A study of hepatitis E outbreak in rural area of Western Maharashtra

Background:In March 2013, cases of acute hepatitis were reported from Lalkuan, Nainital district. We investigated the outbreak to identify the source of infection and to facilitate control measures.Objectives:To study the distribution of hepatitis cases, to find the source of infection, and to initiate the control measures in the affected area.Materials and Methods:We defined a case of acute hepatitis as those cases that had jaundice with at least one of the following symptoms: Dark urine, fever, pain in abdomen, vomiting, and loss of appetite in the affected area between January and March 2013. Door-to-door survey was carried out. Thirteen blood samples were randomly collected from jaundice cases for immunoglobulin M (IgM) antibody for hepatitis A virus (HAV) and hepatitis E virus (HEV). Water samples were collected to test residual chlorine.Results:Total 2,785 individuals were surveyed; of which 240 were suffering from acute viral hepatitis (attack rate (AR) = 8.61%). Out of 13 serum samples, 10 were found positive for HEV IgM antibodies and three cases had IgM antibodies for both HAV and HEV, which confirmed a hepatitis E outbreak. The difference in attack rate of hepatitis of both the sexes was statistically significant (P < 0.001). The attack rate was significantly higher in age groups >12 years of age (P < 0.001). Environmental investigation also confirmed the sewage contamination of drinking water in the distribution system. The attack rate was much higher (29.4%) among those who were exposed to the leaking pipeline than the nonexposed (χ2 = 574.26, P < 0.01).Conclusion:HEV was confirmed as the major etiological agent in this outbreak that was transmitted by contaminated drinking water. The recognition of early warning signals, timely investigation, and application of specific control measures can contain the outbreak.

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“…Similar to other studies in India,(1516) we also found that all cases had jaundice, 78.5% had history of fever and 99.6% had dark colored urine.…”

Section: Discussionsupporting

confidence: 90%

Epidemiological investigation of the jaundice outbreak in Lalkuan, Nainital district, Uttarakhand

Awsathi

Rawat

et al. 2014

Indian J Community Med

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“…Outbreaks of viral hepatitis E in rural area were reported from Rajasthan (1994 and 1999), [7] Maharashtra (2004), [16] and Uttarakhand (2005) [17] states of India. Outbreak of hepatitis E usually occurs in the unimodal outbreak with a highly compressed curve of incidence or it may have a prolonged epidemic with multiple peaks.…”

Section: Discussionmentioning

confidence: 99%

Outbreak of hepatitis E with bimodal peak in rural area of Bhavnagar, India, 2010

Raval

Chauhan

Katara

et al. 2012

Ann Trop Med Public Health

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Context: Rise in the number of jaundice cases were reported on 24 th of June 2010, in Dhola village, India. We investigated the outbreak to identify the source of infection and to facilitate control measures. Materials and Methods: We confirmed the outbreak by reviewing the rate of acute viral hepatitis in the year 2009-10. We defined a case of acute hepatitis as an acute illness with (a) discrete onset of symptoms and (b) jaundice or elevated serum aminotransferase levels, since March 2010 in Dhola village. We described the outbreak in terms of time, place, and person. We tested 20 blood samples of the case patient for hepatitis B surface antigen (HBs Ag), and immunoglobulin M (IgM) antibody for hepatitis A and E. We collected water samples for the bacteriological examination, and to test free chlorine in the water. Results: A total of 137 cases (attack rate 27.2/1000) were reported in this outbreak from March to August 2010. The attack rate was highest among the age group of 20-29 years. The attack rate was significantly higher in male (35/1000) than in female (18/1000). Out of 20 case-patients, 19 were found positive for hepatitis E virus (HEV) IgM antibodies. The water samples taken from households contained more than 10 coliforms in 100 ml sample. The relative risk of developing hepatitis E among people using pipeline water against those using ground water was 3.23 (95% CI of RR 1.59, 6.57). Conclusion: Outbreak that affected Dhola village was due to hepatitis E virus. Fecal contamination of water was the most likely source of this bimodal outbreak of hepatitis E.

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“…Groundwater, crops, and waterways can all become contaminated. Open defecation in backyards and open fields can be another source of fecal contamination of groundwater, crops, and waterways [ 65 ]. In India for example, open defecation is rampant and over 300 million people use this practice for sanitary disposal, leading to widespread contamination of open drinking water sources, such as rivers, streams, and unprotected wells with raw sewage [ 2 ].…”

Section: Modes Of Transmissionmentioning

confidence: 99%

Transmission of Hepatitis E Virus in Developing Countries

Khuroo

Khuroo³

2016

Viruses

145

133

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Hepatitis E virus (HEV), an RNA virus of the Hepeviridae family, has marked heterogeneity. While all five HEV genotypes can cause human infections, genotypes HEV-1 and -2 infect humans alone, genotypes HEV-3 and -4 primarily infect pigs, boars and deer, and genotype HEV-7 primarily infects dromedaries. The global distribution of HEV has distinct epidemiological patterns based on ecology and socioeconomic factors. In resource-poor countries, disease presents as large-scale waterborne epidemics, and few epidemics have spread through person-to-person contact; however, endemic diseases within these countries can potentially spread through person-to-person contact or fecally contaminated water and foods. Vertical transmission of HEV from infected mother to fetus causes high fetal and perinatal mortality. Other means of transmission, such as zoonotic transmission, can fluctuate depending upon the region and strain of the virus. For instance, zoonotic transmission can sometimes play an insignificant role in human infections, such as in India, where human and pig HEV infections are unrelated. However, recently China and Southeast Asia have experienced a zoonotic spread of HEV-4 from pigs to humans and this has become the dominant mode of transmission of hepatitis E in eastern China. Zoonotic HEV infections in humans occur by eating undercooked pig flesh, raw liver, and sausages; through vocational contact; or via pig slurry, which leads to environmental contamination of agricultural products and seafood. Lastly, blood transfusion-associated HEV infections occur in many countries and screening of donors for HEV RNA is currently under serious consideration. To summarize, HEV genotypes 1 and 2 cause epidemic and endemic diseases in resource poor countries, primarily spreading through contaminated drinking water. HEV genotypes 3 and 4 on the other hand, cause autochthonous infections in developed, and many developing countries, by means of a unique zoonotic food-borne transmission.

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A study of hepatitis E outbreak in rural area of Western Maharashtra

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Epidemiological investigation of the jaundice outbreak in Lalkuan, Nainital district, Uttarakhand

Epidemiological investigation of the jaundice outbreak in Lalkuan, Nainital district, Uttarakhand

Outbreak of hepatitis E with bimodal peak in rural area of Bhavnagar, India, 2010

Transmission of Hepatitis E Virus in Developing Countries

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