Presence of Hepatitis E Virus in a RED Deer (Cervus elaphus) Population in Central Italy

Hepatitis E is an acute human disease caused by the hepatitis E virus (HEV). In addition to humans, HEV has been detected in several animal species and is recognized as a zoonotic pathogen. Pigs, wild boar and deer can be reservoir. In this study, we evaluated HEV prevalence in a free‐living red deer (Cervus elaphus) population in central Italy by detecting virus‐specific antibodies and RNA in sera. A total of 35 of 251 red deer sera were positive for anti‐HEV IgG. HEV RNA was detected in 10 of 91 sera examined. Two genomic fragments targeted by diagnostic PCRs in the capsid region were sequenced, both matching with genotype 3 HEV. Overall results confirmed the occurrence of HEV infection in deer also in Italy.     

Increased risk of hepatitis E virus infection in workers occupationally exposed to sheep

Hepatitis E virus (HEV) is an enteric RNA virus from the family Hepeviridae with five genotypes (genotypes 1–4 and 7) known to infect humans. HEV infection is known to have a zoonotic swine origin in industrialized countries. The role of pigs and wild boars as major reservoirs for human infection is today well‐established; however, the list of new animal reservoirs is ever‐expanding as new HEV strains are continuously being found in a broad host range. The recent detection of HEV in sheep stools brings concerns on the possibility of HEV transmission from these animals to humans, particularly in those occupationally exposed. The present work investigated the potential occupational risk of HEV infection in shepherds and sheep milk cheesemakers—workers occupationally exposed to ovine (WOEOs; N = 96)—from a region of the Centre of Portugal (‘Serra da Estrela’) based on the differences of anti‐HEV IgG seroprevalence rates between these professionals and the general population (N = 192). The presence of HEV‐specific antibodies in sheep (N = 90) from the same region was also evaluated. The HEV seroprevalence in WOEOs (29.3%) was found to be significantly higher (p = .0198) when compared with population controls (16.1%) which suggests an increased risk for HEV infection in these workers. HEV‐specific antibodies were also found in 16.6% of the studied sheep showing that HEV circulates in these animals. Further studies are needed to confirm the zoonotic potential of sheep HEV.     

Xenotransplantation and Hepatitis E virus

Xenotransplantation using pig cells, tissues and organs may be associated with the transmission of porcine microorganisms to the human recipient. Some of these microorganisms may induce a zoonosis, that is an infectious disease induced by microorganisms transmitted from another species. With exception of the porcine endogenous retroviruses (PERVs), which are integrated in the genome of all pigs, the transmission of all other microorganisms can be prevented by specified or designated pathogen‐free (spf or dpf, respectively) production of the animals. However, it is becoming clear in the last years that the hepatitis E virus (HEV) is one of the viruses which are difficult to eliminate. It is important to note that there are differences between HEV of genotypes (gt) 1 and gt2 on one hand and HEV of gt3 and gt4 on the other. HEV gt1 and gt2 are human viruses, and they induce hepatitis and in the worst case fatal infections in pregnant women. In contrast, HEV gt3 and gt4 are viruses of pigs, and they may infect humans, induce commonly only mild diseases, if any, and are harmless for pregnant women. The goal of this review was to evaluate the risk posed by HEV gt3 and gt4 for xenotransplantation and to indicate ways of their elimination from pigs in order to prevent transmission to the human recipient.     

Chronic Hepatitis E in Heart Transplant Recipients

Chronic courses of hepatitis E virus (HEV) infections have been described in immunosuppressed patients. We aimed to study the role of HEV infections in heart transplant recipients (HTR). 274 HTR were prospectively screened for HEV infection using an anti‐HEV‐IgG ELISA and HEV‐PCR. In addition, 137 patients undergoing cardiac surgery (non‐HTR) and 537 healthy subjects were studied cross‐sectionally. The anti‐HEV‐IgG seroprevalence was 11% in HTR, 7% in non‐HTR and 2% in healthy controls (HTR vs. healthy controls p<0.0001; non‐HTR vs. healthy controls p<0.01). Anti‐HEV tested positive in 4.0% in control cohorts of other immunocompromised patients (n = 474). Four HTR (1.5%) were chronically infected with HEV as shown by HEV‐PCR and all four patients had liver transaminases of >200 IU/L and histological or clinical evidence of advanced liver disease. In three patients ribavirin treatment was successful with a sustained biochemical and virological response while treatment failed in one cirrhotic patient after ribavirin dose reduction. Heart transplant recipients and patients undergoing cardiac surgery have an increased risk for HEV infections. Chronic hepatitis E may explain elevated liver enzymes in heart transplant recipients. Treatment of HEV infection with ribavirin is effective but the optimal dose and duration of ribavirin therapy remains to be determined.     

Emergent subtype of hepatitis E virus genotype 3 in wild boar in Spain

Wild boar (Sus scrofa) is considered as the main wildlife reservoir of zoonotic hepatitis E virus (HEV) genotypes. The aim of this study was to evaluate the circulation of HEV in free‐ranging wild boar in the Doñana National Park (DNP), Spain. Blood samples were collected from 99 wild boar in the DNP during 2015. Sera were analysed in parallel using indirect ELISA and real‐time RT‐PCR. A total of 57 of the 99 tested animals (57.6%; 95%CI: 47.8%–67.3%) had anti‐HEV antibodies, indicating that this virus is widespread in wild boar in the DNP. HEV RNA was detected in one animal and phylogenetic analysis showed that the sequence isolated belonged to subtype 3r. The results suggest a potential risk of zoonotic transmission of this novel HEV‐3 subtype, which could be of public health concern. Further studies are required to assess the role of wild boar in the epidemiology of HEV‐3r and to determine the infectivity of this emergent HEV subtype in other species, including humans.     

Hepatitis E Virus in Wild Boar in the Central Northern Part of Italy

Hepatitis E virus (HEV) is responsible for sporadic acute hepatitis in developed countries, where the infection is acquired probably through ingestion of contaminated food, in addition to travel‐related cases. In this study, the circulation of HEV in wild boar from nine Italian provinces was evaluated. An overall seroprevalence of 10.2% was found, although there were differences among the provinces, while no samples were positive for HEV RNA detection. This study indicates an active circulation of HEV in the Italian wild boar populations and suggests to consider the zoonotic risk in handling and eating meat from this animal.     

Hepatitis E virus (HEV) infection in haemodialysis patients

BACKGROUND.: The aim of this study was to determine the prevalence of hepatitisE virus (HEV) infection among patients undergoing haemodialysis(HD) and to evaluate whether chronic haemodialysis is associatedwith an increased risk of HEV infection. METHODS.: Serum samples from 420 HD patients and 316 healthy volunteerswere tested for IgG and IgM antibodies to HEV (anti-HEV). Anti-HEVtesting was done by an enzyme immunoassay (EIA) based on recombinantproteins of HEV (Abbott Labs). All anti-HEV IgG positive serawere confirmed using synthetic peptides. RESULTS.: Anti-HEV IgG was confirmed in 27/420 (6.4%) of the HD patientsand in 7/316(2.2%) of the reference group (P=0.007). However,multiple logistic regression analysis showed that the prevalenceof anti-HEV IgG was not significantly higher in HD patientscompared with the reference group, after controlling for ageand sex. No patient was found positive for anti-HEV IgM. Thepresence of anti-HEV was associated with sex in HD patients(P=0.04). No significant association was found between anti-HEVand underlying renal disease, anti-HCV, anti-HBc, blood transfusions,history of elevated transaminases, history of clinical hepatitisand renal transplantation. A marginal association, which wasobserved with the duration of haemodialysis in univariate analysis(P=0.07), was not confirmed in multivariate analysis. CONCLUSIONS.: Chronic haemodialysis is not associated with an increased riskof exposure to HEV, and the high prevalence of anti-HEV IgGin HD patients reported in uncontrolled studies is possiblydue to the confounding effect of age and sex.     

Hepatitis E virus infection in equines in Spain

Hepatitis E (HE) is an important emerging disease in European countries. To analyse the role of equids as potential reservoirs for HE virus (HEV), we determined the prevalence of HEV infection in 861 equines from 464 herds in Spain. HEV RNA in serum was detected in 0.4% (3/692) of horses, 1.2% (1/86) of donkeys and 3.6% (3/83) of mules. Phylogenetic analysis identified the zoonotic genotype 3 as being closely related to viral human and swine strains. In this first report on HEV in equids in Europe, we confirm the susceptibility of horses, donkeys and mules to HEV infection. The low prevalence detected indicates that equids may be considered spillover hosts rather than true reservoirs.     

Hepatitis E Virus-Related Cirrhosis in Kidney-and Kidney–Pancreas-Transplant Recipients

Hepatitis E virus (HEV) infection was thought to be responsible for acute hepatitis that did not become chronic. However, we have recently reported that HEV infection can evolve to chronic hepatitis, at least in solid-organ transplant patients. We report on two cases of rapidly progressive of HEV-related cirrhosis that occurred in two organ-transplant patients. Case 1: A kidney–pancreas-transplant patient developed acute HEV hepatitis 60 months after transplantation, which evolved to chronicity as defined by persisting elevated liver-enzyme levels and positive serum HEV RNA. At 22 months after the acute phase, she presented with cirrhosis and portal hypertension, that is ascites and esophagus varices. Case 2: A kidney-transplant patient developed acute hepatitis 36 months after transplantation, which persisted and remained unexplained for 38 months. Then, HEV RNA was searched for in their serum and stools, and was found to be positive in both. Retrospective analysis of available stored serum, mainly the serum obtained at the acute phase, confirmed the diagnosis of chronic hepatitis E. In both cases, a liver biopsy showed cirrhosis. We conclude that HEV infection cannot only evolve to chronic hepatitis, but can also be responsible for rapidly progressing cirrhosis in organ-transplant patients.     

Hepatitis E virus detected from Chinese laboratory ferrets and farmed mink

A novel genotype of hepatitis E virus (HEV ) has been discovered in ferrets and mink worldwide. However, the situation in China is unknown. Diverse HEV RNA belonging to HEV genotype C2 was detected in this study from 17.5% (18/103) of the laboratory ferrets and 1.9% (2/107) of farmed mink in China. Phylogenetic analysis showed that the ferret HEV strains clustered into three groups with known strains detected from the United States and the Netherlands. Attempted transmission of ferret HEV to two rabbits was not successful. This study confirmed that the C2 genotype of HEV is circulating in China and succeeded in infecting laboratory ferrets with this genotype of HEV . Further studies are required to determine whether the C2 genotype of HEV can infect humans.     

Hepatitis E Virus in Sylvatic and Captive Wild Boar from Portugal

Hepatitis E virus (HEV) is a zoonotic agent today considered a major Public Health issue in industrialized countries. HEV strains belonging to zoonotic genotype 3 are widely present in swine, being today considered important reservoirs for human disease. Unlike in swine, only scarce data are available on the circulation of HEV in wild boar. This study describes the detection and molecular characterization of HEV in livers from sylvatic wild boar hunted in Portugal and destined for consumption. Additionally, the detection of HEV in stools of a confined wild boar population also destined for consumption is also described. A total of 80 liver samples collected during the hunting season of 2011/2012 and 40 stools collected in February 2012 from a wild boar breeding farm in Portugal were tested by a nested broad‐spectrum RT‐PCR assay targeting open reading frame (ORF) 1. Twenty livers (25.0%) and 4 stools (10%) were positive for HEV. Phylogenetic analysis showed that all strains clustered with sequences classified as HEV genotype 3 subgenotype e. To our knowledge, this is the first report documenting the occurrence and molecular analysis of HEV in sylvatic and captive wild boar destined for human consumption in Portugal. This report demonstrates for the first time the circulation of HEV in wildlife reservoirs of Portugal adding knowledge to the epidemiology of HEV in wild boar populations.     

Serological Evidence for a Hepatitis E Virus‐Related Agent in Goats in the United States

Hepatitis E virus (HEV) causes an important public health disease in many developing countries and is also endemic in some industrialized countries. In addition to humans, strains of HEV have been genetically identified from pig, chicken, rat, mongoose, deer, rabbit and fish. While the genotypes 1 and 2 HEV are restricted to humans, the genotypes 3 and 4 HEV are zoonotic and infect humans and other animal species. As a part of our ongoing efforts to search for potential animal reservoirs for HEV, we tested goats from Virginia for evidence of HEV infection and showed that 16% (13/80) of goat sera from Virginia herds were positive for IgG anti‐HEV. Importantly, we demonstrated that neutralizing antibodies to HEV were present in selected IgG anti‐HEV positive goat sera. Subsequently, in an attempt to genetically identify the HEV‐related agent from goats, we conducted a prospective study in a closed goat herd with known anti‐HEV seropositivity and monitored a total of 11 kids from the time of birth until 14 weeks of age for evidence of HEV infection. Seroconversion to IgG anti‐HEV was detected in seven of the 11 kids, although repeated attempts to detect HEV RNA by a broad‐spectrum nested RT‐PCR from the faecal and serum samples of the goats that had seroconverted were unsuccessful. In addition, we also attempted to experimentally infect laboratory goats with three well‐characterized mammalian strains of HEV but with no success. The results indicate that a HEV‐related agent is circulating and maintained in the goat population in Virginia and that the goat HEV is likely genetically very divergent from the known HEV strains.     

Genotype distribution and transmission of hepatitis C virus (HCV) in French haemodialysed patients

BACKGROUND: HCV genotyping was performed to identify the source of HCV infectionin haemodialysed patients. METHODS: Specimens from 48 HCV-infected patients treated in the samedialysis unit were genotyped by line probe assay (LiPA). RESULTS: Thirty-seven patients (77 %) were infected by genotype lb. Onlyfour of the 48 patients were never transfused and three of themhad genotype lb. In two of the three genotype lb-infected patients,seroconver-sion was observed during the follow-up, suggestinga nosocomial HCV infection. Ten of the 44 transfused patientswere infected with genotypes other than lb. Blood products werevery probably the source of infection in these patients. The34 other patients (77.3%) were infected with genotype lb andretrospective analysis failed to identify nosocomial and transfusionalorigin. Eight of the 11 patients with genotypes different from lb werefound in the 16 patients who were more than 55 years old. Onlythree of the eight originated from France. CONCLUSIONS: Blood transfusions and nosocomial infections were the main causesof HCV transmission in haemodialysed patients. Both screeningof blood donors and aseptic measures in haemodialysis unitsmay prevent HCV transmission.     

Hepatitis E Virus and Related Viruses in Animals

Hepatitis E is an acute human liver disease in healthy individuals which may eventually become chronic. It is caused by the hepatitis E virus (HEV) and can have a zoonotic origin. Nearly 57,000 people die yearly from hepatitis E‐related conditions. The disease is endemic in both developing and developed countries with distinct epidemiologic profiles. In developing countries, the disease is associated with inadequate water treatment, while in developed countries, transmission is associated with animal contact and the ingestion of raw or uncooked meat, especially liver. All human HEV are grouped into at least four genotypes, while HEV or HEV‐related viruses have been identified in an increasing number of domestic and wild animal species. Despite a high genetic diversity, only one single HEV serotype has been described to date for HEV genotypes 1–4. The discovery of new HEV or HEV‐related viruses leads to a continuing increase in the number of genotypes. In addition, the genome organization of all these viruses is variable with overlapping open reading frames (ORF) and differences in the location of ORF3. In spite of the role of some domestic and wild animals as reservoir, the origin of HEV and HEV‐related viruses in humans and animals is still unclear. This review discusses aspects of the detection, molecular virology, zoonotic transmission and origin of HEV and HEV‐related viruses in the context of ‘One Health’ and establishes a link between the previous and the new taxonomy of this growing virus family.     

Hepatitis E Virus: First Description in a Pet House Rabbit. A New Transmission Route for Human?

In this work, we identified for the first time hepatitis E virus (HEV) in a pet house rabbit, an adult 7 years old female of domestic rabbit (Oryctolagus cuniculus). Importantly, the resulting phylogenetic tree showed that the HEV strain identified in the pet house rabbit was closely related to a human HEV sequence; this finding reawakens concerns regarding the zoonotic risk represented by HEV in animals and expands to house rabbit the spectrum of potential source of infection for humans. Potential for domestic transmission of HEV to humans should be taken into account.     

Epidemiological investigation of the novel genotype avian hepatitis E virus and co‐infected immunosuppressive viruses in farms with hepatic rupture haemorrhage syndrome,recently emerged in China

Since 2016, hepatic rupture haemorrhage syndrome (HRHS) appeared in chickens of China and caused huge economic loss. To assess the infection status of the avian hepatitis E virus (HEV) and co‐infected viruses, including avian leukosis virus (ALV), reticuloendotheliosis virus (REV), fowl adenovirus (FAdV), and chicken infectious anaemia virus (CIAV), in farms with HRHS, 180 liver samples were collected from 24 farms in different provinces and detected by strict molecular virology methods. Results showed that the positive rates of HEV, ALV, REV, FAdV, and CIAV were 74.44%, 20.00%, 27.78%, 31.11%, and 12.22%, respectively, whereas there are also 112 samples with co‐infection, for a rate of 58%. Meanwhile, the positive rate of HEV decreased gradually with age; the lowest positive rate of ALV (5.76%) and REV (19.23%) appeared in 25–35 weeks age, during which the positive rate of CIAV was the highest (19.23%); the positive rate of HEV in layers (64.00%) was lower than that of broilers (83.33%), but the positive rates of ALV (38.46%) and CIAV (15.38%) in layers were higher than that of broilers (5.88%, 9.80%); the positive rates of HEV (75.88%) and CIAV (15.60%) in parental generation (PG) were higher than that of commodity generation (CG, 64.10%, 0.00%), whereas the positive rate of ALV showed inverse relationship (PG: 14.89%; CG: 38.46%). Additionally, phylogenetic analysis showed that all the avian HEV identified this study belong to a novel genotype, and found the close relationship between the wild strains (REV and CIAV) and corresponding isolates from contaminated vaccine. The data presented in this report will enhance the current understanding of the epidemiology characteristics in farms with HRHS in China.     

Hepatitis E Virus‐Induced Neurological Symptoms in a Kidney‐Transplant Patient with Chronic Hepatitis

It has been shown that hepatitis E virus (HEV) may be responsible for chronic hepatitis in solid‐organ transplant patients. It has also been suggested that HEV may be responsible for atypical neurological symptoms during the acute phase. However, the relationship between the neurological symptoms and HEV infection was based on the detection of anti‐HEV IgM in the sera. Herein, we report a case where neurological symptoms, that is peripheral nerve involvement with proximal muscular weakness that affected the four limbs joints with central nervous‐system involvement and bilateral pyramidal syndrome, occurred in a kidney‐transplant patient who was chronically infected by HEV. For the first time, HEV RNA was detected in the serum and cerebrospinal fluid. In addition, clonal HEV sequences were analyzed in both compartments, that is serum and cerebrospinal fluid. The discovery of quasispecies compartmentalization and its temporal association suggests that neurological symptoms could be linked to the emergence of neurotropic variants.     

Hepatitis E Virus: What Transplant Physicians Should Know

Hepatitis E virus (HEV) infection is an underdiagnosed disease in the developed world. In pediatric and adult organ transplant patients HEV infection can cause chronic hepatitis, which can lead to cirrhosis. Extra‐hepatic manifestations, such as neurological symptoms and kidney injury, have been also reported in transplant patients. In this comprehensive minireview, we summarize the current knowledge on HEV infection in transplant patients, that is, its prevalence, incidence, natural history and therapy.