Retrospective Cohort Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 28, 2016; 22(24): 5568-5577
Published online Jun 28, 2016. doi: 10.3748/wjg.v22.i24.5568
Hepatitis E in Israel: A nation-wide retrospective study
Ortal Erez-Granat, Tamar Lachish, Nili Daudi, Daniel Shouval, Eli Schwartz
Ortal Erez-Granat, Pediatrics Department, Sheba Medical Center, Tel Hashomer, Ramat Gan 5262110, Israel
Tamar Lachish, The Infectious Diseases Unit, Shaare-Zedek Medical Center, Jerusalem 9103102, Israel
Nili Daudi, The Liver Unit, the Hebrew University-Hadassah Medical School, Jerusalem 91120, Israel
Daniel Shouval, The Liver Unit, the Hebrew University-Hadassah Medical Center, Jerusalem 91120, Israel
Eli Schwartz, The Center for Geographic Medicine and Department of Medicine C, Sheba Medical Center, Tel Hashomer, Ramat Gan 5262110, Israel
Author contributions: Erez-Granat O, Schwartz E, Shouval D and Lachish T designed the research; Erez-Granat O performed the research and collected the data by telephone interviews and review of medical records; Daudi N was responsible for the laboratory work and analysis; all authors were responsible for interpretation of the data; Erez-Granat O wrote the paper; Schwartz E, Shouval D and Lachish T revised the paper; all authors were responsible for the final approval of the version to be published.
Supported by Puerto Rico and Gendal foundations (in part); and the Hadassah Liver Unit through an annual payment forwarded by the Hadassah Medical Organization, New-York, United States (to Portoricco-Gendal Endowment).
Institutional review board statement: The study was approved by the Sheba-Medical Centers’ institutional review board.
Informed consent statement: All study participants received mail with the study protocol and were asked for consent to participate in this study. All study participants provided informed consent prior to study enrollment.
Conflict-of-interest statement: The authors have no conflict of interest to declare.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Eli Schwartz, MD, DTMH, Professor, The Center for Geographic Medicine and Department of Medicine C, Sheba Medical Center, Tel Hashomer 52621, Israel. elischwa@post.tau.ac.il
Telephone: +972-3-5308456 Fax: +972-3-5308456
Received: February 4, 2016
Peer-review started: February 9, 2016
First decision: April 14, 2016
Revised: May 11, 2016
Accepted: May 21, 2016
Article in press: May 23, 2016
Published online: June 28, 2016
Abstract

AIM: To investigate the epidemiology, risk factors and clinical course of acute hepatitis E virus (HEV) infection in Israel, an industrialized country.

METHODS: A retrospective analysis of acute HEV cases diagnosed in Israel from 1993 to 2013. Acute HEV was defined by ALT/AST elevation and a positive HEV PCR test or positive anti-HEV-IgM serology. HEV RNA was tested by quantitative reverse transcription PCR. Antibodies to HEV were tested retrospectively using an ELISA assay. HEV-RNA was sequenced using RT-PCR of ORF1 and ORF2 regions to diagnose genotype of the virus. Epidemiologic and clinical data were collected by reviewing the clinical files and through a telephone interview according to a structured questionnaire.

RESULTS: Acute HEV was diagnosed in 68 patients. Among the 59 patients who gave an informed consent and were interviewed, 41% of infections were autochthonous (acquired in Israel), 44% travel-related and 15% imported by foreign workers. Autochthonous patients were mainly females (62.5%), more than half of them pregnant, 26% recalled consuming food or water in areas with poor sanitation, 44% ate non-kosher meat. Fulminant hepatitis developed in 3 patients (5%), all of them were females, two of them with post-partum infection, all acquired the disease in Israel (autochthonous). Israeli travelers with imported infection were predominantly males (73%), acquired the disease in the Indian subcontinent (81%), with 100% reporting having consumed fresh vegetables and drinks with ice cubes abroad. Six patients’ sera were tested for genotype and revealed HEV genotype 1 (all cases acquired in the Indian subcontinent).

CONCLUSION: This is the first report which highlights the existence of hepatitis E as an autochthonous infection in Israel. Imported HEV originates mostly from the Indian subcontinent.

Keywords: Hepatitis E, Autochthonous, Travel, Foreign workers, Pregnancy, Post-partum, India, Nepal, Indian subcontinent, Israel

Core tip: This is the first epidemiologic report on hepatitis E virus (HEV) in Israel. This report demonstrates the significant presence of autochthonous acute HEV in Israel, serving as an example of occurrence in an industrialized country. Suspected risk factors in Israel include consumption of water and food in areas with poor sanitation, exposure to animals and eating a non-Kosher meat. The high risk group for fulminant hepatitis was pregnant women in their final trimester. Additionally, imported HEV, originating mainly from the Indian subcontinent, is also seen in Israel. Awareness of this disease is important both among physicians in Israel as well as those in other industrialized countries.