|Year : 2016 | Volume
| Issue : 8 | Page : 47-50
Prevalence of hepatitis a virus and hepatitis e virus in the patients presenting with acute viral hepatitis at a tertiary care hospital Jaipur Rajasthan
Anshu Mittal, Rameshwari Bithu, Nitya Vyas, Rakesh K Maheshwari
Department of Microbiology, Sawai Man Singh Medical College and Attached Hospitals, Jaipur, Rajasthan, India
|Date of Web Publication||3-Jan-2017|
Department of Microbiology, Sawai Man Singh Medical College and Attached Hospitals, Jaipur - 302 004, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: Hepatitis A virus (HAV) and hepatitis E virus (HEV) causes a self-limiting viral infection, transmitted by feco-oral route. These infections are major health problem worldwide, with a higher incidence in developing countries. Exposure rate of HAV and HEV over a period are different in different parts of country. Objectives: This study was conducted to determine the seroprevalence of HAV and HEV, its seasonal trend and their correlation with serological markers of liver damage at a tertiary care hospital Jaipur Rajasthan. Materials and Methods: A total of 3093 serum samples were tested for IgM HAV and IgM HEV. Relevant data were also collected. Results: A total of 3093 patients were included in the study. Of the 3093, 1654 and 1439 serum samples were tested for IgM HAV and IgM HEV, respectively. Of these, 7.67% and 14.9% were positive for IgM HAV and IgM HEV, respectively. Range of elevated bilirubin in both type of acute hepatitis varied from 1.4 mg% to 37 mg%. In IgM HEV positive patients, bilirubin level was increased in 70.69% cases, whereas aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) levels were elevated in 68.37%, 58.13%, and 31.16% cases, respectively and in IgM HAV positive patients bilirubin level was increased in 57.48% of patients whereas AST (or serum glutamic oxaloacetic transaminase), ALT (or serum glutamic pyruvic transaminase) and ALP levels were elevated in 55.11%, 59.84%, and 42.51% of patients, respectively. Conclusions: The best means of reducing the spread of infection is by promoting simple measures of personal and community hygiene. However, these data will be useful for planning of future vaccination strategies and for better sanitation program in country.
Keywords: Bilirubin, hepatitis A, hepatitis E, serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase
|How to cite this article:|
Mittal A, Bithu R, Vyas N, Maheshwari RK. Prevalence of hepatitis a virus and hepatitis e virus in the patients presenting with acute viral hepatitis at a tertiary care hospital Jaipur Rajasthan. N Niger J Clin Res 2016;5:47-50
|How to cite this URL:|
Mittal A, Bithu R, Vyas N, Maheshwari RK. Prevalence of hepatitis a virus and hepatitis e virus in the patients presenting with acute viral hepatitis at a tertiary care hospital Jaipur Rajasthan. N Niger J Clin Res [serial online] 2016 [cited 2023 May 29];5:47-50. Available from: https://www.mdcan-uath.org/text.asp?2016/5/8/47/197436
| Introduction|| |
Hepatitis A virus (HAV) and hepatitis E virus (HEV) causes a self-limiting viral infection that is transmitted by feco-oral route, primarily through consumption of contaminated food and water. These infections are major health problem worldwide, with a higher incidence in developing countries. Enterically transmitted viral hepatitis is of great public health importance in India. HAV and HEV both are endemic in developing countries like India where conditions of hygiene and sanitation are poor.
HAV infections account for 1.4 million new cases per year worldwide,  and the risk of infection is inversely proportional to levels of sanitation and personal hygiene. Infections due to HAV is mostly asymptomatic, self-limiting and exposure to the virus provides lifelong immunity.  HAV mainly affects infants and young children and in developing countries, nearly all children are infected with HAV by the age of 18 and as the standard of living improves, the peak incidence of hepatitis A moves from young children to older age. 
Hepatitis E prevalence is highest in the East and South Asia regions, accounting for 60% of hepatitis E global incidence. Despite this high endemicity, the sero-prevalence of antibody to HEV is only 25% in young adults. Among the Indian population, there is low sero-prevalence until age 15, reaching up to 40% in young adults. 
Exposure rate of HAV and HEV over a period of time are different in different parts of country and in different socioeconomic groups. 
Hence, this study was conducted to determine the seroprevalence of HAV and HEV, its seasonal trend and their correlation with serological markers of liver damage at a tertiary care hospital Jaipur Rajasthan.
| Materials and Methods|| |
This retrospective study was conducted at the Department of Microbiology, Sawai Man Singh (SMS) Medical College and attached Hospitals in Rajasthan from January 2015 to December 2015. The study population included individuals of all age group who were suspected of acute viral hepatitis and attended SMS group of hospitals. Both in- and out-door patients were included in the study.
A total of 3093 serum samples were tested for IgM HAV and IgM HEV for the detection of acute hepatitis A and acute hepatitis E, respectively, using commercially available ELISA kits (DIA.PRO Diagnostic Bioprobes Srl Jaipur Rajasthan/India). Relevant data regarding age, sex, and levels of total bilirubin, serum amino transferase, and alkaline phosphatase (ALP) was also collected.
| Results|| |
A total of 3093 patients presented with acute hepatitis were included in the study. Of the 3093, 1654 serum samples were tested for IgM HAV. Out of the 1654, 127 (7.67%) were positive for IgM HAV. Of these, 81 (63.77%) were males and 46 (36.22%) were females. Most (45.6%) of the patients were in the age group of 11-20 years. Age-wise distribution of IgM HAV positive patients is shown in [Table 1]. Bilirubin level was increased in 57.48% of patients, whereas aspartate aminotransferase (AST) (or serum glutamic oxaloacetic transaminase), alanine aminotransferase (ALT) or (serum glutamic pyruvic transaminase), and ALP levels were elevated in 55.11%, 59.84%, and 42.51% of patients, respectively [Table 2].
|Table 1: Age - dependent prevalence of hepatitis A virus and hepatitis E virus serological markers|
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|Table 2: Elevated levels of hepatic enzymes in IgM hepatitis A virus and IgM hepatitis E virus positive patients |
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A total of 1439 serum samples were tested for IgM HEV. Of these, 215 (14.9%) patients were positive for IgM HEV. Out of the 215, 150 (69.76%) were males and 65 (30.23%) were females. Most of the patients were in the age group of 21-30 years. Age-wise distribution of IgM HEV positive patients is shown in [Table 1]. In IgM HEV positive patients, bilirubin level was increased in in 70.69% of cases, whereas AST, ALT, and ALP levels were elevated in 68.37%, 58.13%, and 31.16% cases, respectively [Table 2]. Range of elevated bilirubin in both type of acute hepatitis varied from 1.4 mg% to 37 mg %. Seasonal variation of both IgM HAV and IgM HEV positive is shown in [Figure 1].
|Figure 1: Seasonal distribution of hepatitis A virus and hepatitis E virus|
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| Discussion|| |
The global public health impact of enteric hepatitis virus infection is immense. Till now, no attempt has been made to calculate meaningful figures because of relationship between infection and standard of living, sub clinical cases, and under reporting. However, enough studies exist to give general trend of enteric hepatitis.
In the present study, total number of tested patients were 3093. Out of these, 11.05% (342 cases) had positive viral markers for both HAV and HEV. This was comparatively lower than other studies from India. ,
In our study, seroprevalence of HAV was 7.67% while for HEV is 14.9%. HAV prevalence in other studies was 13.3%, 13.63%, and 19.31% while for HEV is 17.3%, 10.54%, and 78.78%. ,, This seroprevalence is comparatively higher than the present study. This lower seropositivity could be either due to a number of tested patients was much more in the present study or due to the lack of awareness about the disease, patients do not present to medical care facilities. Patients try to treat jaundice like symptoms by themselves or believe in tantric due to superstition.
Seroprevalence of both HAV and HEV were higher in males which was similar with other studies. , It is because of greater exposure of males in their professional and social activities.
The present study has shown that HEV infection occur more often in older children and adults (21-30 years) whereas HAV occur mostly in young children (11-20 years). This finding is consistent with other Indian studies and shows that exposure to HAV occurs early in life. HEV infection is less common in young children as anicteric hepatitis or subclinical infections are common in children. 
We also observed that HAV and HEV infection occurred throughout the year although seasonal variation in incidence were evident with maximum number of patients were from June to September, that is, in peak of summer and beginning of rainy season. As HAV and HEV are transmitted enterically, due to the shortage of drinking water supply in summer and cross contamination of drinking water with sewage lead to more chances of infection.
The prevalence of 2.92% (ten cases) with coinfection of HAV and HEV was noted in our study. One study showed lower prevalence (0.8%) of dual infection,  whereas other showed higher prevalence (7.5%, 11.5%). , Out of ten, three patients were in age group of <20 and 7 were in the age group of more than 20 years. As HEV infection is less common in young children, finding of our study support it. One patient with coinfection had very high value of hepatic enzymes (AST-9100 IU/L, ALT-7800 IU/L). This suggests that dual infection with HAV and HEV can lead to severe disease manifestations such as hepatic encephalopathy. A case report by Park et al. support this finding. 
We also observed that patients with acute HEV infection and acute HAV infection 70.69% (152 cases) and 57.48% (73 cases), respectively, had elevated bilirubin (above normal range). Out of these, 16 patients of HEV and seven patients of HAV had very high level of bilirubin (>15 mg%), but level of ALT and AST were within normal range or not much elevated (up to 160 IU/L). This finding suggest that these patients presented late to medical care facility due to less awareness as in early infection bilirubin level is usually not raised however liver enzymes are increased.
| Conclusions|| |
In our study, it is evident that infection with enteric hepatitis viruses is common. The disease can lead to significant economic and social consequences in communities. It can take weeks or months for people recovering from the illness to return to work.
Almost all HAV and HEV infections are spread by feco-oral route. The best means of reducing the spread of infection is by promoting simple measures of personal and community hygiene as handwashing before eating and after toilet; the sanitary disposal of excreta which will prevent contamination of water, food and milk; during epidemics, boiled water should be advocated for drinking purposes.
Preexposure protection in high risk persons for acquiring HAV infection by the use of hepatitis A vaccine is now recommended.
Although there is no commercially available HEV vaccine, improving sanitation conditions and careful procedure in preparing food and chlorination or even boiling the water has been shown to decrease HEV infection.
These two infections cannot be eradicated as these viruses have animal reservoir. However, these data will be useful for planning of future vaccination strategies and for better sanitation program in country.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Hepatitis A vaccines: WHO position paper. Wkly Epidemiol Rec 2000;75:38-44.
Radhakrishnan S, Raghuraman S, Abraham P, Kurian G, Chandy G, Sridharan G. Prevalence of enterically transmitted hepatitis viruses in patients attending a tertiary - Care hospital in South India. Indian J Pathol Microbiol 2000;43:433-6.
Tahaei SM, Mohebbi SR, Zali MR. Enteric hepatitis viruses. Gastroenterol Hepatol 2012;5:7-15.
NCDC Newsletter. Vol 3. issue 1; January-March, 2014. p. 1.
Arankalle VA, Chadha MS, Chitambar SD, Walimbe AM, Chobe LP, Gandhe SS. Changing epidemiology of hepatitis A and hepatitis E in urban and rural India (1982-1998). J Viral Hepat 2001;8:293-303.
Joon A, Rao P, Shenoy SM, Baliga S. Prevalence of hepatitis A virus (HAV) and hepatitis E virus (HEV) in the patients presenting with acute viral hepatitis. Indian J Med Microbiol 2015;33 Suppl S1l:102-5.
Arora D, Jindal N, Shukla RK, Bansal R. Water borne hepatitis A and hepatitis E in Malwa region of Punjab, India. J Clin Diagn Res 2013;7:2163-6.
Al-Naaimi AS, Turky AM, Khaleel HA, Jalil RW, Mekhlef OA, Kareem SA, et al.
Predicting acute viral hepatitis serum markers (A and E) in patients with suspected acute viral hepatitis attending primary health care centers in Baghdad : a0 one year cross-sectional study. Glob J Health Sci 2012;4:172-83.
Kamal SM, Mahmoud S, Hafez T, El-Fouly R. Viral hepatitis A to E in South Mediterranean countries. Mediterr J Hematol Infect Dis 2010;2:e2010001.
Chandra NS, Sharma A, Rai RR, Malhotra B. Contribution of hepatitis E virus in acute sporadic hepatitis in North Western India. Indian J Med Res 2012;136:477-82.
|11.| Park JH, Kim BS, Lee CH, Kim SY, Seo JH, Hur CJ. A case of co infection of hepatitis A and E virus with hepatic encephalopathy. Korean J Med 2011;80 Suppl 2:S101-5.
[Table 1], [Table 2]
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