- and HEV-positive patients were 19.31% and 10.54%, respectively. The seroprevalence of both HAV and HEV in patients with acute viral hepatitis was 11.5%. The prevalence of HAV and HEV among males (68% and 31%) was higher than in females (31% and 20%) and was predominantly seen among young adults. These infections were predominantly seen during end of monsoons and beginning of winter. Conclusion: Though the prevalence of HAV is much higher than that of HEV, co-infection rate of 11.5% mandates the screening for HEV which will be of immense importance in pregnant women and improving levels of personal hygiene among higher socio-economic population. These data will be essential for planning of future vaccination strategies and for better sanitation programme in this part of the country.
Keywords: Acute viral hepatitis, co-infection, Hepatitis A Virus, Hepatitis E Virus, prevalence
|How to cite this article:|
Joon A, Rao P, Shenoy S M, Baliga S. Prevalence of Hepatitis A virus (HAV) and Hepatitis E virus (HEV) in the patients presenting with acute viral hepatitis. Indian J Med Microbiol 2015;33, Suppl S1:102-5
|How to cite this URL:|
Joon A, Rao P, Shenoy S M, Baliga S. Prevalence of Hepatitis A virus (HAV) and Hepatitis E virus (HEV) in the patients presenting with acute viral hepatitis. Indian J Med Microbiol [serial online] 2015 [cited 2020 May 31];33, Suppl S1:102-5. Available from: http://www.ijmm.org/text.asp?2015/33/5/102/150908
| ~ Introduction|| |
Communicable diseases are still the major health problem in our country, and the hepatitis viruses residing in India are usually the endemic forms.
Hepatitis A virus (HAV) is transmitted via the faecal-oral route, and has a global distribution.  HAV infection is a common infection responsible for about 1.4 million new infections worldwide each year.  HAV is a non-enveloped 27-nm, heat-, acid-, and ether-resistant ribonucleic acid (RNA) virus in the genus Hepatovirus of the family Picornaviridae. Antibodies to HAV (anti-HAV) can be detected during acute illness when serum aminotransferase activity is elevated and faecal HAV shedding is still occurring. This early antibody response is predominantly of the IgM class and persists for several months, rarely for 6-12 months. During convalescence, however, anti-HAV of the IgG class becomes the predominant antibody. Hepatitis A remains self-limited and does not progress to chronic liver disease.  With the development of safe and effective hepatitis A vaccines in the early 1990s, understanding hepatitis A epidemiology has taken on new importance, because this information is needed to make well-informed decisions about prevention strategies and appropriate vaccine use.
Hepatitis E virus (HEV) is also an enterically transmitted virus that occurs primarily in Asia, Africa, and Central America. HEV is a non-enveloped virus with a single-stranded positive-sense RNA in the genus Hepevirus of the family Hepeviridae. The IgM and IgG classes of antibodies to HEV (anti-HEV IgM and anti-HEV IgG) can be detected, but the former falls rapidly after acute infection, reaching low levels within 6 months. Currently, serologic testing for HEV infection is not available routinely. 
In most studies of sporadic acute hepatitis and fulminant liver failure in the region, 20-60% of patients have been related to infection with HEV. Among pregnant women with these diseases, the rates of HEV infection have usually been higher than among non-pregnant patients. The seroprevalence rates of prior exposure to HEV are however relatively low, being 10-40% in most studies.  Overall, hepatitis E disease is highly endemic in this region with spurts of sporadic outbreaks and epidemics.
Current trend shows an increase in the prevalence of HAV and HEV co-infection, hence this study was conducted to determine the prevalence of HAV and HEV and their co-infection in patients presenting with AVH.
| ~ Materials and Methods|| |
Study design and population
A cross-sectional study, which included 958 sera of patients during a 2-year period presenting with acute viral hepatitis was considered. The study population included sera of individuals from all age group who were suspected of acute viral hepatitis (AVH) admitted at Kasturba Medical College Hospitals, Mangalore.
On the basis of history, serum samples were analysed for IgM anti HAV and IgM anti-HEV for the detection of acute hepatitis A and acute hepatitis E, respectively using commercially available ELISA kits (General biologicals Corp for HAV IgM ELISA and MP diagnostics for HEV IgM ELISA).
Data collected was fed in to Microsoft Excel and analysis was done using SPSS version 11. Statistical test (chi) 2 was used for analysing qualitative variable and Student 't' test for quantitative variable. P < 0.05 was taken as statistically significant.
| ~ Results|| |
This study was conducted, after obtaining clearance from institutional ethics committee, on total of 958 samples, during a 2-year period in Department of Microbiology, KMC, Mangalore.
The prevalence of HAV and HEV co-infection in patients with acute viral hepatitis was 11.5% (33 cases) [Figure 1]. Among which 28 were male and 5 were females. The age group were the co-infection was prevalent was between 9 years to 35 years.
In our study, [Figure 2] shows that HAV infection was seen in all age group except above the age of 45 years. It was noted that it was more prevalent in the age group between 10 to 30 years. Highest prevalence was in the patients with age between 21-25 years. HEV infection was seen among all age group and maximum prevalence in the age group 21-25 years.
HAV infection in males was 68% and females were 31%. HEV infection in males was 79% and in females was 20%. It was noted that the liver enzymes like alanine amino transferase, aspartate amino transferase were found to be deranged in all the cases.
Four cases of HEV infection during gestational period had fulminant hepatitis, but no mortality was reported. Two cases had fulminant HEV infection along with Wilson`s disease and both died due to severe impairment of liver function.
[Figure 3] shows HAV and HEV seen to be prevalent all around the year with predominance seen towards the end of monsoons and beginning of winters and more so even the co-infection showed a similar seasonal distribution. A peak in HEV was also noted in the beginning of rainy season.
| ~ Discussion|| |
Our study was conducted mainly to determine the prevalence of HAV and HEV and their co-infection in this region. In the present study, only 29.9% of the suspected cases had a positive viral marker. This was comparatively lower than the 49% as seen in another study.  A prevalence of 11.5% cases with co-infection of HAV and HEV was noted in our study. Twelve (36.4%) were positive for anti-HAV IgM only, 7 (21.2%) were positive for anti-HEV IgM only and 14 (42.4%) were positive for antibodies to both viruses in a study by Licel de los Angeles Rodríguez et al. In another study, which included a total of 249, 100% of the adult population 23-86 years of age tested positive for anti-HAV and 11% of the same population had detectable anti-HEV antibodies.  Dual infection was significantly compared to another study done in South India.  Co-infection with HEV and HAV did not affect the prognosis as these cases improved after symptomatic treatment. Acute hepatitis A is usually improved by conservative management, but in another case report it was found that co-infection of HAV and HEV may lead to severe forms of disease such as hepatic encephalopathy.  Generally, the incidence of Hepatitis A is closely related to the socioeconomic conditions of sanitation and hygiene.
We found that prevalence of HAV was more than HEV with respect to age specificity HAV and HEV were predominantly seen among young adults, the risk and severity increases with age in HEV infection. The low prevalence of anti-HEV in children is attributable to lack of exposure to HEV in children.  The HEV infection preferentially reaches teenagers and young adults. In the same study, Hepatitis E was more common in young adults (15-44 years). This seems paradoxical for an enteral infection transmission, in which exposure is theoretically the same for all people subject to the terms of hygiene (Pawlotsky, 2001). It is possible that HEV infection is usually anicteric and goes unnoticed in children. These findings also agree with the results found in some other studies too. , Even in the adult population, the prevalence of HEV infection was markedly lower than that of HAV infection (100%) in Mongolia.  The age-specific sero-prevalence of antibody to HEV was studied in Pune, India. Antibodies to HEV were uncommon in children and reached a peak prevalence of 33-40% in early adulthood.
Four cases of HEV infection during gestational period had fulminant hepatitis. Among them, three were in third trimester and one had tubal pregnancy. We did not find increased mortality with HEV infection during pregnancy because of small number of series involved, this was noted in another study. 
Prevalence of both HAV and HEV were higher in males than in females which has correlated with other studies. , It could be explained by a greater exposure of men in their professional and social activities.
Considering the seasonal variations, HAV and HEV were seen to be prevalent all around the year with predominance seen towards the end of monsoons and beginning of winters and also a peak rise of HEV during beginning of rainy season. Hepatitis E is mainly transmitted by cross contamination of drinking water with sewage. Hepatitis A was more common in winter and Hepatitis E was more common in summer. 
| ~ Conclusion|| |
Though the prevalence of HAV is much higher than that of HEV, a seroprevalence of 10.54% and a co-infection rate of 11.5%, mandates the screening for HEV. This will especially be useful in pregnant women where outcome of infection with HEV is very poor. Clinical diagnosis of acute viral hepatitis must be confirmed by serology to detect all the types of causative viruses (A, B, C and E), since presence of certain predictors cannot be considered as a rule for expecting the type of the virus. Therefore, sustainable availability of the diagnostic kits of all types should be maintained in health care centers.
With similar faecal-oral mode of transmission of Hepatitis A and E viruses and improving levels of personal and food hygiene among higher socio-economic population, periodic surveillance of HAV/HEV exposure pattern may be of immense public health value. The requirement of collaborating of sectors to work together to supply safe water and safe sewage disposal.
As it is evident from our study, infection with both the enteric hepatic viruses (HAV and HEV) is not infrequent. These data will be essential for planning of future vaccination strategies and for better sanitation program in this part of the country.
| ~ Acknowledgement|| |
ICMR STS GRANT 2009.
| ~ References|| |
Jacobsen KH, Koopman JS. Declining hepatitis A seroprevalence: A global review and analysis. Epidemiol Infect 2004;132:1005-22.
World Health Organization, Hepatitis A vaccines: WHO position paper. Wkly Epidemiol Rec 2000;75:38-44.
Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL. Harrison's Principles of Internal Medicine. 5 th
ed.; 2001. p. 1694-710.
World Health Organisation, The Global Prevalence of Hepatitis E Virus Infection and Susceptibility: A Systematic Review; 2010.
Al-Naaimi AS, Turky AM, Khaleel HA, Jalil RW, Mekhlef OA, Kareem SA, et al
. Predicting acute viral hepatitis serum markers (A and E) in patients with suspected acute viral hepatitis attending primary health care centers in Baghdad: A one year cross-sectional study. Glob J Health Sci 2012;4:172-83.
Rodríguez Lay Lde L, Quintana A, Villalba MC, Lemos G, Corredor MB, Moreno AG, et al
. Dual infection with hepatitis A and E viruses in outbreaks and in sporadic clinical cases: Cuba 1998-2003. J Med Virol 2008;80:798-802.
Takahashi M, Nishizawa T, Gotanda Y, Tsuda F, Komatsu F, Kawabata T, et al
. High prevalence of antibodies to hepatitis A and E viruses and viremia of hepatitis B, C, and D viruses among apparently healthy populations in Mongolia. Clin Diagn Lab Immunol 2004;11:392-8.
Radhakrishnan S, Raghuraman S, Abraham P, Kurian G, Chandy G, Sridharan G. Prevalence of enterically transmitted hepatitis viruses in patients attending a tertiary-care hospital in South India. Indian J Pathol Microbiol 2000;43:433-6.
Park JH, Kim BS, Lee CH, Kim SY, Seo JH, Hur CJ. A case of co infection of Hepatitis A and E virus with hepatic encephalopathy. Korean J Med 2011;80 Suppl 2:S101-5.
Kamal SM, Mahmoud S, Hafez T, El-Fouly R. Viral Hepatitis A to E in South Mediterranean Countries. Mediterr J Hematol Infect Dis 2010;2:e2010001.
Pelosi E, Clarke I. Hepatitis E: A complex and global disease. Emerg Health Threats J 2008;1:e8.
Davaalkham D, Enkhoyun T, Takahashi M, Nakamura Y, Okamoto H. Hepatitis A and E Virus infections among children in Mongolia. Am J Trop Med Hyg 2009;81:248-51.
[Figure 1], [Figure 2], [Figure 3]