Genotype distribution and sequence variation of hepatitis E virus, Hong Kong

Hepatitis E virus infection in Hong Kong blood donors

BACKGROUND AND OBJECTIVES

In Hong Kong, the dominant circulating hepatitis E virus (HEV) genotype is type 4, which can cause more severe clinical consequences than type 3. The aim of this study was to determine the HEV prevalence in Hong Kong blood donors.

MATERIALS AND METHODS

Unlinked donation samples (n = 10 000) collected in March to May 2015 were tested for HEV RNA using the Procleix HEV assay in an individual donation format (IDT). A subset of 2000 samples were tested for IgG and IgM anti-HEV using the Wantai enzyme-linked immunosorbent assay (ELISA). Nucleic acid testing (NAT) initial reactive results were retested once, and repeatedly reactive donations were subjected to alternative molecular procedures as confirmation tests.

RESULTS

One in 5000 Hong Kong blood donors was positive for HEV RNA (0·02%). The two RNA positive samples were also IgG and IgM anti-HEV positive. One of the two RNA positive donors could be sequenced revealing genotype type 4. Anti-HEV seroprevalence was estimated as 15·5% among all donors. IgG anti-HEV positive rate for age group 16-20 was 3·1%, and it increased with age to 43·1% for age group 51-60. Sero-positivity was higher in males (male donors 18·1% vs. female donors 13·2%), but it was mostly due to the difference in a specific age group (41-50).

CONCLUSION

Hepatitis E virus RNA positive rate of 0·02% was within the reported range of HEV RNA frequency in developed countries. One donor was confirmed to be genotype 4, which is the dominant genotype in circulation in Hong Kong.

Comparison of acute hepatitis E infection outcome in patients with and without chronic hepatitis B infection: a 10 year retrospective study in three regional hospitals in Hong Kong

BACKGROUND

Acute hepatitis E virus (HEV) infection has recently become the commonest cause of acute viral hepatitis in Hong Kong (HK) with majority of HEV belonging to genotype 4. Studies from China have shown that acute hepatitis E patients with underlying chronic hepatitis B virus (HBV) infection may have a worse outcome than those without. In India where genotype 1 is more prevalent, superinfection with hepatitis E on patients with chronic liver disease including chronic hepatitis B infection can cause liver decompensation.

OBJECTIVES

The study aims to determine the clinical outcome of acute hepatitis E infection in patients with and without chronic hepatitis B infection in HK.

STUDY DESIGN

The rates of liver failure, liver-related mortality and all-cause mortality will be compared between acute hepatitis E patients with and without chronic hepatitis B. Analysis was performed using the Statistical Package for the Social Science (SPSS version 12.0). All statistical tests were two-sided, and statistical significance was taken as p<0.05.

RESULTS

Chronic HBV carriers with acute HEV infection were found to have higher liver failure rate, liver-related mortality and all-cause mortality, but the results did not reach statistical significance. Chronic HBV carriers were found to have statistically significantly lower admission ALT level, lower day 28 serum albumin level and higher day 28 serum ALT level.

CONCLUSIONS

A prospective study with sufficient sample size is needed to confirm whether the clinical outcome of patients with chronic HBV infection is worse compared with patients who were not chronic HBV carriers.

Use of immuno-dominant epitope derived from genotype 4 as a diagnostic reagent for detecting the antibodies against Hepatitis E Virus

Background

Despite the genotype 4 has become the dominant cause of hepatitis E disease in China, none antigen derived from genotype 4 of hepatitis E virus (HEV) was used in current commercial anti-HEV immunoassay, and the serological reactivity of antigen derive from genotype 4 is not well-charactered.

Methods

We expressed and purified the 4 main immuno-dominant epitopes derived from genotype 1 and 4 including ORF2 (410-621aa) of genotype 4, ORF3 (47-114aa) of genotype 4, ORF2 (396-606aa) of genotype 1 and ORF3 (56-123aa) of genotype 4.

Results

The ORF2 of genotype 4 displayed good diagnostics performance according to ROC analysis using in-house panel, and the immunoassays based the ORF2 of genotype 4 was then developed to detect the anti-HEV IgG antibodies and evaluated further in 530 anti-HEV IgG positive specimens and 380 negative specimens. The sensitivity and the specificity is 98.1% (520/530) and 94.7% (360/380) for immunoassay based on ORF2 of genotype 4, 96.6% (512/530) and 92.6% (352/380) for commercial immunoassay based on genotype 1. It is noted that all of the positive samples will be detected by combing two assays together. The anti-HEV immunoassays based on genotype 4 are in accordance with Chinese anti-HEV national standard,and show an good agreement of 95.8% with commercial assay (kappa=0.913, P=0.014).

Conclusions

The immunoassay based on ORF2G4 displays good performance, and combining assay based on genotype 1 together with genotype 4 will benefit the HEV diagnosis in large scale samples.

Genotype analysis of hepatitis E virus from sporadic hepatitis E cases in northern China

Hepatitis E is an important public health problem in many countries. However, there is no definite conclusion about the zoonotic reservoir, transmission patterns and risk factors of hepatitis E in the human population. The aim of this study was to analyze the epidemiological and viral genotype characteristics of hepatitis E cases in northern China. Surveillance was conducted in two hospitals in Liaoning and Hebei province from July 2010 to June 2012. Out of a total of 116 diagnosed patients, 88 (75.9%) were male and 28 (24.1%) were female and most (73%) were in the age group 40-70 years. In both hospitals, cases were diagnosed more frequently in March than in other months. HEV RNA was amplified from 41 patients and characterized by nucleotide sequencing and phylogenetic analysis. Most of the isolates (37 strains, 90.3%) were genotype 4, including subgenotypes 4a, 4b, 4d, 4h, 4i and a new subgenotype. One subgenotype 3a strain was isolated from Baoding, Hebei province. Three genotype 1b strains were found from patients in Jinzhou, Liaoning province. Most of the genotype 4 strains and the genotype 3 strains were phylogenetically related to known swine isolates. In conclusion, the finding that HEV infects mostly middle-aged and elderly men and that the incidence spiked in March may reflect the zoonotic transmission characteristics of HEV infection. Pigs, but not rabbits, were the important reservoirs in this area, because genotype 4 HEV was found to be responsible for the majority hepatitis E cases. However, genotype 1 is still present in northern China. Also, the first isolation of genotype 3 HEV in this area indicates that alternative routes of HEV transmission might exist.

Seroprevalence of hepatitis E virus in Hong Kong, 2008-2009

The public health impact of hepatitis E virus (HEV) infection varies across the world. An HEV vaccine has been recently approved for clinical use in China. Population-specific seroprevalence data are essential for cost-effective assessment of vaccination programs. Here, a cross-sectional study was performed to provide an update on the local seroprevalence of HEV. An archive of serum samples submitted for virological investigation between 2008 and 2009 to a general hospital was used. A total of 450 samples with equal numbers from each gender covering the age groups from 1-10 to >80 years (25 samples per group) were tested for HEV immunoglobulin G (IgG) by enzyme-linked immunoassay. Age- and gender-specific seroprevalence were determined. The HEV IgG positive rate increased from 8% among 1-10 years to 56% among >80 years. The increase in prevalence was constant throughout all age groups without a steeper slope or plateau observed from any age group. The overall positive rate among males was significantly higher than among females (32.9% vs. 24.4%, P = 0.048). The best-fitted seroprevalence curves also suggested a higher positive rate for males across all age groups. Increased HEV IgG positivity was noted in comparison with historical local studies. Collectively, the prevalence of HEV in Hong Kong has increased over the past decade. A large proportion of the population is still susceptible to infection, and all age groups are at risk. Territory-wide vaccination program should be considered.

The molecular epidemiology of hepatitis E virus infection

Molecular characterization of various hepatitis E virus (HEV) strains circulating among humans and animals (particularly swine, deer and boars) in different countries has revealed substantial genetic heterogeneity. The distinctive four-genotype distribution worldwide of mammalian HEV and varying degrees of genetic relatedness among local strains suggest a long and complex evolution of HEV in different geographic regions. The population expansion likely experienced by mammalian HEV in the second half of the 20th century is consistent with an extensive genetic divergence of HEV strains and high prevalence of HEV infections in many parts of the world, including developed countries. The rate and mechanisms of human-to-human transmission and zoonotic transmission to humans vary geographically, thus contributing to the complexity of HEV molecular evolution.

Analysing complete genome sequence of swine hepatitis E virus (HEV), strain CHN-XJ-SW13 isolated from Xinjiang, China: putative host range, and disease severity determinants in HEV

Hepatitis E is a worldwide public health problem, particular in areas where hygiene conditions are poor. Hepatitis E virus (HEV) has at least four genotypes: genotypes 1 and 2 exclusively infect human; while genotypes 3 and 4, are considered to be a zoonotic agent, infecting both humans and animals. This study was aimed at determining why genotype 3 and 4 HEV strains isolated from swine are able to cross species borders, whereas genotype1 and 2 strains isolated from humans are not. The full length genome of the swine HEV isolate CHN-XJ-SW13 was amplified as overlapping fragments using reverse-transcription-nested polymerase chain reaction (RT-nPCR) and rapid amplification of cDNA ends (RACE). The sequence of CHN-XJ-SW13 was compared with those of 90 HEV strains covering genotype 1-4 retrieved from GenBank. Possible regions of the viral genome, specifying the host range of HEV or associated with the severity of hepatitis E disease, were then screened for with the aid of the ALIGNX sequences alignment software package. The CHN-XJ-SW13 swine HEV isolate was determined to be a novel subtype of genotype 4, whose sequence provided several valuable clues for tracing the sources of human HEV infection. 25 specific nucleotide positions were identified to possibly being involved specifying the host range of HEV or determining the severity of hepatitis E disease.

Long-term shedding of hepatitis E virus in the feces of pigs infected naturally, born to sows with and without maternal antibodies

Pigs are presumed reservoirs for hepatitis E virus (HEV) transmission to humans. To examine infection kinetics, two litters of domestic pigs (A and B, each containing 10 piglets) infected naturally with HEV were studied until pigs were 6 months old. Maternal IgG and IgA antibodies were detected in litter A piglets, but not in litter B ones. All pigs shed HEV in feces when they were 30-110 days old, and 17 developed viremia at 40-100 days of age. Phylogenetic analysis revealed a highly close sequence of HEV genotype 3 in all pigs. The serum levels of specific IgG and IgA were similar in all pigs, although IgA was not detected in the feces. Interestingly, the onset of both viremia and seroconversion was delayed significantly in litter A pigs. The kinetics of fecal virus shedding was similar in both litters; shedding was not detected after the pigs were 120 days old. The differences in the infection kinetics between litters A and B suggested that maternal antibodies delayed the onset of viremia and seroconversion. Quantitative real-time reverse transcriptase-polymerase chain reaction revealed that HEV RNA in feces peaked 10 days after initial shedding of approximately 10(6.0) copies/g. The viral load was much lower in the serum than in the feces. At 200 days of age, HEV RNA was found in the internal organs of 3 out of 13 pigs. These study findings improve the understanding of the dynamics of natural HEV transmission in pigs, which could help in controlling virus transmission from pigs to humans.

Application of truncated immunodominant polypeptide from hepatitis E virus (HEV) ORF2 in an assay to exclude nonspecific binding in detecting anti-HEV immunoglobulin M

The diagnosis of recent hepatitis E virus (HEV) infection depends on serologic testing for anti-HEV IgM; however, false-positive results may occur. In the present study, we cloned the ORF2 fragment of genotype 4 HEV and demonstrated that a subregion covering amino acids 459 to 607 in ORF2 forms the immunodominant B-cell epitopes, as it does in genotype 1 viruses. Truncation of several residues from either the N or C terminus of the polypeptide abolished the reactivity of anti-HEV from naturally infected persons. By the combination of high reactivity of the immunodominant polypeptide and poor reactivity of the truncated polypeptide, we established an indirect enzyme-linked immunosorbent assay (ELISA) to detect anti-HEV IgM. In this assay, all 37 sera that were HEV RNA positive reacted with the immunodominant polypeptide but not with the truncated one, and none of 159 sera from healthy persons reacted with either of the polypeptides. In retesting of 117 sera that originally tested positive for anti-HEV IgM, using a Genelabs kit, only 34 were positive and 83 were negative. Western blot analyses and other experiments strongly indicated that these 83 discordant sera were negative for anti-HEV IgM. Furthermore, among the 117 sera, 5 reacted with both the immunodominant and truncated polypeptides, with comparable optical densities at 450 nm. However, their reactivity was demonstrated to result from nonspecific binding. Together, the data indicate that the poor reactivity of a truncated ORF2 polypeptide can be used to exclude nonspecific binding in the detection of anti-HEV IgM.

Serological prevalence of hepatitis E virus in domestic animals and diversity of genotype 4 hepatitis E virus in China

Pigs have been confirmed to be reservoirs of some genotypes of hepatitis E virus (HEV), and other nonhuman species are also likely infected with the virus. To assess the prevalence of HEV infection in domestic animals in China, 3579 serum samples, including 1967 swine, 700 goat, and 912 cattle sera, were collected from 26 provinces across the country and tested for HEV antibodies and antigen using enzyme immunoassays. The results showed that 82.2% of the swine samples, but only 10.4% and 28.2% of cattle and goat sera, were anti-HEV positive respectively. The prevalence of anti-HEV antibody in animals varied from province to province, ranging from 10.9% to 100% in pigs, 0% to 48% in goats, and 0% to 92.9% in cattle. About 1.9% of pigs, 1.6% of goats, and 0.8% of cattle tested in the study were positive for HEV antigen. Some samples, including all HEV antigen-positive samples, were tested for HEV-specific RNA using reverse transcription polymerase chain reaction. Fifteen swine samples, but none from the goats or cattle, were found to be HEV RNA positive. Sequence and phylogenetic analyses classified all the swine HEV isolates into HEV genotype 4, which was further divided into four subgroups. This study demonstrated that HEV infection is widespread in domestic animals, particularly pigs, in China. The HEV genotype infecting pigs in China was genotype 4. However, the isolates displayed considerable genetic diversity.