A persisting outbreak of hepatitis A in Puglia, Italy, 1996: epidemiological follow-up

Foodborne transmission of hepatitis A and hepatitis E viruses: A literature review

Foodborne viruses have been recognized as a growing concern to the food industry and a serious public health problem. Hepatitis A virus (HAV) is responsible for the majority of viral outbreaks of food origin worldwide, while hepatitis E virus (HEV) has also been gaining prominence as a foodborne viral agent in the last years, due to its zoonotic transmission through the consumption of uncooked or undercooked infected meat or derivatives. However, there is a lack of scientific reports that gather all the updated information about HAV and HEV as foodborne viruses. A search of all scientific articles about HAV and HEV in food until March 2020 was carried out, using the keywords "HAV", "HEV", "foodborne", "outbreak" and "detection in food". Foodborne outbreaks due to HAV have been reported since 1956, mainly in the USA, and in Europe in recent years, where the number of outbreaks has been increasing throughout time, and nowadays it has become the continent with the highest foodborne HAV outbreak report. Investigation and detection of HAV in food is more recent, and the first detections were performed in the 1990s decade, most of them carried out on seafood, first, and frozen food, later. On the other hand, HEV has been mainly looked for and detected in food derived from reservoir animals, such as meat, sausages and pate of pigs and wild boars. For this virus, only isolated cases and small outbreaks of foodborne transmission have been recorded, most of them in industrialized countries, due to HEV genotype 3 or 4. Virus detection in food matrices requires special processing of the food matrix, followed by RNA detection by molecular techniques. For HAV, a real-time PCR has been agreed as the standard method for virus detection in food; in the case of HEV, a consensus assay for its detection in food has not been reached yet. Our investigation shows that there is still little data about HAV and HEV prevalence and frequency of contamination in food, prevalent viral strains, and sources of contamination, mainly in developing countries, where there is no research and legislation in this regard. Studies on these issues are needed to get a better understanding of foodborne viruses, their maintenance and their potential to cause diseases.

Hepatitis A Virus Strains Circulating in the Campania Region (2015-2018) Assessed through Bivalve Biomonitoring and Environmental Surveillance

The genetic diversity of Hepatitis A Virus (HAV) circulating in the Campania Region in years 2015–2018 was investigated through the monitoring of sentinel bivalve shellfish and water matrices. Overall, 463 water samples (71 sewage samples, 353 coastal discharge waters, and 39 seawaters samples), and 746 bivalve shellfish samples were analyzed. Positivity for HAV was detected in 20/71 sewage samples, 14/353 coastal discharge waters, 5/39 seawaters, and 102/746 bivalve shellfish. Sixty-one of the positive samples were successfully sequenced and were characterized as genotype IA (n = 50) and IB (n = 11). The prevalent strain circulating in 2015 in both bivalves and waters was the IA strain responsible for the outbreak occurring around the same time in the Naples area. This variant was no longer identified in subsequent years (2017–2018) when, instead, appeared two of the IA variants of the multistate outbreak affecting men who have sex with men (MSM), VRD_521_2016, and RIVM-HAV16–090, with the former prevailing in both shellfish and water environments. HAV IB isolates were detected over the years in shellfish and in water matrices, but not in clinical samples, suggesting that this genotype had been circulating silently. An integrated surveillance system (environment/food/clinical cases) can be a useful tool to monitor changes in viral variants in the population, as well as an early warning system.

Seafood pathogens and information on antimicrobial resistance: A review

Seafood-borne diseases are a major public health hazard in the United States and worldwide. Per capita, seafood consumption has increased globally during recent decades. Seafood importation and domestic aquaculture farming has also increased. Moreover, several recent outbreaks of human gastroenteritis have been linked to the consumption of contaminated seafood. Investigation of seafood-borne illnesses caused by norovirus, and Vibrio, and other bacteria and viruses require a concrete knowledge about the pathogenicity and virulence properties of the etiologic agents. This review explores pathogens that have been associated with seafood and resulting outbreaks in the U.S. and other countries as well as the presence of antimicrobial resistance in the reviewed pathogens. The spectrum of such resistance is widening due to the overuse, misuse, and sub-therapeutic application of antimicrobials in humans and animals.

Synergistic effect of high hydrostatic pressure (HHP) and marination treatment on the inactivation of hepatitis a virus in mussels (Mytilus galloprovincialis)

Consumption of raw or insufficiently cooked mussels contaminated with hepatitis A virus (HAV) is a major cause of infection to humans. The origin of mussels commonly used for the preparation of marinated seafood salads is often unknown, since different producers worldwide undergo a precooking treatment at the original collection site with methods and parameters not always indicated. These treatments could be insufficient for the inactivation of HAV, which is characterized by a high temperature resistance. Both high hydrostatic pressure (HHP) and marinade treatments have been shown to affect HAV vitality. In this study, two treatments (HHP and marinating) were combined in order to assess a potential synergistic effect on the virus vitality. A kinetic test was conducted by subjecting the experimentally-contaminated mussels (HAV titre: 10(6)/ml TCID50) to marinating, and to different HHP treatment (4,000; 5,000; and 6,000 bar for 1, 5, and 9 min). Virus post-treatment vitality was assessed by its ability to grow on cell cultures and by quantitative real-time RT-PCR to evaluate virus resistance under such conditions. Marinating treatment alone (final pH 4.3, and NaCl 2 %) did not inactivate the virus. On the other hand, the use of HHP treatment alone on non-marinated HAV-contaminated mussels was effective only above 5,000 bar for 5 min. The results of the present study elucidate the synergistic effect of a combination between marination and HHP treatments on the inactivation of the virus.

Control of hepatitis A by universal vaccination of children and adolescents: an achieved goal or a deferred appointment?

Temporal trends of Hepatitis A cases and vaccination coverage data against Hepatitis A Virus have been investigated to analyse the impact of the universal routine vaccination strategy more than 10 years from its introduction in Puglia (region of Southern Italy). The basic reproductive number (R(0)) before vaccination introduction and the effective reproductive number (R(e)) after introduction have been calculated. A progressive decrease in incidence has been recorded in Puglia during last 10 years. Vaccination coverage is actually 64.8% (95% CI: 52.7-76.9%) for children aged 12-24 months and of 67.6% (95% CI: 58.4-76.8%) for 12-year-old adolescents. R(0) estimated in 1996 was 2.01; actually R(e) is 0.651. Theoretical age at infection is 31.82 years. Universal routine vaccination aimed at the control of direct transmission remains the milestone in the strategy for the containment of the disease in settings at an intermediate level of endemicity.

An outbreak of hepatitis A in Roma populations living in three prefectures in Greece

An outbreak of hepatitis A virus (HAV) infection affected Roma populations living in three prefectures of northeastern Greece. Between July and November 2007, 124 cases were reported. We carried out investigations to characterize the pathogen, to identify the source of infection and the route of transmission. Using the RT-PCR technique, HAV strains of the same genotype were detected in all sera from a subset of patients with acute disease. These showed more than 99.8% identity, suggesting a common source. A questionnaire was also completed to collect clinical and epidemiological information. The outbreak affected mainly Roma children aged <10 years. An inspection of Roma settlements showed that poor sanitary conditions were associated with the HAV outbreak.

An individual-based model of hepatitis A transmission

Viral hepatitis A, as other endemic diseases, represents a public health priority worldwide. To study long-time scale human pathogens through individual-based simulations, the development of a dynamic network of contacts is required. In this work, we introduce an individual-based model accounting for the birth and death of the individuals, the generation of new households, and the educational career of the individuals, in order to investigate viral hepatitis A dynamics in the most affected Italian areas. Intervention options such as targeted vaccination, social distancing measures (e.g., closure of day care centers and kindergartens) and improvements in standards of living and hygiene are evaluated. Results show that a very low vaccination coverage is sufficient to control hepatitis A in Italy, while its elimination is not possible since new cases are continuously imported from high endemicity areas outside the country. Finally, the considered social distancing measures can be counterproductive since the fraction of recovered individuals does not decline while the age at infection increases, thus augmenting the probability of developing acute symptoms.

Control of hepatitis A by universal vaccination of adolescents, Puglia, Italy

Control of Hepatitis A by Universal Vaccination of Adolescents, Puglia, Italy

Basic mathematical models for the temporal dynamics of HAV in medium-endemicity Italian areas

In some Southern Italy areas Hepatitis A still represents a serious public health issue. In 1996 a big epidemics in Puglia led that region to adopt a mass vaccination programme. In this paper a basic mathematical model for the temporal trends of Hepatitis A Virus (HAV) in Southern Italy is proposed and investigated. The model includes the main distinctive features of HAV in Southern Italy, i.e. multiplicity of exposure factors, and periodic forcing caused by yearly patterns of seafood consumption. The analysis illustrates the role played by the risk factors on equilibria, stability, and the period of HAV oscillations, both natural and in presence of vaccination. The model also fits well temporal trends of HAV in Southern Italy, suggesting that it is a good starting point for more structured modelling.

Epidemiological and virological characterization of a large community-wide outbreak of hepatitis A in southern Italy

A large outbreak of hepatitis A virus (HAV) infection occurred in 2004 in Campania, a region of southern Italy, with 882 cases reported between 1 January and 1 August. The local public health authorities and the Italian National Institute of Health carried out investigations in order to characterize the agent, identify the source of infection and the route of transmission, and implement appropriate control measures. A web-based reporting system enhanced the flow of information between public health authorities, providing real-time epidemic curves and frequency distributions. The same 1B HAV genotype was found in 90% of sera from a subset of patients with acute disease, suggesting a local common source. A case-control study in the municipality with the highest attack rate showed that raw seafood consumption, in particular if illegally sold in water, was strongly associated with HAV illness. Samples of seafood systematically collected from retailers were found contaminated by HAV.

Nucleotide correlation between HAV isolates from human patients and environmental samples

Hepatitis A disease is endemic in Albania even though records from the Medical Authority show outbreaks involving only limited numbers of people. In the city of Lac, 200 people became ill following an outbreak of hepatitis A started on November 2002. The age distribution of the cases shows a peak in the age group 5-9 (43.5%) followed by the age group 10-14 (28%) and the age group 1-4 (18%). No cases were recorded in the age group 0-1. Drinking water and sewage samples were collected, using electropositive cartridges, during the outbreak. Rotavirus was identified by RT-PCR in two out of five drinking water samples; however, all the samples tested negative for HAV and astrovirus. Rotavirus was also identified in three out of five sewage samples from which four were HAV positive. HAV-RNA was identified in 28 (62.2%) out of 45 IgM anti-HAV positive sera collected during the outbreak. Genotype IA was expressed from all the amplified samples. Sequence analysis of the overlapping VP1-2A region shows 97-99% homology with three Italian strains IT-SCH-00, IT-ZAM-01, and IT-CAP-00 and one Spanish strain (Sa 30/06/95), whereas the phylogenetic tree built from the 168 bp sequence of the VP1-2A shows four clusters, one including 24 out of 28 RT-PCR positive sera. Considering the deduced amino acid sequence, only one substitution was identified and reported previously for genotype IB.

Norovirus gastroenteritis general outbreak associated with raw shellfish consumption in south Italy

BACKGROUND

Despite Noroviruses (NV, previously "Norwalk-like viruses") being a leading cause of acute gastroenteritis outbreaks, the impact of NV infection is at present unknown and little information is available about strains circulating in Italy. In April 2002 an outbreak of gastroenteritis occurred in the province of Bari (South-east Italy), involving several households.

METHODS

A retrospective cohort study was performed in order to assess risk factors associated with illness. All households where a case occurred were included in the study. Faecal specimens were collected from ill individuals. NV-specific RT-PCR was performed. Eleven samples of mussels were collected from fish-markets involved in the outbreak. A nested PCR was used for mussel samples.

RESULTS

One hundred and three cases, detected by means of active surveillance, met the case definition. Raw shellfish eating was the principal risk factor for the disease, as indicated by the analytic issues (Risk Ratio: 1.50; IC 95%: 1.18 - 1.89; p < 0.001). NVs were found by means of RT-PCR of all the stool specimens from the 24 patients tested. Eleven samples of shellfish from local markets were tested for the presence or NVs; six were positive by nested PCR and genotypes were related to that found in patients' stools.

CONCLUSION

This is the first community outbreak caused by NVs related to sea-food consumption described in Italy. The study confirms that the present standards for human faecal contamination do not seem to be a reliable indicator of viral contaminants in mussels.

Outbreak of infection with hepatitis A virus (HAV) associated with a foodhandler and confirmed by sequence analysis reveals a new HAV genotype IB variant

An outbreak of infection with hepatitis A virus associated with a foodhandler and involving 26 subjects occurred in Southern Italy. Sequence analysis of the VP3-VP1 and VP1-P2A junctions confirmed that the outbreak was due to a point source and allowed the identification of a new genotype IB variant. This report confirms the usefulness of sequence-based molecular fingerprinting during outbreaks.

Genetic analysis of HAV strains recovered from patients with acute hepatitis from Southern Italy

Southern Italy is an endemic area for HAV infection contributing to the majority of Italian hepatitis A cases. Using molecular analysis, HAV strains have been classified in distinct genotypes and subgenotypes. To characterize HAV wild-type strains circulating in Southern Italy, sequence analysis of VP3-VP1 and VP1/2A junction regions of HAV isolates recovered from 25 patients with acute hepatitis during 2000 and 2001 was carried out. HAV isolates showed a degree of identity, after pairwise comparison with one another, ranging from 91.9-100% in the VP3-VP1 junction region and 89.9-100% in the VP1/2A junction region. All strains belonged to genotype I, with 84% (21/25) of samples clustering in subgenotype IA and 16% (4/25) in subgenotype IB. Cocirculation of subgenotypes IA and IB was observed among isolates from 2000, whereas all strains from 2001 were subgenotype IA. In addition, the subgenotype IA strains formed different clusters, one of which was related closely to some Cuban strains, showing a percent similarity of 98.8% in the 168-base pair segment encompassing the VP1/2A junction and the same amino acid substitution. The latter finding suggests that this subgenotype variant circulates also in the Mediterranean area. The results of the phylogenetic analysis confirm the genetic heterogeneity among HAV strains in Western Europe.

Detection of hepatitis A virus in mussels from different sources marketed in Puglia region (South Italy)

Hepatitis A virus (HAV) infection is endemic in Puglia (South Italy). Epidemiological studies indicate that shellfish consumption, particularly mussels, is a major risk factor for HAV infection, since these products are eaten raw or slightly cooked. Nested reverse transcriptase-polymerase chain reaction (RT-PCR) has been shown to be a sensitive technique for the detection of HAV in mussels. The aim of the present study was to detect the presence of HAV in a large sample of mussels by nested RT-PCR and to confirm the presence of infectious viral particles in positive samples by cell culture infection and RT-PCR confirmation. Two hundred and ninety samples of mussels from different sources were collected between December 1999 and January 2000. One hundred samples were collected before being subjected to depuration, 90 after depuration, and 100 were sampled in different seafood markets. HAV-RNA was detected in 20 (20.0%) of non-depurated mussels, in 10 (11.1%) of depurated samples, and in 23 (23.0%) of samples collected in the shellfish markets, without any significant difference in the prevalence of positive samples by collection sources (chi2 = 4.79, p = 0.09). Of the 53 samples found positive by nested RT-PCR, 18 (34.0%) resulted positive by cell culture assay. No relationship between viral contamination and bacterial contamination was found (p = 0.41). This study confirms the usefulness of molecular techniques in detecting HAV in shellfish and, thus, for the screening of a large sample of naturally contaminated mussels. Improved shellfish depuration methods are needed to obtain virus-safe shellfish and reduce the risk for public human health.

Closed-circuit system for the depuration of mussels experimentally contaminated with hepatitis A virus

In Italy, the consumption of raw or slightly cooked mussels represents the most important risk factor for the transmission of hepatitis A virus (HAV). Although there exist effective methods for the bacterial depuration of contaminated mussels, these methods are poorly effective on enteric viruses. The objective of the present study was to evaluate the effectiveness of a closed-circuit depuration system that uses both ozone and UV light for disinfecting water and that allows salinity and temperature, important parameters for the metabolism of mussels (Mytilus galloprovincialis), to be maintained at constant levels. The results showed that this depuration method decreased the viral load (from 1.72 log 50% tissue culture infective dose [TCID50] ml(-1) to <1 log TCID50 ml(-1) within 24 h and from 3.82 log TCID50 ml(-1) to <1 log TCID50 ml(-1) within 48 h). However, in both cases, after 120 h of depuration, a residual amount of virus capable of replicating in cells was detected. These results show that depuration, even if performed with advanced systems, may not guarantee the absence of virus.