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   Table of Contents      
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 39-42

Enteric Transmitted Hepatitis Viruses in Delhi: Experience from a Tertiary Care Hospital


Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India

Date of Submission11-Mar-2021
Date of Decision02-Apr-2021
Date of Acceptance10-Apr-2021
Date of Web Publication28-Apr-2021

Correspondence Address:
MD, MBBS Shilpee Kumar
Associate Professor, Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi 110029, India.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_23_21

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  Abstract 


Objective: To estimate the seroprevalence of enteric transmitted hepatitis A virus (HAV) and hepatitis E virus (HEV) in patients presented with acute viral hepatitis in a tertiary care hospital, Delhi. Methods: It was a retrospective study from February 2019 to December 2020 conducted in a tertiary care hospital, Delhi. Serum samples from clinically suspected hepatitis patients sent for HAV and HEV testing were included in the study. The samples were tested for HAV and HEV Immunoglobulin (Ig)M antibody by enzyme-linked immunosorbent assay. Data collected in Excel sheet were analyzed using SPSS software version 21. Chi-square and Fischer exact test were used wherever necessary. Results: Viral etiology (HAV or HEV) was found in 122 (18%) patients. IgM HAV was detected in 75 (11%) patients whereas IgM HEV in 47 (7%) patients. The coinfection of HAV and HEV was not observed. HAV infection was significantly more common in pediatric age group 32.8% (59/180; P < 0.001) whereas HEV was significantly more common in adolescent and adult age group 8.6% (42/491; P < 0.001). Conclusions: Periodic surveillance of enteric transmitted viruses causing hepatitis needs to be conducted at hospital as well as community level to ascertain the true burden of the disease and changing epidemiology.

Keywords: HAV, HEV, hepatitis virus, seroprevalence


How to cite this article:
Kashyap S, Pongiyannan L, Kumar S. Enteric Transmitted Hepatitis Viruses in Delhi: Experience from a Tertiary Care Hospital. MAMC J Med Sci 2021;7:39-42

How to cite this URL:
Kashyap S, Pongiyannan L, Kumar S. Enteric Transmitted Hepatitis Viruses in Delhi: Experience from a Tertiary Care Hospital. MAMC J Med Sci [serial online] 2021 [cited 2021 Oct 24];7:39-42. Available from: https://www.mamcjms.in/text.asp?2021/7/1/39/314883




  Introduction Top


World Health Organization (WHO) estimated that worldwide in 2015, hepatitis A virus (HAV) and hepatitis E virus (HEV) caused approximately 11,000 and 44,000 deaths, respectively. These accounted for 0.8% and 3.3% of the mortality due to viral hepatitis, respectively.[1] In India, there are limited data to estimate the real burden of the disease. Though, it is approximated that HAV accounts for 10% to 30% of acute hepatitis and 5% to 15% of acute liver failure; and HEV is responsible for 10% to 40% of acute hepatitis cases and 15% to 45% of acute liver failure cases.[2]

HAV and HEV are transmitted via fecal–oral route either by direct contact with an infectious person or by ingestion of the contaminated food or water. Patients may have subclinical infection or present with acute viral hepatitis (AVH) and most recover in 1 to 2 months with no clinical sequelae. The case fatality rate in HAV and HEV is 0.1% and 1% to 2%, respectively. The case fatality rate in HEV can go up to 10% to 20% in pregnant women.[3]

Antibody to HAV is detected during acute illness and is predominantly of the Immunoglobulin (Ig)M class. It persists for several (∼3) months and rarely for 6 to 12 months. During convalescence, Immunoglobulin G (IgG) class of antibody becomes predominant and remains detectable indefinitely. Similarly, in case of HEV infection, IgM anti-HEV is detected during early acute infection and IgG anti-HEV is detected after the first 3 months.[3] Both passive and active immunization are available for HAV whereas vaccine against HEV, developed by China, is not available globally.[1]

For effective management, prevention, and planning, it is important to have knowledge about real burden and changing trends of the disease. There are various studies conducted in different parts of the country but there are limited data about the seroprevalence of HAV and HEV in and around Delhi in recent past. This study was undertaken to provide an insight about the burden and profile of HAV and HEV in patients presented with AVH.


  Material and Methods Top


Ethics

The principles outlined in the Declaration of Helsinki were followed in the study. The data acquired in this retrospective study were kept anonymized.

Study design

This was a retrospective study.

Site of study

The study was conducted in a 2800 bedded, tertiary care, government hospital situated in Delhi, North India. Its catchment area included Delhi and neighboring states with daily average outpatient department visits of 12,251 per day and inpatient admission of 515 per day.

Study period

The study took place over the period of 23 months from February 2019 to December 2020.

Inclusion criteria

All consecutive samples received in the Department of Microbiology for testing of HAV and HEV infection in clinically suspected AVH were included in the study. The tests results were retrieved from the records and analyzed.

Laboratory investigations

Serum sample was used to detect IgM antibody against HAV and HEV. The tests were performed using commercial kit (Bioneovan Co. Ltd., Beijing, China) based on the enzyme-linked immunosorbent assay as per the manufacturer’s instructions.

Statistical analysis

Data from the manual record (paper and pen) were punched in Excel sheet. The analysis was performed with SPSS software version 21 (SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.). The chi-square (χ2) and Fisher exact test (if the cell frequency was <5) were used to ascertain the statistically significant associations among demographic factors of HAV and HEV infections.


  Results Top


A total of 671 samples were received during the study period in which 291 (43%) were males and 380 (57%) were females. Of which, 180 (26%) belonged to pediatric age group and 491 (73%) to adolescent and adult age group.

Viral etiology (HAV or HEV) was found in 122 (18%) patients. IgM HAV was detected in 75 (11%) patients whereas IgM HEV in 47 (7%) patients. The coinfection of HAV and HEV was not observed.

As showed in [Table 1], the percentage positivity of the IgM antibody against HAV and HEV was significantly higher in males (n = 67; 23%) than in females (n = 55; 14.5%), where P = 0.002. Also, a significantly larger population of pediatric age group (n = 64; 35.6%) was positive for these viruses than adults (n = 58; 11.8%), where P < 0.001. Interestingly, the percentage positivity of viral etiology was significantly lower in 2020 than 2019 (P < 0.001). Further, HAV infection was significantly more common in pediatric age group 32.8% (59/180; P < 0.001) whereas HEV 8.6% (42/491; P < 0.001) was significantly more common in adolescent and adult age group.
Table 1 Age, gender, and year-wise distribution of HAV and HEV infection in patients presented with hepatitis

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  Discussion Top


This study was an effort to understand the burden and distribution of enteric transmitted viruses in patients presented with hepatitis. The seroprevalence of enteric transmitted viruses (HAV and HEV) was 18%, which lies in the range indicated in studies by Barde et al.[4] and Samaddar et al.[5] However, [Table 2] shows that the seroprevalence varies as per time, place, and person and ranged from 11% to 85%.
Table 2 Comparison of seroprevalence of HAV and HEV infection across various studies in India

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In the present study, the seroprevalence of HAV was 11.2%, which is higher than the studies conducted in Delhi in 2008 and 2015. Also, the seroprevalence of HAV ranged from 5% to 54% across the country [Table 2].

The clinical symptoms of the patients infected with HAV vary greatly with the age. Approximately 75% of the children >6 years of age develop characteristic feature of hepatitis or jaundice.[15],[16] Similar phenomenon was also observed in the present study. HAV infection was predominantly found in the pediatric age group (32.8%) presented with hepatitis than the adult population (3.3%) [Table 1]. By the time child reaches the adulthood, most of them are exposed to HAV (>90%) and develop antibodies against it. These antibodies confer life-long immunity and prevent reinfection.[15],[16] This may explain the low seroprevalence of HAV (only 3.3%) in the adult population presented with hepatitis in this study [Table 1].

It is observed that symptomatic HEV infection is more common in adults than children.[6],[17] In the present study also, HEV infection was significantly higher in adults (8.6%) than children (2.8%). Extrahepatic manifestation has also been reported in HEV infection like glomerulonephritis, hematological disorders, pancreatitis, and autoimmune conditions including Henoch–Schönlein purpura, thyroiditis, and myasthenia gravis. Such patients are usually not suspected and hence not tested for HEV, leading to underreporting of HEV infection.[3] Another epidemiologic feature that distinguishes HEV from HAV is the rarity of secondary person-to-person spread. Hence, outbreaks due to consumption of contaminated water, like after monsoon flooding, are observed more than individual sporadic cases.[3] This may explain the lower seroprevalence of HEV (7%) than HAV (11%) observed in this study. However, the seroprevalence of HEV was found much lower than other studies conducted across the country [Table 2].

It is interesting to note that the enteric transmitted viral infection was significantly lower in 2020 (10.8%) than 2019 (23.6%) [Table 1]. Severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2) that was originated from China, quickly spread to different parts of the world and was declared as global pandemic by WHO on March 11, 2020.[18] To reduce the transmission of SARS-CoV-2, Indian government implemented 55-days lockdown (known to be the most stringent in whole world) throughout the country starting March 25, 2020. Also, public awareness was raised to follow social distancing, wearing face mask, washing hands frequently, and avoid large gatherings. This may have led to improved personal hygiene, less consumption of contaminated food and water, and hence resulting in lesser exposure to enteric transmitted viruses. Further, people sought hospital care only in case of severe infection or in emergency, which may be the reason for reduction in reported cases.

The study has certain limitations. It was restricted to patients with symptomatic enteric transmitted viral infection, who accessed hospital care at the site of study. This limits the generalization of the data at the community level. Also, the diagnosis of HAV and HEV infections was based on serology only and was not confirmed by molecular techniques.

To conclude, periodic surveillance of enteric transmitted viruses causing hepatitis needs to be conducted at hospital as well as community level to ascertain the true burden of the disease and changing epidemiology. This will help in effective planning and policy making for control and prevention of these viruses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. Global Hepatitis Report. Geneva: WHO; 2017.  Back to cited text no. 1
    
2.
Ministry of Health and Family Welfare, Government of India. National viral hepatitis control program: operational guidelines. India: MoHFW, GoI; 2018.  Back to cited text no. 2
    
3.
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4.
Barde PV, Chouksey VK, Shivlata L, Sahare LK, Thakur AK. Viral hepatitis among acute hepatitis patients attending tertiary care hospital in central India. Virusdisease 2019;30:367-72.  Back to cited text no. 4
    
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Samaddar A, Taklikar S, Kale P, Kumar CA, Baveja S. Infectious hepatitis: a 3-year retrospective study at a tertiary care hospital in India. Indian J Med Microbiol 2019;37:230-4.  Back to cited text no. 5
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Kalita D, Paul M, Deka S, Badoni G, Gupta P. Simultaneous infection of hepatitis A and hepatitis E viruses amongst acute viral hepatitis patients: a hospital-based study from Uttarakhand. J Family Med Prim Care 2020;9:6130-4.  Back to cited text no. 14
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Agrawal A, Singh S, Kolhapure S, Hoet B, Arankalle V, Mitra M. Increasing burden of hepatitis A in adolescents and adults and the need for long-term protection: a review from the Indian subcontinent. Infect Dis Ther 2019;8:483-97.  Back to cited text no. 16
    
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  [Table 1], [Table 2]



 

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