Epidemiological investigation of the jaundice outbreak in lalkuan, nainital district, uttarakhand

Epidemiological investigation of viral hepatitis E outbreak in two colocated training centers

Background

A high number of jaundice cases were reported from two colocated training centers in North India. This outbreak was investigated to describe the epidemiology, identify risk factors, and recommend preventive and control measures.

Methods

Initial line list was prepared, and case definition was defined as "the presence of icterus or passage of yellow-colored urine with fever/anorexia/vomiting/abdominal pain in a resident of Military Station A between 03/04/2016 to 06/06/2016". Case search was conducted through surveillance. An unmatched 1:1 case-control study was conducted to evaluate the associated risk factors. All cases were tested for hepatitis markers. Environmental investigation of food and water sources was conducted to identify the source of infection.

Results

Of 172 cases, all were males from two co-located military training centers (attack rate, 4.7%). Clinical features included icterus (100%), yellowish discoloration of urine (98.9%), anorexia (97.22%), fever (80%), nausea/vomiting (56%), and abdominal pain (52.77%). Only one case (0.6%) had complication of fulminant hepatitis, and there were no deaths (CFR = 0%). Consumption of juice with ice from juice shops was significantly associated with illness (Odds Ratio-14.3 [95%CI 7.4-27.6]). Of 172 cases, 167 (97.1%) tested anti-HEV-IgM positive. Juice shops in training centers were using ice made from contaminated water with positive coliform test. All other water samples tested satisfactory. No cross-contamination of water pipelines with sewage was observed.

Conclusion

Epidemiological evidence concludes that a large viral hepatitis E outbreak was likely caused by consumption of juice with contaminated ice. Early stoppage of contaminated ice usage led to timely control of the outbreak.

Hepatitis E Virus Infection: Circulation, Molecular Epidemiology, and Impact on Global Health

Infection with hepatitis E virus (HEV) represents the most common source of viral hepatitis globally. Although infecting over 20 million people annually in endemic regions, with major outbreaks described since the 1950s, hepatitis E remains an underestimated disease. This review gives a current view of the global circulation and epidemiology of this emerging virus. The history of HEV, from the first reported enteric non-A non-B hepatitis outbreaks, to the discovery of the viral agent and the molecular characterization of the different human pathogenic genotypes, is discussed. Furthermore, the current state of research regarding the virology of HEV is critically assessed, and the challenges towards prevention and diagnosis, as well as clinical risks of the disease described. Together, these points aim to underline the significant impact of hepatitis E on global health and the need for further in-depth research to better understand the pathophysiology and its role in the complex disease manifestations of HEV infection.

Hepatitis E outbreak in Jaipur due to Genotype IA

Purpose

Suddenly, many cases of fever with jaundice were reported from Sodala area at Jaipur. This outbreak of acute hepatitis at Jaipur Rajasthan was investigated for aetiology and subsequent phylogenetic analysis.

Methods

Blood samples were collected from 106 symptomatic patients of acute hepatitis and 39 pregnant females (with or without symptoms of hepatitis) during an outbreak at Jaipur. The samples were tested for hepatitis A virus (HAV) and hepatitis E virus (HEV) by serological and molecular methods (polymerase chain reaction [PCR]). Sequencing of nested PCR product was done for phylogenetic analysis. Hepatitis B surface antigen (HBs antigen), anti-hepatitis C virus (HCV), anti-Leptospira and anti-scrub typhus IgM enzyme-linked immunosorbent assay (ELISA) was done for patients negative for HEV and HAV.

Results

Among 106 symptomatic patients, HEV IgM was positive in 84/106 (79.2%) patients and HEV RNA in 72/106 (67.9%) patients. Among pregnant women, 6/39 (15.4%) were HEV IgM positive and 5/39 (12.8%) for HEV RNA. One (2.5%) pregnant woman died due to hepatitis. All the isolates belonged to genotype 1A of HEV. All HAV, HEV-negative samples were negative for HBs antigen, HCV antibody, Leptospira and scrub typhus IgM ELISA.

Conclusion

The outbreak was due to HEV genotype 1A. The municipal water supply was contaminated and sanitary conditions and waste disposal were poor in the area. Boiling of drinking water, fixing the water supply pipes and frequent hand washing helped in controlling the outbreak.

Hepatitis E in Italy: A silent presence

Hepatitis E virus (HEV) was discovered in the 1980s and has been considered as being confined to developing countries. The purpose of this critical review was to determine the reported HEV seroprevalence rates in Italy, to identify predisposing factors and individuals at risk and to assess possible importation of HEV by immigrants. A critical review of 159 articles published in PubMed from 1994 to date was done. Only 27 original reports of 50 or more subjects, written in the English or Italian language, were included. Over three decades, the HEV seroprevalence varied from 0.12% to 49%, with the highest rates being reported from the central region of Italy. Risk factors included ingestion of raw pork or potentially contaminated food. The seroprevalence among immigrants ranged from 15.3% to 19.7% in Apulia. Italy has a population of 60656000; the total number of individuals surveyed was only 21.882 (0.036%). A national epidemiological survey program is needed to capture more comprehensive seroprevalence data.

The global burden of hepatitis E outbreaks: a systematic review

Hepatitis E virus (HEV) is responsible for repeated water-borne outbreaks since the past century, representing an emerging issue in public health. However, the global burden of HEV outbreak has not been comprehensively described. We performed a systematic review of confirmed HEV outbreaks based on published literatures. HEV outbreaks have mainly been reported from Asian and African countries, and only a few from European and American countries. India represents a country with the highest number of reported HEV outbreaks. HEV genotypes 1 and 2 were responsible for most of the large outbreaks in developing countries. During the outbreaks in developing countries, a significantly higher case fatality rate was observed in pregnant women. In fact, outbreaks have occurred both in open and closed populations. The control measures mainly depend upon improvement of sanitation and hygiene. This study highlights that HEV outbreak is not new, yet it is a continuous global health problem.