PREVALENCE AND SEVERITY OF ACUTE VIRAL HEPATITIS AND FULMINANT HEPATITIS DURING PREGNANCY: A PROSPECTIVE STUDY FROM NORTH INDIA

Viral hepatitis-induced acute liver failure

Viral hepatitis-induced acute liver failure (ALF) is a preventable cause for liver-related mortality worldwide. Viruses are the most common cause for ALF in developing nations in contrast to the west, where acetaminophen is largely responsible. Viruses may be hepatotropic or affect the liver secondary to a systemic infection. In tropical countries, infections such as leptospirosis, scrub typhus and malaria can mimic the symptoms of ALF. Differentiating these ALF mimics is crucial because they require etiology-specific therapy. Treatment of viral hepatitis-induced ALF is two-pronged and directed towards providing supportive care to prevent organ failures and antiviral drugs for some viruses. Liver transplantation (LT) is an effective modality for patients deteriorating despite adequate supportive care. Early referral and correct identification of patients who require a transplant are important. Liver support devices and plasma exchange have evolved into "bridging modalities" for LT. Preventive strategies such as hand hygiene, use of clean and potable water and inclusion of vaccines against viral hepatitis in the national program are simple yet very effective methods focusing on the preventive aspect of this disease.

Menace of hepatitis E in pregnancy: unleashing the threat of fulminant liver failure

This case report presents a primigravida in her 20s with a history of seizure disorder and chronic cholecystitis, who presented at 30 weeks and 6 days of gestation with upper abdominal pain, fever and vomiting. Initially diagnosed with acute calculous cholecystitis, the patient's condition rapidly deteriorated, resulting in fetal demise and the development of severe complications. Subsequent investigations revealed an enlarged fatty liver and signs of acute liver failure. The diagnosis of acute fatty liver of pregnancy was initially considered but later ruled out, and the patient was diagnosed with hepatitis E based on positive anti-hepatitis E virus IgM antibodies. Prompt termination of pregnancy was performed, followed by intensive care management. After a prolonged hospital stay, the patient recovered and was discharged in stable condition. This case emphasises the importance of considering hepatitis E as a potential cause of acute liver failure in pregnant women and the need for early recognition and multidisciplinary management to achieve favourable outcomes.

The Re-Emergence of Hepatitis E Virus in Europe and Vaccine Development

Hepatitis E virus (HEV) is one of the leading causes of acute viral hepatitis. Transmission of HEV mainly occurs via the fecal-oral route (ingesting contaminated water or food) or by contact with infected animals and their raw meat products. Some animals, such as pigs, wild boars, sheep, goats, rabbits, camels, rats, etc., are natural reservoirs of HEV, which places people in close contact with them at increased risk of HEV disease. Although hepatitis E is a self-limiting infection, it could also lead to severe illness, particularly among pregnant women, or chronic infection in immunocompromised people. A growing number of studies point out that HEV can be classified as a re-emerging virus in developed countries. Preventative efforts are needed to reduce the incidence of acute and chronic hepatitis E in non-endemic and endemic countries. There is a recombinant HEV vaccine, but it is approved for use and commercially available only in China and Pakistan. However, further studies are needed to demonstrate the necessity of applying a preventive vaccine and to create conditions for reducing the spread of HEV. This review emphasizes the hepatitis E virus and its importance for public health in Europe, the methods of virus transmission and treatment, and summarizes the latest studies on HEV vaccine development.

Prevalence of viral hepatitis infection in India: A systematic review and meta-analysis

BACKGROUND

Nowadays, Viral Hepatitis can be comparable to the big three communicable diseases: tuberculosis, HIV/AIDS, and malarial infections. The main purpose of this study was to summarize the prevalence of viral Hepatitis in India from peer-reviewed articles published from February 2000 to February 2021.

MATERIALS AND METHODS

We conducted a systematic search on Science Direct, Scopus, Medline, PubMed, Web of Science, Google Scholar, and other open access journals. We evaluated all relevant papers that looked into the prevalence of viral Hepatitis systematically. Finally, 28 studies on viral Hepatitis published from February 2000 to February 2021 have been selected. These studies have been conducted across the northern, southern, central, eastern, and western regions of India.

RESULTS

Twenty-eight full-text publications were obtained and evaluated consisting of 45,608 research participants. Hepatitis A was found to range from 2.1% to 52.5%. Hepatitis B was found in a wide range of individuals, ranging from 0.87% to 21.4% of the population. Hepatitis C was found to range from 0.57% to 53.7%. The majority of the children were affected by hepatitis A, and 47.4% of third-trimester pregnant mothers were affected by hepatitis E. Diabetes, hospital admission, history of jaundice, history of surgeries, and heterosexual contact were the leading modes of acquiring HBV and HCV infections. As a result of its great magnitude, this disease poses a severe threat to the national healthcare system.

CONCLUSION

Effective public health measures are urgently needed to minimize the burden of viral Hepatitis and eliminate the disease.

Animal Models for Studying Congenital Transmission of Hepatitis E Virus

One of the most intriguing issues in the hepatitis E virus (HEV) field is the significant increase in mortality rates of the mother and fetus when infection occurs in the second and third trimesters of gestation. A virus that is normally self-limiting and has a mortality rate of less than one percent in otherwise healthy individuals steeply rises by up to 30% in these pregnant populations. Answering this pivotal question has not been a simple task. HEV, in general, has been a difficult pathogen to understand in the laboratory setting. A historical lack of ability to efficiently propagate the virus in tissue culture models has led to many molecular aspects of the viral lifecycle being understudied. Although great strides have been made in recent years to adapt viruses to cell culture, this field remains behind other viruses that are much easier to replicate efficiently in vitro. Some of the greatest discoveries regarding HEV have come from using animal models for which naturally occurring strains of HEV have been identified, including pigs and chickens, but key limitations have made animal models imperfect for studying all aspects of human HEV infections. In addition to the difficulties working with HEV, pregnancy is a very complicated biological process with an elaborate interplay between many different host systems, including hormones, cardiovascular, kidneys, respiratory, gastrointestinal, epithelial, liver, metabolic, immune, and others. Significant differences between the timing and interplay of these systems are notable between species, and making direct comparisons between animals and humans can be difficult at times. No simple answer exists as to how HEV enhances mortality in pregnant populations. One of the best approaches to studying HEV in pregnancy is likely a combinatorial approach that uses the best combination of emerging in vitro and in vivo systems while accounting for the deficiencies that are present in each model. This review describes many of the current HEV animal model systems and the strengths and weaknesses of each as they apply to HEV pregnancy-associated mortality. We consider factors that are critical to analyzing HEV infection within the host and how, despite no perfect animal model for human pregnancy mortality existing, recent developments in HEV models, both in vitro and in vivo, are advancing our overall understanding of HEV in the pregnant host.

Chronic Hepatitis C: Acute Exacerbation and Alanine Aminotransferase Flare

The hepatitis C virus (HCV) causes acute and chronic hepatitis, cirrhosis, and hepatocellular carcinoma, as well as extrahepatic manifestations such as malignant lymphoma. Currently, direct-acting antiviral agents (DAAs) against HCV infection can lead to a sustained virological response (SVR) in almost all HCV-infected patients. In this review article, we discuss acute exacerbation and alanine aminotransferase (ALT) flare in patients with chronic HCV infection. Although acute liver failure caused by HCV infection is rare, careful attention should be paid to the cases with ALT elevation during the natural course of chronic HCV infection. HCV genotype 2 infection, the use of rituximab, and a higher dose of corticosteroid are factors associated with HCV acute exacerbation and ALT flare. Treatment regimens for cancer have been interrupted or changed due to ALT flare due to HCV infection in some patients undergoing chemotherapy for cancer. The pathogenesis of HCV acute exacerbation and ALT flare could involve cellular as well as humoral immune responses. In the DAA era, the earlier introduction of DAAs may prevent chronic HCV-infected patients with acute exacerbation and ALT flare from developing into a more severe form, although DAAs may not be effective for all of them.

Viral hepatitis in pregnancy

Viral hepatitis is caused by a heterogenous group of viral agents representing a wide range of phylogenetic groups. Many viruses can involve the liver and cause liver injury but only a subset are delineated as 'hepatitis viruses' based upon their primary site of replication and tropism for hepatocytes which make up the bulk of the liver cell population. Since their discovery, beginning with the agent that caused serum hepatitis in the 1960s, the alphabetic designations have been utilized. To date, we have five hepatitis viruses, A through E, though it is postulated that others may exist. This chapter will focus on those viruses. Note that hepatitis D is included as a subset of hepatitis B, as it cannot exist without concurrent hepatitis B infection. Pregnancy has the potential to affect all aspects of these viral agents due to the unique immunologic and physiologic changes that occur during and after the gestational period. In this review, we will discuss the most common viral hepatitis and their effects during pregnancy.

Epidemiology of liver failure in Asia-Pacific region

The global burden of deaths caused by liver failure is substantial. The Asia-Pacific region is home to more than half of the global population and accounted for 62.6% of global deaths because of liver diseases in 2015. The aetiology of liver failure varies in different countries at different times. Viruses (Hepatitis A, B and E), drugs (herbs and anti-tuberculous drugs), toxins (alcohol use) and autoimmune flares are mainly responsible of majority of liver failure in individuals with normal liver (acute liver failure; ALF); else these may precipitate liver failure in those with chronic liver disease (acute-on-chronic liver failure; ACLF). Concomitant increases in alcohol misuse and metabolic syndrome in recent years are concerning. Ongoing efforts to address liver failure-related morbidity and mortality require accurate contemporary estimates of epidemiology and outcomes. In light of the ever-changing nature of liver disease epidemiology, accurate estimates for the burden of liver failure across the countries are vital for setting clinical, research and policy priorities. In this review, we aimed to describe the current as well as changing epidemiological trends of common liver failure syndromes, ALF and ACLF in the Asia-Pacific region.

Hepatitis E and Pregnancy: An Unholy Alliance Unmasked from Kashmir, India

The adverse relationship between viral hepatitis and pregnancy in developing countries had been interpreted as a reflection of retrospectively biased hospital-based data collection by the West. However, the discovery of hepatitis E virus (HEV) as the etiological agent of an epidemic of non-A, non-B hepatitis in Kashmir, and the documenting of the increased incidence and severity of hepatitis E in pregnancy via a house-to-house survey, unmasked this unholy alliance. In the Hepeviridae family, HEV-genotype (gt)1 from genus Orthohepevirus A has a unique open reading frame (ORF)4-encoded protein which enhances viral polymerase activity and viral replication. The epidemics caused by HEV-gt1, but not any other Orthohepevirus A genotype, show an adverse relationship with pregnancy in humans. The pathogenesis of the association is complex and at present not well understood. Possibly multiple factors play a role in causing severe liver disease in the pregnant women including infection and damage to the maternal-fetal interface by HEV-gt1; vertical transmission of HEV to fetus causing severe fetal/neonatal hepatitis; and combined viral and hormone related immune dysfunction of diverse nature in the pregnant women, promoting viral replication. Management is multidisciplinary and needs a close watch for the development and management of acute liver failure. (ALF). Preliminary data suggest beneficial maternal outcomes by early termination of pregnancy in patients with lower grades of encephalopathy.

Burden of hepatitis E virus infection in pregnancy and maternofoetal outcomes: a systematic review and meta-analysis

Background

There is still a dearth of knowledge on the burden of HEV infection in the global population of pregnant women. Therefore, we conducted a systematic review and meta-analysis to estimate the global burden of HEV infection in pregnancy.

Methods

We searched PubMed, Embase, Web of Knowledge, and Global Index Medicus to identify articles published until January 26, 2020. We considered cross-sectional, case-control, and cohort studies reporting the immunoglobulins M HEV seroprevalence in asymptomatic and symptomatic (jaundice or elevated transaminases) pregnant women or investigating the association between HEV infection and maternofoetal outcomes. We used a random-effects model to pool studies. This review was registered with PROSPERO, CRD42018093820.

Results

For HEV prevalence estimates, we included 52 studies (11,663 pregnant women). The seroprevalence was 3.5% (95% confidence interval: 1.4–6.4) in asymptomatic women (most of whom from high endemic areas). The prevalence in symptomatic women was 49.6% (42.6–56.7) with data only from HEV high endemic countries. In the multivariable meta-regression model, the prevalence was higher in symptomatic women compared to asymptomatic (adjusted prevalence odds ratio [aPOR]: 1.76; 95%CI: 1.61–1.91) and decreased with increasing year of publication (by 10-year) (aPOR: 0.90; 95%CI: 0.84–0.96). The proportion of HEV vertical transmission was 36.9% (13.3–64.2). Risk of bias was low, moderate and high respectively in 12 (23%), 37 (70%), and 4 studies (7%) addressing HEV prevalence estimation. HEV infection was associated with maternal deaths (pooled OR 7.17; 3.32–15.47), low birth weight (OR: 3.23; 1.71–6.10), small for gestational age (OR: 3.63; 1.25–10.49), preterm < 32 weeks (OR: 4.18; 1.23–14.20), and preterm < 37 weeks (OR: 3.45; 2.32–5.13), stillbirth (OR: 2.61; 1.64–4.14), intrauterine deaths (OR: 3.07; 2.13–4.43), and not with miscarriage (OR: 1.74; 0.77–3.90). All studies which assessed the association between HEV infection and maternofoetal outcomes had a moderate risk of bias.

Conclusions

Findings from this study are suggestive of a high burden of HEV infection in pregnancy in high endemic countries, its association with poor maternofoetal outcomes, and a high rate of vertical transmission. This study supports the need for specific strategies to prevent exposure of pregnant women to HEV infection, especially in high endemic areas.

Indian National Association for the Study of the Liver Consensus Statement on Acute Liver Failure (Part 1): Epidemiology, Pathogenesis, Presentation and Prognosis

Acute liver failure (ALF) is an infrequent, unpredictable, potentially fatal complication of acute liver injury (ALI) consequent to varied etiologies. Etiologies of ALF as reported in the literature have regional differences, which affects the clinical presentation and natural course. In this part of the consensus article designed to reflect the clinical practices in India, disease burden, epidemiology, clinical presentation, monitoring, and prognostication have been discussed. In India, viral hepatitis is the most frequent cause of ALF, with drug-induced hepatitis due to antituberculosis drugs being the second most frequent cause. The clinical presentation of ALF is characterized by jaundice, coagulopathy, and encephalopathy. It is important to differentiate ALF from other causes of liver failure, including acute on chronic liver failure, subacute liver failure, as well as certain tropical infections which can mimic this presentation. The disease often has a fulminant clinical course with high short-term mortality. Death is usually attributable to cerebral complications, infections, and resultant multiorgan failure. Timely liver transplantation (LT) can change the outcome, and hence, it is vital to provide intensive care to patients until LT can be arranged. It is equally important to assess prognosis to select patients who are suitable for LT. Several prognostic scores have been proposed, and their comparisons show that indigenously developed dynamic scores have an edge over scores described from the Western world. Management of ALF will be described in part 2 of this document.

The Interplay between Host Innate Immunity and Hepatitis E Virus

Hepatitis E virus (HEV) infection represents an emerging global health issue, whereas the clinical outcomes vary dramatically among different populations. The host innate immune system provides a first-line defense against the infection, but dysregulation may partially contribute to severe pathogenesis. A growing body of evidence has indicated the active response of the host innate immunity to HEV infection both in experimental models and in patients. In turn, HEV has developed sophisticated strategies to counteract the host immune system. In this review, we aim to comprehensively decipher the processes of pathogen recognition, interferon, and inflammatory responses, and the involvement of innate immune cells in HEV infection. We further discuss their implications in understanding the pathogenic mechanisms and developing antiviral therapies.

Indian National Association for the Study of the Liver-Federation of Obstetric and Gynaecological Societies of India Position Statement on Management of Liver Diseases in Pregnancy

Liver diseases occurring during pregnancy can be serious and can progress rapidly, affecting outcomes for both the mother and fetus. They are a common cause of concern to an obstetrician and an important reason for referral to a hepatologist, gastroenterologist, or physician. Liver diseases during pregnancy can be divided into disorders unique to pregnancy, those coincidental with pregnancy, and preexisting liver diseases exacerbated by pregnancy. A rapid differential diagnosis between liver diseases related or unrelated to pregnancy is required so that specialist and urgent management of these conditions can be carried out. Specific Indian guidelines for the management of these patients are lacking. The Indian National Association for the Study of the Liver (INASL) in association with the Federation of Obstetric and Gynaecological Societies of India (FOGSI) had set up a taskforce for development of consensus guidelines for management of patients with liver diseases during pregnancy, relevant to India. For development of these guidelines, a two-day roundtable meeting was held on 26-27 May 2018 in New Delhi, to discuss, debate, and finalize the consensus statements. Only those statements that were unanimously approved by most members of the taskforce were accepted. The primary objective of this review is to present the consensus statements approved jointly by the INASL and FOGSI for diagnosing and managing pregnant women with liver diseases. This article provides an overview of liver diseases occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and the recommended treatment options.

Role of oestrogen and its receptors in HEV-associated feto-maternal outcomes

BACKGROUND

Pregnant women infected with HEV develops adverse pregnancy outcomes like, abortions, intrauterine fetal death, still births, neonatal deaths, preterm delivery and maternal mortality.

AIM

To correlate oestrogen and its receptors ESR1α and ESR2β levels with HEV-associated feto-maternal outcomes.

MATERIAL & METHODS

A total of 142 pregnant women with HEV infection and 142 pregnant controls were included in study from Department of Obstetrics & Gynaecology and Department of Medicine, Maulana Azad Medical College (MAMC) and associated Lok Nayak Hospital (LNH), New Delhi. Three millilitre of blood sample was collected in plain for quantification of oestrogen, and its receptors ESR1α and ESR2β using commercially available third-generation ELISA kits.

RESULTS

The levels of oestrogen, ESR1α and ESR2β were considerably higher in HEV-infected pregnant women (20.11 ± 18.19 ng/mL, 10.58 ± 3.27 ng/mL, 10.42 ± 4.71 ng/mL respectively) than pregnant controls (11.74 ± 6.42 ng/mL, 9.11 ± 1.63 ng/mL, 9.01 ± 1.18 ng/mL respectively)(P < 0.0001). It was found that oestrogen levels were significantly higher in pregnant women infected with HEV who had preterm delivery, low birth weight babies and fetal loss (19.64 ± 17.60 ng/mL, 19.71 ± 17.63 ng/mL, 33.62 ± 23.20 ng/mL respectively) than who had full term delivery, average birth weight babies and live babies (11.71 ± 8.77 ng/mL, 11.99 ± 9.44 ng/mL, 16.58 ± 14.98 ng/mL respectively)(P < 0.05). A significant negative correlation was observed between baby birth weight and oestrogen levels in HEV-infected pregnant women.

CONCLUSION

The high level of oestrogen plays an important role in preterm delivery, low birth weight babies and fetal mortality in pregnant women with HEV infection through placental dysfunction. Moreover, oestrogen level is a significant predictor for preterm delivery and maternal mortality and ESR2β levels is a significant predictor for maternal mortality in pregnant women infected with HEV.

An update of the incidence of fulminant hepatitis due to viral agents during pregnancy

Fulminant hepatitis in pregnant women is one of the major public health issues and remains a challenging clinical problem with extremely high maternal and fetal morbidity and mortality, which, in parallel, viral factors are the most common cause of hepatic disorders and dysfunction during pregnancy that may lead to fulminant hepatic with a fast progression. Therefore, this review helps to inform clinicians about the current status of the incidence of fulminant hepatitis due to viral agents during pregnancy.

Foetomaternal outcomes of hepatitis E infection outbreak in North India

Hepatitis E infection (HEV) in pregnant females, especially in the third trimester is associated with poor foetomaternal outcomes. However, the mechanisms of severe liver injury remain obscure. In a recent HEV outbreak in North India, six pregnant females were detected to be positive for HEV infection with concomitant hepatitis A infection in three pregnant females. None of the pregnant females were positive for hepatitis B or hepatitis C infection. The mortality was 50% in pregnant females. In an outbreak, besides, testing for hepatitis markers and understanding the pathogenesis of HEV infection in pregnancy, improving basic hygienic standards is of utmost importance.

Acute Liver Failure Due to Hepatitis E Virus Infection Is Associated with Better Survival than Other Etiologies in Indian Patients

BACKGROUND AND AIM

Hepatitis E virus (HEV) is a global disease and an important cause of acute liver failure (ALF) in the Indian subcontinent. The aim of this study was to assess the differences in the course of HEV-ALF as compared to other etiologies of ALF.

METHODS

We compared the clinical course, complications, and outcomes of HEV-ALF with other etiologies. We assessed the prognostic factors and compared existing prognostic scores in HEV-ALF patients.

RESULTS

One thousand four hundred and sixty-two ALF patients were evaluated between January 1986 and December 2015. HEV was the etiology of ALF in 419 (28.7%) cases, whereas non-A non-E hepatitis, HBV and anti-tuberculosis therapy (ATT) were the etiologies in 527 (36.0%), 128 (8.8%), and 103 (7.0%) cases, respectively. The frequency of cerebral edema in HEV-ALF (41.3%) was lower than that in non-A non-E ALF (52.9%; P < 0.001) and HBV-ALF (52.8%; P = 0.024). Infection and seizures were significantly less in patients with HEV-ALF compared to non-A non-E and HBV-ALF (P = 0.038 and 0.022, respectively). The survival of HEV-ALF patients was significantly better (55.1%, P < 0.001) than patients of other etiologies-including ATT (30.0%), non-A non-E (38.1%) and HBV (35.9%). In HEV-ALF patients, age, female sex, cerebral edema, prothrombin time >60 s, infection, and total bilirubin were observed as independent predictors of outcome on multivariate logistic regression analysis. Model for end-stage liver disease, acute liver failure study group model and King's College Hospital criteria had poor discriminative accuracy for outcome (area under receiver operator characteristic curve 0.63-0.64) in HEV-ALF.

CONCLUSIONS

Hepatitis E virus-associated ALF has a better outcome than ALF of other etiologies.

Etiology, clinical profile, and outcome of liver disease in pregnancy with predictors of maternal mortality: A prospective study from Western India

BACKGROUND

The aim of this study is to study the etiology, clinical profile, and prognostic factors related to maternal and fetal health in pregnant patients with liver disease in Western India.

METHODS

This study included 103 consecutive pregnant patients with liver dysfunction from August 2013 to July 2015, who underwent regular biochemical tests, viral markers, ultrasound of abdomen, etc. and were followed up for 6 weeks postpartum or until death.

RESULTS

Pregnancy-specific causes of liver dysfunction were found in 39 % (40/103) patients. Liver diseases were most frequent in third trimester 69.9 % (72/103). Etiologies in third trimester were viral hepatitis 36.1 % (26/72), pregnancy induced hypertension (PIH) 30.5 % (22/72), intrahepatic cholestasis of pregnancy 11.1 % (8/72), acute fatty liver of pregnancy (2/72), etc. Hepatitis E was the commonest agent among viral hepatitis 71.8 % (28/39). Causes of maternal mortality (n = 25) were hepatitis E 40 % (10/25), PIH 32 % (8/25), and tropical diseases 20 % (5/25). Fetal mortality (n = 31) was 38.7 % (12/31) in hepatitis E. Maternal mortality was significantly associated with presence of jaundice, fever, abdominal pain, oliguria, anemia, leukocytosis, and coagulopathy. Model for end-stage liver disease (MELD) score >21 predicted maternal mortality with 80 % sensitivity and 91 % specificity (area under the receiver operating characteristic curve = 0.878 and p < 0.001).

CONCLUSIONS

Liver disease was most common in the third trimester of pregnancy. Hepatitis E was the most common cause of liver disease in pregnant women in western India with significant maternal mortality, predicted by high MELD score.

Epizootiological study of rodent-borne hepatitis E virus HEV-C1 in small mammals in Hanoi, Vietnam

There is concern about the zoonotic potential of rodent-borne hepatitis E virus, designated as HEV-C1. However, epizootiological information about HEV-C1 is limited. To address this issue, serum samples from 443 small mammals captured at 5 sites in Hanoi, Vietnam, were examined for anti-HEV-C1 IgG antibodies. In addition, livers of seropositive animals were examined for viral RNA. Anti-HEV-C1 antibodies were detected in 57 (12.9%) of the 443 serum samples. Seropositive animals were found in all of the sites (4.7% to 22.2%). Anti-HEV-C1 antibodies were detected from 48 (12.3%) of 389 Rattus norvegicus and 9 (19.6%) of 46 R. tanezumi, but were not detected from 8 Suncus murinus. Viral RNAs were detected from 13 (22.8%) of the 57 seropositive rodents. The detection rate of viral RNA in seropositive R. tanezumi (66.7%, 6/9) was significantly higher than that in seropositive R. norvegicus (14.6%, 7/48). The results suggest that R. tanezumi is more susceptible than R. norvegicus to HEV-C1 infection. Phylogenetic analysis revealed that Vietnamese strains were divided into 3 clusters in genetic group 2 of HEV-C1. Multiple clusters of viruses were detected at several sites without species specificity, suggesting that 3 clusters of HEV-C1 co-circulate in Hanoi, Vietnam.

The Bama miniature swine is susceptible to experimental HEV infection

The hepatitis E virus (HEV) is one of the main causes of enterically transmitted hepatitis worldwide. Although the mortality rates associated with HEV are generally low, they can be up to 28% in HEV-infected pregnant women, and the elderly are more susceptible. The reasons for this selective severity are unclear, partially because there is no suitable, easy-to-use model in which to study HEV infection. Non-human primates and standard swine have been identified as being sensitive to infection with HEV and have been used for HEV infection studies. However, studies in these animals have been limited by high housing costs and the difficulty of manipulating these animals. In the current study, we established a model of HEV infection using Bama miniature swine. The model is easy to use and is sensitive to infections with HEV genotypes 3 and 4, which are classified as zoonotic HEVs. In this model, infection of Bama miniature swine with HEV genotypes 3 and 4 caused the typical features. All Bama miniature swine that were infected with HEV genotypes 3 and 4 exhibited significant HEV viremia, shedding, anti-HEV antibody responses and partial liver inflammation. Bama miniature swine may serve as an alternative to standard swine models for the study of zoonotic HEV infection and HEV genotype specificity research.

Role of HEV antigen detection in HEV-related acute viral hepatitis and acute liver failure

Detection of HEV antigen presents as an interesting low cost, novel, and rapid diagnostic technique to ascertain HEV viremia where facilities for reverse transcriptase polymerase chain reaction (RT PCR) are sparse. This study was undertaken to assess the relative efficacy of HEV antigen detection by ELISA with currently available diagnostic tests in patients of HEV-related acute viral hepatitis (AVH) and acute liver failure (ALF). This study included 36 ALF and 64 AVH cases. HEV RNA and HEV viral load were determined by RT PCR and real time PCR, respectively. Evidence of recent HEV infection was detected in 45/64 AVH cases and 22/36 ALF cases. IgM anti-HEV antibody, HEV RNA, and HEV antigen were positive in 34/45 (75.56%), 26/45 (57.77%), and 21/45 (46.66%), in the AVH group, and 16/22 (72.72%), 14/22 (63.63%), 12/22 (54.54%) in ALF group, respectively. The concordance between HEV RNA and HEV antigen was 75.56% (P < 0.01) with κ-coefficient of 0.516 and 75.27% (P = 0.07) with κ-coefficient of 0.441 (P = 0.07) in the AVH and ALF patients, respectively, indicating moderate concordance. It was established that HEV antigen detection can be used as a valuable marker of active viremia and a cheaper surrogate to HEV RT PCR, particularly in window period, pregnant and immunocompromised patients, however, it did not correlate with severity of disease or influence the final outcome of illness in any of the study groups. J. Med. Virol 88:2179-2185, 2016. © 2016 Wiley Periodicals, Inc.

Materno-Fetal Outcomes with Viral Hepatitis in Pregnancy

OBJECTIVE

To evaluate materno-fetal outcomes in pregnant women with jaundice.

METHODS

A prospective study was conducted over a period of 6 months in a tertiary care hospital of Delhi, India. 82 pregnant women with jaundice were included. The serum was screened for viral markers, liver function tests, and coagulation status.

RESULTS

The mean age of women was 27.3 ± 4.3 years. 43.9 % (n = 36) women were HEV positive, 36 % (n = 27) HBsAg positive, 4 % (n = 3) HAV positive and 1.3 % (n = 1) HCV positive. Intrahepatic cholestasis was diagnosed in 10.8 % (n = 8) of women. Maternal morbidity was evaluated in terms of chorioamnionitis (5.4 %, n = 3), encephalopathy (26.8 %, n = 15), and coagulopathy (67.9 %, n = 38). There were five maternal deaths, and all were unbooked with HEV-positive status and a bilirubin >15 mg/dl with deranged coagulogram and encephalopathy and IUDs. 79 women delivered vaginally, and three had cesarean section. Of the vaginal deliveries, 59.8 % (n = 49) went into spontaneous labor, and 25.5 % (n = 21) were induced for varied reasons (BPS < 6/10 (38 %, n = 8)) and progressive derangement of LFT (38 %, n = 8). Among the 71 deliveries, 29 (40.8 %) were IUD and 42 (59.1 %) were live born. On analyzing the morbidity data, it was found that HEV-positive women (deranged coagulogram 71.05 %, IUD 75.86 %, encephalopathy 80 %) had a poorer outcome as compared to their HBsAg positive counterparts (deranged coagulogram 10.52 %, IUD 13.79 %, encephalopathy 6.66 %).

CONCLUSION

Urgent redressal of issues pertaining to sanitation and provision for clean drinking water for citizens of India is the need of the hour as HEV is fecooral in transmission.

Prophylaxis against hepatitis E: at risk populations and human vaccines

Hepatitis E is an emerging global disease caused by hepatitis E virus (HEV) infection. While in developing countries the infection was primarily due to poor sanitary conditions through intake of contaminated water or undercooked meats of infected animals, increasing cases of chronic hepatitis E resulting in rapidly progressive liver cirrhosis and end-stage liver disease have been reported in organ transplant patients or in immune compromised patients in developed countries. Fortunately, hepatitis E is now a vaccine preventable disease with a HEV239 based vaccine licensed for human use. Much work is needed to enable its use outside China. This review recounted the development process of the vaccine, outlined the critical quality attributes of the vaccine antigen and, most importantly, listed the populations at risk for HEV infection and the subsequent disease. These at risk populations could benefit the most from the vaccination if the vaccine is widely adopted.

Study of Abnormal Liver Function Test during Pregnancy in a Tertiary Care Hospital in Chhattisgarh

INTRODUCTION

Abnormal liver function tests (LFTs) in pregnancy require proper interpretation in order to avoid pitfalls in the diagnosis. The underlying disorder can have a significant effect on the outcome of both mother and foetus. The present study was done with the objective to study the clinical profile, incidence and possible causes of derangements of liver function tests.

MATERIAL AND METHOD

Eighty pregnant women with abnormal liver dysfunction were studied prospectively. Women with chronic liver disease and drug-induced abnormal liver function test were excluded. All available LFTs including LDH were studied along with some more definitive tests to aid identification of underlying cause. Foetomaternal outcome was noted in all.

RESULT

The incidence of abnormal LFT was 0.9 %. 13/80 (16.75 %) women had liver disorder not specific to pregnancy, whereas 67/80 (83.25 %) women had pregnancy-specific liver dysfunction. Of these, 65(81.25 %) women with liver dysfunction had pre-eclampsia including 11 (13.75 %) with HELLP and six women with eclampsia. 48/65 (60 %) women had pre-eclampsia in the absence of HELLP syndrome or eclampsia. The mean value for bilirubin (mg %) in hypertensive disorders of pregnancy ranged from 1.64 to 3.8, between 5 and 10 for ICP and AFLP and >10 in infective hepatitis. Transaminases were highest in infective hepatitis, whereas alkaline phosphate was highest in ICP. Total 27 (33.75 %) women suffered from adverse outcome with four (5 %) maternal deaths and 23 (28.75 %) major maternal morbidities. 33/80 (41.25 %) women had intrauterine death. 26.25 % babies were small for date.

CONCLUSION

Pregnancy-specific disorders are the leading cause of abnormal liver function test during pregnant state particularly in the third trimester. Pre-eclampsia-related disorder is the commonest. Gestational age of pregnancy and relative values of various liver function tests in different pregnancy-specific and pregnancy nonspecific disorders appear to be the best guide to clinch the diagnosis.

Acute liver failure in pregnancy: Challenges and management

Acute liver failure (ALF) in pregnancy negatively affects both maternal and foetal outcome. The spectrum of liver disease in pregnancy may range from mild asymptomatic transaminitis to fatal and irreversible deterioration in liver functions leading to significant morbidity and even mortality. In this comprehensive review, we searched articles published as review articles, clinical trials, and case series in the Medline from 1970 to 2012. The overall outcome of ALF in pregnancy depends on the aetiology, timely diagnosis, prompt management, and early referral to a centre equipped in managing medical or obstetric complication. The foetal outcome is affected by the stage of pregnancy in which the mother has a deterioration of the liver function, with a worst prognosis associated with first or second-trimester liver failure. When ALF complicates pregnancy, liver transplantation is the one of the viable options. Management protocols need to be individualised for each case keeping in mind the risk versus benefit to both the mother and the foetus.

Pregnancy-related liver disorders

Pregnancy-related liver disorders accounted for 8% of all maternal deaths at our center from 1999 to 2011. Of the three pregnancy-related liver disorders (acute fatty liver of pregnancy (AFLP), HELLP (Hemolysis, elevated liver enzymes, low platelets) syndrome and pre-eclamptic liver dysfunction, which can lead to adverse maternal and fetal outcome, AFLP is most typically under - diagnosed. Risk of maternal death can be minimised by timely recognition and early/aggressive multi-specialty management of these conditions. Urgent termination of pregnancy remains the cornerstone of therapy for some of these life threatening disorders, but recent advancements in our understanding help us in better overall management of these patients. This review focuses on various aspects of pregnancy-related liver disorders.

Epidemiology and associated risk factors of hepatitis e virus infection in plateau state, Nigeria

A cross-sectional study in Nigeria was undertaken to determine the epidemiology, seroprevalence, and associated risk factors, of hepatitis E virus (HEV). A total of 462 subjects were used for the study, categorized into four groups: apparently healthy persons, pregnant women, HIV positive subjects, and animal handlers. Information was obtained from subjects using interviewer-administered questionnaire. Blood samples were collected and analyzed for HEV antibodies (IgG and IgM) using enzyme-linked immunosorbent assay (ELISA) technique. Results obtained were analyzed using Statistical Package for Social Sciences (SPSS) version 17.0 statistical software. The overall seroprevalence of IgG and IgM was 42.7 and 0.9%, respectively. Animal handlers had the highest seroprevalence (66.7%). The associated risk factors for IgM seroprevalence were rural dwelling (P = 0.039, odds ratio (OR) 3.3, 95% confidence interval (CI) 0.7–15.4), blood transfusion (P < 0.001, OR 9.6, 95% CI 2.6–35.6), attending to animals (P = 0.032, OR 4.9, 95% CI 0.9–26.6), and waste disposal (P < 0.001). Factors associated with IgG were age (P = 0.044), location (P < 0.001), marital status (P < 0.001), formal education (P < 0.001), farming as occupation (P < 0.001), rural dwelling (P = 0.001), waste disposal (P < 0.001), alcohol consumption (P = 0.001, OR 2.4, 95% CI 1.4–4.0), open defecation (P < 0.001, OR 2.9, 95% CI 1.4–5.7), attending to animals (P < 0.001, OR 2.3, 95% CI 1.6–3.4), consuming unwashed fruits/vegetables (P < 0.001, OR 4.2, 95% CI 0.3–54.1), and stream/river as a source of drinking water (P < 0.001, OR 3.6, 95% CI 1.6–7.8). Preventive public health measures should be reinforced among all communities, particularly domestic animal handlers and pregnant women. Potable water should be provided for all communities. Data suggest that HEV remains an under-recognized and significant public health problem, warranting further attention and research.

Fetal and neonatal health consequences of vertically transmitted hepatitis E virus infection

Hepatitis E virus (HEV) infections lead to tens of thousands of deaths annually, mostly in developing countries. Hepatitis E poses a significant threat to the health of expectant mothers, a well-noted epidemiologic feature of the disease, but the contribution of vertically transmitted HEV infection to fetal and neonatal morbidity and mortality has received limited attention. Evidence assembled to date suggests that mother-to-child HEV transmission may be frequent and deleterious to the fetus and newborn in pregnancies affected by hepatitis E. Additional work is required to resolve key questions. (1) What risks do subclinical maternal HEV infections and infections early in pregnancy pose to fetal health and development? (2) Does vertical transmission occur during labor and/or breastfeeding and contribute appreciably to neonatal morbidity and mortality? (3) How do treatment decisions for severely ill mothers affect fetal and neonatal outcomes? (4) Can maternal vaccination effectively prevent vertical transmission of HEV?

Hepatitis e and acute liver failure in pregnancy

Hepatitis E virus is a positive strand RNA virus with three open reading frames which is transmitted predominantly through the fecal contamination of water and food. It is the most common cause of acute liver failure in endemic areas. Pregnant women especially from the Indian subcontinent and Africa are at increased risk of contracting acute HEV infection as well as developing severe complications including ALF. Transmission of HEV occurs from mother to unborn child. Both maternal and fetal complications may occur, including abortion, fetal demise, preterm labor and maternal or neonatal death. The precise reasons for increased susceptibility to HEV infection during pregnancy and associated severe disease are still an enigma. Management is supportive and termination of pregnancy is not recommended as a general rule. Prevention of infection is of vital importance, as availability of clean drinking water can reduce the burden of this disease in the community. There is a need for future research to focus on prevention of ALF in pregnancy and to study the disease pathogenesis, which is not explicitly understood at present. The availability of a vaccine may alter the natural course of the disease in this select population which is at risk.

Facility-based review of 296 maternal deaths at a tertiary centre in India: could they be prevented?

AIMS

The aim of this study was to identify causes of maternal mortality at the facility and to assess the standard of care, deficiencies in health services and preventability of these deaths using facility-based maternal death reviews.

MATERIAL AND METHODS

This was a prospective study at a tertiary care hospital that included all women who died during pregnancy or within 42 days of being pregnant during 2005-2010.

RESULTS

A review of 296 maternal deaths revealed that 59% of these occurred in medical wards. Indirect maternal deaths (54%) outnumbered the direct deaths (46%). Main causes were hepatitis (18%), hemorrhage (10%) and puerperal sepsis (10%). Only 5% of the women had received antenatal care at the facility. One-third (34%) were referred from other centers. The majority (74%) were critically sick at admission. Most of the women (62%) died postpartum. Substandard care and deficient health services were identified in 8% and 20% of the cases, respectively. Sixteen (5%) maternal deaths were deemed preventable and another 36 (12%) possibly preventable. Since most of the preventable deaths (12/16) were due to hemorrhage, measures to control postpartum hemorrhage were promoted at the facility. Findings of the maternal death reviews were regularly conveyed to the State Health Department for prioritization and resource allocation to prevent maternal mortality.

CONCLUSION

More maternal deaths occurred in the medical than in the obstetrics wards at the facility. The leading causes were hepatitis, hemorrhage and puerperal sepsis. Most of the deaths were non-preventable as the women were critically sick at admission; however, substandard care and health service deficiency were contributory in some of the cases.

Estimating the burden of maternal and neonatal deaths associated with jaundice in Bangladesh: possible role of hepatitis E infection

OBJECTIVES

We estimated the population-based incidence of maternal and neonatal mortality associated with hepatitis E virus (HEV) in Bangladesh.

METHODS

We analyzed verbal autopsy data from 4 population-based studies in Bangladesh to calculate the maternal and neonatal mortality ratios associated with jaundice during pregnancy. We then reviewed the published literature to estimate the proportion of maternal deaths associated with liver disease during pregnancy that were the result of HEV in hospitals.

RESULTS

We found that 19% to 25% of all maternal deaths and 7% to 13% of all neonatal deaths in Bangladesh were associated with jaundice in pregnant women. In the published literature, 58% of deaths in pregnant women with acute liver disease in hospitals were associated with HEV.

CONCLUSIONS

Jaundice is frequently associated with maternal and neonatal deaths in Bangladesh, and the published literature suggests that HEV may cause many of these deaths. HEV is preventable, and studies to estimate the burden of HEV in endemic countries are urgently needed.

Fatal outbreaks of jaundice in pregnancy and the epidemic history of hepatitis E

Space-time clustering of people who fall acutely ill with jaundice, then slip into coma and death, is an alarming phenomenon, more markedly so when the victims are mostly or exclusively pregnant. Documentation of the peculiar, fatal predisposition of pregnant women during outbreaks of jaundice identifies hepatitis E and enables construction of its epidemic history. Between the last decade of the 18th century and the early decades of the 20th century, hepatitis E-like outbreaks were reported mainly from Western Europe and several of its colonies. During the latter half of the 20th century, reports of these epidemics, including those that became serologically confirmed as hepatitis E, emanated from, first, the eastern and southern Mediterranean littoral and, thereafter, Southern and Central Asia, Eastern Europe, and the rest of Africa. The dispersal has been accompanied by a trend towards more frequent and larger-scale occurrences. Epidemic and endemic hepatitis E still beset people inhabiting Asia and Africa, especially pregnant women and their fetuses and infants. Their relief necessitates not only accelerated access to potable water and sanitation but also vaccination against hepatitis E.

Hepatitis E virus infection as a cause of acute hepatitis in Southern Italy

BACKGROUND

Hepatitis E virus (HEV) is a major cause of acute hepatitis in developing countries, whereas it is not considered a major health problem in Western World.

AIMS

To investigate the spread of HEV and its possible role in causing acute hepatitis in Southern Italy.

METHODS

Four hundred and thirty patients observed from April to December 2009 were studied and grouped as follows: 55 individuals with acute hepatitis (AH), 33 of whom cryptogenic; 321 individuals with chronic liver diseases (CLD), (278 Italians and 43 immigrants); 54 individuals without liver disease (control-group). Serum samples from all cases were tested for IgG anti-HEV antibodies and those positive to this test as well as all AH cases were also tested both for IgM anti-HEV and HEV RNA.

RESULTS

Two of 33 (6%) cryptogenic AH cases were associated with HEV infection as shown by positive IgM anti-HEV test. Both these patients had not travelled to areas at high HEV endemicity. HEV RNA was not found in any sample tested. IgG anti-HEV antibodies were detected in 5.7% of Italians with CLD and 3.7% of the control-group. No immigrant was found positive for any HEV marker.

CONCLUSION

Autochthonous HEV infection is present in Southern Italy where it may cause AH.

A fatal case of acute hepatitis E among pregnant women, Central African Republic

BACKGROUND

Hepatitis E virus (HEV) is a major public health problem in developing countries. HEV infection in pregnant women is more common and more often fatal in the third trimester. The mortality rate due to HEV-induced hepatitis is as high as 15-20 per cent. The present study was designed to determine the potential factors responsible for high mortality rate among pregnant women.

FINDINGS

Twenty one pregnant women attended the Maternity Center of Begoua in the Central African Republic during an outbreak of hepatitis E virus between July and October 2002 with symptoms of acute liver disease. Their mean gestational period was 29.9 (SD 8.3 weeks) and they were aged from 15 to 39 years old. The serology IgM showed that seven women (33%) had acute hepatitis E. Among them, one woman, aged 35 and her newborn died after an apparently normal preterm delivery. The 6 remaining young women, age 18 - 22, had preterm deliveries which included three live babies and three stillborn with one macerated.

CONCLUSIONS

These results suggest that maternal age, in addition to hormonal, immunological and environmental factors, may be a risk factor for fatal outcome.

Swine hepatitis E virus in rural southern China: genetic characterization and experimental infection in rhesus monkeys (Macaca mulatta)

BACKGROUND

In rural areas of southern China, where hepatitis E is endemic, residents generally rear pigs in pigsties near their houses. The study was conducted to assess the possibility that hepatitis E virus (HEV) infections in this region are acquired primarily through contact with swine.

METHODS

One hundred twenty swine fecal samples collected from pigsties located in eight rural communities of southern China were tested for HEV RNA. The swine HEV isolates were analyzed genetically and were experimentally inoculated into rhesus monkeys to determine the potential risk of cross-species infection.

RESULTS

Twenty-nine of the 120 swine fecal samples were positive for HEV RNA. The nucleotide sequences of these swine HEV strains shared 85%-99% identities with the local human genotype 4 isolates and belonged to two subgroups of genotype 4. Importantly, swine HEV strains representing both subgroups induced hepatitis in rhesus monkeys by inoculation with the virus, evidenced by elevated serum alanine transaminase (ALT), viremia, fecal viral shedding, anti-HEV seroconversion, and liver histopathological changes.

CONCLUSIONS

Swine may be the principal reservoir for human HEV infection in rural southern China.