Hepatitis E: a curious Hepatitis E: a curious zoonosiszoonosis

Nicole Pavio (INRA, AFSSA LERPAZ, ENVA)

Ecole Nationale Veterinaire d’Alfort, France

2

Water, soiled food

Genotypes 1, 2

Genotypes 3 et 4

Endemic RegionsEndemic RegionsAsia, Africa, Central AmericaAsia, Africa, Central America

Sporadic CasesSporadic CasesUS, Europe, JapanUS, Europe, Japan

Genotype 3, 4

Environment ?????

????? (Japan: grilled Liver, Sushi)

Cas sporadiques

VHE (2)

VHE (3)

(2)

(1, 2)

VHE (3)

VHE (1)VHE (1) VHE (1)

VHE (1, 4)VHE (1)

VHE (1)

VHE (3, 4)

Régions d’endémie

• Acute Hepatitis * enteric transmission• Incubation time : 40 days • Fulminate Hepatite : 1 -4% (20% pregnancy)

*chronic in recipient transplants and HIV+

Hepatitis E VirusHepatitis E VirusHepeviridaeHepeviridae, , hepevirushepevirus

Q: Is the animal reservoir responsible for zoonotic transmissions ?

Possible animal Réservoirs

33% Japanese cats (n=135) Usui et al, 2004

Animals Countries Ab Prevalence

SwineSwine Worldwide 30-80%

Rat India, Brazil 50-80%

Cat Japan 33%

Dog Brazil 7%

Sheep India, China, Brazil

Goat India, China, Brazil

Wild boarWild boar Japan, France, Germany, Italy, Spain, Hungary

5-42%

Deer Japan, Hungary 2.6%

Chicken USA, Brazil, Australia 20-30%

Bovine Brazil 1.42%

Horse Egypt 13%

Mongoose Japan 8.3%

Crossing the Species Barrier

GenotypeGenotype Natural HostNatural Host Exp ModelsExp Models InfectionInfection

1 & 2 HumanHuman Macaque +

Swine -

Rat +

3 HumanHuman Macaque +

Swine +

SwineSwine Macaque +

Swine +

Chicken nd

Rat nd

Lamb +

Avian ChickenChicken Macaque -

Swine -

Chicken +

Rat nd

Turkey +

nd: not determined

Model of experimental infection in swine

Asymptomatic (few liver lesions, no increase of ASAT,ALAT, feces excretion,

seroconversion)

Extra-hepatic sites of multiplication : small intestine, colon, lymph nodes, high

excretion in bile, spleen, . (Williams et al JCM 2001).

No effect in pregnant gilts (Kasorndorkbua et al 2003).

Few differences of physiopathology between swine and human genotype 3 strains.

Highly contagious R0 = 8.8 (Bouwknegt et al Vet Res 2008)

Asymptomatic

Occurs around 10 weeks (after weaning, lost Ab maternal)

Viral excretion between 12 and 15 weeks, seroconversion at 16-20 weeks

> 90% herds are infected (USA, Europe, Asia)

HEPATITIS E IN SWINE

Natural infection

Model of experimental infection in swine

HEPATITIS E IN SWINE

Bouwknegt

et al Vet Res 2009

HEPATITIS E IN SWINE

Zoonotic transmissions through direct contact with swine or infected pork meat

Increased HEV sero prevalence in exposed personnel (veterinaries, butchers, slaughterhouse).USA 26% (Meng et al 2002)

Sweden 13% (Olsen et al 2006)

Moldavia 51.1% (Drobeniuc et al 2001)

The Netherlands 11% (Bouwknegt et al 2007)

Species of origin Mode of contamination Geno-type Reference

Sika deer Uncooked meat (sushi) 3 Tei et al, 2003

Wild boar Barbecue (partially undercooked) 3 Tamada et al, 2004

Wild boar Barbecue (partially undercooked) 3 Masuda et al, 2005

Pig Grilled or uncooked pig liver 3 Yasuyuki et al, 2003

Zoonotic transmissions through infected food product

Possible transmissions zoonotic with pork products

Confession Muslim Hindu

Prevalence 2% 20%Indonesian study(Surya et al 2005)

Evidence of Zoonotic transmissions

Food product infected by HEV: pork liver in grocery stores

USA (Feagins et al JGV 2007); ARN + = 14/127 (11%); 2/3 infectiousThe Netherlands (Bouwknegt et al J Food Prot 2007); ARN+ 4/62 (6.5%)Japan (Yazaki Y et al J Gen Virol 2003); ARN + = 7/363 (1.9%)

Source of HEV exposure

Inactivation of infectious hepatitis E virus present in commercial pig livers sold in local grocery stores in the United StatesR. Feagins, et al Int J Food Microbiol. 2008 March 31; 123(1-2): 32–37.

HEV-positive pig liverliver homogenate negative for HEV

56°C for 1 hr stir-fried at 191°C for 5 min

boiled in water for 5 min

Other risk factors:Consumption of offal or wild-boar meat (Wichmann O et al , J Infect Dis. 2008)

Japan (Li et al Am J Trop Med Hyg. 2007) Corbicula Japonica

Sea shell

US, Spain and France RNA +Clemente-Casares et al, EID 2003

Wastewater in non endemic regions

Source of HEV exposure

Surface water in non endemic regions (Rutjes SA, EID 2009)

>150 human indigenous cases per year (source: National reference centre)

http://www.cnr.vha-vhe.aphp.fr/cadrecnr.htm

1 to 2 cases of fulminate hepatitis/year

Chronic cases (transplant recipient)

Genotype 3 HEV strains

Seroprevalence : 3.2% in blood donors from Paris area and north west

Boutrouille et al JCM 2007 )

16.4% in blood donors from Toulouse area (30% in

hunters Mansuy et al JMV 2008)

Hepatitis E in France

sewage

Environment ?

Serology

Virology

0123456789

10

0 10 20 30 40 50 60 70 80 90 100

% positifs

N é

leva

ges

> 70% Swine Herds are infected (n=51)

Intra herd prevalence : 25% (2.5 to 80%)

HEV Prevalence in French swine herds

HEV RNA is present in individual fecal samples

HEV RNA is present in slurry manure storage

HEV RNA present in manure storage is infectious (as confirmed by experimental infection of pig)

HEV RNA sequences present in swine are closely related to human strains (Genotype 3c, 3e and 3f).

swJ1

-1 c

apsi

d

swJ1

-3 c

apsi

d

swJ2

-3 ca

psid

swST

HY40

HE-JA20

ORF2

HE-JA4 ORF2

swJL234 ORF2

H. E virus HEV-US1 ORF2

HE-JANGP2 ORF2HE-JA22 ORF2HE-JA7 ORF2

KOR1 capsid protein

UMC7A

H. E virus HEV-US2 ORF2

H. E virus FR45.3 capsid

NLSW36

NLSW20

Fr-4 capsid protein

Fr-11 capsid

SwE FR43 S5 capsid protein

HE MaR7307574 capsid protein

NLSW99

JMO-Hyo03L

JSO-H

yo03

L

JYO

-Hyo

03L

JDEE

R-H

yo03

LJT

H-H

yo03

L

HE

-JA

5 O

RF2

HE

-JO

-198

2 O

RF2

HE-

JA6

OR

F2sw

JL82

OR

F2HE

-JA2

3 O

RF2

HE-J

A9 O

RF2

swJ2

5-1

HE-JA11 ORF2

swJ681 ORF2

H. E vi

rus TW

12SW

H. E vir

us TW3SW nucle

ocapsid

H. E virus TW13SW

H. E vi

rus Fr-1

caps

id

S.HEV swJ791 ORF2

H. E virus FR18 12S capsid

swJ8-2 capsid

H. E virus UK 7518 capsid

S.HEV P143/11/02 capsidH. E virus UK 8734 capsid

H. E virus FR22.6 capsidH. E virus Fr-9 truncated

H. E virus Fr-10 capsidH. E virus Fr-5 capsidNLSW91NLSW85NLSW82NLSW28

H. E virus FR79 capsid

H. E virus Fr-2 capsid

H. E virus 6317147 ORF2

H. E virus VH1 putative capsid

H. E virus Fr-3 capsid

NLSW

97

H. H

EV VH2 putative capsid

protein

H. E

vir us Fr- 13 ca ps idH

. E virus FR

HP

105 capsidH

. E virus FRSPP05 capsid

NLSW

15H. E virus FRHPP305 capsid

H.HEV E11 putative capsidprotein

H. E virus Fr-6b capsid

H. E virus Fr-6a capsid

0.02

3e

3d

FR, UK, JP

3c

3a

3b

3f

FR, SP, NL

FR, NL

USA, CAN, KOR,JP

TW

JP

French HEV ORF2 PhylogenyNeighbors joining tree methodSwine strainsHuman strains

Molecular Virology : phylogenic analyses of French isolatesMolecular Virology : phylogenic analyses of French isolates

Epidemiology: study of Epidemiology: study of clinical cases of HEV within the ANGH networkclinical cases of HEV within the ANGH network

Renou et al, EID 2007 & Renou et al, APT 2008

French Guinea = 1 caseIndigenous cases (no Travel) = 47 cases (89%)1 case of fulminate hepatitisNo particular risk factor identified (private well)

85%(44/52 cases)

15%(8/52 cases)

Geographic Distribution of 53 cases: Increasing Gradient North-> South

12

9*

1

10*

1

21 1

2

11

1

11

1

5

11

Pet Pig (DDSV)

HEV RNA +CNR

HEV RNA +UMR Viro94% homology 94% homology ntnt

ORFORF--1 & ORF1 & ORF--22

Patient acute hepatitisQuestionnaire (DDASS)

85%

15%

Geographic distribution of swine herdsIncreasing Gradient South-> North

Genotypes 3c, 3e et 3f

Indigenous Hepatitis E

Serology 3.2 to 16.4 %>70% positive Herds

Environment

Genotypes3c, 3e et 3f? ?

?Food productscontact

sewagewater

Pigasymptomatic R0 = 8.8

ConclusionsConclusions

AcknowledgmentsAcknowledgments

UMR 1161 Eq VHE

Annie Boutrouille

Aurélie Lunazzi

Audrey Fraisse

Gaetana Di Liberto

Marc Eloit

AFSSA Ploufragan

Jean-Pierre Jolly

Virginie Dorenlor

Christelle Fablet

CHU Purpan

J. Izopet, JM. Mansuy

CHG Hyères

Christophe Renou

CNR VHE

E. Nicand

Inserm U618

P. Coursaget

InVS

E. Delarocque-A

DERNS

A. Thebault