HEPATITIS E VIRUS INFECTIONS IN SPAIN

29th VHPB Meeting“Prevention and control of viral hepatitis in Spain:

Lessons learnt and the way forward” Madrid, Spain, 23-24 November, 2006

Dr. MT Pérez-GraciaDpt. Sanitary Attention, Public and Animal Health.CEU Cardenal Herrera University. Valencia. Spain

Viral HepatitisPrevention Board

Hepatitis E Virus (HEV)

Non-enveloped

27-34 nm in diameter

Fam. Hepeviridae: Genus Hepevirus

Positive-sense single-stranded RNA genome

7.5 kb long

3 ORFs

Genome Organization of HEV

7.5 kb

ORF1 (5079bp)ORF3 (369bp)

ORF2 (1980bp)

M Y P V X H R

Non-structural Structural

M: methyl transferase

Y : Y domain

P: papain-like cysteine protease

V: proline

X: domain

H: helicase

R: RNA-dependent RNA polymerase

Single Single serotypeserotype

ExtensiveExtensive genomicgenomic diversitydiversity: 4 : 4 majormajor genotypesgenotypesGenotypeGenotype 1: 5 1: 5 subtypessubtypesGenotypeGenotype 2: 2 2: 2 subtypessubtypesGenotypeGenotype 3: 10 3: 10 subtypessubtypesGenotypeGenotype 4: 7 4: 7 subtypessubtypes

(Lu et al, Rev Med Virol. 2006;16(1):5-36)

Hepatitis E Virus

Genotype 1 Genotype 2 Genotype 3 Genotype 4

Genotypes 1- 2 Genotypes 2-3 Genotypes 1-4 Genotypes 1-3- 4

•• Hepatitis E virus (HEV) Hepatitis E virus (HEV) isis thethe mainmaincausativecausative agentagent ofof nonnon--A nonA non--B B entericallyenterically transmittedtransmitted hepatitishepatitis

• Most outbreaks associated with fecallycontaminated drinking water

• Minimal person-to-person transmission

Hepatitis E - Epidemiologic Features

SPORADICSPORADICEPIDEMICEPIDEMIC

EPIDEMIOLOGICAL FORMS

SPORADIC HEPATITIS E WITHOUT TRAVELLING HISTORY

ANIMAL RESERVOIR?

HE J et al. 2002HAQSHENAS G et

al. 2001

WANG et al. 2002 MENG XJ et al.1997

Hepatitis E - Epidemiologic Features

HEV causes HEV causes anan acuteacute andand selfself limitedlimited clinicalclinicalpresentationpresentation

• Incubation period: Average 40 daysRange 15-60 days

• Case-fatality rate: Overall, 1%-3%Pregnant women, 15%-25%

• Illness severity: Increased with age

• Chronic sequelae: None identified

Hepatitis E - Epidemiologic Features

Hepatitis E Virus InfectionTypical Serologic Course

Weeks after Exposure

Tite

r

Symptoms

ALTIgG anti-HEV

IgM anti-HEV

Virus in stool

0 1 2 3 4 5 6 7 8 9 10 11 12 13

Virus in serum

•• AntiAnti--HEVHEV IgGIgG

•• AntiAnti--HEVHEV IgMIgM

•• HEVHEV RNARNA nested RT-PCR

ORF3

ORF2

ORF1

Diagnostic Methods of HEVDiagnostic Methods of HEV

Commercial EIA (Recombinant Ags of Burma

and Mexico strains)

Immunoblotting (confirmation)

Enfermedades de Declaración Obligatoria. Centro Nacional de Epidemiología. Instituto de Salud Carlos III

DISTRIBUTION OF NOTIFIED CASES OF VIRAL HEPATITIS DISTRIBUTION OF NOTIFIED CASES OF VIRAL HEPATITIS IN SPAIN (1997IN SPAIN (1997--2004)2004)

47.442.3 41 42.3

45.2

36.9 35

43

05

101520253035404550

1997 1998 1999 2000 2001 2002 2003 2004

Hepatitis A Hepatitis B Hepatitis nonAnonB

2.9%

7.3%

0

2

4

6

8

10

Buti, 1995 Tarragó, 2000 Buti, 2006

5.5%

Anti-HEV in normal population of Spain

Anti-HEV in patients with acute hepatitis of Spain

Buti, 1994 Buti, 1995 Pina, 2000 Pérez-Gracia, 2004

0%

5.6%

8.1%7.7%

0

2

4

6

8

10

Age-specific prevalence of anti-HEV in patients with chronic liver disease in Spain

7.1%

25%

30.8%

37%34%

0

5

10

15

20

25

30

35

40

16-30years

31-40years

41-50years

51-60years

TOTAL

Abe et al. Southeast Asian J Trop Med Public Health, 2006; 37: 90-95

AntiAnti--HEV detection by ELISA and IBHEV detection by ELISA and IB

Echevarría-Mayo JM, Med Clin (Barc), 2006;126(6):234-6

Hepatitis E virus in pigs and sewage of Spain

Urban sewage

Feces samples

Sera samples

0%0%2.7%8.3%

50%43.5%

12.3% 10.1%

23.3%

13.7%

0

10

20

30

40

50

60

Pina, 19

98Pina,

2000

Clemen

te-Cas

ares,

2003

de Deu

s, 20

06Fern

ández

-Barr

edo, 2

006

50%

Slurry lagoons

HEV strains isolated in Spain

52 HEV 52 HEV strainsstrains

6 HEV human6 HEV humanstrainsstrains

29 HEV 29 HEV swineswinestrainsstrains

17 HEV 17 HEV sewagesewagestrainsstrains

Buti et al, J Hepatol 2004AY540115VH51

Pina et al, J Hepatol 2000AF195064-AF195065VH1-VH2

3

AF448920

AY540114

AY570904

ACCESION GENBANK

Pérez-Gracia et al, Acta Virol 2004Sp3

Buti et al, J Hepatol 2004VH4

Buti et al, J Hepatol 2004VH3

REFERENCEABREVIATIONGENOTYPE

HEV strains isolated in human in Spain

Travel Ethiopia

Non travel; HEV autochthonous

GENOTYPE ABREVIATION ACCESION GENBANK REFERENCE

Por 1 AF491002 Clemente-Casares et al, EID 2003

SpswCV2 AY323506 Fdez-Barredo et al, JVDI 2006

3

DQ093564-DQ093569

DQ141118-DQ141126

DQ141127

DQ383734-DQ383745

SpswCV3-8 Fdez-Barredo et al, Can J Vet Res 2006

SpswCV9-17 Fdez-Barredo et al, JVDI 2006

SpswCV19 Fdez-Barredo et al, JVDI 2006

UAB1-UAB12 De Deus et al, Vet Microbiol 2006

HEV strains isolated in swine in Spain

Pina et al, J Hepatol2000AF195063Slaugtherhouse

sewageSP-E11

3Clemente-Casares et

al, EID 2003AF491004-AF491003Urban sewageBCN2, BCN4

Urban sewage

Urban Sewage

ORIGIN

AF490985-AF490997

AF058679

ACCESION GENBANK

Clemente-Casares et al, EID 2003BCN3, BCN5-

BCN16

Pina et al, Appl EnvMicrobiol 1998BCN1

REFERENCEABREVIATIONGENOTYPE

HEV strains isolated in sewage in Spain

AF490997 BCN16 ORF2

AF490992 BCN11 ORF2

AF490988 BCN7 ORF2

AF490994 BCN13 ORF2

AF490986 BCN5 ORF2

AF490995 BCN14 ORF2

AF490990 BCN9 ORF2

AF490987 BCN6 ORF2

AF490985 BCN3 ORF2

AF490993 BCN12 ORF2

AF490989 BCN8 ORF2

AB248520 HE-JA04-1911

AB248522 swJ12-4

AB248521 swJ8-5

AY115488 Arkell

AB074918 JKN-Sap

AF490996 BCN15 ORF2

AF060669 HEV-US2

AF060668 HEV-US1

DQ079627 pig Japan

DQ079625 Human Japan

AB091394 JJT-Kan

AY575859 pSHEV-3

AF082843 Meng strain

AY575858 pSHEV-2

AY575857 pSHEV-1

AB246676 human Japan

AB222184 wild boar JYG1

AB236320 wild mongoose

AB222183 wild boar JTS1

DQ079630 wild boar

DQ079629 human Japan

DQ079632 G3--Swine

AB073912 swine japan

AF490991 BCN10 ORF2

DQ079626 HTN-0618

AB189075 JYO-Hyo03L

AB189074 JTH-Hyo03L

AB189071 JDEER-Hyo03L

AB189073 JSO-Hyo03L

AB189072 JMO-Hyo03L

Genotype 3

DQ450072 swCH31

AY594199 swCH25

DQ079628 W B1-Aichi

AY723745 IND-SW

DQ279091 DQ1

AB220974 HE-JA2

AB108537 CCC220

DQ079631 Li-G4-62

HEE272108 genotype 4

AB193178 JYN-Nii02L

AB099347 HE-JK4

AB193177 JYN-Sap01C

AB091395 JSN-Sap-FH

AB097812 HE-JA1

AB220971 HE-JF3

AB080575

AB220978 HE-JA37

AB220972 HE-JF4

AB161718 JTS-Sap02

AB161719 JYW -Sap02

AB220979 HE-JA41

AB220976 HE-JA28

AB220977 HE-JA36

AB161717 JSM-Sap95

AB220975 HE-JA19

AB220973 HE-JF5

Genotype 4

AY204877Chad

AY540115 VH5 ORF2

X98292 India

D11093 China Human

AF065061Morocco

DQ079624 Myanmar

E17107

D10330 HPEHEV

AF459438 India

AF051830 Nepal

AH006999 HEVBCN

Genotype 1

AY043166 Avian

99

98

96

94

94

85

81

93

91

90

74

89

88

82

0.05

Genotype 3

Genotype 4

Genotype 1

S P A N IS H S W IN E S A M P L E S

A P 0 0 3 4 3 0 J R A 1

A F 3 3 6 2 9 8 N L S W 1 0 5

A F 3 3 6 2 9 7 N L S W9 9

A F 3 3 6 2 9 0 N L S W2 0

A F 08 2843 s w -Men g

AF060 668 HEV -US1

AF060669 HEV-U

S2

AF336299 N

LSW122

AF336291 N

LSW

22

298 300

UK

Swin

e3-1

304

303

3 0 2

U K M a n N T 1 1

U K H u m a n N T 6

A F 5 0 3 5 1 1 P 3 5 4 /1 /0 2

U K H u m a n N T 1

U K H u m a n N T 5U K S w in e 1

A F 5 0 3 51 2 P 14 3 /1 1 /0 2

U K H u ma nN T 7UKHum

anNT8U KH um

a n N T 3

A J2 7 2 1 0 8 C h in a

A F151 962 Ch -T11

M7 4506 Mex ico

A F 06 5061 Mo r occ o

A Y2 0487 7 C had

AF051352 Egypt

D11093 Ja pan

M94177 H

ebei

D11092 X

injiang

X98292 India

X99441 Madras

AF170450 Vietnam

AF051830 Nepal

M73218 Pakistan

D10330 Myanmar

Genotype 3

Genotype 2

Genotype 1

Genotype 4

DQ383735 UAB2

AY323506 SpswCV2

AF195063 E11

DQ093569 SpswsCV8

DQ141126 SPSW SCV17

DQ141125 SPSW SCV16

DQ141123 SPSW SCV14

DQ141119 SPSW MCV10

DQ093565 SpswsCV4

DQ383743 UAB10

DQ383742 UAB9

DQ141124 SPSW SCV15

DQ141121 SPSW MCV12

DQ093566 SpswfCV5

DQ141122 SPSW SCV13

DQ141118 SPSW MCV9

DQ383745 UAB12

DQ383741 UAB8

DQ383736 UAB3

DQ093567 SpswmCV6

DQ093564 SpswfCV3

AF336296 NLSW 97

DQ383738 UAB5

AF195062 VH2 capsid

DQ383740 UAB7

DQ383744 UAB11

DQ383739 UAB6

AF195061 VH1 capsid

AF336295 NLSW 85

AF336292 NLSW 28

AF336294 NLSW 82

UKHumanNT4

DQ383737 UAB4

UKHumanNT2

DQ141120 SPSW MCV11

DQ093568 SpswmCV7

61

65

72

65

8890

63

0.01

Hepatitis E in Spain: Conclusions

HEV should be included in the routine diagnostics of acute and fulminant hepatitis even when no history of travel has been reported by the patient.The development of a reliable serological assay is crucial to estimate the real prevalence of HEV in “non-endemic” areas.HEV is circulating in swine herds of Spain as reported for other industrialized countries.The close relationship observed between swine and human isolates from Spain, supports that swine may be a reservoir of HEV.

Acknowledgements

Manuel RodríguezManuel Rodríguez--IglesiasIglesiasFátima GalánFátima Galán

•• UniversitaryUniversitary Hospital Hospital ofof Puerto Real (Puerto Real (UniversityUniversity ofof CadizCadiz))

•• CEU Cardenal Herrera CEU Cardenal Herrera UniversityUniversity (Valencia)(Valencia)

Salceda FernándezSalceda Fernández--BarredoBarredoCarolina GalianaCarolina GalianaÁngel GarcíaÁngel GarcíaMª Teresa GómezMª Teresa GómezSantiago VegaSantiago Vega