Hepatitis E surveillance in Italy

Maria Elena Tosti

1st ECDC Hepatitis E virus expert panel meeting ECDC Stockholm. 9th-10th December 2015

Centre for Epidemiology, Surveillance and Health Promotion

National Institute of Health - ISS, Rome - Italy

1. routine surveillance in Italy

2. an integrated epidemiological, virological, and environmental surveillance

3. results from a recent prevalence study

4. conclusions

Schedule

classification: A B nonA-nonB unknown

Mandatory surveillance in Italy

Viral hepatitis is included in the national notifiable infectious diseases surveillance system

By Ministry of Health

Diseases at high frequency and/or liable of control interventions

classification: A B C Delta E nonA-nonE

Voluntary surveillance in Italy

Since 1984

SEIEVA surveillance Sistema Epidemiologico Integrato dell’Epatite Virale Acuta

(Integrated Epidemiological System for Acute Viral Hepatitis) By National Institute of Health

Introduced in 2007

target cases: acute hepatitis

network: voluntary Local Health Units

interview by a standardized questionnaire

ascertainment of markers

data flow to coordination centre (ISS)

SEIEVA Methodology

2/11

2/9

5/8

12/15

4/11

5/6

2/5

Local Health Units collaborating with SEIEVA

by December 31st 2014

N° of participating LHUs 151/189 = 79.9%

Covered population 43,951,734 = 77.2%

complete

partial

not participating

Acute hepatitis E: case definition Based on clinical and serological criteria

Clinical criteria:

acute illness compatible with hepatitis

ALT > 10 times the upper limit of the normal range

Serological criteria:

IgM anti-HEV positive

IgM anti-HBc negative

IgM anti-HAV negative

Cases IgM anti-HEV positive, in absence of clinical signs, are included among “acute hepatitis E cases”

Collected information

socio-demographic characteristics

exposure to faecal-oral risk factors (within 6 weeks before disease onset)

laboratory parameters (ALT, AST, bilirubin, INR)

serological markers of infection

clinical course

Hepatitis N° cases %

A 5.174 50.3

B 3.514 34.2

C 876 8.5

E 144 1.4

nonA-nonE* 45 0.4

nonA-nonC** 153 1.5

Unknown 378 3.7

Total 10.285 100.0

* cases negative for hepatitis A, B, C and E viruses

** cases negative for hepatitis A, B and C, and not tested for IgM anti-HEV

Distribution of notified cases by hepatitis type. SEIEVA 2007-2014

Hepatitis A Hepatitis B

Hepatitis C Hepatitis E

nonA-nonE nonA-nonC

Unknown

Hepatitis E

Distribution of notified hepatitis E cases by region. SEIEVA 2007-2014

3 2 18

3 2

6

21

18

17 17

37

acute hepatitis cases where the presence of A, B or C hepatitis viruses has

already been excluded

Geographical area

Test IgM anti-HEV

yes Total

N° (%) N° cases

North 83 (27.3) 304

Centre 123 (35.7) 345

South/Islands 4 (5.6) 71

Total 210 (29.2) 720

Distribution of IgM anti-HEV tests by geographical area and year among possible acute hepatitis E cases. SEIEVA 2007-2014

0%

10%

20%

30%

40%

50%

60%

2007 2008 2009 2010 2011 2012 2013 2014

Year

Mean = 29.2%

Distribution of notified hepatitis E cases by age, gender and nationality. SEIEVA 2007-2014

Characteristics N° (%)

Age

0-14 3 (2.1)

15-24 16 (11.1)

25-34 35 (24.3)

35-54 54 (37.5)

≥ 55 36 (25.0)

median (range) 40.5 (12-87)

Gender

Male 122 (84.7)

Female 22 (15.3)

Nationality

Italian 81 (56.6)

Other 62 (43.4)

Total n° of cases 144

Nationality N° (%)

Bangladesh 29 (46.8)

India 17 (27.4)

Pakistan 10 (16.1)

Bolivia, China, Croatia, Morocco, Peru, Romania

6 (9.7)

Total n° of cases 62 (100.0)

Most of the travel are to the country of origin

Risk factors Italians Other p-value

Shellfish consumption 47.5 30.0 0.048

Raw 35.3 61.5 0.104

Drinking well water 9.1 38.8 <0.001

Travel to endemic areas 16.5 82.8 <0.001

Contact with a jaundice case (within 6 weeks)

0.0 2.4 0.180

Total cases 81 62

Percent of notified hepatitis E cases who report exposure to the listed risk factors by nationality. SEIEVA 2007-2014

Integrated epidemiological, virological, and environmental surveillance of hepatitis E in Italy: emerging disease in

industrialized countries

Granted by MoH

ME Tosti ISS – National Centre for Epidemiology, Surveillance and Health Promotion AR Ciccaglione ISS – Department of Infectious, Parasitic and Immune-Mediated Diseases G La Rosa ISS – Department of Environment and Primary Prevention L Romanò Milan University – Department of Biomedical Sciences for Health

Project conducted within: the SEIEVA network the Italian major reference center for viral hepatitis at ISS the regional reference center for viral hepatitis at Milan University

Settings: 41 LHUs

Study population:

all HEV cases from LHUs able to perform anti-HEV laboratory confirmation

all nonA-nonC cases from LHUs not able to perform anti-HEV laboratory confirmation

Years: 2012-2015

Study population Total cases

to be confirmed 126

E cases 30

Total 156

Study population

E cases 58 (37.2)

nonA-nonE cases 98 (62.8)

Total 156 (100.0)

IgM anti-HEV pos. n (%)

28 (22.2)

30 (100.0)

58 (37.2)

Characteristics Hepatitis

p-value E nonA-nonE

Age % %

10-30 21.4 11.8

0.178 31-45 25.0 33.3

46-60 32.1 23.7

61-87 21.4 31.2

Gender

Male 84.5 55.7 <0.001

Female 15.5 44.3

Nationality

Italian 69.0 83.7 0.032

Other 31.0 16.3

Geogr. area of diagnosis

North 48.3 51.0

0.533 Centre 48.3 41.8

South/Islands 3.4 7.1

Comparison between E and nonA-nonE cases: demographic characteristics

risk factors Hepatitis

p-value E nonA-nonE

% %

Travel 39.3 29.2 0.210

Shellfish consumption 56.8 40.4 0.119

Raw 38.9 0.0 0.095

Berries consumption 25.0 50.0 0.245

Drinking well water 12.9 9.5 0.708

Pork meat consumption 70.3 49.2 0.041

Sausage consumption 60.6 31.3 0.009

Wildfowl consumption 50.0 25.0 0.306

Comparison between E and nonA-nonE cases: risk factors

Study flow-chart with the results of molecular analysis

58 Hep. E cases

45 tested for RNA

40 HEV-RNA positive

17 sequenced

16 G3

1 G4

23 not sequenced

5 HEV-RNA negative

13 not tested for RNA

Croatian travel to Ukraine

all Italians no travels to endemic areas

Molecular analysis of nonA-nonC acute hepatitis cases sent for diagnostic to the ISS laboratory. 2004-2015

124 cases

39 IgM anti-HEV positive

(31.5%)

31 HEV-RNA positive

8 HEV-RNA negative

85 IgM anti-HEV negative

2 HEV-RNA positive

83 HEV-RNA negative

all tested for IgM anti-HEV and

HEV-RNA

33 HEV-RNA positive

11

G1

6

G3

41 acute hepatitis E

on 124 nonA-nonC 33.1%

Geographic Information System (GIS) map of the Wastewater Treatment Plants (WTPs) under study

56 wastewater treatment plants

717 sewage samples

37 positive samples

5.2%

21 Genotype 3

16 Genotype 1

Geographic distribution of HEV-RNA positive samples

Epidemiological study performed in 2014:

Prevalence of HEV infection among blood donors

resident in Abruzzo, central Italy

• cross-sectional study February-March

2014

• serum samples from 313 blood

donors*

• tested for anti-HEV IgM, anti-HEV IgG,

HEV RNA

* unpaid voluntary donors, 18-68 years old, median

age 48; 98.7% Italian subjects, 80.5% male

Lucarelli C, … and Ciccaglione AR. High prevalence of anti-hepatitis E virus

antibodies among blood donors in central Italy. Euro surveillance in press

Laboratory results:

313 blood donors tested: 309 Italians; 4 foreign citizens

80.5% male; median age 48

• 153 positive for anti-HEV IgG: 48.9% (95% CI 0.4-0.5) (Wantai Elisa kit)

• 2 positive for anti-HEV IgM: 1.3% (95% CI 0.1-4.6) (Wantai Elisa kit)

• 2 positive for HEV RNA: blood donor 784: IgM/IgG + ; HEV RNA 100 IU/mL; G3

blood donor 771: IgM/IgG - ; HEV RNA 10,000 IU/mL; G3

Prevalence of anti-HEV IgG by age group

0%

10%

20%

30%

40%

50%

60%

70%

<35 35-44 45-54 ≥55

HEV IgG positive, %

age (years)

(n=82) (n=104) (n=75) (n=54) ANTI-HEV IgG PREVALENCE INCREASED WITH AGE

However, high values were also found in the first age groups

suggesting that viral transmission takes place even at young age

age (years)

Epidemiological study performed in 2014:

As a control: prevalence of HEV infection among

blood donors resident in Lazio, central Italy

9 anti-HEV IgG positive: 9% (95% CI 0.43-0.54)

100 subjects, all Italians

89% male; median age 40

Multivariate analysis

Univariate Analysis Multivariateanalysis

Risk factor PR 95% CI P value APRR 95% CI P value

Sex (M/F) 1.6 0.9-3 0.097 Birth rural area 1.6 1-2.7 0.042 Work with animals 1.7 0.7-4.1 0.189 Contacts with cattle 1.5 0.9-2.4 0,111 Contacts with dogs 0.5 0.3-1 0,028 Kitchen gardening 1.6 1-2.6 0,052 Raw dried pork liver

sausage 4.00 2-8.3 0 2.35 1.5-3.8 0

vegetable

consumption of

own kitchen garden 1.4 0.8-2.5 0,197

usually vegetable

consumption of

own kitchen garden 1.5 0.9-2.4 0,103

the only risk factor independently

associated with past and present infection

was the consumption of

raw dried pork liver sausage (air-dried sausages )

APRR: adjusted prevalence rate ratios

A special food habit of that area

supporting the hypothesis of

zoonotic transmission

Blood donor 771_ISS

Blood donor 784_ISS

Phylogenetic analysis

of HEV typing assay: ORF1 (broad-range MTase assay)

blood donor 784_ISS

clustered with strains from Italian ENVIRONMENTAL SAMPLES

wastewater (central Italy: WTP1496; northern Italy: WTP1929,

WTP1577)

Sequences from 2 blood donors: 771_ISS and 784_ISS

clustered with GENOTYPE 3 GROUP along with:

strains from swine

possible zoonotic origin.

Phylogenetic analysis

of HEV subtyping assay: ORF2 (capsid region)

Sequence from blood donor 771_ISS

• clustered with SUB-GENOTYPE 3c GROUP

the group includes other 7 strains:

• 5 swine: 3 from The Netherland, 2 from Italy

• 1 wild boar: from Germany

• 1 human: from France

in Italy, hepatitis E surveillance is limited to a voluntary system, as SEIEVA

SEIEVA, at present, covers 77% of the Italian population

surveillance is affected by underreporting

HEV is not routinely investigated, as only few laboratories perform anti-HEV tests

laboratory tests performance seems to be increasing

underreporting is probably also attributable to a high percentage of asymptomatic cases

Conclusions

Conclusions

When the specific tests are performed, about 30% acute hepatitis negative for HAV, HBV and HCV are attributable to hepatitis E virus

in all the presented data, G3 and G1 are prevalent in Italy, in human cases as in the environment

microbiological and environmental surveillance is currently performed in Italy only within granted projects, but …

in 2015 started a integrated epidemiological and microbiological surveillance of acute viral hepatitis, supported by the MoH