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Hepatitis E in India
1Department of Pediatric Gastroenterology, S.M.S. Medical College, Jaipur, India. tomar-dr@jpl.vsnl.net.in
Insights
Hepatitis E virus (HEV) causes over 70% of acute hepatitis in children in the subcontinent, primarily spread through contaminated water and food. HEV can be found in various bodily fluids and even insects, with potential for maternal-neonatal transmission.
Area of Science:
- Virology
- Hepatology
- Public Health
Background:
- Hepatitis E virus (HEV) is a significant cause of acute hepatitis in pediatric populations, particularly in the Indian subcontinent.
- HEV strains in India show high genetic similarity to Chinese strains but differ from Mexican strains.
- Over 70% of acute hepatitis cases in children in this region are attributed to HEV, with 80% occurring sporadically.
Purpose of the Study:
- To analyze the characteristics and transmission routes of Hepatitis E virus (HEV) in a large pediatric cohort.
- To investigate the presence of HEV in various environmental sources and bodily fluids.
- To understand the clinical presentation, shedding patterns, and potential treatment options for HEV infection in children.
Main Methods:
- Retrospective analysis of 10,500 pediatric cases with proven HEV infection.
- Detection of HEV in patient samples (urine, respiratory secretions, breast milk) and environmental sources (insects, shellfish).
- Clinical observation of HEV-infected volunteers and patients, including serological and virological assessments.
Main Results:
- Enteric transmission via contaminated water (70%) and food (20%) accounted for 90% of cases; person-to-person spread occurred in 9.5%.
- HEV was detected in urine, respiratory secretions, insects (flies, cockroaches, mosquitoes), and partially cooked seafood.
- Maternal-neonatal transmission was observed in third-trimester infections; HEV was found in breast milk in 5 cases.
- Anicteric HEV forms occurred in 40% of volunteers; virus shedding preceded icteric phases.
- Hepatitis IgG anti-HEV persisted up to 4 years; transfusion-associated hepatitis (TAH) was documented in 5 cases.
- Fulminant/Sub-fulminant Viral Hepatitis (FVH/SVH) occurred in 5% of cases, with alpha-interferon (IFN) and intravenous prostaglandin E1 (PGEl) showing potential benefit.
- Inadequate water chlorination was linked to epidemics; adequate disinfection requires ≥0.5 mg/l residual chlorine for 30 minutes.
Conclusions:
- HEV is a major etiological agent of acute hepatitis in children in the subcontinent, with diverse transmission routes including environmental and potential vectors.
- Understanding HEV shedding patterns and persistence of anti-HEV antibodies is crucial for diagnosis and management.
- Effective public health measures, including adequate water disinfection, are essential for controlling HEV epidemics.
Abstract:
Institute of Pediatric Gastroenterology is superspecialised referral institute for all Pediatric Gastroenterological diseases from all over the country and for adjoining countries. We have our data and experience on 10,500 cases of proven Hepatitis E (HEV) in Pediatric population. HEV is non-enveloped 27-30 nm diameter RNA virus, prototype for alpha-like supergroup of positive stranded RNA virus. Indian HEV strain has 97% nucleotide and 98% amino acid sequence identity with Chinese strains but much diversity with Mexican strain. More than 70% acute hepatitis occurring in Pediatric population in this subcontinent are caused by HEV and 80% of these are sporadic. 90% cases were enterically transmitted, spread primarily by fecally contaminated drinking water (70%) and by food (20%), in 9.5% case spread probably was because of person to person and household contact. We could demonstrate HEV in urine, respiratory secretions. Interestingly we found HEV in insects like Flies, Cockroaches, and also in engorged Bedbugs and in Mosquitoes, apart from briefly boiled Mussels, and partially cooked cockles. Maternal-neonatal transmission could be seen if mother had HEV infection in third trimester of pregnancy. In 5 cases we could demonstrate HEV in breast milk. By studying on 10 volunteers, 40% have anicteric form only accompanied by anorexia, epigastric pain. HEV appeared in serum before the icteric phase. Shedding of virus in stool starts before the icteric phase and continued during the high levels of abnormal ALT. Hepatitis IgG anti-HEV persist up to 4 years. In 5 cases we could establish Transfusion associated Hepatitis (TAH). No chronicity could be documented. 5% cases had fulminant viral Hepatitis (FVH)/Sub fulminant viral Hepatitis (SVH), alpha-interferon (IFN) has been proved beneficial in these cases, further use of intravenous PGEl could also be beneficial. Inadequate chlorination of drinking water was an important additional factor for causing epidemics. A free residual chlorine concentration of at least 0.5 mg/l for minimum of 30 minutes is considered adequate as quality of drinking water.