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Mirzaev UK, Ouoba S, Ko K, Phyo Z, Chhoung C, Ataa AG, Sugiyama A, Akita T, Tanaka J. Systematic review and meta-analysis of hepatitis E seroprevalence in Southeast Asia: a comprehensive assessment of epidemiological patterns. BMC Infect Dis 2024; 24:525. [PMID: 38789918 PMCID: PMC11127338 DOI: 10.1186/s12879-024-09349-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 04/24/2024] [Indexed: 05/26/2024] Open
Abstract
The burden of hepatitis E in Southeast Asia is substantial, influenced by its distinct socio-economic and environmental factors, as well as variations in healthcare systems. The aim of this study was to assess the pooled seroprevalence of hepatitis E across countries within the Southeast Asian region by the UN division.The study analyzed 66 papers across PubMed, Web of Science, and Scopus databases, encompassing data from of 44,850 individuals focusing on anti-HEV seroprevalence. The investigation spanned nine countries, excluding Brunei and East Timor due to lack of data. The pooled prevalence of anti-HEV IgG was determined to be 21.03%, with the highest prevalence observed in Myanmar (33.46%) and the lowest in Malaysia (5.93%). IgM prevalence was highest in Indonesia (12.43%) and lowest in Malaysia (0.91%). The study stratified populations into high-risk (farm workers, chronic patients) and low-risk groups (general population, blood donors, pregnant women, hospital patients). It revealed a higher IgG-28.9%, IgM-4.42% prevalence in the former group, while the latter group exhibited figures of 17.86% and 3.15%, respectively, indicating occupational and health-related vulnerabilities to HEV.A temporal analysis (1987-2023), indicated an upward trend in both IgG and IgM prevalence, suggesting an escalating HEV burden.These findings contribute to a better understanding of HEV seroprevalence in Southeast Asia, shedding light on important public health implications and suggesting directions for further research and intervention strategies.Key pointsResearch QuestionInvestigate the seroprevalence of hepatitis E virus (HEV) in Southeast Asian countries focusing on different patterns, timelines, and population cohorts.FindingsSporadic Transmission of IgG and IgM Prevalence:• Pooled anti-HEV IgG prevalence: 21.03%• Pooled anti-HEV IgM prevalence: 3.49%Seroprevalence among specific groups:High-risk group (farm workers and chronic patients):• anti-HEV IgG: 28.9%• anti-HEV IgM: 4.42%Low-risk group (general population, blood donors, pregnant women, hospital patients):• anti-HEV IgG: 17.86%• anti-HEV IgM: 3.15%Temporal Seroprevalence of HEV:Anti-HEV IgG prevalence increased over decades (1987-1999; 2000-2010; 2011-2023): 12.47%, 18.43%, 29.17% as an anti-HEV IgM prevalence: 1.92%, 2.44%, 5.27%ImportanceProvides a comprehensive overview of HEV seroprevalence in Southeast Asia.Highlights variation in seroprevalence among different population groups.Reveals increasing trend in HEV seroprevalence over the years.Distinguishes between sporadic and epidemic cases for a better understanding of transmission dynamics.
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Affiliation(s)
- Ulugbek Khudayberdievich Mirzaev
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Hiroshima, Minami, 734-8551, Japan
- Department of Hepatology, Research Institute of Virology, Tashkent, Uzbekistan
| | - Serge Ouoba
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Hiroshima, Minami, 734-8551, Japan
- Unité de Recherche Clinique de Nanoro (URCN), Institut de Recherche en Sciences de La Santé (IRSS), Nanoro, Burkina Faso
| | - Ko Ko
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Hiroshima, Minami, 734-8551, Japan
| | - Zayar Phyo
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Hiroshima, Minami, 734-8551, Japan
| | - Chanroth Chhoung
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Hiroshima, Minami, 734-8551, Japan
| | - Akuffo Golda Ataa
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Hiroshima, Minami, 734-8551, Japan
| | - Aya Sugiyama
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Hiroshima, Minami, 734-8551, Japan
| | - Tomoyuki Akita
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Hiroshima, Minami, 734-8551, Japan.
| | - Junko Tanaka
- Department of Epidemiology, Infectious Disease Control and Prevention, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3, Kasumi, Hiroshima, Minami, 734-8551, Japan.
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The Risk of Transfusion-Transmitted Hepatitis E Virus: Evidence from Seroprevalence Screening of Blood Donations. Indian J Hematol Blood Transfus 2021; 38:145-152. [PMID: 33879981 PMCID: PMC8050642 DOI: 10.1007/s12288-021-01428-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 03/18/2021] [Indexed: 01/04/2023] Open
Abstract
Throughout the world, there has been growing concern over the risk of hepatitis E virus (HEV) transmission via blood transfusion. The present study screened blood donor samples for anti-HEV immunoglobulin M (IgM) and immunoglobulin G (IgG). The prevalence of HEV infection was assessed on a total of 1,003 archived serum samples obtained from the National Blood Centre, Malaysia. The samples were collected from healthy blood donor from Klang Valley between 2017 and 2018. All samples were tested for IgM and IgG antibodies to HEV using enzyme-linked immunosorbent assays (ELISA). HEV-specific IgG antibodies were detected in 31/1003 (3.1%; 95% confidence interval [CI] 2.1%–4.4%) and IgM in 9/1003 (0.9%; 95% CI 0.4%–1.7%) samples. In bivariate analysis, there was no significant difference in the prevalence of anti-HEV IgG with respect to gender and district of origin. Although not statistically significant, males had higher odds of having anti-HEV IgG than females (odds ratio [OR] = 2.86; 95% CI 0.95–8.64). All anti-HEV IgG positive individuals were people of Chinese descent. Anti-HEV IgG increased significantly with age, from 0.6% (95% CI 0.1%–2.6%) of 18–30-year-old donors to 7.4% (95% CI 2.7%–17.0%) of donors older than 50 years and was highest among non-professional workers (5.3%; 95% CI 2.5%–10.5%). Increasing age and a non-professional occupation remained significant predictors for anti-HEV IgG in the multivariable analysis. Screening of blood donations for HEV in Malaysia is important to safeguard the health of transfusion recipients. The higher rates of HEV infection in blood from older donors and donors who are non-professional workers may provide insights into targeted groups for blood screening.
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Raji YE, Toung OP, Mohd Taib N, Sekawi ZB. A systematic review of the epidemiology of Hepatitis E virus infection in South - Eastern Asia. Virulence 2020; 12:114-129. [PMID: 33372843 PMCID: PMC7781573 DOI: 10.1080/21505594.2020.1865716] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Hepatitis E virus (HEV) infection is an emerging zoonotic viral disease, with an increasingly international public health challenge. Despite the concerns that the global disease burden may be underestimated. Therefore, evaluation of the disease epidemiology in South – eastern Asia through a systematic review will assist in unraveling the burden of the disease in the subregion. A priori protocol was prepared for the systematic review and followed by a literature search involving five electronic databases. Identified publications were screened for high quality studies and the elimination of bias and relevant data extracted. A total of 4157 citations were captured, and only 35 were included in the review. A wide range of HEV seroprevalence was recorded from 2% (urban blood donors in Malaysia) to 77.7% (lowland communities in Lao PDR). Sporadic HEV infection and epidemics were also detected in the subregion. Indicating hyperendemicity of the disease in South – eastern Asia.
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Affiliation(s)
- Yakubu Egigogo Raji
- Department of Medical Microbiology and Parasitology, Universiti Putra Malaysia 1 , Malaysia.,Department of Pathology, Clinical Microbiology Unit College of Health Sciences Ibrahim Badamasi Babangida University Lapai Nigeria , Nigeria
| | - Ooi Peck Toung
- Department of Veterinary Clinical Studies Faculty of Veterinary Medicine, Universiti Putra Malaysia 2 , Malaysia
| | - Niazlin Mohd Taib
- Department of Medical Microbiology and Parasitology, Universiti Putra Malaysia 1 , Malaysia
| | - Zamberi Bin Sekawi
- Department of Medical Microbiology and Parasitology, Universiti Putra Malaysia 1 , Malaysia
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Ngo DB, Chaibun T, Yin LS, Lertanantawong B, Surareungchai W. Electrochemical DNA detection of hepatitis E virus genotype 3 using PbS quantum dot labelling. Anal Bioanal Chem 2020; 413:1027-1037. [PMID: 33236225 DOI: 10.1007/s00216-020-03061-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 12/30/2022]
Abstract
The aim of this study was to develop a highly specific electrochemical DNA sensor using functionalized lead sulphide (PbS) quantum dots for hepatitis E virus genotype 3 (HEV3) DNA target detection. Functionalized-PbS quantum dots (QDs) were used as an electrochemical label for the detection of HEV3-DNA target by the technique of square wave anodic stripping voltammetry (SWASV). The functionalized-PbS quantum dots were characterized by UV-vis, FTIR, XRD, TEM and zeta potential techniques. As-prepared, functionalized-PbS quantum dots have an average size of 4.15 ± 1.35 nm. The detection platform exhibited LOD and LOQ values of 1.23 fM and 2.11 fM, respectively. HEV3-DNA target spiked serum is also reported.Graphical abstract.
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Affiliation(s)
- Duy Ba Ngo
- School of Bioresources and Technology, King Mongkut's University of Technology Thonburi (KMUTT), Bangkhuntien-Chaitalay Road, Bangkok, 10150, Thailand
| | - Thanyarat Chaibun
- Department of Biomedical Engineering, Faculty of Engineering, Mahidol University, Phutthamonthon, Nakhon Pathom, 73170, Thailand
| | - Lee Su Yin
- Department of Biotechnology, Faculty of Applied Sciences, AIMST University, Jalan, Bukit Air Nasi, 08100, Bedong, Kedah, Malaysia
| | - Benchaporn Lertanantawong
- Department of Biomedical Engineering, Faculty of Engineering, Mahidol University, Phutthamonthon, Nakhon Pathom, 73170, Thailand.
| | - Werasak Surareungchai
- School of Bioresources and Technology, King Mongkut's University of Technology Thonburi (KMUTT), Bangkhuntien-Chaitalay Road, Bangkok, 10150, Thailand. .,Nanoscience and Nanotechnology Graduate Program, Faculty of Science, King Mongkut's University of Technology Thonburi, Pracha Uthit Rd, Bangkok, 10140, Thailand.
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Clinical significance of post-liver transplant hepatitis E seropositivity in high prevalence area of hepatitis E genotype 3: a prospective study. Sci Rep 2020; 10:7352. [PMID: 32355268 PMCID: PMC7192897 DOI: 10.1038/s41598-020-64551-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 04/15/2020] [Indexed: 12/25/2022] Open
Abstract
High hepatitis E (HEV) seroprevalence has been reported in the general population and in post-liver transplant (LT) cases in several regions, including Thailand, with genotype 3 being a predominant genotype. We hypothesized that HEV might persist at a subclinical level and might pose clinical risks in the post-LT period. We performed a cross-sectional study with 108 post-LT patients and found an IgG seroprevalence of 55.6%. Subsequently, 91 cases without clinical evidence of HEV-related hepatitis were enrolled in 1 year of prospective follow-up to determine clinical status, serologies and serum/feces HEV RNA every 4 months. HEV RNA was detected, indicating subclinical infections in patients with or without seropositivity, with an annual incidence of 7.7%. Our results suggest that subclinical HEV infection exists among LT patients in this high-prevalence area. Thus, clinicians should be aware of the possibility of disease reemergence and HEV viral transmission in LT patients.
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Louisirirotchanakul S. Response to Yasri and Wiwanitkit re: "A Nationwide Survey of the Seroprevalence of Hepatitis E Virus Infections Among Blood Donors in Thailand". Viral Immunol 2019; 32:464-465. [PMID: 31750796 DOI: 10.1089/vim.2019.0160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Suda Louisirirotchanakul
- Department of Microbiology, Mahidol University Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
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Jupattanasin S, Chainuvati S, Chotiyaputta W, Chanmanee T, Supapueng O, Charoonruangrit U, Oota S, Louisirirotchanakul S. A Nationwide Survey of the Seroprevalence of Hepatitis E Virus Infections Among Blood Donors in Thailand. Viral Immunol 2019; 32:302-307. [PMID: 31403386 DOI: 10.1089/vim.2018.0146] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Hepatitis E virus (HEV) is a common cause of acute hepatitis infections. Our previous 3-year study at two large Thai hospitals established an occurrence of 4-5% of HEV infections from swine HEV genotype 3 in suspected acute hepatitis patients, with the high incidence in older adults. This study was a serosurvey to determine the prevalence of HEV infections among Thai adults. We obtained sera from 630 healthy blood donors with a median age of 38 (18-64) years who attended Thai Red Cross transfusion units throughout Thailand. The donors were domiciled in 16 provinces in the northern (n = 159), central (n = 193), northeastern (n = 158), and southern (n = 120) regions. The seroprevalence of IgG antibody to HEV (anti-HEV) was determined by the EUROIMMUN test kit, using indirect enzyme-linked immunosorbent assay (ELISA) based on recombinant antigens derived from ORF2 of HEV genotypes 1 and 3. Demographic data, including information related to HEV infection risk (the number of pigs and the proportion of Muslims in each province), were also obtained. The overall anti-HEV prevalence among Thai adults was 29.7%. The frequencies of anti-HEV found in the northern (28.9%, 95% confidence interval [CI] = 22.4-36.4), northeastern (34.8%, 95% CI = 27.8-42.5), and central (35.8%, 95% CI = 29.3-42.7) regions were similar, whereas the frequency in the southern (14.2%, 95% CI = 9.0-21.5) region, known to have a large Muslim population, was low. An increasing frequency of the specific antibody was observed among the elderly. A low HEV infection rate was associated with an Islamic population where there are low number of pigs and low swine consumption. Furthermore, the higher anti-HEV incidences in the northeastern provinces might relate to the local cultural practice of consuming undercooked pork. Besides the need for an HEV vaccination in the future, there is a requirement for rapid early diagnosis; the undertaking of prevention-management campaigns might also reduce the number of infected patients.
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Affiliation(s)
- Sujittra Jupattanasin
- Department of Microbiology, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | - Siwaporn Chainuvati
- Department of Internal Medicine, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | - Watcharasak Chotiyaputta
- Department of Internal Medicine, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | - Tipsuda Chanmanee
- Department of Microbiology, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | - Orawan Supapueng
- Department of Research and Development, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
| | | | - Sineenart Oota
- The National Blood Centre, Thai Red Cross Society, Bangkok, Thailand
| | - Suda Louisirirotchanakul
- Department of Microbiology, Faculty of Medicine, Mahidol University, Siriraj Hospital, Bangkok, Thailand
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8
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Hepatitis E: Current Status in India and Other Asian Countries. JOURNAL OF PURE AND APPLIED MICROBIOLOGY 2019. [DOI: 10.22207/jpam.13.1.15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Pereira JG, Soares VM, de Souza FG, Tadielo LE, Dos Santos EAR, Brum MCS, Henzel A, Duval EH, Spilki FR, da Silva WP. Hepatitis A Virus, Hepatitis E Virus, and Rotavirus in Foods of Animal Origin Traded at the Borders of Brazil, Argentina, and Uruguay. FOOD AND ENVIRONMENTAL VIROLOGY 2018; 10:365-372. [PMID: 30206760 DOI: 10.1007/s12560-018-9357-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/06/2018] [Indexed: 06/08/2023]
Abstract
The aim of this study was to investigate hepatitis A virus (HAV), hepatitis E (HEV), and rotavirus (RV) in fresh and processed meat traded on the border of Brazil with Argentina and Uruguay. In total, 159 samples of raw and processed foods of animal origin were collected in Paso de los Libres, Argentina (n = 53 raw meat, n = 24 processed meat) and Rivera, Uruguay (n = 55 raw meat, n = 18 processed meat), or were seized by the Brazilian International Agricultural Surveillance System-VIGIAGRO (Brazil-Argentina border) (n = 8 raw meat, n = 1 bush meat). All samples were tested for the presence of HAV, HEV, and RV genomes. HAV genes were detected in 18.23% of samples and RV genes in 23.89%. No HEV-positive samples were detected. HAV was also detected in two of the VIGIAGRO samples. Processed meats from Argentina and Uruguay had a higher rate of HAV and RV than raw meat (P > 0.05). The median HAV in the Argentinian and Uruguayan samples was 6.9 × 104 and 3.5 × 103 copies/g, respectively. The presence of RV viral genes in raw meats from Argentina was significant, and this was not observed in processed meats. The presence of HAV and RV genes in a significant portion of products from Argentina and Uruguay is a potential source of human infection. This also indicates precarious conditions of acquisition, processing, and manipulation, which could be improved by improved regulation of food across borders.
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Affiliation(s)
- Juliano Gonçalves Pereira
- Departamento de Higiene Veterinária e Saúde Pública, Faculdade de Medicina Veterinária e Zootecnia, Universidade Estadual Paulista "Júlio de Mesquita Filho", Campus de Botucatu, Rua Prof. Walter Maurício Correa, SN, Botucatu, SP, CEP 18618681, Brazil.
- Universidade Federal de Pelotas, Campus Capão do Leão. Avenida Eliseu Maciel, SN, Capão do Leão, RS, CEP 96010900, Brazil.
| | - Vanessa Mendonça Soares
- Universidade Federal do Pampa, Campus Uruguaiana. BR 472, Km 585, Uruguaiana, RS, CEP 97501970, Brazil
| | - Fernanda Gil de Souza
- Laboratório de Microbiologia Molecular, Instituto de Ciências da Saúde, Universidade Feevale, Rodovia ERS-239, 2755, Novo Hamburgo, RS, CEP 93525075, Brazil
| | - Leonardo Ereno Tadielo
- Universidade Federal do Pampa, Campus Uruguaiana. BR 472, Km 585, Uruguaiana, RS, CEP 97501970, Brazil
| | | | - Mário Celso Sperotto Brum
- Universidade Federal do Pampa, Campus Uruguaiana. BR 472, Km 585, Uruguaiana, RS, CEP 97501970, Brazil
| | - Andreia Henzel
- Laboratório de Microbiologia Molecular, Instituto de Ciências da Saúde, Universidade Feevale, Rodovia ERS-239, 2755, Novo Hamburgo, RS, CEP 93525075, Brazil
| | - Eduarda Hallal Duval
- Universidade Federal de Pelotas, Campus Capão do Leão. Avenida Eliseu Maciel, SN, Capão do Leão, RS, CEP 96010900, Brazil
| | - Fernando Rosado Spilki
- Laboratório de Microbiologia Molecular, Instituto de Ciências da Saúde, Universidade Feevale, Rodovia ERS-239, 2755, Novo Hamburgo, RS, CEP 93525075, Brazil
| | - Wladimir Padilha da Silva
- Universidade Federal de Pelotas, Campus Capão do Leão. Avenida Eliseu Maciel, SN, Capão do Leão, RS, CEP 96010900, Brazil.
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Intharasongkroh D, Thongmee T, Sa-Nguanmoo P, Klinfueng S, Duang-In A, Wasitthankasem R, Theamboonlers A, Charoonruangrit U, Oota S, Payungporn S, Vongpunsawad S, Chirathaworn C, Poovorawan Y. Hepatitis E virus infection in Thai blood donors. Transfusion 2018; 59:1035-1043. [PMID: 30443992 DOI: 10.1111/trf.15041] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/10/2018] [Accepted: 09/20/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hepatitis E virus (HEV) infection in several industrialized and developing countries is associated with the consumption of pork and other meat products, an exposure risk among the majority of blood donors. We aimed to evaluate the prevalence of HEV in plasma from healthy blood donors in Thailand. STUDY DESIGN AND METHODS We screened blood samples collected between October and December 2015, from 30,115 individual blood donors in 5020 pools of six, for HEV RNA using in-house real-time reverse-transcription polymerase chain reaction (RT-PCR). Thrice-reactive samples were subjected to a commercial real-time RT-PCR (cobas HEV test) and evaluated for anti-HEV immunoglobulin M and immunoglobulin G antibodies. Genotyping using nested RT-PCR, nucleotide sequencing, and phylogenetic analysis was performed. RESULTS Twenty-six donors were positive for HEV RNA by the in-house assay, nine of whom were also positive by cobas test. None of the latter were reactive for anti-HEV immunoglobulin M or immunoglobulin G antibodies. Six samples were successfully genotyped and found to be HEV genotype 3. Thus, the frequency of HEV infection among healthy Thai blood donors is 1 in 1158. CONCLUSION The presence of HEV RNA in the Thai blood supply was comparable to the rates reported in western European countries, but higher than in North America and Australia.
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Affiliation(s)
- Duangnapa Intharasongkroh
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thanunrat Thongmee
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pattaratida Sa-Nguanmoo
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sirapa Klinfueng
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ausanee Duang-In
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Rujipat Wasitthankasem
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Apiradee Theamboonlers
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | | | - Sunchai Payungporn
- Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sompong Vongpunsawad
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chintana Chirathaworn
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yong Poovorawan
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Jefferies M, Rauff B, Rashid H, Lam T, Rafiq S. Update on global epidemiology of viral hepatitis and preventive strategies. World J Clin Cases 2018; 6:589-599. [PMID: 30430114 PMCID: PMC6232563 DOI: 10.12998/wjcc.v6.i13.589] [Citation(s) in RCA: 173] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 09/07/2018] [Accepted: 10/16/2018] [Indexed: 02/05/2023] Open
Abstract
Viral hepatitis is one of the major public health concerns around the world but until recently it has drawn little attention or funding from global health policymakers. Every year 1.4 million people die from viral hepatitis-related cirrhosis and liver cancer. However, the majority of the infected population are unaware of their condition. This population have significant obstacles to overcome such as lack of awareness, vulnerability, increased migration, disease stigma, discrimination, as well as poor health resources, conflict in policy development and program implementation. Despite implementing infection control measures over the last few decades eradication or significant disease reduction remains elusive. This study aims to present the current global prevalence status and examines potential elimination strategies. The information for this research were obtained through a systematic review, published scientific literatures, the official websites of various government organisations, international public health organisations and internationally recognised regulatory bodies over a period of 40 years between 1978 and 2018.
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Affiliation(s)
- Meryem Jefferies
- Drug Health, Western Sydney Local Health District, North Parramatta NSW 2151, Australia
| | - Bisma Rauff
- Westmead Institute for Medical Research, Westmead Hospital, Sydney Medical School University of Sydney, Westmead NSW 2145, Australia
| | - Harunor Rashid
- National Centre for Immunisation Research and Surveillance of Vaccine Preventable Diseases, the Children’s Hospital at Westmead, and the Discipline of Child and Adolescent Health, Sydney Medical School, Westmead, NSW 2145, Australia
| | - Thao Lam
- Drug Health, Western Sydney Local Health District, North Parramatta NSW 2151, Australia
| | - Shafquat Rafiq
- Croydon University Hospital NHS Trust, Croydon SE23 2SP, United Kingdom
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Dalton HR, Izopet J. Transmission and Epidemiology of Hepatitis E Virus Genotype 3 and 4 Infections. Cold Spring Harb Perspect Med 2018. [PMID: 29530946 DOI: 10.1101/cshperspect.a032144] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Following the introduction of robust serological and molecular tools, our understanding of the epidemiology of zoonotic hepatitis E virus (HEV) has improved considerably in recent years. Current thinking suggests that consumption of pork meat products is the key route of infection in humans, but it is certainly not the only one. Other routes of infection include environmental spread, contaminated water, and via the human blood supply. The epidemiology of HEV genotype (gt)3 and gt4 is complex, as there are several sources and routes of infection, and it is likely that these vary between and within countries and over time.
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Affiliation(s)
- Harry R Dalton
- Royal Cornwall Hospital, Truro TR1 3LJ, United Kingdom.,European Centre for Environment and Human Health, University of Exeter, Truro TR1 3LJ, United Kingdom
| | - Jacques Izopet
- Department of Virology, Hepatitis E Virus National Reference Centre, Toulouse University Hospital, 31059 Toulouse, France.,Toulouse-Purpan Centre for Pathophysiology, INSERM UMR1043/CNRS UMR 5282, CPTP, Toulouse University Paul Sabatier, 31024 Toulouse, France
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Kosoltanapiwat N, Reamtong O, Okabayashi T, Ampawong S, Rungruengkitkun A, Thiangtrongjit T, Thippornchai N, Leaungwutiwong P, Mahittikorn A, Mori H, Yoohanngoa T, Yamwong P. Mass spectrometry-based identification and whole-genome characterisation of the first pteropine orthoreovirus isolated from monkey faeces in Thailand. BMC Microbiol 2018; 18:135. [PMID: 30332986 PMCID: PMC6192116 DOI: 10.1186/s12866-018-1302-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 10/04/2018] [Indexed: 12/28/2022] Open
Abstract
Background The pteropine orthoreovirus (PRV) was isolated from monkey (Macaca fascicularis) faecal samples collected from human-inhabited areas in Lopburi Province, Thailand. These samples were initially obtained to survey for the presence of hepatitis E virus (HEV). Results Two virus isolates were retrieved by virus culture of 55 monkey faecal samples. Liquid chromatography-tandem mass spectrometry (LC-MS/MS) was successfully used to identify the viruses as the segmented dsRNA orthoreovirus. Phylogenetic analysis of the Lopburi orthoreovirus whole-genomes revealed relationships with the well-characterised PRVs Pulau (segment L1), Cangyuan (segments L2, M3 and S3), Melaka (segments L3 and M2), Kampar (segments M1 and S2) and Sikamat (segments S1 and S4) of Southeast Asia and China with nucleotide sequence identities of 93.5–98.9%. RT-PCR showed that PRV was detected in 10.9% (6/55) and HEV was detected in 25.5% (14/55) of the monkey faecal samples. Conclusions PRV was isolated from monkey faeces for the first time in Thailand via viral culture and LC-MS/MS. The genetic diversity of the virus genome segments suggested a re-assortment within the PRV species group. The overall findings emphasise that monkey faeces can be sources of zoonotic viruses, including PRV and HEV, and suggest the need for active virus surveillance in areas of human and monkey co-habitation to prevent and control emerging zoonotic diseases in the future. Electronic supplementary material The online version of this article (10.1186/s12866-018-1302-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nathamon Kosoltanapiwat
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand.
| | - Onrapak Reamtong
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Tamaki Okabayashi
- Department of Veterinary Sciences, Faculty of Agriculture, University of Miyazaki, Gakuen-kibanadai-nishi-1-1, Miyazaki, 889-2192, Japan.,Mahidol-Osaka Center for Infectious Diseases (MOCID), Research Institute for Microbial Diseases, Osaka University, 3-1 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Sumate Ampawong
- Department of Tropical Pathology, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Amporn Rungruengkitkun
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Tipparat Thiangtrongjit
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Narin Thippornchai
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Pornsawan Leaungwutiwong
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Aongart Mahittikorn
- Department of Protozoology, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Hirotake Mori
- Department of Protozoology, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Thanada Yoohanngoa
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
| | - Prechaya Yamwong
- Department of Microbiology and Immunology, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400, Thailand
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14
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Khounvisith V, Tritz S, Khenkha L, Phoutana V, Keosengthong A, Pommasichan S, Nouanthong P, Hübschen JM, Snoeck CJ, Reinharz D, Muller CP, Black AP, Pauly M. High circulation of Hepatitis E virus in pigs and professionals exposed to pigs in Laos. Zoonoses Public Health 2018; 65:1020-1026. [DOI: 10.1111/zph.12520] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/06/2018] [Accepted: 08/07/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Vilaysone Khounvisith
- Lao-Lux-Laboratory; Institute Pasteur du Laos; Vientiane Lao People's Democratic Republic
- Institut de la Francophonie pour la Médecine Tropicale; Vientiane Lao People's Democratic Republic
| | - Silvia Tritz
- Lao-Lux-Laboratory; Institute Pasteur du Laos; Vientiane Lao People's Democratic Republic
- Department of Infection and Immunity; Luxembourg Institute of Health; Esch-sur-Alzette Luxembourg
| | - Latdavone Khenkha
- Lao-Lux-Laboratory; Institute Pasteur du Laos; Vientiane Lao People's Democratic Republic
| | - Vannaphone Phoutana
- The Faculty of Agriculture; National University of Laos; Xaythany, Vientiane People's Democratic Republic
| | - Amphone Keosengthong
- The Faculty of Agriculture; National University of Laos; Xaythany, Vientiane People's Democratic Republic
| | - Sisavath Pommasichan
- The Faculty of Agriculture; National University of Laos; Xaythany, Vientiane People's Democratic Republic
| | | | - Judith M. Hübschen
- Department of Infection and Immunity; Luxembourg Institute of Health; Esch-sur-Alzette Luxembourg
| | - Chantal J. Snoeck
- Department of Infection and Immunity; Luxembourg Institute of Health; Esch-sur-Alzette Luxembourg
| | - Daniel Reinharz
- Institut de la Francophonie pour la Médecine Tropicale; Vientiane Lao People's Democratic Republic
| | - Claude P. Muller
- Lao-Lux-Laboratory; Institute Pasteur du Laos; Vientiane Lao People's Democratic Republic
- Department of Infection and Immunity; Luxembourg Institute of Health; Esch-sur-Alzette Luxembourg
- Laboratoire National de Santé; Dudelange Luxembourg
| | - Antony P. Black
- Lao-Lux-Laboratory; Institute Pasteur du Laos; Vientiane Lao People's Democratic Republic
| | - Maude Pauly
- Lao-Lux-Laboratory; Institute Pasteur du Laos; Vientiane Lao People's Democratic Republic
- Department of Infection and Immunity; Luxembourg Institute of Health; Esch-sur-Alzette Luxembourg
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15
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Tritz SE, Khounvisith V, Pommasichan S, Ninnasopha K, Keosengthong A, Phoutana V, Camoin M, Hübschen JM, Black AP, Muller CP, Snoeck CJ, Pauly M. Evidence of increased Hepatitis E virus exposure in Lao villagers with contact to ruminants. Zoonoses Public Health 2018; 65:690-701. [PMID: 29888475 DOI: 10.1111/zph.12483] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/28/2018] [Accepted: 05/03/2018] [Indexed: 02/06/2023]
Abstract
Although pigs are the main reservoir, ruminants have also been shown to be susceptible to hepatitis E virus (HEV). We investigated zoonotic transmission of HEV in rural settings of Lao People's Democratic Republic (Lao PDR) where humans are in close contacts with ruminants and where pigs are rare. Villagers with (n = 171, risk group) and without (n = 155, control group) cattle were recruited in seven villages in Vientiane Capital. Owners of pigs were excluded. Blood, as well as information on socio-demographics, animal contact, dietary habits and awareness of zoonoses were collected to assess risk factors. Blood and rectal swabs were collected from cattle (n = 173) and other ruminants (27 goat, 5 buffaloes) to measure anti-HEV antibody and virus prevalence. A similar anti-HEV antibody seroprevalence was found in cattle (6.8%) and other ruminants (8%). HEV RNA was detected in none of the animal rectal swabs and human sera. Anti-HEV IgG seroprevalence was higher in cattle farmers than in the control group (59.1% vs. 43.9%, p = 0.008) and increased significantly with age. Other risk factors included male gender, close contact with cattle and consumption of undercooked meat. We find that HEV is highly endemic in rural Laos and provide first evidence that HEV circulates in free-roaming ruminants with open access to village water sources. Despite some awareness about hygiene, villagers are likely constantly exposed to zoonotic diseases by dietary and lifestyle habits. Cattle farmers had a higher risk of HEV infection than other villagers. Our study highlights the need to raise the awareness of the rural population about water- and food-borne pathogens, and about the role of cattle as a possible source of infection. The knowledge gained on local risk factors and husbandry conditions should guide future awareness raising campaigns and promote appropriate hygienic measures including handwashing and the consumption of safe food and water.
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Affiliation(s)
- Silvia E Tritz
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Grand-Duchy of Luxembourg
| | - Vilaysone Khounvisith
- Lao-Lux-Laboratory, Institute Pasteur du Laos, Vientiane, Lao People's Democratic Republic
| | - Sisavath Pommasichan
- The Faculty of Agriculture, National University of Laos - Nabong Campus, Vientiane, Lao People's Democratic Republic
| | - Khampasong Ninnasopha
- The Faculty of Agriculture, National University of Laos - Nabong Campus, Vientiane, Lao People's Democratic Republic
| | - Amphone Keosengthong
- The Faculty of Agriculture, National University of Laos - Nabong Campus, Vientiane, Lao People's Democratic Republic
| | - Vannaphone Phoutana
- The Faculty of Agriculture, National University of Laos - Nabong Campus, Vientiane, Lao People's Democratic Republic
| | - Margot Camoin
- Veterinarians without Borders-Canada, Ottawa, Ontario, Canada
| | - Judith M Hübschen
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Grand-Duchy of Luxembourg
| | - Antony P Black
- Lao-Lux-Laboratory, Institute Pasteur du Laos, Vientiane, Lao People's Democratic Republic
| | - Claude P Muller
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Grand-Duchy of Luxembourg.,Lao-Lux-Laboratory, Institute Pasteur du Laos, Vientiane, Lao People's Democratic Republic.,Laboratoire National de Santé, Dudelange, Luxembourg
| | - Chantal J Snoeck
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Grand-Duchy of Luxembourg
| | - Maude Pauly
- Department of Infection and Immunity, Luxembourg Institute of Health, Esch-sur-Alzette, Grand-Duchy of Luxembourg
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16
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Bura M, Michalak M, Łagiedo-Żelazowska M, Bukowska A, Bura A, Mozer-Lisewska I. HEV seroprevalence can significantly change after re-assessment. J Med Virol 2018; 90:783-785. [PMID: 29388686 DOI: 10.1002/jmv.25039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/18/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Maciej Bura
- Department of Infectious Diseases, Hepatology and Acquired Immunodeficiencies, Poznan University of Medical Sciences, Poznań, Poland
| | - Michał Michalak
- Department of Computer Science and Statistics, Poznan University of Medical Sciences, Poznań, Poland
| | | | | | - Aleksandra Bura
- Department of Infectious Diseases, Joseph Strus Multidisciplinary City Hospital in Poznan, Poznań, Poland
| | - Iwona Mozer-Lisewska
- Department of Infectious Diseases, Hepatology and Acquired Immunodeficiencies, Poznan University of Medical Sciences, Poznań, Poland
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17
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Intharasongkroh D, Sa-Nguanmoo P, Tuanthap S, Thongmee T, Duang-In A, Klinfueng S, Chansaenroj J, Vongpunsawad S, Theamboonlers A, Payungporn S, Chirathaworn C, Poovorawan Y. Hepatitis E Virus in Pork and Variety Meats Sold in Fresh Markets. FOOD AND ENVIRONMENTAL VIROLOGY 2017; 9:45-53. [PMID: 27580911 DOI: 10.1007/s12560-016-9258-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 08/25/2016] [Indexed: 05/25/2023]
Abstract
Swine is an economically important livestock, yet pork consumption and close contact with pigs are associated with the risk of hepatitis E virus (HEV) infection. Limited data on the prevalence of HEV in Southeast Asia have mainly examined farm animals. To investigate the potential zoonotic transmission of HEV from dietary consumption of pork and variety meats (i.e., offal or organ meats), we obtained 1090 liver, 559 pork meat, and 556 intestine samples from fresh markets in the Bangkok metropolitan area between November 2014 and February 2015. The presence of HEV was assessed using reverse-transcription polymerase chain reaction. Concurrently, 720 bile and 553 fecal samples from a slaughterhouse were also examined. Overall, HEV RNA was found in 0.23 % of the market samples and 3.93 % of the slaughterhouse samples. Fecal and bile samples were more likely to test positive compared to liver, pork, and intestine samples (p < 0.001). Phylogenetic analysis showed that all HEV sequences obtained in this study formed a cluster closely related to genotype 3f. Pork and variety meats derived from pigs are commonly sold in fresh markets throughout Southeast Asia. Here, a relatively low HEV prevalence from pork and variety meats sold in Bangkok was found. Additional studies will be required to further assess potential dietary transmission of HEV elsewhere in the region.
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Affiliation(s)
- Duangnapa Intharasongkroh
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Pattaratida Sa-Nguanmoo
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Supansa Tuanthap
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thanunrat Thongmee
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ausanee Duang-In
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sirapa Klinfueng
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Jira Chansaenroj
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sompong Vongpunsawad
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Apiradee Theamboonlers
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sunchai Payungporn
- Department of Biochemistry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chintana Chirathaworn
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Yong Poovorawan
- Center of Excellence in Clinical Virology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.
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18
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Debes JD, Pisano MB, Lotto M, Re V. Hepatitis E virus infection in the HIV-positive patient. J Clin Virol 2016; 80:102-6. [PMID: 27243210 DOI: 10.1016/j.jcv.2016.05.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 05/16/2016] [Indexed: 12/12/2022]
Abstract
Hepatitis E virus (HEV) is a RNA virus that can cause hepatitis. In immunocompetent individuals, infection with HEV usually leads to asymptomatic seroconversion. However, in immunosuppressed patients, such as transplant recipients, HEV can develop into a chronic infection. Studies regarding the seroprevalence and clinical implications of HEV in patients infected with the human immunodeficiency virus (HIV) are conflicting. Levels of CD4 count in blood seem to be the most widely associated risk factor, while other factors such as meat consumption or proximity to animals are less clearly associated with HEV infection. Progression to chronicity, as well as extrahepatic manifestations of HEV seem rare in HIV, and the implications of HEV in liver disease progression are poorly understood in the HIV-infected. In this review we describe the epidemiology, risk factors, and clinical implications of HEV infection in individuals infected with HIV.
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Affiliation(s)
- Jose D Debes
- Department of Medicine, University of Minnesota, Minneapolis, MN, United States, United States.
| | - Maria Belen Pisano
- Instituto de Virología "Dr. J. M. Vanella" Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Argentina
| | - Martin Lotto
- Instituto de Virología "Dr. J. M. Vanella" Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Argentina
| | - Viviana Re
- Instituto de Virología "Dr. J. M. Vanella" Facultad de Ciencias Médicas, Universidad Nacional de Córdoba, Argentina
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