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Seroprevalence for Hepatitis E and Other Viral Hepatitides among Diverse Populations, Malawi - Volume 21, Number 7—July 2015 - Emerging Infectious Disease journal - CDC

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Seroprevalence for Hepatitis E and Other Viral Hepatitides among Diverse Populations, Malawi - Volume 21, Number 7—July 2015 - Emerging Infectious Disease journal - CDC

Volume 21, Number 7—July 2015


Seroprevalence for Hepatitis E and Other Viral Hepatitides among Diverse Populations, Malawi

Taha E. TahaComments to Author , Laura K. Rusie, Alain Labrique, Mulinda Nyirenda, Dean Soko, Melvin Kamanga, Johnstone Kumwenda, Homayoon Farazadegan, Kenrad Nelson, and Newton Kumwenda
Author affiliations: Johns Hopkins University, Baltimore, Maryland, USA (T.E. Taha, L.K. Rusie, A. Labrique, H. Farazadegan, K. Nelson, N. Kumwenda)Queen Elizabeth Central Hospital, Blantyre, Malawi (M. Nyirenda);Johns Hopkins Research Project, Blantyre (D. Soko, M. Kamanga)University of Malawi, Blantyre (J. Kumwenda)


Data on prevalence of hepatitis E virus (HEV) in Malawi is limited. We tested blood samples from HIV-uninfected and -infected populations of women and men enrolled in research studies in Malawi during 1989–2008 to determine the seroprevalence of HEV, hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Samples were tested for IgG against HEV, total antibodies against HAV and HCV, and presence of HBV surface antigens. Of 800 samples tested, 16.5% were positive for HEV IgG, 99.6% were positive for HAV antibodies, 7.5% were positive for HBV surface antigen, and 7.1% were positive for HCV antibodies. No clear trends over time were observed in the seroprevalence of HEV, and HIV status was not associated with hepatitis seroprevalence. These preliminary data suggest that the seroprevalence of HEV is high in Malawi; the clinical effects may be unrecognized or routinely misclassified.
Hepatitis E virus (HEV) is primarily a waterborne virus that is transmitted by the fecal–oral route. First recognized in the early 1980s, it is now acknowledged to be the primary cause of enterically transmitted non-A, non-B hepatitis (1). HEV has 1 serotype and 4 genotypes (1). Clinical characterization of HEV infection is similar to that of other viral hepatitis infections, ranging from asymptomatic infection to fulminant hepatitis (2). Although illness caused by HEV most often tends to be mild and self-limiting, high rates of illness and death among pregnant women is a unique complication and key epidemiologic feature of HEV infection. Additionally, chronic infection leading to fibrosis and cirrhosis of the liver can occur in the immunosuppressed (3).
Currently, no data on HEV seroprevalence are available for Malawi. However, outbreaks of HEV infection have been documented in several countries in the southern and eastern regions of Africa. In Zambia, the overall seroprevalence of HEV was 42% among 106 adults who participated in a community study in 1999; among children who were included in a prospective study of the same community in 2011, the seroprevalence of HEV was 8% in age group 1–4 years (n = 96), 16% in age group 5–9 years (n = 62), and 36% in age group 10–14 years (n = 36) (4). In northern Uganda, surveillance of health care facilities during 2010–2012 showed that 42% of 347 persons with reported acute jaundice syndrome cases had hepatitis E, 14% had hepatitis B, and 5% had hepatitis C (5). During 2012 in a refugee camp in eastern Kenya, 77.1% of 170 samples from persons with acute jaundice syndrome were positive for HEV IgM, RNA, or both (6). Data from earlier studies in Tanzania suggested either lack of exposure or low levels of HEV among women (7,8). A review of the epidemiology of HEV in Africa by Kim et al. (9) provides a listing of seroprevalence of HEV antibodies in various African countries.
Similar to HEV, HAV is transmitted by the fecal–oral route, although the epidemiology of the viruses is substantially different. Infection with HAV is considered a childhood disease in developing countries; nearly all children are infected at an early age. Disease tends to be mild in children and does not result in chronic infection (10). Unlike HAV and HEV, hepatitis B and C viruses (HBV and HCV) are transmitted through contact with infectious body fluids and can cause acute or chronic infection. Acute infection with HBV or HCV can manifest with a wide range of mild to severe symptoms. Chronic HBV and HCV infection can lead to serious outcomes such as cirrhosis, cancer, and failure of the liver (1112). High HBV and HCV prevalence have been reported in southern Africa, where HIV prevalence is also high (13). HCV prevalence in Africa varies by country; estimates range from 1% to 10% (14). However, it is unclear whether HCV seroprevalence on the basis of antibody testing alone represents a true estimate because a high number of false-reactive results (compared to those for HCV RNA) have been reported in several HIV-prevalent populations in Africa (15,16). The rate of chronic HBV carriers in sub-Saharan Africa is estimated to be >8% (17).
Previous studies have shown that HBV and HCV are prevalent in Malawi. Among patients in hospitals in Malawi, 17.5% tested positive for hepatitis B surface antigen (HBsAg), and samples from 4.5% were HCV antibody–positive (18). Among male sugar estate workers in Malawi, 14.9% tested positive for HBsAg, and samples from 10.6% were HCV antibody–positive (19).
Co-infection of HIV and HBV or HCV leads to accelerated progression of liver disease (13). The interaction of HEV with HIV has not yet been confirmed but is conceivable, and a strong association has been reported among adults in a retrospective study in Zambia in which 28% of HIV-seronegative and 71% of HIV-seropositive adults were found to be HEV seropositive (4). Superinfection with >1 type of hepatitis has been shown to cause severe disease. Children with simultaneous infection of HAV and HEV may experience accelerated disease progression. A study among persons who chronically carried the HBV surface antigen showed rapid clinical deterioration when co-infected with HEV (20). The high prevalence of HIV in Malawi, combined with the severe implications of co-infections with hepatitis viruses, necessitate clarification of the levels of multiple hepatitis virus infections within the same population. The primary aim of this study, conducted in 2012, was to determine the seroprevalence of HEV, as well as HAV, HBV, and HCV, in samples collected during 1989–2008 from diverse adult populations in Malawi.
Dr. Taha is professor of Infectious Disease Epidemiology in the Department of Epidemiology at the Johns Hopkins Bloomberg School of Public Health in Baltimore. His primary research interest is HIV acquisition and transmission and the impact of infectious diseases on the health of children and adults in sub-Saharan Africa.


We thank the Wantai Biological Pharmacy Enterprise Co., Ltd., for donating the HEV IgG ELISA kits for this research. We also thank the technologists in H.F.’s laboratory at the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, for assistance in performing the hepatitis assays.


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Suggested citation for this article: Taha TE, Rusie LK, Labrique A, Nyirenda M, Soko D, Kamanga M, et al. Seroprevalence for hepatitis E and other viral hepatitides among diverse populations, Malawi. Emerg Infect Dis. 2015 Jul [date cited]. http://dx.doi.org/10.3201/eid2107.11748
DOI: 10.3201/eid2107.141748

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