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Iaconelli M, Bonanno Ferraro G, Mancini P, Suffredini E, Veneri C, Ciccaglione AR, Bruni R, Della Libera S, Bignami F, Brambilla M, De Medici D, Brandtner D, Schembri P, D’Amato S, La Rosa G. Nine-Year Nationwide Environmental Surveillance of Hepatitis E Virus in Urban Wastewaters in Italy (2011-2019). INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2059. [PMID: 32244915 PMCID: PMC7143501 DOI: 10.3390/ijerph17062059] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/18/2020] [Accepted: 03/18/2020] [Indexed: 12/19/2022]
Abstract
Hepatitis E virus (HEV) is an emerging causative agent of acute hepatitis worldwide. To provide insights into the epidemiology of HEV in Italy, a large-scale investigation was conducted into urban sewage over nine years (2011-2019), collecting 1374 sewage samples from 48 wastewater treatment plants located in all the 20 regions of Italy. Broadly reactive primers targeting the ORF1 and ORF2 regions were used for the detection and typing of HEV, followed by Sanger and next generation sequencing (NGS). Real-time RT-qPCR was also used to attempt quantification of positive samples. HEV RNA detection occurred in 74 urban sewage samples (5.4%), with a statistically significant higher frequency (7.1%) in central Italy. Fifty-six samples were characterized as G3 strains and 18 as G1. While the detection of G3 strains occurred in all the surveillance period, G1 strains were mainly detected in 2011-2012, and never in 2017-2019. Typing was achieved in 2 samples (3f subtype). Viral concentrations in quantifiable samples ranged from 1.2 × 103 g.c./L to 2.8 × 104 g.c./L. Our results suggest the considerable circulation of the virus in the Italian population, despite a relatively small number of notified cases, a higher occurrence in central Italy, and a noteworthy predominance of G3 strains.
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Affiliation(s)
- Marcello Iaconelli
- Department of Environment and Health - Istituto Superiore di Sanità, 00161 Rome, Italy; (M.I.); (G.B.F.); (P.M.); (C.V.); (S.D.L.); (F.B.)
| | - Giusy Bonanno Ferraro
- Department of Environment and Health - Istituto Superiore di Sanità, 00161 Rome, Italy; (M.I.); (G.B.F.); (P.M.); (C.V.); (S.D.L.); (F.B.)
| | - Pamela Mancini
- Department of Environment and Health - Istituto Superiore di Sanità, 00161 Rome, Italy; (M.I.); (G.B.F.); (P.M.); (C.V.); (S.D.L.); (F.B.)
| | - Elisabetta Suffredini
- Department of Food Safety, Nutrition and Veterinary Public Health, Istituto Superiore di Sanità, 00161 Rome, Italy; (E.S.); (D.D.M.)
| | - Carolina Veneri
- Department of Environment and Health - Istituto Superiore di Sanità, 00161 Rome, Italy; (M.I.); (G.B.F.); (P.M.); (C.V.); (S.D.L.); (F.B.)
| | - Anna Rita Ciccaglione
- Department Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy; (A.R.C.); (R.B.)
| | - Roberto Bruni
- Department Infectious Diseases, Istituto Superiore di Sanità, 00161 Rome, Italy; (A.R.C.); (R.B.)
| | - Simonetta Della Libera
- Department of Environment and Health - Istituto Superiore di Sanità, 00161 Rome, Italy; (M.I.); (G.B.F.); (P.M.); (C.V.); (S.D.L.); (F.B.)
| | - Francesco Bignami
- Department of Environment and Health - Istituto Superiore di Sanità, 00161 Rome, Italy; (M.I.); (G.B.F.); (P.M.); (C.V.); (S.D.L.); (F.B.)
| | - Massimo Brambilla
- Consiglio per la ricerca in agricoltura e l’analisi dell’economia agraria (CREA), Research Centre for Engineering and Agri Food Processing, 24047 Treviglio, BG, Italy;
| | - Dario De Medici
- Department of Food Safety, Nutrition and Veterinary Public Health, Istituto Superiore di Sanità, 00161 Rome, Italy; (E.S.); (D.D.M.)
| | | | - Pietro Schembri
- Regional Department for Health Activities and Epidemiological Observatory of the Sicilian Region, 90146 Palermo, Italy;
| | - Stefania D’Amato
- Ministry of Health, Directorate-General for Prevention, 00144 Rome, Italy;
| | - Giuseppina La Rosa
- Department of Environment and Health - Istituto Superiore di Sanità, 00161 Rome, Italy; (M.I.); (G.B.F.); (P.M.); (C.V.); (S.D.L.); (F.B.)
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Schulz M, Biedermann P, Bock CT, Hofmann J, Choi M, Tacke F, Hanitsch LG, Mueller T. Rituximab-Containing Treatment Regimens May Imply a Long-Term Risk for Difficult-To-Treat Chronic Hepatitis E. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:341. [PMID: 31947836 PMCID: PMC6982013 DOI: 10.3390/ijerph17010341] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 12/23/2019] [Accepted: 12/31/2019] [Indexed: 02/05/2023]
Abstract
Hepatitis E virus (HEV) infection is an emerging disease in industrialized countries which is usually characterized by a self-limited course. However, there is an increased risk of HEV persistence in immunocompromised risk populations, comprising patients following solid organ transplantation or hematological malignancies. Recently, chronic HEV infection following rituximab-containing treatment regimens has been described. Here we report five patients with chronic hepatitis E after prior rituximab therapy for various indications. We determined the immunological characteristics of these patients and analyzed the development of ribavirin (RBV) treatment failure-associated mutations in the HEV genome. One patient became chronically HEV-infected 110 months after administration of rituximab (RTX). Immunological characterization revealed that all patients exhibited significant hypogammaglobulinemia and CD4+ T cell lymphopenia. One patient permanently cleared HEV following weight-based ribavirin treatment while three patients failed to reach a sustained virological response. In depth mutational analysis confirmed the presence of specific mutations associated with RBV treatment failure in these patients. Our cases indicate that rituximab-containing treatment regimens might imply a relevant risk for persistent HEV infection even years after the last rituximab application. Moreover, we provide further evidence to prior observations suggesting that chronically HEV infected patients following RTX-containing treatment regimens might be difficult to treat.
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Affiliation(s)
- Marten Schulz
- Department of Hepatology and Gastroenterology, Charité—Universitätsmedizin Berlin, CVK, 13353 Berlin, Germany; (F.T.); (T.M.)
| | - Paula Biedermann
- Division of Viral Gastroenteritis, Hepatitis Pathogens and Enteroviruses, Department of Infectious Diseases, Robert Koch Institute, 13353 Berlin, Germany; (P.B.); (C.-T.B.)
| | - Claus-Thomas Bock
- Division of Viral Gastroenteritis, Hepatitis Pathogens and Enteroviruses, Department of Infectious Diseases, Robert Koch Institute, 13353 Berlin, Germany; (P.B.); (C.-T.B.)
| | - Jörg Hofmann
- Institute of Virology, Charité Universitätsmedizin Berlin, Labor Berlin—Charité-Vivantes GmbH, 13353 Berlin, Germany;
| | - Mira Choi
- Department of Nephrology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité—Universitätsmedizin Berlin, CVK, 13353 Berlin, Germany; (F.T.); (T.M.)
| | - Leif Gunnar Hanitsch
- Institute of Medical Immunology, Charité—Universitätsmedizin Berlin, 13353 Berlin, Germany;
| | - Tobias Mueller
- Department of Hepatology and Gastroenterology, Charité—Universitätsmedizin Berlin, CVK, 13353 Berlin, Germany; (F.T.); (T.M.)
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